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DRUG ABUSE WARNING NETWORK, 2006:
AREA PROFILES OF DRUG-RELATED MORTALITY



U.S. Department of Health and Human Services
Substance Abuse and Mental Health Services Administration
Office of Applied Studies

ACKNOWLEDGMENTS

This report was prepared by the Office of Applied Studies (OAS), Substance Abuse and Mental Health Services Administration (SAMHSA), and by RTI International (a trade name of Research Triangle Institute, Research Triangle Park, NC). Work by RTI was performed under contract number 280-03-2602. The co-authors are Judy K. Ball, Ph.D., M.P.A., previously of SAMHSA, and Victoria A. Albright, RTI, with the assistance of David Skellan, OAS/SAMHSA.

PUBLIC DOMAIN NOTICE

All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Suggested Citation. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, U.S. Department of Health and Human Services.

Ball, J., & Albright, V., Drug Abuse Warning Network, 2006: Area Profiles of Drug-Related Mortality. Rockville, MD: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, 2009.

ELECTRONIC ACCESS AND COPIES OF PUBLICATION

This publication may be downloaded from http://DAWNinfo.samhsa.gov or from http://oas.samhsa.gov. Or, please call SAMHSA's Health Information Network at

1-877-SAMHSA-7 (1-877-726-4727)
(English and Español)

ORIGINATING OFFICE

Office of Applied Studies
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road, Rockville, MD 20857

May 2009



CONTENTS

ACKNOWLEDGMENTS

DAWN MORTALITY DATA
Drug-related deaths
Drugs
Deaths included in this publication
Standardized death rates

PARTICIPATION IN DAWN 2006

SUMMARY OF FINDINGS

PROFILES AND SPOTLIGHTS
Full profiles
Limitations to data
Abbreviated profiles for selected metropolitan areas
Spotlights
State profiles

STATE PROFILES
Maine
Maryland
Massachusetts
New Hampshire
New Mexico
Oklahoma
Utah
Vermont

METROPOLITAN AREA PROFILES
Albuquerque, NM
Atlanta-Sandy Springs-Marietta, GA
Baltimore-Towson, MD
Barnstable Town, MA
Birmingham-Hoover, AL
Boston-Cambridge-Quincy, MA-NH
Buffalo-Niagara Falls, NY
Burlington-South Burlington, VT
Chicago-Naperville-Joliet, IL-IN-WI
Cleveland-Elyria-Mentor, OH
Denver-Aurora, CO
Detroit-Warren-Livonia, MI
Houston-Sugar Land-Baytown, TX
Indianapolis-Carmel, IN
Kansas City, MO-KS
Los Angeles-Long Beach-Santa Ana, CA
Louisville-Jefferson County, KY-IN
Manchester-Nashua, NH
Milwaukee-Waukesha-West Allis, WI
Minneapolis-St. Paul-Bloomington, MN-WI
New Orleans-Metairie-Kenner, LA
New York-Northern New Jersey-Long Island, NY-NJ-PA
Ogden-Clearfield, UT
Oklahoma City, OK
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD
Phoenix-Mesa-Scottsdale, AZ
Pittsburgh, PA
Portland-South Portland-Biddeford, ME
Portland-Vancouver-Beaverton, OR-WA
Provo-Orem, UT
Salt Lake City, UT
San Diego-Carlsbad-San Marcos, CA
Seattle-Tacoma-Bellevue, WA
Springfield, MA
St. Louis, MO-IL
Tulsa, OK
Washington-Arlington-Alexandria, DC-VA-MD-WV
Worcester, MA

ABBREVIATED PROFILES FOR AREAS WITH FEW DRUG-RELATED DEATHS
Bangor, ME
Fargo, ND-MN
Farmington, NM
Las Cruces, NM
Lawton, OK
Lewiston-Auburn, ME
Pittsfield, MA
Salisbury, MD
Santa Fe, NM
Sioux Falls, SD
St. George, UT

ABBREVIATED PROFILES FOR AREAS WITH LESS THAN 50% POPULATION COVERAGE
Dallas-Fort Worth-Arlington, TX
San Francisco-Oakland-Fremont, CA

AREA SPOTLIGHTS
Albuquerque, NM: Bernalillo County, NM
Atlanta-Sandy Springs-Marietta, GA: Fulton County, GA
Baltimore-Towson, MD: Baltimore City, MD
Baltimore-Towson, MD: Baltimore County, MD
Boston-Cambridge-Quincy, MA-NH: Essex County, MA
Boston-Cambridge-Quincy, MA-NH: Middlesex County, MA
Boston-Cambridge-Quincy, MA-NH: Norfolk County, MA
Boston-Cambridge-Quincy, MA-NH: Suffolk County, MA
Buffalo-Niagara Falls, NY: Erie County, NY
Chicago-Naperville-Joliet, IL-IN-WI: Cook County, IL
Chicago-Naperville-Joliet, IL-IN-WI: Lake County, IL
Denver-Aurora, CO: Adams County, CO
Denver-Aurora, CO: Arapahoe County, CO
Denver-Aurora, CO: Denver County, CO
Detroit-Warren-Livonia, MI: Macomb County, MI
Detroit-Warren-Livonia, MI: Oakland County, MI
Detroit-Warren-Livonia, MI: Wayne County, MI
Indianapolis-Carmel, IN: Marion County, IN
Kansas City, MO-KS: Jackson County, MO
Los Angeles-Long Beach-Santa Ana, CA: Los Angeles County, CA
Los Angeles-Long Beach-Santa Ana, CA: Orange County, CA
Minneapolis-St. Paul-Bloomington, MN-WI: Hennepin County, MN
New Orleans-Metairie-Kenner, LA: Jefferson Parish, LA
New York-Northern New Jersey-Long Island, NY-NJ-PA: Bronx County, NY
New York-Northern New Jersey-Long Island, NY-NJ-PA: Kings County, NY
New York-Northern New Jersey-Long Island, NY-NJ-PA: New York County, NY
New York-Northern New Jersey-Long Island, NY-NJ-PA: Queens County, NY
New York-Northern New Jersey-Long Island, NY-NJ-PA: Suffolk County, NY
New York-Northern New Jersey-Long Island, NY-NJ-PA: Union County, NY
Oklahoma City, OK: Oklahoma County, OK
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Bucks County, PA
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Delaware County, PA
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Montgomery County, PA
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD: Philadelphia County, PA
Portland-Vancouver-Beaverton, OR-WA: Multnomah County, OR
Provo-Orem, UT: Utah County, UT
Salt Lake City, UT: Salt Lake County, UT
Seattle-Tacoma-Bellevue, WA: King County, WA
Seattle-Tacoma-Bellevue, WA: Pierce County, WA
Seattle-Tacoma-Bellevue, WA: Snohomish County, WA
Springfield, MA: Hampden County, MA
St. Louis, MO-IL: St. Louis City, MO
St. Louis, MO-IL: St. Louis County, MO
Tulsa, OK: Tulsa County, OK
Washington-Arlington-Alexandria, DC-VA-MD-WV: District of Columbia

List of Tables
Table 1. Participation of medical examiner/coroner jurisdictions in DAWN, 2006
Table 2. Rates of drug-related deaths and drug-related suicide deaths per 100,000 population, 2006
Table 3. Rates of drug-related deaths and percentage change, 2005 and 2006
Table 4. Metropolitan area profiles and county spotlights
Table 5. State profiles and metropolitan area profiles wholly in those States

List of Figures
Figure 1. Sample metropolitan area profile layout

List of Appendixes
Appendix A: DAWN Mortality Data Collection
Appendix B: Glossary of Terms
Appendix C: Multum Licensing Agreement



DAWN MORTALITY DATA

The Drug Abuse Warning Network (DAWN) is a public health surveillance system that monitors drug-related deaths referred to medical examiners and coroners (ME/Cs) in selected metropolitan areas and States. Findings in this publication reflect data on drug-related deaths that occurred during calendar year 2006 and were reported by participating ME/Cs to DAWN. In selected tables, data from reporting year 2005 are included for comparison. The Office of Applied Studies (OAS) of the Substance Abuse and Mental Health Services Administration (SAMHSA), U.S. Department of Health and Human Services, is responsible for DAWN.

The mortality component of DAWN does not rely on a statistical sample of ME/Cs. Findings cannot be considered representative of ME/Cs that did not participate, and results cannot be extrapolated to the United States as a whole. DAWN mortality data for 2003 and later are not comparable to mortality data for any years prior to 2003 because of changes introduced in the 2003 reporting year.

Drug-related deaths

Since 2003, a DAWN case is any death reviewed by an ME/C that was related to recent drug use. Findings in this publication pertain to drug-related deaths and drug-related suicide deaths reported by participating death investigation jurisdictions as DAWN cases.1

DAWN cases are identified through a retrospective review of decedent case files in each participating death investigation jurisdiction. A DAWN case is any death that is determined by the ME/C as being related to drug use. The relationship between the death and the drug need not be causal; the drug need only be implicated in the death. The drug use may have been for legitimate, therapeutic purposes or for the purpose of drug misuse/abuse, but in either case, the drug use must have been recent.

These eligibility criteria for a DAWN case are intentionally broad and inclusive. Since death record documentation varies in clarity and comprehensiveness across jurisdictions, broad criteria reduce the potential for judgment calls that could cause data to vary systematically and unexpectedly across reporters and jurisdictions. Broad criteria also capture a diverse set of drug-related deaths that support a wide variety of analytical purposes and interests.

For decedents under the age of 21, DAWN cases include deaths where the only drug involved was alcohol. For those 21 or older, there must be at least one other drug involved besides alcohol for the death to be a DAWN case.

The data items submitted on drug-related deaths are described in Appendix A.

Drugs

Drugs that make a death eligible for DAWN include:

Deaths included in this publication

Findings in this publication focus on two major categories of drug-related deaths, based on the manner of death as determined by the ME/C.

  1. Drug-related deaths (other than drug-related suicide deaths) include the following:

    • Natural or accidental deaths with drug involvement. These two categories capture deaths involving medical use, nonmedical use, overuse, and misuse of prescription and over-the-counter medications and drug abuse.
    • Homicide by drug. This category was designed to capture malicious poisonings; that is, the decedent was administered a drug(s) by another person for a malicious purpose.
    • Deaths with drug involvement when manner of death denoted by the ME/C was "could not be determined" (CNBD). This manner of death is assigned by the ME/C when a definitive ruling of suicide, homicide, natural, or accidental death is not possible.
  2. Drug-related suicide deaths include suicide deaths with drug involvement. The determination of suicide is made by the ME/C. Because of the broad eligibility criteria for determining DAWN cases, drug-related suicide deaths include more than deaths due to overdoses. A reported drug may not be the cause of the suicide death even if only one drug was involved. Drug(s) must be a contributing factor, though.

Findings reported in this publication are based on concluded investigations that were submitted by May 10, 2007, for deaths that occurred during 2006. Death investigations that were not concluded by the ME/C by the end of the data collection period are excluded.

Standardized death rates

Death rates (i.e., the number of deaths per 100,000 population) are reported to permit comparisons within or across areas or across demographic subgroups. This use of death rates, as opposed to counts, is important because two areas with similar numbers of drug-related deaths may have vastly different populations. Rates, which take population differences into account, standardized these comparisons.

There are limitations to be considered when comparing death rates. While differences in rates may signify differences in underlying drug-related mortality (or a lack of differences may suggest similarity), other factors may confound such comparisons. For example, State laws dictate which deaths are subject to ME/C review. These laws vary by State and, within each State, by time. Within ME/C offices, toxicology testing practices vary, depending on local concerns, funding, and testing technology. Such factors will affect the number of deaths determined to be DAWN cases and the number of deaths attributed to particular drugs. Small changes in the number of deaths (e.g., an increase of 5 deaths) can result in a large percentage difference if the base is small (e.g., an increase of 5 to 10 deaths is a 100% increase). Even though there is no sampling error in DAWN ME/C data, the possibility of nonsampling errors (i.e., errors in reporting, changes in testing protocols) limits the interpretation of the findings.



PARTICIPATION IN DAWN 2006

DAWN relies on the voluntary cooperation of ME/Cs in selected areas of the United States to provide standardized data on drug-related deaths. For 2006, 175 jurisdictions in 51 metropolitan areas and 217 jurisdictions in 8 States submitted mortality data to DAWN.34

Table 1 provides information on the metropolitan areas and States that participated in 2006. It includes the following:

An awareness of the extent of DAWN's coverage within a given area is needed to interpret DAWN mortality data accurately. ME/C participants in DAWN are not part of a scientific sample at either the metropolitan or the national level. Within a metropolitan area, findings based on participating jurisdictions are not representative of nonparticipating jurisdictions. Reports from only a portion of jurisdictions within a metropolitan area can be extrapolated neither to the metropolitan area as a whole nor to the nation as a whole.5

While the data do not support any representations at a national level, some generalizations can be made at a metropolitan level, even if some ME/Cs do not participate. For example, while only 1 (10%) of the 10 counties that make up the Houston, TX, metropolitan area participated in DAWN in 2006, that county is home to 70 percent of the area's total population. The important consideration is population coverage, not ME/C participation, per se.

Among the metropolitan areas listed in Table 1, population coverage exceeded 90 percent in 31 metropolitan areas, with 100 percent coverage in 27 of those areas. The remaining metropolitan areas had response rates that range from a low of 21 percent in Dallas-Fort Worth-Arlington to 85 percent in Chicago-Naperville-Joliet. Population coverage below 50 percent usually equates to the absence of large jurisdictions.

Table 1
Participation of medical examiner/coroner jurisdictions in DAWN, 2006
Area Total jurisdictions
(counties)
Participating jurisdictions
(counties)
DAWN coverage
Number Percent of total Population Percent of area
population
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (08/2008 update).
Fifty-one metropolitan areas 324 175 54% 98,453,972 76%
Eight States 217 217 100% 23,397,171 100%
Metropolitan areas
Albuquerque, NM 4 4 100% 816,811 100%
Atlanta-Sandy Springs-Marietta, GA 28 8 29% 3,335,970 65%
Baltimore-Towson, MD 7 7 100% 2,658,405 100%
Bangor, ME 1 1 100% 147,180 100%
Barnstable Town, MA 1 1 100% 224,816 100%
Birmingham-Hoover, AL 7 1 14% 656,700 60%
Boston-Cambridge-Quincy, MA-NH 7 7 100% 4,455,217 100%
Buffalo-Niagara Falls, NY 2 2 100% 1,137,520 100%
Burlington-South Burlington, VT 3 3 100% 206,007 100%
Chicago-Naperville-Joliet, IL-IN-WI 14 8 57% 8,034,600 85%
Cleveland-Elyria-Mentor, OH 5 1 20% 1,314,241 62%
Dallas-Fort Worth-Arlington, TX 12 2 17% 1,283,089 21%
Denver-Aurora, CO 10 6 60% 2,332,305 97%
Detroit-Warren-Livonia, MI 6 5 83% 4,375,205 98%
Fargo, ND-MN 2 1 50% 132,525 71%
Farmington, NM 1 1 100% 126,473 100%
Houston-Sugar Land-Baytown, TX 10 1 10% 3,886,207 70%
Indianapolis-Carmel, IN 10 2 20% 998,820 60%
Kansas City, MO-KS 15 4 27% 1,049,877 53%
Las Cruces, NM 1 1 100% 193,888 100%
Lawton, OK 1 1 100% 109,181 100%
Lewiston-Auburn, ME 1 1 100% 107,552 100%
Los Angeles-Long Beach-Santa Ana, CA 2 2 100% 12,950,129 100%
Louisville-Jefferson County, KY-IN 13 1 8% 701,500 57%
Manchester-Nashua, NH 1 1 100% 402,789 100%
Milwaukee-Waukesha-West Allis, WI 4 1 25% 915,097 61%
Minneapolis-St. Paul-Bloomington, MN-WI 13 10 77% 2,653,234 84%
New Orleans-Metairie-Kenner, LA 7 3 43% 532,659 52%
New York-Northern New Jersey-Long Island, NY-NJ-PA 23 10 43% 11,103,957 59%
Ogden-Clearfield, UT 3 3 100% 497,640 100%
Oklahoma City, OK 7 7 100% 1,172,339 100%
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 11 5 45% 3,502,789 60%
Phoenix-Mesa-Scottsdale, AZ 2 1 50% 3,768,123 93%
Pittsburgh, PA 7 1 14% 1,223,411 52%
Pittsfield, MA 1 1 100% 131,117 100%
Portland-South Portland-Biddeford, ME 3 3 100% 513,667 100%
Portland-Vancouver-Beaverton, OR-WA 7 3 43% 1,569,953 73%
Provo-Orem, UT 2 2 100% 474,180 100%
Salisbury, MD 2 2 100% 117,761 100%
Salt Lake City, UT 3 3 100% 1,067,722 100%
San Diego-Carlsbad-San Marcos, CA 1 1 100% 2,941,454 100%
San Francisco-Oakland-Fremont, CA 5 2 40% 954,241 23%
Santa Fe, NM 1 1 100% 142,407 100%
Seattle-Tacoma-Bellevue, WA 3 3 100% 3,263,497 100%
Sioux Falls, SD 4 1 25% 163,281 77%
Springfield, MA 3 3 100% 686,174 100%
St. George, UT 1 1 100% 126,312 100%
St. Louis, MO-IL 17 9 53% 2,373,249 84%
Tulsa, OK 7 7 100% 897,752 100%
Washington-Arlington-Alexandria, DC-VA-MD-WV 20 19 95% 5,239,957 99%
Worcester, MA 1 1 100% 784,992 100%
States
Maine 16 16 100% 1,321,574 100%
Maryland 24 24 100% 5,615,727 100%
Massachusetts 14 14 100% 6,437,193 100%
New Hampshire 10 10 100% 1,314,895 100%
New Mexico 33 33 100% 1,954,599 100%
Oklahoma 77 77 100% 3,579,212 100%
Utah 29 29 100% 2,550,063 100%
Vermont 14 14 100% 623,908 100%

SUMMARY OF FINDINGS

Table 2 reports the rates of drug-related deaths and drug-related suicide deaths per 100,000 population for metropolitan areas and States that participated in DAWN in 2006. Table 3 compares the rates of drug-related deaths in 2006 with those found for 2005 and reports the percentage change. (Comparisons are not made for drug-related suicide deaths because of their small numbers.) Table 3 is limited to those areas where the same jurisdictions participated in 2005 as in 2006. Both tables include indicators of the population coverage in DAWN for 2006.

Table 2
Rates of drug-related deaths and drug-related suicide deaths per 100,000 population, 2006
Metropolitan area or State Rate of drug-related deaths per 100,000 population* DAWN coverage
Deaths Suicide deaths Population Percent of area
population
* Drug-related deaths exclude drug-related suicide deaths.
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (08/2008 update).
Metropolitan areas
Albuquerque, NM 26.0 3.7 816,811 100%
Atlanta-Sandy Springs-Marietta, GA 7.8 0.7 3,335,970 65%
Baltimore-Towson, MD 19.8 1.3 2,658,405 100%
Bangor, ME 12.9 3.4 147,180 100%
Barnstable Town, MA 15.6 3.1 224,816 100%
Birmingham-Hoover, AL 17.5 1.4 656,700 60%
Boston-Cambridge-Quincy, MA-NH 13.4 1.4 4,455,217 100%
Buffalo-Niagara Falls, NY 7.7 1.1 1,137,520 100%
Burlington-South Burlington, VT 15.5 3.4 206,007 100%
Chicago-Naperville-Joliet, IL-IN-WI 12.4 0.8 8,034,600 85%
Cleveland-Elyria-Mentor, OH 17.3 1.4 1,314,241 62%
Dallas-Fort Worth-Arlington, TX 3.9 1.0 1,283,089 21%
Denver-Aurora, CO 13.9 2.4 2,332,305 97%
Detroit-Warren-Livonia, MI 20.2 1.4 4,375,205 98%
Fargo, ND-MN 0.8 2.3 132,525 71%
Farmington, NM 6.3 4.0 126,473 100%
Houston-Sugar Land-Baytown, TX 11.4 1.4 3,886,207 70%
Indianapolis-Carmel, IN 11.3 0.8 998,820 60%
Kansas City, MO-KS 8.3 2.2 1,049,877 53%
Las Cruces, NM 11.3 1.0 193,888 100%
Lawton, OK 4.6 0.9 109,181 100%
Lewiston-Auburn, ME 8.4 0.9 107,552 100%
Los Angeles-Long Beach-Santa Ana, CA 9.8 1.4 12,950,129 100%
Louisville-Jefferson County, KY-IN 10.1 1.0 701,500 57%
Manchester-Nashua, NH 8.2 1.0 402,789 100%
Milwaukee-Waukesha-West Allis, WI 19.6 1.2 915,097 61%
Minneapolis-St. Paul-Bloomington, MN-WI 6.8 1.8 2,653,234 84%
New Orleans-Metairie-Kenner, LA 28.7 0.4 532,659 52%
New York-Northern New Jersey-Long Island, NY-NJ-PA 9.9 0.7 11,103,957 59%
Ogden-Clearfield, UT 11.3 2.0 497,640 100%
Oklahoma City, OK 7.3 1.4 1,172,339 100%
Philadelphia-Camden-Wilmington, PA-NJ-DE-MD 26.0 1.2 3,502,789 60%
Phoenix-Mesa-Scottsdale, AZ 16.9 3.4 3,768,123 93%
Pittsburgh, PA 15.3 1.7 1,223,411 52%
Pittsfield, MA 6.9 0.8 131,117 100%
Portland-South Portland-Biddeford, ME 8.0 1.0 513,667 100%
Portland-Vancouver-Beaverton, OR-WA 11.7 3.0 1,569,953 73%
Provo-Orem, UT 16.0 2.3 474,180 100%
Salisbury, MD 19.5 0.8 117,761 100%
Salt Lake City, UT 19.3 2.6 1,067,722 100%
San Diego-Carlsbad-San Marcos, CA 8.4 1.1 2,941,454 100%
San Francisco-Oakland-Fremont, CA 6.5 2.1 954,241 23%
Santa Fe, NM 16.2 1.4 142,407 100%
Seattle-Tacoma-Bellevue, WA 15.6 3.2 3,263,497 100%
Sioux Falls, SD 0.6 1.2 163,281 77%
Springfield, MA 13.0 1.7 686,174 100%
St. George, UT 9.5 1.6 126,312 100%
St. Louis, MO-IL 13.7 2.2 2,373,249 84%
Tulsa, OK 13.4 1.4 897,752 100%
Washington-Arlington-Alexandria, DC-VA-MD-WV 6.3 1.1 5,239,957 99%
Worcester, MA 13.5 1.4 784,992 100%
States
Maine 9.2 1.7 1,321,574 100%
Maryland 13.6 1.0 5,615,727 100%
Massachusetts 14.2 1.6 6,437,193 100%
New Hampshire 8.9 1.3 1,314,895 100%
New Mexico 19.2 2.8 1,954,599 100%
Oklahoma 8.4 1.2 3,579,212 100%
Utah 15.9 2.4 2,550,063 100%
Vermont 11.5 3.0 623,908 100%
Table 3
Rates of drug-related deaths and percentage change, 2005 and 2006
Metropolitan area or State* Rate of drug-related deaths
per 100,000 population†
Percent change
in rate,
2005 to 2006
DAWN coverage
2005 2006 Population Percent of area
population
* The table is limited to those areas where the same jurisdictions participated in both years.
† Drug-related deaths exclude drug-related suicide deaths.
SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2006 (08/2008 update).
Metropolitan areas
Albuquerque, NM 20.9 26.0 23.9% 816,811 100%
Atlanta-Sandy Springs-Marietta, GA 6.2 7.8 26.1% 3,335,970 65%
Baltimore-Towson, MD 18.0 19.8 10.0% 2,658,405 100%
Barnstable Town, MA 14.6 15.6 6.7% 224,816 100%
Birmingham-Hoover, AL 11.6 17.5 51.2% 656,700 60%
Boston-Cambridge-Quincy, MA-NH 12.7 13.4 5.5% 4,455,217 100%
Buffalo-Niagara Falls, NY 9.3 7.7 -17.2% 1,137,520 100%
Burlington-South Burlington, VT 15.6 15.5 -0.4% 206,007 100%
Chicago-Naperville-Joliet, IL-IN-WI 9.6 12.4 28.8% 8,034,600 85%
Cleveland-Elyria-Mentor, OH 13.6 17.3 27.0% 1,314,241 62%
Denver-Aurora, CO 13.7 13.9 1.5% 2,332,305 97%
Houston-Sugar Land-Baytown, TX 11.7 11.4 -2.7% 3,886,207 70%
Indianapolis-Carmel, IN 6.8 11.3 67.4% 998,820 60%
Kansas City, MO-KS 9.0 8.3 -8.3% 1,049,877 53%
Louisville-Jefferson County, KY-IN 10.9 10.1 -6.9% 701,500 57%
Milwaukee-Waukesha-West Allis, WI 17.9 19.6 9.6% 915,097 61%
New York-Northern New Jersey-Long Island, NY-NJ-PA 8.7 9.9 14.3% 11,103,957 59%
Ogden-Clearfield, UT 11.7 11.3 -4.0% 497,640 100%
Oklahoma City, OK 6.4 7.3 14.5% 1,172,339 100%
Phoenix-Mesa-Scottsdale, AZ 13.9 16.9 21.6% 3,768,123 93%
Pittsburgh, PA 17.8 15.3 -13.9% 1,223,411 52%
Portland-South Portland-Biddeford, ME 10.5 8.0 -24.2% 513,667 100%
Portland-Vancouver-Beaverton, OR-WA 11.4 11.7 2.1% 1,569,953 73%
Provo-Orem, UT 15.8 16.0 1.2% 474,180 100%
Salt Lake City, UT 18.3 19.3 5.2% 1,067,722 100%
San Diego-Carlsbad-San Marcos, CA 10.7 8.4 -21.5% 2,941,454 100%
Springfield, MA 11.4 13.0 14.2% 686,174 100%
St. Louis, MO-IL 10.1 13.7 35.4% 2,373,249 84%
Tulsa, OK 10.5 13.4 27.3% 897,752 100%
Washington-Arlington-Alexandria, DC-VA-MD-WV 5.4 6.3 15.1% 5,239,957 99%
Worcester, MA 11.5 13.5 17.3% 784,992 100%
States
Maine 11.4 9.2 -18.9% 1,321,574 100%
Maryland 11.9 13.6 14.5% 5,615,727 100%
Massachusetts 13.5 14.2 5.4% 6,437,193 100%
New Hampshire 6.7 8.9 33.7% 1,314,895 100%
New Mexico 16.3 19.2 18.4% 1,954,599 100%
Oklahoma 7.2 8.4 16.5% 3,579,212 100%
Utah 15.6 15.9 1.9% 2,550,063 100%
Vermont 11.6 11.5 -0.2% 623,908 100%

PROFILES AND SPOTLIGHTS

DAWN mortality data are reported for metropolitan areas with 30 or more deaths and for all participating States in six figures and tables that span two or more pages. These are referred to as "full profiles." Metropolitan areas with fewer than 30 deaths or areas with less than 50 percent coverage receive an "abbreviated profile" that includes just one of the six tables. Large, individual jurisdictions that are part of a multijurisdictional area and reported 60 or more deaths receive a full profile that is referred to as a "spotlight."

Among the 51 metropolitan areas, full profiles are provided for 38 metropolitan areas. Abbreviated profiles are provided for 11 metropolitan areas that submitted 30 or fewer drug-related deaths and for 2 metropolitan areas with less than 50 percent population coverage. Spotlights are provided for 45 individual jurisdictions.

Table 4 lists the metropolitan area profiles and spotlights for jurisdictions within those areas. Table 5 lists State profiles and profiles for metropolitan areas located wholly within those States.

At the end of this publication, the profiles and spotlights appear in separate sections in alphabetical order by State and metropolitan area name. The Contents to this publication lists the profiles and spotlights in the order in which they appear.

Table 4
Metropolitan area profiles and county spotlights
Type of profile Metropolitan area profile County spotlight(s)
Full Albuquerque, NM Bernalillo County
Full Atlanta-Sandy Springs-Marietta, GA Fulton County
Full Baltimore-Towson, MD Baltimore City
Baltimore County
Abbreviated Bangor, ME None
Full Barnstable Town, MA None
Full Birmingham-Hoover, AL None
Full Boston-Cambridge-Quincy, MA-NH Essex County
Middlesex County
Norfolk County
Suffolk County
Full Buffalo-Niagara Falls, NY Erie County
Full Burlington-South Burlington, VT None
Full Chicago-Naperville-Joliet, IL-IN-WI Cook County
Lake County
Full Cleveland-Elyria-Mentor, OH None
Abbreviated Dallas-Fort Worth-Arlington, TX None
Full Denver-Aurora, CO Adams County
Arapahoe County
Denver County
Full Detroit-Warren-Livonia, MI Macomb County
Oakland County
Wayne County
Abbreviated Fargo, ND-MN None
Abbreviated Farmington, NM None
Full Houston-Sugar Land-Baytown, TX None
Full Indianapolis-Carmel, IN Marion County
Full Kansas City, MO-KS Jackson County
Abbreviated Las Cruces, NM None
Abbreviated Lawton, OK None
Abbreviated Lewiston-Auburn, ME None
Full Los Angeles-Long Beach-Santa Ana, CA Los Angeles County
Orange County
Full Louisville-Jefferson County, KY-IN None
Full Manchester-Nashua, NH None
Full Milwaukee-Waukesha-West Allis, WI None
Full Minneapolis-St. Paul-Bloomington, MN-WI Hennepin County
Full New Orleans-Metairie-Kenner, LA Jefferson Parish
Full New York-Northern New Jersey-Long Island, NY-NJ-PA Bronx County
Kings County
New York County
Queens County
Suffolk County
Union County
Full Ogden-Clearfield, UT None
Full Oklahoma City, OK Oklahoma County
Full Philadelphia-Camden-Wilmington, PA-NJ-DE-MD Bucks County
Delaware County
Montgomery County
Philadelphia County
Full Phoenix-Mesa-Scottsdale, AZ None
Full Pittsburgh, PA None
Abbreviated Pittsfield, MA None
Full Portland-South Portland-Biddeford, ME None
Full Portland-Vancouver-Beaverton, OR-WA Multnomah County
Full Provo-Orem, UT Utah County
Abbreviated Salisbury, MD None
Full Salt Lake City, UT Salt Lake County
Full San Diego-Carlsbad-San Marcos, CA None
Abbreviated San Francisco-Oakland-Fremont, CA None
Abbreviated Santa Fe, NM None
Full Seattle-Tacoma-Bellevue, WA King County
Pierce County
Snohomish County
Abbreviated Sioux Falls, SD None
Full Springfield, MA Hampden County
Abbreviated St. George, UT None
Full St. Louis, MO-IL St. Louis City
St. Louis County
Full Tulsa, OK Tulsa County
Full Washington-Arlington-Alexandria, DC-VA-MD-WV District of Columbia
Full Worcester, MA None
Table 5
State profiles and metropolitan area profiles wholly in those States
State profile Metropolitan area profiles Type of profile
Maine Bangor, ME
Lewiston-Auburn, ME
Portland-South Portland-Biddeford, ME
Abbreviated
Abbreviated
Full
Maryland Baltimore-Towson, MD
Salisbury, MD
Full
Abbreviated
Massachusetts Barnstable Town, MA
Pittsfield, MA
Springfield, MA
Worcester, MA
Full
Abbreviated
Full
Full
New Hampshire Manchester-Nashua, NH Full
New Mexico Albuquerque, NM
Farmington, NM
Las Cruces, NM
Santa Fe, NM
Full
Abbreviated
Abbreviated
Abbreviated
Oklahoma Lawton, OK
Oklahoma City, OK
Tulsa, OK
Abbreviated
Full
Full
Utah Ogden-Clearfield, UT
Provo-Orem, UT
Salt Lake City, UT
St. George, UT
Full
Full
Full
Abbreviated
Vermont Burlington-South Burlington, VT Full

Full profiles

The full profile is composed of six exhibits plus a map and demographic information on the State or metropolitan area and its constituent counties. Figure 1 shows the general layout of the full profile. All profiles observe the following conventions:

Map

Each profile begins with a map displaying the boundaries of the metropolitan area or State and its component counties. 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. 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.

Figure 1
Sample metropolitan area profile layout

Figure 1

D

Both participating and nonparticipating jurisdictions are shown in the map. Jurisdictions that provided mortality data for 2006 are colored white. Jurisdictions in the area that did not provide data are shaded light blue. Areas outside of the metropolitan area or State are shaded darker blue.

Metropolitan area definitions used in this publication are those established by OMB, based on the 2000 decennial U.S. Census and updated in 2003.6 Changes in metropolitan statistical area (MSA) boundaries since 2003 have not altered the metropolitan areas reported on in this publication. By OMB convention, the names of MSAs reflect the largest population centers (i.e., cities) in the MSA. If the relative population size of cities changes (i.e., the second largest becomes the largest), OMB changes the name of the MSA to reflect the new order of cities by size (i.e., the name of the larger city will appear first). This publication uses the name of the MSA that was current at the end of the data collection year.

Next to the map, the following items appear:

Table A: Metro area overview: Deaths and population by county, 2006

Below the map, Table A lists each of the component jurisdictions for the area. Each jurisdiction is numbered to correspond to the numbers shown on the area map. In metropolitan areas that cross State borders, jurisdictions are ordered first by State and then alphabetically by county name. Nonparticipating jurisdictions are included in the list with a shaded background to distinguish them from participating jurisdictions.

Information in Table A for each jurisdiction includes the following:

The top row of the table totals this information for just the participating jurisdictions.

Rates, because they are population adjusted, can be compared across jurisdictions, metropolitan areas, and States. This standardization does not take into account, however, the differences in applicable laws that specify which deaths are subject to ME/C review or other factors that may confound comparisons.

The subsequent tables and figures (B through F) are based on data aggregated across the participating jurisdictions in each metropolitan area or State.

Figure B: Deaths by manner of death, 2006

Figure B is a pie chart that displays manner of death for drug-related deaths and drug-related suicide deaths. The manner of death reported here is that assigned by the ME/C using the categories provided on the U.S. Standard Certificate of Death. Solid-colored slices are reserved for drug-related deaths other than suicides; the patterned slice shows the suicide deaths. Reading clockwise, the manners of death are identified as follows:

Figure C: Top 5 drugs involved: Drug-related deaths, 2006
Top 5 drugs involved: Drug-related suicide deaths, 2006

Separate bar charts show the five most common types of drugs (e.g., opiates/opioids, benzodiazepines) reported to DAWN for drug-related deaths and drug-related suicide deaths across the participating jurisdictions. The number shown above each bar is the number of deaths reported for a specific drug type. The name of the drug type is printed below each bar. Each bar is partitioned to display separately the portion of deaths involving a single drug type (solid blue area in bottom portion of bar) versus multiple drug types (striped area in top of bar). A bar is not printed if there are fewer than four deaths associated with a drug type, and therefore, fewer than five bars may appear. The top 5 drug types are identified from among 17 different drug types, as listed in Table F (see below).

A single death that involved two drugs of different types (e.g., cocaine and heroin) would be counted in two bars (e.g., cocaine and heroin, respectively). As a result, summing the number of deaths reported in each bar will double-count deaths that involved multiple types of drugs. A death that involved two drugs of the same type (e.g., multiple opiates/opioids, such as methadone and heroin) will be counted once (e.g., in the bar for opiates/opioids).

Grouping drugs by drug type eliminates double counting due to the following causes: redundant drug reports (e.g., "cocaine" and its metabolite "benzoylecgonine" being reported for the same death); redundant reports from nonspecific terms (e.g., "heroin" and "opiates" being reported for the same death); and drug reports that may be indistinguishable (e.g., "heroin" and "morphine").

Figure D: Death rates by gender and age: Drug-related, 2006
Death rates by gender and age: Drug-related suicide deaths, 2006

Figure D displays the gender and categorical age of decedents in drug-related deaths and drug-related suicide deaths, in terms of deaths per 100,000 population. Only population in participating jurisdictions is considered in the calculation of these rates. Taking population size into account enables comparisons to be made across age and gender subgroups.

Table E: Place of death, 2006

Table E reports the place of death for drug-related deaths and drug-related suicide deaths. Deaths in emergency departments and other health care facilities have been combined into the single category "Health care facility."

Table F: Drug-related deaths by drug category, 2005-2006

Table F reports, by drug type or drug, the count of drug-related deaths and drug-related suicide deaths for 2005 and 2006. The first row of Table F summarizes deaths across all drug categories; the subsequent rows provide detail for 17 specific drug types or drugs of particular interest.

Data for both 2005 and 2006 are reported when the same jurisdictions participated in both years. If comparable data for 2005 are not available (e.g., due to nonparticipation) or are not comparable to those shown for 2006 (e.g., in the Detroit metropolitan area, Livingston County, MI, participated in 2006 but not in 2005), the columns are left blank.

Counts of drug-related deaths and drug-related suicide deaths include deaths that involved both single and multiple drugs. Summing these deaths across drug types or drugs could result in double counting deaths associated with multiple drug types. To help provide a better understanding of single versus multidrug involvement, counts of single-drug deaths are reported. Single-drug deaths involve the listed drug type or drug and no other, and they are a subset of the total count of deaths.

The 17 drug categories shown in this table are derived from DAWN's standard drug classification scheme and include the following:8

The next six rows in Table F pertain to illicit drugs:

The remaining rows in Table F are devoted to prescription and over-the-counter pharmaceuticals. For this table, heroin is categorized and reported on as an opiate/opioid. Low-frequency drugs have been aggregated into higher-level categories:

Limitations to data

Not every reported substance (drug) is, by itself, the cause of death or even a contributor to the death. DAWN's broad definition of drug involvement requires only that the drug is related to the death. Therefore, even in single-drug deaths, reported drugs may not be a direct cause of death. Furthermore, incidental reporting (i.e., reporting of drugs unrelated to the death) is unavoidable due to ambiguities and insufficiencies in the ME/C's records.

The total number of deaths in some drug categories is often quite small and of limited significance. The intent in reporting small counts is primarily to indicate the relative occurrence of deaths in different drug categories.

Numbers less than four but greater than zero are suppressed.

Abbreviated profiles for selected metropolitan areas

To warrant a full profile, the participating jurisdictions of a metropolitan area in combination must have reported more than 30 drug-related deaths or drug-related suicide deaths, and the area's population coverage must exceed 50 percent. If either of these two conditions was not met, an abbreviated profile is provided for the area. In contrast to full profiles, abbreviated profiles include only a map and Table A (see above).

Spotlights

Spotlights are produced for individual jurisdictions in which 60 or more drug-related deaths were reported. The purpose is to distinguish findings for a single location from those of the metropolitan area as a whole. Spotlights may appear for jurisdictions even if the metropolitan area itself had less than 50 percent population coverage. In some instances, even if a jurisdiction has 60 or more deaths, a spotlight may not be needed. Such is the case when a metropolitan area contains only one county or had only one county participating in DAWN.

Spotlights have essentially the same format as the full metropolitan area profile. Spotlights include the map; Figures B, C, and D; and Tables E and F, as described above. Because of the small numbers, drug-related suicide deaths have been removed from all exhibits except the jurisdiction summary and Figure B.

State profiles

Eight statewide ME/C systems participated in DAWN in 2006. A full profile is provided for each of the following States:

Any metropolitan areas that fell wholly within the eight statewide ME/C systems and reported more than 30 drug-related deaths or drug-related suicide deaths to DAWN in 2006 received a full profile (Table 5).

Additional detail on the DAWN data collection methodology is provided in Appendix A. A Glossary of Terms used in this report appears in Appendix B.

End Notes

1 DAWN uses the terms "death investigation jurisdiction" (or, simply, "jurisdiction") and "county" 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.

2 To be reportable, a nonpharmaceutical substance must be consumed by inhalation, sniffing, or snorting and must have a psychoactive effect when inhaled. Carbon monoxide is excluded from the inhalants reportable to DAWN, as is accidental inhalation of a nonpharmaceutical. Additional information on inhalants is provided in Appendix B: Glossary of Terms.

3 There is overlap between the metropolitan areas and States. In total, usable reports were received from 324 jurisdictions: 107 are only in metropolitan areas, 149 are only in States, and 68 are in both.

4 DAWN uses the metropolitan area definitions established by the Office of Management and Budget (OMB) in 2000 and updated in 2003. See Appendix A for additional detail.

5 Recruitment efforts to increase participation by ME/Cs are ongoing. However, there are no plans to make the mortality component of DAWN national in scope or representative of nonparticipating jurisdictions.

6 Office of Management and Budget, Revised Definitions of Metropolitan Statistical Areas, New Definitions of Micropolitan Statistical Areas and Combined Statistical Areas, and Guidance on Uses of the Statistical Definitions of These Areas, Bulletin No. 03-04, June 6, 2003. (Available at http://www.whitehouse.gov/omb/bulletins/b03-04.html.)

7 Population estimates for 2005 and 2006 were obtained from the U.S. Census Bureau County-Level Population Estimates (CPOP file), Vintage 2006, released August 2007. (Available at http://www.census.gov/popest/estimates.html.)

8 The classification of drugs used by DAWN is derived from the Multum Lexicon, ® 2008, Multum Information Services, Inc. The classification has been modified to meet DAWN's unique requirements (2008). The Multum Licensing Agreement governing use of the Lexicon is provided in Appendix C. (Also available at http://www.multum.com/.)

9 Some examples may assist readers in interpreting this classification. A death that involved heroin and methadone would be counted in the "Opiates/opioids" row, in the "Heroin (specified)" row, and in the "Methadone" row. A death that involved morphine would be counted in the "Opiates/opioids" row and in the "All other opiates/opioids" row. A death that involved both morphine and codeine would be counted in the "Opiates/opioids" row and in the "All other opiates/opioids" row.

10 Note that morphine and unspecified opiates are not grouped in the "Heroin (specified)" category. Morphine is not classified as heroin because it is not possible to differentiate morphine, the metabolite of heroin, from morphine itself. Most drugs in the category "Heroin (specified)" were reported to DAWN as heroin or its metabolite monoacetylmorphine. A few were reported as acetylmorphine, diacetylmorphine, acetylcodeine, monoacetylcodeine, heroin dope, or black tar heroin.

11 The term "morphine" or "free morphine" accounted for most drug reports classified as "morphine," and the term "opiates" accounted for most of the unspecified opiates.

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