Too many Missourians die prematurely due to their use of tobacco, alcohol, and other drugs. By far the largest cause of the three is tobacco, which contributes to an estimated one of five Missouri resident deaths, as explained i n an earlier "Focus" article.¹ The current article will examine the deaths of Missouri residents due to their use of alcohol and other drugs.

Applying the National Center for Health Statistics' definition of alcohol-and drug-related deaths² to Missouri resident deaths for the years 1990-1998, about one percent (4,766) were attributed directl y to alcohol and other drugs. That percentage has risen slightly over the years, from 0.92 percent in 1990 to 1.12 percent in 1998.

The bottom rows of Table 1 show that the number and rate of these deaths have also been increasing over recent years. Missouri's rate has generally been lower than the national rate,³ but the gap is na rrowing. The recent increase raises questions regarding what population group or drug accounts for it. There is no one simple answer.

One factor is that the numbers of deaths in these years do not necessarily reflect usage during those years. Alcohol use accounts for far more deaths than does use of any other substance except tobacco. Because it is legal and does not require a prescr iption, it is used by a much larger number of people than most of the other potentially lethal drugs. But alcohol's contribution to the increase is relatively small, because most of the alcohol-related deaths, such as those attributed to cirrhosis and car diomyopathy, are due to decades of drinking. Only a small minority of alcohol deaths come within hours, as when a person "chugs" a large quantity of alcohol in a short time.

Death certificates provide less information on the duration of use preceding the death for drugs other than alcohol. One exception is the 50 to 70 drug-related suicides per year, which presumably are related to acute overdoses.

Even though the rates of alcohol- and drug-related death at any age are only somewhat related to the ages at which people use the substances, there is a pronounced pattern by age group. The increase is sharpest among middle-aged Missourians as seen in Figure 1. Specifically, deaths in ages 35-44 and 45-54 contributed most to the increase in number of deaths and to the increase in rates. Rates for persons under age 35 and for persons over age 65 have remained relatively stable through the 1990's. For Mi ssouri residents in their forties, however, there were marked increases in deaths due to cirrhosis, alcohol dependence, cocaine, heroin and other drugs.

The data were also examined by gender, but no trend was found. The ratio of males to females in tot al alcohol-and drug-related deaths fluctuated during the decade, with an average of 72.2 percent of the deaths being to males. Females accounted for a slightly smaller percent of the alcohol-related deaths than of the deaths due to other drugs.

Examining the data by race showed that most of the increase was among white Missourians. Deaths due both to alcohol and to other drugs rose for white residents during the period, while a slight rise in black deaths due to other drugs was largely balanced by a decrease in black deaths due to alcohol. This has resulted in a reduction in the ratio of black to white deaths from about 2.7 in the early 1990s to about 2.0 for the past three years.⁴

The most revealing way to analyze this data was by type of drug.⁵ Table 1 allows us to identify at least a few drugs which contributed to the increase shown there.

Comparing 1998 with 1990, the total increase was 145 deaths (31 percent). Twenty of those deaths were suicides, and two were assaults. While alcohol accounted for nearly two-thirds (63.1 percent) of the total alcohol- and drug-related deaths from 1990 through 1998, it contributed only 16 deaths to the increase, or 11.0 percent. Because most of the alcohol deaths are due to long-term use, alcohol death numbers do not fluctuate as dramatically as those due to other drugs can.

Most of the increase between 1990 and 1998 was in deaths due to other drugs. Cocaine and related drugs contributed 34 of the additional deaths, heroin and other opiates 30, and stimulants nine (up from zero). The "other" category includes unspecified " drug abuse" as well as the effects of combinations of drugs, a common and deadly pattern. There were sharp relative increases in those deaths, as well.

Heroin deaths increased for both black and white Missourians, and the increase appears to be indicative of current increasing use.⁶ Cocaine deaths rose for both races, but more sharply among African-Am erican Missourians. All the deaths attributed to stimulants, however, were to white Missourians.

There was also a distinct geographic pattern. The county with the highest rate of both alcohol-and drug-related deaths was St. Louis City, with a rate of alcohol-related deaths nearly three times the state rate, and a drug death rate more than three ti mes the state rate. However, St. Louis City contributed only three deaths to the increase between 1990 and 1998. Jackson County's rates were also somewhat high and are increasing; Jackson County contributed 44 deaths to the increase. St. Louis County, Jef ferson County, and St. Charles County also contributed ten or more deaths each to the increase.

The deaths we have been discussing so far do not represent the entire toll of alcohol and other drugs. In addition to these deaths, which were directly caused by the decedent's use of the substance, there are two other ways that alcohol's contribution to a death can be recorded on death certificates. One is that alcohol is noted as a significant contributing condition in some deaths attributed to other causes. The other is that there is a checkbox for use with deaths due to injury or poisoning which in dicates that the injury was "alcohol-related." In some of these deaths, the decedent did not drink, as in the case of a victim of drunk driving. Neither of those two categories showed the clear increase which took place in directly-caused alcohol- and dru g-related deaths. This is apparently because they deal only with alcohol, rather than with other drugs. There are no comparable categories for capturing deaths to which other drugs contributed or for "drug-related injury." As we saw in Table 1, most of th e increase in the total of alcohol- and drug-related deaths is due to drugs other than alcohol.

Figure 2 shows that these three designations can overlap in any combination. The aggregate of all deaths with any of these designations is 10,768 deaths for Missouri residents during 1990-1998. That number represents 2.3 percent of total deaths during the decade so far, an average of nearly 1,200 deaths per year.

Even that total is an undercount. The alcohol-related injury checkbox is probably underused. Sometimes physicians choose to omit mention of alcohol or drug use because of the possible stigma involved. Fetal deaths due to maternal drinking or drug use a re not included.

Furthermore, deaths represent only one part of the cost of addiction and abuse; other aspects include lost productivity, medical care, incarceration, and family disruption. In Missouri, the agency with primary responsibility for prevention and treatmen t of these problems is the Department of Mental Health's Division of Alcohol and Drug Abuse. Their regional offices (Columbia, Kansas City, St. Louis, Springfield, Poplar Bluff and Rolla) can refer callers to residential and outpatient treatment services as appropriate.⁷ Although they served over 46,000 Missourians in fiscal 1998, they estimate that as many as 342,000 Missourians may need substance abuse treatment.⁸

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