Study: State's overdose deaths are underreported, record-keeping fragmented
A fragmented system of coroners and medical examiners offices in Pennsylvania leads to underreporting of opioid overdose deaths and an incomplete picture of the state's growing drug epidemic, according to a recent University of Virginia study and interviews with experts.
The study, published last week, found that Pennsylvania had the largest gap between opioid deaths reported in a federal database and the author's estimated rate for the state, which was higher.
The database showed 8.5 Pennsylvanians per 100,000 died of an overdose in 2014, while the study's author, Christopher Ruhm, estimated the rate was closer to 17.8 per 100,000.
“Pennsylvania has the combination of pretty high drug death rates and also quite high rates of not reporting the drugs involved,” Ruhm said in an interview.
The study didn't include specific numbers of opioid deaths.
The state Coroners Association estimates about 2,600 people overdosed on drugs — opioids and others — in 2014, a number the association estimates rose to about 4,800 in 2016.
A federal Drug Enforcement Agency report for 2016 states that opioids, including prescription and illicit drugs, were identified in 85 percent of the state's drug-related overdose deaths.
The numbers in the federal database come from death certificates. The certificates in Pennsylvania often list only a general cause of death in drug cases, such as drug toxicity or drug poisoning, Ruhm said.
The certificates in other states more often list specific drugs, he said.
Incomplete data could hamper state and federal efforts to address the overdose deaths, experts said.
Knowing whether people in a given region are dying from prescription drugs or from heroin, for example, can help determine whether a response should emphasize law enforcement or seek to change doctors' prescribing practices.
“The numbers matter. It matters to know where the scope of the problem is,” said Lynn Mirigian, overdose prevention research program director at the University of Pittsburgh Pharmacy Program Evaluation and Research Unit.
Mirigian is part of a coalition of people working to stem overdose deaths. She said the group works with the DEA and other organizations to identify regional drug trends to help tailor solutions.
When the group started looking at local statistics, researchers discovered they couldn't always make direct comparisons from county to county because of variations in the way local death investigators report drug deaths, she said.
In most of Pennsylvania's 67 counties, elected coroners decide what information to put on death certificates. They then transmit the certificates to a vital statistics office run by the state Department of Health, which sends them to the CDC. A few large counties use medical examiners offices, and in a couple of counties, the coroners are appointed, not elected.
Counties use different toxicology labs, and not all labs test for the same panels of drugs, according to a DEA report.
Some states have centralized systems with standardized reporting processes. Ruhm's study suggests those states have more accurate opioid death reporting.
Among the 10 states the study found to have the most accurate opioid death rates, seven have a centralized state medical examiner's office, according to a CDC map of states' death investigation systems.
Among the 10 states with the biggest gaps between reported rates and Ruhm's estimates, nine have county-based systems, according to the map.
In Virginia, a state Ruhm found to have one of the most accurate death rates, a state medical examiner oversees four regional offices. All use the same standardized process for evaluating and reporting overdose deaths, said Rosie Hobron, the state's forensic epidemiologist.
Critical to its accuracy in reporting is its partnership with the state's Department of Forensic Science, which does all of the toxicity testing for the medical examiners offices, Hobron said.
Death certificates nearly always name a specific drug as a cause of death, rarely listing general drug toxicity as the cause, she said.
“Toxicology really is the biggest tool,” she said.
Susan Shanaman, a legislative liaison for the Pennsylvania State Coroners Association, said county coroners sometimes choose to list general toxicity instead of specific drugs to protect the privacy of the dead.
Death certificates are used to close out bank accounts, change vehicle registrations, transfer loans and other transactions where people see what's written on them, Shanaman said.
“There are a ton of reasons that you are using that death certificate publicly,” she said. “Why would you put on a public document a listing of drugs which there's a stigma to?”
State officials do have data sources other than the CDC to draw on.
Shanaman calls all the coroners across the state to collect more specific, de-identified data on drug overdoses to compile an annual report on opioid-related deaths.
She said the association is talking with the CDC about finding a way to report the de-identified data.
The DEA puts out a report that Mirigian said is one of the most detailed overdose reports assembled in any state.
Several organizations and counties around the state contribute data and opioid-response strategies to overdosefreepa.org.
Kenneth Bacha, Westmoreland County's coroner, said he would like to see every coroner in the state use the same type of software to export data in a unified way for all deaths, including opioid drug deaths.
Bacha said the coroners association has a committee dedicated to looking at options for standardized reporting.
As of now, he said, “There's nothing required, nothing automated; some do it manually,” referring to coroners' offices that don't use computers.
Charles Kiessling, the association's president and the Lycoming County coroner, said coroners' offices would likely need bigger budgets to hire people who can use the software systems and dedicate time to the statistics.
Coroners' offices rely on county funding, he said, and many are increasingly overworked as the opioid crisis accelerates.
He said the budget for his office, which covers one of the largest counties in land size in the state, is about $250,000 per year.
Kiessling said efforts to improve reporting should be accompanied by even greater efforts to treat people whose drug use endangers their lives.
“We can look at these numbers and go, ‘Yeah, we have a huge problem,' ” he said. “But we really need to be looking at the living and figure out how we're going to keep them that way.”
Wes Venteicher is a Tribune-Review staff writer. Reach him at 412-380-5676, email@example.com or via Twitter @wesventeicher.