Toxicology testing in the USA: what the 2018 census of medical examiner and coroner offices tells us

In 2021, the U.S. Bureau of Justice Statistics (BJS) published results for the 2018 Census of Medical Examiner and Coroner Offices (CMEC) that provided an update on the medicolegal death investigation system in the USA. The 2018 Census collected data regarding toxicology service provisions, staffing, infrastructure, and practices, some of which were not included in the 2021 published BJS report from more than 1600 responding medical examiner/coroner offices (MECs). The 2018 CMEC was conducted from June 2019 through March 2020 by mail, online, and email. Toxicology-related CMEC data were obtained from BJS's publicly accessible dataset and evaluated in this study. Results from this study include information on toxicology service capability across MECs, including the number and salary of forensic toxicologists, toxicology retention time schedules, laboratory accreditation, professional certification, drug screening practices at the death scene, and whether they request confirmation testing. Overall, internal capabilities for toxicology testing were rare in 2018, with only 78 MECs (5.9%) reporting this function. Large MECs, serving a population of 250 000 or more, comprised about 15% of MECs that responded to the toxicology testing questions, with the rest being evenly divided between MECs that serve small (<25 000) and medium-sized (25 000-249 999) populations. Overall, 57.4% (n = 761) of MECs indicated that their forensic toxicology testing strategy has changed because of the increase in drug-related deaths, 53.9% of MECs (n = 715) perform drug screening tests, and 95.1% (n = 674) confirmed these tests with laboratory toxicology testing. Less than half of MECs reported that they had a toxicology specimen retention schedule (45.3%) or a computerized case management system (44.8%). These data are key to understanding (i) postmortem toxicology policies and practices, (ii) how these practices have evolved, (iii) MEC infrastructure, and (iv) the national importance of these data considering the ongoing drug overdose crisis.