December 28, 2010

Highlights of the 2009 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits

In 2009, nearly 4.6 million emergency room visits were connected to misuse or abuse of drugs, adverse reactions to drugs, or other drug-related consequences.¹ The Drug Abuse Warning Network (DAWN) provides estimates of the number of emergency room admissions associated with particular drugs. DAWN data on individuals who experience drug-related medical emergencies severe enough to require treatment in an emergency department (ED) provide important information on the types of drugs involved in substance abuse and the characteristics of individuals suffering the negative consequences of drug use. The DAWN data reflect the commitment of the Substance Abuse and Mental Health Services Administration (SAMHSA) to provide important health statistics that inform local, State, and Federal public policy by providing a measure of the public health impact from the use of alcohol, illicit drugs, and pharmaceuticals. Such data offer a unique insight into the Nation's substance misuse or abuse problems and thereby help guide prevention, intervention, and treatment programs at the State and local levels.

DAWN data also provide a gauge of the impact of drug-related ED visits on the health care system. The U.S. Food and Drug Administration uses DAWN data for continued surveillance of pharmaceuticals, and the pharmaceutical industry uses these data for post-marketing surveillance of prescription and over-the-counter drugs, for active monitoring of adverse events associated with medications, and for assessing the abuse potential for labeling and scheduling decisions.

This issue of The DAWN Report presents highlights of national estimates of drug-related visits to hospital EDs for 2009, with trends from 2004 to 2009. The findings in this report, including significance tests, are drawn from the DAWN 2009 ED trend tables (available online at https://dawninfo.samhsa.gov/data/).²

In 2009, there were nearly 4.6 million drug-related ED visits of which about one half (49.8 percent, or 2.3 million) were attributed to adverse reactions to pharmaceuticals and almost one half (45.1 percent, or 2.1 million) were attributed to drug misuse or abuse (Table 1).^3,4 Of the 2.1 million ED visits involving drug misuse or abuse, 1.2 million visits involved the misuse or abuse of pharmaceuticals, almost 1.0 million were related to illicit drugs, and about 200,000 visits were associated with underage drinking.^5,6,7 Alcohol was involved in more than 650,000 visits, or slightly less than one third (31.8 percent) of visits resulting from drug misuse or abuse.⁸

Patients aged 20 or younger accounted for 19.1 percent (877,802 visits) of all drug-related ED visits in 2009. About one half (415,351 visits) of these visits involved drug misuse or abuse, representing a rate of 473.3 ED visits per 100,000 population aged 20 or younger. The majority of drug-related ED visits were made by patients aged 21 or older (80.9 percent, or 3,717,030 visits). Of these, slightly less than one half (1,654,784 visits) involved drug misuse or abuse, reflecting a rate of 754.8 visits per 100,000 population aged 21 or older.

In 2009, ED visits resulting from the misuse or abuse of pharmaceuticals occurred at a rate of 405.4 visits per 100,000 population compared with a rate of 317.1 per 100,000 population for illicit drugs (Table 2). About one half of ED visits for misuse or abuse of pharmaceuticals involved pain relievers (194.0 visits per 100,000 population), which were most commonly narcotic pain relievers (e.g., oxycodone and hydrocodone products; 129.4 visits per 100,000 population). More than one third of ED visits for misuse or abuse of pharmaceuticals involved drugs to treat insomnia and anxiety (141.2 visits per 100,000 population), primarily benzodiazepines (e.g., alprazolam, clonazepam, and diazepam; 121.6 visits per 100,000 population).

For ED visits related to the use of illicit drugs, cocaine and marijuana had the highest rates involvement at 137.7 and 122.6 visits per 100,000 population, respectively. ED visits involving alcohol in combination with other drugs occurred at a rate of 169.3 visits per 100,000 population for all age groups. ED visits resulting from underage drinking occurred at a rate of 227.2 visits per 100,000 population aged 20 or younger in 2009.

The majority of drug-related ED visits in 2009 were made by patients aged 21 or older; of a total 4,595,263 drug-related ED visits, 3,717,030 (80.9 percent) were made by patients aged 21 or older. Among ED visits made by patients aged 20 or younger resulting from drug misuse or abuse, after alcohol, marijuana was the most commonly involved illicit drug (125.3 visits per 100,000 population) (Figure 1). For this age group, the rates for ED visits related to all other illicit drugs and all major pharmaceuticals were less than 30 visits per 100,000 population (Figures 1 and 2).

Figure 1. Emergency Department (ED) Visits Involving Major Illicit Drugs, by Age and Drug: 2009

Figure 2. Emergency Department (ED) Visits Involving Misuse or Abuse of Select Pharmaceuticals, by Age and Pharmaceutical: 2009

For adults aged 21 or older, cocaine was involved in 398,229 visits, or 181.6 visits per 100,000 population. In this age group, marijuana was involved in 121.5 visits per 100,000 population, heroin was involved in 89.4 visits per 100,000 population, and stimulants (i.e., amphetamines and methamphetamines) were involved in 37.2 visits per 100,000 population (Figure 1). Among pharmaceuticals, the narcotic pain reliever oxycodone appeared in 71.9 visits per 100,000 population, and the benzodiazepine alprazolam was found in 55.7 visits per 100,000 population (Figure 2). Antidepressants and hydrocodone products each appeared in slightly more than 40 visits per 100,000 population.

The total number of drug-related ED visits increased 81 percent from 2004 (2.5 million visits) to 2009 (4.6 million visits). ED visits involving misuse or abuse of pharmaceuticals increased 98.4 percent between 2004 and 2009, from 627,291 visits in 2004 to 1,244,679 visits in 2009 (Figure 3). The corresponding rates of ED visits related to misuse or abuse of pharmaceuticals per 100,000 population were 214.1 in 2004 and 405.4 in 2009 (Table 3). Unlike pharmaceuticals, the level of ED visits involving illicit drug use was generally stable across that time period. ED visits resulting from alcohol involvement with drug use and underage drinking were also stable.

Figure 3. Drug-Related Emergency Department (ED) Visits, by Type of Visit: 2004 to 2009*

Several of the more commonly misused or abused pharmaceuticals were found to have increased more than 100 percent in ED visit involvement from 2004 to 2009 (Table 4). Of these, the largest increases were observed for oxycodone products (242.2 percent increase), alprazolam (148.3 percent increase), and hydrocodone products (124.5 percent increase). Large percent increases occurred among particular drugs contributing to relatively fewer visits: antidiabetic agents such as insulin (223.6 percent increase) and zolpidem, a drug to induce sleep (154.9 percent increase). Among ED visits involving illicit drugs, only those involving Ecstasy increased more than 100 percent from 2004 to 2009 (123.2 percent increase).

For patients aged 20 or younger, ED visits resulting from misuse or abuse of pharmaceuticals increased 45.4 percent between 2004 and 2009 (116,644 and 169,589 visits, respectively). Among patients aged 21 or older, there was an increase of 111.0 percent. There were no significant changes in the level of ED visits involving illicit drugs for either age group or those involving underage drinking for those aged 20 or younger.

ED visits involving adverse reactions to pharmaceuticals taken as prescribed increased 82.9 percent between 2005 and 2009, from 1,250,377 visits in 2005 to 2,287,273 visits in 2009 (Figure 3).⁹ The rate for adverse reactions ranged from 422.8 visits per 100,000 population in 2005 to 745.0 visits per 100,000 population in 2009 (Table 3).

The majority of adverse reaction visits were made by patients who were 21 or older (1.9 million visits, or 877.3 visits per 100,000 population). In particular, among patients aged 65 or older, the rate was 1,856.8 visits per 100,000 population. This rate represents an 89.2 percent increase from the number of adverse reaction ED visits among patients aged 65 or older in 2005. The type of drugs most commonly involved in adverse reactions for patients aged 65 or older in 2009 were blood modifiers (e.g., coumarin; 405.8 visits per 100,000 population). Other drugs found at high levels were cardiovascular drugs, including beta blockers (328.5 visits per 100,000 population), pain relievers (296.9 visits per 100,000 population), and cancer drugs (117.1 visits per 100,000 population).

The findings in this report demonstrate the increasing importance of pharmaceuticals to total drug-related ED visits. Pharmaceuticals, even those that are sometimes abused, can have very positive effects when used as prescribed or directed. However, when misused or abused, they can lead to serious negative side effects. Between 2004 and 2009, the number of ED visits involving the misuse or abuse of pharmaceuticals increased substantially. About twice as many people experienced ED visits caused by the misuse or abuse of pharmaceuticals in 2009 than in 2004, and this pattern was consistent across age groups.

The findings related to the misuse or abuse of pharmaceuticals call attention to several public health challenges. First, pharmaceuticals do not have the stigma of being illegal, and therefore health educators must change the perception that pharmaceutical drugs are safe to use recreationally. Another public health challenge is ensuring that pharmaceuticals are available for people who depend on them therapeutically, while finding a way to limit access to people who misuse or abuse them. The findings in this report also highlight the importance of heightening emergency room medical staff's awareness of nonmedical use of pharmaceuticals, because these personnel might be the first responders to people in need of intervention and treatment.

The findings in this report also underscore the growing public health problem of adverse reactions to pharmaceuticals when taken as prescribed or recommended. Recently, there has been increased attention on refining drug warning labels (i.e., the text and icons used) to increase patients' understanding of prescription drugs' potential side effects and possible interactions with other drugs and alcohol, regardless of literacy level.^10,11 Beyond these efforts, the increased use of technology in pharmacies—such as software that allows pharmacists to keep a record of a patient's medications and potential interactions or contraindications—is another avenue to increase drug safety. Patients can reduce the potential for adverse reactions by keeping an updated list of all the drugs and supplements that they take so they can present it to doctors and pharmacists whenever they are prescribed a new medication.

This page was last updated on December 10, 2010.

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