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Emergency Department Visits Involving Illicit Drug Use among Males
Emergency Department Visits Involving Illicit Drug Use among Males
Source: Substance Abuse and Mental Health Services Administration
Examines characteristics of emergency department treatment visits involving illicit drug use among males based on annual averages for combined 2004 to 2009 data. Reports trends in age, drug involved, and disposition of the visit.
+ Full Report (PDF)
See also: Emergency Department Visits Involving Illicit Drug Use among Females
New From the GAO
New GAO Reports
Source: Government Accountability Office
1. Homeless Women Veterans: Actions Needed to Ensure Safe and Appropriate Housing. GAO-12-182, December 23.
http://www.gao.gov/products/GAO-12-182
2. Prescription Pain Reliever Abuse: Agencies Have Begun Coordinating Education Efforts, but Need to Assess Effectiveness. GAO-12-115, December 22.
http://www.gao.gov/products/GAO-12-115
Highlights -
http://www.gao.gov/assets/590/587300.pdf
3. Department of Justice: Working Capital Fund Adheres to Some Operating Principles But Could Better Measure Performance and Communicate With Customers. GAO-12-289, January 20.
http://www.gao.gov/products/GAO-12-289
Highlights -
http://www.gao.gov/assets/590/587849.pdf
CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic
CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic
Source: Morbidity and Mortality Weekly Report (CDC)
In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years (Figure 1) has been driven by increased use of a class of prescription drugs called opioid analgesics (1). Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined (Figure 2) (1). In addition, for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substance abuse treatment (2), 35 visit emergency departments (3), 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics (4). Implementing strategies that target those persons at greatest risk will require strong coordination and collaboration at the federal, state, local, and tribal levels, as well as engagement of parents, youth influencers, health-care professionals, and policy-makers.
Overall, rates of opioid analgesic misuse and overdose death are highest among men, persons aged 20–64 years, non-Hispanic whites, and poor and rural populations. Persons who have mental illness are overrepresented among both those who are prescribed opioids and those who overdose on them. Further defining populations at greater risk is critical for development and implementation of effective interventions. The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids (5), and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month (4). In an attempt to treat patient pain better, practitioners have greatly increased their rate of opioid prescribing over the past decade. Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600% (6). That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin (hydrocodone and acetaminophen) every 4 hours for 3 weeks. Persons who abuse opioids have learned to exploit this new practitioner sensitivity to patient pain, and clinicians struggle to treat patients without overprescribing these drugs.
Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (≥100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%–66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11–13). These data suggest that prevention of opioid overdose deaths should focus on strategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion.
The Lancet: Addiction Series
A three-part Series assesses the global public-health toll and policy implications of drug addiction. The first paper summarises data for the prevalence and consequences of problem use of amphetamines, cannabis, cocaine, and opioids. In high-income countries, illicit drug use contributes less to the burden of disease than tobacco, but a substantial proportion of that burden is due to alcohol. Intelligent policy responses to drug problems need better prevalence data for different types of illicit drug use and the harms that their use causes globally. This need is especially urgent in high-income countries with substantial rates of illicit drug use and in low-income and middle-income countries close to illicit drug production areas. The second paper reviews existing drug policies and highlights the need for greater reliance on scientific evidence-based policy making. The final paper examines the value of international drug conventions in protecting public health.
(Free registration required.)
Drug Poisoning Deaths in the United States, 1980–2008
Drug Poisoning Deaths in the United States, 1980–2008
Source: National Center for Health Statistics
Key findings
Data from the National Vital Statistics System Mortality File
- In 2008, poisoning became the leading cause of injury death in the United States and nearly 9 out of 10 poisoning deaths are caused by drugs.
- During the past three decades, the number of drug poisoning deaths increased sixfold from about 6,100 in 1980 to 36,500 in 2008.
- During the most recent decade, the number of drug poisoning deaths involving opioid analgesics more than tripled from about 4,000 in 1999 to 14,800 in 2008.
- Opioid analgesics were involved in more than 40% of all drug poisoning deaths in 2008, up from about 25% in 1999.
- In 2008, the drug poisoning death rate was higher for males, people aged 45–54 years, and non-Hispanic white and American Indian or Alaska Native persons than for females and those in other age and racial and ethnic groups.
Illicit drug related emergency department visits vary by metropolitan area
Major metropolitan areas show significant variation in the rates of emergency department (ED) visits involving illicit drugs. In terms of overall illicit drug-related emergency room visits, Boston has the highest rate (571 per 100,000 population), followed by New York City (555 per 100,000 population), Chicago (507 per 100,000 population), and Detroit (462 per 100,000 population). By comparison the national average was 317 per 100,000 population.
This new report published by the Substance Abuse and Mental Health Services Administration (SAMHSA) was drawn from the agency’s Drug Abuse Warning Network – (DAWN), a public health surveillance system that monitors drug-related emergency department visits throughout the nation. This information was collected from eleven metropolitan areas including Boston, Chicago, Denver, Detroit, Miami (Dade County and Fort Lauderdale Division), Minneapolis, New York (Five Boroughs Division), Phoenix, San Francisco, and Seattle.
Marijuana use continues to rise among U.S. teens, while alcohol use hits historic lows
Marijuana use continues to rise among U.S. teens, while alcohol use hits historic lows (PDF)
Source: Monitoring the Future Study (University of Michigan)
Among the more important findings from this year’s Monitoring the Future survey of U.S. secondary school students are the following:
- Marijuana use among teens rose in 2011 for the fourth straight year—a sharp contrast to the considerable decline that had occurred in the preceding decade. Daily marijuana use is now at a 30-year peak level among high school seniors.
- “Synthetic marijuana,” which until earlier this year was legally sold and goes by such names as “K2” and “spice,” was added to the study’s coverage in 2011; one in every nine high school seniors (11.4%) reported using that drug in the prior 12 months.
- Alcohol use—and, importantly, occasions of heavy drinking—continued a long-term gradual decline among teens, reaching historically low levels in 2011.
- Energy drinks are being consumed by about one third of teens, with use highest among younger teens.
CRS — Synthetic Drugs: Overview and Issues for Congress
Synthetic Drugs: Overview and Issues for Congress (PDF)
Source: Congressional Research Service (via Federation of American Scientists)
Synthetic drugs, as opposed to natural drugs, are chemically produced in a laboratory. Their chemical structure can be either identical to or different from naturally occurring drugs, and their effects are designed to mimic or even enhance those of natural drugs. When produced clandestinely, they are not typically controlled pharmaceutical substances intended for legitimate medical use. Designer drugs are a form of synthetic drugs. They contain slightly modified molecular structures of illegal or controlled substances, and they are modified in order to circumvent existing drug laws. While the issue of synthetic drugs and their abuse is not new, the 112 th Congress has demonstrated a renewed concern with the issue.
Synthetic drug abuse is reported to have dramatically increased between 2009 and 2011. Calls to poison control centers for incidents relating to harmful effects of synthetic cannabinoids and stimulants have increased at what some consider to be an alarming rate. The reported harmful effects of these substances range from nausea to drug-induced psychosis. Due to the unpredictable nature of synthetic drugs and of human consumption of these drugs, the true effects of these drugs are unknown. Many states have responded to this issue by passing synthetic drug laws banning certain synthetic cannabinoids and stimulants.
In March 2011, the Attorney General—through the Drug Enforcement Administration (DEA)— used his temporary scheduling authority to place five synthetic cannabinoids on Schedule I of the Controlled Substances Act (CSA). In October 2011, the DEA used this temporary scheduling authority to add three synthetic stimulants to Schedule I. Concern over the reported increase in use of certain synthetic cannabinoids and stimulants has led some to call on Congress to legislatively schedule specific substances. This is, in part, because congressional action could permanently place certain substances onto Schedule I of the CSA more quickly than might occur through administrative scheduling actions authorized by the CSA.
Several bills have been introduced in the 112 th Congress that confront the issue of synthetic drug use and abuse. These include the Combating Dangerous Synthetic Stimulants Act of 2011 (H.R. 1571, S. 409); the Synthetic Drug Control Act of 2011 (H.R. 1254) and its companion bill—the Dangerous Synthetic Drug Control Act of 2011 (also known as the David Mitchell Rozga Act, S. 605); and the Combating Designer Drugs Act of 2011 (S. 839). While these bills differ substantively from one another, they all aim to legislatively place various synthetic drugs on Schedule I of the CSA. In considering permanent placement of specific synthetic substances on Schedule I of the CSA, there are several issues on which Congress may deliberate. Policymakers may consider the implications on the federal criminal justice system of scheduling certain synthetic substances.’
Another issue up for debate is whether Congress should schedule certain synthetic substances or whether these substances merit Attorney General (in consultation with the Secretary of HHS) scheduling based on qualifications specified in the CSA. Congress may also consider whether or not placing these synthetic drugs on Schedule I would hinder future medical research. In addition, Congress may consider whether it is more efficient to place these drugs on Schedule I of the CSA or to label them as analogue controlled substances under the Controlled Substances Analogue Enforcement Act.
Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999–2008
Source: Morbidity and Mortality Weekly Report (CDC)
Background: Overdose deaths involving opioid pain relievers (OPR), also known as opioid analgesics, have increased and now exceed deaths involving heroin and cocaine combined. This report describes the use and abuse of OPR by state.
Methods: CDC analyzed rates of fatal OPR overdoses, nonmedical use, sales, and treatment admissions.
Results: In 2008, drug overdoses in the United States caused 36,450 deaths. OPR were involved in 14,800 deaths (73.8%) of the 20,044 prescription drug overdose deaths. Death rates varied fivefold by state. States with lower death rates had lower rates of nonmedical use of OPR and OPR sales. During 1999–2008, overdose death rates, sales, and substance abuse treatment admissions related to OPR all increased substantially.
Conclusions: The epidemic of overdoses of OPR has continued to worsen. Wide variation among states in the nonmedical use of OPR and overdose rates cannot be explained by underlying demographic differences in state populations but is related to wide variations in OPR prescribing.
Implications for Public Health Practice: Health-care providers should only use OPRs in carefully screened and monitored patients when non-OPR treatments are insufficient to manage pain. Insurers and prescription drug monitoring programs can identify and take action to reduce both inappropriate and illegal prescribing. Third-party payers can limit reimbursement in ways that reduce inappropriate prescribing, discourage efforts to obtain OPR from multiple health-care providers, and improve clinical care. Changes in state laws that focus on the prescribing practices of health-care providers might reduce prescription drug abuse and overdoses while still allowing safe and effective pain treatment.
Just Released — Prescription Painkiller Overdoses in the US
Prescription Painkiller Overdoses in the US
Source: Centers for Disease Control and Prevention
From press release:
The death toll from overdoses of prescription painkillers has more than tripled in the past decade, according to an analysis in the CDC Vital Signs report released today from the Centers for Disease Control and Prevention. This new finding shows that more than 40 people die every day from overdoses involving narcotic pain relievers like hydrocodone (Vicodin), methadone, oxycodone (OxyContin), and oxymorphone (Opana).
“Overdoses involving prescription painkillers are at epidemic levels and now kill more Americans than heroin and cocaine combined, ” said CDC Director Thomas Frieden, M.D., M.P.H. “States, health insurers, health care providers and individuals have critical roles to play in the national effort to stop this epidemic of overdoses while we protect patients who need prescriptions to control pain. ”
The increased use of prescription painkillers for nonmedical reasons (without a prescription for the high they cause), along with growing sales, has contributed to the large number of overdoses and deaths. In 2010, 1 in every 20 people in the United States age 12 and older—a total of 12 million people—reported using prescription painkillers nonmedically according to the National Survey on Drug Use and Health. Based on the data from the Drug Enforcement Administration, sales of these drugs to pharmacies and health care providers have increased by more than 300 percent since 1999.
“Prescription drug abuse is a silent epidemic that is stealing thousands of lives and tearing apart communities and families across America, ” said Gil Kerlikowske, Director of National Drug Control Policy
. “From day one, we have been laser–focused on this crisis by taking a comprehensive public health and public safety approach. All of us have a role to play. Health care providers and patients should be educated on the risks of prescription painkillers. And parents and grandparents can take time today to properly dispose of any unneeded or expired medications from the home and to talk to their kids about the misuse and abuse of prescription drugs. ”
In April, the Administration released a comprehensive action plan to address the national prescription drug abuse epidemic to reduce this public health burden.
Titled “Epidemic: Responding to America’s Prescription Drug Abuse Crisis
Already, 48 states have implemented state–based monitoring programs designed to reduce diversion and doctor shopping while protecting patient privacy and the Department of Justice has conducted a series of takedowns of rogue pain clinics operating as “pill mills. ” President Obama has also signed into law the Secure and Responsible Drug Disposal Act, which will allow states and local communities to collect and safely dispose of unwanted prescription drugs and support DEA’s ongoing national efforts to collect unneeded or expired prescription drugs which have collected over 300 tons of medications over the past year.
HIV Risk, Prevention, and Testing Behaviors Among Men Who Have Sex With Men — National HIV Behavioral Surveillance System, 21 U.S. Cities, United States, 2008
HIV Risk, Prevention, and Testing Behaviors Among Men Who Have Sex With Men — National HIV Behavioral Surveillance System, 21 U.S. Cities, United States, 2008
Source: Morbidity and Mortality Weekly Report (CDC)
This report summarizes data gathered from 8,175 MSM during the second data collection cycle of NHBS. In addition to having at least one male sex partner, 14% of participants had at least one female sex partner during the past 12 months. Unprotected anal intercourse with a male partner was reported by 54% of the participants; 37% reported having unprotected anal sex with a main male partner (someone with whom the participant had sex and to whom he felt most committed, such as a boyfriend, spouse, significant other, or life partner), and 25% reported having unprotected anal sex with a casual male partner (someone with whom the participant had sex but with whom he did not feel committed, did not know very well, or had sex with in exchange for something such as money or drugs). Noninjection drug use during the past 12 months was reported by 46% of participants. Specifically, 38% used marijuana, 18% cocaine, 13% poppers (amyl nitrate), and 11% ecstasy. Two percent of the participants reported injecting drugs for nonmedical purposes in the past 12 months. Of the participants surveyed, 90% had been tested for HIV during their lifetime, 62% had been tested during the past 12 months, 51% had received a hepatitis vaccination, 35% had been tested for syphilis during the past 12 months, and 18% had participated in an individual- or group-level HIV behavioral intervention.
Drugs of Abuse
Drugs of Abuse (PDF)
Source: Drug Enforcement Administration (U.S. Department of Justice)
Drugs of Abuse is designed to be a reliable resource on the most popularly abused drugs. This publication delivers clear, scientific information about drugs in a factual, straightforward way, combined with scores of precise photographs shot to scale.
Illicit Drug Use among Older Adults
Illicit Drug Use among Older Adults
Source: Substance Abuse and Mental Health Servies Administration
+ An estimated 4.8 million adults aged 50 or older, or 5.2 percent of adults in that age range, had used an illicit drug in the past year
+ Marijuana use was more common than nonmedical use of prescription-type drugs among adults aged 50 to 59 (5.9 vs. 3.6 percent), while nonmedical use of prescription-type drugs was as common as use of marijuana among adults aged 60 or older (1.2 vs. 1.1 percent)
+ Marijuana use was more common than nonmedical use of prescription-type drugs among males aged 50 or older (4.7 vs. 2.5 percent); rates of marijuana use and nonmedical use of prescription-type drugs were similar among females aged 50 or older (1.9 and 2.1 percent, respectively)
Prescription Drug Monitoring Programs
Prescription Drug Monitoring Programs (PDF)
Source: Office of National Drug Control Policy
A PDMP is a tool that can be used to address prescription drug diversion and abuse. PDMPs serve multiple functions, including: patient care tool; drug epidemic early warning system; and drug diversion and insurance fraud investigative tool. They help prescribers avoid drug interactions and identify drug-seeking behaviors or “doctor shopping.” PDMPs can also be used by professional licensing boards to identify clinicians with patterns of inappropriate prescribing and dispensing, and to assist law enforcement in cases of controlled substance diversion.
At the same time, protecting patient privacy is of the utmost importance. PDMPs ensure protection of patient information just as well as, if not better than, any other medical record. Law enforcement may not access patient-specific PDMP data unless they have an active investigation, and healthcare providers can access only the PDMP data relevant to their patients.
See also: Response to the Epidemic of Prescription Drug Abuse (PDF)
Drug Misuse Declared: Findings From the 2010/11 British Crime Survey, England and Wales
Drug Misuse Declared: Findings From the 2010/11 British Crime Survey, England and Wales (PDF)
Source: Home Office
The 2010/11 BCS estimates that 8.8 per cent of adults aged 16 to 59 had used illicit drugs (almost three million people) and that 3.0 per cent had used a Class A drug in the last year (around a million people). Neither estimates were statistically significantly different from the 2009/10 survey.
…
Of the individual types of drug asked about in the survey, there were decreases in the use of powder cocaine between the 2009/10 (2.4%) and 2010/11 BCS (2.1%) and an increase in methadone (from 0.1% to 0.2%); for other types of drugs levels of last year usage remained similar to the previous year.As in previous years, among adults aged 16 to 59, cannabis was the most commonly used type of drug (6.8%, around 2.2 million people), followed by powder cocaine (2.1%, 0.7 million people) and ecstasy (1.4%, 0.5 million people). The 2010/11 BCS shows that levels of ketamine use (at 0.6%) were around double those when questions on the use of this drug were first asked in the 2006/07 BCS (0.3%)
Report finds vast majority of marijuana users aged 12 to 14 get it free from friends and family
Report finds vast majority of marijuana users aged 12 to 14 get it free from friends and family
Source: Substance Abuse and Mental Health Services Administration
A new spotlight report from the Substance Abuse and Mental Health Services Administration (SAMHSA) shows that 70.1-percent of the 523,000 teens aged 12 to 14 who had used marijuana in the past year received the drug for free the last time they used. Only 26.6-percent of these young marijuana users purchased the drug.
A majority of marijuana users aged 12 to 14 (55.6-percent) received their free marijuana from friends, while 10.1-percent received it free from someone in their family.
+ Full Report (PDF)
National survey shows a rise in illicit drug use from 2008 to 2010
National survey shows a rise in illicit drug use from 2008 to 2010
Source: Substance Abuse and Mental Health Services Administration
The use of illicit drugs among Americans increased between 2008 and 2010 according to a national survey conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Survey on Drug Use and Health (NSDUH) shows that 22.6 million Americans 12 or older (8.9-percent of the population) were current illicit drug users. The rate of use in 2010 was similar to the rate in 2009 (8.7-percent), but remained above the 2008 rate (8- percent).
An increased rate in the current use of marijuana seems to be one of the prime factors in the overall rise in illicit drug use. In 2010, 17.4 million Americans were current users of marijuana – compared to 14.4 million in 2007. This represents an increase in the rate of current marijuana use in the population 12 and older from 5.8-percent in 2007 to 6.9-percent in 2010.
Another disturbing trend is the continuing rise in the rate of current illicit drug use among young adults aged 18 to 25 — from 19.6-percent in 2008 to 21.2-percent in 2009 and 21.5-percent in 2010. This increase was also driven in large part by a rise in the rate of current marijuana use among this population.
The annual NSDUH survey, released by SAMHSA at the kickoff of the 22nd annual National Recovery Month (Recovery Month) observance also shows that use rates for nonmedical use of prescription drugs, hallucinogens and inhalants have remained at approximately the same levels as 2009, and are also similar to rates in 2002.
National Drug Threat Assessment 2011
National Drug Threat Assessment 2011 (PDF)
Source: National Drug Intelligence Center (USDoJ)
The National Drug Threat Assessment 2011 is a comprehensive assessment of the threat posed to the United States by the trafficking and abuse of illicit drugs. It was prepared through detailed analysis of the most recent law enforcement, intelligence, and public health data available to the National Drug Intelligence Center through the date of publication. It addressed emerging developments related to the trafficking and use of primary illicit substances of abuse, the nonmedical use of controlled prescription drugs, and the laundering of proceeds generated through illicit drug sales. It also addresses the role that transnational criminal organizations and organized gangs play in domestic drug trafficking, the significant role that the Southwest Border plays in the illicit drug trade, and the societal impact of drug abuse.
See also: The Economic Impact of Illicit Drug Use on American Society 2011 (PDF)
AU — Patterns of mephedrone, GHB, Ketamine and Rohypnol use among police detainees
Patterns of mephedrone, GHB, Ketamine and Rohypnol use among police detainees
Source: Australian Institute of Criminology
Key findings
In recognition of the need for ongoing monitoring of new or less common drug types, the Australian Institute of Criminology (AIC), as part of the Drug Use Monitoring in Australia (DUMA) program, interviewed 824 police detainees about their knowledge of and experience with mephedrone, GHB, Ketamine and Rohypnol.Mephedrone was the least known of the four drugs, with only 221 detainees (27%) reporting knowledge of the drug. Only six detainees (<1%) had used the drug in the previous 12 months, while 30 detainees (4%) knew of someone dealing mephedrone at the time they were interviewed. Detainees in East Perth were the most likely to have reported knowledge of mephedrone.
GHB was known to more than half of all detainees interviewed (53%) and had been used in the 12 months prior to interview by 23 detainees (3%). More detainees had been offered GHB (8%), or knew of a dealer selling GHB (6%), than any of the other four drug types.
Ketamine was known to 43 percent of detainees and had been used by three percent. The prevalence of Ketamine use was equal with GHB, however, knowledge of a current Ketamine dealer was lower (4%).
Rohypnol was the most widely known of the four drug types (59%), however, use of the drug in the 12 months prior to interview was lower than for GHB or Ketamine (1%).
Trends in Emergency Department Visits for Drug-Related Suicide Attempts among Males: 2005 and 2009
Trends in Emergency Department Visits for Drug-Related Suicide Attempts among Males: 2005 and 2009
Source: Substance Abuse and Mental Health Services Administration
+ In 2009, there were 77,971 emergency department (ED) visits for drug-related suicide attempts among males
+ By age group, the number of ED visits for drug-related suicide attempts among males aged 21 to 34 increased 54.6 percent between 2005 (19,024 visits) and 2009 (29,407 visits)
+ Among males aged 21 to 34, the number of visits involving pain relievers showed a statistically significant increase of 60.2 percent (from 7,185 to 11,509 visits), the number of visits involving antidepressants increased 155.2 percent (from 1,519 to 3,876 visits), and the number of visits involving drugs that treat anxiety or insomnia increased 93.4 percent (from 5,018 to 9,706 visits)
+ Between 2005 and 2009, narcotic pain reliever involvement in ED visits for suicide attempts almost doubled among visits made by males aged 35 to 49 (from 2,380 to 4,270 visits) and almost tripled among visits made by males aged 50 or older (from 882 to 2,589 visits)
