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OSAC MEDICOLEGAL DEATH INVESTIGATION SUBCOMMITTEE: 

STRATEGY STATEMENT FOR MEDICAL EXAMINER/CORONER DRUG RELATED DEATH 

INVESTIGATIONS 

Published: February 14, 2018 

PROBLEM STATEMENT

The United States is in the midst of an epidemic of drug overdose deaths. Since 1999, the rate of 

deaths from drug overdoses has nearly tripled (1). There were over 52,404 drug overdose deaths 

in 2015 in the United States, exceeding the per capita death rate of motor vehicle deaths (2). 

Drug overdose deaths are investigated by medical examiners and coroners. The inconsistent 

patchwork of medicolegal death investigation (MDI) systems that exist throughout the United 

States impact the accuracy, timeliness, and availability of mortality data from death certificates 

and other sources (3). These shortcomings undermine efforts to coordinate resources in 

reducing drug-related deaths and make it difficult to mount effective public health, law 

enforcement, and public policy responses to the opioid crisis. Essential to reducing variability in 

the practice of drug-related death investigation and certification and enhancing the quality, 

reliability and accessibility of drug mortality data are 1) adhering to best practices in drug-related 

death investigation conducted by medical examiners and coroners, 2) enhancing drug-related 

death surveillance by medical examiners and coroners through improved communication and 

coordination of MDI data with law enforcement, public health and safety, and 3) strengthening, 

expanding, and promoting interoperability among death investigation case management systems 

and ensuring access to essential case information for quality control and data analysis (4). 

Background

The medical examiner/coroner professional community is in a unique position to help define and 

inform policy decisions at all levels of government regarding the drug death epidemic and fatal 

drug use, abuse, and its consequences. Best practices to improve the quality and consistency of 

death investigation have been recommended by the National Association of Medical Examiners 

(a national medical examiner professional organization) and by Federal agencies such as the 

National Institute of Justice (5,6). These recommendations will both enhance the quality MDI and 

assist law enforcement, public health, and safety responses to the opioid and drug epidemic (5,6). 

In order to reduce variability in the practice of death investigation and certification in response 

to the opioid crisis as well as enhance the quality, reliability, and accessibility of drug mortality 

data, the MDI systems throughout the nation must conduct standardized drug death 

investigation by medical examiners and coroners. Additionally, the collection and dissemination 

of timely, accurate, and reliable drug death statistics to stakeholder agencies are essential to

assist in effective public health, law enforcement, and public policy responses to the national 

drug-death crisis.

Best Practices and Standards for Death Investigation

Consistent and quality drug-related death investigations conducted by medical examiners and 

coroners that adhere to best practices is essential to reduce variability in the practice of drugrelated death investigation and certification and enhance the quality, reliability, and accessibility 
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of drug mortality data. Death investigation best practices and standards—for autopsy, 

toxicology, death scene, medical and prescription history—need to be kept current to address 

the evolving threats from novel psychoactive substances as well as the continued involvement of 

pharmaceutical opioids and other drugs. Adherence to these best practices and standards, which 

include routine toxicological testing of postmortem samples, can be accomplished through 

increased funding and education. Toxicology should include mandatory testing for a standard 

panel of illicit and prescription drug analytes on all suspect deaths. A focused research needs

strategy includes identification of barriers to best practice implementations by medical 

examiners and coroners. 

Timely, Accurate, and Reliable Drug Death Data

Existing multiagency, cross-disciplinary data sharing and investigatory initiatives (e.g., RxStat 

Initiative in New York, Maryland Local Overdose Fatality Review Team) should be expanded to 

support nationwide data coordination (7). Epidemiologists and statisticians can utilize the data 

in conjunction with medical examiners and coroners to inform federal, state and local policy and 

programs. Specific needs include funding for upgrades to outdated and inadequate medical 

examiner/coroner databases, upgrades of medical examiner and coroner information technology

infrastructure, and for developing compatible data systems for interoperability among 

jurisdictions. 

Developing local, regional, and national incident surveillance systems to improve outbreak 

detection of deaths involving illicit opioids (including heroin and illicit fentanyl) is imperative. 

This will allow reporting and monitoring of specific drugs and facilitate a rapid and effective 

response by all stakeholders. 

References

1) Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid Overdose Deaths-United 

States, 2000-2015. MMWR Morb Mortal Wkly Rep. 2016 Dec 30; 65(50-51);1445–1452. 

Available at https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm. 

2) Xu JQ, Murphy SL, Kochanek KD, Arias E. Mortality in the United States, 2015. NCHS data 

brief, no 267. Hyattsville, MD: National Center for Health Statistics. 2016. Available at 

https://www.cdc.gov/nchs/products/databriefs/db267.htm.

3) National Research Council of the National Academies. Strengthening forensic science in the 

United States: A path forward. Washington DC: National Academies Press. 2009. Available 

from: https://www.nap.edu/catalog/12589/strengthening-forensic-science-in-the-unitedstates-a-path-forward.

4) National Science and Technology Council. Strengthening the medicolegal death

investigation system: Improving data systems. Office of Science and Technology Policy. 

Washington DC: 2016. Available at 
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https://obamawhitehouse.archives.gov/sites/default/files/microsites/ostp/NSTC/strengthe

ning_the_medicolegal_death_investigation_system_final.pdf

5) US Department of Justice, Office of Justice, National Institute of Justice. Death 

Investigation: A Guide for the Scene Investigator. Washington, DC: 2011:1-49. Available at 

https://www.ncjrs.gov/pdffiles1/nij/234457.pdf. 

6) Davis GG, National Association of Medical Examiners and American College of Medical

Toxicology Expert Panel on Evaluating and Reporting Opioid Deaths. Position Paper: 

Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to 

Opioid Drugs. Academic Forensic Pathology. 2013 Mar; 3(1):77-83.

7) U.S. Department of Justice. Addressing the heroin and opioid crisis. U S Attorneys Bulletin. 

2016; 64 5. Available at https://www.justice.gov/usao/file/895091/download.