Vital Signs

Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017

Alana M. Vivolo-Kantor, PhD; Puja Seth, PhD; R. Matthew Gladden, PhD; Christine L. Mattson, PhD; Grant T. Baldwin, PhD; Aaron Kite-Powell, MS; Michael A. Coletta, MPH

Disclosures

Morbidity and Mortality Weekly Report. 2018;67(9):279-285.

Results

Among approximately 91 million ED visits captured in NSSP during July 2016–September 2017, a total of 142,557 (15.7 per 10,000 visits) were suspected opioid overdoses. Opioid overdose ED visits in NSSP increased 29.7% from third quarter 2016 (July–September) to third quarter 2017; all five U.S. regions experienced prevalence increases (Figure 1), with the largest in the Midwest (69.7%), followed by the West (40.3%), Northeast (21.3%), Southwest (20.2%), and Southeast (14.0%) (Table 1). Substantial increases occurred among all demographic groups during the same period, including males (30.2%), females (24.0%), and persons aged 25–34 years (30.7%), 35–54 years (36.3%), and ≥55 years (31.9%). Most regions, age groups, and both sexes also experienced significant positive linear trends across all five quarters.

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Figure 1.

Quarterly rate* of suspected opioid overdose, by U.S. region^† — 52 jurisdictions in 45 states, National Syndromic Surveillance Program, July 2016–September 2017^§
Abbreviation: ED = emergency department.
*Per 10,000 ED visits.
^† Northeast Region: HHS Region 1 (Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont), Region 2 (New Jersey and New York), and Region 3 (District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia); Southeast Region: HHS Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee); Southwest Region: HHS Region 6 (Arkansas, Louisiana, New Mexico, and Texas); Midwest Region: HHS Region 5 (Indiana, Illinois, Michigan, Minnesota, Ohio, and Wisconsin) and Region 7 (Iowa, Kansas, Missouri, and Nebraska); West Region: HHS Region 8 (Colorado, Montana, North Dakota, and Utah), Region 9 (Arizona, California, and Nevada) and Region 10 (Alaska, Idaho, Oregon, and Washington).
^§Data current as of December 13, 2017.

Among approximately 45 million ED visits reported by the 16 ESOOS states from July 2016 through September 2017, a total of 119,198 (26.7 per 10,000 visits) were suspected opioid overdoses. Opioid overdose ED visits increased 34.5% from third quarter 2016 to third quarter 2017 (Table 2). Ten states experienced significant increases in prevalence during this period, although substantial variation was observed among states in the same region. For example, in the Northeast, significant increases occurred in Delaware (105.0%), Pennsylvania (80.6%), and Maine (34.0%), but other states, including Massachusetts, New Hampshire, and Rhode Island experienced nonsignificant (<10%) decreases. In the Southeast, a significant increase (31.1%) occurred in North Carolina, a significant decrease (15.0%) occurred in Kentucky, and a small, nonsignificant decrease (5.3%) was observed in West Virginia. In the West, a significant increase (17.9%) occurred in Nevada. All states in the Midwest reported significant increases, including Wisconsin (108.6%), Illinois (65.5%), Indiana (35.1%), Ohio (27.7%), and Missouri (21.4%).

All urbanization levels experienced large and significant increases in ED opioid overdose visits from third quarter 2016 to third quarter 2017, including large central metropolitan (54.1%), medium metropolitan (42.6%), small metropolitan (36.9%), micropolitan (23.6%), large fringe metropolitan (21.1%), and noncore (20.6%) areas. Large central metropolitan areas experienced significant linear increases (Figure 2).

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Figure 2.

Quarterly rate* of suspected opioid overdose, by level of county urbanization^†,§ — 16 states,^¶ Enhanced State Opioid Overdose Surveillance program, July 2016–September 2017**
Abbreviation: ED = emergency department.
*Per 10,000 ED visits.
^†The six classification levels for counties were 1) large central metro: part of a metropolitan statistical area with ≥1 million population and covers a principal city; 2) large fringe metro: part of a metropolitan statistical area with ≥1 million population but does not cover a principal city; 3) medium metro: part of a metropolitan statistical area with ≥250,000 but <1 million population; 4) small metro: part of a metropolitan statistical area with <250,000 population; 5) micropolitan (nonmetro): part of a micropolitan statistical area (has an urban cluster of ≥10,000 but <50,000 population); and 6) noncore (nonmetro): not part of a metropolitan or micropolitan statistical area.
^§The average linear quarterly percentage change (QPC) was significant for large central metro (average QPC = 11.7, 95% confidence interval [CI] = 10.7 to 12.7, p<.001). QPCs for large fringe metro (average QPC = 5.1, 95% CI = −0.3 to 10.7); medium metro (average QPC = 11.4, 95% CI = −1.3 to 25.8); small metro (average QPC = 9.3, 95% CI = −0.1 to 19.5); micropolitan (average QPC = 6.4, 95% CI = −3.1 to 16.9); and noncore (average QPC = 6.4, 95% CI = −2.8 to 16.5) were not significant.
^¶Delaware, Illinois, Indiana, Kentucky, Maine, Massachusetts, Missouri, New Hampshire, New Mexico, Nevada, North Carolina, Ohio, Pennsylvania, Rhode Island, West Virginia, and Wisconsin.
**Data current as of January 8, 2018.

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Table 1. Change in quarterly rates* ^,† for suspected opioid overdose, by U.S. region, ^§ sex, and age group — 52 jurisdictions in 45 states, National Syndromic Surveillance Program, July 2016–September 2017 ^¶
Characteristic	% Change					Average quarterly % change (95% CI)
Characteristic	Q3 2016–Q4 2016	Q4 2016–Q1 2017	Q1 2017–Q2 2017	Q2 2017–Q3 2017	Q3 2016–Q3 2017	Average quarterly % change (95% CI)
Overall	3.89	2.43	13.15	7.68	29.65**	5.6 (1.8 to 9.5)**
U.S. Region
Northeast	5.01	2.17	14.67	-1.40	21.30**	4.7 (-2.4 to 12.2)
Southeast	-9.08	6.32	14.29	3.21	14.03**	5.5 (0.6 to 10.6)**
Southwest	4.85	13.35	4.12	-2.87	20.19**	11.4 (1.1 to 22.9)**
Midwest	20.84	-0.48	3.19	36.73	69.67**	9.2 (4.1 to 14.6)**
West	13.11	1.50	21.28	0.75	40.28**	6.9 (3.4 to 10.5)**
Sex
Male	6.21	2.62	10.66	7.96	30.21**	6.8 (4.4 to 9.2)**
Female	1.93	2.01	11.9	6.57	23.99**	5.8 (2.3 to 9.4)**
Age group (yrs)
15–24	-1.11	-2.69	9.46	1.87	7.31**	2.1 (-1.6 to 5.9)
25–34	5.63	3.65	10.23	8.28	30.67**	6.9 (4.7 to 9.1)**
35–54	6.17	3.72	11.81	10.70	36.28**	8.0 (5.0 to 11.0)**
≥55	9.33	1.03	12.50	6.17	31.93**	7.1 (4.3 to 9.9)**

Abbreviation: CI = confidence interval.
*Per 10,000 emergency department visits.
^†Using the indicator counts and denominators, a rate of ED visits for each quarter was created using the count of suspected opioid overdose ED visits divided by the total number of ED visits for each quarter. Percentage change in rates subtracted the prior quarter from the current quarter then divided by the prior quarter multiplied by 100%.
^§The Northeast region includes HHS Regions 1 (Maine, Massachusetts, New Hampshire, Rhode Island and Vermont), 2 (New Jersey and New York), and 3 (District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia); the Southeast region includes HHS Region 4 (Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee); the Southwest region includes HHS Region 6 (Arkansas, Louisiana, New Mexico, and Texas); the Midwest region includes HHS Regions 5 (Indiana, Illinois, Michigan, Minnesota, Ohio, and Wisconsin) and 7 (Iowa, Kansas, Missouri, and Nebraska); and the West region includes HHS Regions 8 (Colorado, Montana, North Dakota, and Utah), 9 (Arizona, California, and Nevada), and 10 (Alaska, Idaho, Oregon, and Washington).
^¶Data current as of December 13, 2017.
**Statistically significant (p<0.05).

Table 2. Change in quarterly and annual rates* ^,† for suspected opioid overdose, by state — 16 states, ^§ Enhanced State Opioid Overdose Surveillance program, July 2016–September 2017 ^¶
Region/State	% Change					Average quarterly % change (95% CI)
Region/State	Q3 2016–Q4 2016	Q4 2016–Q1 2017	Q1 2017–Q2 2017	Q2 2017–Q3 2017	Q3 2016–Q3 2017	Average quarterly % change (95% CI)
Overall	8.91	9.09	13.06	0.12	34.49**	8.4 (4.8 to 12.0)**
Northeast
Delaware	8.77	10.95	43.00	18.76	104.95**	20.9 (10.5 to 32.2)**
Maine	2.57	-8.13	29.45	9.81	33.95**	7.9 (-2.4 to 19.3)
Massachusetts	-8.48	-11.48	3.11	18.97	-0.62	-1.0 (-11.4 to 10.6)
New Hampshire	-4.33	-17.91	29.67	-8.76	-7.09	-0.8 (-12 to 11.7)
Pennsylvania	29.79	17.51	25.89	-5.94	80.59**	17.0 (5.6 to 29.7)**
Rhode Island	2.80	4.54	5.44	-11.91	-0.18	0.9 (-5.0 to 7.2)
Southeast
Kentucky	-26.94	40.45	3.52	-20.02	-15.04**	0.5 (-16.3 to 20.6)
North Carolina	-0.43	3.28	15.20	10.63	31.05**	7.4 (1.8 to 13.4)**
West Virginia	43.31	-16.64	4.02	-23.77	-5.28	-2.5 (-19.3 to 17.9)
Southwest
New Mexico	26.11	1.51	-5.01	-10.93	8.30	1.2 (-10.4 to 14.4)
Midwest
Illinois	23.13	1.48	2.82	28.80	65.47**	11.1 (2.7 to 20.1)**
Indiana	-10.15	11.20	10.45	22.43	35.11**	8.4 (-1.9 to 19.8)
Missouri	4.77	-1.77	9.54	7.67	21.38**	4.7 (1.2 to 8.3)**
Ohio	22.74	25.67	21.67	-31.94	27.74**	9.6 (-12.2 to 36.7)
Wisconsin	17.12	67.28	3.22	3.14	108.58**	22.3 (4.2 to 43.7)**
West
Nevada	13.69	-9.46	11.37	2.82	17.88**	3.4 (-2.3 to 9.5)