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Build It Better for Public Health: Improved Data Infrastructure Is Vital to Bending the Curve of the Overdose Crisis.

For most decedents, the COD is determined by the attending physician or nurse;however, death investigations are required for cases in which the COD is sudden or unexpected, is not of natural causes, is unattended, or is unexplained.2 Therefore, coroners and medical examiners are typically the authorized certifiers of death in cases involving overdose.3 In this issue of AJPH (p. S36), Merlin et al. provide a timely analysis of overdose surveillance in the health care settings, where deaths may be miscategorized by attending physicians for decedents with underlying illness. According to Centers for Disease Control and Prevention (CDC) data, of the 28 states with county coroners, 22 states do not have a state medical examiner, and half do not require the coroner position to be held by a medical professional or an individual with certified credentials to conduct autopsies, such as pathology, toxicology, and forensic medicine.4 The accuracy of COD related to drugs is higher for medical examiners than for coroners. [...]the specific drug was not listed for 38% of death certificates in states with decentralized county coroner systems, compared with 8% in states with a statewide medical examiner system, leading to underestimates for death rates.3 Even in situations where medical examiners are present, death investigations continue to be substantially underfunded and threaten the accuracy of COD data. COD determination exists within a broader context of institutional racism and racial bias in clinical policy and practice.11 Genomic research has unequivocally determined that race is not a biological categorization;yet, erroneous beliefs persist in the medical community about biological differences between Black and White individuals.12 These biases are associated with clinical recommendations and how services are delivered.13 Recognizing signs that overdose may have occurred is also limited by the lack of foundational training provided by medical institutions for substance use disorder, despite its being a leading COD for unintentional injury.