Quaaludes were popular before my time, but I saw cocaine and methamphetamine sweep the country and witnessed a renewed taste for heroin.
Now, we have the “opioid crisis” – an epidemic of deaths from opiate-type drugs including some never before seen.
The Centers for Disease Control and Prevention estimates that opioid overdoses kill 91 people every day. For each of these deaths:
10 overdose victims are hospitalized.32 drug users visit the emergency room.130 people are drug-dependent.825 people are using controlled drugs for “non-medical” purposes.Drug-death statistics mostly come from studies of death certificates signed by medical examiners and coroners. We may be under-reporting drug deaths by as much as 30 percent.
One problem is cause-of-death wording. When several drugs are detected, it’s impossible to cherry-pick one culprit and cumbersome to list them all, so some certify the cause of death as “multi-drug toxicity.” When researchers search certificates for drugs by name or class, these cases can be missed.
A larger problem is that for many jurisdictions, competent forensic drug testing is neither readily available nor affordable.
Many smaller jurisdictions screen urine and order forensic blood tests only when the urine test is positive. Urine tests are cheap but insensitive. They miss plenty of drugs.
Newly-created illicit opioids are hitting the streets in remarkable numbers. The detection and measurement of some of these “designer drugs” requires methods and instruments available in very few laboratories. Such sophisticated tests are expensive. Few medical examiner or coroner offices can afford to order them routinely.
Laboratories may not have reference samples to test against new drugs. Even if the drug can be measured, the result may be impossible to interpret because reliable information relating drug level to toxicity hasn’t been developed.
Economic pressures in the last decade have caused jurisdictions to cut medical examiner budgets. Some blame the economy for a simultaneous increase in recreational drug-abuse deaths and suicides.
One Florida medical examiner certified 224 drug deaths in 2014 and 582 in 2016. His staff can’t keep up. The chief toxicologist works 14 hours a day, seven days a week.
Coroners and medical examiners must make choices. Cases that were once autopsied no longer are. I used to order full toxicology on all comers. Nobody does that anymore.
If a 60-year-old with a history of heart disease is found dead in bed, the medical examiner or coroner may certify a natural death without an autopsy or drug testing. It’s certain some of these inadequately-examined cases are unrecognized drug deaths.
Government agencies that promulgate policies need information to combat the opioid epidemic. The feds could issue reporting requirements and testing mandates, but state and local jurisdictions don’t have the money to comply. Increased federal funding is unlikely because the focus is on decreasing, rather than increasing, domestic spending.
Medical examiners and coroners have the legal authority to conduct autopsies and order drug tests, but they don’t have enough investigators and pathologists to handle burgeoning caseloads.
Forensic laboratories don’t have the sophisticated instruments and updated methodologies needed to detect and measure new drugs.
Medical examiners and coroners have invaluable epidemiological information about where overdose victims lived and worked, their medical and mental health histories and the circumstances surrounding their deaths. But hardly any offices are equipped to compile this data in an anonymous form and share it with the CDC or the Drug Enforcement Administration.
An underfunded and underutilized forensic death investigation system hampers our ability to confront the opioid epidemic.
Dr. Carol J. Huser, a forensic pathologist, served as La Plata County coroner from 2003-12. She now lives in Florida and Maryland. Reach her at firstname.lastname@example.org.