Underrepresentation of Heroin Involvement in Unintentional Drug Overdose Deaths in Allegheny County, PA

Abstract

Drugs contributing to overdose deaths are listed on death certificates, but their validity is rarely studied. To assess the accuracy of "morphine" and "codeine" listings on death certificates for unintentional overdose deaths in Allegheny County, PA, investigative and laboratory reports were reviewed. Deaths were reclassified as heroin-related if documentation showed 6-monoacetylmorphine in blood or urine, "stamp bags" or drug paraphernalia at scene, history of heroin use, or track marks. Deaths were considered morphine-related if notes indicated morphine use, prescription, or morphine at scene, or codeine-related if the codeine blood level exceeded morphine. Of 112 deaths with morphine but not heroin listed on the death certificate, 74 met heroin criteria and 21 morphine criteria. Of 20 deaths with both morphine and heroin listed, only one met morphine criteria. Of 34 deaths with codeine listed, only five were attributed to codeine. Consideration of patient history, death scene evidence, and expanded toxicology testing may improve the accuracy of death certificate drug listings.

Corrected US opioid‐involved drug poisoning deaths and mortality rates, 1999–2015

“…Second, drug mentions on death certificates may contain errors. For instance, heroin use may sometimes be attributed to morphine or codeine . Third, some ICD‐10 codes lack desired specificity.…”

Carfentanil Outbreak — Florida, 2016–2017

“…Only the presence of 6-acetylmorphine can confirm heroin use; therefore, heroin-involved cases might be undercounted (9). Sensitivity analyses was performed by reclassifying these cases as heroin-involved, but the findings did not change.…”

An analysis of issues in the classification and reporting of heroin‐related deaths

“…Variation in the attribution of heroin‐related deaths has been demonstrated to contribute to the under‐reporting of these cases. The re‐examination of unintentional drug overdose deaths in the United States led to the identification of a large number of heroin‐related deaths that had been attributed to morphine and codeine toxicity, as well as cases that were missed because of inconsistencies in the cause of death certification . Previous studies have demonstrated a reliance on 6‐AM detection, the generally limited use of alternate toxicological markers such as morphine and codeine ratios as evidence of heroin use which can contribute to variability in the attribution of a death to heroin .…”

“…Heroin‐related death investigation can be particularly challenging; because of variability in the detection of heroin‐specific metabolites, toxicological analysis may not be feasible at all, and most cases are complicated by multiple substance use . The challenges associated with the interpretation of toxicity data in heroin‐related death cases have also resulted in the misclassification of heroin‐related deaths as being morphine‐related when heroin‐specific toxicological markers such as 6‐acetylmorphine (6‐AM) are not detected, which further contributes to the under‐reporting of these deaths .…”