Notes from the Field: Opioid Crisis The Medical Examiner’s Office as a Focal Point

By Dr. Thomas Gilson, Medical Examiner, Cuyahoga County, Ohio

June 14, 2018

Opioids in Ohio: A History of Crisis

The opioid crisis has been a rolling mass of fatality events, with changes in what drugs are most responsible over time. Ohio has more overdose deaths than any state in the country and has the second highest per capita drug overdose fatality rate. The recent media spotlight has been on overdose fatalities from illicit drugs, but Ohio’s problem with pain medication can be traced back to the late 1990s and early 2000s, when pharmaceutical companies targeted Ohio and other Appalachian states with aggressive marketing campaigns. “Pill mills” began pumping astounding quantities of prescription opioids into the state, and the overdose death toll rose.

State regulations have since helped bring “pill mills” into check, but from 2010, prescription overdoses plateaued as heroin deaths began to rise. This shift from legal to illicit drugs dramatically changed the nature of the problem. Eighty milligrams of oxycodone will always be 80 milligrams of oxycodone, but there’s no quality control or consistency with heroin or other illicit drugs. With this shift in drug of choice, we saw a fivefold increase in heroin deaths from 2008 to 2013 in our county, followed by an exponential rise in fentanyl-involved fatalities: 37 in 2014, to nearly 100 in 2015, to almost 400 in 2016. Although that spike has begun to slow — to about 470 in 2017 — we also began seeing our first carfentanil fatalities in 2016.

About "Notes from the Field"

NIJ has launched the “Notes from the Field” series to allow leading voices in the field to share their strategies for responding to the most pressing issues on America’s streets today. Learn more.

The Medical Examiner’s Office as a Focal Point

Collaboration is critical between medical examiners, law enforcement, and anyone else working on the opioid response, and a medical examiner’s office can be an ideal focal point to facilitate that collaboration. In Cuyahoga County, we have had various, separate task forces to address public health and criminal justice issues. There’s a lot of overlap between these groups, but we noticed that they rarely interacted. With a foot in both the public health and criminal justice spheres, our office was an obvious focal point to bring together people, agencies, and information.

As an example, our office was particularly well-positioned to facilitate this collaboration because our crime lab falls under the medical examiner’s office, rather than under law enforcement or the prosecutor’s office. This allows my toxicology lab, where we test for the drugs that kill people, to communicate with my drug chemistry lab, which examines the drugs seized on the street. I can’t overemphasize the importance of facilitating connection between these labs if they are separate — as they are in most of the country.

The Power of Partnerships

Interagency partnerships have been key in our county’s opioid response. For example, prosecutors were having a hard time prosecuting cases because traditional overdose investigations produced insufficient evidence from overdose scenes. When we reviewed our heroin overdose data for 2012 and 2013, we saw that 50 percent of cases had some kind of drug paraphernalia on scene. Through partnerships with the Cleveland Police Department and County Sheriff’s Office, we established overdose scene processing protocols. Processing overdose scenes as crime scenes set us up for better prosecution down the road.

Another difficulty in the prosecution of drug dealers was a lack of understanding between prosecutors and medical examiners about death certification of drug overdose deaths and its impact on prosecutions, particularly in deaths involving more than one intoxicant. Stronger partnerships between the medical examiner’s office and the prosecutors have led to a clearer comprehension of the role of various substances in overdose deaths and their relative importance in “but for” causation.

Learning From History

One way Cuyahoga County has facilitated information sharing has been reviews of overdose fatality cases. These reviews have brought all stakeholders to the table — law enforcement, the drug treatment community, public health, toxicology, and others — to share information, identify trends, and glean lessons learned. If you have all the right people in the room, it becomes much easier to communicate and put informed strategies in place.

Retrospective reviews of 2012 overdose cases and prospective reviews of 2013 cases taught us that the majority of the people who were dying were middle-aged men who worked in labor trades, especially construction. It made sense that these people would get injured on the job, be prescribed pain medication, become addicted, and then transition to heroin as pain medication became more expensive or otherwise inaccessible.

These reviews made us question whether we should be reaching out to workers unions and sharing information about their members being at risk. When we saw that 70 percent of the individuals who overdosed fatally had an education level of a high school diploma or less, it was clear we needed to design pre-college prevention and intervention strategies. Similarly, 40 percent of our heroin overdose victims had spent time in jail. Given the high likelihood that they might use drugs upon release, we began to implement risk reduction strategies in jails, especially with inmates awaiting imminent release.

In Cuyahoga County, the medical examiner’s office has served as a focal point to bring together public health and criminal justice agencies, share information, and learn from past cases to improve our prevention and response. We still have one of the highest rates of overdose fatality in the country, and are constantly working to improve our prevention and intervention efforts. In collaborating to share information and learn from past cases, we hope to better understand the scope of the crisis and intervene to put potential victims on a different path that doesn’t end in addiction and the medical examiner’s office.

About Notes From the Field

The National Institute of Justice (NIJ) is the research, development, and evaluation arm of the U.S. Department of Justice. NIJ aims to address the critical questions of the criminal justice field, particularly at the state and local levels.

NIJ Director David Muhlhausen developed the Notes From the Field series to allow leading voices in the field to share their strategies for responding to the most pressing issues on America’s streets today.

Notes From the Field is not a research-based publication. Instead, it presents lessons learned by on-the-ground criminal justice leaders, from years of experience and thinking deeply about criminal justice issues.

About the Author

Dr. Thomas Gilson is the Director of the Cuyahoga County Medical Examiner and Crime Laboratory, which serves the metropolitan area of Cleveland, Ohio. Prior to his appointment to this position in 2011, Dr. Gilson served as Chief Medical Examiner for the State of Rhode Island as well as Deputy Chief Medical Examiner for the City of New York, state of New Hampshire, and state of Connecticut.

Dr. Gilson is certified by the American Board of Pathology in Anatomic, Clinical, and Forensic Pathology. He received his medical degree from the Medical College of Pennsylvania and performed his pathology residency at the University of Cincinnati. He performed his forensic pathology fellowship training in the Office of Chief Medical Examiner for the City of New York. His research interest includes the integration of forensic pathology with public health.

Writing and editorial support was provided by Rianna P. Starheim, a writer with a federal contractor, on assignment at the National Institute of Justice, U.S. Department of Justice.

Date Created: June 14, 2018