The rise in substance use related ED visits was driven by sedatives, stimulants, and hallucinogens, with alcohol and other substance use-related visits being relatively stable .There was a parallel increase in mental health-related visits, with these visits making up 2.34% of total ED visits in 2013 and 3.88% in 2018, representing a 66% relative increase. Among substance-use related visits, the 25-44 age group made up 44.58% of visits, as compared to 35.49% of the non-substance related group . There was also a male predominance among substance use-related visits: males accounted for 63.38% of visits in the substance group vs 41.74% in the reference group . While the West geographic area accounted for only 21.34% of all ED visits, it made up 29.67% of substance use-related visits. In addition, substance use-related visits were much more likely to happen during the night shift , with 27.07% of all substance use-related visits taking place then compared to 14.81% in the reference group . Mental health issues were more prevalent in the substance use group compared to the reference group, present in 14.48% vs 2.99%, respectively. With regard to the primary outcomes, patients associated with substance use-related visits were more likely to undergo any diagnostic study and toxicology screening ; however, they were less likely to have imaging studies . There were no significant differences in the use of medications or procedures between the substance use and reference groups, with the differences in means being 0.08 and 0.04 , respectively . Substance use-related visits were associated with higher odds of admission or transfer to another facility and higher odds of receiving a mental health consult [aOR 5.70; 95% CI: 4.47-7.28; P <0.0001. With regard to stratified analyses those patients with mental health disorders were more likely to have imaging studies,vertical farming system and this reached statistical significance for interaction .

For substance use-related visits without the concurrent presence of a mental health disorder, the aOR of undergoing any imaging study was 0.65 , and for substance use-related visits with concurrent mental health disorder, the aOR of undergoing any imaging study was 1.44 . All substance use-related ED visits were more likely to undergo toxicology screening, but those without concurrent mental health disorders were even more likely to receive screening, with aOR of 11.47 . The presence of a mental health disorder did not have an impact on the relationship between undergoing any diagnostic study in ED and substance use .Consistent with previously published work, our study shows that sedative-, stimulant-, and hallucinogen- related ED visits continue to increase rapidly compared to alcohol and other substances of abuse.Substance use-related ED visits are more likely to result in diagnostic investigations overall, admission or transfer to another facility, and mental health consultations. Conversely, they are less likely to result in imaging studies. While the higher rate of admission/transfer and mental health consultations for substance use- related ED visits has been reported previously,to our knowledge the use of diagnostic services has not yet been assessed at the national level. Among the common substances of abuse, the rapid increase in stimulant-related ED visits in recent years is remarkable; in 2018, the percentage of stimulant-related visits matched that of sedative-related visits , representing approximately 0.7% of total ED visits. This is consistent with other study findings that have reported a rise in prevalence of stimulant use across all age groups from 2010–2014, with adults between 20-64 years the most affected.Our study also showed that the rise in stimulant-related visits was more pronounced in the 18-44 age group , compared to the > 45 years age group . The most frequently cited motivation for stimulant use among adults was performance enhancement,which supports the need to improve public education for young adults on the addictive potential of stimulants and restricting prescriptions to appropriate clinical indications only. Regarding the use of diagnostic services in the ED for substance use-related visits, research has been relatively sparse. Our study showed that substance use-related visits are more likely to receive diagnostic services overall and toxicology screening.

Some studies have called into question the routine practice of ordering urine drug screens for substance-related visits and laboratory studies in general for mental health-related visits, as they have rarely led to changes in management.The American Psychiatric Association and the American College of Emergency Physicians both support targeted diagnostic investigations for patients presenting with acute psychiatric symptoms, instead of routine testing.However, drug testing is often required as part of initial assessment to enter treatment facilities, regardless of medical indication or emergency healthcare team preferences.Although most of the studies on this topic focused on mental health-related ED visits, the often-overlapping presentations of substance- and mental health-related visits argue for standardization of practices to diagnostic services. In terms of the use of imaging studies specifically, both ACEP and the APA support individual assessment of risk factors to guide brain imaging in the ED for mental health-related visits, due to low yield of routine imaging.In contrast to our finding of substance use-related visits being associated with less use of imaging studies, previous work has shown a rising trend in the use of CTalong with the rise of opioid-related visits.However, that study did not assess the use of CT in relation to a non-substance use reference group and did not include other imaging modalities. The lower rate of utilization of imaging studies could be explained by the possibility that imaging was not needed for management or disposition after completion of laboratory screening in substance use-related visits. In addition, since substance use-related visits occurred disproportionately after hours, imaging might not be readily available after hours in smaller centers. Visiting hours were adjusted for as a potential confounder; so the latter explanation is considered less likely. Notably, the presence of a mental health disorder made it more likely for patients with a substance use diagnosis to undergo imaging studies. It is well documented that patients with serious mental health disorders have higher mortality rates than those without, attributable to both injuries and chronic diseases.It is, therefore, possible that additional imaging studies were needed because of increased medical complexity.

Furthermore, the presence of SUDs was associated with significantly increased rates of mental health consultations in the ED, which in turn have been shown to be associated with increased ED length of stay.These findings support the fact that healthcare is more costly for patients with mental health or SUDs, highlighting the need to address physical and mental health in an integrated fashion.In fact, multiple studies have shown the effectiveness of case coordination and combined medical and behavioral health clinics to help decrease substance use- or mental health-related ED visits.Our study results should be interpreted in the context of several limitations. First, only associations and no causal relationships could be made due to the cross-sectional nature of the study. Second, it is possible that some substance use related ED visits represented repeated visits over time, meaning the statistical methods used in the analysis could yield biased results away from the null. As the NHAMCS is an event-level database, it is not possible to ascertain this as data linkage could not be performed. Third, the study results relied heavily on ED reporting and ICD codes, which could be subject to inaccuracies and bias the results toward the null, although steps were taken to mitigate this through staff training. Fourth, due to limitations in sample size, detailed analysis on the specific types of diagnostic services or imaging modalities, with the exception of toxicology screening, were not done. Further studies incorporating data from previous years would be needed to obtain more granular data. Fifth, due to concerns about multiplicity, resource utilization pattern with respect to the subgroups of substances analyzed can only be used for hypothesis-generating purposes. Furthermore, improved screening strategies for substance use in the ED could have contributed to the increase in visits,indoor grow facility following the emergence of evidence demonstrating improved outcomes associated with ED initiated interventions, biasing the results away from the null.Finally, this study did not include information on ED-initiated substance use treatment or outpatient referral pattern over time, making it difficult to comment on specific strategies to help improve care for patients with SUD in the ED. In summary, many of the limitations arose from the design of the survey itself and were difficult to mitigate at the data analysis stage. Marijuana and tobacco co-use is common among young adults . On average, young adults perceive marijuana as less harmful to health, less addictive, and more socially acceptable than tobacco , and are less ready to quit marijuana than cigarettes . While a few studies have found that marijuana users were less likely to quit smoking than non-users , others have found no significant differences in smoking outcomes between marijuana co-users and non-marijuana users . Previous research focused on general adult populations, collected data in-person, and was conducted before the advent of widespread changes in marijuana legalization and social norms . It is unclear whether and to what extent marijuana use interferes with smoking cessation and related outcomes among young adults in an era of rapidly shifting laws and attitudes regarding marijuana. It is particularly important to study young adults in this context, because they are less likely to seek smoking cessation treatment and are more likely to use marijuana than are older adults. Moreover, due to the stigma around marijuana use and its illegal status in many states, collecting data online may be a useful strategy to improve accuracy of self-reported marijuana use and to further examine its relationship with smoking cessation. Lastly, marijuana use has become increasingly accepted in society and increasingly common among cigarette smokers .

Given the widespread availability and acceptability of marijuana among young adults, current tobacco smokers may experience more difficulty quitting than those surveyed in previous decades. As such, this study uses data from a randomized controlled trial of the Tobacco Status Project , a smoking cessation intervention for young adults delivered on Facebook, to examine differences in smoking outcomes between marijuana users and non-marijuana users. Participants were young adult smokers who reported smoking 100+ cigarettes in their lifetime, currently smoking 1+ cigarettes per day 3+ days per week and using Facebook 4+ days per week, and who were English literate. Recruitment consisted of a paid Facebook ad campaign from October 2014 to July 2015 . Clicking on an ad redirected participants to a confidential eligibility survey. Eligible, consented participants were randomly assigned to one of two conditions: 1) the Tobacco Status Project intervention, or 2) referral to the National Cancer Institute’s Smoke free.gov website . Participants in both conditions were included in all analyses except treatment engagement and perceptions . TSP included assignment to a private Facebook group tailored to participants’ readiness to quit smoking, daily Facebook contact with study staff, weekly live counseling sessions, and six additional Cognitive Behavioral Therapy counseling sessions for those ready to quit. Study staff posted once a day for 90 days and participants were asked to comment on the posts. Post content varied by readiness to quit smoking and included strategies informed by the Transtheoretical Model and the U.S. Clinical Practice Guidelines for smoking cessation . Participants were emailed follow-up surveys at 3, 6, and 12 months after the study began. This research was approved by the University of California, San Francisco Institutional Review Board. Nicotine dependence was assessed using the 6-item Fagerström Test of Cigarette Dependence , scored on a scale of 0 to 10, from low to heavy dependence. Daily smoking at baseline was measured with the item, “On average, how many days in a week do you smoke cigarettes ?”. Responses were recoded into daily smoking or non-daily smoking . The Smoking History Questionnaire assessed early smoking as well as usual number of cigarettes smoked per day. The Stages of Change Questionnaire was used to categorize participants into one of three stages of change based on their readiness to quit smoking at baseline. Alcohol is another substance commonly used by young adults, and use of alcohol can co-occur with tobacco and/or marijuana . Hence, we measured alcohol use for possible inclusion as a covariate in the models, using the item, “Have you consumed alcohol in the past 30 days?” .Current marijuana use was measured at each time point using the Staging Health Risk Assessment , based on the Transtheoretical Model stages of change and the Healthy People 2020 goals for the United States .