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CENTER FOR BEHAVIORAL HEALTH STATISTICS AND QUALITY



Drug Abuse Warning Network, 2008:
National Estimates of Drug-Related Emergency Department Visits



U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Behavioral Health Statistics and Quality



ACKNOWLEDGMENTS

This report was prepared by the Center for Behavioral Health Statistics and Quality (CBHSQ), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services (HHS), and by RTI International (a trade name of Research Triangle Institute, Research Triangle Park, NC). Work by RTI was performed under Contract No. 283-07-0207.

PUBLIC DOMAIN NOTICE

All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.

RECOMMENDED CITATION

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2011). Drug Abuse Warning Network, 2008: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. SMA 11-4618. Rockville, MD.

ELECTRONIC ACCESS

This publication may be downloaded from http://DAWNinfo.samhsa.gov or from http://oas.samhsa.gov. Or please call SAMHSA at

1-877-SAMHSA-7 (1-877-726-4727)
(English and Español)

ORIGINATING OFFICE

Center for Behavioral Health Statistics and Quality
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road, Rockville, MD 20857

February 2011



CONTENTS

Acknowledgments

Highlights
All drug-related ED visits
Drug misuse or abuse
Illicit drugs
Drugs and alcohol taken together
Alcohol use by youth and young adults
Nonmedical use of pharmaceuticals
Drug-related suicide attempts
Seeking detox services

Introduction
Major features of DAWN
What is a DAWN case?
What drugs are included in DAWN?
What is covered in this publication?
Hospital participation in 2008
Estimates in this publication
Margin of error for estimates
Comparisons across years
Rates of ED visits per 100,000 population
Limitations to data

Drug Misuse or Abuse
ED visits involving drug misuse or abuse, 2008
Trends in ED visits involving drug misuse or abuse, 2004–2008

Illicit Drugs
ED visits involving illicit drugs, 2008
Trends in ED visits involving illicit drugs, 2004–2008

Alcohol
ED visits involving drugs and alcohol taken together
Alcohol use by youth and young adults
Trends in ED visits involving alcohol, 2004–2008

Nonmedical Use of Pharmaceuticals
ED visits involving nonmedical use of pharmaceuticals, 2008
Trends in ED visits involving nonmedical use of pharmaceuticals, 2004–2008

Drug-Related Suicide Attempts
ED visits involving drug-related suicide attempts, 2008
Trends in ED visits involving drug-related suicide attempts, 2004–2008

Seeking Detox Services
ED visits involving seeking detox services, 2008
Trends in ED visits involving seeking detox services, 2004–2008

List of Tables

Table 1. ED visits involving drug misuse or abuse, by drug combinations, 2008
Table 2. Trends in ED visits involving drug misuse or abuse, by drug combinations, 2004–2008
Table 3. ED visits involving illicit drugs, 2008
Table 4. Rates of ED visits per 100,000 population involving illicit drugs, 2008
Table 5. ED visits involving illicit drugs, by patient demographics, 2008
Table 6. Rates of ED visits per 100,000 population involving illicit drugs, by patient demographics, 2008
Table 7. ED visits and rates involving illicit drugs, by patient disposition, 2008
Table 8. Trends in ED visits involving illicit drugs, by selected drugs, 2004–2008
Table 9. ED visits involving alcohol, 2008
Table 10. ED visits involving drugs and alcohol taken together, by most frequent combinations, 2008
Table 11. ED visits involving drugs and alcohol taken together, by patient demographics, 2008
Table 12. ED visits involving drugs and alcohol taken together, by patient disposition, 2008
Table 13. ED visits involving alcohol, by presence of other drugs, by age groups 12 to 17 and 18 to 20, 2008
Table 14. Trends in ED visits involving alcohol, by presence of other drugs, 2004–2008
Table 15. Trends in ED visits involving alcohol, by presence of other drugs, by age groups 12 to 17 and 18 to 20, 2004–2008
Table 16. ED visits involving nonmedical use of pharmaceuticals, 2008
Table 17. ED visits and rates involving nonmedical use of pharmaceuticals, by patient demographics, 2008
Table 18. ED visits and rates involving nonmedical use of pharmaceuticals, by patient disposition, 2008
Table 19. Trends in ED visits involving nonmedical use of pharmaceuticals, by selected drugs, 2004–2008
Table 20. ED visits involving drug-related suicide attempts, by selected drugs, 2008
Table 21. ED visits involving drug-related suicide attempts, by patient demographics, 2008
Table 22. ED visits involving drug-related suicide attempts, by patient disposition, 2008
Table 23. Drug categories and drugs with increasing involvement in drug-related suicide attempt ED visits, 2004–2008
Table 24. Trends in ED visits for drug-related suicide attempts, by selected drugs, 2004–2008
Table 25. ED visits involving seeking detox services, by selected drugs, 2008
Table 26. ED visits involving seeking detox services, by patient demographics, 2008
Table 27. ED visits involving seeking detox services, by patient disposition, 2008
Table 28. Trends in ED visits involving seeking detox services, by selected drugs, 2004–2008

Table C1. Sample characteristics for 2008 DAWN data collection year
Table C2. Drug-related ED visits and drugs, by type of case, 2008
Table C3. DAWN analytic groups
Table C4. U.S. population by age and gender, 2008

Table D1. Drug-related ED visits, by detailed race/ethnicity, 2008

List of Figures

Figure 1. Rates of ED visits per 100,000 population involving illicit drugs, 2008
Figure 2. Rates of ED visits per 100,000 population involving illicit drugs, by selected drugs, age, and gender, 2008
Figure 3. Rates of ED visits per 100,000 population involving alcohol, by age and gender, 2008
Figure 4. Rates of ED visits per 100,000 population involving alcohol in combination and alcohol alone, by age groups 12 to 17 and 18 to 20, 2008
Figure 5. Rates of ED visits per 100,000 population involving nonmedical use of pharmaceuticals, by age and gender, 2008
Figure 6. Rates of ED visits per 100,000 population involving drug-related suicide attempts, by age and gender, 2008
Figure 7. Rates of ED visits per 100,000 population involving seeking detox services, by age and gender, 2008

List of Appendices

Appendix A: Multum Lexicon End-User License Agreement
Appendix B: Glossary of DAWN Terms, 2008 Update
Appendix C: 2008 DAWN Methodology
Appendix D: Race and Ethnicity in 2008 DAWN


HIGHLIGHTS

This publication presents national estimates of drug-related visits to hospital emergency departments (EDs) for 2008, based on data from the Drug Abuse Warning Network (DAWN). Also presented are comparisons of 2008 estimates with those for 2004, 2006, and 2007. DAWN is a public health surveillance system that monitors drug-related ED visits for the Nation and for selected metropolitan areas. DAWN estimates pertain to the entire United States, including Alaska, Hawaii, and the District of Columbia. The Substance Abuse and Mental Health Services Administration (SAMHSA) is the agency responsible for DAWN. SAMHSA is required to collect data on drug-related ED visits under section 505 of the Public Health Service Act.

DAWN relies on a sample of general, non-Federal hospitals operating 24-hour EDs. The sample is national in scope, with oversampling of hospitals in selected metropolitan areas. In each participating hospital, ED medical records are reviewed retrospectively to find the ED visits that involved recent drug use. All types of drugs—illegal drugs, prescription and over-the-counter pharmaceuticals (e.g., dietary supplements, cough medicine), and substances inhaled for their psychoactive effects—are included. Alcohol is considered a reportable drug when consumed by patients younger than 21. For patients aged 21 or older, though, alcohol is reported only when it is used in conjunction with other drugs.

All drug-related ED visits

In 2008, over 118 million ED visits were made to general-purpose hospitals in the United States; DAWN estimates that over 4.3 million (4,383,494)1 ED visits were associated with drug use, misuse, or abuse. The number of drug-related visits has increased by over 70 percent from 2004 through 2008. This increase reflects jumps seen in the number of drug-related ED visits involving adverse reactions, accidental drug ingestions, and misuse or abuse of prescription drugs and over-the-counter medications.

Drug misuse or abuse

In 2008, DAWN estimates that about 2 million (1,999,861) ED visits resulted from medical emergencies involving drug misuse or abuse. That is the equivalent of more than 650 ED visits per year per 100,000 population.

Of the 2 million visits associated with drug misuse or abuse in 2008,

Although the overall number of ED visits attributable to drug misuse or abuse was stable from 2004 to 2008, increases were seen in ED visits involving nonmedical use of pharmaceuticals with no other drug involvement (97% increase), pharmaceuticals with illicit drugs (60% increase), and pharmaceuticals with alcohol (50% increase).

Illicit drugs

For 2008, DAWN estimates that 993,379 ED visits involved an illicit drug. That is, about half (49.7%) of all the drug misuse or abuse ED visits during the year involved one or more illicit drugs taken alone or in combination with pharmaceuticals, alcohol, or both. Considering just visits for illicit drug involvement:

For each 100,000 persons in the U.S. population, over the course of 2008, there were just under 160 ED visits (158.6) resulting from medical emergencies involving cocaine. This is followed by marijuana (123.1 ED visits per 100,000 population), heroin (66.0), methamphetamine (21.8), PCP (12.3), and amphetamines (10.4). Lower-incidence drugs had rates below 6 visits per 100,000 population. The rate of cocaine involvement was highest for patients aged 35 to 44 (358.7), heroin was highest for those aged 25 to 29 (155.5), and marijuana was highest for those aged 18 to 20 (467.0). Rates of stimulant involvement were more even across the age range of 18 to 44. For visits involving cocaine, heroin, or marijuana, rates were higher for males than females. A little over 40 percent (42.7%) of the patients had some type of follow-up care (i.e., referral to detoxification services, admission to the hospital, or transfer to another facility); most other patients were treated and released.

The level of ED visits involving illicit drugs from 2004 to 2008 appeared stable for cocaine, marijuana, and heroin. However, in the shorter term, ED visits involving cocaine decreased 13 percent from 2007 to 2008. MDMA (Ecstasy) saw an uptick when 2004 and 2008 were compared. This increase does not appear to be a trend, though, as levels of MDMA involvement in the intervening years fluctuated widely. The involvement of stimulants (i.e., amphetamines and methamphetamine) decreased consistently from 2004 to 2007 and remained steady in 2008 at about 90,000 visits. That is about 70,000 fewer visits than seen in 2004.

Drugs and alcohol taken together

Illicit drugs, often in combination with other illicit drugs or pharmaceuticals, were involved in well over half (60.1%) of ED visits involving alcohol and other drugs. One or more pharmaceuticals were also involved in over half (56.2%) of these visits. Drugs for insomnia and anxiety were involved in 24.5 percent of visits, with the largest part of that being benzodiazepines (20.7%). Pain relievers were involved in 22.1 percent of visits, with narcotic pain relievers accounting for over half of that (13.7%). Psychotherapeutic agents (e.g., antidepressants, antipsychotics) were involved in under 10 percent of such visits.

The rate of ED visits per 100,000 population for males (217.1) was higher than that for females (128.5). Rates by age group showed a general pattern of being lower for those under 18 or over 54 and higher for those aged 18 to 54; they were highest of all for those aged 35 to 54.

Almost half (49.0%) of the patients received some sort of follow-up treatment. Nearly a third (30.9%) of patients were admitted to the hospital, 11.2 percent were transferred to another health care facility, and 6.8 percent were referred to a detoxification program.

From 2004 to 2008, no significant increases or decreases were found in the number of ED visits involving alcohol taken in combination with other drugs or alone.

Alcohol use by youth and young adults

In 2008 for youth and young adults (patients aged 12 to 17 and 18 to 20, respectively), 56,727 ED visits involved drugs taken with alcohol; 132,254 ED visits, or about twice as many, involved the use of alcohol alone. Alcohol use, with and without other drugs, increased markedly between these two age groups. The rate of medical emergencies involving use of drugs with alcohol was 78.9 visits per 100,000 youth compared with 286.3 visits for young adults, almost a fourfold increase. The rate of ED visits involving alcohol used alone was 220.7 visits per 100,000 for youth and 596.3 visits for young adults, almost a threefold increase.

Although there were some short-term drops in the number of visits involving alcohol and other drugs for 12- to 17-year-olds between 2006 and 2008, these drops merely offset increases seen in 2006; 2008 levels were similar to those found in 2004 and 2005.

Nonmedical use of pharmaceuticals

For 2008, DAWN estimates that 971,914 ED visits involved nonmedical use of prescription or over-the-counter pharmaceuticals or dietary supplements. Slightly more than half (52.9%) of these visits involved multiple drugs, and 18.8 percent involved alcohol. The rate of nonmedical use of pharmaceuticals did not differ between males and females. Most patients (60.5%) were treated and released after their ED visits.

Central nervous system agents were present in 73.9 percent of visits involving misuse or abuse of pharmaceutical drugs. Pain relievers were involved in 47.1 percent of visits, with 31.5 percent being narcotic pain relievers. The most frequently involved narcotic pain relievers were oxycodone and hydrocodone.

Drugs to treat insomnia and anxiety (anxiolytics, sedatives, and hypnotics) were involved in a third (33.4%) of visits associated with nonmedical use of pharmaceuticals, with the largest portion of these being benzodiazepines. Alprazolam was the most common type of benzodiazepine involved and was present in over 100,000 visits.

Medical emergencies related to nonmedical use of pharmaceuticals increased 81 percent in the period from 2004 to 2008, going from just over a half million visits (536,247 visits) to almost a million (971,914 visits). Contributing to that increase are significant long-term (2004 to 2008) increases in the number of visits involving narcotic pain relievers that jumped by 111 percent, or over 160,000 visits. Specific drugs with increases over 100 percent were fentanyl, hydrocodone, hydromorphone, morphine, and oxycodone.

Drug-related suicide attempts

DAWN estimates that there were almost 200,000 (199,469) medical emergencies for drug-related suicide attempts in 2008. Females were more likely than males to be seen in the ED for a drug-related suicide attempt (76.6 visits per 100,000 population compared with 53.9). Rates are highest for those aged 18 to 20 (141.0 visits per 100,000 population). Nearly two thirds (64.0%) of ED visits for drug-related suicide attempts involved multiple drugs. Almost all (94.6%) involved a prescription drug, over-the-counter medication, or other pharmaceutical. Over two thirds (71.7%) involved central nervous system agents, which were split between pain relievers (37.3%), benzodiazepines (28.0%), and other drugs to treat insomnia and anxiety (14.2%). Just under a third (29.4%) involved psychotherapeutic agents (e.g., antidepressants, antipsychotics) or alcohol (29.9%); almost a fifth (18.4%) involved illicit drugs.

After the ED visits, few patients (19.7%) were just treated and released. Most (78.2%) received some sort of follow-up care (e.g., transfer to another facility, admittance to the hospital, or referral to a detox program).

Overall, the level of ED visits for drug-related suicide attempts was stable from 2004 through 2008. Increases were seen in ED visits involving narcotic pain relievers, benzodiazepines, and other drugs to treat insomnia and anxiety, though. Involvement of narcotic pain relievers rose 58 percent, with hydrocodone rising 66 percent and oxycodone rising 64 percent. Benzodiazepines increased 51 percent, with alprazolam rising 87 percent. Other anxiolytics rose 68 percent, with zolpidem rising 119 percent.

Seeking detox services

DAWN estimates 177,879 drug-related ED visits in 2008 by patients seeking detox or substance abuse treatment services. Males were more likely than females to seek detox services through the ED (74.6 visits per 100,000 population compared with 42.8 visits).

Cocaine was observed in 38.7 percent of visits, heroin in 29.2 percent, marijuana in 18.5 percent, and stimulants in 7.0 percent. Among pain relievers, narcotic pain relievers were observed in 32.9 percent of visits, including oxycodone in 19.3 percent, hydrocodone in 12.1 percent, and methadone in 5.6 percent. Benzodiazepines were observed in 23.4 percent of visits. Alcohol involvement was noted in 36.6 percent of detox visits. Almost three quarters (73.0%) of visits where patients were seeking detox services involved multiple drugs.

About half (47.1%) of the ED patients classified as seeking detox were treated and released and just under half (20.9%) of those patients were referred to detox or treatment services. Another 20.3 percent were admitted to the chemical dependency/detox unit of the hospital, and 17.5 percent were admitted to other units within the hospital. A little less than 10 percent (7.5%) were transferred to another facility. In total, 66.1 percent of patients had some form of follow-up.

Overall, the number of patients seeking detox services through the ED was relatively stable from 2004 through 2008.

INTRODUCTION

This publication presents estimates of drug-related emergency department (ED) visits from the Drug Abuse Warning Network (DAWN) for 2008, with comparison of estimates for 2004, 2006, and 2007. DAWN is a public health surveillance system that monitors drug-related ED visits for the Nation and for selected metropolitan areas. The Center for Behavioral Health Statistics and Quality (CBHSQ) of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, has been responsible for DAWN operations since 1992.

This introduction provides a brief description of the major features of DAWN and the statistics presented in this report. Findings are organized in six sections following this Introduction. Each section focuses on a specific type of ED visit. Appendix B: Glossary of DAWN Terms and Appendix C: 2008 DAWN Methodology provide additional detail on the collection and analysis of the 2008 DAWN data, including response rates.

Major features of DAWN

What is a DAWN case?

A DAWN case is any ED visit involving recent drug use that is implicated in the ED visit. The relationship between the ED visit and the drug use need not be causal. That is, implicated drugs may or may not have directly caused the condition generating the ED visit. The reason a patient used a drug is not part of the criteria for considering a visit to be drug related. These criteria broadly encompass all types of drug-related events, including accidental ingestion and adverse reaction, as well as explicit drug abuse. DAWN does not report current medications (i.e., medications and pharmaceuticals taken regularly by the patient as prescribed or indicated) that are unrelated to the ED visit.

What drugs are included in DAWN?

DAWN collects data on all types of drugs, including

What is covered in this publication?

This publication focuses primarily on ED visits involving drug misuse or abuse. Seven categories of ED visits associated with drug misuse or abuse are highlighted in this publication:

Drug misuse or abuse is an overarching category that includes all ED visits involving drug misuse or abuse. Visits involving the use of illicit drugs are singled out for analysis because they involve substances that are generally illegal and, by definition, constitute substance abuse. Visits involving alcohol used in combination with other drugs are analyzed as a group to better understand the interactive effects of alcohol and drugs on morbidity. ED visits involving underage drinking are studied as an important barometer of dangerous drinking patterns in youths. Nonmedical use of pharmaceuticals refers to ED visits related to the misuse or abuse of prescription or over-the-counter medications or dietary supplements. This might result from taking a higher-than-prescribed or -recommended dose of a pharmaceutical (i.e., contrary to directions or labeling), taking a pharmaceutical prescribed for another individual, being maliciously poisoned by another individual, and abusing pharmaceuticals. Drug-related suicide attempts involve drug overdoses as well as suicide attempts by other means (e.g., by gun) if drugs were involved. "Seeking detox" includes various situations such as nonemergency requests for admission for detox, visits to obtain medical clearance before entry to a detox program, and acute emergencies in which an individual is in distress (i.e., displaying active withdrawal symptoms) and seeking detox.

These categories are defined by drug and type of case as shown in Table C3 in Appendix C. Note that the categories are not mutually exclusive.

Hospital participation in 2008

For 2008, 231 hospitals submitted data that were used for estimation. The overall weighted response rate was 32.9 percent. For the 13 oversampled metropolitan areas and divisions, the individual response rates ranged from 26.8 percent in the Houston metropolitan area to 83.1 percent in the Detroit metropolitan area.2

DAWN cases are found through a retrospective review of medical records in participating hospitals. Across all participating hospitals in 2008, 9.8 million charts were reviewed to find the drug-related ED visits that met the DAWN case criteria. On the basis of the review of charts, 383,977 drug-related visits were found and submitted to the DAWN database, a case rate of 3.9 percent. On average, a DAWN member hospital submitted 1,167 DAWN cases. However, the number of submitted cases varied widely across hospitals, from 0 cases to 6,832 cases (median 896) in a single hospital during 2008.

Estimates in this publication

The estimates provided in this publication represent drug-related ED visits for the United States. The universe of hospitals eligible for inclusion in DAWN includes non-Federal, short-stay, general medical and surgical hospitals in the United States that operate EDs 24 hours a day, 7 days a week. The American Hospital Association's (AHA's) 2001 Annual Survey was used to identify the original frame members. Subsequent AHA surveys are used annually to identify "births" of new hospitals that open and the "deaths" of hospitals that close or merge with other hospitals.

The DAWN sample of hospitals includes an oversampling of hospitals in select metropolitan areas, supplemented with a sample of hospitals from the remainder of the United States, which includes other metropolitan areas as well as nonmetropolitan and rural areas. The metropolitan area boundaries correspond to the definitions issued by the Office of Management and Budget (OMB) in June 2003.

Estimates of drug-related ED visits are calculated by applying weights and adjustments to the data provided by the sampled hospitals participating in DAWN. The primary sampling weights reflect the probability of selection, and separate adjustment factors are included to account for sampling of ED visits, nonresponse, data quality, and the known total of ED visits delivered by the universe of eligible hospitals as reported by the most current AHA survey.

DAWN currently collects drug information using more than 17,000 individual codes.3 These highly detailed codes are grouped up (mapped) to 3,200 drug names. Drug names are then mapped into 500 broader drug categories. About 100 of the more common drugs and drug categories were selected for inclusion in the drug detail tables in this report. Because a single ED visit may involve multiple drugs and the same drug may be reported both under its specific drug name and under its drug category, the sum of ED visits from different rows in the drug detail tables will be greater than the total number of visits. For the same reason, percentages will add to more than 100.

Margin of error for estimates

Because DAWN relies on a sample of hospitals, each estimate produced from the DAWN ED data is subject to sampling variability, referred to as the "margin of error." Margin of error is the variation in the estimate that would be observed naturally if different samples were drawn from the same population using the same procedures. The sampling variability of an estimate in this publication is measured by its relative standard error (RSE). The precision of an estimate is inversely related to its sampling variability, as measured by the RSE. That is, the greater the RSE, the lower the precision.

DAWN estimates with RSE values greater than 50 percent or fewer than 30 ED visits, or both, are regarded as too imprecise for publication and are not shown. An asterisk (*) is displayed in the place of suppressed estimates. Ratios (percentages or rates per 100,000 population) based on suppressed estimates are likewise suppressed.

In this publication, 95 percent confidence intervals (CIs) are included in many of the tables along with the estimates. A 95 percent CI means that if repeated samples were drawn from the same population of hospitals using the same sampling and data collection procedures, the true population value would fall within the confidence interval 95 percent of the time. A CI, which is expressed as a range of values, is useful because the interval reflects both the estimate and its particular margin of error.

Comparisons across years

In this publication, between-year changes are assessed by comparing estimates for 2008 with those for 2004, 2006, and 2007. This publication reports only those between-year changes that are statistically significant at the p < 0.05 level.

Major changes to DAWN were instituted during 2003 as the result of a redesign that altered most of DAWN's core features. Changes included the design of the hospital sample, the drug-related cases eligible for DAWN, the data items submitted on these cases, and the protocol for case finding and quality assurance. These improvements created a permanent disruption in trends. As a result, comparisons cannot be made between old DAWN (2003 and prior years) and the redesigned DAWN (2004 and forward).

Rates of ED visits per 100,000 population

Standardized measures are helpful when comparing levels of drug-related ED visits for different age groups and genders. This publication reports rates of ED visits per 100,000 population by age and gender. Rates are based on population data from the U.S. Census Bureau. If an estimate is suppressed, the rate will also be suppressed. Tables in this publication do not report population-based rates for race/ethnicity categories because race/ethnicity information is often missing from ED records; a dash (—) is displayed instead.

Limitations to data

Information on drug-related visits is based on a sample and is, therefore, subject to sampling variability. Readers are advised to consider the standard error measurements provided in many tables to reflect the sampling variability that occurs by chance because only a sample rather than the entire universe is surveyed. Hospital participation rates in oversampled metropolitan areas typically have been 50 percent or higher. However, the participation rate in the remainder of the United States has been lower, in the range of 20 to 30 percent, since the DAWN redesign in 2003. In any sample survey, a low response rate is of concern because it creates the opportunity for bias. That is, nonparticipating hospitals may have different characteristics than participating hospitals, possibly including differences in the drugs reported, patient disposition, or population demographics. DAWN is addressing these issues by developing statistical and data collection methods that help to avoid or minimize bias and improve response rates within available resources.

Although every effort is made during the data collection phase to collect data accurately and precisely, extant medical records vary in specificity and detail. Therefore, factors that may affect the reliability and accuracy of the findings include the following:

DRUG MISUSE OR ABUSE

ED visits involving drug misuse or abuse, 2008

For 2008, DAWN estimates that there were over 4.3 million drug-related ED visits. Of these, almost 2.0 million ED visits were associated with drug misuse or abuse (Table 1). This estimate includes

Table 1
ED visits involving drug misuse or abuse, by drug combinations, 2008
Drug combinations (1) ED visits (2) Percent of ED visits RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) DAWN excludes ED visits involving alcohol only for patients aged 21 years or older. When present with other drugs, alcohol is reportable for patients of all ages.
NOTE: CI = confidence interval. RSE = relative standard error. A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, drug misuse or abuse 1,999,861 100.0   7.8 1,692,919 2,306,802
Illicit drugs only    509,773   25.5 12.9    381,203    638,343
Alcohol only (age < 21)    132,842     6.6   9.6    107,746    157,938
Nonmedical use of pharmaceuticals only    664,654   33.2   8.6    552,031    777,278
Combinations             —    —    —             —             —
Illicit drugs with alcohol (3)    229,564   11.5 10.9    180,569    278,560
Illicit drugs with any pharmaceuticals    168,541     8.4 14.9    119,215    217,868
Alcohol with nonmedical use of pharmaceuticals    208,985   10.4   7.8    176,871    241,098
Illicit drugs with alcohol and any pharmaceuticals      85,501     4.3 20.3      51,411    119,591

Of the almost 2.0 million drug misuse or abuse visits, about two thirds (65.4%) were associated with a single drug type (illicit drugs, alcohol, or nonmedical use of pharmaceuticals). Illicit drugs alone were involved in 25.5 percent of drug misuse or abuse visits in 2008, nonmedical use of pharmaceuticals alone was involved in 33.2 percent, and consumption of alcohol (and no other drug) by a minor was involved in 6.6 percent.5 The remaining visits (34.6%) involved some combination of illicit drugs, alcohol, and nonmedical use of pharmaceuticals.

These figures do not suggest that the majority of ED drug misuse or abuse visits involved a single drug. In fact, the typical drug-related ED visit involves multiple drugs, but they may be of a common type. For example, an ED visit involving illicit drugs alone often involves more than one illicit drug (e.g., cocaine and marijuana).

Trends in ED visits involving drug misuse or abuse, 2004–2008

This section presents the trends in the estimates of ED visits involving drug misuse or abuse for the period 2004 through 2008 (Table 2). Differences between years are presented in terms of the percentage increase or decrease in visits in 2008 compared with the estimates for 2004 (long-term trends) and 2006 and 2007 (short-term trends). Only statistically significant changes are discussed and displayed in the table.

Table 2
Trends in ED visits involving drug misuse or abuse, by drug combinations, 2004–2008
Drug combinations (1) ED visits,
2004 (2)
ED visits,
2005 (2)
ED visits,
2006 (2)
ED visits,
2007 (2)
ED visits,
2008 (2)
Percent change, 2004, 2008 (3) Percent change, 2006, 2008 (3) Percent change, 2007, 2008 (3)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
All types of drug misuse or abuse 1,619,054 1,616,311 1,742,887 1,883,272 1,999,861
Illicit drugs only    502,136    517,558    536,554    522,650    509,773
Alcohol only (age < 21)    150,988    110,599    126,704    137,369    132,842
Nonmedical use of
pharmaceuticals only
   336,987    444,309    486,276    582,187    664,654 97 37
Combinations             —             —             —             —             —
Illicit drugs with alcohol    338,638    221,823    219,521    237,936    229,564
Illicit drugs with
pharmaceuticals
   105,017    127,245    142,535    143,783    168,541 60
Alcohol with nonmedical use
of pharmaceuticals
   139,716    140,275    171,743    189,444    208,985 50
Illicit drugs with alcohol and
pharmaceuticals
     45,571      54,500      59,553      69,903      85,501

The number of ED visits attributable to drug misuse or abuse was stable from 2004 to 2008. The small changes seen in the estimates each year are within the boundaries of expected sample variation. From 2004 to 2008, however, ED visits related to the use of pharmaceuticals with no other drug involvement rose substantially (97%), as did the use of pharmaceuticals with illicit drugs (60%) and pharmaceuticals with alcohol (50%). These increases reflect over 300,000 more ED visits related to pharmaceuticals alone, over 60,000 more ED visits related to pharmaceuticals and illicit drugs, and almost 70,000 more ED visits related to pharmaceuticals and alcohol in 2008 than in 2004.

By way of comparison, hospitals in the United States delivered a total of more than 118 million ED visits in 2008, an increase of 8.7 percent over 2004. The population of the United States increased 3.8 percent, from 293 million to 304 million, over the same period.

ILLICIT DRUGS

ED visits involving illicit drugs, 2008

For 2008, DAWN estimates that 993,379 ED visits involved one or more illicit drugs (Table 3). Among the approximately 2.0 million drug misuse or abuse ED visits that occurred during 2008, almost half (49.7%) involved one or more illicit drugs. Among visits involving illicit drugs, cocaine was the most commonly involved drug, with 482,188 ED visits (48.5%). Marijuana followed cocaine, with 374,435 ED visits (37.7%). Heroin was involved in 200,666 ED visits, or 20.2 percent of ED visits involving illicit drugs.6 Stimulants, including amphetamines and methamphetamine, were involved in 91,939 ED visits (9.3%).

Table 3
ED visits involving illicit drugs, 2008
Drugs (1) ED visits (2,3) Percent of ED visits (3) RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon is provided in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: CI = confidence interval. RSE = relative standard error. An asterisk (*) indicates that an estimate with an RSE greater than 50% or an estimate based on fewer than 30 visits has been suppressed. NTA = not tabulated above.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, illicit drugs 993,379 100.0 11.5 770,215 1,216,543
Visits involving a single illicit drug 417,633   42.0 13.3 308,791    526,474
Visits involving multiple drugs 575,746   58.0 11.2 449,127    702,365
Cocaine 482,188   48.5 15.4 336,462    627,913
Heroin 200,666   20.2 11.4 155,928    245,404
Marijuana 374,435   37.7 15.1 263,546    485,324
Stimulants   91,939     9.3 16.9   61,464    122,415
Amphetamines   31,534     3.2 17.9   20,460      42,609
Methamphetamine   66,308     6.7 20.8   39,253      93,363
MDMA (Ecstasy)   17,865     1.8 13.7   13,080      22,650
GHB     1,441     0.1 27.4        668        2,213
Flunitrazepam (Rohypnol)            *        *      *            *               *
Ketamine        344     0.0 46.4          31           657
LSD     3,287     0.3 18.6     2,087        4,488
PCP   37,266     3.8 39.0     8,751      65,780
Miscellaneous hallucinogens     6,028     0.6 19.9     3,674        8,382
Inhalants     7,115     0.7 27.6     3,268      10,962
Combinations NTA     3,512     0.4 21.9     2,007        5,016

Other illicit drugs involved in ED visits at lower levels include the following:

The rates of ED visits involving illicit drugs are reported in Table 4. For each 100,000 persons in the U.S. population, over the course of a year, more than 600 (657.7) ED visits involved drug misuse or abuse. About half (326.7) of those visits involved illicit drugs. Cocaine was involved at a rate of 158.6 ED visits per 100,000 population in the United States, followed by marijuana (123.1 ED visits per 100,000 population), heroin (66.0), and stimulants (30.2). Lower-incidence drugs had rates below 13 visits per 100,000 population.

Table 4
Rates of ED visits per 100,000 population involving illicit drugs, 2008
Drugs (1) Rate of ED visits
per 100,000
population (2,3)
RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) All rates are ED visits per 100,000 population. Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: CI = confidence interval. RSE = relative standard error. An asterisk (*) indicates that an estimate with an RSE greater than 50% or an estimate based on fewer than 30 visits has been suppressed. NTA = not tabulated above.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, illicit drugs 326.7 11.5 253.3 400.1
Cocaine 158.6 15.4 110.7 206.5
Heroin   66.0 11.4   51.3   80.7
Marijuana 123.1 15.1   86.7 159.6
Stimulants   30.2 16.9   20.2   40.3
Amphetamines   10.4 17.9     6.7   14.0
Methamphetamine   21.8 20.8   12.9   30.7
MDMA (Ecstasy)     5.9 13.7     4.3     7.4
GHB     0.5 27.4     0.2     0.7
Flunitrazepam (Rohypnol)        *      *        *        *
Ketamine     0.1 46.4   <0.1     0.2
LSD     1.1 18.6     0.7     1.5
PCP   12.3 39.0     2.9   21.6
Miscellaneous hallucinogens     2.0 19.9     1.2     2.8
Inhalants     2.3 27.6     1.1     3.6
Combinations NTA     1.2 21.9     0.7     1.6

Figure 1 displays the rates of ED visits per 100,000 population for the four major types of illicit drugs: cocaine, marijuana, heroin, and stimulants.

Figure 1
Rates of ED visits per 100,000 population involving illicit drugs, 2008

Figure 1   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

Table 5 presents estimates of the number of ED visits in 2008 involving illicit drugs for males and females, different age groups, and race/ethnicity categories. To facilitate comparisons, Table 6 and Figure 2 present the rates of ED visits per 100,000 population for these same groups. The rates for visits involving cocaine, heroin, marijuana, and stimulants were consistently higher for males than for females. Rates of ED visits vary by age: 18- to 20-year-olds had the highest rate of medical emergencies involving marijuana (467.0 per 100,000 population), 25- to 29-year-olds had the highest rates for heroin (155.5), and 35- to 44-year-olds had the highest rates for cocaine (358.7).

Table 5
ED visits involving illicit drugs, by patient demographics, 2008
Patient demographics All illicits (1) Cocaine Heroin Marijuana Stimulants MDMA (Ecstasy) GHB LSD PCP
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, illicit drugs (2,3) 993,379 482,188 200,666 374,435 91,939 17,865 1,441 3,287 37,266
Gender         —         —         —         —       —       —     —     —       —
Male 640,704 306,651 138,607 245,553 52,189   9,439    950 2,483 24,020
Female 352,136 175,465   62,018 128,435 39,744   8,425    487    805 13,246
Unknown            *            *            *            *          *          *        *        *          *
Age         —         —         —         —       —       —     —     —       —
0–5 years     1,282            *            *            *          *          *        *        *          *
6–11 years        793            *            *            *          *          *        *        *          *
12–17 years   58,913     6,229     1,724   46,969   4,494   3,188        *    551   1,423
18–20 years   89,068   15,030   15,217   60,310   9,896   4,012        *    873          *
21–24 years 112,944   33,432   22,452   59,524 12,680   3,790        *    496   6,516
25–29 years 144,840   62,292   33,174   55,519 17,011   4,578    377    648   8,448
30–34 years 110,505   56,899   21,883   37,950 12,641   1,020    181      85   7,095
35–44 years 239,282 152,447   49,555   65,210 20,976      943    309        *   4,854
45–54 years 185,748 124,832   42,596   39,411 10,958          *        *        *   3,195
55–64 years   43,674   27,408   12,495     7,234   2,311          *        *        *          *
65 years and older     5,826     2,817     1,359     1,667      322          *        *        *          *
Unknown        503            *            *            *          *          *        *        *          *
Race/ethnicity         —         —         —         —       —       —     —     —       —
White 475,816 181,461 102,986 215,149 55,834   7,857 1,089 2,535 10,421
Black 295,350 193,082   40,756   93,165   5,468   4,718        *    116 23,522
Hispanic 108,601   55,397   30,225   31,097 10,246   2,356        *      87   1,702
Other or two or more race/ethnicities   10,824     5,587     1,062     2,744   1,614      611        *        *          *
Unknown 102,788   46,661   25,636   32,280          *   2,324    214    426   1,599
Table 6
Rates of ED visits per 100,000 population involving illicit drugs, by patient demographics, 2008
Patient demographics All illicits (1) Cocaine Heroin Marijuana Stimulants MDMA (Ecstasy) GHB LSD PCP
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) All rates are ED visits per 100,000 population. Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell. Rates are not provided for race and ethnicity subgroups because of data limitations.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Rates of ED visits, illicit drugs (2,3) 326.7 158.6   66.0 123.1 30.2  5.9 0.5 1.1 12.3
Gender     —     —     —     —   —   —   —
Male 427.4 204.5   92.5 163.8 34.8   6.3 0.6 1.7 16.0
Female 228.5 113.8   40.2   83.3 25.8   5.5 0.3 0.5   8.6
Age     —     —     —     —   —   —   —
0–5 years     5.1        *        *        *      *      *    *    *      *
6–11 years     3.3        *        *        *      *      *    *    *      *
12–17 years 235.4   24.9     6.9 187.7 18.0 12.7    * 2.2   5.7
18–20 years 689.6 116.4 117.8 467.0 76.6 31.1    * 6.8      *
21–24 years 670.6 198.5 133.3 353.4 75.3 22.5    * 2.9 38.7
25–29 years 678.9 292.0 155.5 260.2 79.7 21.5 1.8 3.0 39.6
30–34 years 563.9 290.3 111.7 193.6 64.5   5.2 0.9 0.4 36.2
35–44 years 563.0 358.7 116.6 153.4 49.4   2.2 0.7    * 11.4
45–54 years 418.6 281.3   96.0   88.8 24.7      *    *    *   7.2
55–64 years 129.7   81.4   37.1   21.5   6.9      *    *    *      *
65 years and older   15.0     7.2     3.5     4.3   0.8      *    *    *      *

Figure 2
Rates of ED visits per 100,000 population involving illicit drugs, by selected drugs, age, and gender, 2008

Figure 2   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

Estimates of ED visits related to illicit drugs reveal that 47.9 percent of patients were White, 29.7 percent were Black, 10.9 percent were Hispanic, 1.1 percent were of other or multiple races/ethnicities, and 10.3 percent were of unknown race/ethnicity. DAWN does not produce population-based rates for race/ethnicity categories because race/ ethnicity information is often missing in ED records.

EDs are a potential site to intercept patients for follow-up treatment for drug use problems. Table 7 displays patient disposition after ED visits involving illicit drugs. A majority (58.7%) of patients were treated and released, about a quarter (26.0%) were admitted to the hospital, and the balance (15.2%) had other outcomes. Overall, 42.7 percent had some form of follow-up, whether it was specifically a referral to a drug detox/dependency program, admission to the hospital, or transfer to another health care facility.

Table 7
ED visits and rates involving illicit drugs, by patient disposition, 2008
Patient disposition ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, illicit drugs 993,379 100.0 326.7
Treated and released 583,501   58.7 191.9
Discharged home 461,678   46.5 151.8
Released to police/jail   48,881     4.9   16.1
Referred to detox/treatment   72,942     7.3   24.0
Admitted to this hospital 258,535   26.0   85.0
ICU/critical care   31,610     3.2   10.4
Surgery     2,193     0.2     0.7
Chemical dependency/detox   34,529     3.5   11.4
Psychiatric unit   66,689     6.7   21.9
Other inpatient unit 123,514   12.4   40.6
Other disposition 151,343   15.2   49.8
Transferred   92,854     9.3   30.5
Left against medical advice   21,905     2.2     7.2
Died     1,467     0.1     0.5
Other   27,945     2.8     9.2
Not documented     7,173     0.7     2.4

Trends in ED visits involving illicit drugs, 2004–2008

This section presents the trends in the estimates of ED visits involving illicit drugs for the period 2004 through 2008 (Table 8). Differences between years are presented in terms of the percentage increase or decrease in visits in 2008 compared with the estimates for 2004 (long-term trends) and 2006 and 2007 (short-term trends). Only statistically significant changes are discussed and displayed in the table.

Table 8
Trends in ED visits involving illicit drugs, by selected drugs, 2004–2008
Drugs (1) ED visits,
2004 (2,3)
ED visits,
2005 (2,3)
ED visits,
2006 (2,3)
ED visits,
2007 (2,3)
ED visits,
2008 (2,3)
Percent change, 2004, 2008 (4) Percent change, 2006, 2008 (4) Percent change, 2007, 2008 (4)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). Thus, the sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
(4) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell. NTA = not tabulated above.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
ED visits, illicit drugs 991,363 921,127 958,164 974,272 993,379
Cocaine 475,425 483,865 548,608 553,530 482,188 −13 
Heroin 214,432 187,493 189,780 188,162 200,666
Marijuana 281,619 279,664 290,563 308,547 374,435
Stimulants 162,435 137,650 107,575   85,043   91,939
Amphetamines   34,085   34,928   32,240   21,545   31,534 46
Methamphetamine 132,576 109,655   79,924   67,954   66,308
MDMA (Ecstasy)   10,220   11,287   16,749   12,748   17,865 75
GHB     1,789     1,036     1,084     2,207     1,441
Flunitrazepam (Rohypnol)            *            *            *            *            *
Ketamine            *        303        270        291        344
LSD     2,146     2,001     4,002     3,561     3,287
PCP   31,342   14,825   21,960   28,035   37,266
Miscellaneous hallucinogens     3,150     3,194     3,898     4,839     6,028
Inhalants     9,523     5,156     5,643     7,920     7,115
Combinations NTA            *     3,201     2,055     3,989     3,512

Overall, the level of ED visits involving illicit drugs from 2004 to 2008 was stable. There were some changes at the drug level, though. There was a 75 percent increase in the involvement of MDMA (Ecstasy) overall between 2004 and 2008, but the level of involvement is relatively small (17,865 visits in 2008), and the trend is uneven. A 46 percent increase in amphetamines-related visits between 2007 and 2008 reverses a large dip seen in 2007 and returns visits to the levels seen in 2004–2006. There was also a small dip (13%) in cocaine involvement between 2007 and 2008.

ALCOHOL

In 2008, over half a million ED visits involved drugs combined with alcohol (Table 9). This represented more than a quarter (26.2%) of all the ED visits involving drug misuse or abuse that year. The combination of drugs and alcohol is of particular concern because many drugs have additive or interactive effects with alcohol that can result in acute intoxication and impairment. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), more than 150 medications interact harmfully with alcohol. These interactions may result in increased risk of illness, injury, and even death. Alcohol's effects are heightened by drugs that depress the central nervous system, such as heroin, opiate pain relievers, benzodiazepines, antihistamines, and antidepressants. Medications for certain disorders, including diabetes, high blood pressure, and heart disease, also can have harmful interactions with alcohol.7

Table 9
ED visits involving alcohol, 2008
Alcohol use category (1) ED visits (2) Percent of
drug misuse/
abuse visits
RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) For patients of all ages, DAWN always records whether alcohol is involved in a drug-related visit. ED visits involving alcohol and no other drug are reportable to DAWN only if the patient is younger than 21. Consequently, DAWN estimates do not represent visits involving just alcohol for adults aged 21 or older.
NOTE: CI = confidence interval. RSE = relative standard error.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Alcohol with drugs (all ages) (3) 524,050 26.2 8.9 432,719 615,381
Alcohol alone (patients <21) (3) 132,842   6.6 9.6 107,746 157,938

The use of alcohol alone by those under age 21 is also of substantial concern. In 2008, there were over 130,000 medical emergencies involving only alcohol for patients under the age of 21. Alcohol abuse has many immediate adverse consequences for youth, and also can lead to higher levels and dangerous patterns of drinking in later years. As an indicator of the prevalence and severity of underage drinking, its consequences, and its trends through the teen years, DAWN reports on ED visits for underage drinking separately for adolescents aged 12 to 17 and 18 to 20.

ED visits involving drugs and alcohol taken together

The types of drugs that accompany alcohol use are displayed in Table 10. Illicit drugs, often in combination with other illicit drugs or pharmaceuticals, were involved in well over half (60.1%) of ED visits involving alcohol and other drugs. One or more pharmaceuticals were also involved in over half (56.2%) of such visits. Drugs for insomnia and anxiety were involved in 24.5 percent of visits, with the largest part of that being benzodiazepines (20.7%). Pain relievers were involved in 22.1 percent of visits, with narcotic pain relievers accounting for over half of that (13.7%). Psychotherapeutic agents (e.g., antidepressants, antipsychotics) were involved in less than 10 percent of such visits.

Table 10
ED visits involving drugs and alcohol taken together, by most frequent combinations, 2008
Drugs reported with alcohol (1) ED visits (2,3) Percent of ED visits (3) Rate of ED visits per
100,000 population (3,4)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
(4) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
(5) Miscellaneous pain reliever products include acetaminophen, tramadol, and pain relievers that were not specified by name. It does not include nonsteroidal anti-inflammatory drugs (such as ibuprofen) or salicylates (such as aspirin).
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, drugs with alcohol 524,050 100.0 172.4
Illicit drugs 315,065   60.1 103.6
Cocaine 180,219   34.4   59.3
Heroin   39,951     7.6   13.1
Marijuana 133,201   25.4   43.8
Stimulants   21,209     4.0     7.0
Methamphetamine   15,901     3.0     5.2
Pharmaceuticals 294,486   56.2   96.9
Psychotherapeutic agents   43,684     8.3   14.4
Antidepressants   31,828     6.1   10.5
SSRI antidepressants   15,871     3.0     5.2
Antipsychotics   16,957     3.2     5.6
Atypical antipsychotics   14,536     2.8     4.8
Central nervous system agents 222,516   42.5   73.2
Pain relievers 115,812   22.1   38.1
Opiates/opioids   86,320   16.5   28.4
Opiates/opioids, unspecified   16,032     3.1     5.3
Narcotic pain relievers   71,592   13.7   23.5
Hydrocodone products   28,599     5.5     9.4
Oxycodone products   26,449     5.0     8.7
Miscellaneous pain reliever products (5)   24,324     4.6     8.0
Acetaminophen products   18,334     3.5     6.0
Anticonvulsants   13,195     2.5     4.3
Anxiolytics, sedatives, and hypnotics 128,222   24.5   42.2
Benzodiazepines 108,646   20.7   35.7
Alprazolam   44,042     8.4   14.5
Clonazepam   20,421     3.9     6.7
Benzodiazepines not otherwise specified   22,790     4.3     7.5
Misc. anxiolytics, sedatives, and hypnotics   22,673     4.3     7.5
Drug unknown   37,551     7.2   12.3

The rate of ED visits per 100,000 population for males (217.1) was higher than that for females (128.5) (Table 11 and Figure 3). Rates by age group showed a general pattern of being lower for those under 18 or over 54 and higher for those aged 18 to 54.

Table 11
ED visits involving drugs and alcohol taken together, by patient demographics, 2008
Patient demographics ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell. Rates are not provided for race and ethnicity subgroups because of data limitations.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, drugs with alcohol 524,050 100.0 172.4
Gender         —      —      —
Male 325,456   62.1 217.1
Female 198,102   37.8 128.5
Unknown            *        *      —
Age         —      —      —
0–5 years            *        *        *
6–11 years            *        *        *
12–17 years   19,752     3.8   78.9
18–20 years   36,975     7.1 286.3
21–24 years   59,900   11.4 355.7
25–29 years   70,038   13.4 328.3
30–34 years   56,112   10.7 286.3
35–44 years 129,368   24.7 304.4
45–54 years 111,375   21.3 251.0
55–64 years   31,083     5.9   92.3
65 years and older     8,600     1.6   22.1
Unknown            *        *      —
Race/ethnicity         —      —      —
White 303,011   57.8      —
Black 109,862   21.0      —
Hispanic   57,465   11.0      —
Other or two or more race/ethnicities     6,474     1.2      —
Unknown   47,239     9.0      —

Figure 3
Rates of ED visits per 100,000 population involving alcohol, by age and gender, 2008

Figure 3   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

Considering race/ethnicity, 57.8 percent of patients were White, 21.0 percent were Black, 11.0 percent were Hispanic, 1.2 percent were of other or multiple race/ethnic groups, and 9.0 percent were of unknown race/ethnicity. DAWN does not produce population-based rates for race/ethnicity categories because race/ethnicity information is often missing from ED records.

The disposition of the drug-and-alcohol combination ED visits is shown in Table 12. About half (49.0%) received some sort of follow-up care: 30.9 percent were admitted to the hospital, 11.2 percent were transferred to another facility, and 6.8 percent were referred to detox.

Table 12
ED visits involving drugs and alcohol taken together, by patient disposition, 2008
Patient disposition ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, drugs with alcohol 524,050 100.0 172.4
Treated and released 275,747   52.6   90.7
Discharged home 218,935   41.8   72.0
Released to police/jail   21,173     4.0     7.0
Referred to detox/treatment   35,639     6.8   11.7
Admitted to this hospital 162,024   30.9   53.3
ICU/critical care   28,601     5.5     9.4
Surgery     1,147     0.2     0.4
Chemical dependency/detox   19,775     3.8     6.5
Psychiatric unit   47,245     9.0   15.5
Other inpatient unit   65,256   12.5   21.5
Other disposition   86,279   16.5   28.4
Transferred   58,916   11.2   19.4
Left against medical advice     9,288     1.8     3.1
Died        977     0.2     0.3
Other            *        *        *
Not documented     3,469     0.7     1.1

Alcohol use by youth and young adults

In 2008 for youth and young adults (patients aged 12 to 17 and 18 to 20, respectively), 56,727 ED visits involved drugs taken with alcohol; 132,254 ED visits, or about twice as many, involved the use of alcohol alone (Table 13 and Figure 4). Alcohol use, with and without other drugs, increases markedly between these two age groups. The rate of medical emergencies involving use of drugs with alcohol was 78.9 visits per 100,000 youth compared with 286.3 visits for young adults, almost a fourfold increase. The rate of ED visits involving alcohol used alone was 220.7 visits per 100,000 for youth and 596.3 visits for young adults, almost a threefold increase.

Table 13
ED visits involving alcohol, by presence of other drugs, by age groups 12 to 17 and 18 to 20, 2008
Alcohol use category (1) ED visits (2) Rate of ED visits
per 100,000
population (3)
RSE (%) 95% CI:
Lower bound
(ED visits)
95% CI:
Upper bound
(ED visits)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: CI = confidence interval. RSE = relative standard error.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Alcohol with drugs, patients aged 12 to 17 19,752   78.9 13.0 14,715 24,789
Alcohol with drugs, patients aged 18 to 20 36,975 286.3   9.6 30,004 43,947
Alcohol alone, patients aged 12 to 17 55,236 220.7   9.9 44,496 65,977
Alcohol alone, patients aged 18 to 20 77,018 596.3 11.0 60,401 93,634

Figure 4
Rates of ED visits per 100,000 population involving alcohol in combination and alcohol alone, by age groups 12 to 17 and 18 to 20, 2008

Figure 4   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

Trends in ED visits involving alcohol, 2004–2008

This section presents the trends in the estimates of ED visits involving alcohol for the period 2004 through 2008 (Table 14). Differences between years are presented in terms of the percentage increase or decrease in visits in 2008 compared with the estimates for 2004 (long-term trends) and 2006 and 2007 (short-term trends). Only statistically significant changes are discussed and displayed in the table.

Table 14
Trends in ED visits involving alcohol, by presence of other drugs, 2004–2008
Alcohol use category (1) ED visits,
2004 (2)
ED visits,
2005 (2)
ED visits,
2006 (2)
ED visits,
2007 (2)
ED visits,
2008 (2)
Percent change, 2004, 2008 (3) Percent change, 2006, 2008 (3) Percent change, 2007, 2008 (3)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, alcohol 674,914 527,198 577,521 634,652 656,892
Alcohol in combination 523,926 416,599 450,817 497,283 524,050
Alcohol alone 150,988 110,599 126,704 137,369 132,842

Looking across patients aged 12 to 20, no significant changes were found from 2004 to 2008 in the number of ED visits related to drinking alcohol, irrespective of whether other drugs were involved.

Although there were some short-term drops in the number of visits involving alcohol and other drugs for 12- to 17-year-olds between 2006 and 2008, these drops merely offset increases seen in 2006; 2008 levels were similar to those found in 2004 and 2005 (Table 15).

Table 15
Trends in ED visits involving alcohol, by presence of other drugs, by age groups 12 to 17 and 18 to 20, 2004–2008
Alcohol use category (1) ED visits,
2004 (2)
ED visits,
2005 (2)
ED visits,
2006 (2)
ED visits,
2007 (2)
ED visits,
2008 (2)
Percent change, 2004, 2008 (3) Percent change, 2006, 2008 (3) Percent change, 2007, 2008 (3)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, alcohol, aged 12 to 17   67,589 62,459   76,760   82,364   74,988
Total ED visits, alcohol, aged 18 to 20 135,313 95,166 105,675 112,563 113,993
Alcohol with drugs, aged 12 to 17   21,555 19,720   24,418   26,403   19,752 −19   −25  
Alcohol with drugs, aged 18 to 20   31,926 27,784   31,702   32,308   36,975
Alcohol alone, aged 12 to 17   46,034 42,739   52,342   55,960   55,236
Alcohol alone, aged 18 to 20 103,387 67,382   73,973   80,255   77,018

NONMEDICAL USE OF PHARMACEUTICALS

ED visits involving nonmedical use of pharmaceuticals, 2008

As used by DAWN, nonmedical use of pharmaceuticals includes

Nonmedical use of pharmaceuticals may involve pharmaceuticals alone or pharmaceuticals in combination with illicit drugs or alcohol. DAWN reporters are careful to distinguish appropriate medical use from nonmedical, or inappropriate, use; only the latter is included in this grouping.8

For 2008, DAWN estimates that 971,914 ED visits involved nonmedical use of prescription medicines, over-the-counter drugs, or other types of pharmaceuticals (Table 16). This represents about a quarter of all drug-related ED visits and about half of ED visits for drug abuse or misuse. Of the total number of medical emergencies requiring immediate care resulting from nonmedical use of pharmaceuticals, over half (52.9%) involved multiple drugs. Alcohol is one of those other drugs in 18.8 percent of visits.

Table 16
ED visits involving nonmedical use of pharmaceuticals, 2008
Drug category and selected drugs (1) ED visits (2,3) Percent of
ED visits (3)
RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both methadone and tramadol will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: CI = confidence interval. CNS = central nervous system. NOS = not otherwise specified. NTA = not tabulated above. RSE = relative standard error. An asterisk (*) indicates that an estimate with an RSE greater than 50% or an estimate based on fewer than 30 visits has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, nonmedical use 971,914 100.0   8.9 801,751 1,142,077
Visits involving a single drug 457,974   47.1   7.6 389,575    526,373
Visits involving multiple drugs 513,940   52.9 11.4 398,867    629,013
Visits involving alcohol 182,959   18.8 10.9 143,855    222,063
PSYCHOTHERAPEUTIC AGENTS 124,331   12.8 10.0 100,040    148,622
Antidepressants   80,881     8.3 10.6   64,129      97,632
MAO inhibitors           *        *      *          *               *
SSRI antidepressants   39,780     4.1 15.5   27,673      51,887
Tricyclic antidepressants   13,246     1.4 15.5     9,231      17,261
Miscellaneous antidepressants     6,956     0.7 15.3     4,872        9,040
Antipsychotics   55,005     5.7   9.7   44,518      65,492
CENTRAL NERVOUS SYSTEM AGENTS 718,119   73.9   9.9 579,000    857,237
Pain relievers 458,210   47.1 10.1 367,365    549,055
Antimigraine agents     1,877     0.2 33.3        651        3,102
Cox-2 inhibitors          *        *      *          *               *
Opiates/opioids 366,815   37.7 12.7 275,208    458,423
Opiates/opioids, unspecified   66,585     6.9 15.6   46,279      86,890
Narcotic pain relievers 305,885   31.5 12.7 229,834    381,935
Buprenorphine products   12,544     1.3 26.2     6,105      18,983
Codeine products     8,235     0.8 15.7     5,702      10,768
Fentanyl   20,179     2.1 16.5   13,649      26,709
Hydrocodone products   89,051     9.2 19.7   54,750    123,352
Hydromorphone products   12,142     1.2 18.1     7,827      16,458
Meperidine products     1,435     0.1 44.1        194        2,676
Methadone   63,629     6.5 15.9   43,758      83,499
Morphine products   28,818     3.0 22.3   16,236      41,399
Oxycodone products 105,214   10.8 15.8   72,679    137,749
Propoxyphene products   13,364     1.4 40.0     2,896      23,832
Nonsteroidal anti-inflammatory agents   30,343     3.1 10.5   24,091      36,594
Ibuprofen   23,539     2.4 12.0   18,011      29,067
Naproxen     4,525     0.5 17.0     3,017        6,034
Salicylates products   13,005     1.3 15.2     9,134      16,877
Misc. pain relievers products   69,146     7.1   8.4   57,807      80,484
Acetaminophen products   49,859     5.1 10.4   39,669      60,049
Tramadol products   11,850     1.2 14.5     8,480      15,219
Tramadol   11,665     1.2 14.6     8,319      15,011
Acetaminophen-tramadol          *        *      *          *               *
Pain medication products NTA     1,521     0.2 20.1        922        2,121
Anorexiants     1,526     0.2 26.1        747        2,305
Anticonvulsants   37,439     3.9 10.3   29,864      45,013
Antiemetic/antivertigo agents     1,661     0.2 30.2        678        2,643
Anti-Parkinson agents     3,802     0.4 25.2     1,921        5,683
Anxiolytics, sedatives, and hypnotics 325,041   33.4 14.5 232,563    417,519
Barbiturates     9,603     1.0 15.1     6,766      12,440
Benzodiazepines 271,698   28.0 15.9 187,260    356,136
Alprazolam 104,762   10.8 20.1   63,475    146,048
Clonazepam   48,385     5.0   8.1   40,734      56,035
Diazepam   26,518     2.7 13.8   19,329      33,707
Lorazepam   36,602     3.8 16.7   24,629      48,574
Benzodiazepines NOS   65,113     6.7 22.2   36,785      93,441
Misc. anxiolytics, sedatives, and hypnotics   58,983     6.1 10.1   47,320      70,645
Diphenhydramine   13,531     1.4 12.3   10,259      16,803
Hydroxyzine     5,647     0.6 26.2     2,747        8,547
Zolpidem   28,262     2.9 15.8   19,495      37,028
Anxiolytics, sedatives, and hypnotics NOS     5,255     0.5 15.5     3,659        6,852
CNS stimulants   18,768     1.9 11.5   14,529      23,006
Amphetamine-dextroamphetamine     6,500     0.7 20.0     3,957        9,042
Caffeine     1,876     0.2 23.3     1,019        2,733
Dextroamphetamine          *        *      *          *               *
Methylphenidate     3,173     0.3 21.0     1,864        4,481
General anesthetics          *        *      *          *               *
Muscle relaxants   54,151     5.6 25.5   27,111      81,191
Carisoprodol   34,155     3.5 27.8   15,561      52,749
Cyclobenzaprine   12,748     1.3 31.7     4,815      20,680
Miscellaneous CNS agents     2,034     0.2 37.3        547        3,522
RESPIRATORY AGENTS   31,414     3.2   9.9   25,297      37,530
Antihistamines     8,282     0.9 26.3     4,019      12,544
Bronchodilators     3,046     0.3 18.7     1,928        4,165
Decongestants     1,160     0.1 23.2        633        1,688
Expectorants     2,089     0.2 39.6        468        3,710
Upper respiratory combinations   14,901     1.5   9.9   12,019      17,782
Respiratory agents NTA     3,660     0.4 13.8     2,668        4,652
CARDIOVASCULAR AGENTS   41,522     4.3   7.4   35,490      47,554
Antiadrenergic agents, centrally acting     6,197     0.6 14.1     4,488        7,905
Beta-adrenergic blocking agents   13,000     1.3 13.7     9,519      16,481
Calcium channel blocking agents     5,857     0.6 16.5     3,966        7,749
Diuretics     4,814     0.5 22.3     2,709        6,919
Cardiovascular agents NTA   22,359     2.3   7.8   18,921      25,798

At 73.9 percent, central nervous system agents were the most common type of drugs reported in the nonmedical-use category of ED visits. These were split between pain relievers (47.1%) and drugs that treat anxiety and insomnia, such as anxiolytics, sedatives, and hypnotics (33.4%). Among pain relievers, the specific drugs seen at higher levels were the narcotic pain relievers oxycodone, hydrocodone, and methadone (10.8%, 9.2%, and 6.5%, respectively).9

Among drugs that treat anxiety and insomnia, benzodiazepines were involved in 28.0 percent of ED visits related to nonmedical use of pharmaceuticals, with alprazolam indicated in 10.8 percent of such visits. Appearing in 3 to 6 percent of ED visits involving nonmedical use of pharmaceuticals were acetaminophen, muscle relaxants, anticonvulsants, and nonsteroidal anti-inflammatory agents (e.g., ibuprofen, naproxen).

Psychotherapeutic agents (e.g., antidepressants and antipsychotics) were involved in 12.8 percent of ED visits related to nonmedical use of pharmaceuticals. The two other major categories of pharmaceuticals are respiratory agents and cardiovascular agents; each was involved in about 3 to 4 percent of these ED visits.

When population size and the margin of error are taken into account, visits for nonmedical use of pharmaceuticals did not differ between males and females (308.9 and 329.8 visits per 100,000 population, respectively) (Table 17 and Figure 5). The rate of ED visit rates for patients aged 18 to 29 was over 500 visits per 100,000 population, whereas the rate for patients aged 30 to 54 was over 400 visits.

Table 17
ED visits and rates involving nonmedical use of pharmaceuticals, by patient demographics, 2008
Patient demographics ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: A dash (—) indicates a blank cell. Rates are not provided for race and ethnicity subgroups because of data limitations.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, nonmedical use 971,914 100.0 319.6
Gender          —      —      —
Male 463,187   47.7 308.9
Female 508,379   52.3 329.8
Unknown        349     0.0      —
Age          —      —      —
0–5 years     4,655     0.5   18.6
6–11 years     4,724     0.5   19.8
12–17 years   70,230     7.2 280.6
18–20 years   71,187     7.3 551.2
21–24 years   97,580   10.0 579.4
25–29 years 115,853   11.9 543.1
30–34 years   89,166     9.2 455.0
35–44 years 182,607   18.8 429.7
45–54 years 184,071   18.9 414.8
55–64 years   81,342     8.4 241.5
65 years and older   70,124     7.2 180.4
Unknown        375     0.0      —
Race/ethnicity          —      —      —
White 680,382   70.0      —
Black 113,037   11.6      —
Hispanic   71,464     7.4      —
Other or two or more race/ethnicities   11,719     1.2      —
Unknown   95,311     9.8      —

Figure 5
Rates of ED visits per 100,000 population involving nonmedical use of pharmaceuticals, by age and gender, 2008

Figure 5   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

In terms of race and ethnicity, 70.0 percent of visits related to nonmedical use of pharmaceuticals involved patients who were White, 11.6 percent were Black, and 7.4 percent were Hispanic. DAWN does not produce population-based rates for race/ethnicity categories because race/ethnicity information is often missing on ED records.

Patient disposition after ED visits associated with nonmedical use of pharmaceuticals appears in Table 18. The majority (60.5%) of patients were treated and released, which is similar to the percentage found for ED visits involving illicit drugs (Table 7, 58.7%). About a quarter (25.5%) of patients were admitted to the hospital, and the balance (14.0%) had other outcomes.

Table 18
ED visits and rates involving nonmedical use of pharmaceuticals, by patient disposition, 2008
Patient disposition ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, nonmedical use 971,914 100.0 319.6
Treated and released 587,687   60.5 193.3
Discharged home 533,547   54.9 175.5
Released to police/jail   24,358     2.5     8.0
Referred to detox/treatment   29,782     3.1     9.8
Admitted to this hospital 247,703   25.5   81.5
ICU/critical care   69,473     7.1   22.8
Surgery            *        *        *
Chemical dependency/detox     3,237     0.3     1.1
Psychiatric unit   49,689     5.1   16.3
Other inpatient unit 124,217   12.8   40.9
Other disposition 136,524   14.0   44.9
Transferred   88,719     9.1   29.2
Left against medical advice   16,761     1.7     5.5
Died            *        *        *
Other   24,123     2.5     7.9
Not documented     5,291     0.5     1.7

Trends in ED visits involving nonmedical use of pharmaceuticals, 2004–2008

This section presents the trends in the estimates of ED visits involving nonmedical use of pharmaceuticals for the period 2004 through 2008 (Table 19). Differences between years are presented in terms of the percentage increase or decrease in visits in 2008 compared with the estimates for 2004 (long-term trends) and 2006 and 2007 (short-term trends). Only statistically significant changes are discussed and displayed in the table.

Table 19
Trends in ED visits involving nonmedical use of pharmaceuticals, by selected drugs, 2004–2008
Drug category and selected drugs (1) ED visits,
2004 (2,3)
ED visits,
2005 (2,3)
ED visits,
2006 (2,3)
ED visits,
2007 (2,3)
ED visits,
2008 (2,3)
Percent change, 2004, 2008 (4) Percent change, 2006, 2008 (4) Percent change, 2007, 2008 (4)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both methadone and tramadol will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
(4) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: CNS = central nervous system. NOS = not otherwise specified. NTA = not tabulated above. An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, nonmedical use 536,247 669,214 741,425 855,838 971,914   81 31   —
PSYCHOTHERAPEUTIC AGENTS   91,268 101,451 112,856 119,787 124,331   —   —
Antidepressants   66,917   67,051   79,682   82,009   80,881   —   —
MAO inhibitors            *            *            *            *            *   —   —
SSRI antidepressants   32,285   30,374   35,370   37,446   39,780   —   —
Tricyclic antidepressants   12,412   14,515   16,564   16,600   13,246   —   —
Miscellaneous antidepressants     9,414     7,452     7,561     9,687     6,956   — −28
Antipsychotics   35,198   44,393   44,733   52,752   55,005   56   —
CENTRAL NERVOUS SYSTEM AGENTS 402,246 489,351 532,584 586,323 718,119   79 35   22
Pain relievers 241,578 294,251 323,579 363,621 458,210   90 42   26
Antimigraine agents        868     1,018     1,191     2,284     1,877   —   —
Cox-2 inhibitors     1,935        765            *        635            *   —   —
Opiates/opioids 172,726 217,594 247,669 286,521 366,815 112 48   28
Opiates/opioids, unspecified   31,846   52,670   50,978   52,997   66,585 109   —
Narcotic pain relievers 144,644 168,376 201,280 237,143 305,885 111 52   29
Buprenorphine products            *            *     4,440     7,136   12,544   —   —
Codeine products     7,171     6,180     6,928     5,648     8,235   —   —
Fentanyl products     9,823   11,211   16,012   15,947   20,179 105   —
Hydrocodone products   39,844   47,192   57,550   65,734   89,051 123   —
Hydromorphone products     3,385     4,714     6,780     9,497   12,142 259 79   —
Meperidine products        782        383     1,440        997     1,435   —   —
Methadone   36,806   42,684   45,130   53,950   63,629   73   —
Morphine products   13,966   15,762   20,416   29,591   28,818 106   —
Oxycodone products   41,701   52,943   64,888   76,587 105,214 152 62   37
Propoxyphene products     6,744     7,648     6,220     7,401     13,364   —   —
Nonsteroidal anti-inflammatory agents   27,362   28,837   27,662   30,822   30,343   —   —
Ibuprofen   22,127   22,268   20,541   20,892   23,539   —   —
Naproxen     4,715     5,190     6,651     7,208     4,525   — −32   −37
Salicylates products     9,580   12,123   10,399     9,724   13,005   —   —
Miscellaneous pain reliever products   44,857   51,881   54,313   56,534   69,146   54   —
Acetaminophen products   39,167   43,558   44,314   43,872   49,859   —   —
Tramadol products     4,849     5,918     6,048     8,039   11,850 144 96   —
Tramadol     3,948     5,427     5,961     7,662   11,665 195 96   —
Acetaminophen-tramadol        909            *            *            *            *   —   —
Pain medication combinations NTA        977        653        898     2,120     1,521   —   —
Anorexiants            *     1,757     1,168        758     1,526   —   —
Anticonvulsants   28,652   27,641   31,169   35,403   37,439   —   —
Antiemetic/antivertigo agents     1,678     1,771     1,360     1,646     1,661   —   —
Anti-Parkinson agents     2,472     1,692     3,816     3,764     3,802   —   —
Anxiolytics, sedatives, and hypnotics 177,394 227,486 233,875 259,983 325,041   83   —
Barbiturates   11,721   14,693   10,991     9,877     9,603   —   —
Benzodiazepines 143,546 189,704 195,625 218,640 271,698   89   —
Alprazolam   46,526   57,419   65,236   80,313 104,762 125   —
Clonazepam   28,178   30,648   33,557   40,920   48,385   72 44   —
Diazepam   15,619   18,433   19,936   19,674   26,518   70   —
Lorazepam   17,674   23,210   23,720   26,213   36,602 107   —
Benzodiazepines NOS   36,039   61,486   58,347   55,346   65,113   —   —
Misc. anxiolytics, sedatives, and hypnotics   31,554   35,561   40,626   43,960   58,983   87 45   34
Diphenhydramine   10,452   10,294   12,291   12,539   13,531   —   —
Hydroxyzine     2,363     2,179     2,678     2,447     5,647   — 131
Zolpidem   12,792   14,730   17,257   18,464   28,262 121 64   53
Anxiolytics, sedatives, and hypnotics NOS     2,657     4,421     3,629     3,364     5,255   98   56
CNS stimulants     9,801   10,965   13,892   18,561   18,768   91   —
Amphetamine-dextroamphetamine     2,303     2,669     5,027     6,372     6,500 182   —
Caffeine     2,736     4,567     4,407     2,165     1,876   −57     —
Dextroamphetamine            *            *            *            *            *   —   —
Methylphenidate     2,446     2,519     2,192     4,782     3,173   —   —
General anesthetics            *            *            *            *            *   —   —
Muscle relaxants   25,934   33,695   38,918   40,769   54,151   —   —
Carisoprodol   14,736   20,082   24,505   27,128   34,155 132   —
Cyclobenzaprine     6,183     7,629     7,142     6,197   12,748   —   —
Miscellaneous CNS agents        869        900        999        924     2,034   —   —
RESPIRATORY AGENTS   22,286   28,017   28,867   31,008   31,414   —   —
Antihistamines     5,761     4,429     4,130     5,096     8,282   —   —
Bronchodilators     2,294     3,043     2,920     3,043     3,046   —   —
Decongestants     1,864     1,309     1,511     1,758     1,160   —   —
Expectorants        832     1,960     2,125     2,293     2,089   —   —
Upper respiratory combinations   10,314   15,837   15,115   16,677   14,901   —   —
Respiratory agents NTA     2,903     3,692     4,296     4,655     3,660   —   —
CARDIOVASCULAR AGENTS   27,396   37,095   36,343   35,608   41,522   52   —
Antiadrenergic agents, centrally acting     3,616     5,125     4,810     4,751     6,197   71   30
Beta-adrenergic blocking agents     7,094     9,824   11,729   11,668   13,000   83   —
Calcium channel blocking agents     3,115     5,434     5,227     4,493     5,857   88   —
Diuretics     3,625     5,332     5,102     5,467     4,814   —   —
Cardiovascular agents NTA   14,930   18,881   17,338   17,879   22,359   —   —

Medical emergencies related to nonmedical use of pharmaceuticals increased 81 percent in the period from 2004 to 2008, rising from just over a half million (536,247) visits to almost a million (971,914) visits. Contributing to this rise are significant long-term (2004 to 2008) increases in the number of visits involving narcotic pain relievers, which increased 111 percent, or over 160,000 visits. ED visits for specific drugs in this category that more than doubled over this period were fentanyl, hydrocodone, hydromorphone, morphine, and oxycodone.

Drugs for anxiety and insomnia (anxiolytics, sedatives, and hypnotics) increased 83 percent overall—almost 150,000 visits, with benzodiazepines accounting for almost 130,000 of the increase. Central nervous system stimulants (e.g., Adderal®, Ritalin®) saw a 91 percent increase, the equivalent of almost 9,000 ED visits.

ED visits involving antipsychotics have gradually increased since 2004, for a net increase of 56 percent. Also, for the first time, long-term increases were seen for cardiovascular agents (52% increase). This may reflect the aging of the U.S. population.

DRUG-RELATED SUICIDE ATTEMPTS

ED visits involving drug-related suicide attempts, 2008

DAWN collects information on suicide attempts that involve drugs and require emergency medical care. These attempts are not limited to drug overdoses. Suicide attempts involving firearms, for example, are included as DAWN cases if drugs were involved at all at the time of the suicide attempt.10

DAWN estimates there were almost 200,000 (199,469) medical emergencies resulting in ED visits for drug-related suicide attempts in 2008 (Table 20). Nearly two thirds (64.0%) of ED visits for drug-related suicide attempts involved multiple drugs. Almost all (94.6%) involved a prescription drug or over-the-counter medication. Slightly less than three quarters (71.7%) involved central nervous system agents (primarily pain relievers and benzodiazepines), just under a third (29.4%) involved psychotherapeutic agents (e.g., antidepressants, antipsychotics), about a fifth (18.4%) involved illicit drugs, and almost a third (29.9%) of such visits involved alcohol.11

Table 20
ED visits involving drug-related suicide attempts, by selected drugs, 2008
Drug category and selected drugs (1) ED visits (2,3) Percent of
ED visits (3)
RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: CI = confidence interval. CNS = central nervous system. NTA = not tabulated above. RSE = relative standard error. An asterisk (*) indicates that an estimate with an RSE greater than 50% or an estimate based on fewer than 30 visits has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, suicide attempts 199,469 100.0 6.7 173,141 225,797
Visits involving a single drug   71,752   36.0 10.4   57,075   86,429
Visits involving multiple drugs 127,717   64.0   7.0 110,160 145,274
Visits involving illicit drugs   36,735   18.4 15.3   25,707   47,763
Visits involving alcohol   59,624   29.9   7.4   50,944   68,304
Visits involving pharmaceuticals 188,651   94.6   6.8 163,339 213,963
Alcohol   59,624   29.9   7.4   50,944   68,304
Alcohol in combination   59,218   29.7   7.5   50,468   67,969
Alcohol alone        406     0.2 45.8          41        770
Non-alcohol illicits   36,735   18.4 15.3   25,707   47,763
Cocaine   19,614     9.8 22.8   10,833   28,394
Heroin     4,249     2.1 23.9     2,256     6,241
Marijuana   17,285     8.7 14.5   12,374   22,195
Stimulants     2,788     1.4 27.8     1,266     4,309
Amphetamines     1,404     0.7 45.1        163     2,645
Methamphetamine     1,553     0.8 34.2        512     2,595
MDMA (Ecstasy)        745     0.4 37.0        205     1,286
GHB            *        *      *            *            *
Flunitrazepam (Rohypnol)            *        *      *            *            *
Ketamine            *        *      *            *            *
LSD            *        *      *            *            *
PCP            *        *      *            *            *
Miscellaneous hallucinogens            *        *      *            *            *
Inhalants            *        *      *            *            *
Combinations NTA            *        *      *            *            *
PSYCHOTHERAPEUTIC AGENTS   58,604   29.4   7.9   49,586   67,622
Antidepressants   40,985   20.5   8.1   34,478   47,491
Phenylpiperazine antidepressants     9,598     4.8 15.5     6,676   12,520
SSNRI antidepressants     5,808     2.9 19.0     3,644     7,972
Duloxetine     1,931     1.0 27.8        879     2,983
Venlafaxine     3,717     1.9 32.0     1,388     6,046
SSRI antidepressants   19,988   10.0 10.4   15,926   24,051
Citalopram     3,563     1.8 22.1     2,017     5,109
Fluoxetine     5,730     2.9 17.6     3,758     7,703
Paroxetine     2,013     1.0 34.6        647     3,378
Sertraline     4,197     2.1 16.5     2,837     5,556
Tetracyclic antidepressants     1,120     0.6 40.7        227     2,013
Tricyclic antidepressants     5,470     2.7 25.9     2,694     8,246
Miscellaneous antidepressants     4,630     2.3 15.3     3,243     6,017
Bupropion     4,137     2.1 16.8     2,774     5,501
Antipsychotics   25,451   12.8 12.4   19,257   31,645
Atypical antipsychotics   21,228   10.6 13.2   15,741   26,715
Olanzapine     1,961     1.0 30.5        788     3,133
Quetiapine   13,522     6.8 15.6     9,399   17,645
Risperidone     2,309     1.2 21.0     1,358     3,260
Phenothiazine antipsychotics     1,076     0.5 30.2        439     1,714
Miscellaneous antipsychotic agents     4,250     2.1 20.8     2,514     5,985
Haloperidol     1,214     0.6 45.5        130     2,298
Lithium     2,948     1.5 21.8     1,686     4,211
CENTRAL NERVOUS SYSTEM AGENTS 142,931   71.7   6.5 124,639 161,222
Pain relievers   74,467   37.3   7.5   63,566   85,369
Opiates/opioids   30,067   15.1   9.7   24,325   35,810
Opiates/opioids, unspecified     3,605     1.8 35.9     1,070     6,140
Narcotic pain relievers   26,817   13.4   9.6   21,792   31,842
Codeine products     2,315     1.2 31.8        872     3,757
Hydrocodone products   11,676     5.9 13.7     8,549   14,804
Hydromorphone products        770     0.4 39.0        181     1,359
Methadone     2,008     1.0 31.7        759     3,258
Morphine products     1,161     0.6 31.6        442     1,879
Oxycodone products     8,760     4.4 16.4     5,936   11,584
Propoxyphene products     1,559     0.8 21.9        891     2,228
Nonsteroidal anti-inflammatory agents   18,657     9.4 11.6   14,427   22,887
Salicylates products     5,351     2.7 19.0     3,363     7,339
Misc. pain relievers products   29,388   14.7   9.1   24,160   34,616
Acetaminophen products   26,406   13.2   9.5   21,514   31,298
Tramadol products     3,057     1.5 27.1     1,435     4,679
Anorexiants        250     0.1 32.4          92        409
Anticonvulsants   14,486     7.3 10.2   11,580   17,393
Anxiolytics, sedatives, and hypnotics   78,990 39.6   7.1   68,044   89,936
Barbiturates     1,480     0.7 43.3        223     2,737
Benzodiazepines   55,823   28.0   7.2   47,974   63,672
Alprazolam   21,220   10.6 13.4   15,655   26,785
Clonazepam   14,571     7.3   8.9   12,037   17,106
Diazepam     5,313     2.7 17.7     3,473     7,153
Lorazepam     9,973     5.0 13.9     7,252   12,694
Temazepam     2,608     1.3 22.5     1,458     3,759
Misc. anxiolytics, sedatives, and hypnotics   28,253   14.2   8.5   23,564   32,942
Buspirone     1,653     0.8 42.6        274     3,033
Diphenhydramine     8,414     4.2 13.3     6,219   10,610
Doxylamine     2,315     1.2 35.0        725     3,905
Hydroxyzine     3,310     1.7 31.5     1,267     5,352
Zolpidem     9,533     4.8 15.1     6,704   12,363
CNS stimulants     3,221     1.6 20.0     1,959     4,484
Muscle relaxants     8,053     4.0 17.6     5,275   10,831
Skeletal muscle relaxants     7,722     3.9 17.8     5,023   10,421
Carisoprodol     3,452     1.7 33.1     1,215     5,688
Cyclobenzaprine     3,438     1.7 21.0     2,023     4,854
RESPIRATORY AGENTS     9,152     4.6 11.6     7,070   11,234
Antihistamines     2,979     1.5 22.0     1,694     4,263
Upper respiratory combinations     4,640     2.3 26.6     2,225     7,055
CARDIOVASCULAR AGENTS   13,140     6.6 19.1     8,213   18,067
Antiadrenergic agents, centrally acting     1,715     0.9 24.0        907     2,523
Beta-adrenergic blocking agents     5,094     2.6 47.4        363     9,826
GASTROINTESTINAL AGENTS     3,606     1.8 18.4     2,307     4,904
HORMONES     2,168     1.1 32.4        793     3,543
METABOLIC AGENTS     3,173     1.6 17.6     2,077     4,270
Antidiabetic agents     2,749     1.4 20.4     1,649     3,848
NUTRITIONAL PRODUCTS     1,789     0.9 26.4        863     2,715
DRUG UNKNOWN   11,363     5.7 16.0     7,789   14,938

After population size and the margin of error are taken into account, the rate of drug-related suicide attempt visits for females (76.6 visits per 100,000 population) was higher than that for males (53.9 per 100,000) (Table 21 and Figure 6). In respect to age, rates ranged from a low of 11.3 visits per 100,000 population for those aged 65 or older to 141.0 visits for those aged 18 to 20. In terms of race/ethnicity, 64.0 percent of the suicide attempts involved patients who were White. DAWN does not produce population-based rates for race/ethnicity categories because race/ethnicity information is often missing from ED records.

Table 21
ED visits involving drug-related suicide attempts, by patient demographics, 2008
Patient demographics ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell. Rates are not provided for race and ethnicity subgroups because of data limitations.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, suicide attempts 199,469 100.0   65.6
Gender          —      —      —
Male   80,841   40.5   53.9
Female 118,118   59.2   76.6
Unknown            *        *      —
Age          —      —      —
0–5 years            *        *        *
6–11 years            *        *        *
12–17 years   23,124   11.6   92.4
18–20 years   18,216     9.1 141.0
21–24 years   19,819     9.9 117.7
25–29 years   25,724   12.9 120.6
30–34 years   18,215     9.1   92.9
35–44 years   42,783   21.4 100.7
45–54 years   34,025   17.1   76.7
55–64 years   12,954     6.5   38.5
65 years and older     4,406     2.2   11.3
Unknown            *        *      —
Race/ethnicity          —      —      —
White 127,735   64.0      —
Black            *        *      —
Hispanic   21,376   10.7      —
Other or two or more race/ethnicities     3,364     1.7      —
Unknown   17,258     8.7      —

Figure 6
Rates of ED visits per 100,000 population involving drug-related suicide attempts, by age and gender, 2008

Figure 6   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

About half (49.7%) of the patients attempting suicide were admitted for inpatient hospital care (Table 22), a fifth (19.7%) were admitted to an ICU/critical care unit, and somewhat smaller numbers were admitted to psychiatric units (15.0%) or other inpatient units (14.7%). A quarter (25.7%) were transferred to another health care facility, and only 14.8 percent were discharged home. Very few died in the ED. However, DAWN does not record deaths for patients who died before arriving at the ED or for patients who died after admission to inpatient units of the hospital.

Table 22
ED visits involving drug-related suicide attempts, by patient disposition, 2008
Patient disposition ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, suicide attempts 199,469 100.0 65.6
Treated and released   39,321   19.7 12.9
Discharged home   29,551   14.8   9.7
Released to police/jail     4,104     2.1   1.3
Referred to detox/treatment     5,666     2.8   1.9
Admitted to this hospital   99,175   49.7 32.6
ICU/critical care   39,291   19.7 12.9
Surgery        421     0.2   0.1
Chemical dependency/detox        301     0.2   0.1
Psychiatric unit   29,853   15.0   9.8
Other inpatient unit   29,309   14.7   9.6
Other disposition   60,973   30.6 20.1
Transferred   51,244   25.7 16.9
Left against medical advice        880     0.4   0.3
Died            *        *      *
Other            *        *      *
Not documented     1,456     0.7   0.5

Trends in ED visits involving drug-related suicide attempts, 2004–2008

This section presents the trends in the estimates of drug-related ED visits involving suicide attempts for the period 2004 through 2008 (Tables 23 and 24). Differences between years are presented in terms of the percentage increase or decrease in visits in 2008 compared with the estimates for 2004 (long-term trends) and 2006 and 2007 (short-term trends). Only statistically significant changes are discussed and displayed in the tables.

In 2004 and 2005, the number of drug-related suicide attempts requiring immediate medical care resulted in 150,000 to 160,000 ED visits annually. There was an increase of over 40,000 visits, 30 percent, from 2005 to 2007. The level stabilized again between 2007 and 2008, by which time the total number of ED visits involving drug-related suicide attempts was just under 200,000 visits. The rise in visits between 2004 and 2008 appears to be associated with increased use of antipsychotics, hydrocodone, oxycodone, alprazolam, and zolpidem. The only noteworthy increase among visits involving illicit drugs was a short-term increase between 2007 and 2008 in visits involving marijuana (43%).

Specific types of drugs with increasing incidence between 2004 and 2008 are included in Table 23. A more complete list of drugs with information on short- and long-term trends is provided in Table 24.

Table 23
Drug categories and drugs with increasing involvement in drug-related suicide attempt ED visits, 2004–2008
Drug category and selected drugs (1) Increase in visits,
2004 to 2008 (2)
Percent increase in visits,
2004 to 2008 (3)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Antipsychotics   7,644   43
Quetiapine   5,214   63
Central nervous system agents 32,834   30
Narcotic pain relievers   9,889   58
Hydrocodone products   4,642   66
Oxycodone products   3,420   64
Drugs for anxiety and insomnia 26,337   50
Benzodiazepines 18,829   51
Alprazolam   9,867   87
Other drugs for anxiety and insomnia 11,463   68
Zolpidem   5,178 119
Table 24
Trends in ED visits for drug-related suicide attempts, by selected drugs, 2004–2008
Drug category and selected drugs (1) ED visits,
2004 (2,3)
ED visits,
2005 (2,3)
ED visits,
2006 (2,3)
ED visits,
2007 (2,3)
ED visits,
2008 (2,3)
Percent change, 2004, 2008 (4) Percent change, 2006, 2008 (4) Percent change, 2007, 2008 (4)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
(4) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: CNS = central nervous system. NTA = not tabulated above. An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, suicide attempts 161,586 151,568 182,805 197,053 199,469   —   —   —
Alcohol   48,726   47,891   54,820   57,319   59,624   —   —   —
Alcohol in combination   48,080   46,806   54,337   56,434   59,218   —   —   —
Alcohol alone        646     1,085        483            *        406   —   —   —
Non-alcohol illicits   34,763   33,784   42,148   37,319   36,735   —   —   —
Cocaine   19,520   19,628   26,510   26,462   19,614   —   —   —
Heroin     4,579     3,167     4,265     4,444     4,249   —   —   —
Marijuana   12,074   11,955   15,272   12,115   17,285   —   —   43
Stimulants     4,535     5,410     4,829     2,665     2,788   —   —   —
Amphetamines     1,560     1,646     2,228        878     1,404   —   —   —
Methamphetamine     3,136     3,853     2,877     1,795     1,553   — −46   —
MDMA (Ecstasy)            *        529     1,239        481        745   —   —   —
GHB            *            *            *            *            *   —   —   —
Flunitrazepam (Rohypnol)            *            *            *            *            *   —   —   —
Ketamine            *            *            *            *            *   —   —   —
LSD            *            *            *            *            *   —   —   —
PCP            *            *            *        768            *   —   —   —
Miscellaneous hallucinogens            *            *            *            *            *   —   —   —
Inhalants            *        794            *            *            *   —   —   —
Combinations NTA            *            *            *            *            *   —   —   —
PSYCHOTHERAPEUTIC AGENTS   44,940   39,145   52,450   57,111   58,604   —   —   —
Antidepressants   33,366   27,086   36,677   38,870   40,985   —   —   —
Phenylpiperazine antidepressants     7,015     6,639     9,029     8,018     9,598   —   —   —
SSNRI antidepressants     3,193     2,941     4,392     6,404     5,808   —   —   —
Duloxetine            *        861     1,541     2,948     1,931   —   —   —
Venlafaxine     3,179     2,080     2,858     3,457     3,717   —   —   —
SSRI antidepressants   18,513   13,377   16,973   18,884   19,988   —   —   —
Citalopram     2,115        886     3,047     3,358     3,563   —   —   —
Fluoxetine     3,477     3,292     3,923     3,790     5,730   —   —   —
Paroxetine     4,509     2,927     2,054     2,071     2,013 −55   —   —
Sertraline     4,852     4,109     4,263     5,413     4,197   —   —   —
Tetracyclic antidepressants     1,749        811     2,200     1,303     1,120   —   —   —
Tricyclic antidepressants     3,555     3,008     4,681     4,152     5,470   —   —   —
Miscellaneous antidepressants     3,337     2,681     3,806     3,939     4,630   —   —   —
Bupropion     3,324     2,570     3,589     3,880     4,137   —   —   —
Antipsychotics   17,807   17,129   22,491   25,479   25,451   43   —   —
Atypical antipsychotics   15,016   14,300   19,429   20,250   21,228   —   —   —
Olanzapine     2,541     2,334     2,666        933     1,961   —   —   —
Quetiapine     8,308     8,649   10,756   14,051   13,522   63   —   —
Risperidone     3,255     2,036     2,536     2,367     2,309   —   —   —
Phenothiazine antipsychotics        956        680     1,574            *     1,076   —   —   —
Miscellaneous antipsychotic agents     2,821     2,354     2,568     3,842     4,250   —   —   —
Haloperidol            *     1,070     1,181        855     1,214   —   —   —
Lithium     1,832     1,281     1,298     2,751     2,948   — 127   —
CENTRAL NERVOUS SYSTEM AGENTS 110,097 103,698 129,735 143,384 142,931   30   —   —
Pain relievers   61,095   54,858   67,623   78,948   74,467   —   —   —
Opiates/opioids   18,939   20,359   27,185   31,476   30,067   59   —   —
Opiates/opioids, unspecified     2,363     2,819     3,129     1,893     3,605   —   —   —
Narcotic pain relievers   16,928   17,801   24,470   29,886   26,817   58   —   —
Codeine products     1,750     2,656     2,349     1,637     2,315   —   —   —
Hydrocodone products     7,034     7,035     8,998   13,238   11,676   66   —   —
Hydromorphone products            *            *        262        796        770   —   —   —
Methadone     1,287     1,596     1,772     3,192     2,008   —   —   —
Morphine products        714     1,210            *     1,690     1,161   —   —   —
Oxycodone products     5,340     4,229     7,842     9,351     8,760   64   —   —
Propoxyphene products     1,888     2,129     2,811     1,754     1,559   —   —   —
Nonsteroidal anti-inflammatory agents   19,114   14,117   15,956   18,810   18,657   —   —   —
Salicylates products     6,211     4,645     5,400     5,976     5,351   —   —   —
Misc. pain reliever products   22,864   22,692   27,371   32,968   29,388   —   —   —
Acetaminophen products   20,701   21,017   25,312   29,861   26,406   —   —   —
Tramadol products     1,742     1,515     1,719     2,816     3,057   —   —   —
Anorexiants            *            *        654            *        250   —   —   —
Anticonvulsants   10,957     9,389   12,580   11,803   14,486   —   —   —
Anxiolytics, sedatives, and hypnotics   52,653   52,022   68,177   72,637   78,990   50   —   —
Barbiturates     1,948     1,219     2,031     1,663     1,480   —   —   —
Benzodiazepines   36,995   35,676   50,431   53,509   55,823   51   —   —
Alprazolam   11,354   14,530   15,633   19,167   21,220   87   —   —
Clonazepam     9,402     9,064   14,173   14,455   14,571   —   —   —
Diazepam     4,630     3,968     5,909     6,912     5,313   —   —   —
Lorazepam     6,065     5,182     6,682     9,527     9,973   —   49   —
Temazepam     2,539     1,803     2,661     2,398     2,608   —   —   —
Misc. anxiolytics, sedatives, and hypnotics   16,790   17,522   21,527   23,349   28,253   68   —   —
Buspirone        268            *        516        950     1,653   —   —   —
Diphenhydramine     7,458     6,583     7,756     7,618     8,414   —   —   —
Doxylamine        454     1,325     1,090     1,098     2,315 410   —   —
Hydroxyzine     2,346     1,795     1,956     2,027     3,310   —   —   —
Zolpidem     4,355     4,972     6,674     7,403     9,533 119   —   —
CNS stimulants     1,654     1,782     1,949     2,208     3,221   —   —   —
Muscle relaxants     5,921     5,785     7,072     9,772     8,053   —   —   —
Skeletal muscle relaxants     5,867     5,677     6,698     9,587     7,722   —   —   —
Carisoprodol     1,864     2,038     3,811     4,301     3,452   —   —   —
Cyclobenzaprine     2,966     2,784     2,096     3,839     3,438   —   —   —
RESPIRATORY AGENTS     8,361     7,662     8,415   10,175     9,152   —   —   —
Antihistamines     2,059     1,650     1,627     3,813     2,979   —   —   —
Upper respiratory combinations     4,818     4,207     3,982     4,067     4,640   —   —   —
CARDIOVASCULAR AGENTS     7,667     5,814     7,965     7,873   13,140   —   —   —
Antiadrenergic agents, centrally acting        995        912     1,929        790     1,715   —   — 117
Beta-adrenergic blocking agents     2,105     1,916     1,999     2,501     5,094   —   —   —
GASTROINTESTINAL AGENTS     2,276     2,542     2,236     2,010     3,606   —   —   —
HORMONES     1,125        702     1,579     2,016     2,168   —   —   —
METABOLIC AGENTS     2,145     3,044     3,719     2,252     3,173   —   —   —
Antidiabetic agents     1,841     2,580     2,941     1,438     2,749   —   —   91
NUTRITIONAL PRODUCTS     1,333     1,105     1,065     2,077     1,789   —   —   —
DRUG UNKNOWN     4,015     6,725     6,704     9,322   11,363 183   69   —


SEEKING DETOX SERVICES

ED visits involving seeking detox services, 2008

The category of visits referred to as "seeking detox" includes various situations such as nonemergency requests for admission for detoxification, visits to obtain medical clearance before entry to a detox program,12 and acute emergencies in which an individual is in distress (i.e., displaying active withdrawal symptoms) and seeking detox. Because detox may be sought through other avenues (e.g., direct admission to a hospital, services provided through private clinics, entry into programs outside the community), the overall demand for detox services is most likely higher than suggested by DAWN estimates.

DAWN estimates that there were 177,879 drug-related ED visits for patients seeking detox or substance abuse treatment services during 2008 (Table 25). Among the illicit drugs, cocaine was observed in 38.7 percent of visits, heroin in 29.2 percent, marijuana in 18.5 percent, and stimulants in 7.0 percent. Among pain relievers, narcotic pain relievers were observed in 32.9 percent of visits, including oxycodone in 19.3 percent, hydrocodone in 12.1 percent, and methadone in 5.6 percent. Benzodiazepines were observed in 23.4 percent of visits. More than one third (36.6%) of ED visits by persons seeking detox involved alcohol.13 Visits for almost three quarters (73.0%) of patients seeking detox involved multiple drugs.

Table 25
ED visits involving seeking detox services, by selected drugs, 2008
Drug category and selected drugs (1) ED visits (2,3) Percent of
ED visits (3)
RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
NOTE: CI = confidence interval. CNS = central nervous system. NTA = not tabulated above. RSE = relative standard error. An asterisk (*) indicates that an estimate with an RSE greater than 50% or an estimate based on fewer than 30 visits has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, seeking detox 177,879 100.0 18.6 112,962 242,796
Visits involving a single drug   47,944   27.0 11.4   37,186   58,702
Visits involving multiple drugs 129,935   73.0 23.2   70,941 188,928
Alcohol   65,166   36.6 14.7   46,445   83,887
Alcohol in combination   64,802   36.4 14.8   46,046   83,559
Alcohol alone        363     0.2 38.0          93        634
Non-alcohol illicits 124,371   69.9 16.3   84,669 164,073
Cocaine   68,824   38.7 17.2   45,569   92,079
Heroin   51,932   29.2 13.5   38,238   65,626
Marijuana   32,887   18.5 25.8   16,242   49,532
Stimulants   12,418     7.0 43.8     1,758   23,077
Amphetamines     2,658     1.5 48.5        132     5,184
Methamphetamine     9,908     5.6 42.8     1,595   18,222
MDMA (Ecstasy)        775     0.4 23.6        416     1,133
GHB            *        *      *            *            *
Flunitrazepam (Rohypnol)            *        *      *            *            *
Ketamine            *        *      *            *            *
LSD          71   <0.1 22.5          40        102
PCP     1,478     0.8 41.6        274     2,681
Miscellaneous hallucinogens            *        *      *            *            *
Inhalants            *        *      *            *            *
Combinations NTA          85   <0.1 38.6          21        149
PSYCHOTHERAPEUTIC AGENTS     3,671     2.1 32.7     1,317     6,024
Antidepressants     1,894     1.1 24.1     1,000     2,787
Antipsychotics            *        *      *            *            *
CENTRAL NERVOUS SYSTEM AGENTS   86,040   48.4 29.8   35,768 136,313
Pain relievers   69,602   39.1 34.2   22,981 116,224
Opiates/opioids   65,630   36.9 33.5   22,489 108,771
Opiates/opioids, unspecified     8,123     4.6 30.2     3,313   12,933
Narcotic pain relievers   58,488   32.9 33.7   19,846   97,130
Codeine products        768     0.4 34.9        242     1,293
Fentanyl products     1,126     0.6 27.6        517     1,735
Hydrocodone products   21,595   12.1 47.1     1,648   41,543
Hydromorphone products     1,447     0.8 27.0        681     2,213
Methadone   10,022     5.6 23.4     5,421   14,623
Morphine products     5,066     2.8 31.7     1,917     8,215
Oxycodone products   34,301   19.3 39.5     7,778   60,825
Anxiolytics, sedatives, and hypnotics   42,178   23.7 34.9   13,345   71,012
Barbiturates        551     0.3 33.5        189        913
Benzodiazepines   41,576   23.4 35.5   12,666   70,486
Alprazolam            *        *      *            *            *
Clonazepam     5,683     3.2 32.2     2,101     9,265
Diazepam            *        *      *            *            *
Lorazepam     2,847     1.6 27.9     1,292     4,403
Temazepam            *        *      *            *            *
CNS stimulants            *        *      *            *            *
Muscle relaxants     1,381     0.8 25.3        697     2,065
RESPIRATORY AGENTS        348     0.2 38.0          88        607
CARDIOVASCULAR AGENTS        227     0.1 46.8          19        435
DRUG UNKNOWN   10,515     5.9 46.3        979   20,051

When population size and the margin of error are taken into account, the rate of seeking detox visits for males (74.6 per 100,000 population) was higher than that for females (42.8 per 100,000 population) (Table 26, Figure 7). Rates of seeking detox visits were over 100 visits per 100,000 population for those aged 18 to 44, peaking at 163.7 for those aged 25 to 29.

Table 26
ED visits involving seeking detox services, by patient demographics, 2008
Patient demographics ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell. Rates are not provided for race and ethnicity subgroups because of data limitations.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, seeking detox 177,879 100.0   58.5
Gender         —     —     —
Male 111,870   62.9   74.6
Female   65,978   37.1   42.8
Unknown            *        *     —
Age         —     —     —
0–5 years            *        *       *
6–11 years            *        *       *
12–17 years     1,575     0.9     6.3
18–20 years   15,785     8.9 122.2
21–24 years   21,283   12.0 126.4
25–29 years   34,918   19.6 163.7
30–34 years   22,045   12.4 112.5
35–44 years   43,982   24.7 103.5
45–54 years   28,873   16.2   65.1
55–64 years     8,351     4.7   24.8
65 years and older     1,040     0.6     2.7
Unknown            *        *     —
Race/ethnicity         —     —     —
White 120,031   67.5     —
Black   29,261   16.4     —
Hispanic   10,164     5.7     —
Other or two or more race/ethnicities        708     0.4     —
Unknown   17,715   10.0     —

Figure 7
Rates of ED visits per 100,000 population involving seeking detox services, by age and gender, 2008

Figure 7   D

SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.

In terms of race/ethnicity, the majority (67.5%) of seeking detox visits involved patients who were White. DAWN does not produce population-based rates for race/ethnicity categories because race/ ethnicity information is often missing in ED records.

About half (47.1%) of the ED patients classified as seeking detox were treated and released (Table 27). There was evidence that just under half (20.9%) of those treated and released were referred to detox or treatment services. Another 20.3 percent were admitted to the chemical dependency/detox unit of the hospital, and 17.5 percent were admitted to other units within the hospital. Less than 10 percent (7.5%) were transferred to another facility. In total, 66.1 percent of patients had some form of follow-up.

Table 27
ED visits involving seeking detox services, by patient disposition, 2008
Patient disposition ED visits (1) Percent of ED visits Rate of ED visits per
100,000 population (2)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) All rates are ED visits per 100,000 population. Population estimates are drawn from the 2008 U.S. Census Bureau Postcensal Resident Population National Population Dataset as of July 1, 2008.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, seeking detox 177,879 100.0 58.5
Treated and released   83,864   47.1 27.6
Discharged home   46,458   26.1 15.3
Released to police/jail            *        *      *
Referred to detox/treatment   37,111   20.9 12.2
Admitted to this hospital   67,218   37.8 22.1
ICU/critical care        807     0.5   0.3
Surgery            *        *      *
Chemical dependency/detox   36,026   20.3 11.8
Psychiatric unit            *        *      *
Other inpatient unit            *        *      *
Other disposition   26,797   15.1   8.8
Transferred   13,276     7.5   4.4
Left against medical advice     4,434     2.5   1.5
Died            *        *      *
Other            *        *      *
Not documented            *        *      *

Trends in ED visits involving seeking detox services, 2004–2008

This section presents the trends in the estimates of ED visits involving seeking detox services for the period 2004 through 2008 (Table 28). Differences between years are presented in terms of the percentage increase or decrease in visits in 2008 compared with the estimates for 2004 (long-term trends) and 2006 and 2007 (short-term trends). Only statistically significant changes are discussed and displayed in the table.

Table 28
Trends in ED visits involving seeking detox services, by selected drugs, 2004–2008
Drug category and selected drugs (1) ED visits,
2004 (2,3)
ED visits,
2005 (2,3)
ED visits,
2006 (2,3)
ED visits,
2007 (2,3)
ED visits,
2008 (2,3)
Percent change, 2004, 2008 (4) Percent change, 2006, 2008 (4) Percent change, 2007, 2008 (4)
(1) The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
(2) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(3) ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and marijuana will appear twice in this table). The sum of visits or rates by drug will be greater than the total, and the sum of percentages by drug will be greater than 100.
(4) This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown.
NOTE: CNS = central nervous system. NTA = not tabulated above. An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed. A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total ED visits, seeking detox 141,867 126,226 118,355 139,908 177,879   —
Alcohol   53,662   47,494   47,102   57,157   65,166   —
Alcohol in combination   51,831   47,154   46,769   56,574   64,802   —
Alcohol alone            *            *            *            *        363   —
Non-alcohol illicits 110,792 101,244   92,385 106,660 124,371   —
Cocaine   62,989   56,061   57,738   65,124   68,824   —
Heroin   47,035   40,895   34,462   42,242   51,932   — 51
Marijuana   25,965   22,486   22,104   25,970   32,887   —
Stimulants   11,760   15,402     8,128     7,161   12,418   —
Amphetamines            *            *     2,034        979     2,658   —
Methamphetamine            *            *     6,211     6,287     9,908   —
MDMA (Ecstasy)        882        511        483        654        775   —
GHB            *            *            *            *            *   —
Flunitrazepam (Rohypnol)            *            *            *            *            *   —
Ketamine            *            *            *            *            *   —
LSD            *            *            *            *          71   —
PCP        827        729        989            *     1,478   —
Miscellaneous hallucinogens            *            *            *            *            *   —
Inhalants            *            *            *            *            *   —
Combinations NTA            *        191            *        216          85   —
PSYCHOTHERAPEUTIC AGENTS     1,419     1,380     1,364     1,654     3,671   —
Antidepressants     1,024     1,195     1,141     1,314     1,894   —
Antipsychotics        459        259        457        536            *   —
CENTRAL NERVOUS SYSTEM AGENTS   44,905   41,265   40,704   52,829   86,040   —
Pain relievers   34,730   30,114   31,690   42,776   69,602   —
Opiates/opioids   33,296   29,330   30,786   41,241   65,630   —
Opiates/opioids, unspecified     4,507     4,246     4,467     4,746     8,123   —
Narcotic pain relievers   29,894   25,550   26,880   37,040   58,488   —
Codeine products        650        347        426            *        768   —
Fentanyl products        704     1,265     1,054     1,359     1,126   —
Hydrocodone products     8,114     8,929     8,092   10,425   21,595   —
Hydromorphone products        962        617            *            *     1,447   —
Methadone     8,109     4,172     5,294     6,886   10,022   — 89
Morphine products     1,638     2,399     3,002     3,341     5,066 209
Oxycodone products   15,917   14,028   14,721   18,880   34,301   —
Anxiolytics, sedatives, and hypnotics   15,748   16,533   16,799   20,365   42,178   —
Barbiturates        852        684        530        722        551   —
Benzodiazepines   14,717   15,734   15,801   19,301   41,576   —
Alprazolam     6,061     6,253     7,063     9,138            *   —
Clonazepam     1,510     1,805     2,119     2,635     5,683 276
Diazepam     2,975     2,058     1,431     3,172            *   —
Lorazepam     1,012        987     1,479     1,980     2,847 181
Temazepam            *            *            *            *            *   —
CNS stimulants            *        829        589     1,049            *   —
Muscle relaxants     1,356     1,204     1,214     1,701     1,381   —
RESPIRATORY AGENTS            *            *            *            *        348   —
CARDIOVASCULAR AGENTS            *        285        302        632        227   —
DRUG UNKNOWN     3,203     2,944     3,175     6,368   10,515   —

The number of patients seeking detox services through the ED was relatively stable from 2004 through 2008. In the short term, between 2006 and 2008, increases were seen in the involvement of heroin (51%) and methadone (89%). These increases merely offset declines seen in the immediately preceding year (2005), and the level of ED visits in 2008 is similar to that seen in 2004. From 2004 to 2008, there were large percentage increases in the involvement of morphine, clonazepam, and lorazepam, although the actual number of visits associated with these drugs remains small.


APPENDIX A

MULTUM LEXICON
END-USER LICENSE AGREEMENT

Every effort has been made to ensure that the information provided by Lexi-Comp, Inc. ("Lexi-Comp") is accurate, up-to-date, and complete, but no guarantee is made to that effect. In addition, the drug information contained herein may be time sensitive. Lexi-Comp information has been compiled for use by healthcare practitioners and end-users in the United States. Lexi-Comp does not warrant that uses outside of the United States are appropriate.

Lexi-Comp's drug information does not endorse drugs, diagnose patients or recommend therapy. Lexi-Comp's drug information is an informational resource designed to assist licensed healthcare practitioners in caring for their patients and/or to serve end-users viewing this Lexi-Comp Product as a supplement to, and not a substitute for, the expertise, skill, knowledge and judgment of healthcare practitioners. Healthcare practitioners should use their professional judgment in using the information provided. The absence of a warning for a given drug or drug combination in no way should be construed to indicate that the drug or drug combination is safe, effective or appropriate for any given patient. Lexi-Comp and its affiliates do not assume any responsibility for any aspect of healthcare administered with the aid of information Lexi-Comp and its affiliates provides.

The information contained herein is not intended to cover all possible uses, directions, precautions, warnings, drug interactions, allergic reactions, or adverse effects. If you have questions about the drugs you are taking, check with your doctor, nurse or pharmacist.

© 2009 Lexi-Comp, Inc. and/or Cerner Multum, Inc.

The Multum Licensing Agreement can be found on the Internet at http://dawninfo.samhsa.gov/drug_vocab.


APPENDIX B

GLOSSARY OF DAWN TERMS, 2008 UPDATE

This glossary defines terms used in data collection activities, analyses, and publications associated with the emergency department (ED) component of the Drug Abuse Warning Network (DAWN).

Accidental ingestion: This category of drug-related ED visits includes those involving the accidental use of a drug, for example, childhood drug poisonings and individuals who take the wrong medication by mistake.

Adverse reaction: This category of drug-related ED visits represents the consequences of using a prescription or over-the-counter pharmaceutical for therapeutic purposes and includes visits related to adverse drug reactions, side effects, drug-drug interactions, and drug-alcohol interactions. Adverse reactions that involve a pharmaceutical with an illicit drug are excluded from this category.

Alcohol use: Alcohol is reportable for all patients when present in combination with one or more other reportable substances. For patients under the age of 21, alcohol is also reportable if it is used alone with no other substance or reportable drug. (See Drug misuse or abuse and Underage drinking.)

Case description: A description of how the drug or drugs were related to the patient's ED visit. The case description, in conjunction with other documentation in the ED medical record, is used to determine whether the ED visit is reportable to DAWN. It is copied verbatim from the patient's chart when possible.

Case type: See Type of case.

Case type other: See Drug misuse or abuse.

Confidence interval (CI): An interval estimate, that is, a range of values around a point estimate that takes sampling error into account. The accepted standard of confidence is 95 percent. Technically, a 95 percent CI means that, if repeated samples were drawn from the same population of hospitals using the same sampling and data collection procedures, the true population value would fall within the confidence interval 95 percent of the time. Practically, a 95 percent CI summarizes both the estimate and its margin of error in a straightforward way with a reasonable degree of confidence.

Diagnosis: The condition(s) for which the patient was treated as determined by the clinician after study.

Disposition: The location or facility to which an ED patient was referred, transferred, or released.

Treated and released includes three categories:

Admitted to this hospital includes five categories of inpatient units:

Other disposition includes five categories:

Drug: A substance that is (a) used as a medication or in the preparation of medication; (b) an illicit substance that causes addiction, habituation, or a marked change in consciousness; or (c) both. Substances reportable to DAWN include alcohol, illicit drugs (e.g., club drugs, cocaine, heroin, marijuana, stimulants), nonpharmaceutical inhalants, prescription drugs (e.g., ADHD drugs, antibiotics, antidepressants, antipsychotics, anticoagulants, beta blockers, birth control pills, hormone replacement, insulin, muscle relaxants, pain relievers, sleeping aids), drugs used in treatment of medical conditions (e.g., respiratory therapy, chemo therapy, radiation therapy), vaccines, dietary supplements, vitamins, and other over-the-counter pharmaceutical products. DAWN publications use the term "drug" to refer to any of these substances. Multiple substances can be reported for each DAWN case. Therefore, the total number of drugs exceeds the total number of DAWN cases reported.

Drug category: A generic grouping of related pharmaceuticals or other substances reported to DAWN, based on the classification system developed by Multum Information Services, a subsidiary of the Cerner Corporation, and modified for use with DAWN. (More information on the Multum system is available at http://www.multum.com/.) In general, the Multum categories reflect the therapeutic uses for prescription and over-the-counter pharmaceuticals.

Additional clarification is provided for the following drug categories, as these are unique to DAWN:

Drug misuse or abuse: A group of ED visits defined broadly to include all visits associated with illicit drugs, alcohol use in combination with other drugs, alcohol use alone among those younger than 21 years, and nonmedical use of pharmaceuticals. (See also Alcohol use, Illicit drug use, Nonmedical use of pharmaceuticals, and Underage drinking.)

Drug-related ED visit: This category includes any ED visit related to recent drug use. To be a DAWN case, a drug needs only to be implicated in the visit; the drug does not have to have caused the visit. (See also Single-drug case.) One patient may make repeated visits to an ED or to several EDs, thus producing a number of visits. The number of unique patients involved in the reported drug-related ED visits cannot be estimated, because no direct patient identifiers are collected by DAWN.

There are some circumstances in which ED visits are not reviewed for DAWN. These include persons who left before being seen by a physician, visits for suture removal, and direct admission to the hospital through the ED for women in labor.

Estimate: A statistical estimate is the value of a parameter (such as the number of drug-related ED visits) for the universe that is derived by applying sampling weights to data from a sample. Estimates of drug-related ED visits are calculated by applying weights and adjustments to the data provided by the sampled hospitals participating in DAWN. The sampling weights reflect the probability of selection; separate adjustment factors account for nonresponse, data quality, and the known total of ED visits delivered by the universe of eligible hospitals as identified by the American Hospital Association (AHA) for the relevant time period.

GHB: Gamma hydroxybutyrate, a hallucinogen and depressant frequently combined with alcohol and other beverages. Also used by bodybuilders to aid in fat reduction and muscle building. For further information, see http://www.drugabuse.gov/infofacts/infofactsindex.html.

Hospital emergency department (ED): To be eligible for DAWN, hospitals must be non-Federal, short-stay, general medical and surgical facilities that operate one or more EDs 24 hours a day, 7 days a week. They must be located in the United States. Specialty hospitals, hospital units of institutions, long-term care facilities, pediatric hospitals, hospitals operating part-time EDs, and hospitals operated by the Veterans Health Administration and the Indian Health Service are excluded. The universe of EDs is identified from the American Hospital Association's Annual Survey Database. Participation in DAWN is limited to hospitals that meet the eligibility criteria for DAWN. (See also Universe.)

Illicit drug use: This category of drug-related ED visits includes all visits related to the use of illicit or illegal drugs. Illicit drugs include

Additional clarification is provided for the following drug categories:

LSD: d-lysergic acid diethylamide, a hallucinogen usually taken orally. For further information, see http://www.drugabuse.gov/infofacts/infofactsindex.html.

Malicious poisoning: See Nonmedical use of pharmaceuticals.

MDMA: Methylenedioxymethamphetamine, a hallucinogen with stimulant effects, usually taken orally. For further information, see http://www.drugabuse.gov/infofacts/infofactsindex.html.

Metropolitan area: An area comprising a relatively large core city or cities and the adjacent geographic areas. Conceptually, these areas are integrated economic and social units with a large population center. Unless otherwise noted, metropolitan area analyses prepared by DAWN use the boundaries established by the Office of Management and Budget (OMB), as updated in 2003.

Nonmedical use of pharmaceuticals: Nonmedical use of pharmaceuticals includes taking more than the prescribed dose of a prescription pharmaceutical or more than the recommended dose of an over-the-counter pharmaceutical or supplement; taking a pharmaceutical prescribed for another individual; deliberate poisoning with a pharmaceutical by another person; and documented misuse or abuse of a prescription drug, an over-the-counter pharmaceutical, or a dietary supplement. Nonmedical use of pharmaceuticals may involve pharmaceuticals alone or pharmaceuticals in combination with illicit drugs or alcohol. Nonmedical use of pharmaceuticals includes prescription and over-the-counter pharmaceuticals in ED visits that are of the following types of cases:

(See also Drug misuse or abuse and Type of case.)

Not otherwise specified (NOS): This is the catchall category for substances that are not specifically named but are qualified as a DAWN case. Terms are classified into an NOS category only when assignment to a more specific category is not possible based on the information in the source documentation (ED patient charts).

Not tabulated above (NTA): This designation is used when drugs or drug categories are not explicitly listed in a table. Low-incidence drugs (or drug categories) falling under a broader drug classification may be summarized into a single row under that classification and labeled as NTA.

Overmedication: See Nonmedical use of pharmaceuticals.

Oversampling: Without oversampling, one would expect a sample to resemble the population from which it was drawn. Oversampling implies the deliberate selection of a much higher proportion of certain types of sampling units than would normally be obtained in a simple, random sample. The deliberate selection of certain types of sample units is done to improve the precision of estimates of the properties of these types of sampling units. This is a form of stratified sampling. (See also Sampling, Sample frame, and Sampling unit.)

p-value: A measure of the probability (p) that the difference between two estimates could have occurred by chance, if the estimates being compared were really the same. The larger the p-value, the more likely the difference could have occurred by chance. For example, if the difference between two DAWN estimates has a p-value of 0.05, it means that there is no more than a 5 percent probability that the difference observed could be due to chance alone.

PCP: Phencyclidine, a hallucinogenic white crystalline powder that is readily soluble in water or alcohol or may be snorted or smoked. For further information, see http://www.drugabuse.gov/infofacts/infofactsindex.html.

Population: See Universe.

Precision: The extent to which an estimate agrees with its mean value in repeated sampling. The precision of an estimate is measured inversely by its standard error (SE) or relative standard error (RSE). In DAWN publications, estimates with RSEs greater than 50 percent are regarded as too imprecise to be published. ED table cells where such estimates would have appeared contain the asterisk symbol (*). (See also Relative standard error.)

Race/ethnicity: Race/ethnicity data in DAWN are collected retrospectively from the medical record. Patients are never interviewed to obtain DAWN data. DAWN follows OMB protocol for collection of race/ethnicity when self-identification of race/ethnicity by the individual is not possible. This approach involves a single question listing six race/ethnicity groups (plus not documented) and allows for multiple responses.14 For reporting, DAWN collapses the reported race/ethnicity information into four mutually exclusive categories, plus an unknown category, as follows:

Race/ethnicity is missing from ED patient records about 10 to 20 percent of the time, although this varies widely by hospital. Detail about multiple races/ethnicities may be lacking as well. Rates of ED visits per 100,000 are not calculated for race/ethnicity categories because of these data limitations.

Rate: A measure of the incidence of drug-related ED visits per 100,000 population. A rate can be calculated for the total population or for any subset defined by characteristics such as age and gender.

Relative standard error (RSE): A measure of an estimate's relative precision. The RSE of an estimate is equal to the estimate's standard error (SE) divided by the estimate itself. For example, an estimate of 2,000 cocaine visits with an SE of 200 visits has an RSE of 0.1 and is multiplied by 100 to change it to a percentage. This resulting RSE percent value is 10 percent. The larger the RSE, the less precise the estimate. Estimates with an RSE of 50 percent or greater are not published by DAWN. (See also Precision.)

Sample frame: A list of units from which the ED sample is drawn. All members of the sampling frame have a known probability of being selected. A sampling frame is constructed such that there is no duplication and each unit is identifiable. Ideally, the sampling frame and the universe are the same. The sampling frame for the DAWN hospital ED sample is derived from the American Hospital Association's Annual Survey Database.

Sampling: Sampling is the process of selecting a proper subset of elements from the full population so that the subset can be used to make inference to the population as a whole. A probability sample is one in which each element has a known and positive chance (probability) of selection. A simple random sample is one in which each member has the same chance of selection. In DAWN, a sample of hospitals is selected to make inference to all hospitals; DAWN uses simple random sampling within strata.

Sampling unit: A member of a sample selected from a sampling frame. For the DAWN sample, the units are hospitals, and data are collected for drug-related ED visits at the responding hospitals selected for the sample.

Sampling weights: Numeric coefficients used to derive population estimates from a sample by adjusting for deviations from the original sample design due to unequal probability sampling, variable nonresponse, and other potential sources of bias.

Seeking detox: This category of drug-related ED visits reflects patients seeking substance abuse treatment, drug rehabilitation, or medical clearance for admission to a drug treatment or detoxification unit. They are classified separately because they often reflect administrative practices that vary across hospitals and may vary over time within the same hospital. Seeking detox visits tend to be concentrated in those facilities that operate specialized inpatient units providing substance abuse treatment or detoxification services, and the largest numbers are found in facilities that require medical clearance for entry into such treatment to be granted in their EDs.

Single-drug case: An ED visit in which only one drug was involved. DAWN collects single-drug ED visits involving alcohol alone only if the patient was younger than 21 years of age.

Statistically significant: A difference between two estimates is said to be statistically significant if the value of the statistic used to test the difference is larger or smaller than would be expected by chance alone. For DAWN ED estimates, a difference is considered statistically significant if the p-value is less than 0.05. (See also p-value.)

Strata (plural), stratum (singular): Subgroups of a universe within which separate ED samples are drawn. Stratification is used to increase the precision of estimates for a given sample size, or, conversely, to reduce the sample size required to achieve the desired level of precision. The DAWN ED sample is stratified into metropolitan area cells plus an additional cell for the remainder of the United States. To ensure thorough coverage within metropolitan areas, the universe of hospitals in each is allocated into substrata identified by (1) two types of hospital ownership (public, private) and (2) up to four size categories (measured in terms of the number of ED visits annually). This allocation creates up to eight substrata in each metropolitan area stratum. Hospitals in the stratum that covers the rest of the United States are stratified first by Census region, type of ownership, and size (also measured in terms of ED visits). A systematic sample is selected from each of the geographic strata.

Suicide attempt: This type of drug-related ED visit captures suicide attempts (e.g., attempted suicide, tried to kill self) that are documented in the medical record and in which a drug was involved. Suicidal gestures, thoughts, or ideation, including attempts to harm oneself, are not included in this category.

Type of case: A classification used to define similar DAWN cases for analysis. Each case must be assigned a type and may not be assigned more than one type. Cases are classified into one of the following eight categories: suicide attempt, seeking detox, alcohol only (age younger than 21), adverse reaction, overmedication, malicious poisoning, accidental ingestion, and other. The case is coded into the first group that meets the inclusion criteria for that group; for example, a patient 34 years of age with hives who took aspirin and no other drug would be classified into the adverse reaction group since it did not qualify as a suicide attempt, seeking detox, or alcohol only (age younger than 21) case.

Underage drinking: DAWN records if alcohol was involved in all drug-related ED visits for patients of all ages. DAWN treats alcohol as an illicit drug for minors. Therefore, DAWN also collects data on ED visits involving alcohol and no other drugs if the patient is under the age of 21. Underage drinking includes all visits by patients under 21 that involve alcohol, regardless of whether other drugs are involved.

Universe: The entire set of units for which generalizations are drawn. The universe for the DAWN ED sample is all non-Federal, short-stay, general medical and surgical hospitals in the United States that operate one or more EDs 24 hours a day, 7 days a week. Specialty hospitals, hospital units of institutions, long-term care facilities, pediatric hospitals, hospitals operating part-time EDs, and hospitals operated by the Veterans Health Administration and the Indian Health Service are excluded. The universe of EDs is identified from the American Hospital Association's Annual Survey Database.


APPENDIX C

2008 DAWN METHODOLOGY

DAWN relies on a longitudinal probability sample of hospitals located throughout the United States, including Alaska and Hawaii. To be eligible for selection into the DAWN sample, a hospital must be a non-Federal, short-stay, general surgical and medical hospital located in the United States, with at least one 24-hour ED. This current approach was first implemented in the 2004 data collection year.

DAWN uses the data from the visits classified as DAWN cases in the selected hospitals to calculate various estimates of drug-related ED visits for the Nation as a whole, as well as for specific metropolitan areas. To calculate these estimates and measure their precision requires the application of sampling and weighting methodologies to the DAWN survey.

This appendix documents the participation of sampled hospitals in 2008 and other related survey methodology topics. Additional detail on the general data collection methods is available in the ED Reference Guide.15

2008 hospital participation

For 2008, 231 hospitals submitted data on 351,697 drug-related ED visits that were used for estimation (Tables C1 and C2). The overall weighted response rate was 32.9 percent. For the 13 oversampled metropolitan areas and divisions, individual response rates ranged from 26.8 percent in the Houston-Baytown-Sugar Land, TX, Metropolitan Statistical Area to 83.1 percent in the Detroit-Warren-Livonia, MI, Metropolitan Statistical Area.

Table C1
Sample characteristics for 2008 DAWN data collection year
Geographic area Total eligible hospitals (1) Eligible hospitals in sample (1) Responding hospitals in sample Response rate for sampled hospitals (%) Design weight response rate (%) Visits weighted response rate (%)
(1) Non-Federal, short-stay hospitals with 24-hour EDs in the United States, based on the American Hospital Association Annual Survey, are eligible for DAWN.
(2) The total number of eligible hospitals includes the sampled and participating hospitals from metropolitan areas shown in this table plus hospitals in the remainder of the United States. Components shown here do not sum to the total.
(3) Metropolitan Statistical Areas (MSAs) and Metropolitan Divisions follow the standard definitions issued by the Office of Management and Budget in June 2003 (available at http:/www.whitehouse.gov/omb/bulletins/b03-04.html), with one exception: for New York, geographic coverage is limited to the subarea comprising the five Boroughs of New York City.
NOTE: MSA = Metropolitan Statistical Area.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total United States (2, 3) 4,592 557 231 41.5 27.5 32.9
Boston-Cambridge-Quincy, MA-NH, MSA      43   29   19 65.5 65.5 69.4
Chicago-Naperville-Joliet, IL-IN-WI, MSA      88   72   30 41.7 42.2 38.1
Denver-Aurora, CO, MSA      16   15   11 73.3 73.3 76.7
Detroit-Warren-Livonia, MI, MSA      35   25   18 72.0 73.8 83.1
Houston-Baytown-Sugar Land, TX, MSA      55   42   13 31.0 34.1 26.8
Miami-Fort Lauderdale-Miami Beach, FL, MSA—Dade County Division      21   16     9 56.3 51.7 56.1
Miami-Fort Lauderdale-Miami Beach, FL, MSA—Fort Lauderdale Division      29   21     9 42.9 41.0 49.9
Minneapolis-St. Paul-Bloomington, MN-WI, MSA      26   26   11 42.3 42.3 53.9
New York-Newark-Edison, NY-NJ-PA, MSA—Five Boroughs Division      48   37   23 62.2 58.8 68.5
Phoenix-Mesa-Scottsdale, AZ, MSA      28   26   14 53.8 53.8 55.6
San Diego-Carlsbad-San Marcos, CA, MSA      16   16     7 43.8 43.8 48.7
San Francisco-Oakland-Fremont, CA, MSA—San Francisco Division      18   18     8 44.4 44.4 48.0
Seattle-Tacoma-Bellevue, WA, MSA      22   22   12 54.5 54.5 64.5
Table C2
Drug-related ED visits and drugs, by type of case, 2008
Type of visit Unweighted
sample data
Weighted
estimates
RSE (%) 95% CI:
Lower bound
95% CI:
Upper bound
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
(2) These are estimates of drugs involved in ED visits. Because a single ED visit may involve multiple drugs, the number of drugs is greater than the number of visits.
NOTE: CI = confidence interval. RSE = relative standard error. A dash (—) indicates a blank cell.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Drug-related ED visits (1)              —                —   —            —            —
Suicide attempt        16,271        199,469   6.7    173,141    225,797
Seeking detox        24,526        177,879 18.6    112,962    242,796
Alcohol only (age < 21)        12,468        132,073   9.6    107,100    157,047
Adverse reaction      138,108     2,157,128   7.9 1,822,484 2,491,772
Overmedication        28,734        396,444   9.9    319,602    473,286
Malicious poisoning             928            7,609 17.4        5,013      10,204
Accidental ingestion          5,860        100,342   7.7      85,152    115,531
Other      124,802     1,212,552 10.2    971,170 1,453,934
Total drug-related ED visits      351,697     4,383,494   6.2 3,847,852 4,919,137
Total drug misuse or abuse visits      197,016     1,999,861   7.8 1,692,919 2,306,802
Total ED visits (all reasons) 11,128,842 118,359,742   0.0            —            —
Drugs (2)              —                —   —            —            —
Suicide attempt        35,086        452,198   6.8    391,906    512,491
Seeking detox        52,655        401,000 22.5    224,326    577,673
Alcohol only (age < 21)        12,468        132,073   9.6    107,100    157,047
Adverse reaction      183,318     2,947,354   9.6 2,393,979 3,500,729
Overmedication        51,617        733,310 11.6    566,026    900,595
Malicious poisoning          1,708          14,527 18.8        9,175      19,878
Accidental ingestion          7,639        130,997   7.7    111,236    150,758
Other      213,956     2,146,567 10.4 1,709,977 2,583,158
Drugs in all drug-related ED visits      558,447     6,958,026   8.2 5,838,755 8,077,297
Drugs in all misuse or abuse ED visits      350,724     3,667,298   9.2 3,004,768 4,329,829

2008 charts reviewed for drug-related ED visits

DAWN cases are found through a retrospective review of medical records in participating hospitals. Across all participating hospitals in 2008, 9,818,812 charts were reviewed to find the drug-related ED visits that met the DAWN case criteria. On the basis of the review of charts, 383,977 drug-related visits16 were found and submitted to the DAWN database, a case rate of 3.9 percent. On average, a DAWN member hospital submitted 1,167 DAWN cases. However, the number of submitted cases varied widely across hospitals, from 0 cases to 6,832 cases (median 896) in a single hospital during 2008.

DAWN data in this publication

Seven types of ED visits related to drug misuse or abuse were defined in this publication:

These categories are defined by drug and type of case as shown in Table C3. Note that the categories are not mutually exclusive.

Table C3
DAWN analytic groups
Analytic category Drugs included Types of cases included
(1) Nonmedical use of pharmaceuticals explicitly excludes ED visits for adverse reactions and accidental ingestions.
(2) Suicide attempts and seeking detox visits are only considered to be drug misuse or abuse if they involve an illicit drug or alcohol for a minor.
All All All
Adverse reaction All drugs Adverse reaction only
Accidental ingestion All drugs Accidental ingestion only
All misuse/abuse All This analytic group is the union of the following four analytic groups. See the definition provided for each of these four groups for detail on the exact drugs and types of cases included in this overall category.
Illicit drugs
  • Cocaine
  • Heroin
  • Marijuana
  • Stimulants (amphetamines and methamphetamine)
  • MDMA
  • GHB
  • Flunitrazepam (Rohypnol)
  • Ketamine
  • LSD
  • PCP
  • Other hallucinogens
  • Nonpharmaceutical inhalants
  • Combinations of illicit drugs
All types of cases except accidental ingestion and adverse reaction
Alcohol
  • Alcohol (with or without other drugs)
All types of cases except accidental ingestion and adverse reaction; patient may be of any age
Underage drinking
  • Alcohol (with or without other drugs)
All types of cases except accidental ingestion and adverse reaction; patient must be under the age of 21
Nonmedical use of pharmaceuticals
  • Prescription drugs (e.g., ADHD drugs, antibiotics, antidepressants, antipsychotics, anticoagulants, beta blockers, birth control pills, hormone replacement, insulin, muscle relaxants, pain relievers, sleeping aids)
  • Dietary supplements
  • Vitamins
  • Other over-the-counter pharmaceutical products
Combination of three types of cases (1):
  • Overmedication (cases of nonmedical use, overuse, or misuse lacking explicit documentation of drug abuse),
  • Malicious poisoning (cases in which the patient was administered a drug by another for a malicious purpose), and
  • Type of case "Other" (cases that could not be assigned to another type of case; includes documented drug abuse).
Drug-related suicide attempts (2) All drugs Suicide attempts only
Visits for the purpose of seeking detox services (2) All drugs Seeking detox only

Population estimates used to generate rates (visits per 100,000 population) for 2008 are provided in Table C4. Standardized rates were not calculated for race and ethnicity subgroups, because the race/ethnicity categories available to DAWN are much less detailed and contain considerably more missing data than the race and ethnicity categories in the census data. Appendix D describes the race and ethnicity data reported for DAWN.

Table C4
U.S. population by age and gender, 2008
Age Total United States (1) Males Females
(1) Population estimates for 2008 are as of 7/29/2009 from the U.S. Census Bureau Postcensal Resident Population National Population Dataset, National estimates by demographic characteristics—single year of age, sex, race, and Hispanic Origin, Monthly Population Estimates. Link: http://www.census.gov/popest/datasets.html. File: NC-EST2008-ALLDATA-R-File18.csv.
Total 304,059,724 149,924,604 154,135,120
0–5 years   25,082,312   12,833,236   12,249,076
6–11 years   23,831,109   12,183,090   11,648,019
12–17 years   25,028,427   12,817,191   12,211,236
18–20 years   12,915,055     6,628,081     6,286,974
21–24 years   16,842,164     8,680,535     8,161,629
25–29 years   21,333,743   10,940,956   10,392,787
30–34 years   19,597,822     9,959,083     9,638,739
35–44 years   42,501,130   21,314,357   21,186,773
45–54 years   44,372,065   21,852,633   22,519,432
55–65 years   33,686,181   16,250,639   17,435,542
65 years and older   38,869,716   16,464,803   22,404,913

APPENDIX D

RACE AND ETHNICITY IN 2008 DAWN

In October 1997, the Office of Management and Budget (OMB) issued a revised standard protocol for race and ethnicity categories used in Federal data collection systems.17 The new protocol permitted separate reporting of race and Hispanic ethnicity, and it incorporated the ability to capture more than one race for an individual, several modifications in nomenclature (e.g., "Black" was changed to "Black or African American"), division of certain categories ("Asian or Pacific Islander" was split into two categories, "Asian" and "Native Hawaiian or Other Pacific Islander"), and elimination of the "other" category. The OMB protocol also permitted a combined format, whereby race and Hispanic ethnicity would be recorded in a single data item, which could still record multiple responses for race, Hispanic ethnicity, or both. The single data item for race and ethnicity is shown in the Drug Abuse Warning Network (DAWN) emergency department (ED) case form.

DAWN collects data retrospectively from medical records. There is no mechanism to obtain data that is missing from the ED records, and patients are never interviewed. Race/ethnicity is missing entirely in about 10 to 20 percent of DAWN case records. When present, detail concerning the race/ethnicity categories of Asian, American Indian or Alaska Native, Native Hawaiian or Pacific Islander, two race/ethnicities, and three race/ethnicities are often not documented.18

For reference, estimates of drug-related ED visits by DAWN's detailed race/ethnicity groups are presented in Table D1. Considering the limitations in the collection of race/ethnicity, this and other DAWN publications report race/ethnicity aggregated into four groups: non-Hispanic White, non-Hispanic Black, Hispanic, and race/ethnicity not tabulated above. All cases reported to DAWN as Hispanic or Latino ethnicity are tabulated as Hispanic race/ethnicity, regardless of race.

Table D1
Drug-related ED visits, by detailed race/ethnicity, 2008
Race/ethnicity ED visits (1)
(1) Estimates of ED visits are based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the United States.
NOTE: An asterisk (*) indicates that an estimate with a relative standard error greater than 50%, or an estimate based on fewer than 30 visits, has been suppressed.
SOURCE: Center for Behavioral Health Statistics and Quality, SAMHSA, Drug Abuse Warning Network, 2008.
Total drug-related ED visits 4,383,494
One race/ethnicity 4,296,110
White 2,781,229
Black or African American    681,238
Hispanic    284,645
Asian        6,264
American Indian or Alaska Native      41,907
Native Hawaiian or Other Pacific Islander                *
Race unknown    493,434
Two races/ethnicities                *
White + Black or African American                *
White + Hispanic                *
White + Asian                *
White + American Indian or Alaska Native                *
Black or African American + Hispanic        1,768
Black or African American + Asian                *
Black or African American + American Indian/Alaska Native                *
Hispanic + Asian                *
Hispanic + American Indian or Alaska Native                *
Asian + American Indian or Alaska Native                *
Three races/ethnicities                *
White + Black or African American + Hispanic                *
White + Hispanic + Asian                *
White + Asian + Native Hawaiian or Other Pacific Islander                *

End Notes

1 Because DAWN is based on a probability sample, there is a margin of error around estimates. For example, the 95 percent confidence interval around the estimate of 4,383,494 drug-related ED visits is 3,847,852 to 4,919,137.
2 Table C1 in Appendix C provides detail on response rates for each metropolitan area.
3 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2009, Multum Information Services, Inc. The classification was modified to meet DAWN's unique requirements (2009). The Multum Licensing Agreement governing use of the Lexicon can be found in Appendix A and on the Internet at http://dawninfo.samhsa.gov/drug_vocab.
4 These four categories of ED visits are not mutually exclusive. The sum of visits or rates by category will be greater than the total, and the sum of percentages will be greater than 100.
5 ED patients aged 21 or older for whom alcohol was the only drug associated with their ED visits are not considered DAWN cases.
6 Heroin ED visits may be underestimated. When drugs related to an ED visit are determined through toxicology tests, often the results do not distinguish heroin from the non-illicit drug category of "unspecified opiates." The number of drug misuse or abuse ED visits involving unspecified opiates is estimated at 73,997 visits, and just under half of these (35,819) were determined through toxicology testing. What portion of these toxicology results is attributable to heroin is unknown.
7 National Institute on Alcohol Abuse and Alcoholism (NIAAA). (2007, February). Frequently asked questions for the general public. Retrieved November 18, 2009, from http://www.niaaa.nih.gov/FAQs/General-English/default.htm#taking_medications.
8 DAWN tries to capture only pharmaceuticals that are related to the ED visit and actively discourages reporting of current medications that are unrelated to the visit. Given the limitations of medical record documentation, though, it is not always possible to distinguish and exclude current medications that are unrelated to the visit. This limitation may have the effect of overstating the variety of pharmaceuticals involved in ED visits.
9 ED records frequently do not distinguish methadone used properly for the treatment of opiate addiction (and not specifically related to the ED visit) from nonmedical methadone use (related to the ED visit). This could result in overreporting the estimated number of ED visits related to methadone, but the extent of the overreporting is unknown.
10 Excluded are suicide-related behaviors documented as something other than actual attempts (e.g., suicidal ideation, suicidal gesture, or suicidal thoughts).
11 Percentages add to greater than 100 percent because visits often involve multiple drugs.
12 Some detox programs, in the hospital or the community, require medical clearance before a person can be admitted to a program. Medical clearance establishes whether a person has any special medical needs (e.g., person is diabetic and needs insulin) or is not suitable to mingle with other patients in the program (e.g., person has an infectious disease or is mentally unstable).
13 The role of alcohol may be underrepresented here because, for patients aged 21 and older, DAWN captures alcohol use only when it is combined with the use of other drugs.
14 See Office of Management and Budget, Revisions to the standards for the classification of Federal data on race and ethnicity, 62 Fed. Reg. 58,782 (October 30, 1997).
15 The ED Reference Guide is available for download from the DAWN Web site, https://dawninfo.samhsa.gov/collect/. The link for the document is https://dawninfo.samhsa.gov/files/collect_2009-2011/ed_reference_guide_2009-2011.pdf.
16 For 2008, more hospitals participated in DAWN than were used in estimation. Therefore, the number of drug-related ED visits from all participating hospitals exceeded the number used for estimation.
17 Revisions to the standards for the classification of Federal data on race and ethnicity, 62 Fed. Reg. 58,782 (October 30, 1997).
18 If two races are reported and the second is reported as unknown, the episode is coded for the known race.

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