Epidemiologic Notes and Reports Dilaudid-Related Deaths -- District of Columbia, 1987

In the period September 2-16, 1987, in the District of Columbia, 12 persons died from the intravenous use of Dilaudid in combination with cocaine and quinine. These deaths represented a 500% increase over the average number of Dilaudid- related deaths for each of the preceding 3 years.

The average age of the decedents was 35 years, with a range of 21-57. Eleven were black, and one was white. Eight were male; four were female. The deaths were distributed throughout the period, with no apparent clustering by day of week. Eight deaths occurred in the morning hours, between 1:00 and 11:30; four of those were concentrated between 4:00 and 6:00. The others died in the late afternoon. Most of the persons died at home, in or near their sleeping quarters. Circumstantial details were similar for seven of the decedents: each apparently was alone at the time he or she used the drug preparation, and each possessed drug paraphernalia.

Autopsy data indicated that lethal levels of Dilaudid (more than 0.01 mg/dL) were present in all but one of the decedents (median level = 0.034 mg/dL). The exception, who had a concentration of 0.008 mg/dL, had been hospitalized 12 hours before death; therefore, most of the drug had probably been metabolized by the time of autopsy. Autopsies showed toxic levels of cocaine (more than 0.10 mg/dL) in four of the decedents (median level for all 12 = 0.08 mg/dL). Ethanol was evident in two decedents, at 50 mg/dL and 100 mg/dL, and urine cannabinoids were found in three decedents. Puncture sites and/or track marks were found on all of the bodies. Three of the decedents had fatty metamorphosis of the liver. One woman was found to be positive for human immunodeficiency virus (HIV-1).

Editorial Note

Editorial Note: The average number of deaths due to the toxic effects of narcotics or cocaine per year in the District of Columbia ranges from 125 to 140. The number for 1987 was 219 or 52% more than that in 1986 (Figure 1).

A study of an epidemic of heroin-related deaths that occurred in the District of Columbia from 1980 through 1982 (1) found the combined use of ethanol and heroin to be a risk factor in fatal overdoses. Lack of tolerance for heroin and higher concentrations of heroin in street preparations were identified as other important risk factors for death from overdose. Temporal clustering was evident; most deaths occurred in the spring and summer, on weekends, between 6 p.m. and midnight. The findings suggested that decedents were sporadic rather than chronic heroin abusers and that they were using the drug in combination with ethanol in a social context. Public health education measures that were recommended at that time to prevent heroin-related deaths focused on informing users of the dangers of heroin use, especially for nonaddictive (i.e., sporadic) purposes, in combination with, or as a substitute for, ethanol (1).

The Dilaudid-related deaths reported here contrast with those from the earlier epidemic of heroin-related deaths. They were relatively evenly distributed over time, and most occurred at home. Extensive track marks on the body of each decedent indicated chronic drug abuse. Circumstantial evidence suggested that most users were alone at the time of drug use. Ethanol, a drug associated with social interaction, was present in only two of the decedents. These findings support the hypothesis that the Dilaudid users were chronic heroin addicts who used the narcotic preparation for their addictions.

Analyses of two drug preparations bought on the street in early September 1987 found them to be whitish-colored Dilaudid powder rather than crushed Dilaudid tablets. Dilaudid tablets (1 to 4 mg) are prescribed for analgesic purposes. Persons who abuse the drug in pill form typically crush it into a yellowish mixture before injecting it. However, these fatalities apparently involved the more potent powder, mixed with quinine and presumably sold on the streets as heroin. Dilaudid powder comes in 15-grain vials, each equivalent to about 1 g or 250 4-mg tablets. This preparation is used at cancer centers in the District and is dispensed at certain pharmacies for home-care treatment of patients with terminal cancer.

In the Dilaudid-related deaths, the decedents were addicts who apparently thought they were injecting heroin and cocaine. Risk factors in these fatal overdoses were both chronicity of narcotic abuse and use of a pharmacologically more potent substitute for heroin. Coincident with the end of this outbreak were media reports that Dilaudid powder was being sold on the streets as heroin. Also at this time, District of Columbia police officers and Drug Enforcement Administration officials increased their surveillance of pharmaceutical sources from which the drug may have been diverted for illicit street sale, and a New Jersey drug dealer who was trying to establish networks for distributing Dilaudid in the District was arrested. Whether these events caused or simply correlated with the end of this cluster of overdose deaths is unknown. However, these actions represent an important and necessary response by local health officials when facts such as the above are known.

Nationally, data for the period 1982-1987 show low endemic levels of Dilaudid abuse at most reporting U.S. metropolitan areas (National Institute on Drug Abuse, Drug Abuse Warning Network, unpublished data). Three cities report a consistently high proportion of patients entering emergency facilities for Dilaudid abuse: New Orleans, Philadelphia, and Washington, D.C. Reports of medical examiners indicate that fewer than five Dilaudid-related deaths have occurred per quarter, except for these 12 overdose deaths in Washington, D.C. Reported by: Statistical and Epidemiologic Analysis Br, National Institute on Drug Abuse. PH Santinga, BS, Office of the Chief Medical Examiner, District of Columbia. Div of Environmental Hazards and Health Effects, Center for Environmental Health and Injury Control, CDC.

References

1. Ruttenber AJ, Luke JL. Heroin-related deaths: new epidemiologic insights. Science 1984; 226:14-20.

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