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Complete Republication: National Association of Medical Examiners Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs

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Abstract

The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following:

1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings.

2. A complete scene investigation extends to reconciliation of prescription information and pill counts.

3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites.

4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and anti-depressant medications.

5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings.

6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate.

7. The best classification for manner of death in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.

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Acknowledgments

The panelists gratefully acknowledge the technical support and expertise that librarians Gale Hannigan and Brian Bunnett of the University of New Mexico Health Sciences Library provided by searching the literature, gathering articles, checking citations and recording the outcome of the review process. In addition, the panelists are thankful for the assistance of Denise McNally of the National Association of Medical Examiners for facilitating the multiple conference calls required to produce the final document.

Disclosures

Funding support for this project was received from the Centers for Disease Control and Prevention (CDC), contract number 00HCUD32011-99784. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC. Drs Aiken, Greg G. Davis, Gill, Goldberger, Melinek, Middleberg, Middleton, Nelson, Perrone and Wax received travel funds from the CDC award to participate in the expert panels. Drs Goldberger and Middleberg received honoraria for their participation in the expert panel. Drs Boyer, Gill, Melinek, Nelson and Goldberger have received fees to be expert consultants and provide testimony in legal matters. Drs Gharibo and Gill have received payments for lectures. Dr. Gill has received royalties from the publication of scientific books and the development of a Medicolegal course. Dr. Middleberg is employed by the NMS laboratory which has done fee-for-service work for the CDC. Dr. Nolte’s institution, the New Mexico Office of the Medical Investigator, received funds from the CDC to support the creation of this paper including his role as principal investigator and receives funds from the National Association of Medical Examiners (NAME) to support his role as Executive Vice President. In addition, Dr. Nolte’s institution has research awards in which he participates from the National Institute of Justice and National Institutes of Health (through Portland State University). Dr. Wax receives funds from the American College of Medical Toxicologists to be the Executive Director.

The opinions and conclusions of this paper have been reviewed and approved by the National Association of Medical Examiners Board of Directors and as such are endorsed by NAME. These opinions and positions are based on a consensus of the current literature, knowledge, and prevailing theories on this topic. As Scientific knowledge and experience grow, NAME reserves the right to revise or update these opinions. The process by which NAME position papers are initiated, written, reviewed, and approved is publically available at https://netforum.avectra.com/temp/ClientImages/NAME/2c26a527-f992-4f70-9d03-7941bff5319d.pdf. All scientific position papers endorsed by the National Association of Medical Examiners automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time. This work is a product of NAME and as such, was not subjected to Academic Forensic Pathology Journal editorial review.

The editors and publication staff do not report any relevant conflicts of interest.

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    Gregory G. Davis MD MSPH and the National Association of Medical Examiners and American College of Medical Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths

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    This article is a complete republication of a primary publication by Academic Forensic Pathology from Acad Forensic Pathol 2013 3 (1): 77-83 with permission

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    Gregory G. Davis MD MSPH and the National Association of Medical Examiners and American College of Medical Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths. Complete Republication: National Association of Medical Examiners Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs. J. Med. Toxicol. 10, 100–106 (2014). https://doi.org/10.1007/s13181-013-0323-x

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