Relevant question: If someone dies and they have both alcohol and an opioid in their bloodstream, do they count against alcohol, opioid, both, or do they try to work out which one killed them?
Forensic toxicology screens are pretty thorough, and benefit from being able to take invasive samples like heart blood, brain, liver, and even eye tissue samples. That provides a lot of flexibility to find any substance that's present and look at relative concentrations and metabolites. Toxicology is usually sufficient in combination with the coroner's report on proximate cause of death; even if multiple substances are found, it's only a problem if they're all able to kill by the relevant mechanism.
In this example, someone with a high alcohol tolerance might die with a potentially-lethal level of alcohol in their blood, and also test positive for opioids. A tox screen should then be able to estimate that they had stopped drinking a few hours before (e.g. high acetaldehyde levels in blood and urine, no alcohol in stomach fluids), then freshly used opioids just before the time of death.
This gets harder if you have drugs with additive effects (e.g. death by respiratory depression, testing positive for heroin and ketamine); the autopsy would list both, but I don't know how the stats are handled. And it seems like a nightmare in the case of drug interactions; I have no idea what happens if somebody dies of serotonin syndrome triggered by mixing alcohol with MAOIs.
Page 160: "Alcohol-induced deaths and drug-induced deaths are mutually-exclusive. However, these deaths may also be considered suicide deaths."
Also, I can't find any more info on what is included here. They just say it doesn't use ICD-10 codes:
>"NCHS has defined selected causes of death groups for analysis of all ages mortality data: Drug-Induced causes, Alcohol-Induced Causes, All Other Causes. The group code values are not actual ICD codes published in the International Classification of Diseases, but are "recodes" defined to support analysis by the Selected Causes of Death groups." https://wonder.cdc.gov/wonder/help/mcd.html#Drug/Alcohol%20I...
EDIT:
If I go to CDC WONDER (https://wonder.cdc.gov/controller/datarequest/D76) and click "Drug/alcohol induced causes" a box populates showing (presumably) ICD-10 codes: X40-44, X60-64, X85, Y10-Y14
That includes stuff you wouldn't expect:
X44:
agents primarily acting on smooth and skeletal muscles and the respiratory system
anaesthetics (general)(local)
drugs affecting the:
· cardiovascular system
· gastrointestinal system
hormones and synthetic substitutes
systemic and haematological agents
systemic antibiotics and other anti-infectives
therapeutic gases
topical preparations
vaccines
water-balance agents and drugs affecting mineral and uric acid metabolism So this could be partially due to "better access to healthcare". More people are being put on blood pressure, etc medications and are dying from over/under-dosing on them. I don't see any reason for them to include X44 in the current study besides trying to mess with the numbers...
EDIT 2:
Indeed, when I selected only x44 on CDC WONDER, here are the results:
Year Deaths per 100k Pop
1999 1.5
2000 1.7
2001 1.9
2002 2.4
2003 2.6
2004 2.9
2005 3.3
2006 3.8
2007 4.2
2008 4.5
2009 4.7
2010 5.0
2011 5.6
2012 5.3
2013 5.5
2014 5.8
2015 6.3
2016 7.4
2017 8.1
Your not wrong, but it's not that super clear cut either.
Presumably this is strategic to hide whatever issue is going on with the "medical drugs" and inflate the apparent problem with "DARE drugs".
X42 governs accidental narcotic poisoning, but only in cases where the drug is specified, and isn't necessarily applied for prescription opioids. The list above for X44 is the 'including' list of suggestions, but the category includes any death from "unspecified drugs". And contributing causes of death are handled under a separate system making it possible to list more drugs in more detail, so the CDC says that both prescription and illicit opioid deaths can crop up under X44.
https://www.cdc.gov/drugoverdose/pdf/pdo_guide_to_icd-9-cm_a...
ICD coding features both an underlying cause of death, the X40-X44 range you're checking, and a "contributing cause" code which attempts to specify the substance involved. In this case, that's the T40.0-T40.6 range. The government guidelines on using WONDER to study opioids include "Please note: X and Y codes must be used in combination with T codes to identify opioid-related deaths."
That's because X42 only covers certain narcotic opioids like heroin, so an X44 opioid overdose is a possibility. Since that's "Accidental poisoning by and exposure to other and unspecified drugs", it could accompany T40.2 ("other opioids") or T40.6 ("unspecified narcotics"). And if the coroner doesn't record anything beyond "accidental drug overdose", then even heroin overdoses will result in X44, T50.9 ("unspecified drugs"). That last case alone apparently describes 25% of all US overdoses.
There's no slight of hand here, just a confusing two-layered classification system.
https://www.samhsa.gov/capt/sites/default/files/capt_resourc...
edit: here's a CDC page listing which primary and contributing causes can go together. Both prescription and illicit opioid deaths can be be filed as X44. https://www.cdc.gov/drugoverdose/pdf/pdo_guide_to_icd-9-cm_a...
That said, I think the specific rationale is that X44 is meant to hold all types of low-frequency poisoning by drugs, and 'unknown drug' usually means "not one of the notable drugs that gets its own code and is tested for". This usually works alright. X45-X49 handle cases like "alcohol poisoning", "tainted food", "inhaled chlorine fumes", and "other/unspecified chemicals", so X44 is only representing drugs. And "poisoning" is separate from "adverse effects" (Y40-Y84), so an allergic reaction or a standard risk like bleeding from warfarin won't get mixed in here. Given that, X44 is just a reasonably narrow category to assign a group of T## codes to. Those go into enormous detail, and have secondary "unknown" categories to handle the case where you know the class of drug but not the specific drug. Totally unknown poisonings are restricted to X44/T50.9 and should be extremely rare.
But this was all designed by 1990; it looked reasonable to divide both X and T categories by "non-opioid analgesic", "anesthetics", and "narcotics". It wasn't until we started widely prescribing strong opioids for pain that "painkillers plus heroin" became a key grouping you'd want to research. That, plus the international nature of the system, also left us with "heroin", "opium", and "other opioids" as the only 3 T codes for this topic. The listed examples for 'other' are morphine and its prodrug codeine; as a result we've got fentanyl and morphine in the same category despite a 100x difference in strength.
Compounding that, the narcotic poisoning (X42/T40) grouping was basically doomed from the beginning through no fault of the designers. It tries to replicate the legal/treaty category of narcotics, which has no biological coherence; what on earth do cocaine and morphine overdose have in common? Why is "cannabis derivative poisoning" singled out in the 'narcotics' section of a document created when the only synthetic cannabinoid in use was a rare antiemetic no one abused?
tl;dr: It was supposed to be a low-frequency grouping with subcategories clarifying about specific drugs, but that fell apart for opioids.
Yes, they put their best medical experts to the task...