SMART Policy Podcast
Podcast by the UT SMART Initiative. Host Jeremy Kourvelas speaks with experts from across the recovery ecosystem - representing healthcare, prevention, law enforcement and more - about local, state and federal drug policy to find out what is and isn't working to make this fight against addiction a little easier.
SMART Policy Podcast
Decoding Autopsies: What Medical Examiners See That Others Miss
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You're listening to the Smart Policy Podcast, a production of the University of Tennessee's Institute for Public Service. When the CDC reports that almost 4,000 Tennesseans died of a drug overdose in 2023, it can be easy to forget that each one of those numbers represents a human being that was found deceased, investigated by law enforcement, and was analyzed by a medical examiner. Every death is an individual story, and each story is only known insofar as we have all the facts. Determining the facts comes down to forensics. And when it comes to the overdose crisis, with drug trends that are constantly changing, forensics is no simple game. Especially when it comes to new drugs like xylazine, designer benzodiazepines, and rare fentanyl analogs.
SPEAKER_02There are times when we have scenes where there is obvious drug payer phenolia present, their toxicology comes back clean. The typical expanded panel on a toxicology does not include these rare drugs.
SPEAKER_00My guest this month is Chris Thomas, the Chief Administration Officer of the Knox County Regional Forensic Center, which serves 23 counties in East Tennessee as one of the state's five regional forensic centers. From his bird's eye view of the overdose crisis, he can tell us a lot about what's happening on the ground, as well as where there are gaps in the system.
SPEAKER_02There is a large, I'll say, undocumented drug problem in the state, and not be not necessarily even just the state, it could be other place in the country. Because when you're dealing with something like a forensic center or a medical examiner's office that's dealing with taxpayer funds, you have to be very careful of where you spend your money, and you only have a certain limited budget.
SPEAKER_00There are many valuable insights into the state of overdose forensics in Tennessee in this conversation, such as how medical examiners rarely get access to mental health records or the proportion of traffic fatalities involving drugs. But the biggest takeaway for me was what the next wave of the drug crisis might be.
SPEAKER_02Coroners are elected, and Tennessee is not a coroner state. So if you hear the term coroner in the state of Tennessee, something's wrong. You should only be hearing the term medical examiner, and that's someone who is appointed by the county mayor uh to serve as the medical examiner and to investigate those deaths. Um Tennessee uh additionally is unique because of our location, specifically, and I know we're going to talk more about this about the um the drug trend, but that 7540 um crossover, that is a major, major highway for uh drug trafficking. And uh a couple years ago, I was attending a uh drug task force for the state meeting, and they were talking about the total number of overdoses for the state. And then I was looking at the overdoses that my office had investigated between Knox and Anderson and the other 21 counties. And at that point in time, we attributed to almost a third of the number for the entire state of Tennessee, which we only have a fourth of the county. So that tells me that there is a larger abundance of drugs coming through this area. But there's actually more reasons for that. And I'll talk about that a little bit too. Several years ago, um, we started seeing new and rare drugs coming into. Of course, it for years had been the fentanyl and methamphetamine, and that had been, you know, your your your two largest drugs, and they still are. Um, however, there started being this um new trend of these certain nidazines that have started coming through, this metatonidazine, protonidazine, and then you had the um um I call the azolams, the bromazolams. And um, what we had found out is um the typical expanded panel on a toxicology uh does not include these rare drugs. Parafluofentanyl was one of them that came in um hot and heavy a few years ago. And we pay a certain price point through our toxicology vendor for an expanded panel, which covers so many drugs. Well, if you wanted one of these drugs also listed and quantified on your toxicology report, the cost for a single test of this drug was almost twice what your total expanded panel cost. So, what happened is we would have to either pay that price, or especially if it was coming from one of our outside counties, we would have to talk to that medical examiner to see if they wanted to cover it. Well, a lot of times they didn't. They're like, okay, we know they had methamphetamine or fentanyl, that's good enough to kill them with. You know, didn't mean to make light of that terminology, but that's really what a medical examiner's job is determining what kills them. So if you have enough information to say what they died from, that's what goes in the death certificate. Right. Well, um, through um the overdose fatality review team meeting, I was introduced to a program called DEA toxicology. And they have a toxicology center there that studies for the DEA these new drugs. And through an agreement, they um offered to test our substances for free. So what we would do is we would send it to our toxicology vendor. If they come back and said, Hey, we think you have one of these substances in there, you know, like, do you want to pay for it? We're like, no, thanks. We would take another vial and we would send it out to um California and we would have it tested, and that's how we got the results. So when I say that we have a lot more drugs in our region, I found out that we are one of the few places that use the DEA for their free toxicology program. A lot of the centers don't want to spend the extra money or time or tracking. So there is a large, I'll say, undocumented drug problem in the state, and not meet not necessarily even just the state, it could be other places in the country because when you're dealing with something like a forensic center or a medical examiner's office that's dealing with taxpayer funds, you have to be very careful of where you spend your money. And you only have a certain limited budget.
SPEAKER_00This so so you what you're saying then is it's not just that this area, so we we obviously do run a major trafficking route, that makes sense, but it's not necessarily that we're exclusively experiencing new emerging threats like nidazines and whatnot, or designer benzodiazepines, it's just that we're one of the few areas testing for it.
SPEAKER_02That's correct. We're the one of the few areas reporting on it. The DEA releases their quarterly findings on their DEA toxicology program, and it does, you will see that there's a heavy presence from East Tennessee, and that's because anytime that we get something out of the ordinary, we send it to DEA. As a matter of fact, there are times when we have scenes where there is obvious drug paraphernalia present, their toxicology comes back clean, not a thing in them. We send that sample anyways to DEA toxicology, and they're able to sometimes find things that you know is not in the expanded panel. They were one of the early ones on the xylozine trials and one of the early ones with uh parafluofentol and metatonidozine. Now, your our toxicology panels have evolved. So um one one of the sub two of the substances, parafluofentyl and xylazine, that did used to be in the um special category, those are now in our expanded panel. So it's like after a few years of it, it will evolve.
SPEAKER_00Do you think overdoses in general are also underreported?
SPEAKER_02Oh, absolutely. Um, I I know that for a fact. Um, one is I a lot of your smaller county medical examiners, they don't have the funds to send every decedent for autopsy or examination to us or any other forensic center. I don't think it's a large number because we do get to see so many, but absolutely there are definitely drug-related deaths that are overlooked and missed.
SPEAKER_00Yeah, that makes a lot of sense. So, like the record will show, you know, respiratory failure or cardiopulmonary arrest or something like that.
SPEAKER_02Correct.
SPEAKER_00Gotcha, gotcha.
SPEAKER_02Especially in older individuals. So, you know, one of our data shows that we have we've had more and more rise and fatalities in individuals over 55 in the last several years. Now, we don't typically do a full autopsy on an older individual suspected of a drug-related death. We will send for toxicology, but go back to that unpopular phrase, we need something to kill them with. We have to have something to put on the death certificate. So if the toxicology comes back negative, there's enough medical history here to show a reason why this individual be would pass away naturally.
SPEAKER_00Uh, and if they have a smoking history, they're over 55, maybe throw in some other cardiovascular risk factors, it's pretty easy to stop there.
SPEAKER_02Exactly. But we'll still run toxicology, and then we just leave that death as pending until we get the toxicology back. You've also got the sort of uh it's it that you have the natural drug-related deaths as well, too, which don't go into the reporting. You have those that die of endocarditis, um, but there's a history of drug-related deaths, but it wasn't necessarily an overdose that killed them.
SPEAKER_00Or sepsis or something else. Yeah.
SPEAKER_02And then you've got um the whole debatable category of alcoholism. Alcoholism is a natural death, it's a disease, it is not considered a drug-related death. Um, during the pandemic, we had a 50% rise in alcoholism-related deaths, but they're natural. That's chronic alcoholism.
SPEAKER_00Sclerosis and liver failure, and right, right, right. That's an interesting split. Because that's, I mean, again, talk about polypharmacy. Alcohol use is still widespread amongst people who use fentanyl and meth because it's there.
SPEAKER_02It absolutely is, and it's a it's a large portion. And um, and let's not even we don't even want to go into the whole uh debate on THC and how it's related. Um, you have I've and I being an outsider, I for the last several years, I get to listen to both sides of the argument. You know, there are those that have called, you know, um uh THC as the gateway drug. You know, they're saying, you know, THC leads to this and this and this and this and this and this. So and then there are those that say THC has no direct correlation. So um once again, I can give you all the numbers in the world that you want. I'm definitely not the person that's going to sit out there and say this is why, this is not why. I leave that up to the experts. My job is to give you the data and tell you what I see.
SPEAKER_00So, speaking of those drugs that are that you are tracking and saying nidazines, you mentioned a couple of others. What other trends should we be aware of? Because, for example, y'all were on the cutting edge of catching xylazine. What should people uh in this space be keeping in mind?
SPEAKER_02Obviously, of course, xylazine is the first one. We were we we started talking about this one years ago. Um, you got to figure all the counties that we serve. We saw the very first case of xylazine in 2018 with one case. The following year, there were five cases. In 2020, there were 20 cases. In 21, there were 40 cases. In 22, there were 72 cases. I'm not finished with last year, but it's over 120 cases of xylosine inside the toxicology in East Tennessee. So that's, you know, we we see almost one, almost a thousand drug-related deaths in the region every year. I think we're probably going to finish somewhere between nine and nine fifty this year once it's all said and done. Um, go back five years ago, and that number used to be in the four or five hundred. So we've doubled the amount each year or uh since in the last five years of how many people will die from a drug-related um illness. Um, and it's it's it's a mixture of things. It's also not just that, it's the quantification. I did a uh fentanyl trend and I looked at the quantifications of fentanyl over the last five years. So once again, this is Ng slash ML, so it's nanograms per milliliter. So in 2018, the averages uh or not the average, the range of all cases was between 0.51 to 140. So that was your range, 0.51 NG MBL MLs to 140. Um, fast forward to the this past year, and I've got a quantification through June 30th. So the range went the bottom range went from 0.51 to 0.31. But that high range went from 140 to 700. 700. And that's not even the highest. Back in 2021, we had a case with 820. Um, that was the highest, but yes, so 0.31 to 700, and that's just for the first six months. So the average in 2018 of amongst all cases of fentanyl was 15.11. The first six months of this year, the average was 28.42.
SPEAKER_00So more people are encountering fentanyl and mixing it with other drugs, and that's killing them. And then there are also individuals that are just taking gargantuan quantities.
SPEAKER_02The quantity is there, the the potency is there, there is no safe amount. So you're literally playing Russian roulette every time you ingest this substance.
SPEAKER_00Are you saying fentanyl is getting more potent?
SPEAKER_02It it seems like like the the strength of it is getting stronger, definitely the the quantification that's being mixed in. So um, whether or not that I can't tell you about the physical size of the sample that they're taking. We know all this stuff's made in clandestine labs. It's not medical grade, it's not something you're gonna pick up in your pharmacy. These are synthetic. Almost all cases have four MPP in it, shows that it's made from synthetic labs or norfentanyl. Um, but it is definitely deadlier, it's stronger. We see overdoses every day of the week. It's polypharmacy. It's people that are, it's more than one drug. It's it's it's never just, it's very rarely just fentanyl, or very rarely just methamphetamine. It's the two in combination with each other, or it's it's methamphetamine and cocaine, it's fentanyl and methane. Um the one trend that is so rare, which is such an odd thing because you hear about it, we have almost no cases of heroin anymore. There's probably less than a dozen deaths related to heroin in a year anymore.
SPEAKER_00Right. That's been something I've been in various trainings and presentations I've given. That fact has astounded people. Uh, that heroin is basically gone.
SPEAKER_02At first, the way it came, it was it was heroin mixed with fentanyl, is heroin cut with fentanyl. And that was your trend. Well, then it got to, and they were telling be careful if heroin it's cut with fentanyl. Then people actually got to where they were taking just fentanyl. And that was the trend. And people would actually admit to saying, hey, I use fentanyl. I mean, that was not a that was not something people said five, six years ago. They didn't say they used fentanyl, they say they were heroin users, and then somebody slipped their fentanyl into them. And then now you've got uh people that are taking fentanyl. Well, now that we're hearing from EMS when they're uh narcanning these individuals and they're being brought out of their high, they're actually being combative and they're upset with the EMS and law enforcement personnel. They are upset that that high was taken away or that low, whatever it is, that was taken away from them. So now you've got the xyosine is being cut into the fentanyl because for the specific purpose of people not wanting to be able to have that taken away from them. Because as we know, it's narcane resistant, so it's not an opioid, so you can't use an opioid antagonist to remove that. We're kidding ourselves if we think xylosine is going to be the last of the new things that people are gonna be taking. Obviously, it's it's rising at such an incredible speed that I do fear that it will, you know, one day replace it. People will just be asking for xyline. Well, they already are. It's a street drug called Trank. So um, you do already have people that are asking for that on the streets, and um something else will replace it in a few years, unfortunately.
SPEAKER_00Do you think nidazines are on track for that?
SPEAKER_02Um, I do not, and here's why, because they came in around 2019-20, kind of um, and they raised up really quick in 20 and 21, and then a lot of them just kind of dropped off. I don't see the nitazines, um, I don't see um metatonazine, pronounzine, hardly at all anymore. What I do see now, the only drug that I'm getting notified of anymore is bromazolam. Um, I get um probably every week or two, I get notified of a case or two with bromazolam in the toxicology. So that is that and xylozine are the two ones that I'm seeing regularly anymore.
SPEAKER_00So bromazolam being a designer of benzodiazepine.
SPEAKER_02It'll be interesting to see the trend. I'm really curious. One of the unique things about being a regional forensic center is um uh a year before last, we were notified um we had three different cases that came in. And actually, one was the city of Knoxville, one was Knox County, one was one of our outside counties that we serve. And all three of them had almost the exact identical toxicology with rare substances almost to the same user. So I actually got those three law enforcement agencies together and I said, you three need to talk because you know, if it wasn't for you know an agency like the forensic center, you they would not have been able to make those connections. And we do believe that there was a singular um dealer that had came into that in my dad, my parents' age, you know, if if someone was a drug user and um someone overdosed, everybody would like be hands off, like, whoa, I'm not touching that. That obviously killed them. Today we go to scenes where someone has died of an overdose, and that place is cleared out because they're like the mentality behind it is whoa, that must be some really good stuff. I want what they have.
SPEAKER_00I have heard Tommy Farmer, uh, he's the director of the Dangerous Drugs Task Force, uh, Tennessee Bureau of Investigation say almost exactly that.
SPEAKER_01This guy's phone was blowing up. Everybody wanted his dope. Even knowing that it resulted in a bunch of overdoses, people wanted his dope.
SPEAKER_00He's got the good stuff, was the thought. It's just uh it's it's a different era for sure, like you said.
SPEAKER_02Which circles back to the, you know, the thought amongst many that you know, substance abuse is a major issue, but it circles back to obviously a deep need for mental health. It is definitely a mindset issue. We also do a comparison in our drug-related death report on drug-related fatalities in which prescriptions to antidepressants, antipsychotics is a combination factor. And you'll see it did drop down this in 22, but in 21, I think it was pretty much close to 50% of all the drug-related fatalities that we had toxicology on also had some sort of antidepressant, antipsychotic, uh, some kind of medication like that involved as well.
SPEAKER_00And so to clarify, you're not saying those psychiatric medications cause the fatality, it's just they were also present indicating mental health treatment.
SPEAKER_02Correct. Yeah, and that's all we're yeah, that they were nowhere, they're not at all listed, of course, on any cause of death, but it just shows you these individuals are in some sort of treatment.
SPEAKER_00Right.
SPEAKER_02We classify, I'd say 90 to 95% of the drug-related deaths that we have, they're classified as accidental. The reason for that is because as a medical examiner, we have the legal authority to subpoena any medical record in the state. So it's back to that state issue, any any medical record in the state of Tennessee. However, there is a federal statute that's sort of a uh a subset of that that prevents us from getting access to substance abuse records and mental health records. So in the process of our investigation of determining the manner of death, we have a large portion taken out from us. So I get a lot of questions about do you think a lot of these overdoses are suicidal in nature? And my answer to that is I have no idea. And we won't have any idea unless I have access to those records because I don't know about tolerance. I don't know about historical drug patterns. The only times we are able to really classify drug-related deaths as suicides is if there's a note. I do believe, with everything in my my bones, that the suicide rate for drug-related deaths is extremely underreported because of lack of ability to investigate. We go through medical records of everything. We send requests to the facilities. Um they used to send them to us, but they've started denying them more in recent years. Um but yeah, most facilities in Tennessee will not share any mental health record with us anymore. Anymore. There was a time when they did. Um, there was a time even when local facilities that worked with individual substance abuse would provide us with records. But as they had updated their legal team, and when we send our administrative subpoenas, they have looked into the laws and said, Oh, wait, right here, CFR, and I don't, I apologize, I don't remember the actual law itself. Um, but the only way to get that is with the judicial subpoena. So the only way to get a judicial subpoena is to actually have charges pending and take the district attorney's office and go in front of the judge to be able to get those records. And they can't do that on a thousand drug-related deaths every year.
SPEAKER_00Okay, so this is actually a really great segue into something you mentioned very briefly up at the top of the conversation about the overdose fatality review team that Knox County had.
SPEAKER_02Our office played a you know a vital role in that team's uh creation and and development. And what we would do is we would take cases and like I said, we would have multiple lines of discipline involved law enforcement, um, mental health, the forensic center. Um, and what we would do is we would take these cases, identify, de identify them, and we would look for gaps. So, what we try to do is we try to figure out where is that where was that cry for help that could have been answered inside this individual's life? Was it During an incarceration? Was it during a rehabilitation program? Was it when they were released of their own recogniz uh of their own recognizance from a you know hospital or facility? But in the overdose fatality review team was we provide that information, we talk about it, and then the presentation would be given back about hey, these are our action items. I don't really know if we ever got to the action items. We were trying to build up a large enough case because we'd only do like five cases a month. So I think through the whole process, we may have gotten through a hundred cases before it's hiatus. And I know they're trying to reformat it now. And of course, we've just raised our hand and said, of course, we will be glad to participate and um uh whenever they decide what they want to do. So we've always believed if we have all this information, but if we don't do anything with the data that we have, then it's useless. So um, what's the point of collecting all this data if we can't make some kind of effective change in our community? I'm I'm I'm chomping at the bit now that 2023 is over and I've got my little numbers ticking and tracking, and I'm getting my reports ready. Now we're about uh 285 cases away from finishing out 23, and then I will be working uh as quick as I can to publish my 2023 drug-related death and my annual report, which on a um average I expect to have it done by May. So um, which would be all the 23 data. I can always give preliminaries of what we got going on. I can tell you 2023 for Knox County, um, it's down, it's gonna be down um uh from 2022, the first time in three years, but it's not when I say down, it's still probably gonna be close to 500. So if not over 500, and last year was around 550. So um you go back to 2019, that number was 291. So we're still seeing way too many drug-related deaths, but it is a slight decline.
SPEAKER_00We here at SMART are very eagerly awaiting that report because for so many reasons that we've talked about in this conversation, Knox County is such a bellwether.
SPEAKER_02And then you've got to look at the I never thought numbers were subjective until I got into this industry. And then I learned they are. Because, for example, the district attorney's office, they keep a uh a constant tracking on their offer-knocks, you know, um website. However, the DA's office and I look at two different things. So the D's office, and and and neither one are right or wrong, um, but it's just what we're looking at. So the D's office is looking for those that took the drugs in Knoxville, overdosed in Knoxville, and you know, died in Knoxville. But medical examiner's jurisdiction, which is our whole bread and butter, the whole thing that we're engaged by, is where you die. Doesn't matter where you got hurt at, it's where you die. We're responsible for any death in Knox and Anderson County. And many, many, many, many people travel here just to die. We have many overdoses that happen in counties and they go to their local hospital and they're transported to UT, Fort Sanders, Park West for a higher level of care and they die there. So, guess what? That's a Knox County death.
SPEAKER_00So they might be a citizen of another county, but because they passed away here, that ends up as a Knox County figure. Interesting.
SPEAKER_02That's correct. So when you see my numbers, um, I I I have this conversation always with the road roadway planning group because I I sit on that panel too, and we talk about roadway fatalities. I'll talk more about that in a second. But my numbers always twice as high. They're like, don't give those numbers. I said, they died here. I said, I I can put a subset and say these are for multiple counties, but uh this is how many people died in Knox County from a motor vehicle fatality. I would say close to 80% of all the fatalities that happen inside the county are in somewhat involved with either um unrestraints uh or having um some sort of substance on board, either by the decedent or the person who hit them, which I don't know anything about the living people.
SPEAKER_00So a quick question, because we pulled a report looking at statewide data, but uh it looks like DUIs that also uh relate to negligent manslaughter, so striking a a pedestrian, for example, are extremely rare.
SPEAKER_02Catch the word that you just said there, DUIs. Right that means catching them and charging them. Right. If we're talking single vehicle fatalities, there is no charges, there is no law enforcement investigation. A lot of these, unfortunately, they just die themselves and they don't take other people with them. And I do think because we get a lot of the pedestrian deaths, and many, many of these pedestrians have substances in their system.
SPEAKER_00The pedestrians themselves, yes.
SPEAKER_02Um, it's usually in the middle of the night walking across. Very rarely is it in I stumbled across the street accidentally. Um, I don't have those particular data, but you know, several of these have been ruled suicides. Um, several of them, of course, are just accidental crossing at the wrong street at the wrong time. Alcohol is a major uh factor.
SPEAKER_00No, I would imagine.
SPEAKER_02But just remember if law enforcement is not investigating, if there's no charges pending, they don't necessarily follow up and gather the toxicology information into Titan. That's something we've been working on here locally so that we can do better at. I mean, that's the great thing about this committee, is that we're all committed to how can we exchange information more accurately so that we have better data.
SPEAKER_00What policy changes might you like to see?
SPEAKER_02Oh, absolutely. My my my favorite policy that I would like changed is, of course, being able to access mental health and substance abuse records so we can have accurate data. All the policy changes I've gotten, that was kind of the the one that stands out. Obviously, there's always little policies that we have. I I understand, and I might be talking about this prematurely, but I understand that there's a request to um somewhere in legislature where they're talking about the medical examiners and they're wanting us to change what we put on death certificates when it comes into fentanyl. And they're wanting us to stop calling it a drug-related death of a fentanyl overdose. They're wanting to call it uh fentanyl poisoning. And apparently the reasoning for this is because some insurance companies are not paying out claims, and it does bother me that someone would want to, you know, say devalue the work that a medical examiner does and think that we can just change it to call it poisoning, so instead of an accidental fentanyl overdose, um just for financial gain of of insurance. It sounds to me like there that needs to be something through commerce and insurance and not through the medical health side of legislation. So I'm another thing that I would be of of some similar use, um I mentioned uh several times in this um uh podcast that um we don't always receive a lot of these individuals from the rural counties due to funding. So I talk to county mayors and county medical examiners all the time. And from a statewide perspective, it's like they're told they have to get all this data, you know, from their drug-related deaths. But yet they don't have the funding from the statewide level to be able to support the costs of sending them for autopsy in many of these cases. So um obviously I know that there was, I went to that uh opioid abatement council, and there's$95 million that's given to the state of Tennessee to, you know, come up with ways to prevent and offer rehabilitation resources and what this is are great, but you also need to be able to investigate those that do die. And when you have a lack of funding, um, it's going to deter from how much access to accurate information that you have. I'm a resource of data, but I'm not a policymaker. So I would just advise that those that are the policymakers who have the ideas and the creative thoughts of how to best utilize this. I mean, I'll be honest, I'm I'm a numbers geek. That's me. So if you want the numbers and you're thinking, if you're wanting to prove or disprove your fact, you can contact me and I can get you all the you know quantitative data to determine if you think what you think is correct or not, which I've done many a times. But it's just about having those right personnel in the right uh places in our other organizations, such as you know, UT's IPS and you know, the Smart Initiative, those individuals, you know, UT's um uh Pathways Project, um, just any other organization that can institute change with some viable data, I can get you some great data. Thank you, Chris.
SPEAKER_00I yeah, I I was gonna say you you call yourself a numbers geek, but man, y'all y'all make this world move, I tell you. Without people looking at the data and and breaking it down in ways that others can understand. It's just such crucial work. Well, thank you very much for joining me for the Smart Policy Podcast. I appreciate it.
SPEAKER_02Oh, my pleasure, Jeremy. Thank you.
SPEAKER_00For more episodes on in-depth discussions on Tennessee policies related to substance use disorder by a range of local experts. Please subscribe to us wherever you get podcasts and visit our website at smart.tennessee.edu. I'm Jeremy Corvellis. Thank you for listening, and see you next month.