Post-mortem cases involving amphetamine-based drugs in The Netherlands. Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999-2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death. In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41-84 mg/L with a median concentration of 3.7 mg/L (n=30). MDMA blood concentrations in the MDMA related deaths (n=20) and in the DUI cases (n=360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n=7). The median concentrations of amphetamine in the amphetamine related deaths (n=13) and the DUI cases (n=208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

Asphyxial deaths: a retrospective study and review of the literature

An increasing death rate as a result of violence constitutes a large group in medicolegal autopsies. Specially, deaths due to asphyxia are one of the most important causes in violence deaths.During the 21-year period from January 1984 to October 2004, there were 134 asphyxial deaths autopsied by the Department of Forensic Medicine, Trakya University, Edirne, Turkey. Asphyxial deaths comprise 15.7% of all forensic autopsies; 20.8% of the cases are aged between 30 and 39 years, and the average age was 41.9 years. Males constitute 79.8% of all the cases.The most frequent method of asphyxiation death is hanging (56 cases, 41.8%), followed by drowning (30.5%) and carbon monoxide poisoning (8.2%). More violent methods, such as ligature or manual strangulations, constitute 2.9% and 2.3% of all asphyxial deaths, respectively. Although it was varying according to the methods of asphyxiation, suicide was found to be the manner of death in the majority of the cases.     

Drug prevalence in drowning deaths in Cuyahoga County, Ohio: a ten-year retrospective study

Previous studies have shown that up to 50% of adult drownings are related to the consumption of alcohol. Little information is available in the literature regarding the possible contribution of ethanol and other drugs to drownings.All records of deaths occurring in Cuyahoga County, Ohio, from 1994-2003, in which drowning was listed as the cause of death, were reviewed. Toxicology analysis was performed on cases where specimens were submitted. Review of the 187 cases showed that the majority (78%) of drowning deaths were ruled as accidents, 26 (14%) as suicide, 5 (3%) as homicide, and 11 (6%) as undetermined.Among the accidental deaths (n=141), 97 (69%) were negative for all drugs, including ethanol, and 30 cases (21%) were positive for ethanol only. Illicit drugs were detected in 4 of the cases (3%). In the suicides (n=26), 16 (62%) were negative for all drugs, including ethanol, and 7 cases (27%) were positive for ethanol only (mean blood alcohol concentration [BAC] 0.03 g/dL). Illicit drugs were detected in 3 of the cases (12%). Two of the 5 homicide cases (40%) were positive for ethanol. There were no cases in which the victim tested positive for illicit drugs.Of the 11 cases ruled as undetermined, 64% (n=7) were negative for all drugs, including ethanol. The remainder of the cases tested positive for ethanol only. There were no cases in which illicit drugs were detected. This study demonstrates that the majority of drowning deaths in Cuyahoga County, Ohio, were not drug related. Deaths in which drugs were detected were typically accidental deaths, with ethanol the most common drug detected.     

Incidence of cannabinoids in medical examiner urine specimens

Cannabinoid use was studied in a nonspecific population of postmortem urine specimens in the State of Maryland. Of 500 sequential specimens screened for cannabinoids by enzyme multiplied immunoassay EMIT, 63 (13%) were initially positive and 58 (12%) were confirmed positive (92%). It was observed that geographic location and race did not correlate with cannabinoid prevalence. Cannabinoid use was observed to be strongly age related, with peak use by the 21- to 25-year-old age group where 22% of the cases were positive. Use of cannabinoids was also closely linked to homicides, which represented nearly half of the positive cases but only 13% of the total cases. When comparing manner of death, the greatest percent of confirmed positives was seen in homicide (26%) and drug-related (17%) deaths. The incidence of cannabinoid use was found to be more than 3 times as great in drug-related (17%) as compared to natural deaths (5%). The percent of cannabinoid-positive cases from vehicle-related accidents was low (6%) and that from nonvehicle-related accidents somewhat higher (10%). Other drugs appeared in cannabinoid-positive cases. Most prevalent was ethanol N = 18, followed by morphine (from heroin, N = 11), quinine N = 11, and cocaine N = 11. Phencyclidine (PCP) occurred twice and several other drugs were reported only once. Of the 25 homicide cases screened for drugs, 64% were positive for some drug including ethyl alcohol. Thus it appears that a high percentage of homicide cases are drug related. Males greatly outnumbered females (56:2) in positive cases, but the number of female specimens received was small.     

Fatal drug poisonings: medico-legal reports and mortality statistics

The entire fatal drug poisoning panorama in Finland is considered in terms of three catergories: accidental, self-inflicted and undetermined (whether accidental or with intent to harm) deaths. The study material consisted of all 500 deaths in 1997 that medical examiners, after examination(s) at the Forensic Toxicology Division (FTD) of the Department of Forensic Medicine, University of Helsinki, officially certified as resulting from drug poisoning. These deaths were matched with data on the same deaths registered at Statistics Finland (SF), the national mortality statistics office. The SF register included 72 additional instances of deaths resulting from drug poisoning. In all but two of these cases, the cause-of-death determination was based on a medico-legal inquest with autopsy and forensic toxicological examination(s) and was certified, in most of the cases, as due to the alcohol component in multiple-toxicant combinations. Reclassifying these deaths at SF to the category of drug component is in accordance with current International Classification of Diseases (ICD-10) regulation of coding "to the medicinal agent when combined with alcohol"; the principle and practice, which is recommended to be amended to equalize the status of alcohol and drug when explicitly stated by a forensic examiner as the principal toxicant in combined poisonings. With regard to manner-of-death, the agreement rates between medico-legally proven deaths from drug poisoning and those registered at SF were 79.8% for accidents, 98.5% for suicides and 0% (nil) for undetermined deaths, at the level of three-character external cause codes (E-code). All deaths originally certified as undetermined were re-assigned, most frequently to the category of accidental death. Since within an advanced and sophisticated medico-legal system, a medical examiner's evidence-based statement, even when the conclusion reached is undetermined (as to intent), should be taken as a compelling argument, the practice of reclassification cannot be considered advisable because assembled information is lost. Concerning the assigned drug-specific groups, the agreement according to the manner-of-death between certifications and registrations was fairly good. From among the accidents, however, opioid poisonings were re-assigned in 11 (29.7%) cases, mostly to the drug abuse/dependence categories, i.e. they were considered as natural deaths by the statistics office. The drug-specific observations were possible only by using the codes from the Anatomical Therapeutic Chemical (ATC) classification of drugs. This is why the incorporation of ATC codes into the ICD system, whenever reasonable, is recommended.     

Fatal poisoning with alcohol and drugs in the Greater Amman County

A study of fatal poisoning due to alcohol and drugs was carried out, to examine the mortality resulting from alcohol and drugs in the Greater Amman County, Jordan. A retrospective review of all autopsy records and certified deaths issued by the Department of Forensic Medicine at Jordan University Hospital in the greater Amman county was undertaken. During the 18 years (1978-1996) 6109 postmortem cases were performed in our department. A total of 60 cases were identified and analyzed according to age, race, sex, manner of death of the victims along with blood alcohol concentration, the drug detected at autopsies, the scene circumstances, and the geographic location of the accident and death.     

Post-mortem cases involving amphetamine-based drugs in the Netherlands: Comparison with driving under the influence cases

In this study we reviewed the post-mortem cases in the years 1999–2004 that were presented at the Netherlands Forensic Institute. The concentrations of amphetamine-based drugs in femoral blood from cases of suspected unnatural death were compared with concentrations in whole blood from non-fatal cases of driving under the influence (DUI cases) and with literature. Furthermore, the combinations with other drugs and/or alcohol were investigated. Amphetamine-based drugs were present in 70 post-mortem cases and 467 DUI cases. The most detected amphetamine-based drug was MDMA, followed by amphetamine. The presence of MDA could usually be explained by metabolism of MDMA. Methamphetamine and MDEA were rarely present. Frequently, the amphetamine-based drugs were taken in combination with alcohol and/or other non-amphetamine-based drugs such as cocaine or cannabinoids. The 70 post-mortem cases were divided into 38 amphetamine-based drug caused (i.e. the amphetamine-based drug directly caused or contributed to the death) and 32 amphetamine-based drug related deaths (i.e. death was not directly caused by the amphetamine-based drug). In the latter category, other (poly)drug intoxications and death by violence or drowning were the most frequent causes of death.In 30 cases, MDMA caused death directly. The range in blood concentrations of MDMA in these cases was substantial, i.e. 0.41–84 mg/L with a median concentration of 3.7 mg/L (n = 30). MDMA blood concentrations in the MDMA related deaths (n = 20) and in the DUI cases (n = 360) varied up to 3.7 and 4.0 mg/L, respectively. Seven victims died from the direct effects of amphetamine; the blood concentration of amphetamine ranged from 0.24 to 11.3 mg/L, with a median concentration of 1.7 mg/L (n = 7). The median concentrations of amphetamine in the amphetamine related deaths (n = 13) and the DUI cases (n = 208) were much lower, i.e. 0.28 and 0.22 mg/L, respectively. Amphetamine blood concentrations up to 6.0 and 2.3 mg/L were seen in the drug related deaths and DUI cases, respectively. The most frequently encountered amphetamine-based drugs in the investigated deaths were MDMA and amphetamine. The majority of MDMA- and amphetamine-caused deaths, i.e. 90% of these deaths, occurred with blood concentrations above 1.5 and 0.80 mg/L, respectively. MDMA and amphetamine blood concentrations in drug related deaths and DUI cases, however, overlap the range of fatal concentrations. Therefore, MDMA or amphetamine concentrations should never be used alone to establish the cause of death.     

The prevalence of drugs in carbon monoxide-related deaths: a retrospective study, 2000-2003

The objective of this study was to review demographic characteristics and drugs detected in carbon monoxide (CO)-related deaths from cases received by the Office of the Cuyahoga County Coroner in Cleveland, Ohio, from 2000-2003. Postmortem reports were reviewed, and decedents for which CO was listed as the cause of death were included. The data were compiled into 3 groups according to the official coroner's verdict as to the manner of death: accident, suicide, and homicide. Included in this study were 122 cases: 84 (69%) accidental, 31 (25%) suicide, and 7 (6%) homicide. Accident decedents were typically white males, aged 40-59 years, residing in Cleveland. Suicide decedents were also middle-aged, white males but residing in the suburbs. Homicide decedents under the age of 6 were characteristically black (N=2), while decedents over the age of 39 were predominately white (N=3). Carboxyhemoglobin (COHb) levels in suicide cases were higher than concentrations measured in accidental deaths. The highest percentage of suicide decedents (36%) had a COHb level>70% saturation, accident decedents (36%) between 50% and 69% saturation, and homicide decedents (71%) below 50% saturation. Ethanol (N=34) was detected in 28% of deaths, and therapeutic and/or abused drugs (N=50) were detected in 41% of deaths. Illicit drugs were detected in 11% of cases (cocaine/metabolites; THC/metabolites), other drug positives were therapeutic medications. The most common drugs detected were antidepressants and antihistamines in suicides and pain medications and antihistamines in accidents.     

Fatal poisoning in drug addicts in the Nordic countries in 2007

The frequency of medico-legally examined fatal poisonings in 2007 among drug addicts was investigated in five Nordic countries; Denmark, Finland, Iceland, Norway, and Sweden. The number of deaths, age, sex, place of death, main intoxicant, and other drugs present in blood samples were recorded to obtain national and comparable Nordic data, as well as data to compare with earlier studies in 2002, 1997, and 1991. Norway had the highest incidence of drug addict deaths by poisoning followed by Denmark, with 8.24 and 6.92 per 100,000 inhabitants, respectively. The death rates in Finland (4.02), Iceland (4.56), and Sweden (3.53) were about half that of Norway and Denmark. Compared with earlier studies, the death rates were unchanged in Denmark and Norway, but increased in Finland, Iceland, and Sweden. In all countries, fewer deaths (29-35%) were recorded in the capital area compared with earlier studies. Females accounted for 11-19% of the fatal poisonings. Iceland deviates with a more equal distribution between men and women (40%). Deaths from methadone overdoses increased in all Nordic countries, and methadone was the main intoxicant in Denmark in 2007, accounting for 51% of the poisonings. In Norway and Sweden, heroin/morphine was still the main intoxicant with a frequency of 68% and 48%, respectively. In Iceland, 3 deaths each were due to heroin/morphine and methadone, respectively. Finland differs from other Nordic countries in having a high number of poisonings caused by buprenorphine and very few caused by heroin/morphine. The total number of buprenorphine deaths in Finland doubled from 16 in 2002 to 32 in 2007, where it constituted 25% of deaths. The general toxicological screening program showed widespread multi-drug use in all countries. The median number of drugs per case varied from 3 to 5. The most frequently detected substances were heroin/morphine, methadone, buprenorphine, tramadol, amphetamine, cocaine, tetrahydrocannabinol, benzodiazepines and ethanol.     

A survey of buprenorphine related deaths in Singapore

Buprenorphine is available in Singapore as substitution treatment for opioid dependence since 2002. This study surveys buprenorphine related deaths in Singapore between September 2003 and December 2004. The aims are to establish the autopsy prevalence of buprenorphine related deaths and the demographical and toxicological profile of the cases. Toxicological screening was performed for all unnatural deaths, deaths involving known drug addicts, as well as when autopsy revealed no obvious cause of death. Twenty-one cases had buprenorphine detected in post-mortem blood and/or urine samples. Eighteen were sudden deaths. There were two fatal falls from height and one death by hanging. All subjects were male. The age range was 24-48 years. Fourteen subjects were between 30 and 39 years of age. The mean age was 35 years. The majority (62%) were Chinese. Eleven (52%) were known drug abusers. For sudden deaths, two groups were identified. Six cases died from natural causes. Blood buprenorphine levels ranged from undetected (detected in urine) to 3.2 ng/mL (mean 1.4 ng/mL). Twelve cases were attributed directly and indirectly to mixed drug poisoning. Blood buprenorphine levels ranged from undetected (detected in urine) to 17 ng/mL (mean 3.2 ng/mL). Nineteen cases showed concurrent abuse of buprenorphine and benzodiazepine, diazepam being the most frequently detected, followed by nitrazepam and midazolam. The availability of buprenorphine as substitution therapy is associated with an increase in buprenorphine related deaths. The danger of co-abuse of buprenorphine and benzodiazepines is highlighted.     

The forensic deaths caused by pesticide poisoning between the years 2006 and 2009 in Izmir, Turkey

Pesticide poisoning is still a significant health problem in Turkey. We conducted a retrospective study of autopsy cases at Izmir Branch of the Council of Forensic Medicine to describe the characteristics of deaths caused by pesticide poisoning between 2006 and 2009. The distributions of the cases according to gender and age were as follows: men 74.1% (n = 40, mean [±SD] age, 44.7 ± 14.1), women 25.9% (n = 14, mean [±SD] age, 39.2 ± 18.9). The majority of pesticide-poisoning deaths were suicides (n = 43, 80%) followed by accidents (n = 4, 8%) and homicide (n = 1, 2%). The manner of death could not be determined in six cases (11%). Suicides mostly occurred at home (n = 26, 63%) (p < 0.05). Methomyl was the most frequent pesticide (n = 9, 17%) among the all cases. This study reported that most of the pesticides found in poisoning cases were highly hazardous types. Combined efforts of medical professionals and law makers are needed for enacting strict laws against highly hazardous pesticides.     

Fatal poisoning in drug addicts in the Nordic countries.

The study includes medicolegally examined fatal poisonings among drug addicts in 1997 in the five Nordic countries: Denmark, Finland, Iceland, Norway and Sweden, and the results are compared to a similar investigation from 1991. A common definition of "drug addict" was applied by the participating countries.The highest death rate by poisoning in drug addicts was observed in Denmark, where it was 6.54 per 10(5)inhabitants, followed by Norway with 6.35, Sweden with 2.21, Finland with 1.63 and Iceland with 1.20 per 10(5)inhabitants. All countries showed a higher death rate in 1997 than in 1991. For all countries the distribution of deaths according to geographical regions showed a decreasing number of drug deaths in the metropolitan area and an increasing number in other cities. Heroin/morphine dominated as the cause of death and was responsible for about 90% of the cases in Norway. In Sweden and Denmark, however, heroin/morphine caused only about 70% of the fatal poisonings. About 30% of the fatal poisonings in Denmark and Sweden were caused by other group I drugs, in Denmark mainly methadone and in Sweden mainly propoxyphene. Apart from two cases in Sweden methadone deaths were not seen in the other Nordic countries. In Finland heroin/morphine deaths have increased from about 10% in 1991 to about 40% in 1997. Forty-four percent of the fatal poisonings in Finland were caused by other group I drugs, mainly codeine and propoxyphene. The two fatal poisonings in Iceland were caused by carbon monoxide. Only few deaths in this investigation were caused by amphetamine and cocaine. A widespread use of alcohol, cannabis and benzodiazepines, especially diazepam, was seen in all the countries.     

Emergence of fentanyl-related deaths in Travis County,Texas and surrounding areas: A retrospective review of postmortem fentanyl-related drug toxicities from 2020 to 2022

The opioid epidemic has affected the United States (US) for decades with fentanyl and its analogs accounting for a recent surge in morbidity and mortality. Currently, there is a relative lack of information characterizing fentanyl-related fatalities specifically in the Southern US. A retrospective study was conducted to examine all postmortem fentanyl-related drug toxicities in Travis County, Texas, encompassing Austin (one of the fastest-growing cities in the US), from 2020 to 2022. Fentanyl contributed to 2.6% and 12.2% of deaths submitted for toxicology between 2020 and 2022, respectively, representing a 375% increase in fentanyl-related deaths over this 3-year period (n = 517). Fentanyl-related fatalities primarily occurred in males in their mid-30s. Fentanyl and norfentanyl concentrations ranged from 0.58 to 320 ng/mL and 0.53 to 140 ng/mL with mean (median) concentrations of 17.2 ± 25.0 (11.0) and 5.6 ± 10.9 (2.9) ng/mL, respectively. Polydrug use was present in 88% of cases, with methamphetamine (or other amphetamines) (25%), benzodiazepines (21%), and cocaine (17%) representing the most frequently identified concurrent substances. Co-positivity rates of various drugs and drug classes widely varied over time. Scene investigations reported illicit powder(s) (n = 141) and/or illicit pill(s) (n = 154) in 48% (n = 247) of fentanyl-related deaths. Illicit oxycodone (44%, n = 67) and illicit “Xanax” (38%, n = 59) pills were frequently reported on scene; however, toxicology only identified oxycodone and alprazolam in 2 and 24 of these cases, respectively. The results of this study provide a better understanding of the fentanyl epidemic in this region creating an opportunity to promote increased awareness, shift focus to harm reduction, and aid in minimizing public health risks.     

A study of drug detection in a postmortem pediatric population

At The Office of the Cuyahoga County Coroner (CCCO), Cleveland, Ohio, it is customary to perform an autopsy and conduct toxicological testing on decedents less than 19 years of age. This study provides a retrospective evaluation of drugs detected in a pediatric postmortem population between the years 1998 and 2002 (n = 730). Demographic information, cause and manner of death, and toxicological results were examined. Blacks comprised 54% of cases, males 59%, and 48% were less than one year of age or stillborn. Forty-two percent of deaths were ruled natural, 27% accident, 13% undetermined, 5% suicide, and 2% homicide. Of the 640 cases subjected to comprehensive testing, 38% of the cases were positive for at least one compound. Resuscitative/treatment drugs were detected most frequently (56% of positive results), followed by illicit drugs (26%), ethanol (11%), carbon monoxide (8%), and antihistamines (6%). Eighty-seven cases contained more than one drug. The deaths of 47 individuals were drug related (6%). In this population, it is recommended that illicit drugs and ethanol are targeted for testing, especially when limited specimens are available for analysis.     

Accidental sharp force injury fatalities.

The authors review all accidental sharp force injury deaths investigated at the Southwestern Institute of Forensic Sciences from 1990 to 1999. Twenty-two cases of accidental sharp force injury were identified, accounting for 0.29% of all accidental deaths (9,562) during the 10-year study period. Included in this series are 5 incised wounds, 11 stab wounds, 4 chop wounds, and 2 deaths caused by dog attacks. About half of the cases involved some type of motorized machinery. The victims' ages ranged from 2 years to 71 years, with most deaths occurring in older teenagers and younger adults. Male subjects (17) were involved much more frequently than female subjects (5). In 50% of the cases, ethanol or other drug use was a possible underlying contributing factor in the accident. The cases are briefly reviewed, and the importance of detailed investigation in manner-of-death certification is emphasized.     

Fatal dextropropoxyphene poisonings in Jutland, Denmark

For many years dextropropoxyphene (dxp) has been the medicament most frequently occurring in drug poisoning cases examined at the Institute of Forensic Medicine, University of Aarhus. This study includes 85 cases of acute fatal poisoning examined in the period 1985-1987 in which dxp alone (40 cases) or in combination with alcohol (29 cases) and/or other drugs (16 cases) contributed significantly to death. Two-thirds of the deceased were men and one-third women. The average age was 37 years for both sexes. More than half of the deceased were drug and/or alcohol misusers. Eighteen were drug addicts. Half of the deaths resulted from accidents, while 40% were suicides. Accidental deaths prevailed among younger men. In a majority of the cases the drug had been taken orally. In these cases the median total blood concentration of dxp and the metabolite nordextropropoxyphene (ndxp) was 17 mg/kg in the suicide cases and 7.1 mg/kg in the accident cases. The corresponding figures for dxp without metabolite were 9.4 mg/kg and 2.2 mg/kg, respectively. The median value of the quotient dxp/ndxp was 1.9 in the suicide cases and 0.5 in the accident cases. The quotient, together with the concentrations of the drug, may therefore indicate the manner of death in many cases.