Alcohol and drug-related deaths from MBD 1999-2002. Slow bu

1
How do we and how should we define and count
poisoning deaths in the United States?
Lois A. Fingerhut, MASpecial Assistant for
Injury Epidemiology, OAERobert N. Anderson,
PhDChief, Mortality Statistics Branch, DVS
2
Objectives

• To consider revising the existing matrix
  definition of poisoning to include relevant codes
  from the F10-F19 series of the Mental and
  Behavioral Disorders chapter of the ICD
• To better understand what is gained from
  analyzing multiple cause of death data for
  poisoning

3
How are poisoning deaths currently defined?

• By the List of 113 Causes (used to rank leading
  causes of death in the US) the underlying cause
  ICD-10 codes for Unintentional poisoning are
  X40-X49
• By the External Cause of Injury Mortality Matrix
  as the underlying cause for poisoning regardless
  of intent Recommended by NCHS and Injury ICE

4
Poisoning is defined in the Matrix by ICD-10
codes by intent ICD also codes broad substance
groups
5
Poisoning deaths- 2002
6
Based on the matrix definition, poisoning was, in
2002,

• 3rd leading cause of injury death overall
• distant 2nd for unintentional injury
• 3rd for suicide
• leading cause for intent undetermined.

7
Should codes be added to the definition of
poisoning?

• Being considered are underlying ICD-10 codes
  F10-F19 for Mental and Behavioral disorders (MBD)
  due to pyschoactive substance use
• The precise wording on the death certificate can
  determine whether a drug or alcohol related death
  is assigned an underlying cause of poisoning or a
  F10-F19 code.

8
F10-F19 If so, which codes should be added?

• 4th digit of these codes
• .0 Acute intoxication
• .1 Harmful use
• .2 Dependence syndrome
• .3-.4 Withdrawal states
• .5 Psychotic disorder
• .6 Amnesic syndrome
• .7 Residual/late onset psychotic disorder
• .8 Other MBD
• .9 Unspecified MBD

3 digit ICD-10 codes

• F10 Alcohol
• F11Opioids
• F12 Cannabinoids
• F13 Sedatives/hypnotics
• F14 Cocaine
• F15 Other stim.,incl. caffeine
• F16 Hallucinogens
• F17 Tobacco
• F18 Volatile solvents
• F19 Mult drug use other psycho. substances

For each 3 digit code .0-.1 and .3-.9
Nondependent abuse .2Dependent abuse
9
F10-F19 Deaths 2002
MBD due to tobacco use (F17) is not included as
a drug. F17 was the underlying cause of 549
deaths in 2002.
10
Alcohol and drug-related deaths from MBD 1999-2002
Slow but steady increases in alcohol-related
(except intoxication) deaths as well as
nondependent drug abuse deaths
11
Multiple cause codes identify the specific drug
or substance

• Multiple cause of death codes are often referred
  to as nature of injury codes for poisoning and
  toxic effects in ICD-10 these are T36-T65.
• Too often they are neglected in analyses.

12
T codes

• T36-T50 Poisoning by drugs, medicaments and
  biological substances
• T51-T65 Toxic effects of substances chiefly
  nonmedicinal as to source
• Using these nature of injury poisoning codes,
  29,974 deaths had at least one mention of a
  poison or toxic substance, and there were a total
  of 49,946 mentions of substances.
• For all underlying-external cause poisoning
  deaths, an average of 1.9 total substances were
  listed per death

13
Leading substances in multiple cause data by
underlying cause of death 2002
Underlying causes of death
Drugs and toxic effect substances mentioned in
multiple cause data
14
WHOs Mortality Reference Group (MRG)

• The MRG makes decisions regarding the application
  and interpretation of ICD to mortality and makes
  recommendations on proposed ICD updates to the
  Update Reference Committee (URC).
• The URC recommends changes to the ICD-10 to the
  Heads of WHO Collaborating Centers for the Family
  of International Classifications each year.

15
The MRG has recommended Deaths due to Acute
Intoxication

• If the death certificate has language that
  includes words that would have resulted in an
  underlying cause code of F10-F19 with a 4th digit
  of 0, the new rule will result in coding to an
  underlying external poisoning code for alcohol.
• The largest impact in the US will be more deaths
  coded to X45 Accidental poisoning by and
  exposure to alcohol because nearly all of the
  F10-F19 codes with a 4th digit of 0 are for
  alcohol (F10.0)

16
Regarding all F10-F19

• If the underlying cause would have resulted in
  any code F10-F19 and the certificate also
  included information ascribed to an external
  cause poisoning code, the new rule will result in
  underlying cause codes going to the external
  causes.
• These changes will increase the number of
  poisoning deaths by an indeterminate amount.
• These changes will be implemented in 2006.

17
Recommendation

• At a minimum, consider expanding the definition
  of poisoning deaths beyond the number based on
  matrix (26,435 deaths in 2002) to include deaths
  due to alcohol intoxication (617 deaths), and
  deaths due to drug non-dependence (1,747)

18
3 leading causes of injury death 2002
Will poisoning soon become the 2nd leading cause
of injury death??
19
Conclusion

• Death certificate wording determines whether a
  drug or alcohol-related death is assigned an
  underlying cause of poisoning or mental or
  behavioral disorder. Recommendations on formal
  definitions must follow broad-based discussions
  among communities of toxicologists, medical
  examiners, and injury epidemiologists.

20
National Academy of Science May 2004

• U.S. Institute of Medicine has recommended that
• WHO should review and reform the ICD codes for
  poisoning This is being done
• NCHS should review the methodology of its
  existing surveys to maximize the value.for
  poison prevention and control. Review of
  mortality definition is underway
• From Forging a Poison Prevention and Control
  System (2004)

21
LFingerhut_at_cdc.gov RNAnderson_at_cdc.gov