Increase in poisoning deaths caused by non-illicit drugs--Utah, 1991-2003

Deaths caused by drug poisoning of unintentional and undetermined intent are an increasing problem in Utah and elsewhere in the United States. To characterize the trend in drug-poisoning deaths in Utah, CDC and the Utah Department of Health analyzed medical examiner (ME) data for 1991-1998 and 1999-2003. This report summarizes the results of that analysis, which determined that, during 1991-2003, the number of Utah residents dying from all drug poisoning increased nearly fivefold, from 79 deaths in 1991 (rate: 4.4 per 100,000 population) to 391 deaths in 2003 (rate: 16.6). This increase has been largely the result of the tripling of the rate (from 1.5 during 1991-1998 to 4.4 during 1999-2003) in poisoning deaths of unintentional or undetermined intent caused by non-illicit drugs (i.e., medications that can be legally prescribed). Further study is needed to understand these trends and to develop strategies to prevent deaths of unintentional or undetermined intent from non-illicit drug poisoning.     

The Changing Metropolitan Designation Process and Rural America

In June 2003, the Office of Management and Budget (OMB) released new county-based designations of Core Based Statistical Areas (CBSAs), replacing Metropolitan Statistical Area designations that were last revised in 1990. In this article, the new designations are briefly described, and counties that have changed classifications are identified. The new designations identify 2 categories of counties or county clusters within CBSAs: Metropolitan Statistical Areas and Micropolitan Statistical Areas. Counties designated as neither are simply referred to as "outside Core Based Statistical Areas." Among counties classified as metropolitan in 1999, 94% are still classified as such, 5% are now micropolitan, and 0.7% are outside CBSAs. The majority of counties that were nonmetropolitan in 1999 remain outside CBSAs (60%), while 28% are now classified as micropolitan and 12% have become metropolitan. The percentage of counties classified as metropolitan has increased from 27.2% to 34.7%, and the population identified as residing in these areas increased from 81% of the total US population to 83%. Some interpretation difficulties may arise in the future, as the naming system lends itself to lumping metropolitan and micropolitan together because of their common designation as CBSAs. The central problem to this classification scheme is that it tracks the urban growth of the nation and its tendency toward agglomeration of markets but pays little attention to the places that are outside CBSAs altogether.     

Methodological issues in the surveillance of poisoning,illicit drug overdose,and heroin overdose deaths in new Mexico

New Mexico leads the nation in poisoning mortality, which has increased during the 1990s in New Mexico and the United States. Most of this increase has been due to unintentional deaths from illicit drug overdoses. Medical examiner and/or vital statistics data have been used to track poisoning deaths. In this study, the authors linked medical examiner and vital statistics records on underlying cause of death, coded using the International Classification of Diseases, Ninth Revision, to assess the extent to which these data sources agreed with respect to poisoning deaths. The authors used multiple-cause files, which are files with several causes listed for each death, to further assess poisoning deaths involving more than one drug. Using vital statistics or medical examiner records, 94.7% of poisoning deaths were captured by each source alone. For unintentional illicit drug and heroin overdose deaths, each data source alone captured smaller percentages of deaths. Deaths coded as E858.8 (unintentional poisoning due to other drugs) require linkage with medical examiner or multiple-cause records, because this code identifies a significant percentage of illicit drug overdose deaths but obscures the specific drug(s) involved. Surveillance of poisoning death should include the use of medical examiner records and underlying- and multiple-cause vital statistics records.     

Rurality and Other Determinants of Early Colorectal Cancer Diagnosis in Nebraska: A 6-Year Cancer Registry Study, 1998-2003

ABSTRACT:  Background: There are no studies of rurality, and other determinants of colorectal cancer (CRC) stage at diagnosis with population-based data from the Midwest. Methods: This retrospective study identified, incident CRC patients, aged 19 years and older, from 1998-2003 Nebraska Cancer Registry (NCR) data. Using federal Office of Management and Budget classifications, we grouped patients by residence in metropolitan, micropolitan nonmetropolitan, or rural nonmetropolitan counties (non-core based statistical areas). In univariate and multivariate logistic regression analyses, we examined the association of the county classification and of other determinants with early (in situ/local) versus late (regional/distant) stage at CRC diagnosis. Results: Of the 6,561 CRC patients identified, 45% were from metropolitan counties, 24% from micropolitan nonmetropolitan counties and 31% from rural nonmetropolitan counties, with 32%, 38%, and 33%, respectively, being diagnosed at an early stage. Multivariate analysis showed micropolitan nonmetropolitan residents were significantly more likely than rural nonmetropolitan residents to be diagnosed at an early stage (adjusted OR, 1.22; 95% CI: 1.05-1.42, P < .05). However, rural nonmetropolitan and metropolitan residents did not significantly differ in the likelihood of early diagnosis. Residents with Medicare rather than those with private insurance (P < .0001), married rather than unmarried residents (P < .01), and residents with rectal cancer rather than those with colon cancer (P < .0001) were more likely to be diagnosed at an early stage. Conclusions: Early CRC diagnosis needs to be increased in rural (non-core) non-metropolitan residents, unmarried residents, and those with private insurance.     

Geospatial Analysis of Drug Poisoning Deaths Involving Heroin in the USA, 2000–2014

We investigate the geographic patterns of drug poisoning deaths involving heroin by county for the USA from 2000 to 2014. The county-level patterns of mortality are examined with respect to age-adjusted rates of death for different classes of urbanization and racial and ethnic groups, while rates based on raw counts of drug poisoning deaths involving heroin are estimated for different age groups and by gender. To account for possible underestimations in these rates due to small areas or small numbers, spatial empirical Baye’s estimation techniques have been used to smooth the rates of death and alleviate underestimation when analyzing spatial patterns for these different groups. The geographic pattern of poisoning deaths involving heroin has shifted from the west coast of the USA in the year 2000 to New England, the Mid-Atlantic region, and the Great Lakes and central Ohio Valley by 2014. The evolution over space and time of clusters of drug poisoning deaths involving heroin is confirmed through the SaTScan analysis. For this period, White males were found to be the most impacted population group overall; however, Blacks and Hispanics are highly impacted in counties where significant populations of these two groups reside. Our results show that while 35–54-year-olds were the most highly impacted age group by county from 2000 to 2010, by 2014, the trend had changed with an increasing number of counties experiencing higher death rates for individuals 25–34 years. The percentage of counties across the USA classified as large metro with deaths involving heroin is estimated to have decreased from approximately 73% in 2010 to just fewer than 56% in 2014, with a shift to small metro and non-metro counties. Understanding the geographic variations in impact on different population groups in the USA has become particularly necessary in light of the extreme increase in the use and misuse of street drugs including heroin and the subsequent rise in opioid-related deaths in the USA.     

Availability of Child Care in Rural Communities: Implications for Workforce Recruitment and Retention

The objective of this study was to identify differences in child care availability by rural–urban location for all counties in Wisconsin, and describe implications for recruitment and retention of health care workforce. We used data on licensed child care slots for young children (age <5), socio-demographic characteristics, women’s and men’s labor force participation, and household structure for all counties in Wisconsin in 2013 (n = 72). Data came from KIDS COUNT, County Health Rankings, and the American Community Survey. We used t tests to analyze bivariate differences in child care availability and community characteristics by metropolitan, micropolitan, and non-core rural location. We then used ordinary least squares regression to analyze the relationship between geographic location and child care slots, adjusting for labor force participation and household structure. Rural counties had significantly fewer licensed child care slots per child than metropolitan and micropolitan counties. These counties also had, on average, higher rates of poverty and higher unemployment than micropolitan and metropolitan counties. The association between geographic location and child care availability remained, even after adjusting for household structure and labor force participation. The number of hours men worked and the percentage of men not working were both negatively associated with available child care slots, whereas there was not a significant relationship between women’s labor force participation and child care availability. Rural areas face health care workforce shortages. Recruitment strategies to overcome shortages must move beyond individual-level incentives to focus on community context and family support, including availability of child care in rural counties.     

Prevalence of Children with Special Health Care Needs in Metropolitan and Micropolitan Statistical Areas in the United States

Objectives We estimate the prevalence of children with special health care needs (CSHCN) in 70 metropolitan and four micropolitan statistical areas across the United States. Methods The data are from the 2001 National Survey of CSHCN, which was sponsored by the Maternal and Child Health Bureau and conducted by the National Center for Health Statistics. Prevalence estimates were generated for 74 metropolitan and micropolitan statistical areas (M/MSAs) and 45 individual counties that were represented by at least 1,000 children in the sample. To generate the estimates, the child-level sample weights (representative at the national and state level) were recalibrated within each M/MSA and county to match Census 2000 counts of the child population by age, sex, and Hispanic ethnicity. Results M/MSA-level and county-level prevalence of CSHCN are compared with national- and state-level prevalence, and within M/MSAs and counties, prevalence is reported by age, sex and race/ethnicity. Most, but not all, M/MSA- or county-level prevalence estimates did not differ significantly from state-level estimates. Some M/MSAs and counties that did not differ from their states in overall prevalence of CSHCN did show some differences in prevalence for certain demographic subgroups. Conclusions Metropolitan health departments and Maternal and Child Health agencies that serve urban areas may find these new small area estimates useful for program planning purposes. This study demonstrates the importance of assessing whether state estimates may approximate local area estimates of the prevalence of CSHCN.     

Changes to the daily pattern of methadone-related deaths in England and Wales, 1993-2003

Previous studies suggest that fatal poisoning deaths involving methadone occur more frequently on the weekends. We assessed changes in the daily pattern of mortality because of methadone poisoning following a review of drug misuse services in 1996 and publication of revised clinical guidelines in 1999. We also compared this to the daily pattern of deaths involving heroin/morphine. The Office for National Statistics provided data on all deaths in England and Wales between 1993 and 2003 for which methadone and heroin/morphine were mentioned on the coroner's certificate of death registration after inquest, with or without alcohol or other drugs. There were 3098 deaths involving methadone. The death rate increased up to 1997 and then declined. Initially, there was a marked excess of deaths occurring on Saturdays. The rate of decline was greatest for deaths occurring on Saturdays. As a result, the Saturday peak disappeared (P = 0.006). There were 6328 deaths involving heroin/morphine. No change in the daily pattern of heroin/morphine deaths was observed during the study period. Although the marked change in the epidemiology of methadone deaths coincided with recommendations for service redevelopment and clinical management of methadone treatment, the contribution of improved prescribing practice or treatment services is unclear.     

The Decrease in the Unintentional Injury Mortality Disparity Between American Indians/Alaska Natives and Non–American Indians/Alaska Natives in New Mexico, 1980 to 2009

Objectives. We tracked the unintentional injury death disparity between American Indians/Alaska Natives and non–American Indians/Alaska Natives in New Mexico, 1980 to 2009.Methods. We calculated age-adjusted rates and rate ratios for unintentional injury deaths and their external causes among American Indians/Alaska Natives and non–American Indians/Alaska Natives. We tested trend significance with the Mann–Kendall test.Results. The unintentional injury death rate ratio of American Indians/Alaska Natives to non–American Indians/Alaska Natives declined from 2.9 in 1980–1982 to 1.5 in 2007–2009. The rate among American Indians/Alaska Natives decreased 47.2% from 1980–1982 to 1995–1997. Among non–American Indians/Alaska Natives, the rate declined 25.3% from 1980–1982 to 1992–1994, then increased 31.9% from 1992–1994 to 2007–2009. The motor vehicle traffic and pedestrian death rates decreased 57.8% and 74.6%, respectively, among American Indians/Alaska Natives from 1980–1982 to 2007–2009.Conclusions. The unintentional injury death rate disparity decreased substantially from 1980–1982 to 2007–2009 largely because of the decrease in motor vehicle crash and pedestrian death rates among American Indians/Alaska Natives and the increase in the poisoning death rate among non–American Indians/Alaska Natives.New Mexico had the highest unintentional injury death rate in the nation for the years 2006 through 2008.1 The unintentional injury death rate in the state, 67.1 deaths per 100 000 population, was 1.7 times higher than the US unintentional injury death rate, 39.7 per 100 000 population. In New Mexico, unintentional injuries are the third leading cause of death for all ages and are the leading cause of death for persons aged 1 to 44 years. From 2007 through 2009, poisoning was the leading cause of unintentional injury death. Motor vehicle crashes and falls were the second and third leading causes of unintentional injury death, respectively. These 3 leading causes of unintentional injury death accounted for 85% of all unintentional injury deaths in the state.Nationally, the unintentional injury death rate among the American Indian/Alaska Native (AI/AN) population in the Indian Health Service Area from 2004 to 2006 was 2.4 times higher than the rate for all races in the United States in 2005.2 Whereas American Indians/Alaska Natives in New Mexico have lower rates of death from heart disease, cancer, chronic obstructive pulmonary disease, and stroke than non–American Indian/Alaska Natives, their unintentional injury death rate is higher than the rate among non–American Indians/Alaska Natives.3 Among New Mexico residents, American Indians had the highest total injury mortality rate from 1958 to 1982.4 However, the trend in the disparity in the unintentional injury death rate between American Indians/Alaska Natives and non–American Indians/Alaska Natives in New Mexico has not been examined.The 2007–2009 AI/AN population in New Mexico averaged 201 952, which represented 10.2% of the state’s population.5 The non–AI/AN population averaged 1 786 436, which represented 89.8% of the state’s population.5 By comparison, American Indians/Alaska Natives comprised 1.1% of the US population for 2007 through 2009.5The purpose of this study was to track the disparity in unintentional injury death and external causes of unintentional injury death between the AI/AN population and the non-AI/AN population in New Mexico from 1980 to 2009.     

Unintentional and undetermined poisoning deaths--11 states, 1990-2001

During 1990-2001, the death rate from poisoning in the United States increased 56%, from 5.0 per 100,000 population in 1990 to 7.8 in 2001. In 2001, of 22,242 poisoning deaths, 14,078 (63%) were unintentional. To describe trends in poisoning deaths, state health professionals in 11 states analyzed vital statistics data for 1990-2001. This report summarizes the results of that analysis, which indicated that increases in state death rates from unintentional and undetermined poisonings varied, but increased by an average of 145%; a total of 89% of poisonings involved drugs and other biologic substances. State public health professionals can use local, state, and national surveillance data to monitor trends in drug misuse and to develop effective interventions that can reduce deaths from drug overdoses.     

Impact of paracetamol pack size restrictions on poisoning from paracetamol in England and Wales: an observational study

BACKGROUND: About 500 drug poisoning deaths involving paracetamol (acetaminophen) occur every year in England and Wales. To reduce the number of deaths, regulations were introduced in 1998 to restrict the sale of paracetamol. In this paper, we evaluate the impact of these regulations. METHODS: Mortality data for England and Wales were provided by the Office for National Statistics. Deaths were defined as due to compound paracetamol (paracetamol in combination with another analgesic, a low dose opioid or other ingredients) or paracetamol only, with or without alcohol or other drugs. The Department of Health provided data on all hospital admissions with a primary diagnosis of paracetamol poisoning. RESULTS: Mortality rates for paracetamol only were similar for males and females, and decreased from about 4.5 to 2.8 per million between 1997 and 1999 and again from about 3.1 to 2.2 per million between 2001 and 2002. These falls may be attributable to random variation in the rates. Deaths involving compound paracetamol, which were not subject to the 1998 regulations, remained relatively constant over the study period. There was evidence of a decreasing trend in paracetamol only mortality rates and this followed overall trends for other drug poisoning excluding opioids and drugs of misuse. Hospital admissions due to paracetamol poisoning increased from about 27 000 to 33 000 between 1995/1996 and 1997/1998 and then decreased to 25 000 in 2001/2002. There were almost 50 per cent more admissions for females than males, with the highest admission rates amongst females aged 15-24 years old. CONCLUSIONS: Between 1993 and 2002, mortality rates and hospital admissions due to paracetamol poisoning declined. However, the contribution of the 1998 regulations to this decline is not clear. Paracetamol poisoning continues to be an important public health issue in England and Wales and represents significant workload for the NHS in England.     

History of residence and lung cancer risk in New Mexico

Participants in a population-based case-control study of lung cancer in New Mexico between 1980 and 1982 were asked to identify all locations where they had resided for six months or more. These residential data were coded at the county and state levels and combined with county-level socioeconomic data from the 1910, 1930, 1950, and 1970 decennial censuses to generate indices of time lived in counties or metropolitan areas of different sizes, degrees of urbanization, or extents of employment in manufacturing industries. Urban residence was not associated with employment of male controls in jobs or industries considered to increase lung cancer risk. However, in the non-Hispanic white female controls, urban residence before age 30 years in a county of 500,000 or more residents was associated with a fourfold higher odds ratio for starting to smoke cigarettes. Male and female non-Hispanic controls who had ever lived in more populous counties smoked more cigarettes per day than did those who had not lived in such counties. Residential history patterns were the same in cases and controls; multiple logistic regression showed no consistent associations of the residence history variables with lung cancer risk.     

Deaths: preliminary data for 2003.

OBJECTIVES: This report presents preliminary U.S. data on deaths, death rates, life expectancy, leading causes of death, and infant mortality for the year 2003 by selected characteristics such as age, sex, race, and Hispanic origin. METHODS: Data in this report are based on a large number of deaths comprising approximately 93 percent of the demographic file and 91 percent of the medical file for all deaths in the United States in 2003. The records are weighted to independent control counts for 2003. For certain causes of death such as unintentional injuries, homicides, suicides, and respiratory diseases, preliminary, and final data differ because of the truncated nature of the preliminary file. Comparisons are made with 2002 final data. RESULTS: The age-adjusted death rate for the United States decreased from 845.3 deaths per 100,000 population in 2002 to 831.2 deaths per 100,000 population in 2003. Age-adjusted death rates decreased between 2002 and 2003 for the following causes: Diseases of heart, Malignant neoplasms, Cerebrovascular diseases, Accidents (unintentional injuries), Influenza and pneumonia, Intentional self-harm (suicide), Chronic liver disease and cirrhosis, and Pneumonitis due to solids and liquids. They increased between 2002 and 2003 for the following: Alzheimer's disease, Nephritis, nephrotic syndrome and nephrosis, Essential (primary) hypertension and hypertensive renal disease, and Parkinson's disease. Life expectancy at birth rose by 0.3 years to a record high of 77.6 years.     

Deprivation and mortality in non-metropolitan areas of England and Wales.

OBJECTIVE: To test the hypothesis that the relationship between deprivation and mortality is weaker among residents of non-metropolitan areas of England and Wales than among residents of metropolitan areas. DESIGN: This study compared mortality, expressed as standardised mortality ratios (SMRs), in residents of metropolitan and non-metropolitan districts at three levels of deprivation classified by an electoral ward deprivation score and by home and car ownership. SMRs were computed for all causes of death, for bronchitis and asthma (ICD9 codes 490-493), and for accident, violence, and poisoning (ICD9 codes 800-999). SETTING: England and Wales. PARTICIPANTS: Members of the longitudinal study of the Office of Population Censuses and Surveys, a quasi-random 1% sample of the population of England and Wales. MAIN RESULTS: There was an association between deprivation and mortality which was clear for all cause mortality, more noticeable for respiratory disease, and less clear for deaths from accident, violence, and poison. In general, the results showed a remarkable similarity between metropolitan and non-metropolitan areas. CONCLUSIONS: This study does not support the hypothesis that the relationship between mortality and deprivation differs between residents of metropolitan and non-metropolitan areas of England and Wales.     

Recent trends in fatal poisoning by opiates in the United States.

Deaths in the United States classified as unintentional poisoning by drugs and medicaments fell from 14.7 per million population in 1975 to 8.8 in 1978, a 40 per cent decrease. Seventy-three per cent of this drop attributable to a reduction in deaths coded to opiates and intravenous narcotism. These two categories accounted for 38 per cent of all unintentional drug deaths in 1975 but only 15 per cent in 1978. There was no simultaneous increase in other drug-related deaths, including suicides, to account for the reduction in deaths coded to opiates. The highest mortality rates and the greatest variation in mortality during 1970-78 occurred in 20-29 year old non-White males. Racial and sex differences in opiate poisoning mortality, notable early in the decade, were greatly reduced by 1978 due to a relatively larger decline in mortality of males and non-Whites. Time trends in mortality from opiate poisoning appear to coincide with variations in the amount of heroin smuggled into the country.     

Leading Causes of Unintentional Injury and Suicide Mortality in Canadian Adults Across the Urban-Rural Continuum

Objective

We examined the leading causes of unintentional injury and suicide mortality in adults across the urban-rural continuum.

Methods

Injury mortality data were drawn from a representative cohort of 2,735,152 Canadians aged ≥25 years at baseline, who were followed for mortality from 1991 to 2001. We estimated hazard ratios and 95% confidence intervals for urban-rural continuum and cause-specific unintentional injury (i.e., motor vehicle, falls, poisoning, drowning, suffocation, and fire/burn) and suicide (i.e., hanging, poisoning, firearm, and jumping) mortality, adjusting for socioeconomic and demographic characteristics.

Results

Rates of unintentional injury mortality were elevated in less urbanized areas for both males and females. We found an urban-rural gradient for motor vehicle, drowning, and fire/burn deaths, but not for fall, poisoning, or suffocation deaths. Urban-rural differences in suicide risk were observed for males but not females. Declining urbanization was associated with higher risks of firearm suicides and lower risks of jumping suicides, but there was no apparent trend in hanging and poisoning suicides.

Conclusion

Urban-rural gradients in adults were more pronounced for unintentional motor vehicle, drowning, and fire/burn deaths, as well as for firearm and jumping suicide deaths than for other causes of injury mortality. These results suggest that the degree of urbanization may be an important consideration in guiding prevention efforts for many causes of injury fatality.Injury is a leading cause of mortality in Canada, accounting for approximately 14,500 deaths each year.¹ Although the majority of injury deaths are unintentional (29.5 deaths per 100,000 inhabitants), intentional deaths due to suicide (11.6 deaths per 100,000 inhabitants) are also common. Research shows that adults in rural areas are disproportionately affected by injury mortality.^2–6 With populations of Western countries aging rapidly, particularly in rural areas,⁷ a better understanding of injury mortality in rural adults becomes increasingly important.Only a limited number of studies have examined the relative contribution of different unintentional and intentional causes to urban-rural differences in injury mortality, despite the potential of cause-specific data to uncover possible underlying mechanisms and pathways for prevention.^8,9 The few studies of unintentional injury that examined causes beyond motor vehicle collisions and falls were limited by dichotomous categorizations of urban and rural areas, which may decrease the ability to capture differences in injury mortality across the range of geographical areas typically present in Western countries. In fact, it has been proposed that a continuum-based approach of urban and rural areas better reflects social, economic, and geographic diversity and may enhance our understanding of health variation across areas.^2,10There is also very limited information on how method-specific suicide mortality varies across the urban-rural continuum. One study found elevated firearm suicide rates in less urbanized areas,¹¹ but data do not exist for more common causes of suicide, such as hanging or poisoning. In light of the identified research gaps, we sought to determine the relationship between the urban-rural continuum and leading causes of unintentional injury and suicide mortality in Canadian adults.