Drugs in postmortem adipose tissues: evidence of antemortem deposition

Postmortem redistribution of cocaine and its metabolites, benzoylecgonine and ecgonine methyl ester in humans: Important variables that might be influencing the central blood / peripheral blood ratio

INTRODUCTION

A big challenge in forensic toxicology is the correct interpretation of the results of quantitative analyses in postmortem cases. Postmortem drug concentrations not necessarily reflect the drug concentrations at the time of death, due to postmortem changes in drug concentrations caused by postmortem redistribution (PMR). Cardiac blood is more prone to PMR related concentration changes than peripheral blood. Because of this difference in susceptibility to PMR related concentration changes, the ratio of cardiac blood concentration/peripheral blood concentration (C/P) of a drug is an often-used marker of PMR. In this study, we investigated the relationship between different potentially significant variables and the C/P ratios of cocaine, benzoylecgonine (BE) and ecgonine methyl ester (EME) in humans. The aim was to elucidate the mechanisms involved in PMR of these substances and potentially provide guidelines aiding forensic toxicologists in the interpretation of postmortem quantitative results of cocaine and its metabolites. To differentiate between postmortem concentration changes due to redistribution versus degradation of cocaine, the relationships between these variables and metabolite/cocaine ratios were investigated as well.

METHOD

Toxicological results of all postmortem cases that were positive for cocaine, BE and/or EME investigated by the Netherlands Forensic Institute between January 1st 2010 and July 31st 2020 were reviewed. The C/P ratios, BE/cocaine ratios and EME/cocaine ratios were determined for all selected cases. Cocaine, BE and/or EME were quantified in both femoral blood and cardiac blood in a total of 148 cases. Ratios were compared between subgroups by performing either a Mann-Whitney U test or a Kruskal-Wallis test followed by post-hoc Mann-Whitney U test.

RESULTS

A statistically significant difference in C/P ratio of EME was observed between trauma and non-trauma cases with median C/P ratios of 2.03 and 1.57, respectively (p value=0.001). A statistically significant difference in EME/cocaine ratio was observed between the BMI subgroups 18.5 - 25.0 kg/m2 and> 25 kg/m2 with median EME/cocaine ratios of 3.79 and 1.58, respectively (p-value<0.001).

CONCLUSION

Postmortem cocaine concentrations should be interpreted with caution, considering the occurrence of both PMR and postmortem degradation. When interpreting postmortem toxicological results in cocaine-related fatalities, it might prove useful to take the above-mentioned variables into account.

Cadmium acute exposure induces metabolic and transcriptomic perturbations in human mature adipocytes

Obesity is considered as a major public health concern with strong economic and social burdens. Exposure to pollutants such as heavy metals can contribute to the development of obesity and its associated metabolic disorders, including type 2 diabetes and cardiovascular diseases. Adipose tissue is an endocrine and paracrine organ that plays a key role in the development of these diseases and is one of the main target of heavy metal accumulation. In this study, we determined by inductively coupled plasma mass spectrometry cadmium concentrations in human subcutaneous and visceral adipose tissues, ranging between 2.5nM and 2.5µM. We found a positive correlation between cadmium levels and age, sex and smoking status and a negative correlation between Cd and body mass index. Based on cadmium adipose tissue concentrations found in humans, we investigated the effects of cadmium exposure, at concentrations between 1nM and 10µM, on adipose-derived human mesenchymal stem cells differentiated into mature adipocytes in vitro. Transcriptomic analysis highlighted that such exposure altered the expression of genes involved in trace element homeostasis and heavy metal detoxification, such as Solute Carrier Family transporters and metallothioneins. This effect correlated with zinc level alteration in cells and cellular media. Interestingly, dysregulation of zinc homeostasis and transporters has been particularly associated with the development of obesity and type 2 diabetes. Moreover, we found that cadmium exposure induces the pro-inflammatory state of the adipocytes by enhancing the expression of genes such as IL-6, IL-1B and CCL2, cytokines also induced in obesity. Finally, cadmium modulates various adipocyte functions such as the insulin response signaling pathway and lipid homeostasis. Collectively, our data identified some of the cellular mechanisms by which cadmium alters adipocyte functions, thus highlighting new facets of its potential contribution to the progression of metabolic disorders.

Postmortem redistribution of morphine in humans: Important variables that might be influencing the central blood/peripheral blood ratio

INTRODUCTION

In the field of forensic toxicology, many unexpected deaths are investigated as to whether toxicological substances may have caused or contributed to someone's death. One of the factors that makes interpretation of the results of quantitative analysis in postmortem toxicology challenging, is that measured postmortem drugs levels may vary according to the sampling site and the interval between death and specimen collection. These site- and time-dependent variations are caused by 'postmortem redistribution' (PMR). Literature shows that there are several factors that determine the degree of PMR, such as cell and tissue changes after death, decomposition and the physicochemical characteristics of drugs. Blood from peripheral sites seems to be less affected by PMR than cardiac blood. Therefore, the ratio of cardiac blood concentration/peripheral blood concentration (C/P) of a drug is often used as a marker of the extent of postmortem redistribution. In this study, we investigated the relationship between different potentially important variables and the C/P ratio of morphine in humans in order to provide new insights that might assist in the interpretation of quantitative results in forensic casework.

METHOD

Toxicological results of all morphine positive postmortem cases investigated by the Netherlands Forensic Institute between January 1, 2010 and July 31, 2020 were reviewed. Morphine was quantified in both femoral and cardiac blood in a total of 103 cases. The C/P ratios were determined for all selected cases. To collect data for this study, all corresponding files were reviewed. C/P ratios were compared between subgroups by performing either a Mann-Whitney U test or a Kruskal-Wallis test, followed by a post-hoc Mann-Whitney U test. Bonferroni correction was performed to correct for the likelihood of a significant result by chance due to multiple testing. After Bonferroni correction, a p-value< 0.004 was considered statistically significant.

RESULTS

The data suggests a relationship between grade of decomposition at autopsy, position of the corpse at discovery, route of administration, attempted resuscitation and the C/P ratio of morphine with p-values of 0.010, 0.026, 0.035 and 0.046, respectively.

CONCLUSION

Grade of decomposition at autopsy, position of the corpse at discovery, route of administration and attempted resuscitation seem to be influencing the C/P ratio of morphine. Of these four variables, the route of administration seems to have the greatest impact.

Histological Changes in Adipose Tissue: An Alarm When Methamphetamine Is Targeted for Weight Loss Purposes

BACKGROUND

Methamphetamine (METH) may be administered for weight loss purposes and to understand the METH side-effects more in details, this study aimed at determining the effect of METH on changes in adipose tissue in experimental rats.

METHODS

Forty five male Wistar rats were randomly allocated to three equal groups. Group 1 was experimental receiving METH [0.4 mg/kg, subcutaneously (S/C), 0.6 mL/rat] for 3 weeks, group 2 was the sham group receiving normal saline (0.6 mL/rat, S/C) and the 3^rd group was the control receiving distilled water, identically. The elevated plus maze test was used to confirm cognitive impairment and distraction as anxiety and to verify addiction to METH by assessing the percent time spent in open arm (OAT), the percent time spent in closed arm (CAT), the percent time spent in central parts and head dipping over the side of the maze. Adipose tissue was assessed histologically 7, 14 and 21-days after interventions.

RESULTS

A significant increase in anxiety level, and histologically inflammation, degeneration and necrosis in adipose tissue were visible after METH use.

CONCLUSION

METH use resulted in a significant inflammation and necrosis in adipose tissue denoting to the dangers of METH use, when recreationally targeted for weight loss purposes.

Is adipose tissue suitable for detection of (synthetic) cannabinoids? A comparative study analyzing antemortem and postmortem specimens following pulmonary administration of JWH-210, RCS-4, as well as ∆9-tetrahydrocannabinol to pigs

Examining fatal poisonings, chronic exposure may be reflected by the concentration in tissues known for long-term storage of drugs. Δ9-tetrahydrocannabinol (THC) persists in adipose tissue (AT), but sparse data on synthetic cannabinoids (SC) are available. Thus, a controlled pig study evaluating antemortem (AM) disposition and postmortem (PM) concentration changes of the SC 4-ethylnaphthalene-1-yl-(1-pentylindole-3-yl)methanone (JWH-210) and 2-(4-methoxyphenyl)-1-(1-pentyl-indole-3-yl)methanone (RCS-4) as well as THC in AT was performed. The drugs were administered pulmonarily (200 µg/kg body weight) to twelve pigs. Subcutaneous (s.c.) AT specimens were collected after 15 and 30 min and then hourly up to 8 h. At the end, pigs were sacrificed and s.c., perirenal, and dorsal AT specimens were collected. The carcasses were stored at room temperature (RT; n = 6) or 4 °C (n = 6) and specimens were collected after 24, 48, and 72 h. After homogenization in acetonitrile and standard addition, LC-MS/MS was performed. Maximum concentrations were reached 0.5-2 h after administration amounting to 21 ± 13 ng/g (JWH-210), 24 ± 13 ng/g (RCS-4), and 22 ± 20 ng/g (THC) and stayed at a plateau level. Regarding the metabolites, very low concentrations of N-hydroxypentyl-RCS-4 (HO-RCS-4) were detected from 0.5 to 8 h. PM concentrations of parent compounds did not change significantly (p > 0.05) over time under both storage conditions. Concentrations of HO-RCS-4 significantly (p < 0.05) increased in perirenal AT during storage at RT. These results suggest a rapid distribution and persistence in s.c. AT. Furthermore, AT might be resistant to PM redistribution of parent compounds. However, significant PM increases of metabolite concentrations might be considered in perirenal AT.

Distribution of Synthetic Cannabinoids JWH-210, RCS-4 and Δ 9-Tetrahydrocannabinol After Intravenous Administration to Pigs

Background:

Synthetic cannabinoids (SCs) have become an increasing issue in forensic toxicology. Controlled human studies evaluating pharmacokinetic data of SCs are lacking and only few animal studies have been published. Thus, an interpretation of analytical results found in intoxicated or poisoned individuals is difficult. Therefore, the distribution of two selected SCs, namely 4-ethylnaphthalen-1-yl-(1-pentylindol-3-yl)methanone (JWH-210) and 2-(4-methoxyphenyl)-1-(1-pentyl-indol-3-yl)methanone (RCS-4) as well as ∆9-tetrahydrocannabinol (THC) as reference were examined in pigs.

Methods:

Pigs (n = 6 per drug) received a single intravenous 200 µg/kg BW dose of JWH-210, RCS-4, or THC. Six hours after administration, the animals were exsanguinated and relevant organs, important body fluids such as bile, and tissues such as muscle and adipose tissue, as well as the bradytrophic specimens dura and vitreous humor were collected. After hydrolysis and solid phase extraction, analysis was performed by LC-MS/MS. To overcome matrix effects of the LC-MS/MS analysis, a standard addition method was applied for quantification.

Results:

The parent compounds could be detected in every analyzed specimen with the exception of THC that was not present in dura and vitreous humor. Moderate concentrations were present in brain, the site of biological effect. Metabolite concentrations were highest in tissues involved in metabolism and/or elimination.

Conclusions:

Besides kidneys and lungs routinely analyzed in postmortem toxicology, brain, adipose, and muscle tissue could serve as alternative sources, particularly if other specimens are not available. Bile fluid is the most appropriate specimen for SCs and THC metabolites detection.

Cannabis and cardiotoxicity

Cannabis is the most commonly consumed illicit drug. It is estimated that 4% of the global population between the ages of 15 and 64 smoked marijuana in 2003. Despite the drug's extreme popularity, reports of cannabis-related stroke and myocardial infarction are so rare as to still be reportable. Cannabinoids, the active compounds contained in marijuana, interact with cardiovascular centers in the brain, but also exert direct effects on vascular tone. Recent animal and in vitro studies have yielded conflicting results, some suggesting minimal effect, others suggesting that cannabinoids may be potent myocardial depressants. The observation that cardiotoxicity has never been reported in cancer patients taking dronabinol, the synthetic form of THC, tends to suggest that animal studies may have overstated the cardiovascular risk, which is probably comparable to that of smoking cigarettes.

Distribution of enantiomers of methadone and its main metabolite EDDP in human tissues and blood of postmortem cases

Knowledge concerning the distribution of methadone in postmortem human tissue and the effect of postmortem redistribution on methadone is today limited making the choice of a suitable substitute for femoral blood difficult when this is not available. Cardiac blood, femoral blood, muscle, and brain tissue concentrations of the enantiomers of methadone and its metabolite 2-ethyl-1,5-dimethyl-3,3-diphenylpyrrolinium were recorded for 155 postmortem cases. Brain and muscle tissue concentrations exceeded the femoral blood concentrations with a median fold of 2.3 and 1.6, respectively, but both had a better correlation than cardiac blood to femoral blood concentrations. The Kruskal-Wallis test showed a significant dependency on time and body mass index for some of the matrix ratios over femoral blood. We conclude brain or muscle tissue may constitute a better alternative for measurement of methadone than cardiac blood for situations in which femoral blood is not available, despite concentrations in both matrices being systematically higher.

Demonstration of ethyl glucuronide in dental tissue samples by liquid chromatography/electro-spray tandem mass spectrometry

INTRODUCTION

Ethyl glucuronide (EtG) has been studied in various tissues and body fluid for determination of alcohol intake. However, no study, dealing with EtG analysis in dental tissue, was performed so far. In this study, we aimed to demonstrate EtG levels in dental tissue.

MATERIALS AND METHODS

Michigan Alcohol Screening Test (MAST) was performed to 29 participants. Following the test, cases were divided into three groups as non-hazardous alcohol users, alcohol abusers and 6 controls who verbally declared that they were abstainers. A total of 29 tooth specimens, obtained from participants, was included in the study. These specimens were analyzed using LC/MS/MS.

RESULTS

All of the participants included in the study were male. According to the MAST outcomes 14 of the participants were non-hazardous alcohol users, and 9 were alcohol abusers, while 6 patients verbally declared that they were abstainers. Dental tissue analyses revealed EtG levels ranging between EtG<LOD and 23.39 pg/mg. EtG levels were observed to be <LOD in dental specimens of 6 abstainer cases. A significant correlation was found between EtG levels measured in the dental tissues and MAST outcomes on the statistical analyses (r=0.914).

CONCLUSION

The findings of the present study demonstrated that dental tissue can be used for detection of alcohol intake, using LC/MS/MS.

Methamphetamine exposure and chronic illness in police officers: significant improvement with sauna-based detoxification therapy

Background: The medical literature reports health hazards for law enforcement personnel from repeated exposure to methamphetamine and related chemical compounds. Most effects appear transitory, but some Utah police officers with employment-related methamphetamine exposures developed chronic symptoms, some leading to disability. This report is of an uncontrolled retrospective medical chart evaluation of symptomatic officers treated with a sauna detoxification protocol designed to reduce the chronic symptoms and improve the quality of life. Methods: Sixty-nine officers consecutively entering the Utah Meth Cops Project were assessed before and after a treatment program involving gradual exercise, comprehensive nutritional support and physical sauna therapy. Evaluations included pre- and post-treatment scores of the Research and Development Corporation (RAND) 36-item Short Form Health Survey (SF-36) in comparison with RAND population norms, pre- and post-treatment symptom score intensities, neurotoxicity scores, Mini-Mental Status Examination, presenting symptom frequencies and a structured evaluation of treatment program safety. Results: Statistically significant health improvements were seen in the SF-36 evaluations, symptom scores and neurotoxicity scores. The detoxification protocol was well tolerated, with a 92.8% completion rate. Conclusions: This investigation strongly suggests that utilizing sauna and nutritional therapy may alleviate chronic symptoms appearing after chemical exposures associated with methamphetamine-related law enforcement activities. This report also has relevance to addressing the apparent ill effects of other complex chemical exposures. In view of the positive clinical outcomes in this group, broader investigation of this sauna-based treatment regimen appears warranted.

Deaths involving contraindicated and inappropriate combinations of serotonergic drugs

In the Australian state of Victoria, all fatalities that were recorded from 2002 through to 2008 involving the use of certain serotonin active drugs (tramadol, venlafaxine, fluoxetine, sertraline, citalopram and paroxetine), were reviewed to assess the incidence of contraindicated or ill advised drug combinations. More than 1,000 were identified of which 326 cases formed the basis of this study. These cases involved contraindicated or inappropriate drug combinations that can lead to adverse drug reactions (ADRs) and subsequent fatal toxicity. Of these, 46% were drug-related, 35% were a result of natural disease and 13% were classified as external injury cases. The remaining cases were those where the cause of death (COD) was unascertained. Tramadol was the most common drug, usually detected alongside a serotonergic antidepressant (in 20% of cases). Twenty-five (8%) cases involved contraindicated drug combinations while the remainder (301 cases, 92%) involved drug combinations that are associated with adverse interactions ranging from minor to major severity. Of these 326 cases, the Coroner determined 166 cases (51%) to be acts of intentional self-harm or drug misuse, with the remainder unascertained or attributed to natural disease. Very few post-mortem reports and Coroners' findings made mention of possible ADRs when such combinations were actually present. The majority of cases comprising contraindicated drug combinations involved the combined use of five drugs (24%) at the time of death. A combination of three to five drugs was most common in cases involving inadvisable drug combinations. Combined drug toxicity was the most common COD, with heart disease the most common co-morbidity.

Collection of biological samples in forensic toxicology

Forensic toxicology is the study and practice of the application of toxicology to the purposes of the law. The relevance of any finding is determined, in the first instance, by the nature and integrity of the specimen(s) submitted for analysis. This means that there are several specific challenges to select and collect specimens for ante-mortem and post-mortem toxicology investigation. Post-mortem specimens may be numerous and can endow some special difficulties compared to clinical specimens, namely those resulting from autolytic and putrefactive changes. Storage stability is also an important issue to be considered during the pre-analytic phase, since its consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample. The knowledge on degradation mechanisms and methods to increase storage stability may enable the forensic toxicologist to circumvent possible difficulties. Therefore, advantages and limitations of specimen preservation procedures are thoroughfully discussed in this review. Presently, harmonized protocols for sampling in suspected intoxications would have obvious utility. In the present article an overview is given on sampling procedures for routinely collected specimens as well as on alternative specimens that may provide additional information on the route and timing of exposure to a specific xenobiotic. Last, but not least, a discussion on possible bias that can influence the interpretation of toxicological results is provided. This comprehensive review article is intented as a significant help for forensic toxicologists to accomplish their frequently overwhelming mission.

Drug residues store in the body following cessation of use: impacts on neuroendocrine balance and behavior--use of the Hubbard sauna regimen to remove toxins and restore health

For decades, scientists have investigated the environmental and human health effects of synthetic chemicals. A growing body of research has illuminated the spectrum of consequences deriving from our reliance these substances and their proliferation in air, water, soil and the food chain. Of particular concern is the fact that residues of many man-made chemicals are now detectible in virtually every person. A key to a chemical's tendency to persist in tissues once it has entered the body is its lipophilicity. Substances that are poorly soluble in water and quite soluble in fat have relatively free access, via lipid-rich cellular membranes, to the cells of all organs including the ability to cross the blood-brain and placental barriers. Substantial data exist demonstrating that in addition to pollutants, drugs and their metabolites dispose to tissues high in fat content, including brain and adipose. While their characteristic lipophilicity permits drugs and medications to reach target tissues, thereby producing therapeutic effects in the present, current perceptions of risk may be ignoring the possibility that adipose accumulations of illicit drugs and pharmaceuticals may lead to future patterns of ill health similar to those associated with exposure to other categories of xenobiotic chemicals. Empirical data are beginning to characterize the myriad regulatory functions of adipose hormones, including roles in cravings, cognitive function, energy level, and inflammation as well as changes in adipose hormone levels associated with drug use. Included in this data are the observation that a rehabilitative treatment intervention introduced by L. Ron Hubbard in 1978 to aid in the broad elimination of chemicals from body stores improves symptoms common to both chemical exposure and drug addiction. The regimen, which includes exercise, sauna bathing, and vitamin and mineral supplementation, is utilized by nearly 70 drug rehabilitation and medical practices in over 20 countries. At present, much more is unknown than is known regarding long-term drug retention and effects. This subject deserves careful evaluation given its potential implications for health and chronic illnesses of poorly defined etiology (such as chronic fatigue syndrome), as well as drug abuse prevention, drug rehabilitation, forensic and legal areas.

Distribution of ethyl glucuronide in rib bone marrow, other tissues and body liquids as proof of alcohol consumption before death

Postmortem ethyl glucuronide (EtG) concentrations in rib bone marrow, liver, muscle, fat tissue, urine, blood and bile have been determined by LC-MS/MS. Samples have been taken from twelve corpses during autopsies. In nine corpses EtG could be detected, corresponding blood ethanol concentrations (BAC) were 0.04-0.37 g%. In three cases, no EtG was found; two of these cases showed postmortem BACs - possibly due to putrefaction - of 0.01 and 0.1g%. In rib bone marrow, which is easily accessible during autopsy, EtG concentrations (0.77-9.36 microg/g) have been lower than in blood (2.24-20.46 microg/mL) in eight of nine cases and comparable or higher than in muscle tissue. Therefore, rib bone marrow has been found suitable as matrix for EtG determination. The highest EtG concentrations have been found in urine in all but one case, where the resorption of ethanol had been incomplete. Second highest EtG concentrations have been detected in liver samples. In two cases with putrefaction, EtG could not be detected. In these cases, the detectable ethanol might have been produced partially or in total by postmortem fermentation. However, instability of EtG during putrefaction cannot be totally excluded which might result in a total loss of EtG.

Preanalytic aspects in postmortem toxicology

The preanalytic phase has been recognized to have a substantial role for the quality and reliability of analytical results, which very much depend on the type and quality of specimens provided. There are several unique challenges to select and collect specimens for postmortem toxicology investigation. Postmortem specimens may be numerous, and sample quality may be quite variable. An overview is given on specimens routinely collected as well as on alternative specimens that may provide additional information on the route of administration, a long term or a recent use/exposure to a drug or poison. Autolytic and putrefactive changes limit the selection and utility of specimens. Some data from case reports as well as experimental investigations on drug degradation and/or formation during putrefaction are discussed. Diffusion processes as well as postmortem degradation or formation may influence ethanol concentration in autopsy specimens. Formalin fixation of specimens or embalmment of the corpse may cause considerable changes of initial drug levels. These changes are due to alterations of the biological matrix as well as to dilution of a sample, release or degradation of the drug or poison. Most important seems a conversion of desmethyl metabolites to the parent drug. Some general requirements for postmortem sampling are given based on references about specimen collection issues, for a harmonized protocol for sampling in suspected poisonings or drug-related deaths does not exist. The advantages and disadvantages of specimen preservation are shortly discussed. Storage stability is another important issue to be considered. Instability can either derive from physical, chemical or metabolic processes. The knowledge on degradation mechanisms may enable the forensic toxicologist to target the right substance, which may be a major break down product in the investigation of highly labile compounds. Although it is impossible to eliminate all interfering factors or influences occurring during the preanalytic phase, their consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample.

Post-mortem toxicology: what the dead can and cannot tell us

The evaluation of postmortem laboratory assays of drugs needs to be performed in a systematic manner. The condition of the body, drug characteristics, matrix and site analysis are factors which need to be considered in the proper interpretation of an autopsy specimen result.

Comparison of urine to sweat patch test results in court ordered testing

A former cocaine and methamphetamine abuser was continuously monitored with both sweat patch and urine testing for approximately 6 months. Thirteen sweat patches were applied and collected, five were positive for cocaine and/or methamphetamine, but all the urine specimens collected were negative at the analytical cut-off levels. The high incidence of false positive sweat patch tests in relation to the sensitivity, specificity, and efficiency of the sweat patch assay is discussed. Possible mechanisms, which can lead to false positive results, are presented. The results of our study raise further questions about the preferential use of the sweat patch in detecting new episodes of drug use in formerly chronic drug users.