774 JOURNAL OF STUDIES ON ALCOHOL AND DRUGS / SEPTEMBER 2011
Hospitalizations for Alcohol and Drug Overdoses in
Young Adults Ages 18–24 in the United States, 1999–2008:
Results From the Nationwide Inpatient Sample
AARON M. WHITE, PH.D.,† RALPH W. HINGSON, SC.D., I-JEN PAN, PH.D.,† AND HSIAO-YE YI, PH.D.†
Division of Epidemiology and Prevention Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health,
5635 Fishers Lane, MSC 9304, Room 2074, Bethesda, Maryland 20892-9304
ABSTRACT. Objective: Recent reports indicate an increase in rates
of hospitalizations for drug overdoses in the United States. The role of
alcohol in hospitalizations for drug overdoses remains unclear. Exces-
sive consumption of alcohol and drugs is prevalent in young adults ages
18–24. The present study explores rates and costs of inpatient hospital
stays for alcohol overdoses, drug overdoses, and their co-occurrence in
young adults ages 18–24 and changes in these rates between 1999 and
2008. Method: Data from the Nationwide Inpatient Sample were used
to estimate numbers, rates, and costs of inpatient hospital stays stem-
ming from alcohol overdoses (and their subcategories, alcohol poison-
ings and excessive consumption of alcohol), drug overdoses (and their
subcategories, drug poisonings and nondependent abuse of drugs), and
their co-occurrence in 18- to 24-year-olds. Results: Hospitalization rates
for alcohol overdoses alone increased 25% from 1999 to 2008, reaching
29,412 cases in 2008 at a cost of $266 million. Hospitalization rates for
drug overdoses alone increased 55%, totaling 113,907 cases in 2008 at
a cost of $737 million. Hospitalization rates for combined alcohol and
drug overdoses increased 76%, with 29,202 cases in 2008 at a cost of
$198 million. Conclusions: Rates of hospitalizations for alcohol over-
doses, drug overdoses, and their combination all increased from 1999 to
2008 among 18- to 24-year-olds. The cost of such hospitalizations now
exceeds $1.2 billion annually. The steepest increase occurred among
cases of combined alcohol and drug overdoses. Stronger efforts are
needed to educate medical practitioners and the public about the risk of
overdoses, particularly when alcohol is combined with other drugs. (J.
Stud. Alcohol Drugs, 72, 774–786, 2011)
or via email at: firstname.lastname@example.org. I-Jen Pan and Hsiao-Ye Yi are with
CSR, Incorporated, Arlington, VA.
Received: March 9, 2011. Revision: May 18, 2011.
†Correspondence may be sent to Aaron M. White at the above address
per year (Schoenborn and Adams, 2010). The vast majority
of drinkers (92%) consume alcohol at or below moderate
levels (1 drink per day and no more than 7 drinks per week
for women or 2 drinks per day and no more than 14 drinks
per week for men; Schoenborn and Adams, 2010). Light
and moderate drinking can be part of a healthy lifestyle for
adults and is associated with cardiovascular benefi ts and
longevity in general (Dawson, 2000; National Institute on
Alcohol Abuse and Alcoholism [NIAAA], 2005). In contrast,
consuming alcohol beyond moderate levels increases the risk
of negative outcomes and is a causal factor in more than 60
types of diseases and injuries (World Health Organization
[WHO], 2011). The WHO estimates that alcohol causes 2.5
million premature deaths worldwide each year, accounting
for 4% of all deaths (6% of all deaths for males and 1%
for females) (WHO, 2011). In the United States, excessive
consumption of alcohol is estimated to cause approximately
79,000 deaths and 2.3 million years of potential life lost an-
nually (Centers for Disease Control and Prevention [CDC],
When consumed in large quantities during a single occa-
sion, alcohol can cause death directly by suppressing brain
N THE UNITED STATES, approximately 61% of the pop-
ulation ages 18 and older consumes alcohol at least once
stem nuclei that control vital refl exes, such as breathing and
gagging to clear the airway (Miller and Gold, 1991). Even a
single session of heavy episodic drinking, commonly defi ned
as fi ve or more drinks per occasion, causes infl ammation
and transient damage to the heart (Zagrosek et al., 2010).
The acute toxic effects of alcohol in the body can manifest
in symptoms of alcohol poisoning, which include vomiting,
slow and irregular breathing, hypothermia, mental confu-
sion, stupor, and death (NIAAA, 2007; Oster-Aaland et al.,
2009). Using data from the global burden of disease study,
the WHO estimated that alcohol poisoning caused 65,700
deaths worldwide in 2002, with 2,700 poisoning deaths oc-
curring in the United States (WHO, 2009).
Excessive consumption of alcohol is particularly common
among those 18–24 years of age, a time of transition from
late adolescence into young adulthood (National Center for
Health Statistics, 2009). Compared with older adults, those
ages 18–24 are more likely to engage in heavy episodic
drinking and to participate in a range of risky behaviors in-
volving alcohol, including driving while intoxicated (Dayan
et al., 2010; Hingson et al., 2009). Approximately 25% of
young people in this age group consume fi ve or more drinks
in a day at least once per month (National Center for Health
Statistics, 2009), and rates are higher (44%) among those
attending college (Wechsler and Nelson, 2008). Relative to
people in older age groups, young adults ages 18–24 con-
sume the most drinks (M = 9.5) per episode of heavy drink-
ing (Naimi et al., 2010). White et al (2006) reported that,
among college freshmen, nearly 1 in 5 (19%) male heavy
WHITE ET AL. 775
episodic drinkers consumed 15 or more drinks in a night,
a potentially lethal level, at least once in a 2-week period.
Hingson et al. (2009) estimated that 609 young adults ages
18–24 died from alcohol poisoning in the United States in
2005 as a result of heavy drinking.
Use of substances other than alcohol also peaks in the
late teenage years and early 20s. In 2009, 21% of 18- to
25-year-olds used one or more illicit drugs each month, and
6% used a prescription drug nonmedically (Substance Abuse
and Mental Health Services Administration [SAMHSA],
2010d). Overdose deaths from illicit and prescription drugs
have increased steeply in the United States in recent years.
In 2007, an estimated 27,658 people ages 15 and older died
from drug poisonings, making deaths from drug overdoses
second only to deaths from motor vehicle crashes as the
leading cause of unintentional injury deaths that year (CDC,
2010a). Rates of deaths from drug overdose more than
doubled for males and tripled for females between 1999 and
2007 (CDC, 2010a). Overdoses from prescription opioid
pain medications increased the most and outnumbered deaths
from heroin and cocaine overdoses combined in 2007 (CDC,
2010a). Based on data from the Nationwide Inpatient Sample
(NIS), which contains data pertaining to roughly 8 million
inpatient discharges each year from a 20% stratifi ed sample
of community hospitals across the country, Coben and col-
leagues (2010) observed a 65% increase between 1999 and
2006 in hospital stays for poisoning by prescription opioids,
sedatives, and tranquilizers.
Alcohol interacts with a wide variety of illicit and
prescription drugs, including opioids and related narcotic
analgesics, sedatives, and tranquilizers (NIAAA, 1995;
Tanaka, 2002). In 2007, data from the Drug Abuse Warn-
ing Network (DAWN) suggested that 26% of all emergency
department visits for drug misuse also involved the use of
alcohol. Alcohol was involved in 17% of emergency depart-
ment visits resulting from use of benzodiazepine sedatives
and tranquilizers and 14% of visits stemming from use of
opioids and related narcotic pain medications (SAMHSA,
2010c). Blood alcohol concentrations (BAC) required for
fatal overdoses are lower when alcohol is combined with
prescription drugs (Jones et al., 2011). An analysis of 1,006
fatal poisonings because of alcohol alone or in combination
with other drugs revealed that the median postmortem BAC
in those who overdosed on alcohol alone was 0.33%, com-
pared with 0.13%–0.17% among those who overdosed on a
combination of alcohol and prescription drugs (Koski et al.,
Data from the National Epidemiologic Study on Alcohol
and Related Conditions indicate that the combined use of
alcohol and other drugs peaks in the 18- to 24-year-old age
range (McCabe et al., 2006). Given the high levels of alcohol
consumption during these years and the combined use of
alcohol and other drugs, it is important to examine the over-
lap in incidences of alcohol overdoses and drug overdoses
in 18- to 24-year-olds. It is possible that the increasing rates
of hospitalizations and deaths because of drug overdoses
reported in previous studies are related to an increase in the
excessive use of alcohol along with these other drugs.
The current study examined rates of inpatient hospital-
izations for alcohol overdoses, other drug overdoses, and
their co-occurrence in 18- to 24-year-olds during the years
1999–2008 using data from the NIS. Overdoses were defi ned
as inpatient discharges indicating alcohol or other drug
poisoning, or excessive consumption of alcohol or other
drugs. Based on recent reports indicating an increase in drug
poisonings in the general population and the high levels of
alcohol and other drug use among those ages 18–24, we
anticipated that rates of inpatient hospitalizations for alcohol
overdoses, drug overdoses, their subcategories (poisoning
and excessive consumption), and their co-occurrence in-
creased among 18- to 24-year-olds in the United States dur-
ing the decade spanning 1999–2008. Based on reports that
overdoses on opioid pain medications and related narcotic
analgesics have increased, we also examined changes in rates
of prescription opioid pain medication and related narcotic
analgesic overdoses and their co-occurrence with alcohol
NIS, years 1999–2008. The NIS is part of the Healthcare
Cost and Utilization Project (HCUP), funded by the Agency
for Healthcare Research and Quality, U.S. Department of
Health and Human Services. It was designed to approxi-
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by the American Hospital Association. The sampling strata
were fi ve hospital characteristics: U.S. region, urban or rural
location, teaching status, ownership and control, and bed
size. All-payer inpatient stays in the sampled hospitals were
included in the NIS, yielding the largest inpatient data set
in the United States, containing data on approximately 8
million discharges each year. The number of participating
states in the HCUP was 24 in 1999 and increased to 42 in
2008, which covered 65% and 95% of the U.S. population,
respectively. With sampling weights, the NIS can be used
to estimate national statistics on hospitalizations. Because
“state” is not one of the sampling strata, the NIS cannot be
used to generate state-level estimates. The unit of the NIS
was an individual discharge record.
The current study examined hospitalization data from the
with poisoning and nondependent abuse of alcohol and drugs
in patients ages 18–24. The NIS uses the International Clas-
Data of interest pertained to hospitalizations associated
WHITE ET AL. 785
Approximately one in fi ve drug overdose cases involved
a concomitant alcohol overdose, indicating that excessive
consumption of alcohol plays a prominent role in many cases
of drug overdose. The cost of hospital stays stemming from
alcohol and drug overdoses exceeded $1.2 billion in 2008.
Stronger efforts to educate medical practitioners and the
public about the risks of combining alcohol and other drugs
could help reduce the number of such hospitalizations.
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