Investigation finds Nebraska is likely under-reporting overdose deaths, costing it prevention money

Derrek Cocchiarella died slowly, lying in his mother’s bed on a warm afternoon in late June, in a house full of family.

He was napping, they thought, sound asleep. Over the course of four hours, they checked on him often. They didn’t recognize his breath gurgling. They didn’t see the bits of foam forming around his mouth.

Then one of Derrek’s younger sisters tried to wake him for a slice of cake, and found him cold to the touch.

In the moments and days after his death, Linette Cocchiarella, Derrek’s mom, struggled to understand. Derrek had freshly returned from rehab. He was finally doing better. How could he just suddenly die?

She called the county attorney’s office, which in Nebraska doubles as the coroner’s office, to ask about an autopsy.

No, she was told, your son’s cause of death has already been determined: Natural causes.

“And I’m like, ‘No,’” said his mother. “‘That’s not even possible. He’s 23.’”

In 2021, the year Derrek died, the state reported 234 deaths from drug-related causes. Nebraska boasted the lowest drug death rate in the country — fewer than 12 deaths per 100,000 people. That’s less than half the national average, continuing Nebraska’s decade-long run as one of the best states in the country at preventing drug overdose deaths.

It’s a point of pride among state leaders, cited by Gov. Jim Pillen when he vetoed a safe syringe bill in 2024. It’s a rationale for inaction, cited by state senators as they debate drug-related bills.

It’s likely costing us tens of millions of federal dollars, too. Nebraska receives the lowest dollar amount per person of any state in the country from federal substance abuse treatment funding.

Just one problem: Our lowest-in-the-nation drug death rate is likely false.

The state has long undercounted drug deaths, say state officials, public health researchers, treatment workers and a new Flatwater Free Press analysis of Centers for Disease Control data showing that Nebraska’s overdose rate and its death rate simply don’t match up.

Consider: Emergency departments in Nebraska, Montana and Texas all reported the same rate of nonfatal overdoses in 2023, about 85 per every 100,000 residents. But data show Montanans and Texans died of overdoses at double the rate of Nebraskans.

Those missed cases add up. If Nebraskans died at the same rate as Montanans, 338 would have died of overdoses in 2023 alone. The state reported 187.

“It’s clear that there’s underreporting based on our existing systems, and that’s unfortunate because everything we do depends on understanding what’s going on in the community. … If you don’t, it’s like driving a car without headlights,” said Dr. Ali Khan, dean of the University of Nebraska Medical Center’s College of Public Health.

There’s a potentially simple explanation, experts say: Both Montana and Texas have medical examiners who determine causes of death.

In Nebraska, that job falls to county attorneys. Many haven’t reported a drug death in years, even decades.

That’s in part because their main responsibility is prosecuting crimes. The county attorney responsible for investigating Derrek’s death told the Flatwater Free Press he doesn’t order autopsies for overdose deaths because, he said, “an overdose is not a criminal act. An overdose is an accident.”

Nebraska’s low overdose rate sets the tone of legislative debate. In recent years, the Legislature has cut $15 million from the state’s behavioral health budget, failed to legalize syringe exchange programs and stalled efforts to enhance penalties for drug-involved deaths.

Along the way, public officials have repeatedly warned that they think deaths are being missed. At a Health and Human Services Committee hearing last year, Assistant Attorney General Mike Guinan told lawmakers he has heard many times that “we are woefully underreporting overdoses in this state.”

That hearing was focused on mandating an overdose mapping program — an attempt to better understand Nebraska’s drug problem in real time.

State Sen. Ben Hansen, a Republican from Blair and chair of the committee, pushed back on the need to more closely track overdoses in rural areas, saying he “wouldn’t imagine they have that many out there.”

Nathaniel Cacy, a public health analyst for the state, cut him off.

“You would be surprised, sir.”

Gone and Uncounted

Paul Weishapl began counting on the day his old friend called, sobbing as he shared the news: My girlfriend died.

Weishapl knew why. The friend did, too. He’d recently had to leave a recovery group meeting that Weishapl was leading to revive his girlfriend with Narcan. She’d overdosed on opioids on his kitchen floor. The police knew, too, he said — everyone knew of her drug use, her previous overdoses.

Through tears, his friend then said something that caught Weishapl’s attention: “I just don’t understand why her death certificate says heart problems.”

Weishapl, now working as a harm reduction instructor at UNMC, knew that wasn’t right. He started paying closer attention at the almost monthly funerals he attended, counting the people he knew were involved with drugs.

Weishapl long ago grew used to morbid tallies, counting up friends he’d buried. That includes his closest friend in prison, who overdosed and died the day he was released. Weishapl had barely escaped the same fate himself, “on a death march” of overdoses and prison stays until he got sober after a two-decade opioid addiction.

But now he started asking more questions about what, exactly, had ended up on each person’s death certificate.

After four years of counting, Weishapl tallied 96 Nebraskans he believes died of overdoses.

Only 25 had an overdose listed on their death certificate.

“Seems like there’s a hell of a lot of people under 30 dying of heart attacks here,” Weishapl said.

His counting led him to Dr. Erin Linde, one of Douglas County’s four contracted forensic pathologists. That team performs almost all of the state’s autopsies.

Nebraska autopsied only 12.5% of deaths that happened outside a medical setting such as a hospital. That ranks among the bottom half of states, according to a FFP analysis of CDC data.

Hall County Attorney Martin Klein, who was responsible for handling Derrek’s death, said he orders an autopsy only when he believes the cause of death is a criminal act and may need it as evidence to prosecute.

He does not order autopsies for suspected overdoses.

When asked how he would know if someone dies of an overdose, Klein said, “We wouldn’t necessarily be able to. We don’t always have a specific cause of death for every person that we encounter.”

Linde tracks the disparity in reported overdoses from her lab. She knows which deaths are sent in to be autopsied and which aren’t.

Some regions of Nebraska report relatively high numbers of nonfatal drug overdoses — people who overdose and show up in emergency rooms. Yet many counties in those regions have never sent a single suspected drug-involved death to be autopsied.

Nebraska’s low overdose rate doesn’t mean there are few overdoses, Linde said. It just means we’re completing fewer autopsies.

“The bottom line is that we have absolutely no idea of what’s actually going on.”

Unlikely Zeroes

Eleven rural Nebraska counties haven’t reported a single drug-involved death over the past 20 years. In county after county, the reported numbers don’t align with expected outcomes.

Hamilton County, home to Aurora and near Grand Island, has nearly 50,000 residents. The health district there reports nonfatal overdose rates similar to the statewide average. Even at the state’s undercounted overdose rate, that would have led to around 28 deaths from 2019 to 2023.

Instead, Hamilton County reported zero.

The same is true for Butler County, which would have reported about 25 deaths. And Richardson, which would have another 24. Both reported none.

From 2019 to 2023, 25 different counties reported zero drug-related deaths. If those counties were actually at the statewide rate, 213 more people would have died of overdoses over that time. Those counties alone would have eliminated Nebraska’s best-in-the-country overdose rate.

“Either they’re really, really good at preventing (fatal) overdoses, or they’re just not ordering autopsies,” Linde said.

The inconsistencies also exist in our cities. Between 2019 and 2023, Nebraska’s metro counties reported lower overdose fatality ratios — the portion of overdoses resulting in death — than similar counties, according to an FFP analysis of data collected by the CDC.

In Lancaster County, roughly 13 out of every 100 overdoses were fatal. That’s fewer deaths than peer counties Fayette County, Kentucky, and Escambia County, Florida, which both had about 20 deaths per 100 overdoses.

Douglas County, too, was lower than its peers, reporting about 15 deaths per 100 overdoses.

A 2019 University of Nebraska at Omaha survey of Nebraska county coroners found that many “do not believe they have adequate knowledge, information, resources, and financial means to accurately and thoroughly complete drug-involved death investigations.”

Brittany Willmore, one of the researchers on the study, called county attorneys around the state and found that they didn’t see drug overdoses as a serious problem in their counties.

“I remember being struck by … this kind of ‘that doesn’t happen here’ sort of perception that they had,” Willmore said. “I thought, ‘What a disservice that probably is to our public health efforts.’”

Willmore’s own mother died of an overdose in Douglas County in 2013. As a 22-year-old, she had no idea how to navigate the death investigation system. She feels lucky that the coroner ordered an autopsy.

“I think it would have always been in the back of my mind, like, ‘Was this a heart attack? Was this a genetic issue?’” Willmore said. “But to then learn that it was in fact a drug overdose gave me closure.”

Struggling for Answers

In the week after Derrek died, his mother Linette, who lives north of Hastings in Hall County, repeatedly called that county attorney’s office. She says she was bounced between the county attorney and others in the office as she tried and failed to find someone who would help.

She grew frustrated. Derrek couldn’t possibly have died naturally, she thought. He was young. He’d been sober, living at a treatment center.

But he’d been in and out of the emergency room. He’d been struggling to breathe. Doctors told him it was panic attacks. Maybe something was wrong with his lungs, his mother thought.

Initially, Hall County authorities said no to an autopsy. They told her that, if the family wanted further answers, they would have to pay for a private autopsy. The cost: $4,500.

Klein confirmed he does not order autopsies, even on young people, unless law enforcement suspects a crime — even when loved ones plead for one.

“Families have been frustrated with me in the past,” Klein said.

In Derrek’s case, after Linette said she spent a week making frustrating phone calls and “jumping through hoops,” the county attorney’s office changed its tune. He would order an autopsy.

Klein said he doesn’t recall why Derrek was ultimately autopsied.

But the grieving family’s frustration was just beginning.

The county attorney’s office told Linette she couldn’t have a copy of the toxicology report. She’d need to get the results through Derrek’s primary care physician.

Klein said his policy is to never release these reports, even to family members, because he orders them only as part of a criminal investigation. He does allow families to bring in a doctor to review reports and explain them from a medical perspective.

Derrek’s mother viewed this refusal as a callous dismissal of Derrek’s death and believes the county attorney’s office “just discounted him as another drug addict.”

“It was rough … I always thought their job was to advocate for the dead person,” Linette said. “And I didn’t feel like Derrek was being advocated for at all.”

County attorneys, doubling as coroners, can generally set their own rules. They can also be influenced by social pressures, especially when they know the family, said Ryan Carruthers, chief clinical officer at CenterPointe, a treatment center in Lincoln and Omaha. They can view leaving overdoses and other stigmatized causes of death off of death certificates as a kindness.

But Derrek’s family wanted to know the truth about his death, even if it involved drugs. They didn’t want to keep secrets. They wanted his death certificate to be factual.

“I want the toxicology reports,” Linette said. “But I was never able to get them … I’ve had to jump through all these hoops and still don’t have anything.”

Why the Uncounted Matter

There’s a way to understand how Nebraska’s undercounting could matter, calculated in potentially lost cash.

In the past decade, Nebraska has received a total of roughly $63 per person — lowest in the country — from SAMHSA’s Center for Substance Abuse Treatment. The national average over that time was about $93 per person.

It’s impossible to know exactly how much Nebraska costs itself by failing to accurately tally drug deaths. But if Nebraska had received even the average amount, the additional funding flowing from D.C. to treat substance abuse would have been $50 million.

This is just one potential impact from the state flying blind on its true number of drug deaths, advocates and experts say.

Less information generally leads to both different public policy decisions and less funding, which is often tied to proving the problem exists, Carruthers said. Less money and less effective laws widen the gap between the resources a community needs and what it actually gets. And that, in turn, leads to more people at risk of dying.

From 2010 to 2022, the drug-involved death rate in Nebraska increased by 73%, said Khan, from UNMC. That worries him, especially because it’s cloaked by the state’s likely undercounting of deaths. Carruthers thinks overdoses are rising, too. CenterPointe, he said, has seen a dramatic jump in opioid overdoses in the past few years.

In 2024, the Nebraska Legislature attempted a solution, passing a bill 30-7 to legalize syringe service programs, which harm reduction workers say reduce fatal overdoses by introducing resources like Narcan and clean needles. Pillen vetoed the bill and the Legislature’s attempt to override his veto failed.

Sen. Jana Hughes, a Republican from Seward, wrote in her weekly newsletter that Pillen cited Nebraska having the lowest opioid overdose rate nationwide in his veto statements.

“While that is good news for Nebraska relative to other states, that is a bit like saying you are the last person to jump out of the plane without a parachute,” Hughes wrote.

In the Legislature, Nebraska’s low overdose ranking has been called “fortunate” and “exciting” by lawmakers. It has also been repeatedly called into question by testifying experts.

“Do we actually need this program if we are one of the lowest ones in the nation currently with overdose death rates …?” Hansen, the senator from Blair, asked during floor debate for the syringe bill.

Hansen said in an interview that he has seen no indication that Nebraska is undercounting overdose deaths.

“Any kind of undercounting of health statistics … I’m surprised by that,” Hansen said. “And it’s something that would need to be addressed.”

Hansen was chair during the committee hearing for the overdose mapping bill, where both Cacy and Guinan testified that the overdose rate may not be accurate. He cannot remember the exchange, Hansen said, but it “would probably lend credibility for the need of (the) bill.”

Derrek’s Truth

Summer turned into fall, then winter, as Derrek’s family waited for the toxicology results. His mom Linette reached out to his pediatrician, the only doctor he had regularly seen before he died, who agreed to review the results.

He called to tell Linette what they found: Derrek’s lungs were in perfect condition. He hadn’t died of natural causes.

He had died of a fentanyl overdose.

The news hurt because Derrek was a “momma’s boy through and through,” his mother says, a boy who’d grown into a young man whose “honesty was overwhelming” and who had never held back telling her the truth.

But he had not told her that he was using again. He’d participated in a treatment program in Norfolk just months before his death. And he seemed to be doing better.

“I thought, ‘Man, he’s finally doing it,’” his sister Lyndsey Lyons said.

The knowledge that he’d died of an overdose didn’t shake his family. They wanted to know more. Lyons said they wanted to openly discuss Derrek’s substance use history, which already wasn’t a secret.

They wanted his death certificate to be as factual as possible.

And they wanted to remember Derrek as he was: witty, caring and smart, Linette said. He had a talent for doing quick math in his head. He loved sneakers. His family is still finding pairs tucked away, years later.

But Derrek also struggled with his mental health. He felt alone, his loved ones say, even in a room full of people. He was baptized three times.

“He just never found peace. He just wasn’t OK being OK,” Linette said. “He was just looking for something or anything to make him fill whatever void was missing.”

In the Hastings area, Derrek, a kid that he’d gotten in trouble with growing up and the person who had sold Derrek the pills that killed him all died within a six-month period in 2021, Lyons said.

Fewer than nine drug-involved deaths were reported in Hall County that year. Derrek was one of the first known fentanyl overdoses, Lyons said.

The paramedics who rushed to the home that day didn’t use Narcan to try to revive Derrek, his mother says. Instead, she saw them — three times — administer an EpiPen, a common emergency treatment for cardiac arrest and allergic reactions.

When Derrek died, the family surrounding him did not know what the blue tint around his lips and fingertips meant. They did not know about the pinpoint eyes or the danger signaled by the gurgling sound he made.

They, and most Hastings residents, did not know what an opioid overdose looked or sounded like, family members said. No one had Narcan.

“If I would have, I think Derrek would be alive today,” Linette said.

Derrek’s mom and sister started a foundation in Derrek’s memory. They have taught area residents how to recognize the signs of an overdose and advocated for Narcan to be widely available. Hastings came a long way fast, Linette said.

Not long after Linette took the phone call from her son’s pediatrician, telling her the truth about why he’d died, she got another call.

A friend told her that a couple of young girls had overdosed at Derrek’s old friend’s house.

This time, the people around them knew what to look for. This time, they had Narcan and gave it to the girls.

This time, they survived.

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This story was originally published by the Flatwater Free Press and distributed through a partnership with The Associated Press.

By DESTINY HERBERS/Flatwater Free Press
Flatwater Free Press