U.S. health officials call the opioid crisis the worst public health crisis in American history. Deaths from opioid drug overdoses have quadrupled in the last 20 to 30 years. In fact, there are more opioid deaths than any other past American epidemic — heroin, crack and even AIDS — and opioids account for more deaths than either car accidents or shootings.

Even so, are opioid deaths underreported? Medical examiners and coroners are obligated to record exact details surrounding causes of death, such as listing the exact drug responsible for the death when death is from an overdose. Although healthcare providers use standardized coding to indicate causes of death, procedures for reporting and completing death certificates vary widely across the U.S., leading researchers of a new study to this alarming conclusion: it is very likely that tens of thousands of opioid-related deaths have been misreported.

New Study Finds Opioid Deaths Likely Underreported

The new study was co-authored by Jeanine Buchanich, a University of Pittsburgh biostatics professor. Researchers examined death certificates nationwide to gather the data. They set out to look for states that had high numbers of unspecified overdose deaths reported, and they discovered tremendous variations in the way different states report this data. For example, Buchanich’s team found that five states listed the cause of overdose as “unspecified” in over 35 percent of their cases occurring between 1999 and 2015. In Pennsylvania alone, the team found that half of all drug overdose deaths had no specific drug reported on the death certificate.

The team used statistical methods to use the number of actual reported opioid overdoses to then extrapolate how many unspecified deaths were likely due to opioids. Using Pennsylvania as an example, they found that in the 1999 to 2015 period, the state had likely underreported over 11,000 fatalities due to opioid overdose.

The University of Pittsburgh study is the latest of several studies to indicate the significant underreporting problem on death certificates. In 2017, a University of Virginia research team found similar results — that underreporting as well as errors in coding on death certificates indicated that opioid-related overdoses were likely 25 percent higher than what had been reported. A bombshell 2016 study out of the University of Washington found that these types of death certificate errors indicated that deaths linked to all drug and alcohol-related overdoses as well as to mental illness had been underreported nearly 200 percent in the last 30 years. 

Variation from state to state is caused by several factors. Lack of sufficient resources is a big contributor, as is lack of oversight expertise. When states use medical examiners (who are medical doctors) rather than coroners, the death certificates tend to be much more complete.

Overwhelming Numbers of Opioid Deaths

The elephant in the room is the sheer magnitude of the opioid problem. It’s so large that many state public health officials simply cannot keep up. Medical examiners and supporting staff are overworked and overwhelmed.

In the past, it has been standard medical practice to autopsy a body when an overdose is suspected. However, many states, like New Hampshire, have abandoned the practice of completely autopsying each body because they simply get too many. If the case is going to trial, or if they don’t know for certain the drugs that were involved in the overdose, a full autopsy will be done. In all other cases, they take samples for a toxicology report. By the time the results come in, the bodies have already been buried or cremated in most cases. Amazingly, each time New Hampshire medical examiners have suspected a drug overdose the toxicology reports have come back positive, every single time.

New Hampshire’s former chief medical examiner Thomas Andrew, now retired, says the situation is far from ideal and that the state medical examiner’s office is not entirely comfortable with the approach, but “we are left with this reality.” Andrew was called back in to work part-time because the state had far too many open cases. New Hampshire isn’t the only state where this is a problem either.

In 2018 in the United States, over 64,000 opioid-related overdoses are anticipated. As medical examiners across the country are overworked and burned out, they will begin to make mistakes and death certificates will likely be miscoded or undercoded.

Opioid Crisis is a “Perfect Storm”

Another issue is that the current number of newly graduating doctors who want to become medical examiners simply is insufficient to handle the barrage of opioid-related overdose cases coming in across the country. The chief medical examiner for Hennepin County in Minnesota describes the situation as “the perfect storm”; his county experienced a 60 percent increase in opioid-related deaths in one year — from 2015 to 2016.

In fact, there are only about 70 accredited medical examiner offices in the United States today. The accreditation board of the National Association of Medical Examiners dictates that the offices — not the individual doctor — perform no more than 250 autopsies each year. More autopsies lead to more mistakes. Too many, and the office is in jeopardy of losing its accreditation.

Perhaps the “perfect storm” description is right. Overdose deaths linked to opioids just keep rising. Too few new medical examiners are being produced by the nation’s medical schools. With the new underreporting research from these universities, the epidemic is likely worse than anyone thought.

Interview: On the Frontline of the Opioid Crisis with MedicineSafe