High Illicit Drug Abuse and Suicide in Organ Donors With Type 1 Diabetes

Organ donors with type 1 diabetes represent a unique population for research. Through a combination of immunological, metabolic, and physiological analyses, researchers utilizing such tissues seek to understand the etiopathogenic events that result in this disorder. The Network for Pancreatic Organ Donors with Diabetes (nPOD) program collects, processes, and distributes pancreata and disease-relevant tissues to investigators throughout the world for this purpose (1). Information is also available, through medical records of organ donors, related to causes of death and psychological factors, including drug use and suicide, that impact life with type 1 diabetes.

We reviewed the terminal hospitalization records for the first 100 organ donors with type 1 diabetes in the nPOD database, noting cause, circumstance, and mechanism of death; laboratory results; and history of illicit drug use. Donors were 45% female and 79% Caucasian. Mean age at time of death was 28 years (range 4–61) with mean disease duration of 16 years (range 0.25–52). Causes of death, based on death certificate, are presented in Table 1. Anoxia was the most common notation, precipitated by a variety of events including drug overdose, myocardial infarction, pulmonary embolism, or cerebral edema. Deaths due to anoxia coincide with a history of illicit substance abuse in 26% (15/57) of cases, and the majority of individuals had positive toxicology upon arrival to medical care. Acidosis (pH <7.3 or HCO₃⁻ <15 mEq/L) was present on admission in 71% (56/79). Those with acidosis were younger (27 vs. 33 years, P < 0.05) and had shorter disease duration (14 vs. 20 years, P < 0.05) than those without acidosis. Documented suicide was found in 8% of the donors, with an average age at death of 21 years and average diabetes duration of 9 years. Three donors were under the age of 18 years and committed suicide via insulin overdose or a self-inflicted gunshot wound.

Similarly, a type 1 diabetes registry from the U.K. found that 6% of subjects’ deaths were attributed to suicide (2). In the U.S. in 2014, suicide was the 10th leading cause of death in people of all ages and the 2nd leading cause of death in individuals aged 10–34 years (3). Additionally, we observed a high rate of illicit substance abuse: 32% of donors reported or tested positive for illegal substances (excluding marijuana), and multidrug use was common. Cocaine was the most frequently abused substance. Alcohol use was reported in 35% of subjects, with marijuana use in 27%. By comparison, 16% of deaths in the U.K. study were deemed related to drug misuse (2).

We fully recognize the implicit biases of an organ donor–based population, which may not be directly comparable to the general population. Nevertheless, the high rate of suicide and drug use should continue to spur our energy and resources toward caring for the emotional and psychological needs of those living with type 1 diabetes. The burden of type 1 diabetes extends far beyond checking blood glucose and administering insulin. The American Diabetes Association’s 2017 guidelines include recommendations for depression and diabetes-specific distress screening (4,5). Still, more needs to be done; when signs of depression, difficulty coping, disordered eating, drug use, or other self-harm behaviors are identified, available mental health care providers, preferably skilled in type 1 diabetes, are needed.