AOD-Related Emergency Visits Carried a Higher Hospitalization Burden in Adolescents With Chronic Disease
A retrospective cohort spanning 45 U.S. children’s hospitals found that alcohol and other drug–related emergency department visits in adolescents with chronic medical conditions were associated with substantially higher odds of hospitalization than visits without a documented substance use diagnosis. The signal was present across both adolescents with chronic conditions and those with complex chronic conditions, and it was strongest for encounters involving mainstream substances such as cannabis.
The scale of the cohort gives the findings unusual weight. Investigators analyzed 1,098,496 emergency department encounters from 2021 through 2023, and 72.9% of those visits involved adolescents classified with chronic conditions rather than complex chronic conditions. AOD-related encounters made up 4.2% of the total. In this setting, substance use was not a background social variable; it was tied to a measurable increase in acute care use and a greater probability of admission from the emergency department.
Mainstream Substances Drove Most Substance-Related Encounters
Mainstream substances accounted for most AOD-related visits in both chronic disease strata, representing 78.0% of AOD-related encounters in the chronic condition group and 76.3% in the complex chronic condition group. The remainder involved illicit or other psychoactive substances, including opioids. Even within a pediatric population already managing significant illness burden, the pattern suggests that everyday-appearing substance use may be easier to overlook than use of illicit drugs, yet it still maps to a strong inpatient signal.
A single one-sentence reality stands out: these were not isolated intoxication visits with low clinical consequence. The hospitalization odds rose sharply once substance use entered the encounter.
For adolescents with chronic conditions, mainstream substance-related ED visits carried an adjusted odds ratio of 2.8 for hospitalization compared with visits without a documented AOD diagnosis, with a 95% confidence interval of 2.68 to 2.94. Among those with complex chronic conditions, the adjusted odds ratio rose to 3.7, with a 95% confidence interval of 3.19 to 4.28. Illicit or other psychoactive substance encounters followed the same direction: adjusted odds ratios were 2.2 for chronic conditions and 3.18 for complex chronic conditions, all with p values below 0.001.
Complex Chronic Illness Amplified the Admission Signal
The gradient across chronic illness severity is clinically plausible. Adolescents with complex chronic conditions often enter the emergency department with narrower physiologic reserve, more medication burden, and a lower threshold for decompensation when alcohol or other drugs complicate their presentation. Even modest intoxication, withdrawal, or drug-related behavioral dysregulation may disrupt chronic disease management, interfere with hydration or nutrition, or cloud assessment of pain, mental status, and adherence. In practice, the emergency physician is not simply deciding whether the substance use itself requires observation; the decision often hinges on whether the chronic disease can be safely stabilized outside the hospital once substance exposure has occurred.
The analysis adjusted for covariates, yet the direction of the association remained consistent. The data suggest that AOD exposure adds an independent layer of risk on top of baseline pediatric medical complexity. In a children’s hospital, that means substance use screening cannot be treated as a peripheral social history item when the presenting patient already has a chronic medical diagnosis.
Racial and Ethnic Differences Appeared Within Each Chronic Disease Stratum
Race and ethnicity modified the relationship between AOD use type and hospitalization within each adolescent chronic medical condition subgroup. The interaction was statistically significant, with p = 0.002, indicating that hospitalization patterns were not uniform across racial and ethnic groups. The study does not measure the reasons for those differences, and the observed pattern should not be reduced to biology alone. Clinical severity at presentation, differing access to outpatient care, referral pathways, documentation practices, family resources, and structural factors inside and outside the hospital may all contribute.
Those disparities matter at the bedside because they influence who gets observed, who gets admitted, and who receives additional evaluation for substance use disorder. If clinicians rely on an unstructured impression of risk, the result can be inconsistent triage and uneven follow-up. Standardized screening offers a path toward more reliable recognition, especially in adolescents whose chronic illness may already dominate the clinical conversation.
Why Pediatric Hospitals Need More Routine Substance Screening
The findings support a more systematic approach to AOD evaluation in pediatric emergency settings. Adolescents with chronic medical conditions occupy a high-risk zone where substance exposure can worsen symptoms, obscure diagnosis, and complicate discharge planning. Cannabis, opioids, and other substances may intersect differently with chronic respiratory disease, neurologic conditions, gastrointestinal disorders, endocrine instability, or immunologic vulnerability, but the common thread is the same: acute presentation becomes harder to manage when substance use is left unidentified.
Because the study relied on encounter-level data, repeat visits from the same adolescent may have contributed more than once to the cohort. Even so, the breadth of the dataset across 45 hospitals reinforces the generalizability of the overall pattern. The emergency department is often the first and only point of contact when substance use intersects with chronic disease, which makes front-end recognition especially important. Without consistent screening, opportunities to identify emerging substance use disorder, initiate counseling, or arrange follow-up can be missed.
Hospitalization Risk Should Shape ED Pathways for Adolescents With Chronic Disease
The clinical takeaway is direct: in adolescents with chronic medical conditions, AOD-related emergency visits are more likely to end in hospitalization than visits without documented substance use, and that risk rises further in complex chronic disease. Mainstream substances accounted for the majority of substance-related encounters, which should discourage any assumption that the greatest concern lies only with clearly illicit drug use. Cannabis and similar substances were the dominant exposure category in this cohort, yet they still aligned with a substantial increase in admission probability.
Future work will need to separate documentation effects from true clinical severity, define which chronic disease categories carry the highest vulnerability, and determine whether standardized screening changes admission patterns or downstream outcomes. For now, the hospital signal is plain: adolescents with chronic illness who present with substance use need more than a routine clearance exam, because the likelihood of hospitalization rises quickly once AOD use enters the picture.