Clinical Therapeutics/Volume 40, Number 2, 2018

Original Research
Sex Differences in Prevalence of Emergency
Department Patient Substance Use
Robert D. Cannon, DO1; Gillian A. Beauchamp, MD1; Paige Roth, MSW1;
Jennifer Stephens, DO2; David B. Burmeister, DO1; David M. Richardson, MD1;
Alanna M. Balbi, BS1; Tennessee D. Park, BA1; Stephen W. Dusza, DrPH1; and
Marna Rayl Greenberg, DO, MPH1
1
Department of Emergency and Hospital Medicine, Lehigh Valley Hospital and Health Network/University
of South Florida Morsani College of Medicine Allentown, Pennsylvania; and 2Department of Internal
Medicine, Lehigh Valley Hospital and Health Network/University of South Florida Morsani College of
Medicine Allentown, Pennsylvania

ABSTRACT diagnosis for the ED visit was alcohol (54.3%; 95%

Purpose: Substance use and misuse is prevalent in
emergency department (ED) populations. While the
prevalence of substance use and misuse is reported,
sex-specific trends in ED populations have not been
documented. We set out to determine the sex-specific
prevalence of ED patient substance use during this
current epidemic.
Methods: A retrospective electronic data abstraction
tool, developed for quality-improvement purposes, was
used to assess ED visits in 3 hospitals in northeastern
Pennsylvania. All patients with ED diagnosis codes for
substance use F10.000 through F 19.999 (excluding
F17 codes for nicotine) were abstracted for network
ED visits at all 3 hospitals. Data points included ED
clinical enrollment site, primary substance used, sex,
date of ED visit, disposition (including left without
being seen, left against medical advice, discharged,
admitted, and treatment in rehabilitation) for
18 months (January 1, 2016 through July 31, 2017).
The categorical parameters of sex, clinical enrollment
site, diagnosis, date of ED visit, and disposition status
were summarized as a proportion of the subject group.
Time series analysis was used to assess trends in
substance use and misuse visits by patient sex.
Findings: A total of 10,511 patients presented to the
EDs during the study time period with a final diagnosis
of a substance use−related reason and were included in
the analysis. The mean age for these patients was 43.6
(SD 16.4) years, and the majority was male (65.6%,
n ¼ 6900). The most common substance in the final
CI, 53.3–55.2), followed by opioids (19.2%; 95% CI,
18.4–19.9) and cannabis (14.4%; 95% CI, 13.7–15.0).
Females tended to be younger than males (42.4 years vs
44.3 years; P o 0.001), and were more likely to be
discharged after the ED visit than males (36.1% vs
32.3%; P o 0.001). When exploring differences in age
by sex and substance, males with a final diagnosis
including alcohol- and cannabis-related issues were
older than females, whereas females diagnosed with
opioid-related reasons were older than males (41.3 vs
38.9 years; P o 0.001).
Implications: There are sex-specific differences in
prevalence of patients presenting with substance use in
the ED setting. (Clin Ther. 2018;40:197–203) & 2018
Elsevier HS Journals, Inc. All rights reserved.
Key words: opioids, prevalence, sex differences,
substance use.
INTRODUCTION
Substance use and misuse is prevalent in emergency
department (ED) populations.1–4 ED patients are
more likely than the general population to use and
misuse substances.5 While tobacco and alcohol-related
morbidity and mortality continue to be reported, more
Accepted for publication December 18, 2017.
https://doi.org/10.1016/j.clinthera.2017.12.013
0149-2918/$ - see front matter
& 2018 Elsevier HS Journals, Inc. All rights reserved.

February 2018 197

 Clinical Therapeutics
recently, specific attention has been brought to the
opioid crisis in the United States.6 Of the 21.5 million
Americans 12 years or older that had a substance use
disorder in 2014, 1.9 million involved prescription
pain relievers and 587,000 involved heroin.7 From
1999 through 2008, overdose death rates, sales, and
substance use disorder treatment admissions related to
prescription pain relievers increased in parallel—the
overdose death rate in 2008 was nearly 4 times the
rate in 1999, while sales of prescription pain relievers
in 2010 were 4 times those in 1999—and the
substance use disorder treatment admission rate in
2009 was 6 times the 1999 rate.8
Sex differences have been implicated as an impor-
tant factor in the etiology, pathophysiology, sequelae,
and treatment of substance use disorders.9 Specifically
in the ED population, explorations of sex differences
in substance use among adult emergency patients
have illustrated that males have a higher prevalence
of substance use, in particular, lifetime use of
nonprescription opioids, as well as methadone or
buprenorphine, are reported to be twice as high for
males as females.9 Other sex-specific differences in
opioid use are more concerning for females. Females
are more likely to take prescription opioids without a
prescription to cope with pain, even when they are
reporting similar pain levels.10 Research also suggests
that females are more likely to misuse prescription
opioids to self-treat for other problems, such as
anxiety or tension.11
While the overall prevalence of substance use and
misuse in the context of the current substance use
epidemic has been reported, sex-specific trends in
substance-related ED visits have been less well docu-
mented.9 We present the sex-specific prevalence in ED
encounters during this current epidemic related to
patient substance use.
PATIENTS AND METHODS
This study was approved by Lehigh Valley Health
Network’s Institutional Review Board using the ex-
pedited review procedure in accordance with regula-
tory requirements. Data on adult ED visits from 3
hospitals in northeastern Pennsylvania were ab-
stracted using a tool that had been developed for
hospital quality improvement. The contributing hos-
pitals were an inner-city hospital with an annual
census of more than 30,000 visits per year (site A), a
198
Level 1 trauma center with an annual census of
90,000 visits per year (site B), and a suburban hospital
with an annual census of 58,000 visits per year
(site C). All patients with International Classification
of Diseases, Tenth Revision, ED final diagnosis code
(s) for substance use F10.000 through F19.999 (ex-
cluding F17 codes for nicotine) were abstracted
electronically by an automated query established by
an information technologist using SAP BusinessOb-
jects Web Intelligence (WebI; SAP.com) who was
blinded to the study protocol for ED visits at all 3
hospitals. Data included ED clinical enrollment site,
primary substance used, sex, date of ED visit, and
disposition (including left without being seen, left
against medical advice, discharged, admitted, and
treated in rehabilitation) for 18 months (January 1,
2016 through July 31, 2017).
Descriptive statistics and graphical methods were used
to assess the distribution of study variables by patient
sex. Univariate analyses included Student t tests and
Pearson χ2 to assess differences in the distribution of
study variables by patient sex. Exact 95% binomial CIs
were calculated for the relative frequency estimates for
each drug. Random effects regression was used to
evaluate differences in age by substance (drug), control-
ling for disposition of patient from the ED. A random
effect was added to these analyses because patient data
were aggregated from 3 separate hospitals within the
same health network. In addition, multinomial logistic
regression was used to evaluate associations between ED
disposition (coded as admitted, discharged, and other)
and patient sex by substance type (coded on three levels:
alcohol, opioids, and other). These analyses included
assessments of the interaction between patient sex and
substance type. Marginal predicted probabilities were
estimated from these models and plotted to help better
visualize the relationship between being admitted and
substance type by patient sex. All regression models
included patient age to control for potential confounding.
Additionally, a time series analysis was completed to
evaluate the overall counts and relative proportions of
substances (drugs) encountered in the ED between
January 1, 2016 and July 31, 2017, out of all the
patients evaluated for drug-related issues. These analyses
aggregated data per month and were stratified by patient
sex. Linear tests for trend were performed to assess any
trends in the data over the course of the evaluation time
frame. All analyses were performed using STATA soft-
ware, version 14.2 (Stata Corp, College Station, Texas).
Volume 40 Number 2
 R.D. Cannon et al.

Table I. Characteristics of patient visits to the emergency department in the Lehigh Valley Health Network
between January 2016 and July 2017 for substance use-related visits.

Variable Coding Overall (n ¼ 10,511) Female (n ¼ 3611) Male (n ¼ 6900) P

Age, y, mean (SD) 43.6 (16.4) 42.4 (16.3) 44.3 (16.4) o0.001
Drug, n (%) Alcohol 5704 (54.3) 1802 (49.9) 3902 (56.6) o0.001
Cannabis 1509 (14.4) 542 (15.0) 967 (14.0) 0.18
Cocaine 431 (4.1) 136 (3.8) 295 (4.3) 0.21
Opioid 2014 (19.2) 829 (23.0) 1185 (17.2) o0.001
Other 853 (8.1) 302 (8.4) 551 (8.0) 0.42
ED disposition, n (%) Admit 4746 (45.2) 1593 (44.1) 3153 (45.7) 0.01
Discharge 3531 (33.6) 1305 (36.1) 2226 (32.3) o0.001
Transfer 249 (2.4) 80 (2.2) 169 (2.5) 0.38
Left AMA 94 (0.9) 23 (0.6) 71 (1.0) 0.04
Observe 222 (2.1) 66 (1.8) 156 (2.3) 0.11
Other 50 (0.5) 24 (0.7) 26 (0.4) 0.05
Missing 1619 (15.4) 550 (14.4) 1099 (15.9) o0.001
Facility, n (%) Site A 1226 (11.7) 386 (10.7) 840 (12.2) 0.04
Site B 5376 (51.2) 1841 (51.0) 3535 (51.2) −
Site C 3909 (37.2) 1384 (38.3) 2525 (36.6) −

AMA ¼ against medical advice; ED ¼ emergency department.

RESULTS the ED visit was alcohol (54.3%; 95% CI, 53.3–55.2),

A total of 10,511 patients presented to the EDs during
the study time period with a final diagnosis that
included substance use−related reasons and were
entered in the analysis (demographics and character-
istics, Table I). Mean age for these patients was 43.6
(SD 16.4) years, and the majority was male (65.6%,
n ¼ 6900). The most common substance diagnosed in
followed by opioids (19.2%; 95% CI, 18.4–19.9) and
cannabis (14.4%; 95% CI, 13.7–15.0). Females
tended to be younger than males (42.4 years vs 44.3
years; P o 0.001), and were more likely to be
discharged after the ED visit than males (36.1% vs
32.3%; P o 0.001). Mean patient age stratified by
substance and sex is presented in Table II. Total ED

Table II. Measures of central tendency of age by patient sex and primary substance related to emergency
department visit.

Overall Female Male

Substance n Mean (SD) n Mean (SD) n Mean (SD)

Alcohol 5704 48.8 (15.9) 1802 46.7 (16.2)* 3902 49.9 (15.9)
Cannabis 1509 33.5 (14.9) 542 32.7 (15.0) 967 33.9 (14.8)
Cocaine 431 42.4 (11.8) 136 39.9 (11.4)* 295 43.5 (11.7)
Opioid 3014 39.9 (14.7) 829 41.3 (15.5)* 1185 38.9 (14.0)
Other 853 35.9 (14.4) 302 37.7 (15.6)* 551 34.9 (13.6)

⁎
Significant differences between sex, based on random effects linear regression model.

February 2018 199

Clinical Therapeutics

visits, by participating hospital and sex for the

Admit Male
Proportion
18-month study period can be found in Table III.

0.348
0.225
0.262
0.056
Overall, patients with diagnoses of alcohol-related
issues were significantly older than patients with
diagnoses of other substances (48.8 vs 37.4 years;
Proportion P o 0.001). Compared with patients diagnosed with

Female
Admit alcohol-related problems, patients diagnosed with

0.202
0.229
0.055
0.312
cannabis-related reasons were 15.2 years younger
(95% CI, 14.4–16.1), patients diagnosed with opioid
reasons were 8.8 years younger (95% CI, 8.1–9.6),
Proportion

and patients diagnosed with cocaine reasons were 6.4

Admitted

0.329
0.055

0.244
0.212
years younger (95% CI, 4.9–7.9). When further
Table III. Total emergency department visits, by participating hospital and sex for the 18-month study period.

exploring differences in age by sex and substance,

males diagnosed with alcohol- and cannabis-related
issues were significantly older than females, and
Population Male

females diagnosed with opioid-related reasons were

Proportion

significantly older than males (41.3 vs 38.9 years;

0.444
0.456
0.428
0.473

P o 0.001).
When exploring the disposition from the ED and
with being admitted as the referent group, males were
14% less likely to be discharged than females (odds
ratio ¼ 0.86; 95% CI, 0.79–0.95). However, these
Population
Proportion

Female

0.544
0.556
0.527
0.572

results were not the same across drug types. Figure 1

presents the predicted probabilities of being admitted
after the patient’s visit the ED by drug type and patient
sex. Males patients had a significantly higher probability
32,778
1153

8759
22,866
Admit

of being admitted after their ED visit than females

Male

(P o 0.001), while females were more likely than

males to be admitted if they had a final diagnosis of
cannabis or opioids (P o 0.001). No difference in the
1518
22,828

34,206
9860
Female
Admit

probability of being admitted was observed between

males and females for cocaine or other substances.
The total number drug-related visits to the ED and
45,695

66,985
2671

18,619
Admit
Total

the substance-specific proportions of patient visits to

the ED between January 1, 2016 and July 31, 2017
for alcohol, cannabis, and opioids are presented in
38,918
125,163
20,606
65,639
Male

Figures 2A and 2B. The number of visits for alcohol-

related issues ranges from 252 to 357 per month,
cannabis 59 to 103, and opioids 82 to 134. No
27,573
73,161
48,705
149,439
Female

appreciable trends were observed for the alcohol or

opioids during this time period, but the count and
relative proportion of cannabis-related ED visits
significantly increased (Ptrend ¼ 0.009), with
274,611
48,180
138,808
87,623
Patient
Location Count
Total

cannabis-related visits increasing, on average, 1.1

visits (95% CI, 0.5–2.0) per month during the
course of the 19 months of observation. Figures 2A,
2B and 3A−3D present the overall proportion and
Site C
Site A
Site B

Total

sex-specific proportions of alcohol, cannabis, and

opioid-related visits to the ED. Overall, males had a

200 Volume 40 Number 2

 R.D. Cannon et al.

A
1

100 150 200 250 300 350 400

.9
Probability of being admitted
.8

Emergency Department Cases (n)

*
.7

* *
.6
.5
.4
.3
.2

50
.1

0
0

Alcohol Cannabis Cocaine Opioid Other

Ap 16

N 016

Ap 17
M 016

M 017
J u 16

ec 6

J u 17
Se 16

J a 16
Au 16

7
M 16

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Ju 6

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16

F e 17
1

01
1

1
20

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0
20

20
20

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20
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20
2
r2

r2
l2

l2
Female Male

ar

ct

ar
ay

ov

ay
g
b

b
n

n
p
n

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D
Alcohol Cannabis Opioid
Figure 1. Bar chart of the marginal predicted
probabilities of being admitted after B

1
emergency department visit for drug-

.9
Proportion of drug-related ED visits
related reasons by substance and

.8
patient sex. *P o 0.05 for differences

.7
.6
in predicted probabilities different by

.5
patient sex.

.4
.3
.2
.1

consistent 2:1 ratio of visits the ED for drug-related

reasons compared with females across the evaluation 16

N 016

Ap 17
6

M 017
16

ec 6

Ju 17
Se 16

Ja 16
6

7
16

M 17
16

Ju 7
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01

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20

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2
r2

r2
l2

l2
ar

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n
period. Much of this difference can be attributed to

p
n

n
Ap

Ju
Au
Fe

Ju
Ja

D
alcohol- and cannabis-related visits. Alcohol Cannabis Opioid

Figure 2. (A) Time series plot of the number of

drug-related emergency department
DISCUSSION
(ED) cases from January 2016 until July
Our findings are consistent with prior literature that
2017 for the top 3 substances (alcohol,
illustrates that alcohol use is the most prevalent cannabis, and opioids). (B) Time series
substance encountered in the ED population and is plot of the proportion of drug-related
more prevalent in men than women.9 Across all ED cases out of all drug-related ED
substances, males had an almost 2:1 ratio of visits to cases from January 2016 until July
the ED compared with females during this time frame. 2017 for the top 3 substances (alcohol,
Despite males having a higher prevalence in ED visits cannabis, and opioids).
than females, there were unique sex-specific
differences in disposition based on substance. For
instance, of the 2 most common substances prescription pain medication overdose, 30 go to the
diagnosed in our study (alcohol and opioids), males ED for prescription pain medication misuse or
were more likely to be admitted for alcohol, but less abuse.12 Future research should be geared toward
likely to be admitted for cannabis or opioids than determining what sex-specific interventions to curb
females. In contrast, females were more likely to be this epidemic are most effective in the ED, as well as
admitted for opioid presentations than males. This other setting opportunities. Additionally, sex-specific
may be correlated with the severity of illness differences in disposition after an ED visit related to
previously reported in the Centers for Disease substance use is worthy of consideration by hospital
Control and Prevention findings that from 1999 administrators and treatment facilities when
through 2010, deaths from pain reliever overdoses determining the resources necessary (such as number
increased more rapidly for females (400%) than for of male and female bed occupancy availability) to
males (265%).12 For every female who dies of a prepare for patients that overdose.

February 2018 201

 Clinical Therapeutics

A C

.25
1
Cannabis
.9

.2
.8
Proportion of Cases
.7

.15
Proportion
.6
.5

.1
.4
.3

.05
.2
.1
0

0
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ct 6

ov 6

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ar 7
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Male Female Proportion - Female Proportion - Male Overall

B D

.3
.7

Alcohol Opioids
.6

.25
.5

.2
Proportion
.4

.15
.3

.1
.2

.05
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Proportion - Female Proportion - Male Overall Proportion - Female Proportion - Male Overall

Figure 3. (A) Time series plot of the proportion of drug-related emergency department (ED) cases from January
2016 until July 2017 by patient sex. (B) Time series plot of the proportion of alcohol-related ED cases
from January 2016 until July 2017 by patient sex. (C) Time series plot of the proportion of cannabis-
related ED cases from January 2016 until July 2017 by patient sex. (D) Time series plot of the proportion
of opioid-related ED cases from January 2016 until July 2017 by patient sex.

Our study time frame for trend analysis was small, coding and the impact on study findings of the inherent
making it difficult to generalize patterns of use for many limitations of coding errors is not known. Due to the
of the substances over such a short period of time. Our method of abstraction, our study did not set out to
sex-specific trends found neither remarkable escalations determine whether this diagnosis of substance use was a
nor diminishing patterns in males or females presenting to new or established diagnosis or if there were other
the ED with opioid diagnoses in this time frame. secondary medical problems that complicated the dispo-
sition (admission). While our findings certainly imply
Limitations association of final diagnosis of substance use−related
Although the study was performed involving both diagnosis to admission, due to limitations of electronic
urban and suburban settings, these findings in northeast- data abstraction they do not clearly illustrate causation in
ern Pennsylvania may not be geographically generalizable all the cases that were analyzed. Out of design conven-
to other ED populations. Our results indicate statistical ience prevalence of tobacco use was not studied. We did
significance in age parameters (eg females tended to be 2 not capture ethnicity, insurance status, or other potential
years younger than males) that may not be clinically as confounders for our results. The impact on the study
significant. Electronic abstraction was based on diagnosis results due to the rate of missing data for disposition is

202 Volume 40 Number 2


not known. Electronic abstraction of the records did not
allow for determining whether females and males were
offered admission with the same frequency or whether
women declined the admission (but were not asked to
sign an against medical advice form).
CONCLUSIONS
There are sex-specific differences in prevalence of
those diagnosed with substance use in the ED setting.
The prevalence of opioid use and the sex-specific
differences in disposition for those with opioid use
in comparison with other substances are worthy of
consideration when determining resources necessary
to combat the substance use and overdose epidemic.
ACKNOWLEDGMENTS
The authors would like to acknowledge the research
operations management of Anita Kurt, PhD, RN, and
the research coordinator assistance of Manuel F.
Colón, BS and Micaela B. Wilson, BA.
AUTHOR CONTRIBUTIONS
All authors provided substantial contributions to con-
ception and design, literature search, acquisition of data,
or analysis and interpretation of data. SD performed the
analysis and created the figures. MRG and SD drafted the
article and all authors equally contributed to its revision
for important intellectual content. All authors gave final
approval of the version of the article to be published.
CONFLICTS OF INTEREST
The authors have indicated that they have no conflicts
of interest regarding the content of this article.
REFERENCES
1. Cherpitel C. Drinking patterns and problems: a compar-
ison of primary care with the emergency room. Subst
Abuse. 1999;20:85–95.
2. Mallonee E, Calvin SL. Emergency Department Visits
Involving Underage Drinking. The New DAWN Report.
Address correspondence to: Marna Rayl Greenberg, DO, MPH, Depart-
ment of Emergency and Hospital Medicine, Lehigh Valley Hospital and
Health Network/University of South Florida Morsani College of Medicine,
1909 Earls Court, Allentown, PA 18103. E-mail: mrgdo@ptd.net
February 2018
R.D. Cannon et al.
Rockville MD: (SAMHSA) Office of Applied Studies;
2006.
3. McDonald AJ, Wang N, Camargo CA. US emergency
department visits for alcohol-related disease and injuries
between 1992 and 2000. Arch Intern Med. 2004;164:
531–537.
4. D’Onofrio G, Becker B, Woolard R. The impact of alcohol,
Tobacco and other drug use and abuse in the emergency
department. Emerg Med Clin N Am. 2006;24:925–967.
5. Cherpitel CJ, Ye Y. Trend in alcohol- and drug-related
emergency department and primary care vistis: data from
four U.S. national surveys (1995-2010). J Stud Alcohol
Drugs. 2012;73:454–458.
6. Center for Behavioral Health Statistics and Quality. Key
substance use and mental health indicators in the United
States: Results from the 2015 National Survey on Drug
Use and Health (HHS Publication No. SMA 16-4984,
NSDUH Series H-51); 2016.
7. Substance Abuse and Mental Health Services Adminis-
tration, Center for Behavioral Health Statistics and
Quality. Behavioral health trends in the United States:
Results from the 2014 National Survey on Drug Use and
Health. Rockville, MD: Substance Abuse and Mental
Health Services Administration; 2015.
8. Centers for Disease Control and Prevention. Vital Signs:
Overdoses of Prescription Opioid Pain Relievers—US
1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:
1487–1492.
9. Beaudoin FL, Baird J, Liu T, Merchant R. Sex differences in
substance use among adult emergency patients: preva-
lence, severity, and need for intervention. Acad Emerg Med.
2015;22:1307–1315.
10. National Institute on Drug Abuse. Substance use in women—
sex and gender differences in substance use (pain relievers—
opioids). https://www.drugabuse.gov/publications/resear
ch-reports/substance-use-in-women/sex-gender-differences-in-
substance-use. Accessed August 9, 2017.
11. McHugh RK, DeVito EE, Dodd D, et al. Gender differ-
ences in a clinical trial for prescription opioid dependence.
J Subst Abuse Treat. 2013;45:38–43.
12. Centers for Disease Control and Prevention. Vital signs:
prescription painkiller overdoses: a growing epidemic,
especially among women. www.cdc.gov/vitalsigns/pre
scriptionpainkilleroverdoses/index.html. Reviewed July 2,
2013. Accessed August 9, 2017.
203