No standard exists in PA to accurately track heroin overdose deaths

Written by Ben Allen, General Assignment Reporter | Apr 9, 2015 4:33 AM

(Harrisburg) -- Heroin abuse has reached crisis levels in the commonwealth and across the Northeast.

But, determining the full scope of the problem is proving harder than one might think.

Without a single standard in Pennsylvania, each of the state's 67 county coroners and medical examiners operate under their own set of rules.

"Well, I would be looking for this 6, what we call 6 mam or monoacetylmorphine. It's a metabolite that is found in heroin," says Dauphin County coroner Graham Hetrick, explaining how his office handles determining when a suspected overdose can actually be called a heroin overdose.



Photo by Ben Allen/witf, courtesy Dauphin County Coroner's office

A typical toxicology report will list "positive findings", which coroners/medical examiners then have to use in making a cause of death determination.

The toxicology report is just one piece that goes into making a final ruling. His staff also looks at evidence that might be found during the investigation.

"We take all drugs that are at the scene, you'll see the pill counter over there," says Hetrick. "We many times see heroin packets in the house, and then we look up, they actually have stamps on them many times, and so we'll try to figure out and document that."

Staff might also talk to people who knew the deceased person. But, Hetrick says the toxicology report is the biggest factor.

This is the process for one office. All 67 counties in Pennsylvania have their own checklist, and often times, it's different.

"Any physical evidence at a scene as far as baggies, syringes, that's collected by the police departments," says Berks County Assistant Chief Deputy Coroner Jonn Hollenbach.

Could that still play a role in making a determination?

"Probably not," he says.

So before anything is even submitted to the state, county coroners already have different factors that could affect a decision on whether a death is a heroin overdose, multi-drug toxicity, or a drug overdose.

Why this matters

"It's absolutely critical," says state Department of Drug and Alcohol Programs Secretary Gary Tennis. "It helps us determine where we need to put health resources, law enforcement resources. It actually is a matter of life and death that we get good statistics. We know that quality varies from county to county and varies from state to state."

Tennis says coroners might defer to the family and mark an overdose as respiratory arrest on the death certificate. If that happens, the heroin epidemic will look smaller than it actually is.

"This is a disease like any other disease. And we absolutely need, 100% accurate reporting. All of government does because we can't address the problem if we don't have a good grasp of exactly what the problem is, where it is, how bad it is, what drugs are involved, who is overdosing, all that information we've got to have."

In York County, the heroin epidemic has hit hard. 56 people died from a heroin overdose last year, up from 17 in 2013. County Coroner Pam Gay says when she took office last year, she decided to make compiling an accurate count of heroin deaths a priority.


Photo by Ben Allen/witf

York County Coroner Pam Gay has aggressively tried to get a handle on heroin's reach in the county, going so far as to document "heroin-related" deaths on top of the numbers submitted to the state.

"Sometimes on death [certificates], heroin's written as a cause of death, sometimes it's not. A lot of it has to do with mixed drug toxicity, and if there's other drugs involved," she says. "It's very confusing in Pennsylvania, as well as other states. And it's very coroner specific, it depends on how the coroner does things. We actually went back and separated out all our opiate overdoses to make sure we were accurate and knew exactly how many heroin [overdoses] we had had."

Gay even goes so far as to do a count for her own office's internal use that includes overdoses where the user may have thought they were getting heroin, but instead took another drug, like fentanyl.

On the western side of the state, in Allegheny County, Medical Examiner Dr. Karl Williams has practically made heroin overdose reporting real-time.

There's still the question of what exactly makes an overdose death heroin-related.

"What they get back from that lab is a list of drugs that are present. It's up to the individual coroner to turn that into a death certificate, so there's no standards with how they do that," says Dr. Williams.

But guidance does exist , from the National Association of Medical Examiners. Dr. Kurt Nolte, who helped write the guidelines, says Pennsylvania has to do better.

"Well I would hope it's not very difficult because [medical] legal death investigations are platforms that are supposed to support public health and public safety," says Dr. Nolte.

What's available right now

The state Department of Health's most-recent publicly available drug overdose numbers are for 2012, and don't go into detail about any specific drugs like heroin. The Department didn't respond to multiple requests for comment.

In early 2014, the Department of Drug and Alcohol Programs started to collect more information. It now asks coroners and medical examiners across the state to fill out a two-page form, with room for listing out every substance that was found in someone's system, plus any evidence collected from the scene.

There are also efforts to collect data from hospitals and ambulance providers, but the Secretary Tennis is frustrated.

He says, "None of those reporting systems are really complete in terms of giving us what we need. I'll admit it we're struggling with trying to figure out how to bring those systems together and give us a more up to date accurate picture."


Photo by Ben Allen/witf

Secretary of Pennsylvania's Department of Drug and Alcohol Programs Gary Tennis, shown here at a recent press conference announcing that State Police cars will be stocked with a life-saving drug called naloxone, has been vocal on importance of rigorous statistics.

Indeed, Tennis sounds unsure about what his agency will eventually have.

Meanwhile, the state Office of Attorney General is also trying to put together its own database, but it's still in the planning stages.

Which means, the best option may be the Pennsylvania State Coroner's Association, which is gathering numbers for 2014 heroin overdose deaths on its own.

"Statistics are very important to really understand the problem and to plan a way to beat the problem," says York County Coroner Pam Gay.

"Me talking about it doesn't enact change at the state level, and I know that."

It's the deaths that grab the attention of lawmakers, public health advocates, and the public. But when overdoses are calculated in different ways and aren't up to date, do they really capture the scope and depth of the problem? Leaders in addressing the heroin epidemic hope it will one day be in decline, and real numbers will prove it.

Coroner Drug Death Report by Ben Allen

This story is part of Real Life l Real Issues: Drugs and Young People, an in-depth multimedia project exploring dangerous drug use. It's a partnership of WITF, the Pennsylvania Association of Intermediate Units and the Pennsylvania Association of Elementary and Secondary School Principals and the Pennsylvania Department of Education.

This story was produced in collaboration with the non-profit journalism outlet PublicSource, based in Pittsburgh. Reporter Jeffrey Benzing contributed to this story. PublicSource's heroin topic page is here.

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