Anita Wadhwani, USA TODAY NETWORK – Tennessee
In 2015, state officials reported at least 1,451 men, women and children died from drug overdoses in Tennessee – but that’s far from an accurate count.
There are likely hundreds more. No one knows the true number.
Drug deaths reported in Tennessee are fundamentally flawed and represent an under-count of the toll taken by opioids, the nation’s most deadly drug epidemic, a USA TODAY NETWORK-Tennessee investigation found.
► In-depth coverage: Tennessee’s opioid crisis
USA TODAY NETWORK-Tennessee found multiple levels of breakdowns in death investigations, making it impossible to sketch the mortality rate from drug abuse or overdoses, including:
- Inconsistencies in how medical examiners, hospitals and law enforcement officials flag possible overdose deaths.
- County budget constraints that limit the number of autopsies performed.
- Incomplete or inaccurate information recorded on death certificates.
“There are so many levels at which the data breaks down that we don’t know what we don’t know,” said Dr. Adele Lewis, deputy state chief medical examiner.
“There is no doubt we are under-counting them (overdose deaths). There is no way that number is reality.’
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A long-standing problem
The opioid overdose crisis is highlighting a longstanding problem of unreliable death investigations that is particularly acute in rural areas that do not have trained forensic pathologists – the same areas where opioids have taken the largest toll.
Without an accurate count, lawmakers, public health officials and law enforcement have no way of knowing the extent of the problem and how to combat it.
There were more opioid prescriptions than people in Tennessee in 2015. More people died of opioid overdoses than vehicle accidents, homicide or suicides in 2012. Between 2010-2015, opioid abuse claimed the lives of 6,039 Tennesseans.
The investigation found that the state’s 95 county medical examiners, who lack training in forensic medicine and are paid very little or work for free, take different approaches to investigating and recording causes of death.
In rural Unicoi County, for example, the coroner heads to the scene of every suspicious drug death, searching for pill bottles and interviewing relatives. Unicoi’s coroner, Ed Herndon, believes state law requires him to order autopsies on every suspected overdose death. It doesn’t – although autopsies are strongly recommended.
In contrast, Campbell County’s longtime medical examiner, Dr. E.G. Cline, relies on a phone call from local police to describe a death scene. He rarely orders autopsies or toxicology tests that would determine all of the drugs in a person’s body to include on a death certificate, because, he says, “the only point of the death certificate is to declare the person dead.”
Death certificates are the single, critical source of information on causes of death.
Money also plays a factor in undercounting overdose deaths.
Autopsies are the most accurate way of determining whether someone died from an overdose.
But they are expensive, costing most counties between $1,600 and $2,000. Many of the county examiners who spoke to USA TODAY NETWORK-Tennessee echoed Dr. Tom Thompson, the medical examiner in Hamblen County: “If we autopsied every overdose, the county would go broke.”
Medical examiners are only one link in a chain of individuals who are responsible for identifying overdose deaths.
Before medical examiners get involved in a death, they must get a call from police or hospitals to flag a suspicious death that requires an investigation.
Those deaths can go unreported when a person succumbs to a heart attack, pneumonia or other illnesses that result from prescription drug abuse. Those deaths should be recorded as opioid-related – but often get categorized as “natural.”
When medical examiners do order autopsies, a body is sent to one of the state’s five forensic centers where trained forensic pathologists perform them.
The five centers send bodily fluids for testing to three different privately-owned toxicology labs, which each test for a different panel of drugs.
A growing national concern
Tennessee is not alone. A working group convened by the White House in 2016 released a report in December noting more than 50 federal programs rely on often-faulty cause-of-death data to create policy.
The group called for strengthening of the nation’s fragmented system for investigating deaths, noting the “need has become increasingly urgent given the sharp rise in deaths involving prescription medication and illicit drugs.”
“Many parts of the country are experiencing deaths in epidemic proportions as a result of the opioid and heroin crisis, while mortality data to inform government policy and programmatic response remains inadequate,” the report said.
► Donald Trump’s drug czar:President ‘committed’ to battling opioid epidemic
In Tennessee the problem is exacerbated by paper records instead of an electronic death registration system that would prompt medical examiners to enter more detailed information. Lewis said state officials hope to have one by next year. Tennessee is one of the few states that lacks one.
Medical examiners take inconsistent approaches
Dr. Scott Portis serves as medical examiner for Benton County and assistant medical examiner for neighboring Henry County. At 76, he hoped to retire to his cabin on Kentucky Lake years ago, but there is no one to take his place.
“I tried to quit but the mayor said ‘I don’t know who would take this on,'” said Portis, a former emergency room director and family practitioner.
By state law, all medical examiners must be physicians. Most are family practitioners – whose full time job is taking care of live people – not heading out to crime scenes or interpreting toxicology reports. Most are paid very little for the extra duties. In Lewis County, Sen. Joey Hensley volunteers as medical examiner in addition to his job as state lawmaker and local physician.
In two counties, long-serving coroners without medical degrees were allowed to retain their positions when state rules changed.
In the state’s largest cities, medical examiners are full-time forensic pathologists who perform autopsies and have a staff of professional death investigators who visit each suspicious death scene.
But in the majority of Tennessee’s 95 mostly-rural counties medical examiners are local doctors given little training beyond a handbook of rules and guidelines to follow.
Portis estimates that 30 to 40 percent of deaths in Benton County are drug overdoses. To determine cause of death, he sends bodily fluids to a lab in Nashville for toxicology tests. To help save the county money, Portis said he consciously reduced the number of autopsies. Before he was medical examiner, the county was paying for 30 or 40 autopsies a year. So far this year he has ordered just four.
“If we think they overdosed, there’s no sense in ordering an autopsy because it will cost us $2,000 and the toxicology report is $200-$400,” Portis said. “It would break the county if we got an autopsy on every drug overdose. We are very prudent in spending the county’s money.”
Autopsies are the most effective way of determining cause of death, according to Lewis. They are recommended for every suspected overdose death in Tennessee, but not required.
A Knox County report on drug deaths last year noted that while the number of autopsies increased by 25 percent over six years, the number of known drug-related cases had doubled.
Relying only on toxicology tests requires a level of training that most of the state’s medical examiners lack, Lewis said. Drugs metabolize at different rates. A person who has developed a tolerance for one prescription drug may test at what would be lethal rates for other individuals.
Small counties, rising autopsy costs
Deaths are expensive for local communities. Counties that routinely order autopsies for drug overdoses have seen sharp increases in costs. In Bradley County, for example, where there were 18 drug related deaths this year by the end of July, the autopsy budget of $68,000 was exhausted by mid-year. Laura Wittmaier, director of the medical examiner’s office, requested an additional $30,000.
A handful of counties in northeast Tennessee who rely on the East Tennessee State University forensic center for autopsies have switched to a different fee model for autopsies. Instead of paying a per-body fee, the counties pay an annual flat rate based on their population. In Washington County, that has meant the medical examiner does not hesitate in ordering an autopsy on a suspected overdose.
“The number of autopsies has ballooned,” said Washington County Mayor Dan Eldridge.
Inconsistent death records
The nation’s death data is compiled by the Centers for Disease Control, which relies on cause of death to track public health trends, such as the number of people dying from diabetes, heart disease or overdoses.
In overdose cases the CDC can track specific trends – such as a rise in opioid or heroin use. But only if medical examiners include the information on the death certificate.
Knox County Juvenile Court Judge Tim Irwin talks about the problems caused opioids in his courtrooms in Knoxville. Michael Patrick/News Sentinel
USA TODAY NETWORK-Tennessee found medical examiners across the state take a vastly different approach to filling out death certificates.
Bradley County Medical Examiner Jeffrey Miller has typically written “polypharmacy overdose” for deaths in which multiple drugs are involved, said Wittmaier, who noted that “lately he’s gotten better at listing specific drugs.”
Portis lists all identified drugs on the death certificate. Joe Fite, medical examiner for Giles County, does not. Instead writes “prescription drug toxicity” and notes all specific drugs on a separate form sent to the department of health that does not get included in death data.
Medical examiners also vary in noting the manner of death for suspected drug overdoses.
► After the OD: Knox County looks at hiring post-naloxone case manager
In Bradley County, the medical examiner typically categorizes overdose deaths as “accidents” unless there is clear evidence of suicide. In Benton County, they are suicides if lethal drug doses are present. In Hamblen County, Thompson takes the unusual step of classifying the majority of overdose deaths as “natural,” because, he said, “death is a natural progression of the disease of addiction.”
Lewis strongly disagrees with that. “Any death from external causes is not natural,” she said.
U.S. Attorney for the Eastern District of Tennessee Nancy Stallard Harr announces the district’s participation in the Department of Justice’s Opioid Fraud and Abuse Detection Unit. Saul Young/News Sentinel
Medical examiners also face the challenge of synthetic drugs that are so new there is no test for them.
“Last year for the first time in my career I put down as cause of death an ‘unknown toxic substance secondary to addiction,'” said Thompson, the medical examiner in Hamblen County. “We knew he overdosed. Despite our best efforts, we couldn’t come up with what he overdosed on. We don’t know what it is. We are getting synthetic drugs from China.”
A study released this year by the University of Virginia found a specific drug was not listed in 19.5 percent of all overdose deaths. The lack of specificity on death certificates could mean overdose deaths are undercounted by as much as 24 percent nationwide, the report concluded.
Hospitals don’t report
In August, 2015, the Knox County Regional Forensic Center issued an 81-page analysis of deaths in the region over a five-year period.
The report noted that it could not account for all deaths, highlighting the lack of reporting by hospitals as one factor. When individuals die in hospitals and then required cremation, local medical examiners are required to certify cause of death.
In some cases, those requests prompted suspicion on the part of medical examiners who then sent bodies for autopsy. The Knox County facility found some were actually drug-related deaths.
The report urged state officials to implement a training program for hospitals and physicians to assure their understanding of reporting requirements and to create a system to “hold these groups accountable” for accurately reporting deaths.
A study by the CDC of Minnesota deaths released in April found that a significant number of opioid related deaths were wrongly recorded as pneumonia or other infectious diseases.
New approaches to collecting data
Lewis and her colleagues are working to address the problem by providing training to medical examiners and by painstakingly reviewing not only death certificates, but supporting records with the goal of providing a more accurate count next year.
They have resorted to paying counties $25 per death to provide detailed forensic reports that help give state health officials a clearer picture of overdose deaths by 2018.
About 45 counties have begun complying, according to Lewis. State law has long required medical examiners to submit those reports, but many don’t, Lewis said.
Lewis said addressing the problem also requires money.
Small counties can’t absorb the cost of numerous autopsies, but the state could appropriate funding to ease that burden.
Michael Eric Dyson, Georgetown University professor, minister and author, offers a view of the role of race in responses to the opioid epidemic following an appearance at the University of Memphis on Feb. 21, 2017. Wochit
Knowing how a life was lost is important not only for public policy, but for loved ones trying to make sense of a tragedy.
“Families need closure,” said Lewis, who has worked with death as a forensic pathologist for 16 years.
Medical professionals want to change how patients think about pain Holly Fletcher, Kyleah Starling
“We don’t know what we don’t know” adequately sums this up–and WE NEED TO KNOW! I had the misfortune of 2 patient deaths due to overdose, patients that I was treating for pain, who did NOT meet the criteria for addiction. I had done everything properly; switching them to long-acting/less-addiction formulations, monitoring the prescribers databases for “doctor shopping”, carefully tracking their responses to treatment in 20 domains of their activities of daily living (ADL) at each visit, had significantly reduced their daily opiate doses.
And they died.
Despite my lowering the amount of prescribed opiates.
The punchline? The medical examiner at the scene documented that there were numerous medicine bottles of controlled substances in the room where my patients died. None of these bottles had my patients names on them. There was also paperwork from their probation officer. Apparently they had a long “rap sheet” including drug trafficking, burglary and other crimes. Obviously, they were meeting their daily opiate needs (desires?) despite my cutting them back. They were simply stealing other folks drugs and dealing drugs to make money.
We need accurate collection of data such as what my patients had. We need that data analyzed and reported as well. If the criminal justice system can do a better job of keeping these folks off of the “street” and clean with ankle monitors and frequent random urine screens we may be able to lower these abysmal rates of death. We also need the carrot, the reward, the buprenorphine therapy to help keep them from craving, using, etc. Carrot first, stick (punishment) if the carrot is not accepted.