National Association of Medical Examiners
Position Paper on the
Certification of Cocaine-Related Deaths
Miller CD. Response to the National Association of Medical Examiners position paper on
the certification of cocaine-related deaths AND Criteria for the interpretation
of cocaine levels in human biological samples and their relation to the cause of death.
February 25, 2004; Internet Restraint Asphyxia Library page:
The following is a copy of the "Letter To The Editor" (and others)
that I Emailed on the SAME DAY I posted the above-cited articles:
February 25, 2004
TO: Vincent J. M. DiMaio, MD; Editor-in-Chief of the
American Journal of Forensic Medicine and Pathology;
Frances R. DeStefano, Publisher of Am J Forensic Med Pathol;
Molly Sullivan, Editorial Office Contact for Am J Forensic Med Pathol;
The Authors of The National Association of Medical Examiners Position Paper
on the Certification of Cocaine-Related Deaths; and
The National Association of Medical Examiners (NAME) Society Office.
RE: Stephens BG, Jentzen JM, Karch S, Wetli CV, Mash DC: National
association of medical examiners position paper on the certification of cocaine-related
deaths. Am J Forensic Med Pathol (March) 2004;25: 11-13.
AND RE: Stephens BG, Jentzen JM, Karch S, Mash DC, Wetli CV: Criteria
for the interpretation of cocaine levels in human biological samples and their relation to
the cause of death. Am J Forensic Med Pathol (March) 2004;25: 1-10.
I am not a physician, nor a medical examiner, nor a certified forensic specialist. I am a paramedic and a court-qualified restraint asphyxia "Expert Witness," with over 11 years of experience specifically dedicated to the in-depth investigation of restraint-related deaths. As such, my never-ending study and research includes examining medical and forensic literature and recommendations related to restraint-related deaths in relationship to cocaine abuse.
FIRST: I sincerely applaud NAME's reasoned and appropriate recommendation that
"7. Blood, serum, and urine levels of cocaine do not necessarily directly correlate to toxic changes or to the cause of death."
Unfortunately, I am deeply concerned by what I believe to be two significant inaccuracies (1), and two serious oversights (2), within NAME's recommendations regarding the investigation and certification of "cocaine-related deaths."
(1) I believe that both the following NAME statements are significantly inaccurate: "Chronic drug use is necessary to induce the changes in the neurochemistry that lead to agitated delirium." ... and ... "A diagnosis of cocaine-induced excited delirium requires a clinical history of chronic cocaine use ...".
ANY medical condition or traumatic injury natural or unnatural that can trigger an "altered level of consciousness" (altered LOC) also has the potential to trigger violently-exertive states of agitated or excited "delirium." As demonstrated by the universally-recognized "AEIOU-TIPS" mnemonic, potential altered LOC causes include:
Infection (especially when accompanied by acute fever)
Overdose (of alcohol and/or prescription/non-prescription drugs)
Trauma (to the Head)
Tumor (in the brain)
Insulin (hypoglycemic states)
Psychosis (acute episodes of)
Stroke (CVA or TIA)
During my 7 years experience as ward staff of a State Psychiatric Hospital, and my 18 years experience as a field-operating paramedic, I've personally witnessed states of violently-exertive agitated or excited delirium being caused by each of the following: seizure, hypoglycemia, acute psychosis, TIA, alcohol abuse, and drug abuse (abuse of either cocaine or drugs other than cocaine). One particularly interesting case of violently-exertive agitated or excited delirium I participated in was triggered merely by an idiosyncratic response to the first-time ingestion of psilocybin mushrooms -- no other drug or alcohol ingestions, and no other medical or traumatic potential altered LOC causes, were associated with that case.
Clearly, a violently-exertive state of agitated or excited delirium can be triggered even in the ABSENCE of any drug use or abuse. Thus, I believe it is a serious error for NAME to concretely state that "Chronic drug use is necessary to induce the changes in the neurochemistry that lead to agitated delirium."
No medical professional can deny that even the "first-time" use of cocaine may trigger an idiosyncratic violently-exertive state of agitated or excited delirium. Furthermore, if the "first-time" or any "occasional" use of cocaine is accompanied by even ONE of the other altered LOC triggers (such as a seizure, or hypoglycemia, or an acute psychotic episode), any "first-time" or "occasional" use of cocaine could easily be accompanied by a violently-exertive episode of agitated or excited delirium. (In fact, in such cases, it would be almost impossible to determine whether it was the cocaine-use OR the other altered-LOC-trigger that was "responsible" for precipitating the violently-exertive state of agitated or excited delirium.) Thus, I believe it also is a serious error for NAME to concretely dictate that, "A diagnosis of cocaine-induced excited delirium requires a clinical history of chronic cocaine use."
(2) The Am J Forensic Med Pathol issue containing NAME's "certification of cocaine-related deaths" recommendations, contains another article by the SAME authors; "Criteria for the interpretation of cocaine levels in human biological samples and their relation to the cause of death." In that article, the authors published the following statements [MY use of bold face for the final statement cited]:
"Ideally, the investigation into the [cocaine-related] death starts at the scene. ... the investigator looks for and notes the ... original position of the deceased at the time of death, ... the presence of any restraints ... The nature and the anatomic location of the restraint are noted. ... Were there any signs of or information about bizarre behavior, struggle with family, neighbors or the police at the time of death, since restrictive or another form of asphyxia needs to be considered. The use of pepper spray, stun guns, Taser, or any blunt force is noted as well, since these items can require additional studies during the investigation or autopsy. ... If the person was restrained, what position was he/she in, and what were the conditions and the duration of the restraint? ... Other pathology always is considered before making a decision that cocaine is the cause of death."
Yet, the fact that many deaths routinely attributed to "cocaine-intoxication" occur DURING application of asphyxial forms of restraint (particularly forceful-prone-restraint) is NOT -- at all -- specifically addressed by NAME's "certification of cocaine-related deaths" discussion or recommendations.
YES. NAME's "certification of cocaine-related deaths" DISCUSSION includes the following statements: "Currently, when all other causes of death have been reasonably eliminated, the recommendation is that cocaine related deaths be certified as accidental." ... and ... "In cases of sudden death related to police actions, the involvement of cocaine as a cause of death should be made with caution."
But, nowhere within the DISCUSSION of NAME's "certification of cocaine-related deaths" recommendations is the common association between asphyxial forms of restraint and deaths routinely attributed to "cocaine-intoxication" specifically addressed in any meaningful manner. And, not even ONE vague inference to the importance of restraint-application investigation is mentioned in NAME's SUMMARY of "certification of cocaine-related deaths" recommendations.
LASTLY; NAME's SUMMARY of recommendations entirely failed to include the conditions under which a cocaine-related death might be certified as "homicide."
I would appreciate it if NAME, and the Am J Forensic Med Pathol's Editor-in-Chief, and the authors of NAME's "certification of cocaine-related deaths" recommendations, would AMEND their first three RECOMMENDATIONS as follows:
1. For all suspected cocaine-related deaths, the complete autopsy examination should be accompanied by a complete scene investigation, as documentation of scene and history information is essential for a competent determination of the cause and manner of death.
2. If the death is associated with physical or mechanical restraint application, particular attention should be paid to the position of the restrained individual at the time of death, in relationship to its restrictive or asphyxial potential. The conditions preceding and during restraint application, the manners of application and anatomic locations of restraint application, and the restraint's duration should be considered. Concomitant use of pepper spray, stun guns, Taser, or any blunt force should also be investigated and considered.
3. A diagnosis of cocaine-induced excited delirium requires a clinical history of typically bizarre and violent psychotic behavior preceding death, and the presence of cocaine or its metabolites in body fluids or tissues found at autopsy. A clinical history of prior nonfatal episodes or a history of frequent (heavy) cocaine use or bingeing prior to the incident is not required for the diagnosis.
I would appreciate it if NAME, and the Am J Forensic Med Pathol's Editor-in-Chief, and the authors of NAME's "certification of cocaine-related deaths" recommendations, would AMEND the last of their RECOMMENDATIONS as follows:
8. Specimens must be properly obtained, stored, and preserved in sodium fluoride to reliably determine the manner of death through forensic analysis. It is better to have more specimens, including ones that show chronic use such as hair, than an insufficient number of specimens to examine. [This is simply an "order change"; the recommendation previously-numbered "10" becoming recommendation number "8."]
9. In the absence of any other pathology, the manner of death in which only the metabolites of cocaine are detected in urine is generally certified as natural.
10.. In the absence of any other pathology, the manner of death where death is sudden and in association with cocaine in the blood is generally considered accidental.
11. In the absence of any other pathology; when blood, serum, and urine levels of cocaine are present; but the circumstances of death included a manner of potentially-asphyxiating restraint application; the manner of death is generally considered to be homicide.
Ms. Charly D. Miller
SEE ALSO: Allegheny County Coroner, Cyril H. Wecht (MD, JD)'s
"REVIEW" of this PAPER:
Response to the NAME position paper
on the certification of cocaine-related deaths.
Am J Forensic Med Pathol (December) 2004;25: 362-363.
"... the adamant refusal of some of our colleagues to even consider
police misconduct and brutality as the underlying feature of such cases is
most regrettable and, in my opinion, morally and ethically indefensible."
RIGHT ON, DR. WECHT!!!
This letter was originally posted in January, 2005.
Should anyone ELSE wish to contact these individuals, regarding
these two Am J Forensic Med Pathol (March) 2004 articles,
HERE are their various addresses:
Am J Forensic Med Pathol Editor-in-Chief
Vincent J. M. DiMaio, MD
Bexar County Chief Medical Examiner
7337 Louis Pasteur
San Antonio, TX 78229-4565
Am J Forensic Med Pathol Publisher
Frances R. DeStefano
Am J Forensic Med Pathol Editorial Office Contact
NAME Society Office
430 Pryor Street SW
Atlanta, GA 30312
STEPHENS, BG: Email: email@example.com
JENTZEN, JM: Email: firstname.lastname@example.org
KARCH, S: Email: email@example.com
WETLI, CV: Email: firstname.lastname@example.org