Increasingly, police respond to confrontations in which the individual demonstrates violent and combative behavior as a result of drug-induced delirium. From medical, legal, and police documents, 61 cases of excited delirium decedents in police custody between 1988 and 1997 are analyzed. In all of the cases, the person fought with and was restrained by police; the person was more likely to die at the scene of the incident or during police transport; and the police were likely to be responding to a disturbance call. In a number of cases, survival time was less than 1 hour. In a majority of cases, acute cocaine toxicity and physical restraint in police custody were contributory to death. The literature is reviewed, analyses of case circumstances are provided, and recommendations for medicolegal investigators and police personnel are discussed.