Forensic Aspects of a Fatal Intoxication Involving Acetaminophen, Citalopram and Trazodone: A Case Report

We report the case of a young man, a former heroin addict, found dead at home by the Police Forces in an advanced state of decomposition. Numerous blisters and unpacked tablets of medications were found all over the bed and on the floor of the room. Multiple injuries to the face, left arm and neck of the deceased were noted. The latter damages were attributed to post-mortem dog bites, since no indications of a possible defense against the animal were observed. The autopsy findings were unremarkable. Toxicological investigations performed on peripheral blood and urine by gas chromatography-mass spectrometry (GC-MS) technique showed the presence of acetaminophen, citalopram and trazodone. Combined drug intoxication was proposed as the cause of death since acetaminophen and trazodone concentrations were comparable with the ones found in fatal cases. Moreover, citalopram concentration in peripheral blood was above the toxic range and in accordance with levels found in fatalities due to poly-drug intoxication.

[Thirty years of nefopam abuse in France]

AIM OF THE STUDY

The use of nefopam is constantly increasing in France. The objectives of this study were to quantify the intensity of the drug dependence signal, to identify the populations at risk and the risk factors of dependence.

METHODS

All serious and non-serious cases of misuse, abuse, drug dependence, overdose and withdrawal syndrome reported to the French Addictovigilance Network since 1988 were reviewed. An analysis of nefopam reimbursement data from the French national EGB (échantillon généraliste des bénéficiaires) database for the period 2006-2017 was also performed.

RESULTS

The drug dependence profile of nefopam is close to that of a psychostimulant. Our literature review and the analysis of spontaneous reports confirm the risk of abuse and dependence of nefopam. In addition to a frequent psychiatric history (depression, psychosis, anxiety), nearly half of the patients also present addictive disorders, including more than one-third with opioid-dependence. In almost half of the 120 reported cases, the main adverse reaction was dependence and the frequency of serious effects was greater than 40%. In nearly 70% of the reported cases, the use was associated with chronic pain, which might explain the prolonged use. Moreover, the analysis of data on the reimbursement of nefopam in the general population showed that one French person out of two, having a prescription for nefopam, presented chronic pain. However, nefopam is only indicated in the treatment of acute painful conditions. Although it does not seem to be associated with a greater risk of abuse or dependence, taking the drug orally is another very frequent off-label use that needs to be regulated.

CONCLUSION

In France, the prescription of nefopam outside of its marketing authorization is regrettable, because it contributes to the development of abuse and drug dependence.

Vitreous humor analysis for the detection of xenobiotics in forensic toxicology: a review

Vitreous humor (VH) is a gelatinous substance contained in the posterior chamber of the eye, playing a mechanical role in the eyeball. It has been the subject of numerous studies in various forensic applications, primarily for the assessment of postmortem interval and for postmortem chemical analysis. Since most of the xenobiotics present in the bloodstream are detected in VH after crossing the selective blood-retinal barrier, VH is an alternative matrix useful for forensic toxicology. VH analysis offers particular advantages over other biological matrices: it is less prone to postmortem redistribution, is easy to collect, has relatively few interfering compounds for the analytical process, and shows sample stability over time after death. The present study is an overview of VH physiology, drug transport and elimination. Collection, storage, analytical techniques and interpretation of results from qualitative and quantitative points of view are dealt with. The distribution of xenobiotics in VH samples is thus discussed and illustrated by a table reporting the concentrations of 106 drugs from more than 300 case reports. For this purpose, a survey was conducted of publications found in the MEDLINE database from 1969 through April 30, 2015.