Another cost of fentanyl in Alaska? More autopsies

The workers in Alaska who determine how someone died are struggling to keep up with a wave of deaths brought on by a yearslong surge in fatal drug overdoses, which has sent more Alaskans to a state laboratory for autopsy than existing resources can accommodate.

As a result of rising overdose deaths connected to fentanyl and other drugs, the Department of Health is requesting more money to deal with the associated costs. According to a note buried deep in Gov. Mike Dunleavy’s proposed budget for 2024, the Medical Examiner Office needs an additional $250,000 in order to deal with rising transportation costs, more expensive lab tests, and a greater volume of work that shows no signs of abating.

“The State Medical Examiner Office has experienced a steady increase in cases each fiscal year. The caseload and the cost of transporting cases to Anchorage for an examination have reached historic highs,” reads the budget request, which was first reported by Northern Journal. “The opioid epidemic has not spared the State of Alaska. An alarming 21 percent average increase in overdose deaths over the past four fiscal years has contributed to the additional cases and examinations performed by the State Medical Examiner Office.”

The primary culprit is fentanyl, a powerful synthetic opioid meant to treat acute pain primarily in medical settings, but which has largely eclipsed heroin and prescription pain pills like OxyContin in Alaska’s illegal drug supply. Fentanyl, often used in combination with other drugs, is causing more Alaskans to fatally overdose.

Small amounts of highly potent powder fentanyl can lead people to underestimate how much they’re putting in their bodies. It’s also sometimes mixed into other drugs as an additive or pressed into pills resembling prescription painkillers, so users might not know they’re taking it.

“The opioid epidemic has gone crazy up here,” said Dr. Gary Zientek, the state medical examiner, who oversees a modest team of 20 forensic pathologists, death investigators, and technicians tasked with conducting hundreds of autopsies a year.

[As opioid overdose deaths continue surging in Alaska, the availability of a lifesaving drug grows]

In 2022, 249 Alaskans were deemed to have died from drug-induced causes, down just slightly from a record high of 260 in 2021, according to the state’s most recent report on vital statistics; the category excludes people who intentionally used drugs to attempt or die by suicide. That’s more than double the 110 people who died from an overdose as recently as 2018. The majority of those fatal overdoses last year — 151 of them — were attributed to fentanyl, which arrived relatively recently in the Alaska drug market and was listed as the cause of death in a mere 11 cases in 2018.

Because of how the state of Alaska classifies and determines deaths from drug overdoses, bodies of the recently deceased have to be brought to Zientek’s office down the road from the State Crime Lab in a quiet patch of East Anchorage, regardless of where the person lived or died. From up and down the road system, hubs and villages and Western Alaska, the capital city and fishing towns all around Southeast, the dead are carried by car or plane for a final evaluation.

“We do the entire state,” Zientek said. “Everybody that we examine comes into this office.”

The State Medical Examiner Office is the final measure of assurance for families and officials that the suspected cause of a person’s death is accurate. If an Alaskan dies from “non-natural” causes — basically everything outside of old age or disease — then under Alaska state statute, the medical examiner has to be notified.

The “non-natural” category is broad, including deaths from violent crime, suicide, accidents and poisoning, among others. If a person dies in a plane crash or avalanche, even though the explanation for their demise appears self-evident, those are treated as non-natural deaths and the body is sent to be examined and ruled on definitively.

Underneath the non-natural umbrella are fatal overdoses. Though family members or investigators may find paraphernalia and other clear signs that drugs killed a person, the statutory requirements kick into gear and law enforcement arranges for the body to be moved to the Medical Examiner Office. In rural Alaska, that can mean freighting cadavers on commercial flights or sometimes chartering a plane, bringing costs of up to $5,000 for transport to the lab, according to Zientek. The state is also responsible for bringing bodies back to the place where the person died, or the community closest to it.

“The transportation costs have increased,” Zientek said. “We’re bringing more bodies into the office for an exam.”

Another cost-driver is lab tests. The Medical Examiner Office sends all of its toxicology samples out of state to a reference lab in Pennsylvania.

“Because there are more overdoses we’re having to test more people,” Zientek said. And, he added, “toxicology costs have increased.”

They’ve started requesting more expanded toxicology panels to catch not just conventional drugs like methamphetamine and fentanyl, but also novel substances that have started appearing in the Lower 48 drug supply like xylazine, an animal sedative increasingly being added to opioids.

[Demand for drug test strips indicates ‘zombie’ opioid additive xylazine is spreading in Alaska]

Not all variables that lead to bumps in deaths end up in Zientek’s lab.

The number of Alaskans who died in 2021 jumped significantly compared to 2019 and 2020, largely because waves of COVID-19 variants hit that year, surging across wide swaths of the state and bringing the hospital system to the verge of collapse. But because succumbing to viral infection is classified as a natural death from disease, not a non-natural death, those mortality upswells did not go for examination before Zientek and his staff.

Alaska is hardly alone among states seeing the drug epidemic strain state services. In the area of Virginia where Zientek used to work, there were so many fatal overdoses that officials implemented rationing policies: In instances where an overdose was the suspected cause of death, the medical examiner’s office would only perform full autopsies on young people.

“The cutoff was if they’re 30 years old, and it looked like a drug overdose, we won’t autopsy them,” Zientek said. “Because of resources.”

One of the reasons for conducting a full death investigation, even in cases where the cause of death appears obvious, is as a backstop to discover potential foul play and as a public health precaution to catch subtleties that might have consequences for others. For example, Zientek said, it would be unconscionable if a homicide went undiscovered because the scene was staged to look like a fatal drug overdose or suicide.

“How do you explain to the family you didn’t bring the body in because it looked like a suicide?” Zientek said. “It’s just more to make sure that what they say happened, happened.”

His office is also dealing with the same kind of challenging labor shortage affecting other parts of the public and private sectors. Forensic pathologists are in demand all over the country, and Zientek said he feels grateful their office has a total of three on staff, including himself. But it has been the same number of people contending with ever-growing demands over the last several years as more and more autopsies are performed every year.

“The number of death calls we get is increasing every year,” Zientek said. “It’s busier, just busy ... it’s a busy office.”