Testing an Age-old Adage: Can Autopsy Findings be of Assistance in Differentiating Opioid Versus Cardiac Deaths?

Given the common occurrence of both opioid and cardiovascular deaths, and the concomitant use of opioids in those with cardiac disease, the present study was undertaken to see whether the old adage of using the triad of cerebral and pulmonary edema and bladder fullness to suggest an opioid death could be used to differentiate deaths due to opioid toxicity from deaths due to cardiac disease. Brain weight, lung weight, and bladder fullness were compared among opioid-related deaths, cardiac deaths, and a control population. It was found that opioid-related deaths were more likely to have heavy lungs, a heavy brain, and a full bladder, while cardiac-related deaths had smaller volumes of urine in the bladder and heavier hearts. In conjunction with a thorough investigation, these findings may be useful to forensic pathologists when determining whether a death is opioid-related, especially in the setting of concomitant cardiac disease.

Can Intoxication Status Be Used as a Prediction Tool for Manner of Death?: A Comparison of the Intoxication Status in Violent Suicides and Homicides.

Determining the manner of death in medicolegal death investigations can be difficult. The investigator relies on many facets of death investigation, including the circumstances of death and autopsy examination. A study was designed to analyze whether the intoxication status of the decedent could be used as another tool in death investigations. The intoxication status of violent (nonoverdose or poisoning) suicides and homicides was retrospectively reviewed and compared. A total of 625 deaths were identified, including 366 suicides and 259 homicides. Age, sex, cause of death, and intoxication status, including the specific drugs present, were analyzed. Gunshot wounds were the most common cause of death in both groups, with hanging being the second most common cause in suicides and sharp force injuries in homicides. Analysis found that although the overall intoxication status for suicides versus homicides did not differ significantly, certain drugs were more prevalent in one group over the other. Specifically, illicit drugs, that is, heroin, cocaine, and methamphetamine, were more likely to be present in homicides, whereas antidepressants or antipsychotics, benzodiazepines, and zolpidem were more common in suicides.

Postmortem Propofol Levels: A Case of Residual Detection Long After Administration.

Propofol has gained notoriety in recent years because of its involvement in high-profile deaths and has increasingly become a drug of misuse and abuse particularly by health care personnel with easy access to it. In addition, propofol has also been used for more nefarious purposes such as murder and suicide. These, coupled with the drug's routine use for both major and minor medical procedures, provide ample opportunities for it to be implicated as a cause of death or contributing factor. In such instances, forensic investigators may be faced with the task of not only detecting the presence of propofol on postmortem toxicology screening, but also determining if it was indeed responsible for the decedent's demise. While propofol has a high volume of distribution, it is thought to equilibrate and be eliminated rapidly and not show significant tissue accumulation. However, this article presents a case illustrating that propofol can accumulate in the tissues and may be found up to a week after administration. This capacity to accumulate implies that postmortem detection does not necessarily confirm administration near the time of death, and further investigation needs to be undertaken to determine the timeline of events in order to rule out other factors, such as recent medical interventions, before attributing the cause of death to the presence of the drug.

Synovial fluid: an alternative toxicologic specimen?

Although blood is the most commonly used specimen in forensic toxicology, it is not always available. In those cases, alternative samples are sought on which to perform toxicology testing. The current study assessed the usefulness of synovial fluid for postmortem cocaine and opiate/opioid testing. One hundred four cases were sampled, with 98 cases being tested representing 24 negative controls and 74 cases positive for cocaine, benzoylecgonine, morphine, 6-monoacetylmorphine, hydrocodone, and/or oxycodone. Synovium demonstrated excellent correlation and predictability when compared with blood, although it was not as sensitive for 6-monoacetylmorphine as either vitreous or urine. The authors recommend further study to assess the usefulness of synovial fluid in postmortem toxicology to include the evaluation of its utilize for more drugs and the development of further assays to use its potential even in limited quantities.

Peripheral postmortem redistribution of morphine.

It is known that postmortem drug concentrations can vary depending on the sampling site and that, in general, central sites have higher drug concentrations than do peripheral sites. It has also been suggested that clamping the femoral vessel before drawing the sample may eliminate possible contribution from central sites. Morphine is a commonly prescribed and commonly encountered opiate medication that is often found in postmortem examinations, both as a cause of death and also as an incidental finding. It is important to understand the degree of postmortem redistribution of morphine to peripheral sites and whether clamping the femoral vessel can eliminate postmortem redistribution of morphine to ensure the correct interpretation of postmortem morphine concentrations. Morphine drug concentrations were evaluated in clamped and unclamped femoral vein blood samples at 3 different times before autopsy, and no significant change in either the clamped or the unclamped femoral vein morphine concentration was seen over time. Furthermore, no significant difference was found between the clamped and unclamped blood concentrations at any period. Therefore, it can be concluded that for morphine, unclamped femoral blood samples do not show significant redistribution from central sites within the first 24 hours after death in bodies kept refrigerated at 4°C.

Morphine concentrations in skeletal muscle.

Skeletal muscle constitutes a large percentage of the total body volume, making it a potentially widely available specimen for drug quantitation when blood is not available for toxicological testing. Morphine is a commonly encountered opiate in postmortem toxicology known to have stable blood concentrations in peripheral vessels. Morphine concentrations were measured in both femoral blood and skeletal muscle to assess the stability and predictability of skeletal muscle concentrations as compared with femoral concentrations. Analysis showed skeletal muscle was a sensitive matrix for the detection of morphine; however, there is significant disparity between the skeletal muscle and blood concentrations with a lack of predictability. The authors conclude that thigh skeletal muscle may be used for qualitative identification of morphine; however, interpretation of quantitative results should not be made as there does not seem to be a clear correlation between femoral blood and skeletal muscle concentrations for morphine.

Should postmortem subclavian blood be considered a peripheral or central sample?

The phenomenon of postmortem redistribution has long been described, but the processes driving it have not, as yet, been fully elucidated. Peripheral blood samples are currently used, when available, in an effort to minimize the effects of postmortem redistribution on drug concentrations, but what sources of blood are peripheral sources? A study was undertaken to determine if postmortem subclavian (SC) blood should be considered a peripheral or central blood sample. Twenty-eight cases were identified in which drugs were quantified in at least 2 of the following blood sources: femoral (F), SC, and heart (H); the concentrations found in each source were compared. Twenty different drugs were analyzed including 6 antidepressants, 6 opioid medications and metabolites, 3 benzodiazepines, 2 antihistamines, 2 sedative hypnotics, and 1 muscle relaxant. Analysis found that SC blood concentrations reflect neither F nor H blood concentrations, with the exception of the benzodiazepines where SC blood concentrations closely mirrored H blood concentrations. Overall, SC blood drug concentrations tended to be 1.3 times greater than F blood and 0.77 times less than H blood. Therefore, it is recommended that the exact source of the blood, rather than simply "peripheral" or "central," be notated on toxicology results to ensure appropriate interpretation.

Fatal cocaine interactions: a review of cocaine-related deaths in Bexar County, Texas.

Although cocaine is a widely abused illicit substance that is known to cause death, deaths due to its use appear to occur in a minority of those who use it. This report was designed to review drug-related deaths due to cocaine, and the concomitant use of other drugs/medications. A retrospective review of drug deaths at the Bexar County Medical Examiner's Office in San Antonio, Texas, was undertaken for cases where cocaine was one of the drugs implicated in causing death. Analysis was performed comparing the concentrations of cocaine and benzoylecgonine present and the absence or presence of other drugs. The data obtained showed that cocaine was toxic over a large range with deaths occurring at concentrations ranging from 0.01 to 78 mg/L. Analyses also indicated an increased lethality when cocaine is used in combination with ethanol, heroin, opiates, and antidepressant/antipsychotic medications, which is consistent with previous reports and research. Antihistamine data showed that there may be relationship between increased toxicity and co-ingestion, although more research is necessary.

What is the lethal concentration of hydrocodone?: a comparison of postmortem hydrocodone concentrations in lethal and incidental intoxications.

Hydrocodone is a semisynthetic opioid medication that is widely used as an analgesic and antitussive. Since 2004 it has been the most commonly prescribed drug in the United States and is often misused as a drug of abuse. Hydrocodone is frequently encountered in the postmortem setting, both as a cause of death and incidentally. Unfortunately, information regarding the concentrations of hydrocodone found with chronic high-dose use is lacking, and interpretation of postmortem concentrations can be difficult. A retrospective review of postmortem and "Driving under the Influence" (DUI) cases in Bexar County Texas in which hydrocodone was present was conducted. The cases were included in the study if they fit the criteria of belonging to 1 of 3 categories: the hydrocodone either caused or was the main contributor to death; the hydrocodone was incidental and definitively did not cause or contribute to death; and the DUI cases. The average hydrocodone concentration in the cases where the hydrocodone caused death was 0.47 mg/L (median, 0.38 mg/L). The average hydrocodone concentration in cases where it was incidental to death was 0.15 mg/L (median, 0.08 mg/L). The average hydrocodone concentration in the DUI cases was 0.09 mg/L (median, 0.08 mg/L). Analysis showed the possibility of postmortem redistribution as well as significant overlap of the concentrations noted in the different groups. Given that no definitive lethal concentration could be delineated, it is recommended that each hydrocodone case encountered be assessed individually to include a thorough medical record review to accurately interpret hydrocodone concentrations. It has also been shown that concentrations as high as 0.3 mg/L peripherally and 1.4 mg/L centrally can be present and not result in death. In addition, further research into hydrocodone concentrations with chronic use and hydrocodone metabolism is necessary.