How do we and how should we define and count poisoning deaths in the United

States?

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Lois A. Fingerhut, MASpecial Assistant for Injury Epidemiology,

OAERobert N. Anderson, PhD

Chief, Mortality Statistics Branch, DVS

Objectives

• To consider revising the existing matrix definition of poisoning to include relevant codes from the F10-F19 series of the Mental and Behavioral Disorders chapter of the ICD

• To better understand what is gained from analyzing multiple cause of death data for poisoning

How are poisoning deaths currently defined?

1. By the List of 113 Causes (used to rank leading causes of death in the US): the underlying cause ICD-10 codes for Unintentional poisoning are X40-X49

2. By the External Cause of Injury Mortality Matrix as the underlying cause for poisoning regardless of intent [Recommended by NCHS and Injury ICE]

Poisoning is defined in the Matrix by ICD-10 codes by intent

ICD also codes broad substance groupsDrug Alcohol Gases

/vapors

Other solid/

liquids

Unintentional X40-X44 X45 X47 X46,X48-X49

Suicide X60-X64 X65 X67 X66,X68-X69

Homicide X85 X88 X86-X87,X89-X90

Undetermined Y10-Y14 Y15 Y17 Y16,Y18-Y19

Legal int. Y35.2

Terrorism *U01.7 *U01.6

Poisoning deaths- 2002

Drug Alcohol Other solid/liq

Gases

/vapors

Percent 89% 2% 1% 8%

Unintentional 66% 16,394 355 161 640

Suicide 21% 3,884 26 157 1,419

Homicide 43 na 5 15

Undetermined 13% 3,197 25 43 71

Legal int. na na na 0

Terrorism na na 0 0

Based on the matrix definition, poisoning was,

in 2002,…

• 3rd leading cause of injury death overall;

• distant 2nd for unintentional injury;

• 3rd for suicide

• leading cause for intent undetermined.

Should codes be added to the definition of poisoning?

• Being considered are underlying ICD-10 codes F10-F19 for Mental and Behavioral disorders (MBD) due to pyschoactive substance use

• The precise wording on the death certificate can determine whether a drug or alcohol related death is assigned an underlying cause of poisoning or a F10-F19 code.

F10-F19: If so, which codes should be

added?

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

psycho. substances

4th digit of these codes: .0 Acute intoxication .1 Harmful use .2 Dependence syndrome .3-.4 Withdrawal states .5 Psychotic disorder .6 Amnesic syndrome .7 Residual/late onset

psychotic disorder .8 Other MBD .9 Unspecified MBD

3 digit ICD-10 codes

For each 3 digit code:.0-.1 and .3-.9= Nondependent abuse .2=Dependent abuse

F10-F19 Deaths: 2002

Acute Harmful Dependence WithdrawalIntoxication use Syndrome state Other Unspecified

.0 .1 .2 .3-.4 .5-.8 .9

Alcohol F10 6,842 617 1,741 3,679 212 195 398

Drugs: 2,137 15 1,399 390 14 8 311

Opioids F11 281 148 75 2 56

Cannabinoids F12 2 1 1

Sedatives/hypnotics F13 3 1 2

Cocaine F14 437 11 266 50 1 6 103

Other stimulants F15 52 4 28 5 1 14

Hallucinogen F16 5 4 1

Volatile solvents F18 5 4 1

Multiple drug/other F19 1,352 948 258 9 1 136

[MBD due to tobacco use (F17) is not included as a drug. F17 was the underlying cause of 549 deaths in 2002.]

Alcohol and drug-related deaths from MBD 1999-2002

Slow but steady increases in alcohol-related (except intoxication) deaths as well as nondependent drug abuse deaths

100

1,000

10,000

1999 2000 2001 2002

Nu

mb

er o

f d

eath

s

Alcohol dependence F10.2

Alcohol, nondependence, F10 (.1,.3-.9)

Alcohol intoxication, F10.0

Drug, nondependence F11-F16, F18-F19 (.0-.1, .3-.9)

Drug dependence, F11-F16, F18-F19 (.2)

Multiple cause codes identify the specific drug or substance

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

• Too often they are neglected in analyses.

“T” codes

• T36-T50: Poisoning by drugs, medicaments and biological substances

• T51-T65: Toxic effects of substances chiefly nonmedicinal as to source

• Using these nature of injury poisoning codes, 29,974 deaths had at least one mention of a poison or toxic substance, and there were a total of 49,946 mentions of substances.

• For all underlying-external cause poisoning deaths, an average of 1.9 total substances were listed per death

Leading substances in multiple cause data by underlying cause of death : 2002

-

1,000

2,000

3,000

4,000

5,000

6,000

Death

s

All other underlying causes (including F10)

Drug Dependence

Drug - NonDependence

Other ext. injury deaths

External Poisoning- Matrix definition

Drugs and toxic effect substances mentioned in multiple cause data

Underlying causes of death

WHO’s Mortality Reference Group (MRG)

• The MRG makes decisions regarding the application and interpretation of ICD to mortality and makes recommendations on proposed ICD updates to the Update Reference Committee (URC).

• The URC recommends changes to the ICD-10 to the Heads of WHO Collaborating Centers for the Family of International Classifications each year.

• If the death certificate has language that includes words that would have resulted in an underlying cause code of F10-F19 with a 4th digit of ‘0’, the new rule will result in coding to an underlying external poisoning code for alcohol.

• The largest impact in the US will be more deaths coded to X45 [Accidental poisoning by and exposure to alcohol] because nearly all of the F10-F19 codes with a 4th digit of ‘0’ are for alcohol (F10.0)

The MRG has recommended: Deaths due to Acute Intoxication

Regarding all F10-F19:

• If the underlying cause would have resulted in any code F10-F19 and the certificate also included information ascribed to an external cause poisoning code, the new rule will result in underlying cause codes going to the external causes.

• These changes will increase the number of poisoning deaths by an indeterminate amount.

• These changes will be implemented in 2006.

Recommendation

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

3 leading causes of injury death: 2002

0 10,000 20,000 30,000 40,000 50,000

MVT

Firearm

Poisoning

Deaths

Matrix definition

Drug- nondependence*

Alcohol intoxication*

Alcohol- other F10's

Alcohol Dependence (.2)

Drug Dependence

Will poisoning soon become the 2nd leading cause of injury death??

Conclusion

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

National Academy of Science May 2004

U.S. Institute of Medicine has recommended that:

WHO should review and reform the ICD codes for poisoning [This is being done]

NCHS should review the methodology of its existing surveys to maximize the value….for poison prevention and control. [Review of mortality definition is underway]

From: Forging a Poison Prevention and Control System (2004)

LFingerhut@cdc.gov

RNAnderson@cdc.gov