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APPENDIX A
DAWN MORTALITY DATA COLLECTION

DAWN data collection

DAWN mortality data are collected in participating medical examiner and coroner offices through a retrospective review of case records for every death investigated by the medical examiner or coroner. Families are never interviewed. The review of source records is performed by a trained DAWN reporter in each member facility. Depending on the needs of the facility, the DAWN reporter may be an employee of the death investigation jurisdiction or an employee of the DAWN operations contractor.

Within each facility that participates in DAWN, the designated DAWN reporter reviews all death records to identify deaths related to drug use. The DAWN reporter submits an electronic case report to the DAWN system for each death that meets the specific case selection criteria.

Deaths eligible for DAWN

A DAWN case is any death related to recent drug use. DAWN includes deaths associated with substance abuse and misuse, both intentional and accidental. DAWN also includes deaths related to the use of drugs for legitimate therapeutic purposes. To be a DAWN case, the relation between the death and the drug need not be causal; the drug needs only to be implicated in the death.

The case criteria are intended to be broad and inclusive and to have few exceptions. DAWN cases are found through a retrospective review of death records.1 Broad criteria take into account the fact that documentation in death records varies in clarity and comprehensiveness across medical examiners/coroners. Broad criteria minimize the potential for judgments that could cause data to vary systematically and unexpectedly across reporters and jurisdictions. In addition, broad criteria are designed to capture a very diverse set of drug-related deaths, which can be aggregated and disaggregated to serve a variety of analytical purposes and the interests of multiple audiences. In DAWN, only recent drug use is included,2 and the reason a patient used a drug is irrelevant.

There are some clearly delineated exceptions to the DAWN case criteria. A death is not a DAWN case if:

Data items collected by DAWN

The case report form showing all the data items collected by DAWN is provided in Figure A-1. This is a representation of the form on paper, whereas all DAWN data are submitted electronically. The electronic system, for example, permits the submission of more drugs than are shown on the paper form.

Manner of death in DAWN

Manner of death is a particularly important part of the death records because it is used to determine if the death is a case of drug misuse/abuse. As depicted in Figure A-2, the DAWN Decision Tree, each death is assigned to one of seven manners of death as follows:

Each DAWN case is assigned to one, and only one, of the seven manner of death categories based on the series of questions and decision rules depicted in the decision tree. Starting at the top, each case is assigned to the first manner of death that applies, even if the case might also meet the rules for a subsequent category. The seven categories were ordered with this in mind.

The final two categories, all other accidental and could not be determined, were designed to capture all of the drug-related deaths that could not be classified in any of the prior case types. Could not be determined cases include those that are ruled by the ME/C explicitly as "could not be determined" (i.e., the evidence was inconclusive with regard to whether the death was accidental, suicide, or homicide).

Figure A-1. DAWN case form

Figure A-1     D

Figure A-2. DAWN decision tree

Figure A-2     D

Drugs included in DAWN

DAWN includes all types of drugs.3 Drugs in DAWN include:

To be reportable, a nonpharmaceutical substance must be consumed by inhalation, sniffing, or snorting, and it must have a psychoactive effect when inhaled. A death involving inhalation of a nonpharmaceutical, psychoactive substance and no other drug qualifies as a DAWN case. Carbon monoxide is excluded from the inhalants, as noted above. Beginning in 2004, deaths involving accidental exposures (e.g., exposure to paint fumes while painting a closet) are excluded as well.

DAWN features that enhance data quality and reliability

Several methods are used to improve the quality and reliability of DAWN data. These include:

In addition to these steps, each ME/C receives a summary of the drug-related deaths submitted for each of his or her jurisdiction(s) after the data for the year are closed out. This final step provided an opportunity for the ME/Cs to approve or reject the data used for this publication. Any rejected data are reconciled to the satisfaction of the ME/C before they are used in this publication.

Participation of medical examiners and coroners

ME/Cs participate in DAWN on a voluntary basis and constitute neither a sample nor a census of ME/Cs in the United States. ME/Cs are invited to join DAWN based on their location in selected metropolitan areas. Recruitment efforts focus primarily on areas where DAWN data are also collected from hospital emergency departments. In addition to recruitment targeted at metropolitan areas, DAWN has added States with centralized medical examiner systems to gain a better understanding of drug-related mortality outside of the targeted metropolitan areas.

A death investigation jurisdiction typically corresponds to a county. In the rare instances with multiple jurisdictions in a single county, the jurisdictions are combined and reported at the county level. For participating states, every county within the state is included in DAWN.

The metropolitan-area definitions used in this publication are those established by the Office of Management and Budget (OMB) and updated in 2003. These definitions can be found in the OMB publication 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, which can be accessed at http://www.whitehouse.gov/omb/bulletins/b03-04.html.

Appendix A footnotes

1 This review is conducted by "DAWN reporters" described above.

2 That is, patients with a history of drug use (and no recent use) are excluded.

3 The classification of drugs used in DAWN is derived from the Multum Lexicon, © 2005, Multum Information Services, Inc. The classification schema was modified to meet DAWN's unique requirements (2006). The Multum Licensing Agreement governing use of the Lexicon is provided in Appendix C and can be found on the Internet at http://www.multum.com.



APPENDIX B
GLOSSARY OF TERMS

This glossary defines terms used in data collection activities, analyses, and publications associated with the mortality component of the Drug Abuse Warning Network (DAWN).

Accidental ingestion: This category includes deaths resulting from accidentally or unknowingly ingesting a drug as denoted by ME/C.

Adverse Reaction to Medication: This category was designed to capture natural or accidental deaths as the result from an adverse reaction to a prescription drug, over-the counter medication, or dietary supplement.

All other accidental: See Drug Misuse.

Body systems: Refers to neurological, cardiovascular, gastrointestinal, genitourinary, respiratory, musculoskeletal, skin and soft tissue, lymphatic, endocrine, head and neck, abdominal and/or multi-system conditions identified in the chain of events that led to the drug-related death. (See also Cause of death.)

Case type: See Manner of death.

Cause of death: The chain of events (diseases, injuries, or complications) that caused the death, as recorded on the death certificate. A death can have multiple causes. The immediate cause is listed first and is followed by contributing causes listed sequentially, ending with the underlying cause. Other significant conditions that contributed to the death are listed separately.

Coroner (C): Death investigation jurisdictions typically use either a medical examiner system or a coroner system. Unlike medical examiners, coroners need not be physicians; usually the only prerequisite for serving as a coroner is that the individual be more than 18 years of age and a resident of the county or district to be served. Coroners are typically elected rather than appointed. They may have jurisdiction over counties or districts within states. (See also Jurisdiction and Medical examiner.)

Could not be determined: See Drug Misuse.

Drug: This refers to a substance that was recorded in a DAWN case report. Substances accepted by DAWN include alcohol, illicit drugs, prescription and over-the-counter pharmaceuticals, dietary supplements, and nonpharmaceutical inhalants. Multiple substances ("drugs") can be reported for each DAWN case. Therefore, the total number of drugs exceeds the total number of DAWN cases reported. (See also Single-drug case.)

Drug category: A generic grouping of related pharmaceuticals or other substances reported to DAWN, based on the classification of Multum Information Services. Multum Information Services, a subsidiary of the Cerner Corporation, is a developer of clinical drug information systems and a drug knowledge base. More information is available at http://www.multum.com. In general, the Multum categories follow the therapeutic uses for prescription and over-the-counter pharmaceuticals.

Additional clarification is provided for the following drug categories:

Drug misuse/abuse: A group defined broadly to include case types related to drug misuse or abuse. Additional clarification is provided for the following case types:

Drug-related death: Any death related to recent drug use. To be a DAWN case, a drug needs only to be implicated in the death; the drug does not have to have caused the death. Even if only one drug is reported, it should not be assumed that the substance was the sole and direct cause of the death. (See also Single-drug case.) Drug-induced deaths are those for which the drug(s) directly caused the death.

Homicide: See Drug Misuse.

Jurisdiction: DAWN uses the term "jurisdiction" to mean the geographic area for which a medical examiner's or coroner's office is responsible. In many States, there is a one-to-one correspondence between jurisdictions and counties. In some States, there are multiple jurisdictions within a given county, or there may be multiple counties covered by a "district" that includes one or more medical examiner or coroner offices. Some States are organized as a single statewide jurisdiction.

Understanding jurisdictions is important because this assists readers in interpreting aggregated data. For publication, DAWN mortality data are aggregated into metropolitan areas, which often comprise multiple jurisdictions. In some States, there are different death investigation procedures for different jurisdictions (most notably, some jurisdictions have medical examiner systems, while others have coroner systems). There are nearly always some differences in death investigation procedures across States (and notably, some metropolitan areas include jurisdictions in multiple states). Readers should be mindful of these variations when interpreting or comparing data.

Manner of death: A classification used to group similar DAWN cases. Each case is coded into one and only one category, the first that applies from the following hierarchy: suicide, homicide by drugs, adverse reaction to medication, overmedication, accidental ingestion, all other accidental, and could not be determined. The manner of death categories used by DAWN draw from but do not duplicate the manner of death recorded on the death certificate. (See DAWN Decision Tree.)

Medical examiner (ME): Death investigation jurisdictions typically use either a medical examiner system or a coroner system. Most medical examiners are licensed physicians or forensic pathologists and are generally appointed (rather than elected). They may have jurisdiction over a county, district, or an entire State. (See also Coroner and Jurisdiction.)

Metropolitan area: An area comprising a relatively large core city or cities and the adjacent geographic areas. Conceptually, these areas are integrated economic and social units with a large population nucleus. This DAWN publication utilizes areas defined by the Office of Management and Budget (OMB) in 2003, based on population data from the 2000 decennial Census.

Overmedication: See Drug Misuse.

Place of death: The location that best describes where the death occurred. The place of death categories on the DAWN data collection form are:

Race/ethnicity: The Office of Management and Budget (OMB) is responsible for standard protocols for the collection of data on race and ethnicity by federal systems, including DAWN. In October 1997, OMB issued a revised standard protocol, which permitted separate reporting of race and Hispanic ethnicity, the ability to capture more than one race for an individual, modifications in nomenclature (e.g., "Black" was changed to "Black or African American"), division of certain categories ("Asian or Pacific Islander" was split into two categories, "Asian" and "Native Hawaiian or Other Pacific Islander"), and elimination of the "Other" category. For data collections, such as DAWN, where self-identification of the individual is not feasible, the revised OMB protocol also permitted a combined format, whereby race and Hispanic ethnicity would be recorded in a single data item, which could still record multiple entries for race and/or Hispanic ethnicity.

Since January 2003, DAWN has collected data on race/ethnicity using the combined format. The race/ethnicity categories on the DAWN data collection forms are as follows:

Despite the increased detail allowed by these categories and the provision for multiple entries, the actual race/ethnicity data reported to DAWN is quite limited because race and ethnicity are often not documented with this level of specificity in patient/decedent records. As a result, the classification used to tabulate DAWN data has a more limited set of categories, as follows:

Single-drug case: A single-drug case is one in which only one drug was involved. Because multiple substances may be recorded for each DAWN case (see Drug), readers should be cautious in interpreting the relationship between a given drug and the number of associated visits or deaths. For example, if the source record for a patient/decedent documented marijuana use, this does not mean that marijuana was the only drug involved in the visit/death or that the marijuana caused the visit/death. One should always consider whether and how many other drugs were used in combination. Even then, attributing a causal relationship between the visit/death and a particular drug may not be possible. DAWN only captures single-drug visits/deaths involving alcohol if the decedent was younger than age 21.

Suicide: This category includes cases denoted by the ME/C as suicide if the decedent took their own life and legal or illegal drugs had been involved: drug use need not have been the cause of death.

Toxic effects: Injury, illness, or damage that can be attributed to the ingestion of a drug. (See also Cause of death.)



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MULTUM LEXICON
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Multum Lexicon
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Lexicon
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