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Mini Review
Ivana Marasovi `uanjara1*, Marija Definis Gojanovi2, Davor Vodopija3


 1Public Health Institutes of Split and Dalmatian County, Vukovarska 46, 21000 Split               
2 Department of Pathology and Forensic Medicine, Split University Hospital, Spin
ieva 1, 21000 Split, Croatia  
 3Croatian Military Academies, Zrinsko-Frankopanska bb, 21000 Split, Croatia





*Corresponding author:
Ivana Marasovi `uanjara
Public Health Institutes Split-Dalmatian County, Split, Croatia
Vukovarska 46, p.p. 194, 21000 Split, Croatia
Tel. +385 21 48 03 73; fax +385 21 53 53 18
E mail: ivana_ms@yahoo.com














ABSTRACT
It is considered, according to statements from different sources, that data on the number of deaths in the population of a certain country or region are accurate and correct, but determining causes of death is, from different reasons, often incorrect. There is, therefore, a justified doubt that there are often less registered drug abuse-related deaths in state registries than there actually are. Hence, this paper tends to show most frequent difficulties when recording mortality resulting from drug abuse.
Keywords: mortality, drug abuse, death certificates.

























Mortality data present an important source of information necessary for the assessment of the population health status, health care planning and selection of health care priorities. This is the reason why recording of these data is of special importance for medical practice, since its poor execution leads to wrong health statistics, incorrect data on disease prevalence and, perhaps, to unbalanced allocation of often scarce resources as a consequence of inaccurate evaluation of the causes of death [1].
Data on mortality resulting from drug abuse and on mortality among drug addicts are used for different purposes. They are a valuable indicator of dimensions of the drug abuse problem in a country or a region, especially when interpreted along with other indicators [2,3]. Studies have shown that, similarly to other mortality causes [1,4,5], certification of drug abuse deaths presents a significant problem in the world, whether they are overdose related deaths or other deaths resulting from drugs consumption [6,7]. The difference in the number of the deceased among various information sources, according to some studies, presents an information support to the hypothesis on underreporting of this mortality [8].

DEATH CERTIFICATES AND COMPLETION THEREOF 
Death certificates present an important source of information in mortality statistics worldwide. Although originally not intended for epidemiologic and other researches, they are essential in processing of demographic and epidemiologic data. Nevertheless, accuracy and comprehensiveness of data received when surveying death certificates have been questioned all over the world [9-12]. According to literature sources, data on the number of deaths in the population of a certain country or region are accurate and correct, but determining causes of death is often incorrect [10,13,14]. This is also confirmed by the study carried out in Croatia, in which the search of  various data sources on persons who died of overdose showed  numbers which were varying among individual data sources, and the total number itself was larger than the total number deriving from the individual data sources [15].
The standard death certificate in Europe follows the recommendations of the World Health Organization (WHO), which recommends that the underlying cause of death should be used for statistical analysis of mortality [10,13]. The underlying cause of death is the disease that triggered the chain of events leading to death, without which death would not have occurred. It should be as etiologically specific as possible.�Non- specific conditions, which actually present mechanisms of death (e.g. sepsis, haemorrhage, respiratory failure, renal failure), have more than one possible cause and are not acceptable as an underlying cause of death [10,16]. Despite that, listing �respiratory arrest or cardio-respiratory arrest� as the underlying cause of death is one of the most common mistakes in death certificates [17]. Except in heart donors, cardiac arrest is a meaningless term; it is simply a condition to be dead and must not be used as an underlying cause of death [10]. It is important to discriminate one more term when completing a death certificate, and that is the immediate cause of death. The immediate cause of death is the final complication resulting from the underlying cause of death, occurring closest to the time of death and directly causing death and, in many cases, cannot be identified as an underlying cause of death. Many physicians think that the current death registration form, which has been recommended by the WHO, is prone to errors and, therefore, requires complete revision [9,18,19]. They consider that the terms like �cause of death�, �immediate cause of death� and "mechanism of death� often confuse medical examiners [10,20-22]. Another potential problem when completing a death certificate is the fact that the process of registering data itself is determined by the medical examiner�s evaluation and depends on his/her level of education and on the process of registering the fatal event. To decide which data are necessary to include is a demanding task [11]. Sometimes, it is not possible to reliably determine occurrences resulting in death, and despite the adequate knowledge and experience, it may happen that a medical examiner, at the moment of deciding on the cause of death, does not have enough helpful information at his/her disposal. This is confirmed by literary data, whereas some researches show that in more than 50% of the cases the cause of death obtained in this way does not correspond to the real cause of death determined by a subsequent autopsy [19].  
It is also necessary to mention that death certificates are not unique and that they differ from a country to country in certain specific characteristics. For example, the certificates used in Croatia until recently differed from those recommended by the WHO. In the report on the cause of death there were no boxes envisaged for describing violent deaths and for entering data relevant to causes of maternal and infant death [23], which could potentially lead to inaccurate recording of certain fatal events.
One of the following possible reasons for the inaccurate/incomplete filling in of death certificates is that upon patient�s death the family usually wants the death certificate to be issued without delay so as to organise the funeral as soon as possible, while the results of toxicological and other analyses have not been finished yet [1,24]. Such death certificates are therefore to be subsequently updated by all means. It is important to stress that correcting/correction of the cause of death is necessary in order to differentiate the �cause� and �mechanism� of death, and to understand the terms �immediate cause of death� and �underlying cause of death�, both terms being included in the standard death certificate form, which is a precondition to complete a death certificate correctly and the basis of good-quality mortality data. 

DEFINITION OF DRUG-RELATED MORTALITY
Problems pertaining to the definition of drug-related deaths were spotted several decades ago. Some information sources include only deaths from overdose, whereas others include drug-related deaths in a wider context [17]. So, for example, in some countries a traffic accident in which a person with skin tracks or with presence of drugs in the blood took part is registered as a drug-related death, while in some other countries a person, under the influence of opioids, falling under a train is registered as a traffic accident [25]. In some countries overdose is not classified as suicide, although objectively speaking it may be, despite the fact that distinguishing between deliberate and accidental overdose is sometimes difficult [25]. Also, people addicted to psychoactive drugs often use a wide range of substances, in particular huge amounts of alcohol, which complicates the attribution of death to certain substances, and this differs significantly from a country to country [25]. The consequence of the existence of differences in defining drug-related mortality among individual countries in the world lies in the fact that some countries report lower mortality rates than they actually are [17]. Hence, it was vital to define the epidemiological indicator of this mortality, which was shown by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), in co-operation with national experts, through two components: deaths that are directly caused by the pharmacological action of one or several substances (drug-induced deaths) and deaths that are indirectly caused by the use of drugs, often with other concurrent factors (e.g. accidents) [17].
Appropriate implementation of these components requires the existence of high-quality information sources: general mortality registries and/or special mortality registries. For the purpose of enabling better quality information in Croatia, the Government Office for Drugs has suggested setting up of the Special Registry of Mortality among Drug Addicts within the Croatian National Institute of Public Health [26].

CORRELATION BETWEEN THE USE OF GENERAL TERMINOLOGY AND/OR CLASSIFICATION
It has been noticed that the correlation between the use of general terminology and/or classification is a major problem in the international comparison of drug-related deaths [27].
An international study conducted in nine European cities may be used to present this issue [27]. In this study �overdoses� are registered as �mental disorders�, �injuries and poisonings�, �ill-defined conditions� or as �other causes�. Such recording is somewhat understandable since at that time the Ninth Revision of the International Classification of Diseases (ICD-9) was used, which simply did not allow more accurate recording of fatal events due to the lack of specific codes [28].
An additional example showing the complexity of this problem is the one pointing out discrepancies even within individual countries, i.e. among institutions dealing with the same issues. So, in the study conducted by Pollock et al., it was established that 75% more cocaine-related deaths were reported to the National Institute of Drug Abuse (NIDA) than to the National Center for Health Statistics (NCHC) in the United States. This discrepancy was caused by the use of unspecific codes in the Ninth Revision of the International Classification of Diseases [29].
The use of the Tenth Revision of the International Classification of Diseases and Related Health Problems improved registering of these fatal events [30], which enabled recording and differentiating of these deaths, whether for people registered as drug addicts (within the category Mental and behavioural disorders F00-F99), with a possibility to use the fourth character in coding for defining drugs responsible for overdose (e.g. F11.0 Mental and behavioural disorders due to use of opioids - acute intoxication), or for those who are not registered drug addicts. For people who are not registered within the category Mental and behavioural disorders F00-F99, the Tenth Revision makes it possible for these deaths to be registered in the categories: T40 Poisoning by narcotics and psychodysleptics (hallucinogens), X40-X49 Accidental poisoning by and exposure to noxious substances, X60-X69 Intentional self-harm  and Y10-Y19 Event of undetermined intent.
Despite improvements achieved by the use of the Tenth Revision, some researchers argue that, in order to have a better specification of causes related to certain drugs, it will be necessary to introduce changes in the next ICD revision. According to their opinion, each drug should have a code of its own comparable to ATC (Anatomical Therapeutic Chemical Classification Index) [31]. In addition, for classification and describing the trends related to drug abuse, equal and specific definitions for drug-related deaths would be needed [31].

TOXICOLOGICAL ANALYSIY AND FORENSIC EXAMINATION
One more problem related to registration of deaths from overdose exists in countries worldwide, and it is caused by the fact that toxicological analyses and forensic examinations are not always undertaken to assess the part that drug abuse plays in causing the death. As a consequence, drug-related deaths are often under-reported in national registers [32]. Also, countries have different guidelines when such fatalities become an object of toxicological and forensic examinations. In the United States, only 20% out of the total number of all deaths are subject to analyses by medical professionals or medical examiners, and there are significant differences within individual states [33]. In certain countries, even when toxicological and forensic analysis has been carried out, it is not necessarily used when registering death. Countries differ in their endeavours and traditions of using the ICD, acts and other pieces of subordinate legislation which refer to registering fatalities, and to the scope of information being transferred from death certificates to national registries [34]. Certain differences exist even within individual countries. So, for example, in the United States, the examination practice varies widely by jurisdiction (whether state, county, municipality, city or town). In some jurisdictions, examination procedures are carried out by licensed physicians, expert forensic pathologists, whereas in others it is not necessary to have a degree in medicine for this job [33].  
Regardless of certain limitations, most researchers agree that toxicological analysis and forensic examination present the best/gold standard for the confirmation of pre-mortem diagnosis, so as to better identify causes of death resulting from overdose, which enables improvement of prevention strategies [35,36]. The results of a study conducted in Norway support this opinion [36]. The study shows that the number of overdose deaths, entered in the police registry, is considerably larger than it actually is. This means that a considerable number of deaths are counted as overdose deaths although there was no evidence of the use of psychoactive drugs in these deaths [36].
In Croatia, improvements in this area should follow implementation of the new Ordinance on the method�of examining the deceased�and determining the time and cause of death (OG 46/2011) and adoption of the Minimal requirements as a recommendation for determining deaths related to the abuse of drugs and psychotropic substances [26], by which these inconsistencies should be avoided.

CONCLUSION
Difficulties in recording mortality resulting from drug abuse are most often a consequence of the use of different methodologies, discrepancies in the coding of different conditions and diseases between the Ninth and Tenth Revision of the International Classification of Diseases, defining of certain causes of deaths due to the use of different protocols, education of medical examiners, etc. These difficulties require undertaking of measures such as the following: standardisation of definitions, standardisation of procedures when recording fatalities, execution of toxicological analyses and forensic examinations and continuous education of physicians, in order for these data to be upgraded and comparable worldwide.






















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