Fatalities from prescription drug abuse are widely undercounted in Texas and in many other states, obscuring the scope of one of the nation’s leading causes of preventable death.
Overdose deaths from all drugs have skyrocketed nationwide, outpacing even motor vehicle accident fatalities. Prescription drug overdoses exceed cocaine and heroin deaths combined and are the main reason death rates have risen among white women between the ages 18 and 54. Those fatalities have become five times more common than in 1999, according to a recent Urban Institute report.
The abuse of painkillers has led to greater heroin use, and overdose deaths involving heroin have risen 172 percent between 2010 and 2013, said Michael Botticelli, director of the White House Office of National Drug Control Policy.
But Texas’ method of tracking prescription drug overdose deaths is flawed, according to data uncovered by the Austin American-Statesman and the Houston Chronicle. It relies on inaccurate or incomplete death certificates to track prescription drug fatalities.
In 2013, for example, 622 deaths reported across Texas were blamed on opioids — mostly painkillers, based on death certificate data. But 798 prescription drug-related deaths were recorded by local medical examiners that year in just 17 of the state’s 254 counties, the Chronicle and Statesman found.
Without an accurate tally, lawmakers and health officials in Texas have no way to know the true impact of the prescription drug epidemic — or where to target prevention and treatment programs that can save lives — even as they publicly declare such deaths have declined.
Last summer, for example, Dr. David Lakey, then the Texas Department of State Health Services commissioner, told a state Senate committee that Texas has one of the nation’s lowest prescription drug fatality rates and that deaths had peaked in 2006.
But Lakey was only referring to certain painkillers, not all prescription drugs, and his report didn’t include information from medical examiners, who use drug screens to identify overdoses.
President Barack Obama has proposed a 2016 budget that includes funds to get “real-time” mortality data, with electronic reporting on fatal overdoses, and grants to help states do better at tracking fatalities.
“You want to have a really good understanding of who is overdosing, where it’s happening and what drugs they were taking,” Botticelli said in an interview Friday.
The Chronicle and the Statesman found that detailed medical examiner reports in Harris, Travis, Dallas, Tarrant and El Paso counties, as well as some smaller counties, attribute many more deaths to prescription drug overdoses than the state reports on opioid overdoses.
The results indicate that it matters greatly who’s investigating the death, how it ends up being classified and who’s doing the counting. For example, prescription drug-related deaths are often characterized on death certificates as “multiple drug toxicity,” which prevents them from being accurately tallied.
Harris County has been identified by federal law enforcement officials as a major center of the nation’s prescription drug overdose epidemic. Drug overdoses account for about a tenth of the caseload for that county’s medical examiner.
In 2013, the state report tallied 179 deaths from pain pills in Harris County; the county medical examiner’s office reported 275 deaths that year. Six of those happened in one 48-hour period that November.
In Travis County, which includes Austin, the state reported 17 deaths from prescription painkillers in its preliminary count of death certificates for 2013, but the administrator of the county’s medical examiner’s office hand-counted 114 deaths involving all kinds of prescription drugs that year.
In Tarrant County, medical examiner’s office officials recorded 44 deaths in 2013 involving specific prescription drugs and an additional 57 fatalities from “mixed drugs.” The state’s count for the county was 24 opioid overdoses.
Others, like Bexar County, make no effort to separate prescription pain pill deaths from those involving heroin.
Many other counties, even such populous suburban ones as Fort Bend, have no medical examiner at all. Determining the cause of death in communities across Texas are about 860 justices of the peace who also sign death certificates, and their opinions can vary widely. A late-stage cancer patient who takes too many prescription drugs could be classified as a natural death by one justice or a prescription drug overdose by another, said Janice Sons, a justice of the peace in Wichita County and president of the Justices of the Peace and Constables Association of Texas.
“We have five justices of the peace in Wichita County, and you present this to them and you will get five different opinions,” Sons said. “With medical examiners, it’s pretty cut and dried.”
Many justices of the peace hail from counties with tight budgets, so there can be pressure to reduce the number of cases they send to a medical examiner for an autopsy, Sons said. And some justices face families who don’t want a drug overdose on the death certificate, she said. The bottom line, she said, is “we’re all human, and you make the best decisions you can.”
Without investigators, medical information and testing, it’s often impossible to know whether “a dead guy on a couch” died from a prescription drug overdose or from natural causes, said Dr. Dwayne Wolf, deputy chief medical examiner of Harris County.
Even when a toxicology screen turns up evidence of an overdose, a process that can take weeks or months, the death certificate has already been filed and often isn’t updated.
Jane Maxwell, a University of Texas researcher in the School of Social Work who each year compiles an authoritative report on Texans’ drug use, said it’s hard to know whether the state’s overdose death rate is really lower than other states or if other states do a better job of counting overdoses. Some states hard hit by the epidemic, including Florida, West Virginia and Kentucky, have a statewide medical examiner system that uses common testing and reporting procedures, resulting in more uniform statistics.
Without a standardized system, there is room for variation, opinion and error. Even when a medical examiner finds that certain drugs caused a death, the death certificate might be vague. With “multi-drug intoxication” named as the cause, it isn’t clear whether hydrocodone, a common prescription pain medicine, or heroin was at fault.
Health officials aren’t trying to obscure the numbers, said Carrie Williams, spokeswoman for the state health services department. In his presentation to the Senate Health and Human Services Committee in August, Lakey’s data was clearly identified by type of drug, she said, adding that there is no death certificate code that captures all prescription overdoses.
“We’re in public health, and we have no reason to undercount the problem,” Williams said.
The committee’s chairman, Sen. Charles Schwertner, a Georgetown Republican and physician, said that while he understands what Lakey presented, “I would certainly like to see data collection improved so we know the magnitude of the problem.”
He has authored a bill this legislative session to better monitor patients who might be “doctor shopping” for drugs.
As for changing the way the state collects data on overdose deaths, “you get into all sorts of logistics in how to implement that … in a state of such a large size,” Schwertner said. “But the bottom line is prescription drug abuse and deaths are a major problem in Texas.”
In Florida, state medical examiners produce annual reports that allow officials to track prescription drug abuse quickly, even as the problem morphs and spreads. They can use data to decide which counties to target for outreach or enforcement.
Harris County medical examiners data show that annual overdose deaths have dropped slightly from more than 300 in 2010 to 275 in 2013 — as state and local officials have collaborated to drive some of the worst pill mills out of business.
Three out of four new heroin users reported having abused prescription opioids first, the CDC said. Heroin is cheaper and pleasures the same part of the brain as prescription painkillers.
Houstonian Jennifer Ruggeri died of liver failure at age 28 after ingesting too many pain pills, medication she was prescribed but wasn’t supposed to have, according to her medical history. “I lost my daughter because she was given the wrong medication, went into a coma and died the next day,” Bari Brochstein-Ruggeri said, as she visited the grave earlier this month to mark the fifth anniversary of her daughter’s death.
She lamented a lack of treatment options for people who want to stop taking potentially addictive pain and anti-anxiety medications. Having state officials use statistics that undercount the problem doesn’t help, she said.
Overdose deaths are a hard issue to get decision-makers to pay attention to because many relatives are afraid to speak out — and it’s difficult for families to sue doctors or hospitals, she said. Some family members face lawsuits from doctors after filing complaints.
“Somebody needs to keep this in the public eye and maybe it will change, so another family doesn’t have to go through what we went through,” Brochstein-Ruggeri said.
An effort by the CDC to capture all prescription drug-related deaths turned up 980 in Texas for 2013. But that didn’t include 1,215 other overdose deaths found in the database for which no legal or illegal drug was specified, according to the CDC. Together, that’s more than four times the number Lakey reported to the Senate committee studying the problem.
The federal government has no way to capture complete data from the approximately 2,300 medical examiners, justices of the peace and coroners all over the country, said Bob Anderson, chief of mortality statistics for the National Center for Health Statistics at the CDC. A voluntary federal program in which some medical examiners participated has been discontinued.
“It’s clear we’re missing a lot of prescription drug deaths,” Anderson said. “This is a problem across the United States. It’s important to communicate that we need the specificity, we need the detail. If we can’t adequately identify which drugs caused the death, we don’t know where to focus prevention efforts.”
Often the cause of an overdose death — whether an accident or the more unusual suicides — isn’t limited to one drug. While painkillers are most commonly involved, other legal drugs also can kill.
In fact, many Texans died either after mixing different kinds of prescription drugs or by combining medications with alcohol or illegal drugs, information from medical examiners shows. Data from Harris County, which keeps highly detailed records, show that hydrocodone and anti-anxiety drugs are most commonly linked to overdoses.
Even now, most medical examiners don’t keep a separate tally on prescription drug overdoses, and several said no one had asked for that before.
It would require a lot of effort — and political will — to overhaul mortality reporting statewide. But experts said the state could immediately create a process to collect data from medical examiners on overdoses in the largest urban areas.
“We are still a developing nation when it comes to death certificates,” said Dr. Gregory J. Davis, a University of Kentucky professor of pathology and laboratory medicine and an assistant state medical examiner. “A lot of it depends on where you live and how meticulous the death investigator is.”
The risk of undercounting, he added, is tragic: “More people will die.”
As the American-Statesman covers the prescription drug epidemic in Texas, reporter Mary Ann Roser teamed up with Lise Olsen of the Houston Chronicle to review medical examiners’ reports from across the state. The research shows how prescription drug overdose deaths are routinely undercounted here and in most states. In past stories, Roser has examined why so few doctors face criminal charges after they are found to have violated prescribing laws and has analyzed how lawmakers are addressing the issue.
American-Statesman reporter Mary Ann Roser appeared on the Texas Standard radio show on April 27, 2015 to discuss how she and Lise Olsen of the Houston Chronicle established that prescription drug overdose deaths are widely underreported in Texas, and most states.