APPENDIX A

DAWN MORTALITY DATA COLLECTION

DAWN data collection

DAWN mortality data are collected in participating medical examiner and coroner (ME/C) offices through a retrospective review of case records for every death investigated by the ME/C. Families are never interviewed. The review of source records is performed by a trained DAWN reporter in each member facility. Depending on the needs of the facility, the DAWN reporter may be an employee of the death investigation jurisdiction or an employee of the DAWN operations contractor.

Within each facility that participates in DAWN, the designated DAWN reporter reviews all death records to identify deaths related to drug use. The DAWN reporter submits an electronic case report to the DAWN system for each death that meets the specific case selection criteria.

Deaths eligible for DAWN

A DAWN case is any death related to recent drug use. DAWN includes deaths associated with substance abuse and misuse, both intentional and accidental. This also includes the use of drugs for legitimate therapeutic purposes. To be a DAWN case, the relation between the death and the drug need not be causal; the drug needs only to be implicated in the death. Only recent drug use is included, and the reason that a patient used a drug is irrelevant.

The case criteria are intended to be broad and inclusive and to have few exceptions. Broad criteria take into account the fact that documentation in death records varies in clarity and comprehensiveness across ME/Cs. Broad criteria minimize the potential for judgments that could cause data to vary systematically and unexpectedly across reporters and jurisdictions. In addition, broad criteria are designed to capture a very diverse set of drug-related deaths, which can be aggregated and disaggregated to serve a variety of analytical purposes and the interests of multiple audiences.

There are some clearly delineated exceptions to the DAWN case criteria. A death is not a DAWN case if:

• There was no evidence of recent drug use.
• The death was not processed by an ME/C.
• The decedent was a drug user but died of natural causes unrelated to the drug use.
• The decedent was a homicide victim, but the method of homicide was not poisoning by drugs.
• The decedent consumed a nonpharmaceutical substance but did not inhale it.
• The death involved inhalation of carbon monoxide and no other reportable substance.
• The decedent had a history of drug use but no recent use.
• Alcohol was the only substance involved, and the decedent was an adult (age 21 or over).
• The only documentation of drug involvement was in toxicology test results.
• The only drugs listed (e.g., current medications) were not related to the death.
• The death was a consequence of undermedication (taking too little of a drug).

Data items collected by DAWN

The case report form showing all the data items collected by DAWN is provided in Figure A-1. This is a representation of the form on paper, whereas all DAWN data are submitted electronically. The electronic system, for example, permits the submission of more drugs than are shown on the paper form.

Manner of death in DAWN

Manner of death is a particularly important part of the death records because it is used to determine if the death is a case of drug misuse or abuse. As depicted in Figure A-2, DAWN decision tree, each death is assigned to one of seven manners of death, as follows:

• Suicide,
• Homicide by drugs,
• Adverse reaction to medication,
• Overmedication,
• Accidental ingestion,
• All other accidental, and
• Could not be determined.

Each DAWN case is assigned to one, and only one, of the seven manner of death categories based on the series of questions and decision rules depicted in the decision tree. Starting at the top, each case is assigned to the first manner of death that applies, even if the case might also meet the rules for a subsequent category. The seven categories were ordered with this in mind.

The final two categories, "All other accidental" and "Could not be determined," were designed to capture all of the drug-related deaths that could not be classified in any of the prior case types. "Could not be determined" cases include those that are ruled by the ME/C explicitly as "could not be determined" (i.e., the evidence was inconclusive with regard to whether the death was accidental, suicide, or homicide).

Drugs included in DAWN

DAWN includes all types of drugs.¹⁴ Drugs in DAWN include:

• Illegal drugs, such as heroin, cocaine, marijuana, and Ecstasy;
• Prescription drugs, such as Prozac®, Vicodin®, OxyContin®, alprazolam, and methylphenidate;
• Over-the-counter (OTC) medications, including aspirin, acetaminophen, ibuprofen, and multi-ingredient cough and cold remedies;
• Dietary supplements, including vitamins, herbal remedies, and nutritional products;
• Psychoactive, nonpharmaceutical inhalants;
• Alcohol in combination with other drugs; and
• Alcohol alone, in patients aged less than 21 years.

To be reportable, a nonpharmaceutical substance must be consumed by inhalation, sniffing, or snorting, and it 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, as noted above. Deaths involving accidental exposures (e.g., exposure to paint fumes while painting a closet) are excluded as well.

DAWN features that enhance data quality and reliability

Several methods are used to improve the quality and reliability of DAWN data. These include:

• Case finding by a retrospective review of death records for every death investigated by a participating ME/C;
• Electronic reporting with automated prompts and data validation;
• Elimination of incidental drug reporting;
• Accurate, specific, and nonredundant drug reporting;
• Inclusion of data items to identify drugs confirmed by laboratory testing;
• Rigorous training and certification of DAWN reporters; and
• In-house review and cleaning of DAWN case reports.

Participation of medical examiners and coroners

ME/Cs participate in DAWN on a voluntary basis and constitute neither a sample nor a census of ME/Cs in the United States. ME/Cs are invited to join DAWN based on their location in selected metropolitan areas. Recruitment efforts focus primarily on areas where DAWN data are also collected from hospital emergency departments. In addition to recruitment targeted at metropolitan areas, DAWN has added States with centralized ME/C systems to gain a better understanding of drug-related mortality outside of the targeted metropolitan areas.

In this publication, the terms "death investigation jurisdiction" (or, simply, "jurisdiction") and "county" are used interchangeably because ME/Cs' offices are typically organized by county. One exception occurs in Niagara County, NY, which is divided into four districts. For reporting purposes, the four districts that make up Niagara County, NY, are treated collectively as a single jurisdiction. For participating states, every county or jurisdiction within each state is included in DAWN.

The metropolitan area definitions used in this publication are those established by the Office of Management and Budget (OMB) based on the 2000 U.S. Census as updated in 2003.¹⁵ OMB issues annual updates to the boundaries and names of metropolitan areas. DAWN ME reports use the name that was current during the data collection year. While there have been several name changes, changes in metropolitan statistical area boundaries since 2003 have not altered the metropolitan areas reported on in this publication.

APPENDIX B

GLOSSARY OF TERMS

This glossary defines terms used in data collection activities, analyses, and publications associated with the mortality component of DAWN.

Accidental ingestion:

This category includes deaths resulting from accidentally or unknowingly ingesting a drug, as denoted by a medical examiner or coroner (ME/C).

Adverse reaction to medication:

This category was designed to capture natural or accidental deaths as the result of an adverse reaction to a prescription drug, over-the-counter (OTC) medication, or dietary supplement.

All other accidental:

See Drug misuse/abuse.

Body systems:

Refers to neurological, cardiovascular, gastrointestinal, genitourinary, respiratory, musculoskeletal, skin and soft tissue, lymphatic, endocrine, head and neck, abdominal, or multisystem conditions identified in the chain of events that led to the drug-related death. (See also Cause of death.)

Case type:

See Manner of death.

Cause of death:

The chain of events (diseases, injuries, or complications) that caused the death, as recorded on the death certificate. A death can have multiple causes. The immediate cause is listed first and is followed by contributing causes listed sequentially, ending with the underlying cause. Other significant conditions that contributed to the death are listed separately.

Coroner (C):

Death investigation jurisdictions typically use either a medical examiner (ME) system or a coroner system. Unlike MEs, coroners need not be physicians; usually, the only prerequisite for serving as a coroner is that the individual be more than 18 years of age and a resident of the county or district to be served. Coroners are typically elected rather than appointed. They may have jurisdiction over counties or districts within States. (See also Jurisdiction and Medical examiner.)

Could not be determined:

See Drug misuse/abuse.

Drug:

This refers to a substance that was recorded in a DAWN case report. Substances accepted by DAWN include alcohol, illicit drugs, prescription and OTC pharmaceuticals, dietary supplements, and nonpharmaceutical inhalants. Multiple substances ("drugs") can be reported for each DAWN case. Therefore, the total number of drugs exceeds the total number of DAWN cases reported. (See also Single-drug case.)

Drug category:

A generic grouping of related pharmaceuticals or other substances reported to DAWN, based on the classification of Multum Information Services. Multum, a subsidiary of the Cerner Corporation, is a developer of clinical drug information systems and a drug knowledge base. (More information is available at http://www.multum.com/.) In general, the Multum categories follow the therapeutic uses for prescription and OTC pharmaceuticals.

Additional clarification is provided for the following drug categories:

• Alcohol alone—DAWN collects data on alcohol when used alone only if the decedent is under age 21.
• Alcohol-in-combination—"Alcohol-in-combination" is the category for alcohol present in combination with another reportable substance (or substances). DAWN does not gather data on alcohol used alone if the decedent is over age 21. For decedents 21 or older, alcohol must be used with another substance to be reported. "Alcohol-in-combination" is reportable for all ages.
• Stimulants—This category includes amphetamines and methamphetamine. Since some drug screens test for amphetamines only as a class, an amphetamine-positive result could indicate amphetamine or methamphetamine. For this reason, amphetamines and methamphetamine are combined for analysis into the category "stimulants." This category does not include other central nervous system stimulants, such as caffeine or methylphenidate.
• Inhalants—This category includes anesthetic gases and psychoactive nonpharmaceutical substances for which the documented route of administration was inhaled, sniffed, or snorted. Accidental exposures to nonpharmaceutical inhalants (e.g., being overcome by paint fumes while painting a closet) are no longer included as DAWN cases. Psychoactive nonpharmaceuticals fall into one of the following three categories: (1) volatile solvents—adhesives (model airplane glue, rubber cement, household glue), aerosols (spray paint, hairspray, air freshener, deodorant, fabric protector), solvents and gases (nail polish remover, paint thinner, correction fluid and thinner, toxic markers, pure toluene, cigar lighter fluid, gasoline, carburetor cleaner, octane booster), cleaning agents (dry cleaning fluid, spot remover, degreaser), food products (vegetable cooking spray; dessert topping spray, such as whipped cream or "whippets"), and gases (butane, propane, helium); (2) nitrites—amyl nitrites ("poppers," "snappers") and butyl nitrites ("rush," "locker room," "bolt," "climax," video head cleaner); and (3) chlorofluorohydrocarbons (freons). Anesthetic gases (e.g., nitrous oxide, ether, chloroform) are presumed to have been inhaled.
• Opiates/opioids—This category includes opiates (narcotic substances derived from opium) and opioids (semisynthetic and synthetic substances with similar narcotic properties). The category is subdivided into (1) heroin (specified)—includes only specific reports of heroin; (2) methadone—whether used in the treatment of opiate addiction or pain; and (3) all other opiates/opioids—includes nonspecific reports of "opiates" and specific named substances, such as codeine, morphine, fentanyl, hydrocodone, oxycodone, and others.

Drug misuse/abuse:

A group defined broadly to include deaths related to drug misuse or abuse. Additional clarification is provided for the following manners of death:

• Overmedication—This category was designed to capture nonmedical use, overuse, and misuse of prescription and OTC medications when this use was not documented as drug abuse.
• Homicide by drug—This category was designed to capture malicious poisonings; that is, the decedent was administered a drug by another person for a malicious purpose. Only cases assigned a manner of death by homicide by the ME/C are classified in this category.
• All other accidental—This category includes all deaths denoted by the ME/C as natural or accidental that could not be assigned to any other case type. By design, most deaths of documented drug abuse will fall into this category.
• Could not be determined—This category includes all deaths with a manner of death denoted by the ME/C as could not be determined. This manner of death is assigned by the ME/C when a definitive ruling of suicide, homicide, natural, or accidental death is not possible.

Drug-related death:

Any death related to recent drug use. To be a DAWN case, a drug needs only to be implicated in the death; the drug does not have to have caused the death. Even if only one drug is reported, it should not be assumed that the substance was the sole and direct cause of the death. (See also Single-drug case.) Drug-induced deaths are those for which the drug(s) directly caused the death.

Homicide:

See Drug misuse/abuse.

Jurisdiction:

DAWN uses the term "jurisdiction" to mean the geographic area for which an ME/C's office is responsible. The terms "death investigation jurisdiction" (or, simply, "jurisdiction") and "county" are used interchangeably because ME/Cs' offices are typically organized by county. The one exception occurs in Niagara County, NY, which is divided into four districts. For reporting purposes, the four districts that make up Niagara County, NY, are treated collectively as a single jurisdiction. Some States are organized in single statewide jurisdictions. DAWN disaggregates state-level returns by county for the purpose of reporting data at the county and metropolitan levels.

Differences in death investigation procedures are often associated with whether the jurisdiction has a medical examiner system or a coroner system. In addition, there are nearly always some differences in death investigation procedures across States. Differences in death investigation procedures limit the comparability of DAWN ME/C findings.

Manner of death:

A classification used to group similar DAWN cases. Each case is coded into one and only one category, the first that applies from the following hierarchy: "Suicide," "Homicide by drugs," "Adverse reaction to medication," "Overmedication," "Accidental ingestion," "All other accidental," and "Could not be determined." The manner of death categories used by DAWN draw from but do not duplicate the manner of death recorded on the death certificate. Figure A-2 depicts the classification hierarchy graphically and provides additional detail on what is included in each category.

Medical examiner (ME):

Death investigation jurisdictions typically use either a medical examiner system (ME) or a coroner (C) system. Most medical examiners are licensed physicians or forensic pathologists and are generally appointed (rather than elected). They may have jurisdiction over a county, district, or an entire State. (See also Coroner and Jurisdiction.)

Metropolitan area:

An area comprising a relatively large core city or cities and the adjacent geographic areas. Conceptually, these areas are integrated economic and social units with a large population center. Unless otherwise noted, metropolitan area analyses prepared by DAWN utilize the boundaries established by the Office of Management and Budget (OMB) as updated in 2003.

Overmedication:

See Drug misuse/abuse.

Place of death:

The location that best describes where the death occurred. The place of death categories on the DAWN data collection form are:

• Emergency department—The death occurred in a hospital emergency department.
• Other health care facility—The death occurred in a hospital unit other than an emergency department, nursing home, hospice, or any other health care institution in which the decedent was receiving care.
• Decedent's home—The death occurred at the decedent's home, apartment, or other dwelling.
• Other—The location of death was documented in the source record but does not fit into any of the preceding categories.
• Not documented—The location of death was not available in the source record.

Race/ethnicity:

OMB is responsible for standard protocols for the collection of data on race and ethnicity by federal systems, including DAWN. In October 1997, OMB issued a revised standard protocol that permitted separate reporting of race and Hispanic ethnicity; the ability to capture more than one race for an individual; modifications in nomenclature (e.g., "Black" was changed to "Black or African American"); division of certain categories ("Asian or Pacific Islander" was split into two categories, "Asian" and "Native Hawaiian or Other Pacific Islander"); and elimination of the "Other" category. For data collections such as DAWN, where self-identification of the individual is not feasible, the revised OMB protocol permits a combined format, whereby race and Hispanic ethnicity are recorded in a single data item that could still record multiple entries for race, Hispanic ethnicity, or both.

Since January 2003, DAWN has collected data on race/ethnicity using the combined format. The race/ethnicity categories on the DAWN data collection forms are as follows:

• White—A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.
• Black or African American—A person having origins in any of the black racial groups of Africa.
• Hispanic or Latino—A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
• Asian—A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
• American Indian or Alaska Native—A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.
• Native Hawaiian or Other Pacific Islander—A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
• Not documented—Used when documentation of race is not available from source records.
  
  

Despite the increased detail allowed by these categories and by the provision for multiple entries, the actual race/ethnicity data reported to DAWN is quite limited because race and ethnicity are often not documented with this level of specificity in patient or decedent records. As a result, the classification used to tabulate DAWN data has a more limited set of categories, as follows:

• White—Anyone meeting the definition of white (above). Those who are identified as white and Hispanic are classified as Hispanic.
• Black—Anyone meeting the definition of black or African American (above). Those who are identified as black or African American and Hispanic are classified as Hispanic.
• Hispanic—Anyone whose ethnicity is Hispanic or Latino (above) is placed in the category Hispanic, regardless of race.
• Race/ethnicity NTA—This includes those categories that are too small to report independently, including two or more races; American Indian or Alaska Native; Asian; and Native Hawaiian or Other Pacific Islander.
• Unknown—Race/ethnicity is unknown. Those who are identified only as Hispanic are classified as Hispanic.
  
  

Single-drug case:

A single-drug case is one in which only one drug was involved. Because multiple substances may be recorded for each DAWN case (see Drug), readers should be cautious in interpreting the relationship between a given drug and the number of associated visits or deaths. For example, if the source record for a patient or decedent documented marijuana use, this does not mean that marijuana was the only drug involved in the visit or death or that marijuana caused the visit or death. One should always consider whether and how many other drugs were used in combination. Even then, attributing a causal relationship between the visit or death and a particular drug may not be possible. DAWN captures single-drug visits or deaths involving alcohol only if the decedent was younger than age 21.

Suicide:

This category includes cases denoted by the ME/C as suicide if the decedent took his or her own life and legal or illegal drugs had been involved; drug use need not have been the cause of death.

Toxic effects:

Injury, illness, or damage that can be attributed to the ingestion of a drug. (See also Cause of death.)

APPENDIX C
MULTUM LEXICON
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Multum Lexicon
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Cerner Multum, Inc.
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Document revised April 1, 2003