Improving risk factor identification for opioid overdose deaths in Tennessee

How to Cite

Nechuta, S. J., Moses, J., Golladay, M., Lewis, A., Goodin, J., & McPheeters, M. (2019). Improving risk factor identification for opioid overdose deaths in Tennessee. Online Journal of Public Health Informatics, 11(1).



To examine specific drugs present based on postmortem toxicology for prescription opioid, heroin, and fentanyl overdoses classified based on ICD-10 coding. To compare drugs identified from postmortem toxicology with those listed on the death certificate for opioid overdoses.


Using death certificates alone to identify contributing substances in drug overdose deaths may result in misclassification and underestimation of the burden of illicit and prescription opioids and other drugs in drug-related deaths. To enable timely and targeted prevention in Tennessee (TN), the identification and monitoring of new drugs and trends in use should utilize toxicology and medicolegal death investigation data directly, as recommended by others 1-3. These data can inform mortality outcome definitions for improved surveillance and risk factor identification 4-7. To our knowledge, this is the first analysis to use statewide linked toxicology and death certificate data in TN.


We identified 615 opioid involved overdose deaths in TN of unintentional (underlying ICD-10 codes: X40-X44) or undetermined (underlying ICD-10 codes: Y10-Y14) intent during June 1st to December 31st 2017. Utilizing the Interim Medical Examiner Database (I-MED), we identified postmortem toxicology reports for 454 cases, which were from one of three national laboratories used by a state Regional Forensic Center. Toxicology data were abstracted and independently verified by two co-authors and linked to the TN death statistical file that included cause of death information (literal text and ICD-10 codes) and demographics. The analysis focuses on cases with an available toxicology report.


We identified 171 prescription opioid overdoses, 221 fentanyl overdoses, and 113 heroin overdoses. Table 1 displays postmortem toxicology profiles for major drugs/classes. For prescription opioid deaths (excluding fentanyl and heroin), positive toxicology results for prescription opioids were as follows: methadone (11%), buprenorphine (14%), hydrocodone (14%), oxycodone (36%) and oxymorphone (also a metabolite, 47%). Benzodiazepines were present in close to 58% of prescription opioid overdoses; stimulants (cocaine, amphetamines, methamphetamines) in about 25%. For fentanyl and heroin deaths, prescription opioids were detected in about 26% and 34%, respectively; stimulants in about 57.9% and 52.2%, respectively, and benzodiazepines 36-37%. Fentanyl was present on toxicology in about half of heroin overdoses, and 6–monoacetylmorphine in 72.6%.


Using medical examiners’ data, including toxicology data, improves estimation of contributing drugs involved in opioid deaths. This analysis provides jurisdiction-specific data on drugs that can help with monitoring trends and informs risk factor identification. Future work includes adding information on prescribed opioid and benzodiazepines using TN’s Prescription Drug Monitoring Database and evaluating demographic variation in contributing drugs between toxicology and DC data to identify susceptible populations.


1. Slavova S, O'Brien DB, Creppage K, Dao D, Fondario A, Haile E, Hume B, Largo TW, Nguyen C, Sabel JC, Wright D, Council of S, Territorial Epidemiologists Overdose S. Drug Overdose Deaths: Let's Get Specific. Public Health Rep.
2. Horon IL, Singal P, Fowler DR, Sharfstein JM. Standard Death Certificates Versus Enhanced Surveillance to Identify Heroin Overdose-Related Deaths. Am J Public Health. 2018;108(6):777-81.
3. Mertz KJ, Janssen JK, Williams KE. Underrepresentation of heroin involvement in unintentional drug overdose deaths in Allegheny County, PA. J Forensic Sci. 2014;59(6):1583-5.
4. Landen MG, Castle S, Nolte KB, Gonzales M, Escobedo LG, Chatterjee BF, Johnson K, Sewell CM. Methodological issues in the surveillance of poisoning, illicit drug overdose, and heroin overdose deaths in new Mexico. Am J Epidemiol. 2003;157(3):273-8.
5. Davis GG, National Association of Medical E, American College of Medical Toxicology Expert Panel on E, Reporting Opioid D. Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. J Med Toxicol. 2014;10(1):100-6.
6. Slavova S, Bunn TL, Hargrove SL, Corey T. Linking Death Certificates, Postmortem Toxicology, and Prescription History Data for Better Identification of Populations at Increased Risk for Drug Intoxication Deaths. Pharmaceutical Medicine. 2017;31(3):155-65.
7. Hurstak E, Rowe C, Turner C, Behar E, Cabugao R, Lemos NP, Burke C, Coffin P. Using medical examiner case narratives to improve opioid overdose surveillance. Int J Drug Policy. 2018;54:35-42.
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