Poisoning Definition

8/12/2019 Poisoning Definition

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How do we and how should we define and

count poisoning deaths in the UnitedStates?

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESCenters for Disease Control and PreventionNational Center for Health Statistics

Lois A. Fingerhut, MA

Special Assistant for Injury Epidemiology, OAERobert N. Anderson, PhD

Chief, Mortality Statistics Branch, DVS


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Objectives

To consider revising the existing matrixdefinition of poisoning to include relevantcodes from the F10-F19 series of theMental and Behavioral Disorders chapterof the ICD

To better understand what is gained from

analyzing multiple cause of death data forpoisoning


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How are poisoning deaths

currently defined?

1. By the List of 113 Causes (used to rank

leading causes of death in the US): theunderlying cause ICD-10 codes for

Unintentional poisoning are X40-X49

2. By the External Cause of Injury Mortality

Matrix as the underlying cause for

poisoning regardless of intent

[Recommended by NCHS and Injury ICE]


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Poisoning is defined in the Matrix by

ICD-10 codes by intent

ICD also codes broad substance groupsDrug Alcohol Gases

/vapors

Other solid/

liquids

Unintentional X40-X44 X45 X47 X46,X48-X49

Suicide X60-X64 X65 X67 X66,X68-X69

Homicide X85 X88 X86-X87,X89-

X90

Undetermined Y10-Y14 Y15 Y17 Y16,Y18-Y19

Legal int. Y35.2

Terrorism *U01.7 *U01.6


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Poisoning deaths- 2002

Drug Alcohol Othersolid/liq

Gases

/vapors

Percent 89% 2% 1% 8%

Unintentional 66% 16,394 355 161 640

Suicide 21% 3,884 26 157 1,419

Homicide 43 na 5 15

Undetermined 13% 3,197 25 43 71

Legal int. na na na 0

Terrorism na na 0 0


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Based on the matrix definition,

poisoning was, in 2002,

3rd leading cause of injury death overall;

distant 2nd for unintentional injury; 3rd for suicide

leading cause for intent undetermined.


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Should codes be added to the

definition of poisoning?

Being considered are underlying ICD-10codes F10-F19 for Mental and Behavioral

disorders (MBD) due to pyschoactivesubstance use

The precise wording on the deathcertificate can determine whether a drug

or alcohol related death is assigned anunderlying cause of poisoning or a F10-F19 code.


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F10-F19:

If so, which codes should be added?

F10 Alcohol

F11Opioids

F12 Cannabinoids

F13 Sedatives/hypnotics

F14 Cocaine

F15 Other stim.,incl. caffeine

F16 Hallucinogens

F17 Tobacco

F18 Volatile solvents

F19 Mult drug use & otherpsycho. substances

4thdigit of these codes:

.0 Acute intoxication

.1 Harmful use

.2 Dependence syndrome

.3-.4 Withdrawal states .5 Psychotic disorder

.6 Amnesic syndrome

.7 Residual/late onsetpsychotic disorder

.8 Other MBD

.9 Unspecified MBD

3 digit ICD-10 codes

For each 3 digi t cod e:

.0-.1 and .3-.9= Nondependen t abuse

.2=Depend ent abu se


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F10-F19 Deaths: 2002

Acute Harmful Dependence Withdrawal

Intoxication use Syndrome state Other Unspecified

.0 .1 .2 .3-.4 .5-.8 .9

Alcohol F10 6,842 617 1,741 3,679 212 195 398

Drugs: 2,137 15 1,399 390 14 8 311Opioids F11 281 148 75 2 56

Cannabinoids F12 2 1 1

edatives/hypnotics F13 3 1 2

Cocaine F14 437 11 266 50 1 6 103

Other stimulants F15 52 4 28 5 1 14

Hallucinogen F16 5 4 1Volatile solvents F18 5 4 1

Multiple drug/other F19 1,352 948 258 9 1 136

[MBD due to tobacco use (F17) is not included as a drug. F17 was the

underlying cause of 549 deaths in 2002.]


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Alcohol and drug-related deaths

from MBD 1999-2002

Slow but steady increases in alcohol-related (except intoxication) deaths

as well as nondependent drug abuse deaths

100

1,000

10,000

1999 2000 2001 2002

Numberofdeaths

Alcohol dependence F10.2

Alcohol, nondependence, F10 (.1,.3-.9)

Alcohol intoxication, F10.0

Drug, nondependence F11-F16, F18-F19 (.0-.1, .3-.9)

Drug dependence, F11-F16, F18-F19 (.2)


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Multiple cause codes identify the

specific drug or substance

Multiple cause of death codes are often

referred to as nature of injury codes; forpoisoning and toxic effects in ICD-10

these are T36-T65.

Too often they are neglected in analyses.


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T codes

T36-T50:Poisoning by drugs, medicaments andbiological substances

T51-T65: Toxic effects of substances chiefly

nonmedicinal as to source

Using these nature of injury poisoning codes,29,974 deaths had at least one mention of a

poison or toxic substance, and there were a totalof 49,946 mentions of substances.

For all underlying-external cause poisoningdeaths, an average of 1.9 total substances were

listed per death


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Leading substances in multiple cause

data by underlying cause of death : 2002

-

1,000

2,000

3,000

4,000

5,000

6,000

Cocain

e

Heroin

Metha

done

Oth

Opioid

s

Oth

SynthNa

rcotic

s

Benzodiaz.

Antid

ep

TxEff

Alc

TxEff

CO

Deaths

All other underlying causes (including F10)

Drug Dependence

Drug - NonDependence

Other ext. injury deaths

External Poisoning- Matrix definition

Drugs and toxic effect substances mentioned in multiple cause data

Underlying causes of death


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WHOs Mortality Reference

Group (MRG)

The MRG makes decisions regarding theapplication and interpretation of ICD to

mortality and makes recommendations onproposed ICD updates to the UpdateReference Committee (URC).

The URC recommends changes to theICD-10 to the Heads of WHOCollaborating Centers for the Family ofInternational Classifications each year.


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If the death certificate has language that

includes words that would have resulted in an

underlying cause code of F10-F19 with a 4thdigit

of 0, the new rule will result in coding to an

underlying external poisoning code for alcohol.

The largest impact in the US will be more deathscoded to X45 [Accidental poisoning by and

exposure to alcohol] because nearly all of the

F10-F19 codes with a 4thdigit of 0 are for

alcohol (F10.0)

The MRG has recommended:

Deaths due to Acute Intoxication


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Regarding all F10-F19:

If the underlying cause would have resulted inany code F10-F19 and the certificate alsoincluded information ascribed to an externalcause poisoning code, the new rule will result inunderlying cause codes going to the externalcauses.

These changes will increase the number ofpoisoning deaths by an indeterminate amount.

These changes will be implemented in 2006.


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Recommendation

At a minimum, consider expanding thedefinition of poisoning deaths beyond the

number based on matrix (26,435 deaths in2002) to include deaths due to alcoholintoxication (617 deaths), and deaths due todrug non-dependence (1,747)


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19/21

Conclusion

Death certificate wording determineswhether a drug or alcohol-related death

is assigned an underlying cause ofpoisoning or mental or behavioraldisorder. Recommendations on formaldefinitions must follow broad-based

discussions among communities oftoxicologists, medical examiners, andinjury epidemiologists.


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National Academy of Science

May 2004

U.S. Institute of Medicine has recommended that:

WHO should review and reform the ICD codes forpoisoning[This is being done]

NCHS should review the methodology of its existingsurveys to maximize the value.for poison

prevention and control.[Review of mortality definition isunderway]

From: Forging a Poison Prevention and Control System (2004)


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Poisoning Definition

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