We know drugs killed this Nebraskan’s brother and many others. But we don’t know which drugs. It’s costing us.

John Anderson awoke in Oakland, California, to the sound of his youngest brother Aidan pounding on his door. Aidan had spent hours taking trains across the state to get to his apartment that morning, just days before Thanksgiving. 

It’s Max, John’s brother told him. “You gotta take me to the airport.” 

A day later, John was back in Omaha too, gathered with his family around the hospital bed of his middle brother Max.

He remembers Max as a 2-year-old flying through the kitchen on rollerblades. Max was a fitting name for him, John said, because he always did everything “to the maximum.” Now he lay uncharacteristically still, his body kept alive by machines.

“I had no concept, not even a figment of a possibility of reality, that something like this could happen,” John said. “I thought that he was going to be fine.”

A week later, after they’d determined Max’s brain was irrevocably damaged, after his loved ones traveled to his bedside to say goodbye, they took him off life support.

His next-door neighbor had sold Max fentanyl. Their mom had a bad gut feeling, drove to Max’s apartment and found him unconscious. 

He’d texted friends about fentanyl in his final days. The Anderson family knew what he’d taken.  

But the doctor who certified Max’s death listed the following causes: anoxic encephalopathy, a condition where the brain does not receive enough oxygen, as a consequence of hypoxic respiratory failure caused by a drug overdose. 

No specific drug was listed. 

Death certificates like Max’s, deaths where the specific drug seems obvious but isn’t mentioned, are more common in Nebraska than you might think. About a quarter of Nebraska’s reported overdose deaths from 2014 to 2020 did not have a drug specified, according to research from the University of Nebraska-Lincoln’s Rural Drug Addiction Research Center.

In 2017, the year Max died, only 65% of overdoses were attributed to a specific drug.

Those incomplete death certificates are a problem in Nebraska, public health researchers and public safety workers told the Flatwater Free Press. They need to know which drugs are threatening lives in their communities so they can promote the right lifesaving treatments. 

Without that, they — and Nebraska — are flying partially blind. 

“If you don’t have real-time, accurate, good information, how are you going to even imagine you’re going to be able to stay on top of the new things coming in?” said Dr. Erin Linde, one of the state’s few forensic pathologists.

Emerging drugs

Every time a person dies of what could be a drug overdose in her county, Butler County Attorney Julie Reiter wants to see the full picture of what’s going on in that person’s body. 

To do that, Reiter orders an autopsy with toxicology. Knowing exactly what they might have taken helps find the source of the drug, whether it’s an illicit seller or a doctor who may be overprescribing opioids.

Here’s one reason it matters, Reiter says: They’re seeing an uptick in drugs like methamphetamine and marijuana being laced with fentanyl. The Nebraskans who use these drugs may not know what they’re buying, or its danger.

“These are the types of things that we’re seeing that we should be concerned about,” Reiter said. “Because if drugs are floating into our community that’s laced with fentanyl, and nobody knows that, and that’s causing death, shouldn’t we be getting to the bottom of that?”

Tracing those drugs closely can help prevent more deaths, Reiter said, because health workers can use that information to promote lifesaving measures like Narcan, and encourage people using drugs to be cautious about laced supplies. 

Toxicology tests show exactly what was in the person’s bloodstream when they died, but they’re expensive and time consuming. Reiter, like Nebraska’s other county attorneys, relies on Douglas County’s morgue for those tests, and to answer her questions from 70 miles away in Butler County. 

She also relies on a Nebraska Department of Health and Human Services reimbursement program to cover the costs of testing suspected overdoses, costs that would otherwise fall on the county. Individual county attorneys’ participation in that program varies, though. The 11 counties in Nebraska’s Panhandle didn’t request a single toxicology test reimbursement in 2023 or 2024. 

And in Nebraska, the only state where county attorneys are exclusively tasked with coroner duties, some have an entirely different approach to their jobs, like Hall County Attorney Martin Klein, who said he doesn’t ever order autopsies on suspected overdoses because an overdose is not a crime. 

Carey Pomykata, who cofounded the substance abuse prevention nonprofit Coalition Rx, started partnering with Douglas County’s Overdose Fatality Review Team in 2024 to assess each overdose death in the county and look for missed opportunities to intervene.

Through that work, Pomykata said she has become meticulous about reporting the circumstances of each death because she knows how important accurate information is to organizations like her own as they try to help in their communities. 

“We’re working really hard to collect that data so that we can know what we’re up against,” Pomykata said.

Detailed data makes a difference in places outside of Nebraska, like in Jose Martinez’s community in Buffalo, New York. There, harm reduction workers warned the local health department about xylazine, an emerging drug, and were rebuffed by an employee saying, “I’m sorry, we don’t have that here.” 

But in New York, less than 5% of overdoses are unspecified, and the health department quickly reports detailed information on the people who experience overdose and the drugs they take. Martinez and his co-workers at the National Harm Reduction Coalition were able to bring xylazine data to the health department, showing deaths starting to rise.

“When people are underreporting numbers … it’s like an artist who’s drawing a picture and they just draw the outline and then they’re done,” said Martinez. “It doesn’t paint the picture. We need the numbers to be as accurate as possible.”

Unspecified, undercounted

Max died under the supervision of doctors a week after his brothers flew back to Omaha to say goodbye. His brain had been killed by a lack of oxygen when he overdosed. 

His death certificate reflects that, with the second listed underlying cause being “drug overdose.” But, despite his hospitalization, his death certificate doesn’t list any specific drug.

When a coroner or doctor fills out a death certificate, they’re supposed to list all conditions that could have led to the death. If drugs were present in the person’s system, each substance should be listed, said Dr. Ali Khan, dean of the University of Nebraska Medical Center’s College of Public Health.

Max’s situation is relatively rare. The majority of overdose deaths, especially involving opioids, occur outside of medical settings like hospitals.

In Nebraska, and other places where elected officials without medical training determine cause of death when it happens outside of a hospital, there’s a well-documented problem of overdoses where the drug used remains a mystery, said Patrick Habecker, a professor with UNL’s Rural Drug Addiction Research Center.

Nationally, the problem is getting better. In 2020, some 95% of overdose deaths did have at least one drug listed, UNL researchers found. And in the Midwest region, more than 90% of these deaths had a specific drug listed. Both the region and the nation’s rates have steadily increased over time. 

But Nebraska’s rate of reported overdose deaths with specified drugs continues to vary widely between 65% and 85% month to month, well below those national and regional rates. 

Max was one of those people killed by an opioid overdose that went uncounted in Nebraska.

Knowing which drugs are spiking in popularity is essential, said Margaret Woeppel, chief nursing and information officer with the Nebraska Hospital Association. Data showing increased opioid use in Nebraska informed a program that the association started to help people transition off of opioids quicker after surgeries.

Nebraska has a higher range of stimulant-only deaths, like cocaine and methamphetamine, which have a different symptomology that is especially likely to be missed or misunderstood as a heart attack, Habecker said. 

With the few overdose deaths having a drug specified, and inconsistencies in that number each month, Habecker’s team found “it is reasonable to assume that Nebraska may undercount the number of psychostimulant-involved overdose deaths.”

Habecker also found that undercounting can have fatal consequences. 

“In Nebraska, the primary response to overdose death has been education and the distribution of naloxone, mostly in the form of Narcan, right?” Habecker said. “Except that’s opioid specific. That doesn’t work for a cocaine- or methamphetamine-related overdose.”

Other states with high stimulant use, like New York, have built overdose prevention centers that  provide supportive oxygen and monitor a person for signs that they may need 911, Habecker said. 

Veterinary tranquilizers, like xylazine, are also gaining popularity, Habecker said. Those drugs will need a different response because they aren’t opioids and can’t be reversed with Narcan.

Breaking the vicious cycle

John lapsed into an addiction himself in the aftermath of Max’s death. He turned to alcohol, began to spiral and became “drunk and hysterical” with anger, unrecognizable to himself. 

Max was an intense kid, John said, probably too smart for his own good. He had been struggling for a while and had been kicked out of high school. As John moved away for college, Max grew more isolated as he watched his peers move on without him. 

Then Max crashed his car and woke up in rehab, where his parents had sent him. It didn’t go well. “Apparently, you can’t force anyone to get sober,” John said.

Not long after, his youngest brother was knocking on his door in California, and Max, who was 20 years old, was gone.

The Anderson family gave victim impact statements when the person who sold Max fentanyl went to court. His parents and some siblings offered forgiveness. John wasn’t ready for that.

He wrote a scathing letter to be read in court, saying that the seller was a mass murderer because he had killed all six members of the Anderson family that day.

“I wanted to blame my parents,” John said. “I wanted to blame the doctors. I wanted to blame the neighbor. I wanted to blame myself. I wanted to blame the city of Omaha. Like, anyone.”

After a few years, he got sober and reconciled with one of Max’s friends who used drugs with him and who John had barred from Max’s funeral. That friend also ended up dying of a fentanyl overdose. 

Now John has experienced firsthand how vicious the cycle of addiction is. He sees now that the only options are to get sober and start talking about it, or to die. 

“It’s such a crazy thing to witness from the inside rather than just being an observer,” John said. “You realize that everyone involved with the substances, they’re not having a good time. They’re powerless, you know?”

John wants to forgive the person who sold Max fentanyl, who he later learned had a rough upbringing with a mother also addicted to drugs. Some days, he believes that he can forgive.  

“Maybe I should’ve had more empathy from the beginning, but I do now,” John said. “I’m just glad to have come out on the other side. I fell into my own addiction right after … It can really happen to anyone.”

John still has questions about how Max died, why he got into those drugs and what went wrong. It’s hard some days, now that his family has started to heal. He doesn’t want to ruin their good days by asking about their worst one. 

This year, he requested a copy of Max’s death certificate to see exactly what was written down: drug overdose, but no specific drug.

Seeing that it doesn’t note the fentanyl that killed Max — knowing that Max is part of the missing data making it harder to save lives — frustrates him.

“There’s no reason why we would have wanted it to say anything else,” John said. “We would have wanted it to reflect the problem — and the truth.”