An analysis of issues in the classification and reporting of heroin‐related deaths

Abstract

Aims To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases. Methods Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes. Results A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroinrelated death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes.

Using death scene and toxicology evidence to define involvement of heroin, pharmaceutical morphine, illicitly manufactured fentanyl and pharmaceutical fentanyl in opioid overdose deaths, 38 states and the District of Columbia, January 2018–December 2019

“…When morphine is listed on the DC as a cause of death it is grouped into the natural and semi-synthetic opioids subcategory, which includes common prescription opioid pain relievers. This is problematic, because studies in the United States [4][5][6] and other countries [7,8] found that death investigation evidence (e.g. drug paraphernalia, decedent's drug use history) indicates that most deaths with morphine detected probably involved heroin instead of pharmaceutical morphine.…”

“…While heroin overdose deaths slightly declined from 2017 to 2019, heroin was involved in 14 019 overdose deaths, or 28% of all opioid overdose deaths, in 2019 [1]. Tracking overdose deaths involving heroin and IMF is challenging, however, because US death certificate (DC) data, considered the gold standard for tracking drug overdose deaths, underestimate heroin involvement [4][5][6][7][8] and do not distinguish between IMF and pharmaceutical fentanyl [9].…”

Addiction stigma and the production of impediments to take-home naloxone uptake

“…This mix of forms of disadvantage, criminalisation and stigmatisation facilitates ‘hidden’ and isolated consumption (Aitken et al., 2002; Fadanelli et al., 2019; Maher and Dixon, 2001) and, in some cases, highly dangerous overdose events that are ill-suited to take-home naloxone. Put simply, where people inject or consume opioids in isolation, administration of overdose reversal medication is less likely to happen (Stam et al., 2018). Moreover, the kinds of complex intersections we are describing here, between disadvantage, suffering and inequality, are unlikely to be remedied by overdose reversal medication alone.…”

The Emerging Drugs Network of Australia – Victoria Clinical Registry: A state‐wide illicit substance surveillance and alert network

“…Individuals presenting to hospital ED with illicit drug toxicity are an important subgroup of people who use drugs that, by the nature of their hospital presentation, provide an opportunity to describe and quantify illicit drug‐related harm. However, the International Classification of Disease coding system currently used in hospitals is known to underestimate the extent of illicit drug intoxication presentations and no specific coding is available for NPS 12,13 . Moreover, standard toxicological screening conducted by hospital pathology services are commonly limited to qualitative identification of broad classes of substances, with no capacity to continually update illicit drug reference libraries or obtain the drug standards required to accurately quantify novel substances.…”