Experts say it matters greatly who's investigating the death, how it ends up being classi ed and who's doing the counting. Many Texas counties, even populous suburban ones like Fort Bend, have no medical examiner. In those places, the cause of death is determined by about 860 justices of the peace who also sign death certi cates, and their opinions can vary widely. A late-stage cancer patient who takes too many prescription drugs could be classi ed 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 ve justices of the peace in Wichita County, and you present this to them and you will get ve di erent 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 certi cate, she said. e 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's Institute of Forensic Sciences. Even when a toxicology screen turns up evidence of an overdose, a process that can take weeks or months, the death certi cate has already been led and often is not updated. Without a standardized system, there is room for variation, opinion and error. Even when a medical examiner nds that certain drugs caused a death, the death certi cate might be vague - listing the cause as multi-drug intoxication - so it's not clear whether hydrocodone, a common prescription pain medicine, or heroin was at fault.
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. President 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," Michael Botticelli, director of the White House O ce of National Drug Control Policy, said in an interview Friday. Data from Harris County, which keeps highly detailed records, show that hydrocodone and anti-anxiety drugs are the most commonly linked to overdoses. We are still a developing nation when it comes to death certificates. 17 "It happens all the time," said the daughter of a man who accidentally overdosed in Houston in 2013. But not even his closest friends know her father died from his medications, the daughter said. His obituary said nothing about it. Others who lost relatives have faced lawsuits from doctors after ling complaints or speaking out. Another mother who lost her daughter to an overdose in Harris County declined comment for that reason. An e ort by the CDC to capture all prescription drug-related deaths turned up 980 in Texas for 2013. But that didn't include another 1,215 overdose deaths for which no legal or illegal drug was speci ed, according to the CDC. Together, that's more than four times the number the state reported for that year. e 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 was discontinued in 2010.
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