DRUG ABUSE WARNING NETWORK (DAWN)

This is a voluntary national data collection system that gathers information on substance abuse that results in visits to hospital emergency departments (ED) in the contiguous United States. Hospitals tracked in the DAWN system include non federal, short-stay, general hospitals that have twenty-four-hour ED—representative of the coterminous United States as a whole—plus a sample of hospitals in twenty-one major metropolitan areas. The system also collects data on drug-related deaths from a non random sample of medical examiners. Such data are published annually in separate reports titled DAWN Medical Examiner Data.

The data collected by the DAWN system represent one of the most widely used national indicators of drug abuse—frequently used by researchers and policymakers to determine the nature and extent of medical consequences of drug use nationally and in the participating metropolitan areas. Although the data are widely used to monitor patterns and trends of drug abuse, DAWN should be used with caution. The DAWN data represent information only on individuals who enter an emergency room because of their drug use. Therefore, the data reflect only the most serious cases of drug abuse. Consequences of drug use that are less severe are not represented in the data. In addition, analysis of the data requires familiarity with the types of cases reportable to DAWN. For example, the emergency-room system contains data not only on Overdose cases, but on individuals seeking Detoxification in an emergency room or those suffering from chronic effects of drug use—situations that do not necessarily require emergency treatment. Therefore, DAWN cases may reflect other phenomena than medical consequences (e.g., changes in nonhospital medical treatment availability).

HISTORY

DAWN was created in 1972 by the U.S. Department of Justice, Drug Enforcement Administra-Tion (DEA), as a surveillance system for new drugs of abuse. Since 1980, the DAWN system has been managed by the National Institute on Drug Abuse (NIDA) and, more recently, the Office of Applied Studies of the Substance Abuse and Men-Tal Health Services Administration (SAMHSA), which currently oversees it.

The Emergency-Room System.

At its outset, the DAWN emergency-room system consisted of a sample of hospitals in twenty-one metropolitan areas and a panel of hospitals representative of the nation as a whole. In subsequent years, however, changes in hospital participation led to a sample that was no longer representative of all hospital EDs in the coterminous United States. Thus, data collected by the DAWN system before 1988 measure drug-related cases only for those hospitals included in the sample; actual estimates of the number of drug deaths and hospital emergencies in the metropolitan areas or across the nation are not available for those years (1972-1987). The primary utility of the data prior to 1988, then, is for examining trends in drug emergencies and deaths in the participating hospitals over time, rather than deriving estimates of actual numbers of cases in the United States.

DAWN data have been collected from a representative sample of eligible hospitals in the coterminous United States. It includes an oversampling from twenty-one metropolitan areas and a National Panel of hospitals sampled from locations outside of these areas. This sample design corrects the limitations of the pre-1988 sample. It also allows for inferences about the actual number of drug-abuse episodes in the contiguous United States and for the separate DAWN metropolitan areas.

DATA COLLECTION

In each participating facility, a reporter, usually a member of the hospital ED or medical records staff, is assigned to conduct data collection. The reporter reviews records for each case appropriate for inclusion in the DAWN system and records demographic information and information about the circumstances of the episode, including the date and time of the ED visit and the reason the person came to the ED. For each drug mentioned, the DAWN report includes the form in which the drug was acquired, its source, and its route of administration. Only one reason for taking substances is recorded. A report for each case is then submitted to SAMHSA for data entry.

The following criteria are used in determining whether a case is reportable to DAWN. For each record, the patient must be between six and ninety-seven years of age and must meet all of the following criteria:

1. The patient was treated in the hospital's emergency department.
2. The patient's presenting problem(s) had been induced by or related to drug use, regardless of whether the drug ingestion occurred minutes or hours before the visit.
3. The case involved the nonmedical use of a legal drug or any use of an illegal drug.
4. The patient's reason for taking the substance(s) included one of the following: (1) Dependence, (2) Suicide attempt or gesture, or (3) psychic effects.

DAWN cases do not include accidental ingestion or inhalation of a substance, nor do they include adverse reactions to prescription or over-the-counter drugs. Up to four substances can be reported for any drug-abuse death or emergency-room case. Alcohol is reportable only when it is used in combination with a reportable substance.

TRENDS IN DRUG-RELATED EMERGENCIES AND DEATHS

Drug-related Episodes in 1999. In 1999, there were an estimated 554,932 drug-related ED episodes in the coterminous United States. Episodes from males and females occurred in about equal numbers.

Dependence (37% of episodes) and suicide (32%) were the most frequently cited motives for drug use. When analyzed by reason for contact in the emergency room, the data show that overdose (OD) was the most frequently cited reason for the majority of episodes (42%), while the remainder of episodes were due to another cause.

In 1999, the largest number of episodes (196,277, or 35% of all episodes) were due to use of Alcohol in combination with other drugs. The other drugs mentioned most frequently were Cocaine (168,763, or 30%), Heroin/ Morphine (84,409, or 15%), amphetamine (11,954, or 2%), and methamphetamine/speed (10,447, or 2%). In 1999, marijuana/hashish mentions exceeded heroin/morphine mentions, changing a rank ordering of illicit drug mentions that had been constant since 1990.

Long-term Trends, 1990-1999. The number of drug-related episodes rose 49 percent from 1990 to 1999, from 371,208 to 554,932. Although males consistently outnumber females in illicit drug mentions, their long-term patterns of growth are similar. From 1990 to 1999, mentions of cocaine and heroin/morphine more than doubled for both males and females. ED mentions of marijuana/hashish in 1999 were five and six times their 1990 levels for males and females, respectively. Mentions of the four major illicit drugs increased from 1990 to 1999 as follows: marijuana/hashish (15,706 to 87,150, or 455%), methamphetamine/speed (5,236 to 10,447, or 100%), heroin/morphine (33,884 to 84,409, or 149%), and cocaine (80,355 to 168,763, or 110%). Emergencies for those over age thirty-five rose significantly over the time period (124%), while the number of episodes for those twenty-five and under increased less than 20 percent.

Among adolescents age twelve to seventeen, mentions of marijuana/hashish increased 489 percent (from 2,170 to 12,784) between 1990 and 1999. This is increase is significant, considering that the number of total drug-related episodes among patients in this age group increased only 7 percent (from 49,109 to 52,783) between 1990 and 1999. In addition, the long-term trends for methamphetamine/speed, cocaine, and heroin/morphine among youth aged twelve to seventeen show increasing use among individuals in this group.

(See also: Abuse Liability of Drugs ; Complications ; Drug Interactions and Alcohol ; Epidemiology of Drug Abuse ; National Household Survey on Drug Abuse )

BIBLIOGRAPHY

Colliver, J. D. (1991). Characteristics and implications of the new DAWN emergency room sample. In Epidemiologic trends in drug abuse, Community Epidemiology Workgroup Proceedings, July. Rockville, MD: National Institute on Drug Abuse.

National Institute on Drug Abuse. (1991). Statistical series: Annual emergency room data, 1991. Data from the Drug Abuse Warning Network. Series I, Number 11-A. Rockville, MD: Author.

National Institute on Drug Abuse. (1991). Statistical Series: Annual medical examiner data, 1991. Data from the Drug Abuse Warning Network. Series I, Number 11-B. Rockville, MD: Author.

Clare Mundell

Revised by Patricia Ohlenroth