Research Shows Relationship Between Alcohol, Drugs and Violence

It is already expected that alcohol and other drugs lead the person to a path of violence, but recently this was proven through research by a group from the School of Medicine of the University of São Paulo (USP). They published the results of a study on the association between alcohol and drug use and the occurrence of violent deaths. The work puts the data of this relationship in numbers, in this case, in the city of São Paulo. The finding is that the consumption of alcohol or at least one type of drug is associated with more than half (55%) of the violent deaths that occurred in the city of São Paulo between 2014 and 2015.

The work is the result of the postdoctoral work of epidemiologist Gabriel Andreuccetti, under the supervision of Professor Heráclito Barbosa de Carvalho, from the Department of Preventive Medicine of the USP School of Medicine, and in collaboration with the Department of Forensic Medicine of the same university, with the University of California, Berkeley, and support from the Forensic Medical Institute (IML) of São Paulo. The article was published in the journal Injury and was supported by FAPESP.

To obtain data for the survey, Andreuccetti employed a probabilistic sampling method using the city of São Paulo as the target population. "The sampled cases were adult victims, fatally wounded, who had a sudden, unexpected, violent or otherwise unnatural cause of death, and who were admitted to the main forensic medical facilities that serve the entire city and its 96 districts," he told Agência FAPESP.

According to the legislation, victims of sudden, unexpected or violent death must be submitted to an autopsy procedure by the medico-legal expert teams (EPML). Every year, there are about 7,000 deaths in São Paulo that fit this classification. The majority are homicides (26%), followed by traffic-related deaths (20%) and suicides (10%).

The work of surveying cases of violent deaths took place between June 2014 and December 2015. To obtain a representative sample of the city, Andreuccetti collected blood samples from cadavers during autopsies by the various EPML in the city, on different days and times of the week, over the course of 19 months.

Victims who received six or more hours of medical treatment due to the injury event or who survived for the same period before death were excluded from the sample.

"There are a large number of cases of people who have been admitted to the hospital and end up at the Forensic Medical Institute. In many of these cases, the fatal injury occurred violently or suddenly, and the victim may have been under the influence of drugs at the time of the accident, crime or suicide. But due to hospitalization for more than six hours, traces of alcohol and drugs in the blood can be influenced after the traumatic event. These cases were excluded from the survey," Andreuccetti said.

The final result of the survey reached a sample of 365 deaths, all violent, sudden or unexpected, that were admitted to the IML. The sample included 104 homicides (28.5% of the total), 56 victims of traffic accidents (or 15.3%), 44 suicides (12.1%), 26 falls (7.1%) and 21 cases of poisoning or intoxication (5.8%). In 114 cases (31.2%), sudden or violent death occurred in ways other than the previous ones.

"Due to several government actions at the beginning of the decade (2010), traffic mortality in São Paulo fell considerably, along with homicide mortality, which has been falling since the last decade. Today, the rate of homicide deaths is higher than in traffic. But São Paulo is an atypical case. In Brazil as a whole, these fluctuations have been much smaller, and many people continue to die from these two causes," Andreuccetti said.

Men and young people

Once the situations where the deaths occurred were established, the next step was to identify which ones had traces of alcohol or drugs in their blood. To this end, blood samples from all victims were comprehensively screened for positive cases for a variety of medications, illicit drugs, and alcohol.

Blood alcohol concentration (via gas chromatography) was checked, as well as the presence of other drugs, including amphetamines, sedatives (tranquilizers) and anxiolytics (barbiturates and benzodiazepines), marijuana, cocaine, opioids (methadone, morphine, heroin) and angel dust (phencyclidine). The presence of drugs in the blood was detected by enzyme-linked immunosorbent assay (ELISA), which was later confirmed by mass spectrometry.

Of the 365 victims, 202 (55.3%) had ingested alcohol before dying, or were under the influence of drugs at the time of death, 63 only ingested alcohol, 92 only used drugs, and 47 did both.

"Out of every two victims, one had traces of alcohol and/or drugs in their blood. This means that more than half of the victims had used alcohol or drugs immediately before they died," Andreuccetti said.

Alcohol was the most prevalent substance among victims who used any type of psychoactive substance, followed by cocaine, marijuana, and tranquilizers and anxiolytics. More specifically, among the 202 victims positive for alcohol and/or drugs, 30.1% ingested alcohol, 21.9% cocaine, 14% marijuana, and 11.5% benzodiazepines. 16.2% used alcohol and any of these drugs.

"We didn't expect such a high prevalence of drugs in the sample. Out of every five victims who used drugs, four used cocaine or marijuana. It's a worrying statistic," Andreuccetti said.

In the case of traffic accident victims, almost half (42.9%) had traces of alcohol in their blood and one in five (21.4%) was under the influence of one or more substances. "This shows that drugs influence interpersonal violence more and alcohol influences traffic accidents," Andreuccetti said.

Regarding homicides, no less than 59.6% of the deaths were accused of the presence of some psychoactive substance or alcohol in the blood, and 16.3% used alcohol and cocaine together.

Regarding suicide cases, alcohol had the lowest representation of the entire sample. Only 9.1% of the suicides had ingested alcohol. On the other hand, it was in this group that the use of benzodiazepines proved to be one of the most prevalent. One in five was under the effect of these drugs (18.2%).

Of the total of 202 deaths positive for alcohol or drug use, there were nine men for every woman. And about one in three victims was under the age of 30. "It is in this range that the largest number of homicide victims in Brazil is concentrated. And it was in this age group that there was a higher prevalence of the use of other drugs, in combination or not with alcohol," Andreuccetti said.

Ethnic participation was similar: half of the dead were white (50.3%) and the other half were individuals of another ethnicity (brown, black, etc.) (49,7%). 60.5% of deaths occurred between 6 p.m. and 6 a.m. People die violently more at night than during the day in the city of São Paulo.

Criminal history

Of the 365 deaths, 15.9% of the victims had a criminal history. Among these, the use of drugs other than alcohol and multiple substance use were higher than among victims who had no criminal history.

Whenever possible, Andreuccetti tried to quantify the victims according to the place where the fatal injury occurred. This was done by verifying the region of the city where the injury event occurred. Thus, it was inferred that most deaths due to violence when under the influence of drugs occur in the center and in the periphery, i.e., where the largest centers of commerce and the low-income population are concentrated, respectively.

"This suggests that there is a socioeconomic component, but in order to know more it would be necessary to carry out a specific study. On the other hand, the use of alcohol associated with these deaths seems to be more widespread throughout the city of São Paulo," Andreuccetti said.

According to the epidemiologist, knowing these statistics is an important step in trying to start reducing the numbers of violent deaths related to alcohol and drug consumption in the city of São Paulo and other large cities in the country.

"All these deaths cause enormous damage to society in terms of hospital services and emergency aid, not to mention the pain for family members and the meaning of the loss due to violence of a person who could continue working, studying and producing," he said.

The article Alcohol in combination with illicit drugs among fatal injuries in Sao Paulo, Brazil: An epidemiological study on the association between acute substance use and injury, by G. Andreuccetti, C.J. Cherpitel, H.B. Carvalho, V. Leyton, I.D. Miziara, D.R. Munoz, A.L. Reingold and N.P. Lemos, is available online