Assessing toxicology testing practices by medical examiners and coroners during the opioid crisis

The National Institute on Drug Abuse awarded Research Triangle Institute (RTI International) $636,838 on June 1, 2026, under the Drug Use and Addiction Research Programs (CFDA 93.279) to assess medical examiner and coroner toxicology testing practices during the opioid crisis.

RTI will develop a typology of medical examiner and coroner triaging practices for suspected overdose deaths, determine which organizational characteristics are associated with triaging approaches, and calculate the national error rate for cases excluded from toxicology testing. The study addresses the gap in understanding how an estimated 2,000 understaffed and under-resourced U.S. medical examiner and coroner offices prioritize toxicology testing when resources cannot accommodate comprehensive testing of all suspected overdose cases. Because federal, state, and local policy and funding decisions rely on overdose mortality counts based on medical examiner and coroner determinations, unstandardized and underdocumented triaging practices introduce systematic bias into national mortality surveillance.

The period of performance runs from June 1, 2026, through March 31, 2029, with place of performance in Durham, North Carolina. The assistance type is a Project Grant.

Abstract

We propose a study to assess medical examiner and coroner (MEC) office triaging practices for deciding which suspected overdose death investigation cases receive toxicology testing. U.S. Federal, state, and local governments make important policy and funding decisions based on the number of overdose deaths annually, but these figures are based on MEC determinations that the cause of death is a drug overdose. Experts acknowledge that overdose mortality numbers are incomplete and inaccurate based on unstandardized, local determinations made by an under-resourced patchwork of an estimated 2,000 U.S. Mecs. Thus, toxicology testing cannot be performed commensurate with minimum recommended standards, necessitating MEC triaging. We define medicolegal death investigation triage to be the process mecs use to prioritize conducting toxicology testing for decedents suspected to have died of a drug overdose. Although triage practices for overdoses help maximize mecs' limited toxicology testing capabilities, they are varied, unstandardized, and understudied. An examination of the triaging practices that exclude toxicology testing is missing, which is crucial for assessing whether these strategies deliver the mortality data required for effective decisions and public health monitoring. The delivery systems framework will guide our evaluation of MEC triage practices to meet the following aims: (1) develop a medical examiner/coroner triaging typology by assessing their extant triage practices as they investigate potential overdose fatalities; (2) determine what medical examiner/coroner organizational characteristics are associated with triaging and triaging typologies; and (3) determine the overall national error rate for triaged overdose cases and how error rates vary by drug toxicology triaging typology and organizational characteristics. To achieve aims 1 and 2, we will survey a random national sample of 500 MEC offices on factors associated with triaging practices. This will allow US to create a typology of common triage practices that drive toxicology testing decisions for suspected overdose cases (aim 1) and determine what MEC characteristics are associated with these triaging typologies (aim 2). To achieve aim 3, we will partner with axis forensic toxicology and 40 diverse mecs to conduct toxicology testing on 1,000 reported overdose cases that did not originally receive toxicology tests given these mecs' triaging practices. We will evaluate the accuracy of triage decisions with the newly obtained toxicology findings (i.e., decision not to test but drug(S) were detected). The proposed new principal investigator (sociologist smiley-mcdonald) is joined by a forensic toxicologist (ROPERO-MILLER), an epidemiologist (KRAL), a statistician (WILLIAMS), and a medicolegal death investigator (KEYES). The study will provide an evidence base for identifying effective triage practices, which will in turn improve future mortality data. Improved mortality statistics will allow governments at all levels to make informed decisions and better mobilize public health resources and overdose response.