Emergency department visits vs. fatalities among substance-impaired underage youths involved in motor vehicle crashes
Introduction
The many adverse consequences of drinking and drug use among individuals younger than the legal drinking age of 21 have been well described over the last two decades. These consequences include mortality; serious morbidity; and social, legal, and psychological consequences (Hingson et al., 2002, Hingson et al., 2009). In particular, a major focus has been fatalities resulting from motor vehicle crashes (MVCs) among alcohol-impaired youths (Hingson, 2012, October 2, Hingson and Howland, 2002, Hingson and Winter, 2003). Recently, impairment by substances other than alcohol, including illicit drugs and misused pharmaceuticals, has begun to receive increased attention as a contributor to MVC mortality for this age group (Movig et al., 2004, National Institutes of Health, U.S. Department of Health and Human Services, 2010). However, the significant morbidity associated with MVCs by youths when alcohol and/or drugs have been involved in the crash has been less thoroughly examined than fatal outcomes.
An important measure of such serious morbidity is the extent of MVC-related emergency department (ED) visits by impaired youths. Visits to the ED following crashes reflect injuries serious enough to warrant prompt medical attention as well as MVCs' public health burden, monetary costs, and impact on individuals (Miller, Levy, Spicer, & Taylor, 2006). Overall, motor vehicle traffic incidents are the second most frequent injury mechanism for ED visits and comprised 10% of all ED cases, or more than 4 million visits, in 2005 (Nawar, Niska, & Xu, 2007). In 2005, approximately 2,700 teens aged 16–19 were killed in traffic incidents; 282,000 were treated and released from the ED at a cost of more than $25 billion. Less is known about MVC ED visits in which substances are involved. This article addresses similarities and differences in patterns of MVC-related ED visits compared with fatalities to inform approaches to targeted public health interventions.
Hingson and Winter (2003) systematically reviewed national mortality trends due to MVC fatalities and reported that in 1982, the first year that the National Highway Traffic and Safety Administration made its nationwide estimates, there were 26,172 alcohol-related traffic deaths for individuals of all ages. By 2002, when improvements from intervention efforts were evident, a 33% reduction had occurred—17,419 deaths overall. There was a disproportionate reduction in alcohol-related deaths for young adults compared to older persons. Among persons aged 16–20, alcohol-related traffic deaths declined by 56% from 5,144 to 2,329, a change due in part to legislation raising the drinking age. The decline was closely related to the blood alcohol concentration (BAC) involved, with the risk of a fatal crash being much higher for young impaired drivers than for non-impaired drivers of the same age or for older drivers (Centers for Disease Control and Prevention, 2013). Centers for Disease Control and Prevention, 2012, Centers for Disease Control and Prevention, 2013, April 17 national figures show further improvement by 2010, when 10,228 people of all ages were killed in alcohol-related crashes, representing about one-third of all traffic-related deaths in the United States. From 1991 to 2011, self-reported drinking and driving among high school students 16 and older declined from 22.3% to 10.3% (Centers for Disease Control and Prevention, 2012). In 2012, of the 3,115 drivers aged 15–20 involved in fatal MVCs, 23% had been drinking.
Despite these significant gains, a “zero tolerance” goal has not been reached, and substance-impaired driving by youths remains a public health concern. Nationally, in 2011, 10% of high school students 16 or older reported drinking and driving over the last 30 days, with 85% of drinking drivers reporting engaging in binge drinking (Youth Risk Behavior Survey; Centers for Disease Control and Prevention, 2012). Hingson and Winter (2003) report that, nationally, although fewer youths than those aged 21 or older reported drinking while driving, when they did drink and drive, youths drank more alcohol, with an average BAC three times higher than that of all drinking drivers.
Temporal patterns of drinking and associated consequences vary (Arfken, 1988) and are influenced by sociocultural factors (Room et al., 2012), although generally night time poses the highest risk, especially for youths. Studies of nighttime fatal crashes among youths show that, in fatal MVCs involving alcohol, as the BAC level in the driver increased, the odds of fatality increased for drivers aged 16–20 and 21–24. Drivers aged 16–20 in nighttime crashes were four times as likely as drivers in daytime crashes to have BACs of .15 or higher. According to the National Highway Safety Traffic Administration, 55% of fatal MVCs among teenagers occurred on Fridays, Saturdays, or Sundays (National Highway Traffic Safety Administration, 2010). Studies have associated nighttime driving, especially on weekends, with fatalities and other consequences (National Highway Traffic Safety Administration, 2013a, National Transportation Safety Board, 2013, Substance Abuse and Mental Health Services Administration, 2013).
The literature on nonfatal MVC injuries and injuries associated with substances other than alcohol, such as illicit drugs and pharmaceuticals, among younger drivers is much smaller than the literature on mortality among alcohol-impaired young drivers.
The sparseness of literature on nonalcoholic substances relative to literature on alcohol reflects a lack of solid epidemiologic data partly because of measurement issues, such as variation in coverage of drugs, completeness of assessment, and sensitivity and specificity in toxicology screens used in different jurisdictions. In addition to these testing issues, legal cutoffs for determining impairment for nonalcoholic substances vary from state to state, and, also, logistical and cost considerations make these studies challenging to conduct.
It has been established that many drugs, both illicit and legally prescribed, can affect safe driving by altering alertness, judgment, and spatial and motor skills (Office of National Drug Control Policy, 2010). The most frequently identified drug in impaired drivers other than alcohol is cannabis. Tests have shown that exposure reduces critical driving tasks such as reaction time, attention, and controlling the position of the vehicle. Overall, its contribution to crash risk is lower than that of alcohol (Romano, Torres-Saavedra, Voas, & Lacey, 2014), occurring in about 10% of fatally injured drivers, versus 40% for alcohol (Brady & Li, 2013). The risk of a MVC after cannabis use is approximately twofold (Hartman & Huestis, 2013); Li, Brady, and Chen (2013) found that the relative risk for a fatal injury increases to 23 when marijuana is combined with alcohol. Impairment varies with individual factors (e.g., smoking technique). Using marijuana in combination with alcohol reduces compensatory driving control strategies (Sewell, Poling, & Sofuoglu, 2009). Blows et al. (2005) found that the risk for car crash injuries for habitual users is higher than for nonhabitual users.
Approximately one in eight drivers tested positive for illicit drugs while driving at night or weekends according to the National Roadside Survey (National Highway Traffic Safety Administration, 2007). In 2010, a similar fraction of high school seniors reported driving after smoking marijuana in the 2 weeks prior to responding to the 2010 Monitoring the Future instrument (Asbridge, 2014, Blows et al., 2005, Hartman and Huestis, 2013, Sewell et al., 2009). Asbridge found that 44% of male and 9% of female college freshmen reported driving after using marijuana in the past month (Asbridge, 2014).
Although these and other data on self-reports of prevalence of driving under the influence of nonalcohol drugs are available, less data have been published on nonfatal outcomes. Extant studies are limited in their ability to understand the national impact of nonfatal outcomes of MVCs. For example, they may not have focused on youths (National Highway Traffic Safety Administration, 2007, National Highway Traffic Safety Administration, 2010), may be confined to regional studies in the United States (Kelly et al., 2004, Walsh et al., 2004), or may have been conducted in other countries (Drummer et al., 2003, Perez et al., 2009, Wiese Simonsen et al., 2013), where norms and laws concerning substance use while driving differ from those in the United States (Perez et al., 2009, Wiese Simonsen et al., 2013). Few studies have addressed temporal aspects and riskiest days of the week and hours of the day in nonfatal MVCs involving substances other than alcohol. One study found that abuse of prescription drugs is not associated with day of the week (Spiller, Bailey, Dart, & Spiller Sarah S., 2010).
The rationale for the study is that there is a gap in the literature because most data on MVCs in underage substance-impaired youths emphasize fatalities, with greater stress on alcohol-related MVCs than on other substances of abuse. Although fatality data for young drinking drivers certainly speaks to the need for intervention, the true magnitude of the public health burden and opportunities for intervention cannot be fully assessed without accounting for nonfatal outcomes resulting in ED visits and the consequences of impairment by substances other than alcohol.
The main objective of this study is to determine the magnitude and pattern of morbidity by examining ED visit data for MVCs associated with substance use (both alcohol and drugs) involving individuals younger than 21 and comparing these patterns to a descriptive census of all fatal MVCs. We use a temporal framework to identify the times of day and days of the week of highest risk for both fatal and nonfatal crashes by substance use categories of alcohol and nonalcohol drugs. An additional objective is to characterize the groups involved in ED visits and fatalities by presenting demographic comparative statistics.
Section snippets
Data
Data were drawn from two sources. The Drug Abuse Warning Network (DAWN) is conducted by the Substance Abuse and Mental Health Services Administration's Center for Behavioral Health Statistics and Quality (SAMHSA/CBHSQ). SAMHSA is part of the U.S. Department of Health and Human Services. DAWN data are derived from a national probability sample of ED visits involving recent use of any drug for any reason. The Fatality Analysis Reporting System (FARS) is a yearly census of all MVCs involving a
Characteristics of the sample
Table 1 shows demographic data for alcohol- and drug-related MVCs in DAWN and FARS. These data refer to substance-involved MVCs. Drivers and passengers in the vehicle are not distinguished and both are included. In DAWN, the total number of alcohol-related visits was 43,005 for 2004–2011. In FARS, the comparable number of fatalities was 12,238 (using FARS imputed BAC for drivers and nonoccupants and police reports for other persons). The ratio of number of ED visits to fatalities is 3.5:1 for
Discussion
From 1991 to 2011, according to the Youth Risk Factor Behavior Survey, the national prevalence of self-reported drinking and driving among high school students declined by 54%, from 22.3% to 10.3% (Centers for Disease Control and Prevention, 2012). In 2011, 26% of students overall reported binge drinking. However, among students who drove after drinking, 85% reported binge drinking. When youths drive after engaging in binge drinking, greater impaired driving is likely to result, given the
Conclusions
This is the first study to elucidate patterns of substance-involved ED visits among individuals younger than 21 and to compare these patterns to fatalities using nationally representative mortality and morbidity data. These analyses show that the contribution of alcohol dominates that of other drugs for both fatalities and ED visits. Underage drinking fatalities peak between midnight and 3 a.m. every day; ED visits usually peak between 3 a.m. and 6 a.m., reflecting the time difference between
Practical implications
A practical implication of these data relates to opportunities for early intervention in the ED. Data suggest that under many circumstances, a substance-involved MVC can be “a teachable moment” when brief intervention and/or referral can be implemented by ED personnel. These approaches merit continued and aggressive implementation (Fell et al., 2009, National Highway Traffic Safety Administration, 2013b, National Transportation Safety Board, 2013). FARS data not reported here show previous
Acknowledgments
The authors would like to thank the anonymous reviewers of the manuscript, and Victoria A. Albright, Janet Heekin, Anne Gering, and Cathy Tokarski for their assistance in the preparation of the manuscript.
Margaret Mattson is a research scientist in the Center for Behavioral Health Statistics and Quality, SAMHSA. She received a PhD in Neurobiology and Behavior from Cornell University and did subsequent course work in Epidemiology at the University of Minnesota and University of Massachusetts Amherst. Before coming to SAMHSA four years ago she was a program officer and researcher at NIH, most recently at NIAAA where she designed and conducted clinical trials of behavioral and pharmacologic
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Margaret Mattson is a research scientist in the Center for Behavioral Health Statistics and Quality, SAMHSA. She received a PhD in Neurobiology and Behavior from Cornell University and did subsequent course work in Epidemiology at the University of Minnesota and University of Massachusetts Amherst. Before coming to SAMHSA four years ago she was a program officer and researcher at NIH, most recently at NIAAA where she designed and conducted clinical trials of behavioral and pharmacologic treatments for alcohol use disorders. In CBHSQ, her interests include substance abuse surveillance and behavioral health.
Rong Cai is a statistician for Ambulatory Care Services Team at the Substance Abuse and Mental Health Services Administration (SAMHSA). She has more than 18 years of experience working in the Public Health Service area. She has a background mathematical statistics and electrical engineering. She graduated from University of Maryland at College Park with MA degree in Mathematical Statistics and Huazhong University of Science and Technology in China with both MS and BS degrees in Electric Engineering. Prior to joining SAMHSA, she served as a mathematical statistician for the National Center for Health Statistics. Her survey experience includes Drug Abuse Warning Network (DAWN), National Hospital Discharge Survey (NHDS), National Survey of Ambulatory Surgery (NSAS), National Nursing Home Survey (NNHS), National Nursing Assistant Survey (NNAS), National Home and Hospice Care Survey (NHHCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS).
Albert Woodward currently leads the behavioral health services research group in CBHSQ, SAMHSA. From 2006 through 2009 he directed outcomes and health services research on the National Cardiovascular Data Registry, which is conducted by the American College of Cardiology. During 1993-1994 he served on the President's Task Force on Health Care Reform as part of the group that produced the behavioral health insurance premium estimates. He has worked for a variety of organizations in the health care sector, including the Appalachian Regional Commission, Blue Cross-Blue Shield, Coopers & Lybrand, and Arthur Young. He has a Ph.D. in economics with distinction in mathematical economics from American University, an M.B.A. in health finance from the Wharton School, and a B.A. from Haverford College.