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58 Medical examiner/coroner systems and state variability in reporting suicide and “unintentional” drug-intoxication deaths: distorting reality and impeding prevention
  1. Ian Rockett1,
  2. Gerald Hobbs2,
  3. Dan Wu Zhejiang3,
  4. Haomiao Jia4,
  5. Kurt B Nolte5,
  6. Gordon S Smith6,
  7. Eric D Caine7
  1. 1Injury Control Research Center, West Virginia University, USA
  2. 2Department of Statistics, West Virginia University, USA
  3. 3University School of Medicine, China
  4. 4Department of Biostatistics, Columbia University, USA
  5. 5Office of the Medical Investigator, University of New Mexico, USA
  6. 6Department of Epidemiology and Public Health, University of Maryland-Baltimore, USA
  7. 7Injury Control Research Center for Suicide Prevention, University of Rochester Medical Center, USA


Statement of purpose The 21st-century surge in national drug-intoxication deaths has been associated with a growing problem of suicide misclassification. Prevention of suicide and lethal drug intoxications depends upon accurate classification of manner of death. This study evaluated interstate variation in reporting drug-intoxication suicides and their potential misclassification according to type of medicolegal death investigation system.

Methods/approach An observational mortality study of all 111,583 drug-intoxication decedents from the 50 states for the period 2008–2010, whose manner of death was suicide, accident, or undetermined intent. Data derived from CDC’s Web-based Injury Statistics Query and Reporting System (WISQARS). The main outcome measure was the rate ratio of combined accident plus undetermined intent to suicide drug-intoxication deaths (indexing potential suicide misclassification), and percentage of intoxication deaths specifying at least one drug (indexing fastidiousness of the death investigation process).

Results Drug-intoxication suicide rates ranged from a high of 3.68 deaths per 100,000 persons in New Mexico to 0.65 per 100,000 in North Dakota. The rate ratio of combined accident and undetermined intent to suicide drug-intoxication deaths ranged from 16.11 in Louisiana (drug-intoxication suicide rate = 0.79 per 100,000) to 2.49 in South Dakota (drug-intoxication suicide rate = 1.74 per 100,000). Adjusting for drug-specification, states with a decentralised coroner system were 46 times more likely to have a high rate ratio (>7.00) of the combined accident plus undetermined intent to suicide drug-intoxication deaths as states with a centralised medical examiner system (95% CI, 3.14–1750.22).

Conclusions Results suggest that the numerous jurisdictions not meeting rigorous standards for conducting medicolegal death investigations are excessively prone to differentially undercounting drug-intoxication suicides.

Significance and contributions There is a national urgency to have uniform state and local death investigation and reporting systems that meet high standards in ascertaining manner of death and providing appropriate surveillance data for evidence-based interventions.

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