How Designer Drugs and the Opioid Epidemic Affect Modern Forensic Practice

This article was originally published in Forensic Magazine. To read the original article click here (http://digital.forensicmag.com/forensics/september_2016/MobilePagedReplica.action?pg=18#pg18)

The decedent was a bright young woman with a promising acting career. She and a friend had spent hours in her apartment memorizing lines for a new play, and wanted to relax. The actress went into the fridge for a pot brownie she had bought at a music festival the day before. A nibble didn’t yield enough of an effect. She took a bigger bite. Then she ate the whole thing. 

Half an hour later, the woman began to act strangely. Instead of reciting the dialogue she was trying to memorize, she started to describe—and react to—vivid visual and auditory hallucinations. She wanted to go out the window. She needed to, she said. The friend had to restrain her. 

But this actress was stronger than her friend. She got to the window. She opened it. She made it out. She died of multiple blunt injuries sustained from a three-storey fall to the pavement below. In the course of their investigation, the police located the woman who had baked the brownies. She told them, first of all, that the brownies were vegan, and also that they had been laced with both marijuana and "Spice"—a designer drug that affects the same cellular receptors as THC. She had purchased the Spice online. Based on the police report and the witness statement about the decedent’s behavior immediately before her death, I requested that the blood specimen be tested for synthetic cannabinoids. The toxicology report came back positive for both THC and a synthetic analog.

Illicit drugs are consumer products, subject to market forces. As law enforcement agencies have found more effective ways to crack down on supplies of the most common recreational drugs, enterprising producers have responded by trafficking new ones, synthetic analogs that alter the chemical structure of known psychotropics. These analogs may cause a much more pronounced high—and they have deleterious properties that can include fatal side effects. Synthetic cannabinoids like the Spice baked into that pot brownie have been linked to psychosis. Ecstasy and Molly, stimulants derived from methamphetamine, cause hypothermia and cardiac arrhythmia. Street drugs marketed as analgesics like alprazolam, oxycodone, and hydrocodone are being adulterated with fentanyl or fentanyl analogs, synthetic opioids that increase the risk of fatal respiratory depression. 

These emerging designer drugs are a headache for us forensic pathologists. Routine toxicology may not even detect them, and if there’s enough of the more common drug in the sample then it can camouflage the novel compound. The pathologist will not even realize it’s there, and won't have the blood tested further to isolate it. A pathologist would only think to look for these synthetic analogues if the toxicology came back negative or if the common-drug levels were so low that they shouldn't have caused death.

Overdoses have reached crisis levels all over the country. Some jurisdictions, such as Richland County in Ohio (http://www.mansfieldnewsjournal.com/story/news/crime/2016/07/25/autopsies-wont-performed-routine-drug-overdose-cases/87524864/), have decided to stop performing autopsies in cases of apparent drug overdose, because they are overwhelmed with bodies. They're stuck between a rock and a hard place. They are violating standard forensic practice and taking a tremendous risk of missing other causes of death by bypassing autopsies, but they’re doing so because of a lack of funding and staffing. An office that exceeds the annual number of autopsies per pathologist will lose accreditation, but the government agencies funding that same office still view drug overdoses through the lens of law enforcement, not public health. According to the Centers for Disease Control and Prevention, the number of drug overdose deaths in the United States is officially at epidemic levels. The rate of deaths has increased 137% since 2000, including a 200% increase in the rate of opioid deaths (http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm). Could street drugs adulterated with synthetic adulterants be to blame? We can't say—not without full autopsies and complete toxicology testing in all overdose cases.  

Without adequate funding at every level of government, we will not be able to track which specific chemical agents are killing people. Police labs need budgets for synthetic drug testing and screening. Medical examiner and coroner offices need money to track the impact and scope of the epidemic. Every death investigation agency in the country would benefit from a federally-funded national database to correlate overdose deaths with illicit drug seizures across state lines. 

But money alone won’t fix the problem—we also need legislative and policy changes. Instead of criminalizing the drug based solely on its chemical composition, legality should be defined by toxicity, the accreditation of manufacturing labs, and distribution method. Our federal agencies need to target online distributors. Medical examiners and coroners need to document medications found at overdose death scenes, check those lists against state databases, and report cases of prescription drug diversion. We also need to alert prescribing physicians in these cases so they can re-evaluate their prescription guidelines. Coroners must certify overdose deaths properly—listing all the medications by name instead of just writing "mixed drug intoxication" on the death certificate, for instance. Medical examiners should work with the Drug Enforcement Administration to apply comprehensive testing techniques to pills collected from death scenes, looking for emerging contaminants and designer drugs. This is especially crucial in cases where the drug levels in the OD are low or do not correspond with the reported symptoms of intoxication. Most importantly, forensic pathologists need to perform autopsies in all cases of apparent overdose, and coroners must staff their offices appropriately to manage the caseload. You should be autopsying these cases. If your toxicology report comes back negative in a presumptive OD because the panel is unable to test for a neoteric designer drug, then you'll have buried a body without providing a cause of death. You will have failed at your job's core mission.

Bottom line: if we don't have enough money to autopsy all deaths that we are required by statute to investigate, then we damn well better be spending what we can on prevention strategies to keep those bodies from piling up. Prevention is more cost effective than investigation in cases of avoidable lethal intoxication. Surplus mortality should not be ordained by the local supply of recreational drugs.

Mind Your Manners: Where Death Certification Ends and Prevention Begins

This article was originally published in Forensic Magazine. To read the original article click here (http://digital.forensicmag.com/forensics/june_2016/MobilePagedReplica.action?pg=18#pg18?)

The police pick up a 45 year old man, a robbery convict, for speeding. The arrest is a parole violation. The man has a history of smoking and substance abuse, and is obese. On his third day back in jail, he refuses to cooperate during a routine search of his cell. The corrections officers address this behavior problem by strapping the man into a restraint chair for several hours until he calms down. After he is released, he immediately starts a fight with another inmate. Once again the guards strap him into the restraint chair, for several more hours, until he is compliant. The man goes back in the chair twice more over the course of the next four days. After the final time, he stands up—and then, without a word, collapses. He's lying on the floor of the jail, unconscious. He is not breathing. The guards initiate CPR immediately, but after a few minutes the man is still not breathing and no longer has a pulse. The guards continue CPR until paramedics arrive ten minutes after the man's collapse. The medics declare him dead.

The forensic pathologist conducting the autopsy finds that the man has a large saddle pulmonary embolus and blood clots in both legs associated with the strap marks from the restraint chair. The cause of death is clear—pulmonary embolus. What's the manner, though? A blood clot traveled from the man's legs to his lungs. Obese smokers commonly develop dangerous blood clots, so should this be certified as natural? The man had been immobilized and showed signs of injury on his legs from the restraint straps, so is this death an accident? But, wait—his immobilization was forced. He had been restrained and injured at the hands of the guards. This prisoner's death should be a homicide. How about undetermined? Suicide is the only manner of death we would categorically discount.

Medical examiners and coroners agonize over manner of death all the time, and for good reason. The cause of death, the disease or injury leading to the lethal event, may be patently clear, but it's the manner of death that the family hears and that the press pounces on. Call an in-custody death such as this one a homicide, and the media will immediately pronounce that the police killed the inmate, even if the corrections officers were only following their training and jail protocol. Call an in-custody death accident or natural, and you might be accused of a cover up. Call it undetermined (a way of saying the death doesn't fully categorize into one manner or another) and no one is happy: You get branded as either unscientific or indecisive. Or both.

What is manner of death? It's a required part of the death certificate, a system of classification most often used for data analysis in the realms of public health and academic research. Every time you read an article that contains information about the ways people die, or compares types of deaths across geographic regions, the researchers likely started their analysis with publicly-available death certificate data, sorted by manner of death.

But manner of death has a social function as well, because, like it or not, we attach different moral value to different ways of dying, even when the mechanism is the same. In my experience, families who have lost a loved-one to a drug overdose don't object to the determination that the cause of death was by acute mixed drug intoxication as much as they object to my manner ruling that the overdose was an accident or a suicide, in some cases because of religious prohibitions against suicide. One Pennsylvania coroner has been in the news lately for classifying overdoses of illegal drugs as homicides, so that the drug dealers will be prosecuted for murder, even if the user injected the drugs himself in order to get high. Sounds like a good idea, right? Drugs are illegal and the dealers should be punished. The problem is, such an approach conflates the duties of scientific death classification with those of law enforcement. Our job is statistical and unbiased, and we need a uniform classification system in order to understand how people die in the real world, and to study regional differences. Coroners in jurisdictions surrounding this Pennsylvania county have avoided following suit with this reclassification of manner in drug deaths.

We in the forensic sciences must work to communicate with the police, the families of decedents, and with the public at large about the different manners of death, about the national standards used in classifying deaths, and about our decision-making process in arriving at a conclusion in each individual case. We must do so as part of our professional duty to public health in seeking to reduce our national burden of avoidable deaths. We spend a lot of time agonizing about the manner—but the determination of manner doesn't matter if we don't then do something to counsel the decedent's family, to explain what happened to the public, and to prevent this from happening again, if what happened was at all preventable.

Some jurisdictions will call our hypothetical case study of the prisoner with the embolus a homicide. Others might call it an accident. A few might even decide this was a natural death. Regardless, they will all be remiss if they stop with cause and manner. We coroners and medical examiners have an ethical duty to do more than just check a box on a death certificate and wait for the inevitable lawsuit. We have a duty to reach out to those in power to change the lethal environment by educating the jail staff and the corrections department managers who write the policies and procedures. If we don't reach out to other professionals in other county agencies, one man's avoidable death will repeat with others under similar circumstances. If we don't publicize it in the press, how will others learn from our experiences and adjust their policies accordingly, before the next death? The next time it happens, what will you do about it? Will you call it another homicide, another accident, another natural death? Whatever your answer, you will have a harder time explaining why another such corpse has come to a slab in the morgue, and why you didn't do anything to stop it getting there. We forensic pathologists are physicians working in the realm of public health. Our job—our duty—does not end with the death certificate.

Don't Share a Bed with Your Baby

It was one of the toughest phone conversations I have made in my 15 years as a forensic pathologist. I had just completed the autopsy of a three month-old infant. He had spent the night sharing an adult bed with his mother and six year-old brother. In the morning they found him prone, with his face against the pillow, dead. During the autopsy I found that blood had pooled under the skin of the baby’s face and abdomen after death, and I documented characteristic areas of pallor where the pillow had pressed against his nose and mouth. He had asphyxiated. After leaving the morgue I had to go pick up the phone and tell a mother she had accidentally smothered her son.

I investigate sudden infant deaths three or four times a year. Parents who lose a child to a bed-sharing accident inevitably ask me why the cause of death isn't SIDS, sudden infant death syndrome. I have to explain that SIDS is a diagnosis of exclusion: the autopsy and scene investigation rule out injury, and we can't find any fatal natural disease. A child who is found face-down with his nose and mouth covered has been injured. The cause of death in such a case is positional asphyxia, and the manner of death is accident. Accidents are avoidable, which makes that postmortem conversation all the harder. The parents blame themselves. I frequently end up in tears along with them. I have three children who were babies not that long ago, and though I’m a doctor I am not made of stone.

My medical colleagues and I were dismayed to read the Los Angeles Times Op-Ed of September 18, 2016 titled "It's OK to sleep next to your infant child. In fact, it's beneficial," showing a photo of a smiling mom sharing an adult bed—with soft blankets and pillows—with her three month-old. The authors, two professors of human development, cite anthropological research while dismissing the recommendations for safe sleep promulgated by medical professionals, including those in the CDC and the American Academy of Pediatrics. This article operates under the fallacy that cross-cultural anecdotes trump hard scientific data. It conflates SIDS deaths with all sudden infant deaths, betraying an ignorance about asphyxial death in unsafe sleep environments. It also ignores differences in death investigation and certification between countries. For instance, the authors cite Japan’s low rate of reported infant mortality while ignoring the fact that fewer than 30% of infant deaths in Japan are autopsied. (Taylor BJ, et al. Arch Dis Child 2015;100:1018–1023. doi:10.1136/archdischild-2015-308239). They press the absurd and dangerous assertion that "the proven benefits of mother-infant co-sleeping far outweigh the largely imaginary risks." These are not imaginary risks. They are real and they are tragic.  According to the CDC, infant asphyxia is the leading accidental cause of death in infants under one year of age. Parents who lose a child to a preventable death and parents whose children end up in a vegetative state after an anoxic brain injury suffer grievously. They have created support organizations like Charlie's Kids and First Candle to educate others about safe sleeping, including co-sleeping without bed-sharing.

There are safe ways of sleeping next to your child in the same room without sharing the same bed, but most parenting websites and magazines do not distinguish between co-sleeping and bed-sharing. Self-appointed parenting experts who actively advocate for bed-sharing ought to recognize the recklessness of such a position. According to ICAN, the Inter-Agency Council on Child Abuse and Neglect, sudden infant deaths in unsafe sleep environments dropped from 69 per year to 35 after a 2013 safe-sleeping campaign in Los Angeles County. Public health outreach saves lives. Misleading parents about published death statistics in the interest of promoting unprovable life-balance benefits is irresponsible, and the endorsement of bed-sharing as a safe approach to co-sleeping is dangerous. Do not share a bed with your infant. It isn't worth the risk of an autopsy.

Ethics and the Forensic Expert: What Would You Do?

This article was originally published in Forensic Magazine. To read the original article click here (http://www.forensicmag.com/articles/2016/03/ethics-and-forensic-expert-what-would-you-do)

An attorney asks you to change your report by omitting mention of evidence that is in dispute. Omitting the information does not alter your opinion; in fact, it significantly strengthens it, but this makes you vulnerable to cross-examination if it is admitted. Do you change your report to omit the information?

You are asked to review a civil wrongful-death case for an attorney. You come to the opinion that the attorney's client is lying to him, and is likely to blame in the death of the decedent. The death was certified by the original autopsy physician as an accident, and the client was never charged. After reviewing the records you think this case is a homicide, and that the attorney’s client did it. Your contract with the attorney has a confidentiality clause. Do you break confidentiality to report the crime to the police?

A couple of years ago I was part of a panel of forensic pathologists who formulated these questions and others, and then posed them to both forensic experts and attorneys. We got very different answers from each group. 

Nearly half the attorneys expected their expert to revise the report. Over three-quarters of forensic experts surveyed said they would refuse to do so. And the unreported homicide? Over half of the experts said they would violate confidentiality to report it to police—while over 80% of attorneys expected the experts to stay mum. (The full article is available here: http://store.academicfp.com/the-ethics-of-working-as-a-retained-forensic-expert)

Ethical questions in science and medicine become hot topics in the press when they touch on taboos like sex or death, and when they affect public health and safety. Recent examples include the ethics of caring for the terminally ill at great cost ("death panels") or empowering those same terminal patients to alleviate their own suffering by ending their lives of their own volition ("assisted suicide"). Even the ethical ecology of self-driving cars has come under scrutiny. Do the algorithms employed to keep the driver safe consider collateral damage, maybe lethal, to pedestrians? (more at http://www.technologyreview.com/view/542626/why-self-driving-cars-must-be-programmed-to-kill/). 

Forensic science is popular on television, yet we don't often hear about the ethical challenges that vex forensic experts. One of the few that gained attention in the press in the past year was a story out of Boston in which an assistant district attorney allegedly tried to influence the testimony of a forensic pathologist in a child abuse case. The pathologist felt "bullied" by the attorney to stick to his original determination of homicide, even though the scientific literature and new evidence in the case did not support it. He memorialized his impression in a note in the Medical Examiner's chart, which was eventually released to the defense; he amended the manner of death, and the ADA dropped the charges, but in another child death case the same ADA was barred by a judge from contacting and attempting to influence another medical examiner. (Full article here: https://www.bostonglobe.com/metro/2015/10/12/medical-examiner-notes-suggest-was-bullied/vtEQVvFXJSIzugGayyJvUN/story.html)

It’s common for non-scientists to attempt to influence the outcome of a forensic investigation. In a 2011 survey published in Academic Forensic Pathology (see: https://www.afpjournal.com/nosubscribers/journal/3&y=2013), a quarter of forensic pathologists surveyed reported that they are considered prosecution witnesses within their jurisdiction, with the expectation that they not cooperate with defense counsel. More than 10% related that elected or appointed officials had exerted pressure on doctors to change their testimony or withdraw as an expert in a specific case. Sixty-four percent of government-employed pathologists reported that their job contract imposed limitations on private consultation.

When scientists are forced to testify exclusively for the government, and any defense or outside consult work is viewed as a "conflict of interest,” everyone suffers. The public stops seeing forensic pathologists as impartial, unbiased scientists. We become instead part of a prosecution team that puts people in jail, period. When that's the public perception and someone dies in police custody, it's no wonder that the investigating medical examiners and coroner's pathologists are accused of bias, while the media present the retained expert hired by the family as "independent." It's much harder to be ethical when you are not independent. It is the very essence of our job to speak out in the public interest, even when speaking out puts us in direct conflict with the government that writes our paychecks.

Ethical questions, by their nature, seldom have a single defensible answer. The best course of action may change due to subtle differences in the circumstances of an individual case. Sometimes we make decisions based on the nuances of personal interactions and life experience that can't be quantified in a survey or codified by a commission. Cultural shifts happen over time; what is considered ethical in one place or time might be egregiously wrong in another. 

We must speak publicly and openly and often about the difficult choices we make as forensic professionals so that we can alert other scientists to the challenges they will face in their careers, and educate attorneys and others who interact with forensic scientists about the differences in our training and professional cultures that will spur conflict. We need the public to understand that when science and medicine evolve with advances in research, our culture evolves too, and the definition of what is ethical or what constitutes a conflict of interest will also change. Everyone would like to think that scientific findings are absolute, and that the scientists who testify in court are the purest sort of empirically rigorous professionals—but court testimony is not a laboratory experiment. It is an opinion: a professional, expert opinion that might change over time, or might differ from the opinion held by another, equally scrupulous forensic professional. Forensic science can include an unexpectedly changeable human component when it intersects with a court of law or with the press. It's an ethical requirement of our job to explain to people what we can do, what we cannot, and what we can argue over.

It's not an easy task. Nothing worth doing ever is. Or, rather—I should say—that's my opinion.

Forensic Radiology and the Medical Examiner

This article was originally published in Forensic Magazine. To read the original article click here (http://www.forensicmag.com/articles/2015/12/forensic-radiology-and-medical-examiner)

It was the first time I had to testify in a case without a dead body. The patient was a 30 year-old Hispanic man who got into a fight with another guy on the street. The emergency room physician told me "it looked like someone tap danced on his face." He had severe facial injuries, including a jaw fracture and bruises that had swollen his eyes shut. He lay unconscious in the hospital for a week, and when he came to, he couldn't remember what had happened—not uncommon with brain-injured patients. Witnesses heard shouting and saw the other guy run away, but didn't witness any beating. When the hospital doctors couldn’t tell the DA how many times the victim was struck, the DA called the Office of the Chief Medical Examiner for a forensic assessment.

I got the man’s medical records and started poring through them, seeking out the times that someone had documented an injury, and drawing each of those on a face diagram. Injuries that align when the face impacts a broad, flat surface are all in a single plane, and counting planes of injury allows me to figure out how the minimum number of times a victim was struck. After going through all the medical and nursing notes and some blurry photos the police had taken of the victim at the hospital, I counted three planes of injury: one under the man’s jaw, another at the forehead, and a third on the opposite side of his face, with the road-rash abrasions I typically see as the result of a fall against pavement. His injuries had to have come from at least three separate impacts.

So, the radiology reports in the medical records documented the bony injury to the face and sinuses—and they also commented on some bruising to the brain. Buried in the description of the findings (but notably omitted in the radiologic diagnoses) was a mention of "swelling" over the scalp. I asked the DA to subpoena the actual CT scans. What I found shocked me. The "swelling" was actually bleeding, in two distinct areas: one on the right back of the head, and another at the left side of the head. Two more planes of injury! The ER doc’s tap dancing analogy was not far off.

I called the DA and told her my opinion. With five planes of injury, this victim was struck at least four times, plus a fall against the pavement—and if he had been struck multiple times in the same location I probably wouldn't be able to tell that there were additional impacts, since they would have occurred along the same plane. After reviewing the radiology from the hospital as well as the medical records, I could attest with medical certainty that these injuries did not come about after a single punch and fall, as the defendant was claiming. When the case went to court I was the only prosecution witness who could tell the jury what actually happened, using the physical evidence from the injured man’s body. His assailant was convicted.

This experience during my fellowship training taught me several lessons about radiology. One was that hospital radiologists tend to focus on bony injuries, and will often omit soft tissue findings entirely. If I hadn't sought out the CT scans and looked at them myself, I would have missed two additional impacts—compounding evidence, in this case of criminal assault. I also learned that just because I am a pathologist doesn't mean I'm not qualified to interpret radiology. As a forensic pathologist, I interpret X-rays most frequently when I'm called to identify decomposed cadavers or when I need to find bullets and other foreign bodies in trauma cases; I also receive radiology reports and hospital scans with a decedent’s medical records, and I study those as a part of the postmortem investigation. They have proven crucial in identifying the cause of death or in directing my autopsy examination in several important cases.

If the patient went to the hospital prior to dying, I can stack the clinical radiological images to create a three-dimensional reconstruction of the body. In one officer-involved shooting case, I used this method to answer the question of whether the victim was facing toward or away from the police when he was shot in the face. So while many forensic offices (including the agency where I currently work) have purchased full body X-rays to improve the speed and accuracy of their radiologic examinations, I really yearn for a CT or MRI scanner with 3-D imaging capacity. I want to see the soft tissues too—not just the bones.

Some radiologic findings, like air emboli following laparoscopic surgery, might be missed entirely at autopsy if a CT or MRI isn't done prior to the autopsy examination. Colleagues have shared with me cases in which CT scans have alerted them to subtle findings—small pulmonary nodules, vertebral artery injury, healing fractures in abused children—prompting them to do a more extensive or targeted dissection to make the forensic diagnosis. Some have gone so far as to perform post-mortem angiography by obtaining expired contrast material from hospital radiology departments and injecting it into a cadaver in order to assess vascular integrity. These scans make excellent courtroom exhibits and are less likely to be thrown out by a judge who doesn't want to upset the jury with gory photos from the autopsy.

Radiology is an imperfect diagnostic avenue for postmortem examination, however. It’s a shadow play. You aren’t looking at the real thing, but rather at a two-dimensional image of it, the shadow cast by the X-rays onto a capture plate, and separated by 1 centimeter intervals between the slices taken of the body. During an autopsy the pathologist is looking at the real thing—and feeling it, and smelling it, and listening to the sounds it makes when she handles it. In the course of thorough postmortem I have found linear non-displaced skull base fractures that weren't visible on radiology and vascular injury no clinician had detected. I have also seen benign congenital lesions misinterpreted as malignancy or trauma. That's why I'm not worried that radiologists with high-tech "virtual autopsies" are going to replace me and my trusty scalpel. Nothing can match the certainty and validity of a direct, hands-on forensic examination. Autopsy means “see for yourself.” You can’t do that by staring at shadows on a screen.

5 Case Studies In Forensic Toxicology

This article was originally published in Forensic Magazine. To read the original article click here (http://www.forensicmag.com/articles/2015/10/five-case-studies-forensic-toxicology)

As a practicing forensic pathologist in a busy urban office, I am confronted every week with a stack of toxicology reports from my cases. Most are simple to interpret—the multiple GSW with (inconsequential) trace cocaine; the slam-dunk OD with a needle in his arm and sky high 6-MAM from heroin. Then there are the challenges. I might get a case with no apparent anatomic cause of death. I pend it, confident that tox will turn something up. But instead the toxicology report shows only prescription drugs in therapeutic levels, or—worse!—it’s completely negative. Interpreting the laboratory findings, deciding whether to pursue additional testing, and coming to a reasonable conclusion in these cases can be difficult. Though I can always call a toxicologist for advice, ultimately I am the one to make the call on cause and manner of death, and I have to be able to defend my determination in court.

So, now that we’ve established the stakes, let’s take a look at five case studies that illustrate the most common errors forensic pathologists make related to toxicology.

Not even doing toxicology

There’s a dead man in his locked trailer, naked in bed, no drug paraphernalia at the scene and no signs of foul play. The local coroner finds out the decedent’s medical history included an untreated dental abscess, and signs the death certificate without performing an autopsy. When the dentist gets sued, what is the first thing the forensic consultant on that case asks for? Toxicology. Luckily, the coroner’s investigator collected enough blood and vitreous humor to perform toxicological analysis—and it shows a sky-high methamphetamine level. This finding dovetails with his dental pathology (“meth mouth" is a known complication of chronic amphetamine abuse), and helps the dentist’s lawyers defend him in the lawsuit. The lesson? Just because there are no drugs at a death scene doesn't mean you shouldn't perform an autopsy to collect specimens for toxicology, especially if the decedent has a history of chronic abuse.

Not communicating with the toxicology lab

A young schizophrenic woman has a psychotic break, and her roommate calls the cops. Responding officers find her ranting, and brandishing a screwdriver. She comes at one of them, and he shoots her to death. The gunshot wounds makes for a clear enough cause of death, but on the toxicology form, the forensic pathologist neglects to inform the toxicologist about the decedent’s prescribed medications. When the tox screen comes back negative, the pathologist then writes in his report that the decedent hadn’t been taking her medication at the time of her death. He never calls the lab to confirm this assumption—but, weeks later, a local newspaper reporter does. When the tox lab then runs the tests for the prescribed antipsychotics, it turns out the result is positive. The pathologist's reputation is damaged. Always remember that routine enzyme-based screens will not pick up all drugs. It pays to double check that the lab tested for any specific medications the decedent was supposed to be taking, especially in a high-profile case.

Looking only at the numbers

One hot summer evening, a guard outside a chronic pain clinic finds the decomposing body of a middle-aged woman in her parked car. She has the keys and her purse still clutched in her hands. She had been seen at the clinic that morning, hours before. The autopsy pathologist finds high levels of multiple opioid analgesics, and determines that the death was an overdose. The family sues the pain clinic and the drug manufacturer. During document discovery the dead woman’s medical records reveal a past diagnosis of cardiac arrhythmia. The drug levels? They were already high because the decedent was a chronic, tolerant user, appropriately prescribed; but they were also spuriously elevated due to post-mortem redistribution, the passive diffusion of drugs in a decomposing body that can cause higher detected levels than when the person was alive. Why did the pathologist ignore the woman's heart disease and blame the drugs? Because the opioid levels were high. You cannot focus solely on the numbers—you have to look at the whole case. In this one, the facts of the case pointed to a sudden cardiac arrest, and not to a slow death by respiratory depression as in an opioid overdose.

No scene investigation

An elderly woman is declared dead in the emergency room. Her husband says that she was snoring all night. He called 911 in the morning, when she wouldn’t wake up. On autopsy the pathologist finds a diseased heart, and signs out the case as a death by natural disease. Then, while preparing the house for the funeral, the husband finds the woman’s recently-prescribed but empty medication bottles, and brings them to the coroner's office. In the toxicology report, the woman’s drug levels appeared high but within therapeutic range, so the pathologist hadn’t considered poisoning as a cause of death. The distended bladder he pulled out of her body on autopsy should have steered him to take a closer look at the tox, however. Sleeping patients who are not intoxicated will wake up and go to the bathroom. A bladder with 400 or 500 ml of urine in it may be a signal that something is causing central nervous system depression. Turns out this was a suicidal overdose of prescription medication. The decedent was not just asleep in bed—she was in a coma, and had been metabolizing the drugs for hours while unconscious. When a patient dies in the hospital, death investigators might not go to the primary scene to collect evidence—such as, in this case, the medications. If the decedent’s husband had not alerted the coroner, her death would have been misclassified as natural.

A negative toxicology report does not mean the death is not drug-related

A psychotic prisoner is booked into jail, and the medical staff there change his usual anti-psychotic medication to a different one that they have in their dispensary. He develops a high fever with altered mental status, and goes to the hospital, where that medication is discontinued. He dies a week later, with pneumonia and kidney failure from muscle breakdown. The hospital blood specimens come up negative for all drugs, so the pathologist consults a forensic toxicologist. The toxicologist reviews the medical records and concludes that the change in prescribed medications at the jail had likely triggered a fatal drug reaction. Post-mortem drug tests can come up negative for many reasons, and drug-drug interactions and adverse reactions can lead to death days or even weeks after they occur. Sometimes a toxicologic cause of death may not be apparent without a thorough review of the medical record and consultation with a forensic toxicologist.

Whew. Daunting? Yes. But avoid these five pitfalls, and you will find that toxicological avenues of death investigation can lead to some of the most interesting cases we forensic pathologists have the privilege of investigating.

Dr. Judy Melinek is a forensic pathologist and does autopsies for for the Alameda County Sheriff Coroner's office in California. Her New York Times Bestselling memoir Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner, co-authored with her husband, T.J. Mitchell, is now out in paperback. She is the CEO of PathologyExpert Inc.