A review of psychoactive drug-involved deaths in nine major United States cities.

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The International Journal of the Addictions. 14(6), 735-758, 1979

A Review of Psychoactive Drug-Involved Deaths in Nine Major United States Cities Louis A. Gottschalk," M.D. Frederick L. McGuire, Ph.D. Jon F. Heiser, M.D Eugene C. Dinovo, Ph.D. Herman Birch, Ph.D. Department of Psychiatry and Human Behavior College of Medicine University of California at lrvine Irvine. California 9271 7

Abstract

Detailed psychosocial and biomedical data were collected on 2,000 psychoactive drug-involved deaths occurring from 1972 through 1974 in nine large cities in the United States. The cases were selected representatively by the medical examiners or cor*To whom requests for reprints should be addressed at Department of Psychiatry and Human Behavior, College of Medicine, University of California Irvine Medical Center, 101 City Drive South, Orange, California 92668.

135 Copyright @ 1979 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.

GOTTSCHALK ET AL.


736

oners in each city. Also, proficiency studies were carried out of the toxicological laboratories associated with these nine cooperating data collection centers. There were striking intercity psychosocial and biomedical differences in these psychoactive drug-involved deaths. These differences were based not simply on demographic regional population differences but also on the kinds of psychoactive drugs used as well as the role of the drug in contributing to death and whether the death was a result of an accident, suicide, homicide, or unknown intent. Also, a lack of uniformity was demonstrated in the quality control of the toxicological laboratories associated with the offices of these nine medical examiners or coroners, which suggests varying degrees of accuracy in resulting medicolegal diagnoses. Hence national programs of drug abuse deterrence or prevention and treatment should deal specifically with the variety of psychoactive druginvolved deaths occurring in different urban areas rather than approaching these problems globally as if they were uniform and homogeneous, and our toxicological proficiency studies accentuate the importance of mandatory quality control studies for all toxicological laboratories in the United States.

INTR 0 D UCTI0 N Reliable and relevant data have been found to be poor concerning the precise etiology of death due to drugs of abuse or other psychoactive drugs except possibly in some of the larger urban areas where adequately staffed professional manpower and facilities are available (Gottschalk et al., 1973). This has been learned through systematic inquiries of medical examiners, coroners, and vital statistics offices throughout the United States, as well as from inquiries of the Bureau of Mortality Statistics, United States Public Health Service of the Department of Health, Education, and Welfare. Moreover, accurate knowledge with respect to the epidemiology of drug-involved deaths in the United States has not been available because precise information has been lacking concerning the numbers and mechanisms of death due to such psychoactive drugs and whether or not there are regional differences with respect to the use of those psychoactive drugs that are leading to fatal consequences. As a result, nationwide efforts to combat and control the use and abuse of dangerous drugs have been hampered. To help deal with these problems, a research team from the Department of Pscyhiatry and Human Behavior,


PSYCHOACTIVE DRUG-INVOLVED DEATHS

131

College of Medicine, University of California, Irvine (U.C.I.) has developed a form for reporting and investigating psychoactive drug-related deaths in the United States (Gottschalk et al., 1973) in order to help improve the uniformity and breadth of information available on the psychosocial and biomedical aspects of drug-related deaths. This U.C.I. reporting form for drug-involved death has recently been used to obtain data from medical examiners or coroners on a representative sample of 2,000 drug-involved deaths occurring during 1972- 1974 from the following nine cities: Chicago, Cleveland, Dallas, Los Angeles, Miami, New York, Philadelphia, San Francisco, and Washington, D.C. (Gottschalk et al., 1975). The principal purpose in obtaining such detailed data from these nine cities was to determine whether the samples of deceased individuals from these different cities would vary with respect to a number of psychosocial and biomedical characteristics. It was also considered that there might be differences with respect to how deaths were investigated and reported by different medical examiner’s or coroner’s offices, and that different reporting centers would vary in the completeness of their data, methods used for gathering data, and the assay of toxicological substances. It was believed that such information could provide valuable clues as to how mortality statistics of these kinds gathered at the national level should be interpreted and would provide relatively uniformly collected data useful for national and regional policy and administrative decision-making toward alleviating drug abuse problems in the United States. The present paper includes a review of intercity psychosocial and biomedical differences found in 2,000 psychoactive drug-involved deaths in nine major United States cities, and gives a summary of toxicological proficiency studies performed in connection with this data collection.

METHODS AND PROCEDURES All medical examiners and coroners participating in this study were equally motivated with the authors in trying to improve the uniformity and reliability of the mortality statistics in the drug abuse and use area. Thus full cooperation was readily assured. The definition of “psychoactive drug-involved death” used for data collection was: Any death referred to a medical examiner or coroner in which psychoactive pharmacological agents were considered to be related to or involved in the fatal event. Instances where alcohol was the sole chemical substance responsiblefor the death were not acceptable for this study, but instances where alcohol, in combination

GOTTSCHALK ET AL.


738

with other psychoactive chemical substances, was involved with the death were acceptable. Instructions were supplied for filling out the reporting form for recording information about psychoactive drug-involved deaths. This form is a 16-page, bound questionnaire consisting of 168 items of inquiry in such data areas as biographic, demographic, on-site investigation, toxicologic, post-mortem, treatment prior to death, and suicide, and it is arranged for computer processing and data analysis (Gottschalk et al., 1973). This reporting form was pretested for reliability and ease of filling out on 300 cases of drug-involved death in three major urban United States cities. (A copy of this form is available from the authors upon request.) Each participating data collection center was advised to select consecutive cases of psychoactive drug-involved death on which there were all data necessary to complete the forms, but not to exercise any other selection criteria. It was indicated that psychoactive drug deaths due to accidental factors, therapeutic misadventure, suicide, homicide, or to unknown factors were equally acceptable. A quota of cases of psychoactive drug-involved deaths to be collected from each city was estimated on the basis of city size and annual death rate, and this quota was adjusted upward for the smaller cities in order to obtain a more adequate sample size, which necessitated a comparable reduction in the quota of cases to be sampled from the larger cities. During data collection certain cities had difficulties meeting their quotas, and some minor readjustments were made. Because of local problems, the rate of data collection varied. Therefore, although the cases were chosen consecutively over weekly or monthly time periods, none was selected during some time periods for some cities. Hence an extended period of time (1972-1974) was required to fill all quotas. However, these samples were considered by the medical examiners or coroners as representative of all psychoactive drug-involved deaths over this time period from each of the nine cities.

RESULTS The total period of time over which these 2,000 psychoactive druginvolved deaths occurred was from 1972 through 1974. Most of the deaths studied for this report occurred during 1973 and in the first 6 months of 1974. However, the specific number of cases obtained from each city covered varying time periods; for example, for Los Angeles, one year (July


739

1973 through June 1974); for Philadelphia, one and three-fourths years (January 1972 through September 1973); and for Washington, over two years (July 1972 through September 1974) (Table 1).


Distribution of On-Site Investigations by Cities

The on-site investigation is an examination of the location where a body is found (Aronson, 1976). This examination, by law carried out under the aegis of the medical examiner or coroner, is an important part of any death investigation involving drug abuse. It is generally carried out by a team of death investigators, under ideal circumstances led by a forensic pathologist, and includes a photographer, police representative, and others. The on-scene investigation includes a description of the environment, systematic observations of the body and its clothing, a thorough search, and recording of all drugs present as well as drug-use paraphernalia. Though an on-site investigation should be an essential part of the determination of the cause of all unattended deaths, it is not routinely carried out in the investigation of all drug-involved deaths for a variety of reasons, the major one being economic. There was a relatively high percentage of on-site investigations in these 2,000 cases of drug-involved deaths. The lowest percentages of these investigations occurred in Philadelphia (62%), New York (63%), and Washington (64%). High percentages of on-site investigations occurred in San Francisco (95.6%), Miami (98.7%), and Los Angeles (100%). Table 1 Time Distribution over Which a Total of 2,000 Psychoactive Drug-Involved Deaths Occurred in Nine Cities City

Deaths

Time period

Chicago Cleveland Dallas Los Angeles Miami New York Philadelphia San Francisco Washington, D.C.

295 150 100 300 151 405 199 250 150

January 1973-June 1974 April 1973-December 1974 January 1973September 1974 July 1973-June 1974 January 1973-December 1974 January 1973-December 1974 January 1972September 1973 January 1973-June 1974 July 1972-September 1974

740

GOTTSCHALK ET AL.


Distribution of Autopsies

There was a very high percentage of autopsies on these deceased persons, the total number of autopsies being 1,885 (94.2%) of the 2,000 cases. Chicago and Philadelphia had the lower percentages (81 and 83%, respectively) of autopsies on these cases; Dallas had 91%, Cleveland had 95%, and Los Angeles had 97%, whereas Miami, New York, San Francisco, and Washington all had autopsies on 100% of these druginvolved deaths. Toxicological Examinations Performed on Drug-Involved Deaths in Nine Cities

The percentage of toxicological examinations in these drug-involved deaths was very high in these nine cities, ranging from 94 to 100%. Toxicological examinations were, in fact, performed on the average of 99.2% of these 2,000 cases. Psychological Autopsies Done on the Samples from Each of the Nine Cities

A psychological autopsy is a thorough retrospective investigation of the decedent’s intention relating to his being dead; that is, it is a study of the psychological aspects of the death (Shneidman, 1976). Such information is obtained by interviewing individuals who knew the decedent’s actions, behavior, and character well enough to report on them. A quite varying proportion of psychological autopsies was done on the drug-involved deaths from these nine cities. A total of 106 psychological autopsies was carried out on these 2,000 cases. Of these 106, Miami reported doing 53%, Chicago 12%, Los Angeles and Cleveland each lo%, Dallas 8%, Philadelphia 4%, San Francisco 2%, New York 1%, and Washington, D.C., 0%. Racial Characteristics of Drug-Involved Deaths in Nine Cities

Figure 1 shows that there were notable differences in the racial distribution of these drug-involved deaths in the nine cities. Whereas in Chicago there was a nearly equal number of Whites and Blacks, there was a large predominance of Whites over Blacks in Cleveland, Dallas, Los Angeles, Miami, and San Francisco in the data submitted. There was a preponderance of Blacks over Whites in New York City, Philadelphia, and Washington. In addition, New York City had 8% Puerto Ricans and

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5.7% Latin Americans, Los Angeles had 17% Mexican-Americans, and San Francisco had 4% Orientals.


Age Distribution of Drug-Involved Deaths by Cities

The age range of 20 to 29 was uniformly a peak period for druginvolved deaths in all nine cities. Secondary peaks occurred in some; for example, at ages 40 to 49 in Cleveland and Dallas, ages 30 to 39 and 40 to 49 in San Francisco, and 10 to 19 in Chicago. Table 2 gives a detailed analysis of the age distribution of drug-involved deaths by cities. Sex Ratios of Drug-Involved Deaths by Cities

The sex ratios of drug-involved deaths varied in the different cities. The predominant trend was for a larger number of male than female deaths. But in two cities, Cleveland and Miami, this trend was reversed, and more women than men died drug-involved deaths (Fig. 2).

Marital Status of Drug-Involved Deaths by Cities

The percentage of legally married persons in this sample varied from 19% (in New York) to 38.7% (in Cleveland). Most of these deceased persons had never been married (46%), ranging, for all marital status categories, from 31% in Dallas and 36% in Los Angeles to 59% in New York. The divorced averaged 12.8% of all marital status categories and the separated averaged 4.7% across all the cities. Occupational Status in Drug-Involved Deaths in Nine Cities

The occupational status of these cases of drug-involved death varied widely across cities (xz = 676.40, df = 64, p < .Owl).In New York 1% of the deceased were classified in the professional occupational category, whereas in Miami there were 9% professional. In Dallas 10% were classified as unskilled and in New York 12%; in Chicago and in Philadelphia, 41 and 30%, respectively, were categorized as unskilled; in Miami 16%, in Los Angeles 19%, in Cleveland 28%, in San Francisco 24%, and in Washington, D.C., 23% were in the unskilled category.

Total

Washington, D.C.

San Francisco

Philadelphia

New York

Miami

Los Angeles

Dallas

Cleveland

Chicago

%

Row % Total N

N

N Row %

N Row % N Row % N Row % N Row % N Row % N Row % N Row % 0.0 O 0.0 12 0.6

O

0.5

O 0.0 2 1.3 3 0.7 1

5.0

O 0.0 1 0.7 5

0-9

6.6 46 11.4 29 14.6 11 4.4 14 9.3 205 10.3

10

47 15.9 16 10.7 9 9.0 23 7.7

10-19

104 52.3 81 32.4 71 47.3 859 42.9

50.1

141 47.8 47 31.3 34 34.0 126 42.0 52 34.4 203

20-29 15.6 21 14.0 14 14.0 61 20.3 21 13.9 95 23.5 39 19.6 46 18.4 30 20.0 313 18.6

46

30-39

18.4 18 12.0 210 13.5

46

29 9.8 33 22.0 22 22.0 41 13.7 19 12.6 39 9.6 23 11.6

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Table 2 Age Distribution of Drug-Involved Deaths by Cities

12 4.1 14 9.3 7 7.0 24 8.0 18 11.9 10 2.5 3 1.5 33 13.2 8 5.3 129 6.4

50-59 11 3.7 17 11.3 9 9.0 17 5.7 12 7.9 3 0.7 0 0.0 19 7.6 6 4.0 94 4.8

60-69


3.1 1 0.7 0 0.0 8 2.7 17 11.3 6 1.5 0 0.0 14 5.6 3 2.0 58 2.9

9

70+

100.0

2,000

20.3 199 9.9 250 12.5 150 7.5

405

295 14.8 150 7.5 100 5.0 300 15.0 151 7.5

Row total

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Chicago N=295

Dallas N=100

.::: Los Angeles N=300

Sex by City

Miami N=151

Philadelphia San Francisco Washington N=250 N=150 N-199

by city.

New York N=405

Fig. 2. Distribution of drug-involved deaths-sex

Cleveland N=150

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Role of Drug in Death in Nine Cities

Differing patterns of the role of the drug@) in death occurred in different cities (Table 3). In Chicago there was reported a high incidence of accidental or “unexpected” death due to the direct effect of one drug (18%), accidental or “unexpected” death due to a drug in combination with some other pharmacologic agent (30%), and homicidal death due to a drug in combination with some physical event outside of the patient’s body (15.6%). In Cleveland there were reported: accidental or “unexpected” deaths due to the direct effect of one drug (23.3%), suicidal deaths due to the direct effect of one drug (34.7%), and accidental or “unexpected” deaths due to a drug in combination with some other pharmacologic agent (21.3%). In Dallas there were 15% accidental or “unexpected” deaths due to the direct effect of one drug, 39% suicidal deaths due to the direct effect of a drug, and 21% of mode unknown due to the direct effect of one drug. In Los Angeles there were 28.3% accidental or “unexpected” deaths due to the direct effect of one drug, and 31.3% accidental or “unexpected” deaths with a drug in combination with some other pharmacologic agent. Miami had a high incidence of accidental or “unexpected” deaths due to the direct effect of a drug (21.2%),suicidal deaths due to the direct effect of one drug (43.773 and suicidal deaths with a drug in combination with some other pharmacologic agent (15.2%). New York City had a high incidence of unknown mode of death due to the direct effect of one drug (16.1%), and unknown mode of death with a drug in combination with some other pharmacologic agent (58.1%). In Philadelphia there was a high incidence of deaths with mode unknown due to the direct effect of a drug (36.2%), and of homicidal deaths with a drug in combination with some physical event outside the patient’s body (36.2%). Sun Francisco had a large occurrence of accidental or “unexpected” deaths due to the direct effect of a drug (21.273, suicidal deaths due to the direct effect of one drug (24.4%),accidental or “unexpected” deaths with a drug in combination with some other pharmacologic agent (18.8%), and suicidal deaths with a drug in combination with some other pharmacologic agent (16.8%). Washington, D.C. had a large occurrence of accidental or “unexpected” deaths due to the direct effect of a drug (30%), suicidal deaths

146

GOTTSCHALK ET AL.

Table Role of Drug in Death

Drug induced


Single drug Accident N 52 Chicago Row % 17.6 Column % 16.4 Cleveland N 35 Row % 23.3 Column % 11.0 Dallas N 15 Row % 15.0 4.7 Column % Los Angeles N 85 Row % 28.3 Column % 26.7 Miami N 32 Row % 21.2 Column % 10.1 0 New York N 0.0 Row % 0.0 Column % Philadelphia 1 N 0.5 Row % 0.3 Column % San Francisco N 53 Row % 21.2 Column % 16.7 Washington, D.C. N 45 Row % 30.0 Column % 14.2 318 Column 15.8 total

Polydrug

Suicide

Homicide

Unknown

Accident

Suicide

Homicide

Unknown

13 4.4 4.2 52 34. 7 16.6 39 39.0 12.5

1 0. 3 33.3 1 0. 7 33.3 0 0.0

9 3.1 4.8

89 30.2 30. 8 32 21.3 11.1 4 4.0 1.4

13 4.4 9.4

2 0.7 100.0

3.6

0 0.0 0.0

6 2.0 2.4 0 0.0 0.0 2 2.0 0.8

94 31.3 32.5 13 8.6 4.5 1 0.2 0.3

22 7.3 15.8 23 15.2 16.5 23 5.7 16.5

0 0.0 0.0 0 0.0 0.0 0 0.0 0.0 0 0.0 0.0

4 2.0

0 0.0

5 2.0 2.0

0.0

1

0. 7 0.5 21 21.0 11.3

2 0.7

7

0

4. 7

0.0

5.0 5 5.0

0.0

0 33 11.0 19.0 10.5 0.0 66 0 0.0 43.7 0.0 21.1 4 1 1.0 0.2 1.333.3

16. 1 34.9

7.5 4.8

0 0.0 0.0

72 36.2 38.7

0 0.0 0.0

0 0.0 0.0

61 24.4 19.5

0 0.0 0.0

14 5.6 7.5

47 18.8 16.3

42 16.8 30.2

1 0.7

9 6.0 3.1 289 14.5

4 2.7 2.9 139 7.0

15

30 20.0 9.6 313 15.7

0

0.0

1.1

1 0.7 0.5 65

0.0

0.5

3 0.2

186 9.2

0.0

0

0.0 0.0 2 0.1

2 0.7 0.8 0

0.0 0.0 234 58.1 92. 1

1.6

1

0.7 0.4 254 12.7

747

PSYCHOACTIVE DRUG-JNVOLVED DEATHS 3 in Nine Cities


Drug related Drug(s) i- illness

Drug(s)

+ external event

Unknown

Accident

Suicide

Homi- Uncide known

1 0.3 3.4 0 0.0 0.0 1 1.0 3.4

2 0.7 5.3 2 1.3 5.3 1 1.0 2.6

28 9.5 50.9 2 1.3 3.6 4 4.0 7.3

9 3.1 25.7 2 1.3 5.7 3 3.0 8.6

46 15.6 24.6 9 6.0 4.8 0 0.0 0.0

3 1.0 23.1 2 1.3 15.4 0 0.0 0.0

28 23 9.3 7.7 37.3 79.3 4 3 2.6 2.0 5.3 10.3 0 0 0.0 0.0 0.0 0 . 0

1 0.3 2.6 0 0.0 0.0 24 6.0 63.2

2 0.7 3.6 4 2.6 7.3 3 0.7

2 0.7 5. 7 1 0.7 2.9 1 0.2 2.9

4 1.3 2. 1 1 0.7

0 0.0 0.0 0 0.0 0.0

6 3.0 10.9

Acci- Suident cide

17 5.8 22.7 3 2.0 4.0 4 4.0 5.3

5.5

8 4.0 10.7

3.4

3 1.5 7.9

10 4.0 13.3

0 0.0 0.0

2 0.8 5. 3

3 1.2

1 0.7 1.3 75 3.7

0 0.0 0.0 29 1.5

3 2.0 7.9 38 1.9

3 2.0

1 0.5

5.5

5.5 55

2.8

10

0.5 5

1.2 2.7

7 1.7 53.8

28.6

72 36.2 38. 5

3 1.2 8.6

8 3.2 4.3

1 0.4 7.7

4 2.7 11.4 35 1.8

42 28.0 22.5 187 9.3

0 0.0

5.0

0

+

Drug($ sequelae of drug abuse Accident 4 1.4

16.7 2 1.3 8.3 1 1.0 4.2 2 0.7 8.3 3 2.0 12.5 2 0.5

8.3 5

Row total

0 0.0 0.0 0 0.0 0.0 0 0.0 0.0

295 14.8

0 0.0 0.0

300

0 0.0 0.0 33 8.2 86.8

150

7.5 100 5.0

15.0

151 7.5

403 20.2

2 1.0 5.3

199 9.9

1

0

0.4 4.2

0.0 0.0

250 12.5

0.0 0.0

2.5 20.8

0.0 13 0.7

Unknown

4 2.7 16.7 24 1.2

150 3 2.0 7.5 7.9 1,998 38 1.9 loo. 0

GOTTSCHALK ET AL.

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due to the direct effect of a drug (20%), and homicidal deaths with a drug in combination with some physical event outside of the patient’s body (28%).


Drug Type in Drug-Involved Deaths in Nine Cities

The drugs involved in the death (in their chemical, generic, brand, or street name) were ranked in order of their importance in the cause of death by whomever made the decision at each coroner’s or medical examiner’s office concerning the role of the drug involved in the death. Usually this was the coroner or medical examiner or his deputy. These drugs were classified into 10 major categories according to the classification developed by Lea, Inc. of Ambler, Pennsylvania. This classification combines the attributes of the principal therapeutic action of the drug with some aspects of its pharmacological nature. The classification, including examples under each heading, follows: narcotics-codeine, Demerol, meperidine, methadone, morphine; analgesics-acetaminophen, aspirin, Darvon, empirin compound, Talwin; barbiturates-amobarbital, pentobarbital, phenobarbital, secobarbital, Tuinal; sedatives-chloral hydrate, ethchlorvynol, glutethimide, methaqualone, Quaalude; tranquilizerschlordiazepoxide, chlorpromazine, Equanil, mesoridazine, perphenazine; “pot” and other psychedelics--marijuana; psychostimulants-amphetamine, cocaine, methamphetamine, Preludin, tenuate; antidepressanzsamitriptyline, Deprol, imipramine, norpramin, Vivactil; ethanol-ethyl alcohol; miscellaneous or “other”-Antabuse, corticoids, digitalis, Maalox, vitamins. The pattern of these drug categories in the nine cities was examined. The drug use patterns varied significantly from city to city (x2 = 628.27, df= 72, p < .OOOl). For the drug ranked first in importance in the cause of death for each case, the drug use patterns in the nine cities were as follows (Fig. 3): Washington, D.C. : Narcotics, 67.8%; analgesics, 10.7%; barbiturates 14.8% New York: Narcotics, 62.8%; ethanol (in combination), 11.2% Philadelphia: Narcotics, 53.5%; barbiturates, 10.4%; ethanol (in combination), 9.0%; miscellaneous, 9.7% Los Angeles: Narcotics, 50.0%; barbiturates, 33.9% Chicago: Barbiturates, 40.2%; narcotics, 45.5% Sun Francisco: Barbiturates, 40.6%; narcotics, 32.1%


PSYCHOACTIVE DRUG-INVOLVED DEATHS 749

,

GOTTSCHALK ET AL.

750

Cleveland: Barbiturates, 19.9%; narcotics, 16.9%; analgesics, 15.4%; ethanol (in combination), sedatives, 10.3%; tranquilizers, 11 19.1% Dallas: Barbiturates, 24.7%; narcotics, 15.7%; analgesics, 20.2%; antidepressants, 9.0% Miami: Barbiturates, 31.5%; narcotics, 11.5%; sedatives, 25.4%; tranquilizers, 10.8%


.Ox;

What accounted for the prominent intercity psychosocial and drug use differences in psychoactive drug-involved deaths in these nine cities? Our first hypothesis was that the intercity demographic differences could be accounted for, in part, by the demographic differences of the populations of the nine cities from which these samples were drawn. That is, the ratio of Black to White and male to female psychoactive druginvolved deaths might parallel the racial and sexual compositions of each of these cities. The same might be said about the variations in occupational status among drug-involved deaths in these cities. Examination of this hypothesis by looking at these demographic ratios in the vital statistics (1971) of these cities led to some very interesting observations and did not corroborate our initial hypothesis. The ratios of the racial distributions within the populations from which each of these urban medical examiners or coroners obtained their cases indicated that five of the nine cities had a significantly different ratio of Black to White drug-involved death cases than was typical of the racial distribution within their populations. The following cities had significantly higher occurrences of Black as compared to White drug-involved deaths than would be expected by the racial distribution within the population: Chicago (x2 = 125.49, p < .001); Cleveland (x2 = 16.76, p < .00l); Los Angeles (x2 = 88.79, p < .001); New York (x2 = 342.88, p < .001); Philadelphia (x2 = 135.66, p < .OOl). The four remaining cities, Dallas, Miami, San Francisco, and Washington, had ratios of Black to White drug-involved deaths similar to the ratio of these races within their populations. The ratio of White to otherthan-Black drug-involved deaths in Dallas, Los Angeles, Miami, and New York was lower than would be expected by the racial distribution in their populations, with more drug-involved deaths occurring proportionately than expected among the minority groups. An examination of the sex distribution of drug-involved deaths per 100,000 persons in the nine cities showed the following male/female ratios: Chicago, 2.6/1 (xz = 59.77, p < .001); Los Angeles, 1.6/1 (x2 = 15.31,


p < .OOl); New York, 3/1 (xz = 107.27, p < .001); Philadelphia, 5.0/1 (x2 = 108.15, p < .001); San Francisco, 1.7/1 (xi’ = 16.65, p < .001); Washington, D.C., 3/1 (x’ = 39.32, p < .OOl); Cleveland, 0.9/1 = 0.180, p > .50); Dallas, 1.5/1 (xz = 3.79, p > .lo); Miami, 1/1 (xz = 0.044, p > .go). In summary, in six of the nine cities male druginvolved deaths, as compared to female, occurred significantly more frequently than would be expected from their distribution in the population. The three exceptions were Cleveland, Dallas, and Miami. Looking at the age distribution per 100,000 persons in the nine cities, the drug-involved deaths were broken down into age groups 10 to 19, 20 to 29,30 to 39,40 to 49, and 50 or above; such deaths did not follow the expected distribution of these age ranges in the population in every one of the cities. The ratio of deaths among persons less than age 29 to more than age 30 was greater, that is, there was a preponderance of younger age ranges in Chicago (1.7/1), New York (1.8/1), Philadelphia (2.2/1), and Washington (1.2/1), whereas in the following cities there was a relative preponderance of older ages among the deceased than would be expected: Cleveland (0.7/1), Dallas (0.7/1), and San Francisco (0.7/1). Clearly, intercity psychosocial and biomedical differences in the role of the drug in these drug-involved deaths must be explained in some other ways than simply demographic differences in the populations of the nine cities. No easy explanations have sprung from our descriptive statistics. There appeared, however, to be definable relationships between various psychosocial characteristics and certain classes of psychoactive drugs influencing the role of the drug toward a fatal outcome. Sex. While male deaths appeared to be more frequent (65 vs 35% of the sample), the pattern of drug usage by the sexes differed markedly. For example, among the narcotic deaths, males were much more often involved than females (78 vs 22%). But in the categories of analgesics, sedatives, and antidepressants female deaths were slightly more numerous than male deaths, and when barbiturates and tranquilizers were involved the sex distribution was nearly equal. Ethanol, however, in combination with a psychoactive drug, played a significant role more often in the deaths of the males (75 vs 25%). As in other findings, the implications were that the female tended more often than the male to be involved in prescription and over-the-counter drugs whereas the male, also involved significantly in these areas, involved himself mostly with the “hard drugs” and ethanol. Age. Narcotics apparently played a more important role in the death of younger people. For example, 56% of narcotic-involved deaths in-

(xz


75 1


152

GOTTSCHALK ET AL.

cluded people between the ages of 20 and 29 and another 19% between 30 and 39. In contrast, of the barbiturate deaths, only 31% of the 20-to-29year-olds and 13% of the 30-to-39-year-olds were so grouped. Among the older people, barbiturates were the most frequent offenders. For example, barbiturates were prominently involved 46% of the time in the deaths of 50-to-59-year-olds, this figure reaching 48% for the 60-year-old group and up to 63% for those aged 70 and over. Race. Narcotics were far more often involved in the deaths of Blacks, Puerto Ricans, Mexican-Americans, and other minorities and far less often were barbiturates so involved when compared with the Whites. When a split was made between “White” and all “other” races, the difference between the death percentage due to narcotics was quite distinct-23 vs 58%. On the other hand, with barbiturates 35% of the White group died in connection with this drug group, but only 11% of the “other” groups died as a result of barbiturates. Employment Status and Occupational Status. Presumably many of the racial differences noted were related to socioeconomic status. For example, among the narcotic users, 41% were unemployed, while only 22% of the barbiturate-involved deaths were so listed-about half as many. Also, among the occupational category of “professional,” 50% were listed in the barbiturate category but only 10% under narcotics, whereas, among the “unskilled,” about 50% were reported involved with narcotics and only 20% with barbiturates. While there was a trend toward higher involvement with analgesics among the “professional” and “semiprofessional” groups, it was not prominent. The other categories appeared to be rather evenly distributed. Highest Grade Completed in School. Educationally, the same distinction continued. For example, among the narcotic deaths, only 3% were college graduates versus 13% for the barbiturate groups. Furthermore, among the college graduates, only 12% were narcotic-involved whereas 45% of their deaths were significantly associated with barbiturates. This type of split, however, did not continue evenly throughout the educational spectrum. Among those with an eighth-grade education or less, the narcotic-barbiturate split was about even (33 vs 37%) whereas those with some high school (but who did not graduate) were more often included with the narcotic grouping (54 vs 27%). The high school graduates and “some college” groups divided themselves about equally between the two drugs. Marital Status. The never-married group showed a strong preference for the narcotic as compared to the barbiturate category (46 vs 2179, a



153

split that closely followed the age trend. Being married or divorced did not seem to produce large differences, but it was interesting to note that the separated group was more often represented among the narcotic category (46 vs 16%)than in the group of deaths due to barbiturates. This suggests a higher level of family disruption among narcotic users than among users of other drug modalities. Among the widowed group, barbiturates were noted as playing a significant role in their deaths as compared with narcotics (44 vs 20%).This was probably a function of being older and alone in addition to being correlated with the age-suicide continuum. Times Married. Multiple marriages apparently did not constitute a significant correlate of the various categories of drug use, although the narcotic group were less often married at least once (24 vs 33 to 52%), again probably a function of their age as well as a further reflection of lives which show a higher level of disruption. Compared with the older and more often widowed barbiturate group, the narcotic group were not so likely to have lived alone (17 vs 40%). Religious Preference. Among those 332 subjects for whom a religious preference could be determined, about equal percentages were Protestant or Catholic (44 and 42%)with 10% Jewish and the remaining 4% of no preference. The Jewish group had only 16% in the narcotics category as opposed to 48 and 33% for the Protestants and Catholics, respectively. Under barbiturates, which obviously have a high association with suicide, religious preferences did not show the expected Catholic bias against suicide; in fact, the Catholics included a higher percentage in this grouping (22 vs 10%)than the Protestants. The Jewish sample, however, included a striking 41% in this category and an additional 19% in the sedative grouping, as opposed to 6 and 3% for the other two religious groups. This may reflect the fact that, at least in some of the cities surveyed, the Jewish population was comprised of older individuals of higher socioeconomic status, which characteristics in turn were negatively correlated with narcotic-involved death.

intercity Differences in the Extent and Quality of the Toxicological Examinations

The results of the toxicological examinations performed by the medical examiners’ or coroners’ laboratories in these 2,000 drug-involved deaths were analyzed, and they have been reported elsewhere (Dinovo et al., 1976). There was considerable variation across cities in the extent of


754

GOTTSCHALK ET AL.

the toxicological examinations and in the number of drug assays quantitated. A brief proficiency testing program was performed in collaboration with the above nine major cities in the United States (Dinovo and Gottschalk, 1976). Drug deaths reported from coroners’ and medical examiners’ offices depend to some extent on test results obtained from their toxicological laboratories. These toxicological examinations are crucial to the judgments of forensic pathologists that drugs are significantly involved. Differences in laboratory procedures, in thoroughness of screening, and in the limits of detection could result in sizable differences in mortality statistics from various reporting areas. Our proficiency studies sought to determine the differences in the quality of toxicological examinations performed by these toxicological laboratories. Five standard samples were used in this study and were submitted to each of the nine participating cities. Three samples consisted of drugs added to clean urine and two samples of drugs added to a 3% solution of human albumin. The 25-ml urine samples and the 10-ml albumin were lyophilized to dryness and capped in vacuo. Some drugs were repeated at the same concentration in different samples. All five specimens were designed to contain 6.5 pg/ml of secobarbital in order to measure the variations in the secobarbital assay for a given laboratory over a period of time. The concentrations chosen in these unknown samples were at low toxic levels in order to provide a moderate challenge to the toxicological methodologies. For each sample, either one urine vial or two albumin vials were sent out to the cities; if requested, more of the sample was sent. Some samples were sent completely unknown, some with partial information (such as “drugs in this vial are neutrals and volatiles” or “this vial contains barbiturates”), and some samples were sent with all drugs contained therein identified. This program was set up to simulate the actual situation prevailing in offices of medical examiners, where variable amounts of information are available for each case. Since an agreement was made with each toxicological laboratory that the results for this proficiency testing would be kept confidential and there would be no identification with respect to what laboratory had obtained what results, all reports and findings from the laboratories were coded numerically so as to maintain complete confidentiality. Hence, in our reporting the findings of these studies, we will not be able to identify the findings by city. All participating laboratories were found to have adequate instrumentation and methodologies to quantitate the psychoactive drugs



755

when they were known to be in the sample. Errors in quantitation, including both false negatives and false positives, were much more frequent in the process of screening for the drugs than in quantitating them. If one could improve the accuracy of screening for psychoactive drugs, the whole toxicological examination would improve in accuracy. Overall, a wide variance was found among the nine cities in the detection, accuracy, and precision of toxicological analysis. This is most certainly a factor in the contribution of variations in the certification of the cause of psychoactive drug-involved deaths in these and other cities in the United States. An illustration of this proficiency testing is provided by the fact that, as indicated above, secobarbital was present at the same concentration (6.5 pg/ml) in all five samples. Table 4 reveals the time course of secobarbital measurements by the toxicological laboratory from each city. As can be seen, a wide range of results were found even in the assay of secobarbital, a rather well-established, supposedly routine assay method. It must be concluded at this time that one source of error in epidemiological and biomedical studies of psychoactive drug-involved deaths includes variance in the toxicological testing.

COMMENT From the above descriptive statistics one can see that there are notable differences between these nine cities in the psychosocial characteristics of the persons dying of psychoactive drug-related deaths and in the classes of the drugs involved. There are also differences between these cities in the extent to which the causes of such deaths are investigated (for example, whether or not an on-site investigation or psychological autopsy is done) and in the extent (Dinovo et al., 1976) or quality (Dinovo and Gottschalk, 1976) of the toxicological studies carried out in connection with these studies. What are the implications of these psychosocial, biomedical, and other intercity differences in psychoactive drug-involved deaths? Since such drug deaths are a direct or indirect result of varying classes of drugs, including narcotics, barbiturates, and other psychoactive drugs, and since different demographic segments of our urban populations are attracted to the use or abuse of these drugs, our national policies directed toward reducing these drug-involved deaths should be tailored to the specific type of drug use and the associated psychosocial characteristics of the people using the drug. Operationally this would mean not limiting programs to

N/R

-

384' 5.4 0.25

5 5.3 1.9

8

4

+ 5.2

4

City 2

5.55b

City 1

4.4 4.8 0. 33

8.5,6.4 6.4 1.8

5.8

3.3

4.9

7.0

7.5

City 4

5.2

4.75b

City 3

6.0 5.9 1.5

6.7

-

3.8

7.17

City 5

4 4.7 0.5

5.3

4.3

5

5.0

City 6

= Drug was found but not quantitated. - = Drug was not found. bOne-half of barbiturate (secobarbital and pentobarbital) concentration. 'Not included in statistics.

"N/R= No response. +

Standard deviation

Mean

August

Urine I1 June Urine V

May

February Urine IV March Serum III

Serum 1

Sample

9.5 4.8 4.1

3.2

1.8

+ +

City 7

Time Study of Secobarbital Measurements by City (concentration= 6.5 pgJml)a

Table 4


5.4 5.8 5.6 1.2

4.8 2.0

3.8

7

6.0

City 9

2.5

N/R

6

6.0

City 8



757

heroin, methadone, or other narcotic use, but including programs involving the use of other psychoactive drug classes and the biomedical consequences peculiar to these drugs. It would also mean differentiating the intent of the victim in the drug death-that is, whether the intent was suicide, homicide, accidental, or unknown, as well as specifying more precisely how the drug was involved in the fatal outcome. National programs not only of treatment but of prevention and deterrence should, in other words, deal specifically with the variety of drug death problems rather than approaching these problems globally. What are the implications of the intercity differences with respect to the degrees of accuracy and precision of toxicology laboratories associated with the offices of the medical examiners and coroners? Clearly, the lack of uniformity of proficiency or quality control indicates a modest to high error variance in our national death statistics and introduces some question into the relative accuracy of forensic pathology, especially as it relates to medicolegal conclusions. Finally, our findings accentuate the importance of the development of mandatory quality control studies for all toxicological laboratories in the United States. ACKNOWLEDGMENT

This investigation was supported by Contract No. 271 -75-3004 from the National Institute on Drug Abuse, Department of Health, Education and Welfare. REFERENCES ARONSON, M.E. The on-site investigation. In L. A. Gottschalk et al. (eds.) Guide to the Investigation and Reporting of Drug Abuse Deaths. Washington, D.C.: Government Printing Office, 1976. DINOVO, E.C., and GOTTSCHALK, L.A. Results of a nine-laboratory survey of forensic toxicology proficiency. Clin. Chem. 22: 843-846, 1976. DINOVO, E.C., et al. Analysis of results of toxicological examinations performed by coroners’ or medical examiners’ laboratories in 2000 drug-involved deaths in nine major United States cities. Clin. Chem. 22: 847-850, 1976. GOTTSCHALK, L.A., et al. The Development of a Uniform System for Reporting and Recording Drug-Related Deaths. Report on Contract No. 271-75-3004 (previously HSM 42-72-139) for the period June 26, 1972-June 25, 1973. National Institute on Drug Abuse, Department of Health, Education, and Welfare, 1973, 2 vols. GOTTSCHALK, L.A., et a]. The Investigation and Reporting of Drug-Involved Deaths. Report on Contract No. 271-75-3004 (previously HSM 42-72-139) for the period June 26, 1973-June 25, 1975. National Institute on Drug Abuse, Department of Health, Education, and Welfare, 1975, p. 625.

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