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Linking Death Certificates, Postmortem Toxicology, and Prescription History Data for Better Identification of Populations at Increased Risk for Drug Intoxication Deaths

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Our objective was to assess and improve the completeness of drug-related information, to evaluate the risk for drug intoxication deaths associated with specific drugs among different demographic groups, and to show the benefit of multi-source surveillance to better target interventions and to inform policy evaluation.


This study linked death certificate, prescription drug monitoring program, and postmortem toxicology data for Kentucky residents aged ≥18 years who died from drug intoxication during 2013–2014.


The most frequently listed contributing drugs were pharmaceutical opioids (60%), alprazolam (35%), and heroin (29%) (not mutually exclusive). The highest death rates from fentanyl (4 per 100,000 Kentucky population aged ≥18 years) and heroin (13 per 100,000) intoxication were among those aged 25–34 years, whereas the highest death rates associated with prescription opioids (excluding morphine and fentanyl) were among those aged 35–54 years (15 per 100,000). Appalachian county residents had a significantly higher intoxication fatality rate (34 per 100,000) than residents from non-Appalachian counties (27 per 100,000). One-quarter of death certificates did not list any specific contributing drug, but postmortem toxicology reports were available for 89% of these cases and provided information on drugs used before death. Analysis of decedents’ controlled substance prescription records suggested drug diversion (e.g., only 36% of the decedents who tested positive for oxycodone had recently filled prescriptions).


The abuse and diversion of drugs significantly impact the health and safety of Kentucky citizens. This study demonstrated the benefit of integrated multi-source drug intoxication fatality surveillance to identify drug misuse and diversion and population groups at high risk for drug poisoning mortality and to inform targeted prevention programs.

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The authors acknowledge the members of the KASPER staff with the Kentucky Cabinet for Health and Family Services, for their support of this project. We also acknowledge the support from the Kentucky Office of Vital Statistics, the Kentucky Medical Examiners Office, and the Kentucky Department for Public Health. The authors would like to thank Jeremy Triplett for providing data on fentanyl submissions to Kentucky State Police crime laboratories.

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Correspondence to Svetla Slavova.

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This project was supported by Grant No. 2014-PM-BX-0010 (Data-Driven Multidisciplinary Approaches to Reducing Prescription Abuse in Kentucky) awarded by the Bureau of Justice Assistance (BJA). The BJA is a component of the Department of Justice’s Office of Justice Program, which includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office of Victims Crime, and the SMART Office. Viewpoints or opinions in this document are those of the authors and do not necessarily represent the official position or policies of the US Department of Justice.

Conflicts of Interest

Svetla Slavova, Terry L. Bunn, Sarah L. Hargrove, Tracey Corey, and Van Ingram have no conflicts of interest.

Ethical Approval

This study was approved by the University of Kentucky and the Kentucky Cabinet for Health and Family Services Institutional Review Boards.

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Slavova, S., Bunn, T.L., Hargrove, S.L. et al. Linking Death Certificates, Postmortem Toxicology, and Prescription History Data for Better Identification of Populations at Increased Risk for Drug Intoxication Deaths. Pharm Med 31, 155–165 (2017).

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