Escalating costs of self-injury mortality in the 21st century United States: an interstate observational study.

BACKGROUND: Estimating the economic costs of self-injury mortality (SIM) can inform health planning and clinical and public health interventions, serve as a basis for their evaluation, and provide the foundation for broadly disseminating evidence-based policies and practices. SIM is operationalized as a composite of all registered suicides at any age, and 80% of drug overdose (intoxication) deaths medicolegally classified as 'accidents,' and 90% of corresponding undetermined (intent) deaths in the age group 15 years and older. It is the long-term practice of the United States (US) Centers for Disease Control and Prevention (CDC) to subsume poisoning (drug and nondrug) deaths under the injury rubric. This study aimed to estimate magnitude and change in SIM and suicide costs in 2019 dollars for the United States (US), including the 50 states and the District of Columbia. METHODS: Cost estimates were generated from underlying cause-of-death data for 1999/2000 and 2018/2019 from the US Centers for Disease Control and Prevention's (CDC's) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Estimation utilized the updated version of Medical and Work Loss Cost Estimation Methods for CDC's Web-based Injury Statistics Query and Reporting System (WISQARS). Exposures were medical expenditures, lost work productivity, and future quality of life loss. Main outcome measures were disaggregated, annual-averaged total and per capita costs of SIM and suicide for the nation and states in 1999/2000 and 2018/2019. RESULTS: 40,834 annual-averaged self-injury deaths in 1999/2000 and 101,325 in 2018/2019 were identified. Estimated national costs of SIM rose by 143% from $0.46 trillion to $1.12 trillion. Ratios of quality of life and work losses to medical spending in 2019 US dollars in 2018/2019 were 1,476 and 526, respectively, versus 1,419 and 526 in 1999/2000. Total national suicide costs increased 58%-from $318.6 billion to $502.7 billion. National per capita costs of SIM doubled from $1,638 to $3,413 over the observation period; costs of the suicide component rose from $1,137 to $1,534. States in the top quintile for per capita SIM, those whose cost increases exceeded 152%, concentrated in the Great Lakes, Southeast, Mideast and New England. States in the bottom quintile, those with per capita cost increases below 70%, were located in the Far West, Southwest, Plains, and Rocky Mountain regions. West Virginia exhibited the largest increase at 263% and Nevada the smallest at 22%. Percentage per capita cost increases for suicide were smaller than for SIM. Only the Far West, Southwest and Mideast were not represented in the top quintile, which comprised states with increases of 50% or greater. The bottom quintile comprised states with per capita suicide cost increases below 24%. Regions represented were the Far West, Southeast, Mideast and New England. North Dakota and Nevada occupied the extremes on the cost change continuum at 75% and - 1%, respectively. CONCLUSION: The scale and surge in the economic costs of SIM to society are large. Federal and state prevention and intervention programs should be financed with a clear understanding of the total costs-fiscal, social, and personal-incurred by deaths due to self-injurious behaviors.

Association of State Social and Environmental Factors With Rates of Self-injury Mortality and Suicide in the United States.

Importance: Self-injury mortality (SIM) combines suicides and the preponderance of drug misuse-related overdose fatalities. Identifying social and environmental factors associated with SIM and suicide may inform etiologic understanding and intervention design. Objective: To identify factors associated with interstate SIM and suicide rate variation and to assess potential for differential suicide misclassification. Design, Setting, and Participants: This cross-sectional study used a partial panel time series with underlying cause-of-death data from 50 US states and the District of Columbia for 1999-2000, 2007-2008, 2013-2014 and 2018-2019. Applying data from the Centers for Disease Control and Prevention, SIM includes all suicides and the preponderance of unintentional and undetermined drug intoxication deaths, reflecting self-harm behaviors. Data were analyzed from February to June 2021. Exposures: Exposures included inequity, isolation, demographic characteristics, injury mechanism, health care access, and medicolegal death investigation system type. Main Outcomes and Measures: The main outcome, SIM, was assessed using unstandardized regression coefficients of interstate variation associations, identified by the least absolute shrinkage and selection operator; ratios of crude SIM to suicide rates per 100 000 population were assessed for potential differential suicide misclassification. Results: A total of 101 325 SIMs were identified, including 74 506 (73.5%) among males and 26 819 (26.5%) among females. SIM to suicide rate ratios trended upwards, with an accelerating increase in overdose fatalities classified as unintentional or undetermined (SIM to suicide rate ratio, 1999-2000: 1.39; 95% CI, 1.38-1.41; 2018-2019: 2.12; 95% CI, 2.11-2.14). Eight states recorded a SIM to suicide rate ratio less than 1.50 in 2018-2019 vs 39 states in 1999-2000. Northeastern states concentrated in the highest category (range, 2.10-6.00); only the West remained unrepresented. Least absolute shrinkage and selection operator identified 8 factors associated with the SIM rate in 2018-2019: centralized medical examiner system (ß = 4.362), labor underutilization rate (ß = 0.728), manufacturing employment (ß = -0.056), homelessness rate (ß = -0.125), percentage nonreligious (ß = 0.041), non-Hispanic White race and ethnicity (ß = 0.087), prescribed opioids for 30 days or more (ß = 0.117), and percentage without health insurance (ß = -0.013) and 5 factors associated with the suicide rate: percentage male (ß = 1.046), military veteran (ß = 0.747), rural (ß = 0.031), firearm ownership (ß = 0.030), and pain reliever misuse (ß = 1.131). Conclusions and Relevance: These findings suggest that SIM rates were associated with modifiable, upstream factors. Although embedded in SIM, suicide unexpectedly deviated in proposed social and environmental determinants. Heterogeneity in medicolegal death investigation processes and data assurance needs further characterization, with the goal of providing the highest-quality reports for developing and tracking public health policies and practices.

Motorcycle Policy and the Public Interest: A Recommendation for a New Type of Partial Motorcycle Helmet Law.

Motorcycle helmet laws are perceived to infringe upon individual rights even though they reduce mortality and health care costs. We describe proposed helmet legislation that protects individual rights and provides incentives for helmet use through a differential motorcycle registration fee that requires higher fees for those who wish to ride without a helmet.

Acute alcohol use among suicide decedents in 14 US states: impacts of off-premise and on-premise alcohol outlet density.

AIMS: To estimate the association between per capita alcohol retail outlet density and blood alcohol concentration (BAC) from 51 547 suicide decedents and to analyse the relationship between alcohol outlet density and socio-demographic characteristics among alcohol-positive suicide decedents in the United States by racial/ethnic groups and method of suicide. DESIGN: Analysis of US data, 2003-11, National Violent Death Reporting System. SETTING: Suicide decedents from 14 US states. PARTICIPANTS: A total of 51 347 suicide decedents tested for BAC. MEASUREMENTS: BAC and levels were derived from coroner/medical examiner reports. Densities of county level on-premises and off-premises alcohol retail outlets were calculated using the 2010 Census. FINDINGS: Multi-level logistic regression models suggested that higher off-premises alcohol outlet densities were associated with greater proportions of alcohol-related suicides among men-for suicides with alcohol present [BAC >0; adjusted odds ratio (AOR) = 1.08, 95% confidence interval (CI) = 1.03-1.13]. Interactions between outlet density and decedents' characteristics were also tested. There was an interaction between off-premises alcohol availability and American Indian/Alaska Native race (AOR = 1.36; 95% CI = 1.10-1.69) such that this subgroup had highest BAC positivity. On-premises density was also associated with BAC >0 (AOR = 1.07; 95% CI = 1.03-1.11) and BAC ≥0.08 (AOR = 1.05; 95% CI = 1.02-1.09) among male decedents. CONCLUSIONS: In the United States, the density of both on- and off-premises alcohol outlets in a county is associated positively with alcohol-related suicide, especially among American Indians/Alaska Natives.

A history of being prescribed controlled substances and risk of drug overdose death.

OBJECTIVE: The abuse of prescription drugs has increased dramatically since 1990. Persons who overdose on such drugs frequently consume large doses and visit multiple providers. The risk of fatal overdose for different patterns of use of opioid analgesics and sedative/hypnotics has not been fully quantified. DESIGN: Matched case-control study. Cases were 300 persons who died of unintentional drug overdoses in New Mexico during 2006-2008, and controls were 5,993 patients identified through the state prescription monitoring program with matching 6-month exposure periods. OUTCOME MEASURES: Death from drug overdose or death from opioid overdose. Exposures were demographic variables and characteristics of prescription history. Crude and adjusted odds ratios (AOR) were calculated. RESULTS: Increased risk was associated with male sex (AOR 2.4, 95% confidence interval [CI] 1.8-3.1), one or more sedative/hypnotic prescriptions (AOR 3.0, CI 2.2-4.2), greater age (AOR 1.3, CI 1.2-1.4 for each 10-year increment), number of prescriptions (AOR 1.1, CI 1.1-1.1 for each additional prescription), and a prescription for buprenorphine (AOR 9.5, CI 3.0-30.0), fentanyl (AOR 3.5, CI 1.7-7.0), hydromorphone (AOR 3.3, CI 1.4-7.5), methadone (AOR 4.9, CI 2.5-9.6), or oxycodone (AOR 1.9, CI 1.4-2.6). Patients receiving a daily average of >40 morphine milligram equivalents had an OR of 12.2 (CI 9.2-16.0). CONCLUSIONS: Patients being prescribed opioid analgesics frequently or at high dosage face a substantial overdose risk. Prescription monitoring programs might be the best way for prescribers to know their patients' prescription histories and accurately assess overdose risk.

Guidelines to implement medical examiner/coroner-based surveillance for fatal infectious diseases and bioterrorism ("Med-X").

Medical examiners and coroners investigate deaths that are sudden, unexplained, and violent. Oftentimes these deaths are a consequence of infections, many of which have public health consequences. Additionally, because deaths from bioterrorism are homicides, they fall under the jurisdiction of medical examiners and coroners. Surveillance for infectious disease-related deaths can enhance the opportunities to recognize these deaths. Beginning in 2000, the New Mexico Office of the Medical Investigator developed and tested a medical examiner surveillance model for bioterrorism and infectious disease mortality ("Med-X") using a set of symptoms to determine which cases should receive an autopsy and a set of pathology-based syndromes for early reporting of cases to public health authorities. This model demonstrated that many of the symptoms had a high predictive value for infections and were useful criteria for autopsy performance. The causative organism was identified for 81% of infections of which 58% were notifiable conditions by public health standards. Uniform criteria for performing autopsies and reporting cases to public health authorities enhance surveillance for notifiable infectious diseases and increase the probability of recognizing fatalities related to bioterrorism. We have developed guidelines for medical examiners, coroners and their public health partners to use in implementing Med-X surveillance in their jurisdictions. These guidelines encompass definitions of symptoms and syndromes, specimen collection and storage procedures, laboratory diagnostic approaches, and processes for case flow, case reporting, and data collection. We also suggest resources for autopsy biosafety information and funding.

John and Jane Doe: the epidemiology of unidentified decedents.

The number of people who cannot be identified at the time of death, sometimes referred to as John or Jane Does, is unknown, and little is known about them as a group. The study's objectives were to estimate the number of annual unidentified deaths, to identify demographic characteristics associated with dying unidentified, to determine whether the rates of such deaths vary geographically or over time, and to better characterize the causes of death. This was a population-based surveillance study of data collected from death certificates from 1979 to 2004 in the U.S. Subjects were selected by the absence of name, date of birth, and Social Security Number on their certificates. Main outcome measures were distributions by age, sex, and underlying cause of death and rates by sex, race, year, and state of death. An average of 413 unidentified persons died each year. The peak year was 1987 with 691 deaths, a rate of 28.5 per 10 million people. The rate declined to 9.7 per 10 million in 2004. Most unidentified decedents were male (80.6%). Unidentified death rates were highest among black people and in the Southwest. Among deaths for which the cause was known, 82.7% were due to injuries. Among injury deaths, 31.8% were homicides. Improvement in identification technology may have reduced rates of unidentified death since the 1980s. In addition, variations in rates of unidentified decedents may reflect changes in risk factors such as homelessness and substance abuse.

Research issues in forensic pathology: a survey of academic institutions employing forensic pathologists.

In an effort to characterize research efforts in forensic pathology, a questionnaire was sent to a representative of each of the 14 academic medical centers that employ full-time faculty forensic pathologists. Responses were received from all 14 (100%) of the institutions queried, representing a total of 39 forensic pathology faculty positions; 21 positions were tenure track and 18 positions were clinical or other tracks. Of the 39 positions, 25 positions (64%) at 10 institutions required some degree of research or scholarly output. Of the 25 forensic pathologists with a research imperative, only 3 (12%) were principal investigators or co-investigators on funded forensic pathology-based projects. The major limitation cited by respondents on the performance of forensic pathology research was the lack of protected time from service responsibilities. Fellowship training in forensic pathology was available at 6 of the 14 respondent institutions. Of these institutions, 4 (67%) had a research requirement for trainees, and 4 (67%) provided research training. In conclusion, very few US medical schools currently employ full-time faculty forensic pathologists. Of these, only a small number of institutions prioritize research by these faculty members. Scant federal funds are available to support research in forensic pathology. Few forensic pathology fellowship programs provide research training. To achieve a robust research agenda in forensic pathology that is sufficient to support the needs of the criminal justice and public health systems will require a paradigm shift in the medicolegal death investigative system and investment by federal agencies.