Brian Peterson admits his office is "under a lot of stress." It's early April and the Milwaukee County chief medical examiner and his staff are waiting on toxicology results from late February. "We should have six people in our lab, but we have three. We should have more sophisticated machinery to help turn the results around more quickly, but we don't have the funding to get it, he says. "Unfortunately, like so many other medical examiner offices in the US, we play the cards we have been dealt, but the numbers keep pouring in."
Peterson is referring to the surge in opioid-related deaths, the reason his office is so backed up. In the last three years, the Wisconsin county has seen heroin fatalities climb steadily, with fentanyl deaths leading the charge—they've nearly quintupled. "Overdoses made up a third of our autopsy cases last year and are growing," he says. "It's a crisis that's not going away." This scenario is replayed in many parts of the US recently, especially in the Northeast, where medical examiners in hard-hit areas like Connecticut, Maryland, and Pennsylvania are struggling to keep up with caseloads that keep ballooning because of opioid overdoses.
The lag time, Peterson says, is making it hard to act quickly. "If you are only finding out why someone died of an overdose three months later, you might be able to provide some good national data that way, but in terms of getting boots on the ground and fixing the issue in a certain neighborhood, you have to have the results faster," he says, adding, "But that would cost money, which is not around."
While staffing and funding are certainly bogging down the efficacy of the American death investigation system, its problems, unfortunately, don't stop there. At its core, it's a poorly regulated setup—one in which discrepancies in training and reporting deaths are diminishing the scope of the opioid epidemic, and delaying necessary action to curb it.
For starters, the framework is messy: Depending on the state and county, US death investigations are spearheaded by either coroners or medical examiners, two positions with vastly different requirements. In Wisconsin, medical examiners like Peterson—who also happens to be this year's president of the National Association of Medical Examiners (NAME)—are appointed by the county executive, approved by the board, and are required to be physicians, more specifically forensic pathologists who complete several years of additional training after medical school to learn all the nuances of death.
Coroners, on the other hand, are generally elected and don't need to specialize: According to the CDC, only 16 states have laws outlining training requirements for coroners, and only four (Kansas, Louisiana, Minnesota, and Ohio) require them to be physicians. Of course, some coroners complete years of secondary education, but in many counties the laws can be extremely lax—they only need to be residents and of voting age.
That has some experts questioning whether or not death investigations in those areas are properly carried out. "Do you want me to tell you whether our water is safe or not?," asks David Hickton, the former US attorney for Western Pennsylvania who was the co-chair of the National Heroin Task Force. "How can I if I'm not a scientist? It's the same with death investigations. I'm sure there are some very good coroners out there, but with the heroin and opioid epidemic being so severe, I believe that appointments like health officials or medical examiners need to meet certain qualifications in order to do their job effectively."
Hickton's point leads to the fact that no one is keeping elected officials in check. There's a presumption in the US that if someone is voted into office, it means they are qualified for that position. In that sense, the world of death investigations is eerily similar to presidential elections. "Ultimately if you are a coroner and you have been elected to that position, who is going to tell you what to do or check your work?" Peterson says. "If you say that John Doe died of a heart rhythm problem, who is going to say you are wrong and how are they going to prove it? Someone, like a politician or big-name executive, would really need to be interested or have their toes stepped on to question how people are doing death investigations."
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Untrained, unmonitored officials can blur the true extent of the opioid epidemic. "In some places a coroner could arrive on a crime scene, see a white powder, think it's cocaine, and sign it out as that without doing an autopsy," Peterson says. "But had they done an autopsy, it could have been fentanyl, and now what you write on the death certificate is wrong." According to the CDC, only 20 states and the DC have laws that are require autopsies to be performed by a pathologist.
It's also important to be able to understand the subtleties of death and toxicology results to determine how someone passed and rule out certain causes of death, something that years of on-the-job experience can't generally compensate for. "Certain drug concentrations change after death so knowledge of toxicology can help you interpret whether it's a suicide or an accident or the drugs played no role at all," says James Gill, chief medical examiner of Connecticut. Earlier this year his office lost their NAME accreditation after going over the maximum number of autopsies an individual medical examiner can complete. This, Gill reveals, was due to the uptick of opioid deaths in the state. According to the CDC, Connecticut is one of the states that's been rocked by synthetic opioids like fentanyl: From 2014 to 2015, death increased 125 percent.
In small towns, the stigma of drug use may also play a role in death investigations. "In some rural counties you have a coroner who is also the funeral director. So imagine if they come across a family that doesn't want 'overdose' or 'heroin' on the death certificate. They may be more willing to concede to their wishes so they don't lose business," Gill says. "Since medical examiners are generally not elected and don't have overlapping political roles, they have more independence."
But it's not always about covering things up. Both Gill and Peterson admit that autopsies are expensive and drug screens struggle to pick up many of the newer versions of fentanyl that are coming out, meaning extra testing is needed—and that costs more. In March 2015, the US Drug Enforcement Administration published a report that suggested the true number of fentanyl-related deaths is most likely higher because "many coroners' offices and state crime laboratories do not test for fentanyl or its analogs unless given a specific reason to do so." Peterson speculates that cost is part of the reason. "We usually spend around $2,000 per month on testing but last month we spent $11,000. Do you think the county is going to increase their budget for us?" Peterson asks. I assume the answer is no. But if testing and reporting isn't happening, how can the problem ever be solved?
Death investigations have another Achilles heel: death certificate reporting. A 2013 study found that 25 percent of death certificates in the US did not specify what types of drugs were involved, listing general causes like "opioid overdose" or "multiple drug intoxication." "It skews our statistics," says Jennifer Sabel, an epidemiologist at the Washington state department of health who analyzes death certificates. "We can still see general patterns relating to the problem of course, but in terms of specificity if someone writes 'opioid' and not 'fentanyl' we don't code them the same way and it can impact the end result." Other words can make a difference too. Writing something like 'toxicity' or 'intoxication' will be coded as an overdose whereas 'abuse' or 'addiction' are assigned a code related to mental health or behavior, Sabel adds.
In an attempt to get the finer details, Sabel's office launched a query program in 2010 that would essentially follow up with coroners and medical examiners if their death certificate data was too vague. For example, if a death certificate came in saying "opioid toxicity" they would query if it was heroin, prescription pain killers, or something else. But because this required extra staffing and thereby extra funding, it meant that the program could only operate intermittently. Currently it's not running.
Ultimately, misreported deaths—whether they're done unintentionally or to placate a family—and vague death certificates lead to distorted data that ends up in public health officials or lawmakers' hands. People in charge need an accurate picture to make decisions. If officials see there is a problem with fentanyl, they will take different action than if the problem was prescription pain killers. If they see a certain neighborhood is succumbing to heroin, they could make sure emergency responders have narcan—an emergency treatment they can give to suspected opioid overdoses—on hand. "We want to catch up to the problem," Hickton says. "We don't want to chase it."
So what's it going to take for death investigations to change? Money, for one. Counties and states need adequate funding to be able to carry out investigations that use trained officials who aren't forced to take short cuts or have to skimp on testing. When I ask Peterson if there's a more efficient and effective method to run labs, he eagerly mentions liquid chromatography-mass spectrometry. "You could do one screening with everything in one pass. Done in the morning, you would have results in the afternoon," he says. But the $500,000 price tag of setting up such a lab makes it a pipe dream with current budgets.
Getting more forensic pathologists on board would also require financial backing. There are currently around 500 medical examiners in the U.S. and to meet the current demand, Gill estimates the need would be around 1200. "We just don't have those numbers, and it would take years to meet that demand," he says, adding that loan forgiveness for medical students would be one way to up enrollment.
With national budget cuts looming, it seems unrealistic to think that death investigations can be completely overhauled, but getting coroners and medical examiners to at least report deaths on certificates more accurately and specifically could address part of the problem. "Many just don't understand to what extent the information they provide is being used, so it's about education. Since we started the query program and since other organizations like the National Center for Health Statistics have done outreach, we've seen [reporting] improve," Sabel says.
More so, experts want to convince the government that death investigations are worth investing in. "Right now a lot of the money goes to the living, to treatment and prevention, and that's understandable," Peterson says. "But what we're doing is also important. However, the dead aren't an interest group—politicians are going to respond to the louder group with more pressing interests. Who speaks for the dead?"
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