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In Opioid Crisis, Why It’s Important to Know Which Drugs Caused a Death

When it comes to understanding heroin and opioid deaths, data matters. But across the country, medical examiners and coroners vary widely in just how much information they provide on death certificates.

In this first in a series of three stories on Connecticut’s drug epidemic, WNPR spoke with the state’s chief medical examiner. 

Connecticut's chief medical examiner said he's running out of room for bodies. Accidental drug overdoses are a big reason why.

The Practical Side of Accidental Overdoses

James Gill walked through the garage in Farmington where the bodies come in, past the tissue donations area, and stopped outside the autopsy room.

“We kind of have a typical board listing all of the decedents for the day,” Gill said, pointing to the list of names on a dry erase board. “Overdose, overdose, overdose, overdose, overdose. That’s just for today.”

Gill is Connecticut’s chief medical examiner. Of the nine people in his custody on that day, four likely died from an accidental drug overdose. The fifth was a probable suicide. Gill said it’s an unfortunately normal situation with a serious practical concern: he’s running out of room for the bodies.

"We've had to buy some extra racks and things so we can store more," he said. "But we really probably need more cooler space. We're kind of outgrowing the storage space here."

In the last two years, Gill’s office has seen a more than 50 percent increase in autopsies, largely due to the spike in accidental drug overdoses. Heroin is the big player. Fentanyl deaths have surged, too.

I sat with Gill in what’s called the “family room” just off the office’s lobby. He was next to a closed-circuit monitor covered in a soft white shroud. It’s the screen on which family members can see a live feed of their loved one’s remains. He told me why data on exactly which drugs killed exactly which people is important.

Credit Jeff Cohen / WNPR
Dr. James Gill, Connecticut's chief medical examiner, sits next to a shrouded monitor used to show family members their loved one's remains.

“Can you tell me, did she suffer? Was she in pain?” he said, recalling a conversation he had with a mother whose daughter died of an accidental drug overdose. A year later, she called Gill to learn more.

“And I explained to her that, with an opioid death, the person just gradually goes to sleep and it’s very painless. And she started crying, you know,” Gill said, fighting tears of his own. “And it gave her some comfort.”

Getting Good Data

There’s another reason good data matters: crafting a public health response to the epidemic. But not all death certificates have all the information they could. When Gill took the job just a few years ago, only 63 percent of the state’s drug deaths had specific drugs listed on the death certificate. Now 99 percent do.

“I found that the doctors here, a lot of them were certifying the deaths as acute or multi-drug intoxication,” Gill said. “And I said, ‘No, we need to spell out what the drugs are that are causing the death.’ So, it would be acute intoxication due to the combined effects of heroin, diazepam, and alcohol, and that’s how we certify the deaths now. We’re very specific about what we’re finding in the toxicology.”

In fact, at 99.6 percent, only Rhode Island fared better than Connecticut in 2014. But not every state reaches this standard. Only about half of deaths in places like Pennsylvania, Indiana, Mississippi, and Louisiana have specific information on the death certificates.

There are a lot of contributing factors that could explain the variation, Gill said.

First, not all people who certify deaths have the same training.

Second, when lots of drugs are involved, some people may not be comfortable picking the drug they think caused that death. Custom could play a role, too -- it’s the “We’ve always done it this way” factor. So might size. Connecticut is small and centralized.

“All of the deaths are examined here by the same group of medical examiners, the same investigators,” Gill said. “So we can kind of establish that common technique and certification ability. Whereas, a lot of jurisdictions, New York, for example, it varies by county.”

Margaret Warner is a health scientist at the National Center for Health Statistics at the Centers for Disease Control and Prevention. She focuses on monitoring trends in mortality, using death certificate data. She agreed that there are lots of variables in play. But one of them is pretty basic: clear communication with the people who determine and report the cause of death.

“The thing that’s different between 2012 and the current year is Dr. Gill, who knows that we want those specific drugs written down on the death certificate, is now writing them down,” Warner said. “So some of it‘s about reaching out to the certifiers to make sure that they know we want the specific drugs involved, which CDC is actively working on.”

Not Every Family Wants to Know

But Dr. Gill said that while the federal and state governments might want as much information as possible, not everyone does.

“I remember one call from a family member who was upset that we put heroin on the death certificate,” he said. “Their son had died of heroin and they didn’t want it on the death certificate because they were afraid that the public was going to hear about it know that that person died of heroin. And I said, ‘I’m sorry. But this is a public health issue.’”

And, judging from the data, it may be one for a long time to come.

This is the first in WNPR’s series of three stories on Connecticut’s drug epidemic. Read the second story here, about the use of Suboxone to treat opioid addiction. Read the third story as well, about the high cost of rehab.

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