Of the 1 338 investigated deaths that occurred during the use of narcotics, 322 were not encompassed by the general concept of overdose (other accidents, suicides and homicides).
Approximately 6 % of the medicolegal autopsies performed in the area and the time period for the study were performed in departments of clinical pathology in hospitals not included in the study (17). As an example, a total of 90 medicolegal autopsies were performed at Innlandet Hospital in Lillehammer during the studied period (17), a fact that may explain why we did not register any unnatural deaths positive for narcotic drugs from Gudbrandsdal police district.
The varying practices in different police districts with regard to requesting a medicolegal autopsy (18, 19) is a weakness of the study. Section 36 of the Health Personnel Act with appurtenant regulations defines the types of deaths that the doctor is obliged to report to the police (20), and Section 228 of the Criminal Procedure Act (21) and Chapter 13 of the Prosecution Instructions (22) state the cases in which the police shall and ought to request a medicolegal autopsy. A medicolegal examination is mandatory only in cases where death is suspected to have been caused by a punishable act or in cases where the deceased is unidentified.
This means that in the remaining cases (accidents, suicides, sudden unexpected deaths etc.) the head of the police district in question is free to decide whether or not to have such an examination performed. This may result in random (in)equalities in numbers and proportions that are not representative of the real prevalence. Moreover, the medicolegally autopsied deaths represented only 4 % of all deaths during this period (17, 23). Because of the varying practices for requesting a medicolegal autopsy, we assume that suicides, fatal accidents and accidental intoxications during drug use are under-registered.
As regards accidental intoxications, our results in terms of age and gender distribution are in accordance with other studies from the same period (15, 16). The question of why the proportion of women suffering accidental intoxications is lower in Western Norway than in the southern and eastern regions merits investigation in more detail. With regard to accidental intoxications, the autopsy rate was most likely quite high (18), and these regional differences in the proportion of women may thus be real. With regard to the other manners of death, such regional differences cannot be assessed with certainty on the basis of our study, due to the variation in practices for requesting autopsies as well as the relatively small number of cases for some of the manners of death in the material from Western Norway.
More than half (66 of 123) of the deaths in the category «other accident» were traffic-related. It has previously been shown that the use of drugs is associated with an elevated risk of accidents, especially traffic accidents (5) – (8). An increased prevalence of other unnatural deaths has also been demonstrated among substance abusers (2, 9, 24). We have not distinguished between «heavy users» and more occasional and recreational drug users, nor between the types and numbers of the drugs that were detected in each individual. It will be important to undertake further studies to obtain more knowledge about the extent to which drug-use careers and types of substances are related to specific risks of accident, suicide or homicide.
We found an increased frequency of intoxication as a suicide method in both genders (more than half of the suicides had been committed by intoxication) when compared to the general suicide population (25). This may indicate that substance abusers are more prone to committing suicide by this method, possibly because they have better access to and a lower threshold for using narcotic substances as well as medicinal products than the population as a whole.
In our study, the proportion of women with homicide as the manner of death was significantly lower than in the police statistics of homicides in general (26). The numbers are too small to draw any conclusions in this respect. The homicide figures registered by the police are not directly comparable to those from the autopsy material, because the definition of homicide is different. Forensic pathologists, as opposed to the police, also regard serious bodily harm resulting in death as a homicide.
The substantial variations among the large urban municipalities regarding the proportion of individuals who die in their home municipality may have an impact on how one should design preventive strategies. The large variations may be related to the access to drugs, as well as the characteristics of the user populations and the user cultures in the various cities. The reasons for these large variations merit further investigation. In the Oslo study of overdose deaths in 2006 – 08 (27), one-third of the deceased were not registered residents of the city. Our study, however, also includes deaths other than those due to overdose. In the case of Oslo, it seems to be a persistent trend that many of those who die from unnatural causes while using drugs are not registered residents of this municipality.
Studies from the same period as in our study, as well as subsequent periods, have shown that most drug-related deaths occur in private homes (13). Our study supports this finding, but also shows that the scene of death strongly co-varies with the manner of death. A large proportion of the deaths occurred with other adults in the vicinity.
Knowledge about where the deaths occur and the fact that very often other adults are present provide important information for the assessment of preventive and life-saving measures.