Dr.

Darinka Mileusnic-Polchan Chris Thomas

Chief Medical Examiner Chief Administrative Officer
Knox County Regional Forensic Center Knox County Regional Forensic Center
2023 Drug-Related Death Report

Table of Contents
Letter from the Chief Medical Examiner......................................................................................................... 2
2023 Key Findings ........................................................................................................................................... 4
Knox & Anderson Counties Age Distribution for Drug-Related Deaths 2019-2023 .................................... 5
Knox & Anderson Counties Gender Distribution for Drug-Related Deaths 2019-2023 ............................... 8
Knox & Anderson Counties Race Distribution for Drug-Related Deaths 2019-2023................................. 10
Knox & Anderson Counties 2023 Drug-Related Deaths by Manner of Death ............................................ 11
Knox & Anderson Counties 2023 Drug-Related Deaths by Location of Occurrence ................................ 12
Knox & Anderson Counties Zip Code Distribution and Injury Location Heat Maps 2023 ........................ 13
Frequency of Drugs Found in Drug-Related Deaths 2023 .......................................................................... 15
Top 10 Drugs Found in Drug-Related Deaths 2019-2023 ............................................................................ 17
Naloxone in Drug-Related Deaths 2023 ....................................................................................................... 17

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2023 Drug-Related Death Report

A Letter From
The Chief Medical Examiner
Of Knox and Anderson Counties
This year’s drug-related death report is slightly optimistic despite a bit of unfavorable news. Some of
the wording might be repetitive from last year’s report, however, bringing awareness of what is
happening in our community will ultimately lead to the appropriate preventative measures, behaviors,
and actions, individual and community based.

Knox County overdose deaths decreased by 5 percent compared to the 2 percent increase in 2022.
Overdose deaths in Anderson County decreased by 6 percent compared to the 22 percent decrease
the previous year. The drug-related death toll and related trends are promising again, similar to 2019
or the pre-COVID year, however mixed drug intoxications continue to be the leading culprit. Fentanyl,
fentanyl analogues, several novel synthetic opioids and other designer drugs including illicit
benzodiazepines continue to be the most abused drugs. Methamphetamine, which is still the
stimulant drug of choice in East Tennessee, is frequently used in combination with opioids. Cocaine
is encountered occasionally, but trails significantly behind methamphetamine abuse. Alcohol
continues to be among the top five most frequently abused substances and as such it usually
contributes to combined drug intoxications. It is also important to keep in mind that many unattended
deaths that fell under the Medical Examiner jurisdiction in 2023 were caused by sequelae of chronic
alcohol abuse, which (unlike accidental acute drug overdose deaths) are classified as natural manner
of death.

In Knox and Anderson counties, the lives of men in the 35 to 44 age group continue to be
disproportionately taken by drugs compared to women (68 percent men versus 32 percent women in
Knox County and Anderson County). In more urban areas, like the City of Knoxville, the ratio of black
to white overdose deaths continued to be approximately 1:9, which is reflective of the community’s
demographic composition. Tragically, the sharpest increase in drug induced deaths in 2023 was in
individuals aged 15 to 24.

When society discusses preventative measures to reduce risks of bad life outcomes, we frequently
focus on objects instead of people. Most drug overdose deaths are mannered as accidents and in
many communities are the number one reason for accidental deaths-surpassing motor vehicle
accidents. That means that in most jurisdictions including ours, most accidents, especially among
young folks, are avoidable. It takes a lot of effort, from parents to educators, to raise and properly
educate our children to become productive members of a society that is free of drugs. Nevertheless,
that sort of approach and world view will save their lives and is worth the effort.

This year, there are even more tongue twisting drugs on the illicit market. They are deadlier than
ever when used alone let alone in combination with other drugs. Snorting and/or intravenous drug
abuse continue to be the predominant modes of intake in drug-related deaths. The combination of
stronger drugs and direct modes of administration (such as injections directly into the blood stream or
the muscle), continue to render naloxone ineffective.

Knox County Regional Forensic Center (RFC) continues to be at the forefront of the antidrug abuse

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2023 Drug-Related Death Report

effort by providing real time insight into the trends and spikes or unusual occurrences in drug-related
deaths. Some of the unusual and unexpected toxic substances have been detected early on in our
jurisdictional area due to our tireless efforts to be on top of the dangerous and reportable toxicologic
trends.

That brings me to the topic of xylazine and Bromazolam, two of the most frequently encountered
substances that used to be detected by our reference toxicology laboratory as “out of scope” drugs.
They used to be rare and unusual, however, both are now in the top six most detected intoxicants
that contributed to the drug-related mortality in 2023 (the table summarizing the frequency of different
substance representation in 2023 drug-related deaths and over the last five years is on the last page
of the report). Xylazine is a veterinary sedative that has shown up in toxicology results frequently
throughout the United States. Acute intoxication resembles opioid toxicity, however chronic side
effects can be even more devastating such as soft tissue necrosis resulting in widespread skin ulcers,
bone marrow infection and sepsis. Bromazolam is a benzodiazepine that was originally developed as
a candidate medication but was never approved for use. The reported effects of intentional use
include “hypnotic” and “sedative” sensations in addition to muscle relaxation and analgesia. Most
often these drugs are combined with more potent substances as fillers or adulterants. Their detection
is important in terms of quantifying their interaction with both potent opioids and stimulants that
makes them more dangerous together. Moreover, tracking their occurrences in our community may
assist the local law enforcement agencies and Drug Enforcement Administration (DEA) in identifying
the sources and pathways of distribution by the major illicit substance suppliers in the country. More
information about the RFC’s participation with the DEA in researching fentanyl and other novel
substance-related deaths can be found here.

On a positive note, raw data collected during the first quarter of 2024 projects continuous decrease in
drug-related deaths. Deadly accidents, especially motor vehicle crashes, and homicides, can
frequently be tragic secondary effects of illicit drug use. That specific data can be found in the
KCRFC Annual Report.

The list of questions about why opioid and other drug problems continue to plague our communities is
unending and as diverse as the victims. After several years of drug-related death reporting, one fact
remains unchanged: If the trend continues, the life expectancy of our residents will continue to
decrease in comparison to other developed modern nations either due to acute short term toxic
effects of drugs or their chronic long term effects on all organ systems leading to serious life
threatening comorbidities.

Darinka Mileusnic-Polchan, MD, PhD

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2023 Drug-Related Death Report

2023 Key Findings

The overdose epidemic in Knox County mirrors the rest of the nation and is growing in magnitude but
also changing in character. Last year, 519 people died from drug overdoses in Knox County
compared to 544 in 2022; and 62 people died in Anderson County compared to 66 in 2022.
Preliminary data for drug-related deaths in 2024 indicates Knox County could see a decreasing trend
for drug-related death cases. Drug-related deaths increasingly involve synthetic opioids (fentanyl and
fentanyl analogs), while those caused by prescription opioids (oxycodone, oxymorphone,
hydrocodone, etc.) are decreasing.

2023 Report Highlights for Knox and Anderson Counties:

 Knox County experienced a 5 percent decrease in drug-related deaths between
2022 to 2023.

 Drug-related deaths in Anderson County decreased by 6 percent from 2022 to 2023.

 Fentanyl and fentanyl analogues (synthetic opioids) were the most frequently
identified drugs in drug-related deaths in 2023.

 Polypharmacy, which is when more than one drug is responsible for death, was
involved in 71 percent of drug-related deaths in Knox County and 74 percent in
Anderson County.

 The five most common drugs identified in drug-related deaths in 2023 were synthetic
opioids, methamphetamine, cocaine, xylazine, and alcohol/ethanol.

 Prescription opioid-related deaths continue to decrease in our jurisdictions.

 People 35 to 44-years-old experienced the most drug deaths in Knox County, but
the sharpest increase was in individuals aged 15 to 24-years-old and ages 75+.

 The presence of anxiolytic, anti-depressant, and anti-psychotic medication was

found in 22 percent of all drug-related deaths in Knox County and 16 percent in
Anderson County

Data and Methods

The Knox and Anderson County Medical Examiner database (MDILog) was queried for possible drug-
related causes of death for cases accepted under medical examiner jurisdiction between January 1,
2023, and December 31, 2023. The initial query included non-motor vehicle accidents, undetermined,
and suicide manners of death. The initial data set was examined to ensure all included cases were
drug-related deaths (as determined by the forensic pathologist of record). Causes of death related to
the chronic effects of drugs and alcohol abuse (bacterial endocarditis, chronic ethanol use, etc.) were
excluded from the dataset.
NIHCM 2021 https://nihcm.org/publications/the-evolution-of-the-opioid-crisis-2000-2018

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2023 Drug-Related Death Report

Knox County
Age Distribution for Drug-Related Cases
2019-2023
160

140

120

100

80

60

40

20

0
Infants 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+
2019 2020 2021 2022 2023

Anderson County
Age Distribution for Drug-Related Cases
2019-2023
30

25

20

15

10

0
Infants 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+
2019 2020 2021 2022 2023

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2023 Drug-Related Death Report

Knox County
2023 Drug-Related Deaths
by Age Distribution
7 2
17 35

86
124

135
113

Infants 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+

Knox County 2023 Drug-Related Deaths

by Age Distribution and the Percentage of Change
Infants 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+

100% 0% -100% 40% -5% -5% -16% 9% -51% 600%

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2023 Drug-Related Death Report

Anderson County
2023 Drug-Related Deaths
by Age Distribution
2 1 2

12 11

17 17

Infants 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+

Anderson County 2023 Drug-Related Deaths

by Age Distribution and the Percentage of Change
Infants 1 to 4 5 to 14 15 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75+

100% 0% 0% -100% 57% -15% 55% -40% -100% 0%

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2023 Drug-Related Death Report

Knox County
Drug-Related Death Distribution by Gender
2019-2023
600

500

400

300

200

100

0
2019 2020 2021 2022 2023
Total Male Female

Anderson County
Drug-Related Death Distribution by Gender
2019-2023
90
80
70
60
50
40
30
20
10
0
2019 2020 2021 2022 2023
Total Male Female

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2023 Drug-Related Death Report

Knox County
2023 Drug-Related Death
Distribution By Gender

32%

68%

Male Female

Anderson County
2023 Drug-Related Death
Distribution By Gender

32%

68%

Male Female

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2023 Drug-Related Death Report

Knox County
Race Distributions for Drug-Related Deaths
2019-2023
500
450
400
350
300
250
200
150
100
50
0
2019 2020 2021 2022 2023
White Black Other

Knox County Anderson County

2023 Drug-Related Death 2023 Drug-Related Death
Distribution by Race Distribution by Race
5 4
63

451
58
White Black Other White Black

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2023 Drug-Related Death Report

Knox County
2023 Drug-Related Deaths
by Manner of Death
8 1

510
Accident Suicide Undetermined

Anderson County
2023 Drug-Related Deaths
by Manner of Death
2

60
Accident Suicide

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2023 Drug-Related Death Report

Knox County
Location 2023 Drug-Related Deaths Occurred
53
Decedents Residence
6
Hospital
58
Hotel/Motel

Abandoned Building
8 242
Other Residence

Jail

Outside
98
Bar/Restaurant/Night Club

6 Other
41 7

Anderson County
Location 2023 Drug-Related Deaths Occurred
6
2 Decedents Residence

7 Hotel/Motel

2 Other Residence

Outside

45
Other

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2023 Drug-Related Death Report

Zip Code Distribution and Heat Maps by Year and County

The following zip code data represents location of injury locations for 2023 drug-related deaths for
which an autopsy or examination for Knox and Anderson Counties was performed at the Knox County
Regional Forensic Center. The data source and notes are listed here for the zip code related pages.

KGIS assisted by creating heat maps. The heat maps represent drug-related deaths based on home
address, location of injury, and location of death.

Data Source:
2023 Maps: MDILog Database and Knox County RFC Medical Examiner Database, 2023, Knoxville,
TN.

Notes:
The Location of Injury Address maps represent where the decedent was discovered and presumably
where the injury occurred.

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2023 Drug-Related Death Report

Knox and Anderson Counties

Analytes Found and Number of Cases
2021-2023
Analyte name 2021 2022 2023
Fentanyl 463 463 437
4-ANPP 417 423 398
Norfentanyl 391 355 345
Methamphetamine 290 295 282
Amphetamine 279 278 267
Naloxone 198 183 194
Delta-9 THC 133 139 130
Benzoylecgonine 94 109 130
Cocaine 52 62 100
Delta-9 Carboxy THC 94 105 98
Ethanol 102 104 98
Xylazine 25 40 85
Gabapentin 83 86 80
Diphenhydramine 108 75 76
Quinine 47 11 58
11-Hydroxy Delta-9 THC 41 33 55
Acetyl Fentanyl 51 19 42
Bromazolam 1 11 34
para-Fluorofentanyl 33 25 33
Alprazolam 45 37 31
Oxycodone - Free 44 28 28
Morphine - Free 71 39 27
Hydroxyzine 24 25 26
Cocaethylene 13 20 26
Amlodipine 1 33 25
Trazodone 20 28 25
Mitragynine 14 13 21
Citalopram / Escitalopram 22 26 20
Methadone 10 18 17
Desmethylsertraline 27 29 16
Acetaminophen 19 18 16
Oxymorphone - Free 30 17 16
7-Amino Clonazepam 28 26 15
Metoprolol 19 16 15
O-Desmethylvenlafaxine 12 10 15

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2023 Drug-Related Death Report

Norbuprenorphine - Free 21 32 14
Mirtazapine 17 10 14
Buprenorphine - Free 16 27 13
Nordiazepam 25 19 13
EDDP 6 11 13
Cyclobenzaprine 15 10 13
Venlafaxine 11 9 13
8-Aminoclonazolam 2 9 12
Beta-hydroxy fentanys 1 8 12
Ecgonie Methyl Ester 0 2 12
Sertraline 21 26 11
Hydrocodone - Free 17 22 11
Promethazine 22 15 11
Metonitazene 27 12 11
Duloxetine 9 7 11
Hydroxybupropion 14 6 11
Norfluoxetine 20 26 10
Diazepam 20 11 10
Midazolam 12 10 10
• These drugs were not necessarily related to the drugs that caused the death but are
listed to show a true picture of what combinations were found among all drug-related
deaths and to illustrate changes in character of drugs taken in combination with deadly
illicit drugs.

• The substances listed above represent those drugs found in ten or more drug-related
deaths.

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2023 Drug-Related Death Report

Knox and Anderson Counties

Top 10 Drugs Found in Drug-Related Deaths
2019-2023
2019 2020 2021 2022 2023
Fentanyl & Fentanyl & Fentanyl & Fentanyl & Fentanyl &
1
Analogues* Analogues* Analogues* Analogues* Analogues*
2 Methamphetamine Methamphetamine Methamphetamine Methamphetamine Methamphetamine
3 Alcohol/Ethanol Heroin Diphenhydramine Cocaine Cocaine
4 Heroin Alcohol/Ethanol Alcohol/Ethanol Alcohol/Ethanol Xylazine
5 Cocaine Cocaine Cocaine Xylazine Alcohol/Ethanol
6 Oxymorphone Gabapentin Gabapentin Alprazolam Bromazolam
7 Alprazolam Diphenhydramine Heroin Diphenhydramine Diphenhydramine
8 Oxycodone Oxycodone Alprazolam Oxycodone Alprazolam
9 Gabapentin Alprazolam Oxycodone Gabapentin Oxycodone
10 Diphenhydramine Oxymorphone Oxymorphone Morphine Gabapentin
*Includes Fentanyl, Acetyl Fentanyl, norfentanyl, para-Fluorofentanyl, Beta-Hydroxy Fentanyl,
Despropionyl-para-fluorofentanyl, Cyclopropyl-fentanyl, and Valeryl Fentanyl

Data Source: MDILog Database 2019-2023 Knoxville, TN

Note:
1. This report only notes the presence of the drugs contributing to death but does not indicate the
appropriate or legal use of a drug.
2. Drug poisoning deaths may involve more than one specific substance.
3. Some drugs are listed as Not Otherwise Specified (NOS) because information was obtained
from sources that did not define the drug type.

2023 DRD Cases with Naloxone Use and Drug Type

Naloxone-
Naloxone- Naloxone-
Rx and Illicit Total
Rx Drug Only Illicit Drug Only
Drug
Knox 4 100 68 172

Anderson 1 5 16 22

Total 5 105 84 194

This report is also available online.

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