AUGUSTA — A bill sponsored by state Rep. Colleen Madigan, D-Waterville, seeks to require substance use disorder and the underlying substances to be listed as a cause of death when it has contributed to a person’s death, but the state’s chief medical examiner said this is not the way to acknowledge the disease’s impact on a person’s life.

At a public hearing Wednesday before the Legislature’s Health and Human Services Committee, Madigan told her fellow lawmakers that her sister’s death inspired her to write LD 228. She was with her sister in January 2022 when she began to have convulsions from alcohol withdrawal and soon went into cardiac arrest. She was rushed to a hospital and 12 hours later, Madigan said, she died in the intensive care unit.

“I wept as I asked if her death certificate would list alcohol withdrawal as her cause of death. She said no, it would not,” Madigan said.

“My sister’s death certificate lists cardiogenic shock and multiple organ failure as the cause of her death. But make no mistake. My sister died of alcohol withdrawal. That’s what started the cascade of gruesome events,” she said.

Madigan said not only is the number of deaths related to alcohol and other substance use disorders likely greater than what vital records reflect, but these disorders are often left off death certificates because of “our own unconscious bias and stigma.”

“We are not ashamed of her. Alcohol use disorder was not who she was. But it did kill her,” she said.


“Our fight to save more lives of those with substance use disorder will not get better unless we can talk openly of this,” she said. “That includes being open and honest about how people die from substance use disorder.”

Maine’s chief medical examiner, Dr. Mark Flomenbaum, told lawmakers Wednesday that he believed LD 228 is “well-intentioned.” As written, however, it would be “almost impossible” to comply with and would set a “terrible precedent by having legislative mandates supersede the judgment of highly trained medical professionals.”

“The working definition of cause of death is the traumatic or natural disease process that perturbs the physiologic to the point where it is no longer compatible with life,” he said.

In cases where a substance contributes to a person’s death, such as a fatal overdose, “here the trauma is acute toxicity.”

Being that substance use disorder is a mental disorder diagnosed by a medical professional after an evaluation on a “living person,” it is “emphatically not a pathological cause of death” appropriate for a death certificate, Flomenbaum argued.

This bill would “mandate that board-certified forensic pathologists make psychiatric diagnoses.”


There is a manner of death section on a death certificate that can address the “circumstances of how or why,” and it is there that Flomenbaum said a medical examiner can list accidental overdose, for example.

Substance use disorder could maybe go there, he said, “if and only if there is a well-documented anti-mortem diagnosis.”

He said he would rather see an additional box where a medical examiner could indicate that substance use contributed to a death, much like the boxes that exist to indicate tobacco use or pregnancy.

“Give us the tools and we’ll do it the right way. This is not the right way,” Flomenbaum said.

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