DAWN mortality data are collected in participating medical examiner and coroner (ME/C) offices through a retrospective review of case records for every death investigated by the ME/C. 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.
A DAWN case is any death related to recent drug use. DAWN includes deaths associated with substance abuse and misuse, both intentional and accidental. This also includes 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. Only recent drug use is included, and the reason that a patient used a drug is irrelevant.
The case criteria are intended to be broad and inclusive and to have few exceptions. Broad criteria take into account the fact that documentation in death records varies in clarity and comprehensiveness across ME/Cs. 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.
There are some clearly delineated exceptions to the DAWN case criteria. A death is not a DAWN case if:
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 is a particularly important part of the death records because it is used to determine if the death is a case of drug misuse or abuse. As depicted in Figure A-2, 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).
DAWN includes all types of drugs.14 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. Deaths involving accidental exposures (e.g., exposure to paint fumes while painting a closet) are excluded as well.
Several methods are used to improve the quality and reliability of DAWN data. These include:
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 ME/C systems to gain a better understanding of drug-related mortality outside of the targeted metropolitan areas.
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. 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. For participating states, every county or jurisdiction within each state is included in DAWN.
The metropolitan area definitions used in this publication are those established by the Office of Management and Budget (OMB) based on the 2000 U.S. Census as updated in 2003.15 OMB issues annual updates to the boundaries and names of metropolitan areas. DAWN ME reports use the name that was current during the data collection year. While there have been several name changes, changes in metropolitan statistical area boundaries since 2003 have not altered the metropolitan areas reported on in this publication.
This glossary defines terms used in data collection activities, analyses, and publications associated with the mortality component of DAWN.
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Document revised April 1, 2003