Blood-positive illicit-drug findings: Implications for cause-of-death certification, classification and coding

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Abstract

National cause-of-death data are important for national health administration, international comparisons and epidemiological research. The process of compiling mortality statistics starts with determination of causes of death, continues with medical death certification and concludes in coding of causes and selection of the underlying cause of death at statistical office. This study assesses how unequivocally and specifically the toxicologically verified intoxication of cannabinoids, opiates, amphetamines and cocaine is represented in diagnostic entries on death certificates and the national cause-of-death database and, ultimately, in the cause-of-death statistics.

Drug-positive deaths, i.e. deaths with blood-positive drug finding(s), the corresponding death certificates and the information entered in Statistics Finland's cause-of-death database were reviewed for the entire years of 2000, 2002 and 2004. Drug influence at the time of death may or may not be related to death. A drug-related condition was reported as the cause of death in 52% of cannabinoid-positive, in 81% of amphetamine-positive, in 98% of opiate-positive and in 100% of cocaine-positive deaths, calculated from the combined three-year material. At Statistics Finland, after validation of the reported information, the distribution was practically the same. From the cause-of-death database, the specific drug-related diagnosis could be identified in 21% of cannabinoid-positive, in 89% of opiate-positive and in 57% of amphetamine-positive deaths. The corresponding proportions of specific drug-related underlying causes in the cause-of-death statistics were even smaller for cannabinoids and amphetamines, 10% and 39%, respectively. In multiple-drug cases, identification was possible only if each drug had been assigned an additional drug-specific code from “T categories” of ICD-10 Chapter XIX. What is noteworthy, however, is that a third of cannabinoid-related and a quarter amphetamine-related cause-of-death diagnoses were assigned unspecific categories of ICD-10 in the multiple-cause database and, more notably, in cause-of-death statistics based on selected underlying causes. For the better specification of drug-related causes of death, we propose that the next ICD revision provide each drug with the code of its own, e.g. one comparable to ATC (Anatomical Therapeutic Chemical Classification Index) codes, to be used for its specification in all positions and combinations, or at least provide compatibility with the ATC's coding system. For classification and describing the trends of drug-related deaths, equal and specific definitions for drug-related deaths would also be needed.

Introduction

Drug abuse can cause death directly, by overdose or by disease or condition caused by the intoxicant, or indirectly contribute to death by deteriorating motor, sensory or cognitive functions. Death can in these cases be said to be due to drug abuse and drug-related.

Deaths suspected to be attributable to the use of illicit drugs are subjected to a forensic cause-of-death investigation [1], [2]. In Finland, this investigation practically always includes a medico-legal autopsy and, consequently, forensic-toxicological examinations [3] conducted centralised at the Department of Forensic Medicine, University of Helsinki.

The presence of a drug in the deceased person's post-mortem samples indicates that the person concerned used or was exposed to the drug before death. Furthermore, the presence of the drug in blood proves that the person had been under the influence of the drug before and at the time of death—the extent to which depends on the drug's characteristics and concentration and on the user's tolerance. In such drug-positive cases, the medical examiner concludes whether the verified drug intoxication had a causal relation to the death or not, and thereafter reports on the death certificate the manner and the originating antecedent cause of death, as well as any other causes of death. Finally, Statistics Finland validates the death certificates, classifies and codes all reported causes of death and selects the underlying cause of death according to the selection and modification rules of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). All causes of death reported on death certificates are registered in the national cause-of-death database. Cause-of-death statistics and the subsequent tabulations of causes of death are based on the selected underlying causes.

Forensic-toxicological examination produces specific information for medical examiner's judgement on the possible causal relation of the illicit drugs to the death concerned. The verified drug-related cause and event should be reported on the death certificate and registered in the cause-of-death database and statistics. The manual compilation of mortality statistics is susceptive to practical measurement changes and human errors [4] as well as to conceptual and normative aberrations and systematic biases [5], [6]. The hierarchical structure of the ICD classification itself and its principle of grouping all possible diseases and morbid conditions into mutually exclusive categories, with unavoidable residual categories “for other and miscellaneous conditions,” lead to a loss in the mortality statistics of specific information reported on the death certificate.

The objective of this study was to assess how unequivocally and specifically the toxicologically verified use of cannabinoids, opiates, amphetamines and cocaine is represented in diagnostic entries on death certificates, in the cause-of-death database and at the cause-of-death statistics, and how the classification and coding of causes of death equal the specific drug information reported on death certificates.

National mortality statistics are of vital importance for national health policy, international comparisons and epidemiological research. It is therefore important that users of cause-of-death data understand its limitations, and that those who produce the data are able to improve its quality.

Section snippets

Material and methods

The study material included all medico-legally examined deaths which occurred in 2000, 2002 and 2004 and in which the autopsy blood sample proved positive for cannabinoids (THC, hashish, marijuana), opiates (heroin, morphine, ethylmorphine, oxycodone, codeine), amphetamines (amphetamine, methamphetamine) or cocaine as determined by established GC or LC mass spectrometric methods. The materials for all the three years were mutually compatible with national cause-of-death investigation, reporting

Demographic features

The total number of deaths in which the deceased was found to be under the influence of cannabinoids, opiates, amphetamines and/or cocaine, i.e. drug-positive deaths in which at least one of these substances was present in blood, was 288: 113 in 2000, 87 in 2002 and 88 in 2004 (Table 1). Only 27 (9.4%) of these were female deaths; the proportion of women varied, however, depending on drug type, from 0% (cocaine) to about 7% (amphetamines). The mean age was 29.4 years, for men 29.6 (distribution

Discussion and conclusions

In Finland (population 5.3 million), annual deaths number 48,000–49,000. The medico-legal autopsy rate is high, and during the years under review, it varied from 21% to 24% of all deaths. This means that 10,000–11,500 medico-legal autopsies are carried out annually. In more than half of the cases, forensic-toxicological examinations are performed. All deaths suspected to have any relation to illicit drug use in Finland are investigated by the police. This investigation practically always

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