STUDY OBJECTIVE: To understand trends in nonfatal firearm injuries by examining rates of firearm injury emergency department (ED) visits stratified by individual- and county-level characteristics. METHODS: Data from participating EDs within 10 jurisdictions in the United States funded through the Centers for Disease Control and Prevention's Firearm Injury Surveillance Through Emergency Rooms program, including the District of Columbia, Florida, Georgia, New Mexico, North Carolina, Oregon, Utah, Virginia, Washington, and West Virginia, were analyzed. We examined trends in firearm injury ED visits by sex, age group, jurisdiction, county-level urbanicity, and county-level social vulnerability from January 2019 to August 2023. Mean weekly rates of firearm injury ED visits and visit ratios (or the proportion of firearm injury-related ED visits of all visits during the surveillance periods with the same period in 2019) were calculated. RESULTS: Compared with 2019, the proportion of ED visits for firearm injury was elevated each year during 2020 to 2023 overall, with the largest observed increase in 2020 (visit ratio=1.59). All 10 Firearm Injury Surveillance Through Emergency Rooms jurisdictions experienced an increase in the proportion of firearm injury ED visits in 2020 (visit ratios ranging from 1.26 in West Virginia and 2.31 in Washington, DC) when compared with 2019. By county-level social vulnerability, the mean weekly rate of firearm injury ED visits was highest in counties with the highest social vulnerability over the entire study period. CONCLUSION: Results highlight the continued burden of firearm injuries in communities with higher social vulnerability. Timely ED data by community social vulnerability can inform public health interventions and resource allocation at local, state, and national levels.

Objectives. To examine trends in overdose deaths by intent and drug category to better understand the recent decrease in overdose suicides amid the overdose epidemic. Methods. We examined trends in rates of overdose deaths by intent (unintentional, suicide, or undetermined) across 9 drug categories from 1999 to 2022 using US National Vital Statistics System mortality data. Results. Unintentional overdoses involving synthetic opioids, polydrug toxicity involving synthetic opioids, psychostimulants, and cocaine increased exponentially with annual percentage changes ranging from 15.0% to 104.9% during 2010 to 2022. The death rates also increased for suicides involving these drugs, especially for psychostimulants (annual percentage change = 12.9% for 2010-2022; P < .001). However, these drugs accounted for relatively small percentages of overdose suicides. The leading drug categories among suicides were antidepressants, prescription opioids, and benzodiazepines, though these deaths have decreased or leveled off in recent years. Conclusions. Different drugs commonly involved in suicides and unintentional overdoses may contribute to their divergent trends. Public Health Implications. Amid the overdose epidemic, safe storage of medications remains a crucial strategy to prevent overdose suicides. The large increases in suicides involving psychostimulants warrant monitoring. (Am J Public Health. Published online ahead of print August 8, 2024:e1-e5. https://doi.org/10.2105/AJPH.2024.307745).

INTRODUCTION: In 2020, suicide was the 12th leading cause of death among adults in the U.S. Previous research has shown that one common precipitating circumstance among adult suicide decedents is experiencing intimate partner problems (IPPs), such as divorce, separation, romantic break-ups, arguments, conflicts, and intimate partner violence. This study examines how precipitating factors differ between IPP- and non-IPP-related suicides. METHODS: In 2022, this study analyzed National Violent Death Reporting System data from adult suicide decedents in 48 states and 2 territories between 2003 and 2020. Multivariable logistic regression models were used to compare precipitating circumstances between IPP- and non-IPP-related suicides, controlling for sociodemographic characteristics. RESULTS: Of the 402,391 suicides, 20% (n=80,717) were known to be IPP-related. Circumstances that significantly increased the odds of IPP-related suicides included a history of suicidal thoughts and attempts and mental health problems (depressed mood, alcohol problem, mental health diagnosis), life stressors (interpersonal violence perpetration and victimization, arguments, financial problems, job problems, family problems), and recent legal problems. Non-IPP-related suicides were more likely to occur among older individuals and to be precipitated by a physical health problem or crime. CONCLUSIONS: The findings can inform prevention strategies that build resiliency and problem-solving skills, strengthen economic support, and identify and assist people at risk for IPP-related suicides. The Centers for Disease Control and Prevention's Suicide Resource for Action and Intimate Partner Violence Prevention resource packages highlight the best available evidence for policies, programs, and practices related to preventing suicides and IPP.

Mental health encompasses a range of mental, emotional, social, and behavioral functioning and occurs along a continuum from good to poor. Previous research has documented that mental health among children and adolescents is associated with immediate and long-term physical health and chronic disease, health risk behaviors, social relationships, education, and employment. Public health surveillance of children's mental health can be used to monitor trends in prevalence across populations, increase knowledge about demographic and geographic differences, and support decision-making about prevention and intervention. Numerous federal data systems collect data on various indicators of children's mental health, particularly mental disorders. The 2013-2019 data from these data systems show that mental disorders begin in early childhood and affect children with a range of sociodemographic characteristics. During this period, the most prevalent disorders diagnosed among U.S. children and adolescents aged 3-17 years were attention-deficit/hyperactivity disorder and anxiety, each affecting approximately one in 11 (9.4%-9.8%) children. Among children and adolescents aged 12-17 years, one fifth (20.9%) had ever experienced a major depressive episode. Among high school students in 2019, 36.7% reported persistently feeling sad or hopeless in the past year, and 18.8% had seriously considered attempting suicide. Approximately seven in 100,000 persons aged 10-19 years died by suicide in 2018 and 2019. Among children and adolescents aged 3-17 years, 9.6%-10.1% had received mental health services, and 7.8% of all children and adolescents aged 3-17 years had taken medication for mental health problems during the past year, based on parent report. Approximately one in four children and adolescents aged 12-17 years reported having received mental health services during the past year. In federal data systems, data on positive indicators of mental health (e.g., resilience) are limited. Although no comprehensive surveillance system for children's mental health exists and no single indicator can be used to define the mental health of children or to identify the overall number of children with mental disorders, these data confirm that mental disorders among children continue to be a substantial public health concern. These findings can be used by public health professionals, health care providers, state health officials, policymakers, and educators to understand the prevalence of specific mental disorders and other indicators of mental health and the challenges related to mental health surveillance.

BACKGROUND: Delta-8 tetrahydrocannabinol (THC) is a psychoactive cannabinoid found in small amounts naturally in the cannabis plant; it can also be synthetically produced in larger quantities from hemp-derived cannabidiol. Most states permit the sale of hemp and hemp-derived cannabidiol products; thus, hemp-derived delta-8 THC products have become widely available in many state hemp marketplaces, even where delta-9 THC, the most prominently occurring THC isomer in cannabis, is not currently legal. Health concerns related to the processing of delta-8 THC products and their psychoactive effects remain understudied. OBJECTIVE: The goal of this study is to implement a novel topic modeling approach based on transformers, a state-of-the-art natural language processing architecture, to identify and describe emerging trends and topics of discussion about delta-8 THC from social media discourse, including potential symptoms and adverse health outcomes experienced by people using delta-8 THC products. METHODS: Posts from January 2008 to December 2021 discussing delta-8 THC were isolated from cannabis-related drug forums on Reddit (Reddit Inc), a social media platform that hosts the largest web-based drug forums worldwide. Unsupervised topic modeling with state-of-the-art transformer-based models was used to cluster posts into topics and assign labels describing the kinds of issues being discussed with respect to delta-8 THC. Results were then validated by human subject matter experts. RESULTS: There were 41,191 delta-8 THC posts identified and 81 topics isolated, the most prevalent being (1) discussion of specific brands or products, (2) comparison of delta-8 THC to other hemp-derived cannabinoids, and (3) safety warnings. About 5% (n=1220) of posts from the resulting topics included content discussing health-related symptoms such as anxiety, sleep disturbance, and breathing problems. Until 2020, Reddit posts contained fewer than 10 mentions of delta-8-THC for every 100,000 cannabis posts annually. However, in 2020, these rates increased by 13 times the 2019 rate (to 99.2 mentions per 100,000 cannabis posts) and continued to increase into 2021 (349.5 mentions per 100,000 cannabis posts). CONCLUSIONS: Our study provides insights into emerging public health concerns around delta-8 THC, a novel substance about which little is known. Furthermore, we demonstrate the use of transformer-based unsupervised learning approaches to derive intelligible topics from highly unstructured discussions of delta-8 THC, which may help improve the timeliness of identification of emerging health concerns related to new substances.

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.

The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates(†) (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs,(§) suicide-related behaviors (including suspected suicide attempts), and drug-involved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health.

INTRODUCTION: It is widely accepted that suicides-which account for more than 47 500 deaths per year in the United States-are undercounted by 10% to 30%, partially due to incomplete death scene investigations (DSI) and varying burden-of-proof standards across jurisdictions. This may result in the misclassification of overdose-related suicides as accidents or undetermined intent. METHODS: Virtual and in-person meetings were held with suicidologists and DSI experts from five states (Spring-Summer 2017) to explore how features of a hypothetical electronic DSI tool may help address these challenges. RESULTS: Participants envisioned a mobile DSI application for cell phones, tablets, or laptop computers. Features for systematic information collection, scene description, and guiding key informant interviews were perceived as useful for less-experienced investigators. DISCUSSION: Wide adoption may be challenging due to differences in DSI standards, practices, costs, data privacy and security, and system integration needs. However, technological tools that support consistent and complete DSIs could strengthen the information needed to accurately identify overdose suicides.

In Reply Schoenbaum and Colpe identify important limitations to our study1 on trends in emergency department (ED) visits for mental health, overdose, and violence before and during the COVID-19 pandemic. Specifically, they highlight 3 aspects of the data from the National Syndromic Surveillance Program (NSSP) at the US Centers for Disease Control and Prevention (CDC) that affected the interpretation of reported trends, including the expanded coverage of the NSSP over time, that analyses were not limited to EDs with consistent participation, and that rates per population were not reported.

During the COVID-19 pandemic, the U.S. firearm homicide rate increased by nearly 35%, and the firearm suicide rate remained high during 2019-2020 (1). Provisional mortality data from the National Vital Statistics System indicate that rates continued to increase in 2021: the rates of firearm homicide and firearm suicide in 2021 were the highest recorded since 1993 and 1990, respectively (2). Firearm injuries treated in emergency departments (EDs), the primary setting for the immediate medical treatment of such injuries, gradually increased during 2018-2019 (3); however, more recent patterns of ED visits for firearm injuries, particularly during the COVID-19 pandemic, are unknown. Using data from the National Syndromic Surveillance Program (NSSP),* CDC examined changes in ED visits for initial firearm injury encounters during January 2019-December 2022, by year, patient sex, and age group. Increases in the overall weekly number of firearm injury ED visits were detected at certain periods during the COVID-19 pandemic. One such period during which there was a gradual increase was March 2020, which coincided with both the declaration of COVID-19 as a national emergency(†) and a pronounced decrease in the total number of ED visits. Another increase in firearm injury ED visits occurred in late May 2020, concurrent with a period marked by public outcry related to social injustice and structural racism (4), changes in state-level COVID-19-specific prevention strategies,(§) decreased engagement in COVID-19 mitigation behaviors (5), and reported increases in some types of crime (4). Compared with 2019, the average number of weekly ED visits for firearm injury was 37% higher in 2020, 36% higher in 2021, and 20% higher in 2022. A comprehensive approach is needed to prevent and respond to firearm injuries in communities, including strategies that engage community and street outreach programs, implement hospital-based violence prevention programs, improve community physical environments, enhance secure storage of firearms, and strengthen social and economic supports.

IMPORTANCE: Suicide prevention is an important component of depression management. Knowledge about depressed adolescents with increased risk for suicide can inform suicide prevention efforts. OBJECTIVE: To describe the risk of documented suicidal ideation within a year following a diagnosis of depression and to examine how the risk of documented suicidal ideation differed by recent violence encounter status among adolescents with new depression diagnoses. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study in clinical settings including outpatient facilities, emergency departments, and hospitals. Using IBM's Explorys database containing electronic health records from 26 US health care networks, this study observed a cohort of adolescents with new depression diagnoses from 2017 to 2018 for up to 1 year. Data were analyzed from July 2020 to July 2021. EXPOSURES: Recent violence encounter was defined by a diagnosis of child maltreatment (physical, sexual, or psychological abuse or neglect) or physical assault within 1 year before depression diagnosis. MAIN OUTCOMES AND MEASURES: The main outcome was diagnosis of suicidal ideation within 1 year following depression diagnosis. Multivariable adjusted risk ratios of suicidal ideation were calculated for overall recent violence encounters and for individual forms of violence. RESULTS: Among a total of 24 047 adolescents with depression, 16 106 (67.0%) were female and 13 437 (55.9%) were White. A total of 378 had experienceda violence (hereafter, encounter group) and 23 669 had not (hereafter, nonencounter group). Following the diagnosis of depression, 104 adolescents with any past-year violence encounter (27.5%) documented suicidal ideation within 1 year. In contrast, 3185 adolescents in the nonencounter group (13.5%) experienced thoughts of suicide following the diagnosis of depression. In multivariable analyses, those with any violence encounter had 1.7 times (95% CI 1.4-2.0) higher risk of documented suicidal ideation compared with those in the nonencounter group (P < .001). Among different forms of violence, sexual abuse (risk ratio, 2.1; 95% CI, 1.6-2.8) and physical assault (risk ratio, 1.7; 95% CI, 1.3-2.2) were associated with significantly increased risk of suicidal ideation. CONCLUSIONS AND RELEVANCE: Among adolescents with depression, persons who experienced past-year violence encounters showed a higher rate of suicidal ideation than those who had not. These findings highlight the importance of identifying and accounting for past violence encounters when treating adolescents with depression to reduce risk of suicide. Public health approaches to prevent violence may help to avert morbidity associated with depression and suicidal ideation.

Lifelong health and well-being are rooted in developmental experiences faced during childhood.1 Adverse childhood experiences (ACEs) are preventable, potentially traumatic events that occur in childhood (age 017 years) such as witnessing or experiencing violence, experiencing neglect, or having a family member attempt or die by suicide. Exposure to ACEs is linked to negative outcomes later in life, including chronic disease; mental health and substance use problems; and even lower education attainment, fewer job opportunities, and decreased earning potential.1, 2, 3, 4, 5 More than 60% of adults report experiencing 1 ACE during childhood, and nearly 1 in 6 adults report experiencing 4 ACEs.6 Recent research suggests that preventing ACEs could potentially reduce millions of cases of heart disease, depression, and other negative health outcomes.6 Given the prevalence of ACEs, their documented impacts on future health and social outcomes, and the potential impacts of prevention efforts, investments in ACE prevention may help to improve public health across the lifespan.

INTRODUCTION: Adverse childhood experiences and overdose are linked in a cycle that affects individuals and communities across generations. The Centers for Disease Control and Prevention's Overdose Data to Action cooperative agreement supports a comprehensive public health approach to overdose prevention and response activities across the U.S. Exposure to traumatic events during childhood can increase the risk for myriad health outcomes, including overdose; therefore, many Overdose Data to Action recipients leveraged funds to address adverse childhood experiences. METHODS: In 2021, an inventory of Overdose Data to Actionfunded activities implemented in 2019 and 2020 showed that 34 of the 66 recipients proposed overdose prevention activities that support people who have experienced adverse childhood experiences or that focus on preventing the intergenerational transmission of adverse childhood experiences. Activities were coded by adverse childhood experience prevention strategy, level of the social ecology, and whether they focused on neonatal abstinence syndrome. RESULTS: Most activities among Overdose Data to Action recipients occurred at the community level of the socialecologic model and under the intervene to lessen harms adverse childhood experience prevention strategy. Of the 84 adverse childhood experiencerelated activities taking place across 34 jurisdictions, 44 are focused on neonatal abstinence syndrome. CONCLUSIONS: Study results highlight the opportunities to expand the breadth of adverse childhood experience prevention strategies across the social ecology. Implementing cross-cutting overdose and adverse childhood experiencerelated activities that span the socialecologic model are critical for population-level change and have the potential for the broadest impact. Focusing on neonatal abstinence syndrome also offers a unique intervention opportunity for both adverse childhood experience and overdose prevention.

STUDY OBJECTIVE: We describe trends in emergency department (ED) visits for initial firearm injury encounters in the United States. METHODS: Using data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program, we analyzed monthly and yearly trends in ED visit rates involving a firearm injury (calculated as the number of firearm injury-related ED visits divided by the total number of ED visits for each month and multiplied by 100,000) by sex-specific age group and US region from 2018 to 2019 and conducted Joinpoint regression to detect trend significance. RESULTS: Among approximately 215 million ED visits captured in the National Syndromic Surveillance Program from January 2018 to December 2019, 132,767 involved a firearm injury (61.6 per 100,000 ED visits). Among males, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 64 years during the study period. Among females, rates of firearm injury-related ED visits significantly increased for all age groups between 15 and 54 years during the study period. By region, rates significantly changed in the northeast, southeast, and southwest for males and females during the study period. CONCLUSION: These analyses highlight a novel data source for monitoring trends in ED visits for firearm injuries. With increased and effective use of state and local syndromic surveillance data, in addition to improvements to firearm injury syndrome definitions by intent, public health professionals could better detect unusual patterns of firearm injuries across the United States for improved prevention and tailored response efforts.

In 2021, a national emergency* for children's mental health was declared by several pediatric health organizations, and the U.S. Surgeon General released an advisory(†) on mental health among youths. These actions resulted from ongoing concerns about children's mental health in the United States, which was exacerbated by the COVID-19 pandemic (1,2). During March-October 2020, among all emergency department (ED) visits, the proportion of mental health-related visits increased by 24% among U.S. children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with 2019 (2). CDC examined changes in U.S. pediatric ED visits for overall mental health conditions (MHCs) and ED visits associated with specific MHCs (depression; anxiety; disruptive behavioral and impulse-control disorders; attention-deficit/hyperactivity disorder; trauma and stressor-related disorders; bipolar disorders; eating disorders; tic disorders; and obsessive-compulsive disorders [OCD]) during 2019 through January 2022 among children and adolescents aged 0-17 years, overall and by sex and age. After declines in weekly visits associated with MHCs among those aged 0-17 years during 2020, weekly numbers of ED visits for MHCs overall and for specific MHCs varied by age and sex during 2021 and January 2022, when compared with corresponding weeks in 2019. Among adolescent females aged 12-17 years, weekly visits increased for two of nine MHCs during 2020 (eating disorders and tic disorders), for four of nine MHCs during 2021 (depression, eating disorders, tic disorders, and OCD), and for five of nine MHCs during January 2022 (anxiety, trauma and stressor-related disorders, eating disorders, tic disorders, and OCD), and overall MHC visits during January 2022, compared with 2019. Early identification and expanded evidence-based prevention and intervention strategies are critical to improving children's and adolescents' mental health (1-3), especially among adolescent females, who might have increased need.

Emergency departments (EDs) in the United States remain a frontline resource for pediatric health care emergencies during the COVID-19 pandemic; however, patterns of health-seeking behavior have changed during the pandemic (1,2). CDC examined changes in U.S. ED visit trends to assess the continued impact of the pandemic on visits among children and adolescents aged 0-17 years (pediatric ED visits). Compared with 2019, pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022. Although visits for non-COVID-19 respiratory illnesses mostly declined, the proportion of visits for some respiratory conditions increased during January 2022 compared with 2019. Weekly number and proportion of ED visits increased for certain types of injuries (e.g., drug poisonings, self-harm, and firearm injuries) and some chronic diseases, with variation by pandemic year and age group. Visits related to behavioral concerns increased across pandemic years, particularly among older children and adolescents. Health care providers and families should remain vigilant for potential indirect impacts of the COVID-19 pandemic, including health conditions resulting from delayed care, and increasing emotional distress and behavioral health concerns among children and adolescents.

BACKGROUND: Cannabis policies are rapidly changing in the United States, yet little is known about how this has affected cannabis-associated emergency department (ED) visits. METHODS: We studied trends in cannabis-associated ED visits and identified differences by visit characteristics. Cannabis-associated ED visits from 2006 to 2018 were identified from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project's (HCUP) Nationwide Emergency Department Sample (NEDS). JoinPoint analysis was used to identify trends from 2006 to 2014, prior to medical coding changes in 2015, and Z-tests were used to compare annual rate changes from 2016 to 2018. Changes in rates from 2017 to 2018 were examined by visit characteristics. RESULTS: From 2006-2014, the rate of cannabis-associated ED visits increased, on average, 12.1% annually (p < 0.05), from 12.3 to 34.7 visits per 100,000 population. The rate increased 17.3% from 2016 to 2017 (p < 0.05) and 11.1% from 2017 to 2018 (p < 0.05). From 2017-2018, rates of visits increased for both males (8.7%; p < 0.05) and females (15.9%; p < 0.05). Patients 0-14 years and 25 years and older had significant rate increases from 2017 to 2018 as did the Midwest region (36.8%; p < 0.05), the Northeast (9.2%; p < 0.05), and the South (4.5%; p < 0.05). CONCLUSIONS: Cannabis-associated ED visits are on the rise and subgroups are at increased risk. Some potential explanations for increases in cannabis-associated ED visits include increased availability of cannabis products, increased use, and diversity of products available in marketplaces. Strategies are needed to prevent youth initiation, limit potentially harmful use among adults, and ensure safe storage where cannabis use is legal.

The United States drug overdose epidemic has reached an all-time high, with 2020 provisional mortality data indicating that over 90,000 lives were lost to drug overdose in the 12-months ending in December 2020. The overdose epidemic has evolved over time with respect to the substances involved in overdose deaths and also with respect to the geographic distribution and epidemiology of deaths involving specific substances. Thus, a nimble approach to addressing the epidemic and preventing future overdoses is needed. CDC's response to the overdose epidemic supports implementation efforts at the state and local levels, where partners can better detect and respond to the evolving drug overdose landscape and implement prevention measures that meet their needs. CDC's framework for responding to the overdose epidemic focuses on five areas: (1) conducting surveillance and research; (2) building state, local and tribal capacity; (3) supporting providers, health systems and payers; (4) partnering with public safety; and (5) empowering consumers to make safe choices. Central to informing the implementation of evidence-based strategies to prevent drug overdose is rigorous research that undergirds the evidence. This Commentary describes recent investments in overdose prevention research and outlines opportunities for ensuring that future research efforts allow for the flexibility necessary to effectively respond to the continually evolving epidemic.

BACKGROUND AND AIMS: Following emergency declarations related to COVID-19 in the United States, many states issued stay-at-home orders and designated essential business categories. Most states allowed medical and/or non-medical adult-use cannabis retailers to remain open. This study assesses changes in cannabis sales across Alaska, Colorado, Oregon, and Washington before and during the pandemic. METHODS: Pre-tax sales data from cannabis marketplaces in four states were analyzed to identify trends from January 2018-December 2020. Mean monthly sales and relative percent change in mean monthly sales were compared by state from April-December (coinciding with the pandemic) in 2018, 2019, and 2020. Differences were assessed using the nonparametric Mann-Whitney-U test. RESULTS: Mean monthly cannabis sales in all four states were higher during the pandemic period in 2020 compared to the same period in 2019. Sales reached a three-year peak in Washington in May 2020 and in Alaska, Colorado, and Oregon in July 2020. From April-December, the percent change in mean monthly sales from 2019 to 2020 was significantly higher than 2018-2019 in all four states, though Alaska saw similar increases between 2018-2019 and 2019-2020. CONCLUSION: To date, cannabis sales in Alaska, Colorado, Oregon, and Washington have increased more during the COVID-19 pandemic than in the previous two years. In light of these increases, data monitoring by states and CDC is warranted to understand how patterns of use are changing, which populations are demonstrating changes in use, and how such changes may affect substance use and related public health outcomes.

INTRODUCTION: Traumatic brain injury is a major cause of death and disability in the U.S., and research shows that individuals who suffer traumatic brain injury have an increased risk for suicide. This study examines the characteristics of suicide decedents with a documented traumatic brain injury history using a database containing circumstantial data on suicides and examines the differences in traumatic brain injury‒ and nontraumatic brain injury‒related suicides within the general population and within individuals with a history of military service. METHODS: Logistic regression models estimated AORs and 95% CIs of suicide among those with and without a previous traumatic brain injury using data from the 2003-2017 National Violent Death Reporting System (analyzed in 2020). RESULTS: From 2003 to 2017, a total of 203,157 suicide decedents were identified, and 993 had a documented traumatic brain injury before suicide. Among those with a documented traumatic brain injury, a higher percentage were White non-Hispanic. Firearm injuries were the most common method of suicide for both groups. Poisoning was more common among decedents with a previous traumatic brain injury than among those without. Male individuals, those who were single, and those who served in the military were 1.4 times more likely to have a documented traumatic brain injury history before the suicide. Almost 1 in 5 suicides (18.9%) documenting traumatic brain injury occurred among individuals with a history of military service. CONCLUSIONS: Comprehensive suicide prevention approaches are imperative. Healthcare providers can play a role in assessing and identifying patients at increased risk of suicide, including those who have experienced falls or injuries that often result in traumatic brain injury, and provide tailored interventions or referrals.

INTRODUCTION: Experiencing violence, especially multiple types of violence, can have a negative impact on youths' development. These experiences increase the risk for future violence and other health problems associated with the leading causes of morbidity and mortality among adolescents and adults. METHODS: Data from the 2019 national Youth Risk Behavior Survey were used to determine the prevalence of high school students' self-reported experiences with physical fighting, being threatened with a weapon, physical dating violence, sexual violence, and bullying. Logistic regression models adjusting for sex, grade, and race/ethnicity were used to test the strength of associations between experiencing multiple forms of violence and 16 self-reported health risk behaviors and conditions. RESULTS: Approximately one half of students (44.3%) experienced at least one type of violence; more than one in seven (15.6%) experienced two or more types during the preceding 12 months. Experiencing multiple types of violence was significantly more prevalent among females than among males and among students identifying as gay, lesbian, or bisexual or not sure of their sexual identity than among heterosexual students. Experiencing violence was significantly associated with higher prevalence of all examined health risks and conditions. Relative to youths with no violence experiences, adjusted health risk and condition prevalence estimates were up to seven times higher among those experiencing two types of violence and up to 21 times higher among those experiencing three or more types of violence. CONCLUSIONS AND IMPLICATIONS FOR PUBLIC HEALTH PRACTICE: Many youths experience multiple types of violence, with potentially lifelong health impacts. Violence is preventable using proven approaches that address individual, family, and environmental risks. Prioritizing violence prevention is strategic to promoting adolescent and adult health.

IMPORTANCE: The coronavirus disease 2019 (COVID-19) pandemic, associated mitigation measures, and social and economic impacts may affect mental health, suicidal behavior, substance use, and violence. OBJECTIVE: To examine changes in US emergency department (ED) visits for mental health conditions (MHCs), suicide attempts (SAs), overdose (OD), and violence outcomes during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study used data from the Centers for Disease Control and Prevention's National Syndromic Surveillance Program to examine national changes in ED visits for MHCs, SAs, ODs, and violence from December 30, 2018, to October 10, 2020 (before and during the COVID-19 pandemic). The National Syndromic Surveillance Program captures approximately 70% of US ED visits from more than 3500 EDs that cover 48 states and Washington, DC. MAIN OUTCOMES AND MEASURES: Outcome measures were MHCs, SAs, all drug ODs, opioid ODs, intimate partner violence (IPV), and suspected child abuse and neglect (SCAN) ED visit counts and rates. Weekly ED visit counts and rates were computed overall and stratified by sex. RESULTS: From December 30, 2018, to October 10, 2020, a total of 187 508 065 total ED visits (53.6% female and 46.1% male) were captured; 6 018 318 included at least 1 study outcome (visits not mutually exclusive). Total ED visit volume decreased after COVID-19 mitigation measures were implemented in the US beginning on March 16, 2020. Weekly ED visit counts for all 6 outcomes decreased between March 8 and 28, 2020 (March 8: MHCs = 42 903, SAs = 5212, all ODs = 14 543, opioid ODs = 4752, IPV = 444, and SCAN = 1090; March 28: MHCs = 17 574, SAs = 4241, all ODs = 12 399, opioid ODs = 4306, IPV = 347, and SCAN = 487). Conversely, ED visit rates increased beginning the week of March 22 to 28, 2020. When the median ED visit counts between March 15 and October 10, 2020, were compared with the same period in 2019, the 2020 counts were significantly higher for SAs (n = 4940 vs 4656, P = .02), all ODs (n = 15 604 vs 13 371, P < .001), and opioid ODs (n = 5502 vs 4168, P < .001); counts were significantly lower for IPV ED visits (n = 442 vs 484, P < .001) and SCAN ED visits (n = 884 vs 1038, P < .001). Median rates during the same period were significantly higher in 2020 compared with 2019 for all outcomes except IPV. CONCLUSIONS AND RELEVANCE: These findings suggest that ED care seeking shifts during a pandemic, underscoring the need to integrate mental health, substance use, and violence screening and prevention services into response activities during public health crises.

IMPORTANCE: Suicide is a leading cause of death in the US. However, official national statistics on suicide rates are delayed by 1 to 2 years, hampering evidence-based public health planning and decision-making. OBJECTIVE: To estimate weekly suicide fatalities in the US in near real time. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional national study used a machine learning pipeline to combine signals from several streams of real-time information to estimate weekly suicide fatalities in the US in near real time. This 2-phase approach first fits optimal machine learning models to each individual data stream and subsequently combines predictions made from each data stream via an artificial neural network. National-level US administrative data on suicide deaths, health services, and economic, meteorological, and online data were variously obtained from 2014 to 2017. Data were analyzed from January 1, 2014, to December 31, 2017. EXPOSURES: Longitudinal data on suicide-related exposures were obtained from multiple, heterogeneous streams: emergency department visits for suicide ideation and attempts collected via the National Syndromic Surveillance Program (2015-2017); calls to the National Suicide Prevention Lifeline (2014-2017); calls to US poison control centers for intentional self-harm (2014-2017); consumer price index and seasonality-adjusted unemployment rate, hourly earnings, home price index, and 3-month and 10-year yield curves from the Federal Reserve Economic Data (2014-2017); weekly daylight hours (2014-2017); Google and YouTube search trends related to suicide (2014-2017); and public posts on suicide on Reddit (2 314 533 posts), Twitter (9 327 472 tweets; 2015-2017), and Tumblr (1 670 378 posts; 2014-2017). MAIN OUTCOMES AND MEASURES: Weekly estimates of suicide fatalities in the US were obtained through a machine learning pipeline that integrated the above data sources. Estimates were compared statistically with actual fatalities recorded by the National Vital Statistics System. RESULTS: Combining information from multiple data streams, the machine learning method yielded estimates of weekly suicide deaths with high correlation to actual counts and trends (Pearson correlation, 0.811; P < .001), while estimating annual suicide rates with low error (0.55%). CONCLUSIONS AND RELEVANCE: The proposed ensemble machine learning framework reduces the error for annual suicide rate estimation to less than one-tenth of that of current forecasting approaches that use only historical information on suicide deaths. These findings establish a novel approach for tracking suicide fatalities in near real time and provide the potential for an effective public health response such as supporting budgetary decisions or deploying interventions.

Published reports suggest that the coronavirus disease 2019 (COVID-19) pandemic has had a negative effect on children's mental health (1,2). Emergency departments (EDs) are often the first point of care for children experiencing mental health emergencies, particularly when other services are inaccessible or unavailable (3). During March 29-April 25, 2020, when widespread shelter-in-place orders were in effect, ED visits for persons of all ages declined 42% compared with the same period in 2019; during this time, ED visits for injury and non-COVID-19-related diagnoses decreased, while ED visits for psychosocial factors increased (4). To assess changes in mental health-related ED visits among U.S. children aged <18 years, data from CDC's National Syndromic Surveillance Program (NSSP) from January 1 through October 17, 2020, were compared with those collected during the same period in 2019. During weeks 1-11 (January 1-March 15, 2020), the average reported number of children's mental health-related ED visits overall was higher in 2020 than in 2019, whereas the proportion of children's mental health-related visits was similar. Beginning in week 12 (March 16) the number of mental health-related ED visits among children decreased 43% concurrent with the widespread implementation of COVID-19 mitigation measures; simultaneously, the proportion of mental health-related ED visits increased sharply beginning in mid-March 2020 (week 12) and continued into October (week 42) with increases of 24% among children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with the same period in 2019. The increased proportion of children's mental health-related ED visits during March-October 2020 might be artefactually inflated as a consequence of the substantial decrease in overall ED visits during the same period and variation in the number of EDs reporting to NSSP. However, these findings provide initial insight into children's mental health in the context of the COVID-19 pandemic and highlight the importance of continued monitoring of children's mental health throughout the pandemic, ensuring access to care during public health crises, and improving healthy coping strategies and resiliency among children and families.

Importance: Understanding changes in the incidence rates and lethality of suicidal acts may explain increasing suicide rates. Objective: To examine trends in the incidence rates and lethality of suicidal acts from 2006 to 2015 among persons aged 10 to 74 years. Design, Setting, and Participants: This cross-sectional study was conducted from May 2, 2018, to January 30, 2019. Medically treated nonfatal suicide attempts were identified from the 2006 to 2015 Nationwide Inpatient Sample and Nationwide Emergency Department Sample databases. Suicides were identified from the 2006 to 2015 mortality files of the National Vital Statistics System. Main Outcomes and Measures: The incidence rate of suicidal acts was calculated by dividing the number of total suicidal acts by the US population. Lethality was measured through the case fatality rates (CFRs) of suicidal acts by dividing the number of suicides by the total number of suicidal acts. Results: A total of 1222419 (unweighted) suicidal acts, which included both suicides and nonfatal suicide attempts, were identified from 2006 to 2015. Overall, the incidence rates of total suicidal acts increased 10% from 2006 to 2015 (annual percentage change [APC], 0.8%; 95% CI, 0.3%-1.3%), and the CFRs of suicidal acts increased 13% during the 2006 to 2015 period (APC, 2.3%; 95% CI, 1.3%-3.3%). In subgroup analyses, incidence rates increased by 1.1% (95% CI, 0.6%-1.6%) per year for female individuals during the 2006 to 2015 period but remained stable for male individuals. The CFRs increased for both sexes (APC, 5.0% [95% CI, 3.1%-6.9%] since 2010 for female individuals; 1.6% [95% CI, 0.6%-2.5%] since 2009 for male individuals). Incidence rates increased among adolescents from 2011 to 2015 and among older adults aged 65 to 74 years throughout the 2006 to 2015 period. Conversely, the CFRs increased since 2009 among persons aged 20 to 44 years (APC, 3.7%; 95% CI, 2.5%-5.0%) and since 2012 for those aged 45 to 64 years (APC, 2.7%; 95% CI, 0.0%-5.4%). Persons aged 20 to 44 years and 45 to 64 years experienced increases in suicidal acts by more lethal means, whereas adolescents and older adults aged 65 to 74 years showed increased incidence by all means. Conclusions and Relevance: This study found increased suicidal acts among female persons, adolescents, and older adults aged 65 to 74 years, implying the need to address emerging or exacerbating suicide risk factors for these populations. The findings on the increased lethality particularly among persons aged 20 to 64 years highlighted the need to reduce access to materials that could be used as lethal means among persons at risk of suicide. These findings on population-level epidemiologic patterns can be used to guide the development of comprehensive suicide prevention strategies.

From July 2009 to June 2018, the rates of multiple-victim, school-associated homicides in the United States fluctuated substantially, with evidence of a significant increase in recent years (1). Data on the effects of such incidents on students' school attendance and perceptions of safety and connectedness are limited (2,3) but important. This study used data from a neighboring within-district school before and after a multiple-fatality shooting at Marjory Stoneman Douglas High School in Parkland, Florida, on February 14, 2018. Self-administered questionnaires were completed by one group of students on February 14 just before the shooting (575) and another group during February 15-21 (502); demographics for these groups appeared similar. Linear and logistic regression analyses controlling for demographic characteristics explored differences between groups for safety-related perceptions or experiences, school connectedness, and absenteeism. Compared with students surveyed before the shooting, students surveyed in the days immediately following the shooting had lower odds of feeling safe at school, higher odds of absenteeism, and higher school connectedness scores. Findings suggest the shooting had an immediate, sizeable effect on safety perceptions and absenteeism among students in a neighboring school. Findings also suggest higher school connectedness following the shooting. Further study of school connectedness, including how to enhance and sustain it, might help schools and communities better respond to traumatic events in the community.

This study examined national trends in self-directed violence in the context of changes in opioid use and depression to better inform prevention measures. Using 2000-2015 National Inpatient Sample (NIS) data, we identified 625,064 hospitalizations for self-directed violence among persons aged >/=10years in the United States. Based on whether co-listing opioid related diagnosis and depression, we categorized hospitalizations for self-directed violence into four comorbid categories as 1) related to opioids alone; 2) related to depression alone; 3) related to both opioids and depression; and 4) related to neither opioids nor depression. Census population estimates served as the denominator for calculating hospitalization rates for self-directed violence. Hospitalization rates for self-directed violence related to opioids doubled from 5.1 per 100,000 persons in 2000 to 11.0 in 2015. The rate of increase was highest for self-directed violence related to both opioids and depression, which increased 9.4% annually during 2000-2011 and then decreased 4.3% annually during 2011-2015. Hospitalizations for self-directed violence related to depression alone remained the predominant category, accounting for approximately 60% of hospitalizations for self-directed violence; the rates among females aged 10-24years were the highest among all subgroups, and rose 7.8% annually since 2011 reaching 93.2 per 100,000 persons in 2015. These findings highlight the importance of assessing the risk for self-directed violence among patients misusing opioids and the importance of treating opioid use disorder and depression, particularly when they co-occur. Prevention and treatment of depression is especially important for young females.

Suicide is a growing public health problem in the United States, claiming approximately 47,000 lives in 2017 (1). However, deaths from suicide represent only a small part of a larger problem because each year millions of persons experience suicidal ideation and engage in suicidal and nonsuicidal self-directed violence, both risk factors for suicide (2). Emergency departments (EDs) are an important setting for monitoring these events in near real time (3-5). From 2001 to 2016, ED visit rates for nonfatal self-harm increased 42% among persons aged >/=10 years (1). Using data from CDC's National Syndromic Surveillance Program (NSSP), ED visits for suicidal ideation, self-directed violence, or both among persons aged >/=10 years during January 2017-December 2018 were examined by sex, age group, and U.S. region. During the 24-month period, the rate of ED visits for suicidal ideation, self-directed violence, or both increased 25.5% overall, with an average increase of 1.2% per month. Suicide prevention requires comprehensive and multisectoral approaches to addressing risk at personal, relationship, community, and societal levels. ED syndromic surveillance data can provide timely trend information and can support more targeted and prompt public health investigation and response. CDC's Preventing Suicide: A Technical Package of Policy, Programs, and Practices includes tailored suicide prevention strategies for health care settings (6).

To understand trends and characteristics in school-associated homicides involving youths, data from CDC's School-Associated Violent Death Surveillance System were analyzed for 393 single-victim incidents that occurred during July 1994-June 2016 and 38 multiple-victim incidents (resulting in 121 youth homicides) during July 1994-June 2018. School-associated homicides consistently represent <2% of all youth homicides in the United States (1,2). The overall 22-year trend for single-victim homicide rates did not change significantly. However, multiple-victim incidence rates increased significantly from July 2009 to June 2018. Many school-associated homicides, particularly single-victim incidents, are similar to youth homicides unrelated to schools, often involving male, racial/ethnic minority youth victims, and occurring in urban settings. The majority of both single-victim (62.8%) and multiple-victim (95.0%) homicides were from a firearm-related injury. A comprehensive approach to violence prevention is needed to reduce risk for violence on and off school grounds.