title: Variable Classification of Drug-Intoxication Suicides across US States: A Partial Artifact of Forensics?
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.
  
  
  CONCLUSIONS
  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.
authors: Injury Control Research Center and Department of Epidemiology, West Virginia University School of Public Health, Morgantown, West Virginia, United States of America.
authors: Ian R H
authors: IR
authors: Rockett
authors: Department of Statistics, West Virginia University, Morgantown, West Virginia, United States of America.
authors: Gerald R
authors: GR
authors: Hobbs
authors: Department of Psychology, Guangdong Medical College, Dongguan, Guandong, China and Department of Social Medicine, Zhejiang University School of Medicine, Hangzhou, China.
authors: Dan
authors: D
authors: Wu
authors: Department of Biostatistics, Mailman School of Public Health, and School of Nursing, Columbia University, New York, New York, United States of America.
authors: Haomiao
authors: H
authors: Jia
authors: Office of the Medical Investigator - Department of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America.
authors: Kurt B
authors: KB
authors: Nolte
authors: Department of Epidemiology and Public Health, University of Maryland, Baltimore, Maryland, United States of America.
authors: Gordon S
authors: GS
authors: Smith
authors: Social Solutions International Inc., Silver Spring, Maryland, United States of America.
authors: Sandra L
authors: SL
authors: Putnam
authors: Injury Control Research Center for Suicide Prevention and Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, United States of America.
authors: Eric D
authors: ED
authors: Caine
mesh_terms: D000061:Accidents, Home / Q000706:statistics & numerical data*; D000293:Adolescent; D000328:Adult; D000368:Aged; D015982:Bias; D002423:Cause of Death; D002648:Child; D002675:Child, Preschool; D003644:Death Certificates; D062787:Drug Overdose / Q000401:mortality*; D005260:Female; D005554:Forensic Medicine / Q000941:ethics; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D011159:Population Surveillance; D055553:Prescription Drugs / Q000633:toxicity*; D013405:Suicide / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology
chemical_list: D055553:Prescription Drugs