Drug Abuse Deaths

in Nine Cities:

A Survey Report

Louis A. Gottschalk, M.D.

Frederick L. McGuire, Ph.D.

Jon F. Heiser, M.D.

Eugene C. Dinovo, Ph.D.

Herman Birch, Ph.D.

NIDA Research Monograph 29

November 1979

DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

Division of Research

5600 Fishers Lane

Rockville, Maryland 20657

For sale by the Superintendent of Documents, U.S. Government Printing Office

Washington, D.C. 20402

Stock Number 017-024-00982-2
The NIDA Research Monograph series is prepared by the Division of Research of

the National Institute on Drug Abuse. Its primary objective is to provide critical reviews of research problem areas and techniques, the content of state-of-the-art

conferences, integrative research reviews and significant original research. Its

dual publication emphasis is rapid and targeted dissemination to the scientific

and professional community.

Editorial Advisory Board

Avram Goldstein, M.D.

Addiction Research Foundation

Palo Alto, California

Jerome Jaffe, M.D.

College of Physicians and Surgeons

Columbia University, New York

Reese T. Jones, M.D.

Langley Porter Neuropsychiatric Institute

University of California

San Francisco, California

William McGlothlin, Ph.D.

Department of Psychology, UCLA

Los Angeles, California

Jack Mendelson, M.D.

Alcohol and Drug Abuse Research Center

Harvard Medical School

McLean Hospital

Belmont, Massachusetts

Helen Nowlis, Ph.D.

Office of Drug Education, DHEW

Washington, D.C.

Lee Robins, Ph.D.

Washington University School of Medicine

St. Louis, Missouri

NIDA Research Monograph series

William Pollin, M.D.

DIRECTOR, NIDA

Marvin Snyder, Ph.D

DIRECTOR, DIVISION OF RESEARCH, NIDA

Robert C. Petersen, Ph.D.

EDITOR-IN-CHIEF

Eleanor W. Waldrop

MANAGING EDITOR

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Drug Abuse Deaths

in Nine Cities:

A Survey Report
ACKNOWLEDGMENTS

This publication originated as a report prepared for the

National Institute on Drug Abuse under Contract 271-75-3004

by the Department of Psychiatry and Human Behavior, College

of Medicine; University of California, Irvine, CA 92717.

The original contract for the project was HSM 42-72-139,

awarded by the National Institute of Mental Health. Project

officers in NIMH and NIDA were Michael S. Backenheimer, Ph.D.,

and Louise G. Richards, Ph.D., of the Psychosocial Branch,

NIDA Division of Research. Many of the tables in the report

have been reworked and consolidated for this monograph by

Dr. Richards.

The U. S. Government does not endorse or favor any specific

commercial product or commodity. Trade or proprietary names

appearing in this publication are used only because they are

considered essential in the context of the studies reported

herein.

Library of Congress catalog card number 80-600013

DHEW publication number (ADM) 80-840

Printed 1980

NIDA Research Monographs are indexed in the Index Medicus.

They are selectively included in the coverage of BioSciences

Information Service, Chemical Abstracts, Psychological

Abstracts, and Psychophamacology Abstracts.

i v
Foreword

The study of drug abuse deaths, while not a topic we approach

with eagerness, is an essential contribution to epidemiology, for

these deaths are the ultimate sequelae of the drug dependence syndrome. The death of a young person dependent on drugs is often

the first warning to a community that it has a drug problem; and

because so many of the deaths occur among otherwise physically

normal young adults, they truly are tragedies. These deaths can

be a barometer, albeit not a perfect one, of the extent and seriousness of drug abuse.

The present study looks at the characteristics of the decedents,

the system of data collection, and the activities involved in certifying a death. These kinds of data have never before been collected in depth on as comprehensive a sample of cases. The findings should serve as a reference for other studies of such incidents for years to come. The conclusions about consistency of

data from medical examiners’ and coroners’ offices show this to

be a problem area. We hope that awareness of present inconsistencies will provide an impetus for the creative thinking that

is needed to improve the usefulness of epidemiological information

from this source.

William Pollin, M.D.

Director

National Institute on Drug Abuse

v 

Contents

Foreword ................... v

List of Tables ................ viii

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Appendix A

Appendix B

Introduction and Overview . . . . . . . . . . . . . . . .

Methods of Study . . . . . . . . . . .

General Description of Cases . . . . . . .

Role of Drugs in Death . . . . . . . . .

Treatment of Victim Prior to Death . . . . .

On-Site Investigations . . . . . . . . .

Postmortem Findings . . . . . . . . . .

Details of the Toxicological Examinations . . .

Sociodemographic Characteristics of Cases . . .

Accidental Deaths . . . . . . . . . . .

Suicides and Homicides . . . . , . . , .

Discussion and Conclusions . . . . . . . .

Reporting Forms and Code Sheets . . . . . .

Survey 1

Form: Report of a Drug-Involved Death . . .

Code Sheets . . . . . . . . . . . .

Survey 2

Form: Reporting Form for Drug-Involved Deaths.

Code Sheets . . . . . . . . . . . .

Specific Psychoactive Drugs and/or the Classes of

Such Drugs Associated With 3004 Drug-Involved

Deaths. . . . . . . . . . . . . . .

. 1

. 7

. 17

. 24

. 29

. 37

. 45

. 68

. 82

. 96

.105

.113

.117

.118

.127

.132

.141

.143

List of NIDA Research Monographs . . . . . . . . . . .173

vii
List of Tables

Table 2.01 Quotas for Number of Cases To Be Collected From

Each City (Survey 1) . . . . . . . . . . 11

Table 2.02 Drug-Involved Deaths by Year and Quarter of

Discovery (Survey 1) . . . . . . . . . . 11

Table 2.03 Quotas for Number of Cases To Be Collected From

Bach City (Survey 2) . . . . . . . . . . 12

Table 3.01 Estimated Actual Cases and Survey Cases of Overdose Deaths for Three Time Periods, in Nine

Cities . . . . . . . . . . . . . . . .

Table 3.02 Major Demographic Characteristics of Weighted

20

Combined Overdose Cases for Three Time Periods . 22

Table 3.03 Selected Characteristics of Weighted Combined

Overdose Cases . . . . . . . . . . . . 23

Table 4.01 Role of Drug in Death Cases, by City (Survey 1). . 26

Table 4.02 Role of Drug in Death Cases, by City (Survey 2). . 27

Table 5.01 Enrollment in Drug Abuse Treatment or Rehabilitation at Time of Death, by City (Survey 2) . . 30

Table 5.02 Most Recent Enrollment in Drug Abuse Treatment

or Rehabilitation, Cases Not Enrolled at Time

of Death, by City (Survey 2) . . . . . . . 32

Table 5.03 Frequency of Participation in Drug Abuse Treatment

or Rehabilitation Programs, by City (Survey 2) . 33

Table 5.04 Incidence of Treatment Given Prior to Death, Responses to Questions in Survey 1 and Survey 2. . 34

Table 5.05 Locations Where Cases Were Treated Prior to Death,

Surveys 1 and 2. . . . . . . . . . . . 35

Table 5.06 Types of Persons Who Treated Decedents Prior to

Death, Surveys 1 and 2 . . . . . . . . . 35

Table 5.07 Types of Management Used in Treatment Prior to

Death, Surveys 1 and 2 . . . . . . . . . 36

Table 6.01 Types of Persons Who Conducted the On-Site Investigations, Surveys 1 and 2 . . . . . . . . 38

viii
Table 6.02 Types of Persons Who Conducted the On-Site

Investigation, by City (Survey 2). . . . . . 39

Table 6.03 Types of Persons First Reporting Events Surrounding the Death (Surveys 1 and 2). . . . . 39

Table 6.04 Incidence of Fingerprinting, by City (Survey 2). . 41

Table 6.05 Incidence of Study of Clothing of Deceased in the

On-Site Investigation, by City (Survey 2) . . . 41

Table 6.06 Bodily Evidence of Fxternal Injury (Surveys 1

and 2). . . . . . . . . . . . . . .43

Table 6.07 External Bodily Evidence of Drug Ingestion in

the On-Site Investigation (Surveys 1 and 2) . . 43

Table 6.08 Evidence of Drug Usage at the Scene, by City

(Survey 2) . . . . . . . . . . . . . 44

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

Table

7.01 Types of Postmortem Examinations (Surveys 1 and 2). 46

7.02 General Health: Postmortem Findings, by (Single)

Drug Type, Surveys l and 2. . . . . . . .48

7.03 Malnutrition and Systemic Infections: Postmortem

Findings, by (Single) Drug Type, Surveys 1 and 2. 49

7.04a External Examination: Postmortem Findings, by

(Single) Drug Type (Survey 1) . . . . . . . 52

7.04b External Examination: Postmortem Findings, by

(Single) Drug Type (Survey 2) . . . . . . . 53

7.05 The Musculoskeletal System: Postmortem Findings,

by (Single) Drug Type, Surveys 1 and 2 . . . . 54

7.06 The Vascular System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2 . . . . . 55

7.07 The Heart: Postmortem Findings, by (Single) Drug

Type, Surveys 1 and 2. 56

7.08a The Respiratory System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2 (Survey 1) . 57

7.08b The Respiratory System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2 (Survey 2) . 58

7.09 The Gastrointestinal System: Postmortem Findings,

by (Single) Drug Type, Surveys 1 and 2 . . . . 59

7.10a The Liver: Postmortem Findings, by (Single) Drug

Type, Surveys 1 and 2 (Survey 1) . . . . . . 60

7.10b The Liver: Postmortem Findings, by (Single) Drug

Type, Surveys 1 and 2 (Survey 2) . . . . . . 61

7.11 The Spleen: Postmortem Findings, by (Single) Drug

Type, Surveys 1 and 2. 62

7.12 The Lymph Nodes: Postmortem Findings, by (Singie)

Drug Type, Surveys l and 2. . . . . . . .63

7.13 The Genitourinary System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2 . . . . . 64

7.14 The Endocrine System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2 . . . . . 65

7.15 The Nervous System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2 . . . . . 66

7.16 Sex of Decedent: Postmortem Findings, by (Single)

Drug Type, Surveys 1 and 2 . . . . . . . . 67

7.17 Age Distribution by (Single) Drug Type, Postmortem

Findings, Surveys 1 and 2 . . . . . . . . 67

i x
Table 8.01

Table 8.02

Table 8.03

Table 8.04

Table 8.05

Table 8.06

Table 8.07

Table 8.08

Table

Table

Table

Table 9.01

Table 9.02

Table 9.03

Table 9.04

Table 9.05

Table 9.06

Table 9.07

Table 9.08

8.09

8.10

8.11

Source of Information on Drugs and Number of

Drugs Involved in the Death, by City (Survey 1) . 69

Types of Results of Drug Assays, by City

(Survey 1) . . . . . . . . . . . . . 71

Drug Assay Patterns for Five Drugs, by City

(Survey 1) . . . . . . . . . . . . . 72

Positive Toxicological Findings Quantitated for

the Most Commonly Found Drugs in Various Physiological Fluids and Tissues (Survey 1) . . . . 73

Quantitative Assays of Most Commonly Found (Generic) Drugs, in Single-plus-Polydrug Cases,

Single Drug Cases, and Single Drug-plus-Ethanol

Cases: Number and Location, Mean Concentration

and SD (Survey 1) . . . . . . . . . . . 75

Types of Results of Drug Assays, by City

(Survey 2) . . . . . . . . . . . . . 76

Drug Assay Patterns for Six Drugs, by City

(Survey 2) . . . . . . . . . . . . . 79

Proportions of Cases in Which Selected Drugs

Were Detected and Ranked First as Cause of

Death, All Cities (Survey 2) . . . . . . . 79

Types of Findings of Drug Tests, by Type of

Tissue or Fluid, All Drugs, All Cities (Survey 2) 80

Positive Toxicological Findings for Ten Commonly

Assayed Drugs, by Various Fluids and Tissues,

All Cities (Survey 2). . .

Quantitative Assays of Most Commonly Found (Generic)

80

Drugs, in Single Drug Cases, Single Drug-plusEthanol Cases and Polydrug Cases: Number and

Location, Mean Concentration and Range . . . . 81

Classes of Drugs Categorized as "Other," by City

(Surveys 1 and 2) . . . . . . . . , . . 84

Class of Drug Involved in Death, by City (Surveys

1 and 2 Combined) . . . . . . . . . . . 85

Age Distribution and Class of Drug Involved in

Death, by City (Surveys 1 and 2 Combined) . . . 86

Sex and Class of Drug Involved in Death, by City

(Surveys 1 and 2 Combined) . . . . . . . . 88

Race and Class of Drug Involved in Death, by City

(Surveys 1 and 2 Combined) . . . . . . . . 89

Marital Status and Class of Drug Involved in

Death, by City (Surveys 1 and 2 Combined) , . . 90

Occupation and Class of Drug Involved in Death,

by City (Surveys 1 and 2 Combined) . . . . . 92

Employment Status and Class of Drug Involved in

Death, by City (Surveys 1 and 2 Combined) . . . 94

Table 10.01 Selected Characteristics of Accidental Death

Cases, by City (Surveys 1 and 2 Combined) . . . 99

Table 10.02 Types of Drugs Responsible for Accidental Deaths,

by City (Surveys 1 and 2). . . . . . . . . . . . . . . . . . 100

x
Table 10.03 Role of Drug in Accidental Death Cases, by City

(Surveys 1 and 2) . . . . . . . . . . .102

Table 10.04 Reporting Source of Accidental Death Cases, by

City (Surveys 1 and 2 Combined). . . . . . .102

Table 10.05 Selected Personal Characteristics of Accidental

Death Cases, by Drug Type (Surveys 1 and 2

Combined) . . . . . . . . . . . . . .103

Table 10.06 Role of Drug in Death and External Bodily Evidence

of Accidental Death Cases, by Drug Type (Surveys 1 and 2 Combined). . . . . . . . . .104

Table 11.01 Proportion of Suicides Among Drug-Related Deaths,

by City (Surveys 1 and 2). . . . . . . . .106

Table 11.02 Selected Characteristics of Suicide Cases, by City

(Surveys 1 and 2 Combined) . . . . . . . .107

Table 11.03 Incidence of Depression and "Signals" Among

Suicide Cases, by City (Surveys 1 and 2 Combined) . . . . . . . . . . . . . . .108

Table 11.04 Types of Drugs Associated With Suicide Cases,

by City (Surveys 1 and 2). . . . . . . . .110

Table 11.05 Proportion of Homicides Among Drug-Related Deaths,

by City (Surveys 1 and 2). . . . . . . . .112

xi

Chapter 1

Introduction and Overview

Deaths resulting from abuse of drugs are the ultimate, irreversible

tragedy in the scale of individual and social costs of that abuse.

Measurement of types and numbers of these deaths plays an important

part in enabling us to understand the nature and extent of the whole

problem of drug abuse, here defined as nonmedical use of psychoactive

drugs. Yet, as is often the case when a new social problem erupts,

the established systems of data collection do not serve us well in

providing information specific enough to form a basis for accurate

assessments. Drug abuse deaths cannot be precisely measured by the

mortality statistics derived from standard death certificates. Statistics such as those regularly issued by the National Center for

Health Statistics on numbers and types of deaths use one broad category for drug-related causes of death; they do not distinguish between licit and illicit drugs, nor between drugs used for medical

and nonmedical purposes. The present study grew out of the need to

collect these kinds of previously unavailable data.

BACKGROUND

By 1970 there was heavy pressure for valid indicators of drug abuse

in the nation, and clearly a new source of data was required. The

project of which the present study is a part was launched to help

meet that need. The larger project also included two conferences, a

toxicology proficiency study of nine laboratories, and a number of

publications, among them the Guide to the Investigation and Reporting

of Drug Abuse Deaths (Gottschalk et al. 1977). The goals of the project, and especially of this study, evolved over the five-year period

from 1972 to 1977 as a reflection of changing national interest and

organizational structures.

The initial goal was to develop a reporting form which would provide

detailed information on persons who died from the abuse of psychoactive drugs. The intention was to distribute this form to medical examiners and organizations whose use of it could provide needed information. At about the same time, in its system for monitoring drug

abuse deaths on a regular basis, the Drug Abuse Warning Network

(DAWN) utilized some of the questions developed in this study.

The reporting form was revised by the investigators after feasibility

testing, and the decision was made to conduct a formal survey of nine

1
cities, using the revised form to determine patterns of drug abuse

deaths. Two years later it was decided to repeat the survey, with

minor additional revisions in the form, to observe what, if any,

changes had taken place in the pattern of deaths.

In their detailed queries about the amounts and types of drugs used,

the circumstances surrounding each death, and the procedures used to

determine the cause and mode of death, these surveys provide more

depth than data gathered from simple death certificates or the DAWN

forms (Drug Enforcement Administration 1973, 1974, 1975). In addition,

this report suggests that types of information and definitions emanating from the medical examiners' offices are not adequate sources

of data for national assessment of drug abuse deaths. There are good

reasons to believe, as will be seen in this report, that such data

may be "soft" and should be accepted as at best crude estimates of

the extent and causes of these deaths.

One indicator that created doubts about the accuracy of the data estimating drug abuse deaths was a toxicology proficiency study that

was carried out concurrently with the surveys described here. Detecting and categorizing drug abuse deaths inevitably depend to a great

extent on the accuracy of the laboratory assays used in investigation

of the deaths.

In the toxicology proficiency study, results of which have been published elsewhere (Dinovo et al. 1976 a, 1976b), five standard drug

samples, each containing one to seven commonly encountered drugs,

were sent to the medical laboratories of the nine cities selected to

report in the surveys. Two separate sets of five "unknown" drug samples were sent, one to two years apart, with graded amounts of information. The assays showed surprisingly large deviations from the

results to be expected based on the content of the samples. The laboratories often reported the absence of drugs which were in fact

present in the test samples. This proportion of false negatives

ranged up to 33 percent for some samples. The ability to assay less

familiar drug types varied among the laboratories; however, accuracy

of quantitation increased greatly in proportion to the amount of

information supplied with each sample.

SURVEYS OF CASES

As has been stated, the investigators developed a form that could be

used for uniform reporting of psychoactive drug-induced or psychoactive drug-related deaths. After the form was pretested and revised,

it was employed to collect cases over a specified time period from

coroners or medical examiners in nine major urban centers: Chicago,

Cleveland, Dallas, Los Angeles, Miami, New York, Philadelphia, San

Francisco, and Washington, D.C. In the first survey, 1972-1974, 2000

cases were collected. In 1975 a second survey collected 1000 cases

in the same nine cities to determine whether there were changes over

time in characteristics associated with the deaths.

The specific data sought in the surveys included demographic characteristics, circumstances surrounding each death, details of toxico2
logical and postmortem investigations, mode of death (accident, suicide, homicide),

death.

and any treatment or management of a case prior to

Crucial to the usefulness of the reporting form was the development

of a schema designed to make important distinctions about the role

of a drug in the death and the relationship of this to the mode of

death:

1. Was the drug the proximal cause of death (induced) or was it

merely incidental or coincidental (related)?

2. If the death was drug-induced, did the drug act alone in its

pharmacological action, in combination with another agent(s)

such as alcohol, or was death caused by an idiosyncratic drug

effect?

3. If the death was only drug-related, what were the other conditions that caused death?

One of the original aims of the survey was to portray the incidence

of drug-involved deaths nationwide as represented roughly by these

nine urban centers. Although the nine were not a sample of cities,

nor did the cases represent rural and other areas, it was thought that

their characteristics as a total set of cases would be illuminating.

Comparability of time periods and definitions across cities proved so

difficult to obtain, however, that this aim was abandoned. Most of

the analysis was made with data from each city kept separate, though

total numbers are available for inspection.

RESULTS OF THE SUFUEYS

The results of the surveys and some reflections on their meaning are

summarized in the remainder of this chapter.

The role of a drug or drugs in each death was tabulated first. About

two-fifths (41 percent) of the deaths reported in Survey 1 were associated with one drug alone; one-third (34 percent) were associated

with one or more drugs in combination with each other or with alcohol

In a small percentage of cases (7 percent) a preexisting and potentially fatal disorder was also present. In 3 percent of cases, a

medical disorder related to drug abuse was a factor in the death.

Drugs were found only coincidentally in another 15 percent of cases.

Information on the events surrounding each death was then tabulated.

In both surveys, the drug abuse treatment status of over 40 percent

of cases was unknown. In those cases where treatment status was

known, very few individuals had been enrolled in a treatment program.

(It should be remembered that these cases also included suicide by

drugs, in which treatment for drug abuse would not be expected.) Also, only a few persons had received emergency treatment immediately

prior to death, a fact that may explain in part why they died. When

emergency treatment was given, it was provided by physicians and consisted primarily of assisted breathing, tracheal help, medication,

or heart massage. Investigations were performed at the site of death

in about 80 percent of the cases. Needle marks and tracks were the

3
most common external evidence of poison or drug ingestion; drug paraphernalia were found about one-third of the time, and drugs were

found at the scene in about one-fourth of the cases.

The two major types of examinations off-site are, of course, postmortem and toxicological. Postmortems were carried out in almost

all cases, and, with few exceptions, by physicians with formal training in pathology. About half the autopsies included microscopic examinations and about one-third included chemical, hematological, or

immunological studies. Profiles of postmortem findings of single

drug cases were drawn for the primary single drug types (such as

barbiturates or narcotics) and found not to differ markedly from

those involving more than one drug or drug(s) in combination with

alcohol. Acute pulmonary edema was common in all drug groups and is

presumably a nonspecific end-stage finding of congestive heart failure and death from overdose. The toxicological examinations differed

considerably among the nine cities. There was a range of 1.6 to 3.5

drugs reported as tested. Overall, the proportion of drugs quantitated was about 75 percent.

For most drugs the amount present in combination with alcohol was

considerably lower than amounts of the same drugs when alone; this

finding was dramatic confirmation of synergistic effects.

The social and demographic characteristics of these cases are of considerable interest. Looking only at the drug-induced (i.e., causedby-drug) cases, there were discernible differences by type of drug.

The narcotic death cases were generally younger than the non-narcotic

cases and more often involved unmarried persons, males, and blacks.

(Los Angeles was an exception, where white cases predominated.) In

all drug categories, the majority of individuals were employed, a

surprising finding.

Mode of death, where it was known, was an important variable in the

study, since it allowed distinctions to be made between users of drugs

for social, recreational, or other nonmedical purposes (“drug abuse”)

and those who used drugs for the final act of suicide. There is concern over suicides, of course, but the former type of drug abuse has

created more anxiety, debate, and involvement of resources over the

past few years. Thus, it was important to look at the major modes

separately to see how they differed and what could be learned from

them about drug abuse deaths.

The mode labeled “accidental” covered what are commonly referred to

as drug abuse cases, though it also included the few cases of therapeutic misadventure that might come to the medical examiner’s

attention. Unfortunately, such large numbers of cases were classified

as “unknown” as to mode of death in New York and Philadelphia that

they were not tabulated for sociodemographic or other characteristics.

(This was one of several instances in which the procedural or other

differences among medical examiners’ offices made generalizations

difficult, if not impossible.) No typical profile of accidental

death could be discerned, but one or two trends were observed. Most

cases were in the young adult age category and males outnumbered fe4
males; whites outnumbered blacks except in Washington, D.C. Among

the leading five types of drugs involved, narcotics accounted for

more than the others, but the percentages reported varied widely by

city.

In contrast to accidental deaths, the cases labeled “definitely suicide” involved more females than males and the victims were somewhat

older than the cases as a whole. Whites were overrepresented among

suicides compared with blacks. Barbiturates were the most commonly

used drug type for suicide in all nine cities and alcohol was present

in about one-fourth of the cases.

Homicide made up about one-tenth of the total number of drug-involved

deaths; most were coincidental with some other physical event, such

as shooting.

CONCLUSIONS

Implications of these findings are discussed from three viewpoints:

the drug abuse problem itself; the quality of information emanating

from medical examiners’ offices; and the feasibility of future epidemiological research.

It is obvious that opiates and barbiturates were the most problematic

drugs; the extent to which this results from the availability of the

substances themselves is open to debate. Young adults who were in

otherwise normal physical condition were frequent victims. Accidental

death (mainly “overdose”) was the most frequent mode and suicide the

second most frequent. The large number of cases classified “unknown”

as to mode is an obstacle to full knowledge of these deaths.

There are several laudable practices carried on across the board in

the nine cities: on-site investigations, conduct of postmortem examinations by qualified pathologists, and the use of toxicological

laboratories as the preferred source of information. The results of

the concurrent toxicology proficiency study and certain other data,

however, create doubts about the reliability of either attribution

or lack of attribution of death to specific drugs. With polydrug

use increasing, this problem may become worse rather than better.

Local autonomy and responsibility for functions other than epidemiology seem to stand in the way of obtaining consistent, reliable information that can be compiled into a national picture. Unless or

until this condition changes, further studies are not likely to

make the picture of drug abuse deaths much clearer.

REFERENCES

Dinovo, E.C., and Gottschalk, L.A. Results of a nine-laboratory

survey of forensic toxicology proficiency.

1976a.

Clin Chem, 22:843-846,

5

315-509 O - 80 - 2
Dinovo, E.C.; Gottschalk, L.A.; McGuire, F.L.; Birch, H.; and

Heiser, J.F. Analysis of results of the toxicological examination

performed by coroners' or medical examiners' laboratories in 2000

drug-involved deaths in nine major U.S. cities. Clin Chem, 22:

847-850, 1976b.

Drug Enforcement Administration. DAWN 1 Analysis. Washington, D.C.;

U.S. Department of Justice, November 1973.

Drug Enforcement Administration. DAWN 2 Analysis. Washington, D.C.:

U.S. Department of Justice, 1974.

Drug Enforcement Administration and National Institute on Drug Abuse.

Project DAWN II. Washington, D.C.: U.S. Department of Justice, 1975.

Gottschalk, L.A.; McGuire, F.L.; Dinovo, E.C.; Birch, H.; and Heiser,

J.F., eds.

Deaths. National Institute on Drug Abuse. DHEW publication No.

Guide to the Investigation and Reporting of Drug Abuse

(ADM) 77-386. Washington, D.C.: Supt. of Docs., U.S. Govt. Print.

Off., 1977.

6
Chapter 2

Methods of Study

Liike the purposes of the study, the methods used in it evolved over

the five-year course of the project. What began as an instrument

feasibility study grew into an epidemiological investigation of

its own--both designed to “piggyback” on the established system of

mortality data collection. Because of the unanticipated difficulties encountered in this “piggybacking,” a third stage of the study--

evaluation of the method--became a necessary consideration. This

evaluative stage was never a formal intention of the study, and only

in retrospect can it be considered an investigation of the comparability of methods among medical examiners in major cities. Decisions made early in the feasibility stage could not be remade in the

epidemiological and evaluative stages. Thus, some results are not

ideal from the sampling or analysis viewpoints but form the basis

of some valuable conclusions about the nature of the process of

“piggybacking” on established data collection systems.

The primary objectives, as noted in the first chapter, were to develop a reporting form capable of collecting comprehensive information on deaths involving psychoactive drugs; to test the form by

collecting data in the offices of medical examiners or coroners in

selected cities; and to describe the characteristics of drug-involved

deaths in major cities, as well as the procedures for reporting

them. Methods for development of the reporting form, selection of

cases, data collection, and analysis of data had to be devised to

carry out the purposes of the study.

DEVELOPMENT OF THE REPORTING FORM

Mortality statistics ordinarily rest on the information gathered

from the death certificate, a relatively standard instrument familiar

to the general public. The death certificate concentrates on information about the identity of the deceased, the place, date, and

cause of death, and details about burial. The brief section on

cause of death asks only the immediate and contributory causes, and

whether the death was accidental, a suicide, a homicide, or undetermined as to mode. This study needed additional items of specifically medical interest available from medical examiners’ files,

such as toxicological findings, types of drugs in evidence, and

postmortem findings. Also, it was important to categorize drug7
involved deaths in such a way as to distinguish drug abuse cases

from other types.

The form went through several revisions before the first wide-scale

data collection. The items in the earliest version resulted from

systematic inquiries of a variety of sources: coroners and medical

examiners; vital statistics offices; medical departments of pathology,

toxicology, and pharmacology; the Bureau of Mortality Statistics,

U.S. Department of Health, Education, and Welfare; and several forensic pathology departments in Europe. In addition, site visits

were made to more than twenty medical examiners' or coroners' offices throughout the United States and Europe to learn what information they deemed important.

Although the form has seven parts, the information requested may be

classified into three general areas: characteristics of the deceased,

circumstances surrounding the death, and the process of investigating the death.

"Characteristics of the deceased" includes not only the obvious

demographic variables (covered primarily in Part I), but also background variables, such as whether the decedent had a history of mental

illness (in Part VI), and details of the deceased's early home life,

and drinking and smoking habits (in Part VII).

"Circumstances of the death" includes items regarding the drug or

combination of drugs used, causal relationship between the drug and

the death, source of the drug, mode of ingestion (all these in

Part I), and treatment of the deceased prior to death (Part V).

"The process of investigating the death" includes items regarding the

on-site investigation (Part II), the toxicological examination (Part

III), and the autopsy (Part IV), questions designed to make the decision-making process accessible and thereby facilitate evaluation

of the adequacy of postmortem procedures.

The entire document was tested by the research team in a pilot study

of 300 cases of psychoactive drug-involved deaths in three representative cities in the United States. Minor changes were made and

the resulting form was the one used in collecting the data of Survey 1. This revised form, entitled "Report of a Drug-Involved Death,*'

is reproduced in Appendix A together with several necessary code

sheets (pages 118-131). The most important of these, Code Sheet

#3, appears below. It includes the major distinctions critical to

the analysis of drug-related deaths, most importantly the differentiation of drug-induced from drug-related deaths.

After Survey 1, the form was again revised. There were six changes

of note: It was requested in Part I that drugs be ranked in order

of importance to eliminate ties; also, more than one source of information identifying the drug was allowed. In Part II events surrounding the death were covered, as well as on-site investigations.

Information about drug screens was asked for every drug listed in

Part III. Part V allowed medications given for reasons other than

8
CODE SHEET #3

Role of Drug Involved in Death

A SCHEMA FOR DEFINING AND CATEGORIZING

DRUG-INVOLVED DEATHS

Survey 1

DRUG-INDUCED

A. Simple or direct -- the drug in question was specifically the

cause of death with no other agent playing a significant role.

01. Accidental or "unexpected"

02. Suicidal

03. Homicidal

04. Unknown

B. Drug in combination with some other potentiating or synergistic

pharmacologic agent, such as alcohol, barbiturates, etc.

05. Accidental or "unexpected"

06. Suicidal

07. Homicidal

08. Unknown

C. Idiosyncratic -- an unexpected effect, such as an anaphylactic

or immune reaction.

09. Accidental or "unexpected"

DRUG-RELATED

D. Drug in combination with some pre-existing and potentially

deadly physiological condition, such as diabetes, chronic heart

condition, etc.

10. Accidental or "unexpected"

11. Suicidal

12. Homicidal

13. Unknown

E. Drug in combination with some physical event outside of the

patient's body, such as death by vehicle or gunfire while under

the influence, etc.

14. Accidental or "unexpected"

15. Suicidal

16. Homicidal

17. Unknown

F. Drug in combination with some medical disorder or disease

probably produced by drug abuse, such as hepatitis, bacterial

endocarditis, tetanus, etc.

18. Accidental or "unexpected"

19. Unknown

9
overdose to be listed, and a question on the mental state of the

deceased was added to Part VI. The final version of the revised

form used in Survey 2 is reprinted in Appendix A.

SELECTION OF CASES

The participating medical examiners and coroners in nine cities

were asked to select cases to be reported that would conform to the

categories of the Code #3 schema, with the qualification that cases

involving ethanol without other psychoactive drugs were to be excluded. The definition of “psychoactive” was left to the discretion

of the persons who selected the cases. For Survey 1 (2000 cases

selected over the period of 1972-1974) the medical examiners and

coroners were allowed to devise their own selection procedure to

obtain representativeness as best they could. This seemed necessary because each city had a different system of filing cases and

the often severe problems of locating cases also differed. For

Survey 2 (1000 cases selected in 1975) certain restrictions were

added to gain comparability between cities as to the time period

sampled.

The sampling quotas for Surveys 1 and 2 differed. For Survey 1 each

city was given a total number of cases to be submitted. Because the

emphasis was on the development of the reporting form itself, the

time periods sampled were not comparable from city to city, nor was

the sampling evenly spread out over time. In an attempt to obtain

more chronologically equivalent samples, in Survey 2 each of the

six largest cities was asked to submit the first portion of the quota

of eligible cases that occurred each month (the portion differed from

city to city) and each of the three smallest cities was asked to submit all the eligible cases that occurred in the eight-month period.

Survey 1 Quotas. The research team assigned a quota to each city

based roughly on its population and on an estimate of its drug problem, because there were no other bases for estimating how many cases

one could reasonably expect from each city. These quotas were modified, however, so that the small cities had proportionally larger

quotas, in order to provide sufficient numbers of cases for analysis.

The initial and final quotas for Survey 1 are shown in table 2.01.

Because of difficulty encountered by the investigators in carrying

out the task, fifty of Dallas’ quota of cases were transferred to

San Francisco. Difficulties were also encountered in maintaining

a consistent time period for all offices, but deviations were tolerated in order to complete quotas. The distribution of dates of

discovery of the Survey 1 deaths by city is seen in table 2.02.

Survey 2 Quotas. Six of the nine cities received letters that included the following paragraph:

“Your city has a quota of (N) cases whose dates of discovery are to

fall between 1 January and 31 August 1975. Select the cases in the

following manner: For each calendar month, take the first (n) cases,

in order of discovery, that fulfill our criteria for a drug-involved

death. Please make sure that no other criterion is used for selection. Let us know if you have difficulty in implementing this procedure.”

10
TABLE 2.01

Quotas for Number of Cases To Be Collected

From Each City (Survey 1, N=2000)

Number of cases

City: Initial quota Final quota

Chicago 300 295

Cleveland 150 150

Dallas 150 100

Los Angeles 300 300

Miami 150 151

New York City 400 405

Philadelphia 200 199

San Francisco 200 250

Washington, D.C. 150 150

TABLE 2.02

Drug-Involved Deaths by Year and Quarter

of Discovery (Survey 1, N=2000)

11
TABLE 2.03

Quotas for Number of Cases to Be Collected

From Each City (Survey 2, N=1004)

Number of cases

Quota

selected monthly Total

City 1 Jan thru 31 Aug 1975 Number

Chicago First 16 cases 128

Cleveland All cases 69

Dallas All cases 61

Los Angeles First 18 cases 144

Miami First 10 cases 80

New York City First 30 cases 240

Philadelphia First 13 cases 103a

San Francisco First 13 cases 104

Washington, D.C. All cases 75

aBecause, in one month, Philadelphia had a total of only 12

eligible cases, this count is one short of the planned quota.

The three remaining cities, Cleveland, Dallas, and Washington, were

requested to submit all eligible cases discovered during the specified

eight months. Quotas for the larger cities were set in proportion

to their caseload; for the smaller cities, the number was set somewhat higher to improve reliability of the resultant statistics. The

quotas and resulting numbers of cases are found in table 2.03.

As epidemiological purposes began to dominate the study, the concern for representativeness became more serious. Since the initial

decision was to cooperate with the medical examiners' and coroners'

offices for data collection, rather than to have data collected by

project personnel, the outcome of sampling procedures rested primarily on the ability of the investigators to communicate their

intentions and on the ability of the offices to comply. Because

of this, no strong claims can be made for generalizability of those

findings to a hypothetical universe of psychoactive drug-involved

deaths in those cities. But with the exceptions noted below, the

results are judged to be a fair representation of each office's perception of such cases in its city.

The cases taken from nine urban areas obviously cannot be generalized

to rural areas. Moreover, the nine areas, not having been selected

at random, cannot be considered representative of urban United States.

Finally, since cases are taken from the files of medical examiners

and coroners they inevitably will not include cases that escaped

their attention.

Some types of cases that may escape the attention of coroners and

medical examiners are, for example, the case of a patient who died

in a hospital from hepatitis caused by an unsterile hypodermic needle

12
used to inject heroin, or the case of a chronically ill person who

committed suicide by taking an overdose of pain-killer, but whose

death was attributed to the illness. Another type of case that

might not escape attention but still escape identification [at least

positive identification) as being due to a psychoactive drug is exemplified by a person killed in an accident caused by his own or

someone else’s impairment of brain function by such a drug. Finally,

to complicate matters even further, there are probably consistent

differences from city to city, both in ability to recognize cases

as being drug-involved and in readiness to classify borderline cases

as being drug-involved.

For all these reasons, the generalizability of these data is severely

limited. The best that can be said is that they indicate the hypothetical population of drug-related deaths in the nine cities, and

even that level of generalizability is further limited to the universe of deaths potentially identifiable from medical examiners’ and

coroners’ records, according to the standards of evidence in each

city. The data from all nine cities are useful for purposes of

comparison of decedents’ characteristics over time, within and among

the cities. To use the data to generalize to other cities or to

the nation as a whole would be unjustified, but they can generate

tenable hypotheses for future study.

After Survey 1 was completed, questions about representativeness

of data from each city were dealt with by an ad hoc inquiry in each

office. The inquiry proceeded as follows:

(1) A questionnaire on sampling procedures was filled out by

all coroners’ or medical examiners’ offices.

(2) A tally was made of all drug-involved deaths processed in

the years sampled in five cities (Cleveland, New York, Philadelphia,

San Francisco, and Washington, D.C.) for the years in which that total was in doubt. The form collected information on the major demographic variables (age, sex, race, marital status), drug(s), and on

the role of the psychoactive drug(s) as a cause of death, as well as

on the date of death and identifying case number.

(3) Official lists of deaths were supplied by three cities (Chicago, Miami, and Los Angeles).

(4) Discrepancies between the original data and those collected

from the tally on particular questions were examined for individual

cities.

(5) Analysis was made on distribution of dates of discovery of

the deaths.

(6) Analysis was made of distribution of cases according to

role of the drug and the mode of death.

On the basis of this inquiry, the following judgments of representativeness were made for Survey 1 for the nine cities:

1. Chicago: Probably representative of 1973; sample contains

at least 85 percent of eligible cases.

2. Cleveland: Probably representative of 1973 and perhaps of

1974; sample contains 90 percent of eligible cases in 1973 and 70

percent in 1974.

3. Dallas: Probably close to a complete count of accidental

13
(overdose) cases; other types of cases may not be as well represented.

4. Los Angeles: Accidental (overdose) cases overrepresented;

1973-1974 thoroughly covered.

5. Miami: Probably representative of 1973-1974.

6. New York: There were discrepancies in types of cases between the survey sample and other distributions! leaving representativeness in doubt. A large proportion classified unknown as to

mode [intention) made the analvsis difficult.

7. Philadelphia: A difference in definition of drug-related

deaths (exclusion of suicide cases who had not used drugs previously)

affects‘representativeness compared with other cities; other-wise,

the sample is probably representative of Philadelphia’s cases during

the Survey 1 period.

8. San Francisco: Probably representative of 1973-1974.

9. Washington, D.C.: Probably representative of 1973-1974.

A potential source of bias of general concern is that cities used

cases drawn from toxicological records rather than from the general

files. If taken only from toxicological records, it is conceivable

that drug-involved cases with negative or threshold toxicological

evidence might have been omitted. Moreover, such cases may be more

common for some roles of a drug in death than for others. The cities

which stated that they did not restrict their research to toxicological records were Cleveland, Los Angeles, and Philadelphia.

Representativeness of Survey 2 was assessed after the fact by interviewing the personnel by telephone. Only in Los Angeles was there

a possibility of discrepancy between sample and universe, created

by a difference in definition: Los Angeles included in its sample

only cases whose primary cause of death was attributed to a drug.

As a result of these investigations, representativeness of Survey 1,

in particular, must remain tentative. The task of obtaining these

samples from separate medical examiners’ or coroners’ offices was

instructive in its own right and useful conclusions can be drawn

from it.

COLLECTION OF DATA

For both surveys, the method of collecting data was to recruit one

or more persons in each of the nine cities to select the cases and

fill out the forms, paying $20 per completed form. When more than

one person collaborated, usually one was a qualified individual who

selected cases and handled any difficulties of interpretation, while

the other transferred the information from the case files to the reporting form. The problem of inducing members of the staff of the

coroner’s or medical examiner’s office to participate in this project

turned out to be unexpectedly difficult in several cities. Filling

out the form was a time-consuming task, and often no one was found

who could spare the time, even with the incentive of $20 per case.

Therefore, outsiders sometimes had to be recruited and made familiar

with the reporting form and the office’s system.

Whether insiders or outsiders finally took on the job, long delays

occurred in some cities before any reporting forms began to be re14
turned, and often further delays occurred during which the forms

ceased to come in. Turnover in personnel in some cities sometimes

left the project abandoned for several weeks. Although certainly

not ideal from the standpoint of scientific rigor, these difficulties

are nonetheless unavoidable in using a system established for other

purposes.

ANALYSIS OF DATA

Most portions of the reporting form were preceded, but certain areas

required coding after data collection. Code Sheet #3, classifying

the role of drug and mode of death, has been discussed. The code

for drug classification was the same as that developed by LEA, Inc.,

of Ambler, Pa., for the initial DAWN reporting. It grouped drugs

according to the following attributes: (1) the principal therapeutic

action of the drug; (2) the chemical or pharmacological nature of

the drug; (3) the classification desired by the client or manufacturer; and (4) the U.S. Food and Drug Administration’s approved usage

of the drug. For purposes of analysis, the classification was reorganized, combining the classes into ten categories: narcotics,

analgesics, barbiturates, sedatives, tranquilizers, marijuana and

psychedelics, psychostimulants, antidepressants, ethanol, and miscellaneous . The “miscellaneous” category included those drugs that

were rarely mentioned and did not fit into other well-populated

categories. One exception to the aforesaid rule was quinine, which,

although it was often mentioned (being a common diluent of heroin),

was still classified under “miscellaneous.” A category for marijuana and psychedelics was included because of potential interest,

but it was so rarely used that it might have been better to include

those drugs in the miscellaneous category. Appendix B lists the

names of the drugs which were entered in the various parts of the

reporting form and is a source of examples of the types of drugs

that were classified under each of the ten categories.

The analysis covered the areas of inquiry of most practical interest

to the sponsoring agency: distribution of drug types and mode of

death; characteristics of accidental, suicidal, and homicidal deaths;

and details of the toxicological, on-site, and off-site examinations.

The small numbers in some cells of some tabulations precluded more

sophisticated analysis or even the computation of percentages that

could be compared across all cities.* A multivariate analysis might

have answered the question of how important certain factors were in

explaining the modes of death, but the data were not amenable to it.

It is hoped that visual inspection of the tabulations will sufficiently illuminate the issues. The data tapes have been deposited

in the Drug Abuse Epidemiology Data Center at Texas Christian University for secondary analysis by interested scholars.

* To avoid misleading comparisons, percentages were not reported

on any cells totaling less than 20. (Editor)

15
METHODOLOGICAL AFTERWORD

A good form on which to record a comprehensive range of information

germane to psychoactive drug-involved deaths does not suffice to

obtain fully reliable information. Many kinds of errors occur in

trying to obtain data from any source with any reporting form. The

investigators tried to keep these errors to a minimum in a number of

ways. They personally examined the case records available in the

medical examiners' offices for completeness and relevance; they worked with individuals at the coroners' offices to fill out portions of

the form and spot-check for errors in recording. When appropriate,

they collected and recorded the data personally instead of delegating

the responsibility to other individuals. Finally, the completed

forms were checked by computer, and a number of computer programs

were written and used to detect errors, omissions, and inconsistencies. Nonetheless, the kinds of errors encountered despite these

precautions serve as a map of possible pitfalls.

I. Errors in the sampling process to achieve representativeness:

A. Selection by the medical examiner or coroner Of Cases from

files according to preconceptions about the distribution of the

kinds of cases.

B. Time sampling errors from the annual pool of cases, either

unsystematic (irregular annual sampling over only a few months) or

systematic (regular sampling over the same few months).

C. Lack of chronological listing of all cases processed by a jurisdiction, and haphazard use of various other lists of deaths by

Poison, suicides, homicides, accidents, and so forth.

II. Errors or inadequacies in the source of information:

A. Errors in recording relevant details in the coroners' files.

B. Omissions or other incomplete data in these files.

C. Delegation of data collection to uninformed or untrained

personnel.

D. Errors intrinsic in the data itself, e.g., in the postmortem,

toxicological assessments,

forth.

certification of cause of death, and so

We hope that others in the future, faced with a similar task of

assessing a new social problem within the limits of a preexistent

data collection system, may find our experiences useful.

16
Chapter 3

General Description of Cases

SUMMARY

By making certain restrictions on the cases and the descriptive

variables considered, data for all or most of the nine cities

were sufficiently comparable to warrant combining them. To attain comparability in the types of cases included, they were

restricted to those for which a drug or combination of drugs was

the direct cause of death (Categories A and B on Code #3), herein

referred to briefly as “overdose deaths.” To attain comparability

in Survey 1 cases, several extra restrictions had to be imposed.

The analyses performed on the data from the Survey 1 time period

had to be restricted to the descriptive variables found on the

tally form used in the ad hoc inquiry that followed Survey 1 (see

page 13): sex, age, race, marital status, drugs involved, and

mode of death. The same tactic also allowed the inclusion of

cases from tallies of Cleveland and San Francisco that supplemented their cases on the reporting form. Additional restrictions

were necessary to attain comparability of sampling period for

Survey 1 cases.

Before combining the data from the various cities, each city’s

results were weighted to represent the estimated number of overdose deaths that had been processed by the medical examiner or

coroner of the city during each of three time periods.

The variables that appear on the tally form were examined and

compared for the three time periods. Males outnumbered females,

and accidental deaths were more numerous than suicides, except

for the “unknowns.” A trend was apparent in two variables, sex .

and type of drug involved. The percentage of males increased

from 58 to 68 percent from the first to the third period, and the

percentage of cases involving narcotics increased from 41 to 55

percent, while the percentage of cases involving barbiturates or

both barbiturates and narcotics decreased.

COMBINED GENERAL DESCRIPTION OF CASES FOR ALL NINE CITIES

The chapters which follow will analyze the results of Surveys 1

and 2 for separate cities. There are good reasons for this

17
strategy: each city's drug-involved death population may have

unique characteristics, and/or each city's medical examiner or

coroner may have a somewhat different conception as to what constitutes a drug-involved death. Nevertheless, there is value in

looking at the combined data from the nine cities. Although they

do not encompass the entire United States, the nine selected

cities do include some of its most populous areas, many of which

are meccas for drug abusers or are places where illicit drugs are

more available than in other parts of the country. Therefore,

results based on all of the cities can be considered a rough

reflection of urban United States.

Creation of Data Sets Combining Cases from the Nine Cities

In order to combine the data of the nine cities into a meaningful

set, the cases had to be reasonably comparable as to type and

time of occurrence.

Not all types of cases could be included in the combined set,

since there were substantial differences from city to city in the

types of cases deemed drug-involved (see chapter 2). The solution to this problem was to include in the combined set only those

cases of drug-induced deaths for which the role of the drug was

direct and not those in which the drug was merely a contributory

cause of death. It is the latter type of case on which those

cities' attitudes seemed to differ most. Moreover, for most

cities, the drug-induced cases made up the great majority of the

samples.

One difficulty with the above solution was that Philadelphia differed substantially from the other cities in Survey 1, even in

its definition of an overdose death, It was therefore considered

necessary to exclude all Philadelphia's Survey 1 cases from the

combined set. Another difficulty was that New York City's method

of selection in Survey 1 seemed to be one which would not lead to

a representative sample even of overdose deaths. Since the contribution of New York to a combined set of data for all the

cities was so large, it was not practical to exclude New York

cases. The solution to this problem took advantage of the fact

that an exhaustive census of drug-involved death cases was obtained from New York on the tally form. If the analyses to be

performed on the combined Survey 1 cases were restricted to those

variables that appeared on the tally form, then cases of overdose

deaths that were available on that form could also be used in

making up a combined set. Thus it was decided that: (1) New

York City's contribution to the combined set of cases for the

time periods of Survey 1 would be taken exclusively from the

tally cases; (2) the other cities' contributions would be taken

from the Survey 1 cases but consist only of those variables found

also on the tally form; and (3) Cleveland's and San Francisco's

Survey 1 contributions would be supplemented by the cases they

added with the tally. (Washington, D.C.'s tally form cases were

not considered suitable for inclusion.) There was no reason for

the Survey 2 combined set to be restricted to the tally form

18
variables, but these variables can be singled out in that set for

comparison with earlier data.

Another requirement for comparability was that the cases to be

combined must have occurred during the same period of time. Although this was true for Survey 2 cases, inspection of table 2.02

indicates that it was not true for Survey 1 cases. To solve this

problem, from the entire span of time covered by Survey 1, two

periods were selected that had good representation from most

cities, and two separate combinations were made for the cases

that occurred in each time period. The two time periods for Survey 1 were July through December 1973 and January through June

1974. The Survey 1 cases that did not occur during either of

these time periods were ignored and do not contribute to any of

the analyses of the combined data reported here. It should be

noted that Chicago did not contribute any cases occurring during

1974, and therefore it is not represented in the second combined

set. (It was because of Chicago's absence from the 1974 data

that Survey 1 was divided into the two time periods described,

which are analyzed separately in this chapter.) Philadelphia, as

mentioned earlier, is not represented in either of the two Survey

1 combined sets.

In summation, three sets of cases were created that combined

cases from the cities. The first set covered the last six months

of 1973, the second covered the first six months of 1974, and

the third covered the first eight months of 1975. All three sets

included only cases of overdose deaths, The first two sets did

not include any cases from Philadelphia, and the second set did

not include any cases from Chicago. The first two sets included

cases available from the tally as well as from Survey 1, and

therefore allowed analysis only of variables that appear on the

tally form. The third set included all cities and allowed analysis of all variables found on the reporting form.

Weighting of the Cases

Before analyzing the combined sets of cases, each city's contribution had to be weighted by taking its sampling fraction into

account. That is, each city's contribution to the combined sets

was made proportional to the total number of overdose cases that

occurred in that city during the sampled period. This was accomplished by multiplying each city's contribution by the ratio

of the number of cases in the total population to the number of

cases in the sample.

The problem then arose of estimating the total number of overdose

deaths that were processed in each of the nine coroners' or

medical examiners' offices during each of the three time periods

to be analyzed. For the third set, which consists of Survey 2,

it was comparatively easy to do this. For Survey 2 the total

number of drug-involved deaths during the eight months sampled in

1975 was reported by each city. We assume that the proportion of

overdose deaths to total drug-involved deaths found in the cases

19
TABLE 3.01

Estimated Actual Cases and Survey Cases

of Overdose Deathsa for Three Time Periods, in Nine Cities

a

 Overdose deaths defined as deaths caused by direct action of drug(s).

b

 Cases excluded from this analysis because of definitional problem.

Categories A and B in Schedule 2.01, Code #3.

c

 No cases contributed to survey in this segment of reporting time.

for which reporting forms were filled out is a good approximation

to the proportion that occurs in all the cases. For example, if

city X claims that 400 eligible cases occurred in the eight

months and we find that 80 of the 100 cases for which we have a

report were overdose cases, then we can estimate that 80 percent

of the 400 (320 cases) were overdose cases. Therefore, in the

combined sample, each of this city's 80 cases would count as

four to contribute 320 cases to the total number. We did not

need to estimate for the three cities that contributed 100 percent of their eligible cases to Survey 2.

Estimating the total number of overdose cases that occurred in

each city during the time periods covered by the two Survey 1

sets (the last six months of 1973 and the first six months of

1974) required a bit of speculative reasoning for most cities.

The exceptions are New York and Cleveland for both time periods

and San Francisco for the second period. For these cities for

which we have the tally data, all cases are included in the two

sets. The estimates for the other cities were derived from tabular and other materials received from the offices in those cities.

Table 3.01 presents the estimates of numbers of overdose cases

for each city for the six-month periods analyzed in 1973 and

1974 and for the eight-month period of Survey 2 in 1975.

20
Findings of the Combined Sets

Table 3.02 presents some summary findings on the variables available in the tally form for the three sets of combined cases. The

findings must be approached cautiously because of the tentative

way in which cases in some of the cities were weighted in the

first two periods. Furthermore, because the 1974 period has no

contribution from Chicago and neither the 1973 nor the 1974 period has any contribution from Philadelphia, differences between

periods may reflect the changing composition of the samples

rather than any total trend. One is struck, nevertheless, by the

remarkable consistencies, rather than by the differences, across

time periods.

The largest category in modes of death was "unknown,” but among

the rest, accidental deaths outnumbered suicides, and homicides

were nearly absent. Average age of the decedents was about 32

years. Opiates outnumbered barbiturates (in single drugs involved) by about two to one. Males outnumbered females, though not by

a large margin.

The proportion of males showed a small increase between the

earlier period and the later ones. It is hard to attribute this

trend to the changing composition of the sample; that is, the

proportion of male overdose deaths in the excluded city, Chicago,

itself increased from 65 percent in 1973 to 75 percent in 1975.

The elimination of Chicago from the 1974 sample should, if anything, cause the male proportion to decrease in that year, It is

also difficult to attribute the increase in the 1975 male proportion to the inclusion of Philadelphia in that year, The male

proportion of that city’s overdose deaths in 1975, 66 percent,

was below the average proportion of 68 percent for the combined

sample. Perhaps future analyses will be able to answer the

question of whether the trend was real or a sampling artifact,

Another tendency apparent in table 3.02 is for cases in which

opiates were involved to increase at the expense of barbiturate

cases and cases involving both barbiturates and opiates. This

may be related to the previously mentioned increase in male cases.

The combined group of Survey 2 overdose death cases can be inspected on all the variables of the reporting form, not only on

those of the tally form. Therefore, table 3.03 presents summaries of some other selected demographic and biographic variables

to help characterize the nature of that sample.

One small finding that stood out was the proportion of decedents

who lived alone -- 26 percent,

were unemployed.

Another was that only 22 percent

Because of the rather large amount of information “unknown” about these cases, firm conclusions are not easy

to draw.

21

315-509 O - 80 - 3
TABLE 3.02

Major Demographic Characteristics of Weighted

Combined Overdosea Cases for Three Time Periods

22
TABLE 3.03

Selected Characteristics of Weighted Combined Overdosea Cases

23
Chapter 4

Role of Drugs in Death

SUMMARY

The role of the drug in death can be reliably classified by

coroners and medical examiners according to a schema that differentiates whether the death was directly induced or merely drugrelated, and by mode of death.

To illustrate the variety of drug roles involved in these deaths,

in Survey 1 (1972-1974), a single psychoactive drug was the specific cause of death in 41 percent of the 2000 cases, and a combination of drugs was responsible in 34 percent. A preexisting

and potentially fatal physiological disorder in combination with

the drug(s) resulted in the death in 7 percent of the cases; and

death resulted from a combination of the drug effects and physical

events outside of the person's body (for example, an auto accident)

in 15 percent.

In the two surveys there were differing patterns across cities of

the roles of the drug(s) in death. Also, except for Chicago,

there were somewhat different distributions of the roles of drugs

within each city from one time period to the other.

ROLE OF DRUGS IN DEATH

The role of the drug involved in the death was classified according to the nineteen categories in Code #3, "A Schema for Defining

and Categorizing Drug-Involved Deaths" (page 9). The classification involves two dimensions: (1) directness of the drug's

action, ranging from simple or direct cause of death to drug in

combination with a physical event outside the patient's body; and

(2) mode of death, ranging from accidental to homicidal, and

including "unknown." All of the coroners' and medical examiners'

offices participating in the study said that this classification

could be quite reliably carried out by their offices.

Of the Survey 1 cases, the following categories of the role of

24
drugs in death constitute the major portion of the causes:

In 41 percent of cases the drug was the specific cause of

death, with no other agent or condition playing a significant role.

In 34 percent of cases the drug led to a lethal outcome

by combining with some other pharmacologic agent such as

alcohol or a barbiturate.

In 10 percent of cases the drug caused death by combining

with some preexisting and potentially fatal physiological

condition such as diabetes or chronic heart disease (7

percent) or drug abuse condition (3 percent).

In 15 percent of cases the drug led to fatal results

through a combination of physical events outside the

patient’s body, such as death by vehicle or gunfire while

under the influence of the drug.

Table 4.01 gives these findings in fuller detail.

Table 4.02 gives the results by role of drug (and mode) in Survey

2, which took place about two years later. It is interesting to

observe that overall patterns changed with time. They also

changed in some of the nine cities. The proportion of “druginduced” deaths was smaller in the earlier survey, and “drugrelated” cases were less frequent in the later one. It is possible

that drug consumption patterns, treatment and rehabilitation

programs, intervention in the criminal justice system, and preventive measures influenced these patterns. It is even possible

that differences in sampling cases over time contributed to the

variations (see chapter 2).

ROLE OF DRUGS IN DEATH, BY CITY

The following differences appeared in individual cities when data

from Surveys 1 and 2 were compared (see tables 4.01 and 4.02).

Chicago: The distribution of roles of drugs in death was similar

in 1973 and 1975.

Cleveland: Single-drug suicides were considerably more frequent

in the first survey than the second, and polydrug-induced accidents were more frequent in the second.

Dallas: There were more single-drug-induced suicides in the first

survey, but more polydrug-induced suicides in the second. There

were also fairly high proportions of unknowns in both surveys.

Los Angeles: Single-drug-induced accidents went down, but polydrug suicides went up from the earlier to the later survey.

Miami: There was a higher incidence of accidental deaths and

25
TABLE 4.01

Role of Drug in Death Cases, by City (Survey 1, N=2000).

26
TABLE 4.02

Role of Drug in Death Cases, by City (Survey 2, N=1004)

27
suicides due to the direct effect of a single drug in the earlier

than the later survey, but polydrug suicides were more frequent

in the later survey.

New York: There were large proportions of cases "unknown” as to

mode in both surveys, making comparisons difficult.

Philadelphia: There was a substantial number of "unknowns.” One

difference noted was a drop in drug-involved homicides from the

first to the second survey.

San Francisco: A somewhat larger proportion of deaths in singledrug accidents and suicides was reported in the earlier survey,

and more polydrug accidents in the later one.

Washington D. C.

accidents in the earlier survey, and a higher proportion of

There was a higher proportion of single-drug

polydrug accidents in the second one.

The only discernible trend both overall and in several of the

separate cities was a shift from single-drug-induced to polydruginduced deaths. These may have reflected changing patterns within

cities, over time, of the role of psychoactive drugs in causing

death, or changing standards over time as different individuals

filled out reporting forms. The notion of representativeness

held by medical examiners and coroners of the demographic and biomedical characteristics of psychoactive drug-involved deaths

processed yearly by their offices was quite flexible and impressionistic. The case selection for the first survey was not random

and relied heavily on the medical examiners’ and coroners’ impressions of representativeness. The later survey aimed for random

selection and, hence, should provide a truer representative sample.

28
Chapter 5

Treatment of Victim Prior to Death

SUMMARY

Inquiries were made about two types of treatment prior to death:

enrollment in a program for drug abuse treatment or rehabilitation

and emergency treatment immediately prior to death. In fairly

large proportions of the cases, there was no information about the

former. Among those cases about whom information was available,

very few had been enrolled at time of death; 8 percent were in methadone maintenance programs. Only a small proportion, reported primarily by physicians, received emergency treatment immediately

prior to death. The major types of management were assisted

breathing, medication, heart massage, and procedures involving the

trachea.

TREATMENT OF VICTIM PRIOR TO DEATH1

Current Enrollment in a Drug Abuse Treatment or Rehabilitation

Program

In Survey 1, a small proportion (21.8 percent) of the 2000 cases

were known to be enrolled at time of death in some kind of treatment

or rehabilitation program. In 31.6 percent, the information was

not known. Questioning in this area was clarified and expanded when

the reporting form was revised for Survey 2, thus making comparisons

between the surveys somewhat difficult.

Among the cases on which information was available in Survey 2, the

overwhelming majority had not been enrolled in a program at time of

death (86.1 percent.). Among those who had been enrolled, the

largest proportion (8.1 percent) were in methadone maintenance (see

table 5.01). Cities varied considerably in the proportions of cases

1. Data for this portion of the study were obtained principally

from responses to Part V (Treatment Prior to Death) of the reporting

form, except for the information concerning drug abuse treatment or

rehabilitation programs, which was contained in Part I (General),

item #24, of the Survey 1 form and in Part I, items #24-26, of the

revised form used in Survey 2.

29
TABLE 5.01

Enrollment in Dug Abuse Treatment or Rehabilitation at Time of Death, by City

(Survey 2, N=1004)

aToo few cases for computing reliable percentages.

bBecause of rounding, all percentages may not add to precisely 100.0%
known or unknown for enrollment in rehabilitation or treatment

programs. Philadelphia, Miami, and New York were the only cities

where a reasonably large proportion could be classified (see table

5.02). A similar pattern of lack of information, with the exception

of Philadelphia, Miami, and New York, is seen in table 5.03, which

summarizes data on frequency of involvement in rehabilitation

programs.

Treatment for Drug Overdose Immediately Prior to Death

A question on recent treatment for overdose was asked on two parts

of the reporting form: Part I, designed as an inclusive short form,

and Part V, designed to gather detailed information on treatment.

Some discrepancy between answers on the two parts occurred in both

surveys.

Eliminating cases where the information was unknown, Part I responses for Survey 1 indicated that only 25.6 percent of cases received

treatment; Survey 2 showed 11.9 percent (table 5.04). Part V

responses were relatively close to those proportions, 21.8 percent

and 13.9 percent, respectively. It is possible that the discrepancy

between results of the two surveys is due to the wording of questions relating to treatment prior to death. (In Survey 2, answers

relating to treatment for gunshot wounds, disease, or other disorders not directly related to treatment for psychoactive drug

ingestion were automatically eliminated.) Major intercity differences in Survey 2 were restricted to a low incidence of treatment

prior to death in San Francisco (6.7 percent) and New York (4.2

percent). The other seven cities had a narrow range of treatment

rates, from 12.0 percent in Washington, D. C. to 19.4 percent in

Philadelphia (table not shown).

Locations Where Decedents Were Treated Prior to Death

As many as three locations could be listed where the decedent was

treated before death. However, the numbers of second and third

responses given were small. The total responses for Survey 1 and

Survey 2 are given in table 5.05. Most treatments were recorded

as given in hospitals (including emergency rooms). Intercity differences were not notable (table not shown).

Persons Who Treated the Decedents for Acute Drug Involvement

Up to three persons could be listed who treated the deceased prior

to death These data are summarized in table 5.06. Most treatments

(66.3 percent for Survey 2, for example) were reported as given by

physicians. Los Angeles differed from the other cities in reporting

treatment by a physician in only 36.7 percent of the cases and in

a uniquely high treatment rate by paramedics (33.3 percent) compared

with the other eight cities (table not shown).

31
TABLE 5.02

Most Recent Enrollment in Drug Abuse Treatment

or Rehabilitation, Cases Not Enrolled at Time

of Death, by City (Survey 2, N=1004)

aBecause of rounding, all percentages may not add to precisely 100.0%.
TABLE 5.03

Frequency of Participation in Drug Abuse

Treatment or Rehabilitation Programs by

City (Survey 2, N=1004)
TABLE 5.04

Incidence of Treatment Given Prior to Death,

Responses to Questions in Survey 1 (N=2000)

and Survey 2 (N=1004)

34
TABLE 5.05

Locations Where Cases Were Treated Prior to Death, Surveys 1 and 2

TABLE 5.06

Types of Persons Who Treated Decedents Prior

to Death, Surveys 1 and 2

35
Types of Medical Management Prior to Death

Respondents could list up to three types of medical procedures

provided the patient before death. Not surprisingly, assisted

breathing, medication, heart massage, and endotracheal intubation

or tracheostomy were the most common types of treatment (see

table 5.07). Intercity differences were not great (table not

shown).

Medications, Given or Taken Within Two Weeks of Death

A tabulation was made listing all drugs reported to have been given

or taken within two weeks of death, following the LEA classification described in chapter 2 (see appendix B, tables 5a through 5d,

pages 143 to 172). It may not be surprising that most of them were

not psychoactive drugs but fell in the "miscellaneous” classification (e.g., antibiotics, cold medicine, and the like), used presumably for other treatment purposes. On the other hand, the large

number of psychoactive drugs (e.g., narcotics, barbiturates, other

sedatives, tranquilizers, and analgesics) also taken by these individuals in the two weeks before death points to the high usage of

these drugs by individuals prone to drug-involved death.

This study gives definite information about actual treatment prior

to death on only 21.8 percent of Survey 1 and 13.9 percent of

Survey 2 cases. There is no information about any drugs that the

rest of the decedents had been taking before death, except for the

psychoactive drugs most likely to have been involved in the death.

Data obtained during the on-site investigation did provide information on the psychoactive drugs found at the scene of death

(chapter 6, table 6.08).

TABLE 5.07

Types of Management Used in Treatment Prior

to Death, Surveys 1 and 2

Percent of Mentionsa

Types of

Management in

Treatment: Survey 1 Survey 2

Vomiting 1.4% 1.3%

Gastric lavage 5.8 3.6

Medication 26.9 22.0

Assisted breathing 22.9 31.4

Tracheal help 13.9 12.6

Heart Massage b 16.5

Dialysis 2.9 b

Observation 4.0 3.6

Other 22.2 9.0

100.0% 100.0%

Number of mentionsa

(446) (223)

aUp to 3 mentions per case were allowed.

bNot asked.

36
Chapter 6

On-Site Investigations

SUMMARY

On-site investigations were performed in 80.0 percent of the 2000

drug-involved deaths in Survey 1 and in 77.3 percent of the 1004

deaths in Survey 2, with an intercity range from 51.0 to 98.6 percent for Survey 2. In order of frequency, these examinations

were usually performed by trained police, coroners’ or medical

examiners’ investigators, regular police, or physicians other

than pathologists.

Events surrounding the death were first reported by a family

member or friend in about two-thirds of the cases. The body was

judged to have been found at the site of death about 90 percent

of the time. About 80 percent of the cases showed no evidence of

external injuries. Motor vehicle accidents were involved in only

2 or 3 percent of the deaths reported in Surveys 1 and 2.

There was external evidence of poison or drug ingestion in about

half of the cases. Needle marks and track marks were the most

common findings. Evidence of drug use at the scene was also present in about half the cases. Needles, vials, or other drug

paraphernalia were found about a third of the time. Drugs were

found at the scene about one-fourth of the time.

ON-SITE INVESTIGATIONS

Extent of On-Site Investigations

On-site investigations were carried out on 80.0 percent of the

2000 drug-involved deaths in Survey 1 and 77.3 percent of the 1004

deaths in Survey 2. There were three cases in Survey 1 and five

cases in Survey 2 in which the respondent could not ascertain

whether an on-site investigation had been performed. There was

some intercity variation, ranging in Survey 2, for example, from

a high of 98.6 percent on-site investigations performed in Los

Angeles to a low of 51.0 percent reported performed in Philadelphia.

Who Conducted the On-Site Investigation

Most on-site investigations were conducted by trained police

(38.2 percent in Survey 1 and 26.3 percent in Survey 2) or regular

37

315-509 O - 80 - 4
TABLE 6.01

Types of Persons Who Conducted the On-Site Investigations,

Surveys 1 and 2

police (18.8 percent in Survey 1 and 23.0 percent in Survey 2), a

coroner's or medical examiner's investigator (23.3 percent in Survey 1 and 34.6 percent in Survey 2) or a physician who was not a

pathologist (10.3 percent in Survey 1 and 13.0 percent in Survey 2).

A complete classification of persons (one or more) who conducted

these on-site investigations is shown in table 6.01. There were

marked intercity differences in the types of persons who performed

these investigations, reflecting the differing administrative

arrangements in the nine cities. This is another situation making

for difficulty in combining data across cities. These differences

for Survey 2 are shown in table 6.02.

Reporting the Events Surrounding Death

The events surrounding these drug-related deaths were primarily

reported by a family member (37.8 percent in Survey 1 and 36.0

percent in Survey 2), a friend (35.4 percent in Survey 1 and 28.5

percent in Survey 2), a bystander (13.4 percent in Survey 1 and

11.1 percent in Survey 2) or the police (10.4 percent in Survey 1

and 13.0 percent in Survey 2) (see table 6.03). Intercity differences in this factor were not great (table not shown).

38
TABLE 6.02

Types of Persons Who Conducted the On-Site Investigation,

by City (Survey 2, N=1004)

TABLE 6.03

Types of Persons First Reporting Events

Surrounding the Death (Surveys 1 and 2)

Percent of Cases

Person First Reporting

Events Surrounding

the Death: SURVEY 1 SURVEY 2

% %

Police 10.4 13.0

Family member 37.8 36.0

Acquaintance or friend 35.4 28.5

Non-involved bystander 13.4 11.1

Attending physician 1.5 6.8

Other medical personnel 1.1 2.3

Other 0.4 2.3

Total 100.0 100.0

Number of casesa(1569) (985)

aExcludes "unknown" and "missing" cases. Numbers represent

bases on which percentages were calculated.

39
Occurrence of Death at Site of Discovery of the Body

Restricting attention to those cases where the information was

available, 93.0 percent of the deaths in Survey 1 and 86.2 percent

in Survey 2 were judged to have occurred at the site of discovery

of the body. Intercity differences were small (table not shown).

Fingerprinting of the Deceased

Fingerprinting was carried out in the majority of the cases in both

Surveys 1 and 2. Marked intercity differences exist. As illustrated

in table 6.04, five the the cities fingerprinted almost all cases

(range 82 percent to 100 percent), while three cities rarely recorded

them (range 2.9 percent to 16.9 percent). Considering the many

potential uses of fingerprints, this variation is hard to understand.

Examination of Clothing

The question on clothing was placed in different sections of the

forms for the two surveys and thus took on somewhat different

meaning in the two versions; only the Survey 2 question, placed in

the section on postmortem, is relevant to the on-site investigations.

As expected, answers to the Survey 2 question reported a much higher

percentage of cases to have had examinations of clothing (61.9

percent). As shown in table 6.05, marked intercity differences

exist, from a high of 88.3 percent of cases with clothing examinations in San Francisco to a low of 11.6 percent in Cleveland.

Bodily Evidence of External Injuries

Most cases showed no evidence of external injuries (80.5 percent in

Survey 1 and 83.3 percent in Survey 2) and intercity differences

were not great (table not shown). The types of external injuries

found are summarized in table 6.06.

Involvement in Motor Vehicle or Industrial Accidents

Motor vehicle accidents were involved in only 2 to 3 percent of

the deaths in Surveys 1 and 2. Industrial accidents were involved

in less than 1 percent of the deaths in either survey (table not

shown).

External Bodily Evidence of Poison or Drug Ingestion

There was no external evidence of poison or drug ingestion in

53.0 percent of cases in Survey 1 and 44.2 percent in Survey 2

(figures not shown). The question on external evidence of poison or

drug ingestion was revised significantly between the two surveys,

making comparison of types of evidence somewhat complicated. Needle

marks were the most common finding, seen in 52.1 percent of Survey 1

mentions and 39.3 percent of Survey 2 mentions. Track marks ranked

second, being reported in 35.5 percent of Survey 1 mentions and

37.2 percent of Survey 2 mentions. Whether the body showed discoloration from possible ingestion of a foreign substance was asked

40
TABLE 6.04

Incidence of Fingerprinting, by City (Survey 2, N = 1004)

TABLE 6.05

Incidence of Study of Clothing of Deceased in the On-Site Investigation, by

City (Survey 2, N = 1004)
only in regard to Survey 1 cases, and only 2.3 percent of those

cases showed such discoloration. These findings are summarized in

table 6.07. Intercity differences were small (table not shown).

Evidence of Drug Usage at Scene

Since the question asked in Survey 2 dealt with evidence of drug

usage at the scene of death more fully than the Survey 1 question,

only Survey 2 responses are reported here. There was no evidence

of drug usage at the scene of death in 46.3 percent of cases (table

not shown). Intercity differences in types of evidence were noted,

as shown in table 6.08.

42
TABLE 6.06

Bodily Evidence of External Injury (Surveys 1 and 2)

aNot asked.

b

In Survey 1, up to 5 responses were tabulated and in Survey 2,

up to 2 responses. These numbers do not include cases where no

evidence was found or the information was missing. In Survey

1, 1312 cases were recorded as "none" and in Survey 2, 843 cases.

TABLE 6.07

External Bodily Evidence of Drug Ingestion in the On-Site

Investigation (Surveys 1 and 2)

Percent of Mentions

External Bodily

Evidence of

Drug Ingestion: Survey 1 Survey 2

% %

Needle marks 52.1 39.3

Track marks 35.5 37.2

Skin puncture a 6.5

Discharge a 13.4

Discoloration b 2.3

Other 12.4 1.4

Number of mentionsc

100.0

(865)

100.0

(666)

aNot asked

bAsked in a separate question with only "yes" or "no" categories

of response. 2.3% of cases reported discoloration.

cUp to 2 responses were tabulated. These numbers do not include

cases where no evidence was found or the information was missing.

In Survey 1, 979 cases were recorded as 'hone" and in Survey 2,

527 cases.

43
TABLE 6.08

Evidence of Drug Usage at the Scene,

by City (Survey 2)
Chapter 7

Postmortem Findings

SUMMARY

Narrative autopsy reports may vary with the recording practices of

the autopsy surgeon, from cryptic to verbose, utilizing a nonuniform, technical vocabulary that is vaguely defined and open to

a wide range of interpretations. Postmortem examinations were

carried out on almost all Survey 1 and 2 cases, and all of them

were done by physicians, most of whom were Board-certified. About

half of the autopsies in both surveys included microscopic examinations, presumably increasing the completeness and accuracy of the

findings. About 30 percent of the cases in both surveys had postmortem chemical, hematological, or immunological studies; practically

none had bacteriological or radiological (X-ray) studies postmortem.

Profiles of the postmortem findings of various classes of drugs

were drawn by selecting those cases in which only one drug or

category of drug was reported to be involved in the death. There

was a close correspondence between these single drug cases and all

cases, suggesting that the single drug cases do not differ significantly from polydrug cases in overall autopsy findings.

There was a suggestion that the analgesic, barbiturate, and tranquilizer-involved victims were in a poorer state of general health

at the time of their death than other psychoactive drug-involved

decedents, perhaps a function of their older age. These data also

confirmed the well-published association of narcotism with tattoos

and the external stigmata of intravenous self-medication? such as

recent and old track marks, subcutaneous fibrosis, and pigmented

scars. Stigmata of intravenous self-medication were also common

for stimulant cases, Acute pulmonary edema was common in all drug

groups and is presumably a nonspecific end-stage finding of congestive heart failure and death from drug overdose.

POSTMORTEM FINDINGS

These data were obtained mainly from responses to Part IV (Postmortem Findings) of the forms used in Surveys 1 and 2, except where

identified as coming from other sections. There are slight inconsistencies between Parts I and IV in reporting the number of autopsies

or postmortem examinations. A possible explanation in Survey I is

45
TABLE 7.01

Types of Postmortem Examinations (Surveys 1 and 2)

that the term "postmortem examination" used in Part IV is more

general and inclusive than the term '"autopsy" used in Part I. All

autopsies are postmortem examinations, but not all postmortem examinations are autopsies. For Survey 2, another explanation may

lie in the variety of specific choices allowed in Part IV, which

included a category "Other" that was completed for five cases and

counted as "No Postmortem." Table 7.01 shows the extent to which

complete autopsies were done: almost 90 percent overall.

The forms were filled out primarily by physicians who performed the

examinations or, in a small percent of the cases, another physician.

The autopsy report was the most difficult part of the medical examiners' and coroners' records to code and is open to the widest

interpretation because of variation in grammatical style of the

autopsy surgeon, the lack of uniform terminology used in describing

various normal and abnormal findings, and so forth.

The nine reporting centers seemed well staffed with highly qualified

autopsy surgeons: In Survey 1, Board-certified forensic pathologists performed 43.0 percent of the examinations. Board-certified

pathologists performed an additional 35.5 percent, and almost all

the others who carried out postmortem examinations had some formal

training in pathology. In Survey 2, the corresponding figures are

57.7 percent, 36.2 percent, and 5.2 percent. Neither survey showed

examinations done by nonphysicians without formal training in

pathology, although 0.9 percent of the examinations in Survey 2

were reported as performed by persons "unknown" (table not shown).

46
In Survey 1, nearly all examinations (94.6 percent) were performed

in local morgues; 1.1 percent were performed in hospitals; and 4.3

percent were done in mortuaries. Also in Survey 2, 97.0 percent

were performed in local morgues; 1.2 percent in hospitals; and 1.6

percent in mortuaries (table not shown).

The large number of histological examinations was surprising. In

Survey 1, 47.4 percent of the cases had some histological studies

done, the majority having hemotoxylin and eosin stains alone (33.9

percent) or together with polarized light (12.2 percent). In Survey 2, 58.2 percent had some histological studies done, the majority having hemotoxylin and eosin stains (57.9 percent); 10.6 percent had polarized light histological studies done (table not

shown).

In contrast, no bacteriology tests were done in over 98 percent of

the cases in both surveys. In Survey 1, 32.4 percent of the cases

had postmortem chemical, hematological, or immunological studies

done. Such studies were done in 30.7 percent of the Survey 2 cases.

Only 2.7 percent of Survey 1 cases, and 2.7 percent of Survey 2

cases were X-rayed. The clothes of the deceased were examined in

17.1 percent of Survey 1 cases. This question was not asked on

Part IV in Survey 2, the question having been transferred to Part

II (table not shown).

The bodies were neither embalmed nor decomposed in the large majority of cases (88.1 percent in Survey 1 and 91.5 percent in

Survey 2). Bodies were decomposed in 8.2 percent of Survey 1 cases;

3.1 percent were embalmed, and 0.2 percent were both decomposed and

embalmed. In Survey 2, 6.5 percent were decomposed, 1.7 percent

were embalmed, and 0.5 percent were both decomposed and embalmed

(table not shown).

Profiles for the postmortem findings of various categories of drugs

were attempted by choosing those cases in which only one drug was

reported, ignoring the presence or absence of alcohol. In Survey

1, 851 of the 2000 cases qualified for this analysis as “single

drug cases." In Survey 2, there were 498 single drug cases. There

is a close correspondence of frequencies of response for each question concerning autopsy findings between the single drug cases and

all 3004 cases, suggesting that the single drug cases do not differ

significantly from the polydrug cases in overall autopsy findings.

Table 7.02 shows the general health rating for the single drug

cases of Surveys 1 and 2. There is a suggestion that the analgesic,

barbiturate, and tranquilizer groups were in fair or poor health

more often than those who died from effects of other drugs, All

psychostimulant drug cases in both samples were judged to be in

good health. This may be because the stimulant drug cases were

younger. Table 7.03 shows a very low incidence of systemic infection and malnutrition in all cases in both surveys, Sedative drug

cases ranked highest for malnutrition in Survey 1 (8 percent), but

cases of sedatives in Survey 2 were too few for reliable percentages,

47
TABLE 7.02

General Health: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2
TABLE 7.03

Malnutrition and Systemic Infections:

Postmortem Findings, by (Single) Drug Type,

Surveys 1 and 2
Table 7.04 documents the well-publicized association of external

stigmata of intravenous self-medication with narcotism: recent

and old track marks, subcutaneous fibrosis, and pigmented scars.

Trauma is also high in the narcotic groups. Tattoos were more

common in narcotics abusers, as has been reported previously.

Perhaps most striking was that only 8 percent of the (single drug)

narcotism cases in Survey 1 and 12 percent in Survey 2 were judged

normal on external examination, compared with 31.0 percent for all

single drug cases in Survey 1 and 30.3 percent in Survey 2. In

both surveys, cases in all single drug classes other than opiates

had remarkably higher percentages of normal examinations.

Table 7.05 lists the postmortem findings for the musculoskeletal

system. The most common finding for all drug cases, at least 50

percent in every category, was normality.

Table 7.06 shows the postmortem findings for the vascular system.

The fact that percentages of sclerosis findings were higher in Survey 2 than in Survey 1 is not easily explained.

Table 7.07 summarizes the postmortem findings for the heart. Normal findings again predominate in both samples; in every category

they are over 50 percent. As with sclerosis in the vascular system,

it is hard to explain why right ventricular dilatation was more

frequent in Survey 1.

Table 7.08 contains the findings from examination of the respiratory

system. In general the frequency of "normal" responses was less

than in other system examinations. "Foam filling tracheobronchial

tree" is most common in narcotic cases. Acute pulmonary edema

seems common in almost all groups. Congestion is common and undoubtedly associated with acute pulmonary edema.

Table 7.09 summarizes the postmortem findings in the gastrointestinal system. Many examinations of this system were normal. Fairly

high percentages of cases of pill residues were found in those

categories of medication normally taken by mouth (analgesics, barbiturates, sedatives, tranquilizers, and antidepressants).

Table 7.10 shows the postmortem findings for the liver. Again,

normal findings predominate. The highest percentages of hepatomegaly

were found in sedative and tranquilizer cases in Survey 1, and narcotic cases in Survey 2. Narcotic cases lead in portal lymphadenopathy (in both surveys).

Tables 7.11 and 7.12 contain the findings for the spleen and lymph

nodes, respectively. The relatively high incidence of lymph nodes

"not studied" (35.8 percent of Survey 1 and 17.2 percent Of Survey

2) suggests that the results were not mentioned in the original

autopsy report in the medical examiner's or coroner's file. Again,

normal findings predominate. Hyperplasia of the lymph nodes was

reported in 9.9 percent of narcotic cases in Survey 1 and in 5 Percent of narcotic cases in Survey 2.

50
Table 7.13 summarizes genitourinary findings. Again, normal findings

predominate in both Surveys 1 and 2. Table 7.14 summarizes findings

of the endocrine system, and table 7.15 summarizes findings of the

nervous system. Nothing of special note was observed.

Tables 7.16 and 7.17 classify the single drug cases by sex and age,

respectively, for Surveys 1 and 2. These findings do not differ

significantly from the findings in the total of 3004 cases. Note

the high incidence of men among narcotic drug cases. Percentages

of women were higher than those of men among the analgesic, barbiturate, and sedative and antidepressant cases in one or both surveys.

As mentioned elsewhere and shown in table 7.17, younger persons were

found more often among narcotic and psychostimulant cases, and older

persons more often among sedative, barbiturate, tranquilizer, and

antidepressant cases.

These results confirm previous findings discussed by Noguchi in

Guide to the Investigation and Reporting of Drug Abuse Deaths

(Gottschalk et al. 1977), and do not appear to define striking new

profiles for the various drug classes.

COMMENTARY

Analysis of reports of postmortem examinations confirmed previously

published observations of postmortem changes in drug-involved deaths.

The monitoring of toxicological proficiency of the project is described in Chapter 8, Details of the Toxicological Examination, and

by Dinovo (1976) . The likelihood is that many drugs in the 3004

cases were present and not detected or possibly detected and not

present. It seems likely that there were actually fewer single drug

and more polydrug cases than reported. Clarification of this issue

may make drug-involved postmortem profiles easier to discover, describe, and define. More substantive problems pertain to deciding

how a drug found at the time of death relates to drugs used predominantly throughout life and whether a drug found at the time of

death is the cause of chronic or acute changes found at postmortem

examination.

REFERENCES

Noguchi, T.T. Post mortem examination. Chapter 3, in Guide to the

Investigation and ReUporting of Dru Abuse Deaths Gottshalk, L.A;

McGuire, F.L.; Dinovo, E.C.; Birch, H.; and Heiser, J.F., eds.

National Institute on Drug Abuse. DHEW Publication No. (ADM) 77-386.

Washington, D.C.: Supt. of Docs., U.S. Govt. Print. Off., 1977.

Dinovo, E.C., and Gottschalk, L.A. Results of a nine-laboratory

survey of forensic toxicology proficiency. Clin Chem, 22:943-946,

1976.

51
TABLE 7.04a

External Examination: Postmortem Findings, by

(Single) Drug Type

a. SURVEY 1

52
TABLE 7.04b

External Examination: Postmortem Findings, by

(Single) Drug Type

b. SURVEY 2

53

315-509 O - 90 - 5
TABLE 7.05

The Musculoskeletal System: Postmortem Findings,

by (Single) Drug Type, Surveys 1 and 2

54
TABLE 7.06

The Vascular System: Postmortem

(Single) Drug Type, Surveys

Findings, by

land 2

55
TABLE 7.07

The Heart: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

56
TABLE 7.08a

The Respiratory System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

a. SURVEY 1

57
TABLE 7.08b

The Respiratory System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

b. SURVEY 2

58
TABLE 7.09

The Gastrointestinal System: Postmortem Findings,

by (Single) Drug Type, Surveys 1 and 2

59
TABLE 7.10a

The Liver: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

a. SURVEY 1

60
TABLE 7.10b

The Liver: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

b. SURVEY 2

61
TABLE 7.11

The Spleen: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

62
TABLE 7.12

The Lymph Nodes: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

63
TABLE 7.13

The Genitourinary System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

64
TABLE 7.14

The Endocrine System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

65
TABLE 7.15

The Nervous System: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

66
TABLE 7.16

Sex of Decedent: Postmortem Findings, by

(Single) Drug Type, Surveys 1 and 2

TABLE 7.17

Age Distribution by (Single) Drug Type, Postmortem

Findings, Surveys 1 and 2

67
Chapter 8

Details of the Toxicological

Examinations

SUMMARY

Separate, extensive analyses of toxicological examinations associated with the psychoactive drug-involved deaths were carried out in

Survey 1 and Survey 2. Different approaches by the nine laboratories to the toxicological examination of biological fluids and tissues were evident in proportions of drugs quantitated, about 75

percent in both surveys. Drugs per case reported as tested ranged

from a high of 3.5 to a low of 1.6 in Survey 1; the range was about

the same in Survey 2.

The following psychoactive drugs were found to have a presumed

fatal synergistic effect with ethanol and other drugs: morphine,

propoxyphene, secobarbital, phenobarbital, amitriptyline, meprobamate, and the phenothiazines.

DETAILS OF THE TOXICOLOGICAL EXAMINATIONS

Analysis of Findings in Survey 1

Respondents in each office could choose one source of information

on drugs from the following: lay informant, (drug) found at scene,

physician, laboratory, or other. In table 8.01 it can be seen that

for all cities the primary information source reported was the toxicology laboratory; the percent for all cities combined was 88.9.

The laboratory was the reporting source for 72.8 percent of cases in

San Francisco, the lowest, and 98.5 percent in Washington, D.C., the

highest. Cleveland cited “lay informant” as the source of information for a high of 21.3 percent of its cases; Miami and San Francisco

cited “found at scene” for highs of 13.8 percent and 19.1 percent respectively.

Another Survey 1 finding that showed variation by city was the

average number of drugs involved per case, The average for the

nine cities was 1.96 drugs per case, ranging from a low of 1.59 for

San Francisco to a high of 2.54 for New York.

There were discrepancies between the numbers of drugs indicated on

the medical examiners’ reports and the numbers found in their separate laboratory reports. In Survey 1, for example, of the 3493

drugs which the medical examiners’ reports cited, 3223 or 92.3 percent were actually reported on the separate laboratory forms. On

68
TABLE 8.01

Source of Information on Drugs and Number of Drugs Involved

in the Death, by City (Survey 1, N=2000)
the other hand, the laboratory forms reported tests on more drugs

than were listed in the medical examiners’ reports. Of the 3909

tests made, 2945 were quantitated, traces or no drug were found in

159, and positive qualitative results were found in 805. This suggests that at least 3750 drugs were identified, 6.8 percent more

than the number listed in the medical examiners’ reports.

Table 8.02 lists the types of results reported by the laboratory

from each city in Survey 1. Washington, D.C. quantitated 100 percent of drugs found, and three other cities, almost 100 percent. In

contrast, New York quantitated only 33.8 percent of its drugs. The

other cities were somewhere between these extremes.

Table 8.03 compiles the laboratory results in Survey 1 for five

drugs, listing for each city the percentage of the total drugs

tested and the percentage of the cases containing the drug. Large

differences existed between cities. Methadone in New York and Washington represented 24.5 percent and 22.1 percent, respectively, of

all drugs tested and was found in 59.8 percent of the cases for New

York and 48.6 percent of the cases for Washington--very high percentages. Methadone was found in much smaller percentages in

Philadelphia, Dallas, Miami, and San Francisco, in less than 1 percent in Los Angeles and Cleveland, and was not reported at all by

Chicago.

Morphine was found in fairly high percentages in several cities,

ranging from a low of 3.6 percent of all drugs tested for Miami to

a high of 27.2 percent of all the drugs tested for Los Angeles. I t

was found in 48.3 percent and 43.1 percent of the cases for Los

Angeles and Chicago, respectively, but in only 6.6 percent of the

cases in Miami. Morphine, of course, is also the metabolite of

heroin; thus, these cases could have been either morphine or heroin

users.

Quinine, an adulterant of heroin, was not reported as tested for in

four cities, including both Chicago and Los Angeles, the leaders in

percentage of cases containing morphine. It was found in about 30

percent of the cases in New York, Washington, D.C., and Philadelphia.

These northeastern seaboard cities seemed to observe a very high incidence of methadone, morphine or quinine cases--much more than the

other cities reporting here.

Washington, D.C. alone among the nine cities submitted many cases

involving phenmetrazine (Preludin) , 19 percent of their total.

Washington, D.C. and Philadelphia showed the highest incidence of

amphetamine-involved deaths. About fifteen percent of the cases

reported from these two cities were found to involve amphetamine,

whereas the average for the other cities was under two percent.

Table 8.04 lists in the first column the total percentages and

numbers of drugs reported in various bodily tissues and fluids.

The blood, urine, liver, bile, and stomach in all were assayed 93

percent at the time.

was blood.

The preferred location for most drug assays

Phenothiazines, amphetamine, methamphetamine, and quinine were preferentially assayed in urine, while bile was the

70
TABLE 8.02

Types of Results of Drug Assays, by City (Survey 1, N=2000)
TABLE 8.03

Drug Assay Patterns for Five Drugs, by City (Survey 1, N=2000)
TABL 8.04

Positive Toxicological Findings Quantitated for the Most

Commonly Found Drugs in Various Physiological Fluids

and Tissues (Survey 1, N=2000)

73
preferred location for morphine assays. The second column lists

the five drugs most commonly found in each tissue or physiological

fluid. Morphine was the most prominent drug in blood and in urine,

followed by methadone. Methadone was quantitated most frequently

in several tissues that were less often tested: liver, lung, kidney,

and stomach.

Table 8.05 lists mean concentrations of the most commonly found drugs

(representing more than 90 percent of the drugs reported). Column

A of table 8.05 compiles the number of cases, the location studied,

the mean concentration found, and the standard deviation for these

drugs in Survey 1. It is worthwhile to compare this table with the

listing of toxic doses in the work by Baselt, Wright and Cravey

(1975). Though the number of cases cited is much lower than the

number given in table 8.05, the concentrations listed are fairly

close to these means. The large number of cases and the standard

deviations presented in table 8.05 add immeasurably to the usefulness

of the data, giving a range of presumed toxic levels.

Columns B and C of table 8.05 give analyses of those drugs for which

data were available on both single drug cases and cases in which

those same drugs were found in combination with alcohol. The table

lists means, standard deviations? and the numbers of such cases.

With the possible exception of diazepam, methadone, and glutethimide, all the other drugs show a higher toxic blood concentration

when present alone than when they were present in combination with

ethanol. Such apparent synergism involved not only barbiturates,

as commonly assumed, but a great variety of other drugs, such as

imipramine, amitriptyline, meprobamate, thioridazine, morphine in

blood and bile, propoxyphene, and methaqualone. The decrease in

toxic concentration was usually considerable, averaging around a

factor of two. The three exceptions noted above might or might not

exhibit these same characteristics in other analyses. Further testing should be done to test and refine this hypothesis.

The concentrations of drug in blood when present alone or in combination (columns B and C) did not seem to follow a consistent pattern.

Some concentrations were found to be higher when present alone: for

example, meprobamate, imipramine, salicylates, three barbiturates

(pentobarbital, secobarbital, and phenobarbital), and methaqualone.

Others, for example, amobarbital, methadone, amitriptyline, and diazepam were found to be lower in concentration when alone. Still

others, for example, thioridazine, propoxyphene, and pentazocine,

were virtually the same.

Survey 2 (1975)

The nine toxicology laboratories associated with the medical examiners’ or coroners’ offices tested a total of 2128 drugs, or 2.2

drugs per case, in Survey 2, as shown in table 8.06. The same percent

of assays, 75 percent, was quantitative in both surveys. The proportion of qualitative results was twice as high in the earlier

survey.

74
TABLE 8.05

Quantitative Assays of Most Commonly Found (Generic) Drugs,

in Single-plus-Polydrug Cases, Single Drug Cases, and Single

Drug-plus-Ethanol Cases: Number and Location, Mean Concentration, and SD (Survey 1, N=2000)

75
TABLE 8.06

Types of Results of Drug Assays, by City, Survey 2 (N=1004)
The patterns vary for results of toxicological examinations in the

nine cities. Chicago, San Francisco, and Washington, D.C. quantitated almost all or nearly all of the drugs reported, consistent

with their earlier results. Cleveland, New York, and Philadelphia

reported relatively more qualitative findings, also consistent with

the earlier survey. Patterns for Dallas and Los Angeles changed

somewhat from the earlier to the later survey; in the later one they

reported a fairly high proportion of negative results, 28.0 percent

and 36.6 percent respectively. The average number of drugs quantitated or tested per case did not change appreciably.

Table 8.07 lists six drugs with positive toxicological findings

(traces, qualitative or quantitative findings) as a function of

location of laboratory. Methadone was detected in 52 percent of the

cases reported by New York--more than three times the percentage of

the next highest city. This pattern was seen also in the earlier

survey. Philadelphia also repeated its pattern of higher proportions of tests occurring for methamphetamine and amphetamine drugs.

Washington, D.C. again was the only city to report phenmetrazine. In

that city it represented 27.0 percent of cases and 14.0 percent of

tested drugs.

Table 8.08 provides numbers and proportions of drugs ranked first

as cause of death, information which was not available in Survey 1.

(Not all cases were able to be so ranked, of course.) It shows that,

on the average, heroin was judged of primary importance as a cause of

death in 87 percent of the cases where it was detected, the highest

percentage reported. Methadone was ranked of primary importance very

often also, in 82 percent of the cases where it was detected, The

others in order were secobarbital, propoxyphene, pentobarbital, phenobarbital, and diazepam.

Table 8.09 shows the distribution of assays and the results for seven

categories of tissue or fluid. Again, as in the earlier survey,

blood tests were performed most frequently, and urine and bile tests

somewhat less often. Among all of the 3960 drug assays, 65 percent

were quantitative, 16 percent were qualitative, 7 percent showed

traces, and 12 percent were negative (figure not shown).

Table 8.10 provides the percentages of positive toxicological findings for the ten most commonly assayed drugs in seven types of tissue

or physiological fluid. Heroin/morphine assayed more often than

others in blood, urine, and especially in bile. (Blood tests were

the most commonly used.) Methadone was assayed more than the others

in stomach contents and the liver. Very few assays were reported in

brain or kidney.

Table 8.11, showing drugs most commonly found in Survey 2, represents

more than 90 percent of the drugs reported. It lists the numbers and

locations, the mean concentrations, and the minimum reported concentrations for single drug cases, single drug plus ethanol cases, and

polydrug cases. Again, the higher concentrations of drugs found

alone in contrast to combinations are evidence of synergistic effects

in causing death. Morphine, propoxyphene, secobarbital, phenobarbital,

77
amitriptyline, phenothiazines and meprobamate again were found to

be synergistic with ethanol and in polydrug cases. The drugs that

did not show a synergistic effect with ethanol were methadone, diazepam, and pentobarbital. These same three drugs did not show

synergism in the 1973-1974 data.

REFERENCES

Baselt, R.C.; Wright, J.A.; and Cravey, R.H. Therapeutic and toxic

concentrations of more than 100 toxicologically significant drugs

in blood, plasma, or serum: A tabulation.

1975.

Clin Chem, 21:44-62,

Dinovo, E.C., and Gottschalk, L.A. Results of a nine-laboratory

survey of forensic toxicology proficiency. Clin Chem, 22:843-846,

1976a.

Dinovo, E.C., and Gottschalk, L.A. More on proficiency testing in

forensic toxicology. Clin Chem, 22:2056, 1976b.

Dinovo, E.C.; Gottschalk, L.A.; McGuire, F.L.; Birch, H.; and

Heiser, J.F. Analysis of results of toxicological examinations

performed by coroners' or medical examiners' laboratories in 2000

drug-involved deaths in nine major U.S. cities. Clin Chem, 22:847-

850, 1976.

Niyogi, S. Drug levels in cases of poisoning. Forensic Sci, 2:

67-98, 1973.

78
TABLE 8.07

Drug Assay Patterns for Six Drugs, by City, Survey 2 (N=1004)

TABLE 8.08

Proportions of Cases in Which Selected Drugs

Were Detected and Ranked First as Cause of

Death, All Citiesa, Survey 2 (N=1004)

79
TABLE 8.09

Types of Findings of Drug Tests, by Type of Tissue

or Fluid, All Drugs, All Cities, Survey 2 (N=1004)

TABLE 8.10

Positive Toxicological Findings for Ten Commonly

Assayed Drugs, by Various Fluids and Tissues, All

Cities, Survey 2 (N=1004)

80
TABLE 8.11

Quantitative Assays of Most Commonly Found (Generic) Drugs, in Single Drug Cases, Single Drug-plusEthanol Cases and Polydrug Cases: Number and Location, Mean Concentration and Range
Chapter 9

Sociodemographic

Characteristics of Cases

SUMMARY

Differences in age, sex, race, marital status, employment status,

and occupation were examined for the predominant drug categories,

overall and for each of the nine cities. Data from the two surveys were combined, since differences between them were not significant. Age was generally lower for the narcotic than for the nonnarcotic deaths; barbiturate cases on the average were somewhat

older. Males and blacks predominated in the narcotic category compared with the other drugs. In certain cities these patterns did

not hold; in Los Angeles, for example, whites predominated among

narcotic cases. More of the narcotic cases were single (never

married) than were the other cases. Surprisingly, the majority in

all drug categories were employed, though occupations tended to be

semiskilled and unskilled, especially in the narcotic category.

SOCIODEMOGRAPHIC CHARACTERISTICS OF CASES

The social and demographic characteristics of all the cases selected

as “drug involved” make it possible to reconstruct the lives of

these individuals before the final act. Their age, sex, race, marital status, employment status and occupation are tabulated by drug

category (the most significant drug involved in the death) and by

city.

Drug categories used are the five with highest overall frequency of

occurrence: narcotics, analgesics, barbiturates, (other) sedatives,

and tranquilizers. A sixth category of “others” was added to account for classes of drugs with very small frequencies that could

not be separately analyzed. Ethanol was classed in the “others”

category when considered the most significant substance involved in

the death and found with one or more other drugs, even though the

number of cases was considerable in some cities. The occurrence of

deaths attributed to drugs in the “others” category, shown in table

9.01, was tabulated by city to show where certain drug types might

have clustered. There does not appear to be a pattern among the

cities, nor among the three drug classes tabulated, except that

marijuana occurrences were virtually absent.

Data from Surveys 1 and 2 were combined in this analysis to provide

larger numbers. Before the samples were combined, the distributions

82
of age, sex, and race between the two samples were compared by chi

square test for each city and for the three major drug categories

(narcotics, analgesics, and barbiturates). There were no significant differences between samples for any of these drug categories

in any of the nine cities (table not shown).

As background to the analysis, a tabulation of drug category by

city is provided. Table 9.02 shows that narcotics were the most

frequent drug correlate of death in six of the nine cities, ranging

from 25.9 percent of cases in Cleveland to 72.6 percent in New York

City, with Washington, D.C. the second highest at 66.2 percent. In

Dallas, Miami and San Francisco, barbiturate cases were more frequent than any others.

Age correlates varied according to the drug category involved (table

9.03). Among narcotic deaths the age distribution clustered in the

20-30 range for most of the cities, with San Francisco, Los Angeles

and Washington, D.C., showing a somewhat more expanded range of

20-40. The ages among barbiturate deaths were more evenly distributed. Miami and Washington, D.C. were exceptions: More than half

of their barbiturate deaths were age 50 or over. In general, the

narcotic death cases were younger than those for whom barbiturates

played the dominant role in death.

Sex distribution, again, varied by drug category (table 9.04). In

each of the cities the narcotic category was dominated by male

cases, ranging from 69.4 percent to 86.8 percent. Among barbiturate

deaths the ratio was more balanced, with male cases ranging between

40 and 60 percent for most of the nine cities.

The categories of race tabulated were white, black, and all other

races (table 9.05). (The last combined category was necessitated

by the small numbers of cases available.) In all cities except Los

Angeles, Miami, and San Francisco, blacks were a larger proportion

than whites in the narcotic drug category; in Washington, 96.0 percent. Whites predominated in all other drug categories, with minor

exceptions. In Washington, blacks also predominated in the analgesic

category.

In all but one city, more narcotic victims than victims of other

drugs had never married. In other drug categories, the distribution

varied without a discernible pattern. (table 9.06). Undoubtedly,

some of the variation in marital status was due to the age distribution in each category, with younger victims more likely never to

have been married.

Findings on employment (tables 9.07 and 9.08) suggest that occupations were not particularly stable or well-paying. Among those

employed, the majority were either semiskilled or unskilled, and

more of the narcotic cases tended to be unskilled. Very few were

listed as professional or semiprofessional. In some cities the

sedative and barbiturate cases included proportionately more occupations at the higher end of the scale, This may be the influence

of age or possibly reflects the occurrence of suicides by drugs

83
among middle-class persons; also, most physician addict cases probably would have fallen into this group.

The majority of drug-involved death cases were persons employed at

time of death, even among the narcotic group. Figures for all

drugs combined ranged from 81.8 percent in San Francisco to 22.3

percent in Philadelphia. Housewives were found more often in the

non-narcotic drug categories. This is consistent with findings reported above on sex and age differences.

TABLE 9.01

Classes of Drugs Categorized as “Other,”

by City, Surveys 1 and 2

84
TABLE 9.02

Class of Drug Involved in Death, by City, Surveys 1 and 2 Combined
TABLE 9.03

Age Distribution and Class of Drug Involved in Death,

by City, Surveys 1 and 2 Combined

(Continued)

86
TABLE 9.03 continued

87
TABLE 9.04

Sex and Class of Drug Involved in Death,

by City, Surveys 1 and 2 Combined

88
TABLE 9.05

Race and Class of Drug Involved in Death,

by City, Surveys 1 and 2 Combined

89
TABLE 9.06

Marital Status and Class of Drug Involved in Death,

by City, Surveys 1 and 2 Combined

(Continued)

90
TABLE 9.06 continued

9 1
TABLE 9.07

Occupation and Class of Drug Involved in Death,

by City, Surveys 1 and 2 Combined

(Continued)

92
TABLE 9.07 continued

93
TABLE 9.08

Employment Status and Class of Drug Involved in Death,

by City, Surveys 1 and 2 Combined

94
TABLE 9.08 continued

95
Chapter 10

Accidental Deaths

SUMMARY

"Accidental deaths" is the category or mode that covers cases referred to in everyday language as "drug abuse" or "overdoses," although it also covers those few cases of therapeutic misuse that may

come to a medical examiner's attention. Deaths in which a single

psychoactive drug or multiple substances were either indirectly or

directly involved are included. In New York and Philadelphia, the

mode of death was coded as "unknown" in large proportions of cases;

the remaining numbers were so low that percentages should be interpreted cautiously.

The mean age of accidental deaths was roughly 30 years. In the

seven cities with sufficient cases, whites outnumbered blacks, except in Washington, D.C., and males consistently outnumbered females.

In the same seven cities, half or more were employed.

Narcotic drugs accounted for more accidental deaths than did other

drugs among the top five single drug types, but the percentages

varied widely by city. Polydrug cases were frequent and seem to be

increasing over time. Blacks and males outnumbered whites and females, respectively, in the narcotic drug category; victims were

somewhat younger than in the other drug categories.

The typical accidental death was difficult to portray, in part because the classification is broad and somewhat inconsistent from

city to city.

ACCIDENTAL DEATHS

The survey defined its purpose as the study of "drug-involved deaths,"

which can encompass a multitude of intentions, situations, and physiological reactions of the victims. Nonetheless, a major interest

in these data was the extent and character of drug abuse deaths or

deaths that come about as a result of individuals' decisions to use

psychoactive drugs outside the supervision of a physician.

In this chapter the group of deaths identified as "accidental" is

examined as a rough approximation of "drug abuse" or "overdose"

deaths. These are cases where the victim may have used the drug(s)

for any number of reasons, but not deliberately to induce death, as

96
in suicides. The substances are limited to psychoactive drugs, but

there is still the possibility that some deaths were the result of

so-called therapeutic misadventures, not drug abuse. It is almost

impossible to identify a pure group of such cases except by carrying out ancillary interviews with family and friends. Though not

ideal as a category, accidental deaths, operationally defined below, serves this need fairly well. Similar analyses were conducted

on suicide and homicide cases, reported in chapter 11.

As described earlier, the study was conducted in two waves separated

by about two years; thus, changes in the statistics from the first

to the second survey can indicate changes in patterns of occurrence

of deaths overall as well as in the nine cities.

Cases were considered accidental if and only if the questions designed to measure mode of death were answered according to the definitions. Code Sheet #3 was used to characterize these cases. There

were several choices of differing mechanisms or manners of death for

which "accidental or 'unexpected'" was the summarizing term (in parts

A, B, D, E, and F of the code). A and B are the most pertinent among

the following, since they identify accidental deaths "caused" by

one or more drugs. The responses from Code #3 were as follows:

Drug-Induced

A. Simple or direct--the drug in question was specifically

the cause of death with no other agent playing a significant role.

01. Accidental or "unexpected"

B. Drug in combination with some other potentiating or

synergistic pharmacologic agent, such as alcohol, barbiturates, etc.

05. Accidental or "unexpected"

C. Idiosyncratic--an unexpected effect, such as an

anaphylactic or immune reaction.

Drug-Related

D. Drug(s) in combination with some pre-existing and

potentially deadly physiological condition, such as

diabetes, chronic heart condition, etc.

10. Accidental or "unexpected"

E. Drug(s) in combination with some physical event outside

of the patient's body, such as death by vehicle or gunfire while under the influence, etc.

14. Accidental or "unexpected"

F. Drug(s) in combination with some medical disorder or

disease probably produced by drug abuse, such as

hepatitis, bacterial endocarditis, tetanus, etc.

18. Accidental or "unexpected"

97
It should be mentioned that in equivocal cases most medical examiners or coroners tend to classify a case as accidental or undetermined rather than suicidal. Much greater care is usually taken to

ensure that a possible homicide (at least of a malicious and willful nature) is not falsely classified as an accidental death, but

it is conceivable that a few such cases slip through and contaminate

the data.

The distribution of cases by mode as well as role of drug (i.e.,

drug-induced vs. drug-related) for each city is displayed in tables

4.01 and 4.02. The total number of accidental deaths coded in both

surveys was 1128, or 37.5 percent (table not shown). Unfortunately,

fairly large proportions of cases in New York and Philadelphia were

coded "unknown" as to mode of death, leaving only 22 and 28 cases,

respectively, for analysis of accidental deaths. The percentages

are provided in most tables, but they should be interpreted cautiously.

CHARACTERISTICS OF VICTIMS

Table 10.01 provides data on the selected demographic and social

characteristics of victims of accidental death in each of the nine

cities in the two surveys combined. The mean age of accidental

death was roughly 30 (table not shown). Table 10.01 combines ages

by five- and ten-year spans. There are some variations from city

to city, with generally highest percentages in the age range of

20 to 29 years. The distribution by sex shows a greater number of

males than females. Omitting New York and Philadelphia, the range

in the combined surveys is from 57.3 percent males in Miami to 76.4

percent in Washington, D.C. In the racial breakdown, for the seven

remaining cities, whites outnumber blacks except in Washington, but

the proportion of blacks in most other cities is rather high (from

20.3 to 46.2 percent); the proportion of "other racial groups" is

high in Los Angeles. The largest group was "never married" (approximately 48 percent in both samples), perhaps reflecting the young age

of the victims. The percent married ranged from 18.0 in Miami to

43.3 percent in Dallas. Again omitting New York and Philadelphia,

half or more of the victims were employed. The percent employed in

those seven cities varied from 50.0 in Dallas to 83.5 in San Francisco

The majority were in skilled, semiskilled, and unskilled occupations.

Table 10.02 shows the distribution of drug types of the drugs most

importantly involved in the accidental deaths. The narcotic category

was clearly the largest for a single drug type in all but one city

(Miami), with barbiturates well behind. There were large variations

by city. Washington, D.C. had 88.8 percent in the narcotic category,

in both surveys combined, whereas Dallas had only 25.0 percent in

that category.

Table 10.03 summarizes the findings on the role of the drug in accidental deaths. A single direct drug effect was by no means the

"cause" in the majority of cases. As many as 51.0 percent (in Los

Angeles, both surveys combined) were polydrug (combined) cases.

Also, the proportion of polydrug cases increased between the first

and second surveys.

98
TABLE 10.01

Selected Characteristics of Accidental Death Cases, by City,

Surveys 1 and 2 Combined

99
TABLE 10.02

Types of Drugs Responsible for Accidental Deaths, by City,

Surveys 1 (N=2000) and 2 (N=1004)

100
Table 10.04 shows who reported the accidental deaths. Most accidental deaths (omitting Philadelphia and New York) were reported by a

family member or a friend. The deceased person was judged to have

died at the site of discovery of the body in 91.6 percent of Survey

1 and 82.9 percent of Survey 2 cases (table not shown).

No external injury was seen in 85.8 percent of Survey 1 and 88.6 percent of Survey 2 cases. A few thermal burns were reported, presumably

due to subjects who fell asleep while smoking. Automobile accidents

were involved in only 4.1 percent of the accidental deaths of Survey

1 and 4.4 percent of Survey 2. Needle and track marks were frequently seen. Previous psychiatric diagnosis involved drug addiction

in 38.1 percent of cases in Survey 1 and 13.3 percent in Survey 2.

There were significant numbers of other psychiatric diagnoses in both

surveys. Fourteen percent of Survey 1 cases and 13.9 percent of Survey 2 were said to be heavy drinkers of alcoholic beverages. This

can be compared with the estimate published a few years earlier that

7 percent of the adult population manifest the behavior of alcohol

abuse (USDHEW 1971) (tables for these figures not shown).

DIFFERENCES BY DRUG CATEGORY

Perhaps of greater interest than the demographic and social characteristics of accidental death cases shown for each city is the

distribution of these characteristics by drug category. Since cases

were few in the separate cities,

(table 10.05) .

only the combined totals are given

There seem to be proportionately more older victims

in the non-narcotic drug categories. Males predominate in the

largest category, narcotic cases, but females outnumber males in

the classes of analgesics and sedatives. Blacks are overrepresented

in the narcotic category (43.8 percent) but less so in the other

drug classes. “Never married” predominates in the narcotic and sedative classes, but there were substantial proportions of married or

previously married victims in the other classes. The narcotic cases

showed the highest rates of employment, compared with barbiturates

and “others” However, there were comparatively large proportions .

of housewives, students, or retired persons in these two classes.

Table 10.06 summarizes the role of the drug in the death event and

the external evidence of drug usage for each category of drug. A

direct pharmacological effect of a single drug is the most common

mechanism of death for essentially all drug categories. However,

death at the time of a physical illness or event did occur in a

fair proportion of cases among the barbiturate deaths. The narcotic drug cases have the highest incidence of stigmata of drug

usage such as needle marks and track marks.

As previously noted, the classification of accidental death is

broad, diffuse, and somewhat inconsistent from city to city. It

is not surprising, therefore, that the picture of the “typical”

accidental death that emerges from this analysis is not as clear

as might be desired,

101

315-509 O - 80 - 8
TABLE 10.03

Role of Drug in Accidental Death Cases, by City,

Surveys 1 (N=2000) and 2 (N=1004)

TABLE 10.04

Reporting Source of Accidental Death Cases, by City,

Surveys 1 and 2 Combined

102
TABLE 10.05

Selected Personal Characteristics of Accidental Death Cases,

by Drug Type, Surveys 1 and 2 Combined

103
TABLE 10.06

Role of Drug in Death and External Bodily Evidence of Accidental

Death Cases, by Drug Type, Surveys 1 and 2 Combined

REFERENCE

U.S. Department of Health, Education, and Welfare. First Special

Report to the U.S. Congress on Alcohol and Health, from the Secretary

of Health, Education, and Welfare, Rosenber, S.S., ed. Washington,

D.C.: Office of the Secretary for Health and Scientific Affairs,

December 1971. p. viii.

104
Chapter 11

Suicides and Homicides

SUMMARY

Suicides made up about one-fourth and homicides about one-tenth of

the cases of drug-involved deaths in the two surveys. Most of the

homicides were cases in which some other physical event such as a

shooting had occurred, but drugs were also found. The cases

labeled “definitely suicide” more often were female and somewhat

older than the cases as a whole; whites were overrepresented. A

very high percentage of suicides were reported as emotionally depressed before death. The most frequent signal they gave was

talking about death. Barbiturates were the most commonly used

drug type in all nine cities; narcotics were rarely used. Alcohol

was also present in about one-fourth of the suicide cases.

Homicides presented a picture almost the reverse of the suicide

cases. Although the cases were too few for formal analysis, they

appeared to be primarily male and black, younger, and in most cases

had prior arrest records.

SUICIDES

Drugs were listed as cause of death in about 31 percent of all suicide cases in the United States in 1971. Among these drug deaths,

barbiturates played a prominent role, being listed about 25 percent of the time (Vital Statistics, 1971). Statistics on deaths

associated specifically with psychotropic drugs and their relationship to suicide have been rather sketchy. One item on the reporting

form required that each death be labeled as one of the following:

(1) definitely suicide; (2) probably suicide; (3) accidental but

suspicious ; (4) definitely not suicide; or (5) unknown (usually due

to missing data). The following analysis is based upon Category 1,

cases listed as “definitely suicide.” Cases coded as “probable” or

“suspicious” were relatively few and undoubtedly represent decisionmaking that differs among the examiners. It should be remembered

that this analysis involves a special type of suicide - not only

were the cases involved with psychotropic drugs, but each ended up

officially as a “coroner’s case.” Therefore, comparisons with

general suicide statistics may give diverse results.

105
TABLE 11.01

Proportion of Suicides Among Drug-Related Deaths, by City,

Survey 1 (N=2000) and Survey 2 (N=1004)

Of the 3004 cases in Surveys 1 and 2, 726 were reported as “definitely suicide." The distributions by survey and city are shown in

table 11.01. Three of the larger cities, New York, Chicago, and

Philadelphia, showed relatively low percentages of suicides among

their drug-involved deaths (under 20 percent). Cleveland, San

Francisco, Washington, D.C., Dallas, and Los Angeles were in a

medium range and Miami had the highest (57 percent for combined

surveys).

Differences among cities may well have reflected local conditions

under which deaths were reported and how likely it was for a suicide to be detected. For example, New York, Chicago, and Philadelphia had large caseloads, subjects with high mobility, limited resources for studying the personal background of each case, and

usually had to accept the evidence provided from the corpse itself

and from the police. Although Los Angeles had to cope with similar

problems. its medical examiner staff was highly oriented toward

clues of suicide. Los Angeles is kown as the place where the

“psychological autopsy” began, and investigative behavioral scientists were still on its staff. Miami, with its older population,

might have been expected to have a higher suicide rate. In addition, its staff frequently used modified psychological autopsies

(for example, telephone interviews with significant others).

Characteristics of Suicide Cases

Selected characteristics of suicide cases by city for each survey

are shown in table 11.02, beginning with the means and standard

deviations of age of death. Combining data from the surveys, the

mean age was between 35 and 45 years, which was somewhat higher

than for other drug-involved deaths. Miami, with its older general population, had the highest mean, 48.4 years.

The general picture of a preponderance of females over males is

consistent with other findings that women are more apt than men

106
TABLE 11.02

Selected Characteristics of Suicide Cases,

by City, Surveys 1 and 2 Combined

107
TABLE 11.03

Incidence of Depression and "Signals" Among Suicide Cases,

by City, Surveys 1 and 2 Combined

108
to use drugs as a means of committing suicide (Berger 1967). Suicide by psychoactive drug was most common among whites. The proportion, generally between 70 and 90 percent, ranged from a low of

71.7 percent white in New York to a high of 93.7 percent in Dallas.

Cases were fairly evenly divided among the three categories of

marital status used in the analysis. In three cities, married

cases were the highest proportion, in two cities, those never married were the highest proportion, and in one city, San Francisco,

the highest proportion were the widowed, divorced, or separated.

In six cities, the majority of suicide victims were employed. In

Philadelphia a large number of students and housewives were reported. Occupational categories were (1) professional and semiprofessional; (2) skilled, semiskilled, and unskilled; and (3) students

and housewives. Generally, in both surveys there were more cases in

the skilled, semiskilled, and unskilled group than in the other two

categories. Suicides by professionals were more common in Miami,

San Francisco, and Washington.

Emotional State and Suicide Signals

A number of emotional symptoms usually accompany suicides, one of

which is depression. In all nine cities, as seen in table 11.03, a

very high percentage of suicide victims (ranging from 82.1 to 97.3

percent) were reported as having been emotionally depressed just

prior to taking their own lives.

Suicide victims often emit "signals" prior to their death, giving

positive indications of contemplating suicide. In most of the

nine cities the most frequent signal employed by the suicide victims appeared to be "talking about death," followed closely by the

"overt threat" of taking one's life. The majority of the remaining

cases apparently did not communicate any desire to take their lives,

or else it was unknown to those investigating the case.

Types of Drugs Used

The type of drug most commonly used in suicide deaths in the nine

cities was barbiturates, which accounted for 48.5 percent of all

drugs used (table not shown). In both surveys combined, cities

varied from 27.5 to 74.8 percent (table 11.04). The next most

common types were analgesics and tranquilizers. Narcotics were

used by a fairly small proportion, which is consistent with an

earlier report (Baden 1972). Only a few cities show any sizable

differences from Survey 1 to Survey 2. In Miami, involvement of

barbiturates doubled between the two surveys.

Alcohol, while by definition not included as a primary cause of

death in these cases, was present in significant amounts in 24 percent of them (table not shown). It is likely, of course, that at

least some of these cases were influenced by the drug-alcohol combination and that perhaps some suicides would not have occurred

under the influence of only one of the substances.

109
TABLE 11.04

Types of Drugs Associated With Suicide Cases, by City,

Survey 1 (N=2000) and Survey 2 (N=1004)

110
HOMICIDES

Among the 3004 cases described in this study, 276, or better than

nine percent, were homicide victims. Involving psychoactive drugs,

they were cases brought to the medical examiner or coroner and

judged to have been murdered. This rate of 920 per 100,000 is several hundred times that of the rate of homicides in the general

population (Herjanic and Meyer 1976). Logically this figure cannot

be compared with the homicide rate for the general population, but

it does seem appropriate to conclude that homicide and drug abuse

are related in some way.

In nearly every instance among these 276 cases, the death occurred

in connection with some physical event outside the victim’s body -

that is, a shooting, stabbing, or similar event (98 percent) while

the victim was under the influence of a psychotropic drug. In a

few cases the drug itself apparently was the instrument of murder..

The incidence of homicides among drug-involved deaths in the nine

cities is seen in table 11.05. Philadelphia, Washington, and

Chicago had the highest proportions of homicides and Dallas, Los

Angeles, and Miami the lowest.

The numbers of homicide cases in some cities were so small that

analysis of their characteristics was not feasible. Can examination

of the raw numbers, the homicides seemed to resemble the narcotics

cases described earlier. One tabulation of prior arrest records of

the homicides suggested that they were drawn almost entirely from

a criminal population (tables not shown).

REFERENCES

Baden, M.M. Homicide, suicide, and accidental death among narcotic

addicts. Hum Pathol, 31(1):91-95, 1972.

Berger, F.M. Drugs and suicides in the United States. Clin Pharmacol Ther, 8:219-223, 1967.

Herjanic, M., and Meyer, D. Psychiatric illness in homicide victims.

Am J Psychiatry, 133(6):691-693, 1976.

U.S. Department of Health, Education Welfare, National Center for

Health Statistics. Vital Statistics of the United States, I(A):

1-164, Washington, D.C.: 1971.

111
TABLE 11.05

Proportion of Homicides Among Drug-Related Deaths,

by City, Survey 1 (N=2000) and Survey 2 (N=1004)

112
Chapter 12

Discussion and Conclusions

This concluding chapter is an attempt to look at the larger implications of a national survey of drug abuse deaths, the results of

which have been summarized in chapter 1 and described in detail in

the remainder of this volume. What do the results suggest about

the relationship between drug abuse deaths and the overall problem

of drug abuse? What do the findings indicate about the established

information system of coroners and medical examiners? And, finally,

what conclusions can be drawn from this study that will be helpful

in future attempts to study drug-involved deaths on a national basis?

The surveys indicate that the two drug types responsible for most

deaths were opiates and barbiturates, with opiates responsible for

twice as many fatalities as barbiturates. As with any other tragic

event, one looks for "blame" or responsibility for the cause. It

is not possible from the design of this study to assign responsibility for the dissemination of opiates and barbiturates. The extent to which substances implicated in the deaths were obtained

through physicians and hospitals was not learned, although that

might be an important area of investigation, if feasible, in future

studies. The present study did note, however, that there was frequent use of psychoactive drugs by victims in the two weeks prior

to death, which implies wide availability of such substances. The

pervasiveness of drugs themselves, for both medical and nonmedical

purposes, must play a role in the incidence of drug-involved deaths.

In looking for the implications of the data about the major types of

substances involved in drug abuse deaths, it must be kept in mind

that the cases selected for study consisted only of those which came

to the attention of authorities empowered to investigate deaths, not

those cases routinely handled within the medical community. This

same caveat applies in attempting to explain major modes of death.

Since accidental and suicidal deaths are the very situations that

mandate the services of medical examiners, it is not surprising that

the most frequent mode was accidental death and the second most

frequent mode was suicide. The large proportion of cases unknown

as to mode should not be considered a particularly unusual phenomenon, considering the many potential uncertainties in these cases.

The large number of "unknowns" does, however, present a major obstacle to full knowledge of drug-involved deaths. The fact that

113
the proportion of unknowns was much larger in some cities than in

others implies that conceptions, techniques, and/or procedures are

not consistent or widely shared among medical examiners’ offices.

As long as this clouded situation exists, the national picture

will not be a clear one; to what extent it can be clarified is a

question for future research and debate.

The facts about the drug-involved cases as persons come mainly

from tabulations of their characteristics (and the circumstances

surrounding their deaths) in two- or three-way classifications,

Data analysis could have continued past the point reached in the

preceding chapters, but fine tabulations turned out to have such

small numbers of cases in some cells that reliable comparisons were

not possible. Multivariate analyses might show whether or not certain clusters of characteristics discriminate strongly among groups

of cases. As mentioned in chapter 2, the data tapes are available

for further analysis to interested scholars through the Drug Abuse

Epidemiology Center at Texas Christian University.

Visual inspection of the tables suggests that there are organizing

principles in the data. Drug types or classes appeared to discriminate rather strongly among the cases, especially the narcotic drugs

in contrast to the other types. The persons who died from narcotic

drugs were more likely than others to be young, male, and black.

Deaths involving barbiturates were more likely than others to be

suicidal, and were typified by whites, females, and older persons.

Intercity differences in victims’ characteristics were not as prominent as differences in drug type and mode of death. The city variations that did appear probably reflected differences in population

characteristics, such as the relatively larger older population of

Miami, and relatively larger black population of Washington, D.C.

More significantly, the proportion of “unknowns” as to mode of

death, mentioned earlier, did vary decidedly among cities. It is

hard to believe that the cases themselves were more difficult to

analyze in some cities than in others, and therefore it is hypothesized that other local conditions were responsible.

Turning to what was learned about procedures in this study, it was

heartening to note that on-site investigations were a widespread

practice, that toxicology laboratories were used as the preferred

source of information, and that the majority of postmortem examinations were conducted by physicians with Board certification in

pathology. Conversely, there was widespread variation among cities

with respect to certain other practices, not all of which are

essential to good decisions. Two of these practices, fingerprinting

and quantitation of drugs, are no doubt limited in some offices

because of budgetary constraints.

More serious questions can be raised about the proficiency of toxicological examinations. The results of the proficiency testing

and the range in number of drugs tested in each case create considerable doubt about the reliability of data on numbers of deaths

attributed to a certain drug or classified as “unknown.” This is

114
especially troublesome at a time when polydrug use is increasing.

(In this study itself, it was found that deaths due to more than

one substance increased as a proportion of all deaths from the

first to the second survey.) Polydrug use by the victims makes

examination more difficult, and when the possibility is added that

some drugs may be missed entirely, the quality of results may be

unsatisfactorily low.

It must be remembered that medical examiners’ offices and the laboratories that serve them are governed by local and State laws,

not by Federal regulations; thus, consistency in procedures cannot

be expected. Also, it must be acknowledged that epidemiology is not

the primary function of these offices. Their main responsibility

is to the executive and judicial branches of their local government,

not to science. Nevertheless, the importance of the information

produced in these offices argues in the public interest for closer

attention to the quality of data.

Local autonomy for medical examiners affects not only the consistency

of procedures used to collect data, but also the basic definitions

that govern data collection. The definitions of “drug-involved”

are not the same in all offices, and the criteria for assigning

cases to specific categories are not standard. Even the hiring of

additional staff to collect data in specified locations to collate

information, as is done in the Federal government’s DAWN project,

does not guarantee consistency. The initial decisions made by medical examiners and their staff constitute the basic data and their

individual decisions prevail. It may be true that a secondary

purpose such as epidemiology cannot easily or efficiently be added

to a primary purpose such as legal investigation without compromises.

This project has produced a base of unique data on drug-involved

deaths in extent of detail not heretofore available in a single

study. It has left us unsatisfied in many ways due to inconsistencies in procedures and definitions used in the original process

of data collection, and has convinced us there are structural barriers to conducting an ideal survey of these incidents. This study

has shown that before further research of this type is planned, it

will be necessary to deal with the thorny issues of lack of consistency in methods, definitions, and practices.

The difficulties and dissatisfactions encountered in this study underscore the fact that the epidemiology of drug abuse is a fledgling

science. Efforts to improve the definition and classification of

drug-involved deaths will benefit the science. But the “bottom

line” is always the human factor--preventing deaths and expanding

the quality of life. Some of the most poignant findings of this

study were the relative youth of the victims and the fact that, except for pulmonary edema, the postmortem findings were largely

normal, suggesting how unnecessary is the tragedy of drug abuse

deaths. The ultimate goal of research of this type must be to save

those who should not yet become statistics.

115

Appendix A: Reporting Forms

REPORTING FORMS AND CODE SHEETS

SURVEY 1. Form: Report of a Drug-Involved Death

Code Sheets #2, #3, #5, and #6

SURVEY 2. Form: Reporting From for Drug-Involved Deaths

Code Sheets #5, #6, and #7

Survey 1

Report of a Drug-Involved Death

GENERAL INSTRUCTIONS

In completing this Report of a Drug-Involved Death, keep in

mind the following:

(1)

(2)

(3)

This report is concerned with cases in which psychoactive

drugs are involved as a primary or contributing cause.

Cases where alcohol alone is the cause of death are not

pertinent.

In Part V,“Treatment Prior to Death,” the section on

page 11 refers to treatment for drug ingestion. The

section on pages 12 and 13 refers to medication of any

kind used in treatment for any reason.*

For cases involving prescriptive drugs or a history of

recent treatment, it is desirable to complete pages 12

and 13, reporting any medication taken (if such

information is available.)*

* In this volume, material on pages 11, 12, and 13 of the

form appears on page 124.

Format of some pages has been altered to fit page size

requirements of the NIDA Research Monograph series.

117

315-509 0 - 80 - 9
118
119
120
121
122
123
124
125
126
LIST OF CODE SHEETS

TO BE USED WITH

SURVEY 1 REPORTING FORM

Report of a Drug-Involved Death

(Coding additions and changes made progressively to accommodate

responses are incorporated into the form reproduced here.)

General Instructions (See page 117)

Code Sheet

#1 *

#2

#3

#4 **

#5

#6

U. S. States, Counties and Cities

Standard Metropolitan Statistical

Areas

Role of Drug Involved in Death

DAWN Drug Header (developed by Lea,

Inc., published 6 September 1973)

Extraction Methods Used

Analytic Methods Used

Used With Part

I, VII

I

I

I, II, III, V

III

III

* Not included. Available upon request from Department of

Psychiatry and Human Behavior, College of Medicine,

University of California, Irvine, CA 92717.

** Not included. For information, write I.M.S. America, Ltd.,

Ambler, Pennsylvania 19002.

127
CODE SHEET #2

FOR

STANDARD METROPOLITAN STATISTICAL AREAS

SAMPLE 1

Code Area

001 Abilene, Texas

002 Akron, Ohio

003 Albany, Ga.

004 Albany-Schnectady-Troy, N.Y.

005 Albuquerque,N. Mex.

006 Allentown-Bethlehem-Easton,Pa.-N.J.

007 Altoona, Pa.

008 Amarillo, Texas

009 Anaheim-Santa Ana-Garden Grove, Ca.

010 Anderson, Ind.

011 Ann Arbor, Mich.

012 Appleton-Oshkosh, Wis.

013 Asheville, N.C.

014 Atlanta, Ga.

015 Atlantic City, N.J.

016 Augusta, Ga.-S.C.

017 Austin, Texas

018 Bakersfield, Ca.

019 Baltimore, Md.

020 Baton Rouge, La.

021

022

023

024

025

026

027

028

029

030

031

032

033

034

035

036

037

038

039

040

041

042

043

044

Bay City, Mich.

Beaumont-Port Arthur-Orange, Texas

Billings, Mont.

Biloxi-Gulfport, Miss.

Binghamton, N.Y.-Pa.

Birminghan, Ala.

Bloomington-Normal, Ill.

Boise City, Idaho

Boston, Mass.

Brideport, Conn.

Bristol, Conn.

Brockton, Mass.

Brownsville-HarlingenSan Benito, Texas

Bryan-College Station, Tex.

Buffalo, N.Y.

Canton, Ohio

Cedar Rapids, Iowa

Champaign-Urbana, Ill.

Charleston, S.C.

Charleston, W. Va.

Charlotte, N.C.

Chattanooga, Tenn.-Ga.

Chicago, Ill.

Cincinnati, Ohio-Ky.-Ind.

045 Cleveland, Ohio

046 Colorado Springs, Col.

047 Columbia, MO.

048 Columbia, S.C.

049 Columbus.Ga.-Ala.

050 Columbus, Ohio

051 Corpus Christi, Texas

052 Dallas, Texas

053 Danbury, Conn.

054 Davenport-Rock Island-Moline,

055 Dation, Ohio Iowa-Ill.

056 Decatur, Ill.

057 Denver, Colo.

058 Des Moines, Iowa

059 Detroit, Mich.

Code Area

060 Dubuque, Iowa

061 Duluth-Superior, Minn.-Wis.

062 Durham, N.C.

063 El Paso, Texas

064 Erie, Pa.

065 Eugene, Oregon

066 Evansville, Ind.-Ky.

067 Fall River, Mass.-R.I.

060 Fargo-Moorhead, N. Dak.-Minn.

069 Fayetteville, N.C.

070 Fitchburg-Leominister, Mass.

071 Flint, Mich.

072 Fort Lauderdale-Hollywood, Fla.

073 Fort Smith, Ark.-Okla.

074 Fort Wayne, Ind.

075 Forth Worth, Texas

076 Fresno, Calif.

077 Godsden, Ala.

078 Gainesville, Fla.

079 Galveston-Texas City, Texas

080 Gary-Harmond-East Chicago, Ind.

081 Grand Rapids, Mioh.

082 Great Falls, Mont.

083 Green Bay, Wis.

084 Greensboro-Winston-Salem-HighPoint, N.C.

085

086

087

088

089

090

091

092

093

094

095

096

097

098

099

100

101

102

103

104

105

106

107

108

109

110

111

112

113

Greenville, S.C.

Hamilton-Middletown. Ohio

Harrisburg, Pa.

Hartford, Conn.

Honolulu, Hawaii

Houston, Texas

Huntington-Ashland, W. Va.-Ky.-Ohio

Huntsville, Ala.

Indianapolis, Inc.

Jackson, Mich.

Jackson, Miss.

Jacksonville, Fla.

Jersey City, N.J.

Johnstown, Pa.

Kalamazoo, Mich.

Kansas City, Mo.-Kansas

Kenosha, Wis.

Knoxville, Tenn.

La Crosse, Wis.

Lafayette, La.

Lafayette-West Lafayette,

Lakes Charles, La.

Lancaster, Pa.

Lansing, Mich.

Laredo, Texas

Ind.

Las Vegas, Nev.

Lawrence-Haverhill, Mass.-N.H.

Lawton, Okla.

Lewiston-Auburn, Maine

114 Lexington, Ky.

115 Lima, Ohio

116 Lincoln, Nebr.

117 Little Rock-North Little Rock,Ark.

118 Lorain-Elyria, Ohio

119 Los Angeles-Long Beach, Ca.

128
Code Sheet #2 (cont)

Code Area

185 St. Joseph, Mo.

186 St. Louis, Mo.-Ill.

187 Salem, Oregon

188 Salinas-Monterey, Calif.

189 Salt Lake City, Utah

190 San Angelo, Texas

191 San Antonio, Texas

192 San Bernardino-Riverside-Ontario. Ca.

193 San Diego, Ca.

194 San Francisco-Oakland, Calif.

195 San Jose, Ca.

196 Santa Barbara, Ca.

197 Santa Rosa, Ca.

198 Savannah, Ga.

199 Scranton, Pa.

200 Seattle-Everett, Wash.

201 Sherman-Denison, Texas

202 Shreveport, La.

203 Sioux City, Iowa-Nebr.

204 Sioux Falls, S. Dak.

205 South Bend, Ill.

206 Spokane, Wash.

207 Springfield, Ill.

208 Springfield, Mo.

209 Springfield, Ohio

210 Springfield-Shicopee-Holy

Mass.-Conn.

Code Area

120 Louisville, Ky.-Ind.

121 Lowell, Mass.

122 Lubbock, Texas

123 Lynchburg, Va.

124 Mecon, Ga.

125 Madison, Wis.

126 Manchester, N.H.

127 Mansfield, Ohio

128 McAllen-Pharr-Edinburg, Texas

129 Memphis, Tenn.-Ark.

130 Meriden, Conn.

131 Miami, Fla.

132 Midland, Texas

133 Milwaukee, Wis.

134 Minneapolis-St. Paul, Minn.

135 Mobile, Ala.

136 Modesto, Calif.

137 Monroe, La.

138 Montgomery, Ala.

139 Muncie, Ind.

140 Muskegon-Muskegon Heights, Mich.

141 Nashua, N.H.

142 Nashville-Davidson, Tenn.

143 New Bedford, Mass.

144 New Britain, Conn.

145 New Haven, Conn.

146 New London-Groton-Norwich, Conn.

147 New Orleans, La.

148 New York, N.Y.

149 Newark, N.J.

150 Newport News-Hampton, Va.

151 Norfolk-Portsmouth, Va.

152 Norwalk, Conn.

153 Odessa, Texas

154 Ogden, Utah

155 Oklahoma City, Okla.

156 Omaha, Nebr.-Iowa

157 Orlando, Fla.

158 Owensboro, Ky.

159

160

Oxnard-Ventura, Ca.

Paterson-Clifton-Passaic. N.J.

161 Pensacola, Fla,

162 Peoria, Ill.

163 Petersburg-Colonial Heights. Va.

164 Philadelphia, Pa.-N.J.

165 Phoenix, Ariz.

166 Pine Bluff, Ark.

167

168

Pittsburgh, Pa.

Pittsfield, Mass.

169 Portland, Maine

170 Portland, Ore-Wash.

171 Providence -Pawtucket-Warwich,

172 Provo-Orem-Utah R.I.-Mass.

173 Pueblo, Col.

174 Recine, Wis.

175 Raleigh, N.C.

176 Reading, Pa.

177 Reno, Nevada

178 Richmond. Va.

179 Roanoke, Va.

180 Rochester, Minn.

181 Rochester, N.Y.

182 Rockford, Ill.

183 Sacramento, Calif.

184 Saginaw, Mich.

211

212

213

214

215

216

217

218

219

220

221

222

223

224

225

226

227

228

229

230

231

232

233

234

235

236

237

238

239

240

241

242

243

Stamford, Conn.

Steubenville-Weirton, Ohio-W. Va.

Stockton, Calif.

Syracuse, N.Y.

Tacoma, Wash.

Tallahassee, Fla.

Tampa-St. Petersburg, Fla.

Terre Haute, Ind.

Texarkana, Tex.-Ark.

Toledo, Ohio-Mich.

Topeka, Kansas

Trenton, N.J.

Tucson, Arizona

Tulsa, Okla

Tuscaloosa, Ala.

Tyler, Texas

Utica-Rome, N.Y.

Vallejo-Napa, Calif.

Vineland-Millville-Bridgeton, N.J.

Waco, Texas

Washington, D.C.-Md.-Va.

Waterbury, Conn.

Waterloo, Iowa

West Palm Beach, Fla.

Wheeling, W. Vs.-Ohio

Wichita, Kansas

Wichita Falls, Texas

Wilkes-Barre-Hazleton, Pa.

Wilmington, Del.-N.J.-Md.

Wilmington, N.C.

Worcester, Mass.

York, Pa.

Youngstown-Warren, Ohio

129
Code Sheet #3

Role of Drug Involved in Death

A SCHEMA FOR DEFINING AND CATEGORIZING

DRUG-INVOLVED DEATHS

Sample 1

DRUG-INDUCED

A. Simple or direct - the drug in question was specifically the

cause of death with no other agent playing a significant role.

01. Accidental or “unexpected”

02. Suicidal

03. Homicidal

04. Unknown

B. Drug in combination with some other potentiating or synergistic

pharmacologic agent, such as alcohol, barbiturates, etc.

05. Accidental or “unexpected”

06. Suicidal

07. Homicidal

08. Unknown

C. Idiosyncratic -- an unexpected effect, such as au anaphylatic

or immune reaction.

09. Accidental or “unexpected”

DRUG-RELATED

D. Drug in combination with some pre-existing and potentially

deadly physiological condition, such as diabetes, chronic heart

condition, etc.

10. Accidental or “unexpected”

11. Suicidal

12. Homicidal

13. Unknown

E. Drug in combination with some physical event outside of the

patient’s body, each as death by vehicle or gunfire while under

the influence, etc.

14. Accidental or "uexpected”

15. Suicidal

16. Homicidal

17. Unknown

F. Drug in combination with some medical disorder or diaeaae

probably produced by drug abuse, such as hepatitis, bacterial

endocarditis, tetanus, etc.

18. Accidental or “unexpected”

19. Unknown

130
CODE SHEETS #5 AND #6

to be used with

REPORT OF A DRUG-INVOLVED DEATH - NIMH Contract No. HSM-42-72-139

(and Supplementary Form for Reporting-Data on Unknown Drug Sample)

Sample 1

CODE SHEET #5 - EXTRACTION MFTHODS USED

01. No extraction used

02. Distillation

03. Direct extraction by ether

04. Direct extraction by chloroform

05. Direct extraction by heptane

06. Extraction by ether after deproteinizing sample

07. Extraction by chloroform after deproteinizing sample

08. Extraction by heptane after deproteinizing sample

09. Ion exchange chromatography

10. Other (specify)

CODE SHEET #6 - ANALYTIC METHODS USED

01. Paper chromatography

02. Thin-layer chromatography

03. Gas-liquid chromatography

04. Absorption chromatography

05. Ultraviolet absorption spectrophotometry

06. Infra-red absorption spectrophotometry

07. Visible absorption spectrophotometry

08. Color test (general and specific)

09. Fluorescence spectrophotometry

10. Mass spectroscopy

11. Immunoassays(RIA)

12. Electron-spin resonance spectroscopy

13. Microcrystal tests

14. Atomic absorption spectroscopy

15. Other (specify)

DRUG

Prefer generic name

in this section

DRUG ASSAY INSTRUCTIONS

Part III, Items 12-21

CONCENTRATION

Code For

0000 - Quantitative traces

or negative

9999 - Qualitative presence;

no measurement

pH

Code For

9 9 - Not applicable

15 - Not adjusted

16 - Physiological

131
Survey 2

REPORTING FORM FOR DRUG INVOLVED DEATHS

132
Survey 2

REPORTING FORM FOR DRUG-INVOLVED DEATHS

PART 1 -General

(Continued)

133

315-509 0 - 80 - 10
Survey 2

REPORTING FORM FOR DRUG INVOLVED DEATHS

134
Survey 2

REPORTING FORM FOR DRUG INVOLVED DEATHS

135
Survey 2

REPORTING FORM FOR DRUG INVOLVED DEATHS

136
Survey 2

REPORTING FORM FOR DRUG INVOLVED DEATHS

137
Survey 2

REPORTING FORM FOR DRUG-INVOLVED DEATHS

138
Survey 2

REPORTING FORM FOR DRUG INVOLVED DEATHS

139
Survey 2

REPORTING FORM FOR DRUG-INVOLVED DEATHS

140
LIST OF CODE SHEETS

USED WITH

REPORTING FORM FOR DRUG-INVOLVED DEATHS

SURVEY 2

Code Sheet Title

#1 * U. S. States, Counties, and Cities

and Areas Outside U. S. A.

#2 ** Standard Metropolitan Statistical

Areas

#3 ** Role of Drug Involved in Death

#4 *** Drug Code (DAWN Drug Header)

developed by Lea, Inc.,

published 6 October 1975

#5

#6

#7

Extraction Methods Used

Analytic Methods Used

Drug Screening Methods

Used With Part

I & VII

I

I

I, II, III,

V, VI

III

III

III

* Not included. Available upon request from Department of

Psychiatry and Human Behavior, College of Medicine,

University of California, Irvine, CA 92717.

** See Survey 1 code sheets.

*** Not included. For information, write I.M.S. America Ltd.,

Ambler, Pennsylvania 19002.

141
U.C.I. REPORTING FORM FOR DRUG-INVOLVED DEATHS

CODE SHEETS #5, #6 and #7 - SAMPLE 2

Toxicological Methods

CODE SHEET #5 - Extraction Methods Used (additional codes added 1/30/76)

01. No extraction used 11. Other (except 12-16 below; specify)

02. Distillation 12. Ethyl acetate

03. Direct extraction by ether 13. Ethylene dichloride

04. Direct extraction by chloroform 14. Hexane

05. Direct extraction by heptane 15. Hexane/isoamyl alcohol

06. Extraction by toluene 16. N-butyl chloride/chloroform

07. Extraction by chloroform-iso- 77. Unknown

propanol

08. Exraction by n-butyl chloride

09. Ion exchange chromatography

CODE SHEET #6 - Analytic Methods Used

01. Paper chromatography 10. Mass spectroscopy

02. Thin-layer chromatography 11. Enzyme multiplied immunotechnique

03. Gas-liquid chromatography (EMIT)

04. Absorption chromatography 12. Free radical assay technique (FRAT)

05. Ultraviolet absorption spectro- 13. Radio-immunoassays (RIA)

photometry 14. Other immunoassays

06. Infra-red absorption spectro- 15. Electron-spin resonance spectroscopy

photometry 16. Microcrystal tests

07. Visible absorption spectrophotometry 17. Atomic absorption spectroscopy

08. Color test (general and specific) 18. Other (specify)

09. Fluorescence spectrophotometry 77. Unknown

CODE SHEET #7 - Drug Screening Methods

1. Drug screen, directly on physiological

fluid or tissue

2. Drug screen after acid extraction

3. Drug screen after neutral extraction

4. Drug screen after alkaline extraction

5. Drug screen, amphoterics

6. Alcohol and other volatiles

pH Code Added

777 = unknown

142
Appendix B: Specific Psychoactive Drugs

and/or the Classes of Such Drugs Associated

with 3004 Drug-Involved Deaths

In the organization and presentation of data obtained from the two

surveys of 3004 psychoactive drug-involved deaths over 1972-1975,

there were so many data and so many ways of looking at the data that

topics of major interest to some readers could be, unfortunately,

glossed over or disregarded. One of these areas of great interest

was the specific psychoactive drugs and/or classes of such drugs

that were associated with these deaths. To provide this broad range

of information to interested readers, it was decided to collect and

present in an appendix summaries of the specific drugs or their

classes related to various aspects of the deaths.

NOTE: In the tables that follow, Surveys 1 and 2 are referred to

as Samples 1 and 2.

List of Tables

B.1 Sample 1. Psychoactive drugs by drug type (mentioned at least

five times in each of four parts of the UCI reporting form)

B.2 Sample 2. Drugs involved in the death (listed in Part I of the

UCI reporting form) by city:

a.

b.

c.

d.

e.

g.

h.

Summary by drug type

Narcotics and quinine

Analgesics

Barbiturates

Sedatives and hypnotics

Tranquilizers

Psychostimulants; antidepressants; marijuana and

psychedelics; alcohol

Miscellaneous drugs

B.3 Drugs found at the scene of death (listed in Part II of the

UCI reporting form)

a. Samples 1 and 2 compared: Summary by drug type

b. Sample 1: Summary of drug type by city

c. Sample 2: Summary of drug type by city

d. Sample 2: Listing of specific drugs by city

143
B.4 Sample 2. Drugs assayed by toxicological laboratories

(listed in Part III of the UCI reporting form)

a. Summary by drug type

b. Listing of specific drugs assayed by city:

Narcotics and quinine

Analgesics

Barbiturates

Sedatives and hypnotics

Tranquilizers

Psychostimulants; antidepressants; marijuana

and psychedelics; alcohol

Miscellaneous drugs

B.5 Other drugs given in treatment or taken prior to death

(listed in Part V of UCI reporting form) .

a. Samples 1 and 2 compared: Summary by drug type

b. Sample 1 by drug type

c. Sample 2. Medications used in treatment for fatal

dose, by drug type and city: Summary and specific

listings

d. Sample 2. Other drugs recently used, by drug type

and city: Summary and specific listings

B.6 Sample 2. History of drug use (listed in Part VI of UCI

reporting form: Question 18, Deceased had history of

drug addiction, dependence, or chronic use, and Question 19, If response to #18 above is "Yes," specify

drugs)

a. Summary of drug type by city

b. Listing of specific drugs by city

144
Table B.1. List of Psychoactive Drugs Mentioned

at Least Five Times in Each of Four Parts of the UCI Reporting Form

Sample 1 (2000 Cases 1972-1974)

KEY: These lists were compiled from responses to questions in four

different parts of the UCI reporting form for drug-involved deaths

used in Sample 1. The specific questions asked are as follows:

Involved Part I item 20

At the Scene Part II item 15

Assayed Part III items 12-21

Given/Taken Part V items 9-16

and may be seen in the Sample 1 form reproduced in Appendix A.

10/28/75 Drug category

DAWN Drug Used in

Code Analysis

40--- NARCOTICS

40005 codeine

40008 et al meperidine, Demerol

40009 Dilaudid

40018 morphine

40166 heroin

40042 methadone

40027 Percodan (oxycodone)

40157 naloxone HCl, Narcan

CATEGORY TOTAL

41--- ANALGESICS

41005 et al aspirin, Empirin, Anacin,

Excedrin, salicylate, APC

41035 et al acetaminophen, Tylenol

41205 et al propoxyphene, Darvon

41550, 41573 Darvocet-N, Darvon-N

41040 Darvon Compound

41263 Darvon Compound-65

41368 et al pentazocine, Talwin

41095 phenacetin

CATBGORY T0TAL

46--- BARBITURATES

46003/4 amobarhital, Amytal

46056/7 secobarbital, Seconal

46013/4 butabarbital, Butisol

46048/038 pentobarbital, Nembutal

46051 phenobarbital

46070 seco-ambarbital, Tuinal

46999 barbiturate sedative,

unspecified

CATEGORY TOTAL

145

Drugs Mentioned at Least

Five Times in:

Part I

Involved

1994

Cases

Part II

At the

Scene

2000

Cases

Part III

Assayed

2000

Cases

31

8

6

520

127

388

7

12

6

12

61

41

8

46

20

6

767

402

1,080 147 1,241

52 7 81

155

5

10

-

58

5

2

15

15

169

222 102

8

8

266

121

239

12

167

150

74

6

81

78

29

60

123

246

15

186

157

71

96 19

859 273

123

921

(Table continued)

6

67

Part V

Given/

Taken

2000

Cases

7

67

6

12

92

11

6

14

6

6

43

15

16

15

15

315-509 O - 80 - 11
Table B.1 continued

10/28/75 Drug Category

DAWN Drug Used in

Code Analysis

47--- SEDATIVES

47013/022 chloral hydrate, Noctec

47118/015 glutethimide, Doriden

47023 methyprylon, Noludar

47028 ethchlorvynol, Placidyl

47063/057 methaqualone, Quaalude

47124/076 flurazepam, Dalmane

47111 methapyrilene, Sleep-eze

CATEGORY TOTAL

5

9

7

9

07--- TRANQUILIZERS

07018 chlorpromazine, Thorazine

07120/061 diazepam, Valium, Serax

07023 et al meprobamate, Miltown,

Equanil, Kesso Bamate

07105/041 chlordiazepoxide, Librium

07089 et al doxepin, Sinequan

07103 phenothiazine

07107 chlorpromazine

07121/036 thioridazine, Mellaril

07068 et al perphenazine/amitriptyline,

Triavil, Etrafon

07001 et al prochlorperazine, Triavil,

Etrafon, Compazine

CATEGORY TOTAL

12---/13--- PSYCHOSTIMULANTS

12004 et al amphetamine, Benzedine,

Dexedrine

12047 methamphetamine

12305 speed

12301 cocaine

13003 et al phemetrazine, Preludin

CATEGORY TOTAL

Drugs Mentioned at Least

Five Times in:

Part I

Involved

1994

Cases

16

37

5

39

59

18

5

179

6

145

22

34

7

42

7

23

286

23

43

2

27

29

124

Part II Part III

At the

Scene Assayed

2000 2000

Cases Cases

Part V

Given/

Taken

2000

Cases

21 15

17 42

8 5

27 39

23 72

30 16

11

126 200 30

17 5

130 170

24 22

38 31

12 6

46

8

14 20

14

6

49

8

257 308

8 29

26

5

12

5

77

30

11 28

19 113

(Table continued)

146
Table B.1 continued

10/28/75 Drug Category

DAWN Drug Used in

Code Analysis

11030-11999

(but including Ritalin) ANTIDEPRESSANTS

11103 et al imipramine, Presamine,

Tufranil

11109/054 amitsiptyline, Elavil

11073 desipramine

11016 methylphenidate HCl,

Ritalin

Involved

1994

Cases

24

68

CATEGORY TOTAL 92

38001 ETHANOL

38001 alcohol - CATEGORY TOTAL

35000-35006 MARIJUANA AND

and 39--- PSYCHEDELICS

35001 marijuana - CATEGORY TOTAL

Other codes MISCELLANEOUS

600

2 1

01026

15014

21047

29037

30014

6

19

32005 6

42025

45073

45104

48001/021

48018

16

5

51057

76002 et al

95026

sodium bicarbonate

isoprotenerol, Isuprel

tetracycline

carbon monoxide

Empirin Compound

with Codeine

quinine

salicylamide

lidocaine

trichlorethanol

diphenylhydantoin sodium,

Dilantin

Dilantin Sodium +

phenobarbital

dexamethasone MSD,

Decadron

adrenalin, epinephrine

salicylic acid

CATEGORY TOTAL

35999 Drug unknown

CATEGORY TOTAL

Various Unidentified drugs

CATEGORY TOTAL

Part I

Drugs Mentioned at Least

Five Times in:

Part II

At the

Secne

2000

Cases

Part III

Assayed

2000

Cases

7

237

14

14

10

282

19

17

29

9

55

2

52 377

3

15

Part V

Given/

Taken

2000

Cases

30 5

67 13

103

656

8

245

74

14

5

26

5

18

7

12

12

18

9

18

69

2

52

Unidentified drugs are those with some coding error that prevented

identification.

147
Table B.2. Psychoactive Drugs Reported es Involved in the Death

(Listed in Part I, UCI Reporting Form)

Sample 2: Summary of Drug Type by City

a Quinine is here treated as an indicator of heroin.

Sample 2. Drugs Involved

Table B.2 continued

NARCOTICSQUININE

a In the data. quinine almost always occurred with heroin; it is therefore treated here not as a

miscellaneous drug, as would be expected from its classification in the LEA code, but as en indicator

of heroin. (Table continued)

148
Table B.2 continued

Sample 2. Drugs Involved ANALGESICS

Sample 2. Drugs Involved

Table B.2 continued

BARBITURATES

(Table continued)

149
Table B.2 continued

SEDATIVES

Sample 2. Drugs Involved AND HYPNOTICS

Sample 2. Drugs Involved

Table B.2 continued

TRANQUILIZERS

(Table continued)

150
Table B.2 continued

PSYCHOSTIMULANTS

ANTIDEPRESSANTS

MARIJUANA & PSYCHEDELICS

Sample 2. Drugs Involved and ETHANOL

Table B.2 continued

Sample 2. Drugs Involved MISCELLANEOUS DRUGS

(Table continued)

151
Table B.2 continued

Sample 2. Drugs Involved MISCELLANEOUS DRUGS

Table B.3a. Psychoactive Drugs Found et the Scene of Death

(Listed in Part II, UCI Reporting Form)

a "UnIdentified drugs" are those in Sample 1 with some coding

error that prevented identificetion. NO such errors occurred in

Sample 2.

152
Table B.3b. Psychoactive Drugs Found at the Scene of Death

(Listed in Part II, UCI Reporting Form)

Sample 1: Summary of Drug Type by City

Table B.3c. Psychoactive Drugs Found at the Scene of Death

(Listed in Part II, UCI Reporting Form)

Sample 2: Summary of Drug Type by City

153
Table B.3d. Psychoactive Drugs Found at the Scene of Death

(Listed in Part II, UCI Reporting Form)

Sample 2: Listings of Specific Drugs by City CHICAGE

CLEVELAND

DALLAS

154
Table B.3d continued

LOS ANGELES

Drugs Found at the Scene MIAMI

155
Table B.3d continued

NEW YORK

Drugs Found at the Scene PHILADELPHIA

156
Table B.3d continued

Drugs Found at the Scene

SAN FRANCISCO

WASHINGTON, D.C.

157
Table B.4. Drugs Assayed by Toxicological Laboratories

(Listed in Pert III, UCI Reporting Form)

Sample 2: Summary of Drug Type by City

a

 In the data, quinine almost always occurred with heroin; it is therefore treated here not as a

miscellaneous drug. as would be expected from its classification in the LEA code. but es an indicator of

heroin.

b

 Including negative, trace, qualitative, and quantitative findings. For detailed analysis of

assays, see Chapter 9.

Table B.4 continued

NARCOTICSSample 2. Drugs Assayed QUININE

a

 Including negative, trace, qualitative, and quantitative findings. For further detail, see

Chapter 9.

b

 Quinine is here treated as an indicator of heroin. (Table continued)

158
Sample 2. Drugs Assayed

Table 8.4 continued

ANALGESICS

Sample 2. Drugs Assayed

Table B.4 continued

BARBITURATES

a

 Including negative, trace, qualitetive, and quantitative findings. For further detail, see

Chapter 9.

(Table continued)

159
Table B.4 continued

SEDATIVES

Sample 2. Drugs Assayed AND HYPNOTICS

a

 Including negative, trace, qualitative, and quantitative findings. For further detail, see

Chapter 9.

Sample 2. Drugs Assayed

Table B.4 continued

TRANQUILIZERS

a Including negative, trace, qualitative, and quantitative findings. For further detail, see

Chapter 9.

(Table continued)

160
Table B.4 continued

Sample 2. Drugs Asseysd PSYCHOSTIMULANTS; ANTIDEPRESSANTS; MARIJUANA AND PSYCHEDELICS; ETHANOL

a

 Including negative, trace, qualitative, and quantitative findings. For further detail, see

Chapter 9.

Sample 2. Drugs Assayed

Table B.4 continued

MISCELLANEOUS

(Table continued)

161

315-509 0 - 80 - 12
Table B.4 continued

Sample 2. Drugs Assayed MISCELLANEOUS continued

a

 Including negative, trace. qualitative, and quantitative findings. For further detail, see

Chapter 9.

Table B.5a Drugs Given in Treatment or Taken Prior to Death

(Listed in Part V, UCI Reporting Form)

Sample 1 and 2 Compared: Summary by Drug Type

162
Table B.5b

Other Drugs Given in Treatment or Taken

Within Two Weeks of Death, by Drug Type

(Listed in Part V, UCI Reporting Form)

Sample 1

2

2

barbiturate sedative 6 PSYCHOSTIMULANTS

pentobarbital 3

barbiturate "Reds" 3

cocaine

amphetamine 3

Carbrital 1 diet pill, unspecified 1

Total 69 Total 5

15

15

13

8

7

BARBITURATES

phenobarbital

Tuinal

Nembutal

Seconal

secobarbital

Trilafon

TRANQUILIZERS

Valium

Librium

Compazine

Thorazine

Triavil

meprobamate

Sinequan

phenothiazine

Stelazine

tranquilizer, unspecified

Mellaril

Miltown

Navane

Quide

Tranxene

2

49

12

9

6

5

4

4

1

1

1

1

1

1

Total 101

ANALGESICS

Darvon

Darvon Compound-65

Talwin

Tylenol

aspirin

salicylate

Anacin

acetaminophen

Darvocet-N

Darvon-N

Empirin Compound

Excedrin

Ponstel

propoxyphene

14

6

6

5

5

4

1

1

1

1

1

1

1

1

Total 47

12

7

6

3

3

2

1

Total 101

Number Drug Name Number

of Listings of Listings

SEDATIVES

67 Placidyl 9

NARCOTICS

methadone

Narcan

Demerol

Percodan

heroin

morphine

Dilaudid

Nalline

Drug Name

Dalmane 8

Doriden 5

Quaalude 4

chloral hydrate 3

methaqualone 3

sleeping pill, unspecified 2

flurazepan 1

paraldehyde 1

Sleep-Eze 1

Total 37

3

163
Sample 1. Other Drugs Given or Taken Table B.5b continued

Drug Name Number

ANTIDEPRESSANTS of Listings

Elavil 12

Drug Name

MISCELLANEOUS

(continued)

Number

of Listings

Tofranil 4

amitriptyline 1

Aventyl HCl 1

imipramine 1

Norpramin 1

Ritalin 1

Vivactil 1

Total 22

MARIJUANA AND PSYCHEDELICS

marijuana 1

Total 1

ETHANOL

alcohol 7

Total 7

MISCELLANEOUS

Dilantin

Isuprel

sodium bicarbonate

Epinephrine

Decadron

adrenaline

penicillin G

atropine sulfate

Aramine injection

18

12

12

10

9

8

7

6

5

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

1

Empirin Comp. with Codeine 4

Keflin 4

Lasix 4

Mysoline 4

calcium gluconate 3

Mannitol 3

Tetracycline 3

antacids unspecified 2

antibiotics, unspecified 2

Colace 2

Dextran 2

"drug unknown" 2

Heparin Sodium 2

Insulin 2

Keflex 2

Maalox 2

Steroid 2

Tedral 2

Xylocaine 2

Aldomet 1

Amesec 1

Amphojel 1

Antabuse 1

APC with codeine 1

Apresoline

Bancaps-C

Bentyl

Bonine

Cogentin

Colbenemid

Contac

Cytomel

dexamethasone

digitalis

Diupres

Dristan

Edecrin

Esidrex

Feosol

Hycodan

Ipecac

Ismelin

Kantrex

Lanoxin

Levo Phed

nitroglycerin

Norlestrin

Ornade

Pentothal

Phenergan

Prednisone

Pyribenzamine

Pyridium

Robaxin

Solu-Medrol

streptomycin

sugar

Sumycin

Tuss-Ornade

vitamin, unspecified

water, steriie 1

Total 178

UNIDENTIFIED DRUGSa

Total 52

TOTAL LISTINGS 620

a

 Unidentified drugs are those in

Sample 1 with some coding error

that prevented identification.

164
Table B.5c. Medications Used in Treatment for Fatal Dose

(Listed in Part V, Questions 8-11, UCI Reporting Form)

Sample 2: Summary of Drug Type by City

Table B.5c. Medications Used in Treatment for Fatal Dose

(Listed in Part V, Questions 8-11, UCI Reporting Form)

Sample 2: Listings of Specific Drugs by City

165
Table B.5c continued

Medications Used In Treatment

166
Table B.5d. Drugs and Medications Recently Used

(Listed In Parr V, Questions 12-16. UCI Reporting Form)

Sample 2: Summary of Drug Type by City

Table B.5d. Drugs and Medication Recently Used

(Listed in Part V, Questions 12-16, UCI Reporting Form)

Drugs and medications taken within two weeks of death for medical or

nonmedical purposes, excluding drugs involved in the death (1. 19)

and drugs used in treatment prior to death (V, 8-11).

(Table continued)

167
Table B.5d continued

Other Drugs Recently Used

168
Other Drugs Recently Used Table B.5d continued

169
Table B.6a. Sample 2: History of Drug Use

(Listed in Part VI, Questions 18 and 19, UCI Reporting Form)

Summary of Drug Type by City

170
Table B.6b. Sample 2. History of Drug Addiction, Dependence,

or Chronic Use (Part VI, Question 19, UCI Reporting Form)

Listing of Specific Drugs by City

171
Drug History

Table B.6b continued

NEW YORK

PHILADELPHIA

SAN FRANCISCO

WASHINGTON, D.C.

172
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1 FINDINGS OF DRUG ABUSE RESEARCH. An annotated bibliography of

NIMH- and NIDA-supported extramural grant research, 1964-74.

Volume 1, 384 pp., Volume 2, 377 pp.

Vol.1: GPO out of stock

Vo1.2: GPO Stock #017-024-0466-9 $5.05

NTIS PB #272 867/AS $22

NTIS PB #272 868/AS $20

173
2 OPERATIONAL DEFINITIONS IN SOCIO-BEHAVIORAL DRUG USE RESEARCH 1975.

Jack Elinson, Ph.D., and David Nurco, Ph.D., editors. Task Force

articles proposing consensual definitions of concepts and terms used

in psychosocial research to achieve operational comparability. 167 pp.

GPO out of stock NTIS PB #246 338/AS $11

3 AMINERGIC HYPOTHESES OF BEHAVIOR: REALITY OR CLICHE? Bruce J.

Bernard, Ph.D., editor. Articles examining the relation of the brain

monoamines to a range of animal and human behaviors.

GPO Stock #017-024-00486-3 $2.25 NTIS PB #246 687/AS $11

4 NARCOTIC ANTAGONISTS: THE SEARCH FOR LONG-ACTING PREPARATIONS.

Robert Willette, Ph.D., editor. Articles reporting current alternative

inserted sustained-release or long-acting drug devices.

GPO Stock #017-024-00488-0 $1.10 NTIS PB #247 096/AS $6

5 YOUNG MEN AND DRUGS: A NATIONWIDE SURVEY. John A. O'Donnell,

Ph.D., et al. Report of a national survey of drug use by men 20-30

years old in 1974-5. 144 pp.

GPO stock #017-024-00511-8 2.25 $ NTIS PB #247 446/AS $11

6 EFFECTS OF LABELING THE "DRUG ABUSER": AN INQUIRY. JAY R.

Williams, Ph.D. Analysis and review of the literature examining

effects of drug use apprehension or arrest on the adolescent. 39 pp.

GPO Stock #017-024-00512-6 $1.05 NTIS PB #249 092/AS $6

7 CANNABINOID ASSAYS IN HUMANS. Robert Willette, Ph.D., editor.

Articles describing current developments in methods for measuring

cannabinoid levels in the human body by immunoassay, liquid and

dual column chromatography and mass spectroscopy techniques. 120 pp.

GPO Stock #017-024-00510-0 $1.95 NTIS PB #251 905/AS $10

8 Rx:3x/WEEK LAAM - ALTERNATIVE TO METHADONE. Jack Blaine, M.D.,

and Pierre Renault, M.D., editors. Comprehensive summary of

development of LAAM (Levo-alpha-acetyl methadol), a new drug for

treatment of narcotic addiction. 127 pp.

Not available from GPO NTIS PB #253 763/AS $10

9 NARCOTIC ANTAGONISTS: NALTREXONE. Demetrios Julius, M.D., and

Pierre Renault, M.D., editors. Progress report of development,

preclinica1 and clinical studies of naltrexone, a new drug for

treatment of narcotic addiction. 182 pp.

GPO Stock #017-024-00521-5 $2.55 NTIS PB #255 833/AS $12

10 EPIDEMIOLOGY OF DRUG ABUSE: CURRENT ISSUES. Louise G. Richards,

Ph.D., and Louise B. Blevens, editors. Conference Proceedings. Examination of methodological problems in surveys and data collection. 259 pp.

GPO Stock #017-024-00571-1 $2.60 NTIS PB #266 691/AS $13

11 DRUGS AND DRIVING. Robert Willette, Ph.D., editor. State-of-theart review of current research on the effects of different drugs on

performance impairment, particularly on driving. 137 pp.

GPO Stock #017-024-00576-2 $1.70 NTIS PB #269 602/AS $11

174
12 PSYCHODYNAMICS OF DRUG DEPENDENCE. Jack D. Blaine, M.D., and

Demetrios A. Julius, M.D., editors. A pioneering collection of papers

to discover the part played by individual psychodynamics in drug dependence. 187 pp.

GPO Stock #017-024-00642-4 $2.75 NTIS PB #276 084/AS $12

13 COCAINE: 1977. Robert C. Petersen, Ph.D., and Richard C.

Stillman, M.D., editors. A series of reports developing a picture

of the extent and limits of current knowledge of the drug, its use

and misuse. 223 pp.

GPO Stock #017-024-00592-4 $3 NTIS PB #269 175/AS $13

14 MARIHUANA RESEARCH FINDINGS: 1976. Robert C. Petersen, Ph.D.,

editor. Technical papers on epidemiology, chemistry and metabolism,

toxicological and pharmacologica1 effects, learned and unlearned behavior, genetic and immune system effects, and therapeutic aspects

of marihuana use. 251 pp.

GPO Stock #017-024-00622-0 $3 NTIS PB #271 279/AS $15

15 REVIEW OF INHALANTS: EUPHORIA TO DYSFUNCTION. Charles Wm.

Sharp, Ph.D., and Mary Lee Brehm, Ph.D., editors. A broad review of

inhalant abuse, including sociocultural, behavioral, clinical, pharmacological, and toxicological aspects. Extensive bibliography. 347 pp.

GPO Stock #017-024-00650-5 $4.25 NTIS PB #275 798/AS $19

16 THE EPIDEMIOLOGY OF HEROIN AND OTHER NARCOTICS. Joan Dunne Rittenhouse, Ph.D., editor. Task Force report on measurement of heroinnarcotic use, gaps in knowledge and how to address them, improved research technologies, and research implications. 249 pp.

GPO Stock #017-024-00690-4 $3.50 NTIS PB #276 357/AS $14

17 RESEARCH ON SMOKING BEHAVIOR. Murray E. Jarvik, M.D., Ph.D.,

et al., editors. State-of-the-art of research on smoking behavior,

including epidemiology, etiotogy, socioeconomic and physical consequences of use, and approaches to behavioral change. From a NIDAsupported UCLA conference. 383 pp.

GPO Stock #017-024-00694-7 $4.50 NTIS PB $276 353/AS $20

18 BEHAVIORAL TOLERANCE: RESEARCH AND TREATMENT IMPLICATIONS.

Norman A. Krasnegor, Ph.D., editor. Conference papers discuss

theoretical and empirical studies of nonpharmacologic factors in

development of tolerance to a variety of drugs in animal and human

subjects. 151 pp.

GPO Stock #017-024-00699-8 $2.75 NTIS PB #276 337/AS $11

19 THE INTERNATIONAL CHALLENGE OF DRUG ABUSE. Robert C. Petersen,

Ph.D., editor. A monograph based on papers presented at the world

Psychiatric Association 1977 meeting in Honolulu.

emerging patterns of drug use,

Emphasis is on

international aspects of research,

and therapeutic issues of particular interest worldwide. 349 pp.

GPO Stock #017-024-00822-2 $4.50 NTIS PB #293 807/AS $19

175
20 SELF-ADMINISTRATION OF ABUSED SUBSTANCES: METHODS FOR STUDY.

Norman A. Krasnegor, Ph.D., editor. Papers from a technical review,

on methods used to study self-administration of various abused substances (drugs, ethanol, food, and tobacco). 246 pp.

Not available from GPO NTIS PB #288 471/AS $15

21 PHENCYCLIDINE (PCP) ABUSE: AN APPRAISAL. Robert C. Petersen,

Ph.D., and Richard C. Stillman, M.D., editors. Monograph derived from

a technical review to assess state-of-knowledge about phencyclidine

and its abuse, and to present areas for additional research. 313 pp.

GPO Stock #017-024-00785-4 $4.25 NTIS PB #288 472/AS $17

22 QUASAR: QUANTITATIVE STRUCTURE ACTIVITY RELATIONSHIPS OF ANALGESICS, NARCOTIC ANTAGONISTS, AND HALLUCINOGENS. Gene Barnett, Ph.D.,

Milan Trsic, Ph.D., and Robert E. Willette, Ph.D., editors. Reports

from an interdisciplinary conference on quantitative structure activity relationships of drugs of abuse. Papers also present techniques

for studying molecular nature of drug-receptor interactions. 487 pp.

GPO Stock #017-024-00786-2 $5.25 NTIS PB #292 265/AS $24

23 CIGARETTE SMOKING AS A DEPENDENCE PROCESS. Norman A. Krasnegor,

Ph.D., editor. Reviews the biological, behavioral,, and psychosocial

factors involved in the onset, maintenance, and cessation of tobacco/

nicotine use, and presents an agenda for further research. 194 pp.

GPO Stock #017-024-00895-8 $4.50 NTIS PB #297 721/AS $13

282 pp.

NTIS PB #80-118755 $12

24 SYNTHETIC ESTIMATES FOR SMALL AREAS: WORKSHOP PAPERS AND DISCUSSION. Joseph Steinberg, editor. Papers from a workshop cosponsored

by NIDA and the National Center for Health Statistics on a class of

statistical approaches that yield needed estimates of data for States

and local areas.

GPO Stock #017-024-00911-3 $5 NTIS PB #299 009/AS $16

25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman A.

Krasnegor, Ph.D., editor. Technical review papers which present commonalities in the behavioral analysis and treatment of substance abuse

(drugs, tobacco, ethanol, food). Agenda for further research. 256 pp.

GPO Stock #017-024-00939-3 $4.50 NTIS PB #80-112428 $15

26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor, Ph.D.,

editor. A summary of current biological, behavioral, and psychosocial research on cigarette smoking behavior. From Part II of the 1979

Report of the Surgeon General on Smoking and Health. 192 pp.

GPO Stock #017-024-00947-4 $4.25

27 PROBLEMS OF DRUG DEPENDENCE, 1979: PROCEEDINGS OF THE 41ST ANNUAL SCIENTIFIC MEETING, COMMITTEE ON PROBLEMS OF DRUG DEPENDENCE, INC.

Louis S. Harris, Ph.D., editor. A comprehensive assemblage of reports of ongoing research on all aspects of drug abuse and drug dependence, including studies of new compounds. Indexed. 483 pp.

In Press

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U.S. GOVERNMENT PRINTING OFFICE : 1980 O - 315-509