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Abdelaal GMM, Hegazy NI, Etewa RL, Elmesallamy GEA. Postmortem redistribution of drugs: a literature review. Forensic Sci Med Pathol 2023:10.1007/s12024-023-00709-z. [PMID: 37715933 DOI: 10.1007/s12024-023-00709-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2023] [Indexed: 09/18/2023]
Abstract
Postmortem drug analysis is crucial in identifying the potential cause and manner of death. However, it is threatened by a significant phenomenon called postmortem redistribution (PMR), which refers to the alterations in drug levels occurring after death. This review aims to describe the PMR phenomenon, the mechanisms involved in the PMR of drugs, the various methods used to predict it, and various artifacts of postmortem drug concentrations. Several mechanisms, including passive diffusion from solid organs that act as drug reservoirs to the surrounding tissues, cadaveric changes after death (e.g., cell death, blood coagulation, hypostasis, and movements), and the putrefactive process, can result in artifacts of postmortem drug concentrations. The drug's chemical and pharmacokinetic properties (such as acidic/basic properties, lipophilicity, protein binding, high volume of distribution, and residual metabolic activity) are additional factors. Several markers, including cardiac blood-to-peripheral blood ratio (C/P), liver-to-peripheral blood ratio (L/P), amino acid markers such as methionine, quantitative structure-activity relationship (QSAR) approach, and F factor, have been proposed for interpreting the liability of drugs to PMR. Several artifacts may affect the reliability of postmortem drug analysis. Peripheral blood is preferred for postmortem drug sample collection. Numerous laboratories evaluate the redistribution potential of drugs after death using the C/P concentration ratio. Nevertheless, the L/P concentration ratio is proposed to be a more reliable marker for PMR determination.
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Affiliation(s)
- Ghadeer M M Abdelaal
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Zagazig University, Zagazig, Egypt.
| | - Nagah I Hegazy
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Rasha L Etewa
- Pathology Department, College of Medicine, Jouf University, Sakaka, Saudi Arabia
| | - Ghada E A Elmesallamy
- Department of Forensic Medicine and Clinical Toxicology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
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2
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Krotulski AJ, Papsun DM, Walton SE, Logan BK. Metonitazene in the United States-Forensic toxicology assessment of a potent new synthetic opioid using liquid chromatography mass spectrometry. Drug Test Anal 2021; 13:1697-1711. [PMID: 34137194 DOI: 10.1002/dta.3115] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/20/2022]
Abstract
Metonitazene is considered a new psychoactive substance (NPS) and emerging potent synthetic opioid, causing increased public health concern beginning in 2020. Metonitazene joins a growing list of new synthetic opioids (NSOs) contributing to deaths among people who use drugs in the United States and other parts of the world. Metonitazene (a 2-benzylbenzimidazole analogue) first appeared in mid-2020 in the recreational drug supply and subsequently began proliferating in death investigation casework towards the end of 2020. Screening and metabolite discovery were performed by liquid chromatography quadrupole time-of-flight mass spectrometry. Quantitative confirmation was performed by liquid chromatography tandem quadrupole mass spectrometry. Metonitazene was confirmed in 20 authentic forensic postmortem cases with an average concentration in blood at 6.3 ± 7.5 ng/ml (median: 3.8 ng/ml, range: 0.5-33 ng/ml, n = 18) and in urine at 15 ± 13 ng/ml (median: 11 ng/ml, range: 0.6-46 ng/ml, n = 14). Metonitazene was the only opioid identified in 30% of cases but was also found in combination with fentanyl (55%) and NPS benzodiazepines, opioids, and hallucinogens (45%). Medical examiners included metonitazene as a drug responsible for the cause of death, and the manner of death was always ruled to be an accident. The metabolism of metonitazene was found to be similar to that of isotonitazene, a closely related analogue. Toxicology laboratories and death investigators should ensure that metonitazene is included in forensic testing protocols, all while remaining vigilant for subsequent NSOs to emerge.
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Affiliation(s)
- Alex J Krotulski
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, Pennsylvania, USA
- College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Sara E Walton
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, Pennsylvania, USA
- College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Barry K Logan
- Center for Forensic Science Research and Education, Fredric Rieders Family Foundation, Willow Grove, Pennsylvania, USA
- College of Life Sciences, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- NMS Labs, Horsham, Pennsylvania, USA
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Wachholz P, Skowronek R, Pawlas N. Cerebrospinal fluid in forensic toxicology: Current status and future perspectives. J Forensic Leg Med 2021; 82:102231. [PMID: 34375840 DOI: 10.1016/j.jflm.2021.102231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/28/2021] [Accepted: 08/05/2021] [Indexed: 12/12/2022]
Abstract
In forensic toxicology, alternative biological materials are very useful and important, e.g. in the case of lack of basic body fluids. One alternative biological material is cerebrospinal fluid (CSF). The procedures of the collection of biological material during the autopsy are performed in accordance with local, usually national recommendations, which most often require updating. It is very difficult to assess the possibility of using CSF as an alternative biological material for toxicological studies for the presence of drugs, intoxicants, including new psychoactive substances (commonly known as designer drugs), psychotropic substances, and ethyl alcohol, based on current data. Previous research suggests that CSF may be useful in toxicological studies, but these aspects need to be investigated more carefully because studies have collected CSF from different sites and often the results of different authors are not comparable. It would be necessary to prepare guidelines, e.g. the site of CSF collection that may influence the results of quantitative analysis. It would also be necessary to replicate some studies with a different collection site or a more recent analytical technique, e.g. for comparative testing of blood ethanol and cerebrospinal fluid. Cerebrospinal fluid can be a valuable information carrier in the absence of classic biological material from an autopsy. Investigating these aspects in more detail could allow the future use of this alternative material for routine toxicology analyzes in a forensic laboratory.
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Affiliation(s)
- Paulina Wachholz
- Department of Pharmacology, Medical University of Silesia in Katowice, Faculty of Medical Sciences in Zabrze, 38 Jordana Street, 41-808, Zabrze, Poland; Toxicology Laboratory ToxLab, 6 Kossutha Street, 40-844, Katowice, Poland
| | - Rafał Skowronek
- Department of Forensic Medicine and Forensic Toxicology, Medical University of Silesia in Katowice, Faculty of Medical Sciences in Katowice, 18 Medyków Street, 40-752, Katowice, Poland.
| | - Natalia Pawlas
- Department of Pharmacology, Medical University of Silesia in Katowice, Faculty of Medical Sciences in Zabrze, 38 Jordana Street, 41-808, Zabrze, Poland
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Rodriguez Salas J, Krotulski AJ, Newman R, Thogmartin JR, Mohr ALA, Logan BK. Concentrations of para-Fluorofuranylfentanyl (FFF) in Paired Central and Peripheral Blood Collected During Postmortem Death Investigations. J Anal Toxicol 2021; 46:358-373. [PMID: 33693685 DOI: 10.1093/jat/bkab025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 02/25/2021] [Accepted: 03/09/2021] [Indexed: 01/03/2023] Open
Abstract
The opioid epidemic in the United States (U.S.) has been associated with an increasing mortality rate in large part due to the emergence and proliferation of synthetic opioids over the last fifteen years. Fentanyl and its analogues have played a large part in these statistics due to their potency and toxicity. Fluorofuranylfentanyl (FFF) is a fentanyl analogue that emerged in the U.S. in 2018 and was associated with numerous adverse events and deaths. During this study, a liquid chromatography tandem mass spectrometry (LC-MS/MS) workflow was developed to accurately identify the isomer of FFF present (ortho- vs. meta- vs. para-) in medicolegal death investigation cases from Pinellas County, Florida. FFF was quantified in central and peripheral blood samples collected at autopsy. In addition, the metabolism of FFF was studied using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS). para-FFF was quantitatively confirmed in 29 postmortem cases; no other isomer of FFF was detected. Central blood concentrations ranged between 0.66 and 73 ng/mL (mean = 11±14 ng/mL, median = 10 ng/mL) and peripheral blood concentrations ranged between 0.53 and 23 ng/mL (mean = 5.7±6.4 ng/mL, median = 2.7 ng/mL). Comparison of central to peripheral blood concentrations were evaluated to determine the possibility of postmortem redistribution (PMR). The metabolism of ortho-FFF was studied and found to undergo metabolic processes similar to fentanyl, producing ortho-fluorofuranyl-norfentanyl, fluoro-4-ANPP, and hydroxylated species. The results of this study demonstrate the toxicity of FFF and its implication in medicolegal death investigations. Laboratories must remain aware of new or re-emerging fentanyl analogues, as they pose significant risks to public health and public safety.
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Affiliation(s)
- Judith Rodriguez Salas
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | - Alex J Krotulski
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | | | | | - Amanda L A Mohr
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA
| | - Barry K Logan
- Center for Forensic Science Research and Education at the Fredric Rieders Family Foundation, Willow Grove, PA.,NMS Labs, Horsham, PA
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Braham MY, Franchi A, Cartiser N, Bévalot F, Bottinelli C, Fabrizi H, Fanton L. Fatal 4-MEC Intoxication: Case Report and Review of Literature. Am J Forensic Med Pathol 2021; 42:57-61. [PMID: 32773434 DOI: 10.1097/paf.0000000000000599] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Synthetic cathinones are one of the major pharmacological families of new psychoactive substances and 4-methylethcathinone (4-MEC) has emerged in recent years as a recreational psychostimulant. We report a case of a 35-year-old man found dead and naked at home by his friend. Although no anatomic cause of death was observed at autopsy, toxicological analysis identified 4-MEC and hydroxyzine at therapeutic level (160 ng/mL). 4-Methylethcathinone was quantified in autopsy samples by a validated method consisting in liquid-liquid extraction and gas chromatography coupled to tandem mass spectrometry: peripheral blood, 14.6 μg/mL; cardiac blood, 43.4 μg/mL; urine, 619 μg/mL; vitreous humor, right 2.9 μg/mL and left 4.4 μg/mL; bile, 43.5 μg/mL; and gastric content, 28.2 μg/mL. The cause of death was 4-MEC intoxication and the manner of death could be either accidental or suicidal. The literature concerning 4-MEC was reviewed, focusing on distribution in classical postmortem matrices and 4-MEC metabolism and postmortem redistribution and stability.
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Affiliation(s)
- Mohamed Yassine Braham
- From the Hospices Civils de Lyon, Edouard Herriot Hospital, Service of Forensic Medicine
| | | | - Nathalie Cartiser
- From the Hospices Civils de Lyon, Edouard Herriot Hospital, Service of Forensic Medicine
| | | | | | - Hervé Fabrizi
- From the Hospices Civils de Lyon, Edouard Herriot Hospital, Service of Forensic Medicine
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Hubbard JA, Navarrete AL, Fitzgerald RL, McIntyre IM. Acidic Drug Concentrations in Postmortem Vitreous Humor and Peripheral Blood. J Anal Toxicol 2021; 45:69-75. [PMID: 31696920 DOI: 10.1093/jat/bkz076] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 06/13/2019] [Accepted: 06/24/2019] [Indexed: 01/31/2023] Open
Abstract
Vitreous humor is a potential alternative matrix for postmortem toxicology drug screens when peripheral blood is unavailable. It is easily and reliably collected and may not suffer from the same postmortem redistribution as seen in blood. Here, we compared the concentrations of 7 acidic drugs (acetaminophen, ibuprofen, naproxen, salicylic acid, carbamazepine, phenobarbital and phenytoin) in peripheral blood and vitreous fluid collected in 89 autopsy cases. Analysis was done by high-performance liquid chromatography with diode-array detection. Overall, we found that vitreous drug concentrations were significantly lower than peripheral blood with median vitreous to peripheral blood (V/PB) ratios ranging from 0.0 to 0.6 (mean, 0.1-0.6). The correlations between the concentrations of over-the-counter analgesics in peripheral blood versus vitreous fluid were poor, with acetaminophen exhibiting the best linearity (R2 = 0.72). The antiepileptic drugs (carbamazepine, phenytoin and phenobarbital) exhibited good correlations between peripheral blood and vitreous humor, with all exhibiting an R2 ≥ 0.95. Overall, we have demonstrated the potential of vitreous fluid as an alternative matrix for the detection of select acidic drugs.
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Affiliation(s)
| | | | | | - Iain M McIntyre
- Department of the Medical Examiner, County of San Diego, CA 92123, USA
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Chan WS, Wong GF, Hung CW, Wong YN, Fung KM, Lee WK, Dao KL, Leung CW, Lo KM, Lee WM, Cheung BKK. Interpol review of toxicology 2016-2019. Forensic Sci Int Synerg 2020; 2:563-607. [PMID: 33385147 PMCID: PMC7770452 DOI: 10.1016/j.fsisyn.2020.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/23/2020] [Indexed: 12/13/2022]
Abstract
This review paper covers the forensic-relevant literature in toxicology from 2016 to 2019 as a part of the 19th Interpol International Forensic Science Managers Symposium. The review papers are also available at the Interpol website at: https://www.interpol.int/content/download/14458/file/Interpol%20Review%20.Papers%202019.pdf.
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Chatterton C, Scott-Ham M. The distribution and redistribution of fentanyl & norfentanyl in post mortem samples. Forensic Sci Int 2018; 284:146-152. [DOI: 10.1016/j.forsciint.2017.12.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/11/2017] [Accepted: 12/16/2017] [Indexed: 10/18/2022]
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