The frequency of deaths resulting from the use of drugs and chemicals in Los Angeles County

Sections

ABSTRACT
Introduction
Method
Results and discussion

Details

Author: R. D. BUDD,, D. M LINDSTROM,, E. C. GRIESEMER and , T. T. NOGUCHI
Pages: 41 to 49
Creation Date: 1983/01/01

The frequency of deaths resulting from the use of drugs and chemicals in Los Angeles County

.

R. D. BUDD,
D. M LINDSTROM,
E. C. GRIESEMER and
T. T. NOGUCHI
Los Angeles County Chief Medical Examiner-Coroner, Los Angeles, California, United States of America

ABSTRACT

A study of the frequency of deaths resulting from the use of drugs and chemicals in Los Angeles County in the period 1947 - 1980 indicated that there was a substantial increase in the number of such deaths in 1968/69. This trend continued until 1976/77 when the number of deaths decreased, and the declining trend continued until 1979/80. An additional study in the period 1974 - 1981, based on the analyses of 35 drugs in biological samples taken in autopsies, showed that those drugs were more often present in overdose cases of death than in drug-related cases of death where drugs were not directly responsible for the occurrence of death. Ethanol and phencyclidine were, however, more frequently found in drug-related cases of death.

Introduction

Drug abuse has been a social problem for many years; but over the past 15 years it has become a serious problem in the United States of America, especially in urban areas such as Los Angeles County.

Two studies on drug use trends among methadone maintenance patients and probationers in Los Angeles County, covering the period 1975 - 1980, have been published [1, 2]. The scope of those studies was, however, too narrow to get an overall picture. This paper presents the results of two broader-based studies carried out in Los Angeles County with the aim of supplementing the results obtained in the two earlier studies.

Method

The first of the studies was undertaken in order to examine the frequency of death as a result of the use of drugs and chemicals in Los Angeles County during the period 1974 - 1980.

The second study analysed the relationship of drugs and death over the period 1974 - 1981. It covered both overdose cases of death, and drug related cases in which drugs were not directly responsible for the occurrence of death. The study focused on the frequency of occurrence of 35 of the drugs most commonly found in biological samples taken from the victims, and does not indicate whether or not they were a factor in death. The pathologists who performed autopsies in both overdose cases of death and drug-related cases of death requested analyses of the drugs involved. Human biological samples were analysed for drugs and poisons by procedures adopted from other authors [ 3] - [ 15] . Gas chromatography was the primary analysis tool, while complementary analyses were performed using gas chromatography/mass spectrometry, thin-layer chromatography, colorimetry, ultraviolet spectrometry, and radioimmunoassay. These methods have been found quite capable of measuring drug concentrations in biological samples with accuracy and precision [ 16] .

Results and discussion

Frequency of death as a result of the use of drugs and chemicals in Los Angeles County 1947 - 1980

Table 1 shows both the number of deaths as the result of the use of drugs and chemicals and the rates per 100,000 population in Los Angeles County during the period 1947 - 1980. There was a slight overall increase from 1947/48 to 1967/68. Then, a substantial increase (66 per cent) occurred in 1968/69 compared with the previous fiscal year. This increase may reflect the beginning of the drug culture which developed on the college campuses in the late 1960s and the early 1970s. A substantial decrease in the number of deaths began in 1976/77 and the declining trend continued in subsequent years. These findings parallel the results obtained in a study indicating a decrease in drug use among the Los Angeles County probationers in the period 1976 - 1979 [ 2] . The reasons for the decrease are not clear, although the decreasing popularity of drugs and the increasing popularity of alcohol occurring in the county might, at least to a certain extent, account for such a decrease.

Analyses of drugs in biological samples taken during autopsies of cases of death 1974 - 1981

The frequency of occurrence of the 35 most commonly found drugs was studied in biological samples of drug overdose cases of death and drug related cases of death in the period 1974 - 1981 (table 2). It should be noted that the occurrence of a given drug in the biological samples of the victim as

Table 1

Deaths due to drugs and chemicals in Los Angeles County, 1947-1980

1947/48
3747000 297 7.9
1948/49
3952000 347 8.8
1949/50
4090000 280 6.9
1950/51
4172220 311 7.5
1951/52
4302415 328 7.6
1952/53
4511737 333 7.4
1953/54
4676863 320 6.8
1954/55
4890567 398 8.1
1955/56
5085864 393 7.7
1956/57
5290246 417 7.9
1957/58
5507429 384 7.0
1958/59
5709011 395 6.9
1959/60
5919368 453 7.7
1960/61
6068148 396 6.5
1961/62
6337000 491 7.8
1962/63
6469000 605 9.4
1963/64
6604000 634 9.6
1964/65
6723000 629 9.4
1965/66
6814000 558 8.2
1966/67
6880000 507 7.4
1967/68
6941000 630 9.1
1968/69
7001000 1044 14.9
1969/70
7044721 1139 16.2
1970/71
7032075 1359 19.3
1971/72
7090452 1152 16.3
1972/73
7098826 1045 14.7
1973/74
7000679 1060 15.1
1974/75
6992299 1080 15.4
1975/76
7018603 1195 17.0
1976/77
7042538 943 13.4
1977/78
7083431 846 11.9
1978/79
7146500 696 9.7
1979/80
7441302 501 6.7

recorded in this study does not mean that the drug found was necessarily a causative factor of death. For example, some fatal overdose cases were the result of drug combinations. In some overdose cases several drugs had been taken, therapeutically or otherwise, but only one in sufficient quantity to be called an overdose. In still other overdose cases, an additional drug such as lidocaine might have been administered in attempts to revive the victim or to counteract the effects of the drug taken in overdose. It should also be noted that some of the drugs detected and indicated in table 2 may be metabolities of other drugs taken before death. Similar considerations apply in drug related cases of death.

Frequency of the occurrence of 35 analysed drugs in biological sampIes taken during autopsies of death cases a, Los Angeles County, 1974-1981;

Table 2

 

Drugs found in overdose cases of death

Drugs found in drug-related cases of death

Drug

1974

1975

1976

1977

1978

1979

1980

1981

1974

1975

1976

1977

1978

1979

1980

1981

Morphine
450 567 387 127 120 85 72 165 53 43 44 56 49 41 40 42
Codeine
82 87 99 119 119 90 120 166 4 5 6 35 34 39 36 34
Methadone
12 19 16 14 16 25 20 27 3 0 1 9 7 4 7 6
Propoxyphene
70 83 71 97 66 35 39 45 10 8 10 16 10 7 5 8
Meperidine
1 9 4 15 4 2 2 5 0 2 4 3 1 1 0 1
Pentozocine
3 7 7 13 7 2 3
l
0 0 1 2 1 0 0 3
Phencyclidine
0 0 5 13 19 26 11 16 0 0 14 49 102 63 93 122
Cocaine
1 7 11 10 11 16 23 24 0 0 0 3 6 5 9 11
Lidocaine
7 8 9 8 5 8 17 21 0 12 31 2 11 6 16 8
Amphetamine
10 4 3 3 2 4 1 1 5 0 2 1 0 0 2
l
Caffeine
0 21 29 33 23 20 18 27 0 5 67 6 5 4 4 3
Diphenhydramine
3 9 9 12 4 1 4 11 0 0 6 4 2 2 3 8
Doxepin
12 13 20 3 25 26 18 19 3 5 2 9
l
5 5 3
Imipramine
15 9 20 11 15 15 11 6 1 2 2 2 0 0 1 2
Desipramine
0 0 0 12 8 1 15 7 0 0 0 2 0 0 0 0
Amitriptyline
36 73 82 70 73 54 39 66 2 9 10 19 13 11 8 5
Nortriptyline
0 0 0 8 13 6 10 7 0 0 0 0 0 0 0 0
Salicylate
8 12 14 16 10 15 20 20 2 0 2 1 3 4 4 0
Phenacetin
2 8 13 27 25 9 15 11 0 0 2 8 1 1 3 1
Acetaminophen
0 0 0 10 18 14 18 38 0 0 0 0 4 5 6 2
Barbiturates
476 527 462 416 334 235 230 209 340 189 221 260 152 131 129 83
Diazepam
101 98 45 88 74 23 18 36 14 17 7 25 27 9 11 13
Chlordiazepoxide
7 20 11 7 6 2 6 1 1 3 2 1 3 0 0 0
Flurazepam
3 6 7 12 12 5 14 10 0 0 1 0 0 3 2 2
Ethanol
355 522 367 256 182 167 166 193 1206 1068 1210 1381 1590 1714 1903 2295
Dilantin
9 16 12 9 4 0 2 4 6 11 5 10 7 4 9 2
Glutethimide
17 14 21 19 21 11 15 30 2 4 2 3 3 0 0 4
Meprobamate
25 31 23 23 28 13 11 15 6 10 6 4 1 7 3 2
Carisoprodol
3 8 1 4 5 2 4 1 0 2 2 1 0 0 0 0
Methaqualone
15 14 10 17 23 14 6 14 1 1 12 9 10 6 6 13
Thioridazine
12 26 18 17 10 9 7 0 11 9 5 17 5 1 4 0
Chlorpromazine
10 17 7 14 7 3 9 2 3 1 5 5 2 0 0 0
Ethclorvynol
27 23 58 30 54 33 11 21 5 2 14 8 5 5 5 4
ChloralHydrate
28 49 41 25 26 23 29 21 5 2 5 4 9 1 5 9
Methyprylon
18 24 13 9 7 9 3 2 2 2 0 1 2 1 0 1

aThe number indicating the frequency of the occurrence of a given drug does not necessarily indicate the number of cases of death as more than one drug could be found in one case of death.

An example is the case of a victim who was taking amitriptyline for depression, codeine for a cough, alcohol with dinner, and then took an overdose of methaqualone when committing suicide. Even though methaqualone was the drug that caused death, the presence of codeine, morphine, amitriptyline, nortriptyline and ethanol were recorded in table 2.

The analyses of drugs in overdose cases showed that the frequency of occurrence of the following drugs decreased substantially during the period 1974 - 1981: barbiturates, diazepam, ethanol, meprobamate, morphine (heroin), methaqualone, amphetamine, propoxyphene, imipramine, thioridazine, chlorpromazine, chloral hydrate and methyprylon. In contrast, the frequency of the occurrence of the following drugs increased : flurazepam, codeine, cocaine, phencyclidine and methadone.

In drug-related cases of death, the frequency of the occurrence of barbiturates decreased, while ethanol, codeine and phencyclidine increased.

A comparison of the data in the two cases showed that most drugs were more commonly found in overdose cases than in drug-related cases of death. In contrast, ethanol and phencyclidine were found much more frequently in drug-related cases than in overdose cases of death. It should be noted that there was a growing popularity of ethanol and phencyclidine in the same period. While lidocaine has increasingly been used as a drug of treatment in attempts to revive victims [ 17] , it was not implicated as a cause of death in any of the cases studied.

Table 3 shows that most overdose deaths occurred in the 20 - 39 age group. The death rate for teenagers decreased from 1970 to 1 980, while that for persons in their thirties increased. One possible explanation is that persons in their twenties when the drug culture peaked in the early 1970s were in their thirties at the time of the survey.

Table 3

Overdose cases of death in 1970, 1976 and 1980: Breakdown by age

(Percentage)

 

Age

Year

9 or below

10-19

20-29

30-39

40-49

50-59

60-69

70 or over

1970 0.3 11 32 16 14 12 8 6
1976 0.6 5 36 23 15 11 5 4
1980 0.6 3 32 29 15 9 6 5

The percentage of overdose deaths occurring among males were similar to those among females except in 1975, when it was considerably higher among males than females (see table 4).

Table 4

Overdose cases of death in 1970, 1975, 1977 and 1980 : Breakdown by sex

(Percentage)

Year

Male

Female

1970 50.9 49.l
1975 60.5 39.5
1977 54.5 45.5
1980 52.0 48.0

The number of overdose deaths that occurred in accidents increased over the period 1960 - 1980 (see table 5) with a slightly reversed trend at the end of the survey. The number of overdose deaths occurring in suicides during the same period showed a variation between the years studied but in general there was a decreasing tendency.

Table 5

Overdose cases of death by mode of death in 1960, 1970, 1976 and 1980 :

Breakdown by mode of death

(Percentage)

Year

Accident

Suicide

Undetermined

1960 20 79 1
1970 31 60 9
1976 64 35 1
1980 52 46 2

The percentages of overdose deaths among blacks and whites were greater than expected on the basis of their relative number in the country population. For Hispanics and Asians the percentages were lower (table 6).

Table 6

Overdose cases of death in 1970, 1975 and 1980: Breakdown by race and ethnic origin

(Percentage)

Year

White

Black

Hispanic

Asian

1970 75 15 8 1
1975 69 15 15 1
1980 74 20 5 2
Proportion of racial or ethnic group in the county population
55-67 11-13 18-30 3-5

References

01

R. D. Budd, "Changes in the frequency of use and abuse of drugs by Los Angeles County methadone maintenance patients: an observation based on urine drug testing in 1975 and 1979", Bulletin on Narcotics (United Nations publication), vol. 33, No. 2 (1981), pp. 27 - 30.

02

R. D. Budd, "Drug use trends among Los Angeles County probationers over the last five years", American Journal of Drug and Alcohol Abuse, vol. 7, 1980, pp. 57 - 69.

03

J. D. H. Cooper, "Estimation of blood ethanol by gas chromatography", Clinica Chimica Acta, vol. 33, 1971, pp. 483 - 485.

04

R. Cleeland and. others, "A imple rapidt 125I radioimmunoassay for the detection of barbiturates in biological fluids", Journal of Forensic Sciences, vol. 20, 1975, pp. 45 - 57.

05

R. R. Skinner, E. G. Gallaher and D. B. Predmore, "Rapid determination of barbiturate by gas chromatography-mass spectrometer", Analytical Chemistry, vol. 45, 1973, pp. 574 - 576.

06

J. V. Jackson, "Extraction methods in toxicology", in "Isolation and identification of drugs", E. G. C. Clarke, ed. (London, The Pharmaceutical Press), pp. 16 - 30.

07

B. S. Finkle, "The identification, quantitative determination and distribution of meprobamate and glutethimide in biological materials", Journal of Forensic Sciences, vol. 12, 1967, pp. 509 - 527.

08

P. E. Haywood, M. W. Horner and H. J. Rylance, "Thin layer chromatography of neutral drugs", Analyst,vol. 92, 1967, pp. 711 - 713.

09

G. R. Nakamura, Y. Liu and T. T. Noguchi, "A method for the separation and determination of neutral compounds in postmortem tissues", Journal of Analytical Toxicology, vol. 5,1981 , pp. I 62 - 164.

10

L. M. Cummins, Y. C. Martin and E. E. Scherfling, "Serum and urine levels of ethchlorvynol in man", Journal of Pharmaceutical Sciences, vol. 60, 1971, pp. 261 - 263.

11

P. Haux, "Ethchlorvynol estimation in urine and serum", Clinica Chimica Acta, vol. 43, 1972, pp. 129 - 141.

12

R. J. Coumbis and B. Kaul, "Distribution of morphine and related compounds in human tissues and biological fluids using radioimmunoassay techniques", Journal of Forensic Sciences, vol. 19, 1974, pp. 307 - 312.

13

G. R. Nakamura and E. L. Way, "Determination of morphine and codeine in postmortem specimens", Analytical Chemistry, vol. 47, 1975, pp. 775 - 778.

14

R. D. Budd and W. J. Leung, "Mass screening and confirmation of phencyclidine (PCP) in urine by radioimmunoassay/TLC", Clinical Toxicology, vol. 18, 1981, pp. 85 - 90.

15

R. D. Budd and D. F. Mathis, "GLC screening and confirmation of barbiturates in postmortem blood specimens", Clinical Toxicology, 1982, in print.

16

G. R. Nakamura, T. T. Noguchi and E. C. Griesemer, "A survey of 70 combined drug deaths in Los Angeles County", Journal of Analytical Toxicology, vol. 3, 1979, pp. 137 - 142.

17

S. D. Nelson and others, "Quantification of lidocaine and several metabolites utilizing chemical-ionization mass spectrometry and stable isotope labeling", Journal of Pharmaceutical Sciences, vol. 66, 1977, pp. 1180 - 1190.