Medical examiner response to the drug overdose epidemic in King County Washington: “Real‐time” surveillance, data science, and applied forensic epidemiology

Abstract

As the overdose epidemic overwhelmed medicolegal death investigation offices and toxicology laboratories, the King County Medical Examiner's Office responded with “real‐time” fatal overdose surveillance to expedite death certification and information dissemination through assembling a team including a dedicated medicolegal death investigator, an information coordinator, and student interns. In‐house testing of blood, urine, and drug evidence from scenes was performed using equipment and supplies purchased for surveillance. Collaboration with state laboratories allowed validation. Applied forensic epidemiology accelerated data dissemination. From 2010 to 2022, the epidemic claimed 5815 lives in King County; the last 4 years accounted for 47% of those deaths. After initiating the surveillance project, in‐house testing was performed on blood from 2836 decedents, urine from 2807, and 4238 drug evidence items from 1775 death scenes. Time to complete death certificates decreased from weeks to months to hours to days. Overdose‐specific information was distributed weekly to a network of law enforcement and public health agencies. As the surveillance project tracked the epidemic, fentanyl and methamphetamine became dominant and were associated with other indicators of social deterioration. In 2022, fentanyl was involved in 68% of 1021 overdose deaths. Homeless deaths increased sixfold; in 2022, 67% of 311 homeless deaths were due to overdose; fentanyl was involved in 49% and methamphetamine in 44%. Homicides increased 250%; in 2021, methamphetamine was positive in 35% of 149 homicides. The results are relevant to the value of rapid surveillance, its impact on standard operations, selection of cases requiring autopsy, and collaboration with other agencies in overdose prevention.

Evaluation of in‐house drug evidence testing by King County Medical Examiner's Office in “real‐time” fatal overdose surveillance

“…Compared to other substances, heroin was more likely associated with evidence described as tar or found in syringes. These observations aligned with those of a previous study showing a declining rate of injecting heroin coincident with a dramatic rise in smoking fentanyl [31]. The high concurrence of acetaminophen with fentanyl provided evidence that acetaminophen is important in the illicit formulation and marketing of fentanyl, especially in pills stamped “M30.” Furthermore, their high concurrence makes acetaminophen a potential marker for fentanyl, which itself may be undetectable in samples by other methods.…”

“…The data presented in this study originated as a component of the KCMEO's "real-time" drug overdose surveillance project described in previous publications [29][30][31][32]. The goals of the surveillance project, as the name suggests, were to expedite death certification and provide timely data for law enforcement and public health agencies, in advance of the extended time required for formal laboratory testing.…”

“…In 2018, the King County Medical Examiner's Office (KCMEO), a division of Public Health -Seattle and King County, in Seattle, Washington, initiated a "real-time" surveillance project using toxicology screening methods for inhouse testing of decedents' blood and urine samples. As part of this project, in-house methods including portable hand-held devices were used for testing of drug evidence collected from suspected overdose death scenes [29][30][31][32]. The project relied on close collaboration with the Washington State Patrol Forensic Laboratory Services Bureau.…”