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OFFICE OF APPLIED STUDIES


Drug Abuse Warning Network, 2004:
Area Profiles of Drug-Related Mortality



U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
http://DAWNinfo.samhsa.gov/



ACKNOWLEDGMENTS

This publication was prepared by the Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (OAS), with RTI International, under Contract No. 280-03-2602. Judy K. Ball, Ph.D., M.P.A. (DAWN Project Director, SAMHSA/OAS), Victoria Albright, M.A. (Project Director, RTI), and Sara Calvin (RTI) wrote the publication. Other significant contributors included Eric Johnson, Ph.D. (RTI), Francine Cannarozzi, M.Ed. (RTI), Erin Mallonee, M.S. (RTI), and Elizabeth Crane, Ph.D., M.P.H. (SAMHSA/OAS). The DAWN data collection was conducted by Westat under Contract No. 283-02-9025, under the direction of Josefina Moran, M.A.

PUBLIC DOMAIN NOTICE

All material appearing in this publication is in the public domain and may be reproduced or copied without permission from the Substance Abuse and Mental Health Services Administration (SAMHSA). However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA. Citation of the source is appreciated. Suggested citation:

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2004: Area Profiles of Drug-Related Mortality. Rockville, MD, 2008.

ELECTRONIC ACCESS OF PUBLICATION

This publication may be downloaded from http://DAWNinfo.samhsa.gov or from http://oas.samhsa.gov. Or, please call SAMHSA's Health Information Network at:

1-877-SAMHSA-7 (1-877-726-4727)
(English and Espaņol).

ORIGINATING OFFICE

SAMHSA, Office of Applied Studies
1 Choke Cherry Road, Room 7-1044, Rockville, MD 20857
August 2008



CONTENTS

Acknowledgments

Understanding DAWN Mortality Data
     Drug-related deaths
     Drugs
     Deaths included in this publication
     Unit of measurement

Understanding the Profiles
     Content of area profiles
     Map
     Table A: Metro-area overview: Deaths and population by county, 2004
     Figure B: Deaths by case type, 2004
     Table C: Place of death, 2004
     Figure D: Top 5 drugs involved in drug misuse deaths and suicides, 2004
     Figure E: Death rates by gender and age, 2004
     Table F: Causes of death, 2004
     Table G: Drug-related deaths by drug category, 2003-2004
     State profiles
     Abbreviated profiles for selected metropolitan areas
     Area spotlight profiles

DAWN Participation in 2004
     Summary of findings

State Profiles
     Maine
     Maryland
     New Hampshire
     New Mexico
     Utah
     Vermont

Metropolitan Area Profiles
     Albuquerque, NM
     Atlanta-Sandy Springs-Marietta, GA
     Baltimore-Towson, MD
     Birmingham-Hoover, AL
     Boston-Cambridge-Quincy, MA-NH
     Buffalo-Cheektowaga-Tonawanda, NY
     Chicago-Naperville-Joliet, IL-IN-WI
     Cleveland-Elyria-Mentor, OH
     Denver-Aurora, CO
     Detroit-Warren-Livonia, MI
     Houston-Baytown-Sugar Land, TX
     Indianapolis, IN
     Los Angeles-Long Beach-Santa Ana, CA
     Louisville, KY-IN
     Miami-Fort Lauderdale-Miami Beach, FL
     Milwaukee-Waukesha-West Allis, WI
     Minneapolis-St. Paul-Bloomington, MN-WI
     New Orleans-Metairie-Kenner, LA
     New York-Newark-Edison, NY-NJ-PA
     Ogden-Clearfield, UT
     Oklahoma City, OK
     Phoenix-Mesa-Scottsdale, AZ
     Pittsburgh, PA
     Portland-South Portland, ME
     Portland-Vancouver-Beaverton, OR-WA
     Provo-Orem, UT
     Salt Lake City, UT
     San Diego-Carlsbad-San Marcos, CA
     Seattle-Tacoma-Bellevue, WA
     St. Louis, MO-IL
     Washington-Arlington-Alexandria, DC-VA-MD-WV

Abbreviated Profiles for Areas with Few Drug-Related Deaths
     Bangor, ME
     Burlington-South Burlington, VT
     Fargo, ND-MN
     Farmington, NM
     Las Cruces, NM
     Lewiston-Auburn, ME
     Manchester-Nashua, NH
     Salisbury, MD
     Santa Fe, NM
     Sioux Falls, SD
     St. George, UT

Abbreviated Profiles for Areas with Less Than 50% Population Coverage
     Dallas-Fort Worth-Arlington, TX
     Kansas City, MO-KS
     Philadelphia-Camden-Wilmington, PA-NJ-DE-MD
     San Francisco-Oakland-Fremont, CA

Area Spotlights
     Albuquerque, NM: Bernalillo County, NM
     Atlanta-Sandy Springs-Marietta, GA: Fulton County, GA
     Baltimore-Towson, MD: Baltimore City, MD
     Baltimore-Towson, MD: Baltimore County, MD
     Boston-Cambridge-Quincy, MA-NH: Essex County, MA
     Boston-Cambridge-Quincy, MA-NH: Middlesex County, MA
     Boston-Cambridge-Quincy, MA-NH: Suffolk County, MA
     Buffalo-Cheektowaga-Tonawanda, NY: Erie County, NY
     Chicago-Naperville-Joliet, IL-IN-WI: Cook County, IL
     Denver-Aurora, CO: Denver County, CO
     Detroit-Warren-Livonia, MI: Macomb County, MI
     Detroit-Warren-Livonia, MI: Oakland County, MI
     Detroit-Warren-Livonia, MI: Wayne County, MI
     Indianapolis, IN: Marion County, IN
     Miami-Fort Lauderdale-Miami Beach, FL: Miami-Dade County, FL
     Miami-Fort Lauderdale-Miami Beach, FL: Palm Beach County, FL
     Minneapolis-St. Paul-Bloomington, MN-WI: Hennepin County, MN
     New Orleans-Metairie-Kenner, LA: Jefferson Parish, LA
     New Orleans-Metairie-Kenner, LA: Orleans Parish, LA
     New York-Newark-Edison, NY-NJ-PA: Bronx County, NY
     New York-Newark-Edison, NY-NJ-PA: Kings County, NY
     New York-Newark-Edison, NY-NJ-PA: New York County, NY
     New York-Newark-Edison, NY-NJ-PA: Queens County, NY
     New York-Newark-Edison, NY-NJ-PA: Suffolk County, NY
     Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Camden County, NJ
     Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Delaware County, PA
     Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Montgomery County, PA
     Portland-Vancouver-Beaverton, OR-WA: Multnomah County, OR
     Salt Lake City, UT: Salt Lake County, UT
     San Francisco-Oakland-Fremont, CA: San Mateo County: CA
     Seattle-Tacoma-Bellevue, WA: King County, WA
     Seattle-Tacoma-Bellevue, WA: Snohomish County, WA
     St. Louis, MO-IL: St. Louis City, MO
     St. Louis, MO-IL: St. Louis County, MO
     Washington-Arlington-Alexandria, DC-VA-MD-WV: District of Columbia

List of Tables
     Table 1. Participation of medical examiner/coroner jurisdictions in DAWN, 2004
     Table 2. Rates of drug misuse deaths and drug-related suicides per 1,000,000 population, 2004
     Table 3. Rates of drug misuse deaths and percentage of change, 2003 and 2004

List of Figures
     Figure 1. Sample metropolitan-area profile layout
     Figure A-1. DAWN case form
     Figure A-2. DAWN decision tree

List of Appendixes
     Appendix A: DAWN Mortality Data Collection
     Appendix B: Glossary of Terms
     Appendix C: Multum Lexicon End-User License Agreement



UNDERSTANDING DAWN MORTALITY DATA

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related deaths referred to medical examiners and coroners (ME/Cs) in selected metropolitan areas and States. Findings in this publication reflect data on drug-related deaths that occurred during calendar year 2004 and were reported by participating medical examiners or coroners (ME/Cs) to DAWN. In selected tables, data from reporting year 2003 are included for comparison. The Office of Applied Studies (OAS) of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, is responsible for DAWN.

Since the mortality component of DAWN does not rely on a statistical sample of ME/Cs, the findings cannot be extrapolated to apply to jurisdictions not participating during 2004. The findings cannot be extrapolated to the United States as a whole. Because of changes introduced to DAWN in 2003, DAWN mortality data for 2004 are only comparable to data for 2003 and should not be compared to mortality data for any prior years.

Drug-related deaths

Findings in this publication all pertain to drug-related deaths reported by participating death investigation jurisdictions as DAWN cases. Since 2003, a DAWN case has been any death reviewed by a ME/C that was related to recent drug use.

DAWN cases are found through a retrospective review of decedent case files in each participating death investigation jurisdiction. The relationship between the death and the drug need not be causal; the drug need only be implicated in the death, and the drug use must have been recent. DAWN cases include deaths associated with drug misuse, whether intentional or accidental, as well as deaths related to the use of drugs for legitimate, therapeutic purposes. This includes, but is not limited to, explicit drug abuse.

These eligibility criteria for a DAWN case are intentionally broad and inclusive. Since death record documentation varies in clarity and comprehensiveness across jurisdictions and among ME/Cs, broad criteria reduce the potential for judgments that could cause data to vary systematically and unexpectedly across reporters and jurisdictions. Broad criteria also capture a very diverse set of drug-related cases, which are able to support a wide variety of analytical purposes and the interests of multiple audiences.

For decedents under the age of 21, DAWN cases include deaths where the only drug involved was alcohol. For those 21 and older, there must be at least one other drug involved besides alcohol for the death to be a DAWN case.

The data items submitted on drug-related deaths are shown in Appendix A.

Drugs

DAWN covers all types of drugs. Drugs eligible for DAWN include:

Deaths included in this publication

Findings in this publication focus on two major categories of drug-related deaths, based on manner of death.

Deaths related to drug misuse, defined broadly to include drug misuse or abuse, include the following:

Drug misuse deaths exclude two types of natural or accidental deaths: deaths that are the consequence of using a prescription or OTC pharmaceutical for therapeutic purposes, and deaths that involve the accidental use of a drug. The former would include deaths related to adverse drug reactions, side effects, and drug-drug or drug-alcohol interactions (but not deaths in which an illicit drug was involved). The latter would include, for example, an accidental poisoning by a child or by an individual who took the wrong medication or wrong dosage by mistake. Accidental ingestion is not synonymous with accidental death, a manner of death assigned by an ME/C.

Drug-related suicides include suicides with drug involvement. The determination of suicide is made by the ME/C. Drug-related suicides include more than "overdoses." That is, a drug that was implicated in the death may not have been the cause of death.

Unit of measurement

Death is the primary measure of interest throughout this publication. To permit comparisons within or across areas or across demographic subgroups, death rates (i.e., the number of deaths per 1,000,000 population) have been added. This use of death rates is important because two areas with similar numbers of drug-related deaths may have vastly different populations, and two areas with similar populations may have different numbers of drug-related deaths. Rates, which take population differences into account, permit standardized comparisons. Other measures should not be compared across areas.

The reader should be cautious, though, in drawing conclusions about differences or changes in the rates of drug misuse deaths or drug-related suicides. While a difference in the rates from one year to the next may signify a difference in drug-related mortality, other factors may confound such comparisons. For example, State laws differ in regard to which deaths are subject to ME/C review. There can be changes from year to year in toxicology testing protocols in a jurisdiction or in the number of cases still pending (i.e., not closed) at the end of the DAWN reporting year. All of these factors can affect the number of deaths determined to be DAWN cases or the number of deaths attributed to particular drugs. It is also important when interpreting change to consider that even small changes in the number of deaths can result in large changes in percentage terms.

UNDERSTANDING THE PROFILES

Mortality data for each participating metropolitan area and State are summarized in a two-page "profile" for that area. Shorter, one-page "spotlights" for individual jurisdictions or counties are also included. All profiles observe the following conventions:

Additional detail on the DAWN data collection methodology is provided in Appendix A. A glossary of terms used in this report appears in Appendix B.

Content of area profiles

Figure 1 shows the general layout of each two-page profile. Each profile has a map and seven components (tables and figures), labeled A through G.

Map

Each profile begins with a map displaying the boundaries of the metropolitan area or State and its component counties. Both participating and nonparticipating jurisdictions are shown. Jurisdictions that provided mortality data for 2004 are white. Jurisdictions in the area that did not provide data are lightly shaded. Areas outside of the metropolitan areas or States are darkly shaded.

A death investigation jurisdiction tends to be consistent with a county, whereas most metropolitan areas and all States comprise multiple counties and, therefore, multiple death investigation jurisdictions. In this publication, the terms "jurisdiction" and "county" are used synonymously to reflect the fact that data are aggregated at the county level, regardless of actual jurisdictional boundaries.2

Metropolitan-area definitions used in this publication are those established by the Office of Management and Budget (OMB), most recently based on the 2000 decennial Census.3 These boundaries were updated in 2003.

Figure 1. Sample metropolitan-area profile layout

Figure 1   D

Next to the map the following items appear:

Only metropolitan areas with more than 50% population coverage are given a full two-page profile. However, readers should always consider population coverage in interpreting these mortality data. For any area with population coverage less than 100%, one should not use the deaths in participating jurisdictions to generalize about deaths in nonparticipating jurisdictions.

Table A: Metro-area overview: Deaths and population by county, 2004

Below the map, Table A lists each of the component jurisdictions for the area, which are numbered to correspond to their location on the area map. In metropolitan areas that cross State borders, jurisdictions are ordered first by State and then by county name. Rows for nonparticipating areas are shaded. Jurisdictions marked with an asterisk (*) are highlighted in separate Area Spotlights. In State profiles, jurisdictions marked with a dagger (†) are featured in metropolitan-area profiles.

An overview of each jurisdiction's data is displayed in the remaining columns of Table A. For each participating jurisdiction, the table displays the number of drug misuse deaths and drug-related suicides, as well as the rate for each category (i.e., the number of deaths per 1,000,000 population). The rate, because it is population-adjusted, can be compared across jurisdictions and across metropolitan areas. This standardization does not take into account, however, the differences in State laws that specify which deaths are subject to ME/C review, nor does it take into account other factors, discussed previously, that may confound comparisons across years.

The final column shows the population for each participating and nonparticipating jurisdiction. This information makes clear for readers the extent of DAWN's coverage of the metropolitan area.

The top row of the table shows totals for the area, a count of participating jurisdictions (in parentheses), and the number of deaths and death rates for all the participating jurisdictions combined.

All subsequent tables and figures (B through G) are based on data aggregated across the participating jurisdictions in each metropolitan area or State.

Figure B: Deaths by case type, 2004

Figure B is a pie chart that shows the relative mix of case types for drug misuse and drug-related suicide deaths.5 Solid slices are reserved for drug misuse cases; the patterned slice shows the suicide deaths. Reading clockwise, the drug misuse cases include:

Table C: Place of death, 2004

Table C summarizes the place of death for drug misuse and drug-related suicide cases separately. Deaths in emergency departments and other health care facilities have been aggregated into the single category "health care facility."

Figure D: Top 5 drugs involved in drug misuse deaths and suicides, 2004

Separate bar charts show the 5 most common drugs reported to DAWN for drug misuse deaths and drug-related suicides. The number shown above each bar is the number of deaths reported for the drug type shown. The bars also display the relative mix of deaths involving a single drug, as opposed to the number involving multiple drugs. The solid bottom portion of the bar represents deaths involving multiple drugs; the top, striped portion of the bar represents deaths involving only a single drug type. When small numbers (fewer than 4 deaths) have been suppressed, fewer than five bars are shown.

The drugs for this figure have been categorized as in Table G (discussed below). Note that the number of deaths cannot be summed across the bars, since multiple types of drugs are frequently involved in drug-related deaths. That is, a death that involved cocaine and heroin would appear in the bar for cocaine and in the bar for opiates/opioids. However, a death that involved two drugs of the same type (e.g., multiple opiates/opioids, such as methadone and heroin) would be counted only once in the bar for opiates/opioids and would be considered a single-drug death.

Grouping drugs in this fashion effectively eliminates double counting of redundant drug reports (e.g., "cocaine" and its metabolite "benzoylecgonine" reported for the same case); of potentially redundant reports from nonspecific terms (e.g., "heroin" and "opiates" reported for the same case); and of drugs that may be indistinguishable (e.g., "heroin" and "morphine"), depending on the time after death or method of testing. Enhanced training and automated prompts for DAWN reporters minimize but cannot eliminate these issues.

It is important also to remember that not every reported substance is, by itself, necessarily a cause of the death or even a contributor to the death. While improved training can reduce incidental reporting (i.e., reporting of drugs unrelated to the death), some incidental reporting will occur as a result of ambiguities in the case records. In some instances, a definitive determination of which drug or drugs contributed to the death may not be possible.

Figure E: Death rates by gender and age, 2004

Figure E displays the demographic characteristics of decedents in drug misuse deaths and suicide deaths, in terms of deaths per 1,000,000 population. Only population in participating jurisdictions is considered in the calculation of these rates. Taking population size into account is especially important for valid comparisons to be made across age and gender subgroups.

Table F: Causes of death, 2004

Table F summarizes drug misuse deaths and drug-related suicides by selected causes of death:

Drug-related deaths often involve multiple causes, so deaths cannot be summed across the causes listed.

Causes of death are reported to DAWN as they appear in text on the death certificate.6 After receipt, each cause of death is coded and classified into categories. The categories were determined empirically, based on frequency of content and relevance to DAWN's audience. A single cause may be classified into multiple categories. For example, a cause of death reported as "heroin overdose" would be classified in two categories: drug-involved (i.e., the drug was denoted in the cause of death) and overdose.

After all causes were coded and classified, the six categories listed above were selected for inclusion in Table F. As might be expected, a drug-related cause of death was present for nearly all DAWN cases.

Table G: Drug-related deaths by drug category, 2003-2004

Table G summarizes the total number of drug misuse deaths and drug-related suicides according to the drug, or drugs, involved for 2004 and, for comparison, 2003. A selection of drug categories including illicit drugs, alcohol, and pharmaceuticals is shown. Deaths for 2003 are not shown when the data did not exist (e.g., due to nonparticipation) or are not comparable to those shown for 2004 (e.g., in Chicago, Cook County is included in 2004 but was a nonparticipant in 2003). Numbers less than 4 are suppressed to protect confidentiality.

The unit of measurement in this table is deaths, not drugs. The typical drug-related death reported to DAWN involves multiple drugs, so deaths cannot be summed across categories without double counting. DAWN cases include both drug-induced and drug-related deaths. As a result, readers should not assume that any given substance was, by itself, the cause of death.

Single-drug deaths. For the current year, the number of single-drug deaths is also shown for each drug category. This is the number of deaths involving the listed drug (or drug type) and no others. In nearly all instances, the number of deaths involving a single drug will be lower than the total number of deaths for which that drug was reported. Even in single-drug deaths, readers should not assume that the drug was necessarily the direct and sole cause of death.

Drug categories. The 17 drug categories shown in this table are unique to this publication but are derived from DAWN's standard drug classification scheme.7

The first row of Table G summarizes deaths and single-drug deaths across all drug categories, those shown and those not shown in the rows below.

The rows following the total summarize deaths for selected drugs (or drug categories). Low-frequency drugs have been aggregated into larger categories. These rows include:

The next six rows in Table G pertain to illicit drugs. Included are:

The remaining rows in Table G are devoted to prescription and over-the-counter pharmaceuticals, as well as heroin, which is listed with the other opiates/opioids. The drug categories included in this section are:

Readers should note that the total number of deaths in any given drug category (with the possible exception of alcohol, cocaine, and opiates/opioids) is often quite small, even in metropolitan areas with a relatively large number of drug misuse deaths. The presentation of these data, despite their low frequency, represents a deliberate effort to provide useful information about the relative occurrence of deaths related to different types of substances. However, numbers less than 4 have been suppressed to protect decedents' identities.

State profiles

Six statewide ME/C systems participated in DAWN in 2004. A full two-page profile is provided for each of the following States:

Metropolitan areas in these States can be found in the metropolitan-area profiles in this publication. Only metropolitan areas that fell wholly within the State and reported more than 30 drug misuse or drug-related suicide deaths to DAWN in 2004 receive full two-page profiles. In 2004, these were:

Abbreviated profiles for selected metropolitan areas

To warrant a full two-page profile, the participating jurisdictions of a metropolitan area (combined) must have reported more than 30 drug misuse or suicide deaths, and the area's population coverage must have exceeded 50%. If either of these two conditions was not met, an abbreviated profile is provided for the area.

In 2004, the following areas warranted abbreviated profiles due to low numbers of reported deaths:

In 2004, the following areas warranted abbreviated profiles because of low population coverage:

Abbreviated profiles include only a map and Table A. These show the specific counties included in the metropolitan area, the population of each, the identities of the component jurisdictions that participated in DAWN in 2004, the number of deaths involving drug misuse or drug-related suicide that were reported by each participating jurisdiction, and the population coverage of the participants relative to the entire area. If the number of participating jurisdictions or the number of reported deaths increases in future years to exceed the established levels, then full two-page profiles will be published for these areas. Likewise, if any area drops below either of these established levels in future years, only a map and Table A will be published for that area.

Area spotlight profiles

Area spotlight profiles focus on drug misuse deaths in key counties and cities within the participating metropolitan areas. As a general rule, spotlight profiles are produced for jurisdictions in which 60 or more misuse deaths were reported. These jurisdictions usually correspond to population centers of a metropolitan area or county containing the city for which the metropolitan area is named. Spotlight profiles are not produced for population centers when fewer than 60 misuse deaths were reported. Drug-related suicide deaths are not covered in spotlight profiles because the numbers so rarely exceed the 60-death threshold.

Spotlight profiles are provided for 35 jurisdictions for 2004. The following examples and exceptions apply:

In a few metropolitan areas, spotlight profiles are provided for multiple counties when their large populations and/or local interest warrants specific listings. These areas include the following:

For some metropolitan areas, no spotlight profiles are necessary because the metropolitan area contains only one county or had only one county participating in DAWN:

In a few metropolitan areas the jurisdictions representing the population centers did not participate in DAWN in 2004, so it was not possible to spotlight these jurisdictions. However, in 2 metropolitan areas with less than 50% population coverage, spotlight profiles were possible for:

All the spotlights profile individual jurisdictions in essentially the same format as the State or full metropolitan-area profiles. The map shows only the spotlighted area relative to the rest of the metropolitan area; summary counts of drug misuse deaths, drug-related suicide deaths, county population, and death rates pertain only to the spotlighted jurisdiction. These, of course, match the counts and rates shown in the full profiles for the relevant jurisdiction.

Spotlights also include Figure B, Table C, Figures D and E, and Tables F and G, as described above. Because of the small numbers, drug-related suicide deaths have been removed from all but the jurisdiction summary and Figure B.

DAWN PARTICIPATION IN 2004

DAWN relies on the voluntary cooperation of medical examiners and coroners (ME/Cs) in selected areas of the United States to provide standardized data on drug-related deaths. For 2004, 150 jurisdictions in 46 metropolitan areas and 126 jurisdictions in 6 States submitted mortality data to DAWN (Table 1).10 All jurisdictions are included for the 6 States–Maine, Maryland, New Hampshire, New Mexico, Utah, and Vermont. The 6 States also contributed 46 of the metropolitan-area jurisdictions. Metropolitan-area definitions adopted by DAWN in 2003 are those established by the Office of Management and Budget (OMB), based on the 2000 decennial Census.11

Among the 46 metropolitan areas, 31 reported more than 30 deaths related to drug misuse, and 14 reported more than 30 drug-related suicide deaths. Full two-page profiles of drug misuse and drug-related suicide deaths are provided for each of the 31 metropolitan areas. Abbreviated profiles are provided for 11 metropolitan areas that submitted 30 or fewer drug misuse deaths and for 4 metropolitan areas with less than 50% population coverage. Cases pending (i.e., incomplete) at the end of the data collection period are excluded. This publication was prepared with data that were submitted by June 10, 2005, for deaths that occurred during 2004.

An awareness of the extent of DAWN's coverage within a given area is essential to an accurate interpretation of DAWN mortality data. The mortality component of DAWN is not national in scope, and since the ME/C participants in DAWN are not part of a scientific sample, it is not possible to extrapolate from participating jurisdictions to the Nation as a whole. Nor is it possible to extrapolate to an entire metropolitan area when some jurisdictions within the metropolitan area do not participate in DAWN. In this publication, participation status for each jurisdiction is a key component of each area's profile.12

Table 1 lists the metropolitan areas and States represented in DAWN for 2004, the total number of death investigation jurisdictions (counties) in each area, the number and percentage of eligible counties for which mortality data were reported to DAWN, and the proportion of the total area's population that is covered by DAWN-participating jurisdictions. Information on population coverage is important because it shows that, although jurisdiction coverage is incomplete in many areas, the most populous counties within a given Metropolitan Statistical Area (MSA) are often represented. For example, Table 1 shows that only 1 (10%) of the 10 counties in the Houston metropolitan area participated in DAWN in 2004, but that county is home to 70% of the area's total population.

Table 1
Participation of medical examiner/coroner jurisdictions in DAWN, 2004
Area Total
jurisdictions
(counties)
Participating jurisdictions
(counties)
Percent of
population in
participating
jurisdictions
Number Percent of total
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (11/2005 update).
Six states 126 126 100% 100%
Forty-six metropolitan areas 311 150   48%   79%
Metropolitan areas
Albuquerque, NM     4     4 100% 100%
Atlanta-Sandy Springs-Marietta, GA   28     8   29%   67%
Baltimore-Towson, MD     7     7 100% 100%
Bangor, ME     1     1 100% 100%
Birmingham-Hoover, AL     7     1   14%   61%
Boston-Cambridge-Quincy, MA-NH     7     7 100% 100%
Buffalo-Cheektowaga-Tonawanda, NY     2     2 100% 100%
Burlington-South Burlington, VT     3     3 100% 100%
Chicago-Naperville-Joliet, IL-IN-WI   14     7   50%   75%
Cleveland-Elyria-Mentor, OH     5     1   20%   63%
Dallas-Fort Worth-Arlington, TX   12     2   17%   20%
Denver-Aurora, CO   10     5   50%   80%
Detroit-Warren-Livonia, MI     6     4   67%   94%
Fargo, ND-MN     2     1   50%   71%
Farmington, NM     1     1 100% 100%
Houston-Baytown-Sugar Land, TX   10     1     10%     70%
Indianapolis, IN   10     2   20%   61%
Kansas City, MO-KS   15     2   13%   14%
Las Cruces, NM     1     1 100% 100%
Lewiston-Auburn, ME     1     1 100% 100%
Los Angeles-Long Beach-Santa Ana, CA     2     1   50%   77%
Louisville, KY-IN   13     1     8%   58%
Manchester-Nashua, NH     1     1 100% 100%
Miami-Fort Lauderdale-Miami Beach, FL     3     2   67%   67%
Milwaukee-Waukesha-West Allis, WI     4     1   25%   61%
Minneapolis-St. Paul-Bloomington, MN-WI   13     7   54%   58%
New Orleans-Metairie-Kenner, LA     7     5   71%   79%
New York-Newark-Edison, NY-NJ-PA   23   10   43%   59%
Ogden-Clearfield, UT     3     3 100% 100%
Oklahoma City, OK     7     1   14%   59%
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD   11     6   55%   49%
Phoenix-Mesa-Scottsdale, AZ     2     1   50%   94%
Pittsburgh, PA     7     1   14%   52%
Portland-South Portland, ME     3     3 100% 100%
Portland-Vancouver-Beaverton, OR-WA     7     3   43%   74%
Provo-Orem, UT     2     2 100% 100%
Salisbury, MD     2     2 100% 100%
Salt Lake City, UT     3     3 100% 100%
San Diego-Carlsbad-San Marcos, CA     1     1 100% 100%
San Francisco-Oakland-Fremont, CA     5     2   40%   23%
Santa Fe, NM     1     1 100% 100%
Seattle-Tacoma-Bellevue, WA     3     2   67%   76%
Sioux Falls, SD     4     1   25%   77%
St. George, UT     1     1 100% 100%
St. Louis, MO-IL   17     9   53%   84%
Washington-Arlington-Alexandria, DC-VA-MD-WV   20   19   95%   99%
States
Maine   16   16 100% 100%
Maryland   24   24 100% 100%
New Hampshire   10   10 100% 100%
New Mexico   33   33 100% 100%
Utah   29   29 100% 100%
Vermont   14   14 100% 100%

Among the metropolitan areas, population coverage exceeded 90% in 21 metropolitan areas, with 100% coverage in 18 of those areas. The remaining metropolitan areas had response rates that range from a low of 14% in Kansas City to 84% in St. Louis. Population coverage below 50% usually equates to the absence of large jurisdictions, such as:

Also notably absent from the 2004 mortality data are:

Los Angeles County and Cook County in Chicago, both absent from DAWN in 2003, submitted mortality data in 2004.

Summary of findings

Table 2 provides a summary of the rates of drug misuse deaths and drug-related suicides per 1,000,000 population for metropolitan areas and States, along with their population and population coverage in DAWN for 2004.

Table 3 provides a summary of drug misuse deaths in 2003 and 2004 for metropolitan areas and States with consistent participation in both years.

Table 2
Rates of drug misuse deaths and drug-related suicides per 1,000,000 population, 2004
Metropolitan area or State Drug
misuse
deaths per
1,000,000
population
Drug-related
suicides
per
1,000,000
population
Population
covered
by DAWN
Total area
population,
2004
Percent of
population
covered
by DAWN
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (11/2005 update).
Metropolitan areas
Albuquerque, NM 188.1 21.8      781,447      781,447 100%
Atlanta-Sandy Springs-Marietta, GA   61.9   7.9   3,148,259   4,708,297   67%
Baltimore-Towson, MD 177.3   8.7   2,639,213   2,639,213 100%
Bangor, ME   87.7 13.5      148,196      148,196 100%
Birmingham-Hoover, AL 144.3 18.2      658,495   1,082,193   61%
Boston-Cambridge-Quincy, MA-NH 100.6 11.3   4,424,649   4,424,649 100%
Buffalo-Cheektowaga-Tonawanda, NY   86.6   8.7   1,154,378   1,154,378 100%
Burlington-South Burlington, VT 112.5 14.7      204,485      204,485 100%
Chicago-Naperville-Joliet, IL-IN-WI   99.0   7.2   7,058,121   9,391,515   75%
Cleveland-Elyria-Mentor, OH 136.2 18.5   1,351,009   2,137,073   63%
Dallas-Fort Worth-Arlington, TX   44.9   19.0   1,158,535   5,700,256   20%
Denver-Aurora, CO 115.2 28.4   1,866,449   2,330,146   80%
Detroit-Warren-Livonia, MI 152.5 12.1   4,223,117   4,493,165   94%
Fargo, ND-MN   31.1   7.8      128,615      181,520   71%
Farmington, NM   56.4 16.1      124,166      124,166 100%
Houston-Baytown-Sugar Land, TX   94.4 18.4   3,644,285   5,180,443   70%
Indianapolis, IN 109.2 19.2      989,460   1,621,613   61%
Kansas City, MO-KS   57.4 17.9      278,555   1,925,319   14%
Las Cruces, NM   69.9 16.1      186,095      186,095 100%
Lewiston-Auburn, ME   74.8   9.3      107,022      107,022 100%
Los Angeles-Long Beach-Santa Ana, CA 104.5 16.8   9,937,739 12,925,330   77%
Louisville, KY-IN   81.4 12.9      700,030   1,200,847   58%
Manchester-Nashua, NH   75.3 12.5      398,574      398,574 100%
Miami-Fort Lauderdale-Miami Beach, FL   92.0 13.9   3,606,830   5,361,723   67%
Milwaukee-Waukesha-West Allis, WI 159.5 32.3      928,018   1,515,738   61%
Minneapolis-St. Paul-Bloomington, MN-WI   46.2 13.7   1,820,108   3,116,206   58%
New Orleans-Metairie-Kenner, LA 227.8 16.3   1,040,482   1,319,589   79%
New York-Newark-Edison, NY-NJ-PA   95.8   7.7 10,993,893 18,709,802   59%
Ogden-Clearfield, UT 119.4 27.2      477,455      477,455 100%
Oklahoma City, OK 196.8 44.1      680,815   1,144,327   59%
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 108.8 21.9   2,830,241   5,800,614   49%
Phoenix-Mesa-Scottsdale, AZ 113.1 19.1   3,501,001   3,715,360   94%
Pittsburgh, PA 168.7 21.6   1,250,867   2,401,575   52%
Portland-South Portland, ME   97.9 13.7      510,791      510,791 100%
Portland-Vancouver-Beaverton, OR-WA 101.1 19.7   1,523,690   2,064,336   74%
Provo-Orem, UT 128.5   4.9      412,361      412,361 100%
Salisbury, MD 130.8 17.4      114,645      114,645 100%
Salt Lake City, UT 168.8 30.4   1,018,826   1,018,826 100%
San Diego-Carlsbad-San Marcos, CA   96.5 21.1   2,931,714   2,931,714 100%
San Francisco-Oakland-Fremont, CA 113.2 15.9      945,261   4,153,870   23%
Santa Fe, NM 144.2 14.4      138,705      138,705 100%
Seattle-Tacoma-Bellevue, WA 139.2 21.5   2,421,417   3,166,828   76%
Sioux Falls, SD     0.0 25.4      157,366      203,324   77%
St. George, UT 118.3 27.3      109,924      109,924 100%
St. Louis, MO-IL   89.1 20.0   2,345,212   2,787,701   84%
Washington-Arlington-Alexandria, DC-VA-MD-WV   52.0   7.9   5,091,886   5,139,549   99%
States
Maine   97.9 20.5   1,317,253   1,317,253 100%
Maryland 117.8   7.2   5,558,058   5,558,058 100%
New Hampshire   75.4 10.8   1,299,500   1,299,500 100%
New Mexico 142.4 22.6   1,903,289   1,903,289 100%
Utah 143.6 22.6   2,389,039   2,389,039 100%
Vermont   99.8 14.5      621,394      621,394 100%
Table 3
Rates of drug misuse deaths and percentage of change, 2003 and 2004
Metropolitan area or State Rate of drug misuse deaths per
1,000,000 population
Percentage change
in rate,
2003 to 2004
Total area
population, 2004
2003 2004
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2004 (11/2005 update).
Metropolitan areas
Albuquerque, NM 204.0 188.1    -7.8%    781,447
Baltimore-Towson, MD 205.6 177.3  -13.8% 2,639,213
Birmingham-Hoover, AL 135.2 144.3     6.7% 1,082,193
Boston-Cambridge-Quincy, MA-NH 109.5 100.6    -8.1% 4,424,649
Buffalo-Cheektowaga-Tonawanda, NY   56.1   86.6   54.4% 1,154,378
Detroit-Warren-Livonia, MI 129.4 152.5   17.9% 4,493,165
Houston-Baytown-Sugar Land, TX   65.3   94.4   44.6% 5,180,443
Indianapolis, IN   73.0 109.2   49.6% 1,621,613
Louisville, KY-IN 101.6   81.4  -19.9% 1,200,847
Milwaukee-Waukesha-West Allis, WI 143.6 159.5   11.1% 1,515,738
Ogden-Clearfield, UT   91.7 119.4   30.2%    477,455
Oklahoma City, OK   91.7 196.8 114.6% 1,144,327
Phoenix-Mesa-Scottsdale, AZ 114.8 113.1    -1.5% 3,715,360
Portland-South Portland, ME   97.0   97.9     0.9%    510,791
Portland-Vancouver-Beaverton, OR-WA   96.4 101.1     4.9% 2,064,336
Provo-Orem, UT 127.8 128.5     0.5%    412,361
Salt Lake City, UT 183.0 168.8    -7.8% 1,018,826
San Diego-Carlsbad-San Marcos, CA 120.1   96.5  -19.7% 2,931,714
Seattle-Tacoma-Bellevue, WA   91.2 139.2   52.6% 3,166,828
States
Maine   88.1   97.9   11.1% 1,317,253
Maryland 126.5 117.8    -6.9% 5,558,058
New Hampshire   87.8   75.4  -14.1% 1,299,500
New Mexico 161.6 142.4  -11.9% 1,903,289
Utah 138.6 143.6     3.6% 2,389,039
Vermont 119.5   99.8  -16.5%    621,394

End Notes

1 To be reportable, a nonpharmaceutical substance must be consumed by inhalation, sniffing, or snorting and must have a psychoactive effect when inhaled. A death involving inhalation of a nonpharmaceutical, psychoactive substance and no other drug qualifies as a DAWN case. Carbon monoxide is excluded from the inhalants reportable to DAWN.

2 These and other terms are defined in Appendix B.

3 Office of Management and Budget, Revised Definitions of Metropolitan Statistical Areas, New Definitions of Micropolitan Statistical Areas and Combined Statistical Areas, and Guidance on Uses of the Statistical Definitions of These Areas, Bulletin No. 03-04, June 6, 2003. Available from http://www.whitehouse.gov/omb/bulletins/b03-04.html.

4 Population estimates for 2004 were obtained from the U.S. Census Bureau County Population at http://www.census.gov/popest/counties/CO-EST2004-01.html.

5 "Case type" and other terms are defined in Appendix B.

6 DAWN does not collect causes of death coded according to the International Classification of Diseases, 10th Revision.

7 The classification of drugs used by DAWN is derived from the Multum Lexicon, © 2005, Multum Information Services, Inc. The classification has been modified to meet DAWN's unique requirements (2006). The Multum Licensing Agreement governing use of the Lexicon is provided in Appendix C and can be found on the Internet at http://www.multum.com/.

8 Overall, 95% of drugs in the category "heroin (specified)" were reported to DAWN as "heroin" or its metabolite "monoacetylmorphine." The remaining 5% were reported as acetylmorphine, diacetylmorphine, acetylcodeine, monoacetylcodeine, or heroin dope. Morphine and unspecified opiates are not included in this "heroin (specified)" category. Morphine is not classified as heroin because it is not possible to differentiate morphine, the metabolite of heroin, from morphine itself. Overall, the term "morphine" or "free morphine" accounted for 98% of reports classified as "morphine," and the term "opiates" accounted for 95% of the unspecified opiates.

9 Some examples may assist readers in interpreting this classification. A death that involved heroin and methadone would be counted once in the "opiates/opioids" category, once in the "heroin (specified)" row, and once in the "methadone" row. A death that involved morphine (prescription morphine or the metabolite for heroin) would be counted in the "opiates/opioids" category and in the row for "all other opiates/opioids." A death that involved both morphine and codeine (a possible indicator for heroin) would be counted once in the "opiates/opioids" category and once in the row for "all other opiates/opioids."

10 In this publication, the terms "jurisdiction" and "county" are used synonymously because ME/Cs are typically organized by county. For comparability across metropolitan areas, the 4 districts that make up Niagara County, NY, are counted as a single jurisdiction.

11 Office of Management and Budget, Revised Definitions of Metropolitan Statistical Areas, New Definitions of Micropolitan Statistical Areas And Combined Statistical Areas, and Guidance on Uses of the Statistical Definitions of These Areas, Bulletin No. 03-04, June 6, 2003. Available from http://www.whitehouse.gov/omb/bulletins/b03-04.html.

12 Recruitment efforts to increase participation by ME/Cs are ongoing. However, there are no plans to make the mortality component of DAWN national in scope.

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