OFFICE OF APPLIED STUDIES

Drug Abuse Warning Network, 2004:

National Estimates of Drug-Related 

Emergency Department Visits

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

http://DAWNinfo.samhsa.gov/
2 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

ACKNOWLEDGMENTS

This publication was prepared by the Substance Abuse and Mental Health Services Administration (SAMHSA), Office 

of Applied Studies (OAS) with RTI International under Contract No. 280-03-2602. Judy K. Ball, Ph.D., M.P.A. (DAWN 

Project Director, SAMHSA/OAS), Scott Novak, Ph.D. (RTI), and Darryl Creel, M.S. (RTI) wrote the publication. Other 

significant contributors included Victoria Albright, M.A. (Project Director, RTI), Karol Krotki, Ph.D. (RTI), Eric Johnson, 

Ph.D. (RTI), Francine Cannarozzi, M.Ed. (RTI), Erin Mallonee, M.S. (SAMHSA/OAS), and Elizabeth Crane, Ph.D., M.P.H. 

(SAMHSA/OAS). The DAWN data collection was conducted by Westat under Contract No. 283-02-9025 under the 

direction of Josefina Moran. 

PUBLIC DOMAIN NOTICE

All material appearing in this publication is in the public domain and may be reproduced or copied without 

permission from the Substance Abuse and Mental Health Services Administration (SAMHSA). However, this

publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office 

of Communications, SAMHSA. Citation of the source is appreciated. Suggested citation:

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse 

Warning Network, 2004: National Estimates of Drug-Related Emergency Department Visits. DAWN 

Series D-28, DHHS Publication No. (SMA) 06-4143, Rockville, MD, 2006.

OBTAINING ADDITIONAL COPIES OF PUBLICATION

Copies may be obtained, free of charge, from the National Clearinghouse for Alcohol and Drug Information (NCADI). 

The NCADI is a service of the Substance Abuse and Mental Health Services Administration (SAMHSA). Write or call 

NCADI at:

National Clearinghouse for Alcohol and Drug Information (NCADI)

P.O. Box 2345, Rockville, MD 20847-2345

301-468-2600 • 1-800-729-6686 • TDD 1-800-487-4889

ELECTRONIC ACCESS TO PUBLICATION

This publication can be accessed electronically through Internet World Wide Web connections:

http://DAWNinfo.samhsa.gov/

http://www.samhsa.gov/

http://www.oas.samhsa.gov/

ORIGINATING OFFICE

Substance Abuse and Mental Health Administration

Office of Applied Studies

1 Choke Cherry Road, Room 7-1044, Rockville, MD 20857

April 2006
 DAWN, 2004: NATIONAL ED ESTIMATES 3

CONTENTS

Page

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Highlights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Total drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

ED visits involving drug misuse/abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Illicit drugs in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Alcohol and drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Alcohol in combination with other drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Alcohol in patients under age 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Non-medical use of pharmaceuticals and drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . 7

Special types of drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Suicide attempts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Seeking detox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Major features of DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

What is a DAWN case? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Types of cases in DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

What drugs are included in DAWN? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Other DAWN features . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Estimates in this publication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Hospital participation in 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

The margin of error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Estimates adjusted for population size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Drug-related ED visits in 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Total drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Drug-related ED visits by type of case . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Drug misuse and abuse in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Illicit drugs in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Alcohol and drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Alcohol in combination with other drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Alcohol only in patients under the age of 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Any alcohol in patients under the age of 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Non-medical use of pharmaceuticals and drug-related ED visits . . . . . . . . . . . . . . . . . . . 39

Non-medical use of pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
4 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Special types of drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Suicide attempt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Seeking detox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

List of Tables

Table 1. DAWN ED sample and response rates: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Table 2. Drug-related ED visits, by type of case: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Table 3. Drug-use and misuse in ED visits in the U.S., by type of drug involvement: 2004 . . . 21

Table 4. Illicit drugs and alcohol in drug-related ED visits: 2004 . . . . . . . . . . . . . . . . . . . . . . . 24

Table 5. Illicit drugs, by type of case: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Table 6. Illicit drugs, by patient characteristics: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Table 7. Alcohol in drug-related ED visits: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Table 8. Alcohol, by type of case: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

Table 9. Drugs reported most frequently with alcohol, by type of case: 2004 . . . . . . . . . . . . . 33

Table 10. Alcohol, by patient characteristics: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Table 11. Alcohol only (age < 21), by patient and visit characteristics: 2004 . . . . . . . . . . . . . 36

Table 12. Alcohol in drug-related ED visits in patients under age 21: 2004 . . . . . . . . . . . . . . 37

Table 13. Non-medical use of pharmaceuticals: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Table 14. Non-medical use of pharmaceuticals, by patient and visit characteristics: 2004 . . . 44

Table 15. Suicide attempt: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Table 16. Suicide attempt, by patient and visit characteristics: 2004 . . . . . . . . . . . . . . . . . . . 49

Table 17. Seeking detox: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Table 18. Seeking detox, by patient and visit characteristics: 2004 . . . . . . . . . . . . . . . . . . . . . 52

List of Figures

Figure 1. Type of case decision tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Figure 2. DAWN ED case form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 3. Drug-related ED visits in the U.S., by type of case: 2004 . . . . . . . . . . . . . . . . . . . . . 21

Figure 4. Illicit drugs in ED visits: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Figure 5. Illicit drugs, ED visit rates by age and gender: 2004 . . . . . . . . . . . . . . . . . . . . . . . . . 30

Figure 6. Alcohol with other drugs, ED visit rates by age and gender: 2004 . . . . . . . . . . . . . . 33

Figure 7. Alcohol only (age < 21), ED visit rates by age and gender: 2004 . . . . . . . . . . . . . . . 35

Figure 8. Non-medical use of pharmaceuticals, ED visit rates by age and gender: 2004 . . . . 43

Figure 9. Suicide attempt, ED visit rates by age and gender: 2004 . . . . . . . . . . . . . . . . . . . . . 50

Figure 10. Seeking detox, ED visit rates by age and gender: 2004 . . . . . . . . . . . . . . . . . . . . . 53

List of Appendixes

Appendix A: Multum Lexicon End-User License Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Appendix B: DAWN Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Appendix C : Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Appendix D: Population Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Appendix E: Race and Ethnicity in Dawn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
 DAWN, 2004: NATIONAL ED ESTIMATES 5

HIGHLIGHTS

T

his publication presents national estimates of drug-related visits to hospital emergency departments (EDs) for 

2004, based on data from the Drug Abuse Warning Network (DAWN). These estimates pertain to the entire 

U.S., including Alaska, Hawaii, and the District of Columbia. The Substance Abuse and Mental Health Services 

Administration (SAMSHA) is the agency responsible for DAWN. SAMHSA is required to collect data on drug-related 

emergency department visits under section 505 of the Public Health Service Act.

DAWN estimates for 2004 are the first to be based on the new, redesigned sample of hospitals, which covers the 

entire U.S. Estimates for 2004 also cover a full 12-month period for the first time since the redesign of DAWN was 

introduced.1 Therefore, the estimates in this publication establish a new baseline against which subsequent years’ 

estimates may be compared. No comparisons with prior years should be made.

DAWN relies on a national sample of general, non-Federal hospitals operating 24-hour EDs. The sample is national 

in scope, with oversampling of hospitals in selected metropolitan areas. Estimates for 2004 are based on data 

submitted by 417 hospitals. In each participating hospital, ED medical records are reviewed retrospectively to find 

the ED visits that were related to recent drug use. All types of drugs—illegal drugs, prescription and over-the-counter 

pharmaceuticals, dietary supplements, and nonpharmaceutical inhalants—are included. Alcohol, when it is the only 

drug implicated in a visit, is included for patients younger than age 21; alcohol, when it is present in combination with 

another drug, is included for patients of all ages.

Total drug-related ED visits

Of an estimated 106 million ED visits in the U.S. during 2004, DAWN estimates that 1,997,993 (95% confidence 

interval (CI): 1,708,205 to 2,287,781) were drug-related.2

ED visits involving drug misuse/abuse

Out of a total of nearly 2 million drug-related ED visits in 2004, DAWN estimates that nearly 1.3 million ED visits 

were associated with drug misuse or abuse. Of those ED visits involving drug misuse or abuse:

■ 30% involved illicit drugs only,

■ 25% involved pharmaceuticals only,

■ 15% involved illicit drugs and alcohol,

■ 8% involved illicit drugs with pharmaceuticals, and

■ 14% involved illicit drugs with pharmaceuticals and alcohol.

1

 For more information about the redesign of DAWN, see Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 

 Drug Abuse Warning Network, 2003: Interim National Estimates of Drug-Related Emergency Department Visits. DAWN Series D-26, DHHS 

 Publication No. (SMA) 04-3972, Rockville, MD, 2004. This and other DAWN publications are available online at http://dawninfo.samhsa.gov/.

2

 The confidence interval accounts for the margin of error of the estimate. It indicates, with a high degree of confidence, that the true population 

value was between 1,708,205 and 2,287,781 drug-related ED visits.
6 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Illicit drugs in ED visits

For 2004, DAWN estimates 940,953 (CI: 773,124 to 1,108,782) drug-related ED visits involved a major substance 

of abuse. DAWN estimates that:

■ Cocaine was involved in 383,350 (CI: 284,170 to 482,530) ED visits.

■ Marijuana was involved in 215,665 (CI: 175,930 to 255,400) ED visits. 

■ Heroin was involved in 162,137 (CI: 122,414 to 201,860) ED visits.

■ Stimulants, including amphetamines and methamphetamine, were involved in 102,843 (CI: 61,520 to 144,166) 

 ED visits.

■ Other illicit drugs, such as PCP, Ecstasy, and GHB, were much less frequent than any of the above.

Taking the margin of error into account, the stimulants (amphetamines and methamphetamine) may be as frequent 

as heroin in drug-related ED visits, but the stimulants are less frequent than cocaine or marijuana. Since some drug 

screens test for amphetamines only as a class, an amphetamine-positive result could indicate amphetamine or 

methamphetamine.

After taking population size and the margin of error into account:

■ The rates of ED visits involving cocaine, marijuana, heroin, and stimulants did not differ between males and 

 females.

■ The rates for patients aged 21 to 54 tended to be similar for cocaine and heroin, with lower rates for younger 

 and older patients.

■ For marijuana, the rates were highest for patients aged 18 to 24.

■ For stimulants, the rates were highest for patients aged 18 to 44.

Alcohol and drug-related ED visits

DAWN estimates that, for 2004, 461,809 (CI: 375,820 to 547,798) drug-related ED visits involved alcohol in 

combination with another drug or alcohol alone in a patient under the age of 21. Thus, nearly a quarter (23%) of all 

drug-related ED visits involved alcohol in one of these forms. Since DAWN does not account for ED visits involving 

alcohol alone in adults, the actual number of ED visits involving alcohol is higher. Alcohol is reported to DAWN when it 

is present in combination with other drugs, regardless of the patient’s age.

Alcohol in combination with other drugs

In 2004, DAWN estimates that 363,641 (CI: 289,516 to 437,766) ED visits involved the use of alcohol in 

combination with another drug. Alcohol was most frequently combined with:

■ Cocaine alone (that is, with no other drug, in 83,816 ED visits),

■ Marijuana alone (33,954 ED visits),

■ Cocaine and marijuana (19,697 ED visits), and

■ Heroin alone (14,669 ED visits).
 DAWN, 2004: NATIONAL ED ESTIMATES 7

Alcohol in patients under age 21

Considering ED visits only for patients under the age of 21, DAWN estimates 96,809 (CI: 76,127 to 117,491) 

drug-related ED visits involved alcohol and no other drug.

Injuries were diagnosed in 29% of the alcohol-only visits, and accidents involving falls or motor vehicles were 

diagnosed in 7%. Most (85%) of these visits resulted in patients being treated and released, usually to home; another 

9% were admitted to inpatient units.

Taking population size and the margin of error into account:

■ The rate of alcohol-only ED visits for patients aged 18 to 20 (456 visits per 100,000 population) was nearly three 

 times that for patients aged 12 to 17 (157 per 100,000).

■ The rates for males and females were equivalent.

Alcohol use by minors also occurs in combination with other drugs. Considering alcohol only and alcohol in 

combination with other drugs, DAWN estimates 60,118 (CI: 44,918 to 75,318) drug-related ED visits for patients aged 

12 to 17 and 82,583 (CI: 67,853 to 97,313) drug-related ED visits for patients aged 18 to 20.

Non-medical use of pharmaceuticals and drug-related ED visits 

DAWN estimates 495,732 (CI: 408,285 to 583,179) ED visits in 2004 for non-medical use—i.e., misuse or abuse—

of prescription or over-the-counter (OTC) pharmaceuticals. Multiple drugs were involved in more than half (57%) of 

these ED visits. The most frequent drugs in these visits were central nervous system (CNS) agents (53% of visits) and 

psychotherapeutic agents (48% of visits).

Among the CNS agents, the most frequent drugs were opiate/opioid analgesics (32% of visits involving non-medical 

use), including single-ingredient (e.g., oxycodone) and combination forms (e.g., hydrocodone with acetaminophen). 

Methadone and single-ingredient and combination forms of oxycodone and hydrocodone were the most frequent 

opioids, occurring in similar numbers of visits:

■ Methadone in 31,874 ED visits (CI: 23,752 to 39,996),

■ Oxycodone/combinations in 36,559 ED visits (CI: 28,964 to 44,154), and

■ Hydrocodone/combinations in 42,491 ED visits (CI: 31,831 to 53,151).

It is not possible to know the extent to which the source of these drugs is a legitimate prescription versus other 

sources nor is it possible to distinguish methadone used for treatment of opiate addiction from the methadone in pill 

form that is prescribed for pain.

Among the psychotherapeutic agents, the anxiolytics (anti-anxiety agents), sedatives, and hypnotics are the most 

frequent, occurring in more than a third (35%) of visits associated with pharmaceutical misuse/abuse. ED visits 

involving benzodiazepines clearly outnumber those involving any of the other types of psychotherapeutic agents. 

DAWN estimates that 144,385 (CI: 115,520 to 173,250) ED visits associated with pharmaceutical misuse/abuse 

involved benzodiazepines in 2004. This is comparable to the number for opiates/opioids.
8 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Taking population size and the margin of error into account:

■ ED visit rates for non-medical use of pharmaceuticals did not differ between females (186 visits per 100,000 

 population) and males (151 per 100,000 population).

■ In terms of age, visit rates were highest for patients aged 18 to 44.

Special types of drug-related ED visits

Suicide attempts

DAWN estimates 121,585 (CI: 108,955 to 134,215) drug-related ED visits associated with suicide attempts for 

2004. The majority of suicide attempt ED visits involved multiple drugs (64%).

In these ED visits for drug-related suicide attempts in 2004:

■ Fewer than one-third (31%) involved alcohol.

■ CNS agents, primarily analgesics (pain relievers), were involved in slightly less than half (47%) and 

 included both prescription and OTC formulations.

■ Over 56% of suicide-related visits included psychotherapeutic agents, such as benzodiazepines or 

 antidepressants.

■ Illicit drugs, such as cocaine (11% of visits) and marijuana (8% of visits), were relatively infrequent.

Seeking detox

DAWN estimates 177,879 (CI: 70,845 to 284,913) drug-related ED visits for patients seeking detox or substance 

abuse treatment services during 2004. However, these visits tend to be concentrated in hospitals with administrative 

policies that require medical clearance in the ED for admission to these specialized units.

More than 60% of ED visits for seeking detox involved multiple drugs. Both illicit and prescription drugs were 

common in these visits:

■ Cocaine (46% of visits) and heroin (30% of visits) were followed in frequency by marijuana (15% of visits) and 

 amphetamine or methamphetamine stimulants (7% of visits).

■ Alcohol in combination with another drug was implicated in about a third (33%) of seeking detox ED visits.

Among the seeking detox ED visits, 7 out of 10 received some type of follow-up care, either inpatient admission, 

referral elsewhere for detox or substance abuse treatment services, or transfer to another health care facility. However, 

a quarter of seeking detox cases may not have received the care they sought because they were discharged to home.
 DAWN, 2004: NATIONAL ED ESTIMATES 9

INTRODUCTION

T

his publication presents final estimates of drug-related emergency department (ED) visits from the Drug Abuse 

 Warning Network (DAWN) for 2004. DAWN is a public health surveillance system that monitors drug-related 

emergency department (ED) visits for the nation and for selected metropolitan areas. DAWN also collects data 

on drug-related deaths investigated by medical examiners and coroners in selected metropolitan areas and States. The 

Office of Applied Studies (OAS) of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. 

Department of Health and Human Services, has been responsible for DAWN operations since 1992.

Major changes to DAWN were instituted at the beginning of 2003. These changes are the result of a redesign that, 

among other improvements, altered most of DAWN’s core features, including the design of the hospital sample and the 

cases eligible for DAWN. These improvements create a permanent disruption in trends. As a result, comparisons cannot 

be made between old DAWN (2002 and prior years) and the new DAWN.

This publication presents national estimates of drug-related ED visits for 2004, based on data collected between 

January 1, 2004 and December 31, 2004. These are final estimates and the first full-year estimates from the new 

DAWN. Therefore, no trends are presented in this publication.

The findings based on the new DAWN hospital sample are representative of the entire United States, and, as such, 

they are generalizable to all 50 States and the District of Columbia.

Major features of DAWN

What is a DAWN case?

One of the most important features of DAWN is its expansive definition of a case:

 A DAWN case is any ED visit related to recent drug use.

DAWN includes ED visits associated with substance abuse/misuse, both intentional and accidental. DAWN also 

includes ED visits related to the use of drugs for legitimate therapeutic purposes. To be a DAWN case, the relation 

between the ED visit and the drug need not be causal; the drug needs only to be implicated in the visit.

The case criteria are intended to be broad and inclusive and to have few exceptions. DAWN cases are found 

through a retrospective review of medical records.3 Broad criteria take into account the fact that documentation in 

medical records varies in clarity and comprehensiveness across hospitals and among clinicians within hospitals. Broad 

criteria minimize the potential for judgments that could cause data to vary systematically and unexpectedly across 

reporters and hospitals. In addition, broad criteria are designed to capture a very diverse set of drug-related cases, 

which can be aggregated and disaggregated to serve a variety of analytical purposes and the interests of multiple 

audiences. In DAWN, only recent drug use is included;4

 the reason a patient used a drug is irrelevant; and the criteria 

are broad enough to encompass all types of drug-related events, including, but not limited to, explicit drug abuse.

3 This review is conducted by data collectors called “DAWN reporters.”

4

 That is, patients with a history of drug use (and no recent use) are excluded.
10 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

There are a few clearly delineated exceptions to the DAWN case criteria. An ED visit is not a DAWN case if:

■ There is no evidence of recent drug use.

■ The patient left the ED without being treated.

■ The patient consumed a non-pharmaceutical substance but did not inhale it.

■ The patient has a history of drug use but no recent use.

■ Alcohol is the only substance involved and the patient is an adult (aged 21 or over).

■ The only documentation of a drug is in toxicology test results.

■ The only drugs listed (e.g., current medications) are not related to the visit.

■ The patient is being treated for a consequence of undermedication (i.e., taking too little of a drug).

Types of cases in DAWN

By design, the broad case criteria yield a diverse set of cases in DAWN. To bring order to this heterogeneous mix 

of DAWN cases, each case is assigned to one of eight case types, which may be analyzed separately or in purposeful 

combinations. The eight case types are:

■ Suicide attempt,

■ Seeking detox,

■ Alcohol only in patients under age 21,

■ Adverse reaction,

■ Overmedication,

■ Malicious poisoning (includes drug-facilitated sexual assault or product tampering),

■ Accidental ingestion, and

■ Other.

Each DAWN case is assigned hierarchically into one and only one case type based on a series of questions and 

rules. To assign case type, DAWN reporters use a decision tree, a graphical depiction of the logic of the case type 

assignment rules (Figure 1). Cases are classified into the first case type that applies. Even if a case might fit into more 

than one type, it is assigned to the first one that applies. The case types were ordered with this in mind.
 DAWN, 2004: NATIONAL ED ESTIMATES 11

Figure 1

Type of case decision tree
12 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

The final category, the case type called other, is reserved for DAWN cases that do not meet any of the rules for 

classification into one of the first seven types. By design, most cases of drug abuse are classified as case type other. 

This approach, which never directly identifies drug abuse, comes from the recognition that medical records frequently 

lack explicit documentation of substance abuse. This lack of documentation may occur for several reasons. First, the 

distinctions among use, misuse, and abuse of drugs are often subjective. Second, if there is a low index of suspicion for 

drug abuse in some types of patients, ED physicians may be unlikely to label those types of patients as drug abusers. 

Third, in many States, insurers may legally deny payment for ED visits related to substance abuse. Thus, financial 

incentives may be a factor to influence documentation practices.

With these eight case types DAWN includes some ED visits that are unrelated to drug abuse. However, using the 

hierarchical decision tree is a method for isolating a set of cases involving drug abuse or misuse. 

What drugs are included in DAWN?

DAWN includes all types of drugs.5 Drugs in DAWN include:

■ Illegal drugs, such as heroin, cocaine, marijuana, and Ecstasy;

■ Prescription drugs, such as Prozac®, Vicodin®, OxyContin®, alprazolam, and methylphenidate;

■ Over-the-counter (OTC) medications, including aspirin, acetaminophen, ibuprofen, and multi-ingredient cough 

 and cold remedies;

■ Dietary supplements, including vitamins, herbal remedies, and nutritional products;

■ Psychoactive, non-pharmaceutical inhalants;

■ Alcohol in combination with other drugs; and

■ Alcohol alone, in patients aged less than 21 years.

To be reportable, a non-pharmaceutical substance must be consumed by inhalation, sniffing, or snorting, and it 

must have a psychoactive effect when inhaled. An ED visit involving inhalation of a non-pharmaceutical, psychoactive 

substance and no other drug qualifies as a DAWN case. Carbon monoxide is excluded from the inhalants. Beginning in 

2004, cases involving accidental exposures (e.g., exposure to paint fumes while painting a closet) are excluded as well.

Other DAWN features

Several methods are used to improve the quality and reliability of DAWN data. These include:

■ Case finding by a retrospective review of ED medical records for every patient treated in a participating ED;

■ Electronic reporting with automated prompts and data validation;

■ Inclusion of data items on the health effects of drug use and additional detail on patient disposition;

■ Elimination of incidental drug reporting;

■ Emphasis on accurate, specific, and non-redundant drug reporting;

■ Inclusion of data items to identify drugs confirmed by laboratory testing;

5 The classification of drugs used in DAWN is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification 

has been modified to meet DAWN’s unique requirements (2004). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.
 DAWN, 2004: NATIONAL ED ESTIMATES 13

■ Systematic training and certification of DAWN reporters; and

■ In-house review and cleaning of DAWN case reports.

The case report form showing all the DAWN data items is provided in Figure 2.

Estimates in this publication

Estimates in this publication were calculated from a probability sample of hospitals by applying sampling weights to 

data from the sample and accounting for the survey design. Only national estimates pertaining to the U.S. are provided.

Estimates for 2004 are, for the first time, representative of the entire 50 States and the District of Columbia. 

Hospitals eligible for the DAWN sample are non-Federal, short-stay, general, surgical and medical hospitals in the 

U.S. that operate 24-hour EDs. The American Hospital Association’s (AHA’s) 2001 Annual Survey is the source of the 

sampling frame. (For a definition of sampling frame and other technical terms used in this publication, see Appendix C, 

Glossary of Terms.)

The DAWN sample of hospitals includes an oversampling of hospitals in selected metropolitan areas supplemented 

with a sample of hospitals from the remainder of the U.S., which includes other metropolitan areas as well as nonmetropolitan and rural areas. The metropolitan area boundaries correspond to the definitions issued by the Office of 

Management and Budget (OMB) in June 2003.

For 2004, the national estimates are calculated as the sum of the estimates from 16 geographic areas (15 

metropolitan areas, divisions, and subareas and the remainder of the U.S.). The sampling weights consist of three 

components:

■ The base sampling weight, calculated as the reciprocal of the sampling probability;

■ An adjustment for nonresponse, based either on complete nonparticipation or failure to provide data on all the 

 reporting days in a given time period; and

■ A post-stratification factor to adjust the total number of ED visits among participating sample hospitals to the 

 total for the eligible population of hospitals as determined from the sampling frame.

The nonresponse adjustment to the sampling weights is designed to account for data that are missing, but not for 

data that are incomplete. Therefore, the data used for this publication were subjected to an intense level of scrutiny. 

The procedures observed for 2004 differed somewhat from those applied in 2003 due to the increased volume of 

data. For 2004, DAWN case eligibility and assignment of type of case were subjected to a multi-stage review involving 

automated “expert system” processing with selective manual verification. First, each record submitted as a DAWN case 

was reviewed by an expert system, which assigned a probability that the record met DAWN case criteria. Records not 

meeting minimum probability thresholds, as well as a subsample of those that did, were reviewed by DAWN staff for 

final case eligibility determinations. Second, the expert system reviewed data items submitted on each DAWN case and 

assigned a probability for each case type. The case type with the highest probability was compared with the case type 

originally reported on the record. When these agreed, the case was flagged as final. When these disagreed or when the 
14 D A W N , 2 0 0 4 : 	 	 N a t i o na l E D E s t i m a t e s

Figure 2

DAWN ED case form
 DAWN, 2004: NATIONAL ED ESTIMATES 15

case type probability did not meet a minimum threshold, the case was reviewed manually to resolve the differences. An 

additional 10% of cases were reviewed manually as a quality control check. Third, all data were checked for internal 

consistency, out-of-range values, missing data, and adherence to skip patterns at data entry and during subsequent 

cleaning processes. 

A fourth and final review focused explicitly on the issue of incomplete data, that is, DAWN cases missed due to 

incomplete chart review or inappropriate application of the case criteria. This review used statistical process control 

methods and information gained from on-site quality audits to identify and evaluate unexpected variability across 

months in the number of medical charts reviewed and the number of DAWN cases submitted for each hospital. 

Hospital participation in 2004 (Table 1)

For 2004, 417 hospitals submitted data that were used for estimation. The weighted response rate varied from 

47.4% in the San Francisco Division of the San Francisco Metropolitan Statistical Area (MSA) to 78.1% in the Buffalo, 

NY MSA. The weighted response rate for hospitals covering the U.S. outside of the 15 metropolitan areas, divisions, and 

subareas was 35.3%.

Across the 417 participating hospitals, more than 12 million charts were reviewed to find the drug-related visits that 

met the DAWN case criteria. Based on the review of charts, 279,564 drug-related visits were found and submitted. On 

average, a DAWN member hospital submitted 670 DAWN cases. However, the number of cases varied widely, from 

4 cases to 7,485 (median 402) in a single hospital during 2004.

The margin of error

Since DAWN relies on a sample of hospitals, each estimate produced from the DAWN ED sample data is subject 

to sampling variability, the so-called “margin of error.” This is the variation in the estimate that would be observed 

naturally if different samples were drawn from the same population using the same procedures. The sampling 

variability of an estimate in this publication is measured by its relative standard error (RSE), which is defined as the 

standard error of the estimate expressed as a percentage of the value of the estimate. The precision of an estimate is 

inversely related to its sampling variability as measured by the RSE. The greater the RSE, the lower the precision.

DAWN estimates with RSE values greater than 50% and estimates less than 30 are regarded as too imprecise for 

publication and are not shown. In the tables, three dots (“...”) are shown in the place of estimates that have an RSE 

greater than 50% or estimates less than 30. Ratios (percentages or rates per 100,000 population) based on suppressed 

estimates are likewise suppressed. Gray shading in a cell indicates that the cell is not applicable. For example, no drugs 

other than alcohol can be present in the “alcohol only” case type category.

In this publication, confidence intervals (CIs) are included in many of the tables and are cited in the text along 

with the estimates. A CI, which is expressed as a range of values, does a better job of reflecting the true nature of the 

statistical estimates because it takes both the estimate and its margin of error into account. A 95% CI means that, if 

repeated samples were drawn from the same population of hospitals using the same sampling and data collection 

procedures, the true population value would fall within the confidence interval 95% of the time.

For readers unfamiliar with these concepts, a more detailed discussion and examples are provided in Appendix B.
16 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Table 1

DAWN ED sample and response rates: 2004

Geographic area Total eligible 

hospitals1

Eligible 

hospitals in 

sample

Responding 

hospitals in 

sample

Response rate 

for sample 

hospitals

Response 

rate for visits 

(weighted)

Total U.S.2 4,438 951 417 43.8 47.6

Metropolitan Statistical Areas (MSAs)3

Atlanta-Sandy Springs-Marietta, 

GA MSA 41 31 15 48.4 57.8

Boston-Cambridge-Quincy, 

MA-NH MSA 41 30 16 53.3 59.6

Buffalo-Cheektowaga-Tonawanda, 

NY MSA 14 14 8 57.1 78.1

Chicago-Naperville-Joliet, 

IL-IN-WI MSA 91 75 34 45.3 47.5

Denver-Aurora, CO MSA 14 14 8 57.1 65.0

Detroit-Warren-Livonia, MI MSA 38 26 20 76.9 72.6

New Orleans-Metairie-Kenner, 

LA MSA 21 21 10 47.6 68.9

Phoenix-Mesa-Scottsdale, AZ MSA 25 25 11 44.0 52.5

St. Louis, MO-IL MSA 37 37 17 45.9 49.1

San Diego-Carlsbad-San Marcos, 

CA MSA 17 17 10 58.8 61.4

Seattle-Tacoma-Bellevue, WA MSA 22 22 12 54.5 54.9

Washington-Arlington-Alexandria, 

DC-VA-MD-WV MSA 34 30 14 46.7 53.0

Metropolitan Divisions and Subareas3

Miami-Miami Beach-Kendall, FL 

Metropolitan Division of Miami-Fort 

Lauderdale-Miami Beach, FL MSA 21 17 11 64.7 68.9

Bronx, Kings, New York, Queens, 

Richmond Counties of New YorkNewark-Edison, NY-NJ-PA MSA 52 40 26 65.0 75.1

San Francisco-San Mateo-Redwood 

City, CA Metropolitan Division of 

San Francisco-Oakland-Fremont, 

CA MSA 18 18 9 50.0 47.4

1 Short-term, general, non-Federal hospitals with 24-hour emergency departments, based on the American Hospital Association (AHA) Annual Survey, 

are eligible for DAWN.

2 Total eligible hospitals in the U.S. include eligible hospitals from metropolitan areas shown and the remainder of the U.S. Therefore, components 

shown do not sum to the total.

3 Metropolitan Statistical Areas (MSAs) and Metropolitan Divisions follow the standard definitions issued by the Office of Management and Budget 

in June 2003 (available at http://www.whitehouse.gov/omb/bulletins/b03-04.html), with one exception: For New York, geographic coverage is 

limited to the subarea comprising the five Boroughs of New York City.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S 17

Estimates adjusted for population size

Standardized measures are needed to make valid comparisons of ED visits and drugs across age and gender 

categories that differ in population size. For age in particular, the size of the underlying population differs considerably 

across age groups; for example, the number of individuals aged 18 to 20 in the U.S. is much lower than the number of 

individuals aged 35 to 44.

To take the size of the underlying population into account, rates of ED visits per 100,000 people are generated 

using population data from the U.S. Bureau of the Census.6 An example is provided in Appendix B, and the population 

estimates used for this publication can be found in Appendix D.

Standardized rates are not calculated for race and ethnicity subgroups because the race and ethnicity categories 

available to DAWN are much less detailed and contain considerably more missing data than the race and ethnicity 

categories in the Census data. Appendix E describes the race and ethnicity data reported to DAWN.

6 Population estimates for 2004, as of July 2005, from U.S. Census Bureau County Population Dataset CO-EST2004-ALLDATA 

(see http://www.census.gov/popest/counties/files/CO-EST2004-ALLDATA.csv).
18 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S
 DAWN, 2004: NATIONAL ED ESTIMATES 19

DRUG-RELATED ED VISITS IN 2004

Total drug-related ED visits (Table 2)

Estimates for the entire universe of DAWN-eligible hospitals in the U.S. are produced by applying sampling weights 

to the data received from the sampled hospitals. Thus, for 2004, 279,564 submitted cases are extrapolated to an 

estimate of 1,997,993 drug-related ED visits. Considering the margin of error, this estimate may range from 1,708,205 

to 2,287,781 drug-related ED visits out of nearly 106 million total ED visits estimated for the U.S.

On average, a drug-related ED visit involved 1.6 drugs.

Drug-related ED visits by type of case (Figure 3)

The distribution of drug-related ED visits across the eight case types is illustrated in Figure 3. Estimates for the U.S. 

show the largest number of cases (35%) fell into the category other. Adverse reaction, which accounted for 30% of 

drug-related ED visits, is second in frequency, followed by overmedication (12%). Patients seeking detox accounted for 

9% of drug-related ED visits. Suicide attempt, which was narrowly defined, accounted for 6% of drug-related visits. 

Visits associated with underage alcohol consumption and no other drug (alcohol only) accounted for 5% of drugrelated ED visits, accidental ingestion 3%, and malicious poisoning 0.3%.

Drug misuse and abuse in ED visits (Table 3)

Among the nearly 2 million ED visits that were drug-related in 2004, DAWN estimates nearly 1.3 million were 

associated with drug misuse or abuse. This figure includes 940,953 (CI: 773,124 to 1,108,782) drug-related ED visits 

that involved illicit drugs or alcohol, and 495,732 (CI: 408,285 to 583,179) ED visits associated with non-medical use 

of pharmaceuticals.

ED visits involving illicit drugs alone accounted for 30% of all visits related to drug misuse/abuse in 2004. ED visits 

involving non-medical use of pharmaceuticals alone accounted for another 25%. Only 8% of drug misuse/abuse visits 

were related to consumption of alcohol by a minor. The remaining visits (37%) involved some combination of illicit 

drugs, alcohol, and/or pharmaceuticals.

ED visits in each of the three major categories—illicit drugs, alcohol, and non-medical use of pharmaceuticals—are 

discussed in greater detail in separate sections in the remainder of this publication.
20 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Drug-related ED visits

Type of case Unweighted 

sample data

Weighted 

estimates1 

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

 bound

Suicide attempt 16,169 121,585 5.3 108,955 - 134,215

Seeking detox 28,800 177,879 30.7 70,845 - 284,913

Alcohol only (age < 21) 11,315 96,809 10.9 76,127 - 117,491

Adverse reaction 71,175 592,044 8.9 488,768 - 695,320

Overmedication 28,707 244,330 10.5 194,046 - 294,614

Malicious poisoning 747 6,026 16.6 4,066 - 7,986

Accidental ingestion 5,796 57,940 7.0 49,990 - 65,890

Other 116,855 701,381 10.6 555,663 - 847,099

Total drug-related visits 279,564 1,997,993 7.4 1,708,205

90,399,603 - 2,287,781

Total ED visits (all reasons) 15,568,029 105,978,433 7.5 121,557,263

Table 2

Drug-related ED visits, by type of case: 2004

Drugs

Type of case Unweighted 

sample data

Weighted 

estimates2

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

 bound

Suicide attempt 34,009 266,459 6.1 234,601 - 298,317

Seeking detox 56,272 357,467 32.9 126,957 - 587,977

Alcohol only (age < 21) 11,315 96,809 10.9 76,127 - 117,491

Adverse reaction 92,571 742,916 9.1 610,410 - 875,422

Overmedication 49,893 447,466 11.1 350,115 - 544,817

Malicious poisoning 1,320 10,416 17.0 6,945 - 13,887

Accidental ingestion 7,398 73,992 6.6 64,421 - 83,563

Other 202,018 1,291,276 9.8 1,019,010 - 1,503,542

Drugs in all drug-related visits2 454,796 3,256,802 7.4 2,784,436 - 3,729,168

1 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

2 These are estimates of drugs. A single ED visit may involve multiple drugs.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 21

Table 3

Drug misuse and abuse in ED visits in the U.S., by type of drug involvement: 2004

Drug involvement1 Estimated 

visits2,3 Percent

All types of drug misuse/abuse 1,254,078 100%

Illicit drugs only 379,609 30%

Alcohol only (age < 21) 98,174 8%

Pharmaceuticals only 313,125 25%

Combinations

Illicit drugs with alcohol4 190,747 15%

Illicit drugs with pharmaceuticals 99,535 8%

Alcohol with phamaceuticals 125,374 10%

Illicit drugs with alcohol and pharmaceuticals 47,515 4%

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in Appendix A 

and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits.

4 DAWN excludes alcohol-only visits for adults. Alcohol, when present with other drugs, is included for all ages.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Figure 3

Drug-related ED visits, by type of case: 2004

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Other

35%

Malicious poisoning

0.3%

Overmedication

12%

Alcohol only

5%

Adverse reaction

30%

Accidental ingestion

3%

Suicide attempt

6%

Seeking detox

9%
22 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S
 DAWN, 2004: NATIONAL ED ESTIMATES 23

ILLICIT DRUGS IN ED VISITS

T

he first method for assessing drug abuse in new DAWN focuses on illicit drugs, regardless of case type.

For 2004, DAWN estimates 940,953 (CI: 773,124 to 1,108,782) drug-related ED visits that involved a major 

substance of abuse (Table 4). This means that nearly half (47%) of all the drug-related ED visits during the year 

involved alcohol or an illicit drug.

DAWN estimates that cocaine was involved in 383,350 (CI: 284,170 to 482,530) ED visits. In other words, 

approximately one in five drug-related ED visits (19%) involved cocaine. 

Marijuana was involved in 215,665 (CI: 175,930 to 255,400) ED visits. Thus, marijuana may be only slightly less 

common than cocaine in drug-related ED visits.

Heroin was involved in 162,137 (CI: 122,414 to 201,860) drug-related ED visits or 8% of drug-related ED visits 

overall. This could, however, be an underestimate. Heroin is an opiate, and some drug screens test for opiates only as a 

class. About three-quarters (74%) of reports of “opiates” submitted to DAWN for 2004 came from toxicology findings, 

so some unknown quantity of these may have been heroin. The number of unspecified opiates in drug-related ED visits 

is estimated at 37,007 (CI: 28,738 to 45,276) visits, or 2% of all drug-related ED visits.

Stimulants, including amphetamines and methamphetamine, were involved in 102,843 (CI: 61,520 to 144,166) 

ED visits, about 5% of drug-related ED visits overall. Amphetamines and methamphetamine are combined for this 

analysis because more than 8 out of 10 (86%) amphetamine reports are derived from toxicology findings.7 Since some 

drug screens test for amphetamines only as a class, an amphetamine-positive result could indicate amphetamine or 

methamphetamine.

Other illicit drugs appeared at much lower frequencies. For 2004, DAWN estimates:

■ MDMA (Ecstasy) in 8,621 (CI: 5,985 to 11,257) ED visits,

■ GHB in 2,340 (CI: 125 to 4,555) ED visits,

■ Ketamine in 227 (CI: 109 to 345) ED visits,

■ LSD in 1,953 (CI: 1,179 to 2,727) ED visits,

■ PCP in 8,928 (CI: 4,920 to 12,936) ED visits, and

■ Miscellaneous hallucinogens in 3,445 (CI: 2,202 to 4,688) ED visits.

By design, DAWN excludes illicit drugs from all case types except suicide attempt, seeking detox, malicious 

poisoning, and other. Also by design, most illicit drug use will be classified in case type other, with most of the 

remainder in suicide attempts and seeking detox cases (Table 5). For example:

■ Cocaine was found in 11% of visits related to suicide attempt and nearly half (46%) of seeking detox visits.

■ Heroin was infrequent (2%) in visits related to suicide attempt, but was present in 30% of seeking detox visits.

■ Marijuana was found in 8% of visits related to suicide attempts and 15% of seeking detox visits. Marijuana was 

 also involved in 15% of ED visits involving malicious poisoning.

7 In 2004, only reports of amphetamines, cathinone, dimethoxymethamphetamine, and methcathinone are classified in this category. Drugs 

specifically identified as amphetamine-dextroamphetamine, benzphetamine, or dextroamphetamine are now classified as CNS stimulants. 

This is a change from 2003 when all these drugs were classified as stimulants.
24 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 1,997,993 7.4 1,708,205 - 2,287,781

Major substances of abuse (includes alcohol) 940,953 9.1 773,124 - 1,108,782

 Alcohol 461,809 9.5 375,820 - 547,798

 Alcohol-in-combination 363,641 10.4 289,516 - 437,766

 Alcohol alone (age < 21 only) 98,168 10.9 77,196 - 119,140

 Cocaine 383,350 13.2 284,170 - 482,530

 Heroin 162,137 12.5 122,414 - 201,860

 Marijuana 215,665 9.4 175,930 - 255,400

 Stimulants 102,843 20.5 61,520 - 144,166

 Amphetamines 32,686 15.5 22,757 - 42,615

 Methamphetamine 73,400 22.7 40,742 - 106,058

 MDMA (Ecstasy) 8,621 15.6 5,985 - 11,257

 GHB 2,340 48.3 125 - 4,555

 Flunitrazepam (Rohypnol) 473 49.3 16 - 930

 Ketamine 227 26.5 109 - 345

 LSD 1,953 20.2 1,179 - 2,727

 PCP 8,928 22.9 4,920 - 12,936

 Miscellaneous hallucinogens 3,445 18.4 2,202 - 4,688

 Inhalants 9,275 15.5 6,457 - 12,093

 Combinations not tabulated above (NTA) 1,524 16.5 1,032 - 2,016

Table 4

Illicit drugs and alcohol in drug-related ED visits: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits. For example, 383,350 visits involved cocaine, and 162,137 visits involved heroin. Visits cannot be summed 

across drugs because drug-related ED visits often involve multiple drugs (e.g., visits involving both cocaine and heroin would be double counted).

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 25

Percent of visits

Cocaine 19% 11% 46% ... ... 17% ... 41%

Heroin 8% 2% 30% ... ... 2% 0% 15%

Marijuana 11% 8% 15% ... ... 15% 0% 25%

Stimulants 5% 3% 7% ... 0% 13% ... 12%

 Amphetamines 2% 2% 1% ... 0% 9% 0% 4%

 Methamphetamine 4% 2% 6% ... ... 5% ... 9%

MDMA (Ecstasy) 0% 0% ... ... ... ... ... 1%

GHB 0% 0% ... ... ... 4% ... 0%

Flunitrazepam 

(Rohypnol) 0% ... ... ... ... ... ... ...

Ketamine 0% ... ... ... ... ... ... 0%

LSD 0% ... 0% ... ... ... 0% 0%

PCP 0% 0% 0% ... ... ... ... 1%

Miscellaneous 

hallucinogens 0% ... 0% ... ... ... ... 0%

Inhalants 0% 0% ... 0% ... ... 6% 1%

Combinations NTA 0% ... 0% ... ... ... ... 0%

Table 5

Illicit drugs, by type of case: 2004

Drug category 

and selected 

drugs1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only (age 

< 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

Drug-related ED visits2,3,4

Total drug-related 

ED visits 1,997,993 121,585 177,879 96,809 592,044 244,330 6,026 57,940 701,381

Cocaine 383,350 13,940 81,439 ... ... 995 ... 286,648

Heroin 162,137 2,986 53,088 ... ... 111 46 105,906

Marijuana 215,665 9,747 27,259 ... ... 879 148 177,380

Stimulants 102,843 4,218 12,151 ... 345 810 ... 84,926

 Amphetamines 32,686 1,894 1,829 ... 341 532 88 27,861

 Methamphetamine 73,400 2,391 10,518 ... ... 281 ... 60,042

MDMA (Ecstasy) 8,621 278 ... ... ... ... ... 7,107

GHB 2,340 ... ... ... ... 231 ... 1,751

Flunitrazepam 

(Rohypnol) 473 ... ... ... ... ... ... ...

Ketamine 227 ... ... ... ... ... ... 144

LSD 1,953 ... 60 ... ... ... ... 1,784

PCP 8,928 418 410 ... ... ... ... 7,779

Miscellaneous 

hallucinogens 3,445 ... 90 ... ... ... ... 3,214

Inhalants 9,275 187 ... 1,165 ... ... 3,338 4,376

Combinations NTA 1,524 ... 222 ... ... ... ... 1,282
26 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Drug category 

and selected 

drugs1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only (age 

< 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

ED visits per 100,000 population2,3,4

Total drug-related 

ED visits 680 41 61 113 202 83 2 20 239

Cocaine 131 5 28 ... ... 0 ... 98

Heroin 55 1 18 ... ... 0 0 36

Marijuana 73 3 9 ... ... 0 0 60

Stimulants 35 1 4 ... 0 0 ... 29

 Amphetamines 11 1 1 ... 0 0 0 9

 Methamphetamine 25 1 4 ... ... 0 ... 20

MDMA (Ecstasy) 3 0 ... ... ... ... ... 2

GHB 1 ... ... ... ... 0 ... 1

Flunitrazepam 

(Rohypnol) 0 ... ... ... ... ... ... ...

Ketamine 0 ... ... ... ... ... ... 0

LSD 1 ... 0 ... ... ... ... 1

PCP 3 0 0 ... ... ... ... 3

Miscellaneous 

hallucinogens 1 ... 0 ... ... ... ... 1

Inhalants 3 0 ... 0 ... ... 1 1

Combinations NTA 1 ... 0 ... ... ... ... 0

Table 5 (continued) 

Illicit drugs, by type of case: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits. For example, 383,350 visits involved cocaine, and 162,137 visits involved heroin. Visits cannot be summed 

across drugs because drug-related ED visits often involve multiple drugs (e.g., visits involving both cocaine and heroin would be double counted).

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 27

Figure 4

Illicit drugs in ED visits: 2004

0

25

50

75

100

125

150

Cocaine Heroin Marijuana Stimulants

131

Rate per 100,000 population

73

35

55

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

 When considered in relation to the population of the U.S., ED visits associated with illicit drugs are relatively 

infrequent, but vary across the major drugs (Figure 4):

■ 131 visits per 100,000 population for cocaine,

■ 73 visits per 100,000 population for marijuana,

■ 55 visits per 100,000 population for heroin, and

■ 35 visits per 100,000 population for stimulants.

The rates of ED visits involving cocaine, marijuana, heroin, and stimulants did not differ between males and females 

after taking population size and the margin of error into account (Figure 5). The rates for patients aged 21 to 54 

tended to be similar for cocaine and heroin, with lower rates for younger and older patients (Table 6 and Figure 5). For 

marijuana, the rates were highest for patients aged 18 to 24. For stimulants, the rates were highest for patients aged 

18 to 44.
28 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Table 6

Illicit drugs, by patient characteristics: 2004

Patient 

characteristics

Selected drugs1

Cocaine Heroin Marijuana Stimulants MDMA 

(Ecstasy) GHB LSD PCP

Drug-related ED visits2,3,4

Total drug-related 

ED visits 383,350 162,137 215,665 102,843 8,621 2,340 1,953 8,928

Gender

 Male 249,942 108,768 141,871 58,700 4,916 1,316 1,786 5,783

 Female 133,296 53,319 73,716 44,138 3,704 ... 167 3,131

 Unknown 112 50 78 ... ... ... ... ...

Age

 0-5 years 253 ... ... ... ... ... ... ...

 6-11 years ... ... 380 ... ... ... ... ...

 12-17 years 11,539 1,400 39,035 6,402 1,429 ... 451 806

 18-20 years 18,404 8,801 27,742 10,028 2,374 423 551 853

 21-24 years 34,564 18,256 32,154 15,542 2,179 ... 339 1,543

 25-29 years 49,153 25,037 28,645 18,340 1,357 404 157 1,246

 30-34 years 55,142 22,474 24,716 14,484 611 308 133 1,670

 35-44 years 127,662 44,864 40,639 24,405 513 326 201 1,724

 45-54 years 73,807 34,383 19,389 11,663 ... ... ... 895

 55-64 years 10,790 5,933 2,311 1,430 ... ... ... ...

 65 years and older1,503 653 403 49 ... ... ... ...

 Unknown 518 188 136 35 ... ... ... ...

Race/ethnicity

 White 145,216 68,297 111,685 60,469 4,108 ... 1,326 4,734

 Black 152,732 41,831 53,955 4,323 2,140 37 268 2,133

 Hispanic 36,888 18,595 18,677 8,904 ... 50 104 861

 Race/ethnicity NTA 4,589 1,607 2,706 1,910 191 ... ... 34

 Unknown 43,925 31,807 28,642 27,238 1,370 291 233 1,165
 DAWN, 2004: NATIONAL ED ESTIMATES 29

Patient 

characteristics

Selected drugs1

Cocaine Heroin Marijuana Stimulants MDMA 

(Ecstasy) GHB LSD PCP

ED visits per 100,000 population2,3,4

Total drug-related 

ED visits 131 55 73 35 3 1 1 3

Gender

 Male 173 75 98 41 3 1 1 4

 Female 89 36 49 ... ... ... 0 ...

Age

 0-5 years 1 ... ... ... ... ... ... ...

 6-11 years ... ... 2 ... ... ... ... ...

 12-17 years 45 6 154 25 6 ... 2 3

 18-20 years 149 71 225 81 19 3 4 7

 21-24 years 205 108 190 92 13 ... 2 9

 25-29 years 251 128 146 94 7 2 1 6

 30-34 years 269 110 121 71 3 2 1 8

 35-44 years 289 102 92 55 1 1 0 4

 45-54 years 177 83 47 28 ... ... ... 2

 55-64 years 37 20 8 5 ... ... ... ...

 65 years and older 4 2 1 0 ... ... ... ...

Table 6 (continued)

Illicit drugs, by patient characteristics: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits. 

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
30 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Figure 5

Illicit drugs, ED visit rates by age and gender: 2004

Cocaine

Marijuana

Heroin

Stimulants

0

50

100

150

200

250

300

65+

12-17

18-20

21-24

25-29

30-34

35-44 

45-54

55-64

6-11

0-5

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

149

205

289

4

251

177 173

89

45

1

269

37

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

2

146

47

98

49

8

92

121

190

154

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

1

225

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

2

83

36

102 108

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

71

6

110

20

128

75

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

0

94

28 41 30

5

55

92

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

81

25

71

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 31

ALCOHOL AND DRUG-RELATED ED VISITS

T

he second method of assessing drug misuse and abuse in DAWN focuses on alcohol: 

 ■ Alcohol used in combination with other drugs, and

■ Alcohol alone, in patients under the age of 21.

For 2004, DAWN estimates 461,809 (CI: 375,820 to 547,798) drug-related ED visits involved alcohol in combination 

with another drug or alcohol alone in a patient under the age of 21. Thus, nearly a quarter (23%) of all drug-related ED 

visits involved alcohol in one of these forms (Table 7).

Alcohol in combination with other drugs (Tables 8-10, Figure 6)

DAWN estimates 363,641 (CI: 289,516 to 437,766) ED visits related to use of alcohol in combination with another 

drug in 2004. Alcohol is reported to DAWN in combination with other drugs, regardless of the patient’s age. These are 

the only alcohol reports received for patients aged 21 and older. Nearly 9 out of 10 (87%) ED visits implicating alcohol 

with another drug were for adult patients. Alcohol in combination appeared in substantial numbers in most case types 

(Table 8):

■ In 30% of ED visits related to suicide attempts,

■ In 34% of seeking detox visits,

■ In 20% of overmedication visits,

■ In 49% of malicious poisoning visits, and

■ In 30% of visits categorized as case type other.

Alcohol was involved with other drugs in about a quarter (27%) of ED visits involving misuse or abuse of drugs—

i.e., overmedication, malicious poisoning, and case type other, considered as a group. Alcohol appeared rarely in 

adverse reactions (1% of visits).

Drug category and selected drugs1 Estimated 

visits2,3 

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound - Upper bound

Total drug-related ED visits 1,997,993 7.4 1,708,205 - 2,287,781 

Alcohol 461,809 9.5 375,820 - 547,798

 Alcohol-in-combination 363,641 10.4 289,516 - 437,766

 Alcohol alone 98,168 10.9 77,196 - 119,140

Table 7

Alcohol in drug-related ED visits: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com. 

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
32 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Drug category 

and selected 

drugs1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

Drug-related ED visits2,3,4 

Total drugrelated ED visits 1,997,993 121,585 177,879 96,809 592,044 244,330 6,026 57,940 701,381

Alcohol 461,809 37,414 60,022 96,809 8,212 47,915 2,935 603 207,897

 Alcohol-incombination 363,641 36,702 59,599 8,200 47,915 2,935 601 207,689

 Alcohol alone 98,168 712 424 96,809 ... ... ... ... ...

Percent of visits

Alcohol 23% 31% 34% 100% 1% 20% 49% 1% 30%

 Alcohol-incombination 18% 30% 34% 1% 20% 49% 1% 30%

 Alcohol alone 5% 1% 0% 100% ... ... ... ... ...

Table 8

Alcohol, by type of case: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits.

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Alcohol was most frequently combined with (Table 9):

■ Cocaine alone (83,816 visits),

■ Marijuana alone (33,954 visits),

■ Cocaine and marijuana (19,697 visits), and

■ Heroin alone (14,669 visits).

Among cases involving misuse or abuse of drugs, DAWN estimates 258,539 (CI: 189,623 to 327,455) ED visits 

involving alcohol in combination with other drugs in 2004. Males accounted for 62% of these visits involving alcohol 

and other drugs, but taking population size into account, males and females had similar rates of such visits. There was 

little variation in rates across the age groups from ages 18 to 44. However, rates of such visits were lower for older and 

younger patients.

In terms of race and ethnicity, 51% of the visits with alcohol in combination involved patients who were white. 

Evaluating the relative frequencies of the other race/ethnicity groups is impeded by missing data; in 14% of visits 

race/ethnicity was unknown.
 DAWN, 2004: NATIONAL ED ESTIMATES 33

Drugs reported 

with alcohol1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

Drug-related ED visits2,3,4

No other drug 98,168 712 424 96,809 ... ... ... ... ...

Cocaine only 83,816 1,566 20,234 ... ... 324 ... 61,686

Marijuana only 33,963 506 2,333 ... ... ... ... 31,099

Cocaine and 

marijuana only 19,697 437 4,973 ... ... 94 ... 14,193

Heroin only 14,669 349 4,565 ... ... ... ... 9,751

Cocaine and 

heroin only 9,992 167 4,181 ... ... ... ... 5,641

Stimulants only 9,525 204 949 ... ... 87 ... 8,269

Alprazolam only 9,035 1,371 717 253 4,097 ... ... 2,590

Table 9

Drugs reported most frequently with alcohol, by type of case: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits.

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update). 

Figure 6

Alcohol with other drugs, ED visit rates by age and gender: 2004

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

1

155

93

46

220 208

77

9

222 213

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

242

169
34 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Patient characteristics

All case types1,2,3,4

Overmedication, malicious 

poisoning, and case 

type other1,2,3,4

All alcohol Alcohol-incombination Alcohol alone Alcohol-in-combination

Total drug-related ED visits 461,809 363,641 98,168 258,539

Gender

 Male 281,019 224,217 56,802 161,412

 Female 180,675 139,322 41,353 97,037

 Unknown 114 102 ... 90

Age

 0-5 years 701 335 366 ...

 6-11 years 283 ... 267 ...

 12-17 years 60,118 19,605 40,512 16,835

 18-20 years 82,583 25,676 56,907 21,004

 21-24 years 37,437 37,436 ... 28,070

 25-29 years 41,592 41,584 ... 29,309

 30-34 years 44,946 44,935 ... 29,931

 35-44 years 106,723 106,720 ... 74,182

 45-54 years 70,440 70,362 ... 47,537

 55-64 years 13,319 13,314 ... 9,006

 65 years and older 3,298 3,289 ... 2,186

 Unknown 369 369 ... 284

Race/ethnicity

 White 250,706 191,860 58,846 130,865

 Black 94,014 86,541 7,473 63,102

 Hispanic 44,747 32,773 11,974 24,509

 Race/ethnicity NTA 6,727 4,570 2,157 3,613

 Unknown 65,614 47,896 17,718 36,451

Table 10

Alcohol, by patient characteristics: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits.

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 35

Alcohol only in patients under the age of 21 (Table 11, Figure 7)

DAWN estimates 96,809 (CI: 76,127 to 117,491) ED visits related to use of alcohol by patients who were younger 

than age 21 in 2004 (Table 4). These numbers increase very little if instances of underage alcohol use in suicide 

attempts and seeking detox cases are also included (Table 11).

Alcohol was specifically indicated in a diagnosis in about two out of three (68%) alcohol-only visits, with toxic 

effects (e.g., “intoxication”) in slightly fewer (57%) visits. Injuries were diagnosed in 29% of alcohol-only visits, and 

accidents, involving falls or motor vehicles, were indicated by diagnosis in 7% (Table 11).

Most (85%) of such visits resulted in patients being treated and released, usually to home; another 9% were 

admitted to inpatient units.

Taking population size into account, the rate of alcohol-only ED visits for ages 18 to 20 (456 visits per 100,000 

population) was 2.9 times that for patients aged 12 to 17 (157 per 100,000). The rates for males and females were 

equivalent.

In terms of race and ethnicity, 60% of the alcohol-only visits involved patients who were white. Evaluating the 

relative frequencies of the other race/ethnicity groups is impeded by missing data; in 18% of visits race/ethnicity was 

unknown.

Figure 7

Alcohol only (age < 21), ED visit rates by age and gender: 2004

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

0

100

200

300

400

500

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

Rate per 100,000 populationRate per 100,000 population

0

100

200

300

400

500

Male Female

2

456

128

97

157

1
36 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Patient characteristics Estimated

visits1,2 Visit characteristics Estimatedvisits1,2

Total drug-related ED visits 96,809

Gender Number of drugs involved

 Male 56,223 Single drug 96,809

 Female 40,573 Multiple drugs

 Unknown ... Alcohol involved 96,809

Age Disposition

 0-5 years 366 Treated and released 82,486

 6-11 years 267 Discharged home 71,324

 12-17 years 39,809 Released to police/jail 9,058

 18-20 years 56,367 Referred to detox/treatment 2,103

 21-24 years Admitted to this hospital 9,025

 25-29 years ICU/critical care 3,614

 30-34 years Surgery 247

 35-44 years Chemical dependency/detox ...

 45-54 years Psychiatric unit 800

 55-64 years Other inpatient unit 4,106

 65 years and older Other disposition 5,298

 Unknown Transferred 3,347

Race/ethnicity Left against medical advice 1,023

 White 58,010 Died ...

 Black 7,314 Other 317

 Hispanic 11,757 Not documented 519

 Race/ethnicity NTA 2,147

 Unknown 17,581

Selected diagnoses3

 Drug-related diagnoses

 Abuse 6,789

 Alcohol 65,742

 Toxic effects 55,412

 Other conditions

 Altered mental status 7,635

 Injuries 27,689

 Psychiatric conditions 6,430

 Depression 3,353

 Suicide (other than attempt) 2,248

 Miscellaneous

 Accidents 6,736

 Fall 907

 Motor vehicle 5,786

Table 11

Alcohol only (age < 21), by patient and visit characteristics: 2004

1 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

2 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

3 Components do not sum to total because multiple diagnoses may be reported for a single visit.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 37

Drug category and selected drugs1 Estimated 

visits2,3

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

bound

Patients aged 12-17

Alcohol 60,118 12.9 44,918 - 75,318

 Alcohol-in-combination 19,605 14.1 14,187 - 25,023

 Alcohol alone 40,512 13.5 29,793 - 51,231

Patients aged 18-20

Alcohol 82,583 9.1 67,853 - 97,313

 Alcohol-in-combination 25,676 7.3 22,002 - 29,350

 Alcohol alone 56,907 11.1 44,526 - 69,288

Table 12

Alcohol in drug-related ED visits in patients under age 21: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Any alcohol in patients under the age of 21 (Table 12)

Alcohol use by minors also occurs in combination with other drugs. Considering alcohol only and alcohol in 

combination with other drugs, DAWN estimates:

■ 60,118 (CI: 44,918 to 75,318) drug-related ED visits for patients aged 12-17, and

■ 82,583 (CI: 67,853 to 97,313) drug-related ED visits for patients aged 18-20.
38 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S
 DAWN, 2004: NATIONAL ED ESTIMATES 39

NON-MEDICAL USE OF PHARMACEUTICALS 

AND DRUG-RELATED ED VISITS

T he third method for assessing drug misuse and abuse in DAWN focuses on the non-medical use of prescription 

 and over-the-counter (OTC) pharmaceuticals. For this assessment, we consider drug-related ED visits related 

to three case types: overmedication, malicious poisoning, and case type other. Overmedication is defined as 

a patient taking more than the prescribed or recommended dose of a prescription or OTC pharmaceutical, and illicit 

drugs are explicitly excluded. Malicious poisoning means the patient was deliberately poisoned or drugged by another 

person. These cases may include drug-facilitated assault, drug-facilitated sexual assault, homicide when the weapon 

was a drug, and product tampering. Visits classified as case type other include pharmaceuticals taken, in general, for 

non-medical purposes that do not meet the criteria for any other DAWN case types, including pharmaceuticals taken 

in combination with illicit drugs. DAWN tries to capture only drugs related to the ED visit and actively discourages 

reporting of current medications that are unrelated. It is important to understand, however, that it is not possible to 

eliminate completely the reporting of current medications from the drugs being misused, and this should be considered 

in interpreting these findings.

Non-medical use of pharmaceuticals (Tables 13-14, Figure 8)

For 2004, DAWN estimates 495,732 (CI: 408,285 to 583,179) ED visits involved non-medical use—i.e., misuse or 

abuse—of prescription or OTC pharmaceuticals or dietary supplements (Table 13). Multiple drugs were involved in 

more than half (57%) of these ED visits (Table 14):

■ Over one-fifth (23%) involved alcohol in combination with another drug.

■ About 14% involved an illicit drug (other than alcohol).

■ About 6% involved alcohol and an illicit drug.

Central nervous system (CNS) agents (53% of visits involving non-medical use) and psychotherapeutic agents (48%) 

were the most frequent drugs in these visits (Table 13). Respiratory agents (4%), cardiovascular agents (6%), and all 

other categories of pharmaceuticals were much less frequent.

Among the CNS agents, the most frequent drugs were opiate/opioid analgesics (32% of non-medical use visits), 

including single-ingredient (e.g., oxycodone) and combination forms (e.g., hydrocodone with acetaminophen). 

Methadone and single-ingredient and combination forms of oxycodone and hydrocodone were the most frequent 

opioids. Once the margin of error is taken into account, these three opioids appear in similar numbers of visits:

■ Methadone in 31,874 ED visits (CI: 23,752 to 39,996),

■ Oxycodone/combinations in 36,559 ED visits (CI: 28,964 to 44,154),

■ Hydrocodone/combinations in 42,491 ED visits (CI: 31,831 to 53,151).

It is not possible to know the extent to which the source of these drugs is a legitimate prescription versus other 

sources. For example, it is not possible to distinguish methadone used for treatment of opiate addiction from the 

methadone in pill form that is prescribed for pain.
40 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

The opioids were followed in frequency by the non-opioid analgesics containing acetaminophen (8% of visits), 

muscle relaxants (6%), and anticonvulsants (5%). DAWN estimates 37,512 (CI: 29,057 to 45,967) ED visits involving 

non-opioid acetaminophen products. The most frequent muscle relaxant in ED visits was carisoprodol, which was 

involved in 17,366 (CI: 11,170 to 23,562) or 4% of ED visits in 2004.

Among the psychotherapeutic agents, the anxiolytics (anti-anxiety agents), sedatives, and hypnotics are the most 

frequent, occurring in more than a third (35%) of visits associated with pharmaceutical misuse/abuse. This category 

of pharmaceuticals includes barbiturates, benzodiazepines, and CNS stimulants such as methylphenidate. ED visits 

involving benzodiazepines clearly outnumber those involving any of the other types of psychotherapeutic agents. 

DAWN estimates that 144,385 (CI: 115,520 to 173,250) ED visits associated with pharmaceutical misuse/abuse 

involved benzodiazepines in 2004. This is comparable to the number for opiates/opioids.

According to DAWN, alprazolam in 49,842 visits (CI: 31,085 to 68,599) and clonazepam in 26,238 visits 

(CI: 20,581 to 31,895) are the most frequent benzodiazepines in ED visits related to pharmaceutical misuse/abuse. 

Benzodiazepines without a specific ingredient named appear in comparable numbers: 37,081 ED visits (CI: 26,470 to 

47,692). Benzodiazepines occurring less frequently but still in substantial numbers include diazepam in 15,733 ED visits 

(CI: 12,064 to 19,402) and lorazepam in 16,926 ED visits (CI: 14,139 to 19,713).

Among the other anxiolytics, sedatives, and hypnotics, the following drugs appear in similar numbers of ED visits:

■ Barbiturates, which are primarily unnamed, in 11,064 ED visits (CI: 7,509 to 14,619),

■ Diphenhydramine8

 in 9,330 ED visits (CI: 7,392 to 11,268), and

■ Zolpidem in 11,362 ED visits (CI: 8,890 to 13,834).

For the ED visits associated with pharmaceutical misuse/abuse, other psychotherapeutic agents of particular interest 

include:

■ Antidepressants in 62,743 ED visits (CI: 51,551 to 73,935) and

■ Antipsychotics, such as quetiapine, in 30,846 ED visits (CI: 22,865 to 38,827).

Methylphenidate, a CNS stimulant that has recently captured much attention, occurs much less frequently. DAWN 

estimates 1,541 ED visits (CI: 1,027 to 2,055) associated with pharmaceutical misuse/abuse involved methylphenidate.

8 This includes only single-ingredient formulations. Many multi-ingredient pharmaceuticals containing diphenhydramine are classified elsewhere, 

e.g., as respiratory agents.
 DAWN, 2004: NATIONAL ED ESTIMATES 41

Selected drug categories and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 495,732 9.0 408,285 - 583,179

PSYCHOTHERAPEUTIC AGENTS 239,829 9.2 196,584 - 283,074

Antidepressants 62,743 9.1 51,551 - 73,935

MAO inhibitors ... 86.5 ... - ...

SSRI antidepressants 30,817 12.5 23,267 - 38,367

Tricyclic antidepressants 10,897 11.0 8,547 - 13,247

Miscellaneous antidepressants 25,218 9.2 20,671 - 29,765

 Antipsychotics 30,846 13.2 22,865 - 38,827

 Anxiolytics, sedatives, and hypnotics 175,115 9.4 142,851 - 207,379

Barbiturates 11,064 16.4 7,509 - 14,619

Benzodiazepines 144,385 10.2 115,520 - 173,250

Alprazolam 49,842 19.2 31,085 - 68,599

Clonazepam 26,238 11.0 20,581 - 31,895

Diazepam 15,733 11.9 12,064 - 19,402

Lorazepam 16,926 8.4 14,139 - 19,713

Benzodiazepines-NOS 37,081 14.6 26,470 - 47,692

Misc. anxiolytics, sedatives, and hypnotics 28,304 8.6 23,533 - 33,075

Diphenhydramine 9,330 10.6 7,392 - 11,268

Hydroxyzine 2,468 18.2 1,588 - 3,348

Zolpidem 11,362 11.1 8,890 - 13,834

Anxiolytics, sedatives and hypnotics-NOS 2,722 26.5 1,309 - 4,135

CNS stimulants 7,972 8.6 6,627 - 9,317

Amphetamine-dextroamphetamine 2,227 16.5 1,508 - 2,946

Caffeine 2,787 14.3 2,005 - 3,569

Dextroamphetamine 408 45.1 47 - 769

Methylphenidate 1,541 17.0 1,027 - 2,055

CENTRAL NERVOUS SYSTEM AGENTS 261,582 8.7 216,976 - 306,188

Analgesics 222,833 8.1 187,457 - 258,209

Antimigraine agents 467 23.1 255 - 679

Cox-2 inhibitors 2,641 18.8 1,667 - 3,615

Opiates/opioids 158,281 8.7 131,292 - 185,270

Opiates/opioids, unspecified 29,461 12.4 22,301 - 36,621

Narcotic analgesics 132,207 9.8 106,813 - 157,601

Buprenorphine/combinations 236 35.9 69 - 403

Codeine/combinations 5,836 11.1 4,566 - 7,106

Fentanyl/combinations 8,000 15.0 5,648 - 10,352

Hydrocodone/combinations 42,491 12.8 31,831 - 53,151

Hydromorphone/combinations 2,779 26.1 1,358 - 4,200

Meperidine/combinations 1,310 22.3 738 - 1,882

Table 13

Non-medical use of pharmaceuticals: 2004
42 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Selected drug categories and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Methadone 31,874 13.0 23,752 - 39,996

Morphine/combinations 12,558 18.2 8,077 - 17,039

Oxycodone/combinations 36,559 10.6 28,964 - 44,154

Propoxyphene/combinations 6,448 16.3 4,388 - 8,508

Non-steroidal anti-inflammatory agents 22,961 9.7 18,596 - 27,326

Ibuprofen 17,934 9.4 14,629 - 21,239

Naproxen 4,817 16.3 3,278 - 6,356

Salicylates/combinations 11,820 16.1 8,090 - 15,550

Miscellaneous analgesics/combinations 41,508 10.6 32,884 - 50,132

Acetaminophen/combinations 37,512 11.5 29,057 - 45,967

Tramadol 2,984 14.7 2,124 - 3,844

Analgesic combinations NTA 1,195 19.4 740 - 1,650

Anorexiants 1,336 20.3 805 - 1,867

Anticonvulsants 26,926 11.2 21,015 - 32,837

Antiemetic/antivertigo agents 1,457 24.0 771 - 2,143

Antiparkinson agents 1,615 18.0 1,045 - 2,185

General anesthetics ... 98.8 ... - ...

Muscle relaxants 28,338 15.2 19,896 - 36,780

Carisoprodol 17,366 18.2 11,170 - 23,562

Cyclobenzaprine 5,932 14.4 4,258 - 7,606

 Miscellaneous CNS agents 854 28.6 376 - 1,332

RESPIRATORY AGENTS 20,340 11.1 15,914 - 24,766

Antihistamines 5,148 19.4 3,190 - 7,106

Bronchodilators 2,351 34.0 785 - 3,917

Decongestants 1,468 20.4 882 - 2,054

Expectorants 1,258 23.7 674 - 1,842

Upper respiratory combinations 9,431 8.9 7,787 - 11,075

Respiratory agents NTA 1,979 16.1 1,354 - 2,604

CARDIOVASCULAR AGENTS 27,286 17.2 18,088 - 36,484

Antiadrenergic agents, centrally acting 3,752 25.2 1,898 - 5,606

Beta-adrenergic blocking agents 7,014 14.8 4,980 - 9,048

Calcium channel blocking agents 2,465 22.8 1,363 - 3,567

Diuretics 3,968 30.4 1,604 - 6,332

Cardiovascular agents NTA 14,886 15.6 10,335 - 19,437

Table 13 (continued)

Non-medical use of pharmaceuticals: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 43

Figure 8

Non-medical use of pharmaceuticals, ED visit rates by age and gender: 2004

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

Taking population size and the margin of error into account, visits for non-medical use of pharmaceuticals did not 

differ between females (186 visits per 100,000 population) and males (151 per 100,000 population) (Figure 8). In terms 

of age, visit rates were highest for patients aged 18 to 44. Visit rates were lowest for patients 11 and younger. In terms 

of race and ethnicity, 65% of visits involved patients who were white. Evaluating the relative frequencies of the other 

race/ethnicity groups is impeded by missing data; in 15% of visits race/ethnicity was unknown.

Patients were treated and released in about half (52%) of ED visits associated with non-medical use of 

pharmaceuticals, but a third (34%) resulted in admission to inpatient hospital units (Table 14). Of those admitted 

to the hospital, about a third (36%) were sent to a critical care unit, and about 16% of those admitted to inpatient 

units went to a psychiatric unit. About 9% of ED visits for non-medical use of pharmaceuticals were transferred to 

another health care facility.

Among the most frequently occurring diagnoses for pharmaceutical misuse were overdose (in 38% of visits), 

depression or another psychiatric condition (23%), and suicide other than an attempt (11%). Diagnoses classified 

as other suicide include suicidal gestures, thoughts, or ideation; suicide attempts were classified separately. Visits 

frequently had diagnoses indicating drug involvement (70%). About 9% of ED visits involving the non-medical use of 

pharmaceuticals involved a diagnosis of pain.

0

100

200

300

400

500

600

Rate per 100,000 populationRate per 100,000 population

0

100

200

300

400

500

600

Male Female

86

252

186

242 280 302

182

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

112

209

250

13 6

151
44 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Patient characteristics Estimated

visits1,2 Visit characteristics Estimatedvisits1,2

Total drug-related ED visits 495,859

Gender Number of drugs involved

 Male 218,326 Single drug 213,241

 Female 277,273 Multiple drugs 282,618

 Unknown ... Alcohol involved 113,136

Age Disposition

 0-5 years 3,076 Treated and released 260,169

 6-11 years 1,457 Discharged home 228,902

 12-17 years 46,281 Released to police/jail 10,175

 18-20 years 37,294 Referred to detox/treatment 21,014

 21-24 years 47,210 Admitted to this hospital 168,899

 25-29 years 49,411 ICU/critical care 60,963

 30-34 years 49,461 Surgery 741

 35-44 years 109,938 Chemical dependency/detox ...

 45-54 years 87,118 Psychiatric unit 27,069

 55-64 years 32,556 Other inpatient unit 75,885

 65 years and older 31,203 Other disposition 66,793

 Unknown 185 Transferred 42,861

Race/ethnicity Left against medical advice 9,297

 White 322,515 Died 1,434

 Black 58,105 Other 3,533

 Hispanic 36,318 Not documented ...

 Race/ethnicity NTA 5,315

 Unknown 73,013

Selected diagnoses3

 Drug-related diagnoses 324,739

 Abuse 80,283

 Drug or alcohol 360,339

 Alcohol 43,950

 Drug 345,588

 Overdose 190,703

 Overmedication 9,744

 Toxic effects 50,256

 Body system (includes infections) 101,997

 Other conditions

 Altered mental status 47,406

 Pain 43,499

 Psychiatric conditions 115,383

 Depression 75,634

 Suicide (other than attempt) 54,983

Table 14

Non-medical use of pharmaceuticals, by patient and visit characteristics: 2004

1 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

2 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

3 Components do not sum to total because multiple complaints or multiple diagnoses may be reported for a single visit.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 45

SPECIAL TYPES OF DRUG-RELATED ED VISITS

T

 his chapter profiles two special types of drug-related ED visits captured by DAWN. Drug-related suicide attempts 

 and seeking detox cases are considered as separate and distinct classes of drug misuse or abuse.

Suicide attempt (Tables 15-16, Figure 9)

DAWN estimates 121,585 (CI: 108,955 to 134,215) ED visits for drug-related suicide attempts in 2004 (Table 15). 

It is important to remember that DAWN includes only those suicide attempts that involve drugs, but these attempts are 

not limited to overdoses. Also included are persons who attempt suicide by other means (e.g., by gun) when drugs are 

involved. Excluded are suicide attempts not involving drugs (e.g., by gun alone) and those documented as something 

other than an attempt (e.g., suicide ideation, gesture, thought, and so forth).

Nearly two-thirds of ED visits for drug-related suicide attempts involved multiple drugs (64%) (Table 16). Alcohol 

was the most frequently implicated drug and was involved in nearly a third (31%) of the ED visits for drug-related 

suicide attempts. Since DAWN excludes visits for adults when alcohol is the only drug, the role of alcohol in suicide 

attempts is probably larger. The most frequent illicit drugs were cocaine (11% of visits) and marijuana (8% of visits), 

but the margins of error for the illicit drugs are quite large and the numbers are relatively small when compared with 

the pharmaceuticals.

More than half (56%) of ED visits for drug-related suicide attempts involved psychotherapeutic agents, and nearly 

half (47%) involved CNS agents. The most commonly used psychotherapeutic agents were benzodiazepines (26%) and 

antidepressants (22%), which were implicated in similar numbers of ED visits. Again, it is not possible to know the 

extent to which these pharmaceuticals may have been prescribed to the patient for a preexisting condition. The CNS 

agents were primarily analgesics (pain relievers), including both prescription and over-the-counter formulations. DAWN 

estimates that the most commonly used pain relievers were acetaminophen/combinations and opiates/opioids, with 

each present in more than a third of visits (39% and 37%, respectively), followed by non-steroidal anti-inflammatory 

agents (NSAIDS, such as ibuprofen and naproxen, 25%), and salicylates/combinations (aspirins, 11%).

Among the 121,585 ED visits involving suicide, the involvement of alcohol or a drug was indicated by diagnosis 

in 65% of visits. The other most frequent diagnoses indicated overdose (61%) and suicide attempt (56%). Psychiatric 

conditions were also implicated in a large proportion of visits (40%), and the psychiatric disorder most frequently 

present was depression (35%).

About half (54%) of the suicide attempts were admitted for inpatient hospital care, and nearly half of these were 

admitted to a critical care unit. Others were admitted to psychiatric (14%) or other inpatient units (15%). Another 26% 

were transferred to another health care facility; only 12% were discharged home. Very few (0.25%) died in the ED. 

However, DAWN does not account for patients who die before arriving at the ED or patients who die after admission to 

inpatient units of the hospital.
46 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 121,585 5.3 108,955 - 134,215

Major substances of abuse

Alcohol 37,414 7.2 32,134 - 42,694

Alcohol-in-combination 36,702 7.2 31,522 - 41,882

Alcohol alone 712 27.4 330 - 1,094

Cocaine 13,940 12.0 10,661 - 17,219

Heroin 2,986 21.0 1,757 - 4,215

Marijuana 9,747 12.6 7,340 - 12,154

Stimulants 4,218 21.0 2,481 - 5,955

Amphetamines 1,894 22.4 1,063 - 2,725

Methamphetamine 2,391 25.8 1,182 - 3,600

MDMA (Ecstasy) 278 36.2 80 - 476

GHB ... 89.4 ... - ...

Flunitrazepam (Rohypnol) ... 92.9 ... - ...

Ketamine ... 43.7 ... - ...

LSD ... 59.5 ... - ...

PCP 418 26.1 204 - 632

Miscellaneous hallucinogens ... 91.9 ... - ...

Inhalants 187 38.4 46 - 328

Combinations NTA ... 58.8 ... - ...

Other substances

PSYCHOTHERAPEUTIC AGENTS 68,238 5.6 60,749 - 75,727

Antidepressants 26,787 6.7 23,269 - 30,305

MAO inhibitors ... 0.0 ... - ...

SSRI antidepressants 13,968 7.7 11,859 - 16,077

Tricyclic antidepressants 2,561 15.3 1,793 - 3,329

Miscellaneous antidepressants 12,150 7.9 10,268 - 14,032

Antipsychotics 12,830 9.3 10,492 - 15,168

Anxiolytics, sedatives, and hypnotics 42,967 6.5 37,493 - 48,441

Barbiturates 1,004 19.7 616 - 1,392

Benzodiazepines 31,695 8.0 26,724 - 36,666

Alprazolam 11,451 12.6 8,623 - 14,279

Clonazepam 8,370 11.2 6,533 - 10,207

Diazepam 3,571 14.4 2,564 - 4,578

Lorazepam 4,973 13.3 3,677 - 6,269

Benzodiazepines-NOS 3,619 19.4 2,243 - 4,995

Table 15

Suicide attempt: 2004
 DAWN, 2004: NATIONAL ED ESTIMATES 47

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Misc. anxiolytics, sedatives, and hypnotics 12,988 8.1 10,926 - 15,050

Diphenhydramine 4,718 13.8 3,442 - 5,994

Hydroxyzine 1,672 15.2 1,174 - 2,170

Zolpidem 4,408 11.0 3,457 - 5,359

Anxiolytics, sedatives and hypnotics-NOS 1,140 20.1 691 - 1,589

CNS stimulants 1,457 19.5 900 - 2,014

Amphetamine-dextroamphetamine 289 39.5 66 - 512

Caffeine ... 51.8 ... - ...

Dextroamphetamine ... 80.4 ... - ...

Methylphenidate 348 33.5 119 - 577

CENTRAL NERVOUS SYSTEM AGENTS 56,763 6.3 49,754 - 63,772

Analgesics 46,259 6.0 40,818 - 51,700

Antimigraine agents 299 39.3 68 - 530

Cox-2 inhibitors 708 19.7 436 - 980

Opiates/opioids 16,889 7.9 14,274 - 19,504

Opiates/opioids, unspecified 1,874 14.9 1,327 - 2,421

Narcotic analgesics 15,133 8.6 12,583 - 17,683

Buprenorphine/combinations ... 101.8 ... - ...

Codeine/combinations 1,431 16.4 970 - 1,892

Fentanyl/combinations ... 65.3 ... - ...

Hydrocodone/combinations 7,325 11.0 5,745 - 8,905

Hydromorphone/combinations ... 54.1 ... - ...

Meperidine/combinations ... 57.7 ... - ...

Methadone 1,207 28.4 535 - 1,879

Morphine/combinations 683 23.8 364 - 1,002

Oxycodone/combinations 3,324 12.1 2,536 - 4,112

Propoxyphene/combinations 2,088 19.3 1,298 - 2,878

Non-steroidal anti-inflammatory agents 11,594 7.7 9,844 - 13,344

Ibuprofen 8,063 9.1 6,624 - 9,502

Naproxen 3,199 16.0 2,195 - 4,203

Salicylates/combinations 5,068 12.4 3,837 - 6,299

Miscellaneous analgesics/combinations 19,019 7.9 16,073 - 21,965

Acetaminophen/combinations 17,847 8.3 14,944 - 20,750

Tramadol 1,045 27.5 482 - 1,608

Table 15 (continued)

Suicide attempt: 2004
48 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Analgesic combinations NTA 428 32.9 152 - 704

Anorexiants 115 33.8 39 - 191

Anticonvulsants 8,643 15.1 6,085 - 11,201

Antiemetic/antivertigo agents ... 54.7 ... - ...

Antiparkinson agents 246 41.5 46 - 446

General anesthetics ... 0.0 ... - ...

Muscle relaxants 5,829 13.5 4,286 - 7,372

Carisoprodol 2,489 19.1 1,558 - 3,420

Cyclobenzaprine 1,996 16.7 1,343 - 2,649

Miscellaneous CNS agents ... 64.9 ... - ...

RESPIRATORY AGENTS 5,879 12.6 4,427 - 7,331

Antihistamines 1,384 26.4 669 - 2,099

Bronchodilators 400 37.9 102 - 698

Decongestants 429 31.2 166 - 692

Expectorants 347 33.7 118 - 576

Upper respiratory combinations 3,098 13.7 2,267 - 3,929

Respiratory agents NTA 625 36.9 172 - 1,078

CARDIOVASCULAR AGENTS 6,258 13.1 4,651 - 7,865

Antiadrenergic agents, centrally acting 592 22.6 329 - 855

Beta-adrenergic blocking agents 2,205 17.6 1,445 - 2,965

Calcium channel blocking agents 766 28.4 339 - 1,193

Diuretics 459 29.3 196 - 722

Cardiovascular agents NTA 3,007 18.1 1,941 - 4,073

Table 15 (continued)

Suicide attempt: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 49

Patient characteristics Estimated

visits1,2 Visit characteristics Estimatedvisits1,2

Total drug-related ED visits 121,585

Gender Number of drugs involved

 Male 45,091 Single drug 43,425

 Female 76,475 Multiple drugs 78,160

 Unknown ... Alcohol involved 37,414

Age Disposition

 0-5 years ... Treated and released 20,770

 6-11 years 31 Discharged home 14,589

 12-17 years 15,299 Released to police/jail 1,025

 18-20 years 11,145 Referred to detox/treatment 5,156

 21-24 years 13,180 Admitted to this hospital 65,129

 25-29 years 14,392 ICU/critical care 29,261

 30-34 years 15,685 Surgery 30

 35-44 years 26,041 Chemical dependency/detox ...

 45-54 years 19,069 Psychiatric unit 16,982

 55-64 years 4,663 Other inpatient unit 18,551

 65 years and older 1,905 Other disposition 35,687

 Unknown ... Transferred 31,822

Race/ethnicity Left against medical advice 506

 White 75,019 Died 308

 Black 14,155 Other 696

 Hispanic 13,572 Not documented ...

 Race/ethnicity NTA 1,519

 Unknown 17,319

Selected diagnoses3

 Drug-related diagnoses 82,254

 Drug or alcohol 79,423

 Alcohol 11,897

 Drug 76,036

 Illicits 5,715

 Other or unspecified drug 72,387

Overdose 73,596

 Toxic effects 12,995

 Other conditions

 Altered mental status 4,347

 Psychiatric conditions 48,947

 Depression 42,898

Suicide 91,561

 Suicide attempt 68,123

 Other suicide-related 24,974

Table 16

Suicide attempt, by patient and visit characteristics: 2004

1 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

2 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

3 Components do not sum to total because multiple diagnoses may be reported for a single visit.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
50 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

 After accounting for population size and the margins of error, the rate of suicide visits for females (51 visits per 

100,000 population) was higher than that for males (31 per 100,000). The rates for patients aged 18 to 34 exceeded 

the rates for younger and older age groups. Although the rate for patients aged 12 to 17 (60 visits per 100,000) was 

lower than that for ages 18 to 34, it exceeded the rate for patients aged 45 and over. Nearly two-thirds (62%) of the 

suicide attempts involved patients who were white. Evaluating the relative frequencies of the other race/ethnicity 

groups is impeded by missing data; in 14% of visits race/ethnicity was unknown.

Figure 9

Suicide attempt, ED visit rates by age and gender: 2004

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

0

20

40

60

80

100

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

Male Female

0

78 77

46

59

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

16

5

60

74

90

31

51

Seeking detox (Tables 17-18, Figure 10)

DAWN estimates 177,879 (CI: 70,845 to 284,913) drug-related ED visits for patients seeking detoxification or 

substance abuse treatment services during 2004. These visits tend to be concentrated in hospitals with administrative 

practices that require medical clearance in the ED for admission to detox or substance abuse treatment units in the 

hospital. Therefore, it is impossible to know the full extent of the demand for these services from this estimate.

More than 60% of the seeking detox ED visits involved multiple drugs. A third (34%) involved alcohol, but for 

adults this includes only alcohol in combination with other drugs. Among the other major substances of abuse, cocaine 

(in 46% of visits) and heroin (30% of visits) occurred most frequently, followed by marijuana (15% of visits) and 

amphetamine or methamphetamine stimulants (7% of visits). Estimates for most pharmaceuticals are too imprecise for 

publication.9

Drug and/or alcohol involvement was indicated by diagnosis in 9 out of every 10 seeking detox visits. Psychiatric 

conditions were diagnosed in 23% of the visits. This suggests co-occurring drug misuse/abuse and mental health 

disorders. Drug abuse was indicated by diagnosis in 57% of the visits.

Among the seeking detox ED visits, 7 out of 10 received some type of follow-up care, either inpatient admission, 

referral elsewhere for detox or substance abuse treatment services, or transfer to another health care facility. However, 

about a quarter of seeking detox cases may not have received the care they sought because they were discharged to 

home.

9 This is not wholly unexpected since the numbers of seeking detox ED visits can vary dramatically across hospitals, and the presence of specialized 

detoxification or substance abuse treatment units is not accounted for in the DAWN sample design.
 DAWN, 2004: NATIONAL ED ESTIMATES 51

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 177,879 30.7 70,845 - 284,913

Major substances of abuse

Alcohol 60,022 26.4 28,964 - 91,080

 Alcohol-in-combination 59,599 26.6 28,527 - 90,671

 Alcohol alone 424 29.6 177 - 671

Cocaine 81,439 28.6 35,787 - 127,091

Heroin 53,088 19.9 32,381 - 73,795

Marijuana 27,259 22.7 15,131 - 39,387

Stimulants 12,151 33.5 4,172 - 20,130

 Amphetamines 1,829 42.0 324 - 3,334

 Methamphetamine 10,518 33.8 3,550 - 17,486

MDMA (Ecstasy) ... 50.9 ... - ...

GHB ... 86.5 ... - ...

Flunitrazepam (Rohypnol) ... 0.0 ... - ...

Ketamine ... 15.9 ... - ...

LSD 60 21.6 35 - 85

PCP 410 38.7 98 - 722

Miscellaneous hallucinogens 90 43.0 14 - 166

Inhalants ... 52.7 ... - ...

Combinations NTA 222 41.3 42 - 402

Table 17

Seeking detox: 2004

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2005, Multum Information Services, Inc. The classification has been 

modified to meet DAWN’s unique requirements (2005). The Multum Licensing Agreement governing use of the Lexicon is provided in 

Appendix A and can be found on the Internet at http://www.multum.com.

2 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

4 Three dots (...) indicate that an estimate with an RSE greater than 50% or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
52 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Patient characteristics Estimated

visits1,2 Visit characteristics Estimatedvisits1,2

Total drug-related ED visits 177,879

Gender Number of drugs involved

 Male 115,316 Single drug 66,182

 Female 62,541 Multiple drugs 111,696

 Unknown ... Alcohol involved 60,022

Age Disposition

 0-5 years ... Treated and released 89,851

 6-11 years ... Discharged home 45,459

 12-17 years 3,000 Released to police/jail 1,174

 18-20 years 10,036 Referred to detox/treatment 43,217

 21-24 years 21,573 Admitted to this hospital 71,017

 25-29 years 28,827 ICU/critical care 450

 30-34 years 28,335 Surgery ...

 35-44 years 50,380 Chemical dependency/detox ...

 45-54 years 30,434 Psychiatric unit 11,514

 55-64 years 4,566 Other inpatient unit 4,401

 65 years and older 579 Other disposition 17,011

 Unknown ... Transferred 10,433

Race/ethnicity Left against medical advice 2,539

 White 110,518 Died ...

 Black 41,128 Other 1,428

 Hispanic 9,641 Not documented 2,532

 Race/ethnicity NTA 1,324

 Unknown 15,268

Selected diagnoses3

 Drug-related diagnoses 158,636

 Abuse 101,454

 Addiction 14,056

 Dependence 28,052

 Detox 15,505

 Withdrawal 17,179

Drug or alcohol 161,601

 Alcohol 25,475

 Drug 157,866

 Illicits 47,469

Other or unspecified drug 117,835

 Other conditions

 Psychiatric conditions 40,520

 Suicide (other than attempt) 11,470

Table 18

Seeking detox, by patient and visit characteristics: 2004

1 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the coterminous U.S.

2 Three dots (...) indicate that an estimate with an RSE greater than 50% has been suppressed.

3 Components do not sum to total because multiple complaints or multiple diagnoses may be reported for a single visit.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
 DAWN, 2004: NATIONAL ED ESTIMATES 53

Taking population size and the margins of error into account, the rate of seeking detox cases was similar across all 

age groups in the 18 to 54 range. The rate of seeking detox visits for males was not significantly different than that for 

females. The lack of significant differences between age and gender subgroups is partially due to large margins of error. 

The majority (62%) of seeking detox visits involved patients who were white. Evaluating the relative frequencies of the 

other race/ethnicity groups is impeded by missing data; in 9% of visits race/ethnicity was unknown.

Figure 10

Seeking detox, ED visit rates by age and gender: 2004

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

147

73 80

42

16

114

138 128

81

12 265+ 12-17 18-20 21-24 25-29 30-34 35-44 45-54 55-64 

6-11

0-5 
54 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S
 DAWN, 2004: NATIONAL ED ESTIMATES 55

Appendixes
56 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S
 DAWN, 2004: NATIONAL ED ESTIMATES 57

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APPENDIX B

DAWN METHODOLOGY

Introduction

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that has monitored drug-related 

emergency department (ED) visits to hospitals since the early 1970s. DAWN was initially established by the Drug 

Enforcement Administration. Then, DAWN was transferred to the U.S. Department of Health and Human Services 

(USDHHS), where the National Institute on Drug Abuse conducted DAWN from 1980 to 1992. Since 1992, the Office 

of Applied Studies (OAS) of the Substance Abuse and Mental Health Services Administration (SAMHSA), USDHHS, has 

been responsible for DAWN operations and reporting.

Since its inception, DAWN has relied on data collected from a sample of hospitals. However, over the years, 

the exact survey methodology has been adjusted to improve the quality, reliability, and generalizability of the 

information produced by DAWN. When the National Institute on Drug Abuse assumed responsibility for DAWN in 

1980, implementation of a sample of hospitals to produce representative estimates for the Nation and for selected 

metropolitan areas became a priority. This sample, refreshed with annual maintenance, continued to support DAWN 

estimates for the coterminous United States and 21 metropolitan areas until 2002. By that time, major population 

shifts and changes in the hospital industry over the preceding two decades made apparent the need for a redesign of 

the sample of hospitals, which was undertaken as part of a wholesale redesign of most major features of DAWN.

Currently, the DAWN survey relies on a longitudinal probability sample of hospitals located throughout the United 

States, including Alaska and Hawaii. Hospitals eligible for selection into the DAWN sample must be non-Federal, 

short-stay, general surgical and medical hospitals located in the United States with at least one 24-hour emergency 

department. This current approach was implemented in the 2004 data collection year, and this publication is the first to 

include estimates based on this sample design.

Under the current methodological design, medical charts for all ED visits within the selected hospitals are reviewed 

retrospectively to find the drug-related cases for submission to DAWN. DAWN includes ED visits associated with 

substance abuse and drug misuse, both intentional and accidental. DAWN also includes ED visits related to the use 

of drugs for legitimate therapeutic purposes. To be a DAWN case, a drug needs only to be implicated in the visit; the 

drug does not need to have caused the visit. Only recent drug use is included; the reason a patient used the drug is 

irrelevant, and the case criteria are broad enough to encompass all types of drug-related events, which include, but are 

not limited to, explicit drug abuse. This approach, which finds ED visits related to drug abuse only indirectly, recognizes 

that medical records (the source of DAWN data) frequently lack explicit documentation of substance abuse, and 

distinctions between use, misuse, and abuse of drugs are often subjective.

DAWN uses the data from the visits classified as DAWN cases in the selected hospitals to calculate various 

estimates of drug-related visits for the Nation as a whole, as well as for specific metropolitan areas. To calculate 

these estimates and measure their precision, the DAWN survey requires the application of sampling and weighting 

methodologies. This appendix documents the sampling, weighting, and variance estimation methodologies used to 

develop estimates based on data collected in 2004.
62 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

1 AHA Annual Survey Database, Fiscal Year 2001 Health Forum LLC, Copyright 2003, One North Franklin Street, Chicago, IL 60606.

2

 Metropolitan Statistical Area is one category of Core Based Statistical Area (CBSA). The other CBSA category is the Micropolitan Statistical Area.

Target population

The target population is drug-related emergency department visits in non-Federal, short-stay, general surgical and 

medical hospitals in the United States with at least one 24-hour emergency department.

Sampling frame

DAWN uses the American Hospital Association (AHA) Annual Survey Database as the basis for its sampling frame. 

The AHA maintains an updated national registry of U.S. hospitals that is estimated to have a coverage rate of 99%.1 A 

health care organization must meet several criteria to be classified as a hospital. These include the provision of patient 

services, diagnostic or therapeutic, for general or specific medical conditions, licensed medical staff, and accreditation 

by organizations such as the Joint Commission on Accreditation of Health Care Organizations. A hospital is considered 

to be eligible for inclusion in the DAWN sampling frame if it is a non-Federal, short-stay, general surgical and medical 

hospital in the United States with at least one 24-hour emergency department. Many DAWN hospitals operate multiple 

emergency departments.

Sample maintenance

DAWN is a longitudinal survey that will be used to analyze trends in drug-related ED visits. In order to keep the 

frame representative of the current population of hospitals, annual sample updates must be performed. The initial 

sample was selected in 2003 from a sampling frame created from the 2001 AHA Annual Survey Database. In every 

subsequent year, the sampling frame is updated to reflect new, closed, merged, and demerged hospitals based on 

updates to the AHA files. These updates include newly eligible hospitals, which are those new hospitals or previously 

ineligible hospitals that are now eligible. Each year the newly eligible hospitals are provided the opportunity to be 

selected into the sample based on the sampling fraction of the stratum in which the newly eligible hospital is located.

Determination of DAWN eligibility

A hospital is considered ineligible if any one of the key criteria that define eligibility is not met. Only those hospitals 

that meet all the criteria are considered eligible. For hospitals where critical eligibility data are missing from the AHA 

database, if one of the non-missing criteria is not met, the hospital is considered ineligible. Otherwise, the hospital is 

considered to have unknown eligibility. For any hospital with unknown eligibility, other variables on the AHA Annual 

Survey Database are used to determine eligibility. If the hospital’s eligibility remains unknown after exploration of these 

additional characteristics, then the hospital may be contacted directly to determine eligibility.

Stratification

DAWN employs a stratified simple random sampling approach to select a representative sample of hospitals for 

inclusion in the DAWN sample. It is important that DAWN produce reliable estimates for major metropolitan areas 

as well as the Nation. Therefore, the first level of stratification is based on geography. There are two geographic 

stratification schemes: one for specified Metropolitan Statistical Areas2 and subdivisions, and one for the remainder of 

the Nation. The second level of stratification is based on ownership and hospital size.
 DAWN, 2004: NATIONAL ED ESTIMATES 63

Metropolitan Statistical Areas and subdivisions. In order to accommodate a planned expansion of the 

metropolitan areas covered by DAWN, a maximum set of metropolitan areas, based on the definitions issued by the 

Office of Management and Budget (OMB) in June 2003, was selected. Which metropolitan areas to include was a topic 

of the DAWN redesign.3 Retention of the existing 21 metropolitan areas was important because there was significant 

demand for estimates for those areas, and addition of the five most populous metropolitan areas in each of the nine 

Census divisions was deemed important to improve DAWN’s geographic and population coverage. This yielded a 

total of 48 metropolitan areas. For many of the 48 metropolitan areas, the June 2003 definitions resulted in larger 

metropolitan areas. In some cases, these larger areas represented a merger of previously separate metropolitan areas. 

However, there continued to be strong interest among users of DAWN statistics in the areas covered by the original 21 

metropolitan areas. In order to address the needs of these users, four of the merged areas were subdivided. For each of 

these areas, there was a sample for the metropolitan area, as well as a sample for each subdivision. This would enable 

DAWN to produce estimates for the metropolitan areas and for the subdivisions. As a result of this process, the final 

metropolitan-area sample included a total of 53 geographic units: 48 metropolitan areas, two subdivisions each for 

three of these metropolitan areas, and three subdivisions for one of these metropolitan areas.

This design recognized that, although each of the 53 geographic units was sampled, not every geographic unit 

would be active in DAWN at any particular point in time.4 One more feature of the design was needed to preserve this 

flexibility. When any geographic unit was inactive, it had to be represented in the national estimate and, consequently, 

in the supplemental sample. Therefore, within each metropolitan area, hospitals were also sampled to serve as that 

metropolitan area’s contribution to the supplemental sample.

Supplemental sample. The sample for the remainder of the Nation is referred to as the supplemental sample 

because it is designed to supplement the samples from the metropolitan areas to yield a national sample. The 

supplemental sample is, in effect, the 54th geographic unit for DAWN and is essential to achieve full coverage of the 

United States. The supplemental sample was formed by first dividing the United States into four Census regions. At any 

point in time, the supplemental sample provides coverage for all areas outside of the 53 metropolitan units described 

above, plus sample representation for the metropolitan areas where DAWN is not active.

Stratification by ownership and size. Within the geographic stratification scheme described above, hospitals 

were further stratified by ownership (public or private) and by size (based on the total number of emergency 

department visits reported for the hospital in the AHA Annual Survey Database). To begin, a cross classification was 

created by categories of ownership status and geographic unit. Within each combination of geographic area and 

ownership status, the number of hospitals determined the number of unique size categories. If there were three or 

fewer hospitals, only one size category was defined. If there were four, five, six, or seven hospitals, two size categories 

were defined. If there were eight or more hospitals, four size categories were defined. In the supplemental sample, 

within each combination of Census region and ownership, there were three size categories. This produced 24 unique 

strata from which to draw the hospitals for the supplemental sample.5

3 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2003: Interim National 

 Estimates of Drug-Related Emergency Department Visits, DAWN Series D-26, DHHS Publication No. (SMA) 04-3972, Rockville, MD, 2004.

4 This design took into account that expansion into additional metropolitan areas would occur over a period of time, but it has been similarly useful 

 for contraction.

5 Four Census regions times two ownership categories times three size categories equals 24 strata.
64 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Target levels of precision

DAWN defines precision in terms of the relative standard error (RSE) of an estimate. The RSE is the standard error 

of the estimate divided by the actual point estimate. DAWN is designed to have RSEs less than or equal to 10% for 

metropolitan area estimates and RSEs less than or equal to 15% for national estimates pertaining to total drug-related 

visits, cocaine visits, heroin visits, and marijuana visits. As discussed below, these desired precision levels are important 

drivers when setting sample size targets.

Sample size and sample allocation

Sample sizes for each geographic area were determined by the area’s targeted precision level in combination 

with the theory of optimal allocation for stratified samples. According to this approach, the variance of the sample 

estimates will be minimized when the sample size, nh, in each sampling stratum is made proportional to the quantity 

WhSh / Ch, where Wh is the proportion of sampling units, Sh is the population standard deviation for the parameter 

being measured, and Ch represents the square root of the cost of sampling in stratum h.

Using these optimum allocation conditions, the minimum required sample sizes necessary to achieve the targeted 

levels of precision in each DAWN area were calculated using the following general considerations:

■ Geographic units for which estimates are desired (national and metropolitan areas described under 

 Stratification),

■ Precision level desired (see Targeted levels of precision),

■ Specific types of estimates for which minimum precision is desired (e.g., estimates of total, cocaine, heroin, and 

 marijuana ED visits), and

■ Cost.

In addition to the above considerations, sampling rates (i.e., the number of sampled hospitals divided by the 

number of eligible hospitals) were also subject to the following constraints:

■ First, if fewer than four hospitals existed in the stratum population, then all hospitals in the stratum were 

 selected into the sample.

■ Second, if the sampling rate for a particular stratum was greater than 90%, then all units in the stratum 

 were selected into the sample.

■ Third, if any calculations produced a sample size smaller than two hospitals, then the sample size was set to 

 two hospitals.

Reduction of bias

Survey error is the extent to which findings from the survey sample differ from those of the population of interest. 

The statistical methodologies described above are designed to minimize error. There are additional sources of error, 

often referred to as bias, that also contribute to overall error. Measuring bias is difficult because it requires accurate 

knowledge about corresponding population values. The DAWN survey methodology includes proven techniques, 

practices, and protocols that reduce the potential for introducing bias. For example, clearly defined criteria are used 

to construct the initial hospital sampling frame. Coverage bias is minimized because the sampling frame has virtually 
 DAWN, 2004: NATIONAL ED ESTIMATES 65

100% coverage of the target population. To minimize possible measurement bias, the individuals who collect data 

for DAWN are provided with specialized and intensive training, automated methods for data entry are used, and the 

data are subject to quality reviews at several points in the data collection process. Additional detail on the survey 

methodologies used to enhance DAWN data quality and reduce bias are provided in the DAWN 2003 interim estimates 

of drug-related ED visits.6

Sampling weights

As discussed above, the DAWN hospitals were selected using stratified simple random sampling with oversampling 

in the selected metropolitan areas. The strata sample sizes were determined through the optimum allocation process. 

Sampling weights are calculated as the inverse of the probability of selection. Then the sampling weights are adjusted 

for nonresponse and by a procedure known as poststratification or benchmark adjustment.

Weighting adjustment for nonresponse

Unit nonresponse occurs when hospitals fail to provide information or provide only partial information. To minimize 

the impact of unit nonresponse, the DAWN weighting plan includes nonresponse adjustment factors that were 

developed and applied within each weighting class. Weighting classes were formed based on the aforementioned 

sampling stratification schemes. Within each weighting class, the nonresponse adjustment factor was calculated as the 

sum of the sampled hospital weights divided by the sum of the weights of the responding hospitals. The nonresponse 

adjustment factors were checked to make sure the adjustments were within reasonable bounds. If a nonresponse 

adjustment factor was out of bounds (either too small or too large), adjacent weighting classes were collapsed and 

new nonresponse adjustment factors were calculated.

When the nonresponse adjustment factors were considered final, a nonresponse-adjusted sampling weight was 

then calculated. For responding hospitals, the nonresponse-adjusted sampling weight was calculated as the product of 

the nonresponse adjustment factor and the sampling weight. For nonresponding hospitals, the hospital nonresponseadjusted sampling weight was set to zero. For each weighting class, a verification check was conducted to ensure that 

the sum of the nonresponse-adjusted sampling weights was equal to the sum of the sampled hospital weights.

Weighting adjustment for population benchmarks (poststratification)

The DAWN weighting plan also includes a poststratification adjustment factor that reconciles the weighted number 

of total visits for responding hospitals with the number of total visits from the most recent AHA Annual Survey 

Database. DAWN used a ratio adjustment within strata to implement this adjustment.

Poststratification strata were formed based on the aforementioned sampling stratification schemes. Within each 

stratum, the adjustment factor was calculated as the ratio of the AHA count of total visits to the weighted sum to total 

visits for responding hospitals. The factors were verified to ensure they were within reasonable bounds. If they were out 

of bounds (either too small or too large), adjacent poststratification strata were collapsed and new poststratification 

adjustment factors were calculated.

6 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2003: Interim National 

 Estimates of Drug-Related Emergency Department Visits, Appendix B, DAWN Series D-26, DHHS Publication No. (SMA) 04-3972, Rockville, MD, 2004. 
66 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

When the poststratification adjustment factors were considered final, a poststratified weight was then calculated. 

The poststratified weight was calculated as the product of the poststratification adjustment factor and the 

nonresponse-adjusted sampling weight. For each poststratification stratum, a validity check was conducted to ensure 

that the sum of the weighted total visits was equal to the corresponding AHA count of total visits from each stratum.

Calculation of estimates

All estimates produced for this publication were calculated using data that had been weighted according to the 

plan described above. Estimates for any variable of interest were determined by summing the poststratified weights for 

all data records in question.

Variance estimation

Each hospital in the DAWN sample was selected through a random process, which theoretically could have been 

repeated many times resulting in many hypothetical samples. Sampling variance or the margin of error refers to the 

extent to which these samples vary. Two measures of this variability are the standard error (SE) and relative standard 

error (RSE), which is defined as the SE expressed as a percentage of the value of the estimate. The precision of an 

estimate is inversely related to the sampling variance, as measured by the RSE. The greater the RSE value, the lower the 

precision.

For example, if there are 10,000 estimated visits involving a given drug, and this estimate has an SE of 500 visits, 

then the RSE value is 5%:

 RSE = SE/Estimate

 RSE = 500/10,000

 RSE = 0.05, or 5%.

In this publication, confidence intervals (CIs) are included in many of the tables and are often cited in the text along 

with the estimates. The 95% CI is calculated as:

 CI = Estimate ± (1.96 x RSE x Estimate)

where 1.96 comes from the table of normal distribution z-values. Ninety-five percent of the normal distribution lies 

between the z-values of ±1.96.

Applying the formula to the example above, the 95% CI would be:

 10,000 ± 1.96 x 0.05 x 10,000 = 10,000 ± 980.0

 Lower limit: 10,000 – 980 = 9,020

 Upper limit: 10,000 + 980 = 10,980

 95% Confidence interval: 9,020 to 10,980.

If repeated samples were drawn from the same population of hospitals using the same sampling and data 

collection procedures, the true population value would fall within the confidence interval 95% of the time.
D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S 67

Variance estimates reported in this publication were determined using Taylor Series Linearization. Variance estimates 

were calculated using SUDAAN® software.

Standardized rates

Standardized measures are needed to make valid comparisons of estimates across age and gender categories. For 

age in particular, the size of the underlying population differs considerably across age groups; for example, the number 

of individuals age 18 to 20 in the U.S. is much lower than the number of individuals age 35 to 44. All other factors 

being the same, a higher estimate of ED visits would be expected to occur naturally for the group that is larger in the 

population.

To take the size of the underlying population into account, rates of ED visits or drugs per 100,000 population were 

calculated using population data from the U.S. Bureau of the Census.7

For each age and gender category, the estimate for a category was divided by the population for that category, 

which was then divided by 100,000. For example, consider an estimate of 1,000 visits for an age group of 1,000,000 

persons and an estimate of 1,000 visits for an age group of 500,000 persons. The rates would be calculated as:

 1,000 / (1,000,000/100,000) = 1,000 / 10

 = 100 visits per 100,000 population

 1,000 / (500,000/100,000) = 1,000 / 5

 = 200 visits per 100,000 population.

Population estimates used to generate rates for this publication are provided in Appendix D.

Standardized rates were not calculated for race and ethnicity subgroups, because the race/ethnicity categories 

available to DAWN are much less detailed and contain considerably more missing data than the race and ethnicity 

categories in the Census data. Appendix E describes the race and ethnicity data reported for DAWN.

Publication criteria

DAWN can produce estimates for thousands of patient characteristics, visit characteristics, and drugs. However, 

some of these estimates are too imprecise or too small to be reliable. In these situations, the estimate was replaced by 

three dots (...) in the published table. Estimates were suppressed (i.e., not published) according to the following rules.

■ The RSE of the estimate was greater than 50%.

 When the RSE is greater than 50%, the lower bound of the 95% confidence interval approaches or includes the 

value zero. A confidence interval that includes zero means that the estimate is not statistically different from zero at 

this precision level.

7 Population estimates for 2004, as of July 2005, from U.S. Census Bureau County Population Dataset CO-EST2004-ALLDATA 

 (see http://www.census.gov/popest/counties/files/CO-EST2004-ALLDATA.csv).
68 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

■ The estimated quantity was less than 30.

Estimates this small constitute rare events, which are based on a small number of cases and have precision levels 

that are difficult to quantify. In many instances, such rare events have variances so large that the estimate would be 

suppressed based on its RSE alone. Rare events that meet RSE criteria for publication are nonetheless based on very 

little data and are deemed too unreliable for publication.

■ When an estimate was suppressed, an estimate or calculation using that estimate was also suppressed.

There are some estimates with an RSE equal to zero. This occurs when the number of ED visits being estimated is 

small and all the hospitals contributing to that estimate were selected with certainty, that is, their sampling probability 

is unity. Strictly speaking, there is no sampling error in such situations and the RSE is equal to zero. These results occur 

almost exclusively in situations with small numbers of ED visits, where the absence of any sampled hospital data is due 

to nonresponse and the small number of hospitals contributing to the estimates. In these situations, the necessary data 

are not available to approximate sampling errors.
 DAWN, 2004: NATIONAL ED ESTIMATES 69

APPENDIX C

GLOSSARY OF TERMS

This glossary defines terms used in data collection activities, analyses, and publications associated with the emergency 

department (ED) component of the Drug Abuse Warning Network (DAWN).

Accidental ingestion: This category of drug-related ED visits includes those involving the accidental use of a drug, 

for example, childhood drug poisonings and individuals who take the wrong medication by mistake.

Adverse reaction: This category of drug-related ED visits represents the consequences of using a prescription or overthe-counter (OTC) pharmaceutical for therapeutic purposes and includes visits related to adverse drug reactions, side 

effects, drug-drug interactions, and drug-alcohol interactions. Adverse reactions that involve a pharmaceutical with an 

illicit drug are exceptions that are excluded from this category.

Alcohol only (age less than 21): This category of drug-related ED visits includes those in which alcohol was the only 

drug involved and the patient was aged less than 21. Although alcohol is an illegal drug for minors, combining these 

cases with other cases involving illicit drugs tends to mask rather than highlight their importance for prevention and 

treatment efforts.

Case description: A description of how the drug(s) was related to the patient’s ED visit. The case description, in 

conjunction with the presenting chief complaint and diagnoses, is used to determine if the ED visit is reportable to 

DAWN. It is copied verbatim from the patient’s chart when possible. 

Case type: See Type of case.

Case type other: See Drug misuse and abuse.

Confidence interval: A “confidence interval” (CI) is an interval estimate, that is, a range of values around a point 

estimate that takes sampling error into account. Ninety-five percent is an accepted standard of confidence. Technically, 

a 95% CI means that if repeated samples were drawn from the same population of hospitals using the same sampling 

and data collection procedures, the true population value would fall within the confidence interval 95% of the time. 

Practically, a 95% CI summarizes both the estimate and its margin of error in a straightforward way with a reasonable 

degree of confidence. Calculation of 95% CIs is discussed in Appendix B.

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

four diagnoses can be entered for each DAWN case.

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

Treated and released includes three categories:

■ Discharged home—“Home” is used as a broad category to mean discharged to the patient’s 

 residence. Home is generally used for people who live locally; however, for students at nearby 
70 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

 universities, home means their university; for travelers who get sick on the road, it may mean their 

 hotel or wherever they are staying, and so forth.

■ Released to police/jail

■ Referred to detox/treatment—The chart indicates that the patient was referred to a substance 

 abuse treatment or detox program, facility, or provider.

Admitted to this hospital includes five categories of inpatient units:

■ ICU/critical care

■ Surgery

■ Chemical dependency/detox

■ Psychiatric unit

■ Other inpatient unit—The inpatient unit was not specified or does not match one of the preceding units.

Other Disposition includes five categories:

■ Transferred—The patient was transferred to another health care facility.

■ Left against medical advice—The patient left the treatment setting without a physician’s approval.

■ Died—The patient died after arriving in the ED but before being discharged, admitted, or transferred.

■ Other—The discharge status is documented in the chart but does not fit into any of the preceding categories.

■ Not documented—The discharge status was not documented in the medical chart.

Drug: This refers to a substance that was recorded in a DAWN case report. Substances accepted by DAWN include 

alcohol, illicit drugs, prescription and over-the-counter pharmaceuticals, dietary supplements, and non-pharmaceutical 

inhalants. Multiple substances (“drugs”) can be reported for each DAWN case. Therefore, the total number of drugs 

exceeds the total number of DAWN cases reported. (See also Single-drug case.) 

Drug category: A generic grouping of pharmaceuticals and other substances reported to DAWN, based on the 

classification of Multum Information Services. Multum Information Services is a subsidiary of the Cerner Corporation 

and a developer of clinical drug information systems and a drug knowledge base. More information is available at 

http://www.multum.com/. In general, the Multum categories follow the therapeutic uses for prescription and over-thecounter pharmaceuticals.

Additional clarification is provided for the following drug categories:

■ Alcohol alone—DAWN collects data on alcohol when used alone only if the patient is under age 21.

■ Alcohol-in-combination—Alcohol-in-combination is the category for alcohol present with another reportable 

 substance. DAWN does not gather data on alcohol used alone if the patient is over age 21. For patients 21 and 

 older, alcohol must be used with another substance to be reported to DAWN. Alcohol-in-combination is 

 reportable for all ages.

■ Amphetamines—This class of substances has been extracted from the category of central nervous system (CNS) 

 stimulants because of its importance as a major substance of abuse. For purposes of classification, 

 “amphetamines” (plural) includes a class of compounds derived from or related to the drug amphetamine. 

 Although some “designer” drugs fall into the class of amphetamines, we choose to report some of them 

 individually as major substances of abuse (e.g., methamphetamine). This category does not include other CNS 

 stimulants, such as caffeine or methylphenidate. 
 DAWN, 2004: NATIONAL ED ESTIMATES 71

■ Combinations not tabulated above (NTA)—This category includes combinations composed of two or more major 

 substances of abuse that are mixed and taken together. For example, “speedball,” which usually refers to the 

 combination of heroin and cocaine taken at once, would be classified as a combination NTA, whereas heroin and 

 cocaine used separately would be classified separately in the categories heroin and cocaine. Combinations 

 consisting of a major substance of abuse and another substance are classified in the category of the major 

 substance (e.g., heroin with scopolamine is classified as heroin).

■ Inhalants—This category includes anesthetic gases and psychoactive non-pharmaceutical substances for which 

 the documented route of administration was inhaled, sniffed, or snorted. Psychoactive non-pharmaceuticals fall 

 into one of the following three categories: (1) volatile solvents—adhesives (model airplane glue, rubber 

 cement, household glue), aerosols (spray paint, hairspray, air freshener, deodorant, fabric protector), solvents and 

 gases (nail polish remover, paint thinner, correction fluid and thinner, toxic markers, pure toluene, cigar lighter 

 fluid, gasoline, carburetor cleaner, octane booster), cleaning agents (dry cleaning fluid, spot remover, degreaser), 

 food products (vegetable cooking spray, dessert topping spray such as whipped cream, whippets), and gases 

 (butane, propane, helium); (2) nitrites—amyl nitrites (“poppers,” “snappers”) and butyl nitrites (“rush,” “locker 

 room,” “bolt,” “climax,” “video head cleaner”); or (3) chlorofluorohydrocarbons (freons). Anesthetic gases 

 (e.g., nitrous oxide, ether, chloroform) are presumed to have been inhaled.

Drug misuse and abuse: A group defined broadly to include case types related to drug misuse or abuse. Additional 

clarification is provided for the following case types:

■ Overmedication—This category was designed to capture non-medical use, overuse, and misuse of prescription 

 and OTC medications that are not documented as drug abuse in the medical chart.

■ Malicious poisoning—This category was designed to cases of drug use in which the patient was administered a 

 drug by another person for a malicious purpose. Drug-facilitated sexual assault is one type of malicious 

 poisoning, but other types of malicious poisonings such as product tampering would be classified in this 

 category as well.

■ Case type Other—This category includes all drug-related ED visits that could not be assigned to any of the 

 other seven types. By design, most cases of documented drug abuse will fall into this category, and most cases 

 in this category will involve use of illicit drugs or non-medical use of drugs and other substances.

Drug-related ED visit: Any ED visit related to recent drug use. This is the definition of a DAWN case effective 

January 1, 2003. To be a DAWN case, a drug needs only to be implicated in the visit; the drug does not have to have 

caused the visit. One patient may make repeated visits to an ED or to several EDs, thus producing a number of visits. 

It is impossible to determine the number of unique patients involved in the reported drug-related ED visits because no 

direct patient identifiers are collected by DAWN.

Estimate: A statistical estimate is the value of a parameter (such as the number of drug-related ED visits) for the 

universe that is derived by applying sampling weights to data from a sample.

Hospital emergency department (ED): The unit of a hospital established and staffed to provide emergency medical 

services. To be eligible for DAWN, the hospital must operate its ED(s) 24 hours a day, 7 days a week. 

Malicious poisoning: See Drug misuse and abuse.
72 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Metropolitan area: An area comprising a relatively large core city or cities and the adjacent geographic areas. 

Conceptually, these areas are integrated economic and social units with a large population nucleus. This DAWN 

publication utilizes areas defined by the Office of Management and Budget (OMB) in 2003, based on population data 

from the 2000 decennial Census.

Not otherwise specified (NOS): Catch-all category for substances that are not specifically named. Terms are 

classified into an NOS category only when assignment to a more specific category is not possible based on information 

in the source documentation (ED patient charts).

Not tabulated above (NTA): Designation used when categories are not presented in complete detail; smaller units 

are combined in the NTA category.

Overmedication: See Drug misuse and abuse.

p-value: A measure of the probability (p) that the difference between two estimates could have occurred by chance, 

if the estimates being compared were really the same. The larger the p-value, the more likely the difference could have 

occurred by chance. For example, if the difference between two DAWN estimates has a p-value of 0.01, it means that 

there is a 1% probability that the difference observed could be due to chance alone.

Population: See Universe.

Precision: The extent to which an estimate agrees with its mean value in repeated sampling. The precision of an 

estimate is measured inversely by its standard error (SE) or relative standard error (RSE). In DAWN publications, 

estimates with RSEs greater than 50% are regarded as too imprecise to be published. ED table cells where such 

estimates would have appeared contain the symbol “...” (3 dots). (See also Relative standard error.)

Race/ethnicity: The Office of Management and Budget (OMB) is responsible for standard protocols for the collection 

of data on race and ethnicity by federal systems, including DAWN. In October 1997, OMB issued a revised standard 

protocol, which permitted separate reporting of race and Hispanic ethnicity, the ability to capture more than one 

race for an individual, modifications in nomenclature (e.g., “Black” was changed to “Black or African American”), 

division of certain categories (“Asian or Pacific Islander” was split into two categories, “Asian” and “Native Hawaiian 

or Other Pacific Islander”), and elimination of the “Other” category. For data collections, such as DAWN, where selfidentification of the individual is not feasible, the revised OMB protocol also permitted a combined format, whereby 

race and Hispanic ethnicity would be recorded in a single data item, which could still record multiple entries for race 

and/or Hispanic ethnicity.

Since January 2003, DAWN has collected data on race/ethnicity using the combined format. The race/ethnicity 

categories on the DAWN data collection forms are as follows:

■ White—A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

■ Black or African American—A person having origins in any of the black racial groups of Africa.

■ Hispanic or Latino—A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish 

 culture or origin, regardless of race.
 DAWN, 2004: NATIONAL ED ESTIMATES 73

■ Asian—A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian 

 subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine 

 Islands, Thailand, and Vietnam.

■ American Indian or Alaska Native—A person having origins in any of the original peoples of North and South 

 America (including Central America), and who maintains tribal affiliation or community attachment.

■ Native Hawaiian or Other Pacific Islander—A person having origins in any of the original peoples of Hawaii, 

 Guam, Samoa, or other Pacific Islands.

■ Not documented—Used when documentation of race is not available from source records.

Despite the increased detail allowed by these categories and the provision for multiple entries, the actual race/ethnicity 

data reported to DAWN is quite limited because race and ethnicity are often not documented with this level of 

specificity in patient/decedent records. As a result, the classification used to tabulate DAWN data has a more limited 

set of categories, as follows:

■ White—Anyone meeting the definition of white (above). Those who are identified as white and Hispanic are 

 classified as Hispanic.

■ Black—Anyone meeting the definition of black or African American (above). Those who are identified as black or 

 African American and Hispanic are classified as Hispanic.

■ Hispanic—Anyone whose ethnicity is Hispanic or Latino (above) is placed in the category Hispanic, regardless 

 of race.

■ Race/ethnicity NTA—This includes those categories that are too small to report independently including: 2 or 

 more races, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander.

■ Unknown—Race/ethnicity is unknown. Those who are identified only as Hispanic are classified as Hispanic.

Relative standard error (RSE): A measure of an estimate’s relative precision. The RSE of an estimate is equal to the 

estimate’s standard error (SE) divided by the estimate itself. For example, an estimate of 2,000 cocaine visits with an 

SE of 200 visits has an RSE of 10%. The larger the RSE, the less precise the estimate. Estimates with an RSE of 50% or 

more are not published by DAWN. (See also Precision and Standard error.)

Sampling: Sampling is the process of selecting a proper subset of elements from the full population so that the 

subset can be used to make inference to the population as a whole. A probability sample is one in which each element 

has a known and positive chance (probability) of selection. A simple random sample is one in which each member has 

the same chance of selection. In DAWN, a sample of hospitals is selected in order to make inference to all hospitals; 

DAWN uses simple random sampling within strata.

Sampling frame: A list of units from which the ED sample is drawn. All members of the sampling frame have a 

probability of being selected. A sampling frame is constructed such that there is no duplication and each unit is 

identifiable. Ideally, the sampling frame and the universe are the same. The sampling frame for the DAWN hospital ED 

sample is derived from the American Hospital Association (AHA) Annual Survey of Hospitals.

Sampling unit: A member of a sample selected from a sampling frame. For the DAWN sample, the units are hospitals, 

and data are collected for all drug-related ED visits at the responding hospitals selected for the sample.

Sampling weights: Numeric coefficients used to derive population estimates from a sample.
74 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Seeking detox: This category of drug-related ED visits captures patient seeking substance abuse treatment, drug 

rehabilitation, or medical clearance for admission to a drug treatment or detoxification unit. They are classified 

separately because they often reflect administrative practices that vary across hospitals and may vary over time within 

the same hospital. Seeking detox visits tend to be concentrated in those facilities that operate specialized inpatient 

units providing substance abuse treatment or detoxification services, and the largest numbers are found in facilities 

that require medical clearance for entry into such treatment to be granted in their EDs.

Single-drug case: A single-drug case is one in which only one drug was involved. Because multiple substances may 

be recorded for each DAWN case (see Drug), readers should be cautious in interpreting the relationship between a 

given drug and the number of associated visits or deaths. For example, if the source record for a patient/decedent 

documented marijuana use, this does not mean that marijuana was the only drug involved in the visit/death or that 

the marijuana caused the visit/death. One should always consider whether and how many other drugs were used in 

combination. Even then, attributing a causal relationship between the visit/death and a particular drug may not be 

possible. DAWN only captures single-drug visits/deaths involving alcohol if the decedent was younger than age 21.

Standard error (SE): A measure of the sampling variability or precision of an estimate. The SE of an estimate is 

expressed in the same units as the estimate itself. For example, an estimate of 10,000 visits with an SE of 500 indicates 

that the SE is 500 visits.

Statistically significant: A difference between two estimates is said to be statistically significant if the value of 

the statistic used to test the difference is larger or smaller than would be expected by chance alone. For DAWN ED 

estimates, a difference is considered statistically significant if the p-value is less than 0.05. (See also p-value.)

Strata (plural), stratum (singular): Subgroups of a universe within which separate ED samples are drawn. 

Stratification is used to increase the precision of estimates for a given sample size, or, conversely, to reduce the sample 

size required to achieve the desired level of precision. The DAWN ED sample is stratified into metropolitan area cells 

plus an additional cell for the remainder of the United States. To ensure thorough coverage within metropolitan areas, 

the universe of hospitals in each is allocated into substrata identified by (a) two types of hospital ownership (public, 

private) and (b) up to four size categories (measured in terms of annual ED visits), creating up to eight substrata in 

each metropolitan area stratum. Hospitals in the stratum that covers the rest of the United States are stratified first by 

Census region, then by state, type of ownership, and size (also measured in terms of ED visits). A systematic sample is 

selected from each of the geographic strata.

Suicide attempt: This category of drug-related ED visits captures suicide attempts (e.g., “attempted suicide,” 

“tried to kill self”) documented in the medical record in which drug use was involved, including non-medical use of 

prescription or OTC pharmaceuticals. Suicidal gestures, thoughts, or ideation, including attempts to “harm” self, are 

assigned to another case type.

Type of case: A classification used to group similar DAWN cases from the diverse set of all drug-related ED visits. 

Each case is coded into one and only one category, the first that applies from the following hierarchy: suicide attempt, 

seeking detox, alcohol only (age < 21), adverse reaction, overmedication, malicious poisoning, accidental ingestion, 

and other. The rules for assignment of DAWN cases to types of cases are defined in the DAWN ED Decision Tree.
 DAWN, 2004: NATIONAL ED ESTIMATES 75

Universe: The entire set of units for which generalizations are drawn. The universe for the DAWN ED sample is 

all non-Federal, short-stay, general medical and surgical hospitals in the United States that operate one or more 

emergency departments 24 hours a day, 7 days a week. Specialty hospitals, hospital units of institutions, long-term 

care facilities, pediatric hospitals, hospitals operating part-time EDs, and hospitals operated by the Veterans Health 

Administration and the Indian Health Services are excluded. The universe of EDs is identified from the American 

Hospital Association’s Annual Survey Database.
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D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S 77

APPENDIX D

POPULATION DATA

Table D1

Population by age and gender: 20041

Age Total U.S. Males Females

Total 293,655,404 144,537,408 149,117,996

0-5 years 23,923,026 12,232,272 11,690,754

6-11 years 23,985,999 12,277,377 11,708,622

12-17 years 25,368,973 12,995,499 12,373,474

18-20 years 12,350,179 6,358,864 5,991,315

21-24 years 16,894,923 8,697,646 8,197,277

25-29 years 19,560,906 9,994,814 9,566,092

30-34 years 20,471,032 10,341,219 10,129,813

35-44 years 44,108,652 22,033,881 22,074,771

45-54 years 41,618,805 20,452,673 21,166,132

55-65 years 29,078,924 13,999,433 15,079,491

65 years and older 36,293,985 15,153,730 21,140,255

 1 Population estimates for 2004, as of July 2005, from U.S. Census Bureau County Population Dataset CO-EST2004-ALLDATA 

 (see http://www.census.gov/popest/counties/files/CO-EST2004-ALLDATA.csv).

 SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).
78 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S
 DAWN, 2004: NATIONAL ED ESTIMATES 79

 APPENDIX E

RACE AND ETHNICITY IN DAWN

In October 1997, the Office of Management and Budget (OMB) issued a revised standard protocol for race 

and ethnicity categories used in Federal data collection systems1. The new protocol permitted separate reporting 

of race and Hispanic ethnicity, and it incorporated the ability to capture more than one race for an individual, a 

few modifications in nomenclature (e.g., “black” was changed to “black or African American”), division of certain 

categories (“Asian or Pacific Islander” was split into two categories, “Asian” and “Native Hawaiian or Other Pacific 

Islander”), and elimination of the “Other” category. For data collections, such as DAWN, where self-identification of 

the individual is not feasible, the OMB protocol also permitted a combined format, whereby race and Hispanic ethnicity 

would be recorded in a single data item, which could still record multiple entries for race and/or Hispanic ethnicity. The 

complete DAWN ED case form, which adopted the combined format in 2003, is reproduced in Figure 2 in this report.

Despite the increased detail allowed by the new categories and the provision for multiple entries, the actual 

race/ethnicity data extracted from source records and submitted to DAWN is quite limited. This is because the source 

documents (that is, the ED medical records from which DAWN data are abstracted) rarely contain such detailed 

information on race/ethnicity of patients.

For reference, estimates of drug-related ED visits by race/ethnicity are presented in Table E1. This analysis, which 

is based on the most detailed coding of race/ethnicity in DAWN case reports, reveals that estimates for the following 

categories are too small to be meaningful:

■ Multiple (i.e., two or more) races/ethnicity (that is, two or more races/ethnicity were documented in the

 source record for the same individual),

■ Hispanic or Latino ethnicity with any specific race indicated,

■ American Indian or Alaska Native,

■ Asian, and

■ Native Hawaiian or Other Pacific Islander.

Therefore, in the tables of estimates in this and other DAWN publications we have retained a more limited set of 

categories: White, Black, and Hispanic. A fourth category called “Race/ethnicity not tabulated above (NTA)” is used to 

tabulate those categories that are too small to report independently.2 All cases reported to DAWN as Hispanic or Latino 

ethnicity are tabulated as Hispanic race/ethnicity, regardless of race.

This lack of detailed race and ethnicity data in DAWN case reports also prevents us from generating rates per 

100,000 population for race and ethnicity categories. Data from the 2000 decennial Census were collected and are 

being tabulated according to the revised race and ethnicity protocol and are therefore incompatible with DAWN 

estimates.

1 See Office of Management and Budget, Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity, Federal Register, 62

FR 58782, October 30, 1997.

2 One exception is that if two races are reported and the second is reported as unknown, the episode is coded for the known race.
80 D A W N , 2 0 0 4 : N A T I O N A L E D E S T I M A T E S

Table E1

Drug-related ED visits, by detailed race/ethnicity: 2004

Race/ethnicity Estimated visits1,2,3

Total drug-related ED Visits 1,997,993

One race/ethnicity 1,989,924

White 1,148,616

Black/African American 366,017

Hispanic 167,679

Asian 4,740

American Indian/Alaska Native 9,578

Native Hawaiian/Other Pacific Islander 2,373

Race Unknown 290,921

Two races/ethnicitIes 8,060

White + Black/African American 821

White + Hispanic 6,506

White + Asian 40

White + American Indian/Alaska Native 102

White + Native Hawaiian/Other Pacific Islander ...

Black/African American + Hispanic 359

Black/African American + Asian ...

Black + Native Hawaiian/Other Pacific Islander ...

Black/African American + American Indian/Alaska Native ...

Hispanic + Asian ...

Hispanic + American Indian/Alaska Native 30

Asian + American Indian/Alaska Native ...

Asian + Native Hawaiian/Other Pacific Islander ...

American Indian/Alaska Native + Native Hawaiian/Other Pacific Islander 166

Three races/ethnicities ...

White + Black/African American + Asian ...

White + Latino + American Indian/Alaskan Native ...

Six races/ethnicities ...

White + Black + Latino + Asian + American Indian/Alaska Native + 

Native Hawaiian/Other Pacific Islander ...

1 These are estimates of ED visits based on a representative sample of non-Federal, short-stay hospitals with 24-hour EDs in the U.S.

2 Estimates are all expressed in visits.

3 Three dots (...) indicate that an estimate with an RSE greater than 50% has been suppressed or an estimate less than 30 has been suppressed.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (09/2005 update).