Opioid Overdose Deaths in 2025
The opioid overdose death investigation remains all too common in coroner and medical examiner offices. That’s despite the reported drop in drug overdose deaths in 2024 and a predicted drop of about 25% in 2025. Yes, other types of drugs—methamphetamine, cocaine, benzodiazepines—are part of the mix, but variations of the synthetic opioid fentanyl have been found in about 75% of all drug overdose investigations in recent years.
The correct terminology for an opioid-related death is drug or opioid intoxication, not overdose. However, overdose is the common usage term, so I will use it in this post.
According to a May 14, 2025 CDC press release, the estimated number of unintentional (accidental) opioid overdose deaths in the United States was 54,743 in 2024 compared to 83,140 in 2023. That sounds like a huge and welcome drop, but because of the lag in drug death reporting, expect final numbers to be higher than these estimates.
Where do these statistics come from? It all begins with a medicolegal death investigation at a coroner or medical examiner office. That’s what this blog post is all about.
Let’s delve into the four key steps of an opioid drug death investigation.
Suspected Opioid Overdose: Scene Investigation
Visual and Environmental Clues
The first rule for the coroner or medical examiner investigator going to the scene? Never assume a death is from a drug overdose, even if that’s what comes through in the dispatch.
Not even if there is drug paraphernalia all over the place, as in the photo. It’s a clue, nothing more. Evidence can be planted and people can die of other causes even if they use illicit drugs.
In fact, never assume anything at a scene. Not suicide, not homicide, not drugs, not “natural” death.
The second rule: Document everything with photos and in a narrative scene report. Drug-related deaths are criminal cases. All scene information is evidence that may be used in court.
Body Clues
The body examination and documentation in an opioid overdose death investigation are the same as for any suspicious death. The best reference is the National Institute of Justice’s 2024 Death Investigation: A Guide for the Scene Investigator.
That said, investigators may find someone who has died of a fentanyl overdose in an unusual body position known as the “fentanyl fold.” Often the decedent is seated on the floor, with the upper body bent over the lower body. Some doctors have attributed the posture to muscle effects, but vertigo may also play a role.
An even more classic finding in an opioid overdose death is what’s known as a foam cone. White or pinkish froth coming up from the lungs covers the nose and mouth. In an older person, this finding could also mean congestive heart failure. In a young person, a foam cone suggests cardiorespiratory failure due to opioid intoxication.
Don’t be Fooled
Ageism has no place when investigating suspected drug death scenes.
The rate of drug overdoses in people over age 55 significantly increased from 2022 to 2023.
I first wrote about opioid poisonings in children in early 2023. Infants, toddlers, and young children are now dying of fentanyl intoxication at alarming rates.
The Role of the Autopsy in the Opioid Overdose Death Investigation
To Autopsy or not to Autopsy
The National Association of Medical Examiners (NAME) 2020 updated position paper on the subject calls the autopsy “an essential component of investigating apparent overdose deaths.” However, due to shortages of forensic pathologists and inadequate funding of death investigation offices, coroners and medical examiners do rely on scene information, medical history, and toxicology in some cases.
The most consistent physical finding in an opioid intoxication death is congestion of the lungs, which can weigh as much as twice normal. The pathologist may also observe cerebral edema (brain swelling), but not as consistently as pulmonary edema.
A careful search for needle tracks may not reveal much these days. That’s because users often ingest opioids by other means such as smoking, swallowing, and transdermal (buprenorphine/Suboxone for example).
Toxicology Testing and Interpretation in the Opioid Overdose Death Investigation
Samples for Toxicology
Toxicology is the only way to confirm an opioid overdose death. A certified laboratory must do the testing. Panels of tests vary: an extended array of tests that includes designer opioids will usually cost over $200.
Urine screening tests done at the time of the autopsy or at a hospital only provide presumptive evidence and are not a substitute for blood or other tissue toxicological testing.
The pathologist or autopsy technician collects fluid and tissue samples for toxicological and other chemical testing at the autopsy. Some offices have their investigators draw samples at the scene or at the morgue, to minimize time since death.
Peripheral blood, usually femoral, is preferred to cardiac blood. It is less likely to be contaminated by, for example, material from the stomach. Urine, vitreous (from the eye), bile, and stomach contents should be collected, although they may not be tested unless confirmation or clarification of blood findings is needed.
Delayed Deaths
When someone dies of a suspected drug overdose in the hospital, the coroner should immediately ask the hospital for the blood drawn at the time of admission. Unfortunately, most hospitals discard blood samples within a certain number of days, often only three . Blood drawn after hospitalization is useless for two reasons: the drug(s) that caused the overdose have probably been metabolized, and the hospital has given the patient multiple other drugs, often including opioids.
Good to Know
What if there’s no blood? This happens occasionally in traumatic accidents (think motorcycles) where the decedent exsanguinated at the scene. In such cases, the lab can test body tissue like liver or muscle.
It’s good practice to collect a hair sample to keep on file. This can be useful for proving chronic use in difficult cases like child overdose deaths.
Interpreting Toxicological Tests
Toxicological tests can’t distinguish between pharmaceutical fentanyl and illegally-made fentanyl. Two clues to illegal fentanyl: multiple other illicit drugs are present and fentanyl levels far exceed the therapeutic range.
The overlap between therapeutic and toxic levels of opioids, including fentanyl, means there is no blood level that is uniformly fatal. Toxicity depends on tolerance, body size, metabolism, drug interactions, and much more. In other words, what kills one person may have little effect on another. This is where the autopsy is important. It’s much more likely the drug(s) caused the death if no other cause of death can be identified.
Putting it all Together: Certifying the Cause and Manner of Death
Who Signs the Death Certificate?
Only a coroner or medical examiner can sign the death certificate.
Cause of Death
If you need a refresher on what a death certificate looks like or how physicians or coroners fill out death certificates, take a look at my earlier blog on cause of death determination.
Intoxication, Toxicity, or Poisoning—not Overdose—are the correct terms for a cause of death statement. Fentanyl toxicity, for example. The name of the drug or drugs should always be included.
In combined drug toxicity deaths, it’s almost impossible to say that one particular drug or some combination of drugs caused the death. That’s why the coroner should list all drugs that may have played a role in the death. Yes, this can get quite lengthy, but it’s important for tracking drug death patterns.
An inadequate cause of death statement: Combined drug intoxication
A complete cause of death statement: Combined drug intoxication with amphetamine, methamphetamine, MDMA, cocaine, and fentanyl.
Compounds like 4-ANPP (precursor to fentanyl) or norfentanyl (metabolite of fentanyl) are generally not included, especially if the active drug is present.
Opioid Overdose Cause of Death Controversies
If the decedent had other medical conditions such as hypertensive heart disease, the pathologist and the coroner’s work becomes more difficult. They must make a clinical judgment about what to list as the primary cause of death (Part 1 of the death certificate) and what to include as a contributory factor (Part 2 of the death certificate).
Should the coroner or medical examiner include mental health diagnoses such as substance use disorder, depression, and bipolar disorder on the death certificate? If the conditions were well-documented in the decedent’s medical history, I believe certifiers should include them in Part 2. Documentation might include hospitalization or treatment by a medical professional for a mental health condition.
Manner of Death
The NAME adheres to “accident” as the best classification for manner of death in an overdose where there is no evidence for suicide or homicide. A previous diagnosis of depression is not in and of itself adequate evidence for suicide.
The vast majority of opioid overdose deaths are classified as “accidents,” even in those cases where prosecutors plan criminal charges such as drug delivery resulting in death.
Conclusions
Thorough opioid overdose death investigations are critical to accurate death certification, tracking the ongoing evolution of the opioid epidemic, and effectively directing prevention efforts.