Withheld: As fentanyl floods in, can death data keep up?

Drug overdoses are estimated to have killed more than 100,000 Americans in 2022 — more than any year before — and the driving force behind the increase is synthetic opioids like fentanyl.  

The overdose epidemic hammered cities and rural areas alike, leaving no region of the country unscathed, including the Mountain West. 

The trend, like most, has been slower to reach Wyoming where the data thus far hasn’t reflected dramatic spikes in deaths seen elsewhere. But fentanyl is flowing into the state and overdose deaths are following in its wake. 

The Wyoming Division of Criminal Investigation presented fentanyl seizure information to lawmakers earlier this year that illustrated the drug’s precipitous rise. Law enforcement seized about 1,600 “dosage units” of fentanyl in 2020 compared to nearly 13,500 units in just the first three quarters of 2022. 

“It clearly shows that fentanyl is very readily available for those people who want to use it,” former Wyoming DCI interim director Forrest Williams told the Joint Judiciary Committee in January. 

And those who do use it — knowingly or not — are at an increased chance of dying. Between 2018 and 2022, the number of overdose deaths linked to man-made opioids like fentanyl increased from 10 to 48 in Wyoming, according to the Wyoming Vital Statistics Service.

Long-term and recreational users aren’t the only ones affected. Babies are being born addicted to the substance, according to January legislative testimony by Dr. April Kranz, a pediatrician with Cheyenne Regional Medical Center.

“I’ve never seen babies require this high [of] doses of morphine as they are requiring just to control their withdrawal symptoms,” she said. 

Other rural states like Alaska and Missouri have used data to help target resources to minimize deaths. But WyoFile found access to timely and accurate data is limited in Wyoming for multiple reasons. 

In part one of this four-part series, WyoFile examined how privacy and accuracy concerns inhibit the release of data that could help shape prevention efforts. In part two, WyoFile investigates inefficiencies and inconsistencies in the way coroners collect and report overdose death data, and how that masks the severity of the opioid crisis in Wyoming.

More potent, more lethal

Fentanyl can be up to 50 times as potent as heroin, making it easy to overdose on. 

Medical professionals use carefully measured and administered doses of the drug to manage patients’ pain. However, when used incorrectly, even medical fentanyl patches have caused overdoses, according to Fremont County Coroner Erin Ivie.

Still, the majority of fentanyl comes into Wyoming as illegal pills, powders and laced substances via Mexican cartels.

Fentanyl precursor chemicals are often created in labs in China before being shipped to cartels in Mexico, according to the Drug Enforcement Administration. From there, the drug is manufactured and pressed into pills or powders before being smuggled into the U.S. 

Illicit fentanyl batches have gotten more dangerous over time, too, as they’re more often mixed with higher concentrations of the drug. Some contain analogs like carfentanil — which is 100 times stronger than fentanyl — or PYRO, which was suspected in a recent Denver overdose death.

Fentanyl is now even being mixed with a non-opioid substance called “xylazine,” which can cause prolonged unconsciousness and rotting wounds that may require amputation. 

U.S. officials have pressured the Mexican government to crack down on the cartels and synthetic opioid trade. Federal reports state that the DEA and Mexican officials dismantled some fentanyl labs and pill presses in 2018 and 2019, but international tension remains around Mexico’s role in stopping the flow of drugs.

Supply, of course, is just one facet of the opioid crisis. 

Looking at the rapidly changing trends in Wyoming next to the national and regional trends, senior research scientist Rodney Wambeam with the Wyoming Survey & Analysis Center, said the state should prepare for the situation to worsen, but he believes officials are doing so. 

“I am not in the know with everybody over there [at the Wyoming Department of Health], but I know definitely people here locally and at the state level are preparing for what’s going to happen here,” he said. 

He knows that’s easier said than done, he said, in part because those most affected “tend to be people that are more marginalized and harder to get hold of.”

The Wyoming Survey & Analysis Center was recently contracted by WDH’s Behavioral Health Division to analyze the state’s opioid and fentanyl data to identify information gaps. That work will include public outreach and listening sessions, Wambeam said.

Death data delay

Efforts are afoot in the Wyoming Department of Health, Department of Criminal Investigation and other state agencies to better communicate overdose data to the public — it’s currently limited. But even the best data distribution practices don’t address the challenge of collecting timely information in the first place. 

Overdose deaths, for example, must be confirmed and reported by county coroners. Most of Wyoming’s 23 elected coroners don’t have medical backgrounds, and as such are expected to consult with a medical practitioner to determine causes of death. Toxicology reports, which can be critical to making a determination, can take weeks. 

Guy Beaudoin, deputy state registrar with Vital Statistics Services, has long been focused on helping coroners collect and report information in a clear and timely manner. It’s not always easy.

“Sometimes elected folks may not like the state telling them what to do, and that’s very evident in today’s environment,” he said. 

When reached in January, for example, vital records statistician Cori Davis said that the agency had been waiting 124 days for a death certification.

Beaudoin has championed standardizing the process by which coroners report and record deaths, but many have their own methods and don’t want to use his, he said. 

It doesn’t help, he said, that institutional knowledge and many of the basic how-tos can be lost in an election cycle. 

“I think that it’s a disservice to all of the residents that we don’t have [a standard system], because one coroner could say [to his replacement], ‘You know, the heck with you, Bob. I don’t like you. You figure it out,’” Beaudoin said. “If we’re dealing with drug overdoses as an example, law enforcement comes in and says ‘I want to look at all of these dockets, show me these dockets’ and the coroner is like, ‘I don’t even know what the hell this guy’s system was before.’”

Natrona County Coroner James Whipps, who uses Beaudoin’s system, said uniform statewide adoption may require legislation — especially if the state wants those using outdated, sometimes all-paper systems to change their ways. 

“A lot of our state is still stuck back in the 1940s in the coroner’s office,” he said. “I don’t know how we drag people kicking and screaming into the future here, but we have to.”

He noted the 2016 arrest of Niobrara County Coroner Lisa Mellott for Medicaid fraud. With her behind bars, he said, law enforcement faced a challenge accessing coroner files housed in her garage.

Whipps believes in the elected coroner system and allowing people to choose who’s in office, but recognizes some sparsely populated counties won’t have qualified candidates run for the position. 

Wyoming forensic pathologist Dr. Tom Bennett also retired earlier this year. He performed 50% of all the autopsies in the state, according to Beaudoin. Many counties now have to take bodies elsewhere. 

Coroners frequently pay to send blood and tissue samples out-of-state for testing, too, with turn-around times that can vary from lab to lab. The state’s own crime lab is often backlogged, though parts of its waiting list have been shrinking.

Timeliness has improved substantially, however, according to Beaudoin, a welcome change that he credits in part to six new coroners taking up the mantle this year. And while Natrona County’s coroner used to be the only one using his standardized case management system, five others now do, too.

Beaudoin still commended other coroners — like Laramie County’s — for providing timely data even if they don’t use his system.

Dr. Brent Blue is Teton County’s coroner; one of the few in Wyoming with a medical background. Blue recognizes the role of timely reporting in understanding the scope of the issue, he said, but he doesn’t use Beaudoin’s system. Instead, his office pays for another proprietary system. “If there had been an advantage [with the other system], I would have used it,” he said.

The Teton County Coroner’s office also reports overdose death information directly to law enforcement, Blue said.

He sends blood and tissue samples to Axis Forensic Toxicology in Indiana for testing, and he said, “Generally, toxicology takes 10 days. The more esoteric the drug is, the longer it takes.”

By early 2023, Blue said he hadn’t seen many fentanyl overdoses in his corner of the state. There was one instance when someone bought the drug on the dark web using cryptocurrency, Blue said. 

“This was literally coming to him via UPS,” he said. 

The coroner system

The efficacy of elected coroner systems is under-researched, said Harvard Medical School postdoctoral scholar Alina Denham. In fact, all aspects of the systems are. She’s studied whether having a state-wide coroner system instead of a medical examiner system — which requires medical training — affected whether specific drugs were listed with overdose deaths. Looking at 2014 and 2018 data, she found it did. 

“We found that an unclassified drug overdose death was more likely to happen in a county with a coroner system,” she said. “An unclassified death was about twice as likely to be in a coroner county than in a medical examiner [in 2014], and then it was four times as likely [in 2018].”

The amount of Wyoming overdoses with unspecified causes decreased from 33% in 2013 to 0% the last few years. In 2022, though, 2% (or two deaths) were unspecified.

Coroners also tend to be active members of a rural community, which can present its own issues, Denham said.

“Sometimes a family, especially in a place where they kind of know the coroner, they might ask not to put [an opioid overdose] on the death certificate, or I don’t know, maybe not to perform the test,” she said. “And that might be part of the problem, especially where families can actually sort of have that influence on what’s on the death certificate.”

Residents in Wyoming have asked for death certificates to not show overdoses, said Levi Wardell with Wiederspahn-Radomsky Chapel of the Chimes funeral home in Cheyenne.

“I get it,” he said. “That would be heartbreaking to see my daughter’s death certificate with an overdose.”

Some Wyoming coroners run, or work directly with, funeral homes. That can create undue pressure: A family asking for changes to a death certificate may also be a customer. 

Wardell said even when people ask for changes in Laramie County, though, the coroner there remains steadfast.

“I know our coroner [Rebecca Reid] would never do that,” he said. “I don’t know if other coroners do shady stuff, but not ours.”

The semi-timely reporting of overdose deaths across Wyoming isn’t the only way to gauge what’s happening, however: A taxpayer-funded database is pushing out near-real-time information on nonfatal and fatal overdoses — but knowledge of, and access to, that potentially life-saving resource is limited.

In part three of this four-part series, WyoFile focuses on that database: what it contains, who can use it and how it can help groups who can’t get direct access.

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WyoFile is an independent nonprofit news organization focused on Wyoming people, places and policy.