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Edwards EM, Searles JS, Shapiro SL. Deaths Involving Drugs in Vermont, 2004 Through 2010. Arch Intern Med. 2011;171(18):1676–1678. doi:10.1001/archinternmed.2011.450
Author Affiliations: Health Surveillance (Dr Edwards), Alcohol and Drug Abuse Programs (Dr Searles), and Office of the Chief Medical Examiner (Dr Shapiro), Vermont Department of Health, Burlington.
In 2009, the National Center for Health Statistics at the Centers for Disease Control and Prevention identified Vermont as having one of the highest rates of death due to overdoses (both accidental and suicide) involving opioid analgesics based on 1 year of data (2006).1 Given this disconcerting finding, we sought to examine deaths involving opioid analgesics over time to obtain a clearer picture of the problem.
In Vermont, the Medical Examiner's Office has statutory authority to investigate deaths when a person dies from violence; suddenly (when in apparent good health); unattended by a physician or a recognized practitioner of a well-established church; by casualty; by suicide; as a result of injury; in jail or prison or in a mental institution; in any unusual, unnatural, or suspicious manner; or in circumstances involving a hazard to public health, welfare, or safety.2
The medical examiner (S.L.S.) provided the 2 analysts (E.M.E. and J.S.S.) with information on all deaths from 2004 through 2010, in which a drug, legal or illegal, contributed to the death. The analysts separately reviewed and coded each death as involving prescription opiates (alone or in combination with other drugs) or other drugs. In doing so, the analysts discovered a number of the “other” deaths were due to anticoagulants, which were then coded separately. Deaths due to other drugs included prescribed drugs such as antidepressants or antihypertensives and illegal drugs (eg, cocaine). We did not make a distinction between suicide, natural, or accidental death.
From 2006 through 2009, the number of deaths involving drugs in Vermont increased from 73 to 93 (Table). From 2009 through 2010, the total number of deaths involving drugs decreased by 16% to 78.
We found that the percentage of drug deaths due to prescription opiates peaked in 2006 at 70% and the number of deaths peaked in 2007 at 56. This number declined 29% to 40 in 2010, approximately half of all drug deaths in that year.
The number of deaths seen by the medical examiner involving anticoagulants increased from 4 in 2006 to 18 in 2010, or 23% of all drug deaths. Most deaths involving anticoagulants were due to falls from a standing height and occurred among the elderly (mean age of death in 2010, 82 years). We do not know if individuals who were taking anticoagulants were within the therapeutic international normalized ratio (INR) or if these individuals should have been using lower doses. We also do not know if individuals taking anticoagulants were indicated for these therapies. Because the deaths in this analysis include only those that involved the medical examiner, similar deaths among individuals on anticoagulation therapy likely are underreported.
In 2006, the Vermont legislature established the Vermont Prescription Monitoring System (VPMS), a Web-based tool that collects information from all claims for scheduled II-IV prescriptions dispensed by all licensed in-state and out-of-state retail and mail-order pharmacies. Prescribers and dispensers started using the system to access the controlled prescription histories of their current patients in May 2009, with data retroactive to July 1, 2008. More than 1300 prescribers and pharmacists registered to use the system as of May 2011. Use of the VPMS by health professionals, combined with heightened awareness of prescription drug misuse in the general public, may have contributed to the decline in deaths involving prescription opiates.
The increasing rate of unintentional overdose deaths, with a particular focus on prescription opioids, is an area of significant current research3-5 and policy6 interest. However, our experience indicates that the manner of death, cause of injury, and drug involved in each death requires close examination over multiple years. We set out to investigate deaths involving prescription opioids and in doing so uncovered another problem involving deaths due to anticoagulants—less sensational, perhaps, but no less important.
These data suggest that physicians should carefully monitor the indicated uses of anticoagulants and the INRs of their patients receiving such therapy. Furthermore, to address underreporting of deaths involving anticoagulants, physicians should consider listing anticoagulation therapy as a contributory cause of death in those deaths in which hemorrhage was a terminal mechanism (eg, hemorrhagic stroke), even with therapeutic INR. Because individuals using anticoagulants bleed more than individuals who are not, regardless of the therapeutic INR, the Vermont medical examiner adds anticoagulation as a contributory cause of death. Improving reporting would help us understand the scope of the problem.
Correspondence: Dr Edwards, Health Surveillance, Vermont Department of Health, 108 Cherry St, PO Box 70, Burlington, VT 05402 (email@example.com).
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Searles. Acquisition of data: Shapiro. Analysis and interpretation of data: Edwards and Searles. Drafting of the manuscript: Edwards. Critical revision of the manuscript for important intellectual content: Searles and Shapiro. Statistical analysis: Edwards.
Financial Disclosure: None reported.