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. 2015 Aug 21;10(8):e0135296.
doi: 10.1371/journal.pone.0135296. eCollection 2015.

Variable Classification of Drug-Intoxication Suicides across US States: A Partial Artifact of Forensics?

Ian R H Rockett  1 , Gerald R Hobbs  2 , Dan Wu  3 , Haomiao Jia  4 , Kurt B Nolte  5 , Gordon S Smith  6 , Sandra L Putnam  7 , Eric D Caine  8
Affiliations

Variable Classification of Drug-Intoxication Suicides across US States: A Partial Artifact of Forensics?

Ian R H Rockett et al. PLoS One. .

Erratum in

Abstract

Background: The 21st-century epidemic of pharmaceutical and other drug-intoxication deaths in the United States (US) has likely precipitated an increase in misclassified, undercounted suicides. Drug-intoxication suicides are highly prone to be misclassified as accident or undetermined. Misclassification adversely impacts suicide and other injury mortality surveillance, etiologic understanding, prevention, and hence clinical and public health policy formation and practice.

Objective: To evaluate whether observed variation in the relative magnitude of drug-intoxication suicides across US states is a partial artifact of the scope and quality of toxicological testing and type of medicolegal death investigation system.

Methods: This was a national, state-based, ecological study of 111,583 drug-intoxication fatalities, whose manner of death was suicide, accident, or undetermined. The proportion of (nonhomicide) drug-intoxication deaths classified by medical examiners and coroners as suicide was analyzed relative to the proportion of death certificates citing one or more specific drugs and two types of state death investigation systems. Our model incorporated five sociodemographic covariates. Data covered the period 2008-2010, and derived from NCHS's Multiple Cause-of-Death public use files.

Results: Across states, the proportion of drug-intoxication suicides ranged from 0.058 in Louisiana to 0.286 in South Dakota and the rate from 1 per 100,000 population in North Dakota to 4 in New Mexico. There was a low correlation between combined accident and undetermined drug-intoxication death rates and corresponding suicide rates (Spearman's rho = 0.38; p<0.01). Citation of 1 or more specific drugs on the death certificate was positively associated with the relative odds of a state classifying a nonhomicide drug-intoxication death as suicide rather than accident or undetermined, adjusting for region and type of state death investigation system (odds ratio, 1.062; 95% CI,1.016-1.110). Region, too, was a significant predictor. Relative to the South, a 10% increase in drug citation was associated with 43% (95% CI,11%-83%), 41% (95% CI,7%-85%), and 33% (95% CI,1%-76%) higher odds of a suicide classification in the West, Midwest, and Northeast, respectively.

Conclusion: Large interstate variation in the relative magnitude of nonhomicide drug-intoxication deaths classified as suicide by medical examiners and coroners in the US appears partially an artifact of geographic region and degree of toxicological assessment in the case ascertainment process. Etiologic understanding and prevention of drug-induced suicides and other drug-intoxication deaths first require rigorous standardization involving accurate concepts, definitions, and case ascertainment.

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Conflict of interest statement

Competing Interests: At the time of the study, S.L.P. worked for Social Solutions, Inc.,* a Small Disadvantaged Business (SDB), through a subcontract with the National Institute on Drug Abuse (NIDA); http://www.socialsolutions.biz/about-us/company-overview/. Her contributions to the research were made in her leisure time. K.B.N. received funding from the Centers for Disease Control and Prevention (CDC) for the development of a position paper for Guidelines for Determining Deaths from Opiate and Opioid Intoxication, principal investigator – 9/30/11-1/30/13 $100,000. This funding led to three publications: Davis GG; National Association of Medical Examiners and American College of Medical Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths. Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. Acad Forensic Pathol 2013;3(1):62-76. Davis GG; National Association of Medical Examiners and American College of Medical Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths. National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. Acad Forensic Pathol 2013;3(1):77-83. Davis GG; National Association of Medical Examiners and American College of Medical Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths. Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. J Med Toxicol 2014;10(1):100-106. There are no patents, products in development or marketed products to declare. This does not alter the authors' adherence to all the PLoS ONE policies on sharing data and materials.

Figures

Fig 1
Fig 1. Percentage of nonhomicide drug-intoxication deaths classified as suicides in quartiles by state and region, United States, 2008–2010.
See this image and copyright information in PMC

References

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