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.
Dr. Judy Melinek, a board-certified forensic pathologist and author blogs about forensic pathology and science in the news.
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Monday, October 17, 2016
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.
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.