Toxicologic findings in suicide: a 10-year retrospective review of Kentucky medical examiner cases

Toxicological Findings of Self-Poisoning Suicidal Deaths: A Systematic Review by Countries

The use of illicit and non-illicit substances is widespread in suicides. The toxicological data may help in understanding the mechanism of death. This systematic review aimed to analyze autopsies related to suicides by consuming poison, focusing on the correlation between substance use and the country of origin to create an alarm bell to indicate that suicide maybe attempted and prevent it. The systematic review was conducted according to the PRISMA guidelines, with the primary objective of identifying autopsies conducted in cases of suicide by consuming poison in specific geographic areas. Significant differences in substances were observed between low-income and Western countries that confirm previous literature data. In rural areas and Asian countries, most suicides by consuming poison involve the use of pesticides, such as organophosphates and carbamates. In Western countries, illicit drugs and medically prescribed drugs are the leading cause of suicide by self-poisoning. Future research should shed light on the correlation between social, medical, and demographic characteristics and the autopsy findings in suicides by self-poisoning to highlight the risk factors and implement tailored prevention programs worldwide. Performing a complete autopsy on a suspected suicide by self-poisoning could be essential in supporting worldwide public health measures and policy makers. Therefore, complete autopsies in such cases must be vigorously promoted.

Alcohol Consumption and 15 Causes of Fatal Injuries: A Systematic Review and Meta-Analysis

INTRODUCTION

The proportion of fatal nontraffic injuries that involve high levels of alcohol use or alcohol intoxication was assessed by cause of injury to generate alcohol-attributable fractions. Updated alcohol-attributable fractions can contribute to improved estimates of the public health impact of excessive alcohol use.

METHODS

Peer-reviewed and gray literature for 1995-2019 on 15 causes of fatal nontraffic injuries in the U.S., Canada, or Mexico were systematically reviewed, and state data systems were queried for available estimates of fatalities with recorded blood alcohol concentration levels and proportions of decedents with blood alcohol concentrations ≥0.10 g/dL by cause of injury. For each injury cause, alcohol-attributable fractions across studies were synthesized by meta-analysis of single proportions using generalized linear mixed models.

RESULTS

In total, 60 published studies and 40 additional population-level data points from 6 state data systems were included. The meta-analyzed alcohol-attributable fractions by cause of injury are as follows: air-space transport (0.03), aspiration (0.24), child maltreatment (0.09), drowning (0.31), fall injuries (0.37), fire injuries (0.34), firearm injuries (0.24), homicide (0.29), hypothermia (0.29), motor vehicle nontraffic crashes (0.42), occupational and machine injuries (0.08), other road vehicle crashes (railroad trespasser injuries) (0.63), poisoning (not alcohol) (0.20), suicide (0.21), and water transport (0.27), yielding an overall median alcohol-attributable fraction of 0.27.

DISCUSSION

Excessive alcohol use is associated with substantial proportions of violent and nonviolent injury deaths. These findings can improve the data used for estimating alcohol-attributable injury deaths and inform the planning and implementation of evidence-based strategies (e.g., increasing alcohol taxes, regulating alcohol outlet density) to prevent them.

Concentrations of Antidepressants, Antipsychotics, and Benzodiazepines in Hair Samples from Postmortem Cases

Certain postmortem case constellations require intensive investigation of the pattern of drug use over a long period before death. Hair analysis of illicit drugs has been investigated intensively over past decades, but there is a lack of comprehensive data on hair concentrations for antidepressants, antipsychotics, and benzodiazepines. This study aimed to obtain data for these substances. A LC-MS/MS method was developed and validated for detection of 52 antidepressants, antipsychotics, benzodiazepines, and metabolites in hair. Hair samples from 442 postmortem cases at the Institute of Legal Medicine of the Charité-University Medicine Berlin were analyzed. Postmortem hair concentrations of 49 analytes were obtained in 420 of the cases. Hair sample segmentation was possible in 258 cases, and the segments were compared to see if the concentrations decreased or increased. Descriptive statistical data are presented for the segmented and non-segmented cases combined (n = 420) and only the segmented cases (n = 258). An overview of published data for the target substances in hair is given. Metabolite/parent drug ratios were investigated for 10 metabolite/parent drug pairs. Cases were identified that had positive findings in hair, blood, urine, and organ tissue. The comprehensive data on postmortem hair concentrations for antidepressants, antipsychotics, and benzodiazepines may help other investigators in their casework. Postmortem hair analysis results provide valuable information on the drug intake history before death. Pattern changes can indicate if drug intake stopped or increased before death. Results should be interpreted carefully and preferably include segmental analysis and metabolite/parent drug ratios to exclude possible contamination.

Male depressive traits in relation to violent suicides or suicide attempts: A systematic review

BACKGROUND

Male sex is a consistently reported risk factor for violent suicide. It has been suggested that this association may be driven by so-called male depression - as operationalized by the Gotland Male Depression Scale (GMDS). The aim of this systematic review was to investigate if males dying by or attempting suicide with violent methods, display symptoms compatible with male depression.

METHODS

This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A systematic search of PubMed, Embase and PsycINFO was performed using search terms covering: male sex, violent suicide/suicide attempt, and symptoms of male depression from the GMDS. Subsequently, a qualitative synthesis of studies meeting predefined inclusion criteria was carried out.

RESULTS

A total of 28 studies reporting on 91,933 violent suicides and 113 violent suicide attempts were included in the qualitative synthesis. The suicide/suicide attempt methods reported in these studies were predominantly shooting, hanging or drowning. The only two symptoms from the GMDS that was reported in relation to violent suicides/suicide attempts was overconsumption of alcohol or drugs and suicide attempts in the biological family. No studies had systematically assessed suicide victims or attempters for symptoms of male depression.

LIMITATIONS

Publication-, selection-, and information biases may have affected this review.

CONCLUSIONS

Symptoms of male depression are rarely reported in relation to violent suicides/suicide attempts. The most likely explanation for this finding is that there has been little focus on this potential association. Future studies should address this void.

Association between suicide death and concordance with benzodiazepine treatment guidelines for anxiety and sleep disorders

OBJECTIVE

Guidelines for management of anxiety and sleep disorders emphasize antidepressant medications and/or psychotherapy as first/second-line and benzodiazepines as third-line treatments. We evaluated the association between suicide death and concordance with benzodiazepine guidelines.

METHODS

Retrospective case-control study of patients with anxiety and/or sleep disorders from health systems across 8 U.S. states within the Mental Health Research Network. Suicide death cases were matched to controls on year and health system. Appropriate benzodiazepine prescribing defined as: no monotherapy, no long duration, and/or age < 65 years. The association between guideline concordance and suicide death was evaluated, adjusting for diagnostic and treatment covariates.

RESULTS

Sample included 6960 patients with anxiety disorders (2363 filled benzodiazepine) and 6215 with sleep disorders (1237 filled benzodiazepine). Benzodiazepine guideline concordance was associated with reduced odds for suicide in patients with anxiety disorders (OR = 0.611, 95% CI = 0.392-0.953, p = 0.03) and was driven by shorter duration of benzodiazepine use with concomitant psychotherapy or antidepressant medication. The association of benzodiazepine guideline concordance with suicide death did not meet statistical significance in the sleep disorder group (OR = 0.413, 95% CI = 0.154-1.11, p = 0.08).

CONCLUSIONS

We found reduced odds for suicide in those with anxiety disorders who filled benzodiazepines in short-moderate duration with concomitant psychotherapy or antidepressant treatment.

Method overtness, forensic autopsy, and the evidentiary suicide note: A multilevel National Violent Death Reporting System analysis

OBJECTIVE

Higher prevalence of suicide notes could signify more conservatism in accounting and greater proneness to undercounting of suicide by method. We tested two hypotheses: (1) an evidentiary suicide note is more likely to accompany suicides by drug-intoxication and by other poisoning, as less violent and less forensically overt methods, than suicides by firearm and hanging/suffocation; and (2) performance of a forensic autopsy attenuates any observed association between overtness of method and the reported presence of a note.

METHODS

This multilevel (individual/county), multivariable analysis employed a generalized linear mixed model (GLMM). Representing the 17 states participating in the United States National Violent Death Reporting System throughout 2011-2013, the study population comprised registered suicides, aged 15 years and older. Decedents totaled 32,151. The outcome measure was relative odds of an authenticated suicide note.

RESULTS

An authenticated suicide note was documented in 31% of the suicide cases. Inspection of the full multivariable model showed a suicide note was more likely to manifest among drug intoxication (adjusted odds ratio [OR], 1.70; 95% CI, 1.56, 1.85) and other poisoning suicides (OR, 2.12; 1.85, 2.42) than firearm suicides, the referent. Respective excesses were larger when there was no autopsy or autopsy status was unknown (OR, 1.86; 95% CI, 1.61, 2.14) and (OR, 2.25; 95% CI, 1.86, 2.72) relative to the comparisons with a forensic autopsy (OR, 1.62, 95% CI, 1.45, 1.82 and OR, 2.01; 95% CI, 1.66, 2.43). Hanging/suffocation suicides did not differ from the firearm referent given an autopsy.

CONCLUSIONS

Suicide requires substantial affirmative evidence to establish manner of death, and affirmation of drug intoxication suicides appears to demand an especially high burden of proof. Findings and their implications argue for more stringent investigative standards, better training, and more resources to support comprehensive and accurate case ascertainment, as the foundation for developing evidence-based suicide prevention initiatives.

Characteristics of self-inflicted drug overdose deaths in North Carolina

BACKGROUND

Drug overdose mortality is a major public health concern in the United States, with prescription opioids contributing substantially to recent increases in drug overdose deaths. Compared to unintentional drug overdose deaths, relatively little data describes intentional self-inflicted drug overdose deaths (i.e., suicide by drug overdose). The aim of this study was to examine the characteristics of self-inflicted drug overdose deaths, overall and in comparison to unintentional drug overdose deaths.

METHODS

We linked vital statistics, prescription drug monitoring program, and toxicology data for self-inflicted and unintentional drug overdose deaths among North Carolina residents in 2012.

RESULTS

Most self-inflicted (79.2%) and unintentional (75.6%) drug overdose decedents had a prescription for a controlled substance within one year of death. Toxicology results revealed that antidepressants contributed to a significantly higher percent of self-inflicted compared to unintentional drug overdose deaths (45.0% vs. 8.1%). Among deaths in which commonly prescribed opioids (oxycodone, hydrocodone) or benzodiazepines (alprazolam, clonazepam) contributed to death, a significantly higher percent of self-inflicted drug overdose decedents had a prescription for the substance within 30days of death compared to unintentional drug overdose decedents.

CONCLUSIONS

The results highlight the use of prescription opioids, benzodiazepines, and antidepressants among self-inflicted drug overdose decedents. Importantly, the results indicate that self-inflicted drug overdose decedents were more likely than unintentional drug overdose decedents to have potential contact with the health care system in the weeks preceding death, offering an opportunity for professionals to identify and intervene on risk factors or signs of distress and potential for self-harm.

A literature review and meta-analyses of cannabis use and suicidality

BACKGROUND

We lack a review of the epidemiological literature on cannabis use (acute use and chronic-usual quantity/frequency and heavy use) and suicidality (suicide death, suicide ideation, suicide attempt).

METHODS

The English language literature on Medline, PsychInfo, Google Scholar, and public-use databases was searched for original articles, critical review reports, and public use data on cannabis use and suicide for the period ranging from 1990-2015 (February). Odds ratios (OR) from random effects in meta-analyses for any cannabis use and heavy cannabis use were calculated.

RESULTS

The acute cannabis-suicidality literature mostly includes descriptive toxicology reports. In terms of death by suicide, the average positive cannabis rate was 9.50% for studies sampling from all suicides, with higher cannabis detection rates amongst suicide decedents by non-overdose methods. We found only 4 studies providing estimates for any chronic cannabis use and death by suicide (OR=2.56 (1.25-5.27)). After deleting duplicates we found 6 studies on any cannabis use and suicide ideation (OR=1.43 (1.13-1.83)), 5 studies on heavy cannabis use and suicide ideation (OR=2.53 (1.00-6.39)), 6 studies on any cannabis use and suicide attempt (OR=2.23 (1.24-4.00)) and 6 studies on heavy cannabis use and suicide attempt (OR=3.20 (1.72-5.94)).

CONCLUSIONS

We currently lack evidence that acute cannabis use increases imminent risk for suicidality. The evidence tends to support that chronic cannabis use can predict suicidality, but the lack of homogeneity in the measurement of cannabis exposure and, in some instances, the lack of systematic control for known risk factors tempered this finding.

Alcohol Use and Firearm Violence

Although the misuse of firearms is necessary to the occurrence of firearm violence, there are other contributing factors beyond simply firearms themselves that might also be modified to prevent firearm violence. Alcohol is one such key modifiable factor. To explore this, we undertook a 40-year (1975-2014) systematic literature review with meta-analysis. One large group of studies showed that over one third of firearm violence decedents had acutely consumed alcohol and over one fourth had heavily consumed alcohol prior to their deaths. Another large group of studies showed that alcohol was significantly associated with firearm use as a suicide means. Two controlled studies showed that gun injury after drinking, especially heavy drinking, was statistically significant among self-inflicted firearm injury victims. A small group of studies investigated the intersection of alcohol and firearms laws and alcohol outlets and firearm violence. One of these controlled studies found that off-premise outlets selling takeout alcohol were significantly associated with firearm assault. Additional controlled, population-level risk factor and intervention studies, including randomized trials of which only 1 was identified, are needed. Policies that rezone off-premise alcohol outlets, proscribe blood alcohol levels and enhance penalties for carrying or using firearms while intoxicated, and consider prior drunk driving convictions as a more precise criterion for disqualifying persons from the purchase or possession of firearms deserve further study.

High Prevalence of Psychotropics Overdose among Suicide Attempters in Korea

Objective

The availability of suicide methods affects the risk of suicide attempts. This study examined the patterns of substances ingested by suicide attempters (SAs) and the characteristics of SAs using psychotropic overdoses.

Methods

Data for 384 of the 462 eligible SAs who used self-poisoning were analyzed. Demographic variables, clinical characteristics, and factors related to the suicide attempts were examined.

Results

There were 256 (66.7%) females and 128 (33.3%) males. Roughly half the SAs ingested psychotropics (n=179, 46.6%). Agricultural chemicals (n=84, 21.9%) were the second most frequently ingested substances, followed by analgesics (n=62, 16.1%), household products (n=27, 7.0%), and other prescribed medications (n=23, 6.0%). Among psychotropics, the most frequently overdosed drugs were sedative-hypnotics, including hypnotics (n=104) and benzodiazepines (n=78). SAs favored Z-drugs and alprazolam. When compared with SAs with non-psychotropic overdoses, significantly more SAs with psychotropic overdoses were female (76% vs. 58.5%, p<0.001) and had a psychiatric history (59.8% vs. 29.8%, p<0.001). They had significantly more previous suicide attempts (0.52±1.02 vs. 0.32±0.80, p<0.05) and lower risk (7.96±1.49 vs. 8.44±1.99, p<0.01) and medical severity (3.06±0.81 vs. 3.37±0.93, p<0.005) scores.

Conclusion

Psychotropic overdose, especially with sedative-hypnotics, was a major method in suicide attempts. It is important that psychiatric patients are carefully evaluated and monitored for suicidality when prescribing psychotropics.

Medications without a patient: potential lethal implications of pharmaceuticals left behind

BACKGROUND

Little has been published on the sources of medications used in suicide by self-poisoning.

AIMS

To examine data on self-poisoning occurring through the use of medications returned to the next of kin after the death of a family member or friend ("returned medication") and to examine public policies relevant to this issue.

METHOD

A review of charts at the Office of the Chief Coroner of Ontario for deaths by self-poisoning suicide in the City of Toronto occurring between 1998 and 2010 was conducted. Information regarding the source of medication used in self-poisoning was extracted. Federal, provincial, and local policies were also examined to determine whether there are guidelines governing returning medication to next of kin.

RESULTS

Of 567 suicide deaths by self-poisoning in Toronto over 13 years, there were eight cases in which returned medication was used in suicide by self-poisoning. No policies prohibiting this type of medication return were identified.

CONCLUSION

Suicide by self-poisoning using returned medications is an important consideration that may not yet be fully appreciated, and has relevance for suicide prevention policies.

Aluminum Phosphide Poisoning-Related Deaths in Tehran, Iran, 2006 to 2013

Metal phosphides such as aluminum phosphide are potent insecticides. This highly toxic substance is used for rice and other grains protection in Iran. Due to its high toxicity potential and easy availability, it is widely used as a suicide poison. This substance has no effective antidote and the incidence of deaths due to its poisoning is increasing day by day in Iran. The present study was conducted to show the increasing incidence of fatal aluminum phosphide poisoning and its toxicological and forensic aspects in an 8-year study, 2006 to 2013. Autopsy sheets were reviewed and cases with the history of aluminum phosphide poisoning were selected. Toxicological analysis results, demographic and necroscopic examination findings were studied. A total of 51.8% of studied cases were female. Most of the cases were between 10 and 40 years old. The manner of death was self-poisoning in 85% of cases. Morphine, ethanol, and amitriptyline were the most common additional drugs detected in toxicological analysis. The incidence of fatal aluminum phosphide poisoning cases referred for phosphine analysis was 5.22 and 37.02 per million of population of Tehran in 2006 and 2013, respectively. The results of this study showed that in spite of ban and restrictions, there was a dramatic increase in the incidence of fatal aluminum phosphide poisoning in Tehran from 2006 to 2013. Safety alert should be highlighted in training program for all population groups about the toxic effects of aluminum phosphide tablets.

Acute Alcohol Toxicity

Acute alcohol (ethanol) toxicity is a definition that encompasses both the metabolic toxicity of alcohol and the association of alcohol with traumatic deaths, suicide, and criminal activities. As with any postmortem measurement, there must be control of postmortem sampling, storage of specimens, and appropriate analysis to ensure that there is not artifactual alcohol production or incorrect measurement of other postmortem alcohols. It is almost unheard of for acute alcohol toxicity to cause death secondary to metabolic effects in a naïve individual, although there has been a recent trend in social media dares that have led to deaths due to isolated episodes of extreme alcohol consumption. However, in most cases, there will be evidence for chronic alcohol misuse at the postmortem examination.

Toxicology findings in suicides: concentrations of ethanol and other drugs in femoral blood in victims of hanging and poisoning in relation to age and gender of the deceased

Over-consumption of alcohol and/or abuse of other drugs are closely linked to attempted or completed suicides. In this retrospective 10-year study (2001-2010), we compared the toxicology findings in hanging suicides (n = 4551) with drug poisoning (intoxication) suicides (n = 2468). The mean age of hanging deaths was 49 ± 19 y (±SD) and 80% were male, compared with a mean age of 52 ± 17 y and 47% males for the intoxication deaths. Poly-drug use was more common in poisoning suicides with an average of 3.6 drugs/case compared with 1.8 drugs/case in hangings. Moreover, 31% of hangings were negative for alcohol and/or drugs. Alcohol was detected (>0.20 g/L) in femoral blood in 30% of hanging suicides (mean 1.39 g/L) and 36% of drug poisonings (mean 1.39 g/L). The median BACs did not depend on the person's age or gender (p > 0.05). Ethanol, paracetamol, citalopram, diazepam, propiomazine, alimemazine and zopiclone were amongst the top-ten drugs detected in both methods of suicide. With the exception of ethanol, the concentrations of drugs in blood were considerably higher in the poisoning deaths, as might be expected. Regardless of the method of suicide, antidepressants and/or antipsychotics were common findings, which could implicate mental health as a significant suicide risk factor.

Characteristics, circumstances and toxicology of sudden or unnatural deaths involving very high-range alcohol concentrations

AIMS

To characterize sudden or unnatural deaths with very high-range blood alcohol concentrations (BACs) presenting to the Department of Forensic Medicine (DOFM) in Sydney between 1 January 1997 and 31 December 2011.

DESIGN

Case series.

SETTING

Sydney, Australia.

CASES

A total of 263 cases of sudden or unnatural death with a BAC of ≥0.300 g/100 ml.

MEASUREMENTS

Case characteristics, circumstances of death, quantitative toxicology, major autopsy findings and serology.

FINDINGS

The mean age of decedents was 46.7 years and 74.5% were male. Pre-existing alcohol problems were noted in 78.7%. Deaths were due to alcohol toxicity/chronic alcoholism (35.0%), combined alcohol/other drug toxicity (14.8%), accidents (18.6%), natural disease (13.3%), suicide (11.0%), homicide (6.8%) and one case was undetermined. Alcohol was a direct, or contributory, cause of death in 84.4% of cases. The overwhelming majority (81.4%) occurred in a home environment, and deaths did not vary by day or month. The mean BAC was 0.371 g/100 ml (range 0.300-0.820 g/100 ml), being highest in alcohol toxicity/chronic alcoholism cases (0.410 g/100 ml). The most frequently detected substances, other than alcohol, were benzodiazepines (31.9%) and opioids (12.9%). Alcohol-related disease was diagnosed in 62.9% of cases. Alcohol-related pathology was prevalent across all categories of death: severe steatosis (35.3%), cirrhosis (22.5%), chronic pancreatitis (15.3%), cardiomyopathy (9.4%) and cerebellar atrophy (9.0%).

CONCLUSIONS

Unnatural deaths with very high-range alcohol concentrations extend well beyond direct toxicity, and alcohol is causal in most cases. Those at greatest risk are middle-aged males, with long histories of alcohol problems.

Acute use of alcohol and methods of suicide in a US national sample

OBJECTIVES

We explored age, gender, and racial/ethnic differences with alcohol use and firearms, hanging or asphyxiation, and poisoning methods of suicide.

METHODS

We analyzed data for 37,993 suicide decedents aged 18 years and older from the 2005-2010 National Violent Death Reporting System database. Multinomial logistic regressions examined associations of method with alcohol use defined by blood alcohol content. Two-way interactions tested the effects of age, gender, and race/ethnicity on the associations between alcohol use and method of suicide.

RESULTS

Alcohol was present among decedents who used the 3 leading methods of suicide: firearm (35.0%), hanging (36.8%), and poisoning (32.7%). Two-way interaction tests suggested that in young and middle adulthood, individuals were more likely to drink alcohol when they used a firearm or hanging (compared with poisoning), but in older adulthood, the reverse was true, with alcohol use more likely with poisoning. Interaction tests also suggested that Asians and Pacific Islanders were most likely to use alcohol in poisonings and that Blacks were least likely to use alcohol in hangings.

CONCLUSIONS

The results suggested that alcohol use before suicide was influenced by several factors, including age, race/ethnicity, and suicide method.

Substances used in completed suicide by overdose in Toronto: an observational study of coroner's data

OBJECTIVE

To identify the substances used by people who die from suicide by overdose in Toronto and to determine the correlates of specific categories of substances used.

METHOD

Coroner's records for all cases of suicide by overdose in Toronto, Ontario, during a 10-year period (1998 to 2007) were examined. Data collected included demographic data, all substances detected, and those determined by the coroner to have caused death. Logistic regression analyses were used to examine demographic and clinical factors associated with suicide by different drug types.

RESULTS

There were 397 documented suicides by overdose (mean age 49.1 years, 50% female). Most substances detected were psychotropic prescription medications (n = 245), followed by other prescription medications (n = 143) and over-the-counter (OTC) medications (n = 83). More than one-half of all suicides by overdose were determined to have only one specific substance as the cause of death (n = 206). In suicides where only one class of substance was present in lethal amounts, OTC medication (n = 48), opioid analgesics (n = 44), and tricyclic antidepressants (n = 44) were most common.

CONCLUSIONS

Suicides by overdose involved the use of different classes of substances, including psychotropic prescription medication, other prescription medications, as well as OTC medications. Physicians and pharmacists should be aware of commonly used prescription and OTC medications in overdose and exercise increased vigilance in prescribing or dispensing them to at-risk patients.

Deaths of opiate/opioid misusers involving dihydrocodeine, UK, 1997-2007

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT

Dihydrocodeine (DHC) is an opioid analgesic sometimes prescribed as an alternative to other medications (e.g. methadone and buprenorphine) for opioid misuse. Its effectiveness is, however, still controversial. DHC prescription rates seem to be related to levels of DHC fatalities, possibly in relation to levels of disregard of the availability of supervised or interval dispensing of opioids, but no large-scale analysis of DHC fatalities has been carried out. We analysed here involvement of DHC in fatalities that occurred between 1997 and 2007 among individuals with a history of opiate/opioid misuse reported to the National Programme on Substance Abuse Deaths (np-SAD).

WHAT THIS STUDY ADDS

DHC, either alone or in combination, was identified in 584 fatalities. Typical cases identified were males in their early thirties. In accidental overdoses, DHC, which had been prescribed to 45% of the victims, was typically identified in combination with other drugs, such as heroin/morphine, methadone and hypnotics/sedatives. Both paracetamol and antidepressants were more typically identified in combination with DHC in suicides. Opiate/opioid misusers should be educated about risks associated with polydrug intake and prescribers should carefully consider a pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction.

AIMS

Although its effectiveness is somewhat controversial, it appears that dihydrocodeine (DHC) is still prescribed in the UK as an alternative to both methadone and buprenorphine for the treatment of opiate addiction.

METHODS

Data covering the period 1997-2007 voluntarily supplied by coroners were analysed. All cases pertaining to victims with a clear history of opiate/opioid misuse and in which DHC, either on its own or in combination, was identified at post-mortem toxicology and/or implicated in death, were extracted from the database.

RESULTS

Dihydrocodeine, either alone or in combination, was identified in 584 fatalities meeting the selection criteria. In 44% of cases it was directly implicated in the cause of death. These cases represented about 6.8% of all opiate/opioid-related deaths during this period. Typical DHC cases identified were White males in their early thirties. Accidental deaths (96%) were likely to involve DHC in combination with other psychoactives, mainly heroin/morphine, hypnotics/sedatives and methadone. Both paracetamol and antidepressants were found in proportionately more suicide cases than in accidental overdoses. DHC had been prescribed to the decedent in at least 45% of cases.

CONCLUSIONS

Opiate/opioid misusers should be educated about risks associated with polydrug intake. More in particular, co-administration of DHC with heroin, methadone and benzodiazepines may increase the risk of accidental fatal overdose. Prescribers should carefully consider pharmacological intervention alternative to DHC (e.g. methadone, buprenorphine) when managing and treating opiate addiction. More resources are required to do prospective research in this area.

Factors associated with not seeking professional help or disclosing intent prior to suicide: a study of medical examiners' records in Nova Scotia

OBJECTIVE

Individual-level data from clinical settings lack information on people who did not seek professional help prior to suicide. We used records of the Nova Scotia Medical Examiner Service (NSMES) to compare people who had contact with a health professional prior to suicide with those who did not.

METHOD

We linked data from the NSMES to routine administrative data of the province.

RESULTS

The NSMES recorded 108 suicides in Nova Scotia from January 1, 2006, to December 31, 2006; there were 90 male and 18 female suicide deaths. Mean and median age at death were 44.73 (SD 13.33) and 44 years, respectively. Patients aged 40 to 49 years made up one-third of the cases (n = 35) and this was the decade of life with the highest number of suicides. This was also the group least likely to have suicidal intent recorded in the NSMES files (χ(2) = 3.86, df = 1, P = 0.05). Otherwise, there were no significant differences between people who sought help, or disclosed intent, prior to suicide and people who did not. The samples in all cases were predominately male and single.

CONCLUSIONS

People aged 40 to 49 years were the age group with the highest absolute number of suicides, but were the least likely to have suicidal intent recorded in the NSMES files. This finding merits further investigation. Medical examiner or coroner data may provide additional information not obtained elsewhere for the surveillance of suicide.

Suicide by gabapentin overdose

Gabapentin is an antiepileptic drug that is prescribed for both FDA-approved and multiple off-label conditions, and has a relatively safe side-effect profile. Rare cases of overdose-related adverse effects have been reported in the literature. Described herein are the circumstances and autopsy findings of a 62-year-old woman with a history of depression, whose death was caused by intentional ingestion of excess gabapentin. The postmortem peripheral blood gabapentin concentration as determined by high-performance liquid chromatography/tandem mass spectroscopy was 88 μg/mL. Previously reported cases of individuals surviving gabapentin overdoses are discussed and compared with this case. Based on a review of the available literature, this appears to be the first published report of a death due solely to gabapentin toxicity.

Attempted suicide, self-harm, and violent victimization among regular illicit drug users

Relationships among attempted suicide, nonsuicidal self-harm, and physical assault were examined in 400 regular users of heroin and/or psychostimulants. Twenty-eight percent had episodes of nonsuicidal self-harm, 32% had attempted suicide, and 95% had been violently assaulted. The number of suicide attempts and nonsuicidal self-harm incidents were correlated (ρ = 0.44). There were also significant correlations between the number of assaults and nonsuicidal self-harm incidents (ρ = 0.17), and suicide attempts (ρ = 0.27). The mean age onset for non-suicidal self-harm (18.9 yrs) was significantly younger than that of initial suicide (22.3 yrs). The age at initial physical assault (16.0yrs) was significantly younger than that of nonsuicidal self-harm and initial suicide attempt. Screening for all forms of violence appears warranted when determining suicide risk for this population.

Self-poisonings with tricyclic antidepressants and selective serotonin reuptake inhibitors in Tehran, Iran

In a prospective hospital-based cohort study, we addressed the question of severity and outcome of antidepressant poisonings in patients who attended the Loghman-Hakim Hospital Poison Center, the only national center in Tehran dedicated for detoxification. The aim of the study was to find out if tricyclic antidepressant (TCA) intoxications require more therapeutic efforts than selective serotonin reuptake inhibitor (SSRI) intoxications. The study was applied over a 7-week period (28 March-20 May 2006). From 3578 intoxications, 334 patients with antidepressant or lithium self-poisoning were identified (9.3% of all poisoning cases; 233 females, 101 males; median age 24 years, min 13, max 70). Compared to SSRI single-substance intoxications (n=17), TCA single-substance intoxications (n=73) were associated with: (1) a significantly lower level of consciousness (P=0.005); (2) a significantly higher admission frequency (80.8 vs. 35.3%; P<0.001); and (3) a higher intubation frequency (13.7 vs. 0%; P=ns). SSRI multiple-substance intoxications were associated with a significantly lower level of consciousness than SSRI single-substance intoxications (P=0.042), while there was no significant difference between TCA multiple- and single-substance intoxications. This study suggests that an overdose with SSRIs results in a more favourable clinical outcome than an overdose with TCAs.

Divergence in contributing factors for suicide among men and women in Kentucky: recommendations to raise public awareness

OBJECTIVES

The primary purpose of this study was to compile demographic information from 1999 to 2005 on suicides and examine specifically toxicology differences between men and women dying by suicide and differences in what type of intimate partner problems (IPPs) were cited as a precipitating circumstance.

METHODS

In addition to death certificate data, coroner investigation reports were available for more than three-quarters of cases in 2005 detailing precipitating factors leading up to suicide. We linked toxicology results to death certificates and coroner investigation reports in the Kentucky Violent Death Reporting System database for statewide analysis.

RESULTS

In 2005, IPP was documented as a contributing factor in 128 (29%) of all suicide cases where the circumstances were known. In 54 (42%) of the 128 cases, the coroner noted that the decedent's intimate was in the process of leaving, breaking up, had recently left, had recently separated, had recently filed for divorce, was awaiting divorce, or had a divorce recently finalized. Of those 54 cases involving IPPs, most (87%) of the suicide victims were men and were significantly different from the women.

CONCLUSIONS

As a result of this study, we have two recommendations: (1) partnering with the media and community-based programs and services to systematically disseminate information on issues such as male IPPs and suicide, and (2) continuing and expanding the use of violent death surveillance to improve risk factor identification. With improved data gathering, targeted interventions can better address the various dynamics influencing the decision to take one's own life.

Drugs and violent death: comparative toxicology of homicide and non-substance toxicity suicide victims

AIMS

To determine the comparative toxicology of death by homicide and suicide by means other than substance toxicity.

DESIGN

Cross-sectional (autopsy reports).

SETTING

Sydney, Australia.

CASES

A total of 1723 cases of violent death were identified, comprising 478 homicide (HOM) cases and 1245 non-substance toxicity suicide (SUI) cases.

FINDINGS

Substances were detected in 65.5% of cases, and multiple substances in 25.8%, with no group differences. Illicit drugs were detected in 23.9% of cases, and multiple illicit in 5.3%. HOM cases were significantly more likely to have an illicit drug [odds ratio (OR) 2.09] and multiple illicits (OR 2.94), detected, HOM cases being more likely to have cannabis (OR 2.39), opioids (OR 1.53) and psychostimulants (OR 1.59) present. HOM cases were, however, significantly less likely to have benzodiazepines (OR 0.53), antidepressants (OR 0.22) and antipsychotics (OR 0.23) present. Alcohol was present in 39.6% of cases (median blood alcohol concentration = 0.12), with no group difference in prevalence.

CONCLUSIONS

The role drugs play in premature death extends far beyond overdose and disease, with illicit drugs associated strongly with homicide.

Toxicology and methods of committing suicide other than overdose

Suicide represents a serious public health problem throughout the world. Toxicology plays a crucial role in the investigation of suicide. Psychoactive substances are recognized in the literature as the main suicide-generating stimuli. Ethanol is known to produce disinhibition and increased self-confidence. Other psychoactive substances can predominantly be central nervous system (CNS) stimulants or depressors. In cases of overdose as a method of suicide, the link between toxicology and the method of suicide is a matter of common sense and requires no additional explanation. On the other hand, in cases of non-overdose suicides this link is much more complex, and has not yet been extensively elucidated. We hypothesize a close relationship between toxicology and the choice of the method of committing suicide other than overdose. Negative findings may reflect either poor prescribed drug compliance in psychiatric patients, or suggest the role of other (non-toxicological) suicide-generating stimuli. On the other hand, positive findings influence the choice of the suicide method in a way that it depends on the prevalence of either stimulation or depression of the CNS, and consequent degree of behavioral aggression. Simplified, if the prevailing effect is CNS stimulation (with an increase in aggression), the method would be more drastic and more immediately fatal one, while with the CNS depression the method would be less immediately fatal and less drastic. There are only a few studies on the prevalence of psychoactive substances amongst completed suicides and even fewer studies have attempted to examine the relationship between substances used and the circumstances surrounding suicide. In evaluation of our hypothesis, we suggest thorough studies of toxicology and the choice of methods of committing suicides other than overdose. The scientific knowledge gained this way will eventually make toxicology a useful target in suicide prevention, especially amongst younger population.

A systematic review of research examining benzodiazepine-related mortality

PURPOSE

This paper will review literature examining the association of benzodiazepine use and mortality.

METHODS

An extensive literature review was undertaken to locate all English-language published articles that examine mortality risk associated with use of benzodiazepines from 1990 onwards.

RESULTS

Six cohort studies meeting the criteria above were identified. The results were mixed. Three of the studies assessed elderly populations and did not find an increased risk of death associated with benzodiazepine use, whereas another study of the general population did find an increased risk, particularly for older age groups. A study of a middle aged population found that regular benzodiazepine use was associated with an increased mortality risk, and a study of 'drug misusers' found a significant relationship between regular use of non-prescribed benzodiazepines and fatal overdose. Three retrospective population-based registry studies were also identified. The first unveiled a high relative risk (RR) of death due to benzodiazepine poisoning versus other outcomes in patients 60 or older when compared to those under 60. A positive but non-significant association between benzodiazepine use and driver-responsible fatalities in on-road motor vehicle accidents was reported. Drug poisoning deaths in England showed benzodiazepines caused 3.8% of all deaths caused by poisoning from a single drug.

CONCLUSION

On the basis of existing research there is limited data examining independent effects of illicit benzodiazepine use upon mortality. Future research is needed to carefully examine risks of use in accordance with doctors' prescriptions and extra-medical use.