Fatal Fentanyl Patch Misuse in a Hospitalized Patient with a Postmortem Increase in Fentanyl Blood Concentration

Opioid‐related mortality happens, even in healthcare settings. We describe serial postmortem fentanyl blood concentrations in a hospital inpatient who fatally abused transdermal fentanyl. This is a single‐patient case report. A 42‐year‐old man with lymphoma was started on transdermal fentanyl therapy while hospitalized for chronic abdominal pain. The patient was last seen awake 1.3 h prior to being found apneic and cyanotic. During the resuscitation attempt, a small square‐shaped film was removed from the patient's oropharynx. Femoral blood was collected 0.5 and 2 h postmortem, and the measured fentanyl concentration increased from 1.6 to 14 ng/mL. Study limitations include potential laboratory or collection errors and missing data. (i) Providers must be vigilant for signs of fentanyl patch abuse. (ii) Postmortem blood concentrations are not static postmortem, likely secondary to decreasing pH, increased aqueous solubility, and tissue redistribution, and are therefore unlikely to accurately represent antemortem blood concentrations.     

'Law in Context' Revisited

Although 'Law in Context' is a well-known motto for law-and-society scholarship, the idea could benefit from closer examination. This paper introduces a principle of `fidelity to context' and suggests that contexts may be transcended by invoking general purposes and principles. These issues have special relevance for contextual analysis of free speech, academic freedom, and other rights and responsibilities. I also consider the relevance of legal pluralism, and the contextual analysis of human rights.     

Direct certification in the national school lunch program expands access for children

Under the policy of direct certification for free school meals, school districts use information shared by state agencies about household eligibility for means‐tested programs in the state in order to determine the potential eligibility for free meals of students enrolled in the district. This information allows districts to automatically approve students in these eligible households for free meals without requiring the household to complete the application process. This paper examines the impacts of direct certification on students' likelihood of becoming certified for free meals, using data from a national survey of school food service directors as well as statelevel administrative data on program participation. A state‐level fixed effects model is estimated to account for the possibility of selection bias. The key finding is that direct certification leads to a statistically significant increase in the number of children getting free school meals. More generally, this finding highlights a promising approach for improving access to means‐tested programs without compromising program integrity. © 2008 by the Association for Public Policy Analysis and Management.