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Causes of death among institutionalized narcotic addicts
J. chron. Dis. 1970, Vol. 22, pp. 733-742. Pergamon Press. Printed in Great Britain
CAUSES OF DEATH AMONG INSTITUTIONALIZED NARCOTIC ADDICTS JOSEPH
D. SAPIRA,*M.D., JOHN C. BALL,? Ph.D. and HARRY PENN,$ M.D. National Institute of Mental Health, Lexington,
Kentucky
(Received 9 October 1968; in revisedform 26 February 1969; further rev&d 26 June 1969) IT IS recognized that narcotic addicts have a high mortality rate due to acute illness associated with drug abuse [l-5]. The use of adulterated drugs and communal syringes predisposes them to death from overdose, endocarditis, tetanus, hepatitis and, formerly, malaria [l-6]. Less is known concerning the effect of chronic opiate abuse on mortality: Does the opiate addict die of ordinary causes, after years of drug abuse, or is he prone to specific diseases which lead to his early death? In order to investigate this question, a retrospective study was performed of all 385 deaths which occurred during hospitalization among 43,215 narcotic addict patients at the Lexington Clinical Research Center since its opening as the U.S. Public Health Service Hospital in 1935. The patients in this study were admitted either because they volunteered for treatment or because they were serving federal prison sentences and were sent to Lexington for treatment and incarceration, pari passu. This study differs from previous research in several ways: (1) the population includes addicts from throughout the United States. It is not restricted to a single city, state or occupational group; (2) there is no selection by race, sex or ethnic group as admissions to the hospital over the past 31 yr have reflected the demographic changes among addicts in general; (3) the sample is older than those of other studies permitting analysis of causes of death following many years of drug use; (4) acute illness was not the principal reason for hospital admission (the considerable distance to the hospital from the patients’ state of residence was of significance in this regard); and (5) the deaths usually occurred following a considerable period of institutionalization with the result that antemortem clinical records were available. METHOD
From May 29, 1935 to December 31, 1966, there were 385 deaths of addict patients at the Lexington hospital. Of the 34,043 male addicts hospitalized during this period 348 died (1.02 per cent); the comparable figure for females was 37 deaths (0.40 per cent of the 9172 female addicts). The cause of death was determined in each case by a detailed review of the clinical course record and, when available, the autopsy findings. An autopsy was performed for 67 per cent of the deaths. The cause of death for each of the 385 patients was *Department TDepartment SDepartment
of Medicine, University of Pittsburgh School of Medicine, Pittsburgh. of Psychiatry, Temple University Medical Center, Philadelphia. of Psychiatry, Strong Memorial Hospital, Rochester. 733
734
JOSEPHD. SAPIRA,JOHN C. BALL and HARRY PENN
determined by two of the authors and a reliability check of this determination effected. This detailed review of the clinical records, autopsy findings and collateral data, was undertaken in order to employ a standard and reliable procedure for ascertaining the cause of hospital death. Non-natural deaths were defined as violent deaths (due to suicide, homicide, or traumatic accident) or drug related. There were 25 such non-natural deaths. All other deaths (N=360) were considered natural, including those related to medical care which we have classified as ‘iatrogenic’. Of these, ‘surgical deaths’ include only those deaths TABLE1.
CAUSEOF DEATHBY PATHOPHYSIOUX~IC MECHANISM AND NUMBEROF AUTOPSIJB FOR 385 ADDICTPATIE~ AT THE LEXINGTONHOSPITAL Deaths in Hospital
PERFORMED
Cause of death by pathophysiologic category
(No.1
(73
Infection Circulation Neoplasia Metabolic Violent Iatrogenic Drug-related Miscellaneous
128 86 68 44 16 10 9 24
33.2 22.3 17.7 11.4 4.2 2.6 2.3 6.2
61 42 27 8 6 8 13
Total
385
100.0
259
Autopsies performed (No.1 94
TABLE 2 Infections Tuberculosis Pulmonary Peritonitis Renal Cerebral tuberculoma Milky Peritonitis Perforated duodenal ulcer Appendicitis Perforated gastric ulcer Perforated gall bladder Perforated intestine, foreign body Ruptured urinary bladder Unknown etiology Infective endocarditis, subacute, acute and remote Pneumonia Cholecystitis Encephalitis Meningitis Septicemia Pulmonary abcess Tetanus Enterocolitis Empyema Total
60
56 1 1 1 1 18
1 2 18 10 1 3 2 1 1 1 1 128
Causes of Death among Institutionalized
Narcotic Addicts
73.5
which occurred in the operative or immediate post-operative period (i.e. within 48 hr) in which the surgery was elective and in which the death was not related directly to the object of surgery. ‘Medical deaths’ includes only deaths due to medical treatment or diagnostic procedures. RESULTS
Deaths are classified by pathophysiologic mechanism in Tables l-5. Many more male deaths occurred than female deaths, as would be expected from our predominantly male population. Since the female deaths did not appear to segregate among pathologic processes they are not shown separately. One-third (33.2 per cent) of the deaths in this study were due to an infectious process. Of these most were due to tuberculosis and bacterial endocarditis which are recognized concommitants of narcotic addiction [l-6]. On the other hand there were only two deaths from septicemia, one death from tetanus, and no deaths from malaria or acute viral hepatitis which are also considered to be diseases of addiction [l-7]. Over one-fifth (22.3 per cent) died from a circulatory disturbance. Sixty-two per cent of these died from cardiac failure. If the patients with complications of hypertension, cardiovascular collapse from septicemia, or bacterial endocarditis had been included in this group, both figures would be even higher. Eight deaths were attributed to bleeding secondary to hepatic portal hypertension. This was somewhat surprising since recent studies of liver disease among narcotic addicts suggested that portal hypertension was not part of the clinical picture [6, 71. In fact, we believe that evidence of portal hypertension in an addict should suggest a history of alcohol abuse (or, in the Puerto Rican patient, schistosomiasis). When these 8 cases of hemorrhage secondary to hepatic portal hypertension were re-examined (Table 6) it was found that only 1 patient had autopsy-verified portal hypertension without evidence of either alcohol abuse or hepatic disease predating addiction. TABLE 3
Circulatory disturbances Cardiac failure Coronary artery disease Rheumatic fever Hypertensive* Luetic
39 9 4 1
Cerebrovascular ‘CVA Cerebral embolism Cavernous hemangioma Internal carotid aneurysm Subarachnoid hemorrhage
16 1 1 1 1
Hemorrhage Portal hypertension Aortic aneurysm Gastric ulcer Duodenal ulcer
53
20
13 8 3 1 1
Total *Thirteen other hypertensive patients died of renal failure and 6 died of a cerebrovascular
86 accident.
736
Joswx D. SM~,
JOHNC. BALL and HARRY PENN
About one-sixth (17.7 per cent) of the deaths were due to a neoplastic process. As would be expected in a predominantly male population, carcinoma of the lung was the most common primary cancer. Four hepatomas were found (Table 6) but 3 of these were clearly complications of Laennec’s cirrhosis due to alcohol abuse. The fourth was presumptively diagnosed as a hepatoma on the basis of an equivocal liver biopsy; unfortunately this diagnosis was never confirmed or rejected. Forty-four patients (11.4 per cent) died a metabolic death. Of the 4 patients with hepatic failure who had a tissue diagnosis of Laennec’s cirrhosis, 2 abused alcohol
TABLE4 Neoplasia Carcinoma Lug Cervix Stomach Bile duct Liver Brain Pal-KXaS Prostate Large intestine Larynx Rectum Pharynx Bladder Perineum Priiary site unknown Other Leukemia Seminoma, testicle Thymoma Osteogenic sarcoma Reticulum cell sarcoma Total
63 27 7 : 4 3 2 2 2 1 : 1 1 2 1 1 1 1 1 68
(Table 6). The absence of diabetic ketoacidosis as a cause of death was consistent with our clinical impression (stated elsewhere) [6] that diabetes mellitus is unusual in addicts and that when it does occur it tends to be quite benign. The 39 deaths from renal failure included 13 listed as ‘nephritis’ or ‘chronic glomerulonephritis’; most were autopsied but the slides were not saved. It is of interest that there were no cases of diabetic glomerulosclerosis. There were only 10 ‘iatrogenic’ deaths. Of the ‘medical’ drug deaths, one involved an overdose of methadone on the withdrawal unit and one was due to the intravenous administration of magnesium sulfate instead of saline in the era when patients worked in the pharmacy. In the ‘miscellaneous’ group there were 7 deaths from bronchial asthma, of which 4 were due to status asthmaticus. This is in keeping with our previous observation of a pulmonary allergic diathesis in the narcotic addict [6].
Causes of Death among Institutionalii
737
Narcotic Addicts
TABLE 5
Metabolic Renal failure Hypertensive ‘Nephritis’ Chronic pyelonephritis Chronic glomerulonephritis Miscellaneous Hepatic failure, cirrhosis
39 13 9 7 4 6 5 Total
44
Violent 13 2 1
Suicide Accidents Homicide Total
16
Iatroaenic Surgical Inguinal hemiorrhaphy Thyroidectomy Prostate resection Cataract extraction Frontal lobotomy, elective Medical Wrong medicine Methadone overdose Barium enema complication
7 2 2 1 : 3 1 1 1 Total
10
Drug related 4
Drug toxicity Opiate overdose Methanol
3 1
Withdrawal Barbiturates Alcohol
4 1
5
Total
9
Miscellaneous 7
Bronchial asthma Chronic lung disease Acute pancreatitis Intestinal obstruction ‘Sudden death Myasthenia gravis ‘Collagen disease’ Reduction femur fracture, post-op Repair gastrojejunocolic fistula, post-op Repair gastrojejunocolic fistula, post-op Arterial occlusion, post-op Whipple procedure, post-up
: 2 2 1 1 1 1 1 1 1 Total
24
JOSEPH D. SAPIM, JOHN C. BALL and HARRY
738
PENN
Violent deaths accounted for only 4.2 per cent of the total. This is much lower than in other reports [8, 91, possibly due to the restrictive nature of institutionalization. The death of 9 patients was directly attributable to drug abuse. One patient died of delirium tremens the day of admittance (in 1939). Four patients died during withdrawal from barbiturates (the first such death was in 1943, the last in 1960); these 4 deaths occurred from 6 to 13 days after hospitalization. The 4 remaining drugrelated deaths were caused by overdose. Two older patients (61 and 69 yr) died within 6 hr of admittance from overdose of opiates. Finally, 1 patient died from an overdose of cleaning fluid, while another died from consumption of contraband codeine. Further analysis within pathophysiologic categories was considered inappropriate since the study period 1935-1966 was a time of marked change in the demographic characteristics of narcotic addiction in the United States, as well as a period of unprecedented change in the therapeutic modalities available to the physician. Table 7 shows mortality and demographic data for 8 time periods. The first column indicates the increase of opiate addiction among Negroes following World War II. The second column depicts the younger age of Negro patients at hospital admission compared with white patients, although this age difference has decreased in recent years. Column three depicts the decline in deaths in recent years. The fourth and sixth columns show the consistently earlier age at death of the Negro patients and their lower death rate in all but the last time period. The principal reason for the TABLE 6.
Diagnosis Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Gastric hemorrhage ‘UGI’ hemorrhage f : Hepatoma, superimposed on cirrhosis 10. Hepatoma, superimposed on cirrhosis 11. Hepatoma. superimposed on cirrhosis 12. Compatible with hepatoma, R.O. metastatic, C.A. 13. Cirrhosis 14. Cirrhosis 15. Cirrhosis 16. Cirrhosis 17. Cirrhosis 1.
2. 3. 4. 5. 6. 7.
DEATHSFROMCOMPLICATIONSOFHEPATICDISEASE*
Alcohol abuse
Known hepatic disease prior to drug use
Yes
Yes Yes Yes Yes Yes No
YeS No
No No
Autopsy
No,
Yes
No No No No Yes No Yes No No
biopsy Yes
Yes
No
Yes
Yes
No
No,
No
No
No No No Yes
No No No No No
Yes Yes
Yf2.S Yes
No
biopsy Yes Yes No
Yes Yes
Yes
*Fifty-nine per cent of these patients had a history of alcohol abuse, vs. a comparable incidence of 30 per cent in the non-hepatic deaths. If patients with prior hepatic disease and patients without a tissue diagnosis are excluded, 75 per cent of addicts dying of hepatic disease had a history of alcohol abuse, 2) times the rate among all other addicts.
2103 2741
2631
2255 2908 2331
1943-1946 1947-1950
1951-1954
1955-1958 1959-1962 1963-1966
13,134
2907 2395 1800
3026
376 1680
528
422
Negro
39.5
37.8 34.5 33.6
41.5
43.5 43.4
42.0
40.0
White
29.4
29.0 30.5 30.9
27.1
33.1 27.6
33.5
34.0
Negro
Mean age of admissions
(2)
284
23 14 4
47
56 45
51
44
White
44
6 5 4
3
8 8
8
2
Negro
(3) Deaths in hospital, number of
HOSPITAL AND AND RACE*
(4)
WHO
DIED DURING
50.1
51.8 52.1 59.5
51.1
49.3 53.2
48.3
45.2
40.8
35.3 43.6 40.5
40.0
45.4 36.5
42.1
28.0
Negro
Mean age, at death White
NUMBER
19.2
20.0 26.0 19.8
19.9
19.4 20.8
19.1
14.3
White
13.8
12.7 17.6 12.5
14.7
19.3 12.0
11.5
4.0
Negro
(5) Mean years of drug use to death
14.2
10.2 4.8 1.7
17.9
26.6 16.4
23.1
15.3
White
? 8 @ 9 5 0 -3.4
i _. z i =: w
5 g
B 6
B 2 %
b:
2.1 2.1 2.2
1.0
21.3 4.8
15.2
4.7
Negro
(6) Deaths per 1000 first admissions
HOSPITALIZATION BY PERIOD OF ADMISSION
*Because of the small numbers involved, tabulations are not given for racial groups such as Chinese, Japanese or American Indian.
20,057
2210
1939-1942
Total
2878
1935-1938
White
First admissions number of
(1)
NUMBER OF ADDICT PATIENTSADMITTEDTO THE LEXINGTON
Period of admission, or death
TABLE 7.
740
JOSEPHD. S~IRA, JOHN C. BALL and HARRY PENN
mortality differences between the hospitalized Negro and white addicts appears to be the older age of the white patients. It is relevant to note that the Negro-white difference in observed death rates (column 6, Table 7) is not due to a longer history of addiction among the Negro patients, as they had fewer years of drug use than the white patients prior to death. Finally, the marked decrease of the death rate in recent years is considered to reflect both the younger age of the hospital population and general improvements in medical care. To study this last factor we calculated the death rate due to infectious processes for each period (Table 8). It was found that the antibiotic era was followed by a notable decrease in deaths due to infection. Unfortunately, there is no true ‘control’ data to which our results can be compared. It would be desirable to have age, race, and sex specific mortality data for all 43,215 former addict patients, but this is not available nor is it feasible to obtain. Nonetheless, an analysis of hospital deaths within this selected patient population over 30 yr does atford a means of observing the relative frequency (or absence) of specific causes of death and tracing changes in hospital mortality over the 3 decade period. As mentioned previously, most reports on the cause of death among narcotic addicts are of necessity skewed towards those patients presenting themselves with acute illness. Most follow-up studies have been primarily concerned with the patient’s addiction status following treatment and causes of death are not broken down into disease categories. Two exceptions are the reports of Vaillant [9] and O’Donnell [8]. Vaillant reported only 20 deaths, and the exact cause of death is not given in each instance. O’Donnell accepted the cause of death as that written on the death certificate [8]. If the 385 cases in this study are reclassified according to the classification used for O’Donnell’s 150 cases we find that the leading causes of ‘natural’ death in both series are almost the same: heart disease, neoplasia, tuberculosis and central nervous system-vascular disease. In order to compare the Lexington Hospital deaths among addict patients with that of the U.S. population, the 348 male cases have been reclassified according to the categories used in the U.S. Vital statistics (Table 9). Similarly, we have listed the percentage distribution of deaths for all U.S. males between 45 and 49 yr of age (the smallest interval including the mean age of death in the Lexington group) and between 20 and 64 yr of age (the largest interval). It is apparent that tuberculosis and nephritis TABLE 8.
NUMBER AND RATE OF MALE DEATHSFROM INFECXIONSBY YEAR OF HOSPITALADMISSION
Year of deaths and admissions
First admissions all males
Male deaths due to infection
Infectious deaths per 1000 male first admissions
1935-1938
3358
15
4.5
1939-1942
2841
29
10.2 10.0
1943-1946
2695
27
1947-1950
4604
25
5.4
1951-1954
5835
17
2.9
1955-1958
5227
4
0.8
1959-1962
5345
3
0.6
1963-1966
4138
2
0.5
34.043
122
3.6
Total
Causes of Death among Institutionalized
Narcotic Addicts
741
TABLET. CAUSEOFDEATH ~0~348 MALEADDI~~PATIENTSAT LEXINGTON
Lexington U.S. males U.S. males males 4549 (1950) [6] 20-64 (1950) [6] (%) (%) (%)
Causes of death Tuberculosis, all forms Syphilis and its sequelae Other infective and parasitic diseases Malignant neoplasms Benign neoplasms Diabetes mellitus Anemias Meningitis (except meningococcal and tbc) Diseases of cardiovascular system Chronic and unspecified nephritis Influenza and pneumonia Bronchitis Ulcer of stomach and duodenum Appendicitis Hernia and intestinal obstruction Gastritis, duodenitis, enteritis, colitis Cirrhosis of liver Acute nephritis and nephritis with edema Hyperplasia of prostate Congenital malformations Symptoms, senility and ill-defined conditions All other diseases Accidents Suicide, homicide
17.2
5.8
z!i 16:7 0.3 -
k: 13:5 0.4 0.9
0.6 30.5 4.3 1.4 0.9 2.6 1.7
8.: 46:0 1.7 2.5 0.1 1.4 0.4 0.5 0.2 2.8
1.1 6.3 2.9 1; 1.9 3.4 3.4
o”*: 0:4 1.4 5.2 9.6 4.8
4.8
1.6 2.2
0.3 (kc., (% (N.C.) (N.C.) (N.C.) 8.2 10.7 4.6
*Not coded as such.
were more frequent causes of addict deaths than would be expected if this were but a random sample of the U.S. male population. It is likely that our population is skewed toward chronic illness, in the same sense that earlier studies have been skewed toward acute illness. The exact incidences will probably be intermediate between the values in these two types of study but their elucidation will require extensive post-hospitalization follow-up of the type planned under the Narcotic Addict Rehabilitation Act. CONCLUSIONS
A review of the causes of death among narcotic addicts during hospitalization at the Lexington Clinical Research Center reveals a broader spectrum of disease than is apparent from similar studies originating from medical facilities concerned with acute illness. Heart disease (including infective endocarditis), tuberculosis, and carcinoma of the lung accounted for over half of the deaths. On the other hand tetanus, acute viral hepatitis, malaria, and opiate overdose (which are usually considered to be diseases of addiction) together accounted for less than 2 per cent of the deaths. REFERENCES 1.
Helpem M, Rho 66: 2391, 1966
Y-M : Deaths from narcotism in New York City. New York State J Med
742 2.
JOSEPHD. SAPIRA,JOHN C. BALL and HARRY PENN
Siegel H, Helpem M, Ehrenreich T: The diagnosis of death from intravenous narcotics. J Forensic Sci 11: 1,1%6 3. Mason P : Mortality among young narcotic addicts. J Mount Sinai Hasp 34 : 4,1967 4. Cherubin CE : The medical seauelae of narcotic addiction. Ann Intern Med 67 : 23. 1%7 5. Luoria DB, Hensle T, Rose ?: The major medical complications of heroin addiction. Ann Intern Med 67 : 1,1967 6. Sapira JD : The narcotic addict as a medical patient. Am J Med 45 : 555, 1968 7. Sapira JD, Jasinski DR, Gordodetsky CW: Liver disease in narcotic addicts. II The role of the needle. Clin Pham~ Therap 9: 725, 1968 8. O’Donnell JA: A follow-up ot narcotic addxts. Am 3 Ortbopsych 34: 948. 1964 9. Vaillant GE: Twelve year follow-up of New York narcotic addicts. II. The natural history of a chronic disease. New Eng J Med 275 : 1282, 1966 10. Vital statistics of the United States, 1950, Vol. III. Dept. of Health, Education and Welfare (U.S. Government Printing Office, 1953) Table 56 11. Vital statistics of the United States, 1950, Vol. 53. Dept. of Health, Education. and Welfare (U.S. Government Printing Office. 1953) Table 1
CAUSES OF DEATH AMONG INSTITUTIONALIZED NARCOTIC ADDICTS JOSEPH
D. SAPIRA,*M.D., JOHN C. BALL,? Ph.D. and HARRY PENN,$ M.D. National Institute of Mental Health, Lexington,
Kentucky
(Received 9 October 1968; in revisedform 26 February 1969; further rev&d 26 June 1969) IT IS recognized that narcotic addicts have a high mortality rate due to acute illness associated with drug abuse [l-5]. The use of adulterated drugs and communal syringes predisposes them to death from overdose, endocarditis, tetanus, hepatitis and, formerly, malaria [l-6]. Less is known concerning the effect of chronic opiate abuse on mortality: Does the opiate addict die of ordinary causes, after years of drug abuse, or is he prone to specific diseases which lead to his early death? In order to investigate this question, a retrospective study was performed of all 385 deaths which occurred during hospitalization among 43,215 narcotic addict patients at the Lexington Clinical Research Center since its opening as the U.S. Public Health Service Hospital in 1935. The patients in this study were admitted either because they volunteered for treatment or because they were serving federal prison sentences and were sent to Lexington for treatment and incarceration, pari passu. This study differs from previous research in several ways: (1) the population includes addicts from throughout the United States. It is not restricted to a single city, state or occupational group; (2) there is no selection by race, sex or ethnic group as admissions to the hospital over the past 31 yr have reflected the demographic changes among addicts in general; (3) the sample is older than those of other studies permitting analysis of causes of death following many years of drug use; (4) acute illness was not the principal reason for hospital admission (the considerable distance to the hospital from the patients’ state of residence was of significance in this regard); and (5) the deaths usually occurred following a considerable period of institutionalization with the result that antemortem clinical records were available. METHOD
From May 29, 1935 to December 31, 1966, there were 385 deaths of addict patients at the Lexington hospital. Of the 34,043 male addicts hospitalized during this period 348 died (1.02 per cent); the comparable figure for females was 37 deaths (0.40 per cent of the 9172 female addicts). The cause of death was determined in each case by a detailed review of the clinical course record and, when available, the autopsy findings. An autopsy was performed for 67 per cent of the deaths. The cause of death for each of the 385 patients was *Department TDepartment SDepartment
of Medicine, University of Pittsburgh School of Medicine, Pittsburgh. of Psychiatry, Temple University Medical Center, Philadelphia. of Psychiatry, Strong Memorial Hospital, Rochester. 733
734
JOSEPHD. SAPIRA,JOHN C. BALL and HARRY PENN
determined by two of the authors and a reliability check of this determination effected. This detailed review of the clinical records, autopsy findings and collateral data, was undertaken in order to employ a standard and reliable procedure for ascertaining the cause of hospital death. Non-natural deaths were defined as violent deaths (due to suicide, homicide, or traumatic accident) or drug related. There were 25 such non-natural deaths. All other deaths (N=360) were considered natural, including those related to medical care which we have classified as ‘iatrogenic’. Of these, ‘surgical deaths’ include only those deaths TABLE1.
CAUSEOF DEATHBY PATHOPHYSIOUX~IC MECHANISM AND NUMBEROF AUTOPSIJB FOR 385 ADDICTPATIE~ AT THE LEXINGTONHOSPITAL Deaths in Hospital
PERFORMED
Cause of death by pathophysiologic category
(No.1
(73
Infection Circulation Neoplasia Metabolic Violent Iatrogenic Drug-related Miscellaneous
128 86 68 44 16 10 9 24
33.2 22.3 17.7 11.4 4.2 2.6 2.3 6.2
61 42 27 8 6 8 13
Total
385
100.0
259
Autopsies performed (No.1 94
TABLE 2 Infections Tuberculosis Pulmonary Peritonitis Renal Cerebral tuberculoma Milky Peritonitis Perforated duodenal ulcer Appendicitis Perforated gastric ulcer Perforated gall bladder Perforated intestine, foreign body Ruptured urinary bladder Unknown etiology Infective endocarditis, subacute, acute and remote Pneumonia Cholecystitis Encephalitis Meningitis Septicemia Pulmonary abcess Tetanus Enterocolitis Empyema Total
60
56 1 1 1 1 18
1 2 18 10 1 3 2 1 1 1 1 128
Causes of Death among Institutionalized
Narcotic Addicts
73.5
which occurred in the operative or immediate post-operative period (i.e. within 48 hr) in which the surgery was elective and in which the death was not related directly to the object of surgery. ‘Medical deaths’ includes only deaths due to medical treatment or diagnostic procedures. RESULTS
Deaths are classified by pathophysiologic mechanism in Tables l-5. Many more male deaths occurred than female deaths, as would be expected from our predominantly male population. Since the female deaths did not appear to segregate among pathologic processes they are not shown separately. One-third (33.2 per cent) of the deaths in this study were due to an infectious process. Of these most were due to tuberculosis and bacterial endocarditis which are recognized concommitants of narcotic addiction [l-6]. On the other hand there were only two deaths from septicemia, one death from tetanus, and no deaths from malaria or acute viral hepatitis which are also considered to be diseases of addiction [l-7]. Over one-fifth (22.3 per cent) died from a circulatory disturbance. Sixty-two per cent of these died from cardiac failure. If the patients with complications of hypertension, cardiovascular collapse from septicemia, or bacterial endocarditis had been included in this group, both figures would be even higher. Eight deaths were attributed to bleeding secondary to hepatic portal hypertension. This was somewhat surprising since recent studies of liver disease among narcotic addicts suggested that portal hypertension was not part of the clinical picture [6, 71. In fact, we believe that evidence of portal hypertension in an addict should suggest a history of alcohol abuse (or, in the Puerto Rican patient, schistosomiasis). When these 8 cases of hemorrhage secondary to hepatic portal hypertension were re-examined (Table 6) it was found that only 1 patient had autopsy-verified portal hypertension without evidence of either alcohol abuse or hepatic disease predating addiction. TABLE 3
Circulatory disturbances Cardiac failure Coronary artery disease Rheumatic fever Hypertensive* Luetic
39 9 4 1
Cerebrovascular ‘CVA Cerebral embolism Cavernous hemangioma Internal carotid aneurysm Subarachnoid hemorrhage
16 1 1 1 1
Hemorrhage Portal hypertension Aortic aneurysm Gastric ulcer Duodenal ulcer
53
20
13 8 3 1 1
Total *Thirteen other hypertensive patients died of renal failure and 6 died of a cerebrovascular
86 accident.
736
Joswx D. SM~,
JOHNC. BALL and HARRY PENN
About one-sixth (17.7 per cent) of the deaths were due to a neoplastic process. As would be expected in a predominantly male population, carcinoma of the lung was the most common primary cancer. Four hepatomas were found (Table 6) but 3 of these were clearly complications of Laennec’s cirrhosis due to alcohol abuse. The fourth was presumptively diagnosed as a hepatoma on the basis of an equivocal liver biopsy; unfortunately this diagnosis was never confirmed or rejected. Forty-four patients (11.4 per cent) died a metabolic death. Of the 4 patients with hepatic failure who had a tissue diagnosis of Laennec’s cirrhosis, 2 abused alcohol
TABLE4 Neoplasia Carcinoma Lug Cervix Stomach Bile duct Liver Brain Pal-KXaS Prostate Large intestine Larynx Rectum Pharynx Bladder Perineum Priiary site unknown Other Leukemia Seminoma, testicle Thymoma Osteogenic sarcoma Reticulum cell sarcoma Total
63 27 7 : 4 3 2 2 2 1 : 1 1 2 1 1 1 1 1 68
(Table 6). The absence of diabetic ketoacidosis as a cause of death was consistent with our clinical impression (stated elsewhere) [6] that diabetes mellitus is unusual in addicts and that when it does occur it tends to be quite benign. The 39 deaths from renal failure included 13 listed as ‘nephritis’ or ‘chronic glomerulonephritis’; most were autopsied but the slides were not saved. It is of interest that there were no cases of diabetic glomerulosclerosis. There were only 10 ‘iatrogenic’ deaths. Of the ‘medical’ drug deaths, one involved an overdose of methadone on the withdrawal unit and one was due to the intravenous administration of magnesium sulfate instead of saline in the era when patients worked in the pharmacy. In the ‘miscellaneous’ group there were 7 deaths from bronchial asthma, of which 4 were due to status asthmaticus. This is in keeping with our previous observation of a pulmonary allergic diathesis in the narcotic addict [6].
Causes of Death among Institutionalii
737
Narcotic Addicts
TABLE 5
Metabolic Renal failure Hypertensive ‘Nephritis’ Chronic pyelonephritis Chronic glomerulonephritis Miscellaneous Hepatic failure, cirrhosis
39 13 9 7 4 6 5 Total
44
Violent 13 2 1
Suicide Accidents Homicide Total
16
Iatroaenic Surgical Inguinal hemiorrhaphy Thyroidectomy Prostate resection Cataract extraction Frontal lobotomy, elective Medical Wrong medicine Methadone overdose Barium enema complication
7 2 2 1 : 3 1 1 1 Total
10
Drug related 4
Drug toxicity Opiate overdose Methanol
3 1
Withdrawal Barbiturates Alcohol
4 1
5
Total
9
Miscellaneous 7
Bronchial asthma Chronic lung disease Acute pancreatitis Intestinal obstruction ‘Sudden death Myasthenia gravis ‘Collagen disease’ Reduction femur fracture, post-op Repair gastrojejunocolic fistula, post-op Repair gastrojejunocolic fistula, post-op Arterial occlusion, post-op Whipple procedure, post-up
: 2 2 1 1 1 1 1 1 1 Total
24
JOSEPH D. SAPIM, JOHN C. BALL and HARRY
738
PENN
Violent deaths accounted for only 4.2 per cent of the total. This is much lower than in other reports [8, 91, possibly due to the restrictive nature of institutionalization. The death of 9 patients was directly attributable to drug abuse. One patient died of delirium tremens the day of admittance (in 1939). Four patients died during withdrawal from barbiturates (the first such death was in 1943, the last in 1960); these 4 deaths occurred from 6 to 13 days after hospitalization. The 4 remaining drugrelated deaths were caused by overdose. Two older patients (61 and 69 yr) died within 6 hr of admittance from overdose of opiates. Finally, 1 patient died from an overdose of cleaning fluid, while another died from consumption of contraband codeine. Further analysis within pathophysiologic categories was considered inappropriate since the study period 1935-1966 was a time of marked change in the demographic characteristics of narcotic addiction in the United States, as well as a period of unprecedented change in the therapeutic modalities available to the physician. Table 7 shows mortality and demographic data for 8 time periods. The first column indicates the increase of opiate addiction among Negroes following World War II. The second column depicts the younger age of Negro patients at hospital admission compared with white patients, although this age difference has decreased in recent years. Column three depicts the decline in deaths in recent years. The fourth and sixth columns show the consistently earlier age at death of the Negro patients and their lower death rate in all but the last time period. The principal reason for the TABLE 6.
Diagnosis Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Ruptured esoph varices Gastric hemorrhage ‘UGI’ hemorrhage f : Hepatoma, superimposed on cirrhosis 10. Hepatoma, superimposed on cirrhosis 11. Hepatoma. superimposed on cirrhosis 12. Compatible with hepatoma, R.O. metastatic, C.A. 13. Cirrhosis 14. Cirrhosis 15. Cirrhosis 16. Cirrhosis 17. Cirrhosis 1.
2. 3. 4. 5. 6. 7.
DEATHSFROMCOMPLICATIONSOFHEPATICDISEASE*
Alcohol abuse
Known hepatic disease prior to drug use
Yes
Yes Yes Yes Yes Yes No
YeS No
No No
Autopsy
No,
Yes
No No No No Yes No Yes No No
biopsy Yes
Yes
No
Yes
Yes
No
No,
No
No
No No No Yes
No No No No No
Yes Yes
Yf2.S Yes
No
biopsy Yes Yes No
Yes Yes
Yes
*Fifty-nine per cent of these patients had a history of alcohol abuse, vs. a comparable incidence of 30 per cent in the non-hepatic deaths. If patients with prior hepatic disease and patients without a tissue diagnosis are excluded, 75 per cent of addicts dying of hepatic disease had a history of alcohol abuse, 2) times the rate among all other addicts.
2103 2741
2631
2255 2908 2331
1943-1946 1947-1950
1951-1954
1955-1958 1959-1962 1963-1966
13,134
2907 2395 1800
3026
376 1680
528
422
Negro
39.5
37.8 34.5 33.6
41.5
43.5 43.4
42.0
40.0
White
29.4
29.0 30.5 30.9
27.1
33.1 27.6
33.5
34.0
Negro
Mean age of admissions
(2)
284
23 14 4
47
56 45
51
44
White
44
6 5 4
3
8 8
8
2
Negro
(3) Deaths in hospital, number of
HOSPITAL AND AND RACE*
(4)
WHO
DIED DURING
50.1
51.8 52.1 59.5
51.1
49.3 53.2
48.3
45.2
40.8
35.3 43.6 40.5
40.0
45.4 36.5
42.1
28.0
Negro
Mean age, at death White
NUMBER
19.2
20.0 26.0 19.8
19.9
19.4 20.8
19.1
14.3
White
13.8
12.7 17.6 12.5
14.7
19.3 12.0
11.5
4.0
Negro
(5) Mean years of drug use to death
14.2
10.2 4.8 1.7
17.9
26.6 16.4
23.1
15.3
White
? 8 @ 9 5 0 -3.4
i _. z i =: w
5 g
B 6
B 2 %
b:
2.1 2.1 2.2
1.0
21.3 4.8
15.2
4.7
Negro
(6) Deaths per 1000 first admissions
HOSPITALIZATION BY PERIOD OF ADMISSION
*Because of the small numbers involved, tabulations are not given for racial groups such as Chinese, Japanese or American Indian.
20,057
2210
1939-1942
Total
2878
1935-1938
White
First admissions number of
(1)
NUMBER OF ADDICT PATIENTSADMITTEDTO THE LEXINGTON
Period of admission, or death
TABLE 7.
740
JOSEPHD. S~IRA, JOHN C. BALL and HARRY PENN
mortality differences between the hospitalized Negro and white addicts appears to be the older age of the white patients. It is relevant to note that the Negro-white difference in observed death rates (column 6, Table 7) is not due to a longer history of addiction among the Negro patients, as they had fewer years of drug use than the white patients prior to death. Finally, the marked decrease of the death rate in recent years is considered to reflect both the younger age of the hospital population and general improvements in medical care. To study this last factor we calculated the death rate due to infectious processes for each period (Table 8). It was found that the antibiotic era was followed by a notable decrease in deaths due to infection. Unfortunately, there is no true ‘control’ data to which our results can be compared. It would be desirable to have age, race, and sex specific mortality data for all 43,215 former addict patients, but this is not available nor is it feasible to obtain. Nonetheless, an analysis of hospital deaths within this selected patient population over 30 yr does atford a means of observing the relative frequency (or absence) of specific causes of death and tracing changes in hospital mortality over the 3 decade period. As mentioned previously, most reports on the cause of death among narcotic addicts are of necessity skewed towards those patients presenting themselves with acute illness. Most follow-up studies have been primarily concerned with the patient’s addiction status following treatment and causes of death are not broken down into disease categories. Two exceptions are the reports of Vaillant [9] and O’Donnell [8]. Vaillant reported only 20 deaths, and the exact cause of death is not given in each instance. O’Donnell accepted the cause of death as that written on the death certificate [8]. If the 385 cases in this study are reclassified according to the classification used for O’Donnell’s 150 cases we find that the leading causes of ‘natural’ death in both series are almost the same: heart disease, neoplasia, tuberculosis and central nervous system-vascular disease. In order to compare the Lexington Hospital deaths among addict patients with that of the U.S. population, the 348 male cases have been reclassified according to the categories used in the U.S. Vital statistics (Table 9). Similarly, we have listed the percentage distribution of deaths for all U.S. males between 45 and 49 yr of age (the smallest interval including the mean age of death in the Lexington group) and between 20 and 64 yr of age (the largest interval). It is apparent that tuberculosis and nephritis TABLE 8.
NUMBER AND RATE OF MALE DEATHSFROM INFECXIONSBY YEAR OF HOSPITALADMISSION
Year of deaths and admissions
First admissions all males
Male deaths due to infection
Infectious deaths per 1000 male first admissions
1935-1938
3358
15
4.5
1939-1942
2841
29
10.2 10.0
1943-1946
2695
27
1947-1950
4604
25
5.4
1951-1954
5835
17
2.9
1955-1958
5227
4
0.8
1959-1962
5345
3
0.6
1963-1966
4138
2
0.5
34.043
122
3.6
Total
Causes of Death among Institutionalized
Narcotic Addicts
741
TABLET. CAUSEOFDEATH ~0~348 MALEADDI~~PATIENTSAT LEXINGTON
Lexington U.S. males U.S. males males 4549 (1950) [6] 20-64 (1950) [6] (%) (%) (%)
Causes of death Tuberculosis, all forms Syphilis and its sequelae Other infective and parasitic diseases Malignant neoplasms Benign neoplasms Diabetes mellitus Anemias Meningitis (except meningococcal and tbc) Diseases of cardiovascular system Chronic and unspecified nephritis Influenza and pneumonia Bronchitis Ulcer of stomach and duodenum Appendicitis Hernia and intestinal obstruction Gastritis, duodenitis, enteritis, colitis Cirrhosis of liver Acute nephritis and nephritis with edema Hyperplasia of prostate Congenital malformations Symptoms, senility and ill-defined conditions All other diseases Accidents Suicide, homicide
17.2
5.8
z!i 16:7 0.3 -
k: 13:5 0.4 0.9
0.6 30.5 4.3 1.4 0.9 2.6 1.7
8.: 46:0 1.7 2.5 0.1 1.4 0.4 0.5 0.2 2.8
1.1 6.3 2.9 1; 1.9 3.4 3.4
o”*: 0:4 1.4 5.2 9.6 4.8
4.8
1.6 2.2
0.3 (kc., (% (N.C.) (N.C.) (N.C.) 8.2 10.7 4.6
*Not coded as such.
were more frequent causes of addict deaths than would be expected if this were but a random sample of the U.S. male population. It is likely that our population is skewed toward chronic illness, in the same sense that earlier studies have been skewed toward acute illness. The exact incidences will probably be intermediate between the values in these two types of study but their elucidation will require extensive post-hospitalization follow-up of the type planned under the Narcotic Addict Rehabilitation Act. CONCLUSIONS
A review of the causes of death among narcotic addicts during hospitalization at the Lexington Clinical Research Center reveals a broader spectrum of disease than is apparent from similar studies originating from medical facilities concerned with acute illness. Heart disease (including infective endocarditis), tuberculosis, and carcinoma of the lung accounted for over half of the deaths. On the other hand tetanus, acute viral hepatitis, malaria, and opiate overdose (which are usually considered to be diseases of addiction) together accounted for less than 2 per cent of the deaths. REFERENCES 1.
Helpem M, Rho 66: 2391, 1966
Y-M : Deaths from narcotism in New York City. New York State J Med
742 2.
JOSEPHD. SAPIRA,JOHN C. BALL and HARRY PENN
Siegel H, Helpem M, Ehrenreich T: The diagnosis of death from intravenous narcotics. J Forensic Sci 11: 1,1%6 3. Mason P : Mortality among young narcotic addicts. J Mount Sinai Hasp 34 : 4,1967 4. Cherubin CE : The medical seauelae of narcotic addiction. Ann Intern Med 67 : 23. 1%7 5. Luoria DB, Hensle T, Rose ?: The major medical complications of heroin addiction. Ann Intern Med 67 : 1,1967 6. Sapira JD : The narcotic addict as a medical patient. Am J Med 45 : 555, 1968 7. Sapira JD, Jasinski DR, Gordodetsky CW: Liver disease in narcotic addicts. II The role of the needle. Clin Pham~ Therap 9: 725, 1968 8. O’Donnell JA: A follow-up ot narcotic addxts. Am 3 Ortbopsych 34: 948. 1964 9. Vaillant GE: Twelve year follow-up of New York narcotic addicts. II. The natural history of a chronic disease. New Eng J Med 275 : 1282, 1966 10. Vital statistics of the United States, 1950, Vol. III. Dept. of Health, Education and Welfare (U.S. Government Printing Office, 1953) Table 56 11. Vital statistics of the United States, 1950, Vol. 53. Dept. of Health, Education. and Welfare (U.S. Government Printing Office. 1953) Table 1