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Al-Asmari AI, Alharbi H, Al-Zahrani AE, Zughaibi TA. Heroin-Related Fatalities in Jeddah, Saudi Arabia, between 2008 and 2018. TOXICS 2023; 11:248. [PMID: 36977013 PMCID: PMC10099738 DOI: 10.3390/toxics11030248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 02/20/2023] [Accepted: 02/27/2023] [Indexed: 06/18/2023]
Abstract
To date, epidemiological studies have not evaluated heroin-related deaths in the Middle East and North African regions, especially Saudi Arabia. All heroin-related postmortem cases reported at the Jeddah Poison Control Center (JPCC) over a 10-year period (21 January 2008 to 31 July 2018) were reviewed. In addition, liquid chromatography electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) was utilized to determine the 6-monoacetylmorphine (6-MAM), 6-acetylcodeine (6-AC), morphine (MOR), and codeine contents in unhydrolyzed postmortem specimens. Ninety-seven heroin-related deaths were assessed in this study, and they represented 2% of the total postmortem cases at the JPCC (median age, 38; 98% male). In the blood, urine, vitreous humor, and bile samples, the median morphine concentrations were 280 ng/mL, 1400 ng/mL, 90 ng/mL, and 2200 ng/mL, respectively; 6-MAM was detected in 60%, 100%, 99%, and 59% of the samples, respectively; and 6-AC was detected in 24%, 68%, 50%, and 30% of the samples, respectively. The highest number of deaths (33% of total cases) was observed in the 21-30 age group. In addition, 61% of cases were classified as "rapid deaths," while 24% were classified as "delayed deaths." The majority (76%) of deaths were accidental; 7% were from suicide; 5% were from homicide; and 11% were undetermined. This is the first epidemiological study to investigate heroin-related fatalities in Saudi Arabia and the Middle East and North African region. The rate of heroin-related deaths in Jeddah remained stable but increased slightly at the end of the study period. Most patients were heroin-dependent abusers and from the middle-aged group. The availability of urine, vitreous humor, and bile specimens provided valuable information regarding the opioids that were administered and the survival time following heroin injection.
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Affiliation(s)
- Ahmed I. Al-Asmari
- Laboratory Department, Ministry of Health, King Abdul-Aziz Hospital, Jeddah 21442, Saudi Arabia
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
| | - Hassan Alharbi
- Poison Control and Forensic Chemistry Center, Ministry of Health, Jeddah 21176, Saudi Arabia
| | | | - Torki A. Zughaibi
- King Fahd Medical Research Center, King Abdulaziz University, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah 21589, Saudi Arabia
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2
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Glicksberg L, Dempsey SK, Casey BK. Heroin and fentanyl in Dallas County: A 5-year retrospective review of toxicological, seized drug, and demographical data. J Forensic Sci 2023; 68:222-232. [PMID: 36303261 DOI: 10.1111/1556-4029.15155] [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: 08/17/2022] [Revised: 09/22/2022] [Accepted: 10/10/2022] [Indexed: 12/31/2022]
Abstract
The opioid epidemic resulted in an increase in identifications of fentanyl, fentanyl analogs, and heroin, among other opioids, in the toxicology and seized drug analysis fields over the past several years. The Dallas County Southwestern Institute of Forensic Sciences, comprised of the Toxicology Laboratory and Drug Analysis Laboratory, observed a rise in fentanyl-positive analyses in both laboratories. Fentanyl positivity increased from 1.1% to 3.4% in the Toxicology Laboratory over the five years of this study, whereas 6-monoacetylmorphine (6-MAM) positivity remained relatively stable at approximately 2%. Similarly, in the Drug Analysis Laboratory, the fentanyl positivity rate changed from 0.03% to 0.60%, whereas heroin identification remained stable at approximately 8-9%. Based on data obtained from toxicology submissions, a typical fentanyl or heroin user was a white male in their late 30s. The average concentration of fentanyl in postmortem cases, antemortem cases, and 6-MAM in postmortem specimens was 9.7 ng/ml, 5.5 ng/ml, and 68.4 ng/ml, respectively. Poly-drug use was evident, with benzodiazepines being the most commonly co-administered drug with fentanyl (49.4%). Multiple drugs were identified via analysis of clandestine tablets submitted to the Drug Analysis Laboratory, including fentanyl and/or heroin in combination with compounds such as cocaine, etizolam, and acetaminophen. The most frequently identified clandestine tablet was "M367," typically manufactured to contain acetaminophen and hydrocodone, but was found to contain fentanyl or heroin. The results from this study aid in the understanding of the current opioid trends in Dallas County and provides an opportunity for comparison to other populations and geographical regions.
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Affiliation(s)
- Lindsay Glicksberg
- Dallas County Southwestern Institute of Forensic Sciences, Dallas, Texas, USA
| | - Sara K Dempsey
- Dallas County Southwestern Institute of Forensic Sciences, Dallas, Texas, USA
| | - Brittany K Casey
- Dallas County Southwestern Institute of Forensic Sciences, Dallas, Texas, USA
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3
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Strasiotto L, Ellis A, Daw S, Lawes JC. The role of alcohol and drug intoxication in fatal drowning and other deaths that occur on the Australian coast. JOURNAL OF SAFETY RESEARCH 2022; 82:207-220. [PMID: 36031248 DOI: 10.1016/j.jsr.2022.05.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/16/2021] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Alcohol and drug (illicit or prescription) intoxication impairs motor skills, coordination, decision making abilities, hazard perception, and is known to increase the risk of death in coastal environments. Prior coastal safety research has focused largely on the impact of alcohol on drowning, with less research on the influence of drugs and leaving a significant number of other non-drowning fatalities largely excluded, despite being preventable with mitigation of injuries or medical factors. METHOD This retrospective cross-sectional study explored the impact of alcohol and drugs on unintentional Australian drowning deaths and other coastal fatalities over a 16-year period to identify higher-risk populations and coastal activity groups for which alcohol/drug use is increased. RESULTS It was found that alcohol, benzodiazepines/sedatives, and amphetamine usage was prevalent in coastal deaths. Of the 2,884 coastal deaths, 80.6% of decedents had known toxicological data. Alcohol and/or drug intoxication contributed to 23% of coastal drowning deaths and 19% of fatalities. For drowning and other fatalities combined, 8.7% were due to alcohol, 8.7% due to drugs, and 4.1% due to both alcohol and drugs. Australian-born decedents were more likely to involve alcohol (RR = 1.7, 95%CI = 1.26-2.3, p < 0.001), drugs (RR = 2.62, 95%CI = 1.85-3.7, p < 0.001), or both alcohol and drugs (RR = 4.43, 95%CI = 2.51-7.82, p < 0.001) with an increased risk identified in Indigenous Australian populations (RR = 2.17, 95%CI = 1.12-4.24, p = 0.04). The impact of alcohol and drug intoxication varied by activity, with Personal Watercraft users more likely to die due to alcohol intoxication (RR = 2.67, 95%CI = 1.23-5.78, p = 0.035), while scuba divers (RR = 0, p < 0.001), snorkelers (RR = 0.14, 95%CI = 0.036-0.57, p < 0.001), and rock fishers (RR = 0.46, 95%CI = 0.22-0.96, p = 0.03) were less likely. Recreational jumping and fall-related coastal deaths were more likely to involve alcohol and alcohol/drugs combined. PRACTICAL APPLICATIONS This study identifies factors to further investigate or target with prevention strategies to decrease the holistic burden of mortality due to alcohol and/or drug usage on the Australian coast.
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Affiliation(s)
- Luke Strasiotto
- Surf Life Saving Australia, Bondi Beach, NSW 2026, Australia
| | - Annabel Ellis
- Surf Life Saving Australia, Bondi Beach, NSW 2026, Australia
| | - Shane Daw
- Surf Life Saving Australia, Bondi Beach, NSW 2026, Australia
| | - Jasmin C Lawes
- Surf Life Saving Australia, Bondi Beach, NSW 2026, Australia
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Al-Asmari AI, Alharbi H, Zughaibi TA. Post-Mortem Analysis of Heroin Biomarkers, Morphine and Codeine in Stomach Wall Tissue in Heroin-Related Deaths. TOXICS 2022; 10:473. [PMID: 36006152 PMCID: PMC9413540 DOI: 10.3390/toxics10080473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/07/2022] [Accepted: 08/11/2022] [Indexed: 06/15/2023]
Abstract
Toxicological analysis of some cases can be complicated by poor sample quality caused by decomposition. Although heroin-related deaths have been researched extensively, the interpretation of toxicology findings in these cases is challenging, especially in instances where blood samples are unavailable. Thus, it is important to develop analytical methods for different sample types. In this study. a method for the quantification of 6-monoacetylmorphine, 6-acetylcodeine, morphine, and codeine in postmortem stomach wall tissue using liquid chromatography coupled with tandem mass spectrometry was developed and validated. All calibration curves prepared with the stomach wall tissue were linear and ranged from 0.5−1000 ng/g with determination coefficients of >0.99 and a lower limit of quantification of 1.0 ng/g. The coefficients of variation for within-run precision and between-run precision were <9%. Matrix effects of stomach wall tissues and their extraction recoveries were investigated and ranged from −19% to +17% and 76% to 80%, respectively. Among the 16 analyzed heroin-related death cases, 6-monoacetylmorphine, 6-acetylcodeine, morphine, and codeine were detected in 75%, 31%, 100%, and 94% of all stomach wall tissues with median concentrations of 90 ng/g, 20 ng/g, 140 ng/g, and 30 ng/g, respectively. This study provides new data on the distribution of 6-monoacetylmorphine, 6-Acetylcodeine, morphine, and codeine in postmortem stomach wall tissue and suggests the usefulness of alternative matrices for investigating heroin-related fatalities when blood samples are unavailable. In addition, the prevalence of 6-monoacetylmorphine in the stomach wall tissue was higher than that in the liver and kidney tissues.
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Affiliation(s)
- Ahmed I. Al-Asmari
- Laboratory Department, Ministry of Health, King Abdul-Aziz Hospital, P.O. Box 6470, Jeddah 21442, Saudi Arabia
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
| | - Hassan Alharbi
- Poison Control and Forensic Chemistry Center, Ministry of Health, P.O. Box 21543, Jeddah 21176, Saudi Arabia
| | - Torki A. Zughaibi
- King Fahd Medical Research Center, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
- Department of Medical Laboratory Sciences, Faculty of Applied Medical Sciences, King Abdulaziz University, P.O. Box 80216, Jeddah 21589, Saudi Arabia
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Edvardsen HME, Clausen T. Opioid related deaths in Norway in 2000-2019. Drug Alcohol Depend 2022; 232:109281. [PMID: 35042099 DOI: 10.1016/j.drugalcdep.2022.109281] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/03/2022]
Abstract
AIMS The aim of the study is to present autopsy-based findings of the most prevalent opioids in overdose deaths in Norway from 2000 to 2019, as such data are lacking in the current literature. METHODS Data on cause of death obtained from the Norwegian Cause of Death Registry (NCoDR) were linked with forensic toxicological results from forensic autopsies. RESULTS From year 2000 the annual numbers of overdose deaths decreased, specifically during 2000-2003, thereafter a relatively stable annual number was observed. Opioids were detected in 93% of the cases. Heroin related deaths have decreased, whereas medical opioids for pain treatment have increased with time. Men in their early 40's dominate the overall numbers of deaths, but significantly different sex patterns emerge when studying the specific drugs. During the past 20 years, the mean age at overdose death has increased by 10 years (from 33 to 43 years). Overdose deaths without any illicit drugs present at autopsy have increased in recent years. These deaths, where only potentially prescription medications were detected, were more common among women and with higher age. CONCLUSIONS In Norway during the past 20 years, we observe a dynamic shift in overdose deaths caused by heroin and illicit drugs, to include a gradually increasing trend of overdose deaths from pill based pain medications and also methadone and buprenorphine. This warrants a shift in preventive responses, as the target groups differ.
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Affiliation(s)
- Hilde Marie Erøy Edvardsen
- Section for Drug Abuse Research, Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway.
| | - Thomas Clausen
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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6
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Lappas NT, Lappas CM. Heroin. Forensic Toxicol 2022. [DOI: 10.1016/b978-0-12-819286-3.00024-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fugelstad A, Bremberg S, Hjelmström P, Thiblin I. Methadone-related deaths among youth and young adults in Sweden 2006-15. Addiction 2021; 116:319-327. [PMID: 32533568 DOI: 10.1111/add.15152] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 05/10/2020] [Accepted: 06/10/2020] [Indexed: 01/06/2023]
Abstract
AIMS To identify methadone-related deaths and determine the prevalence among youth and young adults in Sweden 2006-15. DESIGN, SETTING AND PARTICIPANTS National retrospective registry study comparing data from all forensic autopsy examinations and toxicology cases involving methadone during 2006-15 in individuals aged 15-29 years with police records, previous pharmaceutical prescriptions and health-care episodes. MEASUREMENTS Multinomial logistic regression. To assess the factors contributing to the deaths, we compared individuals with and without previous substance use treatment and opioid use-related diagnoses with regard to previous opioid agonist treatment (OAT), psychiatric care and previous pain medication. To assess the circumstances of deaths, we analyzed the presence of other drugs and other factors at time of death. FINDINGS We identified 269 methadone-related deaths, and the rate increased during the study period. Seventy-two (27%) cases had not previously received substance use treatment, 112 (42%) had received treatment but had no opioid use-related diagnosis and 85 (32%) had received treatment and had an opioid use-related diagnosis. In total, only 10 individuals had been prescribed methadone during the year before death. Prescriptions of benzodiazepines (60%), antidepressants (62%) and opioids for pain (22%) the year before death were common. Most deaths occurred during sleep with a time lag from ingestion of methadone. CONCLUSION Prescription opioid- and methadone-related deaths increased in the group aged 15-29 years in Sweden between 2006 and 2015. Exposure to non-prescribed methadone and prescribed benzodiazepines, antidepressants and opioids for pain appears to be common in drug-related deaths in youth and young adults in Sweden.
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Affiliation(s)
- Anna Fugelstad
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Sven Bremberg
- Department of Public Health, Karolinska Institute, Stockholm, Sweden
| | | | - Ingmar Thiblin
- Department of Surgical Sciences, Section for Forensic Medicine, Uppsala University, Uppsala, Sweden
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Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid and Other Drugs. Am J Forensic Med Pathol 2021; 41:152-159. [PMID: 32404634 DOI: 10.1097/paf.0000000000000550] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The National Association of Medical Examiners convened an expert panel to update the association's evidence-based recommendations for investigating and certifying deaths associated with opioids and other misused substances to improve death certificate and mortality data for public health surveillance. The recommendations are as follows:1. Autopsy provides the best information on a decedent's medical condition for optimal interpretation of toxicology results, circumstances surrounding death, medical history, and scene findings. The panel considers autopsy an essential component of investigating apparent overdose deaths.2. Scene investigation includes reconciling prescription information and medication counts. Investigators should note drug paraphernalia or other evidence of using intoxicating substances.3. Retain blood, urine, and vitreous humor whenever available. Blood from the iliofemoral vein is preferable to blood from more central sites.4. A toxicological panel should be comprehensive, including potent depressant, stimulant, and antidepressant medications. Detecting novel substances present in the community may require special testing.5. When death is attributed to a drug or combination of drugs (as cause or contributing factor), the certifier should list the drugs by generic name in the autopsy report and death certificate.6. The best classification for manner of death in an overdose without any apparent intent of self-harm is "accident."
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Nedahl M, Johansen SS, Linnet K. Brain-blood ratio of morphine in heroin and morphine autopsy cases. Forensic Sci Int 2019; 301:388-393. [DOI: 10.1016/j.forsciint.2019.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/23/2019] [Accepted: 06/05/2019] [Indexed: 11/16/2022]
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10
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Ketola RA, Ojanperä I. Summary statistics for drug concentrations in post‐mortem femoral blood representing all causes of death. Drug Test Anal 2019; 11:1326-1337. [DOI: 10.1002/dta.2655] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/16/2019] [Accepted: 05/20/2019] [Indexed: 11/12/2022]
Affiliation(s)
- Raimo A. Ketola
- National Institute for Health and Welfare, Forensic Toxicology P.O. Box 30 FI‐00271 Helsinki Finland
| | - Ilkka Ojanperä
- National Institute for Health and Welfare, Forensic Toxicology P.O. Box 30 FI‐00271 Helsinki Finland
- Department of Forensic MedicineUniversity of Helsinki P.O. Box 40 FI‐00014 Helsinki Finland
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Slavova S, Delcher C, Buchanich JM, Bunn TL, Goldberger BA, Costich JF. Methodological Complexities in Quantifying Rates of Fatal Opioid-Related Overdose. CURR EPIDEMIOL REP 2019; 6:263-274. [PMID: 31259141 PMCID: PMC6559129 DOI: 10.1007/s40471-019-00201-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
PURPOSE OF REVIEW Effective responses to the US opioid overdose epidemic rely on accurate and timely drug overdose mortality data, which are generated from medicolegal death investigations (MDI) and certifications of overdose deaths. We identify nuances of MDI and certification of overdose deaths that can influence drug overdose mortality surveillance, as well as recent research, recommendations, and epidemiological tools for improved identification and quantification of specific drug involvement in overdose mortality. RECENT FINDINGS Death certificates are the foundation of drug overdose mortality surveillance. Accordingly, counts and rates of specific drug involvement in overdose deaths are only as accurate as the drug listed on death certificates. Variation in systematic approaches or jurisdictional office policy in drug overdose death certification can lead to bias in mortality rate calculations. Recent research has examined statistical adjustments to improve underreported opioid involvement in overdose deaths. New cause-of-death natural language text analysis tools improve quantification of specific opioid overdose mortality rates. Enhanced opioid overdose surveillance, which combines death certificate data with other MDI-generated data, has the potential to improve understanding of factors and circumstances of opioid overdose mortality. SUMMARY The opioid overdose crisis has brought into focus some of the limitations of US MDI systems for drug overdose surveillance and has given rise to a sense of urgency regarding the pressing need for improvements in our MDI data for public health action and research. Epidemiologists can stimulate positive changes in MDI data quality by demonstrating the critical role of data in guiding public health and safety decisions and addressing the challenges of accurate and timely overdose mortality measures with stakeholders. Education, training, and resources specific to drug overdose surveillance and analysis will be essential as the nation's overdose crisis continues to evolve.
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Affiliation(s)
- Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY USA
- Kentucky Injury Prevention and Research Center, University of Kentucky, 333 Waller Ave, Suite 242, Lexington, KY 40504 USA
| | - Chris Delcher
- Department of Pharmacy Practice and Science, Institute for Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Kentucky, Lexington, KY USA
| | - Jeannine M. Buchanich
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA USA
| | - Terry L. Bunn
- Kentucky Injury Prevention and Research Center, University of Kentucky, 333 Waller Ave, Suite 242, Lexington, KY 40504 USA
- Department of Preventive Medicine and Environmental Health, College of Public Health, University of Kentucky, Lexington, KY USA
| | - Bruce A. Goldberger
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Julia F. Costich
- Kentucky Injury Prevention and Research Center, University of Kentucky, 333 Waller Ave, Suite 242, Lexington, KY 40504 USA
- Department of Health Management and Policy, College of Public Health, University of Kentucky, Lexington, KY USA
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Stam NC, Gerostamoulos D, Pilgrim JL, Smith K, Moran L, Parsons S, Drummer OH. An analysis of issues in the classification and reporting of heroin-related deaths. Addiction 2019; 114:504-512. [PMID: 30397976 DOI: 10.1111/add.14486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 09/02/2018] [Accepted: 11/01/2018] [Indexed: 11/28/2022]
Abstract
AIMS To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases. METHODS Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes. RESULTS A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroin-related death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes. CONCLUSIONS In Victoria, Australia, in 2012 and 2013, the overall number of heroin-related deaths was under-reported by 32% compared with the number of deaths currently identified by the Australian Bureau of Statistics and reported by the Australian Institute of Health and Welfare.
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Affiliation(s)
- Nathan C Stam
- Department of Forensic Medicine, Monash University, Melbourne, Australia.,Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, Melbourne, Australia.,Victorian Institute of Forensic Medicine, Melbourne, Australia
| | - Jennifer L Pilgrim
- Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Karen Smith
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia.,Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lauren Moran
- Mortality Data Centre, Health and Vital Statistics Section, Australian Bureau of Statistics, Brisbane, Australia
| | - Sarah Parsons
- Department of Forensic Medicine, Monash University, Melbourne, Australia.,Victorian Institute of Forensic Medicine, Melbourne, Australia
| | - Olaf H Drummer
- Department of Forensic Medicine, Monash University, Melbourne, Australia
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13
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Stam NC, Gerostamoulos D, Gerstner-Stevens J, Scott N, Smith K, Drummer OH, Pilgrim JL. Determining the effective dose of street-level heroin: A new way to consider fluctuations in heroin purity, mass and potential contribution to overdose. Forensic Sci Int 2018; 290:219-226. [DOI: 10.1016/j.forsciint.2018.07.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 07/11/2018] [Accepted: 07/12/2018] [Indexed: 01/04/2023]
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14
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Thaulow CH, Øiestad ÅML, Rogde S, Andersen JM, Høiseth G, Handal M, Mørland J, Vindenes V. Can measurements of heroin metabolites in post-mortem matrices other than peripheral blood indicate if death was rapid or delayed? Forensic Sci Int 2018; 290:121-128. [DOI: 10.1016/j.forsciint.2018.06.041] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 06/27/2018] [Accepted: 06/28/2018] [Indexed: 10/28/2022]
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15
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Stam NC, Pilgrim JL, Drummer OH, Smith K, Gerostamoulos D. Catch and release: evaluating the safety of non-fatal heroin overdose management in the out-of-hospital environment. Clin Toxicol (Phila) 2018; 56:1135-1142. [DOI: 10.1080/15563650.2018.1478093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Nathan C. Stam
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | | | - Olaf H. Drummer
- Department of Forensic Medicine, Monash University, Melbourne, Australia
| | - Karen Smith
- Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, Melbourne, Australia
- Victorian Institute of Forensic Medicine, Melbourne, Australia
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Stam NC, Gerostamoulos D, Dietze PM, Parsons S, Smith K, Lloyd B, Pilgrim JL. The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths. Forensic Sci Int 2017; 281:18-28. [DOI: 10.1016/j.forsciint.2017.10.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 09/11/2017] [Accepted: 10/10/2017] [Indexed: 10/18/2022]
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17
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Maas A, Madea B, Hess C. Confirmation of recent heroin abuse: Accepting the challenge. Drug Test Anal 2017; 10:54-71. [DOI: 10.1002/dta.2244] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 06/30/2017] [Accepted: 06/30/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Alexandra Maas
- Department of Forensic Toxicology; University Bonn, Institute of Forensic Medicine; Bonn Germany
| | - Burkhard Madea
- Department of Forensic Toxicology; University Bonn, Institute of Forensic Medicine; Bonn Germany
| | - Cornelius Hess
- Department of Forensic Toxicology; University Bonn, Institute of Forensic Medicine; Bonn Germany
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Lucyk SN, Nelson LS. Toxicosurveillance in the US opioid epidemic. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:168-171. [PMID: 28735771 DOI: 10.1016/j.drugpo.2017.05.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 05/25/2017] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Scott N Lucyk
- Department of Emergency Medicine, University of Calgary, Calgary, Alberta, Canada; Poison and Drug Information Service (PADIS), Alberta Health Services, 1403-29 Street NW, Calgary, Alberta, T2N 2T9, Canada.
| | - Lewis S Nelson
- Rutgers New Jersey Medical School, 185 S Orange Ave, Newark, NJ, 07103, USA
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Labay LM, Catanese CA. Illicit Drug Delivery Via Administration of Human Blood. J Forensic Sci 2017; 63:644-647. [PMID: 28580580 DOI: 10.1111/1556-4029.13573] [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: 04/09/2017] [Revised: 05/08/2017] [Accepted: 05/09/2017] [Indexed: 11/30/2022]
Abstract
The physiological, psychological, and social consequences associated with illicit drug use are well documented. In addition to the effects directly related to the drug(s), the delivery mechanism can precipitate other serious health conditions. A case is reported where an individual stopped by law enforcement was discovered to be in possession of a vial containing a red-colored fluid, which the person stated was blood and contained fentanyl. Analysis by headspace GC, ELISA, and LC-TOF/MS screening in with mass spectral confirmation revealed the presence of several substances, including ethanol, methamphetamine, amphetamine, MDA, 6-monoacetylmorphine, codeine, morphine, alprazolam, delta-9 THC, ephedrine, pseudoephedrine, and norpseudoephedrine; serology testing verified the fluid was consistent with human blood. Methamphetamine was present at a dosage form amount (11 mg). The purpose of this study was to detail the analytical findings, interpret their meaning, and discuss the public health concerns associated with the drug delivery by the administration of human blood.
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Slavova S, Bunn TL, Hargrove SL, Corey T, Ingram V. Linking Death Certificates, Postmortem Toxicology, and Prescription History Data for Better Identification of Populations at Increased Risk for Drug Intoxication Deaths. Pharmaceut Med 2017. [DOI: 10.1007/s40290-017-0185-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Abstract
In recent years, there has been a substantial increase in opioid use and abuse, and in opioid-related fatal overdoses. The increase in opioid use has resulted at least in part from individuals transitioning from prescribed opioids to heroin and fentanyl, which can cause significant respiratory depression that can progress to apnea and death. Heroin and fentanyl may be used individually, together, or in combination with other substances such as ethanol, benzodiazepines, or other drugs that can have additional deleterious effects on respiration. Suspicion that a death is drug-related begins with the decedent's medical and social history, and scene investigation, where drugs and drug paraphernalia may be encountered, and examination of the decedent, which may reveal needle punctures and needle track marks. At autopsy, the most significant internal finding that is reflective of opioid toxicity is pulmonary edema and congestion, and frothy watery fluid is often present in the airways. Various medical ailments such as heart and lung disease and obesity may limit an individual's physiologic reserve, rendering them more susceptible to the toxic effects of opioids and other drugs. Although many opioids will be detected on routine toxicology testing, more specialized testing may be warranted for opioid analogs, or other uncommon, synthetic, or semisynthetic drugs.
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Post-mortem concentrations of drugs determined in femoral blood in single-drug fatalities compared with multi-drug poisoning deaths. Forensic Sci Int 2016; 267:96-103. [DOI: 10.1016/j.forsciint.2016.08.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/26/2016] [Accepted: 08/05/2016] [Indexed: 11/17/2022]
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23
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Lotfi A, Karimi S, Hassanzadeh J. Preconcentration of codeine in pharmaceutical and human urine samples by multi-walled carbon nanotubes and its spectrophotometric determination. CAN J CHEM 2016. [DOI: 10.1139/cjc-2016-0312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A rapid and efficient solid phase extraction method was established for the preconcentration of codeine prior to its simple determination by spectrophotometry. The extraction process is based on the multi-walled carbon nanotubes (CNTs) containing –COOH functional groups. These CNTs showed a great affinity for the low quantities of codeine in certain condition. Various extraction factors including buffer type, concentration and its pH, ionic buffer, incubation time, and eluent were optimized to achieve high sensitivity. The calibration graph was linear in the codeine concentration range of 0.001–4 mg·L−1, with a detection limit (3s) of 0.4 μg·L−1. The relative standard deviation (RSD %) for the repetitive determination of 0.01, 0.5, and 2 mg·L−1 codeine (n = 5) were 1.56%, 2.01%, and 1.63%, respectively. Furthermore, comparison with other reported methods showed that the presented method has suitable characteristics. Finally the method was successfully used to accurately determine codeine in pharmaceutical and human urine samples.
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Affiliation(s)
- Ali Lotfi
- Young Researchers and Elite Club, Tabriz Branch, Islamic Azad University, Tabriz, Iran
| | - Sepideh Karimi
- Department of Chemistry, Varamin (Pishva) Branch, Islamic Azad University, Varamin, Iran
| | - Javad Hassanzadeh
- Young Researchers and Elite Club, Tabriz Branch, Islamic Azad University, Tabriz, Iran
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Ellis AD, McGwin G, Davis GG, Dye DW. Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses. Forensic Sci Med Pathol 2016; 12:243-7. [PMID: 27114260 PMCID: PMC4967084 DOI: 10.1007/s12024-016-9780-2] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Heroin has a half-life of 2-6 min and is metabolized too quickly to be detected in autopsy samples. The presence of 6-acetylmophine (6-AM) in urine, blood, or other samples is convincing evidence of heroin use by a decedent, but 6-AM itself has a half-life of 6-25 min before it is hydrolyzed to morphine, so 6-AM may not be present in sufficient concentration to detect in postmortem samples. Codeine is often present in heroin preparations as an impurity and is not a metabolite of heroin. Studies report that a ratio of morphine to codeine greater than one indicates heroin use. We hypothesize that the ratio of morphine to codeine in our decedents abusing drugs intravenously will be no different in individuals with 6-AM present than in individuals where no 6-AM is detected, and we report our study of this hypothesis. METHODS All accidental deaths investigated by the Jefferson County Coroner/Medical Examiner Office from 2010 to 2013 with morphine detected in blood samples collected at autopsy were reviewed. Five deaths where trauma caused or contributed to death were excluded from the review. The presence or absence of 6-AM and the concentrations of morphine and codeine were recorded for each case. The ratio of morphine to codeine was calculated for all decedents. Any individual in whom no morphine or codeine was detected in a postmortem sample was excluded from further study. Absence or presence of drug paraphernalia or evidence of intravascular (IV) drug use was documented in each case to identify IV drug users. The proportion of the IV drug users with and without 6-AM present in a postmortem sample was compared to the M/C ratio for the individuals. RESULTS Of the 230 deaths included in the analysis, 103 IV drug users with quantifiable morphine and codeine in a postmortem sample were identified allowing for calculation of an M/C ratio. In these IV drug users, the M/C ratio was greater than 1 in 98 % of decedents. When controlling for the absence or presence of 6-AM there was no statistically significant difference in the proportion of IV drug users when compared to non IV drug users with an M/C ratio of greater than 1 (p = 1.000). CONCLUSION The M/C ratio in IV drug users, if greater than 1, is seen in deaths due to heroin toxicity where 6-AM is detected in a postmortem sample. This study provides evidence that a M/C ratio greater than one in an IV drug user is evidence of a death due to heroin toxicity even if 6-AM is not detected in the blood. Using the M/C ratio, in addition to scene and autopsy findings, provides sufficient evidence to show heroin is the source of the morphine and codeine. Listing heroin as a cause or contributing factor in deaths with evidence of IV drug abuse and where the M/C ratio exceeds 1 will improve identification of heroin fatalities, which will allow better allocation of resources for public health initiatives.
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Affiliation(s)
- Ashley D Ellis
- Virginia Commonwealth University School of Medicine, 1101 E. Marshall Street, PO Box 980662, Richmond, VA, 23298, USA
| | - Gerald McGwin
- University of Alabama at Birmingham, 1515 6th Ave. S, Birmingham, AL, 35233, USA
| | - Gregory G Davis
- University of Alabama at Birmingham, 1515 6th Ave. S, Birmingham, AL, 35233, USA
| | - Daniel W Dye
- University of Alabama at Birmingham, 1515 6th Ave. S, Birmingham, AL, 35233, USA.
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Darke S, Duflou J. The toxicology of heroin-related death: estimating survival times. Addiction 2016; 111:1607-13. [PMID: 27082514 DOI: 10.1111/add.13429] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 02/05/2016] [Accepted: 04/14/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIMS The feasibility of intervention in heroin overdose is of clinical importance. The presence of 6-monoacetyl morphine (6MAM) in the blood is suggestive of survival times of less than 20-30 minutes following heroin administration. The study aimed to determine the proportions of cases in which 6MAM was present, and compare concentrations of secondary metabolites and circumstances of death by 6MAM status. DESIGN Analysis of cases of heroin-related death presenting to the Department of Forensic Medicine Sydney, 1 January 2013-12 December 2014. SETTING Sydney, Australia. CASES A total of 145 cases. The mean age was 40.5 years and 81% were male. MEASUREMENTS Concentrations of 6MAM, free morphine, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Circumstances of death included bronchopneumonia, apparent sudden collapse, location and other central nervous system (CNS) depressants. FINDINGS 6MAM was detected in 43% [confidence interval (CI) = 35-51%] of cases. The median free morphine concentration of 6MAM-positive cases was more than twice that of cases without 6MAM (0.26 versus 0.12 mg/l). 6MAM-positive cases also had lower concentrations of the other major heroin metabolites: M3G (0.05 versus 0.29 mg/l), M6G (0.02 versus 0.05 mg/l) with correspondingly lower M3G/morphine (0.54 versus 2.71) and M6G/morphine (0.05 versus 0.50) ratios. Significant independent correlates of 6MAM were a higher free morphine concentration [odds ratio (OR) = 1.7], a lower M6G/free morphine ratio (OR = 0.5) and signs of apparent collapse (OR = 6.7). CONCLUSIONS In heroin-related deaths in Sydney, Australia during 2013 and 2014, 6- monoacetyl morphine was present in the blood in less than half of cases, suggesting that a minority of cases had survival times after overdose of less than 20-30 minutes. The toxicology of heroin metabolites and the circumstances of death were consistent with 6- monoacetyl morphine as a proxy for a more rapid death.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, Australia.,Department of Forensic Medicine Sydney, NSW Health Pathology, Sydney Medical School, University of Sydney, NSW, Australia
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Drug-related deaths with evidences of body packing: Two case reports and medico-legal issues. Leg Med (Tokyo) 2016; 20:23-6. [DOI: 10.1016/j.legalmed.2016.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 02/29/2016] [Accepted: 03/13/2016] [Indexed: 01/08/2023]
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Ahlner J, Holmgren A, Jones AW. Demographics and post-mortem toxicology findings in deaths among people arrested multiple times for use of illicit drugs and/or impaired driving. Forensic Sci Int 2016; 265:138-43. [PMID: 26901639 DOI: 10.1016/j.forsciint.2016.01.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Revised: 01/20/2016] [Accepted: 01/21/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUND Multiple arrests for use of illicit drugs and/or impaired driving strongly suggests the existence of a personality disorder and/or a substance abuse problem. METHODS This retrospective study (1993-2010) used a national forensic toxicology database (TOXBASE), and we identified 3943 individuals with two or more arrests for use of illicit drugs and/or impaired driving. These individuals had subsequently died from a fatal drug poisoning or some other cause of death, such as trauma. RESULTS Of the 3943 repeat offenders 1807 (46%) died from a fatal drug overdose and 2136 (54%) died from other causes (p<0.001). The repeat offenders were predominantly male (90% vs 10%) and mean age of drug poisoning deaths was 5 y younger (mean 35 y) than other causes of death (mean 40 y). Significantly more repeat offenders (46%) died from drug overdose compared with all other forensic autopsies (14%) (p<0.001). Four or more drugs were identified in femoral blood in 44% of deaths from poisoning (drug overdose) compared with 18% of deaths by other causes (p<0.001). The manner of death was considered accidental in 54% of deaths among repeat offenders compared with 28% for other suspicious deaths (p<0.001). The psychoactive substances most commonly identified in autopsy blood from repeat offenders were ethanol, morphine (from heroin), diazepam, amphetamines, cannabis, and various opioids. CONCLUSIONS This study shows that people arrested multiple times for use of illicit drugs and/or impaired driving are more likely to die by accidentally overdosing with drugs. Lives might be saved if repeat offenders were sentenced to treatment and rehabilitation for their drug abuse problem instead of conventional penalties for drug-related crimes.
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Affiliation(s)
- Johan Ahlner
- Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden
| | - Anita Holmgren
- Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden
| | - Alan Wayne Jones
- Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden.
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28
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Zheng D, Hu H, Liu X, Hu S. Application of graphene in elctrochemical sensing. Curr Opin Colloid Interface Sci 2015. [DOI: 10.1016/j.cocis.2015.10.011] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Mertz KJ, Janssen JK, Williams KE. Underrepresentation of Heroin Involvement in Unintentional Drug Overdose Deaths in Allegheny County, PA. J Forensic Sci 2014; 59:1583-5. [DOI: 10.1111/1556-4029.12541] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 09/13/2013] [Accepted: 10/12/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Kristen J. Mertz
- Department of Epidemiology; Graduate School of Public Health; University of Pittsburgh; Pittsburgh PA 15261
| | - Jennifer K. Janssen
- Allegheny County Office of the Medical Examiner; 1520 Penn Avenue Pittsburgh PA 15222
| | - Karl E. Williams
- Allegheny County Office of the Medical Examiner; 1520 Penn Avenue Pittsburgh PA 15222
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Complete republication: National Association of Medical Examiners position paper: Recommendations for the investigation, diagnosis, and certification of deaths related to opioid drugs. J Med Toxicol 2014; 10:100-6. [PMID: 24132519 PMCID: PMC3951636 DOI: 10.1007/s13181-013-0323-x] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings. 2. A complete scene investigation extends to reconciliation of prescription information and pill counts. 3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites. 4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and anti-depressant medications. 5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings. 6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate. 7. The best classification for manner of death in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is "accident." Reserve "undetermined" as the manner for the rare cases in which evidence exists to support more than one possible determination.
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31
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Davis GG. National Association of Medical Examiners Position Paper: Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs. Acad Forensic Pathol 2013. [DOI: 10.23907/2013.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings. 2. A complete scene investigation extends to reconciliation of prescription information and pill counts. 3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites. 4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and anti-depressant medications. 5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings. 6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate. 7. The best classification for manner of death in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.
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Affiliation(s)
- Gregory G. Davis
- Jefferson County Coroner/Medical Examiner Office University of Alabama at Birmingham
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32
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Davis GG. Recommendations for the Investigation, Diagnosis, and Certification of Deaths Related to Opioid Drugs. Acad Forensic Pathol 2013. [DOI: 10.23907/2013.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The American College of Medical Toxicology and the National Association of Medical Examiners convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of the toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance. The panel finds the following: 1. A complete autopsy is necessary for optimal interpretation of toxicology results, which must also be considered in the context of the circumstances surrounding death, medical history, and scene findings. 2. A complete scene investigation extends to reconciliation of prescription information and pill counts. 3. Blood, urine, and vitreous humor, when available, should be retained in all cases. Blood from the femoral vein is preferable to blood from other sites. 4. A toxicological panel should be comprehensive and include opioid and benzodiazepine analytes, as well as other potent depressant, stimulant, and antidepressant medications. 5. Interpretation of postmortem opioid concentrations requires correlation with medical history, scene investigation, and autopsy findings. 6. If death is attributed to any drug or combination of drugs (whether as cause or contributing factor), the certifier should list all the responsible substances by generic name in the autopsy report and on the death certificate. 7. The best classification for manner in deaths due to the misuse or abuse of opioids without any apparent intent of self-harm is “accident.” Reserve “undetermined” as the manner for the rare cases in which evidence exists to support more than one possible determination.
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Affiliation(s)
- Gregory G. Davis
- Jefferson County Coroner/Medical Examiner Office University of Alabama at Birmingham
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Bu J, Zhan C, Huang Y, Shen B, Zhuo X. Distinguishing Heroin Abuse from Codeine Administration in the Urine of Chinese People by UPLC-MS-MS. J Anal Toxicol 2013; 37:166-74. [DOI: 10.1093/jat/bks093] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
This paper is the thirty-fourth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2011 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurologic disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration (Section 16); and immunological responses (Section 17).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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35
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Morphine to codeine concentration ratio in blood and urine as a marker of illicit heroin use in forensic autopsy samples. Forensic Sci Int 2012; 217:216-21. [DOI: 10.1016/j.forsciint.2011.11.007] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2011] [Revised: 10/17/2011] [Accepted: 11/05/2011] [Indexed: 11/22/2022]
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36
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Quantitative analysis of amphetamine in femoral blood from drug-poisoning deaths compared with venous blood from impaired drivers. Bioanalysis 2011; 3:2195-204. [DOI: 10.4155/bio.11.222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Amphetamine is a major drug of abuse worldwide. Here we compare the concentrations of this stimulant amine in femoral blood in drug fatalities with venous blood from impaired drivers. Method: Amphetamine was determined in blood by isotope-dilution GC–MS after liquid–liquid extraction. Results: Amphetamine was the only drug identified in 36 fatalities at mean (median) and highest concentrations of 2.0 mg/l (1.5 mg/l) and 14.0 mg/l. In multiple-drug deaths (n = 383), the concentrations were 0.94 mg/l (0.4 mg/l) and 13.3 mg/l. In impaired drivers with amphetamine as the only drug (n = 6138), the concentrations were 1.0 mg/l (0.8 mg/l) and 11.9 mg/l, compared with 0.78 mg/l (0.6 mg/l) and 22.3 mg/l in multidrug users (n = 8250). Conclusion: Fatal amphetamine poisonings cannot be identified on the basis of the concentration in blood alone, owing to the development of tolerance and the toxicity of co-ingested substances.
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