Behind the Scenes of the Overdose Crisis
June 20, 2023
The opioid overdose crisis remains a serious threat to public health across the United States. From the beginning, medical examiners and coroners have been on the front lines of this crisis, and data from their investigations have been critical to informing the opioid overdose discussion. As many of the nation’s largest pharmaceutical companies were sued for their role in fueling the opioid crisis, prosecuting state and local attorneys general offices brought forth experts in the field of substance use disorder and public health as witnesses to the impacts these companies had on the opioid crisis, including state and local medical examiners and coroners (MEC), who provided critical data and expert testimony during the trials.
To better understand the role of MECs in the litigation and the ongoing overdose crisis, we partnered with Michele Trofatter, technical advisor at the CDC Foundation, to share the perspectives of medical examiners and coroners from across the country including those of Dr. Kurt Nolte, Dr. Tom Gilson and Dr. James Gill, who all served as expert witnesses during the national litigation.
Data collected by medical examiners and coroners plays an important role in monitoring what prescription and illicit drugs are involved in deaths across the country. Much of our understanding of the devastating toll of the overdose crisis comes from data on drug intoxication deaths collected by medical examiners and coroners during the course of their medicolegal investigations.
The mortality information documented on death certificates continues to play an important role monitoring the overdose crisis, including what drugs are present at the time of death. Through careful investigation of the death, as well as toxicological exams, MECs track and monitor who is dying and from what drug or drugs. In the earliest days of the crisis, they raised the alarm when intoxication deaths from pharmaceuticals increased. Today, medical examiners and coroners continue to play a critical role in monitoring these death trends in an increasingly volatile drug market.
The impact of their data is far reaching. Within a county or state, the medical examiner or coroner may work with local public health professionals, law enforcement and others to help prevent future deaths by providing real time information on deaths. This can play a key role in prevention and other coordinated harm reduction strategies. On a wider level, medical examiners and coroners work with and alert many national groups (including the Centers for Disease and Control and Prevention, Drug Enforcement Administration, Food and Drug Administration, High Intensity Drug Trafficking Areas program, Office of National Drug Control Policy and others) when new drugs are detected in their investigations.
As lawsuits arose against some of the nation’s top pharmaceutical companies and drug stores, many states used mortality data as evidence and/or called medical examiners and coroners as witnesses in these cases. For example in New Mexico Dr. Kurt Nolte, the state’s chief medical examiner, was deposed by the amalgamated defendants and then testified as a “fact” witness in the civil trial, providing information on deaths that were investigated and certified. In Ohio, as part of the bellwether trials, 16 of the county’s 40 deposition discovery hours were covered by Dr. Tom Gilson, chief of the Cuyahoga County Medical Examiner’s Office, who testified as an individual subject matter expert and as the county representative. An additional eight deposition hours were covered by the Medical Examiner’s Office chief of operations. And in Connecticut, Dr. James Gill, the state’s chief medical examiner, provided critical information on drug overdose deaths for the state. Testimony from these and other medical experts resulted in judgments totaling billions of dollars against several large pharmaceutical companies and drug stores, presenting a unique opportunity for the U.S. to fund treatment solutions for substance use disorder and the overdose epidemic.
Unfortunately, like many others on the frontlines of the opioid crisis, medical examiners and coroners have seen demands on their time increase dramatically. With the rising number of intoxication deaths, their ability to investigate other deaths has been impacted. The increased workload impacts budgets and staffing, as every suspected drug intoxication requires an investigation by the medical examiner or coroner. In the U.S., there were over 100,000 drug intoxication deaths in 2022. These intoxication cases alone would require investigations by 400 of the estimated 600 full-time practicing forensic pathologists in the U.S. Additional costs include body transportation, toxicology testing, supplies, transcription, histology, imaging and more. Despite the increase in demand for these services, many offices have staff shortages that have led to overtime and the need for per diem staff to carry out the needed investigations.
Informed by The Principles for the Use of Funds from the Opioid Litigation, which provides information for state and local decision makers as they plan for the distribution of the litigation settlement funds, jurisdictions across the country may consider how to ease this burden on state and local medical examiners and coroners by:
- Hiring additional staff members at medicolegal death investigation (MDI) offices–including forensic pathologists, autopsy technicians, medicolegal death investigators and administrative staff–to address workforce shortages and ensure that MDI offices have adequate staffing levels to conduct thorough and accurate death investigations;
- Hiring epidemiologists to work in MDI offices to help with the increasing demands for information to help monitor and prevent deaths;
- Investing in information technology infrastructure for MDI offices–including access to electronic health records, digital case management systems and data analytics tools–to improve death investigations’ accuracy and timeliness and facilitate data sharing and analysis across agencies;
- Purchasing new equipment and supplies for MDI offices and toxicology labs–such as CT scanners, microscope cameras and other specialized tools–to improve the accuracy and efficiency of death investigations and ensure that MDI offices have the resources to conduct thorough investigations, and;
- Supporting wellness initiatives for MDI offices and those who struggle with the emotional toll of this work.
Currently, MDI offices depend on funding from the county or state. Coordination of existing funding should be considered before any additional funding decisions are made.
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Michele Trofatter, MPH, MLS(ASCP) is a technical advisor for the CDC Foundation. She began her career in the clinical laboratory and clinical research. She has over 30 years of Public Health experience and has spent the past 10 years devoted to alleviating the overdose epidemic and being an ally for harm reduction and people with substance use disorder and lived experience.