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Opioid Overdose Death: Death Reporting
The manner of death, based on the investigation of the circumstances by a coroner or state medical examiner, is determined to be:
- homicide, or
Circumstances included in the cause of death investigation are:
- scene findings,
- autopsy results,
- toxicology reports, and
- health history.
In an opioid overdose death, scene findings may include:
- frothy ‘foam cone’ from the mouth,
- intact pills in the stomach,
- needles present at the scene,
- prescription history,
- pill counts,
- needle track marks, or
- prescription pills at the scene.
An indicator that a particularly potent product was involved in the death, like fentanyl or carfentanyl, includes when a needle is still in the person’s arm or body, indicating an almost instantaneous death upon injection.
Opioid overdose death resulting from a prescription opioid is usually classified as an accidental or undetermined death. Often there is an assumption that when the death involves prescription medications prescribed to the person who died, that this person was using the prescription medications appropriately, as prescribed, and without risk for overdose. With prescription pain pills, it is difficult to determine if the pills were used as prescribed by the decedent, obtained from family or friends for a pain-related reason, or bought with an intent to get high. If a person dies of a natural cause, for example a heart attack or infectious disease, that death would be categorized as natural, even if prescription opioids are found at the scene or prescribed in the patient’s history. This may contribute to an under-reporting of opioid-related deaths.
One of the most challenging ethical considerations for medical examiners and coroners is their role in determining intent, or attempting to figure out what a person was trying or not trying to do before they died. There is a substantial amount of variability among medical examiners’ and coroners’ approach to a death investigation. For example, while one medical examiner might determine an overdose death to be an accidental poisoning, another medical examiner would say that it is undetermined because there was no witness, and no way to rule out that it was suicide or homicide. Opioid overdose deaths are most commonly found to be an accidental/unintentional death. Accidental death is operationally defined to be totally unforeseen and unexpected. Some medical examiners or coroners, however, may say that that if heroin was injected in a body, that a resulting death cannot be understood as totally unforeseen and unexpected, therefore, this heroin death may be determined to be a suicide or undetermined. In order for a death to be classified as a suicide, there must be evidence of the intent to die, such as a suicide note found at the scene.
To determine burden of proof, the general guidelines in coroner and state medical examiner’s training state there needs to be:
- 50% reasonable probability for natural deaths,
- 70% preponderance of evidence for accidental deaths,
- 90% clear and convincing evidence for suicide deaths,
- more than 90% beyond a reasonable doubt for homicide deaths, and
- 100% beyond a doubt for any cause of death.
Some medical examiners would require “beyond a reasonable doubt” or more than 90% certainty in order to determine the burden of proof for a suicide. The amount, detail, and reliability of evidence is limited, sometimes difficult to obtain, and often incomplete.
Toxicology results are very useful in determining the drug type(s) and dosage; however, they do not measure anything about the user’s tolerance. It is common for findings to be ambiguous in opioid overdose death investigations. For example, the person may have had a history of depression, a history of chronic pain, a past non-fatal overdose with unclear intent, ambiguous residual pill counts, and/or the toxicology results are very high for opioids, but ambiguous for intent.
All of these factors make interpreting toxicology results and death investigations complex, and subsequently difficult to determine the cause of death with a high degree of certainty.
Melissa Pasquale, MD is a Forensic Pathologist and works for the Office of Chief Medical Examiner in Atlanta, Georgia and presented at the annual Center for Disease Control (CDC) Prevention for States Conference.
Please visit the Opioid Dashboard for more information on opioid overdose death, nonfatal overdose, use, misuse, substance use disorder, prescribing practices, supply, diversion, harm reduction, co-occurring conditions, and social determinants of health.