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In my last piece, we discussed the artificial inflation of CDC data in regard to overdose deaths, deaths which are the basis of CDC’s and the federal government’s argument for why a guideline for prescribing opioids was required, however; there are other points of confusion when it comes to data compilation that I didn’t touch on in that piece for brevity. We are going to go into some of that now and the focus of this article will be more about local data collection and the process of death investigation.
Before, we discussed more of an overview or “macrocosm” in regard to overdose death data at the federal level and how it’s compiled, but now we are going to discuss an overview of the “microcosm”, all of the smaller moving pieces, agencies and individuals involved in recording these deaths at the local level and how differences in jurisdictions can affect data compilation and statistics at both the state and federal levels.
Overview: How Information is Collected at the Local Level
There is a specific term for death investigation called medicolegal death investigation or MDI. MDI is employed to ascertain and certify the manner and cause of death, specifically in cases where death is sudden, unexplained, or appears to be unnatural. While death certificates are based on the US Standard Certificate of Death , death certificates vary by jurisdiction as far as how they are completed (including other important steps in the death investigation process), so the data that is captured also varies by jurisdiction making it nearly impossible to track the same variables over time at the state or national levels.
Recommendations have been made by multiple stakeholders in regard to how we might improve the process of death investigation for overdoses in particular, I will list only a few here while also focusing on the systemic issues that exist within the local processes currently. “Recommendations for certifying opioid-related deaths are set out in three important papers, as described below. The first of these, a position paper from the National Association of Medical Examiners (NAME), presented evidence-based recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. The recommendations called for a complete death scene investigation, with a comprehensive toxicology panel and interpretation of toxicology results in the context of circumstances of death, listing all responsible substances by generic names on death certificates, and classification of deaths due to misuse or abuse of opioids without any apparent intent of self-harm as “accidents”. 
Essentially what this paper is saying here and what it goes on to say later is there is no national standard for the investigation, diagnosis, and certification of deaths related to opioid drugs, documenting cause of death on death certificates, distinguishing between “drug-caused” and “drug-detected” deaths, toxicology screening or a standardized approach for increased death surveillance, specifically relating to overdose surveillance. The authors of these papers are not alone in their interpretation of the way local death investigations are carried out. We will discuss this in detail as I dig deeper into how this process is carried out.
It’s also of import to note that the coding system that is used (ICD-10) does not always make it easy to identify specific drugs as they are often included in broad groups or categories which can make it difficult to elucidate the specific drug(s) or even the class of drug most likely to have been the catalyst to death. “Of special interest is T50.9 (other and unspecified drugs). When a drug overdose death record includes T50.9 as the only contributing drug code in the range T36–T50, it typically means that no drug name or drug class was listed on the death certificate.” 
This is consistent with research that I have done which makes it clear that some decedents may have “overdose” listed as the cause of death without anything other than that on the death certificate, despite toxicology not being performed in many cases among other important nuances that I will detail later. No one agency has quality control over the entire death investigation process which is probably a good thing, however these agencies should work more closely to ensure accuracy.
Myriad Agencies & Individuals Responsible for Death Investigation
Drug overdose surveillance data is generated by multiple actors, most of which are completely separate entities with their own policies and procedures and this may not be an exhaustive list of those processes or actors, but it will give you an overview of the local processes that take place when an “overdose death” occurs.
“Notably, the data used in drug overdose mortality surveillance is generated by multiple agencies and actors, with no single agency having quality control oversight of the entire process (Fig. 1).”
“Fig. 1 Medicolegal death investigation, certification, registration, surveillance, and epidemiology of drug overdose deaths. Abbreviations: Medicolegal Death Investigation (MDI), Medical Examiners and Coroners (ME/Cs), Enhanced State Opioid Overdose Surveillance (ESOOS), State Unintentional Drug Overdose Reporting System (SUDORS), Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC)”
“Drug overdose mortality surveillance relies on the ability of the medicolegal death investigation (MDI) system to generate death certificates with complete and specific information on drugs that are responsible for or contributed to overdose deaths. However, lack of routinely performed comprehensive toxicology testing, analytical challenges to detection and quantification of novel synthetic opioids, and errors in death certificate completion can introduce bias in quantifying the involvement of specific drugs in drug overdose mortality.” 
The above paper is making it clear that there are serious issues to be considered when looking at the overdose statistics, both in how the raw data is collected and how data are then compiled and this is just at the local level. The local collection of information at a death scene or at the morgue is not as glitzy as cable TV has led multiple generations to believe, in fact, some offices that process decedents do not even have computers or x-ray machines, contrary to what you may have seen on CSI or the like with the instant 3D images of the human body and internal damage.
Distorted Conceptions of the Death Investigation Process & Varying Technological Capabilities by Region
“Death investigations in the U.S. are often carried out in settings that bear little resemblance to the glitzy, high-tech morgues shown on television. When a death occurs under suspicious circumstances, the investigation into its cause is overseen by a coroner, often an elected official with no medical background, or a medical examiner, usually a doctor who specializes in forensic pathology.” 
As CBS News reports: “long delays in receiving death certificates and autopsy reports…can not only compound grief, but also can create financial hardships by holding up life insurance payouts and other benefits. The delays are driven largely by underfunding, a severe shortage of medical examiners and relatively low pay when compared with other medical specialties.” 
Except, it’s not only families that are adversely impacted by the lack of resources, there are also widely varying technological capabilities and other problems which can adversely impact public health response to certain threats, as well as adverse impacts to those who are the target of public health interventions. At a recent Association of State and Territorial Health Officials (ASTHO) stakeholder meeting, “a few participants noted the importance of considering states’ varying capacities with technology in general… For example, one state represented at the meeting doesn’t have computers in all coroners’ offices”  and some jurisdictions do not have in-house toxicology labs or even x-ray machines making it difficult to complete death certificates in an efficient, accurate and timely manner.
While “some death investigation units do a commendable job” … “New Mexico has a new facility equipped with a full-body CT scanner to help detect hidden injuries. Virginia has an efficient, thorough system, staffed by more than a dozen highly trained doctors. The autopsy suite in its Richmond headquarters is as sophisticated and sanitary as a top hospital.”  Still, a “National Academy of Sciences’ study found far-reaching and acute problems. Across the country, the academy said, coroners and medical examiner offices are struggling with inadequate resources, poor scientific training and substandard facilities and technology. Their limitations can have devastating consequences.”  To find out what some of those consequences are aside from my interpretations, I encourage you to read this PBS report in full, it’s an exceptional exposé.
Errors in Death Data & Reporting
It’s important to recognize that “counts and rates of overdose deaths involving specific drugs are only as accurate as the drugs listed on death certificates. If drugs are not listed because of a certifier’s systematic approach or jurisdictional office policy, rate quantifications could be severely biased. Warner et al. showed that states with centralized medical examiner systems had on average higher percentage completeness on listed drugs (92%), compared with states with decentralized systems (medical examiner (71%), hybrid ME/C (73%), or coroner (62%)).” Another thing to keep in mind that I touched on is that “multiple studies have reported that common ME/C errors in death certification can affect the accuracy of death certificate data for public health action. Hanzlick provides an excellent review on the important role of ME/Cs in generating MDI data for epidemiological research and the public health impact of MDIs in the USA.“ 
Conversely, there are ways in which abrupt changes in drug specificity could inadvertently skew the statistics: “A cautionary example illustrating the effects of an abrupt change in degree of drug specification comes from South Carolina (SC). The reported age-adjusted prescription opioid-related poisoning (T40.2–T40.4) mortality rate in SC was 4.7/100,000 in 2013, rising to 9.3/100,000 in 2014. The twofold increase could be interpreted mistakenly as a sudden worsening in opioid overdose deaths in SC. However, in reality, it primarily reflected an impressive increase in the percentage of drug poisoning death certificates that listed specific contributing drugs (57.7% in 2013; 94.4% in 2014), attributable to the January 2014 implementation of a SC Office of Vital Statistics process to collect specific drug names for all deaths.“ 
What the above referenced paper didn’t mention was that most in the United States live and or die in an area where only a coroner is available and with a 62% accurate disposition rate in regard to drug specificity on death certificates, it’s easy to see how biased the data truly is when you consider all of the nuances of how data collection varies regionally, as well as education level and other variables that contribute to regional differences and go on to influence state and national statistics. To see an application with statistics of what areas have coroners rather than medical examiners, take a look at this ProPublica Forensics API. The entry regarding drug specificity is particularly alarming considering that many stakeholders have recommended changes in how this data is collected by states. It doesn’t appear that government actors are sophisticated enough to recognize the ways in which their process changes are affecting patients via the federal response which is based on deliberately skewed data at the federal level. We won’t discuss some of the other variables that are contributing to distorting the data until I release Part 3 of this series but there is more to consider that I don’t believe most Americans have thought about because of how this process is portrayed in popular culture. The way the overdose crisis is framed to the public via mass media is simply hysterical while glamorizing a process that has myriad serious system failures.
Already in our overview of how overdose data is collected at the local level, some very troublesome information is coming to light, information that federal agencies are well aware of, and yet they do not make an attempt to explain that the data may be “severely biased” because of systemic failures which are occurring at the local level and federal levels. This in turn creates a zeitgeist around opioids in the public consciousness and wider culture that is simply not accurate, but that doesn’t stop federal agencies from selecting interventions into people’s lives that the data does not even support. What do I mean by that? We will discuss that much more in Part 3 but the premise since the beginning of the overdose crisis has been that patients and their physicians are a main driver of the crisis and its resulting deaths, however; when we dig even deeper into this issue, it will become even more apparent that there is simply not enough evidence to justify the response we have and are witnessing.
Based on just the overview, it’s clear that not only is the CDC lacking a common sense approach to the overdose data and or their interventions, but local jurisdictions also have badly ingrained system failures which don’t appear to have a quick or financially sustainable fix. The local data are what the CDC statistics are based on and we see nothing but problems everywhere we look as it relates to death investigation. In the next piece, we will discuss who actually gets an autopsy or toxicology screening and you may be very surprised to learn what the statistics are on collecting information for those two practices. Typically, we assume that toxicology screening and autopsies are standard in any case where a death does not immediately appear to be due to natural causes, but this simply is not the case and the statistics will frighten you.
There are serious systemic issues when it comes to government sourced data, whether it’s compiled at the local or national level and that is simply unacceptable when that data is being used as an excuse to force taper patients off of medications that were keeping them stable and, in many cases, alive, while that same data is responsible for other interventions into patient lives which I will detail in a different series in the future. It’s time to begin asking some very uncomfortable questions, and it’s time that the American public began challenging some of the ideas that are ingrained in us by those with power. It’s not clear how many of each state’s officials actually know about these problems, they may just not know how the data is compiled and just take the word of federal agencies that drastic measures must be taken in each state to “combat the opioid crisis” and “protect our children”. With that, it’s of import to note that children and other extremely vulnerable groups are far more vulnerable now than they’ve been in many years as it relates to the medical machine, this experiment in public health intervention, and how they are and will be treated in the future due to the hysteria and subterfuge that dominate this topic, and nobody with addiction nor recreational drug users have been “saved” because of it.
Special thanks to the administrator of truth0rdare.com, the patient community, as well as others who wish to remain anonymous; (you know who you are!) thank you all for your contributions, support and guidance.
 CDC, U.S. STANDARD CERTIFICATE OF DEATH — REV. 11/2003 https://www.cdc.gov/nchs/data/dvs/death ... al-acc.pdf
 Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose: Svetla Slavova, Chris DelcherJeannine M. Buchanich, Terry L. Bunn, Bruce A. Goldberger, Julia F. Costich https://link.springer.com/article/10.10 ... 19-00201-9
 Autopsies in the U.S.A. Krista Kjellman Schmidt, Al Shaw and Jennifer LaFleur, ProPublica, Jan. 31, 2011 https://projects.propublica.org/forensics/
 Families suffer due to medical examiner shortage: AP https://www.cbsnews.com/news/families-s ... -shortage/
 Association of State and Territorial Health Officials 2018 http://www.astho.org/Rx/Improving-Drug- ... ng-Report/
 The Real CSI: How America’s Patchwork System of Death Investigations Puts The Living At Risk https://www.pbs.org/wgbh/pages/frontlin ... /real-csi/
Dez Nelson is the Founder and Administrator for the National Advocacy Access Clinic (NAAC), a national advocacy project that aims to help restore, protect and defend medical choice and patient centered care via education, training and advocacy, and to accurately record the crisis in delivery of care which is unfolding in the United States. You can follow Dez Nelson on Twitter here or you can visit NAAC here.
© National Advocacy Access Clinic (2016- 2020) All rights reserved. Content does not constitute a medical consultation or legal advice. Please see a certified medical professional for medical advice or consult an attorney for legal advice.
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