The effects of the (fentanyl‐fueled) drug overdose epidemic on medicolegal death investigation in the United States

The evolving opioid epidemic in the United States, fueled by illicit fentanyl, has greatly increased deaths from illicit drug use. These nonnatural deaths require formal death investigation. The National Association of Medical Examiners states in its Forensic Autopsy Performance Standards that autopsy remains a necessary component for proper investigation of suspected acute overdose deaths. If a death investigation office lacks adequate resources to investigate all deaths under its jurisdiction while meeting expected standards, then that office may be forced to consider altering its protocols for investigation by changing the types of deaths investigated or the extent of its investigations. Drug death investigations take longer to complete because novel illicit drugs and mixtures of drugs complicate toxicological analyses, prolonging a family's wait for completion of a death certificate and autopsy report. Public health agencies must also wait for results, but some agencies have developed mechanisms for rapid notification of preliminary results to allow timely deployment of public health resources. The increased deaths have strained the resources of medicolegal death investigation systems throughout the United States. Given the significant workforce shortage of forensic pathologists, newly trained forensic pathologists are too few to meet the demand. Nevertheless, forensic pathologists (and all pathologists) must make time to present their work and themselves to medical students and pathology trainees to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology and to provide a model that can encourage interest in a career in forensic pathology.


| INTRODUC TI ON
The United States has entered the third decade of the current opioid use epidemic, based on the rise in deaths from prescription opioids that began in 2001-2002 [1]. The rise began with prescription opioid use, but around 2015, the use of fentanyl and other synthetic opioids (other than methadone) began to rise sharply, and by 2016, fentanyl and similar opioids became the most common illicit opioid associated with drug deaths [1]. At the same time, overdose deaths involving cocaine and methamphetamine were also increasing [1]. In early 2020, the COVID-19 pandemic began, and overdose deaths in the United States, already high, increased in 2020 by 31% compared with 2019 [2], and then increased an additional 14% in 2021 compared with 2020 [1]. This article examines the effects of these overdose deaths on medicolegal death investigation in the United States, discussing both the current ramifications of an overloaded system and implications for the future of death investigation.

| MATERIAL S AND ME THODS
Publicly available data sources were accessed for information on deaths since 2000 at the national (United States), state (Virginia), and county levels (Jefferson County, Alabama and King County, Washington). The data included total deaths in the United States [3] and annual reports for the three medical examiner systems (Virginia [4], Jefferson County [5], and King County [6]). Figure 1  Office came from office records. Figure 2 shows these three interrelated aspects of the Jefferson County, Alabama Coroner/Medical Examiner Office displayed by year. As in Figure 1, 2 has been normalized to the first year for which data are shown (2005) so that three different numbers at different scales can be compared visually.

| RE SULTS
In Figure 1

| D ISCUSS I ON OF PRE S ENT CIRCUMS TAN CE S
In its most recently adopted and published position paper on the investigation, diagnosis, and certification of deaths related to opioids and other drugs, the National Association of Medical Examiners (NAME) did not alter its recommended standard for performing an autopsy in suspected overdoses [7], nor has NAME altered its Forensic Autopsy Performance Standards calling for autopsy in suspected overdoses (specifically B3.7) [8]. Consequently, an office's ability to handle this increased caseload while following the NAME Standards depends on the office budget and staffing. As shown in If an office lacks adequate resources to investigate all the deaths that fall under its jurisdiction while meeting expected standards, then an office may decide to alter its protocols for investigation by changing the types of deaths investigated (assuming or declining jurisdiction) or by changing the extent of its investigation (e.g., performing an external examination rather than an autopsy or reducing the scope or type of toxicological analyses). Ongoing research is seeking to identify protocols for accurate certification of drug deaths without performing a complete autopsy. A recent study from the New Mexico Office of the Medical Investigator, which utilized full-body • The increase in overdose deaths has revealed the critical shortage of forensic pathologists (FPs).
• Increasing the FP workforce requires intensive multi-agency efforts and individual FP interactions.
postmortem CT imaging as a screening tool, showed promising results [9], but the majority of U.S. medicolegal death investigation systems lack the resources and personnel available to implement a program of postmortem CT scans. Of course, the NAME Standards requiring autopsy as part of overdose death investigation apply only to death investigations in the United States. Other nations do not necessarily require an autopsy for every suspected overdose.
As the report by Spencer et al. shows, fentanyl is not the only drug that has increased in prevalence since 2015 [1]. The continuing emergence of novel psychoactive substances, including novel synthetic opioids, has challenged toxicologists, medical examiners and coroners, law enforcement, and drug control agencies [10].
Challenges in detecting these novel psychoactive substances include their rapid proliferation, variable geographic distribution, limitations to and variable extent of toxicologic testing, resource requirements for the development of validated detection systems, and timely availability of information about the potency and toxicology of these substances. In addition, cocaine, methamphetamine, heroin, and other drugs are often mixed with or used at the same time as fentanyl [11], so that an individual death may be associated with a cocktail of substances, increasing the complexity of testing and the interpretation for each death. Multidrug use may complicate or prevent the identification of novel psychoactive substances and novel synthetic opioids. For example, a death may be attributed to a combination of potentially lethal detectable drugs (e.g., fentanyl, heroin, methamphetamine, cocaine) while omitting a potentially lethal but novel psychoactive substance because it cannot be detected by the currently used laboratory methodology and would only be identified by a specialized, well-resourced reference forensic toxicology laboratory [10].
The effects of the opioid and fentanyl epidemic on medicolegal death investigation extend beyond the immediate concerns of office protocols related to which deaths will be accepted for investigation and how individual cases will be examined. administrative duties required to maintain proper the function of an office. Over time, "stealing" from administrative responsibilities to satisfy the needs of clinical responsibilities will not be sustainable.
Public health agencies must also wait for the complete results, which can adversely affect the timely implementation of efforts focused on preventing drug-caused deaths and warning the public of specific dangers. In order to address this issue, the King County Medical Examiner's Office in Seattle developed a program to speed up the cause of death determination for potential overdose deaths, facilitating more rapid death certification and communication of drug death information to the public health system [12]. From 2019 to 2021, the structured project utilized scene investigation, autopsy findings, and "real-time" in-house testing of blood, urine, and drug evidence from death scenes. Testing focused on multiple drugs, including fentanyl, cocaine, methamphetamine, and other opioids.
Using this structured program, the office was able to certify the majority of drug-related deaths, usually within several days after death.
Overall, this approach provided accurate results for about 90% of the cases. Complete toxicology testing was still performed by a forensic toxicology laboratory, and the results were used to amend death certificates if necessary and to provide the most complete and accurate information to public health and other agencies. Timely availability of information of 90% accuracy was sufficient for many public health needs, including public communications and warnings, ongoing planning for prevention efforts, and facilitating distribution of naloxone and fentanyl test strips to specific locations or groups.

| D ISCUSS I ON OF FUTURE EFFEC TS OF THE OPI OID/FENTANYL EPIDEMI C ON MEDICOLEG AL DE ATH INVE S TIG ATION
As already discussed, the epidemic of fentanyl use and the resulting increase in mortality has increased the workload in medicolegal death investigation offices around the United States. No end to this epidemic is in sight, so the burdens placed on death investigation offices and forensic toxicology laboratories will continue until illicit drug use becomes less common. Increases in caseload will likely continue, and toxicology analyses will remain complex. For example, xylazine, an animal tranquilizer, which was once seen only rarely in drug deaths, has become a common constituent of drug material in drug deaths [13].
Lack of quality training for pathologists in autopsy pathology limits the opportunities for encouraging and interesting medical students in a career as a forensic pathologist simply because the students are never exposed to the possibility of that career path [14].
It is important that the medical specialty of Pathology be taught to medical students by pathologists who are devoted to the importance of their work, who represent the diversity of the specialty (forensic and autopsy pathology, as well as the many subspecialties of anatomic and clinical pathology), and who represent pathology well. Weedn and Melendez have succinctly summarized many of the issues contributing to the current forensic pathology workforce crisis [14], including pertinent historical perspectives, concerns about medical student and pathology resident education, the elimination of funding for autopsies, the lack of support for autopsy in depart- in recognition of the important medical examination that it is [14].
Likewise, it is important that autopsy be recognized and included as an essential part of medical education, resident training, and patient care, to include students, trainees, and practicing physicians, as well as other involved healthcare professionals, such as nurses and physician assistants [14]. It is critical that capable pathologists meet and engage with their peers in other medical specialties, as well as those in administrative and governmental positions, to emphasize the importance of pathology to medical practice. If we pathologists do not take to the hallways and classrooms to proclaim the importance of our work, then no one will do it for us. Restoration of adequate or generous funding for forensic pathology offices, important though that is, will not correct the overall workforce shortage if there are insufficient numbers of people choosing forensic pathology as a profession.

| SUMMARY
The current and evolving opioid epidemic, fueled by illicit fentanyl, has increased overdose deaths, straining the resources of medicolegal death investigation systems throughout the United States. Given the current significant workforce shortage of forensic pathologists, the numbers of newly trained forensic pathologists are too few to meet the demand [14]. Forensic pathologists (and all pathologists) must make time to present their work and themselves before medical students and pathology trainees, as well as to other medical practitioners, in order to encourage an understanding of the importance of quality medicolegal death investigation and autopsy pathology. There is evidence for hope. The National Association of Medical Examiners is working with governmental, academic, and pathology and other medical professional organizations to encourage autopsy and forensic pathology as a career and to advocate for appropriate supportive resources, using a multi-faceted action plan. Likewise, the number of medical students interested in pathology as a career may be increasing: After several "lean" years for pathology in the national residency match, all anatomic pathology or combined anatomic/clinical pathology training positions in the United States filled in 2023 [15]. The efforts of Pathology program directors and course directors are making a difference in the career choices of medical students. It is time for each forensic pathologist to join this work.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors have no conflicts of interest to declare.