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National Association of Medical Examiners Position Paper on the Certification of Cocaine-Related Deaths

Stephens, Boyd G. MD; Jentzen, Jeffrey M. MD; Karch, Steven MD; Wetli, Charles V. MD; Mash, Deborah C. PhD

American Journal of Forensic Medicine & Pathology:
Case Report
Abstract

The National Association of Medical Examiners Committee on Cocaine-related Deaths recommends that the following guidelines be applied in the process of documenting, interpreting, and certifying potential cocaine-related fatalities. The committee cautions that the investigation of any drug-related death requires a complete investigation of the circumstances of death, the death scene, and past medical history. It is also necessary to have the results of the forensic toxicological analysis and those of a complete forensic autopsy examination prior to formulating an opinion as to the cause and manner of death. Cocaine should be considered the underlying cause of the death when 1 or more of the following is true: (1) the circumstances surrounding the death can be associated with an acute cocaine exposure and there are no supervening causes of death; (2) the immediate cause of death is directly due to a readily identifiable mechanism or disease such as a gunshot wound or a stroke, yet the acute use of cocaine was the direct underlying cause of the trauma or the disease process; and (3) chronic cocaine use leads to a disease that results in an ultimately fatal pathologic process leading to organ injury and death. The committee further cautions that reported drug levels may not directly relate to the toxic or lethal effects of the drug upon the patient. These guidelines are intended for use by practicing medical examiners and physicians who certify drug deaths, as well as providing education tools for students.

A substantial portion of all the deaths reviewed by medical examiners and coroners relates to the use of cocaine. The Drug Abuse Warning Network survey of medical examiner offices indicated that in 2000, there were 4043 reported deaths related to the use of cocaine.1 Because of reported inconsistencies in the interpretation of the antemortem and postmortem effects of cocaine on morbidity and mortality, the National Association of Medical Examiners (NAME) believes that this review will be of practical value to the practicing physician and toxicologist. There have been attempts in the past to provide written guidelines to assist medical examiners with the process of certification of cocaine-related deaths.2 Previous surveys upon the subject have documented an inconsistent pattern of interpretation of the data by various medical examiners practicing in the field. The analysis of drug-related deaths requires that the medical examiner have a full understanding of the results of the investigation of the death and competence in the interpretation of drug concentrations.

Author Information

From the Office of the Chief Medical Examiner, City and County of San Francisco, San Francisco, California (B.G.S., S.K.); the Milwaukee County Medical Examiner’s Office, Milwaukee, Wisconsin (J.M.J.); the Medical Examiner’s Office, Suffolk County, New York (C.V.W.); and the Department of Neurology, University of Miami School of Medicine, Miami, Florida (D.C.M.).

Manuscript received May 23, 2003; accepted October 4, 2003.

Reprints: Boyd Stephens, MD, Office of the Chief Medical Examiner, City and County of San Francisco, Hall of Justice, 850 Bryant Street, San Francisco, CA 94103-4603. E-mail: boyd.stephens@sfgov.org.

© 2004 Lippincott Williams & Wilkins, Inc.