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Judy Melinek, M.D.

Heath Ledger. Philip Seymour Hoffman. Tom Petty. Prince.

The list is staggering—victims of accidental opioid overdose, taken away at the height of their careers. The press focuses on celebrities, but physicians who treat patients in emergency rooms and chronic pain clinics all over our nation are watching the bloom of an epidemic. The patients are the ordinary victims: the high school quarterback addicted to opioids after shoulder surgery; the contractor who still needs disability paperwork and more pills months after an occupational injury; the office worker with chronic pain from fibromyalgia. Their pain is real, but their deaths are avoidable. Their addiction extorts steep but hidden costs throughout our society. The impact of opioid addiction to individual productivity and national GDP was estimated at $504 billion in 2015. I’ve heard from employers in fields like construction and trucking who can’t fill needed jobs because applicants can’t pass the drug test. The opioid epidemic is killing our people and maiming our economy.

What is the impact to physicians?

We’ve all encountered doctors who are hesitant to treat chronic pain patients because of concerns about overmedicating, or being flagged for investigation by hospital systems or state databases. They’re afraid—not without reason—that they might get sued or even prosecuted over an overdose death. Their under-medicated patients then resort to heroin or other street drugs—which can be laced with synthetic drugs that are even more likely to kill them.

What is the impact to forensic pathologists?

From a forensic pathology perspective, it is rarely a single drug that kills someone. More often, I find that users overdose on a combination of several drugs, some prescribed and some purchased on the street or borrowed from friends or relatives. It is also not unusual for me to see overdoses in patients who have been stable on their medications for a while but decided to add some alcohol to the mix after a night out with friends, not knowing about the synergistic respiratory depressant effects. Underlying medical disease also plays a role in increasing the likelihood of death from opioids. If an obese patient has obstructive sleep apnea, the likelihood of a nighttime apneic episode and fatal cardiac arrhythmia increases if they are also on multiple opioid analgesics for conditions such as osteoarthritis, a disease which is more common in obese individuals.

What is the impact to public health?

Coroners’ offices overwhelmed with opioid cases aren’t hiring more forensic pathologists to meet the workload. Instead they are doing fewer autopsies with the same staff by ordering external examinations with toxicology on suspected overdoses. This is a violation of forensic pathology death investigation guidelines. It has triggered a crisis of public accountability as families of the deceased question whether there was a complete forensic investigation. We already have only half the forensic pathologists nationally we need to examine the current caseload, without factoring in the steep climb in drug overdoses. Forensic pathologists are burning out, quitting or shifting to other specialties. It’s a death spiral in death investigation, and it’s happening all over the nation.

When should a pathologist do an autopsy?

The apparently “lethal” levels of opioids in any addict’s system may be normal for that highly drug-tolerant individual—and inside those individuals I frequently find another cause of death that is only evident after I use my scalpel to uncover it. For example, I once autopsied a woman who had collapsed in the kitchen while cooking eggs. She had a fentanyl patch on her right arm. When I tested her fentanyl level, it was in the “fatal” range for most individuals. Then I reviewed her medical records and found that she had been following her doctor’s instructions and slowly tapering down her daily dosage. Our medio-legal investigators analyzed her pharmaceutical data and counted the remaining prescribed patches at the death scene, confirming that she wasn’t over-utilizing the fentanyl. Furthermore, her autopsy revealed significant heart disease that would explain a sudden collapse while engaging in routine daily activities. A cardiac arrhythmia drops you suddenly. Fentanyl overdoses generally don’t.

That woman’s fatal heart attack is a natural manner of death—but I was also trained to autopsy everyone who has a substance abuse history because these patients die disproportionately from accidents, including drug intoxications and trauma that may not be evident unless you cut into the body. An intoxicated stumble can cause a lethal subdural hemorrhage without external evidence of head injury. Hepatitis C cirrhosis can cause a coagulopathy, which increases the risk of internal bleeding, and hep-C is common among injection drug users. Without doing an autopsy, I would potentially miss the real cause of death. This is why an external examination with toxicology is likely to result in incorrect death certificates that artificially inflate the rate of opioid mortality.

What has been the government’s response?

The federal government hasn’t put enough money into the fight against our national opioid epidemic. They declare emergencies and issue press releases, but no federal agency has allocated resources that come close to matching the rhetorical bluster. Meanwhile, state-level public health officials want and need to hire treatment professionals, acquire and distribute opioid-blocking emergency injectors, and research novel pain treatments that don’t require opioids. They don’t have the funds to meet these needs.

What has to be done?

Chronic pain is not going away, and we cannot allow its treatment to continue to be a leading cause of excess mortality in the United States. In order to tackle the opioid epidemic we need a multifaceted public health approach that engages practitioners who are prescribing the drugs, funds drug rehabilitation care completely, and boosts the operating budgets of front-line agencies like medical examiners and coroners, poison control, and first responders. Law enforcement tactics are reactive and will not prevent deaths. We doctors need to advocate for our patients—and we need to lobby politicians to support legislation that comes with funding attached. Beating back this tide won’t be easy. We, as a nation, cannot do it on the cheap. We can’t afford to.

Dr. Judy Melinek is a forensic pathologist who performs autopsies for the Alameda County Sheriff Coroner's office in California. Her New York Times Bestselling memoir “Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner,” co-authored with her husband, writer T.J. Mitchell, is now out in paperback. She is also the CEO of PathologyExpert Inc.

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