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Drug-Related Emergency Visits

Home / Current Reseach / Drug-Related Emergency Visits

New Report on 2021 Drug-Related Emergency Department Visits

The Drug Abuse Warning Network, also known as the DAWN, recently released its nationwide report on 2021 findings from drug-related emergency department (ED) visits.

Here are a few of the highlights from the 2021 report:

Weighted National Estimates for All Drug-Related ED Visits

Patients aged 26 to 44 had the highest percentage (40%) of all drug-related ED visits, followed by patients aged 45 to 64 (32%), with the majority being males (61%).
The greatest proportion of all drug-related ED visits was with White patients at 61% while patients who were Black or African American were at 15%. Additionally, the majority of these drug-related ED visits were among those patients who were not Hispanic or Latino (75%).

Weighted National Estimates for the Top Five Drugs in Drug-Related ED Visits

The top five drugs involved in drug-related ED visits were alcohol (42%), opioids (15%), methamphetamine (11%), marijuana (11%), and cocaine (5%).
Fentanyl-related ED visits increased in 2021 from nearly 17% at the end of the first quarter to nearly 29% at the end of the year.
Heroin-related visits peaked at 27% and then dropped in the last quarter to nearly 23% while other opioid-related visits topped out early in the year at almost 30%, dipping to almost 23% at year’s end.
Young adult patients aged 18 to 25 had the second highest percentage of ED visits related to marijuana (27%) and fentanyl (17%).

As a data collection program of the Substance Abuse and Mental Health Services Administration (SAMHSA), the DAWN provides important and early ED visit monitoring data aimed to understand the scope and significance of the substance use problem in the United States. Please download the report to view the additional detailed information, charts, and figures.

Download the Report

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Clusters of substance use and mental health variables with emergency room visits in U.S. adults: The 2020 National Survey on Drug Use and Health

Data sources used.

National Survey on Drug Use and Health 2020 (NSDUH-2020-DS0001)

How emergency department visits for substance use disorders have evolved during the early COVID-19 pandemic

Affiliations.

1 US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America. Electronic address: [email protected].
2 The Heller School for Social Policy and Management, Brandeis University, Waltham, MA, United States of America.
3 Northwestern University, Pritzker School of Law and Kellogg School of Management, Evanston, IL, United States of America.
4 US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Allegheny Health Network, Erie, PA, United States of America.
5 US Acute Care Solutions, Canton, OH, United States of America.
6 Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America.
7 US Acute Care Solutions, Canton, OH, United States of America; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA, United States of America.
PMID: 33994360
PMCID: PMC9581895
DOI: 10.1016/j.jsat.2021.108391

Objective: Higher opioid overdoses and drug use have reportedly occurred during the COVID-19 pandemic. We provide evidence on how emergency department (ED) visits for substance use disorders (SUD) changed in the early pandemic period.

Methods: Using retrospective data from January-July 2020 compared to January-July 2019, we calculated weekly 2020/2019 visit ratios for opioid-related, alcohol-related, other drug-related disorders, and all non-COVID-19 visits. We assess how this ratio as well as overall visit numbers changed after the mid-March 2020 onset of general pandemic restrictions.

Results: In 4.5 million ED visits in 2020 and 2019 to 108 EDs in 18 U.S. states, SUD visits were higher in early 2020 compared to 2019. During the peak-pandemic restriction period (March 13-July 31), non-COVID-19, non-SUD visits fell by approximately 45% early on, and then partly recovered with an average decline of 33% relative to 2019 levels. Visits for opioid-related, alcohol-related, and other drug-related disorders also declined, although less sharply, with an average drop of 17%, which was similar across SUD types. The visit ratios for 2020/2019 partially or fully recovered later in our sample period, depending on SUD type, but did not exceed early-2020 levels. However, substantial variation occurred across SUD types and across states. SUD visit declines were most prominent in the 65+ age group, except for alcohol-related visits where trends were similar across ages. SUD visits arriving by ambulance declined less or increased relative to self-transport visits, and ED deaths were rare.

Conclusions: The 2020/2019 ratios of SUD ED visits fell substantially early in the COVID-19 pandemic, yet less than non-SUD, non-COVID ED visits. SUD ED visit ratios partly or fully recovered to 2019 levels by early June 2020, but did not exceed early 2020 ratios.

Keywords: Alcohol; COVID-19; Drug use; Emergency department; Opioids; Overdose; Substance use.

Publication types

Emergency Service, Hospital
Retrospective Studies
Substance-Related Disorders* / epidemiology

Introduction
Conclusions
Article Information

Estimates and 2-sided 95% CIs (error bars) were calculated from statistical weighting of 96 925 cases from 60 nationally representative hospitals participating in the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance Project for 2017-2019, Centers for Disease Control and Prevention. The population of each age group for 2017-2019 was calculated with intercensal estimates produced by the US Census Bureau. Patient age was missing for 13 cases (data not shown).

Estimates were calculated from statistical weighting of 96 925 cases from 60 nationally representative hospitals participating in the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance Project for 2017-2019, Centers for Disease Control and Prevention. The population of each age group for 2017-2019 was calculated with intercensal estimates produced by the US Census Bureau. The estimate of ED visits for abuse, misuse, or overdose without indication of intent for children younger than 5 years is based on fewer than 20 cases and is considered statistically unstable. Patient age was missing for 13 cases (data not shown).

eTable. Illustrative Cases of US Emergency Department Visits for Medication Harms by Intent of Medication Use, 2017-2019

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Budnitz DS , Shehab N , Lovegrove MC , Geller AI , Lind JN , Pollock DA. US Emergency Department Visits Attributed to Medication Harms, 2017-2019. JAMA. 2021;326(13):1299–1309. doi:10.1001/jama.2021.13844

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US Emergency Department Visits Attributed to Medication Harms, 2017-2019

1 Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
2 Lantana Consulting Group, Atlanta, Georgia

Question What were the most frequent medication types and intents of use associated with emergency department (ED) visits for medication harms in the US in 2017-2019?

Findings In this cross-sectional nationally representative sample that included 60 US EDs between 2017 and 2019, annual estimates of the most frequent medication types and intents of use associated with ED visits attributed to medication harms (adverse events) were therapeutic use of anticoagulants (4.5/1000 population) and diabetes agents (1.8/1000 population) for patients aged 65 years or older; therapeutic use of anticoagulants (0.6/1000 population) and diabetes agents (0.8/1000 population) for patients aged 45 to 64 years; nontherapeutic use of benzodiazepines (1.0/1000 population) and prescription opioids (0.7/1000 population) for patients aged 25 to 44 years; and unsupervised medication exposures (2.2/1000 population) and therapeutic use of antibiotics (1.4/1000 population) for children younger than 5 years.

Meaning Visits to US EDs attributed to medication harms in 2017-2019 were frequent and varied by medication type, intended use, and patient age.

Importance Assessing the scope of acute medication harms to patients should include both therapeutic and nontherapeutic medication use.

Objective To describe the characteristics of emergency department (ED) visits for acute harms from both therapeutic and nontherapeutic medication use in the US.

Design, Setting, and Participants Active, nationally representative, public health surveillance based on patient visits to 60 EDs in the US participating in the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance Project from 2017 through 2019.

Exposures Medications implicated in ED visits, with visits attributed to medication harms (adverse events) based on the clinicians’ diagnoses and supporting data documented in the medical record.

Main Outcomes and Measures Nationally weighted estimates of ED visits and subsequent hospitalizations for medication harms.

Results Based on 96 925 cases (mean patient age, 49 years; 55% female), there were an estimated 6.1 (95% CI, 4.8-7.5) ED visits for medication harms per 1000 population annually and 38.6% (95% CI, 35.2%-41.9%) resulted in hospitalization. Population rates of ED visits for medication harms were higher for patients aged 65 years or older than for those younger than 65 years (12.1 vs 5.0 [95% CI, 7.4-16.8 vs 4.1-5.8] per 1000 population). Overall, an estimated 69.1% (95% CI, 63.6%-74.7%) of ED visits for medication harms involved therapeutic medication use, but among patients younger than 45 years, an estimated 52.5% (95% CI, 48.1%-56.8%) of visits for medication harms involved nontherapeutic use. The proportions of ED visits for medication harms involving therapeutic use were lowest for barbiturates (6.3%), benzodiazepines (11.1%), nonopioid analgesics (15.7%), and antihistamines (21.8%). By age group, the most frequent medication types and intents of use associated with ED visits for medication harms were therapeutic use of anticoagulants (4.5 [95% CI, 2.3-6.7] per 1000 population) and diabetes agents (1.8 [95% CI, 1.3-2.3] per 1000 population) for patients aged 65 years and older; therapeutic use of diabetes agents (0.8 [95% CI, 0.5-1.0] per 1000 population) for patients aged 45 to 64 years; nontherapeutic use of benzodiazepines (1.0 [95% CI, 0.7-1.3] per 1000 population) for patients aged 25 to 44 years; and unsupervised medication exposures (2.2 [95% CI, 1.8-2.7] per 1000 population) and therapeutic use of antibiotics (1.4 [95% CI, 1.0-1.8] per 1000 population) for children younger than 5 years.

Conclusions and Relevance According to data from 60 nationally representative US emergency departments, visits attributed to medication harms in 2017-2019 were frequent, with variation in products and intent of use by age.

Efforts to assess and address medication harms typically categorize harmful events according to how patients intended to use the medications. When patients use their medications in recommended dosages and at recommended intervals for approved indications yet still experience harmful effects, these effects are considered adverse reactions from therapeutic use. 1 Clinicians and patients may unintentionally make medication errors that lead to harms; however, patients can also intentionally use medications in ways that are not recommended. 2 , 3 Some patients intentionally take their medications in amounts higher than recommended, take medications prescribed for others, or take medications for unapproved indications. The underlying reason for such nontherapeutic use may be categorized as misuse, substance use disorder, or self-harm, or in some cases may not be possible to determine by treating clinicians. 4 If harms from both therapeutic and nontherapeutic use are assessed concurrently, clinicians and policymakers can make more complete assessments of medication risks to patients.

The US Centers for Disease Control and Prevention (CDC) collaborates with the US Consumer Product Safety Commission (CPSC) and the US Food and Drug Administration (FDA) to conduct active, nationally representative public health surveillance for emergency department (ED) visits for harms attributed to medication use. 5 , 6 In this study, surveillance data from 2017-2019 were used to calculate national estimates of ED visits for acute harms related to therapeutic and nontherapeutic medication use.

The National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance Project (NEISS-CADES) is a collaborative effort of CDC, CPSC, and FDA. This active public health surveillance system is based on a representative sample of hospitals in the United States and its territories, which includes 60 hospitals with at least 6 beds and a 24-hour ED. 7

Trained CPSC abstractors at each hospital review medical records of ED visits to identify harms (adverse events) attributed to medications used for any reason. An adverse event case was defined as an incident ED visit for a condition or harm that the treating clinician explicitly attributed to the use of a drug or a drug-specific effect based on the clinicians’ diagnoses and supporting data documented in the medical record (eg, documentation of supratherapeutic international normalized ratio in a patient taking warfarin, hypoglycemia in a patient taking insulin, oversedation in a patient taking prescription opioids). 5 , 8 Medication harms included adverse reactions to therapeutic doses, medication overdoses for any intent, medication errors, unsupervised exposures by children, and secondary injuries (eg, choking on a pill). CPSC abstractors record up to 4 implicated medications, intent of medication use, free-text narratives of the event (including clinical manifestations, documented medication errors, relevant preceding events, and concurrent illicit drug or alcohol use), clinician diagnoses, laboratory testing, treatments administered, and discharge disposition.

CDC codes reported clinical manifestations according to the Medical Dictionary for Regulatory Activities (MedDRA, version 9.1) and standardizes implicated medications by active ingredient according to pharmacologic classification. Data collection for the NEISS-CADES Project is considered a public health surveillance activity by federal human subjects oversight bodies and does not require human subjects review or institutional review board approval. 9

Cases included ED visits from January 1, 2017, through December 31, 2019, in which prescription or over-the-counter medications, dietary supplements (eg, herbals, vitamins, minerals), homeopathic products, or vaccines were implicated by the treating clinician or documented by toxicology testing. Patients’ intent of medication use was classified as therapeutic or nontherapeutic use (eTable in the Supplement ). Therapeutic use included use as directed or unintentional errors by adults or adolescents. Nontherapeutic use included (1) unsupervised exposures by children aged 10 years or younger; (2) misuse (trying to use medication for a salutary effect but not using it as directed [eg, taking someone else’s prescription medication or taking additional doses for greater effect]); (3) abuse (clinician diagnosis of abuse or documentation of recreational use or use for euphoric or psychotropic effects); (4) self-harm (using medication to intentionally injure oneself); or (5) overdoses without documentation of therapeutic intent, misuse, abuse, or self-harm (eg, patients found unresponsive or unable or unwilling to provide description of circumstances or intent). Although concern has been raised that the term abuse may contribute to stigma, 10 , 11 it is used here because the term remains commonly used by clinicians in medical documentation. ED visits for medication withdrawal, therapeutic failures, occupational exposures, and harms from medications received in the ED were excluded. Follow-up visits for previously diagnosed medication harm events and deaths in or en route to the ED were also excluded.

Cases were weighted by CPSC according to the inverse probability of selection, adjusted for nonresponse and hospital nonparticipation, and poststratified to adjust for changes in the total number of hospital ED visits each year. 12 Based on these cases, national estimates (weighted percentages and weighted rates) of ED visits with corresponding 2-sided 95% CIs were calculated with the SURVEYMEANS procedure in SAS version 9.4 (SAS Institute) to account for the sample weights and complex sample design. The NEISS-CADES estimates for the 3-year period were divided by 3 to obtain the mean annual estimates. Estimates were considered statistically significantly different if their 2-sided 95% CIs were nonoverlapping. If 2 estimates had overlapping CIs, significance was determined by calculating 2-sided 95% CIs for the difference between estimates. To estimate age-specific population rates of ED visits, intercensal estimates from the US Census Bureau were used. 13 Estimates based on small numbers of cases (<20), or total (3-year) estimates less than 1200 were considered statistically unstable and are not shown. Estimates with coefficients of variation greater than 30% may be statistically unstable and are noted. Cases were not included in calculation of national estimates of a value when that value was missing. The numbers of cases with missing values for age (13 cases), sex (2 cases), and disposition (16 cases) out of 96 925 cases were trivial (≤0.03%), so imputation was not considered necessary.

Between 2017 and 2019, based on 96 925 cases (mean patient age, 49 years; 55% female), there were an estimated 6.1 (95% CI, 4.8-7.5) ED visits for therapeutic and nontherapeutic medication harms combined per 1000 population annually. Population rates of ED visits for therapeutic and nontherapeutic medication harms combined among patients aged 5 to 14 years were lower (1.8 [95% CI, 1.4-2.2] per 1000 population) than the mean rate for the population overall ( Figure 1 ). Population rates of ED visits for therapeutic and nontherapeutic medication harms combined were not significantly different for patients aged 15 to 24 years (5.6 per 1000 population) through 55 to 64 years (6.5 per 1000 population) (rate difference, −0.9 [95% CI, −2.7 to 0.9] per 1000 population). However, among patients aged 15 to 24 years, an estimated 61.8% (95% CI, 57.4%-66.1%) of ED visits for medication harms involved nontherapeutic use compared with an estimated 22.1% (95% CI, 17.8%-26.4%) of ED visits for medication harms among patients aged 55 to 64 years. Population rates of ED visits for therapeutic and nontherapeutic medication harms combined were higher for patients aged 65 years or older than for those younger than 65 years (12.1 vs 5.0 [95% CI, 7.4-16.8 vs 4.1-5.8] per 1000 population).

Overall, an estimated 38.6% of ED visits for medication harms required subsequent hospitalization, with hospitalization rates lowest for patients younger than 5 years (11.2%; 95% CI, 9.8%-12.5%) and highest for those aged 75 years or older (48.9%; 95% CI, 43.0%-54.8%) ( Table 1 ). Overall, ED visits for medication harms involved more female patients (54.6%; 95% CI, 53.1%-56.2%) than male patients (45.4%; 95% CI, 43.8%-46.9%). Medication harm was attributed to effects of a single medication in an estimated 78.5% of ED visits; however, subsequent hospitalization was required more commonly when more than 1 medication was implicated (49.9% vs 35.5%; 95% CI, 46.3%-53.4% vs 31.7%-39.2%).

Overall, an estimated 69.1% of ED visits involved harms after therapeutic use of medications and an estimated 30.9% of them involved harms after nontherapeutic use; however, subsequent hospitalization was more common after nontherapeutic use (54.7% vs 31.3%; 95% CI, 49.7%-59.7% vs 26.2%-36.4%). Hospitalization rates varied by intent of use, ranging from 10.5% after allergic reactions to 80.1% after intentional self-harm.

Anticoagulants were implicated in an estimated 14.9% of ED visits for medication harms overall and in more visits involving therapeutic use of medications (21.5%; 95% CI, 16.5%-26.4%) than any other class of medications ( Table 2 ). Analgesics were implicated in an estimated 13.9% of ED visits for medication harms overall, but only an estimated 33.0% of these visits involved therapeutic use. Similarly, sedative/hypnotic agents were implicated in an estimated 12.2% of ED visits for medication harms overall, but only an estimated 13.7% of these visits involved therapeutic use. Alcohol or illicit substances (eg, marijuana, heroin, cocaine, unspecified opioids) were frequently involved in ED visits for medication harms from nontherapeutic use of analgesics and sedative/hypnotic agents, including an estimated 49.1% (95% CI, 45.5%-52.8%) of ED visits for nontherapeutic use of prescription opioids and an estimated 66.3% (95% CI, 62.6%-69.9%) of visits for nontherapeutic use of benzodiazepines.

Considering only therapeutic use of medications, ED visits for medication harms involving diabetes agents (13.7%; 95% CI, 11.8%-15.6%) and antibiotics (12.8%; 95% CI, 10.8%-14.9%) were more common than those involving analgesics (6.6%; 95% CI, 5.7%-7.5%). Among all classes of cardiovascular agents, centrally acting antiadrenergics (eg, clonidine) was the only class for which there were fewer ED visits for medication harms involving therapeutic use (36.8%; 95% CI, 27.8%-45.8%) compared with nontherapeutic use.

Medications commonly available over-the-counter (ie, nonsteroidal anti-inflammatory drugs, nonopioid analgesics, single-ingredient antihistamines, and cough and cold medications) were implicated in an estimated 10.0% (95% CI, 8.6%-11.4%) of visits overall, but only an estimated 30.8% (95% CI, 26.6%-35.1%) of these visits involved therapeutic use. The proportions of ED visits for medication harms involving therapeutic use were lowest for barbiturates (6.3% therapeutic use), benzodiazepines (11.1% therapeutic use), nonopioid analgesics (15.7% therapeutic use), and single-ingredient antihistamines (21.8% therapeutic use).

Among patients aged 65 years or older, an estimated 95.8% (95% CI, 94.6%-97.1%) of ED visits for medication harms involved therapeutic use, and the population rate of ED visits for medication harms owing to therapeutic use (11.6 [95% CI, 6.9-16.3] per 1000 population) was higher than that for all medication harms in any other age group ( Figure 2 ). In contrast, among patients younger than 45 years an estimated 52.5% (95% CI, 48.1%-56.8%) of ED visits for medication harms involved nontherapeutic use. Among patients younger than 5 years, an estimated 47.1% (95% CI, 43.4%-50.8%) of ED visits for medication harms involved unsupervised medication exposures (2.2 [95% CI, 1.8-2.7] per 1000 population). The population rate of ED visits for medication harms involving self-harm was highest among patients aged 15 to 24 years (2.0 [ 95% CI, 1.6-2.4] per 1000 population). Medications commonly available over-the-counter (ie, nonsteroidal anti-inflammatory drugs, nonopioid analgesics, single-ingredient antihistamines, and cough and cold medications) were implicated in an estimated 45.2% (95% CI, 43.1%-47.2%) of self-harm visits, and an estimated 25.7% (95% CI, 23.9%-27.6%) of self-harm visits were attributed to antidepressants. The population rate of ED visits for medication harms involving abuse, misuse, or overdose without indication of intent was highest among patients aged 25 to 44 years (1.6 [95% CI, 1.2-2.0] per 1000 population). An estimated 44.9% of these visits (95% CI, 40.5%-49.2%) were attributed to benzodiazepines; an estimated 37.9% (95% CI, 32.3%-43.4%), to prescription opioids.

Among patients younger than 5 years, 4 of the 10 most frequently implicated drug products in ED visits for medication harms were antibiotics, with more than 95% of these ED visits attributed to therapeutic use ( Table 3 ). The population rate of ED visits for medication harms from therapeutic use of all antibiotics was 1.4 (95% CI, 1.0-1.8) per 1000 population for children younger than 5 years. In contrast, therapeutic use was rarely involved in ED visits in which acetaminophen, ibuprofen, diphenhydramine, melatonin, or lisinopril were implicated. Among patients aged 5 to 14 years, 3 medications that can be used to treat attention-deficit/hyperactivity disorder (methylphenidate, clonidine, and guanfacine) were among the 10 most frequently implicated drug products in ED visits, but the population rates of ED visits for these medication harms (0.1 [95% CI, 0.07-0.14] per 1000 population) was lower than rates for the 10 most frequently implicated products for other age groups.

Among patients aged 15 to 24 years, 5 psychiatric medications (alprazolam, sertraline, trazadone, quetiapine, and fluoxetine) and 3 over-the-counter medications (ibuprofen, acetaminophen, and diphenhydramine) were among the 10 most frequently implicated products in ED visits for medication harms, with only an estimated 5.3% to 23.2% of visits involving therapeutic use.

Among patients aged 25 to 44 years, 6 of the 10 most frequently implicated products are used for treating pain (acetaminophen/oxycodone, oxycodone, gabapentin, and ibuprofen) or addiction to pain medications (methadone and buprenorphine/naloxone), with an estimated 59.8% to 89.8% of these visits involving nontherapeutic use. The population rate of ED visits for medication harms from nontherapeutic use of all prescription opioids was 0.7 (95% CI, 0.5-0.9) per 1000 population for patients aged 25 to 44 years.

Among patients aged 15 to 24 years and 25 to 44 years, alprazolam was the most frequently implicated drug product in ED visits for medication harms, and it was the third most frequently implicated drug product among patients aged 45 to 64 years, with an estimated 97.3%, 93.9%, and 87.0% of visits involving nontherapeutic use, respectively. The population rate of ED visits for medication harms from nontherapeutic use of all benzodiazepines was 0.9 (95% CI, 0.6-1.1) per 1000 population for patients aged 15 to 24 years and 1.0 (95% CI, 0.7-1.3) per 1000 population for patients aged 25 to 44 years. However, an estimated 61.3% (95% CI, 57.4%-65.3%) of ED visits involving alprazolam also involved alcohol or illicit substances.

Among patients aged 45 years or older, insulin and warfarin were the 2 most frequently implicated drug products, with insulin implicated in an estimated 11.1% of ED visits for medication harm among patients aged 45 years or older and warfarin implicated in an estimated 20.7% of visits among those aged 65 years or older. The population rate of ED visits attributed to therapeutic use of all diabetes agents and all anticoagulants was 0.8 (95% CI, 0.5-1.0) and 0.6 (95% CI, 0.4-0.8) per 1000 population, respectively, for patients aged 45 to 64 years. Among patients aged 65 years or older, the population rate of ED visits attributed to therapeutic use of all diabetes agents and all anticoagulants and was 1.8 (95% CI, 1.3-2.3) and 4.5 (95% CI, 2.3-6.7) per 1000 population, respectively.

ED visits attributed to medication harms were frequent in the US in 2017-2019 and varied by medication type, intended use, and patient age. Direct-acting oral anticoagulants (DOACs) require less rigorous management than warfarin because of more predictable pharmacologic profiles and lower rates of major bleeding 14 , 15 ; however, with increased use, they are important contributors to medications associated with ED visits for medication harms. Nearly as many ED visits were attributed to DOACs (5.9%) as to warfarin (8.4%). There have been recent efforts to improve therapeutic use of anticoagulant medications in outpatient settings, including improving the processes for periprocedural management and transitioning between agents and recognizing sentinel bleeding. 16 In 2019, the Joint Commission updated its national patient safety goals to specifically address DOACs, and their expert management, in addition to that of older anticoagulants, is being integrated into emerging anticoagulation stewardship efforts. 17 , 18 Consideration could also be given to incorporating measurement of anticoagulant adverse events into quality measures and improvement activities 19 while ensuring that anticoagulants continue to be prescribed when indicated.

Efforts to reduce unintended harms from diabetes medications have also increased recently, particularly for older adults. National treatment guidelines have been updated 20 - 23 and campaigns initiated 24 to balance risks and benefits of tight glycemic control in patients with high risk of hypoglycemia (eg, history of severe hypoglycemia, limited life expectancy, extensive comorbid conditions). New injectable diabetes agents with reduced risk of hypoglycemia have been introduced, but insulin remains the cornerstone of diabetes treatment. 25 Optimizing insulin prescribing, improving glucose monitoring and insulin delivery systems, and supporting patients’ knowledge and actions in balancing their diabetes medication dosing, diet, and activities are approaches being used to reduce hypoglycemic events. 26 - 28

The CDC guideline for prescribing opioids for chronic pain (2016) 29 and FDA’s recent (2020) boxed warning for benzodiazepines 30 advise judicious prescribing of opioids and benzodiazepines for patients for whom these drugs are indicated and limiting excess supply available to others to reduce risk of adverse events, particularly among young and middle-aged adults. However, the finding that, overall, most visits involving nontherapeutic use of these medication classes also involved use of alcohol or illicit substances suggests opportunities for interventions that extend beyond judicious prescribing of prescription drugs. 31 Reducing ED visits for the most common medication harms among adolescents and young adults may also involve measures beyond improving clinician prescribing and that address underlying problems of mental health and substance use because an even higher proportion (>60%) of ED visits involved nontherapeutic medication use, and many involved over-the-counter or psychiatric medications. 32 , 33

Reducing ED visits for the most common medication harms among young children could target inappropriate antibiotic prescribing, as well as unsupervised exposures. With intensive efforts, pediatric antibiotic overprescribing can be reduced, 34 and the addition of flow restrictors to bottles of liquid medications has been shown to decrease unsupervised ingestions and related ED visits. 35 , 36 Increasing use of outpatient antimicrobial stewardship, broader implementation of flow restrictors, and enhanced safety packaging for pills, such as unit-dose packaging and child-resistant pill organizers, have potential to further reduce ED visits. 37 - 39 Although older children (5-9 years) had the lowest rates of ED visits for medication harms, opportunities may exist for judicious prescribing of antibiotics and addressing nontherapeutic use of over-the-counter and attention-deficit/hyperactivity disorder medications. 40

This study has several limitations. First, it likely underestimated the prevalence of medication harms from therapeutic and nontherapeutic use of medications because it did not include medication harms diagnosed and treated outside of EDs or those not likely to be diagnosed in EDs (eg, low-severity or insidious events, those that did not contribute to the patient’s chief concern, or those that required extensive evaluation to diagnose), or medication harms that resulted in deaths that occurred before the ED visit or in the ED (owing to variability in how such deaths were documented in ED medical record systems). Second, although the most common drug classes and products implicated in ED visits for medication harms were identified, appropriateness of prescribing could not be assessed. Third, population rates of ED visits for medication harms should be interpreted with caution because not every individual would have had medication exposure. Rates were not calculated by frequency of each specific medication exposure because data were not available for the range and specificity of products assessed and, although appropriate for comparisons within a class of medications, a single measure of exposure has limitations for comparing rates across medication classes, dose forms, and dosages. Fourth, for most visits involving nontherapeutic use, information to determine whether medications were prescribed to patients or obtained through other means was not available. Fifth, it is possible that intent of use was misclassified for some patients because they may have misreported intentionality or may have arrived to EDs unresponsive and unable to report intentionality, and clinicians may not have correctly identified or fully documented intentionality or details leading to the visit.

According to data from 60 nationally representative US emergency departments, visits attributed to medication harms in 2017-2019 were frequent, with variation in products and intent of use by age.

Corresponding Author: Daniel S. Budnitz, MD, MPH, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Rd, NE, Mailstop V18-4, Atlanta, GA 30329 ( [email protected] ).

Accepted for Publication: July 29, 2021.

Author Contributions: Dr Budnitz had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Budnitz, Shehab, Lind, Pollock.

Acquisition, analysis, or interpretation of data: Budnitz, Shehab, Lovegrove, Geller.

Drafting of the manuscript: Budnitz, Shehab, Lind.

Critical revision of the manuscript for important intellectual content: Shehab, Lovegrove, Geller, Lind, Pollock.

Statistical analysis: Lovegrove.

Administrative, technical, or material support: Budnitz, Shehab, Lovegrove, Geller, Lind.

Supervision: Budnitz, Pollock.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention (CDC).

Additional Contributions: We thank Kathleen O. Rose, RN, Sandra K. Goring, RN, Arati Baral, MS, and Alex Tocitu, MBA, from Northrop Grumman (contractor to CDC) and Nina J. Weidle, PharmD, from Chenega Government Consulting (contractor to CDC) for medical abstraction and programming assistance, as well as Tom Schroeder, MS, Elenore Sonski, CPC, Herman Burney, MS, and data abstractors from the Consumer Product Safety Commission for assistance with data acquisition. No one received compensation for their contributions.

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Abbreviations: ED, emergency department; NH, non-Hispanic; SUD, substance use disorder
Notes: Because the analysis included patient county of residence designations, the population was limited to observations with a patient county of residence within a State that participates in the HCUP NEDS. Therefore, the study population excluded ED visits with unknown or foreign patient residence or where the patient residence county was not in a State that participates in the HCUP NEDS. The number of ED visits was rounded to the nearest hundred. All percentages are column percentages except where indicated. Sex, age, and primary expected payer were missing for <1% of SUD-related ED visits; patient race and ethnicity information was missing for <2% of SUD-related ED visits.
* Percentages of all ED visits in the racial/ethnic group are shown.
† Self-pay/No charge: includes self-pay, no charge, charity, and no expected payment.
‡ Social vulnerability designation is based on patient county of residence. Patient residence counties were classified as most vulnerable (counties with social vulnerability index values in the fourth quartile) versus less vulnerable (counties with social vulnerability index values in the lower three quartiles).
Source: Agency for Healthcare Research and Quality (AHRQ), Healthcare Cost and Utilization Project (HCUP), Nationwide Emergency Department Sample (NEDS), 2019
Nearly half (49.5 percent) of all SUD-related ED visits were for patients aged 18–44 years, with slight variation by patient race and ethnicity. Over half of SUD-related ED visits for Asian/Pacific Islander non-Hispanic (NH), Hispanic, and other NH race/ethnicity patients were for individuals aged 18–44 years (59.2, 57.9, and 56.8 percent of visits, respectively). Slightly less than half of SUD-related ED visits for Black NH and White NH patients were for individuals aged 18–44 years (48.9 and 47.0 percent, respectively).
Over one-third (36.8 percent) of SUD-related ED visits were expected to be paid by Medicaid, regardless of the patient's race and ethnicity. Over one-third of SUD-related ED visits had a primary expected payer of Medicaid (36.8 percent), followed by one-fifth that were expected to be self-pay/no charge or to be paid by private insurance (20.0 and 19.9 percent, respectively). SUD-related ED visits for Black NH and Hispanic individuals were more likely to have an expected payer of Medicaid or self-pay/no charge than those for Asian/Pacific Islander NH and White NH individuals (Medicaid: 42.8 and 40.1 vs. 36.8 and 33.9 percent; self-pay/no charge: 22.3 and 27.4 vs. 17.8 and 17.4 percent). Moreover, SUD-related ED visits for Asian/Pacific Islander NH and White NH individuals were more likely to have an expected payer of private insurance than those same visits for Black NH and Hispanic individuals (29.8 and 22.6 vs. 13.2 and 16.7 percent, respectively).
One-fourth (25.4 percent) of SUD-related ED visits were for patients from the most vulnerable communities, with substantial variation by patient race and ethnicity. Nearly 45 percent of SUD-related ED visits for Hispanic patients were for individuals from the most vulnerable communities, followed by 37.0 percent of SUD-related ED visits for Black NH patients. Less than one in five SUD-related ED visits for White NH and Asian/Pacific Islander NH patients were for individuals from the most vulnerable communities.

Figure 2. Population rates of SUD-related ED visits by race and ethnicity and sex, 2019

Notes: All rates are based on the U.S. population specific to each racial and ethnic group and sex. Because the analysis included patient county of residence designations, the population was limited to observations with a patient county of residence within a State that participates in the HCUP NEDS. Therefore, the study population excluded ED visits with unknown or foreign patient residence or where the patient residence county was not in a State that participates in the HCUP NEDS. Sex was missing for <1% of SUD-related ED visits; patient race and ethnicity information was missing for <2% of SUD-related ED visits.

Bar chart showing the rate per 1,000 population of substance use disorder (SUD)-related emergency department (ED) visits in 2019 by sex and by race and ethnicity (Asian/Pacific Islander non-Hispanic [NH], Black NH, Hispanic, White NH, and other NH). Data are provided in Supplemental Table 1 .

The population rate of SUD-related ED visits was approximately twice as high for males as for females, regardless of race and ethnicity. The difference in the population rates of SUD-related ED visits between males and females was highest for Hispanic individuals in 2019: the rate was 2.7 times higher for Hispanic males than for Hispanic females.
For both males and females, the population rate of SUD-related ED visits was highest among Black non-Hispanic individuals and lowest among Asian/Pacific Islander non-Hispanic individuals. The rate of SUD-related ED visits was higher for Black non-Hispanic (NH) males than for males of other racial and ethnic groups (66.9 vs. 7.6–54.5 ED visits per 1,000 population). The rate of SUD-related ED visits also was higher for Black NH females than for females of other racial and ethnic groups (31.4 vs. 3.2–25.7 ED visits per 1,000 population). Asian/Pacific Islander NH males and females had the lowest rates of SUD-related ED visits (7.6 and 3.2 ED visits per 1,000 population, respectively).

Figure 3. Population rates of SUD-related ED visits by race and ethnicity and age, 2019

Notes: All rates are based on the U.S. population specific to each racial and ethnic group and age group. Because the analysis included patient county of residence designations, the population was limited to observations with a patient county of residence within a State that participates in the HCUP NEDS. Therefore, the study population excluded ED visits with unknown or foreign patient residence or where the patient residence county was not in a State that participates in the HCUP NEDS. Age was missing for <1% of SUD-related ED visits; patient race and ethnicity information was missing for <2% of SUD-related ED visits.

Bar chart showing the rate per 1,000 population of substance use disorder (SUD)-related emergency department (ED) visits in 2019 by age and by race and ethnicity (Asian/Pacific Islander non-Hispanic [NH], Black NH, Hispanic, White NH, and other NH). Data are provided in Supplemental Table 2 .

The population rate of SUD-related ED visits was highest among individuals aged 18–44 and 45–64 years; however, differences were noted across racial and ethnic groups. The rate of SUD-related ED visits was lowest among individuals aged 0–17 years regardless of race and ethnicity, with a rate of 2.6 ED visits per 1,000 population (ranging from 0.7 for Asian/Pacific Islander non-Hispanic (NH) individuals to 3.0 for other NH race/ethnicity individuals). The population rate of SUD-related ED visits was highest among individuals aged 18–44 and 45–64 years (39.5 and 41.9 ED visits per 1,000 population, respectively). However, differences were noted across racial and ethnic groups. Black NH, Hispanic, and other NH race/ethnicity adults aged 45–64 years had higher rates of SUD-related ED utilization than individuals of the same race and ethnicity in other age groups. In contrast, among Asian/Pacific Islander NH individuals, adults aged 18–44 years had a higher rate of SUD-related ED visits than those in other age groups.
The highest and lowest population rate of SUD-related ED visits varied by age and racial and ethnic group. Black NH and other NH race/ethnicity individuals aged 18–44 and 45–64 years had the highest rates of SUD-related ED visits across racial and ethnic groups and all age groups (61.1 and 82.0 ED visits per 1,000 population for Black NH individuals; 63.6 and 77.7 ED visits per 1,000 population for other NH race/ethnicity individuals). Asian/Pacific Islander NH individuals had the lowest rate of SUD-related ED visits across all racial and ethnic groups and age groups.

Figure 4. Population rates of SUD-related ED visits by race and ethnicity and urban/rural location, 2019

Notes: All rates are based on the U.S. population specific to each racial and ethnic group and patient location group. Urban/rural location is assigned based on county of patient residence. Because the analysis included patient county of residence designations, the population was limited to observations with a patient county of residence within a State that participates in the HCUP NEDS. Therefore, the study population excluded ED visits with unknown or foreign patient residence or where the patient residence county was not in a State that participates in the HCUP NEDS. Patient race and ethnicity information was missing for <2% of SUD-related ED visits.

Bar chart showing the rate per 1,000 population of substance use disorder (SUD)-related emergency department (ED) visits in 2019 by urban/rural location and by race and ethnicity (Asian/Pacific Islander non-Hispanic [NH], Black NH, Hispanic, White NH, and other NH). Data are provided in Supplemental Table 3 .

Twenty-nine out of every 1,000 individuals had an ED visit related to SUDs. The rate of SUD-related ED visits in 2019 was slightly lower among individuals living in rural areas and higher among those living in metropolitan and micropolitan areas. Individuals living in rural areas had a rate of SUD-related ED visits of 24.4 per 1,000 population; the rate was 29.7 and 28.7 per 1,000 population among those living in micropolitan and metropolitan areas, respectively.
Among Asian/Pacific Islander non-Hispanic (NH) individuals, rates were lowest for those living in metropolitan areas (5.1 per 1,000 population) compared with other areas.
Among Black NH individuals, rates were lowest for those living in rural areas and highest for those living in metropolitan areas (30.0 and 49.5, respectively).
Among Hispanic individuals, rates were lowest among those living in micropolitan areas (13.6) compared with other areas.
Among White NH individuals, rates were lowest for those living in rural areas (22.6) compared with other areas.
Among other NH race/ethnicity individuals, rates were lowest for those living in micropolitan areas and highest for those living in rural areas (31.9 and 45.1, respectively).

Figure 5. Population rates of SUD-related ED visits by race and ethnicity and community social vulnerability, 2019

Notes: Community social vulnerability is assigned based on patient county of residence. All rates are based on the U.S. population specific to each racial and ethnic group and social vulnerability group. Patient residence counties were classified as most vulnerable (counties with social vulnerability index values in the fourth quartile) versus less vulnerable (counties with social vulnerability index values in the lower three quartiles). Because the analysis included patient county of residence designations, the population was limited to observations with a patient county of residence within a State that participates in the HCUP NEDS. Therefore, the study population excluded ED visits with unknown or foreign patient residence or where the patient residence county was not in a State that participates in the HCUP NEDS. Patient race and ethnicity information was missing for <2% of SUD-related ED visits.

Bar chart showing the rate per 1,000 population of substance use disorder (SUD)-related emergency department (ED) visits in 2019 by community social vulnerability and by race and ethnicity (Asian/Pacific Islander non-Hispanic [NH], Black NH, Hispanic, White NH, and other NH). Data are provided in Supplemental Table 4 .

In 2019, the highest rate of SUD-related ED visits was among Black non-Hispanic individuals living in the most socially vulnerable communities. Across racial and ethnic groups, Black non-Hispanic (NH) individuals living in the most socially vulnerable communities had the highest rate of SUD-related ED visits (54.4 per 1,000 population). The rate for Black NH individuals living in less socially vulnerable communities was the third highest rate (45.4) and similar to the rate for other NH race/ethnicity individuals living in the most socially vulnerable communities (46.9).
The rate of SUD-related ED visits was higher among individuals living in the most socially vulnerable communities versus less socially vulnerable communities for all racial and ethnic groups except Asian/Pacific Islander non-Hispanic individuals. Generally, those living in the most socially vulnerable communities had a higher rate of SUD-related ED visits than those living in less socially vulnerable communities, ranging from 10.7 percent higher for Hispanic individuals to 24.1 percent higher for other NH race/ethnicity individuals. However, the opposite was true for Asian/Pacific Islander NH individuals, who had a 20.0 percent lower rate for those living in the most socially vulnerable versus less socially vulnerable communities.
Notes: All rates are based on the U.S. population specific to each racial and ethnic group. SUD types are not mutually exclusive. Because the analysis included patient county of residence designations, the population was limited to observations with a patient county of residence within a State that participates in the HCUP NEDS. Therefore, the study population excluded ED visits with unknown or foreign patient residence or where the patient residence county was not in a State that participates in the HCUP NEDS.
ED visits involving alcohol-related disorders were the most common SUD-related ED visit across all racial and ethnic groups in 2019. There were 14.3 alcohol-related ED visits per 1,000 population in 2019, followed by cannabis-, stimulant-, and opioid-related disorders (6.0, 5.2, and 4.9 per 1,000 population, respectively). Regardless of racial and ethnic group, the alcohol-related ED visit population rate was higher than the population rate of all other SUD-related ED visits, with rates ranging from 2.8 per 1,000 population among Asian/Pacific Islander non-Hispanic (NH) individuals to 23.9 per 1,000 population among other NH race/ethnicity individuals. Across all racial and ethnic groups, alcohol-related ED visit rates per 1,000 population were approximately three times higher than any other type of SUD-related ED visit rate, with two exceptions. The population rate for cannabis- and stimulant-related ED visits for Black NH individuals was 15.6 and 11.4 per 1,000 population, respectively, versus 19.4 for alcohol-related disorders.
Black non-Hispanic individuals had the highest rate of ED visits involving cannabis-, stimulant-, and opioid-related disorders, whereas White non-Hispanic individuals had the highest rate of ED visits involving sedative-related disorders. Black NH individuals had the highest rate of ED visits related to cannabis-related disorders (15.6 per 1,000 population vs. 0.9–7.1 for other racial and ethnic groups), stimulant-related disorders (11.4 vs. 1.1–6.3), and opioid-related disorders (6.5 vs. 0.7–5.7). White NH individuals had the highest rate of ED visits related to sedative-related disorders (1.1 per 1,000 population vs. 0.2–0.9 for other racial and ethnic groups). Asian/Pacific Islander NH individuals consistently had the lowest rate of ED visits per 1,000 population for all specific types of SUDs included in this analysis, ranging from 0.2 for sedative-related disorders to 2.8 for alcohol-related disorders per 1,000 population.

Healthcare Cost and Utilization Project (HCUP) Statistical Briefs provide basic descriptive statistics on a variety of topics using HCUP administrative healthcare data. Topics include hospital inpatient, ambulatory surgery, and emergency department use and costs, quality of care, access to care, medical conditions, procedures, and patient populations, among other topics. The reports are intended to generate hypotheses that can be further explored in other research; the reports are not designed to answer in-depth research questions using multivariate methods.

The estimates in this Statistical Brief are based upon data from the HCUP 2019 Nationwide Emergency Department Sample (NEDS). Supplemental sources included the Agency for Healthcare Research and Quality Social Determinants of Health Database a and population denominator data for use with HCUP databases, derived from information available from the U.S. Census Bureau. b

Diagnoses and Clinical Classifications Software Refined (CCSR) for ICD-10-CM Diagnoses For emergency department (ED) visits that are treated and released, the first-listed diagnosis represents the condition, symptom, or problem identified in the medical record to be chiefly responsible for the ED services provided. In cases where the first-listed diagnosis is a symptom or problem, a diagnosis has not been established (confirmed) by the provider. For ED visits that result in an inpatient admission, the first-listed diagnosis is the principal diagnosis , the condition established after study to be chiefly responsible for the patient's admission to the hospital. Secondary diagnoses are conditions that coexist at the time of the ED visit or inpatient admission, that require or affect patient care treatment received or management, or that develop during the inpatient stay. All-listed diagnoses include the first-listed (principal) diagnosis plus the secondary conditions.

The CCSR aggregates ICD-10-CM diagnosis codes into a manageable number of clinically meaningful categories. c The CCSR is intended to be used analytically to examine patterns of healthcare in terms of cost, utilization, and outcomes; rank utilization by diagnoses; and risk-adjust by clinical condition. The CCSR capitalizes on the specificity of the ICD-10-CM coding scheme and allows ICD-10-CM codes to be classified in more than one category. Approximately 10 percent of diagnosis codes are associated with more than one CCSR category because the diagnosis code documents either multiple conditions or a condition along with a common symptom or manifestation. ICD-10-CM coding definitions for each CCSR category presented in this Statistical Brief can be found in the CCSR reference file , available at www.hcup-us.ahrq.gov/toolssoftware/ccsr/ccs_refined.jsp#download . For this Statistical Brief, v2021.2 of the CCSR was used.

MBD017: Alcohol-related disorders
MBD018: Opioid-related disorders
MBD019: Cannabis-related disorders
MBD020: Sedative-related disorders
MBD021: Stimulant-related disorders
MBD022: Hallucinogen-related disorders
MBD023: Inhalant-related disorders
MBD025: Other specified substance-related disorders

Types of hospitals included in the HCUP Nationwide Emergency Department Sample The Nationwide Emergency Department Sample (NEDS) is based on ED data from community acute care hospitals, which are defined as short-term, non-Federal, general, and other specialty hospitals available to the public. Included among community hospitals are pediatric institutions and hospitals that are part of academic medical centers. Excluded are long-term care facilities such as rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals. Hospitals included in the NEDS have EDs, and no more than 90 percent of their ED visits result in admission.

Unit of analysis The unit of analysis is the ED visit, not a person or patient. This means that a person who is seen in the ED multiple times in 1 year will be counted each time as a separate visit in the ED.

Population rate of SUD visits equals the number of SUD visits divided by the number of U.S. residents multiplied by 1,000.

Large Central Metropolitan: Counties in a metropolitan area with 1 million or more residents that satisfy at least one of the following criteria: (1) containing the entire population of the largest principal city of the metropolitan statistical area (MSA), (2) having their entire population contained within the largest principal city of the MSA, or (3) containing at least 250,000 residents of any principal city in the MSA
Large Fringe Metropolitan: Counties in a metropolitan area with 1 million or more residents that do not qualify as large central metropolitan counties
Medium Metropolitan: Counties in a metropolitan area of 250,000–999,999 residents
Small Metropolitan: Counties in a metropolitan area of 50,000–249,999 residents
Micropolitan: Counties in a nonmetropolitan area of 10,000–49,999 residents
Rural: Counties in a nonmetropolitan and nonmicropolitan area

Expected payer To make coding uniform across all HCUP data sources, the primary expected payer for the ED visit combines detailed categories into general groups:

Medicare: includes fee-for-service and managed care Medicare
Medicaid: includes fee-for-service and managed care Medicaid
Private insurance: includes commercial nongovernmental payers, regardless of the type of plan (e.g., private health maintenance organizations [HMOs], preferred provider organizations [PPOs])
Self-pay/No charge: includes self-pay, no charge, charity, and no expected payment
Other payers: includes other Federal and local government programs (e.g., TRICARE, CHAMPVA, Indian Health Service, Black Lung, Title V) and Workers' Compensation

ED visits that were expected to be billed to the State Children's Health Insurance Program (SCHIP) are included under Medicaid.

For this Statistical Brief, when more than one payer is listed for an ED visit, the first-listed payer is used.

Social vulnerability The Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) Social Vulnerability Index (SVI) is a measure of a community's ability to prevent human suffering and financial loss during a disaster. The SVI uses U.S. Census data to determine the social vulnerability of every census tract. Census tracts are subdivisions of counties for which the census collects statistical data. The SVI ranks each tract on 15 social factors, including poverty, lack of vehicle access, and crowded housing, and groups them into four related themes (socioeconomic status, household composition and disability, minority status and language, housing type and transportation). Each tract receives a separate ranking for each of the four themes, as well as an overall ranking. Detailed descriptions of the CDC/ATSDR SVI and data downloads are available at www.atsdr.cdc.gov/placeandhealth/svi/index.html . Social vulnerability designation in this Statistical Brief is based on the overall SVI measure in the patient county of residence. Patient residence counties with social vulnerability index values in the fourth quartile are included in the most vulnerable communities category. Counties with social vulnerability index values in the lower three quartiles are included in the less vulnerable communities category.

Reporting of race and ethnicity Data on Hispanic ethnicity are collected differently among the States and also can differ from the Census methodology of collecting information on race (White, Black, Asian/Pacific Islander, American Indian/Alaska Native, Other [including mixed race]) separately from ethnicity (Hispanic, non-Hispanic). State data organizations often collect Hispanic ethnicity as one of several categories that include race. Therefore, for multistate analyses, HCUP creates the combined categorization of race and ethnicity for data from States that report ethnicity separately. When a State data organization collects Hispanic ethnicity separately from race, HCUP uses Hispanic ethnicity to override any other race category to create a Hispanic category for the uniformly coded race and ethnicity data element, while also retaining the original race and ethnicity data. This Statistical Brief reports race and ethnicity for the following categories: Asian/Pacific Islander non-Hispanic (NH), Black NH, Hispanic, White NH, and other NH race/ethnicity.

The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ). HCUP databases bring together the data collection efforts of State data organizations, hospital associations, and private data organizations (HCUP Partners) and the Federal government to create a national information resource of encounter-level healthcare data. HCUP includes the largest collection of longitudinal hospital care data in the United States, with all-payer, encounter-level information beginning in 1988. These databases enable research on a broad range of health policy issues, including cost and quality of health services, medical practice patterns, access to healthcare programs, and outcomes of treatments at the national, State, and local market levels.

HCUP would not be possible without the contributions of the following data collection Partners from across the United States:

The HCUP Nationwide Emergency Department Sample (NEDS) is a unique and powerful database that yields national estimates of emergency department (ED) visits. The NEDS was constructed using records from both the HCUP State Emergency Department Databases (SEDD) and the State Inpatient Databases (SID). The SEDD capture information on ED visits that do not result in an admission (i.e., patients who were treated in the ED and then released from the ED, or patients who were transferred to another hospital); the SID contain information on patients initially seen in the ED and then admitted to the same hospital. The NEDS was created to enable analyses of ED utilization patterns and support public health professionals, administrators, policymakers, and clinicians in their decision making regarding this critical source of care. The NEDS is produced annually beginning in 2006. Over time, the sampling frame for the NEDS has changed; thus, the number of States contributing to the NEDS varies from year to year. The NEDS is intended for national estimates only; no State-level estimates can be produced. The unweighted sample size for the 2019 NEDS is 33,147,251 (weighted, this represents 143,432,284 ED visits).

For other information on hospitalizations related to substance use disorders and differences in hospitalizations by patient race and ethnicity, refer to the Mental and Substance Use Disorders as well as the Race and Ethnicity HCUP Statistical Briefs topic areas located at www.hcup-us.ahrq.gov/reports/statbriefs/sbtopic.jsp .

For additional HCUP statistics, visit:

HCUP Fast Stats at https://datatools.ahrq.gov/hcup-fast-stats for easy access to the latest HCUP-based statistics for healthcare information topics
HCUPnet, HCUP's interactive query system, at https://datatools.ahrq.gov/hcupnet
HCUP Summary Trend Tables at www.hcup-us.ahrq.gov/reports/trendtables/summarytrendtables.jsp for monthly information on hospital utilization

For more information about HCUP, visit www.hcup-us.ahrq.gov/ .

For a detailed description of HCUP and more information on the design of the Nationwide Emergency Department Sample (NEDS), please refer to the following database documentation:

Agency for Healthcare Research and Quality. Overview of the Nationwide Emergency Department Sample (NEDS). Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality. Updated October 2021. www.hcup-us.ahrq.gov/nedsoverview.jsp . Accessed November 8, 2022.

Owens PL (AHRQ), Moore BJ (IBM). Racial and Ethnic Differences in Emergency Department Visits Related to Substance Use Disorders, 2019. HCUP Statistical Brief #301. December 2022. Agency for Healthcare Research and Quality, Rockville, MD. www.hcup-us.ahrq.gov/reports/statbriefs/sb301-ED-Substance-Use-Disorders-Race-2019.pdf .

The authors would like to acknowledge the contributions of Minya Sheng of IBM.

AHRQ welcomes questions and comments from readers of this publication who are interested in obtaining more information about access, cost, use, financing, and quality of healthcare in the United States. We also invite you to tell us how you are using this Statistical Brief and other HCUP data and tools, and to share suggestions on how HCUP products might be enhanced to further meet your needs. Please email us at [email protected] or send a letter to the address below:

Joel W. Cohen, Ph.D., Director Center for Financing, Access and Cost Trends Agency for Healthcare Research and Quality 5600 Fishers Lane Rockville, MD 20857

This Statistical Brief was posted online on December 8, 2022.

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Emergency Department Visit Rates by Selected Characteristics: United States, 2020

NCHS Data Brief No. 452, November 2022

PDF Version (430 KB)

Christopher Cairns, M.P.H., Jill J. Ashman, Ph.D., and J.M. King, M.P.H

Key findings

What was the ED visit rate in 2020, and did visit rates vary by age group?

What were ed visit rates by sex and race and ethnicity, and did these rates vary, what were the ed visit rates for each primary expected source of payment, and did these rates vary, what percentages of ed visits were related to covid-19, definitions, data source and methods, about the authors, suggested citation.

Data from the National Hospital Ambulatory Medical Care Survey

The overall emergency department (ED) visit rate was 40 visits per 100 people in 2020.
The ED visit rate was highest for infants under age 1 year (68 visits per 100 infants), followed by adults aged 75 and over (63 per 100 people).
The ED visit rate for non-Hispanic Black or African-American people (70 visits per 100 people) was highest compared with other racial and ethnic groups.
The ED visit rate for patients with private insurance was lowest, while the rate for patients with Medicaid, Children’s Health Insurance Program, or other state-based programs was highest compared with all other primary expected sources of payment.
Of all ED visits in 2020, 6.7% had a mention of COVID-19.

In 2020, an estimated 131 million emergency department (ED) visits occurred in the United States, with 19.0% of adults reporting a visit and 4.7% of children reporting two or more visits in the past 12 months ( 1–3 ). In that time, over 20 million cases of COVID-19 caused a disruption in access to and use of care ( 4 ). This report presents characteristics of ED visits, including those with mentions of COVID-19, by age group, sex, race and ethnicity, and primary expected source of payment, using data from the 2020 National Hospital Ambulatory Medical Care Survey (NHAMCS) ( 5 ).

Keywords : COVID-19, emergency care, patient characteristics, National Hospital Ambulatory Medical Care Survey

An estimated 131 million ED visits occurred in 2020, with a total ED visit rate of 40 visits per 100 people ( Figure 1 ).
The ED visit rates for infants under age 1 year (68 visits per 100 infants) and adults aged 75 and over (63 visits per 100 people) were higher compared with all other age groups.
The ED visit rate for children aged 1–17 years (29 visits per 100 children) was lower than the rates for all adult age groups.
ED visit rates were similar for adults aged 18–74, ranging from 39 to 43 visits per 100 people.

Figure 1. Emergency department visit rate, by age group: United States, 2020

The 2020 ED visit rates for females (42 visits per 100 people) and males (39) were similar ( Figure 2 ).
In 2020, the ED visit rate was highest for non-Hispanic Black or African-American people (70 visits) compared with non-Hispanic White (39), Hispanic or Latino (34), and non-Hispanic people of other races (20).

Figure 2. Emergency department visit rate, by sex and race and ethnicity: United States, 2020

The ED visit rate was highest for patients with Medicaid, Children’s Health Insurance Program (CHIP), or other state-based programs (85 visits per 100 people) and lowest for patients with private insurance (18) ( Figure 3 ).
The ED visit rate for patients with Medicare (47 visits) was higher compared with rates among uninsured patients (33) and patients with other primary expected sources of payment (29).

Figure 3. Emergency department visit rate, by primary expected source of payment: United States, 2020

An estimated 6.7% of ED visits in 2020 had any mention of COVID-19 ( Figure 4 ).
From January through April 2020, the percentage of ED visits with a suspected case of COVID-19 was 0.3%.
From April through December 2020, the percentage of ED visits with a confirmed case of COVID-19 was 1.8%.
The percentage of ED visits with a COVID-19 test or screening was 3.3%.
The percentage of ED visits with other mentions of COVID-19, including visits by patients with suspected exposure to COVID-19, was 1.8%.

Figure 4. Percentage of emergency department visits with mentions of COVID-19: United States, 2020

In 2020, an estimated 131 million ED visits occurred, with a total ED visit rate of 40 visits per 100 people. The ED visit rates for both infants under age 1 year and adults aged 75 and over were higher than rates for all other age groups. The ED visit rate for non-Hispanic Black or African-American people was higher than the rates for people of all other racial and ethnic groups. The ED visit rate for patients with Medicaid, CHIP, or other state-based programs was highest compared with all other sources of payment, while the rate for patients with private insurance was lowest.

Data in this report show that in 2020, an estimated 6.7% of all ED visits had a mention of COVID-19. During the very early stages of the pandemic, before the International Classification of Diseases, 10th Revision, Clinical Modification (ICD–10–CM) diagnosis code for COVID-19 was created and implemented, approximately 0.3% suspected cases of COVID-19 were identified among ED visits, based on other existing codes. After implementation of the ICD–10–CM code U07.1 starting April 1, 2020, an estimated 1.8% of all ED visits from April through December were identified as a confirmed case of COVID-19. Additionally, 3.3% included a test or screening for COVID-19, and 1.8% were identified as a patient with suspected exposure to COVID-19 or included some other mention of COVID-19, not identified above.

COVID-19 measures : These measures are not mutually exclusive because a patient may have been coded as both a confirmed and tested case, for example.

Any mention of COVID-19: Consists of all other measures listed in the categories below.
Confirmed case of COVID-19: Consists of any listed diagnosis with ICD–10–CM code U07.1. The code U07.1 was created and implemented starting April 1, 2020.
Suspected case of COVID-19: Before the implementation of code U07.1, the following ICD–10–CM codes for any listed diagnosis were used to determine the percentage of ED visits with potential COVID-19 hospital encounters: J12.81, J12.89, J20.8, J22, J40, J80, and J98.8.
Tested or screened for COVID-19: Consists of any listed diagnosis with ICD–10–CM codes Z11.52 and Z11.59 and any mention of COVID-19 testing or screening in validated verbatim item notes or medication fields.
Other mentions of COVID-19: Consists of any listed diagnosis with ICD–10–CM codes Z20.822, Z20.828, and Z03.818 for suspected exposure to COVID-19 and any mention of COVID-19 in validated verbatim item notes or medication fields with no reference to testing or screening.
The following ICD–10–CM codes related to COVID-19 were considered but not included in the analysis due to a lack of records in the data: B97.29 and Z86.16.

ED visit rates : Calculated by dividing the number of ED visits by estimates of the U.S. civilian noninstitutionalized population (obtained from the U.S. Census Bureau’s Population Division) for selected characteristics including age group, sex, and race and ethnicity. Visit rates for a patient’s primary expected source of payment are based on the patient’s primary expected source of payment and proportional insurance data from the 2020 National Health Interview Survey .

Primary expected source of payment : During data collection, all sources of payment were collected. For patients with more than one source of payment, the hierarchy below was used (with Medicare counted first and self-pay and no charge counted last) to combine payments into one mutually exclusive variable (primary expected source of payment).

Medicare: Partial or full payment by Medicare plan includes payments made directly to the hospital and payments reimbursed to the patient. Charges covered under a Medicare-sponsored prepaid plan are included.
Medicaid: Partial or full payment by Medicaid plan includes payments made directly to the hospital or reimbursed to the patient. Charges covered under a Medicaid-sponsored prepaid plan (health maintenance organization, for example), managed Medicaid, or CHIP and other state-based programs are included.
Private: Partial or full payment by a private insurer (such as BlueCross BlueShield) includes payments made directly to the hospital or reimbursed to the patient. Charges covered under a private insurance-sponsored prepaid plan are included.
Uninsured: Includes self-pay and no charge or charity. Self-pay is charges paid by the patient or patient’s family that will not be reimbursed by a third party. Self-pay includes visits for which the patient is expected to be ultimately responsible for most of the bill, even if the patient never actually pays it. This does not include copayments or deductibles. No charge or charity are visits for which no fee is charged (such as charity, special research, or teaching).
Other: Includes worker’s compensation and other sources of payment not covered by the previous categories, such as TRICARE, state and local governments, private charitable organizations, and other liability insurance (such as automobile collision policy coverage).

Race and ethnicity : Race and Hispanic ethnicity were collected separately, imputed, and converted into a single combined variable that includes non-Hispanic White, non-Hispanic Black or African American, Hispanic or Latino, and non-Hispanic people of other races. The category “Non-Hispanic Other” includes Asian, Native Hawaiian or Other Pacific Islander, and American Indian or Alaska Native people, and people of two or more races. For 2020, 15.3% of unweighted race data and 11.8% of unweighted ethnicity data were missing for ED visits; race and ethnicity were imputed for these missing records. Race and ethnicity data were imputed on the data file using a model-based, single, sequential, regression imputation method. Missing race values were imputed to be White, Black, or Other. Hispanic or Latino ethnicity was imputed to be Hispanic or Latino or non-Hispanic or Latino.

Data for this report are from NHAMCS, an annual nationally representative survey of nonfederal, general, and short-stay hospitals ( 5 ). NHAMCS provides data on the use and provision of ambulatory care services in hospital EDs. In 2020, the weighted NHAMCS response rate was 76.1%. Data analyses were performed using the statistical packages SAS version 9.4 (SAS Institute, Cary, N.C.) and SAS-callable SUDAAN version 11.0 (RTI International, Research Triangle Park, N.C.). Two-tailed t tests with a significance level of p < 0.05 were used to determine statistically significant differences between ED visit rates.

Christopher Cairns and Jill J. Ashman are with the National Center for Health Statistics, Division of Health Care Statistics. J.M. King is with RELI Group, Inc.

Cairns C, Kang K. National Hospital Ambulatory Medical Care Survey: 2020 emergency department summary tables . 2022.
National Center for Health Statistics. Percentage of having a hospital emergency department visit in past 12 months for adults aged 18 and over, United States, 2020 . Interactive summary health statistics for adults—2019–2021. Generated interactively: August 22, 2022
National Center for Health Statistics. Percentage of two or more hospital emergency department visits in the past 12 months for children under age 18 years, United States, 2020 . Interactive summary health statistics for children—2019–2021. Generated interactively: August 22, 2022.
Centers for Disease Control and Prevention. COVID data tracker . 2022.
National Center for Health Statistics. 2020 NHAMCS micro-data file. 2022.

Cairns C, Ashman JJ, King JM. Emergency department visit rates by selected characteristics: United States, 2020. NCHS Data Brief, no 452. Hyattsville, MD: National Center for Health Statistics. 2022. DOI: https://dx.doi.org/10.15620/cdc:121837 .

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Parents Often Bring Children to Psychiatric E.R.s to Subdue Them, Study Finds

Many parents bring children to emergency rooms to manage aggressive behaviors. But the visits offer little long-term benefit, doctors said.

An entrance to a hospital emergency room, with bright red letters spelling out "Emergency" on the awning, at dusk.

By Ellen Barry

For emergency room doctors, they are a dispiriting and familiar sight: Children who return again and again in the grip of mental health crises, brought in by caregivers who are frightened or overwhelmed.

Much has been written about the surge in pediatric mental health emergency visits in recent years, as rates of depression and suicidal behavior among teens surged. Patients often spend days or weeks in exam rooms waiting for a rare psychiatric bed to open up, sharply reducing hospital capacity.

But a large study published on Tuesday found a surprising trend among adolescents who repeatedly visited the hospital. The patients most likely to reappear in emergency rooms were not patients who harmed themselves, but rather those whose agitation and aggressive behavior proved too much for their caregivers to manage.

In many cases, repeat visitors had previously received sedatives or other drugs to restrain them when their behavior became disruptive.

“Families come in with their children who have severe behavioral problems, and the families really just are at their wit’s end, you know,” said Dr. Anna M. Cushing, a pediatric emergency room physician at Children’s Hospital Los Angeles and one of the authors of the study. “Their child’s behavior may be a danger to themselves, but also to the parents, to the other children in the home.”

The findings, published in the journal JAMA Pediatrics, analyzed more than 308,000 mental health visits at 38 hospitals between 2015 and 2020.

Compared with patients presenting with suicidal or self-harming behavior, those with psychotic disorders were 42 percent more likely to revisit the emergency department within six months, the study found; patients with impulse control disorders were 36 percent more likely; and patients with disorders like autism and A.D.H.D. were 22 percent more likely. Patients who required medications to subdue them were 22 percent more likely to revisit than patients who did not.

The results suggest that researchers should focus more attention on families whose children have cognitive and behavioral problems, and who may turn to emergency rooms for respite, Dr. Cushing said.

“I’m not sure we’ve been spending as much time talking about these agitated and behaviorally disregulated patients, at least on a national scale,” she said.

The frequency of revisits suggests that the care they receive in emergency rooms “is really not adequate,” she said.

Guidelines recommend that so-called chemical restraints — benzodiazepines or antipsychotics administered by injection or through an intravenous drip — be used as a last resort because they can be traumatizing or cause physical injury to the patient, medical staff or caregivers, said Dr. Ashley A. Foster, an assistant professor of emergency medicine at the University of California San Francisco.

The use of these drugs in pediatric emergency rooms has increased in recent years. Between 2009 and 2019, chemical restraint use increased by 370 percent, while mental health emergency room visits increased by 268 percent, according to a study that Dr. Foster and her colleagues published last year.

The drugs were used more often on Black patients, as well as on male patients between the ages of 18 and 21, the study found. Dr. Foster described those disparities as “concerning, and motivation for thinking about how to enhance equitable care.”

Dr. Christine M. Crawford, a child and adolescent psychiatrist at Boston Medical Center, said caregivers for children with behavioral disorders often turn to emergency rooms when “it gets to the point where someone could get hurt.”

“They enter sixth, seventh, eighth grades — that’s when we see those families that have been struggling for a long time,” said Dr. Crawford, who is also an assistant professor at Boston University School of Medicine.

Families in this situation, she said, “are quite isolated,” often hiding their struggles from friends and relatives. Emergency room treatment is comforting to caregivers but offers little long-term benefit, she said.

“It’s just putting a Band-Aid on the problem,” she said. “They go back home and they’re still waiting for that appointment to meet with a therapist.”

Dr. Andrea E. Spencer, a psychiatrist and researcher at Lurie Children’s Hospital of Chicago, said behavioral disorders might be dismissed as less pressing than suicidal thoughts or self-harm, when in fact “they are very high-risk behaviors and they are dangerous behaviors.”

“There is a tendency to sort of watch and wait and deprioritize those kids in terms of who are the most severe, and then they have the tendency to just get worse,” she said, adding that public hospitals might be reluctant to accept them as inpatients because they are disruptive.

“In many ways, these kids are actually harder to treat,” she said.

The JAMA study found that overall visits to pediatric emergency rooms for mental health crises increased 43 percent from 2015 to 2020, rising by 8 percent per year on average, with an increase in emergency visits for every category of mental illness. By comparison, emergency room visits for all medical causes rose by 1.5 percent annually.

Nearly one-third of visits were related to suicidal ideation or self-harm, and around one-quarter of patients presented with mood disorders, followed by anxiety disorders and impulse control disorders. Around 13 percent of patients made a repeat visit within six months.

“It causes a lot of moral distress for many of us, just because it doesn’t feel like the emergency department is always the right place or best place to take care of many of our patients,” Dr. Cushing said.

“But,” she added, “they really don’t have anywhere else to go.”

Ellen Barry covers mental health. She has served as The Times’s Boston bureau chief, London-based chief international correspondent and bureau chief in Moscow and New Delhi. She was part of a team that won the 2011 Pulitzer Prize for International Reporting. More about Ellen Barry

Emergency room visits for self-harm skyrocketed between 2011 and 2020, study finds

T he number of emergency visits to hospitals in the U.S. for suicide attempts increased markedly between 2011 and 2020, a University of Connecticut researcher reports in the June 4 issue of the American Journal of Psychiatry . The rise emphasizes the country's enormous unmet need for mental health services.

The number of lives lost to suicide in the U.S. has climbed alarmingly over the past decade, with close to a half-million between 2011 and 2022, according to the federal Centers for Disease Control and Prevention (CDC). Suicide rates have risen by 35% since 2000. The rate of self-harm has risen too, even in age groups not previously considered at risk, such as children.

Out of all visits to the emergency department in 2011, only 0.6% involved self-harm. That number had risen to 2.1% of all emergency department visits by 2020, according to data from the National Hospital Ambulatory Medical Care Survey, a yearly sampling of hospitals across the nation by the CDC.

The data was analyzed by UConn School of Medicine psychiatric epidemiologist Greg Rhee and colleagues from the Mayo Clinic, Columbia University, Yale University School of Medicine, and the Veterans Administration Connecticut Healthcare System. The figures per 100,000 people increased from 261 per 100,000 in 2011 to 871 in 2020.

"When we translate the data to percent change, it is an 18.8% increase, which is huge," Rhee says. Their most striking increase was in self-harm visits for adults over 65, which went up by 30% annually. But every age group saw double digit annual increases, including children ages 5 to 11.

The increase in suicide and suicide attempts has already been noticed by the U.S. government, which introduced a new crisis phone number two years ago, 988, at which people can access crisis counseling and get referrals to further resources. But other recent analyses by Rhee and his colleagues have shown that there are still high barriers to mental health care.

"Intentional self-harm is preventable. We can potentially reduce suicide or suicide-related events. There are multiple ways. A lot of individuals undergoing mental distress could be taken care of so that they don't harm themselves," Rhee says.

More information: Tanner J. Bommersbach et al, National Trends in Emergency Department Visits for Suicide Attempts and Intentional Self-Harm, American Journal of Psychiatry (2024). DOI: 10.1176/appi.ajp.20230397

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Data Source

2022 drug abuse warning network (dawn) releases.

This report presents 2022 data from the Drug Abuse Warning Network (DAWN).

DAWN: Findings from Drug-Related Emergency Department Visits, 2022

2022 DAWN Releases Frequently Asked Questions

1. where did the data for the 2022 report come from.

The 2022 report is based on drug related data abstracted from the emergency departments (ED) of 53 participating hospitals.

2. What is different between the Final 2021 report and the 2022 report?

The 2022 report includes the rates for the top 6 drugs involved in emergency department (ED) visits and significance testing to support findings on results. This report also provides expanded analyses on ED visits related to more than 1 drug (polysubstance).

3. Can estimates be compared between the Final 2021 report and the 2022 report?

Between the Final 2021 and the 2022 report, there were no significant changes to data collection methods or the number of participating hospitals. Findings from the 2022 report can be compared to 2021 with caution due to slight changes in analytic substance surveillance definitions. Analytic definitions were developed utilizing DAWN’s codes to improve standardization and enable more comprehensive reporting. This differs from the 2021 report, which utilized a mixed method of codes and text searches to identify the top five drugs.

4. What if a drug is not mentioned in the 2022 report?

The annual report presents the top substances involved in drug-related ED visits, therefore not all drugs collected within DAWN make it to the findings. For example, xylazine is collected in DAWN, but weighted estimates for xylazine were not large enough to be included in the top six substances involved in drug-related ED visits.

5. How should this report be cited?

Substance Abuse and Mental Health Services Administration. (2023). Drug Abuse Warning Network: Findings from Drug-Related Emergency Department Visits, 2022; Publication PEP23-07-03-001. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data.

2022 Report

Annually, the Drug Abuse Warning Network (DAWN) releases nationally representative data on key findings from drug-related emergency department visits. DAWN’s latest annual report includes data from drug-related ED visits in 2022, and is organized into the following sections:

Nationally representative weighted estimates, including percent and rates per 100,000, for all drug-related ED visits by age, sex, race, ethnicity, census region, and quarter
Nationally representative weighted estimates, including percent and rates per 100,000, for the top drugs involved in drug-related ED visits by age, sex, race, ethnicity, census region, and quarter
Nationally representative weighted estimates for different types of opioids involved in opioid-related ED visits
Nationally representative weighted estimates for drug-related ED visits involving more than one substance
Drugs that are new to DAWN’s drug vocabulary and classification system

In addition to these sections, the final report provides a description of the methodology for the DAWN hospital selection, data collection process, and weighting and analysis procedures.

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Note: In the table below, the Additional Information column contains links to information including fact sheets, EUA letters of authorization, regulatory information, decision memos, health care provider information, and Federal Register notices.

The HHS Secretary declared that circumstances exist justifying the authorization of emergency use of drugs and biological products during the COVID-19 pandemic, pursuant to section 564 of the FD&C Act, effective March 27, 2020. The EUA subsequently issued by FDA is listed in the table below this blue box.

Amended Determination of a Public Health Emergency or Significant Potential for a Public Health Emergency Pursuant to Section 564(b) of the FD&C Act (effective March 15, 2023; Federal Register notice March 20, 2023)

Also see: Recommendations for Investigational COVID-19 Convalescent Plasma

View the list Emergency Use Authorizations for Drugs and Non-Vaccine Biological Products , for additional information including letters of authorization, fact sheets, Dear Health Care Provider letters, and additional information about COVID-19 therapeutics.

View the FDA’s COVID-19 Drugs page to see all products approved to treat COVID-19 without any remaining EUA authorized uses.

Revocation notices for COVID-19 drug and biological product EUAs are available at: Emergency Use Authorization--Archived Information .

Transition guidances update

March 24, 2023 - The FDA finalized two guidances: Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency and Transition Plan for Medical Devices Issued Emergency Use Authorizations (EUAs) Related to Coronavirus Disease 2019 (COVID-19) . The guidances outline the FDA’s general recommendations to transition from certain policies adopted and operations implemented during the COVID-19 pandemic to normal operations, including the FDA’s recommendations for:

Developing a transition implementation plan,
Submitting a marketing submission, and
Taking other actions with respect to these devices.

The FDA encourages stakeholders to review the two final guidances, attend the webinar noted below, and reach out to the FDA if they have questions. In particular, for manufacturers that are planning to seek marketing authorization for their devices, the FDA recommends beginning work on a marketing submission, including a transition implementation plan, as described in the guidances.

Transition Plan for Medical Devices That Fall Within Enforcement Policies Issued During the Coronavirus Disease 2019 (COVID-19) Public Health Emergency
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Webinar on Guidances on COVID-19 Transition Plans for Medical Devices (April 18, 2023)

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On February 4, 2020 , the Secretary determined pursuant to section 564 of the FD&C Act that there is a public health emergency that has a significant potential to affect national security or the health and security of United States citizens living abroad and that involves a novel (new) coronavirus (nCoV) first detected in Wuhan City, Hubei Province, China in 2019 (2019-nCoV).

On the basis of this determination, the HHS Secretary issued three declarations related to medical devices:

Determination of Public Health Emergency (effective February 4, 2020), and declaration that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for detection and/or diagnosis of the virus that causes COVID-19
Emergency Use Declaration (effective March 2, 2020), that circumstances exist justifying the authorization of emergency use of personal respiratory protective devices during the COVID-19 outbreak
Emergency Use Authorization Declaration (effective March 24, 2020), that circumstances exist justifying the authorization of emergency use of medical devices, including alternative products used as medical devices, due to shortages during the COVID-19 outbreak

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IVDs for Management of COVID-19 Patients

On February 29, 2020, the FDA issued an immediately in effect guidance with policy specific to development of in vitro diagnostic tests during this public health emergency. This guidance was updated on March 16, 2020, May 4, 2020, and May 11, 2020. On September 27, 2022, FDA updated this policy to ensure continued access to tests while encouraging the transition of these important public health tools to traditional premarket review pathways. The updated policy describes the FDA’s intent to review only a small subset of new EUA requests for diagnostic tests and encourages developers of all test types interested in marketing authorization to pursue authorization through the de novo classification or 510(k) clearance pre-market review pathways.

CDC has granted a right of reference to the performance data contained in CDC's EUA (FDA submission number EUA200001) to any entity seeking an FDA EUA for a COVID-19 diagnostic device.

Templates for these EUA submissions are available to help facilitate the preparation, submission, and authorization of an EUA.

For additional information, see Policy for Coronavirus Disease-2019 Tests During the Public Health Emergency (Revised) , FAQs on Diagnostic Testing for SARS-CoV-2 , EUA Authorized Serology Test Performance , and CLIA and University Laboratory Testing FAQ (CMS).

SARS-CoV-2 Diagnostic Tests for COVID-19 that have been granted a De Novo, 510(k) clearance or PMA

For a list of all molecular SARS-CoV-2 diagnostic tests that have been cleared or granted De Novo classification, see devices with product codes QOF and QQX in FDA’s medical devices databases for 510(k) and De Novo. For a list of all antigen SARS-CoV-2 diagnostic tests that have been cleared or granted De Novo classification, see devices with product code QVF in FDA’s medical devices databases for 510(k) and De Novo. For a list of all SARS-CoV-2 serology tests that have been cleared or granted De Novo classification, see devices with product code QVP in FDA’s medical devices databases for 510(k) and De Novo.

510(k) Premarket Database
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Personal Protective Equipment (PPE)

Please see the page Personal Protective Equipment EUAs for current EUAs.

For additional information, see Recent Final Medical Device Guidance Documents , and Non-NIOSH Approved Respirator FAQ .

See Revoked EUAs for Non-NIOSH-Approved Disposable Filtering Facepiece Respirators and Decontamination and Bioburden Reduction Systems below for information about June 30, 2021 EUA revocations.

Please see the following pages for EUA templates and additional information about other types of medical device EUAs for COVID-19:

Revoked EUAs for Non-NIOSH-Approved Disposable Filtering Facepiece Respirators (FFRs) and Decontamination and Bioburden Reduction Systems

On June 30, 2021, the FDA announced the revocation of the following EUAs:

Imported, Non-NIOSH-Approved Disposable Filtering Facepiece Respirators (effective July 6, 2021)
Non-NIOSH-Approved Disposable Filtering Facepiece Respirators Manufactured in China (effective July 6, 2021)
Decontamination and Bioburden Reduction System EUAs for Personal Protective Equipment (effective June 30, 2021)

As of the effective date of the revocations, these devices will no longer be authorized for use by health care personnel in health care settings.

For additional information, please see Update: FDA No Longer Authorizes Use of Non-NIOSH-Approved or Decontaminated Disposable Respirators - Letter to Health Care Personnel and Facilities [ARCHIVED]. Historical information regarding these EUAs can be found on Historical Information about Device Emergency Use Authorizations and Emergency Use Authorization--Archived Information .

Medical Device Federal Register notices

Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (through April 10, 2020)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (April 11, 2020- May 15, 2020)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (May 15, 2020- September 14, 2020)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (September 15, 2020 - February 15, 2021)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (February 16, 2021- May 31, 2021)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (June 1, 2021 - September 10, 2021)
Emergency Use Authorization: Certain Medical Devices during COVID-19 (September 11, 2021 - January 24, 2022)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (January 25, 2022 - June 15, 2022)
Emergency Use Authorization: Certain Medical Devices during COVID-19 (June 16, 2022 - December 6, 2022)
Emergency Use Authorization: Certain Medical Devices during COVID-19 (December 7, 2022 - February 24, 2023)
Authorization of Emergency Use of a Medical Device During COVID-19; Availability (March 24, 2023)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (April 14, 2023 - December 8, 2023)
Authorization of Emergency Use of Certain Medical Devices During COVID-19; Availability (December 9, 2023 - April 19, 2024)
Authorization and Revocations of Emergency Use of Certain In Vitro Diagnostic Devices for Detection and/or Diagnosis of COVID-19; Availability (for one authorization effective May 28, 2021, and three revocations effective July 19, 2022)
Revocation notices for device EUAs are available at: Historical Information about Device Emergency Use Authorizations

back to About EUAs

mpox EUA Information

Mpox vaccine euas.

On November 28, 2022, the World Health Organization announced , and the U.S. government supported , renaming monkeypox disease to mpox. In response to this action by the WHO, federal public health agencies will adopt the mpox name in correspondence with the medical community and American public from this point forward.

Effective August 9, 2022 , pursuant to section 564 of the FD&C Act, the HHS Secretary declared :

There is a public health emergency related to monkeypox, or significant potential for a public health emergency, that affects, or has the significant potential to affect, national security or the health and security of United States citizens living abroad that involves monkeypox virus; and
On the basis of this determination, circumstances exist justifying the authorization of emergency use of vaccines.

Vaccine EUAs subsequently issued by FDA are listed in the table below.

PREP Act declaration: Effective September 28, 2022, the HHS Secretary amended the declaration first issued on October 10, 2008, and amended and republished effective January 1, 2016 for smallpox countermeasures and countermeasures against other orthopoxviruses pursuant to section 319F-3 of the Public Health Service Act to emphasize that the declaration applies to monkeypox virus, to expand the categories of providers authorized to administer vaccines and therapeutics against smallpox (variola virus), monkeypox virus, and other orthopoxviruses in a declared emergency, and to extend the duration of the declaration. About PREP Act declarations

mpox In Vitro Diagnostics EUAs

Effective September 7, 2022, pursuant to section 564 of the FD&C Act, the HHS Secretary declared :

On the basis of the August 9th determination , the Secretary of HHS has subsequently declared that circumstances exist justifying the authorization of emergency use of in vitro diagnostics for the detection and/or diagnosis of infection with the monkeypox virus, including in vitro diagnostics that detect and/or diagnose infection with non-variola Orthopoxvirus , pursuant to section 564 of the FD&C Act, subject to the terms of any authorization issued under that section. See from HHS: HHS Secretary Becerra Issues 564 Declaration to Expand the Availability of Testing for Monkeypox

Diagnostic EUAs subsequently issued by FDA are listed in the table on this page: Monkeypox Emergency Use Authorizations for Medical Devices .

Additional information for product developers is available at:

Policy for Monkeypox Tests to Address the Public Health Emergency
Monkeypox Emergency Use Authorizations for Medical Devices (including EUA templates)

Note that FDA previously cleared real-time polymerase chain reaction (PCR) tests that detect non-variola orthopoxvirus DNA, including the virus that causes mpox. Learn more about these tests: Monkeypox Tests (In Vitro Diagnostic (IVD) Devices) .

On October 20, 2022, FDA also published lists of certain laboratories that have notified FDA of their laboratory developed monkeypox diagnostic test ( LDT ), modification to an FDA-cleared or EUA-authorized monkeypox diagnostic test, or laboratory developed monkeypox serology test, as described in Sections IV.A.2, IV.A.3, and IV.C, respectively, of the Policy for Monkeypox Tests to Address the Public Health Emergency . While FDA has not reviewed the laboratory’s validation of the listed tests and has not issued EUAs for these tests, we are providing this information to promote transparency.

For additional information about monkeypox (mpox), see: FDA mpox Response and Monkeypox and Medical Devices .

The tables below provide information on current EUAs:

Anthrax EUAs

Ebola virus eua information, freeze dried plasma information, h7n9 influenza eua information, middle east respiratory syndrome coronavirus (mers-cov) eua information, nerve agent eua information, zika virus eua information.

Information about EUAs that are no longer in effect is available on our EUA archive page .

The 2016 FDA Doxycycline Emergency Dispensing Order and CDC Doxycycline Emergency Use Instructions (EUI) together replace the need for the doxycycline mass dispensing EUA (issued on July 21, 2011). Therefore, the doxycycline emergency dispensing order and EUI should be used by stakeholders for anthrax preparedness and response instead of the mass dispensing EUA. The July 21, 2011, doxycycline mass dispensing EUA, and the October 14, 2011, National Postal Model anthrax EUA will be terminated by FDA, and notice of such termination will be published in the Federal Register . For additional information, see Emergency Use Authorization--Archived Information .

back to list of current EUAs

Ebola preparedness and response updates from FDA (all agency activities)

For more information about the diagnostics below, also see Emergency Use Authorizations for Medical Devices: 2014 Ebola Virus Emergency Use Authorizations .

Ebola Diagnostic Tests with De Novo, 510(k) or PMA

OraQuickEbola Rapid Antigen Test - On October 10, 2019, FDA allowed marketing (PDF, 255 KB) of a rapid diagnostic test (RDT) to detect Ebola virus antigens (proteins) in human blood from certain living individuals and samples from certain recently deceased individuals suspected to have died from Ebola (cadaveric oral fluid). The OraQuick Ebola Rapid Antigen Test is the first rapid diagnostic test the FDA has allowed to be marketed in the U.S. for Ebola virus disease (EVD). The test provides a rapid, presumptive diagnosis that must be confirmed. Also see the FDA news release: FDA allows marketing of first rapid diagnostic test for detecting Ebola virus antigens The OraQuick Ebola Test was reviewed under the De Novo premarket review pathway , a regulatory pathway for low-to-moderate-risk devices of a new type. Along with this marketing authorization, the FDA is establishing criteria, called special controls, that determine the requirements for demonstrating accuracy, reliability and effectiveness of tests intended to identify Ebola virus antigens. These special controls, when met along with general controls, provide a reasonable assurance of safety and effectiveness for tests of this type. This action also creates a new regulatory classification, which means that subsequent devices of the same type with the same intended use may go through the FDA’s 510(k) pathway, whereby devices can obtain clearance by demonstrating substantial equivalence to a predicate device.

Also see FDA News Release: FDA takes action to support American military personnel by granting an authorization for freeze-dried plasma product to enable broader access while the agency works toward approval of the product (July 10, 2018)

For more information about the diagnostics below, also see Emergency Use Authorizations for Medical Devices: 2013 H7N9 Influenza Emergency Use Authorization (Potential Emergency) .

For more information about the diagnostics below, also see Emergency Use Authorizations for Medical Devices: 2013 Coronavirus Emergency Use Authorization (Potential Emergency) .

On July 9, 2018, FDA approved (PDF, 49 KB) the 2 mg Atropine Auto-Injector manufactured by Rafa Laboratories, Ltd., for the treatment of poisoning by susceptible organophosphorous nerve agents having cholinesterase activity as well as organophosphorous or carbamate insecticides in adults and pediatric patients weighing over 90 lbs [41 kg] (generally over 10 years of age). For more information about the approved 2 mg Rafa Atropine Auto-Injector, see the product label (PDF, 482 KB). The EUA detailed in the table below is still in effect.

Zika virus response updates from FDA

For more information about the diagnostics below, also see Emergency Use Authorizations for Medical Devices: Zika Virus Emergency Use Authorization .

Draft EUA review templates for Zika are available by email request to: [email protected]

Laboratory personnel using Zika diagnostic assays under EUA are encouraged to report performance concerns directly to FDA at [email protected] , in addition to reporting concerns to the manufacturer.

Zika Diagnostic Tests with De Novo, 510(k), or PMA

ZIKV Detect 2.0 IgM Capture ELISA - On May 23, 2019, FDA authorized marketing (PDF, 175 KB) of the ZIKV Detect 2.0 IgM Capture ELISA to detect Zika virus immunoglobulin (IgM) antibodies in human blood. The ZIKV Detect 2.0 IgM Capture ELISA is the first Zika diagnostic test the FDA has allowed to be marketed in the U.S.; previously, tests for detecting Zika virus IgM antibodies—including the ZIKV Detect 2.0 IgM Capture ELISA—had been authorized only for emergency use under the FDA’s EUA authority. Also see the FDA news release: FDA authorizes marketing of first diagnostic test for detecting Zika virus antibodies
ADVIA Centaur Zika test – On July 17, 2019, FDA cleared the ADVIA Centaur Zika test. This is the second Zika diagnostic test FDA has allowed to be marketed in the U.S. for detecting Zika virus IgM antibodies. Previously, the test had been authorized only for emergency use under FDA’s EUA authority.
LIAISON XL Zika Capture IgM Assay II – On October 28, 2019, FDA cleared the LIAISON XL Zika Capture IgM Assay II for detecting Zika virus IgM antibodies. Previously, the test had been authorized only for emergency use under FDA’s EUA authority.
DPP Zika IgM Assay System – On June 3, 2020, FDA cleared a similar DPP Zika IgM System for detecting Zika virus IgM antibodies. Previously, the test had been authorized only for emergency use under FDA’s EUA authority.
Coronavirus Disease 2019 (COVID-19)
Summary of Process for EUA Issuance
Current Emergency Use Authorizations for Medical Devices
FAQs: What happens to EUAs when a public health emergency ends?
How to Submit a Pre-EUA for In vitro Diagnostics (IVDs) to FDA (for test manufacturers)
Information for Laboratories Implementing IVD Tests Under EUA
Process for Publishing Emergency Use Authorizations for Medical Devices During Coronavirus Disease 2019 (June 2, 2020)
Emergency Use Authorization--Archived Information
Emergency Dispensing Orders
21st Century Cures Act: MCM-Related Cures Provisions
Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (PAHPRA)
Public Readiness and Emergency Preparedness (PREP) Act
HHS Public Health Emergency EUA Authorization Declarations
Ebola Preparedness and Response Updates from FDA
Zika Virus Response Updates from FDA
Historical Information about Device Emergency Use Authorizations

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West J Emerg Med
v.23(2); 2022 Mar

Substance Use-related Emergency Department Visits and Resource Utilization

Weiwei beckerleg.

* The Ottawa Hospital, Division of General Internal Medicine, Ottawa, Ontario, Canada

† University of Ottawa, Faculty of Medicine, Ottawa, Ontario, Canada

Joel Hudgins

‡ Boston Children’s Hospital, Division of Emergency Medicine, Boston, Massachusetts

§ Harvard Medical School, Boston, Massachusetts

Introduction

Substance use-related visits to the emergency department (ED) have been linked to higher service delivery costs, although little is known about the specific services used. Our goal In this study was to describe the recent trends of substance use-related ED visits and assess the association between substance use and specific ED resource utilization.

We performed a retrospective, cross-sectional study using the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from 2013–2018. All ED visits in the United States for patients ≥18 years of age were included. The primary exposure was having substance use included as a chief complaint or diagnosis, which we identified using the International Classification of Diseases, 9th and 10th revisions, codes. The primary outcome was the use of diagnostic services (including laboratory studies and cardiac monitoring) or imaging studies in the ED.

The study sample included 95,506 visits in the US, extrapolating to over 619 million ED visits nationwide. The total number of ED visits remained stable during the study period, but substance use-related visits increased by 45%, with these visits making up 2.93% of total ED visits in 2013 and 4.25% in 2018. This increase was primarily driven by stimulant-, sedative- (opioids and benzodiazepines), and hallucinogen-related visits. Mental health-related visits rose in parallel by 66% during the same period. Compared to non-substance use-related visits, substance use-related visits were more likely to undergo any diagnostic study (adjusted odds ratio [aOR] 1.28; 95% confidence interval (CI): 1.11–1.47; P = 0.001), toxicology screening (aOR 10.15; 95% CI: 8.84–11.66), but less likely to have imaging studies (aOR 0.62; 95% CI: 0.56–0.68; P <0.0001). In stratified analyses, substance use-related visits with concurrent mental health disorders were more likely to undergo imaging studies (aOR 1.56; 95% CI: 1.09–2.22), while findings were opposite for those without concurrent mental health disorders (aOR 0.64; 95% CI: 0.51–0.71; P for interaction <0.0001).

Substance use- and mental health-related ED visits are rising, and they are associated with increased resource utilization. Further studies are needed to provide more guidance in the approach to acute services in this vulnerable population.

INTRODUCTION

Substance use is associated with multiple adverse health outcomes, including increased rates of infectious disease, mental health disorders, and mortality. 1 These outcomes are rapidly increasing over time, with recent data showing that the age-standardized mortality rate due to substance use disorders (SUD) increased by 618.3% between 1980–2014 in the United States. 1 The most common causes of death associated with substance use were injuries and poisoning, along with other external causes. 2 Among people ages 15–49 in the US, SUDs and intentional injuries make up close to one third of all deaths. 1 The poor outcomes associated with substance use, along with its rising prevalence and low treatment rates, create a significant public health issue. 3 From 2004–2013 the proportion of US adults receiving treatment for SUDs stayed at 1.2–1.3%, representing less than 20% of the population affected. 4

In light of the low treatment rates, it is not surprising that emergency department (ED) visits related to substance use have risen rapidly. 5 This increase has created predictable challenges for emergency clinicians and the healthcare system overall, as substance use-related ED visits have been linked to increased length of stay, higher service delivery costs, and higher rates of hospital admissions. 6 – 9 In addition, increasing ED utilization has outpaced similar increases in hospital inpatient care, meaning the burden of these increased visits has fallen disproportionately on EDs and emergency clinicians. 10 While resource utilization is high in this population, it remains unclear which specific resources are used in the ED for these visits on a national scale.

Identifying the resource utilization pattern for substance use-related visits could help inform resource allocation and potentially increase standardization of care. This could in turn lead to reduction in unnecessary testing or treatment, and eventually reduce the strain on emergency physicians and the healthcare system overall. With this rationale in mind, we aimed to describe the trends of substance use-related ED visits among US adults nationwide over a five-year period, beginning in 2013, and to evaluate the relationship between substance use and ED resource utilization.

This was a retrospective, cross-sectional study using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), which is conducted by the National Center for Health Statistics (NCHS). 11 We included data from January 1, 2013–December 31, 2018. The NHAMCS is an annual, national probability sample of ambulatory care visits throughout the US and collects data on visits to hospital-based EDs. The survey employs a four-stage probability design with samples of area primary sampling units (PSU, hospitals within PSUs, clinics within outpatient departments, and patient visits within emergency service areas (ESA). Within each ESA, patient visits were systematically selected over a randomly assigned four-week reporting period. There were approximately 2000 PSUs that covered 50 states and the District of Columbia, and approximately 600 hospitals. Data collection was overseen by the US Bureau of the Census, which provided field training on data abstraction for participating hospital staff.

Ethics approval was obtained from the research ethics board at our home institution.

Population Health Research Capsule

What do we already know about this issue?

Substance use-related visits to the emergency department (ED) have been increasing and are linked to higher service delivery costs.

What was the research question?

We aimed to assess the association between substance use and specific ED resource utilization.

What was the major finding of the study?

Patients with substance use-related ED visits are more likely to undergo diagnostic tests, including toxicology screening.

How does this improve population health?

Results from this study support the need for future studies to provide guidance in the approach to acute services for substance use-related ED visits.

Study Population

All ED visits for patients ≥18 years of age were included. We excluded visits to the ED made by patients younger than 18, visits for which the chief complaint or diagnoses were missing, and visits with missing data on use of diagnostic services, medications, procedures, disposition decision, or use of mental health consultation services.

Exposures and Covariates

The primary exposure was defined as having substance use listed as a chief complaint or diagnosis in the visit, as identified by the International Classification of Diseases 9 th and 10 th revisions (ICD) codes. The ICD codes were taken from previously published briefs by the Health Care Utilization Project. 5 , 12 Substances of interest included alcohol (ethanol), opioids, cannabis, cocaine, amphetamines, hallucinogens, and other recreational substances of abuse that affect the central nervous system. Substances were further broken down into five categories as defined by previous literature: 1) alcohol; 2) opioid, sedative/hypnotic, or anxiolytic; 3) cocaine, amphetamine, psychostimulant, or sympathomimetic; 4) cannabis or hallucinogen; and 5) other/unspecified or combined. 7 The reference group consisted of ED visits without substance use as a diagnosis or chief complaint.

Covariates of interest were defined a priori and identified from literature review. 6 – 8 They included age, gender, ethnicity, homelessness, burden of comorbidities, presence of mental health disorder, geographical region, metropolitan statistical area, payment source, day of visit, and arrival time. Mental health disorder was treated as a separate diagnosis from SUD to specifically examine the trend of substance use-related visits and to emulate previous studies in this area.

The primary outcomes of interest consisted of the use of any diagnostic services, toxicology screens or imaging studies in the ED. Diagnostic services included laboratory investigations, toxicology screens, imaging studies, electrocardiograms, and cardiac monitoring. Imaging studies included all imaging carried out in the ED, such as radiographs, ultrasounds, computed tomography (CT), and magnetic resonance imaging. Secondary outcomes consisted of number of procedures performed (eg, intravenous fluids, casts, intubation, lumbar puncture, etc), number of medications administered, disposition, and use of mental health consultation services in the ED. These variables were identified using pre-existing matching labels in the NHAMCS database. 11

Statistical analysis

The NHAMCS used a multistage estimation procedure to produce essentially unbiased estimates. The first step included inflation by reciprocals of selection probabilities, which was the product of the probability at each sampling stage. The second step adjusted for survey nonresponse, which included inflating weights of visits to hospitals or EDs similar to nonrespondent units, depending on the pattern of missingness. During data analysis, survey procedures were used (using the svy command) and patient visit weights were applied to obtain the total estimated ED visits from sampled visits (using the PATWT variable). As per the NHCS, sampled visits with relative standard error of 30% or more and observations that were based on fewer than 30 sampling records may yield unstable estimates. These were specifically indicated and later excluded from analysis.

We performed univariate analysis using chi-squared test to assess the association between substance use and each of the categorical covariates. To test for linear trend in substance use-related visits over time, we applied a logistic regression model with substance use as the dependent variable and time (measured in years) as the independent variable. Univariate and multivariable logistic regression were used to assess the unadjusted and adjusted associations between substance use and each of the outcomes, respectively. All listed covariates, with the exception of mental health disorder, were included in the multivariable model. We reported odds ratios for all logistic regression analyses, along with 95% confidence intervals. For the primary and secondary outcomes of interest, P -value for significance was determined to be 0.005 after applying Bonferroni correction, to minimize family-wise error rate in the setting of multiple comparisons. To evaluate mental health disorder as a potential effect modifier, we assessed the relationship between substance use and primary outcomes using a stratified analysis. The P -value for interaction was obtained from a multivariable logistic regression model. Missing data were handled using complete case analysis, given that the percentage of missingness was small, and complete data were available for both the exposures and outcomes. All data analyses were carried out using STATA version 15 (StataCorp LLC, College Station, TX).

From 2013–2018, substance use-related ED visits increased from 2.926 to 4.132 million visits, or from 2.93% to 4.25% of total ED visits during the same period, which translates to a 45% relative increase. Non-substance use-related ED visits (reference group) remained stable during the same period, with 93.17 million visits in 2018 compared to 96.98 million visits in 2013. The rise in substance use-related ED visits was driven by sedatives, stimulants, and hallucinogens, with alcohol and other substance use-related visits being relatively stable ( Figure 1 ). There was a parallel increase in mental health-related visits, with these visits making up 2.34% of total ED visits in 2013 and 3.88% in 2018, representing a 66% relative increase.

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Temporal trend of substance use- and mental health-related emergency department visits over time.

ED , emergency department.

Among substance-use related visits, the 25–44 age group made up 44.58% of visits, as compared to 35.49% of the non-substance related group ( P <0.0001). There was also a male predominance among substance use-related visits: males accounted for 63.38% of visits in the substance group vs 41.74% in the reference group ( P <0.0001). While the West geographic area accounted for only 21.34% of all ED visits, it made up 29.67% of substance use-related visits. In addition, substance use-related visits were much more likely to happen during the night shift (11 pm – 7 am), with 27.07% of all substance use-related visits taking place then compared to 14.81% in the reference group ( P <0.0001) ( Table 1 ). Mental health issues were more prevalent in the substance use group compared to the reference group, present in 14.48% vs 2.99%, respectively.

Descriptive table of baseline demographic characteristics of study population by exposure categories.

With regard to the primary outcomes, patients associated with substance use-related visits were more likely to undergo any diagnostic study (adjusted odds ratio [aOR] 1.28; 95% CI: 1.11–1.47, P = 0.001) and toxicology screening (aOR 10.15; 95% CI: 8.84–11.66; P <0.0001); however, they were less likely to have imaging studies (aOR 0.62; 95% CI: 0.56–0.68; P <0.0001) ( Table 2 ).

Logistic regression models predicting any diagnostic test and any imaging performed in the emergency department.

Any diagnostic study includes laboratory investigations, radiology services, and others such as cardiac monitoring. Any imaging includes all radiology services such as radiographs, computed tomography, magnetic resonance imaging, and ultrasound.

OR , odds ratio; CI , confidence interval.

There were no significant differences in the use of medications or procedures between the substance use and reference groups, with the differences in means being 0.08 (95% CI: −0.06–0.21; P = 0.28) and 0.04 (95% CI: 0.01–0.07; P = 0.02), respectively ( Table 3 ). Substance use-related visits were associated with higher odds of admission or transfer to another facility (aOR 1.73; 95% CI: 1.53–1.96; P <0.0001) and higher odds of receiving a mental health consult [aOR 5.70; 95% CI: 4.47–7.28; P <0.0001).

Regression models predicting use of medications and procedures, disposition, and mental health consultations in the emergency department.

Reference group consists of visits without substance use as a diagnosis.

With regard to stratified analyses those patients with mental health disorders were more likely to have imaging studies, and this reached statistical significance for interaction ( P <0.0001). For substance use-related visits without the concurrent presence of a mental health disorder, the aOR of undergoing any imaging study was 0.65 (95% CI: 0.58–0.72), and for substance use-related visits with concurrent mental health disorder, the aOR of undergoing any imaging study was 1.44 (95% CI: 1.03–2.00). All substance use-related ED visits were more likely to undergo toxicology screening, but those without concurrent mental health disorders were even more likely to receive screening, with aOR of 11.47 (95% CI: 9.87–13.35). The presence of a mental health disorder did not have an impact on the relationship between undergoing any diagnostic study in ED and substance use ( Table 4 ).

Subgroup analysis for primary outcomes by presence of mental health disorder.

Consistent with previously published work, our study shows that sedative-, stimulant-, and hallucinogen-related ED visits continue to increase rapidly compared to alcohol and other substances of abuse. 6 , 13 , 14 Substance use-related ED visits are more likely to result in diagnostic investigations overall, admission or transfer to another facility, and mental health consultations. Conversely, they are less likely to result in imaging studies. While the higher rate of admission/transfer and mental health consultations for substance use-related ED visits has been reported previously, 7 , 15 to our knowledge the use of diagnostic services has not yet been assessed at the national level.

Among the common substances of abuse, the rapid increase in stimulant-related ED visits in recent years is remarkable; in 2018, the percentage of stimulant-related visits matched that of sedative-related visits (including opioid, benzodiazepines, and other sedatives), representing approximately 0.7% of total ED visits. This is consistent with other study findings that have reported a rise in prevalence of stimulant use across all age groups from 2010–2014, with adults between 20–64 years the most affected. 16 Our study also showed that the rise in stimulant-related visits was more pronounced in the 18–44 age group (OR 1.28), compared to the > 45 years age group (OR 1.13). The most frequently cited motivation for stimulant use among adults was performance enhancement, 17 which supports the need to improve public education for young adults on the addictive potential of stimulants and restricting prescriptions to appropriate clinical indications only.

Regarding the use of diagnostic services in the ED for substance use-related visits, research has been relatively sparse. Our study showed that substance use-related visits are more likely to receive diagnostic services overall (including both laboratory and imaging studies) and toxicology screening. Some studies have called into question the routine practice of ordering urine drug screens for substance-related visits and laboratory studies in general for mental health-related visits, as they have rarely led to changes in management. 18 , 19 The American Psychiatric Association (APA) and the American College of Emergency Physicians (ACEP) both support targeted diagnostic investigations for patients presenting with acute psychiatric symptoms, instead of routine testing. 20 , 21 However, drug testing is often required as part of initial assessment to enter treatment facilities, regardless of medical indication or emergency healthcare team preferences. 22 Although most of the studies on this topic focused on mental health-related ED visits, the often-overlapping presentations of substance- and mental health-related visits argue for standardization of practices to diagnostic services.

In terms of the use of imaging studies specifically, both ACEP and the APA support individual assessment of risk factors to guide brain imaging in the ED for mental health-related visits, due to low yield of routine imaging. 20 , 21 There are no recommendations made regarding substance use-related visits given limited evidence. In contrast to our finding of substance use-related visits being associated with less use of imaging studies, previous work has shown a rising trend in the use of CT along with the rise of opioid-related visits. 6 However, that study did not assess the use of CT in relation to a non-substance use reference group and did not include other imaging modalities. The lower rate of utilization of imaging studies could be explained by the possibility that imaging was not needed for management or disposition after completion of laboratory screening in substance use-related visits. In addition, since substance use-related visits occurred disproportionately after hours, imaging might not be readily available after hours in smaller centers. Visiting hours were adjusted for as a potential confounder; so the latter explanation is considered less likely.

Notably, the presence of a mental health disorder made it more likely for patients with a substance use diagnosis to undergo imaging studies. It is well documented that patients with serious mental health disorders have higher mortality rates than those without, attributable to both injuries and chronic diseases. 2 It is, therefore, possible that additional imaging studies were needed because of increased medical complexity. Furthermore, the presence of SUDs was associated with significantly increased rates of mental health consultations in the ED, which in turn have been shown to be associated with increased ED length of stay. 24 These findings support the fact that healthcare is more costly for patients with mental health or SUDs, highlighting the need to address physical and mental health in an integrated fashion. 23 In fact, multiple studies have shown the effectiveness of case coordination and combined medical and behavioral health clinics to help decrease substance use- or mental health-related ED visits. 25 , 26

LIMITATIONS

Our study results should be interpreted in the context of several limitations. First, only associations and no causal relationships could be made due to the cross-sectional nature of the study. Second, it is possible that some substance use-related ED visits represented repeated visits over time, meaning the statistical methods used in the analysis could yield biased results away from the null. As the NHAMCS is an event-level database, it is not possible to ascertain this as data linkage could not be performed. Third, the study results relied heavily on ED reporting and ICD codes, which could be subject to inaccuracies and bias the results toward the null, although steps were taken to mitigate this through staff training.

Fourth, due to limitations in sample size, detailed analysis on the specific types of diagnostic services or imaging modalities, with the exception of toxicology screening, were not done. Further studies incorporating data from previous years would be needed to obtain more granular data. Fifth, due to concerns about multiplicity, resource utilization pattern with respect to the subgroups of substances analyzed can only be used for hypothesis-generating purposes. Furthermore, improved screening strategies for substance use in the ED could have contributed to the increase in visits, following the emergence of evidence demonstrating improved outcomes associated with ED-initiated interventions, biasing the results away from the null. 27 Finally, this study did not include information on ED-initiated substance use treatment or outpatient referral pattern over time, making it difficult to comment on specific strategies to help improve care for patients with SUD in the ED. In summary, many of the limitations arose from the design of the survey itself and were difficult to mitigate at the data analysis stage.

Substance use- and mental health-related ED visits are rising and are associated with increased resource utilization. Increasing mental health support will continue to be needed in the ED, along with support for ED clinicians in the management of common substances of abuse, especially sedatives and stimulants. Additional studies are needed to understand the pattern of resource utilization in the ED for substance use- and mental health-related visits, and to assess the optimal approach to acute care management for these visits.

Section Editor: Erin Dehon, PhD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Conflicts of Interest : By the West JEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

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Gritman’s emergency services are always open and ready to handle a wide range of medical and trauma cases. If you have a medical emergency, please call 911.

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Hospital Emergency Visits Involving Drugs
Opioid Overdose-Related Visits to Emergency Rooms Increased Sharply
Drug-Related Emergency Visits
Legal and Illegal: Emergency Room Visits for Various Drugs : Health
Emergency Room Visits Plunge During COVID-19 Pandemic

COMMENTS

Preliminary Findings from Drug-Related Emergency Department Visits
Preliminary Findings from Drug-Related Emergency Department Visits, 2021. An analysis of 2021 preliminary data presents (1) nationally representative weighted estimates for the top five drugs in drug-related ED visits, (2) the assessment of monthly trends and drugs involved in polysubstance ED visits in a subset of sentinel hospitals, and (3) the identification of drugs new to DAWN's Drug ...
Emergency department visits related to opioid overdoses up
Opioid-related overdose visits increased to 3,486 in 2020 from 3,285 and 3,020 in 2019 and 2018, respectively. Previous research by this team found an immediate and significant decrease in emergency department visits during the first few months of the COVID-19 pandemic, a trend that continued throughout 2020.
PDF Findings from Drug-Related Emergency Department Visits, 2021
DAWN is a nationwide public health surveillance system that captures data on ED visits related to recent substance use and misuse directly from the electronic health records of participating hospitals. In 2021, the DAWN identified 149,021 (unweighted) drug-related ED visits from 52 participating hospitals.
PDF Preliminary Findings from Drug-Related Emergency Department Visits
KEY FINDINGS BY DRUGS. The top five drugs involved in drug-related ED visits in 2021 were alcohol (39.33% of all drug-related ED visits), opioids (14.07%), methamphetamine (11.02%), marijuana (10.78%), and cocaine (4.71%). Fentanyl-related ED visits rose throughout 2021, peaking in quarter 4. Heroin-related ED visits rose from quarter 1 through ...
QuickStats: Rate of Emergency Department Visits
The rate of emergency department visits with a primary diagnosis of a substance use disorder among adults increased from 74.4 per 10,000 population during 2018-2019 to 103.8 during 2020-2021. Between these two periods, this rate increased 42% among patients aged 18-34 years (from 86.1 to 122.5) and 38% among patients aged ≥35 years ...
Opioid Overdose-Related Emergency Department Visits and Accidental
Anecdotal commentaries of either drug supply disruption, increased syringe requests, and/or overdoses have been reported in the media. Here, we describe that during the first weeks of a COVID-19 pandemic, emergency room presentations and deaths related to opioid overdose may increase during an isolation period.
Drug-Related Emergency Visits
The top five drugs involved in drug-related ED visits were alcohol (42%), opioids (15%), methamphetamine (11%), marijuana (11%), and cocaine (5%). Fentanyl-related ED visits increased in 2021 from nearly 17% at the end of the first quarter to nearly 29% at the end of the year. Heroin-related visits peaked at 27% and then dropped in the last ...
Clusters of substance use and mental health variables with emergency
Clusters of substance use and mental health variables with emergency room visits in U.S. adults: The 2020 National Survey on Drug Use and Health Published: October 2023. Publisher: Journal of Affective Disorders. Resource Number: 10.1016/j.jad.2023.07.017.
How emergency department visits for substance use disorders have
Visits for opioid-related, alcohol-related, and other drug-related disorders also declined, although less sharply, with an average drop of 17%, which was similar across SUD types. The visit ratios for 2020/2019 partially or fully recovered later in our sample period, depending on SUD type, but did not exceed early-2020 levels.
Drug-related emergency department visits: prevalence and risk factors
In this study, 19.7% of the ED visits were classified as drug-related. The prevalence of drug-related ED visits/DRHAs in earlier studies varies between 1.3 and 41.3% [ 1, 2, 6 - 11 ]. The prevalence revealed in the present study is however, in line with one prior study investigating drug-related ED visits [ 2 ], reporting a prevalence of 22.5%.
US Emergency Department Visits Attributed to Medication Harms
Among patients aged 15 to 24 years and 25 to 44 years, alprazolam was the most frequently implicated drug product in ED visits for medication harms, and it was the third most frequently implicated drug product among patients aged 45 to 64 years, with an estimated 97.3%, 93.9%, and 87.0% of visits involving nontherapeutic use, respectively.
Emergency Department Visits by Patients with Substance Use Disorder in
Study Population. We performed a cross-sectional study on the adult patients (age≥ 18 years) (N = 27,609) in the National Hospital Ambulatory Medical Care Survey-Emergency Department subfile (NHAMCS-ED) from 2016-2017. 19 The NHAMCS-ED is a nationally representative, multistage, stratified probability sample of ED visits in the United States, administered by the National Center for Health ...
Racial and Ethnic Differences in Emergency Department Visits Related to
December 2022 Pamela L. Owens, Ph.D., and Brian J. Moore, Ph.D. Introduction An estimated 20.4 million people aged 12 years and older were diagnosed with a substance use disorder (SUD) in 2019, with many receiving care or accessing the behavioral healthcare system through the emergency department (ED). 1 The prevalence of SUD remained stable between 2015 and 2019, 1 yet SUD-related ED visits ...
Estimates of Emergency Department Visits in the United States, 2016-2021
This visualization depicts both counts and rates of emergency department visits from 2016-2021 for the 10 leading primary diagnoses and reasons for visit, stratified by selected patient and hospital characteristics. Rankings for the 10 leading categories were identified using weighted data from 2021 and were then assessed in prior years ...
Drug Abuse Warning Network
The Drug Abuse Warning Network (DAWN) is a nationwide public health surveillance system that captures data on emergency department visits related to recent substance use and misuse directly from the electronic health records of participating hospitals. SAMHSA administered DAWN from 1992 through 2011 (legacy DAWN) and reestablished the current version of DAWN in 2018.
Products
In 2020, an estimated 131 million emergency department (ED) visits occurred in the United States, with 19.0% of adults reporting a visit and 4.7% of children reporting two or more visits in the past 12 months ().In that time, over 20 million cases of COVID-19 caused a disruption in access to and use of care ().This report presents characteristics of ED visits, including those with mentions of ...
National Trends in Emergency Department Visits for Suicide Attempts and
The weighted number of emergency department visits for suicide attempts and intentional self-harm increased from 1.43 million, or 0.6% of total emergency department visits, in 2011-2012 to 5.37 million, or 2.1% of total emergency department visits in 2019-2020 (average annual percent change, 19.5%, 95% CI=16.9, 22.2).
2021 Drug Abuse Warning Network (DAWN) Releases
This final report focuses on key findings from drug-related emergency department visits collected by the Drug Abuse Warning Network (DAWN) in 2021. The information presented in the report is organized into the following sections: Weighted national estimates, including percent and unadjusted rates per 100,000, for all drug-related ED visits by ...
Parents Often Bring Children to Psychiatric E.R.s to Subdue Them, Study
The JAMA study found that overall visits to pediatric emergency rooms for mental health crises increased 43 percent from 2015 to 2020, rising by 8 percent per year on average, with an increase in ...
Rise in ED Visits for Suicide Attempts in the United States
The number of ED visits owing to suicide attempts and intentional self-harm increased from 1.43 million in 2011-2012 to 5.37 million in 2019-2020 (average annual percent change, 19.5%; 95% CI, 16. ...
Emergency room visits for self-harm skyrocketed between 2011 and 2020
The figures per 100,000 people increased from 261 per 100,000 in 2011 to 871 in 2020. "When we translate the data to percent change, it is an 18.8% increase, which is huge," Rhee says. Their most ...
2022 Drug Abuse Warning Network (DAWN) Releases
Annually, the Drug Abuse Warning Network (DAWN) releases nationally representative data on key findings from drug-related emergency department visits. DAWN's latest annual report includes data from drug-related ED visits in 2022, and is organized into the following sections: In addition to these sections, the final report provides a ...
Emergency Use Authorization
Under section 564 of the Federal Food, Drug, and Cosmetic Act (FD&C Act ), when the Secretary of HHS declares that an emergency use authorization is appropriate, FDA may authorize unapproved ...
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Learn up-to-date facts and statistics on alcohol consumption and its impact in the United States and globally. Explore topics related to alcohol misuse and treatment, underage drinking, the effects of alcohol on the human body, and more. Find up-to-date statistics on lifetime drinking, past-year drinking, past-month drinking, binge drinking ...
World Health Organization (WHO)
The United Nations agency working to promote health, keep the world safe and serve the vulnerable.
Substance Use-related Emergency Department Visits and Resource
From 2013-2018, substance use-related ED visits increased from 2.926 to 4.132 million visits, or from 2.93% to 4.25% of total ED visits during the same period, which translates to a 45% relative increase. Non-substance use-related ED visits (reference group) remained stable during the same period, with 93.17 million visits in 2018 compared to ...
City of Moscow
Created Date: 3/24/2020 5:03:43 PM
Alex M.
THE CITY OF MOSCOW PUBLIC HEALTH EMERGENCY ORDER No. 20-01 MASS GATHERINGS, RESTAURANTS AND BARS March 20,2020 COVID-l9, is a respiratory disease caused by the SARS-CoV-2 virus, which is a new strain of coronavirus that had not been previously identified in humans and can easily spread from person to person, which can result in serious illness or death ...
Emergency Department
Our emergency department team is here for your emergencies around the clock. Gritman's emergency services are always open and ready to handle a wide range of medical and trauma cases. If you have a medical emergency, please call 911. Our emergency physicians, nurses and technicians have all gone through extensive training to provide immediate ...
Department of Human Services
Overview. Our mission is to assist Pennsylvanians in leading safe, healthy, and productive lives through equitable, trauma-informed, and outcome-focused services while being an accountable steward of commonwealth resources. Report Abuse or Neglect. Report Assistance Fraud. Program Resources & Information.

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Substance Use-related Emergency Department Visits and Resource Utilization

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INTRODUCTION

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Exposures and Covariates

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LIMITATIONS

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Our emergency department team is here for your emergencies around the clock.

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Gritman Achieves Level IV Trauma Care Designation

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