Suicide by Fentanyl

Fentanyl is a potent, short-acting narcotic analgesic widely used as surgical anaesthetic. This article presents a case in which fentanyl was self-injected by a 41-year old nurse, an employee at the hospital emergency department, who was found dead at home. She had no known history of drug and alcohol abuse. Two syringes, one empty and one filled with a clear liquid, were found near the body, while a needle was stuck into her hand.

Toxicological analysis showed fentanyl poisoning. Fentanyl overdose was declared the cause of death and the manner of death was classified as suicide.

To our knowledge, death due to the intravenous injection of fentanyl has not previously been reported in Croatia.

Akzidentelle Intoxikation durch unbeschriftete, generische transdermale Fentanylpflaster nach unzureichender Aufklärung

A somnolent 78-year-old male patient was brought to our emergency room by an ambulance with the presumptive diagnosis of stroke. Cranial computed tomography provided no evidence. On the intensive care unit of the neurosurgical department the patient was completely undressed. Covered by a sock and underwear the ICU staff found five unlabeled, transparent patches. Under the presumptive diagnosis of an opioid intoxication by a transdermal therapeutic system naloxone was infused over 3 days. The patient reported after rapidly awaking that fentanyl patches had been prescribed by his family practitioner the day before. The patient recovered without any sequelae.

Fentanyl concentrations in 23 postmortem cases from the hennepin county medical examiner's office

The purpose of this study was to compare blood fentanyl concentrations in fentanyl-related deaths with fentanyl concentrations found incidentally at autopsy, as well as with fentanyl concentrations found in hospitalized patients receiving fentanyl. Between the years 1997 to 2005, 23 fentanyl-positive postmortem cases were identified. Nineteen of 23 (82.6%) cases were deemed to be drug overdoses. Fentanyl alone was responsible for 8 of the 19 (42.1%) overdose deaths. Mean and median fentanyl concentrations were 36 (SD 38) microg/L and 22 microg/L, respectively, range 5-120 microg/L. Seven of the cases were accidental, one undetermined. The remaining 11 of the 19 (57.9%) cases were mixed drug overdoses. Fentanyl concentrations in these cases were 31 (SD 46) microg/L, range 5-152 microg/L. All of the mixed drug overdoses were determined to be accidental. Four cases where fentanyl was considered an incidental postmortem finding were determined to be natural deaths. In hospitalized inpatients (n = 11) receiving fentanyl 2 of the patients receiving fentanyl for chronic pain for more than 3 months had concentrations of 8.5 microg/L and 9.9 microg/L. The other nine inpatient concentrations were less than 4 microg/L. In conclusion, blood fentanyl concentrations found in cases where fentanyl alone was determined to be the cause of death were similar to cases where fentanyl was part of a mixed drug overdose. There was also considerable overlap between fentanyl concentrations in fentanyl-related overdose deaths compared to hospitalized patients being treated for chronic pain. Fentanyl concentrations in postmortem cases must be interpreted in the context of the deceased's past medical history and autopsy findings.

[Delayed encephalopathy following acute fentanyl intoxicication]

We report an 84-year-old woman who suffered from acute fentanyl intoxication followed by delayed encephalopathy. She used fentanyl patch at her ached knee joint and stayed in the covered table with a heat source underneath. Serum concentration of fentanyl suddenly elevated and she developed coma due to acute fentanyl intoxication. She gradually recovered, however, she showed consciousness disturbance again at 15th day and developed neurological symptoms including mutism, pyramidal tract signs, frontal lobe signs and parkinsonism. These symptoms also steadily improved without specific treatment, and became able to talk with colleagues and walk with assistance at 90th day. We considered that delayed encephalopathy due to periodic anoxia caused by fentanyl intoxication occurred in the present patient; however, the neurological sequelae were relatively mild as compared with reported cases of carbon monoxide intoxication. Neuroprotective effect of fentanyl may have contributed to the better prognosis in the present patient.

Blood levels of 3-methylfentanyl in 3 fatal poisoning cases

Three fatal poisoning cases due to 3-methylfentanyl are described. In each case, the death was accidental and occurred after injection of the opioid combined with amphetamine, heroin, or other drugs. The victims' ages, ranging from 30 to 41 years, were higher than those typically found in heroin poisonings in Finland. The blood concentrations of cis-3-methylfentanyl, measured here for the first time by a specific tandem mass spectrometric method, ranged from 0.3 to 0.9 microg/L (mean 0.5 microg/L). These values are significantly lower than the levels reported for alpha-methylfentanyl and fentanyl in fatal poisonings. Repeated seizures of fentanyl and its analogs have been reported in Europe close to the Russian border.

Fatal outcome in a child after ingestion of a transdermal fentanyl patch

The case history and toxicological findings of a fatal fentanyl intoxication due to ingestion of a transdermal patch are presented. A 1-year-old otherwise healthy girl was put to bed and 2 h later she was found dead. The autopsy revealed a 25-microg/h (4.2 mg) transdermal fentanyl patch in the stomach. Toxicological analysis by liquid chromatography-tandem mass spectrometry with positive electrospray ionization yielded fentanyl and norfentanyl concentrations in the peripheral blood of 5.6 and 5.9 ng/ml, heart blood 19.0 and 8.9 ng/ml, and liver 235 and 26 ng/g, respectively. The cause of death was determined to be a fentanyl overdose. The investigation established that the child has unintentionally swallowed the patch, which had been lying on the floor.

Fentanyl-Related Deaths in Ontario, Canada: Toxicological Findings and Circumstances of Death in 112 Cases (2002-2004)

In order to characterize fentanyl-related deaths in the province of Ontario, Canada, a retrospective study of all cases in which fentanyl was quantitated in blood was conducted for the time period between 2002 and 2004. A total of 112 fentanyl-related deaths were identified. Decedents ranged in age from 4 to 93 years and comprised 63 men and 49 women. A variety of routes of administration of the drug were identified: transdermal application of Duragesic patches, intravenous injection of patch contents or fentanyl citrate solution, oral/transmucosal administration, and volatilization and inhalation of Duragesic systems. Blood fentanyl concentrations were determined for all modes of drug administration and are provided. There were 54 cases in which death was attributed solely to fentanyl intoxication; the mean blood concentration was 25 microg/L (range: 3.0-383 microg/L). This concentration range overlapped with blood fentanyl concentrations measured among cases where the presence of the drug was considered incidental. For example, a mean blood concentration of 12 microg/L was observed among 12 cases of natural death (range: 2.7-33 microg/L). Detailed case reports of six individuals are also included and provide additional insight into the use of this drug for both therapeutic and illicit means.

Suspected secondary thiafentanil intoxication in a captive mountain lion (Puma concolor)

Inadvertent ingestion of thiafentanil oxalate by a captive adult female mountain lion (Puma concolor) caused a prolonged clinical syndrome that included sedation and depression, muscle tension, and myopathy that was incompletely antagonized by naltrexone HCl. A serum chemistry profile revealed markedly elevated creatinine phosphokinase (CK; 490,450 IU/l), alanine aminotransferase (ALT; 1,896 IU/l), and aspartate aminotransferase (AST; 4,321 IU/l) 2 days after onset. The affected animal's condition gradually improved over the next 15 days in response to supportive therapy that included diazepam (5 mg as needed), Normasol R (3 l/day), dexamethasone (tapering dose starting at 1 mg/kg), and ketoprofen (1 mg/kg). She eventually recovered completely. Based on these observations, carcasses of animals immobilized with thiafentanil should be marked and disposed of properly to preclude opportunities for secondary exposure and potential intoxication in scavenging species. In addition, caution is advised when using thiafentanil in animals that could be preyed upon before full metabolism of the drug.

LC-MS/MS analysis of fentanyl and norfentanyl in a fatality due to application of multiple Durogesic transdermal therapeutic systems

Fentanyl is a potent synthetic narcotic analgesic administered in the form of a transdermal patch for the management of chronic pain. A 78-year-old woman with a history of cancer was found dead in bed. She was lying on her back. The external examination revealed 10 Durogesic transdermal therapeutic systems (100 microg/h fentanyl) on the body. Liquid-liquid extraction and liquid chromatography tandem mass spectrometry with electrospray source in positive ionization mode was applied for the quantitation of fentanyl and its major metabolite norfentanyl in the post-mortem samples. Fentanyl-d5 and norfentanyl-d5 were used as internal standards. Multiple reaction monitoring was used for specific detection. Calibration was performed by addition of standard solutions to drug-free matrix (blood, urine and liver) prior to extraction. The method showed good linearity for fentanyl and norfentanyl over a concentration range of 5-150 microg/L in reconstituted extracts with coefficients of determination equal or greater than 0.998. Percent mean within-day precision and accuracy of 0.9-1.0% and 99.4-101.1% for fentanyl and 2.0-4.5% and 93.1-101.0% for norfentanyl were obtained. Mean extraction recoveries varied between 95.5% and 100.3% for fentanyl and 39.2-57.4% for norfentanyl. The following fentanyl (norfentanyl) concentration in the post-mortem samples were measured; 28.6 microg/L (3.0 microg/L) in right and 28.2 microg/L (3.5 microg/L) in left subclavian blood, 21.3 microg/L (<2 microg/L) in right and 20.9 microg/L (<2 microg/L) in left femoral blood, 37.6 microg/L (4.2 microg/L) in right and 33.9 microg/L (4.4 microg/L) in left ventricular blood, 282.9 microg/L (121.2 microg/L) in urine, 688.2 microg/L in stomach contents, 122.5 microg/L (25.4 microg/L) in bile, 19.5 microg/L (< 2 microg/L) in vitreous humour, 203.0 microg/kg (26.6 microg/kg) in liver and 78.6 microg/kg (46.3 microg/kg) in kidney. We concluded that the woman's death was caused by acute intoxication with fentanyl. The manner of death was presumed to be suicide due to excessive administered Durogesic transdermal therapeutic systems.

Pharmacogenomics as Molecular Autopsy for Forensic Toxicology: Genotyping Cytochrome P450 3A4*1B and 3A5*3 for 25 Fentanyl Cases

Pharmacogenomics, the study on genetic contributions to drug action may help in certifying fentanyl toxicity. Fentanyl is used clinically as an adjunct to surgical anesthesia and for chronic pain management. Its toxicity may be partially due to cytochrome P450 (CYP) 3A4*1B and 3A5*3 variant alleles, resulting in variable fentanyl metabolism. In this study, we examined 25 fentanyl-related deaths (22 Caucasians, 1 African-American, and 2 Native-Americans) from the Milwaukee County Medical Examiner's Office and referral cases. Fentanyl and norfentanyl in postmortem blood samples were analyzed by radioimmunoassay and liquid chromatography-mass spectrometry-mass spectrometry. The samples were then genotyped for CYP3A4*1B and 3A5*3 using Pyrosequencing. Genotyping showed: 1 CYP3A4*1B homozygous and CYP3A5*3 heterozygous, 1 compound CYP3A4*1B and CYP3A5*3 heterozygous, 22 CYP3A4*1B wild type and CYP3A5*3 homozygous, and 1 CYP3A5*3 and CYP3A4*1B wild type. CYP variant allelic frequencies of the 25 cases were 6% for CYP3A4*1B and 92% for CYP3A5*3, compared with normal Caucasian CYP3A4*1B, 3-8%, and CYP3A5*3, 85-95%. The mean fentanyl concentration and metabolic ratio of fentanyl to norfentanyl of the 2 cases with CYP3A4*1B and CYP3A5*3 variants were 12.8 and 1.4 microg/L, respectively, lower than those of 22 cases with wild type CYP3A4*1B and CYP3A5*3 homozygous variants, 16.7 and 7.3 microg/L, respectively. The postmortem/in vivo data provided the first scientific evidence that CYP3A5 is involved in the fentanyl metabolism, and homozygous CYP3A5 *3 causes impaired metabolism of fentanyl, and genotyping CYP3A4*1B and 3A5*3 variants may help to certify the fentanyl toxicity.

Are one or two dangerous? Opioid exposure in toddlers

Ingestions of opioid analgesics by children may lead to significant toxicity as a result of depression of the respiratory and central nervous systems. A review of the medical literature was performed to determine whether low doses of opioids are dangerous in the pediatric population under 6 years old. Methadone was found to be the most toxic of the opioids; doses as low as a single tablet can lead to death. All children who have ingested any amount of methadone need to be observed in an Emergency Department (ED) for at least 6 h and considered for hospital admission. Most other opioids are better tolerated in ingestions as small as one or two tablets. Based on the limited data available for these opioids, we conclude that equianalgesic doses of 5 mg/kg of codeine or greater require 4 to 6 h of observation in the ED. Data for propoxyphene and all extended-release preparations are limited; their prolonged half-lives would suggest the need for longer observation periods. All opioid ingestions leading to respiratory depression or significant central nervous system depression require admission to an intensive care unit.

Fentanyl and its analogues in clinical and forensic toxicology

Fentanyl and its analogues are commonly named synthetic opiates. Some compounds from fentanyl group (e.g. fentanyl, alfentanil, sufentanil, remifentanil) are used as anaesthetic and analgesic of high potency and short duration of action. Effects of acting fentanyls are indistinguishable from those produced by nasal inhalation of street heroin. In view of this, fentanyls are very "attractive" for the narcotic market. In least years an increase in number of reports about illegal production and non-medical use of fentanyl and its analogues have appeared. Numerous fentanyl analogues are sold under one name synthetic heroine or China white. Fentanyl and its analogues also can be used as gas warfare agents. One of fentanyl-related compound was used during action of easing hostages from Dubrovka theatre. Because of respiratory depression, which was caused by used compound, died over 100 hostages. Because of high potency fentanyl-related compounds are used in very low doses. So fentanyls appear in biological material in very low concentrations, not higher than several nanograms per millilitre or per gram. The drugs in these concentrations cannot be detected by means of routinely used screening procedures. Therefore direct methods for determination of this group of compounds are needed. Screening method for determination of fentanyl and its analogues was elaborated and validated. Liquid chromatography-mass spectrometry (LC/MS) technique was applied. The method is characterised by the limit of quantification (LOQ) and the limit of detection (LOD) ranged from 0.6 to 2 ng/ml and from 0.2 to 0.6 ng/ml, respectively for four above-mentioned compounds. The method was used for determination of fentanyl in three forensic cases. The blood, bile and blood from lung samples were taken during autopsy of persons who died shortly after surgical procedure in which fentanyl was used as an adjunct to general anaesthesia.

Deaths after intravenous misuse of transdermal fentanyl

Fentanyl is a potent synthetic opioid used as a general anesthetic and analgetic. Fatal outcome from intravenous misuse of transdermal fentanyl is rare, and there are few such reports in literature. Here we report two cases of fatal intravenous injection of the content from fentanyl patches. Both were male drug addicts, found dead within a one week interval in the same apartment. Post-mortem femoral blood was screened for amphetamines, cannabinoids, cocaine, and opioids with immunological methods (EMIT II) and further with headspace gas chromatography for alcohol and with liquid chromatography mass spectrometry (LC-MS) for different drugs, including fentanyl. Confirmatory analysis of fentanyl and morphine was performed by gas chromatography-mass spectrometry (GC-MS). In the first case, the toxicological analysis revealed fentanyl (2.7 ng/mL), morphine (31.4 ng/mL), and ethanol (1.1 g/L) in postmortem blood and amphetamine, cannabinoids, morphine, and ethanol (1.4 g/L) in postmortem urine. In the second case, the analysis revealed fentanyl (13.8 ng/mL), 7-aminoclonazepam (57.1 ng/mL), and sertralin (91.9 ng/mL) in postmortem blood and a small amount of ethanol (0.1 g/L) in postmortem urine. Police investigation revealed that both the deceased had bought the patches from the same source. The present cases demonstrate the possibility of intravenous misuse of transdermal patches and the risk of fatal outcome.

Fentanyl patch abuse: naloxone complications and extracorporeal membrane oxygenation rescue

Fentanyl patches offer a novel, but increasingly common method of drug abuse. We describe a patient who developed severe respiratory dysfunction after fentanyl patch abuse via insufflation, naloxone administration and aspiration. After other aggressive interventions failed to correct worsening hypoxemia, extracorporeal membrane oxygenation (ECMO) was initiated and led to complete recovery. To our knowledge, this is the 1st reported case of ECMO being used to correct severe pulmonary dysfunction associated with opioid abuse. The risks associated with naloxone administration are discussed.

Fatal Intravenous Fentanyl Abuse

The transdermal fentanyl system delivers a specific dose at a constant rate. Even after the prescribed application time has elapsed, enough fentanyl remains within a patch to provide a potentially lethal dose. Death due to the intravenous injection of fentanyl extracted from transdermal patches has not been previously reported. We present 4 cases in which the source of fentanyl was transdermal patches and was injected. In all of these cases, the victim was a white male who died at home. Case 1 was a 35-year-old with no known history of drug use, who was found by his wife on the floor of his workshop. Police recovered a fentanyl patch, needle, and syringe at the scene. Case 2 was a 38-year-old with a known history of drug use whose family claimed that he was in a treatment program that used fentanyl patches for unknown reasons. His brother found him dead in bed, and law enforcement officers found a hypodermic needle beside the body; a ligature around his left hand, and apparent needle marks between his first and second digits were also noted. Case 3 was a 42-year-old with a recent attempted suicide via overdose who was found dead at his home. An empty box of fentanyl patches, Valium, Ritalin, and 2 syringes were found at the scene. Case 4 was a 39-year-old found by his mother, who admitted to removing a needle with attached syringe from the decedent's arm. Medications at the scene included hydrocodone, alprazolam, zolpidem, and fentanyl patches. All reported deaths were attributed to fentanyl intoxication, with blood concentrations ranging from 5 to 27 microg/L.