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How do we and how should we define and

count poisoning deaths in the United


States?
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Disease Control and Prevention
National Center for Health Statistics
Lois A. Fingerhut, MA
Special Assistant for Injury Epidemiology, OAE
Robert N. Anderson, PhD
Chief, Mortality Statistics Branch, DVS
Objectives
To consider revising the existing matrix
definition of poisoning to include relevant
codes from the F10-F19 series of the
Mental and Behavioral Disorders chapter
of the ICD
To better understand what is gained from
analyzing multiple cause of death data for
poisoning


How are poisoning deaths
currently defined?

1. By the List of 113 Causes (used to rank
leading causes of death in the US): the
underlying cause ICD-10 codes for
Unintentional poisoning are X40-X49
2. By the External Cause of Injury Mortality
Matrix as the underlying cause for
poisoning regardless of intent
[Recommended by NCHS and Injury ICE]
Poisoning is defined in the Matrix by
ICD-10 codes by intent
ICD also codes broad substance groups
Drug Alcohol Gases
/vapors
Other solid/
liquids
Unintentional X40-X44 X45 X47 X46,X48-X49
Suicide X60-X64 X65 X67 X66,X68-X69
Homicide X85 X88 X86-X87,X89-
X90
Undetermined Y10-Y14 Y15 Y17 Y16,Y18-Y19
Legal int. Y35.2
Terrorism *U01.7 *U01.6
Poisoning deaths- 2002
Drug Alcohol Other
solid/liq
Gases
/vapors
Percent 89% 2% 1% 8%
Unintentional 66% 16,394 355 161 640
Suicide 21% 3,884 26 157 1,419
Homicide 43 na 5 15
Undetermined 13% 3,197 25 43 71
Legal int. na na na 0
Terrorism na na 0 0
Based on the matrix definition,
poisoning was, in 2002,
3rd leading cause of injury death overall;
distant 2nd for unintentional injury;
3rd for suicide
leading cause for intent undetermined.

Should codes be added to the
definition of poisoning?
Being considered are underlying ICD-10
codes F10-F19 for Mental and Behavioral
disorders (MBD) due to pyschoactive
substance use
The precise wording on the death
certificate can determine whether a drug
or alcohol related death is assigned an
underlying cause of poisoning or a F10-
F19 code.


F10-F19:
If so, which codes should be added?
F10 Alcohol
F11Opioids
F12 Cannabinoids
F13 Sedatives/hypnotics
F14 Cocaine
F15 Other stim.,incl. caffeine
F16 Hallucinogens
F17 Tobacco
F18 Volatile solvents
F19 Mult drug use & other
psycho. substances
4
th
digit of these codes:
.0 Acute intoxication
.1 Harmful use
.2 Dependence syndrome
.3-.4 Withdrawal states
.5 Psychotic disorder
.6 Amnesic syndrome
.7 Residual/late onset
psychotic disorder
.8 Other MBD
.9 Unspecified MBD

3 digit ICD-10 codes
For each 3 digit code:
.0-.1 and .3-.9=Nondependent abuse
.2=Dependent abuse
F10-F19 Deaths: 2002
Acute Harmful Dependence Withdrawal
Intoxication use Syndrome state Other Unspecified
.0 .1 .2 .3-.4 .5-.8 .9
Alcohol F10 6,842 617 1,741 3,679 212 195 398
Drugs: 2,137 15 1,399 390 14 8 311
Opioids F11 281 148 75 2 56
Cannabinoids F12 2 1 1
Sedatives/hypnotics F13 3 1 2
Cocaine F14 437 11 266 50 1 6 103
Other stimulants F15 52 4 28 5 1 14
Hallucinogen F16 5 4 1
Volatile solvents F18 5 4 1
Multiple drug/other F19 1,352 948 258 9 1 136
[MBD due to tobacco use (F17) is not included as a drug. F17 was the
underlying cause of 549 deaths in 2002.]
Alcohol and drug-related deaths
from MBD 1999-2002
Slow but steady increases in alcohol-related (except intoxication) deaths
as well as nondependent drug abuse deaths
100
1,000
10,000
1999 2000 2001 2002
N
u
m
b
e
r

o
f

d
e
a
t
h
s
Alcohol dependence F10.2
Alcohol, nondependence, F10 (.1,.3-.9)
Alcohol intoxication, F10.0
Drug, nondependence F11-F16, F18-F19 (.0-.1, .3-.9)
Drug dependence, F11-F16, F18-F19 (.2)
Multiple cause codes identify the
specific drug or substance
Multiple cause of death codes are often
referred to as nature of injury codes; for
poisoning and toxic effects in ICD-10
these are T36-T65.
Too often they are neglected in analyses.
T codes
T36-T50: Poisoning by drugs, medicaments and
biological substances
T51-T65: Toxic effects of substances chiefly
nonmedicinal as to source

Using these nature of injury poisoning codes,
29,974 deaths had at least one mention of a
poison or toxic substance, and there were a total
of 49,946 mentions of substances.
For all underlying-external cause poisoning
deaths, an average of 1.9 total substances were
listed per death



Leading substances in multiple cause
data by underlying cause of death : 2002
-
1,000
2,000
3,000
4,000
5,000
6,000
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All other underlying causes (including F10)
Drug Dependence
Drug - NonDependence
Other ext. injury deaths
External Poisoning- Matrix definition
Drugs and toxic effect substances mentioned in multiple cause data
Underlying causes of death
WHOs Mortality Reference
Group (MRG)
The MRG makes decisions regarding the
application and interpretation of ICD to
mortality and makes recommendations on
proposed ICD updates to the Update
Reference Committee (URC).

The URC recommends changes to the
ICD-10 to the Heads of WHO
Collaborating Centers for the Family of
International Classifications each year.
If the death certificate has language that
includes words that would have resulted in an
underlying cause code of F10-F19 with a 4
th
digit
of 0, the new rule will result in coding to an
underlying external poisoning code for alcohol.

The largest impact in the US will be more deaths
coded to X45 [Accidental poisoning by and
exposure to alcohol] because nearly all of the
F10-F19 codes with a 4
th
digit of 0 are for
alcohol (F10.0)
The MRG has recommended:
Deaths due to Acute Intoxication
Regarding all F10-F19:
If the underlying cause would have resulted in
any code F10-F19 and the certificate also
included information ascribed to an external
cause poisoning code, the new rule will result in
underlying cause codes going to the external
causes.

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

These changes will be implemented in 2006.
Recommendation
At a minimum, consider expanding the
definition of poisoning deaths beyond the
number based on matrix (26,435 deaths in
2002) to include deaths due to alcohol
intoxication (617 deaths), and deaths due to
drug non-dependence (1,747)


3 leading causes of injury death:
2002
0 10,000 20,000 30,000 40,000 50,000
MVT
Firearm
Poisoning
Deaths
Matrix definition
Drug- nondependence*
Alcohol intoxication*
Alcohol- other F10's
Alcohol Dependence (.2)
Drug Dependence
Will poisoning soon become the 2
nd
leading cause of injury death??
Conclusion
Death certificate wording determines
whether a drug or alcohol-related death
is assigned an underlying cause of
poisoning or mental or behavioral
disorder. Recommendations on formal
definitions must follow broad-based
discussions among communities of
toxicologists, medical examiners, and
injury epidemiologists.

National Academy of Science
May 2004
U.S. Institute of Medicine has recommended that:

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

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

From: Forging a Poison Prevention and Control System (2004)
LFingerhut@cdc.gov

RNAnderson@cdc.gov