Prevalence
of Cocaine Committed
Who
Peter M. Marzuk, Marina Stajic,
Objective: New
City.
The
at autopsy
Method: age
M.D., Ph.D.,
61
males had
who
recent
cocaine
tigators have
ofregional
and
ofcocaine
use
Additional
M
uch
use
(Am
J Psychiatry
recent
attention
who
days
committed
City
immediately
needed
1992;
Feb.
27,
1991;
revision
AmJPsychiatry
0
1 992
American
this
was
149:3,
March
period,
which
3%-5%,
preceding
to determine
these
death
how
firearms suggested
results
by young
cocaine
may
this
to have use,
twice
contrast that
to
the
suggest persons
the to
or Hispanic
likely
ethanol
act as a risk
period.
alcohol use at the committed suicide use among young
were In
in de-
preva-
prevalence
commit
factor
been inves-
as likely to the results
current
a high who
the
for
suicide.
suicide.
149:371-375)
been
received
Psychiatric
with
available
black,
most and
M.D.
persons under were conducted
young,
were
City
Ph.D.,
metabolites
during
cocaine and person who ofcocaine
Conclusions:
Mann,
widely
City
were
C. Leon,
cocaine
York
variables
methods.
properly
focused
July
17,
1991;
accepted
Aug. 16, 1991. From the Laboratory ofPsychopharmacology and the Department of Psychiatry and Public Health, Cornell University Medical College; and the Office of the Chief Medical Examiner, New York City. Address reprint requests to Dr. Marzuk, Department of Psychiatry, CornellUniversity Medical College, 1300 York Ave., New York, NY 10021. Supported by an American Suicide Foundation grant to Dr. Marzuk, grant DA-06534 from the National Institute on Drug Abuse to Drs. Tardiff and Marzuk, and an Irma T. Hirschl Trust Career Scientist award to Dr. Mann. The authors thank Charles Hirsch, M.D., and his staff for their assistance. Copyright
who injury
suicide
other
during
York
Persons the fatal
demographic
on the association between cocaine use and nising homicide rates. However, the link between cocaine use and suicide has not been adequately investigated. Several studies have shown that chronic cocaine users experience intense suicidal ideation, particularly in the withdrawal phase, which can last for several days immediately following a cocaine binge (1-3). In addition, alcohol abuse, a major risk factor for suicide, is common among cocaine users (2). Evaluation of the role of cocaine in suicide assumes added urgency in view of both the large proportion of
Received
of
records ofall a i-year period
during
45%.
for
used
surveys
are
has
city
became
“
in New
toxicological
before
who
those
in New
in the
studies
“crack prevalence
suicide and
was
controlling
household
of cocaine
suicide
individuals as
the
in the
immediately
After
that
called
determine
characteristics, suicide methods, and In one of every five cases studied, the days ofhis or her death. The prevalence
committed
cocaine
ofcocaine
autopsy suicide
alcohol
users.
found used
lence
who used
to
committed
ofthe
committed
determine demographic time of death. Results: had used cocaine within Hispanic
the form who
reviews had
Tardiff, M.D., M.P.H., Andrew B. Morgan, M.P.H., and J. John
sought
in persons
who
and
980s
authors
Individual
of
Kenneth Edward
In the mid-i
York
tected
Use Among Residents of New York Suicide During a One-Year Period
Association.
1992
polysubstance
abusers among young persons who comthe rising suicide rate in the 1 960s and 1970s among young males (4). The San Diego Suicide Study, conducted in the early 1980s, found that 30% of the persons under age 30 who committed suicide had histories of cocaine use, but it did not estimate the prevalence of cocaine use either at autopsy or in the general community (4). In 1986, 7% of all cocainepositive deaths in New York City were suicides (5). By 1985 a new, potent, inexpensive, smokable alkaloidal form of cocaine called “crack” had become widely available in New York City. The purpose of this study was to determine the prevalence of cocaine use among persons who committed suicide and the demographic characteristics of this group during this crack epidemic. mit
suicide
and
METHOD All cases certified as suicides by the New York City medical examiner that occurred among city residents during the calendar year 1985 were eligible for the study. This year was chosen because it corresponded to the latest full calendar year immediately before the most recent regional survey of cocaine use among the general
371
COCAINE
USE AND
SUICIDE
population of New York City. A list of all suicides classified according to ICD-9 codes E950 through E9S9 was provided by the Office of Biostatistics of the New York City Health Department. Cases of individuals who were not residents of New York City but committed suicide within its geographic boundaries and cases of residents whose suicides were certified in other jurisdictions
were
not
eligible
for
the
study.
In
addition,
cases in which the manner of death was determined” (ICD-9 codes E980-E989) The medical examiner’s records were viewed in their entirety at the Office of cal Examiner of New York City to
certified as “unwere ineligible. individually rethe Chief Mediascertain demo-
graphic
of injury,
data;
time,
date,
and
location
death,
and autopsy; results of police and medical examiner investigations; previous hospital records if available; and toxicological findings. For the purpose of determining the demographic characteristics
related
to
cocaine
use
and
suicide,
we
confined our analysis to persons aged 60 years or less who had been screened for cocaine at autopsy and who had died within 48 hours after a self-inflicted injury. Previous studies have shown that the prevalence of cocaine metabolites detected at autopsy in persons older than 60 is negligible (5, 6). Survival
time,
defined
as the period
from
injury to death, was also determined who had received medical care prior survival
time
in excess
of 48 hours
self-inflicted
for all individuals to their deaths. prohibits
A
inferences
about cocaine use at the time of lethal injury. A number of studies have shown that little cocaine metabolite is detectable in urine, by homogeneous enzyme assay at detection limits of 0.3 mg/liter, beyond 48 hours (7-9). Other studies suggest that metabolites can be detected in heavy
users
up
to
120
hours
or more
after
use
(10,
1 1 ). In practice, this discrepancy in detection time had little appreciable effect on this sample of suicides, as the vast majority of individuals died within 48 hours after injury.
The
small
group
that
had
prolonged
survival
times survived for longer than 120 hours. In some cases, the lethal injury was accomplished in secret, and the dead person was discovered hours to days following the injury. For these individuals who did not receive medical care after the injury, survival time was indeterminate but was presumed to be less than 48 hours. Urine and blood specimens obtained at autopsy were stored at 4 #{176}C until assay. The principal metabolite of cocaine, benzoylecgonine, was screened in urine sampIes by means of a homogeneous enzyme immunoassay. A sample was considered positive if benzoylecgonine was detected at a concentration of 0.3 mg/liter or more. Analysis was repeated on all positive urine specimens. In addition, substantiation of positive results in urine specimens was obtained by radioimmunoassay for cocaine and/on metabolites in blood. In some cases in which urine was not readily available at autopsy, blood was screened by radioimmunoassay. Results were considered positive by radioimmunoassay if cocaine
centrations
372
and/or
greater
benzoylecgonine
than
were
0. 1 mg/liter.
detected
Blood
at con-
specimens
considered positive by radioimmunoassay were, dition, analyzed for cocaine by gas chromatography.
Head ethanol
space gas chromatography analysis. Specimens were
the blood ethanol concentration more. In cases in which blood
in ad-
was used to perform considered positive if was alcohol
2 mmol/liter concentrations
on
were 7 mmol/liten on more, gas chromatography was done to assess brain concentrations. Data were analyzed with the SPSS and BMDP Statistical Software. Differences in proportions were assessed with chi-squane compare
done
tests, and analyses of variance group means. A logistic regression
to examine
the association
of hypothesized
tons (sociodemographic suicide) and cocaine
characteristics use. The logistic
was
the risk
with other
used
to estimate
each level predictors.
two-tailed
were used to analysis was
predic-
and methods of regression model
of cocaine
use associated
of a given Statistical
predictor, controlling for all significance was defined as a of less than 0.05.
probability
RESULTS There
were
749 cases of suicide among New York in the study year, of which 570 involved persons aged 60 years or less. In this sample of 570 cases, 482 persons had survival times under 48 hours and were screened for cocaine. In the remaining 88 cases, excluded from this study, most persons had sunvival times that exceeded 48 hours, and in a few, toxicology screens were not available because of family objections to autopsy. Both the mean age and the racial composition of the smaller, excluded group (N=88) differed significantly from those of the study group (N= 482): the excluded group was older (mean ages=41.7 years [SD=12.8} and 35.4 years [SD=10.8], respectively; F=24.21, df=1, 568, p
of Cocaine Committed
Who
Peter M. Marzuk, Marina Stajic,
Objective: New
City.
The
at autopsy
Method: age
M.D., Ph.D.,
61
males had
who
recent
cocaine
tigators have
ofregional
and
ofcocaine
use
Additional
M
uch
use
(Am
J Psychiatry
recent
attention
who
days
committed
City
immediately
needed
1992;
Feb.
27,
1991;
revision
AmJPsychiatry
0
1 992
American
this
was
149:3,
March
period,
which
3%-5%,
preceding
to determine
these
death
how
firearms suggested
results
by young
cocaine
may
this
to have use,
twice
contrast that
to
the
suggest persons
the to
or Hispanic
likely
ethanol
act as a risk
period.
alcohol use at the committed suicide use among young
were In
in de-
preva-
prevalence
commit
factor
been inves-
as likely to the results
current
a high who
the
for
suicide.
suicide.
149:371-375)
been
received
Psychiatric
with
available
black,
most and
M.D.
persons under were conducted
young,
were
City
Ph.D.,
metabolites
during
cocaine and person who ofcocaine
Conclusions:
Mann,
widely
City
were
C. Leon,
cocaine
York
variables
methods.
properly
focused
July
17,
1991;
accepted
Aug. 16, 1991. From the Laboratory ofPsychopharmacology and the Department of Psychiatry and Public Health, Cornell University Medical College; and the Office of the Chief Medical Examiner, New York City. Address reprint requests to Dr. Marzuk, Department of Psychiatry, CornellUniversity Medical College, 1300 York Ave., New York, NY 10021. Supported by an American Suicide Foundation grant to Dr. Marzuk, grant DA-06534 from the National Institute on Drug Abuse to Drs. Tardiff and Marzuk, and an Irma T. Hirschl Trust Career Scientist award to Dr. Mann. The authors thank Charles Hirsch, M.D., and his staff for their assistance. Copyright
who injury
suicide
other
during
York
Persons the fatal
demographic
on the association between cocaine use and nising homicide rates. However, the link between cocaine use and suicide has not been adequately investigated. Several studies have shown that chronic cocaine users experience intense suicidal ideation, particularly in the withdrawal phase, which can last for several days immediately following a cocaine binge (1-3). In addition, alcohol abuse, a major risk factor for suicide, is common among cocaine users (2). Evaluation of the role of cocaine in suicide assumes added urgency in view of both the large proportion of
Received
of
records ofall a i-year period
during
45%.
for
used
surveys
are
has
city
became
“
in New
toxicological
before
who
those
in New
in the
studies
“crack prevalence
suicide and
was
controlling
household
of cocaine
suicide
individuals as
the
in the
immediately
After
that
called
determine
characteristics, suicide methods, and In one of every five cases studied, the days ofhis or her death. The prevalence
committed
cocaine
ofcocaine
autopsy suicide
alcohol
users.
found used
lence
who used
to
committed
ofthe
committed
determine demographic time of death. Results: had used cocaine within Hispanic
the form who
reviews had
Tardiff, M.D., M.P.H., Andrew B. Morgan, M.P.H., and J. John
sought
in persons
who
and
980s
authors
Individual
of
Kenneth Edward
In the mid-i
York
tected
Use Among Residents of New York Suicide During a One-Year Period
Association.
1992
polysubstance
abusers among young persons who comthe rising suicide rate in the 1 960s and 1970s among young males (4). The San Diego Suicide Study, conducted in the early 1980s, found that 30% of the persons under age 30 who committed suicide had histories of cocaine use, but it did not estimate the prevalence of cocaine use either at autopsy or in the general community (4). In 1986, 7% of all cocainepositive deaths in New York City were suicides (5). By 1985 a new, potent, inexpensive, smokable alkaloidal form of cocaine called “crack” had become widely available in New York City. The purpose of this study was to determine the prevalence of cocaine use among persons who committed suicide and the demographic characteristics of this group during this crack epidemic. mit
suicide
and
METHOD All cases certified as suicides by the New York City medical examiner that occurred among city residents during the calendar year 1985 were eligible for the study. This year was chosen because it corresponded to the latest full calendar year immediately before the most recent regional survey of cocaine use among the general
371
COCAINE
USE AND
SUICIDE
population of New York City. A list of all suicides classified according to ICD-9 codes E950 through E9S9 was provided by the Office of Biostatistics of the New York City Health Department. Cases of individuals who were not residents of New York City but committed suicide within its geographic boundaries and cases of residents whose suicides were certified in other jurisdictions
were
not
eligible
for
the
study.
In
addition,
cases in which the manner of death was determined” (ICD-9 codes E980-E989) The medical examiner’s records were viewed in their entirety at the Office of cal Examiner of New York City to
certified as “unwere ineligible. individually rethe Chief Mediascertain demo-
graphic
of injury,
data;
time,
date,
and
location
death,
and autopsy; results of police and medical examiner investigations; previous hospital records if available; and toxicological findings. For the purpose of determining the demographic characteristics
related
to
cocaine
use
and
suicide,
we
confined our analysis to persons aged 60 years or less who had been screened for cocaine at autopsy and who had died within 48 hours after a self-inflicted injury. Previous studies have shown that the prevalence of cocaine metabolites detected at autopsy in persons older than 60 is negligible (5, 6). Survival
time,
defined
as the period
from
injury to death, was also determined who had received medical care prior survival
time
in excess
of 48 hours
self-inflicted
for all individuals to their deaths. prohibits
A
inferences
about cocaine use at the time of lethal injury. A number of studies have shown that little cocaine metabolite is detectable in urine, by homogeneous enzyme assay at detection limits of 0.3 mg/liter, beyond 48 hours (7-9). Other studies suggest that metabolites can be detected in heavy
users
up
to
120
hours
or more
after
use
(10,
1 1 ). In practice, this discrepancy in detection time had little appreciable effect on this sample of suicides, as the vast majority of individuals died within 48 hours after injury.
The
small
group
that
had
prolonged
survival
times survived for longer than 120 hours. In some cases, the lethal injury was accomplished in secret, and the dead person was discovered hours to days following the injury. For these individuals who did not receive medical care after the injury, survival time was indeterminate but was presumed to be less than 48 hours. Urine and blood specimens obtained at autopsy were stored at 4 #{176}C until assay. The principal metabolite of cocaine, benzoylecgonine, was screened in urine sampIes by means of a homogeneous enzyme immunoassay. A sample was considered positive if benzoylecgonine was detected at a concentration of 0.3 mg/liter or more. Analysis was repeated on all positive urine specimens. In addition, substantiation of positive results in urine specimens was obtained by radioimmunoassay for cocaine and/on metabolites in blood. In some cases in which urine was not readily available at autopsy, blood was screened by radioimmunoassay. Results were considered positive by radioimmunoassay if cocaine
centrations
372
and/or
greater
benzoylecgonine
than
were
0. 1 mg/liter.
detected
Blood
at con-
specimens
considered positive by radioimmunoassay were, dition, analyzed for cocaine by gas chromatography.
Head ethanol
space gas chromatography analysis. Specimens were
the blood ethanol concentration more. In cases in which blood
in ad-
was used to perform considered positive if was alcohol
2 mmol/liter concentrations
on
were 7 mmol/liten on more, gas chromatography was done to assess brain concentrations. Data were analyzed with the SPSS and BMDP Statistical Software. Differences in proportions were assessed with chi-squane compare
done
tests, and analyses of variance group means. A logistic regression
to examine
the association
of hypothesized
tons (sociodemographic suicide) and cocaine
characteristics use. The logistic
was
the risk
with other
used
to estimate
each level predictors.
two-tailed
were used to analysis was
predic-
and methods of regression model
of cocaine
use associated
of a given Statistical
predictor, controlling for all significance was defined as a of less than 0.05.
probability
RESULTS There
were
749 cases of suicide among New York in the study year, of which 570 involved persons aged 60 years or less. In this sample of 570 cases, 482 persons had survival times under 48 hours and were screened for cocaine. In the remaining 88 cases, excluded from this study, most persons had sunvival times that exceeded 48 hours, and in a few, toxicology screens were not available because of family objections to autopsy. Both the mean age and the racial composition of the smaller, excluded group (N=88) differed significantly from those of the study group (N= 482): the excluded group was older (mean ages=41.7 years [SD=12.8} and 35.4 years [SD=10.8], respectively; F=24.21, df=1, 568, p
