"The way it's going, I think we will see 80 cases," Chief Medical Examiner Dr. Kanthi De Alwis said last week after her office received two new cases within days of each other. "We have to do something. To me, this is an epidemic."

Through August, 44 deaths have been listed as crystal methamphetamine-related — a broad category that includes everything from its immediate toxic effects to suicides and homicides committed by people high on the drug.

Those deaths hit an all-time high of 62 in 2002, but last year dipped to 56 deaths.

The toxic effects of the drug remain the leading cause of death for the past three years. And it has taken a greater percentage of victims, even when the total number of deaths declined slightly in 2003. That year, 58 percent of the victims succumbed to the toxic effects of the drug.

"It's crazy," De Alwis said. "We're facing a big problem and someone has to do something. This is too many for this small community."

But the medical examiner and her chief investigator — Susan Siu — believe there are many other crystal methamphetamine-related deaths in the community that have been previously listed as strokes, heart attacks and bronchial asthma. Use of the drug has been linked to enlargement of the heart and high blood pressure — the kinds of things that can cause all three medical problems, De Alwis said.

Forwarding on cases

De Alwis wants to know how many of those cases can be traced to crystal methamphetamine. This spring she called O'ahu hospital administrators and asked them to forward certain types of cases.

She told them she had seen a growing trend in recent months. Mortuaries and the state health office that handles death certificates had questioned cases in which crystal methamphetamine was listed as a contributing factor on the death certificate.

Deaths attributed to these causes have always been considered natural, De Alwis said. Use of the drug, however, changes it entirely.

"When people go in with a stroke it is, most of the time, due to high blood pressure," she said. "But what we are finding now is that these strokes, which may get listed as a natural death from high blood pressure or hypertension, are actually people who have been using crystal meth on a long-term basis as well as having crystal meth in their system. Those are not natural deaths."

And the amount being used does not have to be large to be lethal, she said. Even a small amount can trigger a sudden heart attack or stroke, De Alwis said. "These are all considered toxic effects, not necessarily an overdose like with other drugs," she said.

Siu believes these new kinds of cases are going to have a dramatic effect on the way doctors view crystal methamphetamine.

"They may wake up and they might see that this is happening more than they believe," Siu said. "I just know we are missing a lot."

In March, the medical examiner convinced The Queen's Medical Center — the state's major trauma hospital — to forward cases, but doctors there were apprehensive about the idea. De Alwis had to remind them that she had the legal authority and training to classify a death.

Patients who die at a hospital within 24 hours of being admitted, automatically become a medical examiner's case and are subject to an autopsy. That doesn't happen if they survive longer than that — even if emergency room doctors doing routine drug screening found crystal methamphetamine in their body.

Dr. Kristine O'Phelan, a neurointensivist at Queen's who treats patients with brain injuries, said the medical examiner's request "is reasonable," but added it can put doctors in an ethical bind when family members want to know why their loved one needs to be autopsied.

Drug history is private

Under the rules of doctor-patient confidentiality, she is allowed to say what a person died from, but cannot reveal certain kinds of private information, including the person's drug history, she said.

That means she cannot tell them the medical examiner suspects their loved one's death was linked to crystal methamphetamine.

"I think it becomes difficult because if the family does ask why, you can't give them any information," O'Phelan said.

The medical examiner's request stirred debate among doctors at Queen's because some families will not be comfortable with an autopsy, O'Phelan said.

"I was not one of the most supportive people in this quest," O'Phelan said. "My real dedication is to the patients and to the families. I would hate to make an already horrible situation worse for a family. So that takes a lot of finesse to figure out how on earth you are going to meet these requests being asked of us by the medical examiner."

She doesn't know of any cases where this happened, but decided if this happens to one of her patients, she'll say very little.

"I am hoping the medical examiner will explain it," O'Phelan said.

More research needs to be done to understand the relationship between crystal methamphetamine and the kind of stroke that causes bleeding in the brain, which can be fatal and is normally caused by untreated high blood pressure, O'Phelan said.

"I think it definitely contributes," she said. "I think that we don't know how much and I think a study needs to be done to show exactly how much it increases your risk. That's the question. The average person has a certain percentage risk of bleeding in the brain. So if you take meth, what does that do to that percentage? Double it? Triple it?"

For De Alwis, the new cases offer the potential for greater understanding. Learning more about the drug can prevent deaths and that outweighs the possible burden of increased work in a busy office, she said.

"We are not here to just determine how a person died," De Alwis said. "It is not the proper justice to the community if you don't give proper statistics and educate the people that this is what you are dying of if you use this drug."