A study in the American Journal of Preventive Medicine says that opioid overdose deaths have been under-reported across the country, including in Kansas and Missouri.
University of Virginia researcher Christopher Ruhm analyzed death certificates from 2016 and 2017, looking for overdose deaths in which the drug that caused the death was not specified. He used statistical probability models to project how many were opioid-related.
“The correction procedures developed here supply a more accurate understanding of geographic differences in drug poisonings and supply important information to policymakers attempting to reduce or slow the increase in fatal drug overdoses,” Ruhm’s study said.
Under Ruhm’s analysis, Missouri’s opioid death rate in 2014 jumped from 11.5 per 100,000 people to 14 per 100,000 people — the 15th largest increase in the nation. Kansas’ death rate moved from 6.0 per 100,000 people to 8.1 per 100,000 people — the 19th highest increase.
Kerri Tesreau, the acting director of the Community and Public Health Division of the Missouri Department of Health and Senior Services, said her agency is bound by what’s listed on death certificates when it calculates death rates and does not use statistical projections.
But she didn’t dispute Ruhm’s analysis of opioid death rates.
“I think we would all agree there’s a good possibility it’s under-reported,” Tesreau said.
Dr. Randall Williams, the director of the Missouri health department, said there are several challenges in reporting opioid deaths accurately, including toxicology reports that reveal several different drugs in the system of people who died.
In those cases it can be tough to single out which drug caused death, or even whether the death was drug-related.
“(The death certificate) may just say ‘drug overdose’ and to an extreme it might just say ‘cardiac arrest,’” Williams said.
In some cases it can take a specialized forensic pathologist to sort out a cause of death. Williams said there’s only about 500 of those in the United States and only about a dozen in Missouri.
Right now they’re mainly located in major metro areas like St. Louis and Kansas City. Given the physical and emotional toll of the job, Williams said it’s hard to find more.
“I believe that you’re almost born to be a forensic pathologist,” Williams said. “You almost have to be destined to do it.”
Even in counties that have a forensic pathologist, the challenge of rising opioid death rates is causing strain.
The president of the National Medical Examiners Association told the Pew Charitable Trusts last month that offices nationwide are swamped with overdose deaths and medical examiners are working overtime to determine causes of death amid an “opioid tsunami.”
Jackson County medical examiner Diane Peterson, a forensic pathologist, said her office has felt the wave crashing. There were 101 opioid-related deaths recorded in the county in 2016.
“This has increased our caseload,” Peterson said in a emailed statement. “The cost of toxicology tests are increasing, due to increased possibility of designer drug use, as well as more frequent need to quantify positive screens.”
The designer drugs are sometimes made from synthetic fentanyl, a highly concentrated form of morphine. Peterson said they don’t show up on some screens, leading to false negatives.
She said she’s also concerned about exposing her staff to powdered forms of the drugs both at the scene of overdose deaths and during autopsies.
“These challenges are being realized in coroner and medical examiner offices throughout the country,” Peterson said. “Many offices are becoming overwhelmed by the increases in caseload and costs. This is affecting accreditation statuses in some offices.”
Peterson said her office performs extra tests when they get an initial negative but still think drugs played a role in the death. She’s also making sure her workers have protective equipment.
At the state level Tesreau said Missouri is working with the Centers for Disease Control to look at multiple-drug overdose reports and try to go back to the original medical examiner and coroner files to see if there’s information that could lead to a more specific cause of death.
Williams said it’s worth the time and effort to try and get a more precise measure of just how many people in Missouri are being killed by opioids.
“What I hear from everyone — legislators, Medicaid, hospitals, people in public health - is that we feel we need a very comprehensive and integrated initiative in a coordinated fashion to determine the full and accurate scope of the problem,” Williams said.