OFFICE OF APPLIED STUDIES

Drug Abuse Warning Network, 2003:

Interim National Estimates of Drug-Related 

Emergency Department Visits

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

http://DAWNinfo.samhsa.gov/
2 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

ACKNOWLEDGMENTS

This publication is based on data developed for the Substance Abuse and Mental Health Services Administration 

(SAMHSA), Office of Applied Studies (OAS) by Westat under Contract No. 277-00-6114 and Contract No. 283-02-9025. 

Dr. Judy Ball (DAWN Project Director, SAMHSA/OAS), Carol Morin (Project Director), Evarilla Cover, James Green, Joseph 

Sonnefeld, Diane Steele, and Tracy Williams at Westat and Erin Mallonee at SAMHSA/OAS wrote the publication. Other 

significant contributors at Westat included K.C. Lee, Nita Lemanski, Ann Parker, Debra Reames, Dale Spivey, Pat Stouffer, 

and Lois White. 

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, 2003: Interim National Estimates of Drug-Related Emergency Department Visits. 

DAWN Series D-26, DHHS Publication No. (SMA) 04-3972. Rockville, MD, 2004

OBTAINING ADDITIONAL COPIES OF PUBLICATION

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

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

NCADI at:

National Clearinghouse for Alcohol and Drug Information (NCADI)

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

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

ELECTRONIC ACCESS TO PUBLICATION

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

http://DAWNinfo.samhsa.gov/

http://www.samhsa.gov/

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

ORIGINATING OFFICE

SAMHSA, Office of Applied Studies

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

December 2004
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 3

CONTENTS

Page

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

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

 Major features of new DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

 Drug abuse in new DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

 Total drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

 Drug-related ED visits by case type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

 Illicit drugs in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

 Alcohol and drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

 Drug misuse and abuse in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

 Other types of drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

 Suicide attempts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

 Seeking detox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

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

 The re-design of DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Major features of the new design . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

 What is a DAWN case? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

 Types of cases in new DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

 What drugs are included in new DAWN? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

 Other improvements in new DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Estimates in this publication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

 Hospital participation in 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

 The margin of error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

 Estimates adjusted for population size . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Defining drug abuse in the new DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Defining drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

 Exclusions from drug misuse and abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Drug-related ED visits in Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Total drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Drug-related ED visits by case type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Illicit drugs in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Alcohol and drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Alcohol in combination with other drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Alcohol only in patients under the age of 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Any alcohol in patients under the age of 21 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
4 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

CONTENTS

Page

Drug misuse and abuse in ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Overmedication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Malicious poisoning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Case type other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Overmedication, malicious poisoning, and case type other combined . . . . . . . . . . . . . . . . . . . 59

Other types of drug-related ED visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Suicide attempt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Seeking detox . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

Adverse reaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70

Accidental ingestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

List of Tables

Table 1. Drug misuse and abuse in new DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Table 2. Comparison of major features, new DAWN versus old DAWN . . . . . . . . . . . . . . . . . . . 16

Table 3. ED sample information and response rates: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . 23

Table 4. Drug-related ED visits by type of case: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Table 5. Illicit drugs and alcohol in drug-related ED visits: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . 34

Table 6. Illicit drugs, by type of case: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Table 7. Illicit drugs, by patient characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

Table 8. Alcohol in drug-related ED visits: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Table 9. Alcohol, by type of case: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Table 10. Drugs reported most frequently with alcohol, by type of case: Q3-Q4 2003 . . . . . . 43

Table 11. Alcohol, by patient characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Table 12. Alcohol only (age < 21), by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . 46

Table 13. Alcohol in drug-related ED visits in patients under age 21: Q3-Q4 2003 . . . . . . . . . 47

Table 14. Overmedication: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Table 15. Overmedication, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . 51

Table 16. Malicious poisoning: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Table 17. Malicious poisoning, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . 54

Table 18. Case type other: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Table 19. Case type other, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . 58

Table 20. Overmedication, malicious poisoning, and case type other: Q3-Q4 2003 . . . . . . . . 61

Table 21. Overmedication, malicious poisoning, case type other, 

 by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

Table 22. Suicide attempt: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Table 23. Suicide attempt, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . 66

Table 24. Seeking detox: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

Table 25. Seeking detox, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . . . . . 69

Table 26. Adverse reaction: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 5

CONTENTS

Page

Table 27. Adverse reaction, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . . . 72

Table 28. Accidental ingestion: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Table 29. Accidental ingestion, by patient and visit characteristics: Q3-Q4 2003 . . . . . . . . . . . 75

Table B1. Type of case re-assignments: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

Table E1. Population by age and gender by metropolitan area, 2003 . . . . . . . . . . . . . . . . . . . . 99

Table F1. Drug-related ED visits, by detailed race/ethnicity: Q3-Q4 2003 . . . . . . . . . . . . . . . . 104

List of Figures

Figure 1. Type of case decision tree . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 2. DAWN ED case form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figure 3. Drug-related ED visits, by type of case: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . 31

Figure 4. Illicit drugs in ED visits: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Figure 5. Illicit drugs, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . 40

Figure 6. Alcohol with other drugs, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . 43

Figure 7. Alcohol only (age < 21), ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . 45

Figure 8. Overmedication, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . . . 50

Figure 9. Malicious poisoning, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . 52

Figure 10. Case type other, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . . 56

Figure 11. Overmedication, malicious poisoning, and case type other, 

 ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Figure 12. Suicide attempt, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . . 64

Figure 13. Seeking detox, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . . . 67

Figure 14. Adverse reaction, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . . . . 71

Figure 15. Accidental ingestion, ED visit rates by age and gender: Q3-Q4 2003 . . . . . . . . . . . 74

List of Appendixes

Appendix A: Multum Lexicon End-User License Agreement . . . . . . . . . . . . . . . . . . . . . . . . . . . 79

Appendix B: Technical Notes: Changes to Improve the Quality of DAWN Data . . . . . . . . . . . 83

Appendix C: Glossary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Appendix D: Estimates and Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Appendix E: Population Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99

Appendix F: Race and Ethnicity in DAWN . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
6 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 7

HIGHLIGHTS

T

his is the first publication to use data from the new Drug Abuse Warning Network (DAWN). Virtually every 

feature of DAWN, except its name, changed in 2003. In this publication, we refer to “new DAWN” to 

emphasize for readers that it is very different.

DAWN data and estimates for 2003 are not comparable to those for any prior years. Therefore, no trends are 

presented. 2003 was a period of transition between “old” and “new” DAWN. The transition to the new sample of 

hospitals began in 2003, but is not yet complete. As a result, the estimates in this publication are based on data from 

260 hospitals and apply only to the coterminous U.S. No estimates will be published for metropolitan areas for 2003. 

Major features of new DAWN

Beginning in 2003, a DAWN case is any ED visit related to recent drug use.

New DAWN includes ED visits associated with substance abuse and drug misuse, both intentional and accidental. 

New DAWN also includes ED visits related to the use of drugs for legitimate therapeutic purposes. None of these, not 

even the substance abuse cases, are comparable to DAWN cases from prior years.

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. 

Only recent drug use is included, the reason a patient used the drug is irrelevant, and the case criteria are broad enough 

to encompass all types of drug-related events, which include, but are not limited to, explicit drug abuse. This approach, 

which finds ED visits related to drug abuse only indirectly, recognizes that medical records (the source of DAWN data) 

frequently lack explicit documentation of substance abuse, and distinctions between use, misuse, and abuse of drugs are 

often subjective. This solves many problems inherent in the case criteria used by DAWN from 1972 to 2002.

To bring order to the heterogeneous mix of DAWN cases, each case is assigned to one of eight case types, 

hierarchically, as illustrated in the figure on the next page. The eight case types are:

n Suicide attempt;

n Seeking detoxification;

n Alcohol only in patients under age 21;

n Adverse reaction;

n Overmedication;

n Malicious poisoning (includes drug-facilitated sexual assault or product tampering);

n Accidental ingestion; and

n Other.

The final case type, which is called other, is designed to capture all of the drug-related ED visits that could not be 

classified in any of the prior seven case types. Other is the case type category designed to capture most drug abuse 

cases.
8 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

02 SEEKING DETOX

• Seeking substance abuse treatment 

• Medical clearance for drug treatment 

admission

• Seeking drug rehabilitation

This is a DAWN Case.

Answer the following questions in order. Assign Type of Case to first Yes.

01 SUICIDE ATTEMPT

• "Suicide attempt"

• Completed suicide

• Attempted to kill self

03 ALCOHOL ONLY (AGE < 21)

• Patient under age 21 and alcohol is 

the only drug

04 ADVERSE REACTION

• Allergic reactions

• Drug interactions

• "Side effect" of drug

07 ACCIDENTAL INGESTION

• Accidental child poisoning

• Took wrong medication

05 OVERMEDICATION

• Tried to make up a missed dose

• Forgot they had taken a dose

• Treated symptoms that did not 

subside with recommended dose

06 MALICIOUS POISONING

• Drug-facilitated assault

• Drug-facilitated rape

• Homicide with drug as the weapon

• Product tampering

08 OTHER

• Any DAWN Case not assigned above

• Most illicit drug use

• Toxicity due to drugs

• Withdrawal

• Psych evaluation with drugs detected 

Is this a DAWN Case? Based on documentation in the chart, 

was the ED visit for a condition induced by or related to drug use?

• Withdrawal

• Other drug(s) and alcohol are involved

• Patient is age 21 or over

• Unexpected reaction to illicit drugs

• Toxicity without documentation of "adverse reaction"

• Too little medication

• Took less than prescribed dose

• Illicit drugs

• Malicious poisoning

• Accidental ingestion (e.g., children ingesting drugs)

1. Does the chart indicate that the patient attempted suicide using a drug?

6. Does the chart indicate that the patient was deliberately poisoned or drugged by 

another person? 

5. Did the patient exceed the prescribed dose of a prescription drug or the 

recommended dose of an over-the-counter medication or dietary supplement?

4. Does the chart indicate that the patient had an "adverse reaction" to a 

prescription drug, over-the-counter medication, or dietary supplement?

3. Is the patient under age 21 and alcohol is the only drug mentioned in the chart?

2. Does the chart indicate that the patient was seeking detox or drug treatment?

7. Does the chart indicate that the drug was used accidentally or unknowingly? 

• "Suicide ideation"

• No documentation of suicide attempt

• Psych evaluation

• Tried to harm self

• Accidental ingestion

YES

DAWN Decision Tree

YES

Rev. 9/26/2003

STOP

Not a DAWN Case NO

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

YES

NO
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 9

Drug abuse in new DAWN

For analysis, we have defined three categories of ED visits related to drug misuse and abuse. These categories, 

designed to parallel the approach of the National Survey on Drug Use and Health (NSDUH), are based on:

n Use of illicit drugs;

n Use of alcohol, in combination with other drugs and alcohol alone in minors; and

n Non-medical use (“misuse”) of pharmaceuticals (prescription or over-the-counter [OTC]) (Table 1).

Table 1

Drug misuse and abuse in new DAWN

NOTE: Suicide attempt and seeking detox cases are analyzed separately, but may be combined selectively with non-medical use. Non-medical use 

excludes adverse reaction and accidental ingestion cases. 

Nature of drug 

misuse/abuse Defined by Specifics

Use of illicit drugs Drug n Cocaine, heroin, marijuana, major stimulants (including 

amphetamines and methamphetamine), MDMA (Ecstasy), 

GHB, flunitrazepam (Rohypnol), ketamine, LSD, PCP, other 

hallucinogens, non-pharmaceutical inhalants, combinations 

of illicit drugs

Use of alcohol Drug

Case type

n Alcohol in combination with other drugs

n Alcohol only in patients age less than 21 

Non-medical use of 

pharmaceuticals and 

other substances

Combination of 3 

case types

n Overmedication (cases of non-medical use, overuse, and misuse of 

prescription and OTC medications)

n Malicious poisoning (cases in which the patient was administered 

a drug by another for a malicious purpose)

n Other (cases that could not be assigned to another case type; 

includes documented drug abuse)
10 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Total drug-related ED visits

For the third and fourth quarters of 2003, DAWN estimates 627,923 drug-related ED visits for the entire 

coterminous U.S. Considering the margin of error (i.e., taking sampling error into account and calculating a 95% 

confidence interval [CI]), this estimate may range from 535,619 to 720,227 drug-related ED visits out of more than 52 

million total ED visits in the coterminous U.S. during the same period.

Overall, drug-related ED visits averaged 1.7 drugs per visit, including illicit drugs, alcohol, prescription and OTC 

pharmaceuticals, dietary supplements, and non-pharmaceutical inhalants.

Drug-related ED visits by case type

n The largest number of cases (over one-third) fell into case type other. This is expected, given the rules for 

assigning drug-related visits to case type.

n Adverse reactions accounted for a quarter of drug-related ED visits.

n Overmedication cases accounted for less than a fifth of drug-related ED visits (17%).

n Ten percent of drug-related ED visits were for patients seeking detox. These cases are classified separately 

because they tend to be concentrated in hospitals that require ED clearance for admission to their specialized 

detox units.

n Suicide attempts, narrowly defined to exclude suicide ideation and gestures, accounted for 6% of drug-related 

ED visits.

n Visits associated with underage consumption of alcohol alone (with no other drug involved) accounted for 4% of 

drug-related ED visits.

n Accidental ingestion of drugs accounted for 3% of drug-related ED visits.

n Malicious poisonings were the least frequent, 0.2% of drug-related ED visits.

Illicit drugs in ED visits

For Q3-Q4 2003, DAWN estimates 305,731 (CI: 230,228 to 381,234) drug-related ED visits involved a major 

substance of abuse. This means that nearly half of all drug-related ED visits involved alcohol or an illicit drug. For 

particular drugs, DAWN estimates that:

n Cocaine was involved in 125,921 (CI: 67,429 to 184,413) ED visits. In other words, approximately 1 in 5 drugrelated ED visits (20%) involved cocaine.

n Marijuana was involved in 79,663 (CI: 39,067 to 120,259) ED visits. Thus, marijuana may be as common as 

cocaine in drug-related ED visits.

n Heroin was involved in 47,604 (CI: 31,369 to 63,839) drug-related ED visits or 8% of drug-related ED visits 

overall. Unspecified opiates, some of which may be heroin, occurred in 24,623 (CI: 12,510 to 36,736) visits, 

or 4% of all drug-related ED visits.

n Stimulants, including amphetamines and methamphetamine, were involved in 42,538 (CI: 20,860 to 64,216 

ED visits or about 7% of drug-related ED visits overall.

n Other illicit drugs, such as PCP, Ecstasy, and GHB, were much less frequent than any of the above.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 11

Alcohol and drug-related ED visits

For Q3-Q4 2003, DAWN estimates 141,343 (CI: 116,965 to 165,721) drug-related ED visits involved alcohol in 

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

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

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

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

For Q3-Q4 2003, DAWN estimates:

n 118,724 (CI: 94,291 to 143,157) ED visits involved the use of alcohol in combination with another drug.

n 22,619 (CI: 16,452 to 28,652) ED visits were related to the use of alcohol by patients who were younger than 

age 21.

n The rate of alcohol-only ED visits for ages 18 to 20 (118 visits per 100,000 population) was three times that for 

patients age 12 to 17 (37 per 100,000). The rates for males and females were equivalent.

Considering all ED visits for patients between the ages of 12 and 20 that involved alcohol (that is, alcohol alone 

plus alcohol in combination with other drugs), DAWN estimates:

n 16,770 (CI: 12,037 to 21,503) alcohol-related ED visits for patients age 12-17, and

n 21,262 (CI: 16,386 to 26,138) alcohol-related ED visits for patients age 18-20.

Drug misuse and abuse in ED visits

When overmedication, malicious poisoning, and case type other are combined, DAWN estimates 332,046 

(CI: 268,266 to 395,826) visits related to drug misuse or abuse in Q3-Q4 2003. More than half (54%) of these visits 

involved multiple drugs.

Alcohol or an illicit drug was involved in nearly two-thirds (65%) of these drug-related ED visits. The specific drugs 

most commonly associated with these ED visits included:

n Cocaine (in 28% of visits), alcohol (26%), and marijuana (20%), which were similar in frequency, when the 

margin of error is considered.

n Heroin and major stimulants (amphetamines/methamphetamine), which were each involved in 10% of visits.

n Non-medical use of benzodiazepines (anti-anxiety medications) and opiates/opioid analgesics (pain relievers), 

which each accounted for 17% of visits.

Males outnumbered females in cases classified as case type other. Females outnumbered males in overmedication 

and malicious poisoning cases. However, when the three case types are considered in combination, differences 

between males and females disappear.
12 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Other types of drug-related ED visits

Suicide attempts

DAWN estimates 40,044 (CI: 33,607 to 46,481) drug-related ED visits associated with suicide attempts for Q3-Q4 

2003. On average, these suicide attempts involved 2.2 drugs per case; about 39% involved only a single drug.

In suicide attempts for Q3-Q4 2003:

n About one-quarter (26%) involved alcohol.

n Central nervous system (CNS) agents, primarily analgesics (pain relievers), were involved in about half (56%) and 

included both prescription and OTC formulations.

n Psychotherapeutic agents, including benzodiazepines and antidepressants, were implicated in 45% of visits.

n Illicit drugs, such as cocaine (11% of visits) and marijuana (9% of visits), were relatively infrequent.

Seeking detox

DAWN estimates 61,506 (CI: 34,985 to 88,027) drug-related ED visits for patients seeking detoxification services 

during Q3-Q4 2003. However, as noted previously, these visits tend to be concentrated in hospitals with administrative 

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

On average, the seeking detox visits involved 2.1 drugs per visit; less than 40% involved only a single drug. Both 

illicit and prescription drugs were common in ED visits for patients seeking detox:

n Cocaine (in 47% of visits) and heroin (25% of visits) were followed in frequency by marijuana (14% of visits) 

and amphetamine or methamphetamine stimulants (9% of visits).

n Opioid pain relievers and benzodiazepines appeared to be more frequent than many of the illicit drugs. 

Opioids, such as hydrocodone and oxycodone, were implicated in 31% of seeking detox visits, and 

benzodiazepines in 19%.

n Alcohol in combination with another drug was implicated in about a third (33%) of seeking detox ED visits.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 13

INTRODUCTION

T

he Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related 

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

data on drug-related deaths investigated by medical examiners and coroners in selected metropolitan areas 

and States. The Office of Applied Studies (OAS) of the Substance Abuse and Mental Health Services Administration 

(SAMHSA), U.S. Department of Health and Human Services, has been responsible for DAWN operations since 1992.

Major changes to DAWN were instituted at the beginning of 2003. These changes are the result of a re-design that 

altered virtually every feature of DAWN, except its name. In this publication, we sometimes refer to “new DAWN” to 

emphasize its differences.

Since this is the first publication from the new DAWN, it begins with a review of the design changes and explains 

their implications for understanding findings from new DAWN. These discussions of the various aspects of the new 

design, including how DAWN now defines drug abuse, are followed by the initial findings from data collected under 

this new design.

The findings in this publication are interim national estimates of drug-related ED visits, based on data for the 

third and fourth quarters (Q3-Q4, July-December) of 2003. The term “interim” is used because this is a period of 

transition between “old” and “new” DAWN. In this context, “interim” does not mean preliminary. These are final 

estimates. Trends are not presented here because data and estimates for 2003 are not comparable to those produced 

or published for any prior year.

Even so, estimates in this publication do not reflect all of the changes planned. For example, the transition to a new 

sample of hospitals began in 2003, but is not yet complete. When fully implemented, the new sample will represent 

hospitals in the entire U.S. The estimates in this publication are based on the sample of hospitals that applies only to 

the coterminous U.S. For metropolitan areas, no estimates, interim or otherwise, will be published for 2003.

The re-design of DAWN

The re-design of DAWN began in 1997. An expert panel convened by SAMHSA/OAS was asked the most 

fundamental of questions: Should DAWN continue? The experts responded that DAWN should continue, but required 

major improvements.

The rationale for fundamental change was straightforward. While the population of the U.S. and its health care 

system changed dramatically over three decades, the DAWN protocol had remained essentially static. A probability 

sample of hospitals had been introduced in DAWN in the 1980s to support the generation of national estimates. 

However, the other main features of DAWN, from the cases and data items collected to the choice of metropolitan 

areas, were historical artifacts that did not reflect the realities of today’s health care system or necessarily fulfill the 

needs of DAWN’s users. This led to misunderstandings about DAWN’s design and its data, misinterpretation and 

criticism of its findings, and unfounded assumptions about whom and what it represented.
14 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

SAMHSA/OAS initiated a two-year evaluation of design alternatives that resulted in a set of recommendations for 

a new design.1 The recommendations addressed virtually every feature of DAWN. Many of these features were field 

tested during the evaluation.

Implementation of the new design began in 2003. There was no period of overlap between old and new DAWN. A 

side-by-side comparison of DAWN’s features before and after the re-design is shown in Table 2 and is discussed next.

Major features of the new design

What is a DAWN case?

One of the most important features of the new 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 need not be causal; the drug needs only to 

be implicated in the visit.

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

through a retrospective review of medical records.2 Broad criteria take into account the fact that documentation in 

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

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

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

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

audiences.

DAWN cases include ED visits associated with substance abuse, but also include drug misuse, intentional or 

accidental, as well as visits related to the use of drugs for legitimate therapeutic purposes.

DAWN cases also include:

n Alcohol only (age < 21). ED visits by minors that involve alcohol and no other drug.

n Withdrawal. Patients in active withdrawal.

n Drug seekers. Patients attempting to procure drugs, but only if there is evidence of recent drug use.

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

n There is no evidence of recent drug use.

n The patient left the ED without being treated.

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

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

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

1 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. This publication is available online at 

http://DAWNinfo.samhsa.gov/.

2 This review is conducted by data collectors called “DAWN reporters.”
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 15

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

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

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

The case criteria adopted for new DAWN solve many problems inherent in the previous criteria. From 1972 to 2002, 

a DAWN case was defined as a visit related to drug abuse, and drug abuse was determined by the patient’s intent. 

That is, an ED visit was a DAWN case if the patient’s reason for taking the drug was dependence, suicide attempt or 

gesture, or to achieve psychic effects. DAWN cases could involve the use of an illegal drug, the non-medical use of a 

legal one, or the inhalation of a non-pharmaceutical substance. Visits were excluded, regardless of the drug involved, 

if the “intent to abuse” was absent.

Certainty with regard to a patient’s intention is frequently not evident in medical records. Therefore, identification 

of drug abuse cases based on positive or explicit indicators in medical charts is often impossible and certainly varies 

systematically across EDs, among clinicians within EDs, and among patients. Financial incentives, whereby an insurer 

can legally deny payment for ED visits related to substance abuse, may be a factor to influence documentation 

practices. Further, the lack of clear and objective distinctions between use, misuse, and abuse also influence 

documentation in ways that are probably systematic but indiscernible. As a result, if the case criteria based on intent 

were strictly applied, cases involving use or misuse of a drug would be lost when the source record lacked explicit 

documentation of abuse as defined by DAWN. Thereby, ED visits of interest to DAWN users were excluded. If the 

criteria were applied improperly or inconsistently (a more likely scenario), the resulting data would be systematically 

flawed. Moreover, the resulting cases included a mix of acute and chronic conditions, based on drug use that occurred 

a few hours or years before the visit.

The new case criteria solve all of these problems. In new DAWN, only recent drug use is included; 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.
16 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

New DAWN (began 2003) Old DAWN (ended 2002)

Cases reported to DAWN

All types of drug-related ED visits ED visits related to drug abuse only

Simple case criteria:

Any ED visit related to recent drug use

Complex case criteria:

ED visits related to drug abuse, defined as the use of an illicit 

drug or the non-medical use of a licit drug for one of the 

following purposes:

n Suicide attempt or gesture

n Dependence

n To achieve psychic effects

Current or recent drug use Drug abuse at any time:

n Current or recent drug abuse

n Past (history of) drug abuse

Patient’s intent is not considered Patient’s intent to abuse a drug was key

8 case types assigned hierarchically:

n Suicide attempt

n Seeking detox

n Alcohol only (age < 21)

n Adverse reaction (to prescription or over-the-counter 

drugs)

n Overmedication

n Malicious poisoning

n Accidental ingestion

n Other (any case not categorized above)

1 case type with 3 subcategories:

n Suicide attempt or gesture

n Seeking detox

n Other drug abuse

Patients of any age Patients age 6 to 97

Drugs reported to DAWN

Only those drugs related to the ED visit Any drug

All types of drugs:

n Illicit drugs

n Prescription and over-the-counter medications

n Dietary supplements

n Non-pharmaceutical inhalants

Same

Maximum of 6 drugs, plus alcohol Maximum of 4 drugs, plus alcohol

“Alcohol-in-combination” reportable for any case;

“Alcohol only” for patients age < 21

“Alcohol-in-combination” only

Current medications unrelated to the visit are not reportable Current medications reportable, even when unrelated to the 

visit

Other data items

Whether each drug was confirmed by toxicology No information about laboratory confirmation

Information about health:

n Chief complaints

n Diagnoses

No information about health

Expanded categories for patient disposition:

n 3 categories for treated and released

n 5 categories for patients admitted to the hospital

Limited categories for patient disposition:

n 1 category for treated and released

n 1 category for patients admitted to the hospital

No information about form or source Included form and source of substance

6 categories for route of administration 7 categories for route of administration

Table 2

Comparison of major features, new DAWN versus old DAWN
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 17

New DAWN (began 2003) Old DAWN (ended 2002)

Other changes

Case finding by retrospective review of medical charts for all 

patients treated in the ED

Mix of chart review and screening methods

Rigorous reporter training and quality assurance Limited oversight

Performance feedback to hospitals and reporters Limited feedback

Sample of hospitals

Sample of hospitals to represent the complete U.S. Sample of hospitals to represent the coterminous U.S.

Eligible hospitals: Short-term, general, non-Federal hospitals 

operating 24-hour EDs

Same

Metropolitan areas represented:

n New boundary definitions based on 2000 Census

n Oversampling in 22 areas

n Expansion to additional areas planned

Metropolitan areas represented:

n Boundary definitions based on 1980 Census

n Oversampling in 21 areas

National estimates based on:

n Oversampling in designated metropolitan areas

n “Supplementary sample” representing hospitals outside 

those areas

National estimates based on:

n Oversampling in designated metropolitan areas

n “National panel” sample representing hospitals outside 

those areas

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004.

Table 2 (continued)

Comparison of major features, new DAWN versus old DAWN

Types of cases in new DAWN

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

heterogeneous mix of DAWN cases, each case is assigned to one of eight case types, which may be analyzed separately 

or in purposeful combinations. The eight case types are:

n Suicide attempt;

n Seeking detoxification;

n Alcohol only in patients under age 21;

n Adverse reaction;

n Overmedication;

n Malicious poisoning (includes drug-facilitated sexual assault or product tampering);

n Accidental ingestion; and

n Other.

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

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

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

than one type, it is assigned to the first one that applies. The case types were ordered with this in mind.
18 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Figure 1

Type of case decision tree

02 SEEKING DETOX

• Seeking substance abuse treatment 

• Medical clearance for drug treatment 

admission

• Seeking drug rehabilitation

This is a DAWN Case.

Answer the following questions in order. Assign Type of Case to first Yes.

01 SUICIDE ATTEMPT

• "Suicide attempt"

• Completed suicide

• Attempted to kill self

03 ALCOHOL ONLY (AGE < 21)

• Patient under age 21 and alcohol is 

the only drug

04 ADVERSE REACTION

• Allergic reactions

• Drug interactions

• "Side effect" of drug

07 ACCIDENTAL INGESTION

• Accidental child poisoning

• Took wrong medication

05 OVERMEDICATION

• Tried to make up a missed dose

• Forgot they had taken a dose

• Treated symptoms that did not 

subside with recommended dose

06 MALICIOUS POISONING

• Drug-facilitated assault

• Drug-facilitated rape

• Homicide with drug as the weapon

• Product tampering

08 OTHER

• Any DAWN Case not assigned above

• Most illicit drug use

• Toxicity due to drugs

• Withdrawal

• Psych evaluation with drugs detected 

Is this a DAWN Case? Based on documentation in the chart, 

was the ED visit for a condition induced by or related to drug use?

• Withdrawal

• Other drug(s) and alcohol are involved

• Patient is age 21 or over

• Unexpected reaction to illicit drugs

• Toxicity without documentation of "adverse reaction"

• Too little medication

• Took less than prescribed dose

• Illicit drugs

• Malicious poisoning

• Accidental ingestion (e.g., children ingesting drugs)

1. Does the chart indicate that the patient attempted suicide using a drug?

6. Does the chart indicate that the patient was deliberately poisoned or drugged by 

another person? 

5. Did the patient exceed the prescribed dose of a prescription drug or the 

recommended dose of an over-the-counter medication or dietary supplement?

4. Does the chart indicate that the patient had an "adverse reaction" to a 

prescription drug, over-the-counter medication, or dietary supplement?

3. Is the patient under age 21 and alcohol is the only drug mentioned in the chart?

2. Does the chart indicate that the patient was seeking detox or drug treatment?

7. Does the chart indicate that the drug was used accidentally or unknowingly? 

• "Suicide ideation"

• No documentation of suicide attempt

• Psych evaluation

• Tried to harm self

• Accidental ingestion

YES

DAWN Decision Tree

YES

Rev. 9/26/2003

STOP

Not a DAWN Case NO

YES

YES

YES

YES

YES

NO

NO

NO

NO

NO

NO

YES

NO
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 19

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

classification into 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:

n Medical records frequently lack explicit documentation of substance abuse, and

n Distinctions by clinicians between use, misuse, and abuse of drugs are often subjective.

This occurs for several reasons. First, there is no bright line to distinguish non-medical use, overuse, misuse, and 

abuse, so the distinctions are subjective. Second, if there is a low index of suspicion for drug abuse in some types of 

patients, ED physicians may be unlikely to label those types of patients as drug abusers. Third, in many States, insurers 

may legally deny payment for ED visits related to substance abuse. Thus, financial incentives may be a factor to 

influence documentation practices.

Obviously, DAWN now includes some ED visits that are unrelated to drug abuse. Therefore, a method for isolating a 

set of cases involving drug abuse is necessary. This method is described in the chapter entitled Defining Drug Abuse in 

the New DAWN.

What drugs are included in new DAWN?

DAWN includes all types of drugs.3 Drugs eligible for DAWN include:

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

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

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

and cold remedies;

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

n Psychoactive, non-pharmaceutical inhalants;

n Alcohol in combination with other drugs; and

n Alcohol alone, in patients age less than 21 years.

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

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

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

Other improvements in new DAWN

Many other changes were implemented to improve the quality and reliability of DAWN data. These include:

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

n Conversion from paper to electronic reporting with automated prompts and data validation;

n Addition of data items on the health effects of drug use and additional detail on patient disposition;

n Elimination of incidental drug reporting;

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

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

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

provided in Appendix A and can be found on the Internet at http://www.multum.com.
20 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

n Addition of data items to identify drugs confirmed by laboratory testing;

n Systematic training and certification of DAWN reporters; and

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

A discussion of these improvements is provided in Appendix B. The case report form showing all the DAWN data 

items is shown in Figure 2.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 21

Figure 2

DAWN ED case form

6. Patient’s Home ZIP Code

Otherwise, mark [x] one response:

1 No fixed address (e.g., homeless)

2 Institution (e.g., shelter/jail/hospital)

8 Not documented

4. Time of Visit

1 a.m.

2 p.m.

3 military

13. Diagnosis List up to 4 diagnoses noted in the patient’s chart. Do not list ICD codes.

1 3

2 4

Department of Health and Human Services Substance Abuse and Mental Health Services Administration

Drug Abuse Warning Network (DAWN) 

Emergency Department Case Form

HOUR MINUTES

3. Date of Visit

1. Facility ID

PATIENT INFORMATION

8. Race/Ethnicity

Mark [x] one or more:

White

Black or African American

Hispanic or Latino

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Not documented

7. Sex

1 Male

2 Female

8 Not documented

5. Age

1 Less than 1 year

8 Not documented

2. Cross-reference 

(for facility use only)

9. Case Description Describe how the drug(s) was related to the ED visit. 

Copy verbatim from the patient’s chart when possible.

10. Chief Complaint Mark [x] all that apply:

Overdose Seeking detox

Intoxication Accident/injury/assault

Seizures Abscess/cellulitis/skin/tissue

Altered mental status Chest pain

Psychiatric condition Respiratory problems

Withdrawal Digestive problems

Other (specify):

11. Substance(s) Involved Using available documentation, list all substances that caused or 

contributed to the ED visit. Record substances as specifically as possible (i.e., brand [trade] 

name preferred over generic name preferred over chemical name, etc.). Do not record the 

same substance by two different names.

Mark [x] if 

confirmed by

SAMHSA USE ONLY Substance (record verbatim) toxicology test

1 1 2 3 4 5 8

2 1 2 3 4 5 8

3 1 2 3 4 5 8

4 1 2 3 4 5 8

5 1 2 3 4 5 8

6 1 2 3 4 5 8

7 C 2 0 0 0 2 9 Alcohol involved? 1 Yes 2 No 8 Not documented 1 2 3 4 5 8

SMA 100-1 REV. 12/2002 SEE BURDEN STATEMENT ON BACK

Oral

Not documented

Other

Route of Administration

Circle one:

InjectedInhaled, sniffed, snorted

12. Type of Case

Mark [x] the first category that applies:

01 Suicide attempt

02 Seeking detox

03 Alcohol only (age < 21)

04 Adverse reaction

05 Overmedication

06 Malicious poisoning

07 Accidental ingestion

08 Other

FOR SAMHSA USE ONLY

FORM NUMBER

MONTH DAY YEAR

Smoked

2 0

14. Disposition Mark [x] one:

Treated and released: Admitted to this hospital: Other disposition:

01 Discharged home 04 ICU/Critical care 09 Transferred

02 Released to police/jail 05 Surgery 10 Left against medical advice

03 Referred to detox/ 06 Chemical dependency/detox 11 Died

treatment 07 Psychiatric unit 96 Other

08 Other inpatient unit 98 Not documented

FORM APPROVED

OMB. NO. 0930-0078

EXPIRES 12/31/2005
22 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Estimates in this publication

Estimates in this publication were derived by applying sampling weights to the data collected from the probability 

sample of hospitals. Only national estimates pertaining to the coterminous U.S. are provided.

The transition to the new sample of hospitals was not completed in 2003, so estimates in this publication are based 

on the existing sample from 1988. Hospitals eligible for the DAWN 1988 sample were non-Federal, short-stay, general, 

medical and surgical hospitals in the coterminous U.S. that operated 24-hour EDs. The sampling frame came from the 

American Hospital Association’s (AHA) 1984 and 1985 Annual Surveys of Hospitals. (For a definition of sampling frame 

and other technical terms used in this publication, see Appendix C, Glossary of Terms.) The characteristics of this sample 

have been described in detail previously.4

The 1988 sample included an oversampling of hospitals in 21 metropolitan areas supplemented with a sample of 

hospitals from the remainder of the coterminous U.S., which includes other metropolitan areas and rural areas. The 

metropolitan area boundaries corresponded to the Office of Management and Budget (OMB) 1983 definitions of 

Metropolitan Statistical Areas (MSAs) and Primary Metropolitan Statistical Areas (PMSAs), which were based on the 

1980 census, with a few exceptions. The size of the 1988 sample has changed over time as hospitals closed, merged 

with others, or become ineligible, while others have been added as part of annual sample maintenance efforts.

National estimates are the sum of the estimates from the 22 geographic units (21 metropolitan areas and the 

remainder of the coterminous U.S.). The weights are calculated for each quarter of data using a three-component 

model that considers:

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

n An adjustment for non-response, based either on complete non-participation or failure to provide data on all the 

reporting days in a given time period; and

n A post-stratification (benchmark) factor, applied within metropolitan areas, to adjust the total number of ED 

visits among participating sample hospitals to the total for the eligible population of hospitals as determined 

from the sampling frame.

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

for data that are incomplete. Therefore, considering the many changes to DAWN, an intense level of scrutiny was 

given the data for this publication. For 2003, case eligibility and type of case assignment were subjected to 100% 

blind double review. All cases in which the first and second reviewers did not agree were sent to a third reviewer for 

adjudication. A final review focused explicitly on the possibility of incomplete data, that is, DAWN cases missed due 

to incomplete chart review or inappropriate application of the case criteria. As a result of this final step, all data for 

37 hospitals (39 EDs) and an additional 69 hospital months (71 ED months) were deemed unusable and were deleted 

from the final data used for estimation.

4 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Emergency Department Trends From the Drug Abuse 

Warning Network, Final Estimates 1995-2002. DAWN Series D-24, DHHS Publication No. (SMA) 03-3780, Rockville, MD, 2003.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 23

Hospital participation in 2003 (Table 3)

For quarters 3 and 4 of 2003, 260 out of 518 sampled hospitals submitted usable data. This 50% response rate 

varied from 22% in Los Angeles to 73% in Washington, DC. Response by hospitals covering the coterminous U.S. 

outside of the 21 metropolitan areas was 59%.

Hospitals participating in DAWN varied in size from about 300 total ED visits to more than 60,000 in the two 

quarters covered by this publication. In total, more than 5 million ED visits occurred in the 260 hospitals.

On average, a DAWN member hospital submitted 260 DAWN cases (about 43 per month) involving an average of 

1.7 drugs per case. However, the number of cases varied widely, from 2 cases to more than 3,000 in a single hospital 

during Q3-Q4 2003. The proportion of ED visits that were drug-related also varied, from less than 1% to about 9%.

Table 3

ED sample information and response rates: Q3-Q4 2003

Metropolitan area Total eligible 

hospitals1

Eligible 

hospitals in 

sample

Responding 

hospitals in 

sample

Response rate 

for sample 

hospitals

Response 

rate for visits 

(unweighted)

Total coterminous U.S. 4,558 518 260 50.2 50.9

Atlanta 32 18 12 66.7 75.1

Baltimore 21 21 12 57.1 52.0

Boston 44 24 13 54.2 46.7

Buffalo 10 10 7 70.0 75.0

Chicago 62 33 15 45.5 43.0

Dallas 30 18 7 38.9 48.1

Denver 14 14 4 28.6 40.4

Detroit 39 18 7 38.9 36.9

Los Angeles 73 37 8 21.6 28.5

Miami 22 18 6 33.3 50.7

Minneapolis 25 18 8 44.4 52.0

New Orleans 23 16 9 56.3 54.4

New York 78 34 13 38.2 39.0

Newark 24 16 8 50.0 41.3

Philadelphia 58 29 19 65.5 70.9

Phoenix 23 17 10 58.8 69.6

St. Louis 33 24 11 45.8 49.5

San Diego 17 17 9 52.9 63.4

San Francisco 18 18 9 50.0 38.5

Seattle 20 15 10 66.7 65.6

Washington, DC 28 15 11 73.3 78.6

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
24 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

The margin of error

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

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

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

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

error of the estimate expressed as a percentage of the estimate. The precision of an estimate is related to its sampling 

variability as measured by the RSE; the greater the RSE, the lower the precision.

DAWN estimates with RSE values of 50% or higher are regarded as too imprecise for publication and are not 

shown. In the tables, 3 dots (“...”) are shown in the place of estimates that have an RSE of 50% or higher.

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

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

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

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

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

For readers unfamiliar with these concepts, a more detailed discussion and examples are provided in Appendix D.

Estimates adjusted for population size

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

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

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

individuals age 35 to 44.

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

generated using population data from the U.S. Bureau of the Census.5 An example is provided in Appendix D, and the 

population estimates used for this publication can be found in Appendix E.

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

available to DAWN are much less detailed than the race and ethnicity categories in the Census data. Appendix F 

describes the race and ethnicity data reported to DAWN.

5 Population counts from U.S. Census 2000 Summary File 1 (SF-1) (see http://www.census.gov/Press-Release/www/2001/sumfile1.html). 

Population estimates for 2003, as of July 1, 2003, from U.S. Census Bureau County Population Dataset CO-EST2003-ALLDATA 

(see http://www.census.gov/popest/counties/files/CO-EST2003-alldata.csv).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 25

DEFINING DRUG ABUSE IN THE NEW DAWN

I

n 2003, DAWN cases began to include any ED visit related to recent drug use. Included are visits directly caused by 

the use, misuse, or abuse of a drug(s), as well as visits where the use, misuse, or abuse of a drug(s) contributed to 

the patient’s condition but did not cause it. Included also are visits where a drug was merely implicated and visits 

where the drug’s involvement as cause or contributor is not well defined.

While designating “drug abuse” cases in new DAWN is more challenging than before, the diversity of cases also 

provides new analytical opportunities and more flexibility than was possible before. This chapter will discuss the 

strategy used to define ED visits that are related to drug abuse and of interest to the substance abuse community.

Defining drug abuse

The model for DAWN’s new analytic strategy comes from the National Survey on Drug Use and Health (NSDUH).6 

The NSDUH focuses on three categories of drug use: use of illicit drugs, use of alcohol, and non-medical use of 

pharmaceuticals.7 In DAWN, three similar categories of drug use can be isolated based on two factors: the drugs 

involved in the ED visit and the case type.

The result is a set of three categories of ED visits used in this publication to present findings on drug misuse and 

abuse:

n Use of illicit drugs;

n Use of alcohol, in combination with other drugs or alcohol alone in patients under the age of 21; and

n Non-medical use (“misuse” or “abuse”) of pharmaceuticals (prescription or OTC).

First, a category of ED visits related to the use of illicit drugs or inhalants, regardless of case type, can be created. 

For this publication, this includes ED visits involving the use of drugs previously termed “major substances of abuse”:

n Cocaine

n Heroin

n Marijuana

n Major stimulants, including amphetamines and methamphetamine

n MDMA (Ecstasy)

n Gamma hydroxy butyrate (GHB)

n Flunitrazepam (Rohypnol)

n Ketamine

n Lysergic acid diethylamide (LSD)

n Phencyclidine (PCP)

n Other hallucinogens

n Non-pharmaceutical inhalants

n Combinations of the above

6 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results From the 2002 National Survey on Drug Use and 

Health: National Findings. NHSDA Series H-22, DHHS Publication No. (SMA) 03-3836, Rockville, MD, 2003.

7 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 2004 National Survey on Drug Use and Health: CAI Specs 

for Programming English Version. Contract No. 283-03-9028, Project No. 8726, Deliverable 2. Rockville, MD, December 2003.
26 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Second, two categories of ED visits related to alcohol use can be developed:

n Alcohol in combination with other drugs, based on drugs reported, regardless of case type.

n Alcohol only in patients age less than 21. This category will be based solely on case type.8 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.

Third, a category for non-medical use of prescription and OTC drugs9 can be defined based on case type, specifically, 

by combining three case types:

n Overmedication. This category was designed to capture non-medical use, overuse, and misuse of prescription and 

OTC medications that are not documented as drug abuse in a medical chart.

n Malicious poisoning. This category was designed to capture cases of drug use in which the patient was 

administered a drug by another 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.

n Case type other. As discussed previously, this case type includes all cases that could not be assigned to any of 

the other seven types. By design, most cases of documented drug abuse will fall into this category, and most 

cases in this category will involve non-medical use of drugs and other substances.

Two remaining case types are analyzed separately, but may be combined selectively with the non-medical use 

category for particular applications or audiences. These include:

n Suicide attempt. Suicide attempts that involve prescription or OTC pharmaceuticals undoubtedly represent nonmedical use of these drugs. Only documented suicide attempts (e.g., “attempted suicide,” “tried to kill self”) 

are classified in this category. Suicidal gestures, thoughts, or ideation, including attempts to “harm” self, are 

assigned to another case type.

n Seeking detox. These visits 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 provide substance abuse treatment services, and the largest numbers are found in facilities 

that require medical clearance for such treatment in their EDs.

8 Cases of underage drinking that were classified as suicide attempt or seeking detox will remain in those categories for analysis.

9 Unlike the NSDUH, DAWN includes medical as well as non-medical use of pharmaceuticals and includes pharmaceuticals sold over-the-counter as 

well as by prescription.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 27

Exclusions from drug misuse and abuse

In this publication, our definition of non-medical use consistently excludes the two remaining case types:

n Adverse reaction. Adverse reactions represent the consequences of using a prescription or OTC pharmaceutical 

for therapeutic purposes and include visits related to adverse drug reactions, side effects, drug-drug interactions, 

and drug-alcohol interactions. Adverse reactions that involve a pharmaceutical and an illicit drug are exceptions 

that are excluded from this category.

n Accidental ingestion. This category includes cases involving the accidental use of a drug, for example, childhood 

drug poisonings and individuals who take the wrong medication or wrong dosage by mistake.
28 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 29

DRUG-RELATED ED VISITS IN Q3-Q4 2003

Total drug-related ED visits (Table 4) 

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

to the data received from the sampled hospitals. Thus, 67,583 submitted cases are extrapolated to an estimate of 

627,923 drug-related ED visits. Considering the margin of error, this estimate may range from 535,619 to 720,227 

drug-related ED visits out of more than 52 million total ED visits estimated for the coterminous U.S.

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

The distribution of drug-related ED visits across the eight case types is illustrated in Figure 3. The pie chart on the 

top (A) illustrates the estimated mix of case types for the coterminous U.S. For comparison, the bottom pie (B) shows 

the mix of case types in unweighted data.

Estimates for the coterminous U.S. show the largest number of cases (over one-third) fell into the category 

other. Adverse reaction, which accounted for a quarter of drug-related ED visits, is second in frequency, followed by 

overmedication (17%). Ten percent of drug-related ED visits were for patients seeking detox. Suicide attempt, which 

was narrowly defined, accounted for 6% of drug-related visits. Visits associated with underage alcohol consumption 

and no other drug (alcohol only) accounted for 4% of drug-related ED visits, accidental ingestion 3%, and malicious 

poisoning 0.2%.
30 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Table 4

Drug-related ED visits, by type of case: Q3-Q4 2003

Drug-related ED visits

Type of case Unweighted 

sample data

Weighted 

estimates1 

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

bound

Suicide attempt 3,981 40,044 8.2 33,607 - 46,481

Seeking detox 9,421 61,506 22.0 34,985 - 88,027

Alcohol only (age < 21) 2,894 22,552 13.8 16,452 - 28,652

Adverse reaction 9,319 155,006 14.4 111,257 - 198,755

Overmedication 9,321 105,401 8.2 88,461 - 122,341

Malicious poisoning 166 1,300 25.0 663 - 1,937

Accidental ingestion 1,167 16,769 13.3 12,398 - 21,140

Other 31,314 225,345 14.4 161,743 - 288,947

Total drug-related visits 67,583 627,923 7.5 535,619 - 720,227

Total ED visits (all reasons) 5,268,743 52,336,352 0.0

Drugs

Type of case Unweighted 

sample data

Weighted 

estimates2

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

bound

Suicide attempt 8,218 86,856 9.5 70,684 - 103,028

Seeking detox 18,204 128,598 24.6 66,593 - 190,603

Alcohol only (age < 21) 2,894 22,552 13.8 16,452 - 28,652

Adverse reaction 11,479 185,109 14.2 133,590 - 236,628

Overmedication 16,353 194,184 8.3 162,595 - 225,773

Malicious poisoning 307 2,314 22.6 1,289 - 3,339

Accidental ingestion 1,436 20,873 13.4 15,391 - 26,355

Other 55,385 416,788 15.5 290,168 - 543,408

Drugs in all drug-related visits2 114,276 1,057,275 8.5 881,134 - 1,233,416

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 31

Figure 3

Drug-related ED visits, by type of case: Q3-Q4 2003

A. Estimates for the coterminous U.S.

B. Unweighted sample data

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

Other

35%

Malicious poisoning

0.2%

Overmedication

17%

Alcohol only

4%

Adverse reaction

25%

Accidental ingestion

3%

Suicide attempt

6%

Seeking detox

10%

Other

46%

Malicious poisoning

0.2%

Overmedication

14%

Alcohol only

4%

Adverse reaction

Accidental ingestion 14%

2%

Suicide attempt

6%

Seeking detox

14%

Other

35%

Malicious poisoning

0.2%

Overmedication

17%

Alcohol only

4%

Adverse reaction

25%

Accidental ingestion

3%

Suicide attempt

6%

Seeking detox

10%

Other

46%

Malicious poisoning

0.2%

Overmedication

14%

Alcohol only

4%

Adverse reaction

Accidental ingestion 14%

2%

Suicide attempt

6%

Seeking detox

14%
32 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 33

ILLICIT DRUGS IN ED VISITS

T

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

For Q3-Q4 2003, DAWN estimates 305,731 (CI: 230,228 to 381,234) drug-related ED visits that involved 

a major substance of abuse (Table 5). This means that nearly half of all the drug-related ED visits during this period 

involved alcohol or an illicit drug. 

DAWN estimates that cocaine was involved in 125,921 (CI: 67,429 to 184,413) ED visits. In other words, 

approximately 1 in 5 drug-related ED visits (20%) involved cocaine.

Marijuana was involved in 79,663 (CI: 39,067 to 120,259) ED visits. Thus, marijuana may be as common as 

cocaine in drug-related ED visits.

Heroin was involved in 47,604 (CI: 31,369 to 63,839) drug-related ED visits or 8% of drug-related ED visits overall. 

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

Among the drug reports to DAWN, nearly 9 out of 10 (87%) reports of “opiates” come from toxicology findings, so 

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

estimated at 24,623 (CI: 12,510 to 36,736) visits, or 4% of all drug-related ED visits.

Stimulants, including amphetamines and methamphetamine, were involved in from 42,538 (CI: 20,860 to 64,216) 

ED visits, about 7% of drug-related ED visits overall. Amphetamines and methamphetamine are combined for this 

analysis because about three-quarters of amphetamine reports are derived from toxicology findings. Since some 

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

methamphetamine.

Other illicit drugs appeared at much lower frequencies. For Q3-Q4 2003, DAWN estimates:

n MDMA (Ecstasy) in 2,221 (CI: 923 to 3,519) ED visits;

n GHB in 990 (CI: 535 to 1,445) ED visits;

n Ketamine in 73 (CI: 24 to 122) ED visits;

n LSD in 656 (CI: 352 to 960) ED visits;

n PCP in 4,581 (CI: 2,139 to 7,023) ED visits;

n Miscellaneous hallucinogens in 684 (CI: 304 to 1,064) ED visits; and

n Non-pharmaceutical inhalants in 1,681 (CI: 999 to 2,363) ED visits.

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

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

remainder in suicide attempts and seeking detox cases (Table 6). For example:

n Cocaine was found in 11% of visits related to suicide attempt and nearly half (47%) of seeking detox visits.

n Heroin was infrequent (1%) in visits related to suicide attempt, but was present in a quarter of seeking detox visits.

n Marijuana was found in 9% of visits related to suicide attempts and 14% of seeking detox visits. Marijuana was 

also involved in 16% of malicious poisoning visits.
34 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 627,923 7.5 535,619 - 720,227

Major substances of abuse (includes alcohol) 305,731 12.6 230,228 - 381,234

 Alcohol 141,343 8.8 116,965 - 165,721

 Alcohol-in-combination 118,724 10.5 94,291 - 143,157

 Alcohol alone 22,619 13.8 16,502 - 28,736

 Cocaine 125,921 23.7 67,429 - 184,413

 Heroin 47,604 17.4 31,369 - 63,839

 Marijuana 79,663 26.0 39,067 - 120,259

 Stimulants 42,538 26.0 20,860 - 64,216

 Amphetamines 18,129 18.0 11,734 - 24,524

 Methamphetamine 25,039 36.6 7,078 - 43,000

 MDMA (Ecstasy) 2,221 29.8 923 - 3,519

 GHB 990 23.4 535 - 1,445

 Flunitrazepam (Rohypnol) ... 86.8 ... - ...

 Ketamine 73 34.3 24 - 122

 LSD 656 23.6 352 - 960

 PCP 4,581 27.2 2,139 - 7,023

 Miscellaneous hallucinogens 684 28.3 304 - 1,064

 Inhalants 1,681 20.7 999 - 2,363

 Combinations not tabulated above (NTA) 1,346 35.4 413 - 2,279

Table 5

Illicit drugs and alcohol in drug-related ED visits: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. For example, 125,921 visits involved cocaine, and 47,604 visits involved heroin. Visits cannot be summed 

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 35

Drug category and 

selected drugs1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

Drug-related ED visits2,3,4

Total drug-related 

ED visits 627,923 40,044 61,506 22,552 155,006 105,401 1,300 16,769 225,345

Cocaine 125,921 4,544 29,035 ... ... 91,818

Heroin 47,604 495 15,428 14 31,667

Marijuana 79,663 3,603 8,705 202 ... 67,131

Stimulants 42,538 1,692 5,794 ... 1,167 194 ... 32,374

 Amphetamines 18,129 1,141 1,056 ... 1,149 77 ... 14,056

 Methamphetamine 25,039 ... 4,755 ... ... ... ... 18,921

MDMA (Ecstasy) 2,221 35 ... 23 1,886

GHB 990 ... 7 ... 856

Flunitrazepam 

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

Ketamine 73 ... ... 63

LSD 656 ... 183 2 ... 326

PCP 4,581 187 453 24 3,917

Miscellaneous 

hallucinogens 684 43 ... ... 637

Inhalants 1,681 12 392 ... 640 626

Combinations NTA 1,346 ... 24 1,213

Percent of visits

Cocaine 20% 11% 47% 41%

Heroin 8% 1% 25% 1% 14%

Marijuana 13% 9% 14% 16% 30%

Stimulants 7% 4% 9% 1% 15% 14%

 Amphetamines 3% 3% 2% 1% 6% 6%

 Methamphetamine 4% 8% 8%

MDMA (Ecstasy) 0% 0% 2% 1%

GHB 0% 0% 0%

Flunitrazepam 

(Rohypnol)

Ketamine 0% 0%

LSD 0% 0% 0% 0%

PCP 1% 0% 1% 2% 2%

Miscellaneous 

hallucinogens 0% 0% 0%

Inhalants 0% 0% 1% 4% 0%

Combinations NTA 0% 0% 1%

Table 6

Illicit drugs, by type of case: Q3-Q4 2003
36 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Drug category and 

selected drugs1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

ED visits per 100,000 population2,3,4

Total drug-related 

ED visits 217 14 21 8 54 36 0 6 78

Cocaine 44 2 10 ... ... 32

Heroin 16 0 5 0 11

Marijuana 28 1 3 0 ... 23

Stimulants 15 1 2 ... 0 0 ... 11

 Amphetamines 6 0 0 ... 0 0 ... 5

 Methamphetamine 9 ... 2 ... ... ... ... 7

MDMA (Ecstasy) 1 0 ... 0 1

GHB 0 ... 0 ... 0

Flunitrazepam 

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

Ketamine 0 ... ... 0

LSD 0 ... 0 0 ... 0

PCP 2 0 0 0 1

Miscellaneous 

hallucinogens 0 0 ... ... 0

Inhalants 1 0 0 ... 0 0

Combinations NTA 0 ... 0 0

Table 6 (continued)

Illicit drugs, by type of case: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. For example, 125,921 visits involved cocaine, and 47,604 visits involved heroin. Visits cannot be summed 

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 37

 When considered in relation to population, ED visits associated with illicit drugs are relatively low, but vary across 

the major drugs (Figure 4):

n 44 visits per 100,000 population for cocaine;

n 28 visits per 100,000 population for marijuana;

n 16 visits per 100,000 population for heroin; and

n 15 visits per 100,000 population for stimulants.

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

after taking population size and the margin of error into account. The rates for patients ages 21 to 54 tended to be 

similar as well, with lower rates for younger and older patients (Table 7 and Figure 5). Marijuana was the exception, 

with the highest rates for patients age 18 to 24.

Figure 4

Illicit drugs in ED visits: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

10

20

30

40

50

60

Cocaine Marijuana Heroin Stimulants

44

ED visits per 100,000 population

16 15

28
38 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient 

characteristics

Selected drugs1

Cocaine Heroin Marijuana Stimulants MDMA 

(Ecstasy) GHB LSD PCP

Drug-related ED visits2,3,4

Total drug-related 

ED visits 125,921 47,604 79,663 42,538 2,221 990 656 4,581

Gender

 Male 78,293 30,205 53,162 25,389 1,523 513 616 3,377

 Female 47,483 17,330 26,340 17,142 698 477 39 1,202

 Unknown 145 68 ... ... ...

Age

 0-5 years ... 7 7 ...

 6-11 years ... 15 ... 1 6

 12-17 years ... 411 12,202 3,739 ... ... 71 ...

 18-20 years 7,274 2,714 11,923 4,917 688 274 57 ...

 21-24 years 11,892 6,200 10,230 6,096 ... 65 ... 934

 25-29 years 14,765 7,724 8,806 5,833 ... 133 ... 573

 30-34 years 17,922 6,216 10,017 6,818 ... 60 184 901

 35-44 years 46,175 14,921 17,215 10,062 77 277 ... 516

 45-54 years 21,030 8,151 8,128 3,617 11 5 9 ...

 55-64 years 2,729 1,131 957 552 ...

 65 years and older 452 104 ... 23 ...

 Unknown 112 25 11 8 10 ... ...

Race/ethnicity

 White 62,581 25,209 47,175 31,098 927 847 562 1,442

 Black 40,184 10,194 17,644 1,193 564 9 18 2,331

 Hispanic 11,264 4,515 7,574 3,364 ... ... ... 554

 Race/ethnicity NTA 2,005 428 1,180 756 ... ... 26 31

 Unknown 9,887 7,258 6,092 6,127 185 ... 32 223

Table 7

Illicit drugs, by patient characteristics: Q3-Q4 2003
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 39

Patient 

characteristics

Selected drugs1

Cocaine Heroin Marijuana Stimulants MDMA 

(Ecstasy) GHB LSD PCP

ED visits per 100,000 population2,3,4

Total drug-related 

ED visits 44 16 28 15 1 0 0 2

Gender

 Male 56 21 38 18 1 0 0 2

 Female 32 12 18 12 0 0 0 1

Age

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

 6-11 years ... 0 ... 0 0

 12-17 years ... 2 48 15 ... ... 0 ...

 18-20 years 66 25 109 45 6 3 1 ...

 21-24 years 81 42 69 41 ... 0 ... 6

 25-29 years 74 39 44 29 ... 1 ... 3

 30-34 years 85 29 47 32 ... 0 1 4

 35-44 years 99 32 37 22 0 1 ... 1

 45-54 years 54 21 21 9 0 0 0 ...

 55-64 years 11 4 4 2 ...

 65 years and older 1 0 ... 0 ...

Table 7 (continued)

Illicit drugs, by patient characteristics: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. 

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
40 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Figure 5

Illicit drugs, ED visit rates by age and gender: Q3-Q4 2003

Cocaine

Marijuana

Heroin

Stimulants

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

20

40

60

80

100

120

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

66

81 85

99

1

74

54

11

56

32

0

20

40

60

80

100

120

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

0 0

44

21

38

18

4

37

47

69

109

48

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

0

20

40

60

80

100

120

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

0 0

39

21 21

4

32 29

42

25

2

12

0

20

40

60

80

100

120

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

0

29

9

18 12

2

22

32

41 45

15

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 41

ALCOHOL AND DRUG-RELATED ED VISITS

T

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

n Alcohol used in combination with other drugs, and

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

For Q3-Q4 2003, DAWN estimates 141,343 (CI: 116,965 to 165,721) ED visits involved alcohol in combination with 

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

visits involved alcohol in one of these forms (Table 8).

Drug category and selected drugs1 Estimated 

visits2,3 

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

bound

Total drug-related ED visits 627,923 7.5 535,619 - 720,227

Alcohol 141,343 8.8 116,965 - 165,721

 Alcohol-in-combination 118,724 10.5 94,291 - 143,157

 Alcohol alone 22,619 13.8 16,502 - 28,736

Table 8

Alcohol in drug-related ED visits: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

Alcohol in combination with other drugs (Tables 8-11, Figure 6)

DAWN estimates 118,724 (CI: 94,291 to 143,157) ED visits related to use of alcohol in combination with another 

drug in Q3-Q4 2003. Alcohol is reported to DAWN in combination with other drugs, regardless of the patient’s age. 

These are the only alcohol reports received for patients age 21 and older.

Nearly 9 out of 10 (87%) ED visits implicating alcohol with another drug were for adult patients.

Alcohol in combination appeared in substantial numbers in most case types:

n In 26% of ED visits related to suicide attempts;

n In 33% of seeking detox visits;

n In 22% of overmedication visits;

n In 59% of malicious poisoning visits; and

n In 28% of visits categorized as case type other.

Alcohol appeared rarely in adverse reactions (1% of visits).
42 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Alcohol was most frequently combined with:

n Cocaine alone (24,049 visits),

n Marijuana alone (10,310 visits),

n Cocaine and marijuana (5,754 visits), and

n Heroin alone (5,160 visits).

Considering cases involving misuse or abuse of drugs—overmedication, malicious poisoning, and case type other—

as a group, DAWN estimates 86,407 (CI: 68,455 to 104,359) ED visits involving alcohol in combination with other 

drugs in Q3-Q4 2003. Males accounted for 62% of the visits involving alcohol and other drugs, but taking population 

size into account, males and females had similar rates of such visits. There was little variation in rates across the age 

groups from ages 18 to 54. However, rates of such visits were lower for older and younger patients.

In terms of race and ethnicity, 61% of the visits with alcohol in combination involved patients who were white, 17% 

black, and 10% Hispanic.

Drug category 

and selected 

drugs1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

Drug-related ED visits2,3,4 

Total drug-related 

ED visits 627,923 40,044 61,506 22,552 155,006 105,401 1,300 16,769 225,345

Alcohol 141,343 10,447 20,124 22,552 1,686 22,871 765 ... 62,771

 Alcohol-incombination 118,724 10,429 20,075 1,686 22,871 765 ... 62,771

 Alcohol alone 22,619 18 49 22,552

Percent of visits

Alcohol 23% 26% 33% 100% 1% 22% 59% 28%

 Alcohol-incombination 19% 26% 33% 1% 22% 59% 28%

 Alcohol alone 4% 0% 0% 100%

Table 9

Alcohol, by type of case: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 43

Figure 6

Alcohol with other drugs, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

20

40

60

80

100

120

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

0

59 53

30

15

73 76

29

3

72 69

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

75

Drugs reported 

with alcohol1

All case 

types

Type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other

Drug-related ED visits2,3

Cocaine only 24,049 349 6,351 187 17,162

No other drug 22,619 18 49 22,552

Marijuana only 10,310 132 777 5 9,396

Cocaine and 

marijuana only 5,754 52 1,286 4,416

Heroin only 5,160 32 1,554 3,573

Alprazolam only 2,675 417 164 12 1,490 5 587

Cocaine and 

heroin only 2,534 14 1,167 1,353

Acetaminophen 

only 1,820 733 140 907 40

Methamphetamine 

only 1,806 5 318 8 1,476

Atenolol only 1,610 1,610

Table 10

Drugs reported most frequently with alcohol, by type of case: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update). 
44 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient characteristics

All case types1,2,3,4

Overmedication, malicious 

poisoning, and case 

type other1,2,3,4

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

Total drug-related ED visits 141,343 118,724 22,619 86,407

Gender

 Male 86,478 74,681 11,797 53,533

 Female 54,724 43,919 10,805 32,791

 Unknown 142 124 18 83

Age

 0-5 years 38 ... 23 11

 6-11 years ... 9 ... 7

 12-17 years 16,770 7,259 9,511 6,173

 18-20 years 21,262 8,308 12,954 6,544

 21-24 years 10,609 10,609 8,312

 25-29 years 13,729 13,729 9,682

 30-34 years 15,426 15,426 10,088

 35-44 years 35,242 35,242 24,554

 45-54 years 23,270 23,270 17,527

 55-64 years 3,724 3,724 2,826

 65 years and older 1,054 1,054 617

 Unknown 78 78 ...

Race/ethnicity

 White 87,335 73,174 14,161 52,712

 Black 21,957 20,211 1,746 15,094

 Hispanic 14,496 11,607 2,890 8,835

 Race/ethnicity NTA 2,601 1,982 619 1,615

 Unknown 14,954 11,750 3,203 8,151

Table 11

Alcohol, by patient characteristics: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 45

Alcohol only in patients under the age of 21 (Tables 8-9 and 12, Figure 7)

DAWN estimates 22,552 (CI: 16,452 to 28,652) ED visits related to use of alcohol by patients who were younger 

than age 21 in Q3-Q4 2003 (Table 4). These numbers rise very little (to 22,619 [CI: 16,502 to 28,736] visits) if the few 

instances of underage alcohol use in suicide attempts and seeking detox cases are also included (Tables 8-9).

The most frequent chief complaint was intoxication (83% of visits), followed by accident/injury/assault (15%), 

altered mental status (13%), and digestive problems (5%), which include nausea and vomiting.

Alcohol was specifically indicated in a diagnosis in about 2 out of 3 (68%) alcohol-only visits, with toxic effects 

(e.g., “intoxication”) in slightly fewer (62%). Injuries were diagnosed in 16% of alcohol-only visits, and accidents, 

involving falls or motor vehicles, were indicated by diagnosis in 4%. This is not inconsistent with the incidence of chief 

complaints of accident/injury/assault. It is important to remember that external sources of injury may be documented 

in parts of the medical record other than chief complaint and diagnoses.

Nearly 9 out of 10 (87%) of such visits resulted in patients being treated and released, usually to home; another 9% 

were admitted to inpatient units.

Taking population size into account, the rate of alcohol-only ED visits for ages 18 to 20 (118 visits per 100,000 

population) was three times that for patients age 12 to 17 (37 per 100,000). The rates for males and females were 

equivalent.

In terms of race and ethnicity, 63% of the alcohol-only visits involved patients who were white, 13% Hispanic, and 

8% black.

Figure 7

Alcohol only (age < 21), ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

20

40

60

80

100

120

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

0

28 24

118

37
46 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 22,552

Gender Number of drugs involved

 Male 11,758 Single drug 22,552

 Female 10,777 Multiple drugs

 Unknown 18 Alcohol involved 22,552

Age Disposition

 0-5 years 23 Treated and released 19,596

 6-11 years ... Discharged home 17,621

 12-17 years 9,485 Released to police/jail 1,148

 18-20 years 12,912 Referred to detox/treatment ...

 21-24 years Admitted to this hospital 2,109

 25-29 years ICU/critical care ...

 30-34 years Surgery ...

 35-44 years Chemical dependency/detox 42

 45-54 years Psychiatric unit 202

 55-64 years Other inpatient unit 901

 65 years and older Other disposition ...

 Unknown Transferred ...

Race/ethnicity Left against medical advice 43

 White 14,120 Died

 Black 1,734 Other 31

 Hispanic 2,887 Not documented 123

 Race/ethnicity NTA 618

 Unknown 3,193

Chief complaint(s)3 Selected diagnoses3

 Overdose 214 Drug-related diagnoses

 Intoxication 18,697 Abuse 1,710

 Seizures 45 Alcohol 15,260

 Altered mental status 2,980 Toxic effects 14,012

 Psychiatric condition 659 Other conditions

 Withdrawal 8 Altered mental status 817

 Seeking detox ... Injuries 3,683

 Accident/injury/assault 3,387 Psychiatric conditions 1,118

 Abscess/cellulitis/skin/tissue ... Depression 534

 Chest pain 38 Suicide (other than attempt) 271

 Respiratory problems 110 Miscellaneous

 Digestive problems 1,059 Accidents 998

 Other 1,606 Fall 69

 Motor vehicle 929

Table 12

Alcohol only (age < 21), by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 47

Any alcohol in patients under the age of 21 (Table 13)

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

combination with other drugs, DAWN estimates:

n 16,770 (CI: 12,037 to 21,503) drug-related ED visits for patients age 12-17, and

n 21,262 (CI: 16,386 to 26,138) drug-related ED visits for patients age 18-20.

Drug category and selected drugs1 Estimated 

visits2,3

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper 

bound

Patients age 12-17

Alcohol 16,770 14.4 12,037 - 21,503

 Alcohol-in-combination 7,259 20.1 4,399 - 10,119

 Alcohol alone 9,511 17.2 6,305 - 12,717

Patients age 18-20

Alcohol 21,262 11.7 16,386 - 26,138

 Alcohol-in-combination 8,308 15.1 5,849 - 10,767

 Alcohol alone 12,954 16.9 8,663 - 17,245

Table 13

Alcohol in drug-related ED visits in patients under age 21: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
48 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 49

DRUG MISUSE AND ABUSE IN ED VISITS

T

he third method for assessing drug misuse and abuse in new DAWN focuses on particular types of drug-related 

ED visits: overmedication, malicious poisoning, and case type other.

Overmedication (Tables 14-15, Figure 8)

Overmedication is defined as a patient taking more than the prescribed or recommended dose of a prescription 

or OTC pharmaceutical. DAWN estimates 105,401 (CI: 88,461 to 122,341) drug-related ED visits for Q3-Q4 2003 

involved overmedication.

The drugs most frequently involved in overmedication ED visits were:

n Psychotherapeutic agents (52% of visits), including antidepressants, antipsychotics, and drugs classified as 

anxiolytics, sedatives, and hypnotics, particularly the benzodiazepines; and

n Central nervous system (CNS) agents (52% of visits), including both prescription and OTC analgesics (pain 

relievers), anticonvulsants, and muscle relaxants.

On average, the ED visits related to overmedication involved 1.8 drugs per case; about half (52%) involved multiple 

drugs. About one-fifth (22%) involved alcohol in combination with other drugs.

The chief complaints associated with overmedication included overdose (84% of visits), altered mental status 

(19%), and psychiatric conditions (15%). More than one complaint may be recorded for a single visit.

The most frequently occurring diagnoses for overmedication cases were overdose (in 57% of visits), depression or 

another psychiatric condition (24%), and other suicide (11%). Diagnoses classified as other suicide include suicidal 

gestures, thoughts, or ideation; suicide attempts are classified separately. Visits related to overmedication frequently 

had diagnoses indicating drug involvement (53%) or alcohol (6%).

About 4 out of 10 (42%) of such visits were treated and released, but another 4 out of 10 (42%) resulted in 

admission to inpatient hospital units, with 18% being admitted to critical care. About 14% were transferred to 

another health care facility.

Overmedication cases more frequently involved females than males, with 45 visits per 100,000 population for 

females and 27 per 100,000 population for males. Among the age groups, the highest rate (96 per 100,000) was for 

patients age 18 to 20. Patients age 12 to 17 and patients age 21 to 54 had similar rates (from 41 to 57 visits per 

100,000). Visit rates were lower for patients in the oldest (55 and over) age categories and lowest for patients 11 and 

younger.

In terms of race/ethnicity, 72% of overmedication visits involved patients who were white.
50 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Figure 8

Overmedication, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

20

40

60

80

100

120

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

4 1

19

57

41

27

45

28

44 50 54

96

54

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

Drug category and selected drugs1 Estimated 

visits2,3

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 105,401 8.2 88,461 - 122,341

Psychotherapeutic agents 54,420 10.2 43,540 - 65,300

 Antidepressants 19,534 10.2 15,630 - 23,438

 Antipsychotics 8,888 14.5 6,362 - 11,414

 Anxiolytics, sedatives, and hypnotics 34,420 12.0 26,325 - 42,515

 Benzodiazepines 26,193 11.4 20,340 - 32,046

CNS agents 54,557 8.7 45,255 - 63,859

 Analgesics 43,692 10.1 35,043 - 52,341

 Opiates/opioids 20,830 10.9 16,381 - 25,279

 Nonsteroidal anti-inflammatory agents 7,894 14.5 5,650 - 10,138

 Salicylates/combinations 5,223 31.4 2,009 - 8,437

 Miscellaneous analgesics/combinations 15,902 17.9 10,324 - 21,480

 Anticonvulsants 6,569 13.3 4,856 - 8,282

 Muscle relaxants 8,016 14.6 5,723 - 10,309

Table 14

Overmedication: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 51

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 105,401

Gender Number of drugs involved

 Male 38,035 Single drug 50,769

 Female 67,182 Multiple drugs 54,632

 Unknown ... Alcohol involved 22,871

Age Disposition

 0-5 years 905 Treated and released 44,028

 6-11 years 308 Discharged home 39,734

 12-17 years 13,681 Released to police/jail 1,378

 18-20 years 10,457 Referred to detox/treatment 2,916

 21-24 years 7,987 Admitted to this hospital 44,488

 25-29 years 11,396 ICU/critical care 19,367

 30-34 years 10,522 Surgery 10

 35-44 years 20,568 Chemical dependency/detox 675

 45-54 years 15,969 Psychiatric unit 8,575

 55-64 years 6,967 Other inpatient unit 15,861

 65 years and older 6,626 Other disposition 16,884

 Unknown 14 Transferred 14,248

Race/ethnicity Left against medical advice 1,303

 White 76,338 Died ...

 Black 8,541 Other 307

 Hispanic 7,763 Not documented 852

 Race/ethnicity NTA 2,250

 Unknown 10,509

Chief complaint(s)3 Selected diagnoses3

 Overdose 88,708 Drug-related diagnoses

 Intoxication 5,659 Abuse 5,783

 Seizures 487 Drug or alcohol 57,907

 Altered mental status 20,132 Alcohol 6,812

 Psychiatric condition 15,351 Drug 56,249

 Withdrawal ... Overdose 60,394

 Seeking detox 25 Overmedication 2,466

 Accident/injury/assault 1,367 Toxic effects 8,391

 Abscess/cellulitis/skin/tissue 961 Body system (includes infections) 10,426

 Chest pain 1,722 Other conditions

 Respiratory problems 3,216 Altered mental status 4,174

 Digestive problems 3,527 Pain 2,864

 Other 9,684 Psychiatric conditions 24,974

 Depression 19,604

 Suicide (other than attempt) 11,885

Table 15

Overmedication, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
52 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Malicious poisoning (Tables 16-17, Figure 9)

DAWN estimates 1,300 (CI: 663 to 1,937) drug-related ED visits related to malicious poisoning for Q3-Q4 2003. 

Multiple drugs were involved in 63% of ED visits related to malicious poisoning, and 59% involved alcohol. Malicious 

poisoning means the patient was deliberately poisoned or drugged by another person. These cases may include drugfacilitated assault, drug-facilitated sexual assault, homicide when the weapon was a drug, and product tampering.

Alcohol was the most frequently occurring substance (59%) in ED visits related to malicious poisoning. Other drugs 

involved in these visits included marijuana (in 16% of visits), stimulants (15%), and opiate/opioid analgesics (14%). It 

is important to note, however, that the standard errors for the individual drug categories are quite high (usually more 

than 40%), and the estimates of ED visits are quite small.

Altered mental status was the most frequent chief complaint. However, other chief complaints (those that did not 

fit into pre-assigned categories) occurred in nearly half (47%) of visits associated with malicious poisonings.

The most frequently occurring diagnoses for malicious poisoning cases were altered mental status (11%), other 

infections (8%), or toxic effects (8%). DAWN estimates 7% of malicious poisoning cases had a diagnosis of assault, 

sexual assault, or sexual abuse. More than one-quarter (29%) of malicious poisoning visits had diagnoses indicating 

the involvement of a drug or alcohol.

Although the rates of malicious poisoning ED visits were very low across the board, the typical case appeared to be 

female, white, and age 25 to 29. The vast majority (87%) of patients were treated and released.

Figure 9

Malicious poisoning, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

10

20

30

40

50

60

Rate per 100,000 populationRate per 100,000 population

0

10

20

30

40

50

60

Male Female

0 1 1 1 3

0 0 0 1 65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 53

Drug category and selected drugs1 Estimated 

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower 

bound

- Upper

bound

Total drug-related ED visits 1,300 25.0 663 - 1,937

Major substances of abuse

Alcohol 765 27.8 348 - 1,182

 Alcohol-in-combination 765 27.8 348 - 1,182

 Alcohol alone

Cocaine ... 56.0 ... - ...

Heroin 14 48.7 0 - 28

Marijuana 202 45.9 20 - 384

Stimulants 194 47.9 12 - 376

MDMA (Ecstasy) 23 24.5 11 - 35

GHB ... 74.2 ... - ...

Flunitrazepam (Rohypnol) ... 51.7 ... - ...

PCP 24 40.6 4 - 44

Other substances

Opiates/opioid analgesics 183 48.4 9 - 357

Table 16

Malicious poisoning: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
54 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 1,300

Gender Number of drugs involved

 Male 311 Single drug ...

 Female 989 Multiple drugs 822

 Unknown Alcohol involved 765

Age Disposition

 0-5 years ... Treated and released 1,130

 6-11 years 6 Discharged home 1,115

 12-17 years ... Released to police/jail 9

 18-20 years 57 Referred to detox/treatment ...

 21-24 years 91 Admitted to this hospital 28

 25-29 years 571 ICU/critical care 12

 30-34 years 195 Surgery

 35-44 years 184 Chemical dependency/detox

 45-54 years 24 Psychiatric unit ...

 55-64 years ... Other inpatient unit 9

 65 years and older ... Other disposition ...

 Unknown Transferred ...

Race/ethnicity Left against medical advice 17

 White 1,089 Died

 Black 102 Other ...

 Hispanic 35 Not documented 6

 Race/ethnicity NTA ...

 Unknown 72

Chief complaint(s)3 Selected diagnoses3

 Overdose ... Drug-related diagnoses

 Intoxication 252 Drug or alcohol 385

 Seizures Alcohol 67

 Altered mental status 454 Drug 363

 Psychiatric condition 11 Illicits 215

 Withdrawal Other unspecified drug 160

 Seeking detox Toxic effects 109

 Accident/injury/assault ... Other conditions

 Abscess/cellulitis/skin/tissue ... Altered mental status 147

 Chest pain 35 Miscellaneous

 Respiratory problems 19 Assault 90

 Digestive problems 77 Assault 11

 Other 614 Sexual assault/abuse 81

Table 17

Malicious poisoning, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 55

Case type other (Tables 18-19, Figure 10)

DAWN estimates 225,345 (CI: 161,743 to 288,947) drug-related ED visits for Q3-Q4 2003 could not be classified 

into any of the seven case types discussed previously. On average, these visits involved 1.8 drugs per case; 46% 

involved a single drug and 54% multiple drugs. Alcohol was involved in 28% of other drug-related visits.

Drugs involved in these visits included alcohol, major substances of abuse, and pharmaceuticals taken, in general, 

for non-medical purposes. The most frequent drugs were:

n Cocaine, in 41% of visits;

n Marijuana, in 30%;

n Alcohol, in 28%;

n Heroin, in 14%;

n Major stimulants, including amphetamines and methamphetamine, in 14%;

n Benzodiazepines, in 13%; and

n Opiates/opioid analgesics (pain relievers), in 16%.

Common chief complaints included psychiatric conditions (in 23% of visits), altered mental status (21%), overdose 

(19%), and intoxication (10%). More than half (58%) of patients were treated and released, but nearly a third (32%) 

were admitted to inpatient units for additional care.

The most frequently occurring diagnoses for ED visits in the other category were drug abuse (32%), depression or 

another psychiatric condition (23%), and overdose (11%). More than half (62%) of these drug-related ED visits had 

diagnoses indicating the involvement of a drug, either illicit drugs (25%), a non-illicit or unspecified drug (38%), or 

alcohol (9%).

Drug-related ED visits in the case type other category more often involved males than females. The rates were 

95 visits per 100,000 population for males and 61 per 100,000 for females. By age, the highest rates (from 124 to 

188 visits per 100,000 population) occurred in ages 18 to 44. The rates for younger patients age 12 to 17 and older 

patients age 45 to 54 were similar (74 and 90 visits per 100,000, respectively) and lower than the rates for ages 18 to 

44. The lowest rates (23 and below) were evident for the oldest patients, age 55 and above.

In terms of race/ethnicity, 57% of these drug-related ED visits involved patients who were white, 22% black, and 

9% Hispanic.
56 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Figure 10

Case type other, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

0 0

148

90 95

61

23

132 124

158

188

74

1265+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 57

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 225,345 14.4 161,743 - 288,947

Major substances of abuse

Alcohol 62,771 15.2 44,071 - 81,471

 Alcohol-in-combination 62,771 15.2 44,071 - 81,471

 Alcohol alone

Cocaine 91,818 25.4 46,107 - 137,529

Heroin 31,667 18.6 20,123 - 43,211

Marijuana 67,131 26.6 32,131 - 102,131

Stimulants 32,374 27.5 14,924 - 49,824

 Amphetamines 14,056 19.1 8,793 - 19,319

 Methamphetamine 18,921 37.8 4,903 - 32,939

MDMA (Ecstasy) 1,886 28.9 818 - 2,954

GHB 856 25.6 427 - 1,285

Flunitrazepam (Rohypnol) ... 119.7 ... - ...

Ketamine 63 32.9 22 - 104

LSD 326 30.2 134 - 518

PCP 3,917 30.4 1,583 - 6,251

Miscellaneous hallucinogens 637 30.3 259 - 1,015

Inhalants 626 25.8 308 - 944

Combinations NTA 1,213 37.8 313 - 2,113

Other substances

Benzodiazepines 28,727 17.5 18,874 - 38,580

Opiates/opioid analgesics 36,232 18.3 23,237 - 49,227

Table 18

Case type other: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
58 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 225,345

Gender Number of drugs involved

 Male 134,405 Single drug 102,993

 Female 90,672 Multiple drugs 122,352

 Unknown 268 Alcohol involved 62,771

Age Disposition

 0-5 years 42 Treated and released 129,990

 6-11 years 65 Discharged home 111,578

 12-17 years 18,633 Released to police/jail 7,661

 18-20 years 20,551 Referred to detox/treatment 10,751

 21-24 years 23,348 Admitted to this hospital 71,713

 25-29 years 29,410 ICU/critical care 12,946

 30-34 years 26,199 Surgery 644

 35-44 years 61,592 Chemical dependency/detox 2,446

 45-54 years 35,480 Psychiatric unit ...

 55-64 years 5,743 Other inpatient unit 22,153

 65 years and older 4,121 Other disposition 23,642

 Unknown 160 Transferred 14,725

Race/ethnicity Left against medical advice 4,806

 White 129,234 Died 599

 Black 49,905 Other 1,271

 Hispanic 20,155 Not documented 2,241

 Race/ethnicity NTA 3,724

 Unknown 22,328

Chief complaint(s)3 Selected diagnoses3

 Overdose 42,708 Drug-related diagnoses

 Intoxication 23,490 Abuse-related 125,351

 Seizures 8,627 Abuse 72,613

 Altered mental status 46,291 Dependence 6,205

 Psychiatric condition 51,857 Overdose 25,903

 Withdrawal 16,653 Toxic effects 19,071

 Seeking detox 2,164 Withdrawal 12,300

 Accident/injury/assault 11,861 Drug or alcohol 139,043

 Abscess/cellulitis/skin/tissue 15,906 Other conditions

 Chest pain 19,466 Abscess/cellulitis 7,955

 Respiratory problems 13,636 Altered mental status 11,792

 Digestive problems 14,933 Injuries 9,432

 Other 42,592 Pain 19,452

 Psychiatric conditions 52,195

 Suicide (other than attempt) 20,842

Table 19

Case type other, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 59

Overmedication, malicious poisoning, and case type other combined 

(Tables 20-21, Figure 11)

One of the primary goals of the new DAWN is to capture ED visits related to illicit drugs and the non-medical use 

of licit ones. When ED visits classified as overmedication and those classified as other are considered side by side, they 

appear to be complementary. Overmedication patients are more frequently female, whereas patients in the other case 

type are more frequently male. The race/ethnicity of overmedication patients is more frequently white, whereas the 

cases classified as case type other have a higher proportion of black patients. In terms of age, the youngest age groups 

and the oldest tend to appear more frequently in overmedication cases than in case type other, which has higher 

concentrations in the age groups in the middle (ages 18 to 44).

When the three case types associated with drug misuse and abuse (overmedication, malicious poisoning, and case 

type other) are combined, the following profile emerges. DAWN estimates 332,046 (CI: 268,266 to 395,826) such 

visits in Q3-Q4 2003. Less than half (46%) of these drug-related ED visits involved only a single drug.

Major substances of abuse were involved in nearly two-thirds (65%) of these drug-related ED visits. The specific 

drugs most commonly associated with these ED visits included:

n Cocaine (in 28% of visits), alcohol (26%), and marijuana (20%), which were similar in frequency, when the 

margin of error is considered;

n Heroin and major stimulants, which were each involved in 10% of visits; and

n Non-medical use of benzodiazepines and opiates/opioid analgesics, which each accounted for 17% of visits.

Overdose (40% of visits), altered mental status (20%), and psychiatric conditions (20%) were the most frequent 

chief complaints. About half (53%) of visits resulted in the patient being treated and released, whereas 35% were 

admitted for inpatient care (10% to critical care units).

Although only 24% of visits had a diagnosis explicitly documenting drug abuse, more than half (60%) of visits 

had diagnoses related to drug abuse (e.g., addiction, dependence, IVDA/IVDU, withdrawal). The diagnoses for these 

cases illustrate the variety in medical documentation for drug-related ED visits. Drug involvement was documented in 

a diagnosis in 59% of visits, including alcohol in 8%, illicit drugs in 17%, and non-illicit or unspecified drugs in 43%. 

Other frequent diagnoses were overdose (26% of visits), depression or another psychiatric condition (23%), other 

suicide (10%), and toxic effects (8%).

When considered in combination, the differences in ED visit rates between males and females disappear, as the 

higher concentration of females in overmedication and malicious poisoning cases offset the higher concentrations of 

males in case type other. In terms of age, the rates for patients age 18 to 20 become similar to those for patients age 

21 to 29. The youngest patients (up to age 11) had the lowest rates, followed by the oldest (age 55 and over).

The combination of the three case types results in a racial/ethnic mix of patients that is 62% white, 18% black, and 

8% Hispanic.
60 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Figure 11

Overmedication, malicious poisoning, and case type other,

ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

50

100

150

200

250

300

Rate per 100,000 populationRate per 100,000 population

0

50

100

150

200

250

300

Male Female

4 1

208

131

107

50

174 176

213

284

128

3165+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

123
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 61

Drug category and selected drugs1 Estimated

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower

bound - Upperbound

Total drug-related ED visits 332,046 9.8 268,266 - 395,826

Major substances of abuse

Alcohol 86,407 10.6 68,455 - 104,359

 Alcohol-in-combination 86,407 10.6 68,455 - 104,359

 Alcohol alone

Cocaine 92,187 25.4 46,294 - 138,080

Heroin 31,681 18.6 20,131 - 43,231

Marijuana 67,333 26.5 32,361 - 102,305

Stimulants 33,735 26.5 16,213 - 51,257

 Amphetamines 15,283 18.1 9,862 - 20,704

 Methamphetamine 19,058 37.5 5,050 - 33,066

MDMA (Ecstasy) 1,910 28.6 840 - 2,980

GHB 978 23.7 523 - 1,433

Flunitrazepam (Rohypnol) ... 86.8 ... - ...

Ketamine 63 32.9 22 - 104

LSD 328 30.1 134 - 522

PCP 3,941 30.2 1,609 - 6,273

Miscellaneous hallucinogens 639 30.3 259 - 1,019

Inhalants 626 25.8 308 - 944

Combinations NTA 1,213 37.8 313 - 2,113

Other substances

Benzodiazepines 54,947 11.0 43,101 - 66,793

Opiates/opioid analgesics 57,245 12.2 43,556 - 70,934

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

Table 20

Overmedication, malicious poisoning, and case type other: Q3-Q4 2003
62 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 332,046

Gender Number of drugs involved

 Male 172,750 Single drug 154,240

 Female 158,843 Multiple drugs 177,806

 Unknown 452 Alcohol involved 86,407

Age Disposition

 0-5 years 952 Treated and released 175,148

 6-11 years 379 Discharged home 152,427

 12-17 years 32,467 Released to police/jail 9,048

 18-20 years 31,065 Referred to detox/treatment 13,673

 21-24 years 31,426 Admitted to this hospital 116,229

 25-29 years 41,377 ICU/critical care 32,324

 30-34 years 36,917 Surgery 655

 35-44 years 82,344 Chemical dependency/detox 3,121

 45-54 years 51,474 Psychiatric unit ...

 55-64 years 12,716 Other inpatient unit 38,023

 65 years and older 10,755 Other disposition 40,669

 Unknown 174 Transferred 28,977

Race/ethnicity Left against medical advice 6,126

 White 206,661 Died 774

 Black 58,548 Other 1,692

 Hispanic 27,953 Not documented 3,100

 Race/ethnicity NTA 5,975

 Unknown 32,909

Chief complaint(s)3 Selected diagnoses3

 Overdose 131,570 Drug-related diagnoses

 Intoxication 29,401 Abuse-related 197,756

 Seizures 9,113 Abuse 78,436

 Altered mental status 66,877 Dependence 6,673

 Psychiatric condition 67,220 Overdose 86,326

 Withdrawal 16,906 Toxic effects 27,571

 Seeking detox 2,189 Withdrawal 12,467

 Accident/injury/assault 13,524 Drug or alcohol 197,200

 Abscess/cellulitis/skin/tissue 16,976 Other conditions

 Chest pain 21,223 Abscess/cellulitis 8,231

 Respiratory problems 16,871 Altered mental status 16,113

 Digestive problems 18,538 Injuries 11,033

 Other 52,890 Pain 22,347

 Psychiatric conditions 77,190

 Suicide (other than attempt) 32,727

Table 21

Overmedication, malicious poisoning, case type other, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 63

OTHER TYPES OF DRUG-RELATED ED VISITS

T

his chapter profiles the four remaining types of drug-related ED visits captured by new DAWN. Among these, 

suicide attempt and seeking detox cases are considered as separate and distinct classes of drug misuse or 

abuse, for reasons discussed previously. In contrast, adverse reaction cases typically result from the use of 

pharmaceuticals for therapeutic purposes, and accidental ingestion cases are, as the name implies, accidents involving 

drugs.

Suicide attempt (Tables 22-23, Figure 12)

DAWN estimates 40,044 (CI: 33,607 to 46,481) ED visits associated with drug-related suicide attempts for Q3-Q4 

2003.10 It is important to remember that new DAWN includes only those suicide attempts that involve drugs. Included 

are persons who attempt suicide by drug overdose and by other means when drugs are involved. Excluded are suicide 

attempts not involving drugs (e.g., by gun alone) and those documented as something other than an attempt (e.g., 

suicide ideation, gesture, thought, and so forth).

On average, the drug-related suicide attempts involved 2.2 drugs per case; about 39% involved only a single drug. 

About one-quarter (26%) involved alcohol.

The most frequent chief or presenting complaint was overdose (90%). The most frequent diagnoses indicated 

suicide attempt (in 71% of visits), overdose (57%), and depression or another psychiatric condition (29%). Depression 

was a diagnosis in 26% of the ED visits identified as suicide attempts. Involvement of alcohol or a drug was indicated 

by diagnosis in 53% of visits, with 8% indicating alcohol and 50% indicating a drug. Illicit drugs were cited by 

diagnoses in 4% of visits.

In suicide attempts, the most frequent major substances of abuse other than alcohol were cocaine (11% of visits) 

and marijuana (9% of visits), but the margin of error for each of these drugs is quite large. Central nervous system 

agents, primarily analgesics (pain relievers), were involved in about half (56%) of suicide-related visits and included 

both prescription and OTC formulations. Psychotherapeutic agents, including benzodiazepines and antidepressants, 

were implicated in 45% of the suicide-related ED visits.

More than half (58%) of the suicide attempts were admitted for inpatient hospital care, primarily in critical care 

(31%) or psychiatric (16%) units. Another 29% were transferred to another health care facility; 10% were discharged 

home.

Nearly two-thirds (64%) of the suicide attempts involved patients who were white, with black and Hispanic patients 

occurring in nearly equal numbers. After accounting for population size, the rate of suicide visits for females (18 visits 

per 100,000 population) was double that for males (9 per 100,000). The rate for patients age 21 to 24 (40 per 

100,000) exceeded the rates for most other age groups. The rates for adolescents and young adults age 12 to 20 were 

comparable to rates for adults age 25 to 44.

10 Even though DAWN has always had a category for suicides, in years prior to 2003 the category encompassed suicide attempts, ideation, 

gestures, and thoughts. Therefore, this category is not comparable to any provided previously.
64 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Figure 12

Suicide attempt, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

10

20

30

40

50

60

Rate per 100,000 populationRate per 100,000 population

0

10

20

30

40

50

60

Male Female

23

11 9

18

23

18

40

28

21

3 65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 

5
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 65

Drug category and selected drugs1 Estimated

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower

bound - Upperbound

Total drug-related ED visits 40,044 8.2 33,607 - 46,481

Major substances of abuse

Alcohol 10,447 12.6 7,868 - 13,026

 Alcohol-in-combination 10,429 12.6 7,854 - 13,004

 Alcohol alone 18 38.1 4 - 32

Cocaine 4,544 44.7 563 - 8,525

Heroin 495 45.2 56 - 934

Marijuana 3,603 38.1 912 - 6,294

Stimulants 1,692 36.7 475 - 2,909

 Amphetamines 1,141 40.9 226 - 2,056

 Methamphetamine ... 52.6 ... - ...

MDMA (Ecstasy) 35 36.5 10 - 60

GHB ... 135.7 ... - ...

Flunitrazepam (Rohypnol)

Ketamine ... 187.3 ... - ...

LSD ... 72.5 ... - ...

PCP 187 49.9 5 - 369

Miscellaneous hallucinogens

Inhalants 12 42.0 2 - 22

Combinations NTA ... 82.2 ... - ...

Other substances

Psychotherapeutic agents 18,207 11.3 14,175 - 22,239

 Antidepressants 7,479 15.1 5,266 - 9,692

 Benzodiazepines 9,143 16.6 6,168 - 12,118

CNS agents 22,348 8.6 18,581 - 26,115

 Analgesics 18,029 10.0 14,495 - 21,563

 Opiates/opioids 8,047 14.4 5,775 - 10,319

Table 22

Suicide attempt: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
66 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 40,044

Gender Number of drugs involved

 Male 13,089 Single drug 15,559

 Female 26,923 Multiple drugs 24,485

 Unknown 32 Alcohol involved 10,447

Age Disposition

 0-5 years Treated and released 4,563

 6-11 years ... Discharged home 3,886

 12-17 years 5,190 Released to police/jail ...

 18-20 years 3,100 Referred to detox/treatment 500

 21-24 years 5,879 Admitted to this hospital 23,033

 25-29 years 4,539 ICU/critical care 12,272

 30-34 years 3,765 Surgery ...

 35-44 years 10,760 Chemical dependency/detox 196

 45-54 years 4,289 Psychiatric unit 6,519

 55-64 years 1,313 Other inpatient unit 4,044

 65 years and older 1,185 Other disposition 12,447

 Unknown 15 Transferred 11,681

Race/ethnicity Left against medical advice ...

 White 25,460 Died 11

 Black 3,859 Other ...

 Hispanic 3,947 Not documented ...

 Race/ethnicity NTA 853

 Unknown 5,925

Chief complaint(s)3 Selected diagnoses3

 Overdose 36,094 Drug-related diagnoses

 Intoxication 1,983 Drug or alcohol 21,359

 Seizures 36 Alcohol 3,166

 Altered mental status 7,310 Drug 20,027

 Psychiatric condition 11,342 Illicits 1,646

 Withdrawal ... Other or unspecified drug 19,259

 Seeking detox ... Overdose 22,635

 Accident/injury/assault ... Toxic effects 3,676

 Abscess/cellulitis/skin/tissue ... Other conditions

 Chest pain 277 Altered mental status 1,873

 Respiratory problems ... Psychiatric conditions 11,644

 Digestive problems 358 Depression 10,494

 Other 2,265 Suicide 28,415

 Suicide attempts 25,926

 Other suicide-related 2,924

Table 23

Suicide attempt, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 67

Seeking detox (Tables 24-25, Figure 13)

DAWN estimates 61,506 (CI: 34,985 to 88,027) drug-related ED visits for patients seeking detoxification services 

during Q3-Q4 2003. However, as noted previously, these visits tend to be concentrated in hospitals with administrative 

practices that require medical clearance in the ED for admission to detox units. Therefore, it is impossible to know the 

full extent of the demand for detox services from this estimate.

On average, the seeking detox visits involved 2.1 drugs per case; less than 40% involved only a single drug. Onethird (33%) involved alcohol, but for adults this includes only alcohol in combination with other drugs.

The most frequent presenting complaint was seeking detox (96%), with 13% presenting with a psychiatric 

condition, and 8% in withdrawal. The most frequent diagnoses were drug abuse (in 55% of visits), depression or 

another psychiatric condition (26%), dependence (16%), and withdrawal (9%). Drug and/or alcohol involvement was 

indicated by diagnoses in 88% of seeking detox visits. Substance abuse, based on a diagnosis of abuse, dependence, 

addiction, withdrawal, etc., was diagnosed in 90% of seeking detox visits.

Among the other major substances of abuse, cocaine (in 47% of visits) and heroin (25% of visits) occurred most 

frequently, followed by marijuana (14% of visits) and amphetamine or methamphetamine stimulants (9% of visits). 

Opioid pain relievers and benzodiazepines appeared to be more frequent than many of the illicit drugs. Opioids, such 

as hydrocodone and oxycodone, were implicated in 36% of seeking detox visits, and benzodiazepines in 19%. Again, 

it is important to remember that 60% of seeking detox visits implicated more than one drug.

A quarter of seeking detox cases apparently did not receive the care they sought, because they were discharged 

to home. Only 1 in 3 such cases (32%) was admitted to inpatient detoxification or chemical dependency units in the 

same hospital; 1 in 5 (22%) was referred elsewhere for detox or treatment; 5% were transferred to another health care 

facility.

More than two-thirds (69%) of those seeking detox were white, and black patients were more frequent (18%) than 

Hispanic patients (5%). Patients seeking detox tended to be older, with nearly half (49%) age 35 and over.

After accounting for population, the rate of seeking detox cases was similar across all age groups in the 18 to 44 

range. The rate of seeking detox visits for females was not significantly different from that for males.

Figure 13

Seeking detox, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

10

20

30

40

50

60

Rate per 100,000 populationRate per 100,000 population

0

10

20

30

40

50

60

Male Female

45

23

16

6

41

50

42 44

4 1

27

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 
68 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Drug category and selected drugs1 Estimated

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower

bound - Upperbound

Total drug-related ED visits 61,506 22.0 34,985 - 88,027

Major substances of abuse

Alcohol 20,124 22.4 11,288 - 28,960

 Alcohol-in-combination 20,075 22.4 11,261 - 28,889

 Alcohol alone 49 26.2 24 - 74

Cocaine 29,035 23.4 15,719 - 42,351

Heroin 15,428 21.1 9,048 - 21,808

Marijuana 8,705 26.8 4,132 - 13,278

Stimulants 5,794 41.2 1,115 - 10,473

 Amphetamines 1,056 38.8 252 - 1,860

 Methamphetamine 4,755 46.4 431 - 9,079

MDMA (Ecstasy) ... 68.7 ... - ...

GHB 7 43.5 1 - 13

Flunitrazepam (Rohypnol)

Ketamine ... 124.2 ... - ...

LSD 183 49.0 7 - 359

PCP 453 30.6 181 - 725

Miscellaneous hallucinogens 43 36.9 12 - 74

Inhalants 392 26.2 190 - 594

Combinations NTA 24 45.0 2 - 46

Other substances

Benzodiazepines 11,391 37.9 2,930 - 19,852

Opiates/opioid analgesics 22,027 34.7 7,047 - 37,007

Table 24

Seeking detox: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 69

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 61,506

Gender Number of drugs involved

 Male 38,217 Single drug 23,552

 Female 23,224 Multiple drugs 37,954

 Unknown ... Alcohol involved 20,124

Age Disposition

 0-5 years Treated and released 29,118

 6-11 years Discharged home 15,240

 12-17 years 1,026 Released to police/jail 119

 18-20 years 4,790 Referred to detox/treatment 13,760

 21-24 years 6,198 Admitted to this hospital 26,663

 25-29 years 8,945 ICU/critical care ...

 30-34 years 10,607 Surgery ...

 35-44 years 18,932 Chemical dependency/detox 19,507

 45-54 years 9,110 Psychiatric unit 5,672

 55-64 years 1,627 Other inpatient unit 1,332

 65 years and older 258 Other disposition 5,725

 Unknown ... Transferred 3,195

Race/ethnicity Left against medical advice 1,588

 White 42,458 Died

 Black 10,942 Other 411

 Hispanic 2,803 Not documented 532

 Race/ethnicity NTA 542

 Unknown 4,761

Chief complaint(s)3 Selected diagnoses3

 Overdose 826 Drug-related diagnoses

 Intoxication 1,391 Abuse-related 55,081

 Seizures 450 Abuse 33,856

 Altered mental status 2,468 Addiction 4,380

 Psychiatric condition 8,295 Dependence 10,129

 Withdrawal 5,056 Detox 6,324

 Seeking detox 59,353 Withdrawal 5,273

 Accident/injury/assault 420 Drug or alcohol 53,828

 Abscess/cellulitis/skin/tissue 1,237 Alcohol 6,681

 Chest pain 880 Drug 52,535

 Respiratory problems 517 Illicits 14,050

 Digestive problems 1,228 Other or unspecified drug 41,226

 Other 2,066 Other conditions

 Psychiatric conditions 16,146

 Depression 12,228

 Suicide (other than attempt) 3,222

Table 25

Seeking detox, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
70 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Adverse reaction (Tables 26-27, Figure 14)

As noted previously, adverse reaction cases in new DAWN are limited to prescription and OTC pharmaceuticals. 

Any involvement of illicit drugs is classified elsewhere. Adverse reactions exclude unexpected reactions to illicit 

drugs, toxicities lacking documentation of adverse reaction, and undermedication (i.e., taking too little of a prescribed 

medication).

For Q3-Q4 2003, DAWN estimates 155,006 (CI: 111,257 to 198,755) ED visits associated with adverse reactions. 

Only 14% of such cases involved multiple drugs, and very few (1%) involved alcohol in combination with another drug.

The prescription drugs most frequently implicated in adverse reaction visits included:

n Anti-infectives in 51,516 (CI: 35,765 to 67,267) visits;

n CNS agents in 36,634 (CI: 26,079 to 47,189) visits; and

n Psychotherapeutic agents in 19,964 (CI: 14,133 to 25,795) visits.

About 4 out of 10 (42%) ED visits associated with adverse reactions had chief complaints classified as abscess/

cellulitis/skin/tissue, which includes hives and rashes commonly seen in allergic drug reactions. These were followed in 

frequency by digestive problems (15%), altered mental status (12%), and respiratory problems (12%).

About 4 out of 10 ED visits associated with adverse reactions had diagnoses indicating adverse drug effects (43%) 

or specific drug involvement (49%), and 14% had diagnoses indicating allergies or allergic reactions. About one-third 

(33%) of ED visits related to adverse reactions had diagnoses indicating involvement of a particular body system, e.g., 

skin and soft tissue (14%), cardiovascular (7%), gastrointestinal (6%), etc.

Patients were discharged home in about 9 out of 10 (92%) of the ED visits related to adverse reactions, but 8% 

were admitted to inpatient units.

Drug category and selected drugs1 Estimated

visits2,3,4

Relative 

standard error 

(RSE)

95% Confidence interval

Lower

bound - Upperbound

Total drug-related ED visits 155,006 14.4 111,257 - 198,755

Psychotherapeutic agents 19,964 14.9 14,133 - 25,795

CNS agents 36,634 14.7 26,079 - 47,189

Anti-infectives 51,516 15.6 35,765 - 67,267

Table 26

Adverse reaction: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 71

The characteristics of patients treated for adverse reactions in EDs look quite different from those in case types 

discussed previously. About 11% of visits involved patients younger than age 12, and 19% involved patients age 

65 and older. Patients age 35-64 accounted for about a third (37%) of such visits. However, taking population into 

account, the rates of ED visits (per 100,000 population) associated with adverse reactions varied little across the age 

groups from young adults to the elderly. However, the rate for females was higher than that for males.

About 7 out of 10 (71%) of adverse reaction visits involved patients who were white, 10% black, and 5% Hispanic.

Figure 14

Adverse reaction, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

20

40

60

80

100

120

Rate per 100,000 populationRate per 100,000 population

0

20

40

60

80

100

120

Male Female

44

24

66

52

41

66

58

48

57

70 67

30

8665+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 
72 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 155,006

Gender Number of drugs involved

 Male 57,395 Single drug 133,359

 Female 97,571 Multiple drugs 21,647

 Unknown 39 Alcohol involved 1,686

Age Disposition

 0-5 years 10,676 Treated and released 142,035

 6-11 years 6,296 Discharged home 141,897

 12-17 years 7,540 Released to police/jail 56

 18-20 years 7,347 Referred to detox/treatment 81

 21-24 years 10,351 Admitted to this hospital 11,727

 25-29 years 13,184 ICU/critical care ...

 30-34 years 11,999 Surgery 31

 35-44 years 22,463 Chemical dependency/detox ...

 45-54 years 20,585 Psychiatric unit 815

 55-64 years 14,715 Other inpatient unit 9,559

 65 years and older 29,830 Other disposition 1,244

 Unknown 20 Transferred ...

Race/ethnicity Left against medical advice 71

 White 110,291 Died ...

 Black 16,096 Other 59

 Hispanic 8,148 Not documented 473

 Race/ethnicity NTA 2,026

 Unknown 18,444

Chief complaint(s)3 Selected diagnoses3

 Overdose 414 Drug-related diagnoses

 Intoxication 99 Adverse drug effects 66,669

 Seizures 1,337 Drug or alcohol 76,002

 Altered mental status 18,762 Alcohol 958

 Psychiatric condition 1,955 Drug 75,807

 Withdrawal 278 Body systems (includes infections) 51,716

 Seeking detox ... Respiratory 6,024

 Accident/injury/assault 1,075 Cardiovascular 11,518

 Abscess/cellulitis/skin/tissue 65,749 Gastrointestinal 9,032

 Chest pain 7,478

 Skin and soft tissue 

 (excludes abscess/cellulitis) 21,958

 Respiratory problems 18,596 Head and neck 5,714

 Digestive problems 23,292 Other conditions

 Other 58,563 Allergies 20,977

 Altered mental status 4,879

 Psychiatric conditions 4,521

Table 27

Adverse reaction, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 73

Accidental ingestion (Tables 28-29, Figure 15)

For Q3-Q4 2003, DAWN estimates 16,769 (CI: 12,398 to 21,140) ED visits associated with accidental ingestion 

of drugs. Accidental ingestions include accidental child poisonings as well as patients who took the wrong medication 

by mistake.

Most accidental ingestions (84%) involved a single drug. So few accidental ingestions involved major substances of 

abuse that reliable estimates could not be produced for those drugs. For Q3-Q4 2003, the drugs most frequently cited 

in accidental ingestion were:

n CNS agents (26% of visits), primarily analgesics, including acetaminophen and nonsteroidal anti-inflammatory 

agents such as ibuprofen; and

n Psychotherapeutic agents (17% of visits), primarily benzodiazepines; other anxiolytics, sedatives, and hypnotics, 

including diphenhydramine and zolpidem; and antidepressants.

In about 10% of visits, the accidental ingestion involved an unknown drug.

In terms of chief complaint, 42% of the accidental ingestion visits presented with overdose. Unfortunately, 44% 

could not be classified in any of the major complaint categories. Diagnoses indicated accidental ingestion (24%) or 

overdose (15%). About half (55%) of accidental ingestion visits had a diagnosis indicating drug involvement.

The majority (82%) of accidental ingestion visits resulted in patients being treated and released, while 13% were 

admitted for inpatient care.

Drug category and selected drugs1 Estimated

visits2,3

Relative 

standard error 

(RSE)

95% Confidence interval

Lower

bound - Upperbound

Total drug-related ED visits 16,769 13.3 12,398 - 21,140

Psychotherapeutic agents 2,816 17.4 1,856 - 3,776

CNS agents 4,347 16.7 2,924 - 5,770

Drug unknown 1,593 24.9 815 - 2,371

Table 28

Accidental ingestion: Q3-Q4 2003

1 This classification of drugs is derived from the Multum Lexicon, Copyright 2004, Multum Information Services, Inc. The classification has been 

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

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

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

3 Estimates are all expressed in visits. Visits cannot be summed across drugs because drug-related ED visits often involve multiple drugs.

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
74 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

 The rates of accidental ingestion visits were highest for children under the age of 6. DAWN estimates 57 ED 

visits per 100,000 population for this age group. Patients 65 and over were the next most frequent age category 

(5% of cases), but the rate of such visits was quite low (2 per 100,000 population). However, it is important to note 

that elderly patients who exceeded a recommended dose of a prescribed medication (e.g., because they forgot they 

had already taken a dose or to make up for a missed dose) would be classified in overmedication, not in accidental 

ingestion. Accidental ingestion occurred at similar rates for females and males.

About two-thirds (68%) of visits related to accidental ingestion involved patients who were white, 7% black, and 

8% Hispanic.

Figure 15

Accidental ingestion, ED visit rates by age and gender: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

0

10

20

30

40

50

60

Rate per 100,000 populationRate per 100,000 population

0

10

20

30

40

50

60

Male Female

57

0 1 1 2

7 5

65+ 

12-17

18-20 

21-24 

25-29 

30-34 

35-44 

45-54 

55-64 

6-11

0-5 
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 75

Patient/visit characteristics Estimated

visits1,2 Patient/visit characteristics Estimatedvisits1,2

Total drug-related ED visits 16,769

Gender Number of drugs involved

 Male 9,492 Single drug 14,058

 Female 7,278 Multiple drugs 2,712

 Unknown Alcohol involved ...

Age Disposition

 0-5 years 13,920 Treated and released 13,764

 6-11 years ... Discharged home 13,657

 12-17 years ... Released to police/jail ...

 18-20 years ... Referred to detox/treatment

 21-24 years 59 Admitted to this hospital 2,138

 25-29 years ... ICU/critical care ...

 30-34 years 299 Surgery

 35-44 years ... Chemical dependency/detox

 45-54 years ... Psychiatric unit

 55-64 years 212 Other inpatient unit 1,803

 65 years and older 760 Other disposition 867

 Unknown Transferred ...

Race/ethnicity Left against medical advice ...

 White 11,483 Died

 Black 1,230 Other ...

 Hispanic 1,420 Not documented 41

 Race/ethnicity NTA 260

 Unknown 2,378

Chief complaint(s)3 Selected diagnoses3

 Overdose 7,000 Drug-related diagnoses

 Intoxication ... Accidental ingestion 4,069

 Seizures ... Drug or alcohol 9,158

 Altered mental status 1,415 Alcohol 6

 Psychiatric condition 5 Drug 9,153

 Withdrawal Illicits 386

 Seeking detox Other or unspecified drug 8,982

 Accident/injury/assault 1,545 Overdose 2,570

 Abscess/cellulitis/skin/tissue ... Toxic effects 827

 Chest pain ...

 Respiratory problems 877

 Digestive problems 653

 Other 7,393

Table 29

Accidental ingestion, by patient and visit characteristics: Q3-Q4 2003

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

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

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
76 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 77

Appendixes
78 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 79

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82 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

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D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 83

APPENDIX B

TECHNICAL NOTES:

CHANGES TO IMPROVE THE QUALITY OF DAWN DATA

Introduction

The changes to DAWN introduced in 2003 include many designed to improve the quality and reliability of the data. 

The following changes are discussed in this appendix:

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

n Conversion from paper to electronic reporting.

n Addition of data items to characterize the health effects of drug use and more specifically identify patient 

disposition.

n Elimination of incidental drug reporting.

n Emphasis on accurate, specific, non-redundant drug reporting.

n Confirmation of drugs by laboratory testing.

n Systematic training and certification of DAWN reporters.

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

Case finding by direct chart review

DAWN cases are found through a retrospective review of ED medical records for every patient treated in a 

participating ED. Patients or families are never interviewed. There is no sampling of patients or visits. In each 

participating facility, a trained DAWN reporter performs the review of medical records to find DAWN cases. For 

each DAWN case found, the reporter abstracts 14 data items from the source record and submits these data items 

electronically to the central database. The reporter also submits a tally of the total number of ED visits for the facility 

and the total number of charts reviewed for each month. No other information is submitted on ED visits that are not 

DAWN cases.

In very large hospitals, direct chart review means that tens of thousands of ED charts are reviewed to find the 

DAWN cases. Studies conducted during the evaluation found that alternate methods of case finding were substantially 

inferior to direct chart review.11 The studies showed that screening methods based on ED logs or diagnosis codes 

assigned for billing missed large numbers of DAWN cases.

Conversion from paper to electronic reporting

Data for new DAWN are submitted electronically via eHERS,12 a secure, Internet-based data entry system. eHERS 

provides the technological means for validating DAWN data as they are entered. Built-in edits and prompts provide 

immediate feedback to the DAWN reporter so that errors can be corrected while the reporter still has the medical 

chart available. Intelligent prompts improve the quality of the drug data received. In addition, electronic data entry 

11 Redesigning DAWN’s Case Definition, Data Elements and Case Screening Procedures in 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, pp. 99-126.

12 eHERS is the electronic Hospital Emergency Reporting System.
84 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

eliminates the processing and management of paper forms, eliminates the manual effort of double-keying data, and 

streamlines data management processes. Full conversion to electronic data entry was achieved early in 2004.

Improvements to data items

New DAWN collects presenting complaint(s), diagnoses, and a verbatim case description taken from the medical 

chart. Although DAWN has been a public health surveillance system operated by the U.S. Department of Health and 

Human Services for at least two decades, this marks the first time that DAWN collects data on the health of those 

treated in EDs for drug-related problems.

Up to 4 diagnoses are collected from the medical record for each DAWN case. The diagnoses are text; they are 

not coded according to the International Classification of Diseases (ICD-9-CM or ICD-10) or any other standard. Since 

these diagnoses include a mixture of medical and psychiatric conditions, symptoms, references to body systems, drugs 

and drug-taking behavior, and external events such as accidents, the taxonomy for analysis was developed empirically 

using DAWN data from Q3-Q4 2003. About 2% of the DAWN cases received had diagnoses that were completely 

missing or could not be classified.

Disposition is not a new data item, but it has been expanded to provide additional detail, including referrals to 

detoxification/substance abuse treatment and the type of unit for inpatient admissions. Participating facilities use the 

detailed disposition categories to better understand the demands that DAWN cases place on specialized treatment 

units, the type of units affected, and the need for such units where they do not exist. For example, for the first time, 

DAWN can assess the volume of patients who present to EDs seeking detoxification services and whether they receive 

those services, through direct admission or referral.

The case report form showing all the DAWN data items was shown in Figure 2.

Improvements to drug data

Other important changes have been made to improve the reliability and specificity of the drug data collected by 

DAWN.

n Elimination of incidental drug reporting

Incidental drug reporting is the inclusion of drugs or substances that are not related to the ED visit. Under the new 

DAWN data collection protocol, reporters are instructed to record only those substances that are related to the ED visit. 

They should not report drugs that are taken as prescribed or labeled and are unrelated to the condition that brought 

the patient to the ED.

Current medications are typically listed in the medical chart and may show up in toxicology test results, but are 

frequently unrelated to the ED visit. Incidental reporting of current medications in old DAWN made interpretation of 

some findings, particularly the high numbers of OTC medications, problematic at best.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 85

n Emphasis on accurate, specific, non-redundant drug reporting

The detailed drug vocabulary used by DAWN has been described elsewhere.13 Because collecting accurate and 

specific drug information is DAWN’s central responsibility, several new requirements have been integrated into the data 

collection protocol for new DAWN.

First, electronic data entry via eHERS provides the means for DAWN reporters to select complicated drug names 

from a list. This reduces the possibility of transcription errors and automatically associates the drug name with 

its numeric code. The latter was a separate step, performed manually after data submission, when the data were 

submitted on paper forms.

Second, training and prompts in eHERS emphasize entering drugs as specifically as possible. Brand (trade) names, 

the most specific, are preferred over generic names, which are preferred over chemical or non-specific classes. For 

example, Xanax® (a brand name) is more specific than alprazolam (a generic name), which is more specific than 

benzodiazepine (the therapeutic class). To assist DAWN reporters in making these determinations, drug names 

are color-coded in eHERS to indicate levels of specificity. If a drug class (e.g., benzodiazepine) is entered, a pop-up 

message prompts the reporter to review the chart for a specific benzodiazepine.

Third, potentially redundant entries are discouraged. For example, an entry of Xanax® and benzodiazepine for the 

same DAWN case may be redundant. Since the best time to adjudicate errors of this type is when the reporter has the 

chart available, eHERS automatically prompts the reporter when a potential duplicate has been entered.

Fourth, if a drug name found in an ED chart does not appear in the eHERS vocabulary list, the reporter enters the 

new name verbatim into a text field along with a description of the drug, if available. This is particularly valuable for 

recording new street names and linking them to their proper ingredients and category. Each new entry is reviewed 

before an addition to the permanent drug vocabulary is made.

Fifth, new prescription drugs are added to the drug vocabulary when they are approved for marketing by the Food 

and Drug Administration (FDA).

n Confirmation of drugs by laboratory testing

An indicator denoting whether a particular drug was confirmed by laboratory testing now accompanies each drug 

reported to DAWN. This is the first time that DAWN has had any explicit confirmation of the drug data. While this is 

an improvement, these indicators are subject to variations in drug testing protocols across hospitals. When testing is 

not performed, no confirmatory data are possible.

13 Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Emergency Department Trends From DAWN: Preliminary 

Estimates January-June 2001 with Revised Estimates 1994-2000. DAWN Series D-20, DHHS Publication No. (SMA) 02-3634, Rockville, MD, 

2001. The classification of drugs in use by DAWN is derived from the Multum Lexicon, Copyright © 2004, Multum Information Services, Inc. The 

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

provided in Appendix A and can be found on the Internet at http://www.multum.com/.
86 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

 Quality assurance in new DAWN

The primary objective of new quality assurance protocols is to identify points in the data collection processes where 

threats to data quality can be avoided or identified and corrected.

The quality of DAWN data may be compromised if: (1) all charts are not reviewed or charts are reviewed 

incompletely; (2) ED visits not meeting the case criteria are reported (false positives); (3) ED visits meeting the case 

criteria are not reported (false negatives); (4) case types are assigned incorrectly; (5) data items are not coded or 

contain inaccurate values; (6) the same case is reported multiple times; or (7) tallies of ED visits and/or charts reviewed 

are inaccurate. This section describes key changes in the methods used to identify and resolve discrepancies in new 

DAWN data that arise from these threats.

Systematic training and certification of DAWN reporters

Quality assurance in the new DAWN starts with training of DAWN reporters.

The accuracy and completeness of the data submitted to DAWN depend on a careful review of each ED chart; an 

excellent understanding of the DAWN case criteria and data items; accurate abstraction of demographic and drug 

information; and faithful adherence to the data collection and confidentiality protocols. Each DAWN facility has one 

or more DAWN reporters to perform these tasks on the facility’s behalf. The reporter may be a member of the hospital 

staff who conducts DAWN data collection as part of his or her job or during off-duty hours, or an employee of the 

DAWN contractor who conducts DAWN data collection on behalf of the facility. All DAWN reporters are required 

to use direct review of ED medical charts to find DAWN cases, extract relevant data items, and submit the data 

electronically to DAWN.

Each DAWN reporter receives a Reference Guide and a computer-based training tutorial (CBTT). The Reference 

Guide documents all the activities and processes that DAWN data collection requires. It serves as a permanent 

reference for the reporter and is updated periodically. To be certified as a DAWN reporter, each reporter must 

successfully complete the CBTT. The CBTT includes a set of interactive lessons specific to the new case criteria and 

individual data items. Explanations in the CBTT are followed by examples of reportable and non-reportable visits 

drawn from actual case files as well as practice exercises for the reporter to apply the concepts covered by each lesson. 

The CBTT concludes with a mastery test designed to assess the reporter’s comprehension of all the lessons covered. 

The reporter must pass the mastery test in order to receive the credential that authorizes him or her to begin reporting 

DAWN data.

DAWN reporters also receive additional hands-on training and periodic performance feedback and have access to a 

toll-free technical assistance help line. Periodic quality assurance audits provide opportunities for additional training, if 

needed. New reporters who are employees of the contractor are audited before the end of their probationary periods.

Starting in 2004, the DAWN performance report for ED directors was initiated. This report, which summarizes 

total ED visits, charts reviewed, and DAWN cases submitted for each month, is sent to each facility’s ED director each 

quarter, as a final check on the completeness of DAWN data. ED directors receiving the quarterly performance report 

are asked to review the numbers and notify the DAWN contractor if the numbers appear suspect in any way.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 87

In-house review and cleaning of DAWN case reports

After submission, each DAWN case report is reviewed for case eligibility, case type assignment, completeness, 

accuracy, and duplication. When necessary, reviewers modify the data in existing records, but the original data are 

retained along with a record of the change, including date, time, and the reviewer’s initials. Changes are summarized 

and used as performance feedback to DAWN reporters.

The case description entered on each DAWN case report is used to validate the DAWN case determination. The 

case description describes how the drug was related to the ED visit using text (verbatim, whenever possible) from the 

medical chart. For 2003, every case was independently reviewed for eligibility. This method follows a model used 

successfully by the Consumer Product Safety Commission’s National Electronic Injury Surveillance System (NEISS), 

which collects product-related injury cases through direct review of ED charts in hospitals across the U.S.

A workgroup of SAMHSA/OAS and contractor staff met regularly to discuss ambiguous cases and case descriptions 

in order to refine and clarify reporting guidelines for reviewers and DAWN reporters alike. The decision tree for 

assigning type of case was a product of these discussions. The need for the workgroup declined over time as the rules 

became clearer and everyone gained experience with the new DAWN protocol.

In addition to the error and validity checks performed at data entry by eHERS, in-house data management staff 

conducted range checks, consistency checks, frequency checks, and problem resolution to monitor and clean the data 

submitted to DAWN.

Review of the case type data item was as important as review of case eligibility. For 2003, case eligibility and type 

of case assignment were subjected to 100% blind double review. All cases in which the first and second reviewers did 

not agree were sent to a third reviewer for adjudication.

Review of case types in the aggregate is also informative. A mix of case types that deviates from established norms 

(e.g., low rates of underage drinking, adverse reactions, accidental poisonings, or inpatient admissions) may indicate a 

potential problem.

Impact of review and data cleaning on 2003 data

The intensive reviews of case type, case description, and diagnoses revealed some reporting problems in the 

2003 data. Given the scope of the changes introduced in 2003, data for the first two quarters (Q1-Q2) of 2003 were 

deemed too incomplete and unreliable for use.

For drug-related ED visits in Q3-Q4 2003, problems in the assignment of case type (see Table B1) were detected in:

n 54% of cases originally coded as suicide attempt;

n 36% of cases originally coded as malicious poisoning;

n 25% of cases originally coded as accidental ingestion;

n 24% of cases originally coded as overmedication;

n 14% of cases originally coded as case type other; and

n 11% of cases originally coded as adverse reaction.
88 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Most of these problems were relatively easy to remedy, once the source of the misunderstanding was uncovered. For 

example, initial reluctance to code large numbers of cases into case type other came from a concern that a category 

called other could not be frequent or important. Other necessary clarifications included:

n Suicide cases should include only documented suicide attempts (and exclude suicide gestures, thoughts, ideation, 

and so forth), a more restrictive definition than in old DAWN.

n Adverse reaction cases should include only licit drugs (and exclude “unexpected reactions” to illicit drugs, a 

category from old DAWN).

n Overmedication cases should include only licit drugs (and are not synonymous with “overdose”).

n Malicious poisoning should not include all types of “poisoning.”

Once the data for the complete period were assembled, one final review focused on the possibility of incomplete 

data, that is, DAWN cases missed due to incomplete chart review or inappropriate application of the case criteria. As 

a result of this final step, all data for 37 hospitals (39 EDs) and an additional 69 hospital months (71 ED months) were 

deemed unusable and were deleted from the final data used for estimation.

Final type 

of case

Original type of case

Suicide 

attempt

Seeking 

detox

Alcohol 

only 

(age < 21)

Adverse 

reaction

OvermedicationMalicious 

poisoning

Accidental 

ingestion Other Total

Suicide 

attempt 3,739 8 4 1 48 1 180 3,981

Seeking detox 73 8,560 13 5 8 1 761 9,421

Alcohol only 

(age < 21) 2 4 2,829 1 2 2 54 2,894

Adverse 

reaction 8 3 8,693 246 14 355 9,319

Overmedication 3,010 12 1 153 2,879 9 243 3,014 9,321

Malicious 

poisoning 3 2 2 2 107 11 39 166

Accidental 

ingestion 31 25 1 1,026 84 1,167

Other 1,322 536 53 843 600 45 68 27,847 31,314

Total 8,157 9,123 2,902 9,729 3,808 166 1,364 32,334 67,583

Table B1

Type of case re-assignments: Q3-Q4 2003

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).
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APPENDIX C

GLOSSARY OF TERMS

This glossary defines terms used in data collection activities, analyses, and publications associated with the 

emergency department (ED) component of the Drug Abuse Warning Network (DAWN).

Case description: A description of how the drug(s) was related to the patient’s ED visit. The case description, in 

conjunction with the chief complaint and diagnosis, is used to determine if the ED visit is reportable to DAWN. 

It is copied verbatim from the patient’s chart when possible. 

Chief complaint: The symptom(s) or condition(s) for which the patient was seeking treatment in the ED. Includes the 

following categories: 

n Overdose—A condition associated with consumption of an excessive or toxic quantity of a drug or other 

substance.

n Intoxication—The condition produced by the toxic effect of a drug(s), often alcohol.

n Seizures—Neurologic events associated with abnormal electrical activity in the brain. Seizures manifest clinically 

as a change in consciousness, motor sensory, or behavioral symptoms.

n Altered mental status—Abnormal changes in basic mental functioning. Patient or those in attendance may state 

that the patient is disoriented as to time and place, is delirious, is having hallucinations, is combative, or exhibits 

other symptoms of that nature. 

n Psychiatric condition—In DAWN, a general term used to denote mental illness or psychological dysfunction, 

specifically those mental, emotional, or behavioral problems not caused by a physical disease. These include 

suicidal ideation, depression, schizophrenia, bipolar disorder, and so forth.

n Withdrawal—The physical state/symptoms produced by abstention from drugs to which the person is addicted.

n Seeking detox—Cases characterized by documentation in the chart that the patient is seeking “detox,” “rehab,” 

or medical clearance or help for a drug problem.

n Accident/injury/assault—Cases involving self-inflicted injuries or injuries resulting from fights, accidents, or 

assaults with documented use of substances.

n Abscess/cellulitis/skin/tissue—Cases involving cellulitis, abscess, infection, or skin problems such as rashes.

n Chest pain—A category of symptoms associated with pain or discomfort in the chest or upper thorax.

n Respiratory problems—A category of conditions associated with breathing. Examples include shortness of breath, 

coughing, and wheezing.

n Digestive problems—A category of conditions associated with the gastrointestinal system. Examples include 

indigestion, nausea, vomiting, diarrhea, and constipation.

n Other—Complaints that do not fit into the pre-recorded categories.
90 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Confidence interval: A “confidence interval” (CI) is an interval estimate, that is, a range of values around a point 

estimate that takes sampling error into account. Ninety-five percent is an accepted standard of confidence. 

Technically, a 95% CI means that if repeated samples were drawn from the same population of hospitals 

using the same sampling and data collection procedures, the true population value would fall within the 

confidence interval 95% of the time. Practically, a 95% CI summarizes both the estimate and its margin of 

error in a straightforward way with a reasonable degree of confidence. Calculation of 95% CIs is discussed 

in Appendix D.

Coterminous U.S.: The contiguous 48 States and Washington, DC; excludes Alaska and Hawaii. 

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

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

Treated and released includes three categories:

n 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.

n Released to police/jail 

n Referred to detox/treatment—The chart indicates that the patient was referred to a substance abuse treatment or 

detox facility or provider.

Admitted to this hospital includes five categories:

n ICU/Critical care

n Surgery

n Chemical dependency/detox

n Psychiatric unit

n Other inpatient unit—The inpatient unit was not specified or does not match one of the preceding units.

Other Disposition includes five categories:

n Transferred—The patient was transferred to another health care facility.

n Left against medical advice—The patient left the treatment setting without a physician’s approval.

n Died—The patient died after arriving in the ED but before being discharged, admitted, or transferred.

n Other—The discharge status is documented in the chart but does not fit into any of the preceding categories.

n Not documented

Drug: This refers to a substance that was recorded in a DAWN case report. In addition to alcohol, up to 6 substances 

(“drugs”) can be reported for each ED visit. Therefore, the total number of drugs exceeds the total number 

of ED visits. Even when only one drug is reported, it should not be assumed that the substance was the sole 

and direct cause of the visit; allowances should be made for reportable drugs not listed or other contributory 

factors. (See also Single-drug case.)
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Drug category: A generic grouping of pharmaceuticals and other substances reported to DAWN, based on the 

classification of Multum Information Services. Multum Information Services is a subsidiary of the Cerner 

Corporation and a developer of clinical drug information systems and a drug knowledge base. More 

information is available at http://www.multum.com/. In general, the Multum categories follow the therapeutic 

uses for prescription and over-the-counter pharmaceuticals.

 Additional clarification is provided for the following drug categories: 

n Alcohol alone—DAWN collects data on alcohol when used alone only if the patient is under age 21.

n Alcohol-in-combination—Alcohol-in-combination is the category for alcohol present in combination with another 

reportable substance. DAWN does not gather data on alcohol used alone if the patient is over age 21. For 

patients 21 and older, alcohol must be used with another substance to be reported. Alcohol-in-combination is 

reportable for all ages.

n Amphetamines—This class of substances has been extracted from the category of central nervous system 

(CNS) stimulants because of its importance as a major substance of abuse. For purposes of classification, 

“amphetamines” (plural) includes a class of compounds derived from or related to the drug amphetamine. 

Although some “designer” drugs fall into the class of amphetamines, we choose to report some of them 

individually as major substances of abuse (e.g., methamphetamine). This category does not include other CNS 

stimulants, such as caffeine or methylphenidate. 

n 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).

n Inhalants—This category includes anesthetic gases and psychoactive non-pharmaceutical substances for which 

the documented route of administration was inhaled, sniffed, or snorted. Psychoactive non-pharmaceuticals fall 

into one of the following 3 categories: (1) volatile solvents—adhesives (model airplane glue, rubber cement, 

household glue), aerosols (spray paint, hairspray, air freshener, deodorant, fabric protector), solvents and gases 

(nail polish remover, paint thinner, correction fluid and thinner, toxic markers, pure toluene, cigar lighter fluid, 

gasoline, carburetor cleaner, octane booster), cleaning agents (dry cleaning fluid, spot remover, degreaser), food 

products (vegetable cooking spray, dessert topping spray such as whipped cream, whippets), and gases (butane, 

propane, helium); (2) nitrites—amyl nitrites (“poppers,” “snappers”) and butyl nitrites (“rush,” “locker room,” 

“bolt,” “climax,” “video head cleaner”); or (3) chlorofluorohydrocarbons (freons). Anesthetic gases (e.g., 

nitrous oxide, ether, chloroform) are presumed to have been inhaled.

Drug-related ED visit: Any ED visit related to recent drug use. To be a DAWN case, a drug needs only to be implicated 

in the visit; the drug does not have to have caused the visit. One patient may make repeated visits to an ED or 

to several EDs, thus producing a number of visits. It is impossible to determine the number of unique patients 

involved in the reported drug-related ED visits because no patient identifiers are collected.

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.
92 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

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 

with EDs that are open 24 hours a day, 7 days a week, and located in the coterminous United States. Specialty 

hospitals, hospital units of institutions, long-term care facilities, pediatric hospitals, hospitals operating parttime EDs, hospitals in Alaska and Hawaii, and hospitals operated by the Veterans Health Administration and 

the Indian Health Service are excluded.

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. The 

current DAWN ED sample, which was designed in the 1980s, is based on the definitions of Metropolitan 

Statistical Areas (MSAs) and Primary Metropolitan Statistical Area (PMSAs) issued by the Office of 

Management and Budget (OMB) in 1983, with a few exceptions.

Not otherwise specified (NOS): Catch-all category for substances that are not specifically named in the listing. Terms 

are classified into an NOS category only when assignment to a more specific category is not possible based on 

information in the source documentation (ED patient charts).

Not tabulated above (NTA): Designation used when categories are not presented in complete detail; smaller units are 

combined in the NTA category.

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 of 50% or higher 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: Beginning in January 2000, the race and ethnicity categories collected on DAWN cases changed to 

match a change in the standard protocol issued by the OMB in 1997. The 1997 protocol permits separate 

reporting of race and Hispanic ethnicity, the ability to capture more than one race for an individual, 

modifications in nomenclature (e.g., “Black” was changed to “Black or African American”), division of certain 

categories (“Asian or Pacific Islander” was split into two categories, “Asian” and “Native Hawaiian or Other 

Pacific Islander”), and elimination of the “Other” category.

 The race/ethnicity categories on the DAWN data collection forms are as follows:

n White—A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

n Black or African American—A person having origins in any of the black racial groups of Africa.
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 93

n Hispanic or Latino—A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish 

culture or origin, regardless of race.

n 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.

n 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.

n Native Hawaiian or Other Pacific Islander—A person having origins in any of the original peoples of Hawaii, 

Guam, Samoa, or other Pacific Islands.

n Not documented—Used when documentation of race is not available from source records.

Despite the increased detail allowed by these categories, the actual race/ethnicity data reported to DAWN changed 

very little because race and ethnicity are often not documented with this level of specificity in patient/decedent records. 

As a result, we have retained the classification used previously to tabulate DAWN data. The one exception is that 

we now collapse the less commonly used categories into a category termed “Not tabulated above (NTA)” instead of 

“Other.” Categories used to tabulate race and ethnicity data in the ED publications are:

n White—Anyone meeting the definition of white (above). Those who are identified as white and Hispanic are 

classified as Hispanic.

n 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.

n Hispanic—Anyone whose ethnicity is Hispanic or Latino (above) is placed in the category Hispanic, regardless of 

race.

n Race/ethnicity NTA—This includes those categories that are too small to report independently including: 2 or more 

races, American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander.

n Unknown—Race and ethnicity are unknown. Those who are identified only as Hispanic are classified as Hispanic.

Relative standard error (RSE): A measure of an estimate’s relative precision. The RSE of an estimate is equal to the 

estimate’s standard error (SE) divided by the estimate itself. For example, an estimate of 2,000 cocaine visits 

with an SE of 200 visits has an RSE of 10%. The larger the RSE, the less precise the estimate. Estimates with 

an RSE of 50% or more are not published by DAWN. (See also Precision and Standard error.)

Sampling: Sampling is the process of selecting a proper subset of elements from the full population so that the subset 

can be used to make inference to the population as a whole. A probability sample is one in which each 

element has a known and positive chance (probability) of selection. A simple random sample is one in which 

each member has the same chance of selection. In DAWN, a sample of hospitals is selected in order to make 

inference to all hospitals; DAWN uses simple random sampling within strata.

Sampling frame: A list of units from which the ED sample is drawn. All members of the sampling frame have a 

probability of being selected. A sampling frame is constructed such that there is no duplication and each unit 

is identifiable. Ideally, the sampling frame and the universe are the same. The sampling frame for the DAWN 

hospital ED sample is derived from the American Hospital Association (AHA) Annual Survey of Hospitals.

Sampling unit: A member of a sample selected from a sampling frame. For the DAWN sample, the units are hospitals, 

and data are collected for all drug-related ED visits at the responding hospitals selected for the sample.
94 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Sampling weights: Numeric coefficients used to derive population estimates from a sample.

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.

Strata (plural), stratum (singular): Subgroups of a population 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 21 

metropolitan area cells plus an additional cell for the remainder of the coterminous U.S. Then, within these 

cells strata are defined according to the annual number of ED visits, whether the hospital is located inside or 

outside the central city of the metropolitan area, and by the presence or absence of an organized outpatient 

department, alcohol/chemical dependence inpatient unit, or both. The strata are as follows: 

Stratum Annual ED visits Location within 

metropolitan area

Outpatient department or alcohol/

chemical dependence inpatient unit

In the 21 DAWN metropolitan areas:

0 >80,000 Not applicable Not applicable

1 <80,000 Central city Both

2 <80,000 Central city One only

3 <80,000 Central city Neither

4 <80,000 Outside central city Both

5 <80,000 Outside central city One only

6 <80,000 Outside central city Neither

In the remainder of the coterminous U.S.:

0 >80,000 Not applicable Not applicable

7 <80,000 Not applicable Both

8 <80,000 Not applicable One only

9 <80,000 Not applicable Neither

Note: Stratum “0” is defined for each of the 21 metropolitan areas and for the remainder of the coterminous U.S. See Drug 

Abuse Warning Network Sample Design and Estimation Procedures: Technical Report, November 1997.

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.)

Single-drug visit: A single-drug visit is one in which only one drug was involved. Because multiple substances may 

be recorded for each DAWN case (see Drug), readers should exercise caution in interpreting the relationship 

between a given drug and the number of associated ED visits. For example, if records for a given patient 

documented marijuana use, this does not mean that marijuana was the only drug involved in the ED visit or 

that the marijuana caused the ED visit. One should always consider whether and how many other drugs were 

used in combination, but even then attributing a causal relationship between the visit and a particular drug 
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 95

may not be possible. Additionally, DAWN can only provide single-drug visit totals for alcohol if the patient was 

younger than age 21.

Type of case: A classification used to group similar DAWN cases. Each case is coded into one and only one category, 

the first that applies from the following hierarchy: Suicide attempt, seeking detox, alcohol only (age < 21), 

adverse reaction, overmedication, malicious poisoning, accidental ingestion, and other. 

Universe: The entire set of units for which generalizations are drawn. The universe for the DAWN ED sample is all nonFederal, short-stay, general medical and surgical hospitals in the coterminous United States with EDs operating 

24 hours a day, 7 days a week. (See also Coterminous U.S.).
96 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 97

APPENDIX D

ESTIMATES AND RATES

DAWN estimates and the margin of error

Each hospital in the DAWN sample was selected to represent itself and other hospitals in its area with similar 

characteristics. Therefore, each estimate produced from the sample data is subject to sampling variability, the so-called 

“margin of error,” which 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 is measured by its 

standard error (SE) and relative standard error (RSE), which is defined as the SE expressed as a percentage of the value 

of the estimate. The precision of an estimate is related to the degree of sampling variability as measured by the RSE; 

the greater the RSE value, the lower the precision.

For example, if there are 10,000 estimated visits involving a given drug and this estimate has an SE of 500, then 

the RSE value is 5%:

 RSE = SE/Estimate

 RSE = 500/10,000

 RSE = 0.05

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

with the estimates. A CI, which is expressed as a range of values, is useful because it reflects both the estimate and its 

corresponding RSE. If the sampling distribution for the estimate is normal, then the 95% CI would be calculated as:

 CI = Estimate ± 1.96 x RSE x Estimate

where 1.96 comes from the table of normal distribution z-values. Ninety-five percent of the normal distribution lies 

between the z-values of ±1.96.

Applying the formula to the example above, the 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

 Confidence interval: 9,020 to 10,980

This 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.

DAWN estimates with RSE values of 50% or higher are regarded as too imprecise for publication and are not 

shown in tables. With an RSE of 50%, the 95% CI for an estimate ranges from 2% to 198% of the estimate’s value. In 

the tables, 3 dots (“...”) have been substituted for estimates that have an RSE of 50% or higher.
98 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Estimates adjusted for population size

Standardized measures are needed to make valid comparisons of estimates across age and gender categories. For 

age in particular, the size of the underlying population differs considerably across age groups; for example, the number 

of individuals age 18 to 20 in the U.S. is much lower than the number of individuals age 35 to 44. A higher estimate 

for the larger group in the population would be expected to occur naturally.

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

calculated using population data from the U.S. Bureau of the Census.14

For each age and gender category, the estimate for a category is divided by the population for that category, which 

is 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 for this publication are provided in Appendix E.

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

available to DAWN are much less detailed than the race and ethnicity categories in the Census data. Appendix F 

describes the race and ethnicity data reported for DAWN.

14 Population counts from U.S. Census 2000 Summary File 1 (SF-1) (see http://www.census.gov/Press-Release/www/2001/sumfile1.html). 

Population estimates for 2003, as of July 1, 2003, from U.S. Census Bureau County Population Dataset CO-EST2003-ALLDATA 

(see http://www.census.gov/popest/counties/files/CO-EST2003-alldata.csv).
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 99

Gender and age Coterminous U.S. Atlanta Baltimore Boston Buffalo Chicago Dallas 

TOTAL .............................................. 288,861,182 4,276,139 2,616,229 4,032,129 941,293 6,562,831 3,653,034 

0-5 years ........................................ 24,419,263 393,285 212,459 318,095 71,696 585,327 363,655 6-11 years ...................................... 26,323,729 402,433 240,267 337,678 82,866 606,042 352,878 12-17 years .................................... 25,300,894 364,903 225,201 310,327 80,604 557,747 324,714 18-20 years .................................... 10,949,464 155,414 86,383 119,841 31,854 244,582 145,761 21-24 years .................................... 14,757,533 228,088 114,846 198,045 42,564 359,592 212,784 25-29 years .................................... 19,913,605 368,974 166,472 303,395 54,769 526,241 322,260 30-34 years .................................... 21,161,469 389,673 197,128 336,337 64,008 525,516 323,116 35-44 years .................................... 46,726,438 770,236 452,875 696,384 150,787 1,055,502 639,279 45-54 years .................................... 39,218,789 582,635 377,591 562,336 131,404 850,444 459,386 55-64 years .................................... 25,326,545 315,871 235,771 350,717 86,967 537,709 255,565 65 years and older ......................... 34,763,454 304,627 307,236 498,975 143,775 714,129 253,636 

MALES ............................................. 140,993,545 2,105,361 1,251,420 1,942,660 448,926 3,189,547 1,821,507 

0-5 years ........................................ 11,923,786 192,036 103,834 155,507 35,202 286,341 177,609 6-11 years ...................................... 12,846,262 196,950 117,440 164,650 40,264 296,309 172,877 12-17 years .................................... 12,344,279 176,890 110,564 151,299 39,407 272,472 157,853 18-20 years .................................... 5,364,144 73,805 43,435 57,831 15,640 117,815 68,615 21-24 years .................................... 7,405,079 112,657 60,512 101,915 21,697 180,477 104,244 25-29 years .................................... 10,029,078 184,899 87,731 155,552 28,321 263,871 158,961 30-34 years .................................... 10,678,914 195,654 103,284 171,807 33,057 262,954 158,353 35-44 years .................................... 23,797,884 391,697 236,243 356,617 78,289 537,876 317,443 45-54 years .................................... 20,107,818 302,593 196,958 292,327 68,162 442,111 234,437 55-64 years .................................... 13,218,283 162,453 123,480 184,901 46,595 286,596 131,743 65 years and older ......................... 20,152,111 181,144 181,329 297,063 85,732 426,461 149,393 

FEMALES ......................................... 147,867,637 2,170,778 1,364,809 2,089,469 492,367 3,373,284 1,831,527 

0-5 years ........................................ 12,495,566 201,252 108,626 162,587 36,494 298,986 186,045 6-11 years ...................................... 13,477,520 205,483 122,824 173,029 42,600 309,735 180,003 12-17 years .................................... 12,956,472 188,010 114,639 159,028 41,198 285,273 166,860 18-20 years .................................... 5,585,321 81,609 42,948 62,011 16,215 126,767 77,146 21-24 years .................................... 7,352,454 115,432 54,334 96,130 20,867 179,115 108,540 25-29 years .................................... 9,884,527 184,074 78,741 147,843 26,447 262,370 163,299 30-34 years .................................... 10,482,555 194,019 93,845 164,529 30,950 262,562 164,763 35-44 years .................................... 22,928,554 378,539 216,632 339,768 72,499 517,626 321,836 45-54 years .................................... 19,110,970 280,041 180,633 270,008 63,242 408,332 224,950 55-64 years .................................... 12,108,262 153,418 112,292 165,816 40,372 251,112 123,822 65 years and older ......................... 14,611,343 123,484 125,907 201,912 58,042 287,668 104,243 

1 Average 2003 civilian noninstitutional population estimated using data from 2 Census Bureau data files: 2000 Census Counts by Age, Sex, and Race (ASR files); 

Population Estimates (CPOP file). 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

Table E1 – Population by age and gender by metropolitan area, 20031
100 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S Gender and age Detroit Los Angeles Miami Minneapolis New Orleans New York New

TOTAL ............................................. 4,634,526 9,871,506 2,341,167 2,971,098 1,289,516 9,418,583 1,959

0-5 years ...................................... 398,351 944,781 185,960 262,028 109,119 784,536 1716-11 years ..................................... 443,772 999,118 205,056 279,483 119,493 813,972 17912-17 years ................................... 401,502 861,504 200,015 267,325 121,544 738,766 16018-20 years ................................... 161,401 407,858 88,635 104,704 52,749 345,111 6221-24 years ................................... 210,330 576,728 117,857 150,740 67,544 527,826 8625-29 years ................................... 321,044 812,184 170,008 218,795 87,542 768,861 12630-34 years ................................... 352,378 836,546 180,203 242,926 90,634 796,605 15335-44 years ................................... 769,867 1,579,092 376,156 534,647 206,670 1,507,324 33845-54 years ................................... 647,273 1,197,709 295,155 411,305 181,653 1,221,556 27455-64 years ................................... 392,676 726,433 216,434 228,635 109,904 824,127 17865 years and older ......................... 535,933 929,553 305,687 270,509 142,664 1,089,899 228

MALES ............................................ 2,252,261 4,867,554 1,125,053 1,467,126 614,110 4,461,151 942

0-5 years ....................................... 194,244 461,120 90,726 128,103 53,480 383,775 836-11 years ..................................... 216,396 488,680 100,453 136,353 58,341 398,352 8712-17 years ................................... 196,052 420,288 98,179 130,424 59,960 361,693 7818-20 years ................................... 78,455 197,605 44,010 50,531 27,005 169,950 3021-24 years ................................... 106,831 285,094 60,260 76,155 35,788 274,035 4325-29 years ................................... 164,237 402,517 86,368 109,693 46,573 401,231 6530-44 years ................................... 179,045 411,866 91,385 121,591 47,471 411,487 7935-44 years ................................... 392,859 792,635 193,637 267,421 108,671 782,342 17445-54 years ................................... 331,953 621,174 155,935 208,262 94,816 655,449 14455-64 years ................................... 204,338 383,623 115,774 117,339 58,268 455,287 9365 years and older ........................ 317,854 539,348 179,386 158,101 85,035 663,831 135

FEMALES......................................... 2,382,265 5,003,952 1,216,114 1,503,972 675,406 4,957,432 1,017

0-5 years ....................................... 204,109 483,661 95,234 133,925 55,640 400,762 876-11 years ..................................... 227,375 510,437 104,603 143,131 61,153 415,618 9212-17 years ................................... 205,449 441,217 101,836 136,901 61,583 377,073 8118-20 years ................................... 82,946 210,254 44,625 54,173 25,744 175,160 3221-24 years ................................... 103,499 291,634 57,597 74,585 31,756 253,791 4225-29 years ................................... 156,807 409,667 83,640 109,102 40,969 367,631 6130-34 years ................................... 173,333 424,680 88,818 121,335 43,163 385,119 7335-44 years ................................... 377,008 786,456 182,519 267,226 97,999 724,981 16345-54 years ................................... 315,319 576,534 139,220 203,043 86,837 566,106 13055-64 years ................................... 188,338 342,810 100,660 111,296 51,636 368,840 8465 years and older ........................ 218,078 390,205 126,301 112,409 57,629 426,069 92

1 Average 2003 civilian noninstitutional population estimated using data from 2 Census Bureau data files: 2000 Census Counts by Age, Sex, and Race (ASR file

Population Estimates (CPOP file). 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

Table E1 – Population by age and gender by metropolitan area, 20031 (continued)
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 101

Gender and age Phoenix St. Louis San Diego San Francisco Seattle Washington, DC

TOTAL ................................................ 3,389,260 2,568,909 2,930,886 1,695,211 2,400,820 4,807,766

0-5 years ........................................ 323,998 211,211 258,793 108,588 187,121 415,2906-11 years ...................................... 315,664 238,487 273,914 112,039 200,905 434,17312-17 years .................................... 283,529 235,966 244,476 104,064 192,543 390,95718-20 years .................................... 143,350 94,526 115,316 47,904 84,001 146,96421-24 years .................................... 196,601 120,403 173,380 85,298 122,304 235,69925-29 years .................................... 272,207 166,264 230,047 154,505 188,082 371,46130-34 years .................................... 266,368 179,620 233,634 163,546 206,710 416,03135-44 years .................................... 525,224 431,350 483,058 294,434 433,441 869,99245-54 years .................................... 406,379 352,960 375,737 251,900 357,674 705,47555-64 years .................................... 268,104 222,706 218,579 155,046 194,642 410,00865 years and older ......................... 387,835 315,416 323,952 217,886 233,396 411,717

MALES 1,690,418 1,235,348 1,450,898 843,708 1,194,048 2,334,613

0-5 years ........................................ 158,183 103,210 126,343 53,023 91,146 203,4236-11 years ...................................... 154,104 116,766 133,305 54,657 97,760 212,38412-17 years .................................... 137,779 115,606 119,169 50,549 93,940 190,97918-20 years .................................... 68,150 46,524 57,134 22,355 41,170 70,66721-24 years .................................... 93,682 62,783 85,415 42,254 61,042 121,11425-29 years .................................... 130,863 86,109 111,843 75,209 92,505 190,90330-34 years .................................... 128,054 92,633 114,706 77,796 100,795 214,23635-44 years .................................... 259,820 221,941 240,661 142,353 214,644 447,48945-54 years .................................... 208,472 183,201 191,958 127,102 180,878 369,05555-64 years .................................... 140,876 117,348 114,975 80,302 98,107 211,88465 years and older ......................... 218,859 187,443 184,480 125,903 134,783 241,020

FEMALES 1,698,842 1,333,561 1,479,988 851,503 1,206,772 2,473,153

0-5 years ........................................ 165,815 108,002 132,450 55,567 95,975 211,8666-11 years ...................................... 161,560 121,723 140,609 57,381 103,145 221,79212-17 years .................................... 145,751 120,358 125,307 53,515 98,603 199,97518-20 years .................................... 75,201 48,002 58,183 25,550 42,831 76,29721-24 years .................................... 102,919 57,620 87,966 43,044 61,262 114,58525-29 years .................................... 141,344 80,155 118,204 79,296 95,577 180,55830-34 years .................................... 138,314 86,987 118,928 85,750 105,914 201,79535-44 years .................................... 265,404 209,410 242,396 152,081 218,796 422,50345-54 years .................................... 197,907 169,759 183,779 124,798 176,796 336,42055-64 years .................................... 127,228 105,358 103,604 74,744 96,535 198,12565 years and older ......................... 168,976 127,974 139,472 91,983 98,614 170,696

1 Average 2003 civilian noninstitutional population estimated using data from 2 Census Bureau data files: 2000 Census Counts by Age, Sex, and 

Race (ASR files); and County-Level Population Estimates (CPOP file). 

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).

Table E1 – Population by age and gender by metropolitan area, 20031 (continued)
102 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S
D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S 103

APPENDIX F

RACE AND ETHNICITY IN DAWN

Beginning in January 2000, the race and ethnicity categories used by DAWN changed to match a revised standard 

protocol issued by the Office of Management and Budget (OMB).15 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. The complete DAWN ED case form is reproduced in Figure 2 in 

this report.

Despite the increased detail allowed by the new categories, the actual race and ethnicity data extracted from source 

records and submitted to DAWN changed very little. This is because the source documents (that is, the ED medical 

records from which DAWN data are abstracted) rarely contain such detailed information on race and ethnicity of 

patients.

For reference, estimates of race and ethnicity in drug-related ED visits are presented in Table F1. This analysis, 

which is based on the most detailed coding of race and ethnicity in DAWN case reports, reveals that estimates for the 

following categories are too small to be meaningful:

n Two or more races and/or ethnicity (that is, 2 or more races and/or ethnicity were documented in the source 

record for the same individual),

n Hispanic or Latino ethnicity with any specific race indicated,

n American Indian or Alaska Native,

n Asian, and

n Native Hawaiian or Other Pacific Islander.

Therefore, in the tables of estimates in this and other DAWN publications we have retained the categories used 

previously to tabulate DAWN data, with one exception. A new category called “Race/ethnicity not tabulated above 

(NTA)” is used to tabulate those categories that are too small to report independently.16 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.

15 See Office of Management and Budget, Revisions to the Standards for the Classification of Federal Data on Race and Ethnicity, Federal Register, 62

FR 58782, October 30, 1997.

16 One exception is that if two races are reported and the second is reported as unknown, the episode is coded for the known race.
104 D A W N , 2 0 0 3 : I N T E R I M N A T I O N A L E D E S T I M A T E S

Table F1

Drug-related ED visits, by detailed race/ethnicity: Q3-Q4 2003

Race/ethnicity Estimated

visits1,2,3

Total drug-related visits 627,923

One race/ethnicity 622,917

 White 410,473

 Black/African American 92,409

 Hispanic 47,157

 Asian 1,064

 American Indian/Alaska Native 3,391

 Native Hawaiian/Other Pacific Islander ...

 Race unknown 67,610

Two races/ethnicity 4,999

 White + Black/African American 339

 White + Hispanic 4,127

 White + Asian ...

 White + American Indian/Alaska Native ...

 Black/African American + Hispanic 43

 Black/African American + Asian ...

 Black/African American + American Indian/Alaska Native ...

 Hispanic + Asian ...

 Hispanic + American Indian/Alaska Native 11

 Asian + American Indian/Alaska Native 7

 American Indian/Alaska Native + Native Hawaiian/Other Pacific Islander ...

Three races/ethnicity 8

 White + Black/African American + Hispanic 8

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

24-hour EDs in the coterminous U.S.

2 Estimates are all expressed in visits.

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

SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2003 (03/2004 update).