Emerging Trends of Self-Harm Using Sodium Nitrite in an Online Suicide Community: Observational Study Using Natural Language Processing Analysis

Background

There is growing concern around the use of sodium nitrite (SN) as an emerging means of suicide, particularly among younger people. Given the limited information on the topic from traditional public health surveillance sources, we studied posts made to an online suicide discussion forum, "Sanctioned Suicide," which is a primary source of information on the use and procurement of SN.

Objective

This study aims to determine the trends in SN purchase and use, as obtained via data mining from subscriber posts on the forum. We also aim to determine the substances and topics commonly co-occurring with SN, as well as the geographical distribution of users and sources of SN.

Methods

We collected all publicly available from the site's inception in March 2018 to October 2022. Using data-driven methods, including natural language processing and machine learning, we analyzed the trends in SN mentions over time, including the locations of SN consumers and the sources from which SN is procured. We developed a transformer-based source and location classifier to determine the geographical distribution of the sources of SN.

Results

Posts pertaining to SN show a rise in popularity, and there were statistically significant correlations between real-life use of SN and suicidal intent when compared to data from the Centers for Disease Control and Prevention (CDC) Wide-Ranging Online Data for Epidemiologic Research (⍴=0.727; P<.001) and the National Poison Data System (⍴=0.866; P=.001). We observed frequent co-mentions of antiemetics, benzodiazepines, and acid regulators with SN. Our proposed machine learning-based source and location classifier can detect potential sources of SN with an accuracy of 72.92% and showed consumption in the United States and elsewhere.

Conclusions

Vital information about SN and other emerging mechanisms of suicide can be obtained from online forums.

Research, practice, and data informed investigations of child and youth suicide: A science to service and service to science approach

BACKGROUND

Suicide rates for children and adolescents have been increasing over the past 2 decades. In April 2023, the National Institute of Mental Health (NIMH) convened a two-day workshop to address child and youth suicide.

PURPOSE

The workshop focus was to discuss the state of the science and stimulate a collaborative response between researchers, death investigators, and data collection teams to build a science to service and service to science approach toward understanding - and ultimately preventing - this growing problem of child and youth suicide.

HIGHLIGHTS

Topics that meeting participants highlighted as worthy of further consideration for research and practice were: increasing awareness among death investigators, medical examiners, and coroners that child suicide deaths under age 10 years do occur and should be investigated and documented accordingly; emphasizing the value of science based protocols for child and youth death investigations to enhance consistency of approaches; and articulating needs for postvention services to suicide loss survivors.

OUTCOMES

The importance of collecting an accurate and complete cause and manner of death (i.e., unintentional, suicide, homicide, undetermined) among all child decedents, and demographic information such as race, ethnicity, and sexual/gender minority status was underscored as critical for enhanced surveillance. For prevention efforts, approaches to assessing and understanding suicidal thoughts and behaviors among diverse groups of children, and the variability in proximal and distal risk factors are needed to inform opportunities for preventive interventions for diverse communities. The need for consistent measures and processes to improve death investigations, fatality review committees, and coordination between data collection systems and agencies was also raised.

PRACTICAL APPLICATIONS

Collaborations among researchers, death investigators, and data collection teams can help to fully describe the child and youth suicide crisis and provide actionable information for new research, and prevention and response efforts.

Suicidal Thoughts and Behaviors Among High School Students - Youth Risk Behavior Survey, United States, 2021

Suicide is the third leading cause of death among high school-aged youths aged 14-18 years. The 2021 suicide rate for this age group was 9.0 per 100,000 population. Updating a previous analysis of the Youth Risk Behavior Survey during 2009-2019, this report uses 2019 and 2021 data to examine high school students' reports of suicidal thoughts and behaviors. Prevalence estimates are reported by grade, race and ethnicity, sexual identity, and sex of sexual contacts. Unadjusted logistic regression models were used to calculate prevalence differences comparing 2019 to 2021 and prevalence ratios comparing suicidal behavior between subgroups across demographic characteristics to a referent group. From 2019 to 2021, female students had an increased prevalence of seriously considered attempting suicide (from 24.1% to 30%), an increase in making a suicide plan (from 19.9% to 23.6%), and an increase in suicide attempts (from 11.0% to 13.3%). In addition, from 2019 to 2021, Black or African American (Black), Hispanic or Latino (Hispanic), and White female students had an increased prevalence of seriously considered attempting suicide. In 2021, Black female students had an increased prevalence of suicide attempts and Hispanic female students had an increased prevalence of suicide attempts that required medical treatment compared with White female students. Prevalence of suicidal thoughts and behaviors remained stable overall for male students from 2019 to 2021. A comprehensive approach to suicide prevention with a focus on health equity is needed to address these disparities and reduce prevalence of suicidal thoughts and behaviors for all youths. School and community-based strategies include creating safe and supportive environments, promoting connectedness, teaching coping and problem solving, and gatekeeper training.

Drugs and Drug Classes Involved in Overdose Deaths Among Females, United States: 1999-2017

Background: Drug overdose deaths among U.S. women have risen steadily from 1999 to 2017, especially among certain ages. Various studies report involvement of drugs and drug classes in overdose deaths. Less is known, however, regarding the combinations that are most often indicated on death certificates, particularly among females. Analyzing mutually, exclusive drug/drug class combinations listed on death certificates of females are the objective of this study. Materials and Methods: Mortality data for U.S. female residents were obtained from the 1999 to 2017 National Vital Statistics System (n = 260,782). Analyses included deaths with an underlying cause of death based on International Classification of Diseases, 10th Revision (ICD-10) codes for drug overdoses. The drug/drug class involved included individual 4-digit ICD-10 codes in the range T36.0-T50.9, including poisoning deaths due to all drugs, excluding alcohol. Years from 1999 to 2017 were grouped in six 3-year categories with the most recent year (2017) left separate for analysis. All drug overdose deaths were analyzed in mutually exclusive categories. Results: From 1999 to 2017, the top-listed drug/drug class overall and by year grouping was solely "other and unspecified drugs, medicaments and biological substances"; however, that listing dropped from 25.8% from the 1999 to 2001 period to 14.1% in 2017. Overall, the next most frequent single drug/drug class mentions were "natural and semisynthetic opioids" (20,951; 8.0%) and "cocaine" (10,882; 4.2%). Two of the top five drug/drug class combinations included benzodiazepines ("natural and semisynthetic opioids"/"benzodiazepines" and "methadone"/"benzodiazepines"). Conclusions: Analyzing trends in drugs and drug classes involved in female drug overdose deaths is a critical foundation for developing gender-responsive public health interventions. Reducing high-risk drug use by improving prescribing practices, preventing drug use initiation, and addressing use of multiple drugs can help prevent overdose deaths.

Changes in Suicide Rates - United States, 2019 and 2020

Suicide was among the 10 leading causes of death in the United States in 2020 among persons aged 10-64 years, and the second leading cause of death among children and adolescents aged 10-14 and adults aged 25-34 years (1). During 1999-2020, nearly 840,000 lives were lost to suicide in the United States. During that period, the overall suicide rate peaked in 2018 and declined in 2019 and 2020 (1). Despite the recent decline in the suicide rate, factors such as social isolation, economic decline, family stressors, new or worsening mental health symptoms, and disruptions to work and school associated with the COVID-19 pandemic have raised concerns about suicide risk in the United States. During 2020, a total of 12.2 million U.S. adults reported serious thoughts of suicide and 1.2 million attempted suicide (2). To understand how changes in suicide death rates might have varied among subpopulations, CDC analyzed counts and age-adjusted suicide rates during 2019 and 2020 by demographic characteristics, mechanism of injury, county urbanization level, and state. From 2019 to 2020, the suicide rate declined by 3% overall, including 8% among females and 2% among males. Significant declines occurred in seven states but remained stable in the other states and the District of Columbia. Despite two consecutive years of declines, the overall suicide rate remains 30% higher compared with that in 2000 (1). A comprehensive approach to suicide prevention that uses data driven decision-making and implements prevention strategies with the best available evidence, especially among disproportionately affected populations (3), is critical to realizing further declines in suicide and reaching the national goal of reducing the suicide rate by 20% by 2025 (4).

Non-fatal injury data: characteristics to consider for surveillance and research

BACKGROUND

All data systems used for non-fatal injury surveillance and research have strengths and limitations that influence their utility in understanding non-fatal injury burden. The objective of this paper was to compare characteristics of major data systems that capture non-fatal injuries in the USA.

METHODS

By applying specific inclusion criteria (eg, non-fatal and non-occupational) to well-referenced injury data systems, we created a list of commonly used non-fatal injury data systems for this study. Data system characteristics were compiled for 2018: institutional support, years of data available, access, format, sample, sampling method, injury definition/coding, geographical representation, demographic variables, timeliness (lag) and further considerations for analysis.

RESULTS

Eighteen data systems ultimately fit the inclusion criteria. Most data systems were supported by a federal institution, produced national estimates and were available starting in 1999 or earlier. Data source and injury case coding varied between the data systems. Redesigns of sampling frameworks and the use of International Classification of Diseases, 9th Revision, Clinical Modification/International Classification of Diseases, 10th Revision, Clinical Modification coding for some data systems can make longitudinal analyses complicated for injury surveillance and research. Few data systems could produce state-level estimates.

CONCLUSION

Thoughtful consideration of strengths and limitations should be exercised when selecting a data system to answer injury-related research questions. Comparisons between estimates of various data systems should be interpreted with caution, given fundamental system differences in purpose and population capture. This research provides the scientific community with an updated starting point to assist in matching the data system to surveillance and research questions and can improve the efficiency and quality of injury analyses.

Changes in Suicide Rates - United States, 2018-2019

Suicide is the 10th leading cause of death in the United States overall, and the second and fourth leading cause among persons aged 10-34 and 35-44 years, respectively (1). In just over 2 decades (1999-2019), approximately 800,000 deaths were attributed to suicide, with a 33% increase in the suicide rate over the period (1). In 2019, a total of 12 million adults reported serious thoughts of suicide during the past year, 3.5 million planned a suicide, and 1.4 million attempted suicide (2). Suicides and suicide attempts in 2019 led to a lifetime combined medical and work-loss cost (i.e., the costs that accrue from the time of the injury through the course of a person's expected lifetime) of approximately $70 billion (https://wisqars.cdc.gov:8443/costT/). From 2018 to 2019, the overall suicide rate declined for the first time in over a decade (1). To understand how the decline varied among different subpopulations by demographic and other characteristics, CDC analyzed changes in counts and age-adjusted suicide rates from 2018 to 2019 by demographic characteristics, county urbanicity, mechanism of injury, and state. Z-tests and 95% confidence intervals were used to assess statistical significance. Suicide rates declined by 2.1% overall, by 3.2% among females, and by 1.8% among males. Significant declines occurred, overall, in five states. Other significant declines were noted among subgroups defined by race/ethnicity, age, urbanicity, and suicide mechanism. These declines, although encouraging, were not uniform, and several states experienced significant rate increases. A comprehensive approach to prevention that uses data to drive decision-making, implements prevention strategies from CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices with the best available evidence, and targets the multiple risk factors associated with suicide, especially in populations disproportionately affected, is needed to build on initial progress from 2018 to 2019 (3).

Fall-related traumatic brain injury in children ages 0-4 years

INTRODUCTION

Falls are the leading cause of traumatic brain injury (TBI) for children in the 0-4 year age group. There is limited literature pertaining to fall-related TBIs in children age 4 and under and the circumstances surrounding these TBIs. This study provides a national estimate and describes actions and products associated with fall-related TBI in this age group.

METHOD

Data analyzed were from the 2001-2013 National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP), a nationally representative sample of emergency departments (ED). Case narratives were coded for actions associated with the fall, and product codes were abstracted to determine fall location and product type. All estimates were weighted.

RESULTS

An estimated 139,001 children younger than 5 years were treated annually in EDs for nonfatal, unintentional fall-related TBI injuries (total = 1,807,019 during 2001-2013). Overall, child actions (e.g., running) accounted for the greatest proportion of injuries and actions by others (e.g., carrying) was highest for children younger than 1 year. The majority of falls occurred in the home, and involved surfaces, fixtures, furniture, and baby products.

CONCLUSIONS

Fall-related TBI in young children represents a significant public health burden. The majority of children seen for TBI assessment in EDs were released to home. Prevention efforts that target parent supervision practices and the home environment are indicated. Practical applications: Professionals in contact with parents of young children can remind them to establish a safe home and be attentive to the environment when carrying young children to prevent falls.

Societal determinants of violent death: The extent to which social, economic, and structural characteristics explain differences in violence across Australia, Canada, and the United States

In this ecological study, we attempt to quantify the extent to which differences in homicide and suicide death rates between three countries, and among states/provinces within those countries, may be explained by differences in their social, economic, and structural characteristics. We examine the relationship between state/province level measures of societal risk factors and state/province level rates of violent death (homicide and suicide) across Australia, Canada, and the United States. Census and mortality data from each of these three countries were used. Rates of societal level characteristics were assessed and included residential instability, self-employment, income inequality, gender economic inequity, economic stress, alcohol outlet density, and employment opportunities). Residential instability, self-employment, and income inequality were associated with rates of both homicide and suicide and gender economic inequity was associated with rates of suicide only. This study opens lines of inquiry around what contributes to the overall burden of violence-related injuries in societies and provides preliminary findings on potential societal characteristics that are associated with differences in injury and violence rates across populations.

•

This study opens lines of inquiry around what contributes to the overall burden of violence-related injuries in societies.

•

Differences in homicide and suicide death between and within countries may be explained by social, economic, and structural characteristics.

•

Residential instability, self-employment, and income inequality were associated with rates of both homicide and suicide.

•

Gender economic inequity was associated with rates of suicide only.

Opioid-related US hospital discharges by type, 1993-2016

OBJECTIVE

To classify and compare US nationwide opioid-related hospital inpatient discharges over time by discharge type: 1) opioid use disorder (OUD) diagnosis without opioid overdose, detoxification, or rehabilitation services, 2) opioid overdose, 3) OUD diagnosis or opioid overdose with detoxification services, and 4) OUD diagnosis or opioid overdose with rehabilitation services.

METHODS

Survey-weighted national analysis of hospital discharges in the Healthcare Cost and Utilization Project National Inpatient Sample yielded age-adjusted annual rates per 100,000 population. Annual percentage change (APC) in the rate of opioid-related discharges by type during 1993-2016 was assessed.

RESULTS

The annual rate of hospital discharges documenting OUD without opioid overdose, detoxification, or rehabilitation services quadrupled during 1993-2016, and at an increased rate (8% annually) during 2003-2016. The discharge rate for all types of opioid overdose increased an average 5-9% annually during 1993-2010; discharges for non-heroin overdoses declined 2010-2016 (3-12% annually) while heroin overdose discharges increased sharply (23% annually). The rate of discharges including detoxification services among OUD and overdose patients declined (-4% annually) during 2008-2016 and rehabilitation services (e.g., counselling, pharmacotherapy) among those discharges decreased (-2% annually) during 1993-2016.

CONCLUSIONS

Over the past two decades, the rate of both OUD diagnoses and opioid overdoses increased substantially in US hospitals while rates of inpatient detoxification and rehabilitation services identified by diagnosis codes declined. It is critical that inpatients diagnosed with OUD or treated for opioid overdose are linked effectively to substance use disorder treatment at discharge.

The need to improve information on road user type in National Vital Statistics System mortality data

Objectives: Both the National Vital Statistics System (NVSS) and the Fatality Analysis Reporting System (FARS) can be used to examine motor vehicle crash (MVC) deaths. These 2 data systems operate independently, using different methods to collect and code information about the type of vehicle (e.g., car, truck, bus) and road user (e.g., occupant, motorcyclist, pedestrian) involved in an MVC. A substantial proportion of MVC deaths in NVSS are coded as "unspecified" road user, which reduces the utility of the NVSS data for describing burden and identifying prevention measures. This study aimed to describe characteristics of unspecified road user deaths in NVSS to further our understanding of how these groups may be similar to occupant road user deaths. Methods: Using data from 1999 to 2015, we compared NVSS and FARS MVC death counts by road user type, overall and by age group, gender, and year. In addition, we examined factors associated with the categorization of an MVC death as unspecified road user such as state of residence of decedent, type of medical death investigation system, and place of death. Results: The number of MVC occupant deaths in NVSS was smaller than that in FARS in each year and the number of unspecified road user deaths in NVSS was greater than that in FARS. The sum of the number of occupant and unspecified road user deaths in NVSS, however, was approximately equal to the number of FARS occupant deaths. Age group and gender distributions were roughly equivalent for NVSS and FARS occupants and NVSS unspecified road users. Within NVSS, the number of MVC deaths listed as unspecified road user varied across states and over time. Other categories of road users (motorcyclists, pedal cyclists, and pedestrians) were consistent when comparing NVSS and FARS. Conclusions: Our findings suggest that the unspecified road user MVC deaths in NVSS look similar to those of MVC occupants according to selected characteristics. Additional study is needed to identify documentation and reporting challenges in individual states and over time and to identify opportunities for improvement in the coding of road user type in NVSS.

US hospital discharges documenting patient opioid use disorder without opioid overdose or treatment services, 2011-2015

BACKGROUND

Understanding more about circumstances in which patients receive an opioid use disorder (OUD) diagnosis might illuminate opportunities for intervention and ultimately prevent opioid overdoses. This study aimed to describe patient and clinical characteristics of hospital discharges documenting OUD among patients not being treated for opioid overdose, detoxification, or rehabilitation.

METHODS

We assessed patient, payer, and clinical characteristics of nationally-representative 2011-2015 National Inpatient Sample discharges documenting OUD, excluding opioid overdose, detoxification, and rehabilitation. Discharges were clinically classified by Diagnostic Related Group (DRG) for analysis.

RESULTS

Annual discharges grew 38%, from 347,137 (2011) to 478,260 (2015), totaling 2 million discharges during the study period. The annual discharge rate increased among all racial/ethnic groups, but was highest among the non-Hispanic black population until 2015, when non-Hispanic whites had a slightly higher rate (164 versus 162 per 100,000 population). Female patients and Medicaid and Medicare as primary payer accounted for an increasing annual proportion of discharges. Just 14 DRGs accounted for nearly 50% of discharges over the study period. The most prevalent primary treatment received during OUD inpatient stays was for psychoses (DRG 885; 16% of discharges) and drug and alcohol abuse or dependence symptoms (including withdrawal) or (non-opioid) poisoning (DRG 894, 897, 917, 918; 12% of discharges).

CONCLUSIONS

Now nearly half a million yearly US hospital discharges for a range of primary treatment include patients' diagnosis of OUD without opioid overdose, detoxification, or rehabilitation services. Inpatient stays present an important opportunity to link OUD patients to treatment to reduce opioid-related morbidity and mortality.

Ability to monitor driving under the influence of marijuana among non-fatal motor-vehicle crashes: An evaluation of the Colorado electronic accident reporting system

INTRODUCTION

As more states legalize medical/recreational marijuana use, it is important to determine if state motor-vehicle surveillance systems can effectively monitor and track driving under the influence (DUI) of marijuana. This study assessed Colorado's Department of Revenue motor-vehicle crash data system, Electronic Accident Reporting System (EARS), to monitor non-fatal crashes involving driving under the influence (DUI) of marijuana.

METHODS

Centers for Disease Control and Prevention guidelines on surveillance system evaluation were used to assess EARS' usefulness, flexibility, timeliness, simplicity, acceptability, and data quality. We assessed system components, interviewed key stakeholders, and analyzed completeness of Colorado statewide 2014 motor-vehicle crash records.

RESULTS

EARS contains timely and complete data, but does not effectively monitor non-fatal motor-vehicle crashes related to DUI of marijuana. Information on biological sample type collected from drivers and toxicology results were not recorded into EARS; however, EARS is a flexible system that can incorporate new data without increasing surveillance system burden.

CONCLUSIONS

States, including Colorado, could consider standardization of drug testing and mandatory reporting policies for drivers involved in motor-vehicle crashes and proactively address the narrow window of time for sample collection to improve DUI of marijuana surveillance. Practical applications: The evaluation of state motor-vehicle crash systems' ability to capture crashes involving drug impaired driving (DUID) is a critical first step for identifying frequency and risk factors for crashes related to DUID.

The Epidemiology of Unintentional and Violence-Related Injury Morbidity and Mortality among Children and Adolescents in the United States

Injuries and violence among young people have a substantial emotional, physical, and economic toll on society. Understanding the epidemiology of this public health problem can guide prevention efforts, help identify and reduce risk factors, and promote protective factors. We examined fatal and nonfatal unintentional injuries, injuries intentionally inflicted by other (i.e., assaults and homicides) among children ages 0–19, and intentionally self-inflicted injuries (i.e., self-harm and suicides) among children ages 10–19. We accessed deaths (1999–2015) and visits to emergency departments (2001–2015) for these age groups through the Centers for Disease Control and Prevention’s (CDC) Web-based Injury Statistics Query and Reporting System (WISQARS), and examined trends and differences by age, sex, race/ethnicity, rural/urban status, and injury mechanism. Almost 13,000 children and adolescents age 0–19 years died in 2015 from injury and violence compared to over 17,000 in 1999. While the overall number of deaths has decreased over time, there were increases in death rates among certain age groups for some categories of unintentional injury and for suicides. The leading causes of injury varied by age group. Our results indicate that efforts to reduce injuries to children and adolescents should consider cause, intent, age, sex, race, and regional factors to assure that prevention resources are directed at those at greatest risk.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas-United States

PROBLEM/CONDITION

Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies.

REPORTING PERIOD

Illicit drug use and drug use disorders during 2003-2014, and drug overdose deaths during 1999-2015.

DESCRIPTION OF DATA

The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers' camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40-X44, X60-X64, X85, and Y10-Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC's National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan).

RESULTS

Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003-2005 to 2012-2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12-17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003-2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2).

INTERPRETATION

Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012-2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern.

PUBLIC HEALTH ACTIONS

Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC's guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates.

Illicit Drug Use, Illicit Drug Use Disorders, and Drug Overdose Deaths in Metropolitan and Nonmetropolitan Areas - United States

PROBLEM/CONDITION

Drug overdoses are a leading cause of injury death in the United States, resulting in approximately 52,000 deaths in 2015. Understanding differences in illicit drug use, illicit drug use disorders, and overall drug overdose deaths in metropolitan and nonmetropolitan areas is important for informing public health programs, interventions, and policies.

REPORTING PERIOD

Illicit drug use and drug use disorders during 2003-2014, and drug overdose deaths during 1999-2015.

DESCRIPTION OF DATA

The National Survey of Drug Use and Health (NSDUH) collects information through face-to-face household interviews about the use of illicit drugs, alcohol, and tobacco among the U.S. noninstitutionalized civilian population aged ≥12 years. Respondents include residents of households and noninstitutional group quarters (e.g., shelters, rooming houses, dormitories, migratory workers' camps, and halfway houses) and civilians living on military bases. NSDUH variables include sex, age, race/ethnicity, residence (metropolitan/nonmetropolitan), annual household income, self-reported drug use, and drug use disorders. National Vital Statistics System Mortality (NVSS-M) data for U.S. residents include information from death certificates filed in the 50 states and the District of Columbia. Cases were selected with an underlying cause of death based on the ICD-10 codes for drug overdoses (X40-X44, X60-X64, X85, and Y10-Y14). NVSS-M variables include decedent characteristics (sex, age, and race/ethnicity) and information on intent (unintentional, suicide, homicide, or undetermined), location of death (medical facility, in a home, or other [including nursing homes, hospices, unknown, and other locations]) and county of residence (metropolitan/nonmetropolitan). Metropolitan/nonmetropolitan status is assigned independently in each data system. NSDUH uses a three-category system: Core Based Statistical Area (CBSA) of ≥1 million persons; CBSA of <1 million persons; and not a CBSA, which for simplicity were labeled large metropolitan, small metropolitan, and nonmetropolitan. Deaths from NVSS-M are categorized by the county of residence of the decedent using CDC's National Center for Health Statistics 2013 Urban-Rural Classification Scheme, collapsed into two categories (metropolitan and nonmetropolitan).

RESULTS

Although both metropolitan and nonmetropolitan areas experienced significant increases from 2003-2005 to 2012-2014 in self-reported past-month use of illicit drugs, the prevalence was highest for the large metropolitan areas compared with small metropolitan or nonmetropolitan areas throughout the study period. Notably, past-month use of illicit drugs declined over the study period for the youngest respondents (aged 12-17 years). The prevalence of past-year illicit drug use disorders among persons using illicit drugs in the past year varied by metropolitan/nonmetropolitan status and changed over time. Across both metropolitan and nonmetropolitan areas, the prevalence of past-year illicit drug use disorders declined during 2003-2014. In 2015, approximately six times as many drug overdose deaths occurred in metropolitan areas than occurred in nonmetropolitan areas (metropolitan: 45,059; nonmetropolitan: 7,345). Drug overdose death rates (per 100,000 population) for metropolitan areas were higher than in nonmetropolitan areas in 1999 (6.4 versus 4.0), however, the rates converged in 2004, and by 2015, the nonmetropolitan rate (17.0) was slightly higher than the metropolitan rate (16.2).

INTERPRETATION

Drug use and subsequent overdoses continue to be a critical and complicated public health challenge across metropolitan/nonmetropolitan areas. The decline in illicit drug use by youth and the lower prevalence of illicit drug use disorders in rural areas during 2012-2014 are encouraging signs. However, the increasing rate of drug overdose deaths in rural areas, which surpassed rates in urban areas, is cause for concern.

PUBLIC HEALTH ACTIONS

Understanding the differences between metropolitan and nonmetropolitan areas in drug use, drug use disorders, and drug overdose deaths can help public health professionals to identify, monitor, and prioritize responses. Consideration of where persons live and where they die from overdose could enhance specific overdose prevention interventions, such as training on naloxone administration or rescue breathing. Educating prescribers on CDC's guideline for prescribing opioids for chronic pain (Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain-United States, 2016. MMWR Recomm Rep 2016;66[No. RR-1]) and facilitating better access to medication-assisted treatment with methadone, buprenorphine, or naltrexone could benefit communities with high opioid use disorder rates.

Research on the Translation and Implementation of Stepping On in Three Wisconsin Communities

Objective

Falls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin.

Methods

The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used.

Results

The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits.

Conclusion

Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.

Injury Deaths Among U.S. Females: CDC Resources and Programs

Injury death rates are lower for women than for men at all ages, but we have a long way to go in understanding the circumstances of injury fatalities among females. This article presents resources that can be used to examine the most recent data on injury fatalities among females and highlights activities of CDC's Injury Center. The National Center for Injury Prevention and Control's (NCIPC's) Web-based Injury Statistics Query and Reporting System, an online surveillance database, can be used to examine injury deaths. We present examples that show the 2015 number of female fatal injuries by age group and injury cause and method, as well as a 2008-2014 county-level map of female fatal injury rates. In 2015, there were 68,572 injury fatalities of females of age ≥1 year, equivalent to 1 death every 7 minutes. Injuries were the leading cause of death for females of ages 1-41 years and the sixth-ranked cause of female death overall. Falls were the leading cause of injury death overall (and for women ≥70 years), unintentional poisonings were second, and motor vehicle traffic injuries were third. NCIPC funds national organizations, state health agencies, and other groups to develop, implement, and promote effective injury and violence prevention and control practices. Five key programs are discussed. Presenting data on injury fatalities is an essential element in identifying meaningful prevention efforts. Further investigation of the causes and impact of female injury fatalities can refine the public health approach to reduce this injury burden.

Modified Delphi Consensus to Suggest Key Elements of Stepping On Falls Prevention Program

Falls among older adults result in substantial morbidity and mortality. Community-based programs have been shown to decrease the rate of falls. In 2007, the Centers for Disease Control and Prevention funded a research study to determine how to successfully disseminate the evidence-based fall prevention program (Stepping On) in the community setting. As the first step for this study, a panel of subject matter experts was convened to suggest which parts of the Stepping On fall prevention program were considered key elements, which could not be modified by implementers.

METHODS

Older adult fall prevention experts from the US, Canada, and Australia participated in a modified Delphi technique process to suggest key program elements of Stepping On. Forty-four experts were invited to ensure that the panel of experts would consist of equal numbers of physical therapists, occupational therapists, geriatricians, exercise scientists, and public health researchers. Consensus was determined by percent of agreement among panelists. A Rasch analysis of item fit was conducted to explore the degree of diversity and/or homogeneity of responses across our panelists.

RESULTS

The Rasch analysis of the 19 panelists using fit statistics shows there was a reasonable and sufficient range of diverse perspectives (Infit MnSQ 1.01, Z score -0.1, Outfit MnSQ 0.96, Z score -0.2 with a separation of 4.89). Consensus was achieved that these elements were key: 17 of 18 adult learning elements, 11 of 22 programming, 12 of 15 exercise, 7 of 8 upgrading exercises, 2 of 4 peer co-leader's role, and all of the home visits, booster sessions, group leader's role, and background and training of group leader elements. The top five key elements were: (1) use plain language, (2) develop trust, (3) engage people in what is meaningful and contextual for them, (4) train participants for cues in self-monitoring quality of exercises, and (5) group leader learns about exercises and understands how to progress them.

DISCUSSION

The Delphi consensus process suggested key elements related to Stepping On program delivery. These elements were considered essential to program effectiveness. Findings from this study laid the foundation for translation of Stepping On for broad US dissemination.

Trends in the Distribution of Opioids in Puerto Rico, 1999-2013

OBJECTIVE

Limited information has been published about opioid prescribing practices in Puerto Rico. The objective of this study was to create baseline trends of opioids distributed over a period of fourteen years in Puerto Rico.

METHODS

We examined data from the U.S. Drug Enforcement Administration's Automation of Reports and Consolidated Orders System (ARCOS) for the period 1999-2013. ARCOS data reflects the amount of controlled substances legally dispensed. Analyses include the distribution of opioids (in morphine milligram equivalent kg per 10,000 persons) by year and entity (pharmacy, hospital, practitioner).

RESULTS

The distribution of four drugs (fentanyl, hydromorphone, methadone, oxycodone) increased over 100% between 1999 and 2013. The distribution of two drugs (hydrocodone and meperidine) declined between 1999 and 2013. Oxycodone distribution grew from 0.13 MME kg grams per 10,000 persons in 1999 to 0.29 MME kg in 2013.

CONCLUSION

ARCOS data showed that the overall amount of opioid pain relievers distributed in Puerto Rico increased by 68% between 1999 and 2013. Currently, prescription opioid pain reliever overdose deaths in Puerto Rico do not appear to be skyrocketing as they are in the mainland U.S. However, the ongoing problem with prescription opioid pain reliever overdoses in certain areas should serve as a warning to monitor consumption of opioid pain relievers, as well as changes in prescription drug abuse, overdoses, and deaths.

Location of fatal prescription opioid-related deaths in 12 states, 2008-2010: Implications for prevention programs

INTRODUCTION

Prescription opioid pain reliever overdose is a major public health issue in the United States. To characterize the location of drug-related deaths, we examined fatal prescription opioid and illicit drug-related deaths reported in 12 states.

METHODS

Data are from the Substance Abuse and Mental Health Services Administration's Drug Abuse Warning Network (DAWN). Medical examiners or coroners in 12 states (MA, MD, ME, NH, NM, OK, OR, RI, UT, VA, VT, WV) reported details of state-wide drug-related mortality during 2008-2010. DAWN data included location and manner of death, age, race, and drugs involved. Deaths were coded into three categories: prescription opioid-related, illicit drug-related, and cases that involved both a prescription opioid and an illicit drug.

RESULTS

During a 3-year period, there were 14,091 opioid or illicit drug-related deaths in 12 states. More than half of the prescription opioid-related deaths in all states, except Maryland, occurred at home, rather than in public or in a health care facility. Although it was still the predominant category, lower percentages of illicit drug-related deaths occurred at home.

CONCLUSION

Prescription opioid overdoses have increased substantially, and the location of the person at the time of death can have important public health implications for interventions.

PRACTICAL APPLICATIONS

This paper highlights that bystander support can be a critical lifesaving factor in drug related deaths but may be more likely for illicit drug-related deaths than for prescription opioid-related deaths.

Middle-Aged and Older People with AIDS

This article explores the stability and changes in national trends related to AIDS rates, transmission routes, and risk factors from the mid-1980s to 1997. The authors show that while the numbers of AIDS cases have grown dramatically for all age groups, the proportion of cases for persons age 50 and older (at diagnosis) has remained a fairly stable 10% of the total case load, resulting in more than 60,000 cases in 1997. Contrary to popular belief, the most prevalent transmission route for middle-aged and older people has always been through sexual contact. While middle-aged and older people may be at reduced risk compared to younger age groups, these data also reveal a disturbing trend. People age 50 and older continue to be less knowledgeable about AIDS risks, perceive themselves to be at lower risk, and, for those with known AIDS-related risks, have made fewer behavioral accommodations to avoid such risksas compared to younger people. With recent data indicating a faster rise in new AIDScases among the 50-plus population, middle-aged and older people can no longer beignored in AIDS prevention or treatment efforts.

Changes in Obesity Prevalence Among Women Aged 50 Years and Older

Obesity is an important public health issue facing Americans of all ages. Behavioral Risk Factor Surveillance System data are used to illustrate the change in body mass index distribution in just one decade (1990-2000) in women aged = 50. The sample size ranged from 18,474women = 50 in 1990 to 45,820 in 2000. Forwomen aged = 50, there is a slight decline in the prevalence of underweight (from 3.1% in 1990 to 2.4% in 2000) and a significant increase in obesity (from 14.4% to 21.7%). Not smoking, having less education, being in poor health, having diabetes, and not exercising are all associated with increased odds of being obese. Although factors significantly related to obesity in older women are consistent with those previously identified in younger women, the weight group distributions in olderwomen differ. The physical and social influences of age and gender need to be incorporated into health promotion programs.

Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012

INTRODUCTION

Opioid analgesic prescriptions are driving trends in drug overdoses, but little is known about prescribing patterns among medical specialties. We conducted this study to examine the opioid-prescribing patterns of the medical specialties over time.

METHODS

IMS Health's National Prescription Audit (NPA) estimated the annual counts of pharmaceutical prescriptions dispensed in the U.S. during 2007-2012. We grouped NPA prescriber specialty data by practice type for ease of analysis, and measured the distribution of total prescriptions and opioid prescriptions by specialty. We calculated the percentage of all prescriptions dispensed that were opioids, and evaluated changes in that rate by specialty during 2007-2012. The analysis was conducted in 2013.

RESULTS

In 2012, U.S. pharmacies and long-term care facilities dispensed 4.2 billion prescriptions, 289 million (6.8%) of which were opioids. Primary care specialties accounted for nearly half of all dispensed opioid prescriptions. The rate of opioid prescribing was highest for specialists in pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%). The rate of opioid prescribing rose during 2007-2010 but leveled thereafter as most specialties reduced opioid use. The greatest percentage increase in opioid-prescribing rates during 2007-2012 occurred among physical medicine/rehabilitation specialists (+12.0%). The largest percentage drops in opioid-prescribing rates occurred in emergency medicine (-8.9%) and dentistry (-5.7%).

CONCLUSIONS

The data indicate diverging trends in opioid prescribing among medical specialties in the U.S. during 2007-2012. Engaging the medical specialties individually is critical for continued improvement in the safe and effective treatment of pain.

Preventing unintentional injuries in the home using the Health Impact Pyramid

Injuries continue to be the leading cause of death for the first four decades of life. These injuries result from a confluence of behavioral, physical, structural, environmental, and social factors. Taken together, these illustrate the importance of taking a broad and multileveled approach to injury prevention. Using examples from fall, fire, scald, and poisoning-related injuries, this article illustrates the utility of an approach that incorporates a social-environmental perspective in identifying and selecting interventions to improve the health and safety of individuals. Injury prevention efforts to prevent home injuries benefit from multilevel modifications of behavior, public policy, laws and enforcement, the environment, consumer products and engineering standards, as demonstrated with Frieden's Health Impact Pyramid. A greater understanding, however, is needed to explain the associations between tiers. While interventions that include modifications of the social environment are being field-tested, much more work needs to be done in measuring social-environmental change and in evaluating these programs to disentangle what works best.

Prescription practices involving opioid analgesics among Americans with Medicaid, 2010

Recent state-based studies have shown an increased risk of opioid overdose death in Medicaid populations. To explore one side of risk, this study examines indicators of potential opioid inappropriate use or prescribing among Medicaid enrollees. We examined claims from enrollees aged 18-64 years in the 2010 Truven Health MarketScan® Multi-State Medicaid database, which consisted of weighted and nationally representative data from 12 states. Pharmaceutical claims were used to identify enrollees (n=359,368) with opioid prescriptions. Indicators of potential inappropriate use or prescribing included overlapping opioid prescriptions, overlapping opioid and benzodiazepine prescriptions, long acting/extended release opioids for acute pain, and high daily doses. In 2010, Medicaid enrollees with opioid prescriptions obtained an average 6.3 opioid prescriptions, and 40% had at least one indicator of potential inappropriate use or prescribing. These indicators have been linked to opioid-related adverse health outcomes, and methods exist to detect and deter inappropriate use and prescribing of opioids.

Variation among states in prescribing of opioid pain relievers and benzodiazepines--United States, 2012

INTRODUCTION

Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation.

METHODS

CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines.

RESULTS

In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone.

CONCLUSIONS

Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.

IMPLICATIONS FOR PUBLIC HEALTH

State policy makers might reduce the harms associated with the abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

Alcohol involvement in opioid pain reliever and benzodiazepine drug abuse-related emergency department visits and drug-related deaths - United States, 2010

The abuse of prescription drugs has led to a significant increase in emergency department (ED) visits and drug-related deaths over the past decade. Opioid pain relievers (OPRs) and benzodiazepines are the prescription drugs most commonly involved in these events. Excessive alcohol consumption also accounts for a significant health burden and is common among groups that report high rates of prescription drug abuse. When taken with OPRs or benzodiazepines, alcohol increases central nervous system depression and the risk for overdose. Data describing alcohol involvement in OPR or benzodiazepine abuse are limited. To quantify alcohol involvement in OPR and benzodiazepine abuse and drug-related deaths and to inform prevention efforts, the Food and Drug Administration (FDA) and CDC analyzed 2010 data for drug abuse-related ED visits in the United States and drug-related deaths that involved OPRs and alcohol or benzodiazepines and alcohol in 13 states. The analyses showed alcohol was involved in 18.5% of OPR and 27.2% of benzodiazepine drug abuse-related ED visits and 22.1% of OPR and 21.4% of benzodiazepine drug-related deaths. These findings indicate that alcohol plays a significant role in OPR and benzodiazepine abuse. Interventions to reduce the abuse of alcohol and these drugs alone and in combination are needed.

Vital signs: variation among States in prescribing of opioid pain relievers and benzodiazepines - United States, 2012

BACKGROUND

Overprescribing of opioid pain relievers (OPR) can result in multiple adverse health outcomes, including fatal overdoses. Interstate variation in rates of prescribing OPR and other prescription drugs prone to abuse, such as benzodiazepines, might indicate areas where prescribing patterns need further evaluation.

METHODS

CDC analyzed a commercial database (IMS Health) to assess the potential for improved prescribing of OPR and other drugs. CDC calculated state rates and measures of variation for OPR, long-acting/extended-release (LA/ER) OPR, high-dose OPR, and benzodiazepines.

RESULTS

In 2012, prescribers wrote 82.5 OPR and 37.6 benzodiazepine prescriptions per 100 persons in the United States. State rates varied 2.7-fold for OPR and 3.7-fold for benzodiazepines. For both OPR and benzodiazepines, rates were higher in the South census region, and three Southern states were two or more standard deviations above the mean. Rates for LA/ER and high-dose OPR were highest in the Northeast. Rates varied 22-fold for one type of OPR, oxymorphone.

CONCLUSIONS

Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.

IMPLICATIONS FOR PUBLIC HEALTH

State policy makers might reduce the harms associated with abuse of prescription drugs by implementing changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.

Drug-induced deaths - United States, 1999-2010

Drug-induced deaths include all deaths for which drugs are the underlying cause, including those attributable to acute poisoning by drugs (drug overdoses) and deaths from medical conditions resulting from chronic drug use (e.g., drug-induced Cushing's syndrome). A drug includes illicit or street drugs (e.g., heroin and cocaine), as well as legal prescription and over-the-counter drugs; alcohol is not included. Deaths from drug overdose have increased sharply in the past decade. This increase has been associated with overdoses of prescription opioid pain relievers, which have more than tripled in the past 20 years, escalating to 16,651 deaths in the United States in 2010. Most drug-induced deaths are unintentional drug poisoning deaths, with suicidal drug poisoning and drug poisoning of undetermined intent comprising the majority of the remainder.

Associations between pain clinic density and distributions of opioid pain relievers, drug-related deaths, hospitalizations, emergency department visits, and neonatal abstinence syndrome in Florida

BACKGROUND

Community-level associations between pain clinics and drug-related outcomes have not been empirically demonstrated.

METHODS

To explore these associations we correlated overdose death rates, hospital-discharge rates for drug-related hospitalizations including neonatal abstinence syndrome, and emergency department rates for drug-related visits with registered pain clinic density and rate of opioid pills dispensed per person at the county-level Florida in 2009. Negative binomial regression was used to model the crude associations and associations adjusted for exposure measures and county demographic characteristics.

RESULTS

An estimated 732 pain clinics operated in Florida in 2009, a rate of 3.9/100,000 people. Among the 67 counties in Florida, 23 (34.3%) had no pain clinics, and three had 90 or more. Adjusted negative binomial regression determined no significant association between pain clinic rate and drug-related outcomes. However, rates of drug-caused, opioid-caused, and oxycodone-caused death correlated significantly with rates of opioid and oxycodone pills dispensed per person in adjusted analyses. For every increase of one pill in the rate of oxycodone pills per person, there was a 6% increase in the rate of oxycodone-related overdose death.

CONCLUSIONS

Although pain clinics, some of which are "pill mills," are clearly a source of drugs used nonmedically, their impact on health outcomes might be difficult to quantify because the pills they prescribe might be consumed in other counties or states. The impact of "pill mill" laws might be better measured by more proximal measures such as the number of such facilities.

Fatal unintentional injuries in the home in the U.S., 2000-2008

BACKGROUND

From 1992 to 1999, an average of more than 18,000 unintentional home injury deaths occurred in the U.S. annually.

PURPOSE

The objective of this study was to provide current prevalence estimates of fatal unintentional injury in the home.

METHODS

Data from the 2000-2008 National Vital Statistics System were used in 2011 to calculate average annual rates for unintentional home injury deaths for the U.S. overall, and by mechanism of injury, gender, and age group.

RESULTS

From 2000 to 2008, there was an annual average of 30,569 unintentional injury deaths occurring in the home environment in the U.S. (10.3 deaths per 100,000). Poisonings (4.5 per 100,000) and falls (3.5 per 100,000) were the leading causes of home injury deaths. Men/boys had higher rates of home injury death than women/girls (12.7 vs 8.2 per 100,000), and older adults (≥80 years) had higher rates than other age groups. Home injury deaths and rates increased significantly from 2000 to 2008.

CONCLUSIONS

More than 30,000 people die annually in the U.S. from unintentional injuries at home, with the trend rising since the year 2000. The overall rise is due in large part to the dramatic increase in deaths due to poisonings, and to a lesser degree falls at home. Unintentional home injuries are both predictable and preventable. Through a multifaceted approach combining behavioral change, adequate supervision of children, installation and maintenance of safety devices, and adherence to building codes, safety regulations and legislation, home injuries can be reduced.

Smoke alarm giveaway and installation programs: an economic evaluation

BACKGROUND

The burden of residential fire injury and death is substantial. Targeted smoke alarm giveaway and installation programs are popular interventions used to reduce residential fire mortality and morbidity.

PURPOSE

To evaluate the cost effectiveness and cost benefit of implementing a giveaway or installation program in a small hypothetic community with a high risk of fire death and injury through a decision-analysis model.

METHODS

Model inputs included program costs; program effectiveness (life-years and quality-adjusted life-years saved); and monetized program benefits (medical cost, productivity, property loss and quality-of-life losses averted) and were identified through structured reviews of existing literature (done in 2011) and supplemented by expert opinion. Future costs and effectiveness were discounted at a rate of 3% per year. All costs were expressed in 2011 U.S. dollars.

RESULTS

Cost-effectiveness analysis (CEA) resulted in an average cost-effectiveness ratio (ACER) of $51,404 per quality-adjusted life-years (QALYs) saved and $45,630 per QALY for the giveaway and installation programs, respectively. Cost-benefit analysis (CBA) showed that both programs were associated with a positive net benefit with a benefit-cost ratio of 2.1 and 2.3, respectively. Smoke alarm functional rate, baseline prevalence of functional alarms, and baseline home fire death rate were among the most influential factors for the CEA and CBA results.

CONCLUSIONS

Both giveaway and installation programs have an average cost-effectiveness ratio similar to or lower than the median cost-effectiveness ratio reported for other interventions to reduce fatal injuries in homes. Although more effort is required, installation programs result in lower cost per outcome achieved compared with giveaways.

The National Center for Injury Prevention and Control on its 20th Anniversary: a safe future and the importance of 20

In recognition of NCIPC's role in creating a safer world, we brought together 20 contributions for this Journal of Safety Research Anniversary Supplement that represents the breadth of our work while acknowledging that we cannot truly represent the depth of the work over the past two decades. The Center's current focal and cross-cutting areas are highlighted in the articles of this Supplement and cover a range of activities from violence prevention, unintentional injury, to acute care and rehabilitation. The Supplement also contains contributions from partners and highlights the resources of the Center.

Slipping and tripping: fall injuries in adults associated with rugs and carpets

BACKGROUND

Falls are a leading cause of unintentional injury among adults age 65 years and older. Loose, unsecured rugs and damaged carpets with curled edges, are recognized environmental hazards that may contribute to falls. To characterize nonfatal, unintentional fall-related injuries associated with rugs and carpets in adults aged 65 years and older.

METHODS

We conducted a retrospective analysis of surveillance data of injuries treated in hospital emergency departments (EDs) during 2001-2008. We used the National Electronic Injury Surveillance System-All Injury Program, which collects data from a nationally representative stratified probability sample of 66 U.S. hospital EDs. Sample weights were used to make national estimates.

RESULTS

Annually, an estimated 37,991 adults age 65 years or older were treated in U.S. EDs for falls associated with carpets (54.2%) and rugs (45.8%). Most falls (72.8%) occurred at home. Women represented 80.2% of fall injuries. The most common location for fall injuries in the home was the bathroom (35.7%). Frequent fall injuries occurred at the transition between carpet/rug and non-carpet/rug, on wet carpets or rugs, and while hurrying to the bathroom.

CONCLUSIONS

Fall injuries associated with rugs and carpets are common and may cause potentially severe injuries. Older adults, their caregivers, and emergency and primary care physicians should be aware of the significant risk for fall injuries and of environmental modifications that may reduce that risk.

Adult opinions about the age at which children can be left home alone, bathe alone, or bike alone: Second Injury Control and Risk Survey (ICARIS-2)

PROBLEM

This study describes adult opinions about child supervision during various activities.

METHODS

Data come from a survey of U.S. adults. Respondents were asked the minimum age a child could safely: stay home alone; bathe alone; or ride a bike alone. Respondents with children were asked if their child had ever been allowed to: play outside alone; play in a room at home for more than 10 minutes alone; bathe with another child; or bathe alone.

RESULTS

The mean age that adults believed a child could be home alone was 13.0 years (95% CI=12.9-13.1), bathe alone was 7.5 years (95% CI=7.4-7.6), or bike alone was 10.1 years (95% CI=10.0-10.3). There were significant differences by income, education, and race.

DISCUSSION

Assessing adult's understanding of the appropriate age for independent action helps set a context for providing guidance on parental supervision. Guidelines for parents should acknowledge social norms and child development stages.

IMPACT ON INDUSTRY

Knowledge of social norms can help guide injury prevention messages for parents.

Gender differences in seeking care for falls in the aged Medicare population

BACKGROUND

One third of adults aged ≥65 years fall annually, and women are more likely than men to be treated for fall injuries in hospitals and emergency departments.

PURPOSE

The aim of this study was to examine how men and women differed in seeking medical care for falls and in the information about falls they received from healthcare providers.

METHODS

This study, undertaken in 2010, analyzed population-based data from the 2005 Medicare Current Beneficiary Survey (MBCS), the most recent data available in 2010 from this survey. A sample of 12,052 community-dwelling Medicare beneficiaries aged ≥65 years was used to examine male-female differences among 2794 who reported falling in the previous year, sought medical care for falls and/or discussed fall prevention with a healthcare provider. Multivariable logistic regression analyses were conducted to determine the factors associated with falling for men and women. P-values ≤0.05 were considered significant.

RESULTS

Nationally, an estimated seven million Medicare beneficiaries (22%) fell in the previous year. Among those who fell, significantly more women than men talked with a healthcare provider about falls and also discussed fall prevention (31.2% [95% CI=28.8%, 33.6%] vs 24.3% [95% CI=21.6%, 27.0%]). For both genders, falls were most strongly associated with two or more limitations in activities of daily living and often feeling sad or depressed.

CONCLUSIONS

Women were significantly more likely than men to report falls, seek medical care, and/or discuss falls and fall prevention with a healthcare provider. Providers should consider asking all older patients about previous falls, especially older male patients who are least likely to seek medical attention or discuss falls with their doctors.

Nonfatal unintentional injuries in children aged <15 years in Nicaragua

The objective of this study was to describe the nonfatal unintentional injuries among children aged <15 years treated in four emergency departments (EDs) in Nicaragua. The 2004 Injury Surveillance System included all cases of injuries that attended the four hospital EDs (n = 37,577). We analysed the records of 13,426 children aged <15 years who sustained nonfatal unintentional injuries. The leading causes of injuries were falls (50.5%), blunt force trauma (13.2%) and transport-related incidents (11.5%). Transport-related injuries primarily involved cyclists (42.3%) and motor-vehicle passengers (32.5%). Ten per cent of the injured children were hospitalised. This is the first study to present the epidemiology of nonfatal unintentional injuries among children treated in EDs in Nicaragua. Unintentional injuries are an important cause of morbidity, but the burden remains largely unaddressed. The implementation of the already well-established transportation-related prevention strategies should be a priority. Prevention of falls (falls being the leading cause of injury among children) demands further study.

Home Injuries: Potential for Prevention

There are approximately 18 000 injury-related deaths at home each year. Some of the leading causes of home injury deaths are falls, fire/ burns, poisonings, choking/suffocations, and drownings. Many more home injuries are treated at emergency departments, in doctors’ offices, or with self-care at home. Children and older adults are especially at risk for home injuries, and environmental factors can contribute to population disparities in home injuries. The causes and circumstances of home injuries are complex and multifaceted. This article provides an overview of the epidemiology and burden of home injuries and reviews the evidence for prevention by life stage. Reducing the risk of injuries at home is challenging, but fortunately there many ways that practitioners can help promote safer behaviors and help change home environments for patients and their families.

Self-reported falls and fall-related injuries among persons aged>or=65 years--United States, 2006

PROBLEM

In 2005, 15,802 persons aged>or=65 years died from fall injuries. How many older adults seek outpatient treatment for minor or moderate fall injuries is unknown.

METHOD

To estimate the percentage of older adults who fell during the preceding three months, the Centers for Disease Control and Prevention (CDC) analyzed data from two questions about falls included in the 2006 Behavioral Risk Factor Surveillance System (BRFSS) survey.

RESULTS

Approximately 5.8 million (15.9%) persons aged>or=65 years reported falling at least once during the preceding three months, and 1.8 million (31.3%) of those who fell sustained an injury that resulted in a doctor visit or restricted activity for at least one day.

DISCUSSION

This report presents the first national estimates of the number and proportion of persons reporting fall-related injuries associated with either doctor visits or restricted activity.

SUMMARY

The prevalence of falls reinforces the need for broader use of scientifically proven fall-prevention interventions.

IMPACT ON INDUSTRY

Falls and fall-related injuries represent an enormous burden to individuals, society, and to our health care system. Because the U.S. population is aging, this problem will increase unless we take preventive action by broadly implementing evidence-based fall prevention programs. Such programs could appreciably decrease the incidence and health care costs of fall injuries, as well as greatly improve the quality of life for older adults.

Translation of an effective tai chi intervention into a community-based falls-prevention program

Tai chi--moving for better balance, a falls-prevention program developed from a randomized controlled trial for community-based use, was evaluated with the re-aim framework in 6 community centers. The program had a 100% adoption rate and 87% reach into the target older adult population. All centers implemented the intervention with good fidelity, and participants showed significant improvements in health-related outcome measures. This evidence-based tai chi program is practical to disseminate and can be effectively implemented and maintained in community settings.

Injuries among infants treated in emergency departments in the United States, 2001-2004

OBJECTIVE

The objective of this study was to present a detailed examination of unintentional injuries in infants < or = 12 months of age treated in emergency departments.

METHODS

We conducted a retrospective analysis of data for infants < or = 12 months of age from the National Electronic Surveillance System-All Injury Program for 2001-2004. Sample weights provided by the National Electronic Surveillance System-All Injury Program were used to make national estimates.

RESULTS

An estimated 1,314,000 injured infants were treated in US emergency departments for nonfatal unintentional injuries during the 4-year period of 2001-2004, approximately 1 infant every 1.5 minutes. Falls were the leading cause of nonfatal unintentional injuries for infants. Overall, the patients were more likely to be male (55.2%) than female (44.8%). Contusions/abrasions were the leading diagnosis overall (26.7%). Contusion/abrasion, laceration, hematoma, foreign-body, and puncture injuries occurred most frequently to the head or neck region. More than one third of fractures (37.2%) were to the arm or hand. Bed was the product most frequently noted as being involved in the injury event for every age except 2 and 12 months (car seat was the most frequently noted product at 2 months of age, and stairs were top ranked at 12 months). Product rank changed markedly as age increased.

CONCLUSIONS

The influences of the social environment, the physical environment, and products change as infants mature in the first year of life; this was substantiated in our study by the shift in the relative importance of products involved in injuries according to month of age. The concept that aspects of safety must adapt in anticipation of developmental stage is critical.