Cannabis-Involved Emergency Department Visits Among Persons Aged <25 Years Before and During the COVID-19 Pandemic

United States, 2019-2022

Douglas R. Roehler, PhD; Herschel Smith IV, MPH; Lakshmi Radhakrishnan, MPH; Kristin M. Holland, PhD; Abigail L. Gates, MSPH; Alana M. Vivolo-Kantor, PhD; Brooke E. Hoots, PhD

Disclosures

Morbidity and Mortality Weekly Report. 2023;72(28):758-765.

Abstract and Introduction

Abstract

To understand trends in U.S. cannabis-involved emergency department (ED) visits (i.e., those for which cannabis use was documented in the chief complaint or a discharge diagnosis) among young persons aged <25 years during the COVID-19 pandemic, CDC used National Syndromic Surveillance Program data to examine changes in ED visits during 2019–2022. Mean weekly cannabis-involved ED visits among all young persons were higher during the COVID-19 pandemic in 2020, 2021, and 2022, compared with corresponding periods in 2019. Large increases in cannabis-involved ED visits throughout the COVID-19 pandemic compared with prepandemic surveillance periods in 2019 were identified among persons aged ≤10 years. ED visit rates among children and adolescents aged 11–14 years did not differ by sex until the first half of the 2020–21 school year (2020, weeks 37–53), when ED visit rates among females surpassed those among males. Improving clinicians' awareness of rising cannabis-involved ED visits might aid in early diagnosis of cannabis intoxication among young persons. Further, increasing adults' knowledge regarding safe cannabis storage practices, strengthening youths' coping and problem-solving skills through evidence-based prevention programs, and modifying cannabis packaging to decrease appeal to youths might help prevent intentional and unintentional cannabis use.

Introduction

Approximately 18.7% of U.S. persons aged ≥12 years used cannabis in 2021.* Expansion of legalization of medical and nonmedical cannabis^† has contributed to increased availability and use of cannabis by adults,^[1] and Monitoring the Future data show that youth's perception of the risk of cannabis use has declined.^§ The COVID-19 pandemic has been associated with increases in substance use for some youths;^[2] however, cannabis-involved emergency department (ED) visits began increasing statistically significantly several years before the start of the pandemic among all age groups except ages 15–24 years.^[3]

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Next Section

Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

*https://www.samhsa.gov/data/sites/default/files/2022-12/2021NSDUHFFRHighlights092722.pdf
^† https://www.ncsl.org/health/state-medical-marijuana-laws
^§ https://monitoringthefuture.org/wp-content/uploads/2022/12/mtf2022.pdf

Table 1. Average weekly number of cannabis-involved* emergency department visits ^† among persons aged <25 years, by age group and sex — National Syndromic Surveillance Program, United States, 2019–2022
Year and epidemiologic weeks^§	Average weekly no. of cannabis-involved ED visits by age group, yrs
	≤10			11–14			15–24
	All	Females	Males	All	Females	Males	All	Females	Males
2019
1–11	18.7	9.5	9.3	105.1	49.9	55.1	2,117.5	914.9	1,198.1
12–23	21.9	11.2	10.8	113.9	51.7	62.1	2,316.1	1,007.8	1,303.1
24–36	20.8	10.3	10.5	90.5	41.9	48.2	2,223.5	977.6	1,240.3
37–53	22.2	10.7	11.5	120.6	58.3	62.1	2,426.1	1,053.6	1,366.3
2020
1–11 (prepandemic)	23.3	10.8	12.4	138.5	67.8	70.5	2,531.1	1,119.5	1,403.7
12–23 (second half of school year)	30.4	14.3	16.0	69.8	37.3	32.4	2,275.8	1,013.2	1,257.4
24–36 (summer)	42.8	20.9	21.8	90.8	47.0	43.6	2,555.7	1,177.3	1,370.8
37–53 (first half of school year)	40.3	20.1	20.3	96.4	52.7	43.2	2,364.0	1,095.6	1,261.7
2021
1–11	48.5	24.9	23.5	108.4	63.1	44.9	2,533.1	1,205.8	1,319.5
12–23 (second half of school year)	67.0	32.6	34.3	133.3	76.8	55.8	2,813.2	1,347.2	1,456.1
24–36 (summer)	63.3	30.5	32.7	97.0	56.8	40.0	2,373.5	1,140.2	1,225.6
37–53 (first half of school year)	47.4	24.1	23.3	147.3	88.0	58.9	2,309.2	1,128.4	1,173.3
2022
1–11	57.9	27.4	30.5	184.5	112.9	71.0	2,351.1	1,131.0	1,211.7
12–23 (second half of school year)	66.7	30.7	35.8	209.3	126.0	83.3	2,774.3	1,385.8	1,380.4
24–36 (summer)	71.5	36.2	35.1	127.0	75.0	51.6	2,345.9	1,157.8	1,174.6
37–53 (first half of school year)	66.1	33.6	32.2	187.8	110.9	76.5	2,314.5	1,147.7	1,156.1

Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*NSSP collects free-text reason for visit (chief complaint), discharge diagnosis, and patient demographic details. Free-text keywords and diagnostic codes combined using Boolean searches were used to create a keyword syndrome to identify ED visits involving cannabis. CDC developed and validated a definition for cannabis-involved ED visits using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes F12.1, F12.2, F12.9, or T40.7 or chief complaint text indicating cannabis use (e.g., "smoke weed" or "ingest hash").
^†NSSP receives anonymized medical record information from approximately 75% of nonfederal EDs nationwide. To reduce the artifactual impact of changes in reporting patterns, analyses were restricted to facilities with more consistent reporting of more complete data (coefficient of variation ≤40 and average weekly informative discharge diagnosis ≥75% complete during 2019–2022).
^§A standardized method of counting weeks to allow for the comparison of data year after year; epidemiologic weeks start on a Sunday and end on a Saturday. Four periods were analyzed: prepandemic (epidemiologic weeks 1–11), second half of school year (epidemiologic weeks 12–23), summer (epidemiologic weeks 24–36), and first half of school year (epidemiologic weeks 37–53).

Table 2. Average weekly rate* and visit ratio ^† of cannabis-involved emergency department visits ^§ among persons aged <25 years, by age group — National Syndromic Surveillance Program, United States, 2019–2022
Period, epidemiologic weeks^¶ and metric	Age group, yrs
	≤10				11–14				15–24
	All	Females	Males	Visit ratio (95% CI)** by sex^††	All	Females	Males	Visit ratio (95% CI)** by sex^††	All	Females	Males	Visit ratio (95% CI)** by sex^††
Cannabis-involved ED visit rate
1–11, 2019	0.9	0.9	0.8	1.2 (0.9–1.5)	21.2	19.5	23.0	0.8 (0.8–1.0)	106.5	73.8	160.7	0.5 (0.4–0.5)
12–23, 2019	1.1	1.2	1.0	1.2 (1.0–1.5)	22.5	20.4	24.6	0.8 (0.7–0.9)	112.9	80.1	165.2	0.5 (0.5–0.5)
24–36, 2019	1.2	1.3	1.1	1.2 (0.9–1.5)	21.9	20.7	23.0	0.9 (0.8–1.0)	109.4	79.1	156.2	0.5 (0.5–0.5)
37–53, 2019	1.0	1.1	1.0	1.1 (0.9–1.3)	23.2	22.9	23.5	1.0 (0.9–1.1)	116.4	82.3	170.8	0.5 (0.5–0.5)
1–11, 2020	1.0	1.0	1.0	1.0 (0.8–1.3)	25.8	24.6	27.1	0.9 (0.8–1.0)	119.5	85.8	173.3	0.5 (0.5–0.5)
12–23, 2020	4.2	4.3	4.1	1.1 (0.9–1.3)	38.9	40.5	37.3	1.1 (0.9–1.2)	188.2	142.2	254.0	0.6 (0.5–0.6)
24–36, 2020	4.5	4.8	4.3	1.1 (1.0–1.3)	32.4	32.8	31.9	1.0 (0.9–1.2)	151.4	116.7	202.6	0.6 (0.6–0.6)
37–53, 2020	4.1	4.5	3.8	1.2 (1.0–1.4)	32.4	34.2	30.3	1.1 (1.0–1.3)	143.5	108.8	197.7	0.6 (0.5–0.6)
1–11, 2021	5.0	5.5	4.5	1.2 (1.0–1.5)	37.7	40.6	34.0	1.2 (1.1–1.3)	162.0	125.4	220.1	0.6 (0.6–0.6)
12–23, 2021	4.6	4.9	4.3	1.1 (1.0–1.3)	34.9	39.1	30.0	1.3 (1.2–1.4)	152.9	120.9	201.7	0.6 (0.6–0.6)
24–36, 2021	3.6	3.7	3.4	1.1 (1.0–1.3)	23.9	27.8	19.8	1.4 (1.3–1.6)	117.7	93.6	154.3	0.6 (0.6–0.6)
37–53, 2021	2.5	2.8	2.2	1.2 (1.1–1.4)	32.2	38.3	26.0	1.5 (1.4–1.6)	117.7	94.5	153.8	0.6 (0.6–0.6)
1–11, 2022	3.8	3.9	3.7	1.0 (0.9–1.2)	45.5	53.2	36.9	1.4 (1.3–1.6)	133.6	105.1	178.2	0.6 (0.6–0.6)
12–23, 2022	3.4	3.4	3.4	1.0 (0.9–1.2)	44.4	53.3	35.5	1.5 (1.4–1.6)	144.6	119.0	184.1	0.6 (0.6–0.7)
24–36, 2022	4.0	4.5	3.6	1.2 (1.1–1.4)	32.5	39.3	25.9	1.5 (1.4–1.7)	122.4	100.2	154.4	0.7 (0.6–0.7)
37–53, 2022	2.7	2.9	2.4	1.2 (1.1–1.4)	35.8	43.2	28.7	1.5 (1.4–1.6)	117.6	96.1	150.1	0.6 (0.6–0.7)
Cannabis-involved ED visit ratio (95% CI) during pandemic compared to corresponding surveillance periods in 2019**
1–11, 2020^§§	1.0	1.0	1.0	—	25.8	24.6	27.1	—	119.5	85.8	173.3	—
12–23, 2020	4.0 (3.4–4.6)	3.7 (2.9–4.6)	4.2 (3.4–5.3)	—	1.7 (1.6–1.9)	2.0 (1.8–2.2)	1.5 (1.3–1.7)	—	1.7 (1.6–1.7)	1.8 (1.7–1.8)	1.5 (1.5–1.6)	—
24–36, 2020	3.7 (3.2–4.3)	3.6 (3.0–4.5)	3.8 (3.1–4.6)	—	1.5 (1.4–1.6)	1.6 (1.4–1.8)	1.4 (1.2–1.6)	—	1.4 (1.4–1.4)	1.5 (1.4–1.5)	1.3 (1.3–1.3)	—
37–53, 2020	4.1 (3.6–4.7)	4.3 (3.6–5.2)	4.0 (3.3–4.8)	—	1.4 (1.3–1.5)	1.5 (1.4–1.6)	1.3 (1.2–1.4)	—	1.2 (1.2–1.3)	1.3 (1.3–1.4)	1.2 (1.1–1.2)	—
1–11, 2021	5.8 (5.0–6.9)	6.0 (4.8–7.5)	5.6 (4.5–7.1)	—	1.8 (1.6–1.9)	2.1 (1.9–2.3)	1.5 (1.3–1.7)	—	1.5 (1.5–1.6)	1.7 (1.7–1.7)	1.4 (1.3–1.4)	—
12–23, 2021	4.4 (3.8–5.0)	4.2 (3.5–5.1)	4.5 (3.7–5.5)	—	1.5 (1.4–1.7)	1.9 (1.7–2.1)	1.2 (1.1–1.4)	—	1.4 (1.3–1.4)	1.5 (1.5–1.6)	1.2 (1.2–1.3)	—
24–36, 2021	2.9 (2.5–3.3)	2.8 (2.3–3.4)	3.0 (2.5–3.6)	—	1.1 (1.0–1.2)	1.3 (1.2–1.5)	0.9 (0.8–1.0)	—	1.1 (1.1–1.1)	1.2 (1.2–1.2)	1.0 (1.0–1.0)	—
37–53, 2021	2.4 (2.2–2.8)	2.6 (2.2–3.1)	2.3 (2.0–2.8)	—	1.4 (1.3–1.5)	1.7 (1.5–1.8)	1.1 (1.0–1.2)	—	1.0 (1.0–1.0)	1.2 (1.1–1.2)	0.9 (0.9–0.9)	—
1–11, 2022	4.4 (3.8–5.2)	4.2 (3.4–5.3)	4.7 (3.7–5.8)	—	2.2 (2.0–2.3)	2.7 (2.5–3.0)	1.6 (1.4–1.8)	—	1.3 (1.2–1.3)	1.4 (1.4–1.5)	1.1 (1.1–1.1)	—
12–23, 2022	3.2 (2.8–3.7)	2.9 (2.4–3.6)	3.5 (2.9–4.3)	—	2.0 (1.9–2.1)	2.6 (2.4–2.9)	1.4 (1.3–1.6)	—	1.3 (1.3–1.3)	1.5 (1.5–1.5)	1.1 (1.1–1.1)	—
24–36, 2022	3.3 (2.9–3.7)	3.4 (2.8–4.1)	3.2 (2.6–3.8)	—	1.5 (1.4–1.6)	1.9 (1.7–2.1)	1.1 (1.0–1.3)	—	1.1 (1.1–1.1)	1.2 (1.1–1.2)	1.0 (1.0–1.0)	—
37–53, 2022	2.6 (2.3–3.0)	2.8 (2.4–3.3)	2.5 (2.1–2.9)	—	1.5 (1.5–1.6)	1.9 (1.7–2.0)	1.2 (1.1–1.3)	—	1.0 (1.0–1.0)	1.2 (1.1–1.2)	0.9 (0.9–0.9)	—

Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*Rate is the number of cannabis-involved ED visits per 10,000 ED visits. NSSP collects free-text reason for visit (chief complaint), discharge diagnosis, and patient demographic details. Free-text keywords and diagnostic codes combined using Boolean searches were used to create a keyword syndrome to identify ED visits involving cannabis. CDC developed and validated a definition for cannabis-involved ED visits using International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes F12.1, F12.2, F12.9, or T40.7 or chief complaint text indicating cannabis use (e.g., "smoke weed" or "ingest hash").
^†Visit ratios were calculated by dividing the rate of cannabis-related ED visits during the surveillance period by the rate of cannabis-related ED visits during the reference period. The reference period is the 2019 period (i.e., epidemiologic weeks) corresponding to the surveillance period. Ratios >1 indicate a higher rate of cannabis-related ED visits during the surveillance period than the reference period. Visit ratio analyses did not include weeks 1–11, 2020 as a reference period.
^§NSSP receives anonymized medical record information from approximately 75% of nonfederal EDs nationwide. To reduce the artifactual impact of changes in reporting patterns, analyses were restricted to facilities with more consistent reporting of more complete data (coefficient of variation ≤40 and average weekly informative discharge diagnosis ≥75% complete during 2019–2022).
^¶A standardized method of counting weeks to allow for the comparison of data year after year; epidemiologic weeks start on a Sunday and end on a Saturday. Four periods were analyzed: prepandemic (epidemiologic weeks 1–11), second half of school year (epidemiologic weeks 12–23), summer (epidemiologic weeks 24–36), and first half of school year (epidemiologic weeks 37–53).
**95% CIs that exclude 1 are statistically significant.
^††Visit ratios by sex were calculated by dividing the rate of female cannabis-related ED visits during the surveillance period by the rate of male visits during the same period. Ratios >1 indicate a higher rate of female than male cannabis-involved ED visits during the specified surveillance period.
^§§Visit ratios were not calculated for weeks 1–11, 2020 because this surveillance period is still considered prepandemic.