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

The work is a result of the postdoctoral fellowship of Gabriel Andreuccetti, epidemiologist with the supervision of Professor Heraclitus Barbosa de Carvalho, of the Department of Preventive Medicine of the Faculty of Medicine of USP, and in collaboration with the Department of Legal Medicine of the same university, with the University of California, Berkeley, and support from the Legal Medical Institute (IML) in São Paulo. The article was published in the journal Injury and counted on the support of FAPESP.

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

According to legislation, victims of sudden, unexpected or violent death must undergo an autopsy procedure by medical-legal expert teams (EPML). Annually, occur in Sao Paulo about 7 thousand deaths that fall into this classification. Most are homicides (26%), followed by deaths related to car accidents (20%) and suicides (10%).

The work of surveying cases of violent deaths occurred between June 2014 and December 2015. To obtain a representative sample of the city, collected blood samples from Andreuccetti cadavers during autopsies by the city's various EPMLs 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 event of injury or who survived for the same period before death were excluded from the sample.

"There are a lot of cases of people who have checked into the hospital and are going to the Legal Medical Institute. In many of these cases, the fatal injury occurred suddenly or violently, and the victim may have been under the influence of drugs at the time of the accident, murder or suicide. But due to hospitalization for more than six hours, traces of alcohol and drugs in the blood can undergo influence after the traumatic event. These cases were excluded from the survey, "Andreuccetti said.

The final result of the survey got a sample with 365 deaths, all violent, sudden or unexpected, that they entered the MORGUE. 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 previous ones.

"Due to several governmental actions in the beginning of the decade (2010), the car traffic mortality in Sao Paulo fell considerably, along with the homicide mortality that has been falling since the last decade. Today the murder rate is higher than in car traffic. But São Paulo is an atypical case. In Brazil as a whole, these fluctuations were much smaller, and they continue to die a lot for these two causes, "Andreuccetti said.

Men and young people

Once identified where the situations of deaths occurred, the next step was to identify those who had traces of alcohol or drugs in their blood. To do so, blood samples from all victims were subjected to a comprehensive screening of positive cases for a variety of drugs, illicit drugs and alcohol.

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

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

"Of every two victims, one had remnants of alcohol and/or drugs in the blood. That means more than half the victims used alcohol or drugs just before they died, "Andreuccetti said.

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

"We did not expect such high drug prevalence at sampling. Of the five victims who used drugs, four used cocaine or marijuana. It's a worrying fact, "Andreuccetti said.

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

With regard to homicides, in the less than 59.6% of the deaths were the presence of any psychoactive substance or alcohol in the blood, and 16.3 percent used alcohol and cocaine together.

Regarding suicide cases, alcohol had the lowest representation of all sampling. Only 9.1% of 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 were 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 each woman. And about one in three of the victims were 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 greater prevalence of the use of other drugs, in combination or not with alcohol, "Andreuccetti said.

Ethnic participation proved to be similar: half of the dead were white (50.3%) and the other half composed of individuals of another ethnicity (Browns, blacks, etc.) (49.7%). 60.5% of deaths occurred during the 6 P.M. to 6 A.M.. Die violently at night than during the day in the city of São Paulo.

Ethnic participation was similar: half of the dead were white (50.3%) and the other half were individuals of other ethnic groups (browns, blacks, etc.) (49.7%). 60.5% of the deaths occurred in the period from 6:00 pm to 6:00 am. It dies of violent form more at night than of day in the city of São Paulo.

Criminal history

The revealing fact is that of the 365 deaths, 15.9% of the victims had some criminal history. Among these, the use of drugs other than alcohol and multiple use of substances were greater than among victims who had no criminal history.

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

"This suggests that there is a socioeconomic component, but 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 begin reducing the number of violent deaths related to alcohol and drug use in the city of São Paulo and other major cities in the country.

"All these deaths causes enormous damage to society in terms of hospital services and emergency relief, not to mention pain for family members and the significance of the loss of violence by the person who could continue to work, study and produce," he said.

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, g. Andreuccetti, C.J. Cherpitel, H.B. Carvalho, v. Leyton, I.D. Miziara, D.R. Munoz, A.L. Reingold and N.P. Lemos, is avaliable online