The effects of the (fentanyl‐fueled) drug overdose epidemic on medicolegal death investigation in the United States

Abstract

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.

Kratom safety and toxicology in the public health context: research needs to better inform regulation

“…The authors highlight the co-positivity of MG with other drugs and also suggest that MG blood concentrations greater than 1,000 ng/mL may be more likely to be associated with severe adverse events (AEs) including death, however, to date there are insufficient data to define a fatal MG blood concentration. Papsun et al also supported the need for comprehensive toxicology testing prior to assigning cause of death (Gudin et al, 2013;Ossiander, 2014;Davis et al, 2020;Davis and Fligner, 2023).…”

“…As discussed below, kratom-associated deaths almost always include the presence of toxic concentrations of other substances. Many reports do not include comprehensive toxicological testing to determine if a kratom-associated death was likely appropriately attributed to kratom (see the following for recommended types of evidence to support determinations of causality in substance related deaths: Gudin et al, 2013 ; Ossiander, 2014 ; Davis et al, 2020 ; Davis and Fligner, 2023 ). Kratom may be found onsite at an opioid fatality due to its use in managing OUD and withdrawal.…”

Introduction to the JFS Special Section on Fentanyl and its Analogs in Forensic Science

“…The final articles are on forensic pathology and forensic toxicology [13][14][15][16][17][18][19]. There is a Case Report [20] that serves as a path forward in the detection of "fentanyls," other novel synthetic opioids (NSO), and novel psychoactive substances (NPS).…”

“…Medical Examiners are overwhelmed by the epidemic and the number of deaths resulting from it. Harruff et al [14] and Davis et al [13] describe the impact in more detail. This impacts the issuing of death certificates, which can now take several weeks as the offices await toxicology results.…”