Trends in Drug Poisoning Deaths Among Adolescents and Young Adults in the United States, 2006-2015.

OBJECTIVE: Despite the rising toll of drug poisoning deaths in the United States, the extent of the problem among adolescents and young adults ages 15-24 years has received relatively little attention. We examined sociodemographic characteristics and state trends in drug poisoning deaths among adolescents and young adults from 2006 to 2015 and estimated the costs of drug poisoning mortality in this population. METHOD: We used the National Vital Statistics System's Multiple Cause of Death files from 2006 to 2015. We analyzed trends using Joinpoint regression analysis and calculated total costs of drug poisoning deaths, including medical costs, work loss costs, and quality of life loss, based on widely used cost estimates. RESULTS: Drug poisoning death rates (per 100,000 population) in adolescents and young adults increased from 8.1 in 2006 to 9.7 in 2015. The rates increased significantly for Whites (1.7% per year) and Asian/Pacific Islanders (4.3% per year) from 2006 to 2015 and for Blacks (11.8% per year) from 2009 to 2015. By U.S. region, the rates increased significantly in the Midwest (4.4% per year) from 2006 to 2015 and in the Northeast (11.0% per year) from 2009 to 2015. Trends varied by age group, intent for drug poisoning, drug category (i.e., opioids, pharmaceutical drugs excluding opioids, illicit drugs excluding opioids, and unspecified drugs), urbanization level, and state. The estimated costs of drug poisoning deaths among adolescents and young adults totaled approximately $35 billion in 2015. CONCLUSIONS: Trends in drug poisoning deaths and estimated costs inform state-specific prevention and intervention efforts.

Incidence and costs of injuries to children and adults in the United States.

BACKGROUND: Injuries are a leading cause of death and acquired disability, and result in significant medical spending. Prior estimates of injury-related cost have been limited by older data, for certain population, or specific mechanisms. FINDINGS: This study estimated the incidence of hospital-treated nonfatal injuries in the United States (US) in 2013 and the related comprehensive costs. Injury-related emergency department (ED) visits and hospitalizations were identified using 2013 Healthcare Cost and Utilization Project (HCUP) data. Models estimated the costs of medical spending and lost future work due to injuries in 2013 U.S. dollars. A total of 31,038,072 nonfatal injury-related hospitalizations and ED visits were identified, representing 9.8 per 100 people. Hospital-treated nonfatal injuries cost an estimated $1.853 trillion, including $168 billion in medical spending, $223 billion in work losses, and $1.461 trillion in quality of life losses. CONCLUSIONS: Approximately one in 10 individuals in the US is treated in the hospital for injury each year, with high corresponding costs. These data support priority-setting to reduce the injury burden in the US.

Building the Child Safety Collaborative Innovation and Improvement Network: How does it work and what is it achieving?

OBJECTIVE: This study investigated whether the Child Safety Collaborative Innovation and Improvement Network (CS CoIIN) framework could be applied in the field of injury and violence prevention to reduce fatalities, hospitalizations and emergency department visits among 0-19 year olds. SAMPLE: Twenty-one states/jurisdictions were accepted into cohort 1 of the CS CoIIN, and 14 were engaged from March 2016 through April 2017. A quality improvement framework was used to test, implement and spread evidence-based change ideas (strategies and programs) in child passenger safety, falls prevention, interpersonal violence prevention, suicide and self-harm prevention and teen driver safety. PROCEDURES: Outcome and process measure data were analyzed using run chart rules. Descriptive data were analyzed for participation measures and descriptive statistics were produced. Qualitative data were analyzed to identify key themes. RESULTS: Seventy-six percent of CS CoIIN states/jurisdictions were engaged in activities and used data to inform decision making. Within a year, states/jurisdictions were able to test and implement evidence-based change ideas in pilot sites. A small group showed improvement in process measures and were ready to spread change ideas. Improvement in outcome measures was not achieved; however, 25% of states/jurisdictions identified data sources and reported on real-time outcome measures. CONCLUSIONS: Evidence indicates the CS CoIIN framework can be applied to make progress on process measures, but more time is needed to determine if this will result in progress on long-term outcome measures of fatalities, hospitalizations and emergency department visits. Seventeen states/jurisdictions will participate in cohort 2.

Perils of police action: a cautionary tale from US data sets.

OBJECTIVE: To count and characterise injuries resulting from legal intervention by US law enforcement personnel and injury ratios per 10 000 arrests or police stops, thus expanding discussion of excessive force by police beyond fatalities. DESIGN: Ecological. POPULATION: Those injured during US legal police intervention as recorded in 2012 Vital Statistics mortality census, 2012 Healthcare Cost and Utilization Project nationwide inpatient and emergency department samples, and two 2015 newspaper censuses of deaths. EXPOSURE: 2012 and 2014 arrests from Federal Bureau of Investigation data adjusted for non-reporting jurisdictions; street stops and traffic stops that involved vehicle or occupant searches, without arrest, from the 2011 Police Public Contact Survey (PPCS), with the percentage breakdown by race computed from pooled 2005, 2008 and 2011 PPCS surveys due to small case counts. RESULTS: US police killed or injured an estimated 55 400 people in 2012 (95% CI 47 050 to 63 740 for cases coded as police involved). Blacks, Native Americans and Hispanics had higher stop/arrest rates per 10 000 population than white non-Hispanics and Asians. On average, an estimated 1 in 291 stops/arrests resulted in hospital-treated injury or death of a suspect or bystander. Ratios of admitted and fatal injury due to legal police intervention per 10 000 stops/arrests did not differ significantly between racial/ethnic groups. Ratios rose with age, and were higher for men than women. CONCLUSIONS: Healthcare administrative data sets can inform public debate about injuries resulting from legal police intervention. Excess per capita death rates among blacks and youth at police hands are reflections of excess exposure. International Classification of Diseases legal intervention coding needs revision.

The Evaluation of a Workplace Program to Prevent Substance Abuse: Challenges and Findings.

Workplace consequences of alcohol and drug abuse include poor performance, fighting, insubordination, and occupational injuries. To address the need for workplace substance abuse prevention, the PREVENT program, originally designed for the United States Navy, was adapted to the railroad workforce. This study evaluates the impact of the PREVENT program on alcohol use and smoking among young adults ages 18-29 in the railroad industry. We discuss challenges to study protocol faced by this evaluation in the reality of the workplace. PREVENT is a 2-day health promotion program that includes substance abuse and smoking modules. Using a prospective controlled before-after study design, we compare self-reported alcohol use and smoking pre- versus post-intervention among PREVENT participants versus a comparison group of workers. Comparison and case group non-equivalency at baseline is controlled for using a propensity score. The study sample suffered high losses to follow-up. In the analysis, we included those lost to follow up and applied an intent-to-treat approach that assumed, conservatively, that substance use by non-respondents was identical pre and post. In regression analysis PREVENT participants showed significant declines in drinking levels post-intervention compared to comparison workers, controlling for baseline and demographic factors. Relative to pre-intervention levels PREVENT participants consumed 56 % fewer drinks (relative rate = 0.44, 95 % CI 0.23-0.85) and consumed alcohol on 32 % fewer days (relative rate = 0.68, 95 % CI 0.50-0.93) compared to comparison workers. Changes in smoking behaviors were not significant. We conclude that PREVENT is a promising program for reducing alcohol abuse.

School and work status, drug-free workplace protections, and prescription drug misuse among Americans ages 15-25.

OBJECTIVE: We assessed the prevalence and characteristics of prescription drug misuse among youth ages 15-25 to examine differences by student and employment status, and associations with workplace antidrug policies and programs. METHOD: Multivariate logistic regressions analyzed associations in weighted data on the 20,457 young adults in the combined 2004-2008 National Surveys on Drug Use and Health. Demographic controls included sex, race, community size, and age group. RESULTS: After we accounted for demographic controls, at ages 15-25, students were less likely than nonstudents to misuse prescription drugs. Segmenting student from nonstudent groups, working consistently was associated with a further reduction in misuse for those ages 18-25. When we controlled for demographics and substance use history, both Employee Assistance Program (EAP) services and awareness that one's employer had a drug-free workplace policy were associated with significantly lower misuse of prescription drugs (OR = 0.85 for each program, 95% CI [0.73, 1.00] and [0.72, 1.00]). Associations of workplace antidrug policies and programs with marijuana use and with Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, criteria for alcohol abuse and dependence contrasted sharply with these patterns. All four aspects were significantly associated with lower marijuana use. None was associated with problem drinking. CONCLUSIONS: Protective effects of drug-free workplace policy and EAPs persist after other substance use was controlled for. Comparing the effects of workplace programs on illicit drug use and problem drinking versus prescription misuse suggests that those protective associations do not result from selection bias. Thus, drug-free workplace policies and EAPs appear to help protect younger workers against prescription misuse. If workplace substance use disorder programs focused prevention messages and interventions on prescription drug misuse, their impact on misuse might increase.

A fresh look at the costs of non-fatal consumer product injuries.

BACKGROUND: Products under the purview of the Consumer Product Safety Commission are involved in a large share of injuries and injury costs in the USA. METHODS: This study analyses incidence data from the National Electronic Injury Surveillance System (NEISS) and cost data based on the Injury Cost Model, integrated with the NEISS. We examined the magnitude of non-fatal consumer product related injury, the distribution of products involved in these injuries and the cost of these injuries. We compared these findings with an earlier identical study from 2000. RESULTS: In 2008-2010, 43.8% of the annual 30.4 million non-fatal injuries treated in hospital emergency departments involved consumer products. Of these consumer product related injuries, in 2009-2010, just three product groups accounted for 77% of the $909 billion annual cost: sports and recreation; home structures and construction materials; and home furnishings and fixtures. Sports and recreation was a leading cause of injury costs among 5-24-year-olds, particularly football, basketball, bicycling, baseball/softball and soccer. Since 1996, football surpassed basketball in becoming the number one cause of injury costs for children aged 10-19 years and the fifth ranked cause of product related injury costs overall. Among those over age 30 years, stairs and floors were a leading cause of consumer product related injury costs, in particular among those over age 70 years where they were responsible for over one-fifth of costs. CONCLUSIONS: The findings of this study highlight priority areas for intervention and generate questions for future research.

Hospital-admitted injury attributable to alcohol.

BACKGROUND: Primary data collection has established that alcohol causes injuries treated in the emergency department. No comparable data exist for injuries admitted to hospital. Data on the injury risks of heavy drinkers relative to other drinkers also are sparse. METHODS: We estimated (i) whether regular heavy drinkers have higher hospitalized injury risks than other people when alcohol-negative and (ii) how much hospitalized injury risk of regular heavy drinkers and other drinkers rises when alcohol-positive. We combined national alcohol consumption data with alcohol metabolism rates to estimate hours spent alcohol-positive versus alcohol-negative during a year for heavy drinkers versus other people. A literature review provided hospitalized nonfatal injury rates for these groups by alcohol involvement. RESULTS: Relative to other alcohol-negative people aged 18 and older, heavy drinkers have an estimated relative risk of hospitalized injury of 1.4 when alcohol-negative and 4.3 when alcohol-positive. Others have an estimated relative risk of 1.0 when alcohol-negative and 6.8 when alcohol-positive. Thus, alcohol greatly raises injury risk. The excess risk patterns persist for a wide range of sensitivity analysis values. Of hospitalized injuries, an estimated 21% are alcohol-attributable including 36% of assaults. CONCLUSIONS: Drinking alcohol is a major cause of hospitalized injury. Heavy drinkers lead risky lifestyles. They tolerate alcohol better than most drinkers, but their injury risks still triple when they drink. Our approach to attribution is a valuable complement to more costly, more precise approaches that rely heavily on primary data collection. It works for any severity of injury. Applying it only requires an existing alcohol consumption survey plus data on alcohol involvement in targeted injuries.

Quality-adjusted life years lost to road crash injury: updating the injury impairment index.

The Injury Impairment Index (III) has long been used internationally to estimate the quality-adjusted life year (QALY) losses associated with crash injuries. The III has major limitations, notably its lack of detailed validation, but it is widely used and estimates from it are regularly published. It is based on physician estimates of typical impairment on 6 dimensions of functioning (cognitive, mobility, bending/grasping/lifting, sensory, pain and cosmetic), supplemented with data on work-related disability. This paper reports on a literature synthesis used to update the III scoring algorithm that converts impairment levels by dimension into a combined QALY loss score. An extensive international literature search identified 13 health status scales, some of them with multiple scorings. From the scorings, we extracted utility scores for each level of each dimension of the III. We also searched for direct utility estimates for III dimension endpoints (e.g., blindness, deafness). Median and inter-quartile ranges were computed by scale point to represent the uncertainty range of preference weights within each III dimension and level. Average QALY losses per injury by MAIS were computed using the updated preference weight ranges applied to 2000-2006 U.S. crash data. The updated QALY loss estimates are lower than those computed with the QALY weights developed in 1990. This paper's tables of estimated average QALY losses by MAIS, injury type, and body region injured can be applied to future and existing injury data in order to estimate the impact of injury on quality of life and measure health status.

Random alcohol testing reduced alcohol-involved fatal crashes of drivers of large trucks.

OBJECTIVE: This study examined the impact of random alcohol testing, implemented on August 1, 1994, on the likelihood that the driver of a large truck involved in a fatal motor vehicle crash was alcohol-involved. METHOD: Among fatal crashes, the proportion of alcohol-positive large truck drivers (intervention group) was compared with the proportion of alcohol-positive light passenger vehicle drivers (control group). Annual Fatality Analysis Reporting System (FARS) data (1988-2003) were compiled for each of the 50 states and Washington, D.C., for the control and intervention groups. Using these pooled cross-sectional data, logistic regression modeled the likelihood that a driver was alcohol-positive (blood alcohol concentration > 0) before compared with after random alcohol testing. We attributed the difference-in-difference (the difference in likelihoods of being alcohol positive pretesting versus post-testing in large truck versus passenger vehicle drivers) to the impact of random testing. RESULTS: Drivers of large trucks were 18.6% less likely to be alcohol-involved after random testing was implemented than before random testing (odds ratio [OR] = 0.814, 95% confidence interval [CI]: 0.713-0.930). The control group of passenger car drivers was 4.7% less likely to be alcohol-involved after random testing was implemented (OR = 0.953, 95% CI: 0.924-0.983). The net reduction in the odds of alcohol involvement for drivers of large trucks was 14.5% (OR = 0.855, 95% CI: 0.748-0.976). CONCLUSIONS: Controlling for the general declining trend in alcohol-involved drivers in fatal crashes, random alcohol testing was correlated with a 14.5% reduction in alcohol involvement among large truck drivers.

Substance abuse and the uninsured worker in the United States.

Although millions of US workers lack health insurance, the relationship of insurance coverage with substance abuse and access to workplace treatment services remains unexplored. Our analysis shows uninsured workers have higher rates of heavy drinking and illicit drug use than insured workers. Young and part-time workers are, moreover, less likely to have insurance coverage than workers with lower substance abuse risks. Compared to the insured, uninsured workers have less access to employee assistance programs (EAPs) and less drug and alcohol testing by employers. The effectiveness of workplace substance abuse programs and policies designed for insured populations is untested among uninsured workers. Issues include EAP effectiveness with referrals to public treatment and the return on investment for adding coverage of substance abuse treatment. Workers in countries with universal health insurance but inadequate treatment capacity may face similar problems to uninsured workers in the US.

Issues in using state hospital discharge data in injury control research and surveillance.

This study evaluates the quality of injury-related coding in state hospital data and their usefulness to injury researchers. Using 1997 hospital discharge records from 19 states, hospitalized non-fatal injury-related cases were identified by first selecting all cases that met broad criteria for injury, and then dropping cases that appeared incorrectly coded as injuries and cases related to medical care. Based on our criteria, 1,129,980 non-fatal hospitalized cases were identified as probable acute injuries. Three-quarters were coded with a traditional injury diagnosis in the primary diagnosis field, and 90% had a traditional injury diagnosis somewhere in the first six diagnosis fields. Of cases with an injury diagnosis code in the first three diagnosis fields, 88.1% were E coded. E coding completeness varied by state, with some states reporting high rates of E coding by using non-specific E codes. Other challenges included E-coded cases where no injury diagnosis was reported and apparent miscoding of the E code. We conclude that it is possible to combine multiple states' data if researchers are aware of the challenges they may encounter. In order to capture all injury-related cases, it is important to scan secondary diagnosis fields.

Effectiveness and benefit-cost of peer-based workplace substance abuse prevention coupled with random testing.

Few studies have evaluated the impact of workplace substance abuse prevention programs on occupational injury, despite this being a justification for these programs. This paper estimates the effectiveness and benefit-cost ratio of a peer-based substance abuse prevention program at a U.S. transportation company, implemented in phases from 1988 to 1990. The program focuses on changing workplace attitudes toward on-the-job substance use in addition to training workers to recognize and intervene with coworkers who have a problem. The program was strengthened by federally mandated random drug and alcohol testing (implemented, respectively, in 1990 and 1994). With time-series analysis, we analyzed the association of monthly injury rates and costs with phased program implementation, controlling for industry injury trend. The combination of the peer-based program and testing was associated with an approximate one-third reduction in injury rate, avoiding an estimated $48 million in employer costs in 1999. That year, the peer-based program cost the company $35 and testing cost another $35 per employee. The program avoided an estimated $1850 in employer injury costs per employee in 1999, corresponding to a benefit-cost ratio of 26:1. The findings suggest that peer-based programs buttressed by random testing can be cost-effective in the workplace.

Societal costs of underage drinking.

OBJECTIVE: Despite minimum-purchase-age laws, young people regularly drink alcohol. This study estimated the magnitude and costs of problems resulting from underage drinking by category-traffic crashes, violence, property crime, suicide, burns, drownings, fetal alcohol syndrome, high-risk sex, poisonings, psychoses, and dependency treatment-and compared those costs with associated alcohol sales. Previous studies did not break out costs of alcohol problems by age. METHOD: For each category of alcohol-related problems, we estimated fatal and nonfatal cases attributable to underage alcohol use. We multiplied alcohol-attributable cases by estimated costs per case to obtain total costs for each problem. RESULTS: Underage drinking accounted for at least 16% of alcohol sales in 2001. It led to 3,170 deaths and 2.6 million other harmful events. The estimated $61.9 billion bill (relative SE = 18.5%) included $5.4 billion in medical costs, $14.9 billion in work loss and other resource costs, and $41.6 billion in lost quality of life. Quality-of-life costs, which accounted for 67% of total costs, required challenging indirect measurement. Alcohol-attributable violence and traffic crashes dominated the costs. Leaving aside quality of life, the societal harm of $1 per drink consumed by an underage drinker exceeded the average purchase price of $0.90 or the associated $0.10 in tax revenues. CONCLUSIONS: Recent attention has focused on problems resulting from youth use of illicit drugs and tobacco. In light of the associated substantial injuries, deaths, and high costs to society, youth drinking behaviors merit the same kind of serious attention.

Impact of a workplace peer-focused substance abuse prevention and early intervention program.

BACKGROUND: PeerCare is a workplace peer intervention program that focuses on changing workplace attitudes toward on-the-job substance use and trains workers to recognize, intervene with, and refer coworkers who have a problem. METHODS: Monthly injuries at the study company (January 1983 through June 1996) were compared to counts at four other companies in the same industry. Using these panel data, fixed-effects negative binomial regression measured the association of the percentage of the workforce covered by PeerCare with the workplace injury rate. RESULTS: For every 1% increase in the workforce covered with PeerCare, the risk of injury declined by 0.9984 (95% confidence interval, 0.9975-0.9994). These findings suggest that, by June 1996, when 86% of the workforce was covered under PeerCare, the program had reduced injury rates by an average 14% per month. CONCLUSIONS: The findings support the implementation of peer intervention programs as a means to reduce workplace injuries.

Alcohol involvement in burn, submersion, spinal cord, and brain injuries.

BACKGROUND: Alcohol is involved in many injuries, but estimates of this involvement vary considerably. Most information pertains to deaths although most injuries are nonfatal. MATERIAL/METHODS: The portion of fatal and nonfatal injuries involving alcohol was determined from a comprehensive Oklahoma surveillance system that tracks persons killed or hospitalized due to burns, submersions, spinal cord injuries (SCIs), and traumatic brain injuries (TBIs). Logistic regression was used to determine factors that explain the percentage of alcohol involvement in fatal versus nonfatal cases. RESULTS: The victim was alcohol involved in 17% of fire burns, 4% of scald burns, 24% of submersions, 34% of SCIs, and 41% of TBIs where involvement was known. Large differences existed in total alcohol involvement between age and gender groups and between fatal and nonfatal cases of fire burns (31% vs.11%) and submersions (33% vs. 6%). Large differences also existed in victim alcohol involvement between fatal and nonfatal cases of intentional SCIs (0% vs. 48%) and TBIs (38% vs. 70%). Those who imbibed during the day were not at excess risk of scald injury, but they were twice as likely to suffer a serious fire burn, 3 times as likely to suffer a spinal cord injury, 3.5 times as likely to suffer a submersion injury, and 2 to 4 times as likely to suffer a TBI. These excess risks persisted for all age groups between 15 and 64, with the excess risk especially high for underage drinkers aged 15 to 20. In contrast, people aged 65 and older did not appear to be at excess risk on days that they imbibed. CONCLUSIONS: A large percentage of fatal and nonfatal injuries as classified by diagnosis group involve alcohol. People who had been drinking were substantially more likely to suffer serious nonfatal and fatal injuries other than scald burns.

Worker substance use, workplace problems and the risk of occupational injury: a matched case-control study.

OBJECTIVE: This study examines the tendency toward problem behavior as an explanation for the relationship between problem substance use and occupational injury. METHOD: The authors used a matched case-control study nested in a cohort of 26,413 workers, in which cases (n = 3,994) were workers suffering an occupational injury. Five controls per case (n = 19,970) were selected from the cohort of workers active on the day of the injury and matched on job type. Conditional logistic regression modeled the association of problem substance use with occupational injury, controlling for problem behaviors and worker characteristics. Problem substance use was indicated indirectly if any of the following were alcohol/drug-involved during the comparison period: Employee Assistance Program visit, excused absence or disciplinary action. Discipline records identified minor (absenteeism) and serious (dishonesty, theft, assault, harassment, disrespect) problem behaviors during the comparison period. RESULTS: The odds of injury among workers with an indicator of problem substance use was 1.35 (p = .015) times greater than the odds among workers without an indicator, controlling for job type and demographics as well as adjusting for exposure. This ratio declined to 1.21 (p = .138) when problem behaviors were also controlled for. Minor and serious problem behaviors were significantly associated with occupational injury (odds ratio [OR] = 1.73, p < .001, and OR = 2.19, p < .001, respectively), controlling for demographics and substance use. CONCLUSIONS: The relationship of problem substance use with occupational injury was weak when problem behaviors were controlled for, suggesting that this relationship, observed in previous studies, may be explained by a workers tendency toward problem behaviors. Workplace injury prevention programs should address the expression of problem behaviors as a complement to drug and alcohol deterrent programs.

Blood alcohol content (BAC)-negative victims in alcohol-involved injury incidents.

AIMS: To understand better how often BAC-negative victims suffer fatal and non-fatal alcohol-involved injuries. DESIGN: We analyzed 1988-1993 data from Oklahoma surveillance systems that track all people killed or hospitalized due to burns, submersions and spinal cord injuries (SCIs) and investigate alcohol use by victims and any others who contributed to their injuries. MEASUREMENTS: Percentage of victims BAC-positive and percentage of victims BAC-negative in alcohol-involved incidents. FINDINGS: Of 5107 cases studied, alcohol involvement was known for 4773 (93%), 1882 fire burns (93%), 1560 scald and other burns (97%), 698 submersions (92%) and 967 spinal cord injuries (89%). By type of injuries, BAC-negative victims were 4%, 13%, 6% and 8% of alcohol-involved cases, respectively. CONCLUSION: A sizeable number of BAC-negative victims suffer alcohol-involved injuries. Although alcohol is not the cause of some of these injuries, alcohol policy changes probably could avert others.

Evaluation of the Utah student injury reporting system.

The Utah Student Injury Reporting System (SIRS), implemented in 1984 to monitor injuries to students in grades K-12 in Utah schools, has served as a model for surveillance systems created by other states and some European countries. This paper evaluates the Utah experience in developing and administering the SIRS. The evaluation identifies usefulness of the system, discusses the sensitivity of the system in detecting school injuries, estimates the system's costs, and provides suggestions to other states and districts interested in building a cost-effective and efficient surveillance instrument.