Differences in overdose deaths by intent: Unintentional & suicide drug poisonings in North Carolina, 2015-2019.

Comprehensive fatal overdose prevention requires an understanding of the fundamental causes and context surrounding drug overdose. Using a social determinants of health (SDOH) framework, this descriptive study examined unintentional and self-inflicted (i.e., suicide) overdose deaths in North Carolina (NC), focusing on specific drug involvement and contextual factors. Unintentional and suicide overdose deaths were identified using 2015-2019 NC death certificate data. Specific drug involvement was assessed by searching literal text fields for drug mentions. County-level contextual factors were obtained from NC Institute of Medicine and County Health Rankings, encompassing five SDOH domains (economic stability, social/community context, health care access/quality, education access/quality, neighborhood/built environment). Descriptive statistics were calculated by intent for drug involvement and a variety of contextual factors. During 2015-2019, 9% of NC drug overdose deaths were self-inflicted and 89% were unintentional (2% other/undetermined). Unintentional overdoses largely involved illicit drugs [fentanyl (47%), cocaine (33%), heroin (29%)]. Suicide overdoses frequently involved prescription opioids [oxycodone (18%), hydrocodone (10%)] and antidepressants (32%). Overall, overdose deaths tended to occur in under-resourced counties across all SDOH domains, though unintentional overdoses occurred more often among residents of under-resourced counties than suicide overdoses, with differences most pronounced for economic stability-related factors. There are notable distinctions between unintentional and suicide overdose deaths in demographics and drug involvement, though the assessment of SDOH demonstrated that overdose mortality is broadly associated with marginalization across all domains. These findings highlight the value of allocating resources to prevention and intervention approaches that target upstream causes of overdose (e.g., housing first, violence prevention programs).

Pediatric opioid fatalities: What can we learn for prevention?

The aim of this study was to highlight 19 cases investigated by the North Carolina Office of the Chief Medical Examiner over the last 12 years involving accidental or undetermined manner of death opioid ingestions leading to fatalities in young children. These pediatric ingestions have closely mirrored the opioid epidemic in adults transitioning from prescription medications to illicit drugs including fentanyl and fentanyl analogues. Unlike a typical adult ingestion for purposes of self-harm or pleasure, poisonings in toddlers and infants are usually the result of curiosity, exploration, a decreased sense of danger, or imitation of adult or older sibling behavior. Eleven of the decedents were between the ages of 8 and 24 months. Among the cases were 12 prescription opioid exposure deaths and 7 illicit drug poisonings. A majority of the decedents were found unresponsive in an unkept home and/or in unsafe sleeping spaces with easy access to drugs or drug materials, which stresses the importance of safe pediatric sleeping conditions. After a complete pathological investigation, several of the cases had physical or scene evidence demonstrating that foil, plastic, or paper small enough to be ingested can contain enough potent opioid to cause death. Details from the toxicological investigation are included for each case to provide postmortem whole blood drug concentrations for forensic practitioners. Accidental pediatric poisonings are preventable. Risk reduction through improving awareness and education of the dangers of opioids is a key factor in mitigating these tragedies.

Literal text analysis of poly-class and polydrug overdose deaths in North Carolina, 2015-2019.

BACKGROUND: The literal text on death certificates was leveraged to enhance the examination of trends in the specific drugs and drug combinations involved in North Carolina (NC) overdose deaths from 2015 to 2019. METHODS: Using NC death certificate data, overdose deaths included those with a drug poisoning as the underlying ICD-10 cause-of-death code (n = 10,117). The literal text from three death certificate fields were searched for drug mentions by integrating a tool developed by the Council of State and Territorial Epidemiologists Overdose Subcommittee with search terms originating from a National Center for Health Statistics/Food and Drug Administration collaboration. Descriptive statistics were calculated to evaluate substance classes, specific drugs, and drug combinations most frequently involved in these deaths over time. RESULTS: From 2015-2019, polydrug involvement in NC overdose deaths increased (71% in 2015 to 75% in 2019). During the study period, opioid involvement shifted from heroin and/or oxycodone in 2015 to predominantly fentanyl in 2019, with fentanyl involvement increasing from 15% to 58%. Psychostimulant involvement increased for both cocaine (2015: 21%, 2019: 35%) and methamphetamine (2015: 3%, 2019: 13%). Benzodiazepine involvement, including alprazolam and clonazepam, declined during the study period, while the involvement of alcohol and antiepileptics/sedative-hypnotics, specifically gabapentin, remained stable. The top polydrug combinations in 2019 were fentanyl + cocaine (15% of all overdose deaths), fentanyl + heroin (10%), fentanyl + cocaine + heroin (6%), and fentanyl + methamphetamine (4%). CONCLUSIONS: Incorporation of literal text methodology into ongoing overdose surveillance can facilitate the identification of specific, emerging drugs and combinations and inform targeted overdose prevention approaches.

Takayasu Arteritis in a 19-Year-Old Black Male: Case Report and Review of the Literature.

Takayasu arteritis (TA) is a rare idiopathic vasculitis of large blood vessels. Prevalence is highest in Japan, with predominance in young females. Classic signs and symptoms include limb claudication, decreased/absent distal pulses, vascular bruits, and blood pressure discrepancy between arms. Without treatment, progression leads to mural fibrosis, stenosis, hypertension, thrombus formation, and ischemic changes of surrounding tissue. Takayasu arteritis is usually a clinical and radiographic diagnosis and has a low mortality rate with effective treatment. Here, we present an unexpected case of TA in a 19-year-old black male diagnosed at autopsy. No suggestion of vasculitis was noted during antemortem workup. Takayasu arteritis may be encountered in the forensic setting in cases of sudden death in a young person, especially in the context of an atypical demographic.

Suicidal Drug Overdoses in New Mexico: A 5-year Retrospective Review.

To better understand the changing toxicology trends in suicidal drug overdoses in the setting of an increased national trend of multidrug overdoses, a retrospective review of electronic records from New Mexico's Office of the Medical Investigator database was performed between 2008 and 2012 to assess the drug type and current risk factors in suicide deaths. Information on demographics, circumstances, suicide risk factors, toxicology findings, and death certificates was collected and analyzed. Three hundred and forty-two suicide cases of suicide overdoses were identified. Decedents were predominantly female (61.8%). Scene investigation revealed risk factors including suicide ideation (47.4%), previous suicide attempts (38%), and suicide note (38%). Psychiatric illness was present in 72% of cases, with depression being the most common illness. Chronic pain was seen in 27.2% of cases. Most deaths were attributed to multiple drugs (76%). Utilizing the toxicology information will assist in creating public awareness and provide a framework to support targeted efforts to attempt to prevent future suicides.

Lightning deaths: a retrospective review of New Mexico's cases, 1977-2009.

To better understand lightning deaths, a retrospective review of electronic records from New Mexico's Office of the Medical Investigator database was performed between 1977 and 2009 to update and assess current risk factors. Information on demographics, circumstances, autopsy, and death certificates were collected and analyzed. Fifty-four decedents were identified, ages 2-71 years old (mean 34 years old), 42 males and 12 females. Common racial/ethnic groups were non-Hispanic Whites and American Indians (together comprising 72% of all cases). Physical findings were often related to the heat carried by the electrical current including clothing alterations (29.6%) and burning of skin (53.7%). Most deaths occurred on weekend afternoons in summer months, associated with recreational activities or agricultural work, and rural locations (77.8%). Utilizing the demographic information, clustered events, and associated outdoor activities will assist in creating public awareness and provide a framework to support targeted warnings in an attempt to prevent future deaths.

Utility of a grief services program for medical examiners' offices.

Medical examiner/coroner's (ME/C) offices investigate sudden, violent, and unexpected deaths, leaving those close to the deceased suffering traumatic loss with little in terms of support and counseling. We investigated a grief services program (GSP) at the New Mexico Office of the Medical Investigator (OMI) to better understand the needs of bereaved individuals, identify the services provided, and propose our findings as a model for others. A total of 1085 contacts occurred over 1 year, with the majority occurring at OMI (60.5%), followed by telephone (23.1%). Support was primarily provided to those suffering a loss due to homicide (28.8%) and suicide (26.1%). The roles grief counselors play in the setting of a GSP and ME/C office are multiple. Given the frequent utilization of OMI's GSP and diverse reasons for visits, it is apparent there is a need for GSPs at ME/C offices, particularly given the traumatic nature of deaths investigated by ME/Cs.