Death‐certificate–recorded autopsy utilization in U.S. intoxication deaths, 2003–2023: National trends, benchmark comparison, and state heterogeneity

Drug intoxication deaths increasingly fall under medicolegal jurisdiction, yet national trends in death-certificate-recorded autopsy utilization for community intoxication deaths are not well characterized. Using CDC WONDER MCOD tabulations (2003-2023), we performed a retrospective cross-sectional analysis. Primary analyses were restricted to a community/emergency department (Community/ED) subset (home; dead on arrival; outpatient/ER; other; or unknown). The outcome was intoxication autopsy utilization among deaths with known autopsy status (Yes/[Yes+No]), modeled with Joinpoint regression. We also described Community/ED autopsy workload proxy and intoxication share, estimated a national historical-baseline gap in intoxication autopsies under a 2006-2011 baseline utilization rate, and compared state changes between 2018-2019 and 2022-2023. Total all-place intoxication deaths increased from 348,082 (2003-2012) to 411,446 (2020-2023). In the Community/ED subset, autopsy utilization declined from 84.74% (2003) to 69.78% (2023), with a joinpoint in 2018 and a steeper decline during 2018-2023 (annual percent change, -3.09%/year); the largest year-to-year decrease was 2019-2020 (-5.01 percentage points). The homicide autopsy benchmark (all places) remained 98.06%-98.82%. All-cause Community/ED autopsies increased from 128,494 (2003) to 216,842 (2023), and the intoxication deaths share rose from 12.56% to 30.15%. The historical-baseline gap reached 13,867 fewer intoxication autopsies than expected in 2023. From 2018-2019 to 2022-2023, age-adjusted intoxication mortality increased in 49 states while Community/ED autopsy utilization declined in 33. Death-certificate-recorded community intoxication autopsy utilization declined amid rising intoxication burden, with substantial state heterogeneity and widening historical-baseline gaps, highlighting implications for medicolegal capacity and death-certificate autopsy documentation.