In Part II of this exposé, we discussed an overview of how medicolegal death investigations (MDI) are carried out, the agencies and individuals involved, the data that is captured, errors in data and or interpretation, the lack of a standardized approach to death investigation, and other problems related to how these investigations are carried out.
We’re going to start this piece by delving into more shocking information in regard to process failures in local death investigation and expound on some of the issues we discussed previously, and we’re going to discuss how these issues destroy the credibility of the alarmist data being proffered up as justification for denying a particular type of care to millions of people. This information also discredits the federal agencies responsible for the narrative surrounding the overdose crisis, not only for exploiting the known system failures that exist at the local level, but also for their own intentional manipulation of the statistics at the national level among other things.
Extreme Variations in Education & Training of Death Investigators
The Association of State and Territorial Health Officials (ASTHO) mentions that education is an important issue that needs to be addressed when it comes to drug specificity on death certificates for both medical examiners and coroners, however, the problems don’t stop there. 
According to ProPublica, PBS FRONTLINE and NPR:
“The qualifications of those who oversee death investigations vary widely from state to state — and, in some areas, from county to county. But the main divide is between medical examiner systems, run by doctors specially trained in forensic pathology, and coroner systems, run by elected or appointed officials who often do not have to be doctors.”
“In many places, the person tasked with making the official ruling on how people die isn’t a doctor at all. In nearly 1,600 counties across the country, elected or appointed coroners who may have no qualifications beyond a high-school degree have the final say on whether fatalities are homicides, suicides, accidents or the result of natural or undetermined causes.” 
While I’m not anti-coroner (rather, pro-training), it seems absolutely absurd to me that we are relying on data collected by people who often have absolutely no medical training, and this data goes on to inform public policy. There’s no doubt that the profession requires reform but that will prove to be difficult at best without better incentives for those already working in the field as well as appropriate resources among other things.
While the truth is often stranger than fiction, the truth gets even more bizarre when you realize that many of the physicians who carry out death investigations are not even certified to carry out such a task:
“Many of the nation’s busiest coroner and medical examiner offices employ physicians who are not certified. A survey of more than 60 of the nation’s largest medical examiner and coroner offices by ProPublica, PBS “FRONTLINE” and NPR found 105 doctors who have not passed the exam — or more than 1 in 5 doctors on their full-time and part-time staffs.” 
It’s important to note that “by most estimates the United States has only 400 to 500 full-time forensic pathologists. It’s a tiny cadre of professionals for a country where roughly 2.5 million people die every year.” 
Keep in mind that most people live in an area where only a coroner is available and that PBS FRONTLINE and NPR surveyed some of the nation’s busiest coroner and medical examiner offices that employ actual physicians. Investigating the smaller ones that don’t process as many decedents may yield even more interesting information. Many of these doctors who aren’t certified failed their exams repeatedly and these are the folks along with coroners who often have no training at all that are sending data up the line that make it to CDC via state vital statistics. Another thing to consider is that these investigators have an incredibly high case load which creates an environment where these offices become a breeding ground for oversights and mistakes which have also been studied in depth by PBS FRONTLINE and NPR in their eye opening piece on the subject, and this piece does not stand alone, there have been many other articles and even studies carried out by others that have communicated similar issues.
The endemic problems and failures in the field have even made it into popular culture in recent weeks via HBO:
Few Actually Receive an Autopsy
It’s important to recognize that not every decedent that dies under suspicious circumstances goes through the entire death investigation process, at least not in the way it’s been depicted on popular TV shows. The fact of the matter is, few receive an autopsy. A little over 8% of US decedents are autopsied annually and this percentage is not likely to improve any time in the near future due to funding and other constraints.
The CDC says that: “From 1972 through 2007 autopsy rates declined for deaths from disease conditions from 16.9 percent to 4.3 percent and generally increased from 43.6 percent to 55.4 percent for deaths from external causes. The rates for deaths from ill-defined conditions were 26.4 percent in 1972 and 29.1 percent in 2007”. 
With these statistics, it’s even more curious to consider the official narrative as it relates to the overdose crisis. If many chronic disease patients with painful conditions were on opioid therapy at the time of death which were certainly at least nominal contributors to the overdose crisis if the CDC’s narrative and data are correct, the fact that only 4.3 percent of these types of patients are autopsied within the whole 8% of autopsies conducted annually means that true causes of death may have been missed in a large percentage of these patients which would make the statistics wrong, again.
The remaining 95.7% of these patients did not receive an autopsy which would have either confirmed or altered the cause of death, whether circumstantial or not, if the disposition was “overdose”. What do I mean by that? Well, when death investigators log a cause of death on a death certificate for “overdose”, oftentimes they will use circumstantial evidence to support their disposition such as pill bottle’s, prescription history, the presence of illicit drugs or drug paraphernalia at the scene. In many cases this is how the disposition is reached without ever conducting an autopsy.
For very sick chronic disease patients who have “overdose” listed on the death certificate (who may have actually died due to complications of disease), it seems absurd not to conduct an autopsy in these cases and instead rely on circumstantial evidence found at the death scene or via prescription history. In some cases, when toxicology screening is actually carried out, the simple words “opioids” or “overdose” may be logged on the death certificate if this class of drugs is found during the screening process, but it doesn’t necessarily mean that the drugs, prescription or otherwise, were the catalyst to death; it simply means that the drugs were present. Still, in many cases the cause of death is listed as an “overdose”, even if that hasn’t been definitively proven.
It’s important to note that “previous work has shown that about 25% of U.S. overdose deaths had no drugs specified on the death certificate.”  Authors of the paper I just quoted use this percentage to make the claim that drug overdose deaths are likely much higher but that is a dangerous assumption, especially considering how few actually receive an autopsy (or toxicology screening for that matter).
When you really dig into the infrastructure we have for “tracking” these things, it’s wrought with serious problems, much of which we discussed in Part II of this exposé. If autopsies are performed only 8% of the time, then it’s impossible to say in other cases whether drugs were actually the cause of death in some cases, especially if toxicology screening was also left out. It’s obvious that a complete system overhaul of our death investigation system is required if we are to source even half accurate statistics on the overdose (or any health) crisis and there are other serious problems when it comes to state vital statistics as well which I will detail another time. When it comes to intervening in American lives, we need facts not extrapolations based on personal bias, lack of resources or other systemic issues and unfortunately, much of how this information is collected is based on opinion related to circumstantial evidence and formed by individuals that for the most part lack education, certification, resources or a standardized approach to collecting MDI information. These are problems that the CDC and other federal agencies are keenly aware of and appear to have exploited for their own purposes.
These kinds of issues in large part are why it was so easy for the CDC (and others) to dupe the nation using garbage data which was then communicated to you, the public, via hysterical news coverage which make it seem as if your own grandma will get “addicted” to pain killers if they’re within several feet them. When you begin to look deeper into this information, it becomes clear that much of the official narrative surrounding overdose death rates is engineered and I will go into depth on all of the remaining issues we haven’t covered yet in the future.
It’s also of import to note that in some states, it’s admitted that if every overdose or suicide was investigated to the point where the disposition was beyond reproach, it would be “all consuming” and many offices simply don’t have the resources to keep up. They essentially won’t bother if it’s an “obvious” cause of death.
“Because of the grueling pace, the state has had to impose limits on the types of cases it investigates…If we did an autopsy on every suicide, it would be all consuming, as with drug overdoses.” 
The main takeaway is that we’re missing the mark if death investigation has this many systemic problems and we aren’t even done detailing them all yet.
Toxicology Screening is not Always Carried Out When Drug Overdose is Suspected
It’s not only autopsies that are often not completed for the reasons stated above, it’s also become routine not to complete toxicology screens: “medical examiner and coroner offices are overtaxed, so it has become routine to complete minimal toxicology and often no autopsy, even though this is against all standards. The offices are doing their best to keep up.” 
“Forensic toxicology testing is essential for the accurate identification of involved drugs, including the novel psychoactive substances (NPS). However, the USA has no nationally-accepted best practices, standards, or guidelines for postmortem toxicology testing. Further, it is noteworthy that many ME/C jurisdictions do not test all suspected drug overdose deaths for NPS drugs, including fentanyl and fentanyl analogs.” 
So essentially, many simply don’t even bother testing for NPS drugs like fentanyl or its analogues despite the fact that its presence on the streets has prompted a state of national emergency. A standard national criteria for toxicology testing just may be helpful in guiding different jurisdictions on what they should be testing for. Toxicology tests are also expensive and the staff needed to interpret the findings carry costs as well. Further, funding for toxicology is an endemic issue and often the reason why minimal toxicology testing has become routine, these issues should really be resolved before we craft policies that interrupt people’s lives. Maybe the federal government would be wise to upgrade the nation’s death investigation infrastructure so that we might have something other than garbage data to rely on for public health policy. Instead, they focus on arresting doctors and destroying peoples lives because a tiny percentage of people addict or overdose on street drugs (which they’d know if they were half way competent).
CDC Duped the Nation
Many decedents who end up with “drug overdose” as their cause of death on the death certificate will also only have one drug or a class of drugs listed, even if it’s possible that multiple drugs or even diseases were involved in catalyzing death which doesn’t bode well for continuing faith in a system that is continually screaming that the sky is falling. Even so, class of drug is simply too broad when you consider the amount of illicit drugs on the street. Drug specificity on death certificates is an absolute must if this information is going to continue to be used to justify interventions into people’s lives and medical care, most of which is based on conflation of terms, shoddy data collection and or intentional manipulation of statistics.
It’s pretty clear based on the fact that prescription opioids are now essentially impossible for patients to obtain, that illicit substances are what drive the overdose crisis but you can see how this would be missed by CDC and others if many ME/Cs do not test all suspected drug overdose deaths for NPS drugs including fentanyl and its analogues. The types of fentanyl that are out on the streets are never prescribed by physicians, they’re illicitly manufactured street drugs that are currently killing with impunity. As I mentioned in Part I with a quote from CDC, “because heroin and morphine are metabolized similarly, some heroin deaths might have been misclassified as morphine deaths” which also skews the statistics on “prescription opioids”. The “prescription opioid crisis” is an artificial crisis and as such, it’s not difficult to see why overdoses are expected to rise despite heavy handed federal interventions into patient care and people’s lives. Public health officials are focusing public health interventions in the wrong direction and I’m beginning to think it’s intentional. Why do I say that?
In 2016, the CDC published a study detailing 59 deaths in Minnesota between 2006 and 2015 where decedents died of pneumonia and also had a prescription for opioids. The CDC made the case that such deaths should be recorded as “overdose deaths”, instead of pneumonia. 
Here’s a confused monkey…
It’s interesting that CDC was going out of its way to look for decedents with opioid prescriptions that died of pneumonia in the middle of the crisis. If they were so confident that this was a “prescription drug overdose crisis” and their data “proves it”, then it seems peculiar at best for them to go on a fishing expedition to find decedents who died of pneumonia who also had a prescription for opioids and then call for those deaths to be re-categorized as “overdose deaths”.   I’m curious how many other times they may have engaged in this type of fishing expedition. It’s important to recognize that “opioid deaths are a bureaucratic category, not a scientific conclusion.”  The CDC report goes on to say that “we described UNEX-identified deaths with toxic opioid levels found at autopsy during 2006–2015”  only, there is no known reliable deadly dose for opioids because every person is different in regard to how their bodies process drugs.  
Another thing to consider is that without knowing the time of death, it’s difficult to gauge how much of a drug a person may have taken. This is due to a process called postmortem drug redistribution. “Postmortem redistribution (PMR) refers to the changes that occur in drug concentrations after death. It involves the redistribution of drugs into blood from solid organs such as the lungs, liver, and myocardium.”  A “toxic dose” for you may be a perfectly therapeutic dosage for someone like me or vice versa so other variables do need to be considered for an accurate cause of death. The simple presence of opioids whether found via toxicology or circumstantial evidence (and no subsequent toxicology screen) should not automatically decide the disposition but CDC and other federal agencies have exploited these problems in MDI to suit their own agenda. Billions in tax payer money is just waiting to be grabbed up after all and it would be a tragedy if researchers and others couldn’t have some of it.
Accurate analysis of overdose mortality data is complicated by varying technological capabilities between jurisdictions, including a lack of toxicology screening or autopsy in most cases, educational variation within the field, and a lack of resources and funding. The data itself is complicated by bias, uneducated opinions, intentional manipulation of data and shoddy investigative work that isn’t backed up by autopsy or toxicology in most cases.
These kinds of systemic issues are simply unacceptable and the way information is sourced in many of these cases should automatically exclude this type of data from influencing public health policy and interventions into peoples lives that have harmed far more people than they’ve helped.
We will discuss more about how these policies and interventions are harming people in future articles but one thing is clear, the systemic problems within government, both state and federal, are close to insurmountable and yet we’re expected to put our trust, lives, and healthcare in the hands of government while they experiment with what doesn’t work because their agenda is more important to them and that’s just not something the American people should stand for in an age where technology and knowledge are ubiquitous.
Special thanks to the administrator of truth0rdare.com, for their incredible arguments which they allowed me to expound on in this piece, Josh Bloom, PhD for his work explaining metabolism rates among other important nuances, and finally the patient community for their steadfast support. Thank you all for your contributions, support and guidance.
 Association of State and Territorial Health Officials 2018 http://www.astho.org/Rx/Improving-Drug-Spec-and-Comp-on-Death-Certs-for-Overdose-Deaths-Meeting-Report/
 The Real CSI: How America’s Patchwork System of Death Investigations Puts The Living At Risk https://www.pbs.org/wgbh/pages/frontline/post-mortem/real-csi/
 CDC — The Changing Profile of Autopsied Deaths in the United States, 1972–2007 https://www.cdc.gov/nchs/products/databriefs/db67.htm
 Drug Overdose Deaths: Let’s Get Specific https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4547584/ Svetla Slavova, PhD
 Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose: Svetla Slavova, Chris DelcherJeannine M. Buchanich, Terry L. Bunn, Bruce A. Goldberger, Julia F. Costich https://link.springer.com/article/10.1007/s40471-019-00201-9
 Red Pill on Opiate Deaths http://truth0rdare.com/2018/03/17/red-pill-on-opiate-deaths/
 Deaths Associated with Opioid Use and Possible Infectious Disease Etiologies Among Persons in the Unexplained Death (UNEX) Surveillance System — Minnesota, 2006–2015 https://www.cdc.gov/media/dpk/cdc-24-7/eis-conference/pdf/Infectious-disease-complicates-opioid-overdose-deaths.pdf Victoria Hall, R. Lynfield, N. Wright, L. Hiber, J. Palm, J. Christensen, K. Smith, S. Holzbauer
 Opioid Policies Based On Morphine Milligram Equivalents Are Automatically Flawed https://www.acsh.org/news/2018/10/23/opioid-policies-based-morphine-milligram-equivalents-are-automatically-flawed-13529 Josh Bloom, Ph.D.