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.