Our recent paper highlights an often-overlooked aspect of pedestrian safety: the role alcohol and drug use play in falls that occur outdoors, particularly on streets and sidewalks. We used data from the National Emergency Medical Services Information System (NEMSIS), which collects and standardizes data from EMS agencies across the USA, to describe the prevalence of drug and alcohol use among falls requiring EMS response. We analyzed the data by location of the fall and distinguished between falls with an indication of syncope or heat illness, as alcohol may play a different role in these falls.

Using over 1.8 million records of falls requiring EMS response in 2019, we found that overall, 7.4% of falls had an indication of drug or alcohol involvement, yet among falls that occurred outdoors on a street or sidewalk 21.2% had an indication of substance involvement. Across almost all age groups the prevalence of alcohol involvement was higher for falls occurring on streets and sidewalks compared with falls occurring indoors. Among those experiencing falls on streets and sidewalks without accompanying syncope or heat illness, adults ages 21-64 had the highest proportion of falls reported to involve alcohol. Further, EMS reports for male patients were more likely to include a report of alcohol and/or drugs than for female patients across all fall locations. The highest prevalence of alcohol use alone, at 25.1%, was found among men experiencing falls on streets and sidewalks, without accompanying syncope or heat illness.

We also found that falls involving alcohol and/or drugs resulted in more severe injury. Falls with a notation of alcohol, drug or both alcohol and drug use were more likely to have Glasgow Coma Scores indicative of moderate or severe head trauma compared with falls without a notation of substance use, particularly among falls that occurred on a street or sidewalk. Substance-involved falls were also more likely to occur during the evening and nighttime compared to during the day.  

Our findings suggest that substance use is present in a large proportion of falls that occur on streets and sidewalks, particularly among men and adults between the ages of 21 and 64. Additionally, falls occurring during the evening and nighttime hours are more likely to involve alcohol, further suggesting that falls on streets and sidewalks that involve alcohol may be in close proximity to businesses that serve alcohol. This is consistent with previous findings that suggest a higher density of alcohol serving establishments is associated with both increased alcohol consumption and increased pedestrian injury from motor vehicles. The increased prevalence of injurious falls involving alcohol among men and adults ages 21–64 is consistent with the higher prevalence of alcohol consumption in these groups in the USA.

These results have significant policy implications, particularly as cities work to revitalize their downtown areas after the COVID-19 pandemic. In many cities downtown revitalization plans include the development and promotion of nightlife or entertainment districts. Our study suggests that substance use may be an important risk factor for injurious falls, and therefore cities should consider policies and infrastructure that can help mitigate injury risk as they plan their downtown developments. Implementing appropriate lighting for commercial areas, improving maintenance of sidewalks and curb cuts and of roadbeds at street crossings can all help mitigate risk of pedestrian injury. States and cities might also re-evaluate policies around nightlife districts and open container laws that encourage the consumption of alcohol while walking.