Suicides may be overreported and accidents underreported among fatalities due to dextropropoxyphene

Among prescribed drugs in Sweden dextropropoxyphene (DXP) is the medical co mpound most frequently responsible for self-inflicted fatal poisonings. To analyze the process leading to the classification of the manner of death in cases of fatalities where DXP caused or contributed to death, a set of exp licit and implicit operational criteria was applied retrospectively to fata l DXP poisonings among autopsy cases performed at one department of forensi c medicine in Sweden during the six-year period from 1992 to 1997. DXP fatality was found in 113 (2.6%) of the total 430 autopsy cases. Suicid e was recorded in 84 (74%) of these cases, and an undetermined manner of de ath in 24 (21%). Explicit unambiguous expressions of the intent of the decedent were found i n 29 (26%) of the 109 analyzed cases. (In four cases no analysis could be p erformed.) In 46 cases only implicit and no explicit criteria were found. T he total number of implicit criteria in individual cases without explicit c riteria never exceeded three and in 34 cases no criteria of any type were d ocumented. It is concluded that the classification of the manner of death at DXP fatal ities was often based on very limited grounds when the operational criteria were used as a standard for comparison. Information from relatives, friend s and others concerning the decedent was rarely accessible. The shortage of information probably led to deficiencies in the death statistics concernin g DXP fatalities. Considerable underreporting of accidents and probable ove rreporting of suicides were found. Failure to report DXP death, as accidents may delay discovery of the high t oxicity of this drug. This might be one of the reasons why the DXP fatality rate is still constantly high ill Sweden, while both Denmark and Norway ha ve managed to decrease their DXP death rates by vast restrictions, based on alarming reports of accidental DXP fatalities. In order to guarantee valid death statistics concerning self-inflicted pois oning, the information base leading to classification of the manner of deat h has to be enlarged. This requires implementation of new routines, includi ng interviews of relatives, acquaintances and significant others to Set the information needed to assess the decedent's intention to die. Operational criteria may facilitate the difficult classification process by providing a structured standard, and the set of explicit and implicit criteria applied in this study is recommended.