Letter to the Editor

The article by Walley et al, ¹ “The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015,” concerns us. Our general experience in Cuyahoga County, Ohio, is similar to the experience of the authors in Massachusetts: illicit opioids are overtaking legal opioid pain relievers in overdose fatalities in our jurisdiction. However, the large percentage of opioid-related overdose deaths (21%) excluded by the authors because of inadequate toxicology testing is concerning. This percentage seems unacceptably high and substantially differs from our experience in Cuyahoga County. Our experience is that <5% of fatal overdose deaths are certified without at least the scope of toxicology testing described by the authors. This scope is considered adequate, not exhaustive, according to the National Association of Medical Examiners. ² The article also did not clarify whether fentanyl testing was routinely performed; fentanyl was not among the drugs listed in the Methods section, but it did appear in the Results section. It would be a serious shortcoming if any of these “complete” screens lacked testing for fentanyl and its analogs, given the frequency with which fentanyl and its analogs show up in toxicology testing in decedents. In 2018, fentanyl and its analogs were involved in 67% of opioid-related fatalities. ³

Of additional concern is the absence of any mention of the percentage of overdose decedents who underwent autopsy. The National Association of Medical Examiners recommends full autopsy for suspected overdose fatalities. ² In some jurisdictions, performing an autopsy for all suspected overdose fatalities is difficult because of the burden placed on death investigation systems by the opioid crisis. It is a mistake, however, to substitute toxicology testing for autopsy as a routine practice in apparent overdose fatalities to determine the cause of death. The error rates from limited examination are unknown but may be substantial if other comorbidities are present. ⁴ It would be helpful to know the percentage of the decedents who underwent autopsy in the study by Walley et al.

The narrow view the authors took by focusing on active prescriptions at the time of death is troubling. These persons represented a small fraction of the general overdose cohort. The findings of Walley et al may create complacency about the relative importance of opioid pain relievers in the opioid crisis. The authors noted that the percentage of fatal overdose victims who had a prescription for opioid pain relievers steadily increased with further “look back” during a 12-month period before death, ultimately rising to more than half of the decedents. In our experience in Cuyahoga County, approximately 60% to 65% ⁵ of our fentanyl-related overdose victims had a prescription for a legal controlled substance within 2 to 3 years of their death, and this trend persisted in 2018 (unpublished data, Cuyahoga County Medical Examiner’s Office, September 2019). That opioid pain relievers are minimal in illicit drug trade in Cuyahoga County is indirect evidence that the legal supply of opioid pain relievers is an important factor in the initiation and maintenance of substance abuse in our illicit drug–using populations. Persons who die of an illicit drug overdose may have been introduced to opioids through prescription opioid pain relievers, and when that supply was no longer available, they transitioned to using illicit drugs. This transition from prescription opioid pain relievers to illicit drugs does not necessarily imply that opioid pain relivers were neither overprescribed nor diverted. Shifting attention away from prescribed opioid pain relievers could have substantial negative public health consequences because they are a pathway to the use of illicit drugs. The pathways and transitions in addiction are complex and varied for each person, and it is beneficial to review data in addition to cause of death toxicology such as a death scene narrative to understand the complete picture.