State officials say the four-year death toll from opioid overdoses in Arkansas is likely higher than the 800 found in a federal database.
They just aren't sure how much higher -- mostly because county coroners don't have a consistent system for investigating deaths and because of gaps in training those coroners.
Because of unreliable data, Arkansas was left out of national research on opioid overdose deaths.
Kermit Channell, executive director of the state Crime Laboratory, points to his own agency's numbers as evidence of "us missing something."
More than half of the bodies sent to the Crime Lab for autopsies on drug overdoses have prescription opioids in their systems, Channell said.
The lab conducted 207 drug overdose-related autopsies in 2016 and 300 last year.
But the official tally of prescription opioid deaths doesn't make up nearly half of all reported drug overdose deaths. For example, in 2014, Arkansas reported that 163 of 405 overdose deaths were tied to prescription opioids -- not nearly the correct ratio of what investigators are seeing in the lab, Channell explained.
In other bodies sent to the lab, those that weren't overdoses, "some form of prescription opioids were found onboard," he said.
Incomplete data kept Arkansas from being included in a new report that found opioid-involved deaths rose between 2015 and 2016, regardless of victims' age, race and sex. The study, released March 29 by the federal National Center for Injury Prevention and Control, looked at fatal overdose information from 31 states and Washington, D.C.
Researchers relied on drug overdose deaths noted in a database called the National Vital Statistics System, which is maintained by the U.S. Centers for Disease Control and Prevention.
Researchers examined only states that submitted reliable data on drug-involved deaths. To be included in the report, 80 percent of a state's drug overdose death certificates had to name at least one specific drug in 2015 and 2016. Arkansas did not meet that standard.
A 2015 Public Health Reports article also found that drug overdoses remain underreported across the country.
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In about 25 percent of drug overdose cases nationally, death certificates did not include a specific drug. Instead, cause of death was attributed to "other and unspecified drugs," the article found.
States with centralized medical examiner systems were much more likely to have more detailed information on drug overdose deaths, according to the report.
In Arkansas, the system isn't centralized. The Crime Lab doesn't handle all overdose investigations; many are handled by county coroners.
Those elected coroners often don't have medical backgrounds. State law doesn't require it. The law requires only that coroners be at least 18 years old, registered voters, live in the county served and lack felony arrests.
That means coroners' reports are "not as thorough as they could be," said Kevin Cleghorn, president of the Arkansas Coroner's Association.
For instance, Cleghorn said, someone might have died from cardiac arrest, but a coroner might fail to note that the heart attack was induced by opioid use. Or multiple drugs are found in someone's system, like a benzodiazepene such as Xanax, in addition to an opioid, but only the benzodiazepene's presence is documented.
Some certificates for drug overdose deaths fail to include any specific drug information, he added.
Cleghorn also believes that deaths stemming from opioid misuse, such as traffic wrecks or heart attacks, aren't being noted in medical reports.
Arkansas is one of 14 states that does not have specific training requirements for coroners, yet coroners can access crime scenes involving deaths, issue subpoenas, handle toxicology samples and determine causes of death.
Free medical and death-investigation training have been available to the state's coroners and their deputies since 2014.
Under a 2017 law, "certified coroners" are entitled to salary increases. These coroners must complete the death-investigation training.
Only 69 of at least 325 coroners or deputy coroners have completed the state course thus far.
Eighteen Arkansas coroners are certified through the American Board of Medicolegal Death Investigators. Board certification goes to coroners with "basic knowledge and demonstrated proficiency in the standards of practice" to conduct competent death investigations and those with at least 640 hours of death-investigation experience.
Skipping such training creates disparities in coroner reporting across the state, Cleghorn said.
"Until you know what you're truly facing, you can't really know what to do," he said. "How do you counteract it, how do you fight it, if you don't know what the true enemy is?
"That is what these drugs are -- they're our enemy. They're killing our people."
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