The Drug Abuse Warning Network

Evidence of our nation’s drug crisis is staggering. More than 2 million people in the United States suffer from an opioid use disorder. Opioid-related hospitalizations, illnesses, and treatment admissions continue to increase relentlessly. Overdose deaths skyrocketed more than 380 percent from 1999 to 2016. Communities across the nation are decimated, measured in the number of children left parentless, families destroyed, and health care and welfare systems overwhelmed. With an average of 115 people dying every day from overdoses, in October 2017 President Trump declared the opioid crisis a nationwide public health emergency.

In 2018, the Executive Office reached out to the Substance Abuse and Mental Health Services Administration (SAMHSA) to re-establish the Drug Abuse Warning Network (DAWN)—a system to monitor drug-related emergency department (ED) visits. The hospital emergency room is often the first place where public-health officials see signs of outbreaks. What worked to alert the nation to Ebola and SARS epidemics also works to alert us to for life-threatening drug abuse. ED records can be used to identify surges in illicit drug use (e.g., heroin or cocaine), prescription drug abuse (e.g., opiates or benzodiazepines), and unexpected interactions between over-the-counter drugs.

From 2004 to 2013, RTI managed the reporting arm of the first implementation of DAWN. We maintained the sample of reporting hospitals, compiled records of ED visits, and built out estimates of the drugs involved for both the nation as a whole and major urban centers. SAMHSA used DAWN findings to target program resources to areas of greatest need. National, state, and local health professionals, policymakers, law- enforcement officers, and pharmacologists used DAWN to understand the consequences of drug use and abuse and to identify emerging trends and changing patterns.

Since its inception in 1976, one of DAWN’s most significant impacts was building a metric to watch drug abuse patterns. Prior to DAWN, reporting on substance abuse consisted mostly of tragic personal stories and sensational headlines. The metrics produced by DAWN make it possible to identify successful outcomes, promote continuous improvement, and enable strategic decision making.

Even better, DAWN is not limited to traditional substances of abuse; over half of drug-related ED visits involve use of drugs as prescribed by doctors. (I was personally excited to present on life-threatening medical emergencies that result when older adults are prescribed inappropriate medications.) DAWN provides a credible, reproducible, and fact-based accounting of our nation’s involvement with all drugs, and is the bellwether of successful strategies to counter drug-abuse trends. 

Over its history, DAWN has had a major impact on public health policy. The White House Office of National Drug Control Policy used this program to monitor national trends; the Drug Enforcement Administration for surveillance; and the pharmaceutical industry (at the direction of the Food and Drug Administration) to conduct post-marketing surveillance of prescription and over-the-counter pharmaceuticals.   

DAWN in Action: Identifying Trends in Drug Misuse and Abuse

DAWN is like the canary in the coal mine—it discerns substance-abuse trends before anyone else can. Here are a few examples in which SAMHSA used DAWN data to alert the public:

• Methadone-Related Emergency Department Visits Involving Nonmedical Use. DAWN identified a sharp spike in methadone-related ED visits between 2004 and 2009, two-thirds of which involved another drug (most often anxiety or insomnia medications and/or narcotic pain relievers).
• Emergency Department Visits Involving Narcotic Pain Relievers. A significant percentage of ED visits for abuse of prescription drugs involved narcotic pain relievers, such visits increasing by 117 percent between 2005 and 2011. Oxycodone was the most common narcotic pain reliever used in ways contrary to doctors’ instructions.
• Benzodiazepines in Combination with Opioid Pain Relievers or Alcohol. When benzodiazepines (e.g., anti-anxiety medications such as Valium, Xanax, and Ativan) were combined with opioids or alcohol, DAWN data showed this increased the predicted risk for ED patients by 24 to 55 percent.

RTI researchers, in collaboration with SAMHSA, have also used DAWN data in international forums to explore adverse outcomes of drug use as prescribed.  Two examples include

• Medical emergencies: A strategy to assess and identify potentially inappropriate medications for older persons, presented at the 2012 Nordic Conference on Gerontology in Copenhagen, Denmark
• ED visits involving drug-related suicide attempts in the United States, 2004–2009, presented at the 2011 annual conference of the International Association for Suicide Prevention in Beijing, China

DAWN Rises Again

With direction from the Executive office, SAMHSA is re-establishing DAWN.  The new DAWN will include a much-needed public-facing online dashboard. It will begin with a small sample of hospitals, and the dashboard will focus on rapid reporting of outbreaks in drug-use trends. Over the next several years, DAWN will increase its sample to include hospitals from rural EDs (often the first place emerging drug trends are spotted) as well as major urban areas. Public-health officials will soon have the data and tools needed to spot new drug trends in close to real time and increase the efficacy of their response.