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Overcoming the limitations of ‘accident’ as a manner of death for drug overdose mortality: case for a death certificate checkbox
  1. Ian R H Rockett1,2,
  2. Eric D Caine3,2,
  3. Hilary S Connery4,5,
  4. Kurt B Nolte6
  1. 1 Epidemiology, West Virginia University, Morgantown, West Virginia, USA
  2. 2 Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
  3. 3 Injury Control Research Center for Suicide Prevention, University of Rochester Medical Center, Rochester, New York, USA
  4. 4 Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts, USA
  5. 5 Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
  6. 6 Pathology and Radiology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
  1. Correspondence to Dr Ian R H Rockett, Epidemiology, West Virginia University, Morgantown, WV 26505, USA; irockett{at}


Collectively, the epidemic increases in the United States of opioid-related deaths and suicides during the first two decades of the 21st century have exposed shortcomings in current forensic and epidemiological approaches for determining and codifying manner of death—a vital function fulfilled by medical examiners, coroners and nosologists—the foundation for the National Violent Death Reporting System (NVDRS), an incident-based surveillance system providing individual-level information on decedent characteristics, manner, cause and circumstances of suicide, homicide and other violent injury deaths. Drug intoxication deaths are generally classified as ‘accidents’ or unintentional, a fundamental mischaracterisation; most arose from repetitive self-harm behaviours related to substance acquisition and misuse. Moreover, given the burden of affirmative evidence required to determine suicide, many of these ‘accidents’ likely reflected unrecognised intentional acts—that is, suicides. Addition of a simple checkbox for self-injury mortality on the death certificate would enrich the National Death Index and NVDRS, and in turn, inform prevention and clinical research, and enhance the evaluation of prevention programmes and therapeutic regimens.

  • poisoning
  • suicide/self-harm
  • mortality
  • drugs
  • mental health

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  • Contributors IRHR conceived the manuscript. All authors were involved in the writing and provided final approval of the submission.

  • Funding The work was partially supported by Grant R49CE002093 from the National Center for Injury Prevention and Control of the US Centers for Disease Control and Prevention.

  • Disclaimer The views expressed are those of the authors and do not necessarily represent the position or policy of the US Centers for Disease Control and Prevention or the US Government.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.