Injecting Someone Who ODs Called a Homicide in Maryland

There’s a difference between a drug overdose and a homicide, even if the drug was heroin and the person who died was injected by a friend. At least, that is the view of Maryland’s chief medical examiner, David R. Fowler, MD, as reported in The Baltimore Sun this spring. But now, Dr. Fowler has done just that: declared a homicide in which a person was injected by someone—a friend, as it turned out—and then died. Amber Brown and her girlfriend drank alcohol and injected each other with heroin in Baltimore one night. Amber Brown fell asleep and didn’t wake up.

Typically, Dr. Fowler calls the hundreds of drug overdoses that occur in his state each year “undetermined,” because he doesn’t believe in labeling a death a homicide—or labeling it with any cause at all—unless there is evidence, notably from witnesses.

In fact, using toxicology records alone to determine cause of death is not scientifically accurate. Someone who is opioid tolerant, for example, might have a high level in the body—enough to kill an opioid-naïve user—but may have died of something else. That’s why chief medical examiners look for other signs related to the death. Was the deceased jogging at the time, and fell over clutching the chest? Perhaps the death was a heart attack. In fact, Ms. Brown had complained of chest pains before she and her friend took alcohol and heroin, according to The Baltimore Sun.

Assuming that drugs caused a death is difficult enough—not to mention assuming that someone else was responsible for administering the drugs.

A few years ago the Substance Abuse and Mental Health Services Administration (SAMHSA) was obsessed with the idea that methadone overdoses were related to methadone diverted from opioid treatment programs. Finally, when all the data were in, the truth was clear: the methadone that was responsible for overdoses was coming from pain prescriptions—and in many cases, the person taking the methadone was opioid naïve, or actually taking it for pain, but unaware that the medication has a very long half-life (is eliminated from the body very slowly, thus additional doses can build up to dangerous levels). Not getting high or feeling pain relief immediately, a person may take another pill.

And in what was a very sad series of unintended consequences over the course of a decade, it was the crackdown on oxycodone (OxyContin), combined with the low cost of methadone, that led to an increased use of methadone for pain, and in turn the entire prescription opioid abuse and overdose crisis has wound up with a crackdown on pain prescribing altogether. Some people who legitimately need pain prescriptions are being denied them, as physicians, wary of being investigated, cut down on their prescribing. At the same time, people who are addicted will need someplace to go for treatment, or will find some other way to avoid withdrawal. They may buy buprenorphine on the street—that buprenorphine/naloxone (Suboxone) is being diverted is already well known—or they may just turn to heroin. Will there be fewer overdoses, or more?

In the case of Amber Brown, whose family has not been located, the autopsy concluded the cause of death was heroin intoxication, and the reason it was easy to call her death a homicide was that the police knew someone else had injected her.

Whether or not there will be criminal charges against the friend, whose name has not been released by police, has not yet been decided. Maryland has one of the nation’s strongest substance abuse treatment programs, especially in medication-assisted treatment for opioid addiction, and there’s a movement in the state to have fewer “undetermined” drug overdose deaths and more identified causes and more people to blame. Kudos to Dr. Fowler for his adherence to medical evidence over the course of his 20 years as the state’s chief medical examiner. Let’s hope he can continue to stand firm as the calls for someone to blame—and punish—for overdoses inevitably mount.