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Mæhle BO, Eide GE, Morild I, Lilleng PK. Petechial hemorrhages, ethanol, and opioids in victims from intoxication. Forensic Sci Int 2022; 338:111406. [PMID: 35908337 DOI: 10.1016/j.forsciint.2022.111406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 07/04/2022] [Accepted: 07/19/2022] [Indexed: 11/04/2022]
Abstract
Petechial hemorrhages are of interest to forensic pathologists because of their association with pressure on the neck. This study shows the associations between ethanol, opioids in blood and the risk of petechiae in conjunctivae and eye lids of 865 medico-legally examined victims from intoxication, 112 (12.9 %) with petechiae. Livor mortis on the front, face down body position, higher body weight, and younger age of the victims were independently associated with higher risk of petechiae. These variables were used for adjustment in the logistic regression analyzes. We found associations between ethanol, opioids, and the risk of petechiae when analyzed simultaneously. The association between ethanol and the risk of petechiae differed in opioid negative and positive victims (interaction, p = 0.028). In the opioid negative group, the association was J-formed, victims with low to medium level ethanol having lower risk (OR = 0.77) than those without ethanol or opioids, whereas high ethanol level gave a 4-fold higher risk (OR = 3.97). In the opioid positive group, the J-formed pattern was reversed. Victims with low to medium level ethanol had more than 4 times higher risk (OR = 4.65), whereas high level ethanol gave a slightly elevated risk (OR = 1.34) only compared to no ethanol or opioids. The results suggest that ethanol and opioids have a complex association with the risk of petechiae independent of livor mortis, initial body position, body weight, and age in victims from intoxication. Of practical value for the post-mortem examination is that the pathologist must consider both the ethanol level and the presence of opioids when judging the significance of petechiae in the eye regions.
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Affiliation(s)
- Bjørn Ove Mæhle
- The Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, and Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Inge Morild
- The Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Peer Kaare Lilleng
- The Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Jakobsson G, Truver MT, Wrobel SA, Gréen H, Kronstrand R. Heroin-Related Compounds and Metabolic Ratios in Postmortem Samples Using LC-MS-MS. J Anal Toxicol 2021; 45:215-225. [PMID: 33031535 PMCID: PMC7953417 DOI: 10.1093/jat/bkaa157] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 09/14/2020] [Accepted: 10/07/2020] [Indexed: 12/02/2022] Open
Abstract
Analysis of postmortem samples with the presence of morphine can sometimes be challenging to interpret. Tolerance complicates interpretation of intoxications and causes of death due to overlap in therapeutic and fatal concentrations. Determination of metabolites and metabolic ratios can potentially differentiate between abstinence, continuous administration, and perhaps time of administration. The purpose of this study was to (a) develop and validate a method for quantitation of morphine-3β-D-glucuronide, morphine-6β-D-glucuronide, normorphine, codeine-6β-D-glucuronide, norcodeine, codeine, 6-acetylmorphine, and ethylmorphine in urine using liquid chromatography–tandem mass spectrometry; (b) apply the method to opiate related deaths; (c) compare metabolic ratios in urine in different causes of death (CoD) and after different drug intakes and (d) compare heroin intoxications in rapid and delayed deaths. Validation parameters such as precision, bias, matrix effects, stability, process efficiency, and dilution integrity were assessed and deemed acceptable. Lower limits of quantitation ranged from 0.01–0.2 μg/mL for all analytes. Autopsy cases (n=135) with paired blood and urine samples were analyzed. Cases were divided into three groups based on CoD; opiate intoxication, intoxication with other drugs than opiates, and other CoD. The cases were classified by intake: codeine (n=42), heroin (n=36), morphine (n=49), and ethylmorphine (n=3). Five cases were classified as mixed intakes and excluded. Heroin intoxications (n=35) were divided into rapid (n=15) or delayed (n=20) deaths. Parent drug groups were compared using metabolic ratio morphine-3β-D-glucuronide/morphine and significant differences were observed between codeine vs morphine (p=0.005) and codeine vs heroin (p≤0.0001). Urine and blood concentrations, and metabolic ratios in rapid and delayed heroin intoxications were compared and determined a significant difference for morphine (p=0.001), codeine (p=0.009), 6-acetylmorphine (p=0.02) in urine, and morphine (p=0.02) in blood, but there was no significant difference (p=0.9) between metabolic ratios. Morphine-3β-D-glucuronide results suggested a period of abstinence prior to death in 25% of the heroin intoxications.
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Affiliation(s)
- Gerd Jakobsson
- *Author to whom correspondence should be addressed. E-mail:
| | - Michael T Truver
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83, Linköping, Sweden
| | - Sonja A Wrobel
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 587 58, Linköping, Sweden
| | - Henrik Gréen
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 587 58, Linköping, Sweden
| | - Robert Kronstrand
- Division of Drug Research, Department of Biomedical and Clinical Sciences, Faculty of Medicine, Linköping University, 581 83, Linköping, Sweden
- Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 587 58, Linköping, Sweden
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3
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Alcohol Interaction with Cocaine, Methamphetamine, Opioids, Nicotine, Cannabis, and γ-Hydroxybutyric Acid. Biomedicines 2019; 7:biomedicines7010016. [PMID: 30866524 PMCID: PMC6466217 DOI: 10.3390/biomedicines7010016] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/21/2019] [Accepted: 02/27/2019] [Indexed: 12/18/2022] Open
Abstract
Millions of people around the world drink alcoholic beverages to cope with the stress of modern lifestyle. Although moderate alcohol drinking may have some relaxing and euphoric effects, uncontrolled drinking exacerbates the problems associated with alcohol abuse that are exploding in quantity and intensity in the United States and around the world. Recently, mixing of alcohol with other drugs of abuse (such as opioids, cocaine, methamphetamine, nicotine, cannabis, and γ-hydroxybutyric acid) and medications has become an emerging trend, exacerbating the public health concerns. Mixing of alcohol with other drugs may additively or synergistically augment the seriousness of the adverse effects such as the withdrawal symptoms, cardiovascular disorders, liver damage, reproductive abnormalities, and behavioral abnormalities. Despite the seriousness of the situation, possible mechanisms underlying the interactions is not yet understood. This has been one of the key hindrances in developing effective treatments. Therefore, the aim of this article is to review the consequences of alcohol's interaction with other drugs and decipher the underlying mechanisms.
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Peters FT, Steuer AE. Antemortem and postmortem influences on drug concentrations and metabolite patterns in postmortem specimens. ACTA ACUST UNITED AC 2018. [DOI: 10.1002/wfs2.1297] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Frank T. Peters
- Institute of Forensic Medicine Jena University Hospital Jena Germany
| | - Andrea E. Steuer
- Department of Forensic Pharmacology and Toxicology, Zurich Institute of Forensic Medicine University of Zurich Zurich Switzerland
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Concheiro M, Chesser R, Pardi J, Cooper G. Postmortem Toxicology of New Synthetic Opioids. Front Pharmacol 2018; 9:1210. [PMID: 30416445 PMCID: PMC6212520 DOI: 10.3389/fphar.2018.01210] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 10/04/2018] [Indexed: 01/09/2023] Open
Abstract
One hundred fifteen Americans die every day from opioid overdose. These overdose fatalities have been augmented by the increased availability of potent synthetic opioids, such as fentanyl and its derivatives. The death rate of synthetic opioids, other than methadone, increased by 72.2% from 2014 to 2015, and doubled from 2015 to 2016, situating the USA in the midst of an opioid overdose epidemic. The analytical identification of these opioids in postmortem samples and the correct toxicological data interpretation is critical to identify and implement preventive strategies. This article reviews the current knowledge of postmortem toxicology of synthetic opioids and the chemical and pharmacological factors that may affect drug concentrations in the different postmortem matrices and therefore, their interpretation. These factors include key chemical properties, essential pharmacokinetics parameters (metabolism), postmortem redistribution and stability data in postmortem samples. Range and ratios of concentrations reported in traditional and non-traditional postmortem specimens, blood, urine, vitreous humor, liver and brain, are summarized in tables. The review is focused on fentanyl and derivatives (e.g., acetyl fentanyl, butyryl fentanyl, carfentanil, furanyl fentanyl, 4-methoxybutyrylfentanyl, 4-fluorobutyrylfentanyl, ocfentanil) and non-traditional opioid agonists (e.g., AH-7921, MT-45, U-47700). All of these data are critically compared to postmortem data, and chemical and pharmacological properties of natural opioids (morphine), semi-synthetic (oxycodone, hydrocodone, hydromorphone, and oxymorphone), and synthetic opioids (methadone and buprenorphine). The interpretation of drug intoxication in death investigation is based on the available published literature. This review serves to facilitate the evaluation of cases where synthetic opioids may be implicated in a fatality through the critical review of peer reviewed published case reports and research articles.
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Affiliation(s)
- Marta Concheiro
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY, United States
| | - Rachel Chesser
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY, United States
| | - Justine Pardi
- Department of Forensic Toxicology, New York Office of the Chief Medical Examiner, New York, NY, United States
| | - Gail Cooper
- Department of Forensic Toxicology, New York Office of the Chief Medical Examiner, New York, NY, United States
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Pérez-Mañá C, Papaseit E, Fonseca F, Farré A, Torrens M, Farré M. Drug Interactions With New Synthetic Opioids. Front Pharmacol 2018; 9:1145. [PMID: 30364252 PMCID: PMC6193107 DOI: 10.3389/fphar.2018.01145] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 09/21/2018] [Indexed: 12/31/2022] Open
Abstract
Fentanyl, fentanyl analogs, and other new synthetic opioids (NSO) have burst onto the illegal drug market as new psychoactive substances (NPS). They are often sold as heroin to unsuspecting users and produce euphoria through their agonist action on μ- opioid receptors. Their high consumption, often combined with other substances, has led to multiple intoxications during recent years. In some countries, such as the United States, the consumption of opioids, whether for medical or recreational purposes, has become epidemic and is considered a public health problem. Fentanyl analogs are more potent than fentanyl which in turn is 50 times more potent than morphine. Furthermore, some fentanyl analogs have longer duration of action and therefore interactions with other substances and medicines can be more serious. This review is focused on the potentially most frequent interactions of opioid NPS taking into account the drugs present in the reported cases of poly-intoxication, including other illegal drugs of abuse and medication. Substances involved are mainly antidepressants, antihistamines, antipsychotics, benzodiazepines, analgesics, anesthetics, psychostimulants, other opioids, alcohol, and illegal drugs of abuse. The interactions can be produced due to pharmacokinetic and pharmacodynamic mechanisms. Naloxone can be used as an antidote, although required doses might be higher than for traditional opioid intoxications. It is crucial that doctors who habitually prescribe opioids, which are often misused by patients and NPS users, be aware of designer opioids' potentially life-threatening drug-drug interactions in order to prevent new cases of intoxication.
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Affiliation(s)
- Clara Pérez-Mañá
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| | - Esther Papaseit
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
| | - Francina Fonseca
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Adriana Farré
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Marta Torrens
- Drug Addiction Unit, Institute of Neuropsychiatry and Addictions, Hospital del Mar Medical Research Institute, Barcelona, Spain
- Department of Psychiatry and Legal Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Magi Farré
- Clinical Pharmacology Unit, Hospital Universitari Germans Trias i Pujol (HUGTP-IGTP), Badalona, Spain
- Department of Pharmacology, Therapeutics and Toxicology, Autonomous University of Barcelona, Barcelona, Spain
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Thaulow CH, Øiestad ÅML, Rogde S, Karinen R, Brochmann GW, Andersen JM, Høiseth G, Handal M, Mørland J, Arnestad M, Øiestad EL, Strand DH, Vindenes V. Metabolites of Heroin in Several Different Post-mortem Matrices. J Anal Toxicol 2018; 42:311-320. [DOI: 10.1093/jat/bky002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Cecilie Hasselø Thaulow
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Åse Marit Leere Øiestad
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Sidsel Rogde
- Department of Forensic Sciences, Section of Forensic Pathology and Clinical Forensic Medicine, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, PO Box 1171 Blindern, N-0318 OSLO, Norway
| | - Ritva Karinen
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Gerd Wenche Brochmann
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Jannike Mørch Andersen
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Gudrun Høiseth
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Marte Handal
- Department of Mental Disorders, Norwegian Institute of Public Health, PO Box 4404 Nydalen, N-0403 OSLO, Norway
| | - Jørg Mørland
- Norwegian Institute of Public Health, PO Box 4404 Nydalen, N-0403 OSLO, Norway
- Institute of Clinical Medicine, University of Oslo, PO Box 1171 Blindern, N-0318 OSLO, Norway
| | - Marianne Arnestad
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Elisabeth Leere Øiestad
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
- School of Pharmacy, University of Oslo, PO Box 1068 Blindern, N-0316 Oslo, Norway
| | - Dag Helge Strand
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
| | - Vigdis Vindenes
- Department of Forensic Sciences, Section of Forensic Toxicology, Oslo University Hospital, PO Box 4950 Nydalen, N-0424 Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, PO Box 1171 Blindern, N-0318 OSLO, Norway
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Gomes T, Juurlink DN, Mamdani MM, Paterson JM, van den Brink W. Prevalence and characteristics of opioid-related deaths involving alcohol in Ontario, Canada. Drug Alcohol Depend 2017; 179:416-423. [PMID: 28867560 DOI: 10.1016/j.drugalcdep.2017.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 07/10/2017] [Accepted: 07/14/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND While it is well known that patients receiving opioids should refrain from alcohol consumption, little is known about the involvement of alcohol in opioid-related deaths. METHODS We conducted a population-based analysis of opioid-related deaths in Ontario with and without alcohol involvement between 1993 and 2013, and reported rates overall and stratified by manner of death. We compared the characteristics of individuals who died of an opioid overdose based on the presence or absence of alcohol involvement. RESULTS The rate of opioid-related deaths increased 288% from 11.9 per million (95% confidence interval (CI) 9.8-13.9 per million) in 1993-46.2 per million (95% CI 42.6-49.8 per million) in 2013. The rate of opioid-related deaths without alcohol involvement increased 388% from 7.4 per million to 36.1 per million, while deaths involving alcohol increased by 125% from 4.5 per million to 10.1 per million. Therefore, although the annual number of opioid-related deaths involving alcohol rose, the proportion of opioid-related deaths involving alcohol declined from 37.8% in 1993-21.9% by 2013. Generally, opioid-related deaths involving alcohol were less likely to involve other central nervous system depressants, and more likely to occur among men and those with a history of alcohol use disorder. CONCLUSIONS Although the relative contribution of alcohol in opioid-related deaths has declined, 1 in 5 fatal opioid overdoses still involved alcohol in 2013. Our findings highlight the ongoing need for targeted messaging around risks of opioids alone, and in combination with alcohol and other CNS depressants.
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Affiliation(s)
- Tara Gomes
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5 B 1W8, Canada; The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, Ontario, M5S 3M2, Canada.
| | - David N Juurlink
- The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; The Sunnybrook Research Institute, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada
| | - Muhammad M Mamdani
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5 B 1W8, Canada; The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; The Department of Medicine, St. Michael's Hospital, 30 Bond St., Toronto, Ontario, M5 B 1W8, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College St., Toronto, Ontario, M5S 3M2, Canada
| | - J Michael Paterson
- The Institute for Clinical Evaluative Sciences, 2075 Bayview Ave, Toronto, Ontario, M4N 3M5, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, 155 College St., Toronto, Ontario, M5T 3M6, Canada; Department of Family Medicine, McMaster University, 100 Main St. W., Hamilton, Ontario, L8P 1H6, Canada
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Center University of Amsterdam, Meibergdreef 9, 1105, AZ Amsterdam-Zuidoost, Netherlands
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Pepin G, Cheze M, Dumestre-Toulet V, Eysseric H, Labat L. Conduite automobile et opiacés : bases bibliographiques pour un consensus de la Société française de toxicologie analytique. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2015. [DOI: 10.1016/j.toxac.2015.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Trends in licit and illicit drug-related deaths in Florida from 2001 to 2012. Forensic Sci Int 2014; 245:178-86. [DOI: 10.1016/j.forsciint.2014.10.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/08/2014] [Accepted: 10/11/2014] [Indexed: 12/15/2022]
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