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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 38-42

Characteristics of Suicides Caused by Drug Overdose in the State of Maryland


1 Collaborative Innovation Center of Judicial Civilization and Institute of Evidence Science and Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing; Department and Key Laboratory of Forensic Pathology, Guangdong Provincial Public Security, Shijiazhuang; Department of Forensic Medicine, Shanxi Medical University, Taiyuan, China; Division of Forensic Pathology, University of Maryland, School of Medicine, Maryland, USA
2 Department and Key Laboratory of Forensic Pathology, Guangdong Provincial Public Security, Shijiazhuang, China
3 Department of Forensic Pathology, Hebei Medical University, Shijiazhuang, China
4 Center of Forensic Science, East China University of Political Science and Law, Shanghai, China
5 Collaborative Innovation Center of Judicial Civilization and Institute of Evidence Science and Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing; Department of Forensic Medicine, Shanxi Medical University, Taiyuan, China
6 Division of Forensic Pathology, University of Maryland, School of Medicine, Maryland, USA
7 Department of Forensic Medicine, Shanxi Medical University, Taiyuan, China; Division of Forensic Pathology, University of Maryland, School of Medicine, Maryland, USA
8 Collaborative Innovation Center of Judicial Civilization and Institute of Evidence Science and Key Laboratory of Evidence Science, China University of Political Science and Law, Beijing; Department of Forensic Medicine, Shanxi Medical University, Taiyuan, China; Division of Forensic Pathology, University of Maryland, School of Medicine, Maryland, USA

Date of Web Publication29-May-2015

Correspondence Address:
Ling Li
Division of Forensic Pathology, University of Maryland, School of Medicine, State of Maryland, 900 West Baltimore Street, Baltimore, Maryland 21223, USA

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2349-5014.157910

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  Abstract 

Suicidal drug overdose is a major public health issue. In the United States, every year more than 33,000 people commit suicides. Our study focused on the characteristics of suicide victims in the state of Maryland. Material and methods: This study was a retrospective review of autopsy cases of all suicide deaths caused by drug (s) or drug (s) with alcohol intoxication investigated by the OCME in Maryland over a 7-year period from January 2004 to December 2011. All deaths investigated by the OCME that require autopsy examination are subject to comprehensive toxicology testing for drugs and alcohol. The screen tests were performed using gas chromatography (GC) and radioimmunoassay techniques. All detected drugs and/or metabolites were confirmed using GC-mass spectrometry (GC-MS). Results: From 2004 to 2011, 434 deaths were certified as suicide. Of the 434 suicidal overdose deaths, 84% were white, 11% were African-American, and about 5% were either Hispanic or Asian. The male and female ratio was almost equal. Their ages ranged 15-82 years. Of the 434 suicidal drug overdose deaths, 277 victims (63.8%) consumed a single drug type and 157 (36.2%) consumed more than one type of drug. Of the 277 single-drug overdose cases, 71.1% suicides were due to prescription drugs, 23.5% due to over-the-counter drugs, and 5.4% due to street/recreational drugs. Among single-type prescription drugs, analgesic (N = 76), antidepressant (N = 45), and neuroleptic (N = 35) classes were the three leading type of drugs used in suicidal deaths. Oxycodone, morphine, quetiapine, and amitriptyline were the most common prescription drugs in suicidal overdose. Diphenhydramine was the leading over-the-counter drug. Of the 157 victims who consumed more than one drug, combined prescription drugs were present in 54.1%, mixed prescription and over-the-counter drugs in 29.3%, and prescription drugs/over-the-counter drugs and street drugs in 16.6% of cases. Of the multiple-drug overdose suicides, 66.2% cases involved antidepressants. Discussion: Suicide is found in every age, racial, and ethnic group. In the USA, poisoning is thethird-leading method of suicide, following firearm injuries and hanging/strangulation. Our study indicates that prescription drugs, such as those in the opioid analgesic, neuroleptic, and antidepressant class (e.g., oxycodone, morphine, quetiapine, amitriptyline, doxepin, and citalopram), are of special concern in the context of suicidal overdose deaths in the state of Maryland. Therefore, addressing the problems of intentional drug overdose in our society is worthy of public attention.

Keywords: Antidepressants, drug overdose, epidemiology, forensic autopsy, forensic science, suicide, opioid analgesics, toxicology


How to cite this article:
Li L, Liao X, Zhang G, Sun D, Yang T, Yun K, Phipps R, Zhang X, Ripple MG, Fowler D. Characteristics of Suicides Caused by Drug Overdose in the State of Maryland. J Forensic Sci Med 2015;1:38-42

How to cite this URL:
Li L, Liao X, Zhang G, Sun D, Yang T, Yun K, Phipps R, Zhang X, Ripple MG, Fowler D. Characteristics of Suicides Caused by Drug Overdose in the State of Maryland. J Forensic Sci Med [serial online] 2015 [cited 2018 Oct 21];1:38-42. Available from: http://www.jfsmonline.com/text.asp?2015/1/1/38/157910


  Introduction Top


The World Health Organization (WHO) estimates that more than 800,000 people die globally every year from suicide; it is the second-leading cause of death in 15-29-year-olds. [1] This indicates an annual global age-standardized suicide rate of 11.4 per 100,000 population. [2] According to the Centers for Disease Control and Prevention (CDC), every year more than 33,000 people (11.5 per 100,000 population) end their own lives, making suicide the 11th-leading cause of death in the USA. [3]

Suicide is found to differing degrees in every age, racial, and ethnic group. [4]

International studies on suicide indicate that suicidal behavior and, in particular, the preferred suicide method, varies between countries. [5] In most countries, hanging was the most frequently reported method of suicide, followed by poisoning and drowning or jumping from heights. [6],[7],[8] In the USA, poisoning was the third-leading method of suicide, following firearm assistance and hanging/strangulation. Seventy-five percent of suicides by poisoning were due to drugs and/or alcohol overdose versus other types of poison, such as carbon monoxide. [3],[9]

Our objective was to document the epidemiologic characteristics of victims of suicide in the state of Maryland from 2004 to 2011 due to drug overdose in our forensic autopsy population.


  Materials and Methods Top


The Office of the Chief Medical Examiner (OCME) in Baltimore is responsible for conducting death investigations and certifying the cause and manner of unnatural and unexplained deaths, including homicides, suicides, unintentional injuries, drug-related deaths, deaths in custody, and other deaths that are sudden or unexpected in the state of Maryland. All deaths investigated by the OCME that require autopsy examination are subject to comprehensive toxicology testing for drugs and alcohol. Specimens including heart blood, femoral or subclavian blood, urine, bile, vitreous humor, stomach contents, kidney, and liver were collected from each victim at autopsy unless the condition of the victim's body precluded collection. In individuals who had died after several hours or days of hospitalization, not only was the blood collected at autopsy, but the medical facility in which the individual had been treated was contacted to provide admission blood for toxicological analysis.

The biological samples were screened for more than 100 drugs, including antidepressants, antihistamines, benzodiazepines, neuroleptics, sympathomimetic amines, acid/neutral drugs, acetaminophen, salicylate, common cardiac drugs, atropine, lidocaine, benztropine, zolpidem, cyclobenzaprine, carisoprodol/meprobamate, meperidine, tramadol, methadone, codeine, hydrocodone, oxycodone, propoxyphene, fentanyl, heroin, morphine, cocaine and its metabolites, phencyclidine amphetamine, methamphetamine, and volatile substances. The screen tests were performed using gas chromatography (GC) and radioimmunoassay techniques.

All detected drugs and/or metabolites were confirmed using GC-mass spectrometry (GC-MS). [10]

This study was a retrospective review of autopsy cases of all suicide deaths caused by drug (s) or drug (s) with alcohol intoxication investigated by the OCME in Maryland over a 7-year period from January 2004 to December 2011. Cases due to alcohol intoxication alone were excluded from this study. The cases were analyzed as to (i) manner of death in context of all drug (s) or drug (s) with alcohol intoxication; (ii) general characteristics of the victims (age, gender, and race); (iii) personal information including any medical or drug history; and (iv) autopsy findings with focus on the types of drugs detected by toxicology testing.


  Results Top


From 2004 to 2011, a total of 5580 deaths were determined to be the result of drug(s) or drug(s) with alcohol intoxication in the state of Maryland. Of the 5580 cases, 434 (7.8%) deaths were certified as suicide, 175 (3.1%) deaths as accident, 8 (0.2%) deaths as homicide, and 4963 (88.9%) deaths with manner of death classified as "undetermined" [Table 1]. It is the policy of the medical examiner's office that the manner of death is certified as "undetermined" if the subject died of drug abuse. Of the deaths due to street/recreational drugs, about 95% of the cases were classified as "undetermined" because of drug abuse, most likely due to accidental overdose rather than being intentional deaths. The street/recreational drugs made up only 5% of the suicide. [Figure 1] showed that a total of 40981 citizens of Maryland committed suicide by various methods between 2004 and 2011. The most common method of suicide was firearm injuries, followed by asphyxia due to handing/ligature strangulation/plastic bag over head, and drug overdose.
Figure 1: Total suicides by cause in Maryland (2004-2011).

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Table 1: Total deaths due to drug/drug with alcohol intoxication by manner in Maryland, 2004 - 2011


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The age distribution of suicide drug overdose was showed in [Figure 2]. Their ages ranged 15-82 years, with the majority of victims in their 40s and 50s. More males (N = 3304) committed suicide than females (N = 777) in Maryland between 2004 and 2011. However, the ratio of male and female suicide by drug overdose was almost equal (M: F = 1.04:1). Of the 434 suicidal overdose deaths, 84% were white, 11% were African American, and about 5% were either Hispanic or Asian [Table 2]. The distribution of suicidal drug overdose deaths by month showed higher frequencies in May, August, and December in Maryland.
Figure 2: Age distribution of suicide drug deaths in Maryland (2004-2011).

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Table 2: Suicides by gender and race in Maryland (2004-2011)


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[Table 3] showed the drug distribution of suicidal overdose by a single drug type. Of the 434 suicide drug overdose deaths, 277 (63.8%) victims consumed a single drug type and 157 (36.2%) consumed more than one type of drugs. Of the 277 single drug overdose cases, 71.1% suicides were due to prescription drugs, 23.5% due to over-the-counter drugs, and only 5.4% due to street/recreational drugs. Among single-type prescription drugs, analgesic, antidepressant, and neuroleptic classes were the three leading types of drugs used in suicide deaths. Of the analgesics, oxycodone (N = 24), morphine (N = 22), and tramadol (N = 8) were the three leading drugs. Of the antidepressants, amitriptyline (N = 12), doxepin (N = 8), and citalopram (N = 5) were the three leading drugs. Quetiapine (N = 22) was the leading neuroleptic drug. Of the over-the-counter drugs, diphenhydramine (N = 47) was the leading drug.
Table 3: Suicides by single drug in Maryland (2004 - 2011)


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[Table 4] showed that 157 victims consumed more than one drug; there were 54.1% cases of combined prescription drugs overdose, 29.3% cases of mixed prescription and over-the-counter drugs overdose, and prescription drugs/over-the-counter drugs and street drugs overdose in 17.6% cases. Of the 157 cases, 66.2% (N = 104) involved antidepressants, 61.1% (N = 78) involved prescribed analgesic drugs, and 35.7% involved neuroleptic drugs (N = 56). Of the 104 antidepressants, tricyclic antidepressants (N = 32) and selective serotonin-reuptake inhibitors (N = 25) were the main types of drugs. Deaths were due to combined drug(s) and alcohol intoxication in 68 cases.
Table 4: Suicides by mixed drugs in Maryland


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Investigation revealed that the majority (82.2%, 359/434) of the victims had a history of depression or bipolar disorder and/or anxiety disorders, posttraumatic distress disorder, or schizophrenia. More than 62.7% (272/434) suicide victims were tested positive for antidepressants and/or neuroleptics/benzodiazepines. Of the 434 cases, 37.3% (162/434) had a history of previous suicide ideation or attempts. Only 18.9% (82/434) victims left a suicide note. Of the 434 suicide cases, 67 (15.4%) victims had a history of significant medical disease, such as terminal cancers, severe chronic obstructive pulmonary disease, and congested heart failure.


  Discussion Top


According to newly published data, drug overdose deaths in the USA, either intentional or unintentional, increased for the 11 th straight year in 2010. [3] Suicidal drug overdose is still a major public health issue. Opioid analgesics and antidepressants are of special concern in the context of suicidal overdose deaths in the USA. Therefore, addressing the problems of intentional drug overdose in our society is worthy of public attention.

There are significant differences in the nature of the agents involved in the suicide drug deaths between developing countries and developed countries. [6],[11],[12],[13],[14]

Ingestion of organophosphorus pesticide was the most commonly used method for suicide in many Asian countries and in Latin America, [6],[7],[8],[11],[13] whereas pharmaceutical drugs were the most common means of suicidal overdose in the developed countries. [3],[12],[15],[16],[17] It has been reported that minor tranquilizers such as benzodiazepines were the drugs most commonly involved in intentional drug overdose cases in Ireland and Spain, [15],[17] while paracetamol was the most commonly used drug in intentional drug overdose cases in England. [16]

According to CDC reports from the National Violent Death Reporting System, prescription drugs such as those in the opioid, benzodiazepine, and antidepressant class (e.g., oxycodone, diazepam, and fluoxetine) were the leading type used in suicide deaths in the USA, while over-the-counter drugs such as acetaminophen were the second-leading substance type used in suicides. [18] Our study showed a similar pattern to that reported by the CDC. The majority of suicidal drug overdose deaths in Maryland were due to prescription drugs. Among prescription drugs, the analgesic, antidepressant, and neuroleptic classes were the three leading types of drugs used in suicide. Oxycodone, morphine, quetiapine, amitriptyline, doxepin, and citalopram were the common prescription drugs in suicidal overdose. But diphenhydramine was the most common over-the-counter drug used in suicide. The drugs used in suicide are generally thought to reflect the availability/ease of access for the population or prescription patterns of that country. [19],[20]

Many of the drugs used in suicides are either easily available, as in the case of over-the-counter drugs such as diphenhydramine, or are commonly prescribed to treat various physical and mental health conditions, such as analgesics, antidepressants, and neuroleptics/benzodiazepines. Our data revealed that the majority (82.2%) of suicide victims had a history of depression or bipolar disorder and/or anxiety disorders, posttraumatic distress disorder, or schizophrenia. More than 62% suicide victims tested positive for antidepressants and/or neuroleptics/benzodiazepines. Many of these deaths could have been prevented by limiting access to those substances. If lethal substances are not available when people are under psychological or emotional stress and despair, the ability to commit suicide is limited. [18] It has been reported by many studies that a history of affective disorder or psychiatric morbidity and previous suicidal ideation or attempt(s) greatly increase risk of death from suicide. [21],[22],[23],[24],[25] Our study also indicated that although fewer than 20% of suicide victims left suicide notes, more than one-third (37.3%) of them had history of previous suicide ideation or attempt(s).


  Conclusion Top


Suicide is still a major public health issue and is found in every age, racial, and ethnic group. In the USA, poisoning is the third-leading method of suicide, following firearm injuries and hanging/strangulation. Our study indicates that prescription drugs, such as those in the opioid analgesic, neuroleptic, and antidepressant class (e.g., oxycodone, morphine, quetiapine, amitriptyline, doxepin, and citalopram), are of special concern in the context of suicidal overdose deaths in the state of Maryland. Therefore, addressing the problems of intentional drug overdose in our society is worthy of public attention.


  Acknowledgment Top


This study was supported by the Scientific Research Foundation for the Returned Overseas Chinese Scholars, State Education Ministry [(2013) 1792], Training Programmers Foundation for the Beijing Talents (2013D002023000002).

 
  References Top

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