Increased lung weight in fatal intoxications is not unique to opioid drugs

Causes and circumstances of death in stimulant and opioid use-A comparative study

AIMS

To investigate the individual characteristics, causes and circumstances around deaths in stimulant use, and to examine how individuals who died with stimulants in their body differ from individuals who died with opioids in their body.

METHODS

This study includes individuals who died during the years 2000-2018 and underwent a forensic autopsy at Forensic Medicine in Lund, Skåne County, Sweden. All individuals over 18 years of age with stimulants (n = 310), opioids (n = 2,039) or both stimulants and opioids (n = 385) in the body at the time of death, were included. The three groups were assessed regarding gender, age, place of death, BMI, other substances detected in forensic toxicological analysis, organ weights and underlying and contributing causes of death. The data were analysed by frequency and proportion calculations, cross-tabulations and comparisons of medians.

RESULTS

The median age at death of the study population (n = 2,734) was 45.5 years (interquartile range ☯IQR] 32-60 years) and 73.2% were men. The most common cause of death in the stimulant group was suicide (26.8%), higher proportion compared to the opioid group (20.8%) (p = 0.017) and in the polysubstance group accidental poisoning (38.2%), higher proportion compared to the opioid group (18.0%) (p<0.001). Death by transport accidents was significantly associated with the stimulant group (p<0.001) as well as death by other accidents (p = 0.016).

CONCLUSIONS

Individuals who died with stimulants in their body died at a higher rate from suicide, transport accidents and other accidents, compared to individuals who died with opioids in their body. This study indicates the need to identify and prevent psychiatric conditions, elevated suicide risk, and risk-taking behaviors among people who use stimulants.

Preanalytical factors influencing the results of ethanol analysis in postmortem specimens

Excessive drinking and drunkenness are underlying factors in many fatal accidents, which make the quantitative determination of ethanol in postmortem (PM) specimens an essential part of all unnatural death investigations. The same analytical methods are used to determine ethanol in blood taken from living and deceased persons although the interpretation of the results is more complicated in medical examiner cases owing to various preanalytical factors. The biggest problem is that under anaerobic conditions ethanol can be produced naturally in decomposed bodies by microbial activity and fermentation of blood glucose. Ways are needed to differentiate antemortem ingestion of ethanol from PM synthesis. One approach involves the determination of ethanol in alternative specimens, such as bile, cerebrospinal fluid, vitreous humor and/or urine, and comparison of results with blood alcohol concentration (BAC). Another approach involves the analysis of various alcohol biomarkers, such as ethyl glucuronide, ethyl sulfate and/or phosphatidylethanol or the urinary metabolites of serotonin 5-hydroxytryptophol/5-hydroxyindoleacetic acid (5-HTOL/5-HIAA). If ethanol had been produced in the body by microbial activity, the blood samples should also contain other low-molecular volatiles, such as acetaldehyde, n-propanol and/or n-butanol. The inclusion of 1-2% w/v sodium or potassium fluoride, as an enzyme inhibitor, in all PM specimens is essential to diminish the risk of ethanol being generated after sampling, such as during shipment and storage prior to analysis. Furthermore, much might be gained if the analytical cut-off for reporting positive BAC was raised from 0.01 to 0.02 g% when PM blood is analyzed. During putrefaction low BACs are more often produced after death than high BACs. Therefore, when the cadaver is obviously decomposed, a pragmatic approach would be to subtract 0.05 g% from the mean analytical result. Any remaining BAC is expected to give a more reliable indication of whether alcohol had been consumed before death.

Influence of the toxicological status on the diagnosis of fatal drowning

Drowning is the leading cause of death by accident of everyday life in people under 25 years of age. Xenobiotics are frequently involved in drowning cases but their influence on the diagnosis of fatal drowning has not been studied so far. This preliminary study aimed to assess the influence of an alcohol and/or a drug intoxication on the autopsy signs of drowning, and on the results of diatom analyses in drowning deaths. Twenty-eight autopsy cases of drowning including 19 freshwater drownings, 6 seawater drownings, and 3 brackish water drownings were prospectively included. Toxicological and diatom tests were performed in each case. The influence of alcohol and other xenobiotics on drowning signs and diatom analyses was assessed separately then in combination through a global toxicological participation score (GTPS). Diatom analyses showed positive results in lung tissue in every case. No significant association was found between the degree of intoxication and the diatom concentration in the organs, even after considering freshwater drowning cases only. The vast majority of the traditional autopsy signs of drowning were not significantly affected by the individual toxicological status either, with the exception of lung weight which tended to raise in case of intoxication, probably due to the pulmonary edema and congestion increase. Further research on larger autopsy samples is needed to confirm the results of this exploratory study.