A new report released last week found Pinellas and Pasco counties leading the state in an alarming count — the number of people fatally overdosing on the most lethal prescription drugs.
That leads to two possible conclusions, both dismaying. Either the Pinellas and Pasco communities are at the epicenter of Florida's prescription drug epidemic, or drug abuse deaths only seem highest in these counties because other regions are not reporting theirs so completely.
And if the second is true, the statewide problem is even worse than experts think.
"Either it's real, we really are higher, or they're under-reporting elsewhere," said Dr. Jon Thogmartin, the Pinellas-Pasco medical examiner.
The report from the Florida Medical Examiners Commission found that 2,710 deaths in Florida last year were caused by prescription drug overdoses, up 8.9 percent from 2009. That's almost eight people a day.
But if other regions of the state are under-reporting, that number could be much higher.
"I've always felt that the numbers that are reported in the annual report actually underestimate the problem because some cases simply don't get reported for one reason or another," said Bruce Goldberger, professor and director of toxicology at the University of Florida College of Medicine.
The calculus of drug deaths in Florida reveals a lot about the science, the detective work and the human tragedy of trying to quantify an epidemic in which legal drugs are killing far more Floridians than illegal ones such as heroin and cocaine.
In the latest report, the Pinellas-Pasco district led the state in 2010 in deaths from all six of the most lethal prescription drugs — oxycodone, alprazolam (Xanax), methadone, hydrocodone (Vicodin), morphine and diazepam (Valium).
The Hillsborough Medical Examiner's Office also reports some of the highest number of deaths in the state, but not as many as Pinellas-Pasco, which has a slightly higher population.
This isn't the first year Pinellas and Pasco have reported some of the highest death tolls.
As supervisor of the Pinellas Strategic Diversion Task Force, sheriff's Sgt. Dan Zsido finds it "alarming" that Pinellas is a leader. But he's not necessarily disagreeing.
"I believe that we possibly have more people that are addicted right now in this area," he said after reviewing the report. "Now, for whatever reason, we're first and we're really going to have to look at why."
Pinellas and Pasco have larger populations than many rural counties, which could help explain their numbers. After adjusting for population, both counties remain high — though not the highest — in per capita deaths from alprazolam, diazepam, hydrocodone and methadone. Pasco County had one of the highest rates of oxycodone deaths.
Yet overall, prescription drugs still are killing more people locally than in far larger counties such as Miami-Dade and Broward.
Even after working to standardize procedures, Florida's medical examiners are quick to admit some things differ from district to district. And that could have an effect on which deaths get evaluated and which don't.
For starters, not everyone goes to a medical examiner's office. The doctors at these offices perform autopsies on people who die violently or from suspected drug overdoses but generally not in cases where the deaths appear to be from natural causes.
Thogmartin said Pinellas and Pasco law enforcement officers are well-trained to look for evidence of drug abuse that might not be obvious — for example, a man with heart problems who dies, but who also had a knee problem and a hydrocodone prescription. Deputies will check the number of pills in the bottle to see if the man was using them faster than prescribed, which could have led to an overdose.
If more cases like that get referred to the medical examiner's office, then more drug deaths are likely to be counted.
Thogmartin said the Pinellas-Pasco office also uses its own toxicology lab that tests extensively for drugs. That could turn up more drug deaths. It's also true that the state lacks a uniform approach to toxicology testing.
Even basic reporting has sometimes been spotty, medical examiners admit. Prior to this year, for example, some doctors in the Miami office were simply failing to fill out a form to indicate a prescription drug death, said Dr. Lee Hearn, director of the toxicology lab at the Miami-Dade Medical Examiner's Office.
Experts say a new statewide electronic system should correct many problems.
There is also a human factor. More than most people realize, establishing a cause of death due to drug abuse is a judgment call, medical examiners say.
"If you have five different medical examiners looking at the same case you may get two or three different opinions," Hearn said.
For any given drug, there is no precise lethal level. Some people die if their blood alcohol content reaches 0.25, but some people actually survive and even function with higher levels, said Miami-Dade Medical Examiner Bruce A. Hyma.
And different drugs are often mixed together, creating more variables to evaluate. Some autopsies are not performed until several days after death, which can make the evaluation even more difficult.
"As doctors say, there's a lot of art involved and a lot of personal preference involved," said Goldberger, a Ph.D. who runs the UF toxicology lab. "And all of this can lead to some subjective differences between districts."
Whether such differences explain why Pinellas and Pasco sit at the top of the list, Goldberger noted the evidence is clear on the most alarming finding: The trendline is up.
"Clearly too many people die every day in the state of Florida as a consequence of the use, misuse and abuse of prescription drugs," he said.