An Underestimation of Heroin Deaths Due to the Use of "Acute Opiate Intoxication" on Death Certificates.

Introduction: Deaths due to drug intoxications in the United States have increased. Public health agencies track the specific intoxicants using death certificate data in order to develop and focus prevention strategies. Criteria used to decide what deaths need toxicological investigation and how these deaths are certified will affect this data.

Methods: We retrospectively reviewed the investigative, autopsy, and toxicology reports of 118 fatal intoxications that were certified as "acute opiate intoxication."

Results: Of the 113 decedents in whom morphine was detected, 84 were determined to involve heroin. For 61 of 84 heroin deaths, the heroin diagnosis was based upon the detection of diacetylmorphine, 6-acetylmorphine, and/or a lower blood codeine to morphine concentration. For 23 of 84 deaths, the determination was based upon morphine detection and illicit substances and/or paraphernalia at the scene. Of the 61 of 84 heroin deaths diagnosed by direct toxicology results, 33 of the 61 (54%) did not have illicit substances or paraphernalia at the scene. Toxicology identified 33 of 84 (39%) heroin fatalities that would not have been distinguished from morphine intoxication by the scene investigation.

Conclusions: The majority of deaths due to opioids can be further classified based upon the toxicological analysis and scene investigation. As heroin deaths may have no illicit substances/paraphernalia at the scene, investigators should not solely base their decision to perform an autopsy/toxicology on the scene absence of illicit drugs/paraphernalia. In our study sample, if toxicology testing were to be only performed when illicit substances/paraphernalia were found at the scene, a high portion of heroin deaths (39%) would have been missed.