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OCR for page 63
Chapter 3
PUBLIC HEALTH PROBLEMS ASSOCIATED WITH USE OF HYPNOTIC DRUGS
The availability of hypnotics and tranquilizers to relieve insomnia
and anxiety imposes burdens on the public, including mortality from drug
overdose, whether intentional or accidental; the treatment of nonfatal
overdose emergencies; the increased crime and lost production due to
abuse of and addiction to these drugs; and the increased mortality and
morbidity from traffic and industrial accidents caused by people whose
functioning is impaired by drugs.
Although economists have imputed dollar costs to some of these
problems, 1/ this chapter only describes the problems in terms of the
number of people affected. There is no national system to monitor the
extent of drug misuse and abuse, and thus it is impossible to draw con-
clusions about relationships between drug problems deriving from normal
medical practice and those of use of drugs for non-medical purposes.
The importance of the data problem is suggested by a study of
suicides committed in St. Louis County, Missouri, in 1968 and 1969. The
author found that at least 16 of 32 persons who committed suicide with
drugs had recently been given prescriptions for hypnotics in amounts
that were potentially lethal. The prescribed drugs apparently were used
in the suicide in most of the 16 cases. 2/ If such a pattern could be
proved on a national scale, the policy implications for closer moni-
toring of prescription size and refills would be clear. In one study,
two-thirds of suicides had been preceded by medical visits in the pre-
vious 4 to 6 weeks; 7/ however, the direct source of the drugs used in
most suicides, or implicated in accidental overdose deaths, is not
readily available information.
Because the focus of this study is the use of prescription drugs,
the following discussion does not include adverse effects of alcohol
alone. However, as has been described in Chapter 1 of this report, the
combination of hypnotics or tranquilizers with alcohol can prove
fatal.
A. Suicide and Accidental Overdose
In 1976, almost 27,000 suicides were reported, constituting about
one percent of all deaths. 3/ Firearms and hanging were the means
used most often; drugs have been in the third place since the early
1960s, and were reported in 11 percent of suicide deaths in 1976
(Table 1~.
-63-
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It has been suggested that suicides are under-reported by as much
much as 100 percent, 4/ and that many of those not reported are due to
drugs. The reasons for this include the general reluctance of some
coroners or medical examiners to assign a death as suicide unless the
evidence is very clear. Many coroners offices do not have the necessary
toxicological facilities or staff to establish the fact of a drug
overdose. 5/ If all suicides were accurately reported, it is possible
that ingestion of drugs would be the second most common means.
Male suicide rates in the United States are three times as high as
those for females, and rates for whites are twice as high as for blacks.
In recent years, however, suicide rates for black males have been
· e
ncreas 1ng.
Suicide rates tend to increase with age. In the past twenty
years, however, the increase in the number of suicides committed by
young people has outraced their numerical increase as a segment of the
population. The result is that age differences in suicide rates have
become less dramatic. For example, the suicide rate for the 20 to 24
year age group in 1955 was slightly more than 5 per 100,000, compared
with 25 for the 65 to 69 year group. In 1975, the comparable rates
were 17 and 19, respectively. Increases of similar magnitude in the
suicide rates were seen in each five year age group through age 34
during this 20 year period. This increase in suicide rates among the
younger age groups, together with evidence of increasingly widespread
use of drugs for intoxication 6/ and the growing use of drugs as a
means of suicide, led to much \of the demand during the 1960s for
controls on prescription drugs, particularly barbiturates.
In 1954, barbiturates were reported as the cause of death in four
percent of the 16,000 suicides in the United States and in 84 percent
of the 865 drug-related suicides. During the next ten years, suicide
deaths in which drugs were used increased more than threefold to 2,666,
with barbiturate deaths accounting for most of the increase. In 1963,
barbiturates were used in ten percent of all suicides, accounting for
for 75 percent of drug suicides.
By 1968, although the number of drug suicides remained at about
2,600, barbiturates were identified as the means of death in only
61 percent of the cases; use of other drugs was increasing. A sharp
drop in numbers of prescriptions written for barbiturates from 1970
to 1976 was paralleled by a decrease in suicides using these drugs
(Figure 1~; by 1976, they accounted for only 30 percent of drug
suicides (Table 2~.
Although there was a 50 percent drop in the barbiturate suicide
rate from 1970 to 1976, the overall rate of suicides from drugs declined
—65—
OCR for page 66
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1. 1 1 1 1 1 1
1969 1971 1973 1975 1977
YEAR
Source: National Center for Health Statistics, Mortality Branch
National Prescription Audit, IMS America, Ltd.
—66-
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only 13 percent. The total number of drug suicides remained stable,
due partly to the growing use of antidepressants and tranquilizers
(Table 2~. However, the largest proportion of suicides were committed
using drugs coded as "other and unspecified." 8/
Despite some methodological weaknesses, 9/ data reported from the
Drug Abuse Warning Network (DAWN) indicate the relative involvement
of different drugs. 10/ Medical examiners reported 3,464 deaths from
May 1976 to April 1977. Heroin, or its metabolite, morphine, was
identified in 1,079 of these deaths; in 421 of these it was the only
drug mentioned. D-Propoxyphene (Darvon(R)) was the second drug most
often mentioned being cited in 421 deaths; in 160 deaths, it was
the only drug mentioned. Although diazepam (Valium(R)) was the next
most-often mentioned drug, it was reported as used alone in only 19
of the 317 deaths in which it was involved. The single barbiturate
most often reported in the DAWN deaths was secobarbital. This drug
was involved in 299 deaths; in 102 deaths it was used alone, according
to the medical examiner report.
Over half the reported drug overdose deaths involved the use of
more than two substances, although an examination of the deaths in
which multiple drugs were used shows the pervasiveness of alcohol. 11/
In Los Angeles county, where there are about 1,200 drug deaths a
year, barbiturates are most commonly the drugs involved. However, the
mortality rate in the county from barbiturates fell from 9 per 100,000
population in 1972 to 7.5 in 1975. Data from the medical examiner's
office show a compensating increase in the numbers of drug deaths due to
the use of 'other hypnotics and various antidepressants and tranquil-
izers," as well as in deaths due to combinations of drugs with alcohol.
Additionally, an increase in drug deaths involving d-propoxyphene
(Darvon (R)) has been recorded in Los Angeles, along with an increasing
tendency for suicides to "clear out the medicine cabinet." 12/ The
office estimates that as much as 84 percent of all drug deaths in
Los Angeles involve more than one drug.
Similar patterns, although on a much smaller scale, are reported
for 1976 and 1977 in Onondaga County, New York, which includes the
city of Syracuse. In 1976, eight of 21 drug deaths involved the use
of a barbiturate. One year later, of 24 deaths involving drugs, only
two involved a barbiturate; diazepam, d-propoxyphene, and alcohol
were the most frequently mentioned drugs, in combination with each
other or other antidepressants, major tranquilizers, non-barbiturate
hypnotics and minor tranquilizers.
-68-
OCR for page 69
Although suicides from all drugs have fallen about 13 percent
since 1970, deaths from accidental overdose have risen about 7
percent. Much of this increase, both in the numbers of deaths
and the mortality rates, has occurred in the 20 to 29 year age group
which also has high rates of use of over-the-counter drugs and
alcohol (Tables 3 and 4~. Some of the increase is believed due to
the combination of alcohol and drugs thought of as "safe," such as
diazepam. Alcohol has been shown to be involved in many drug-related
deaths, and the potential lethality of drug-alcohol combinations
probably is not fully appreciated by physicians, their patients,
or persons combining these drugs.
Although in 1976 people over 65 accounted for only 11 percent of
the population, they accounted for 15 percent of all drug-involved
suicides. However, the elderly receive 25 percent of prescription
drugs and more than 30 percent of tranquilizers and hypnotics, so that
in terms of drug availability they could be described as under-
represented among drug suicides. 13/
At the other end of the age scale, the 15 to 24 year group
receives only about nine percent of prescription drugs and seven
percent of sedative-hypnotics, yet they account for 15 percent of
drug suicides. 14/
Suicide Attempts
In addition to 7,500 to 8,000 deaths a year from intentional
drug overdose, it has been estimated that there are eight to 16
times as many failed attempts at suicide with drugs. One study
reports drugs to be used in 48 percent of cases, which suggests
a conservative estimate of about 100,000 suicides attempted annually
with use of drugs. 16/ About two-thirds of such attempts are made
by women. _ /,17/
Physicians questioned about the seriousness of intent of their
patients attempting suicide with drugs have estimated that only about
one-third wanted to die. 16/,18/ Suicide attempts with drugs may be
impulsive acts that might have less serious consequences if the amount
of the drugs made available were more severely restricted. When the
size of single prescriptions for barbiturates was restricted in
Australia, there was a decline in barbiturate suicides; there was no
compensatory increase in suicides by other means. 15/,19/ More
appropriate prescribing, a restriction on the size of a single
prescription, and monitoring of refills, could save lives. 7/,19/
-69-
OCR for page 70
TABLE 3. DRUG-RELATED SUICIDES AND ACCIDENTAL OVERDOSE DEATHS (1968-1976)
Suicides Accidental Overdose Deaths
Age
Groups
< 10
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80+
6
110
162
189
205
250
319
288
286
273
186
139
109
64
49
All Ages 2635
1968 1970 1972 1974 1976
12
174
384
303
238
278
32-6
326
287
254
216
181
134
74
82
3251
16 16 16
144 133 135
366 292 326
316 335 354
264 275 300
268 232 268
306 270 258
318 281 254
270 296 255
260 217 224
252 156 183
160 145 146
122 107 120
64 90 86
96 60 81
3222 2904 3002
1968 1970 1972 1974 1976
160 132 154 89 83
10 22
171 332
245 534
191 301
167 209
140 153
141 165
101 132
89 127
76 102
56 88
44 57
41 48
30 38
30 64
1692 2505
18
290
544
374
152
144
144
146
84
102
110
50
52
70
80
2516
Source: U.S. Department of Health, Education and Welfare, National Center for
Health Statistics, Mortality Branch
-70-
16 16
281 189
610 656
468 578
250 281
164 185
156 154
141 125
100 118
101 98
96 89
69 68
63 51
51 57
84 99
2742 2839
OCR for page 71
TABLE 4. DRUG-RELATED SUICIDES AND ACCIDENTAL OVERDOSE RATES PER 100,000
POPULATION (1968-1976)
Suicide Rate Accidental Overdose Rates
Age
Groups 1968 1970 1972 1974 1976 1968 1970 1972 1974 1976
o
10-14 .03 .06 .08 .08 .05 .05 .11 .09 .08 .08
15-19 .06 .92 .73 .65 .65 .99 1.75 1.46 1.37 .01
20-24 1.11 2.47 2.15 1.63 1.73 1.68 3.44 3.20 3.41 3.49
25-29 1.50 2.28 2.15 2.11 2.03 1.51 2.26 2.54 2.95 3.32
30-34 1.88 2.10 2.19 2.07 2.14 1.53 1.85 1.26 1.88 2.00
35-39 2.21 2.55 2.45 2.06 2.29 1.24 1.40 1.32 1.46 1.58
40-44 2.57 2.74 2.64 2.39 2.33 1.14 1.39 1.24 1.38 1.39
45-49 2.43 2.69 2.65 2.38 2.18 .85 1.09 1.22 1.19 1.07
50-54 2.62 2.58 2.32 2.48 2.13 .81 1.14 .72 .84 .99
55-59 2.82 2.54 2.57 2.10 2.08 .78 1.02 1.01 .98 .91
60-64 2.21 2.49 2.80 1.69 1.97 .67 1.01 1.22 1.04 .96
65-69 2.05 2.58 2.16 1.85 1.76 .65 .81 .68 .88 .82
70-74 2.07 2.45 2.21 1.88 2.12 .78 .88 .94 1.10 .86
75-79 1.72 1.90 1.62 2.29 2.12 .81 .98 1.77 1.30 1.41
80 ~ 1.38 2.19 2.38 1.38 1.72 .85 1.71 1.98 1.93 2.11
All Ages 1.31 1.61 1.56 1.38 1.41 .84 1.24 1.22 1.31 1.33
Source: U.S. Department of Health, Education and Welfare, National Center for
Health Statistics, Mortality Branch.
OCR for page 72
B. Traffic Safety
There have been few studies in the United States to determine the
role of drugs in traffic accidents, although the role of alcohol in
traffic accidents has been widely studied and a cause and effect rela-
tionship is generally recognized. 20/ In a study of 100 victims of
automobile accidents in North Carolina (both drivers and pedestrians),
alcohol alone was found in 46 percent of the cases, and a drug plus
alcohol was found in three percent of the victims. Drugs alone were
found in only five victims, all pedestrians. More than 80 percent of
the victims in whom alcohol was found would have been considered legally
drunk. 21/
In another study of 503 fatally injured drivers from all parts of
the United States, 11 percent evidenced a sedative or hypnotic drug in
their blood or urine. Of these, 54 percent also evidenced non-zero
blood alcohol levels and in about 45 percent of cases, these concen-
trations were above 0.10 percent, the legal definition of intoxication
in most states. 22/
Norwegian researchers compared findings from blood samples obtained
from 74 non-fatal traffic accident victims to those from a control group
of 204 people not involved in accidents. Forty-six percent of the
accident victims had blood alcohol concentrations in the intoxicated
range; 11 percent showed diazepam in the blood sample, about half of
these at the high end of the therapeutic range; a further 8 percent
showed both alcohol and diazepam present. These findings were compared
to the reference group in which alcohol or diazepam was found in only
three percent of cases, and in no case were the two substances found
together. One person in the reference group had a blood alcohol
concentration above the intoxicated level. 23/
In a similar Finnish study, diazepam alone was found in five
percent of injured drivers compared to two percent of a control
group. 24/ These data indicate an association between diazepam and
non-fatal traffic accidents 9 but further studies and baseline data
are needed before a causal relationship can be demonstrated. Both
studies confirm, however, that the use of alcohol remains the pre-
dominant traffic safety hazard.
Apart from the ubiquity of alcohol in traffic accidents, there
are other problems in establishing a causal role for drugs. First,
there are no reliable estimates of the use of hypnotic drugs among
the driving population in the Onited States, so it is difficult to
establish whether the proportion of accident victims in whom drugs
are found deviates from the expected value based on general popula-
tion use.
-72-
OCR for page 73
Second, the detection of drugs and the measurement of their levels
varies depending on such factors as the screening method used, the sen-
sitivity of the instruments used, and the method of handling samples
from the accident site to the laboratory. The last is especially
important since many drugs are chemically unstable even in dead tissue,
unless it is frozen. 25/
Third, until recently, there has been a tendency in most studies
to screen blood and urine samples for the relatively easily detected
drugs such as alcohol, opiates, and the barbiturates, while toxico-
logical testing for the most widely prescribed drugs, diazepam and
flurazepam, has been rare. More information should be forthcoming
now that relatively simple tests have been devised for assaying serum
levels of N-desalkylflurazepam (flurazepam's long-acting metabolite),
diazepam, and N-desmethyldiazepam (diazepam's long-acting metabo-
lite). 26/
C. Non-medical Use of Drugs
The National Institute on Drug Abuse has for several years
conducted a survey of the extent of non-medical use of drugs by the
general population (Table 5~. 27/ "Non-medical use" was defined as a
report by the respondent that a particular drug was used "to see
what it was like" or "to enjoy the feeling it gave" and "not because
it was needed." Although the number of responses is too small to
project to the total population, it is worth noting that 85 percent
of the users of these drugs were 18 to 25 years old, the group least
likely to receive them through a prescription.
In a survey during 1976, the 1,800 clinics that receive federal
funds for drug treatment programs reported 210,000 admissions. Sixty-
four percent of those admitted reported their primary drug of abuse
was heroin or another opiate; barbiturates were reported by almost
five percent, or about 9,800 people. Forty-five percent of the
barbiturate abusers were younger than 21, although only 21 percent
of all admissions were in this age group. 28/*
*About 30 percent of clients citing barbiturates as their primary
drug of abuse indicated current usage of less than once a month, and
another 18 percent indicated using the drug once a week or less. It is
difficult, therefore, to understand what level of abuse or addiction the
CODAP data represent.
-73-
OCR for page 74
Adults 18+ N=2,411 N=3,071 N=2,590 N=3,222
TABLE 5. NON-MEDICAL USE OF DRUGS IN PAST MONTH (1972-1977)
1972 1974 1976 1977 1976-1977
change
Marihuana and/or hashish 8.0 a/ 7.0 7.9 8.2 NS
Inhalants * * * * NS
Hallucinogens .7 .6 * .5 NS
Cocaine .9 .7 .7 1.0 NS
Heroin * * * * NS
Other Opiates 11 * * * §
b/
Stimulants (Rx) ~ 1.0 1.2 1.0 NS
b/
Sedatives (Rx) ~ * .9 .6 NS
b/
Tranquilizers (Rx) ~ * .8 .8 NS
Alcohol 11 58.0 58.8 58.0 NS
Cigarettes ~ 41.0 40.7 40.5 NS
a/
_/
Marihuana only
Non-medical use. Estimates in 1977 based on split sample: N=1647.
*Less than .5%
NS: not significant; §: significance level not calculated because categories not
comparable.
Snot asked.
Source: National Institute on Drug Abuse, National Survey on Drug Abuse: 1977,
Volume 1, Main Findings. (Table 11~.
- 74 -
OCR for page 75
These treatment programs represent about half of all known drug
treatment programs in the United States. Clients usually enter the
programs when their drug use interferes with their daily functioning.
They may be admitted on a voluntary basis or referred from such agencies
as the Bureau of Prisons or the Veterans Administration. Another survey
indicates that units that do not receive federal funds treat about the
same number of clients, which suggests that there are about 20,000
people with a recognized problem with barbiturates in the United
States. 29/
The extent of the problems with the benzodiazepines is especially
difficult to ascertain but is a source of growing concern in the medical
community. _ /-33/ Data for the first quarter of 1978 indicate that
about 2,400 people sought treatment of a primary problem with any kind
of tranquilizer or non-barbiturate hypnotic drugs. 34/ This suggests
that each year there are at least 5,000 people in federal programs
whose functioning is impaired by dependence on tranquilizers, and
another 4,000 with problems deriving from the use of non-barbiturate
hypnotics. Again, assuming a similar number in non-federal programs,
there appear to be at least 19,000 people with a primary problem
related to the use of non-barbiturate tranquilizers and hypnotics.
Barbiturates represent a secondary drug of abuse for five percent
of federal program clients; tranquilizers and other hypnotics are
secondary drugs of abuse for four percent. After eliminating duplicate
counting of individuals whose primary and secondary drugs of abuse are
both tranquilizers or hypnotics, it appears there are about 32,000
people for whom these drugs represent a secondary problem. 34/
-75-
OCR for page 76
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1
2
3
4
5
6
7
8
9
10
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—76—
OCR for page 77
DAWN Tape - As of January 7, 1977.
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Wold, C.I., Characteristics of 26,000 suicide prevention center
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Linnoila, M., Tranquilizers and driving, Accid. Anal. and Prev. 8:
15-19, 1976.
Turk, R.F., McBay, A.J., and Hudson, P., Drug involvement in automobile
driver and pedestrian fatalities, Journal of Forensic Sciences 19:
90-97, 1974.
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Bo, O., Haffner, J.F.W., et al, Ethanol and diazepam as causative
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national Conference on Alcohol, Drugs, and Driving, Toronto,
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Linnoila, M., Psychomotor effects of drugs and alcohol on healthy
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Linnoila, M., Dorrity, F., Rapid gas chromatographic assay of serum
diazepam, N-desmethyldiazepam, N-desalkyflurazepam; Acta Pharmacologia
et Toxicology, 41: 458-464, 1977.
National Institute on Drug Abuse, National Survey on Drug Abuse: 1977
Vol. 1. Main Findings. DREW Publication No. (ADM) 78-618, U.S.
Government Printing Office, Washington, D.C. 1977.
National Institute on Drug Abuse, Sc~ciscical Series, Annual Summary
Report 1977, Data from the Client Oriented Data Acquisition Process
-
(CODAP), Series E, Number 1, DHEW Publication No. (ADM) 78-547.
National Institute on Drug Abuse, Statistical Series, Executive Report
April 1977, Data from the National Drug Abuse Treatment Utilization
Survey (NDATUS), Series F. Number 3, DHEW Publication No.(ADM) 77-534.
Ryan, H.F., Merrill, F.B. et al., Increase in suicidal thoughts and
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Maletzky, B.M. and Klotter, J., Addiction to diazepam,
Journal of the Addictions 11: 95-115, 1976.
Internationa :
Woody, G.E., O'Brien, C.P. and Greenstein, R., Misuse and abuse of
diazepam: An increasingly common medical problem.
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Representative terms from entire chapter:
health statistics
