OFFICE OF APPLIED STUDIES 

Drug Abuse Warning Network, 2006: 

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 DAWN, 2006: NATIONAL ED ESTIMATES 

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) and Victoria Albright, M.A. (Project Director, RTI) wrote the publication. 

Other significant contributors included CAPT Kathy M. Poneleit, M.P.H. (SAMHSA/OAS), Erin Mallonee, M.S. 

(Analyst, RTI), Karol Krotki, Ph.D. (Statistician, RTI), Leyla Stambaugh, Ph.D. (Analyst, RTI), and Peter Frechtel, M.A. 

(Statistician, RTI). The DAWN data collection was conducted by Westat under Contract No. 283-02-9025 under the 

direction of Josefina Moran, M.A. 

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, 2006: National Estimates of Drug-Related Emergency Department Visits. DAWN Series D-30, DHHS 

Publication No. (SMA) 08-4339, Rockville, MD, 2008. 

OBTAINING ADDITIONAL COPIES OF PUBLICATION 

This publication may be downloaded from http://DAWNinfo.samhsa.gov or from http://oas.samhsa.gov. 

Hard copies may be obtained from http://oas.samhsa.gov/copies.cfm. 

Or please call SAMHSA’s Health Information Network at: 

1-877-SAMHSA-7 (1-877-726-4727) 

(English and Español). 

ORIGINATING OFFICE 

Substance Abuse and Mental Health Services Administration 

Office of Applied Studies 

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

August 2008 
DAWN, 2006: NATIONAL ED ESTIMATES 3

CONTENTS 

Page 

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

Highlights .......................................................................................................................................... 7

ED visits involving drug misuse/abuse ......................................................................................... 7

Illicit drugs in ED visits .................................................................................................................. 8

Alcohol and drug-related ED visits ................................................................................................ 8

Alcohol in combination with other drugs .................................................................................... 8

Alcohol in patients under age 21 ............................................................................................... 9

Nonmedical use of pharmaceuticals ............................................................................................. 9

Comparisons in drug misuse and abuse: 2004, 2005, and 2006 ................................................ 10

Special types of drug-related ED visits ....................................................................................... 10

Suicide attempts ..................................................................................................................... 10

Seeking detox ......................................................................................................................... 11

Introduction .................................................................................................................................... 13

Major features of DAWN ............................................................................................................. 13

What is a DAWN case? .......................................................................................................... 13

What drugs are included in DAWN? ....................................................................................... 13

What is covered in this publication? ........................................................................................ 14

Hospital participation in 2006 ..................................................................................................... 14

Estimates in this publication ....................................................................................................... 15

Margin of error for estimates ...................................................................................................... 15

Comparisons across years ......................................................................................................... 16

Margin of error for comparisons across years ............................................................................ 16

Estimates adjusted for population size ....................................................................................... 16

Drug Misuse and Abuse in ED Visits ............................................................................................ 17

Illicit Drugs in ED Visits ................................................................................................................. 19

Alcohol in ED Visits ....................................................................................................................... 27

Alcohol in combination with other drugs (Tables 5-6, Figure 3) .................................................. 27

Alcohol-related ED visits in patients under the age of 21 (Table 7) ............................................ 30

ED visits for underage alcohol use (Tables 4, 8, Figure 4) ......................................................... 30

Nonmedical Use of Pharmaceuticals ............................................................................................ 33

Nonmedical use of pharmaceuticals (Tables 9-10, Figure 5) ...................................................... 33
4 DAWN, 2006: NATIONAL ED ESTIMATES 

CONTENTS 

Page 

Comparisons of ED Visits: 2004, 2005, and 2006 ........................................................................ 41

Drug misuse and abuse in ED visits (Table 11) .......................................................................... 41

Illicit drugs in ED visits (Table 12) .............................................................................................. 43

Alcohol in ED visits (Tables 13-14) ............................................................................................. 44

Nonmedical use of pharmaceuticals (Table 15) .......................................................................... 45 

Special Types of Drug-Related ED Visits ..................................................................................... 49

Suicide attempts (Tables 16-17, Figure 6) .................................................................................. 49

Suicide attempt ED visits: 2004, 2005, and 2006 (Table 18) ...................................................... 54

Seeking detox (Tables 19-20, Figure 7) ..................................................................................... 58

Seeking detox ED visits: 2004, 2005, and 2006 (Table 21) ........................................................ 62

List of Tables 

Table 1 Drug misuse and abuse in ED visits in the U.S., by type of drug involvement: 

2006 .......................................................................................................................... 18 

Table 2 Illicit drugs in ED visits: 2006 ..................................................................................... 20 

Table 3 Illicit drugs, by patient characteristics: 2006 .............................................................. 23 

Table 4 Alcohol in drug-related ED visits: 2006 ...................................................................... 27 

Table 5 Alcohol in combination, by patient and visit characteristics: 2006 ............................. 28 

Table 6 Drugs most frequently reported with alcohol: 2006 .................................................... 29 

Table 7 Alcohol in drug-related ED visits in patients under age 21: 2006 ............................... 30 

Table 8 Alcohol only (age < 21), by patient and visit characteristics: 2006 ............................ 31 

Table 9 Nonmedical use of pharmaceuticals: 2006 ................................................................ 34 

Table 10 Nonmedical use of pharmaceuticals, by patient and visit characteristics: 2006 ......... 37 

Table 11 Drug misuse and abuse in ED visits in the U.S., by type of drug involvement: 

2004, 2005, and 2006 ................................................................................................ 42 

Table 12 Illicit drugs in ED visits: 2004, 2005, and 2006 .......................................................... 43 

Table 13 Alcohol in drug-related ED visits: 2004, 2005, and 2006 ........................................... 44 

Table 14 Alcohol in drug-related ED visits in patients under age 21: 2004, 2005, and 2006 .... 44 

Table 15 Nonmedical use of pharmaceuticals ED visits: 2004, 2005, and 2006 ...................... 45 

Table 16 Suicide attempts: 2006 .............................................................................................. 50 

Table 17 Suicide attempts, by patient and visit characteristics: 2006 ....................................... 53 

Table 18 Suicide attempts: 2004, 2005, and 2006 ................................................................... 55 

Table 19 Seeking detox: 2006 .................................................................................................. 59 

Table 20 Seeking detox, by patient and visit characteristics: 2006 .......................................... 60 

Table 21 Seeking detox: 2004, 2005, and 2006 ....................................................................... 62
DAWN, 2006: NATIONAL ED ESTIMATES 5

CONTENTS 

Page 

List of Figures 

Figure 1 Rates of ED visits involving selected illicit drugs: 2006 ............................................. 22

Figure 2 Illicit drugs, ED visit rates by age and gender: 2006 .................................................. 25

Figure 3 Alcohol with other drugs, ED visit rates by age and gender: 2006 ............................. 29

Figure 4 Alcohol only (age < 21), ED visit rates by age and gender: 2006 .............................. 32

Figure 5 Nonmedical use of pharmaceuticals, ED visit rates by age and gender: 2006 .......... 39

Figure 6 Suicide attempts, ED visit rates by age and gender: 2006 ........................................ 54 

Figure 7 Seeking detox, ED visit rates by age and gender: 2006 ............................................ 61

List of Appendixes 

Appendix A: Multum Lexicon End-User License Agreement ........................................................ 65 

Appendix B: Glossary of Terms .................................................................................................... 69 

Appendix C: DAWN Data Collection and Statistical Methods ....................................................... 77 

Appendix D: Race and Ethnicity in DAWN ................................................................................... 99 
6 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 7

HIGHLIGHTS 

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

2006, based on data from the Drug Abuse Warning Network (DAWN). Also presented are comparisons of 2006 

estimates with those for 2004 and 2005. DAWN is a public health surveillance system that monitors drugrelated ED visits for the Nation and for selected metropolitan areas. DAWN estimates pertain to the entire United 

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

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

ED visits under section 505 of the Public Health Service Act. 

DAWN relies on a 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. 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 (OTC) 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. 

The 2006 estimates introduce several improvements made to the DAWN sampling and estimation methodology. 

In order to ensure comparability between estimates for 2004, 2005, and 2006, the improvements were applied 

retrospectively to 2004 and 2005 data, resulting in small changes as compared to early published estimates. 

ED visits involving drug misuse/abuse 

In 2006, hospitals in the United States delivered a total of 113 million ED visits, and DAWN estimates that 

1,742,887 (confidence interval [CI]: 1,451,086 to 2,034,688)1 ED visits were associated with drug misuse or abuse. Of 

those ED visits: 

 31% involved illicit drugs only, 

 28% involved pharmaceuticals only, 

 7% involved alcohol only in patients under the age of 21, 

 13% involved illicit drugs with alcohol, 

 10% involved alcohol with pharmaceuticals, 

 8% involved illicit drugs with pharmaceuticals, and 

 3% involved illicit drugs with pharmaceuticals and alcohol. 

 

1 The 95% confidence interval (CI) accounts for the margin of error of the estimate. It indicates, with a high degree of confidence, that 

the true population value was between 1,451,086 and 2,034,688 drug-related ED visits. 

T 
8 DAWN, 2006: NATIONAL ED ESTIMATES 

Illicit drugs in ED visits 

For 2006, DAWN estimates that 958,164 (CI: 690,218 to 1,226,110) ED visits involved an illicit drug. Thus, over 

half (55%) of all the drug misuse/abuse ED visits during the year involved an illicit drug either alone or in combination 

with other types of drugs. DAWN estimates that: 

 Cocaine was involved in 548,608 ED visits (CI: 374,579 to 722,636), 

 Marijuana was involved in 290,563 ED visits (CI: 238,737 to 342,388), 

 Heroin was involved in 189,780 ED visits (CI: 119,525 to 260,035), 

 Stimulants, including amphetamines and methamphetamine, were involved in 107,575 ED visits (CI: 66,105 

to 149,046), and 

 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, cocaine was more frequent than any of the other illicit drugs. The 

stimulants (amphetamines and methamphetamine) were less frequent than marijuana and as frequent as heroin. 

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

 The rates of ED visits involving cocaine, marijuana, and heroin were higher for males than females, but the 

rates for stimulants did not differ by gender, 

 For cocaine, the rates for patients aged 18 to 54 were similar,2with lower rates for younger and older 

patients, 

 For heroin, the rates were highest for patients aged 21 to 54, 

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

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

Alcohol and drug-related ED visits 

For 2006, DAWN estimates that 577,521 (CI: 501,944 to 653,048) ED visits involved either alcohol in 

combination with another drug (all ages) or alcohol alone for patients under the age of 21. This is about one third 

(33%) of all drug misuse/abuse ED visits. 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 2006, DAWN estimates 450,817 (CI: 383,818 to 517,816) ED visits related to use of alcohol in combination 

with other drugs. Alcohol was most frequently combined with: 

 Cocaine alone (101,588 visits), 

 Marijuana alone (41,653 visits), 

 Cocaine and marijuana (21,241 visits), and 

 Heroin alone (14,958 visits). 

 

2 That is, the rates for the age categories 18 to 20, 21 to 24, 25 to 29, 30 to 34, 35 to 44, and 45 to 54 were not significantly different. 
DAWN, 2006: NATIONAL ED ESTIMATES 9

Alcohol in patients under age 21 

DAWN estimates 76,760 (CI: 60,318 to 93,202) alcohol-related ED visits for patients aged 12 to 17, and 105,675 

(CI: 82,757 to 128,593) alcohol-related ED visits for patients aged 18 to 20. Alcohol is an illegal drug for both of these 

age groups. 

About two thirds (69%) of the alcohol-related ED visits for minors involved alcohol and no other drug. Taking 

population size and the margin of error into account: 

 The rate of alcohol-only ED visits for patients aged 18 to 20 (581 visits per 100,000 population) was 2.8 times 

that for patients aged 12 to 17 (204 per 100,000), and 

 Males and females had similar rates. 

Nonmedical use of pharmaceuticals 

For 2006, DAWN estimates that 741,425 (CI: 674,198 to 808,652) ED visits involved nonmedical use of 

prescription or OTC pharmaceuticals or dietary supplements. The majority of these visits (54%) involved multiple 

drugs. 

Central nervous system (CNS) agents (present in 50% of nonmedical-use visits) and psychotherapeutic agents 

(44%) were the most frequent drugs reported in the nonmedical-use category of ED visits. 

Among the CNS agents, the most frequent drugs were opiate/opioid analgesics (present in 33% of nonmedicaluse visits), including single-ingredient formulations (e.g., oxycodone) and combination forms (e.g., hydrocodone with 

acetaminophen). Methadone, together with 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 appeared in 

similar numbers of visits: 

 Hydrocodone/combinations in 57,550 ED visits (CI: 43,701 to 71,398), 

 Oxycodone/combinations in 64,888 ED visits (CI: 49,746 to 80,030), and 

 Methadone in 45,130 ED visits (CI: 35,870 to 54,389). 

It is not possible to know, based on the documentation available in ED medical records, the extent to which the 

source of these drugs is a legitimate prescription, as opposed to other sources, nor is it possible to distinguish 

methadone used for treatment of opiate addiction from the methadone in pill form, which is prescribed for pain. In fact, 

methadone may be one of the most ambiguous drugs to categorize in DAWN. When a patient on opioid replacement 

therapy presents to an ED, methadone may be routinely documented in the medical record, but without sufficient 

detail to distinguish whether the methadone specifically was related to the ED visit. 

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

most frequent, occurring in almost a third (32%) of visits associated with nonmedical use of pharmaceuticals. ED 

visits involving benzodiazepines clearly outnumber those involving any of the other types of psychotherapeutic 

agents. DAWN estimates that 195,625 (CI: 167,789 to 223,461) ED visits associated with nonmedical use of 

pharmaceuticals involved benzodiazepines in 2006. 
10 DAWN, 2006: NATIONAL ED ESTIMATES 

Taking population size and the margin of error into account: 

 ED visit rates for nonmedical use of pharmaceuticals did not differ between females and males, and 

 ED visit rates were highest for patients aged 18 to 44. 

Comparisons in drug misuse and abuse: 2004, 2005, and 2006 

In 2006, hospitals in the United States delivered a total of 113 million ED visits, an increase of 3.9% over 2004. 

The population of the United States increased 2.9%, from 294 million to 302 million, over the same period. 

According to DAWN, the total number of ED visits attributable to drug misuse and abuse was stable across 2004, 

2005, and 2006. That is, the apparent difference is within the margin of error. Across the different types of drug 

involvement, changes were detected for visits involving: 

 pharmaceuticals alone (i.e., with no other type of drug), which increased 44% from 2004 to 2006; 

 pharmaceuticals used in combination with illicit drug(s), which increased 36% from 2004 to 2006; and 

 pharmaceuticals used in combination with alcohol, which increased 22% from 2005 to 2006. 

Regarding the significant increases detected, it is worthwhile to consider that the number of pharmaceuticals 

dispensed for legitimate therapeutic uses may be increasing over time, and DAWN estimates are not adjusted to take 

such increases into account. Nor do DAWN estimates take into account the increases in the population or in ED use 

between 2004 and 2006. 

No significant changes in ED visits from 2004 to 2006, or from 2005 to 2006, were detected for any of the major 

illicit drugs (cocaine, heroin, marijuana, and stimulants) or for alcohol. 

ED visits related to nonmedical use of pharmaceuticals increased 38% in the period from 2004 to 2006. Among 

the drugs most frequently implicated in nonmedical use, notable changes from 2004 to 2006 occurred for 

psychotherapeutic agents (31%) and CNS agents (32%). Within these two categories, visits involving 

benzodiazepines increased 36%, and visits involving opiate/opioid analgesics increased 43%. Among the 

opiates/opioids, visits involving hydrocodone/combinations increased 44%, and visits involving 

oxycodone/combinations increased 56%. 

DAWN is not able to assess whether increases or decreases in ED visits associated with specific 

pharmaceuticals are related to changes in the quantity of these pharmaceuticals being prescribed for therapeutic 

uses. 

Special types of drug-related ED visits 

Suicide attempts 

DAWN estimates 182,805 (CI: 154,185 to 211,424) ED visits for drug-related suicide attempts in 2006.3 Nearly 

two thirds (65%) of ED visits for drug-related suicide attempts involved multiple drugs. 

 

3 Though a drug was implicated in each visit, these attempts are not limited to drug overdoses. 
DAWN, 2006: NATIONAL ED ESTIMATES 1 1

In these ED visits for drug-related suicide attempts in 2006: 

 The large majority of drug-related suicide attempts (92%) involved pharmaceuticals, 

 More than half (58%) included psychotherapeutic agents, such as benzodiazepines or antidepressants, 

 Slightly less than half (45%) involved CNS agents, primarily analgesics (pain relievers), including both 

prescription and OTC formulations, 

 Nearly one third (30%) involved alcohol (but DAWN data exclude visits for adults when alcohol is the only 

drug), and 

 About one quarter (23%) involved an illicit drug. 

Overall, there was no significant change in ED visits for drug-related suicide attempts during the time period from 

2004 to 2006, but an increase was detected from 2005 to 2006. Increases were evident from 2004 to 2006, as well as 

2005 to 2006, for some of the pharmaceuticals frequently involved in suicide attempts, such as benzodiazepines and 

opiate/opioid pain relievers. 

Seeking detox 

DAWN estimates 118,355 (CI: 90,171 to 146,540) drug-related ED visits for patients seeking detoxification or 

substance abuse treatment services during 2006. 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 within the 

hospital. Therefore, these visits do not encompass the full extent of the demand for these services. 

Nearly two thirds (65%) of the seeking detox ED visits involved multiple drugs. Illicit drugs and alcohol were 

common in these visits: 

 Cocaine (49% of visits) and heroin (29%) were followed in frequency by marijuana (19%) and amphetamine 

or methamphetamine stimulants (7%), and 

 Alcohol in combination with another drug was implicated in 40% of seeking detox ED visits. 

Among the seeking detox ED visits, nearly 7 out of 10 (69%) 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, more than one quarter (27%) of seeking detox cases might not have received the care they 

sought, because they were discharged to home. 

No significant changes in ED visits from 2004 to 2006, or from 2005 to 2006, were detected for seeking detox ED 

visits overall, or for alcohol or the illicit drugs involved in these visits. 
12 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 1 3

INTRODUCTION 

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

Warning Network (DAWN) for 2006, with comparison of estimates for 2004 and 2005. DAWN is a public health 

surveillance system that monitors drug-related ED visits for the Nation and for selected metropolitan areas. 

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 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. 

To be a DAWN case, the relationship between the ED visit and the drug use need not be causal; the drug needs 

only to be implicated in the visit. This approach accommodates cases where one or more drugs were involved but 

may or may not have directly caused the condition generating the ED visit, but at the same time avoids inclusion of 

current medications that are unrelated. Only recent drug use is included;4 the reason a patient used a drug need not 

be specified; and the criteria are broad enough to encompass all types of drug-related events, including explicit drug 

abuse. See Appendix C: DAWN Data Collection and Statistical Methods for a full description of DAWN cases and 

data collected on those cases. 

What drugs are included in DAWN? 

DAWN collects data on all types of drugs, including:5

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

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

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

and cold remedies, 

 Dietary supplements, such as vitamins, herbal remedies, and nutritional products, 

 Psychoactive, nonpharmaceutical inhalants,6

 Alcohol in combination with other drugs, and 

 Alcohol alone, in patients aged less than 21 years.7

 

4 That is, patients with a history of drug use (and no recent use) are excluded. 

5 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). The Multum Licensing Agreement governing use of the 

Lexicon is provided in Appendix A. 

6 To be reportable, a nonpharmaceutical substance must be consumed by inhalation, sniffing, or snorting and must have a psychoactive 

effect when inhaled. An ED visit involving inhalation of a nonpharmaceutical, psychoactive substance qualifies as a DAWN case even if 

no other drug was present. Carbon monoxide is excluded from the inhalants. Since 2004, cases involving accidental exposures (e.g., 

exposure to paint fumes while painting a closet) have been excluded as well. 

7 ED visits related to alcohol use alone are excluded for patients aged 21 and over. 

T 
14 DAWN, 2006: NATIONAL ED ESTIMATES 

In some cases, the medical record includes only nonspecific drug categories (for instance, “benzodiazepines” or 

“opiates”). These situations are noted in DAWN publications with the abbreviation “NOS” or “Not Otherwise 

Specified.” In addition, due to the multitude of drugs included in the DAWN drug vocabulary, it is not possible to show 

all drugs or even all types of drugs in this publication. In these situations, a residual group of drugs may be referred to 

in a table with the abbreviation “NTA” or “Not Tabulated Above.”

What is covered in this publication? 

While the full array of drug-related ED visits covered by DAWN is very broad, this publication focuses primarily 

on ED visits involving drug misuse and abuse. The national estimates of ED visits associated with drug misuse and 

abuse are presented in terms of the following three categories: 

 Illicit drugs, 

 Alcohol, and 

 Nonmedical use of pharmaceuticals. 

The illicit drugs category covers ED visits involving the use of substances that are generally illegal. The alcohol 

category includes alcohol used in combination with other drugs and alcohol used alone in patients under 21, but 

excludes alcohol used alone in patients aged 21 and over. Nonmedical use of pharmaceuticals includes ED visits 

related to the misuse or abuse of prescription or OTC medications or dietary supplements. Nonmedical use includes 

taking a higher than prescribed or recommended dose of a pharmaceutical (i.e., contrary to directions or labeling), 

taking a pharmaceutical prescribed for another individual, malicious poisoning of the patient by another individual, and 

substance abuse involving pharmaceuticals.8

In addition, this report includes a separate section on two special types of ED visits: drug-related suicide 

attempts and patients “seeking detox.” The latter includes patients who present to the ED seeking detoxification 

services or entry into a substance abuse treatment program. These visits tend to be concentrated in hospitals with 

administrative practices requiring medical clearance in the ED for admission to detox or substance abuse treatment 

units within the hospital. Drug-related ED visits involving suicide attempts or seeking detox are excluded from the 

category of nonmedical use of pharmaceuticals. 

Hospital participation in 2006 

For 2006, 205 hospitals submitted data that were used for estimation. The overall weighted response rate was 

26.1%. For the 12 oversampled metropolitan areas and divisions, the individual response rates ranged from 30.8% in 

the Houston metropolitan area to 71.2% in the Detroit metropolitan area. Additional detail on response rates is 

provided in Appendix C. 

DAWN cases are found through a retrospective review of medical records in participating hospitals. Across all 

participating hospitals in 2006, 9.8 million charts were reviewed to find the drug-related ED visits that met the DAWN 

case criteria. Based on the review of charts, 346,946 drug-related visits were found and submitted. On average, a 

 

8 Excluded are suicide attempts involving pharmaceuticals, accidental ingestions, visits for patients seeking detoxification services or 

entry into a substance abuse treatment program, and visits associated with the therapeutic use of pharmaceuticals. 
DAWN, 2006: NATIONAL ED ESTIMATES 1 5

DAWN member hospital submitted 1,077 DAWN cases. However, the number of submitted cases varied widely 

across hospitals, from 7 cases to 6,782 cases (median 820) in a single hospital during 2006. 

Estimates in this publication 

Estimates in this publication were calculated by applying sampling weights, nonresponse adjustments, and 

poststratification adjustments to data from the probability sample of hospitals. Only national estimates pertaining to 

the entire United States—50 States and the District of Columbia—are provided in this publication. 

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

the United States that operate 24-hour EDs. The American Hospital Association’s (AHA) 2001 Annual Survey is the 

source of the sampling frame. Subsequent AHA surveys are used annually to refresh the sample. For a definition of 

sampling frame and other technical terms used in this publication, see Appendix B: Glossary of Terms. 

The DAWN sample of hospitals includes an oversampling of hospitals in selected metropolitan areas (referred to 

as oversample areas), supplemented with a sample of hospitals from the remainder of the United States, which 

includes other metropolitan areas, as well as nonmetropolitan and rural areas. The metropolitan area boundaries 

correspond to the definitions issued by the Office of Management and Budget (OMB) in June 2003. National 

estimates are calculated as the sum of the estimates from oversample areas plus the estimate for the remainder of 

the United States after taking into account nonresponse, the volume of ED visits delivered by the universe of eligible 

hospitals in each area, and data quality factors. A more detailed discussion of the DAWN sample of hospitals and 

estimation procedures is provided in Appendix C. 

Margin of error for estimates 

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

sampling variability, referred to as the “margin of error.” 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). 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 quantities less than 30 are regarded as too imprecise 

for publication and are not shown. Three periods (“...”) are displayed in the place of suppressed estimates. 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, drugs other than alcohol cannot be present in 

an “alcohol-only” category. 

In this publication, 95% confidence intervals (CIs) are included in many of the tables and are cited in the text 

along with the estimates. 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. A CI, which is expressed as a range of values, is useful because the interval reflects both 

the estimate and its particular margin of error. 
16 DAWN, 2006: NATIONAL ED ESTIMATES 

For readers unfamiliar with these statistical concepts, additional descriptions and examples are provided in 

Appendix C. 

Comparisons across years 

In this publication, between-year changes are assessed by comparing estimates for 2006 to those for 2004 and 

to those for 2005. 

Major changes to DAWN were instituted at the beginning of 2003 as the result of a redesign that altered most of 

DAWN’s core features. Changes included the design of the hospital sample, the drug-related cases eligible for 

DAWN, the data items submitted on these cases, and the protocol for case finding and quality assurance. These 

improvements created a permanent disruption in trends. As a result, comparisons cannot be made between old 

DAWN (2002 and prior years) and the redesigned DAWN (2004 and forward).9

Margin of error for comparisons across years 

DAWN analysts tested each set of estimates between two years to ascertain if the difference exceeded its 

margin of error. To be reported in this publication as a change, the difference between estimates for two years must 

be statistically significant, that is, the difference must exceed the margin of error. Differences that are not statistically 

significant indicate that there was no real change between the two years. Appendix C provides additional detail on the 

method of testing for significant differences between estimates for different years. 

Estimates adjusted for population size 

Standardized measures are needed to make valid comparisons of ED visits 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 United States is much lower than the number 

of individuals aged 35 to 44. 

This publication reports rates of ED visits per 100,000 persons for unsuppressed estimates. Rates are generated 

using population data from the U.S. Bureau of the Census.10An example of how these rates are generated and the 

2006 population estimates used for this publication are found in Appendix C. 

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 D: Race and Ethnicity in DAWN, describes the race and ethnicity 

data reported to DAWN. 

 

9 For DAWN, 2003 was a transition year: 2003 data reflected some of the new features (e.g., the expanded case criteria) but also some 

of the old (e.g., the old sample of hospitals). Full-year estimates were not published for 2003, and the estimates that were published 

are not comparable to those from prior or subsequent years. 

10 Population estimates for 2006 are, as of 6/9/2008, from the U.S. Bureau of Census Postcensal Resident Population National 

Population Dataset, National estimates by demographic characteristics – single year of age, sex and race, and Hispanic Origin, 

Monthly Population Estimates. Link: http://www.census.gov/popest/datasets.html. File: NC-EST2007-ALLDATA-R-File14.csv. 
DAWN, 2006: NATIONAL ED ESTIMATES 1 7

DRUG MISUSE AND ABUSE IN ED VISITS 

or 2006, DAWN estimates that over 1.7 million ED visits were associated with drug misuse or abuse (Table 1). 

This estimate includes: 

 958,164 ED visits (CI: 690,218 to 1,226,110) that involved illicit drugs alone or in combination with other 

drugs, 

 577,521 ED visits (CI: 501,994 to 653,048) that involved the use of alcohol alone or in combination with other 

drugs, and 

 860,108 ED visits (CI: 787,298 to 932,918) associated with nonmedical use of pharmaceuticals alone or in 

combination with other drugs.11

Of the 1.7 million drug misuse/abuse visits, about two thirds (66%) were associated with a single drug type (illicit 

drugs, alcohol, or nonmedical use of pharmaceuticals). ED visits involving illicit drugs alone accounted for 31% of all 

visits related to drug misuse/abuse in 2006. ED visits involving nonmedical use of pharmaceuticals alone accounted 

for another 28%. About 7% of drug misuse/abuse visits were related to consumption of alcohol (and no other drug) by 

a minor.12 The remaining visits (34%) involved some combination of illicit drugs, alcohol, and/or nonmedical use of 

pharmaceuticals. 

This does not suggest that the majority of ED drug misuse/abuse visits involved a single drug. In fact, the typical 

drug-related ED visit involves multiple drugs, but these may be of a common type. For example, an ED visit involving 

illicit drugs alone often involves more than one illicit drug (e.g., cocaine and heroin). 

ED visits in each of the three major categories—illicit drugs, alcohol, and nonmedical use of pharmaceuticals— 

are discussed in greater detail in separate sections of this publication. 

 

11 These three categories of ED visits are not mutually exclusive, and the sum of the estimates is greater than the total number of drug 

misuse/abuse visits. See Appendix C for additional detail on the type of ED visits included in each category. 

12 ED patients over the age of 21 for whom alcohol was the only drug associated with their ED visits are not considered DAWN cases. 

F 
18 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 1 

Drug misuse and abuse in ED visits in the U.S., by type of drug involvement: 2006 

Drug involvement1 Estimated 

visits2

Percent 

of visits 

Relative 

standard 

error (RSE)

95% Confidence interval 

Lower 

bound - Upper bound 

All types of drug misuse/abuse 1,742,887 100% 8.5 1,451,086 - 2,034,688

Illicit drugs only 536,554 31% 18.3 343,920 - 729,189

Alcohol only (age < 21) 126,704 7% 12.5 95,766 - 157,642

Pharmaceuticals only 486,276 28% 5.8 430,721 - 541,832

Combinations 

Illicit drugs with alcohol3 219,521 13% 13.5 161,230 - 277,812

Illicit drugs with pharmaceuticals 142,535 8% 10.4 113,561 - 171,510

Alcohol with pharmaceuticals 171,743 10% 5.8 152,240 - 191,246

Illicit drugs with alcohol and pharmaceuticals 59,553 3% 9.8 48,079 - 71,028

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 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, 2006 (03/2008 update).
DAWN, 2006: NATIONAL ED ESTIMATES 1 9

ILLICIT DRUGS IN ED VISITS 

o better understand the role of specific drugs and types of drugs in ED visits, this publication provides more 

detailed analysis of three drug categories: illicit drugs, alcohol, and nonmedical use of pharmaceuticals. This 

section focuses on ED visits involving illicit drugs. 

For 2006, DAWN estimates that 958,164 (CI: 690,218 to 1,226,110) ED visits involved an illicit drug (Table 2). 

Thus, over half (55%) of all the drug misuse/abuse ED visits during the year involved illicit drugs, either alone or in 

combination with another drug type. 

DAWN estimates that cocaine was involved in 548,608 (CI: 374,579 to 722,636) ED visits. In other words, close 

to one in three drug misuse/abuse ED visits (31%) involved cocaine. 

Marijuana was involved in 290,563 (CI: 238,737 to 342,388) ED visits. Although it was associated with the 

second highest number of drug misuse/abuse ED visits for illicit drugs, marijuana was involved in approximately half 

as many ED visits as cocaine. 

Heroin was involved in 189,780 (CI: 119,525 to 260,035) ED visits, or approximately 11% of drug misuse/abuse 

ED visits overall. This is likely an underestimate, though, because some portion of heroin use has been unavoidably 

classified as an “unspecified opiate.” Heroin is an opiate, and some drug screens test for opiates only as a class. 

Nearly two thirds (64%) of reports of “opiates” submitted to DAWN for 2006 came from toxicology findings, so some 

unknown quantity of these may have been heroin. The number of drug misuse/abuse ED visits involving unspecified 

opiates is estimated at 55,674 (CI: 42,590 to 68,757) visits. 

Stimulants, including amphetamines and methamphetamine, were involved in 107,575 (CI: 66,105 to 149,046) 

ED visits, about 6% of drug misuse/abuse ED visits. Amphetamines and methamphetamine are combined for this 

analysis because some drug screens test for amphetamines only as a class. Consequently, an amphetamine-positive 

result could indicate amphetamine or methamphetamine. Nearly all (99%) of the reports of amphetamines submitted 

to DAWN came simply as “amphetamine” and 65% of those were derived from toxicology findings. 

Other illicit drugs appeared at much lower frequencies. For 2006, DAWN estimates: 

 MDMA (Ecstasy) in 16,749 ED visits (CI: 11,470 to 22,028), 

 PCP in 21,960 ED visits (CI: 5,518 to 38,403), 

 Miscellaneous hallucinogens in 3,898 ED visits (CI: 2,591 to 5,205), 

 LSD in 4,002 ED visits (CI: 1,945 to 6,059), 

 GHB in 1,084 ED visits (CI: 517 to 1,652), and 

 Ketamine in 270 ED visits (CI: 29 to 511). 

T 
20 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 2 

Illicit drugs in ED visits: 2006 

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

Drug-related ED visits 

Total drug misuse/abuse ED visits 1,742,887 8.5 1,451,086 - 2,034,688 

ED visits, illicit drugs 958,164 14.3 690,218 - 1,226,110 

Cocaine 548,608 16.2 374,579 - 722,636 

Heroin 189,780 18.9 119,525 - 260,035 

Marijuana 290,563 9.1 238,737 - 342,388 

Stimulants 107,575 19.7 66,105 - 149,046 

Amphetamines 32,240 11.4 25,034 - 39,446 

Methamphetamine 79,924 25.1 40,653 - 119,194 

MDMA (Ecstasy) 16,749 16.1 11,470 - 22,029 

GHB 1,084 26.7 517 - 1,652 

Flunitrazepam (Rohypnol) ... ... ... - ... 

Ketamine 270 45.6 29 - 511 

LSD 4,002 26.2 1,945 - 6,059 

PCP 21,960 38.2 5,518 - 38,403 

Miscellaneous hallucinogens 3,898 17.1 2,591 - 5,205 

Inhalants 5,643 15.9 3,886 - 7,400 

Combinations not tabulated above (NTA) 2,055 26.0 1,007 - 3,103 
DAWN, 2006: NATIONAL ED ESTIMATES 2 1

Table 2 (continued)

Illicit drugs in ED visits: 2006 

Drug category and selected drugs1

ED visits 

per 100,000 

population2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

ED visits per 100,000 population 

Total drug misuse/abuse ED visits 576.7 8.5 480.1 - 673.2 

ED visits, illicit drugs 317.0 14.3 228.4 - 405.7 

Cocaine 181.5 16.2 123.9 - 239.1 

Heroin 62.8 18.9 39.5 - 86.0 

Marijuana 96.1 9.1 79.0 - 113.3 

Stimulants 35.6 19.7 21.9 - 49.3 

Amphetamines 10.7 11.4 8.3 - 13.1 

Methamphetamine 26.4 25.1 13.5 - 39.4 

MDMA (Ecstasy) 5.5 16.1 3.8 - 7.3 

GHB 0.4 26.7 0.2 - 0.5 

Flunitrazepam (Rohypnol) ... ... ... - ... 

Ketamine 0.1 45.6 0.0 - 0.2 

LSD 1.3 26.2 0.6 - 2.0 

PCP 7.3 38.2 1.8 - 12.7 

Miscellaneous hallucinogens 1.3 17.1 0.9 - 1.7 

Inhalants 1.9 15.9 1.3 - 2.4 

Combinations not tabulated above (NTA) 0.7 26.0 0.3 - 1.0 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving both cocaine and 

heroin will appear twice in this table). Summing ED visits as reported will produce incorrect and inflated counts of ED 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, 2006 (03/2008 update). 

When considered in relation to the population of the United States, ED visits associated with illicit drugs vary 

across major drugs of abuse (Figure 1): 

 182 visits per 100,000 population for cocaine, 

 96 visits per 100,000 population for marijuana, 

 63 visits per 100,000 population for heroin, and 

 36 visits per 100,000 population for stimulants. 
22 DAWN, 2006: NATIONAL ED ESTIMATES 

Figure 1 

Rates of ED visits involving selected illicit drugs: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 

The rates of ED visits involving cocaine, marijuana, and heroin were higher for males than for females, after 

taking population size and the margin of error into account, but there was not a gender difference for stimulants 

(Figure 2). For cocaine the rates per 100,000 population were highest among patients aged 18 to 54, with lower rates 

for younger and older patients (Table 3, Figure 2). For heroin, the rates were highest for patients aged 21 to 54, while 

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

aged 18 to 44. 

In terms of race/ethnicity, 44% of the visits related to any illicit drug use involved patients who were white. 

However, evaluating the relative frequencies across the race/ethnicity groups is impeded by missing data; 

race/ethnicity was unknown in 11% of illicit drug-related visits overall, and the percentage was higher for some drugs 

(e.g., 13% for heroin and 20% for stimulants). 
DAWN, 2006: NATIONAL ED ESTIMATES 2 3

Table 3 

Illicit drugs, by patient characteristics: 2006 

Patient 

characteristics 

Selected drugs1

All 

illicits Cocaine Heroin Marijuana Stimulants MDMA 

(Ecstasy) GHB LSD PCP 

Drug-related ED visits2,3

ED visits, illicit 

drugs 958,164 548,608 189,780 290,563 107,575 16,749 1,084 4,002 21,960 

Gender 

Male 631,052 354,268 129,914 195,063 68,638 10,835 824 3,297 15,298 

Female 326,846 194,121 59,744 95,478 38,930 5,915 261 705 6,661 

Unknown 266 ... ... ... ... ... ... ... ... 

Age 

0-5 years 855 585 ... ... ... ... ... ... ... 

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

12-17 years 58,428 10,984 1,661 44,088 7,740 4,524 ... 1,045 1,242 

18-20 years 71,973 26,802 8,299 44,146 8,487 3,997 ... 1,075 1,718 

21-24 years 105,043 47,515 17,119 46,388 16,453 4,217 ... 611 5,118 

25-29 years 126,699 63,945 26,607 42,626 20,489 1,928 121 ... 5,637 

30-34 years 107,718 67,820 23,657 28,904 15,000 1,124 175 ... 2,714 

35-44 years 264,430 181,912 57,155 49,571 26,170 417 ... ... 3,088 

45-54 years 176,026 122,028 42,662 26,367 10,068 ... ... ... 2,271 

55-64 years 39,767 23,177 11,049 6,947 2,680 ... ... ... ... 

65 years and 

older 5,929 3,499 1,456 1,071 ... ... ... ... ... 

Unknown 388 300 ... 68 ... ... ... ... ... 

Race/ethnicity 

White 421,775 215,718 78,470 154,081 57,582 8,140 720 2,898 6,087 

Black 295,041 213,797 49,522 75,835 6,638 4,392 ... ... ... 

Hispanic 126,529 63,692 35,781 31,528 ... 1,528 ... ... ... 

Race/ethnicity 

not tabulated 

above (NTA) 

7,830 3,206 1,656 1,871 1,893 90 ... ... ... 

Unknown 106,990 52,194 24,351 27,248 21,658 ... 130 ... 1,625 
24 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 3 (continued)

Illicit drugs, by patient characteristics: 2006 

Patient 

characteristics 

Selected drugs1

All 

illicits Cocaine Heroin Marijuana Stimulants MDMA 

(Ecstasy) GHB LSD PCP 

ED visits per 100,000 population2,3

ED visits, illicit 

drugs 317.0 181.5 62.8 96.1 35.6 5.5 0.4 1.3 7.3 

Gender 

Male 423.5 237.8 87.2 130.9 46.1 7.3 0.6 2.2 10.3 

Female 213.3 126.7 39.0 62.3 25.4 3.9 0.2 0.5 4.3 

Age 

0-5 years 3.5 2.4 ... ... ... ... ... ... ... 

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

12-17 years 229.6 43.2 6.5 173.3 30.4 17.8 ... 4.1 4.9 

18-20 years 567.9 211.5 65.5 348.3 67.0 31.5 ... 8.5 13.6 

21-24 years 618.7 279.9 100.8 273.2 96.9 24.8 ... 3.6 30.1 

25-29 years 597.0 301.3 125.4 200.9 96.5 9.1 0.6 ... 26.6 

30-34 years 548.0 345.0 120.4 147.1 76.3 5.7 0.9 ... 13.8 

35-44 years 610.7 420.1 132.0 114.5 60.4 1.0 ... ... 7.1 

45-54 years 400.7 277.8 97.1 60.0 22.9 ... ... ... 5.2 

55-64 years 121.5 70.8 33.7 21.2 8.2 ... ... ... ... 

65 years and 

older 15.7 9.2 3.8 2.8 ... ... ... ... ... 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 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, 2006 (03/2008 update).
DAWN, 2006: NATIONAL ED ESTIMATES 2 5

Figure 2 

Illicit drugs, ED visit rates by age and gender: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
26 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 2 7

ALCOHOL IN ED VISITS 

mong all the drugs collected by DAWN, alcohol is unique. An ED visit related to alcohol use qualifies as a 

DAWN case under only two conditions: (1) the alcohol is found in combination with other drugs, regardless of 

patient age; or (2) the alcohol is found alone (i.e., not in combination with other drugs) in a patient under the 

age of 21. ED visits associated with alcohol use, particularly among underage patients, represent a significant public 

health and policy concern and are examined in detail in this section. 

For 2006, DAWN estimates that 577,521 (CI: 501,994 to 653,048) ED visits involved either alcohol in 

combination with another drug (all ages) or alcohol alone for patients under the age of 21. This is about one third 

(33%) of all drug misuse/abuse ED visits (Table 4). Of all these ED visits involving alcohol, about one fifth (22%) 

involved patients under the age of 21 who used alcohol alone, that is, with no other drug. 

Table 4 

Alcohol in drug-related ED visits: 2006 

Drug category and selected drugs1 Estimated 

visits2,3

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper 

bound 

Total drug misuse/abuse ED visits 1,742,887 8.5 1,451,086 - 2,034,688 

ED visits, alcohol 577,521 6.7 501,994 - 653,048 

Alcohol in combination 450,817 7.6 383,818 - 517,816 

Alcohol alone 126,704 12.5 95,766 - 157,642 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 Estimates are all expressed in visits. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 

Alcohol in combination with other drugs (Tables 5-6, Figure 3) 

DAWN estimates 450,817 (CI: 383,818 to 517,816) ED visits related to use of alcohol in combination with 

another drug(s) in 2006. Alcohol in combination with other drugs is reported to DAWN regardless of the patient’s age. 

These are the only alcohol reports received for patients aged 21 and older. It is these adult patients who account for 

nearly 9 out of 10 ED visits (87%) implicating alcohol with another drug (Table 5). 

Males accounted for 63% of visits involving alcohol in combination with other drugs (Table 5). Taking population 

size and the margin of error into account, males had higher rates of such visits than females (Figure 3). There was 

little variation in rates across the age groups from ages 18 to 54. ED visit rates were lower for older and younger 

patients. 

A 
28 DAWN, 2006: NATIONAL ED ESTIMATES 

In terms of race/ethnicity, 57% of the visits with alcohol in combination involved patients who were white. 

Evaluating the relative frequencies across the race/ethnicity groups is impeded by missing data; in 10% of visits 

race/ethnicity was unknown. 

Table 5 

Alcohol in combination, by patient and visit characteristics: 2006 

Patient characteristics Estimated 

visits1,2

 Visit characteristics Estimated 

visits 1,2

ED visits, alcohol in combination 450,817 

Gender Number of drugs involved 

Male 284,425 Single drug 

Female 166,278 Multiple drugs 450,817 

Unknown ... Alcohol involved 450,817 

Age Disposition 

0-5 years ... Treated and released 234,061 

6-11 years ... Discharged home 192,114 

12-17 years 24,418 Released to police/jail 15,664 

18-20 years 31,702 Referred to detox/treatment 26,283 

21-24 years 44,914 Admitted to this hospital 155,708 

25-29 years 53,936 ICU/critical care 35,474 

30-34 years 44,304 Surgery 429 

35-44 years 133,489 Chemical dependency/detox 12,935 

45-54 years 88,078 Psychiatric unit 49,858 

55-64 years 21,915 Other inpatient unit 57,011 

65 years and older 7,453 Other disposition 61,048 

Unknown 175 Transferred 40,915 

Race/ethnicity Left against medical advice 8,977 

White 256,104 Died ... 

Black 95,003 Other ... 

Hispanic 51,076 Not documented 2,791 

Race/ethnicity not tabulated above 

(NTA) 4,240 

Unknown 44,394 

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

United States. 

2 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, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 2 9

Figure 3 

Alcohol with other drugs, ED visit rates by age and gender: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 

Alcohol was most frequently combined with (Table 6): 

 Cocaine alone (101,588 visits), 

 Marijuana alone (41,653 visits), 

 Cocaine and marijuana (21,241 visits), and 

 Heroin alone (14,958 visits) 

Table 6 

Drugs most frequently reported with alcohol: 2006 

Drugs reported with alcohol1 Estimated visits2

No other drug 126,704 

Cocaine only 101,588 

Marijuana only 41,653 

Cocaine and marijuana only 21,241 

Heroin only 14,958 

Stimulants only 7,895 

Alprazolam only 8,007 

Cocaine and heroin only 10,628 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update).
30 DAWN, 2006: NATIONAL ED ESTIMATES 

Alcohol-related ED visits in patients under the age of 21 (Table 7) 

For individuals under age 21, alcohol is an illegal drug, and ED visits related to both alcohol alone and alcohol in 

combination are reported to DAWN for this age group. Considering alcohol alone and alcohol in combination with 

other drugs, DAWN estimates: 

 76,760 (CI: 60,318 to 93,202) alcohol-related ED visits for patients aged 12 to 17, and 

 105,675 (CI: 82,757 to 128,593) alcohol-related ED visits for patients aged 18 to 20. 

Nearly 7 in 10 (69%) of the alcohol-related ED visits for minors involved alcohol alone, a finding that is similar for 

patients aged 12 to 17 and patients aged 18 to 20 (Table 7). 

Table 7 

Alcohol in drug-related ED visits in patients under age 21: 2006 

Drug category and selected drugs1 Estimated 

visits2

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper 

bound 

Patients aged 12-17 

ED visits, alcohol 76,760 10.9 60,318 - 93,202 

Alcohol in combination 24,418 9.0 20,134 - 28,703 

Alcohol alone 52,342 14.6 37,323 - 67,360 

Patients aged 18-20 

ED visits, alcohol 105,675 11.1 82,757 - 128,593 

Alcohol in combination 31,702 8.9 26,193 - 37,211 

Alcohol alone 73,973 14.1 53,502 - 94,444 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 

ED visits for underage alcohol use (Tables 4, 8, Figure 4) 

For 2006, DAWN estimates 126,704 (CI: 95,766 to 157,642) ED visits related to use of alcohol alone (i.e., not in 

combination with another drug) by patients who were younger than age 21 (Table 4). Nearly all (99%, or 125,888 

visits) of those visits represent underage drinking that was not related to either a suicide attempt or a request for 

admission to detox or substance abuse treatment program (Table 8). 

Taking population size into account, the rate of these alcohol-only ED visits for patients aged 18 to 20 (581 visits 

per 100,000 population) was 2.8 times that for patients aged 12 to 17 (204 per 100,000). Males and females had 

similar rates (Figure 4). 
DAWN, 2006: NATIONAL ED ESTIMATES 3 1

In terms of race/ethnicity, 58% of these alcohol-only visits involved patients who were white. Evaluating the 

relative frequencies of the race/ethnicity groups is impeded by missing data; in 16% of visits, race/ethnicity was 

unknown (Table 8). 

Most (90%) of the alcohol-only ED visits resulted in patients’ being treated and released, usually to home; 

another 6% were admitted to inpatient units (Table 8). 

Table 8 

Alcohol only (age < 21), by patient and visit characteristics: 2006 

Patient characteristics Estimated 

visits1,2

 Visit characteristics Estimated 

visits1,2 

ED visits, alcohol only (age < 21)3 125,888 

Gender Number of drugs involved 

Male 71,306 Single drug 125,888 

Female 54,574 Multiple drugs 

Unknown ... Alcohol involved 125,888 

Age Disposition 

0-5 years ... Treated and released 112,671 

6-11 years ... Discharged home 102,839 

12-17 years 51,901 Released to police/jail 7,870 

18-20 years 73,598 Referred to detox/treatment 1,962 

21-24 years Admitted to this hospital 7,479 

25-29 years ICU/critical care 1,123 

30-34 years Surgery 90 

35-44 years Chemical dependency/detox ... 

45-54 years Psychiatric unit 943 

55-64 years Other inpatient unit 5,197 

65 years and older Other disposition 5,738 

Unknown Transferred 3,506 

Race/ethnicity Left against medical advice 688 

White 73,624 Died ... 

Black 7,427 Other 1,032 

Hispanic 23,602 Not documented 501 

Race/ethnicity not tabulated above 

(NTA) 1,709 

Unknown 19,526 

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

United States. 

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

3 This table is limited to ED visits classified as “alcohol only (age < 21)” and excludes visits classified as either “suicide attempt” or 

“seeking detox.” Therefore, the estimate of total visits is slightly lower than reported in Table 4. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update).
32 DAWN, 2006: NATIONAL ED ESTIMATES 

Figure 4 

Alcohol only (age < 21), ED visit rates by age and gender: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 3 3

NONMEDICAL USE OF PHARMACEUTICALS 

se of illicit drugs is, by definition, substance abuse. For pharmaceuticals, however, distinguishing medical 

from nonmedical use is more complicated.13 In DAWN, “medical use” means taking a prescription or over-thecounter (OTC) pharmaceutical as prescribed or recommended, and “nonmedical use” is use that does not 

meet the definition of medical use.14 Thus, nonmedical use of pharmaceuticals includes taking more than the 

prescribed dose of a prescription pharmaceutical or more than the recommended dose of an OTC pharmaceutical or 

supplement; taking a pharmaceutical prescribed for another individual; deliberate poisoning with a pharmaceutical by 

another person; and documented misuse or abuse of a prescription or OTC pharmaceutical or dietary supplement. 

Nonmedical use of pharmaceuticals may involve pharmaceuticals alone or pharmaceuticals in combination with illicit 

drugs or alcohol. 

A cautionary note: DAWN tries to capture only drugs that are related to the ED visit and actively discourages 

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

possible, given the limitations of medical record documentation, to eliminate completely the reporting of current 

medications, and this should be considered when one interprets these findings. Also, it is not possible to know, based 

on the documentation available in ED medical records, the extent to which pharmaceuticals came from legitimate 

prescriptions versus other sources. 

Nonmedical use of pharmaceuticals (Tables 9-10, Figure 5) 

For 2006, DAWN estimates that 741,425 (CI: 674,198 to 808,652) ED visits involved nonmedical use of 

prescription or OTC pharmaceuticals or dietary supplements (Table 9). The majority of these visits (54%) involved 

multiple drugs (Table 10): 

 Approximately one fifth (19%) of all nonmedical-use ED visits involved alcohol, 

 One fifth (21%) involved pharmaceuticals in combination with an illicit drug, and 

 About 6% involved pharmaceuticals in combination with both alcohol and an illicit drug. 

Central nervous system (CNS) agents (50% of nonmedical-use visits) and psychotherapeutic agents (44%) were 

the most frequent drugs reported in the nonmedical-use category of ED visits (Table 9). Respiratory agents (4%), 

cardiovascular agents (5%), and all other types of pharmaceuticals were much less frequent. 

Among the CNS agents, the most frequent drugs were opiate/opioid analgesics (33% of nonmedical-use visits), 

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

acetaminophen). Methadone, together with 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 appeared in 

similar numbers of visits: 

 

13 DAWN cases are identified through a retrospective review of medical charts. Given the limitations of medical record documentation, 

we have concluded that distinguishing misuse from abuse reliably is not feasible. 

14 Taking less than the prescribed or recommended dose is not considered “nonmedical use.” 

U 
34 DAWN, 2006: NATIONAL ED ESTIMATES 

 Hydrocodone/combinations in 57,550 ED visits (CI: 43,701 to 71,398), 

 Oxycodone/combinations in 64,888 ED visits (CI: 49,746 to 80,030), and 

 Methadone in 45,130 ED visits (CI: 35,870 to 54,389). 

Table 9 

Nonmedical use of pharmaceuticals: 2006 

Selected drug categories and selected drugs1 Estimated 

visits2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

ED visits, nonmedical use 741,425 4.6 674,198 - 808,652 

PSYCHOTHERAPEUTIC AGENTS 323,999 4.2 297,495 - 350,504 

Antidepressants 79,682 8.7 66,026 - 93,338 

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

SSRI antidepressants 35,370 14.6 25,248 - 45,491 

Tricyclic antidepressants 16,564 17.6 10,844 - 22,285 

Miscellaneous antidepressants 7,561 28.5 3,344 - 11,778 

Antipsychotics 44,733 8.7 37,080 - 52,387 

Anxiolytics, sedatives, and hypnotics 233,875 5.8 207,294 - 260,457 

Barbiturates 10,991 18.2 7,068 - 14,913 

Benzodiazepines 195,625 7.3 167,789 - 223,461 

Alprazolam 65,236 11.2 50,911 - 79,561 

Clonazepam 33,557 12.1 25,580 - 41,534 

Diazepam 19,936 9.8 16,108 - 23,764 

Lorazepam 23,720 10.0 19,079 - 28,361 

Benzodiazepines NOS 58,348 21.7 33,575 - 83,120 

Misc. anxiolytics, sedatives, and hypnotics 40,626 10.5 32,304 - 48,947 

Diphenhydramine 12,291 11.0 9,643 - 14,939 

Hydroxyzine 2,678 17.7 1,749 - 3,606 

Zolpidem 17,257 16.6 11,633 - 22,882 

Anxiolytics, sedatives, and hypnotics NOS 3,629 14.5 2,601 - 4,657 

CNS stimulants 13,892 16.5 9,401 - 18,383 

Amphetamine-dextroamphetamine 5,027 26.9 2,377 - 7,677 

Caffeine 4,407 22.0 2,509 - 6,305 

Dextroamphetamine ... ... ... - ... 

Methylphenidate 2,192 28.2 980 - 3,404 
DAWN, 2006: NATIONAL ED ESTIMATES 3 5

Table 9 (continued)

Nonmedical use of pharmaceuticals: 2006 

Selected drug categories and selected drugs1 Estimated 

visits2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

CENTRAL NERVOUS SYSTEM AGENTS 373,138 5.4 333,720 - 412,556 

Analgesics 323,579 5.5 288,441 - 358,717 

Antimigraine agents 1,191 29.2 509 - 1,873 

Cox-2 inhibitors ... 68.9 ... - ... 

Opiates/opioids 247,669 6.9 214,160 - 281,177 

Opiates/opioids, unspecified 50,978 12.6 38,416 - 63,540 

Narcotic analgesics 201,280 8.2 168,954 - 233,606 

Buprenorphine/combinations 4,440 41.6 823 - 8,057 

Codeine/combinations 6,928 18.4 4,433 - 9,424 

Fentanyl/combinations 16,012 27.3 7,441 - 24,583 

Hydrocodone/combinations 57,550 12.3 43,701 - 71,398 

Hydromorphone/combinations 6,780 23.6 3,649 - 9,911 

Meperidine/combinations 1,440 38.7 349 - 2,532 

Methadone 45,130 10.5 35,870 - 54,389 

Morphine/combinations 20,416 14.2 14,750 - 26,082 

Oxycodone/combinations 64,888 11.9 49,746 - 80,030 

Propoxyphene/combinations 6,220 18.6 3,955 - 8,485 

Nonsteroidal anti-inflammatory agents 27,662 8.9 22,846 - 32,479 

Ibuprofen 20,541 8.6 17,071 - 24,011 

Naproxen 6,651 17.9 4,314 - 8,987 

Salicylates/combinations 10,399 14.5 7,444 - 13,354 

Miscellaneous analgesics/combinations 54,313 7.9 45,938 - 62,687 

Acetaminophen/combinations 44,314 9.0 36,482 - 52,146 

Tramadol/combinations 6,048 16.2 4,128 - 7,969 

Tramadol 5,961 16.4 4,050 - 7,873 

Acetaminophen-tramadol ... ... ... - ... 

Analgesic combinations not tabulated above (NTA) 898 30.8 355 - 1,441 

Anorexiants 1,168 28.2 522 - 1,815 

Anticonvulsants 31,169 13.2 23,099 - 39,238 

Antiemetic/antivertigo agents 1,360 32.6 491 - 2,230 

Anti-Parkinson agents 3,816 31.5 1,457 - 6,174 

General anesthetics ... ... ... - ... 
36 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 9 (continued)

Nonmedical use of pharmaceuticals: 2006 

Selected drug categories and selected drugs1 Estimated 

visits2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

Muscle relaxants 38,918 16.5 26,325 - 51,510 

Carisoprodol 24,505 23.2 13,352 - 35,658 

Cyclobenzaprine 7,142 13.1 5,308 - 8,976 

Miscellaneous CNS agents 999 31.9 374 - 1,623 

RESPIRATORY AGENTS 28,867 10.3 23,053 - 34,681 

Antihistamines 4,130 20.8 2,450 - 5,809 

Bronchodilators 2,920 21.1 1,713 - 4,128 

Decongestants 1,511 31.0 593 - 2,428 

Expectorants 2,125 29.7 887 - 3,363 

Upper respiratory combinations 15,115 12.0 11,550 - 18,680 

Respiratory agents NTA 4,296 18.5 2,740 - 5,852 

CARDIOVASCULAR AGENTS 36,343 9.8 29,391 - 43,294 

Antiadrenergic agents, centrally acting 4,810 14.4 3,455 - 6,166 

Beta-adrenergic blocking agents 11,729 21.5 6,788 - 16,671 

Calcium channel blocking agents 5,227 16.4 3,546 - 6,907 

Diuretics 5,102 20.4 3,060 - 7,145 

Cardiovascular agents NTA 17,338 10.7 13,699 - 20,977 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 ED visits often involve multiple drugs. Such visits will appear multiple times in this table (e.g., a visit involving oxycodone and 

hydrocodone will appear twice in this table). Summing ED visits as reported will produce incorrect and inflated counts of ED 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, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 3 7

Table 10 

Nonmedical use of pharmaceuticals, by patient and visit characteristics: 2006 

Patient characteristics Estimated 

visits1,2

 Visit characteristics Estimated 

visits 1,2

ED visits, nonmedical use 741,425 

Gender Number of drugs involved 

Male 353,066 Single drug 341,796 

Female 388,084 Multiple drugs 399,629 

Unknown ... 

Age Disposition 

0-5 years 6,360 Treated and released 430,260 

6-11 years 4,366 Discharged home 392,512 

12-17 years 65,268 Released to police/jail 17,646 

18-20 years 51,972 Referred to detox/treatment 20,102 

21-24 years 71,351 Admitted to this hospital 223,622 

25-29 years 73,753 ICU/critical care 64,777 

30-34 years 66,650 Surgery 876 

35-44 years 157,450 Chemical dependency/detox ... 

45-54 years 131,797 Psychiatric unit 49,413 

55-64 years 50,933 Other inpatient unit 104,633 

65 years and older 61,346 Other disposition 87,543 

Unknown 181 Transferred 49,514 

Race/ethnicity Left against medical advice 16,097 

White 508,708 Died 1,574 

Black 77,553 Other ... 

Hispanic 59,847 Not documented 5,459 

Race/ethnicity not tabulated above 

(NTA) 8,433 

Unknown 86,884 

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

United States. 

2 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, 2006 (03/2008 update). 

Note that ED records frequently do not distinguish methadone used for treatment of opiate addiction from the 

methadone in pill form that is prescribed for pain. In fact, methadone may be one of the most ambiguous drugs to 

categorize in DAWN. When a patient on opioid replacement therapy presents to an ED, methadone may be routinely 

documented in the medical record, but without sufficient information to distinguish whether the methadone was 

related to the ED visit. 
38 DAWN, 2006: NATIONAL ED ESTIMATES 

The opioids were followed in frequency by the nonopioid analgesics containing acetaminophen (6% of 

nonmedical-use visits), muscle relaxants (5%), anticonvulsants (4%), and nonsteroidal anti-inflammatory agents 

(NSAIDs, 4%). DAWN estimates 44,314 (CI: 36,482 to 52,146) nonmedical-use visits involving nonopioid 

acetaminophen products. The most frequent muscle relaxant in nonmedical-use visits was carisoprodol, which was 

involved in 24,505 (CI: 13,352 to 35,658), or 3%, of nonmedical-use ED visits in 2006. 

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

most frequent, occurring in 233,875 (CI: 207,294 to 260,457) or about a third (32%) of visits associated with 

nonmedical use of pharmaceuticals. This category of pharmaceuticals includes barbiturates and benzodiazepines. ED 

visits involving benzodiazepines clearly outnumber those involving any of the other types of psychotherapeutic 

agents. DAWN estimates that 195,625 (CI: 167,789 to 223,461) ED visits associated with nonmedical use of 

pharmaceuticals involved benzodiazepines in 2006. 

According to DAWN, the most frequently named benzodiazepines were alprazolam in 65,236 (CI: 50,911 to 

79,561) ED visits and clonazepam in 33,557 (CI: 25,580 to 41,534) ED visits. Benzodiazepines without a specific 

ingredient named appeared in similar numbers: 58,348 (CI: 33,575 to 83,120) ED visits. Benzodiazepines occurring 

less frequently but still in substantial numbers included lorazepam in 23,720 (CI: 19,079 to 28,361) ED visits and 

diazepam in 19,936 (CI: 16,108 to 23,764) ED visits. 

Among the other anxiolytics, sedatives, and hypnotics, the following drugs appeared in similar numbers of 

nonmedical-use ED visits: 

 Zolpidem in 17,257 ED visits (CI: 11,633 to 22,882), 

 Barbiturates, which are primarily unnamed, in 10,991 ED visits (CI: 7,068 to 14,913), and 

 Diphenhydramine15 in 12,291 ED visits (CI: 9,643 to 14,939). 

For the ED visits associated with nonmedical use of pharmaceuticals, other psychotherapeutic agents of interest 

include antidepressants and antipsychotics. DAWN estimates: 

 Antidepressants in 79,682 ED visits (CI: 66,026 to 93,338), and 

 Antipsychotics, such as quetiapine, in 44,733 ED visits (CI: 37,080 to 52,387). 

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

estimates that 2,192 (CI: 980 to 3,404) nonmedical-use ED visits involved methylphenidate. 

Taking population size and the margin of error into account, visits for nonmedical use of pharmaceuticals did not 

differ between females (253 visits per 100,000 population) and males (237 visits per 100,000 population) (Figure 5). 

In terms of age, visit rates were highest for patients aged 18 to 44 and were lowest for patients aged 11 and younger. 

 

15 This includes only single-ingredient formulations. Many multi-ingredient pharmaceuticals containing diphenhydramine are classified 

elsewhere, e.g., as respiratory agents. 
DAWN, 2006: NATIONAL ED ESTIMATES 3 9

In terms of race and ethnicity, 69% of visits related to nonmedical use of pharmaceuticals involved patients who 

were white (Table 10). Evaluating the relative frequencies of the race/ethnicity groups is impeded by missing data; in 

12% of visits, race/ethnicity was unknown. 

Patients were treated and released in about half (58%) of ED visits associated with nonmedical use of 

pharmaceuticals, with most discharged home (91%) and only 5% referred to detox or substance abuse treatment. In 

one third (30%) of all nonmedical-use visits, patients were admitted to inpatient hospital units (Table 10). Of those 

admitted to the hospital, about one third (29%) were sent to a critical care unit, about 22% to a psychiatric unit, and 

about half (47%) to other inpatient units. About 7% of ED visits for nonmedical use of pharmaceuticals resulted in 

transfers to another health care facility. 

Figure 5 

Nonmedical use of pharmaceuticals, ED visit rates by age and gender: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
40 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 4 1

COMPARISONS OF ED VISITS: 2004, 2005, AND 2006 

his chapter presents the comparison of the estimates of ED visits for 2006 to prior years. Differences between 

years are presented in terms of the percent increase or decrease in visits in 2006 compared to the estimates 

for 2004 or 2005. Only statistically significant changes are discussed and are shown as changes in the tables. 

However, with only three years’ estimates to compare, caution is urged in interpreting these significant differences as 

trends. 

Drug misuse and abuse in ED visits (Table 11) 

In 2006, hospitals in the United States delivered a total of 113 million ED visits, an increase of 3.9% over 2004. 

The population of the United States increased 2.9%, from 294 million to 302 million, over the same period. 

According to DAWN, the number of ED visits attributable to drug misuse and abuse was stable from 2004 to 

2006 (Table 11).16 That is, the apparent difference is within the margin of error. Across the different types of drug 

involvement, changes were detected for visits involving: 

 pharmaceuticals alone (i.e., with no other type of drug), which increased 44% from 2004 to 2006; 

 pharmaceuticals used in combination with illicit drug(s), which increased 36% from 2004 to 2006; and 

 pharmaceuticals used in combination with alcohol, which increased 22% from 2005 to 2006. 

Regarding the significant increases detected, it is worthwhile to consider that the number of pharmaceuticals 

dispensed for legitimate therapeutic uses may be increasing over time, and DAWN estimates are not adjusted to take 

this into account. Nor do DAWN estimates take into account the increases in the population or in ED use between 

2004 and 2006. 

 

16 In this publication, drugs are classified using the Drug Reference Vocabulary that was current as of May 2007. 

T 
42 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 11 

Drug misuse and abuse in ED visits in the U.S., by type of drug involvement: 2004, 2005, and 2006 

Drug involvement1

Estimated visits2 Percent change3

2004 2005 2006 2004, 2006 2005, 2006 

All types of drug misuse/abuse 1,619,054 1,616,311 1,742,887 

Illicit drugs only 502,136 517,558 536,554 

Alcohol only (age < 21) 150,988 110,599 126,704 

Pharmaceuticals only 336,987 444,309 486,276 44% 

Combinations 

Illicit drugs with alcohol 338,638 221,823 219,521 

Illicit drugs with pharmaceuticals 105,017 127,245 142,535 36% 

Alcohol with pharmaceuticals 139,716 140,275 171,743 22% 

Illicit drugs with alcohol and 

pharmaceuticals 45,571 54,500 59,553 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 4 3

Illicit drugs in ED visits (Table 12) 

No changes from 2004 to 2006, nor from 2005 to 2006, were detected for ED visits involving major illicit drugs: 

cocaine, marijuana, heroin, and stimulants (Table 12). 

Table 12 

Illicit drugs in ED visits: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2 Percent change3

2004 2005 2006 2004, 2006 2005, 2006 

Total drug misuse/abuse ED visits 1,619,054 1,616,311 1,742,887 

ED visits, illicit drugs 991,363 921,127 958,164 

Cocaine 475,425 483,865 548,608 

Heroin 214,432 187,493 189,780 

Marijuana 281,619 279,664 290,563 

Stimulants 162,435 137,650 107,575 

Amphetamines 34,085 34,928 32,240 

Methamphetamine 132,576 109,655 79,924 

MDMA (Ecstasy) 10,220 11,287 16,749 64% 48% 

GHB 1,789 1,036 1,084 

Flunitrazepam (Rohypnol) ... ... ... 

Ketamine ... 303 270 

LSD 2,146 2,001 4,002 100% 

PCP 31,342 14,825 21,960 

Miscellaneous hallucinogens 3,150 3,194 3,898 

Inhalants 9,523 5,156 5,643 -41% 

Combinations not tabulated above 

(NTA) ... 3,201 2,055 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
44 DAWN, 2006: NATIONAL ED ESTIMATES 

Alcohol in ED visits (Tables 13-14) 

No significant changes in alcohol-related ED visits occurred during the period from 2004 to 2006, nor for the 

period 2005 to 2006 (Tables 13-14). These findings were consistent for all the alcohol-related ED visits: alcohol 

overall, alcohol in combination with other drugs, and alcohol alone in underage patients. 

Table 13 

Alcohol in drug-related ED visits: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2 Percent change3

2004 2005 2006 2004, 2006 2005, 2006 

Total drug misuse/abuse ED visits 1,619,054 1,616,311 1,742,887 

ED visits, alcohol 674,914 527,198 577,521 

Alcohol in combination 523,926 416,599 450,817 

Alcohol alone 150,988 110,599 126,704 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 

Table 14 

Alcohol in drug-related ED visits in patients under age 21: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2 Percent change3

2004 2005 2006 2004, 2006 2005, 2006 

Patients aged 12-17 

ED visits, alcohol 67,589 62,459 76,760 

Alcohol in combination 21,555 19,720 24,418 

Alcohol alone 46,034 42,739 52,342 

Patients aged 18-20 

ED visits, alcohol 135,313 95,166 105,675 

Alcohol in combination 31,926 27,784 31,702 

Alcohol alone 103,387 67,382 73,973 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 4 5

Nonmedical use of pharmaceuticals (Table 15) 

ED visits related to nonmedical use of pharmaceuticals increased 38% in the period from 2004 to 2006 

(Table 15). Among the drugs most frequently implicated in nonmedical use, the following changes from 2004 to 2006 

are notable: 

 Psychotherapeutic and CNS agents increased 31% and 32%, respectively. 

 Anxiolytics, sedatives, and hypnotics increased 32% overall, with benzodiazepines increasing 36%. 

 Opiate/opioid analgesics increased 43%, with hydrocodone/combinations increasing 44%, 

oxycodone/combinations increasing 56%, and unspecified opiates increasing 60%. 

For the period 2005 to 2006, no change was detected in the overall number of ED visits related to nonmedical 

use of pharmaceuticals nor were changes noted for the substances most frequently implicated in nonmedical-use 

visits. 

Table 15 

Nonmedical use of pharmaceuticals ED visits: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

ED visits, nonmedical use 536,247 669,214 741,425 38% 

PSYCHOTHERAPEUTIC AGENTS 247,324 308,655 323,999 31% 

Antidepressants 66,917 67,051 79,682 

MAO inhibitors ... ... ... 

SSRI antidepressants 32,285 30,374 35,370 

Tricyclic antidepressants 12,412 14,515 16,564 

Miscellaneous antidepressants 9,414 7,452 7,561 

Antipsychotics 35,198 44,393 44,733 

Anxiolytics, sedatives, and hypnotics 177,394 227,486 233,875 32% 

Barbiturates 11,721 14,693 10,991 

Benzodiazepines 143,546 189,704 195,625 36% 

Alprazolam 46,526 57,419 65,236 40% 

Clonazepam 28,178 30,648 33,557 

Diazepam 15,619 18,433 19,936 

Lorazepam 17,674 23,210 23,720 

Benzodiazepines NOS 36,039 61,486 58,347 

Misc. anxiolytics, sedatives, and 

hypnotics 31,554 35,561 40,626 29% 

Diphenhydramine 10,452 10,294 12,291 

Hydroxyzine 2,363 2,179 2,678 

Zolpidem 12,792 14,730 17,257 

Anxiolytics, sedatives, and 

hypnotics NOS 2,657 4,421 3,629 
46 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 15 (continued)

Nonmedical use of pharmaceuticals ED visits: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

CNS stimulants 9,801 10,965 13,892 42% 

Amphetamine-dextroamphetamine 2,303 2,669 5,027 118% 

Caffeine 2,736 4,567 4,407 

Dextroamphetamine ... ... ... 

Methylphenidate 2,446 2,519 2,192 

CENTRAL NERVOUS SYSTEM 

AGENTS 282,296 336,900 373,138 32% 

Analgesics 241,578 294,251 323,579 34% 

Antimigraine agents 868 1,018 1,191 

Cox-2 inhibitors 1,935 765 ... 

Opiates/opioids 172,726 217,594 247,669 43% 

Opiates/opioids, unspecified 31,846 52,670 50,978 60% 

Narcotic analgesics 144,644 168,376 201,280 39% 20% 

Buprenorphine/combinations ... ... 4,440 

Codeine/combinations 7,171 6,180 6,928 

Fentanyl/combinations 9,823 11,211 16,012 

Hydrocodone/combinations 39,844 47,192 57,550 44% 

Hydromorphone/combinations 3,385 4,714 6,780 

Meperidine/combinations 782 383 1,440 

Methadone 36,806 42,684 45,130 

Morphine/combinations 13,966 15,762 20,416 46% 

Oxycodone/combinations 41,701 52,943 64,888 56% 

Propoxyphene/combinations 6,744 7,648 6,220 

Nonsteroidal anti-inflammatory 

agents 27,362 28,837 27,662 

Ibuprofen 22,127 22,268 20,541 

Naproxen 4,715 5,190 6,651 

Salicylates/combinations 9,580 12,123 10,399 

Miscellaneous analgesics/ 

combinations 44,857 51,881 54,313 

Acetaminophen/combinations 39,167 43,558 44,314 

Tramadol/combinations 4,849 5,918 6,048 

Tramadol 3,948 5,427 5,961 

Acetaminophen-tramadol 909 ... ... 

Analgesic combinations not 

tabulated above (NTA) 977 653 898 
DAWN, 2006: NATIONAL ED ESTIMATES 4 7

Table 15 (continued)

Nonmedical use of pharmaceuticals ED visits: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

Anorexiants ... 1,757 1,168 

Anticonvulsants 28,652 27,641 31,169 

Antiemetic/antivertigo agents 1,678 1,771 1,360 

Anti-Parkinson agents 2,472 1,692 3,816 

General anesthetics ... ... ... 

Muscle relaxants 25,934 33,695 38,918 50% 

Carisoprodol 14,736 20,082 24,505 

Cyclobenzaprine 6,183 7,629 7,142 

Miscellaneous CNS agents 869 900 999 

RESPIRATORY AGENTS 22,286 28,017 28,867 

Antihistamines 5,761 4,429 4,130 

Bronchodilators 2,294 3,043 2,920 

Decongestants 1,864 1,310 1,511 

Expectorants 832 1,960 2,125 155% 

Upper respiratory combinations 10,314 15,837 15,115 

Respiratory agents NTA 2,903 3,692 4,296 

CARDIOVASCULAR AGENTS 27,396 37,095 36,343 

Antiadrenergic agents, centrally acting 3,616 5,125 4,810 

Beta-adrenergic blocking agents 7,094 9,824 11,729 

Calcium channel blocking agents 3,115 5,434 5,227 

Diuretics 3,625 5,332 5,102 

Cardiovascular agents NTA 14,930 18,881 17,338 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

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

4 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
48 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 4 9

SPECIAL TYPES OF DRUG-RELATED ED VISITS 

his chapter profiles two special types of drug-related ED visits captured by DAWN: drug-related suicide 

attempts and seeking detox cases. These are analyzed by DAWN as separate and distinct classes of drug 

misuse or abuse. 

Suicide attempts (Tables 16-17, Figure 6) 

DAWN estimates 182,805 (CI: 154,185 to 211,424) ED visits for drug-related suicide attempts in 2006 

(Table 16). Although DAWN includes only suicide attempts that involve drugs, these attempts are not limited to drug 

overdoses. If there is drug involvement in a suicide attempt by other means (e.g., by gun), the case is included as 

drug related. However, suicide attempts not involving drugs at all (e.g., by gun alone) are excluded. Also excluded are 

suicide-related behaviors documented as something other than actual attempts (e.g., suicidal ideation, suicidal 

gesture, or suicidal thoughts). 

Nearly two thirds (65%) of ED visits for drug-related suicide attempts involved multiple drugs (Table 17). Alcohol, 

either in combination with other drugs or alcohol alone in patients under age 21, was the most frequently implicated 

drug and was involved in one third (30%) 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. Illicit drugs 

were involved in just under one quarter (23%) of the ED visits for drug-related suicide attempts. The most frequently 

reported illicit drugs were cocaine (15% 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. 

Pharmaceuticals were involved in the majority (92%) of ED visits for drug-related suicide attempts, and it is not 

possible, based on ED medical record documentation, to measure the extent to which these pharmaceuticals may 

have been prescribed to the patient for a preexisting condition. More than half (58%) of ED visits for drug-related 

suicide attempts involved psychotherapeutic agents, and 45% involved central nervous system (CNS) agents. The 

most commonly used psychotherapeutic agents were benzodiazepines (48% of suicide-attempt visits involving 

psychotherapeutics) and antidepressants (35%). The CNS agents were primarily analgesics (pain relievers) and 

included both prescription and over-the-counter (OTC) formulations. DAWN estimates that the most commonly used 

pain relievers were opiates/opioids and acetaminophen/combinations, which were each present in approximately a 

third (33% and 31%, respectively) of suicide-attempt visits involving CNS agents, followed by nonsteroidal antiinflammatory agents (NSAIDs, such as ibuprofen and naproxen, 19%) and salicylates/combinations (aspirins, 7%). 

About half (55%) of the suicide attempts were admitted for inpatient hospital care. A fifth (21%) were admitted to 

an ICU/critical care unit; others were admitted to psychiatric units (18%) or other inpatient units (16%). Another 25% 

were transferred to another health care facility; only 14% were discharged home. Very few died in the ED. However, 

DAWN does not record deaths for patients who died before arriving at the ED or patients who died after admission to 

inpatient units of the hospital. 

T 
50 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 16 

Suicide attempts: 2006 

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, suicide attempts 182,805 8.0 154,185 - 211,424 

Major substances of abuse 

Alcohol 54,820 5.4 48,993 - 60,647 

Alcohol in combination 54,337 5.4 48,587 - 60,087 

Alcohol alone 483 44.4 63 - 903 

Non-alcohol illicits 42,148 23.3 22,914 - 61,382 

Cocaine 26,510 26.6 12,705 - 40,316 

Heroin 4,265 28.3 1,903 - 6,627 

Marijuana 15,272 26.4 7,371 - 23,174 

Stimulants 4,829 18.8 3,048 - 6,610 

Amphetamines 2,228 25.8 1,104 - 3,353 

Methamphetamine 2,877 27.5 1,327 - 4,427 

MDMA (Ecstasy) 1,239 46.9 101 - 2,377 

GHB ... ... ... - ... 

Flunitrazepam (Rohypnol) ... ... ... - ... 

Ketamine ... ... ... - ... 

LSD ... ... ... - ... 

PCP ... 71.8 ... - ... 

Miscellaneous hallucinogens ... ... ... - ... 

Inhalants ... ... ... - ... 

Combinations not tabulated above (NTA) ... ... ... - ... 

Other substances 

PSYCHOTHERAPEUTIC AGENTS 106,128 7.6 90,385 - 121,871 

Antidepressants 36,677 12.7 27,570 - 45,784 

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

SSRI antidepressants 16,973 10.9 13,357 - 20,589 

Tricyclic antidepressants 4,681 28.1 2,107 - 7,255 

Miscellaneous antidepressants 3,806 28.8 1,660 - 5,953 

Antipsychotics 22,491 13.4 16,566 - 28,416 

Anxiolytics, sedatives, and hypnotics 68,177 7.1 58,632 - 77,723 

Barbiturates 2,031 41.8 367 - 3,696 

Benzodiazepines 50,431 7.5 43,030 - 57,832 

Alprazolam 15,633 14.2 11,291 - 19,974 

Clonazepam 14,173 12.4 10,726 - 17,620 
DAWN, 2006: NATIONAL ED ESTIMATES 5 1

Table 16 (continued)

Suicide attempts: 2006 

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

Diazepam 5,910 24.4 3,086 - 8,733 

Lorazepam 6,682 13.6 4,904 - 8,460 

Benzodiazepines NOS 7,080 35.9 2,092 - 12,069 

Misc. anxiolytics, sedatives, and hypnotics 21,527 9.7 17,443 - 25,611 

Diphenhydramine 7,756 14.6 5,543 - 9,970 

Hydroxyzine 1,957 23.6 1,053 - 2,860 

Zolpidem 6,674 13.6 4,890 - 8,458 

Anxiolytics, sedatives, and hypnotics NOS 1,406 25.7 698 - 2,115 

CNS stimulants 1,949 33.1 683 - 3,214 

Amphetamine-dextroamphetamine 559 47.5 38 - 1,079 

Caffeine ... ... ... - ... 

Dextroamphetamine ... ... ... - ... 

Methylphenidate 633 39.6 141 - 1,124 

CENTRAL NERVOUS SYSTEM AGENTS 82,442 7.3 70,683 - 94,201 

Analgesics 67,623 7.4 57,880 - 77,366 

Antimigraine agents ... ... ... - ... 

Cox-2 inhibitors ... ... ... - ... 

Opiates/opioids 27,185 9.9 21,928 - 32,442 

Opiates/opioids, unspecified 3,129 23.5 1,686 - 4,573 

Narcotic analgesics 24,470 10.0 19,695 - 29,244 

Buprenorphine/combinations ... ... ... - ... 

Codeine/combinations 2,349 22.7 1,306 - 3,392 

Fentanyl/combinations ... ... ... - ... 

Hydrocodone/combinations 8,998 11.4 6,981 - 11,016 

Hydromorphone/combinations 262 49.5 8 - 516 

Meperidine/combinations ... ... ... - ... 

Methadone 1,772 29.3 755 - 2,788 

Morphine/combinations ... 50.5 ... - ... 

Oxycodone/combinations 7,842 18.9 4,934 - 10,750 

Propoxyphene/combinations 2,811 26.9 1,331 - 4,292 

Nonsteroidal anti-inflammatory agents 15,956 15.0 11,280 - 20,632 

Ibuprofen 12,064 15.0 8,523 - 15,605 

Naproxen 3,726 20.9 2,201 - 5,252 

Salicylates/combinations 5,400 10.4 4,294 - 6,506 
52 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 16 (continued)

Suicide attempts: 2006 

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower 

bound - Upper bound 

Miscellaneous analgesics/combinations 27,371 9.3 22,367 - 32,376 

Acetaminophen/combinations 25,312 9.2 20,757 - 29,867 

Tramadol/combinations 1,719 23.6 925 - 2,512 

Tramadol 1,372 26.6 656 - 2,088 

Acetaminophen-tramadol ... ... ... - ... 

Analgesic combinations NTA 920 44.7 114 - 1,726 

Anorexiants 654 31.5 251 - 1,058 

Anticonvulsants 12,580 12.3 9,548 - 15,612 

Antiemetic/antivertigo agents ... ... ... - ... 

Anti-Parkinson agents ... 51.9 ... - ... 

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

Muscle relaxants 7,072 14.4 5,071 - 9,074 

Carisoprodol 3,811 23.3 2,068 - 5,554 

Cyclobenzaprine 2,096 23.3 1,140 - 3,052 

Miscellaneous CNS agents ... ... ... - ... 

RESPIRATORY AGENTS 8,415 13.5 6,182 - 10,647 

Antihistamines 1,627 22.0 925 - 2,329 

Bronchodilators ... ... ... - ... 

Decongestants 1,347 32.9 479 - 2,215 

Expectorants 1,068 33.8 361 - 1,775 

Upper respiratory combinations 3,982 16.8 2,670 - 5,294 

Respiratory agents NTA 660 32.8 235 - 1,084 

CARDIOVASCULAR AGENTS 7,965 16.5 5,389 - 10,542 

Antiadrenergic agents, centrally acting 1,930 26.8 917 - 2,942 

Beta-adrenergic blocking agents 1,999 20.3 1,202 - 2,795 

Calcium channel blocking agents 1,040 28.2 466 - 1,614 

Diuretics ... 51.0 ... - ... 

Cardiovascular agents NTA 3,298 23.2 1,799 - 4,798 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

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

4 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 5 3

Table 17 

Suicide attempts, by patient and visit characteristics: 2006 

Patient characteristics Estimated 

visits1,2

 Visit characteristics Estimated 

visits 1,2

Total drug-related ED visits, suicide 

attempts 182,805 

Gender Number of drugs involved 

Male 71,657 Single drug 64,143 

Female 111,137 Multiple drugs 118,661 

Unknown ... 

Age Disposition 

0-5 years ... Treated and released 31,528 

6-11 years ... Discharged home 25,149 

12-17 years 20,506 Released to police/jail 2,080 

18-20 years 14,232 Referred to detox/treatment 4,299 

21-24 years 18,855 Admitted to this hospital 101,409 

25-29 years 21,877 ICU/critical care 37,821 

30-34 years 17,095 Surgery ... 

35-44 years 44,237 Chemical dependency/detox ... 

45-54 years 32,970 Psychiatric unit 32,682 

55-64 years 8,462 Other inpatient unit 30,129 

65 years and older 4,352 Other disposition 49,867 

Unknown ... Transferred 45,234 

Race/ethnicity Left against medical advice 458 

White 114,972 Died ... 

Black 28,491 Other ... 

Hispanic 18,058 Not documented 1,747 

Race/ethnicity not tabulated above 

(NTA) 2,095 

Unknown 19,188 

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

United States. 

2 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, 2006 (03/2008 update). 

After accounting for population size and the margin of error, the rate of drug-related suicide visits for females (73 

visits per 100,000 population) was higher than that for males (48 per 100,000) (Figure 6). In general, the rates for 

patients aged 18 to 54 exceeded the rates for younger and older age groups. The rate for patients aged 12 to 17 (81 

visits per 100,000) exceeded the rates for patients aged 55 and over. 
54 DAWN, 2006: NATIONAL ED ESTIMATES 

Figure 6 

Suicide attempts, ED visit rates by age and gender: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 

In terms of race/ethnicity, 63% of the suicide attempts involved patients who were white. Evaluating the relative 

frequencies of the race/ethnicity groups is impeded by missing data; in 10% of visits, race/ethnicity was unknown. 

Suicide attempt ED visits: 2004, 2005, and 2006 (Table 18) 

Overall, there was no significant change in ED visits for drug-related suicide attempts from 2004 to 2006, but an 

increase was detected from 2005 to 2006 (Table 18). Increases were evident from 2004 to 2006 for some of the drugs 

frequently involved in suicide attempts, such as benzodiazepines, which increased 36%, and opiate/opioid 

analgesics, which increased 44%. 
DAWN, 2006: NATIONAL ED ESTIMATES 5 5

Table 18 

Suicide attempts: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

Total drug-related ED visits, suicide 

attempts 161,586 151,568 182,805 21% 

Major substances of abuse 

Alcohol 48,726 47,891 54,820 

Alcohol in combination 48,080 46,806 54,337 

Alcohol alone 646 1,085 483 

Cocaine 19,520 19,628 26,510 

Heroin 4,579 3,167 4,265 35% 

Marijuana 12,074 11,955 15,272 

Stimulants 4,535 5,410 4,829 

Amphetamines 1,560 1,646 2,228 

Methamphetamine 3,136 3,853 2,877 

MDMA (Ecstasy) ... 529 1,239 

GHB ... ... ... 

Flunitrazepam (Rohypnol) ... ... ... 

Ketamine ... ... ... 

LSD ... ... ... 

PCP ... ... ... 

Miscellaneous hallucinogens ... ... ... 

Inhalants ... 794 ... 

Combinations not tabulated above (NTA) ... ... ... 

Other substances 

PSYCHOTHERAPEUTIC AGENTS 88,034 82,144 106,128 29% 

Antidepressants 33,366 27,086 36,677 

MAO inhibitors ... ... ... 

SSRI antidepressants 18,513 13,377 16,973 

Tricyclic antidepressants 3,555 3,008 4,681 

Miscellaneous antidepressants 3,337 2,681 3,806 

Antipsychotics 17,807 17,129 22,491 

Anxiolytics, sedatives, and hypnotics 52,653 52,022 68,177 29% 31% 

Barbiturates 1,949 1,219 2,031 

Benzodiazepines 36,995 35,676 50,431 36% 41% 

Alprazolam 11,354 14,530 15,633 

Clonazepam 9,403 9,064 14,173 56% 

Diazepam 4,630 3,968 599 
56 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 18 (continued)

Suicide attempts: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

Lorazepam 6,065 5,182 6,682 

Benzodiazepines NOS 4,426 3,343 7,080 

Misc. anxiolytics, sedatives, and 

hypnotics 16,790 17,522 21,527 

Diphenhydramine 7,458 6,583 7,756 

Hydroxyzine 2,346 1,795 1,956 

Zolpidem 4,355 4,972 6,674 

Anxiolytics, sedatives, and 

hypnotics NOS 1,859 2,147 1,406 

CNS stimulants 1,654 1,782 1,949 

Amphetamine-dextroamphetamine ... ... 559 

Caffeine ... 450 ... 

Dextroamphetamine ... ... ... 

Methylphenidate ... 818 633 

CENTRAL NERVOUS SYSTEM 

AGENTS 73,949 66,321 82,442 24% 

Analgesics 61,095 54,858 67,623 23% 

Antimigraine agents ... ... ... 

Cox-2 inhibitors 807 514 ... 

Opiates/opioids 18,939 20,359 27,185 44% 34% 

Opiates/opioids, unspecified 2,363 2,819 3,129 

Narcotic analgesics 16,928 17,801 24,470 45% 37% 

Buprenorphine/combinations ... ... ... 

Codeine/combinations 1,750 2,656 2,349 

Fentanyl/combinations ... ... ... 

Hydrocodone/combinations 7,034 7,035 8,998 

Hydromorphone/combinations ... ... 262 

Meperidine/combinations ... ... ... 

Methadone 1,287 1,596 1,772 

Morphine/combinations 714 1,210 ... 

Oxycodone/combinations 5,340 4,229 7,842 85% 

Propoxyphene/combinations 1,888 2,129 2,811 

Nonsteroidal anti-inflammatory 

agents 19,114 14,117 15,956 

Ibuprofen 13,609 10,917 12,064 

Naproxen 4,383 3,224 3,726 

Salicylates/combinations 6,211 4,645 5,400 
DAWN, 2006: NATIONAL ED ESTIMATES 5 7

Table 18 (continued)

Suicide attempts: 2004, 2005, and 2006 

Drug category and selected drugs1

Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

Miscellaneous 

analgesics/combinations 22,864 22,692 27,371 

Acetaminophen/combinations 20,701 21,017 25,312 

Tramadol/combinations 1,742 1,515 1,719 

Tramadol 1,528 1,079 1,372 

Acetaminophen-tramadol ... ... ... 

Analgesic combinations NTA ... ... 920 

Anorexiants ... ... 654 

Anticonvulsants 10,957 9,389 12,580 

Antiemetic/antivertigo agents ... ... ... 

Anti-Parkinson agents 80 543 ... 

General anesthetics ... ... ... 

Muscle relaxants 5,921 5,785 7,072 

Carisoprodol 1,864 2,038 3,811 

Cyclobenzaprine 2,966 2,784 2,096 

Miscellaneous CNS agents ... ... ... 

RESPIRATORY AGENTS 8,361 7,662 8,415 

Antihistamines 2,059 1,650 1,627 

Bronchodilators ... ... ... 

Decongestants ... ... 1,347 

Expectorants ... 474 1,068 

Upper respiratory combinations 4,818 4,207 3,982 

Respiratory agents NTA ... 1,244 660 

CARDIOVASCULAR AGENTS 7,667 5,814 7,965 

Antiadrenergic agents, centrally acting 995 912 1,929 

Beta-adrenergic blocking agents 2,105 1,916 1,999 

Calcium channel blocking agents 879 193 1,040 438% 

Diuretics ... 539 ... 

Cardiovascular agents NTA 3,661 3,024 3,298 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

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

4 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
58 DAWN, 2006: NATIONAL ED ESTIMATES 

Seeking detox (Tables 19-20, Figure 7) 

DAWN estimates 118,355 (CI: 90,171 to 146,540) drug-related ED visits for patients seeking detoxification or 

substance abuse treatment services during 2006. These “seeking detox” 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 within the hospital. Therefore, this estimate does not encompass the full extent of the demand for 

these services. 

Nearly two thirds (65%) of the seeking detox ED visits involved multiple drugs, and more than one third (40%) of 

all seeking detox ED visits involved alcohol (Table 19). However, the role of alcohol may be underrepresented here, 

because for adults aged 21 and older this includes only alcohol in combination with other drugs. Among the illicit 

drugs, cocaine (49% of visits) and heroin (29% of visits) occurred most frequently, followed by marijuana (19% of 

visits) and amphetamine or methamphetamine stimulants (7% of visits). Among the pharmaceuticals, 

psychotherapeutic agents, which were primarily benzodiazepines (13%), and CNS agents, which were primarily 

opiate/opioid analgesics (26%), were notable. Among the opiates/opioids, hydrocodone/combinations and 

oxycodone/combinations were most frequent. 

Among the seeking detox ED visits, nearly 7 out of 10 (69%) 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 (Table 20). However, about one quarter (27%) of seeking detox cases may not have received the care 

they sought because they were discharged to home. 

Taking population size and the margin of error into account, the rates of seeking detox visits were similar across 

all age groups in the 18 to 44 range. The rate of seeking detox visits for males (51 per 100,000 population) was 

higher than that for females (27 per 100,000 population). 

In terms of race/ethnicity, the majority (59%) of seeking detox visits involved patients who were white. Evaluating 

the relative frequencies of the race/ethnicity groups is impeded by missing data; in 9% of visits race/ethnicity was 

unknown. 
DAWN, 2006: NATIONAL ED ESTIMATES 5 9

Table 19 

Seeking detox: 2006 

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, seeking detox 118,355 12.1 90,171 - 146,540 

Major substance of abuse 

Alcohol 47,102 14.3 33,887 - 60,316 

Alcohol in combination 46,769 14.3 33,646 - 59,892 

Alcohol alone ... 57.5 ... - ... 

Non-alcohol illicits 92,385 12.6 69,548 - 115,223 

Cocaine 57,738 14.1 41,815 - 73,661 

Heroin 34,462 14.6 24,611 - 44,312 

Marijuana 22,104 16.4 14,983 - 29,226 

Stimulants 8,128 26.2 3,955 - 12,301 

Amphetamines 2,034 26.1 993 - 3,074 

Methamphetamine 6,211 31.2 2,407 - 10,014 

MDMA (Ecstasy) 483 35.7 145 - 821 

GHB ... ... ... - ... 

Flunitrazepam (Rohypnol) ... ... ... - ... 

Ketamine ... ... ... - ... 

LSD ... 54.3 ... - ... 

PCP 989 41.5 184 - 1,794 

Miscellaneous hallucinogens ... ... ... - ... 

Inhalants ... ... ... - ... 

Combinations not tabulated above (NTA) ... 50.3 ... - ... 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related 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, 2006 (03/2008 update). 
60 DAWN, 2006: NATIONAL ED ESTIMATES 

Table 20 

Seeking detox, by patient and visit characteristics: 2006 

Patient characteristics Estimated 

visits1,2

 Visit characteristics Estimated 

visits 1,2

Total drug-related ED visits, 

seeking detox 118,355 

Gender Number of drugs involved 

Male 76,659 Single drug 40,924 

Female 41,528 Multiple drugs 77,432 

Unknown ... 

Age Disposition 

0-5 years ... Treated and released 69,063 

6-11 years ... Discharged home 32,430 

12-17 years 3,759 Released to police/jail 791 

18-20 years 8,757 Referred to detox/treatment 35,842 

21-24 years 11,135 Admitted to this hospital 35,278 

25-29 years 17,804 ICU/critical care 897 

30-34 years 12,799 Surgery ... 

35-44 years 36,665 Chemical dependency/detox 22,540 

45-54 years 22,222 Psychiatric unit 6,902 

55-64 years 4,521 Other inpatient unit 4,869 

65 years and older 681 Other disposition 14,015 

Unknown ... Transferred 10,049 

Race/ethnicity Left against medical advice 1,947 

White 69,867 Died ... 

Black 25,448 Other 1,447 

Hispanic 11,397 Not documented 573 

Race/ethnicity not tabulated above 

(NTA) 737 

Unknown 10,907 

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

United States. 

2 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, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 6 1

Figure 7 

Seeking detox, ED visit rates by age and gender: 2006 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
62 DAWN, 2006: NATIONAL ED ESTIMATES 

Seeking detox ED visits: 2004, 2005, and 2006 (Table 21) 

No significant changes in ED visits from 2004 to 2006, or from 2005 to 2006, were detected for seeking detox ED 

visits overall, or for alcohol or the illicit drugs involved in these visits (Table 21). 

Table 21 

Seeking detox: 2004, 2005, and 2006 

Drug category and selected drugs1 Estimated visits2,3 Percent change4

2004 2005 2006 2004, 2006 2005, 2006 

Total drug-related ED visits, seeking 

detox 141,867 126,226 118,355 

Major substances of abuse 

Alcohol 53,662 47,494 47,102 

Alcohol in combination 51,831 47,154 46,769 

Alcohol alone ... ... ... 

Cocaine 62,989 56,061 57,738 

Heroin 47,035 40,895 34,462 

Marijuana 25,965 22,486 22,104 

Stimulants 11,760 15,402 8,128 

Amphetamines ... ... 2,034 

Methamphetamine ... ... 6,211 

MDMA (Ecstasy) 882 511 483 

GHB ... ... ... 

Flunitrazepam (Rohypnol) ... ... ... 

Ketamine ... ... ... 

LSD ... ... ... 

PCP 827 729 989 

Miscellaneous hallucinogens ... ... ... 

Inhalants ... ... ... 

Combinations not tabulated above 

(NTA) ... 191 ... 

1 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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

United States. 

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

4 This column denotes statistically significant (p < 0.05) increases or decreases between estimates for the periods shown. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
DAWN, 2006: NATIONAL ED ESTIMATES 6 3

Appendices 
64 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 6 5

APPENDIX A 

MULTUM LEXICON 

END-USER LICENSE AGREEMENT

1. Introduction 

A. This License Agreement (the “License”) applies to the Multum Lexicon database (the “Database”). This License 

does not apply to any other products or services of Cerner Multum, Inc. (“Multum”). A “work based on the Database” 

means either the Database or any derivative work under copyright law; i.e., a work containing the Database or a 

substantial portion of it, either verbatim or with modifications. A translation of the Database is included without 

limitation in the term “modification”. Each end-user/licensee is addressed herein as “you”. 

B. Your use of the Database acknowledges acceptance of these restrictions, disclaimers, and limitations. you 

expressly acknowledge and agree that Multum is not responsible for the results of your decisions resulting from the 

use of the Database, including, but not limited to, your choosing to seek or not to seek professional medical care, or 

from choosing or not choosing specific treatment based on the Database. 

C. Every effort has been made to ensure that the information provided in the Database is accurate, up-to-date, and 

complete, but no guarantee is made to that effect. In addition, the drug information contained herein may be time 

sensitive. 

D. Multum does not assume any responsibility for any aspect of healthcare administered or not administered with the 

aid of information the Database provides. 

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APPENDIX B 

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 

over-the-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. Most instances of alcohol as the only drug in patients under age 21 are classified in the alcohol only 

(age < 21) case type. However, some are classified as suicide-attempt or seeking detox, case types that precede 

alcohol only (age < 21) in sequence. 

Case description: A description of how the drug(s) was related to the patient’s ED visit. The case description, in 

conjunction with other documentation in the ED medical record, 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 (CI): 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 C. 

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

Disposition: The location or facility to which an ED patient was referred, transferred, or released. 
70 DAWN, 2006: NATIONAL ED ESTIMATES 

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 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: 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 nonpharmaceutical 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 related pharmaceuticals or 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—The category for alcohol present with another reportable substance. DAWN does not 

gather data on alcohol used alone if the patient is aged 21 years or older. 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, 
DAWN, 2006: NATIONAL ED ESTIMATES 7 1

“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. 

 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 nonpharmaceutical substances for 

which the documented route of administration was inhaling, sniffing, or snorting. Psychoactive 

nonpharmaceuticals 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. 

 Stimulants—This category includes amphetamines and methamphetamine. Since some drug screens test for 

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

methamphetamine. For this reason, amphetamines and methamphetamine are combined for analysis into the 

category “stimulants.” This category does not include other CNS stimulants, such as caffeine or 

methylphenidate. 

Drug misuse and abuse: A group of ED visits defined broadly to include all visits associated with illicit drugs, alcohol 

use in combination with illicit drugs or alcohol alone among those younger than 21 years, and nonmedical use of 

pharmaceuticals. Nonmedical use of pharmaceuticals includes prescription and OTC pharmaceuticals in ED visits that 

are of the following case types: 

 Overmedication—This category was designed to capture nonmedical 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 capture 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. 

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. 

The number of unique patients involved in the reported drug-related ED visits cannot be estimated, because no direct 

patient identifiers are collected by DAWN. 
72 DAWN, 2006: NATIONAL ED ESTIMATES 

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): Only hospitals that meet eligibility criteria for DAWN are recruited to 

participate. To be eligible, hospitals must be non-Federal, short-stay, general medical and surgical facilities that 

operate one or more EDs 24 hours a day, 7 days a week, and be located in the United States. Specialty hospitals, 

hospital units of institutions, long-term care facilities, pediatric hospitals, hospitals operating part-time EDs, and 

hospitals operated by the Veterans Health Administration and the Indian Health Service are excluded. The universe of 

EDs is identified from the American Hospital Association’s Annual Survey Database. (See also Universe.) 

Malicious poisoning: See Drug misuse and abuse. 

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 June 30, 2003, based on 

population data from the 2000 decennial Census. 

Not otherwise specified (NOS): The 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): The 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: According to the standard protocol issued by OMB in 1997, 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, 2006: NATIONAL ED ESTIMATES 7 3

 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 detail allowed by these categories, race and ethnicity are often not documented with this level of 

specificity in patient/decedent records. As a result, categories used to tabulate race and ethnicity data in the 

publications are: 

 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 the 

following: two or more races, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific 

Islander. 

 Unknown—Race/ethnicity is unknown. Those who are identified only as Hispanic are classified as Hispanic. 

Rate: A measure of the incidence of drug-related ED visits per 100,000 population. A rate can be calculated for the 

total population or for any subset defined by characteristics such as age and gender. 

Relative standard error (RSE): A measure of an estimate’s relative precision. The RSE of an estimate is equal to the 

estimate’s standard error (SE) divided by the estimate itself. For example, an estimate of 2,000 cocaine visits with an 

SE of 200 visits has an RSE of 10%. The larger the RSE, the less precise the estimate. Estimates with an RSE of 

50% or greater 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 Database. 

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. 
74 DAWN, 2006: NATIONAL ED ESTIMATES 

Sampling weights: Numeric coefficients used to derive population estimates from a sample by adjusting for 

deviations from the original sample design due to unequal probability sampling, variable nonresponse, and other 

potential sources of bias. 

Seeking detox: This category of drug-related ED visits captures patients seeking substance abuse treatment, drug 

rehabilitation, or medical clearance for admission to a drug treatment or detoxification unit. They are classified 

separately because they often reflect administrative practices that vary across hospitals and may vary over time 

within the same hospital. Seeking detox visits tend to be concentrated in those facilities that operate specialized 

inpatient units providing substance abuse treatment or detoxification services, and the largest numbers are found in 

facilities that require medical clearance for entry into such treatment to be granted in their EDs. 

Single-drug case: 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 captures single-drug visits/deaths involving alcohol only if the patient /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, and 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 a drug was involved. 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, 
DAWN, 2006: NATIONAL ED ESTIMATES 7 5

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 in 

Appendix C. 

Universe: The entire set of units for which generalizations are drawn. The universe for the DAWN ED sample is all 

non-Federal, short-stay, general medical and surgical hospitals in the United States that operate one or more EDs 24 

hours a day, 7 days a week. Specialty hospitals, hospital units of institutions, long-term care facilities, pediatric 

hospitals, hospitals operating part-time EDs, and hospitals operated by the Veterans Health Administration and the 

Indian Health Services are excluded. The universe of EDs is identified from the American Hospital Association’s 

Annual Survey Database. 
76 DAWN, 2006: NATIONAL ED ESTIMATES 
DAWN, 2006: NATIONAL ED ESTIMATES 7 7

APPENDIX C 

DAWN DATA COLLECTION AND STATISTICAL METHODS 

Introduction 

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that has monitored drugrelated 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 (NIDA) 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 NIDA 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 ED. This 

current approach was first implemented in the 2004 data collection year. 

DAWN uses the data from the visits classified as DAWN cases in the selected hospitals to calculate various 

estimates of drug-related 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 data collection methods and the sampling, weighting, and variance estimation 

methodologies used to develop estimates for the DAWN data collected for 2004, 2005, and 2006. 

Target population 

The target population is drug-related ED visits in non-Federal, short-stay, general surgical and medical hospitals 

in the United States with at least one 24-hour ED. 

Hospital sample 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 
78 DAWN, 2006: NATIONAL ED ESTIMATES 

99%.1 A health care organization must meet several criteria to be classified as a hospital by the AHA. 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 ED. Many DAWN hospitals 

operate multiple EDs. 

Determination of DAWN eligibility 

A hospital is considered ineligible if any one of the key criteria that define eligibility (non-Federal, short-stay, 

general surgical and medical hospitals located in the United States, with at least one 24-hour ED) 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, any one of the nonmissing criteria can render it ineligible. Otherwise, the hospital is 

considered to have unknown eligibility. For any hospital with unknown eligibility, other variables in the AHA Annual 

Survey Database are used to determine eligibility. If the hospital’s eligibility remains unknown, additional data sources 

are consulted to determine eligibility. 

DAWN data collection 

DAWN ED data are collected through a retrospective review of ED medical records for patients treated in the 

ED. Patients or families are never interviewed. The review of source records is performed by a trained DAWN 

Reporter in each member facility. Depending on the needs of the facility, the DAWN Reporter may be an employee of 

the hospital or an employee of the DAWN operations contractor. 

For each facility that participates in DAWN, the designated DAWN Reporter reviews all medical records to find 

ED visits related to drug use. The DAWN Reporter submits an electronic case report to the DAWN system for each 

ED visit that meets the specific case selection criteria. DAWN Reporters also track, on a copy of the ED registration 

log, their progress in reviewing the universe of ED visits. 

Data items collected by DAWN 

The case report form showing all the collected DAWN data items is provided in Figure C1. 

 

1 AHA Annual Survey Database, Fiscal year 2001 Health Forum LLC, Copyright 2003, One North Franklin Street, Chicago, IL 60606. 
DAWN, 2006: NATIONAL ED ESTIMATES 7 9

Figure C1 

DAWN ED case form 
80 DAWN, 2006: NATIONAL ED ESTIMATES 

DAWN features that enhance data quality and reliability 

Several methods are used to improve the quality and reliability of DAWN data, including the following: 

 Retrospective review of ED medical records for every patient treated in participating EDs, 

 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, 

 Accurate, specific, and nonredundant drug reporting, 

 Inclusion of data items to identify drugs confirmed by laboratory testing, 

 Rigorous training and certification of DAWN Reporters, and 

 In-house review and cleaning of DAWN case reports (see later section, Reduction of Bias, for more details). 

ED visits eligible for DAWN 

A DAWN case is any ED visit related to recent drug use. DAWN includes ED visits associated with substance 

abuse and 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. 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 visits that can be aggregated or disaggregated to serve a variety of analytical 

purposes and the interests of multiple audiences. In DAWN, only recent drug use is included,2 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. 

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

 There is no evidence of recent drug use. 

 The patient left the ED without being treated. 

 The patient consumed a nonpharmaceutical 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 as a consequence of undermedication (i.e., taking too little of a drug). 

 

2 That is, patients with a history of drug use (and no recent use) are excluded. 
DAWN, 2006: NATIONAL ED ESTIMATES 8 1

Types of cases in DAWN 

By design, DAWN’s broad case criteria yield a diverse set of visits. To bring order to this heterogeneous mix of

ED visits, each visit is assigned to one of eight types, which may be analyzed separately or in purposeful 

combinations. The eight types of visits are: 

 Suicide attempt, 

 Seeking detoxification, 

 Alcohol only in patients under age 21, 

 Adverse reaction, 

 Overmedication, 

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

 Accidental ingestion, and 

 Other. 

DAWN Reporters assign each DAWN case to one, and only one, of the eight case types, based on a series of 

questions and decision rules. The questions and rules are organized as a decision tree (Figure C2). Starting at the 

top, each case is assigned to the first case type that applies, even if the case might also meet the rules for a 

subsequent category. The eight case types were ordered with this in mind. 

The final category in the decision tree is called Other and it is reserved for DAWN visits 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 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 powerful factor to influence documentation practices. 

Drugs included in DAWN 

DAWN includes all types of drugs:3

 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, nonpharmaceutical inhalants, 

 Alcohol in combination with other drugs, and 

 Alcohol alone, in patients aged less than 21 years. 

 

3 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2007, Multum Information Services, Inc. The 

classification was modified to meet DAWN’s unique requirements (2007). 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.
82 DAWN, 2006: NATIONAL ED ESTIMATES 

Figure C2 

Type of case decision tree 
DAWN, 2006: NATIONAL ED ESTIMATES 8 3

To be reportable, a nonpharmaceutical 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 nonpharmaceutical, 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 one is painting a closet) are 

excluded as well. 

Hospital participation 

For 2006, 205 hospitals submitted data on 269,339 drug-related ED visits that were used for estimation 

(Tables C1 and C2). The overall weighted response rate was 26.1%. For the 12 oversampled metropolitan areas and 

divisions, individual response rates ranged from 30.8% in the Houston-Baytown-Sugar Land, TX Metropolitan 

Statistical Area to 71.2% in the Detroit-Warren-Livonia, MI Metropolitan Statistical Area. 

For 2005, 224 hospitals submitted data on 268,128 drug-related ED visits that were used for estimation. The 

overall weighted response rate in 2005 was 28.9%. There were 13 oversampled areas in 2005 with response rates 

ranging from 31.1% to 77.3%. 

For 2004, 220 hospitals submitted data on 168,841 drug-related ED visits that were used for estimation. The 

overall weighted response rate in 2004 was 23.9%. There were 13 oversampled areas in 2004 with response rates 

ranging from 35.3% to 70.8%. 

Charts reviewed for drug-related ED visits 

DAWN cases are found through a retrospective review of medical records in participating hospitals. Across all 

participating hospitals in 2006, 9,837,481 charts were reviewed to find the drug-related ED visits that met the DAWN 

case criteria. Based on the review of charts, 346,946 drug-related visits4 were found and submitted to the DAWN 

database, a case rate of 3.5%. On average, a DAWN member hospital submitted 1,077 DAWN cases. However, the 

number of submitted cases varied widely across hospitals, from 7 cases to 6,782 cases (median 820) in a single 

hospital during 2006. 

Across all participating hospitals in 2005, 11,472,887 charts were reviewed to find the drug-related ED visits that 

met the DAWN case criteria. Based on the review of charts, 374,276 drug-related visits were found and submitted, a 

case rate of 3.3%. On average, a DAWN member hospital submitted 843 DAWN cases. The number of DAWN cases 

varied widely, from 1 case to 9,021 (median 525) for a single hospital. 

Across all participating hospitals in 2004, 13,299,739 charts were reviewed to find the drug-related ED visits that 

met the DAWN case criteria. Based on the review of charts, 307,094 drug-related visits were found and submitted, a 

case rate of 2.3%. On average, a DAWN member hospital submitted 609 DAWN cases. The number of DAWN cases 

varied widely, from 1 case to 7,485 (median 377) for a single hospital. 

 

4 For 2004-2006, more hospitals participated in DAWN than were used in estimation. Therefore, the number of drug-related ED visits 

from all participating hospitals exceeded the number used for estimation. 
84 DAWN, 2006: NATIONAL ED ESTIMATES 

Table C1 

Data collection year 2006 

Geographic area 

Total 

eligible 

hospitals1

Eligible 

hospitals 

in sample 

Responding

hospitals 

in sample 

Percent 

Response 

rate for 

sampled 

hospitals 

Design 

weight 

response 

rate 

Visits 

weighted 

response 

rate 

Total U.S.2 4,568 544 205 37.7 24.9 26.1 

Metropolitan Statistical Areas (MSAs)3

Boston-Cambridge-Quincy, MA-NH 

MSA 40 29 17 58.6 58.5 57.3 

Chicago-Naperville-Joliet, IL-IN-WI 

MSA 90 74 27 36.5 37.7 36.2 

Denver-Aurora, CO MSA 15 15 9 60.0 60.0 68.1 

Detroit-Warren-Livonia, MI MSA 37 24 16 66.7 69.7 71.2 

Houston-Baytown-Sugar Land, TX 

MSA 47 42 12 28.6 28.3 30.8 

Minneapolis-St. Paul-Bloomington, 

MN-WI MSA 27 27 10 37.0 37.0 44.0 

Phoenix-Mesa-Scottsdale, AZ MSA 28 26 14 53.8 53.8 58.1 

San Diego-Carlsbad-San Marcos, CA 

MSA 16 16 8 50.0 50.0 55.7 

Seattle-Tacoma-Bellevue, WA MSA 24 22 10 45.5 45.5 55.2 

Metropolitan Divisions and Subareas3

Miami-Miami Beach-Kendall, FL 

Metropolitan Division of Miami-Fort 

Lauderdale-Miami Beach, FL MSA 

22 16 8 50.0 46.7 50.1 

Bronx, Kings, New York, Queens, 

Richmond Counties of New YorkNewark-Edison, NY-NJ-PA MSA 

50 39 21 53.8 46.1 55.0 

San Francisco-San Mateo-Redwood 

City, CA Metropolitan Division of San 

Francisco-Oakland-Fremont, CA MSA 

18 18 8 44.4 44.4 54.2 

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. 
DAWN, 2006: NATIONAL ED ESTIMATES 8 5

Table C2 

Drug-related ED visits, by type of case: 2006 

Unweighted 

sample data 

Weighted 

estimates1

Relative 

standard 

error (RSE) 

95% Confidence interval 

Lower bound Upper bound 

Drug-related ED visits 

Suicide attempt 11,840 182,805 8.0 154,185 - 211,424 

Seeking detox 18,789 118,355 12.1 90,171 - 146,540 

Alcohol only (age < 21) 9,940 125,888 12.5 95,087 - 156,690 

Adverse reaction 93,507 1,526,010 9.3 1,247,859 - 1,804,161 

Overmedication 20,643 285,828 6.2 250,991 - 320,664 

Malicious poisoning 750 8,817 13.1 6,546 - 11,088 

Accidental ingestion 4,117 79,011 9.1 64,855 - 93,166 

Other 109,753 1,115,141 13.0 832,069 - 1,398,213 

Total drug-related ED visits 269,339 3,441,855 6.1 3,033,110 - 3,850,600 

Total drug misuse/abuse visits 164,334 1,742,887 8.5 1,451,086 - 2,034,688 

Total ED visits (all reasons) 8,930,694 113,110,132 0.0 - 

Drugs2

Suicide attempt 25,096 402,907 9.1 331,056 - 474,758 

Seeking detox 38,909 243,297 13.3 180,091 - 306,502 

Alcohol only (age < 21) 9,940 125,888 12.5 95,087 - 156,690 

Adverse reaction 120,016 2,055,783 11.1 1,608,379 - 2,503,188 

Overmedication 35,340 506,476 6.6 441,034 - 571,919 

Malicious poisoning 1,295 15,293 12.7 11,482 - 19,105 

Accidental ingestion 5,200 98,613 9.1 81,048 - 116,178 

Other 183,642 1,936,561 10.7 1,531,598 - 2,341,524 

Drugs in all drug-related ED 

visits 419,438 5,384,819 6.3 4,716,771 - 6,052,867 

Drugs in all misuse/abuse ED 

visits 282,938 3,086,984 7.2 2,649,699 - 3,524,268 

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update). 
86 DAWN, 2006: NATIONAL ED ESTIMATES 

DAWN data in this publication 

For analysis, three categories of ED visits related to drug misuse and abuse were defined. These categories, 

designed to parallel the approach of the National Survey on Drug Use and Health, are based on: 

 Use of illicit drugs, 

 Use of alcohol, in combination with other drugs, and alcohol alone in patients under the age of 21, and 

 Nonmedical use of pharmaceuticals (e.g., prescription or OTC drugs). 

These three categories are defined by drug and case type as shown in Table C3. Because multiple drugs may be 

involved in a single visit, these categories are not mutually exclusive. A drug-related ED visit involved 1.6 drugs, on 

average, in 2004, 2005, and 2006. 

Table C3 

ED visits related to drug misuse and abuse in DAWN 

Type of drug 

involvement Drugs included Case types included 

Use of illicit drugs – Cocaine 

– Heroin 

– Marijuana 

– Stimulants (amphetamines and 

methamphetamine) 

– MDMA 

– GHB 

– Flunitrazepam (Rohypnol) 

– Ketamine 

– LSD 

– PCP 

– Other hallucinogens 

– Nonpharmaceutical inhalants 

– Combinations of illicit drugs 

All case types 

Use of alcohol – Alcohol in combination with other 

drug(s) 

– Alcohol only in patients under the 

age of 21 

All case types, regardless of age 

Cases with alcohol as the sole drug appear only in the following 

case types for patients under age 21 

– Suicide attempts 

– Seeking detox 

– Alcohol only (age < 21) 

Nonmedical use of 

pharmaceuticals 

– Prescription and OTC 

pharmaceuticals 

– Dietary supplements 

Combination of three case types 

– Overmedication (cases of nonmedical use, overuse, misuse 

lacking explicit documentation of drug abuse) 

– Malicious poisoning (cases in which the patient was 

administered a drug by another for a malicious purpose) 

– Case type Other (cases that could not be assigned to another 

case type; includes documented drug abuse) 

NOTE: In this publication the case types of suicide attempt and seeking detox are analyzed separately, but for other purposes they 

might be considered as nonmedical use. Nonmedical use, though, should never include adverse reaction or accidental 

ingestion cases.
DAWN, 2006: NATIONAL ED ESTIMATES 8 7

Sampling and estimation 

DAWN sample design 

The redesign of the DAWN system introduced in 2003 altered most of the major features of the DAWN data 

collection and included a new sample of hospitals that constituted the DAWN. The new sampling plan, fully 

implemented for the first time for the 2004 estimates, formed a nationally representative panel of hospitals to be 

followed longitudinally for the indefinite future. Briefly, this new design is a probability-based, stratified, one-stage 

sample. A complete and accurate list of all hospitals in the United States was drawn and, from that, all hospitals 

meeting the criteria for the target sample frame were identified. Samples were drawn to provide the capability to make 

estimates for the Nation as well as select Metropolitan Statistical Areas (MSAs) and divisions (Table C4). Each year 

the sample frame is updated to account for new hospitals. 

The stratified design called for drawing oversamples of hospitals in 48 MSAs; in four of those 48 MSAs, 

additional oversamples were drawn for a total of nine divisions.5 In effect, there are 53 nonoverlapping geographic 

areas (44 whole MSAs and nine divisions). (See Table C4 for list of MSAs and divisions6 where oversamples were 

drawn.) These areas are collectively referred to as oversample areas, or OS areas. 

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.7 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.8 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, 2 subdivisions each for 3 of these metropolitan areas, 

and 3 subdivisions for one of these metropolitan areas. 

 

5 The four MSAs where samples were drawn for divisions are Los Angeles, Miami, New York, and San Francisco. The division 

definitions used by DAWN follow Census Bureau definitions of Metropolitan Divisions, except in New York where the three 

submetropolitan areas were defined uniquely based on local input. 

6 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 and http://www.census.gov/population/www/estimates/metrodef.html). 

7 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network: Development of 

a New Design (Methodology Report). DAWN Series M-4, DHHS Publication No. (SMA) 02-3754, Rockville, MD, 2002. 

8 When metropolitan areas were redefined in June 2003 based on data from the 2000 decennial Census, several legacy MSAs were 

merged with other MSAs to form new, much larger MSAs. However, a strong constituency of DAWN data users still needed estimates 

for the pre-merger areas. Because of this, four of the 48 metropolitan areas—Los Angeles, Miami, New York, and San Francisco—

were subdivided into a total of nine divisions, corresponding to the constituents’ areas of interest. 
88 DAWN, 2006: NATIONAL ED ESTIMATES 

Table C4 

Oversample (OS) areas in DAWN sample design 

Atlanta-Sandy Springs-Marietta, GA* 

Austin-Round Rock, TX 

Baltimore-Towson, MD* 

Birmingham-Hoover, AL 

Boston-Cambridge-Quincy, MA-NH* 

Bridgeport-Stamford-Norwalk, CT 

Buffalo-Cheektowaga-Tonawanda, NY* 

Chicago-Naperville-Joliet, IL-IN-WI* 

Cincinnati-Middletown, OH-KY-IN 

Cleveland-Elyria-Mentor, OH 

Columbus, OH 

Dallas-Fort Worth-Arlington, TX* 

Denver-Aurora, CO* 

Detroit-Warren-Livonia, MI* 

Hartford-West Hartford-East Hartford, CT 

Honolulu, HI 

Houston-Baytown-Sugar Land, TX 

Indianapolis, IN 

Kansas City, MO-KS 

Los Angeles-Long Beach-Santa Ana, CA* 

Los Angeles-Long Beach-Santa Ana, CA – Los Angeles 

division (contains Los Angeles-Long Beach-Glendale, 

CA Metropolitan Division) 

Los Angeles-Long Beach-Santa Ana, CA – Orange 

County division (contains Santa Ana-Anaheim-Irvine, 

CA Metropolitan Division) 

Las Vegas-Paradise, NV 

Louisville, KY-IN 

Memphis, TN-MS-AR 

Miami-Fort Lauderdale-Miami Beach, FL* 

Miami-Fort Lauderdale-Miami Beach, FL – Fort 

Lauderdale division (contains Fort LauderdalePompano Beach-Deerfield Beach, FL, and West Palm 

Beach-Boca Raton-Boynton Beach, FL, Metropolitan 

Divisions) 

Miami-Fort Lauderdale-Miami Beach, FL – Miami-Dade 

County division (contains Miami-Miami Beach-Kendall, 

FL Metropolitan Division) 

Minneapolis-St. Paul-Bloomington, MN-WI* 

Nashville-Davidson—Murfreesboro, TN 

New Haven-Milford, CT 

New Orleans-Metairie-Kenner, LA* 

New York-Newark-Edison, NY-NJ-PA* 

New York-Newark-Edison, NY-NJ-PA – New Jersey division 

(contains Middlesex, Monmouth, Ocean, Somerset, 

Essex, Hunterdon, Morris, Sussex, Union, Bergen, 

Hudson, Passaic Counties, NJ, and Pike County, PA) 

New York-Newark-Edison, NY-NJ-PA – New York Suburban 

division (contains Nassau, Putnam, Rockland, Suffolk, 

Westchester Counties, NY) 

New York-Newark-Edison, NY-NJ-PA – New York City, 

5 Boroughs division (contains Bronx, Kings, New York, 

Queens, Richmond Counties, NY) 

Omaha-Council Bluffs, NE-IA 

Philadelphia-Camden-Wilmington, PA-NJ-DE-MD* 

Phoenix-Mesa-Scottsdale, AZ* 

Pittsburgh, PA 

Portland-Vancouver-Beaverton, OR-WA 

Providence-New Bedford-Fall River, RI-MA 

Riverside-San Bernardino-Ontario, CA 

Rochester, NY 

Sacramento-Arden-Arcade-Roseville, CA 

Salt Lake City, UT 

San Antonio, TX 

San Diego-Carlsbad-San Marcos, CA* 

San Francisco-Oakland-Fremont, CA* 

San Francisco-Oakland-Fremont, CA – Oakland division 

(contains Oakland-Fremont-Hayward, CA Metropolitan 

Division) 

San Francisco-Oakland-Fremont, CA – San Francisco 

division (contains San Francisco-San Mateo-Redwood 

City, CA Metropolitan Division) 

Seattle-Tacoma-Bellevue, WA* 

St. Louis, MO-IL* 

Tampa-St. Petersburg-Clearwater, FL 

Tucson, AZ 

Washington-Arlington-Alexandria, DC-VA-MD-WV* 

Wichita, KS 

*

 Denotes a legacy area. Two separate legacy areas (New York and Newark) are contained in the New York-Newark-Edison, NY-NJPA Metropolitan Statistical Area. 
DAWN, 2006: NATIONAL ED ESTIMATES 8 9

Sampled hospitals in each of the OS areas were stratified by hospital size (up to four categories based on

volume of ED visits) and ownership type (public and private). (Size categories were determined independently for 

each OS area.) The stratification plan included an additional geographic construct for the remainder of the United 

States outside the OS areas. Hospitals in the remainder area were stratified into 24 remainder strata based on four 

regions (Northeast, South, Midwest, West), hospital size (three size categories based on volume of ED visits), and 

ownership type (public and private). 

To begin, a cross classification was created by categories of ownership type and geographic unit. Within each 

combination of geographic area and ownership type, 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 remainder 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 remainder sample.9

The DAWN national estimates are the sum of the estimates for OS areas and the remainder area. Using a 

formula, the national estimate is depicted as: 

ba

i

i +⎟

⎟

⎠

⎞

⎜

⎜

⎝

⎛

∑=

53

1

where ai is the estimate for OS area i, 53 is the number of OS areas, and b is the remainder area estimate. 

It was never expected that DAWN would be able to expand data collection into all 53 OS areas. Instead, the 

expectation was that DAWN would build up gradually to the number of OS areas its budget could support. The DAWN 

sample design was conceived to provide the flexibility to change gradually over time in terms of the number of OS 

areas where data were collected, while providing the statistical infrastructure to enable the production of reliable and 

representative estimates for the Nation and select OS areas, regardless of their number. 

To accomplish this, the DAWN design incorporates an approach whereby a subset of the hospitals within the OS 

areas was identified a priori as having a dual-purpose in estimation. Referred to as “dual-purpose hospitals,” these 

designated hospitals can contribute to an estimate for the OS area in which they are located or they can contribute to 

the estimate for the remainder area. Dual-purpose hospitals carry two probabilities of selection (POS) and two stratum 

identifiers. One POS/stratum is associated with membership in an OS-area sample and the other is associated with 

membership in the remainder-area sample.10

 

9 Four Census regions times two ownership categories times three size categories equals 24 strata. 

10 In addition, a portion of hospitals in the nine oversampled divisions were identified a priori to serve in their MSA-level oversample and 

were assigned an OS area level POS/stratum for that third purpose. Therefore, hospitals in the four MSAs with division-level 

oversampling can have up to three nonzero POS/strata: (1) a POS/stratum for membership in the MSA; (2) a POS/stratum for 

membership in the division; and (3) a POS/stratum for membership in the remainder area. 
90 DAWN, 2006: NATIONAL ED ESTIMATES 

Figure C3 depicts the initial sample as it was drawn to provide: 

 individual samples from a series of OS areas, 

 dual-purpose hospitals within those areas, and 

 a remainder sample to represent the rest of the country. 

Figure C3 

Original DAWN sample design 

For estimation for each data year, the first step is to determine which role each sampled hospital will play in that 

year’s estimates. To do this, the response rates and nonresponse patterns for each OS area are reviewed to 

determine data quality. Those OS areas with acceptable data quality are allowed to stand on their own as the basis 

for separate estimates. These are referred to as “stand-alone OS areas.” All hospitals in stand-alone OS areas, 

including those originally designated as being in the dual-purpose subsample, are considered to be “oversample 

hospitals” in the OS areas, and they contribute to the OS-area estimate using their OS-area POS/stratum. 
DAWN, 2006: NATIONAL ED ESTIMATES 9 1

If it is determined based on response rates and bias analyses that an OS area cannot stand alone, the design 

provides that the OS area is eliminated as a separate area but becomes part of the remainder area. In this instance: 

 only those dual-purpose hospitals that are designated a priori to contribute to the remainder-area estimate 

are retained in the remainder-area subset, 

 these hospitals contribute to the remainder-area estimate using their remainder-area POS/stratum, and 

 data from any other hospitals in the OS area are excluded from the national estimates. 

Figure C4 depicts the assignment of dual-purpose hospitals to either an OS area or the remainder area and the 

exclusion of OS hospitals outside of stand-alone OS areas that are not designated as dual purpose. 

Figure C4 

DAWN design in practice 
92 DAWN, 2006: NATIONAL ED ESTIMATES 

After it is determined which OS areas will be stand alone, the DAWN national estimates as reported in this 

publication are the sum of the estimates for stand-alone OS areas plus the remainder area. Using a formula, the 

national estimate is depicted as: 

ba

i

i +⎟

⎟

⎠

⎞

⎜

⎜

⎝

⎛

∑=

53

1

where ai is the estimate for stand-alone OS area i, 53 is the number of stand-alone OS areas, and b is the remainder 

area estimate inclusive of dual-purpose hospitals in OS areas that are not stand alone. 

It is important to note that the definition of the remainder area and the remainder sample of hospitals is designed 

to be fluid; hospital membership in the remainder sample changes from year to year depending on the response rates 

and data quality within the OS areas. 

Sample maintenance 

Because DAWN is a longitudinal survey that will be used to analyze trends in drug-related ED visits over time, 

annual updates to the sample are performed to ensure that the sample remains representative of the target 

population. 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. 

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 

100% coverage of the target population. To minimize 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 is provided in an earlier DAWN publication.11 

 

11 See Appendix B, Technical Notes: Changes to Improve the Quality of DAWN Data in: 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. 
DAWN, 2006: NATIONAL ED ESTIMATES 9 3

Sample size and sample allocation 

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 drugrelated visits, cocaine visits, heroin visits, and marijuana visits. As discussed below, these desired precision levels are 

important drivers for setting sample size targets. 

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 

Wh

Sh /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 Target 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 these 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. 

 Finally, if any calculations produced a sample size smaller than two hospitals, then the sample size was set 

to two hospitals. 

Response rate calculations 

In 2006, the initial DAWN sample included 1,286 hospitals divided among 53 OS areas (48 MSAs and nine 

divisions) and one remainder area. Response rates and nonresponse bias analyses were assessed to determine 

which of these 53 OS areas could stand alone (Figure C3). Once this determination was made, hospitals that were 

neither dual-purpose nor located in a stand-alone OS area were treated as if they were not sampled. For 2006, this 

has the effect of reducing the sample from 1,286 hospitals to 544 hospitals, which is the number used for purposes of 

computing the unweighted response rates (Table C1). 

Of the 53 original oversample areas, a total of 12 areas (nine metropolitan areas and three submetropolitan 

areas) were determined to be able to stand alone in 2006. A total of 13 areas were determined to be able to stand 
94 DAWN, 2006: NATIONAL ED ESTIMATES 

alone in 2004 and 2005. The 13th OS area was New Orleans-Metairie-Kenner, LA. These determinations yielded a 

sample size of 556 hospitals in 2004 and 562 hospitals in 2005. 

Sampling weights 

The DAWN hospitals are selected using stratified simple random sampling with oversampling in selected 

metropolitan areas. The stratum sample sizes were determined through an optimum allocation process. Sampling 

weights are first calculated as the inverse of the probability of selection and then adjusted for variable nonresponse 

and by a procedure known as “poststratification,” or benchmark adjustment. 

Within-hospital weighting adjustment 

Within-hospital nonresponse occurs when a hospital provides incomplete data. To minimize the impact of withinhospital nonresponse, the DAWN weighting plan includes nonresponse adjustment factors that were developed and 

applied for each month of data collection within each facility. The within-hospital nonresponse adjustment factor is 

calculated as the total number of ED visits within a month within a facility divided by the total number of reviewed 

charts for that same facility-month. 

The within-hospital weights are applied to the case data by month and by facility. That is, the visit counts for a 

given facility-month are first summed for each drug and then multiplied by the corresponding within-hospital 

adjustment factor for that facility-month. The weighted totals are then summed over all facilities and months to give a 

total weighted visit count for each drug for each hospital. 

Weighting adjustment for hospital nonresponse 

Hospital-level nonresponse occurs when hospitals fail to provide any data. To minimize the impact of hospital 

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 is calculated as the sum of the sampled 

hospital weights divided by the sum of the weights of the responding hospitals. The hospital nonresponse adjustment 

factors are checked to make sure the adjustments are within reasonable bounds. If a nonresponse adjustment factor 

is out of bounds (either too small or too large), adjacent weighting classes are collapsed and new nonresponse 

adjustment factors are calculated. 

When the hospital-level nonresponse adjustment factors are considered final, a nonresponse-adjusted sampling 

weight was then calculated as the product of the nonresponse adjustment factor and the sampling weight. 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 of total 
DAWN, 2006: NATIONAL ED ESTIMATES 9 5

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. 

When the poststratification adjustment factors were considered final, a poststratified weight was then calculated. 

The final weight was calculated as the product of the poststratification adjustment factor and the nonresponseadjusted sampling weight. For each poststratification stratum, a validity check was conducted to ensure that the sum 

of the poststratified weighted total visits was equal to the corresponding AHA count of total visits from each stratum. 

Special consideration was given to New Orleans because Hurricane Katrina (on August 29, 2005) and its 

aftermath caused serious disruptions to the operations of hospitals and, consequently, the DAWN data collection 

process for the remaining four months of the year. Weight adjustments were implemented by referring to the AHA 

total counts in combination with a case-by-case study of each hospital in the New Orleans metropolitan area.12 Based 

on these studies, estimates were made of the proportion of the year that each hospital was open and serving the 

public. These were used to adjust the AHA totals, which in turn serve as input for population benchmark counts for 

New Orleans. 

Total drug-related ED visits 

Estimates for the entire universe of DAWN-eligible hospitals in the United States are produced by applying 

poststratified weights to the data received from the sampled hospitals. Thus, for 2006, 269,339 submitted cases were 

extrapolated to an estimate of 3,441,855 drug-related ED visits. Considering the margin of error, this estimate may 

range from 3,033,110 to 3,850,600 drug-related ED visits out of more than 113 million total ED visits estimated for the 

United States (Table C2). 

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 first summing the case totals within 

facility-month, applying the within-hospital weight, summing to the hospital level, applying the final hospital weight, 

and summing over all hospitals. 

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 the relative 

standard error (RSE), which is defined as the SE of the estimate divided by the estimate itself. 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. 

 

12 Information provided by the Louisiana Hospital Association, the Louisiana Public Health Institute, the City of New Orleans Health 

Department, and available at numerous websites maintained by individual hospitals, news organizations, and State and Federal 

agencies was invaluable in conducting this assessment. We are grateful for their assistance. 
96 DAWN, 2006: NATIONAL ED ESTIMATES 

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 

within 1.96 standard deviations of the mean. 

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% CI: 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 values would fall within the confidence interval 95% of the time. 

Both between- and within-hospital variance components were accounted for. Within-hospital variance was 

estimated using a replication strategy by which two random replicates were created within each hospital and the 

variance between the two replicates represented the within-hospital contribution. Typically, this component was 

considerably smaller than the between-hospital variance that was calculated as the variance between weighted 

hospital totals within each stratum. 

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 aged 18 to 20 in the United States is much lower than the number of individuals aged 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. 
DAWN, 2006: NATIONAL ED ESTIMATES 9 7

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

calculated using population data from the U.S. Bureau of the Census.13

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 2006 are provided in Table C5. 

Table C5 

Population by age and gender: 20061

Gender and age Total United States Males Females 

Total 302,225,862 149,002,083 153,223,779 

0-5 years 24,640,694 12,601,585 12,039,109 

6-11 years 23,807,562 12,174,360 11,633,202 

12-17 years 25,447,520 13,037,107 12,410,413 

18-20 years 12,674,580 6,507,886 6,166,694 

21-24 years 16,977,014 8,780,282 8,196,732 

25-29 years 21,221,621 10,871,501 10,350,120 

30-34 years 19,655,279 9,974,102 9,681,177 

35-44 years 43,297,681 21,691,759 21,605,922 

45-54 years 43,932,378 21,623,741 22,308,637 

55-65 years 32,737,374 15,786,874 16,950,500 

65 years and older 37,834,159 15,952,886 21,881,273 

1 Population estimates for 2006 are, as of 6/9/2008, from the U.S. Bureau of Census Postcensal Resident Population National 

Population Dataset, National estimates by demographic characteristics – single year of age, sex and race, and Hispanic Origin, 

Monthly Population Estimates. Link: http://www.census.gov/popest/datasets.html. File: NC-EST2007-ALLDATA-R-File14.csv. 

Standardized rates were not calculated for race and ethnicity subgroups, because the race/ethnicity categories 

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

categories in the Census data. Appendix D describes the race and ethnicity data reported for DAWN. 

 

13 Population estimates for 2006 are, as of 6/9/2008, from the U.S. Bureau of Census Postcensal Resident Population National 

Population Dataset, National estimates by demographic characteristics – single year of age, sex and race, and Hispanic Origin, 

Monthly Population Estimates. Link: http://www.census.gov/popest/datasets.html. File: NC-EST2007-ALLDATA-R-File14.csv.
98 DAWN, 2006: NATIONAL ED ESTIMATES 

Determination of significant differences between years 

Comparisons in the estimates of ED visits between years are presented in the form of percentage differences. 

These are calculated as the 2006 estimate minus the 2004 estimate divided by the 2004 estimate. For shorter term 

comparisons, these are calculated as the 2006 estimate minus the 2005 estimate divided by the 2005 estimate. The 

result is presented as a percentage, which is shown only if the difference between the two years is statistically 

significant. Tests for the significance of differences between two years consider the variance of each year’s estimate 

and the covariance between the two. Thus, hospitals that appear in both samples and provide data in both years 

contribute to the covariance and, thus, decrease the overall sampling variance beyond the combined contribution of 

the two samples. The variance estimation process used to establish significance takes into account this overlap 

between the two annual samples. 

Publication criteria 

DAWN can produce estimates for thousands of drugs, patient characteristics, and visit characteristics, but some 

of these estimates are too imprecise, too small, or based on too little data 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% CI approaches or includes the value zero. A CI 

that includes zero means that the estimate is not statistically different from zero at this precision level. 

 The weighted or unweighted quantity of ED visits 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 because of 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. 

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, 2006: NATIONAL ED ESTIMATES 9 9

APPENDIX D 

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 systems.1 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 (no patient is interviewed for DAWN), 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 single data item for race and ethnicity is shown in the DAWN ED case form 

that has been used since 2003 (Appendix C, Figure C1). 

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 (i.e., 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 D1. 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/ethnicities (i.e., two or more races/ethnicities 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, 62 

Fed. Reg. 58,782 (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. 
100 DAWN, 2006: NATIONAL ED ESTIMATES 

Table D1 

Drug-related ED visits, by detailed race/ethnicity: 2006 

Race/ethnicity Estimated visits1,2

Total drug-related ED visits 3,441,855 

One race/ethnicity 3,411,056 

White 2,132,810 

Black/African American 524,420 

Hispanic 298,668 

Asian 5,765 

American Indian/Alaska Native 29,396 

Native Hawaiian/Other Pacific Islander 3,875 

Race unknown 416,122 

Two races/ethnicities 30,798 

White + Black/African American 717 

White + Hispanic 28,394 

White + Asian 110 

White + American Indian/Alaska Native 32 

Black/African American + Hispanic 699 

Black/African American + Asian ... 

Black/African American + American Indian/Alaska Native 216 

Hispanic + Asian ... 

Hispanic + American Indian/Alaska Native 366 

Asian + American Indian/Alaska Native ... 

Three races/ethnicities ... 

White + Black/African American + Hispanic ... 

White + Hispanic + Asian ... 

White + Asian + 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

United States. 

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (03/2008 update).