Lethal poisoning by zipeprol in drug addicts

Two cases of lethal intoxication involving or due to oral ingestion of zipeprol are described. The two cases concerned abusers of the substance for nonmedical purposes. Data regarding the distribution of the unmodified drug in biological fluids and tissues are presented.     

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.     

Deaths among drug addicts in Denmark in 1968-1986

In the period 1968-1986 a total of 1618 fatalities among drug addicts were investigated at the three University Institutes of Forensic Medicine in Denmark. The annual number rose from 5 in 1968 to 163 in 1980, thereafter there has been a gradual fall to 121 in 1986. About 80% were males. The average age has risen from 22/23 years in the early 1970s to 31 years in 1986, and the percentage of addicts with a duration of abuse more than 10 years has increased gradually; both facts indicate a decrease in the recruitment among the quite young. In the whole period morphine was abused, supplemented by various medicines. Amphetamine was abused in the first years and again in 1986. The percentages of addicts with an abuse of alcohol and of addicts dying after a period of abstinence lasting more than 1 year, respectively, have increased. No essential changes were observed regarding distribution of residence or of the cause and manner of death. In the poisoning cases the predominant drug of poisoning was morphine/heroin, in all the years constituting approx. 30-50%. The second most frequent drugs of poisoning in the first half of the period was barbiturate, in the last half dextropropoxyphene and methadone. Only very few cases dying of cocaine poisoning were present and deaths due to so-called designer drugs have not been observed.     

Iliac cancellous bone in drug addicts: a histomorphometric study

Histomorphometry was used to determine structural bone changes in drug addicts. Iliac crest bone biopsies were obtained at autopsy from 28 subjects (21 male, 7 female, aged 18 to 45 years) who had a history of drug abuse and had died due to overdose of illicit drugs. For histomorphometry, undecalcified sections were investigated using the Merz grid. The following histomorphometric indices were measured and calculated: BV/TV, BS/BV, Tb.Th, Tb.N, Tb.Sp, OV/TV, OS/BS, Ob.S/BS, O.Th, ES/BS, Oc.S/BS, and N.Oc/T.A. In 28 controls (24 male, 4 female, aged 17 to 47 years) trabecular bone specimens were investigated in the same way. The parameters in drug addicts did not show any correlation to age, body weight, height or sex differences. Trabecular bone volume and trabecular thickness were slightly but not significantly increased (BV/TV: 23.37 +/- 5.77% (mean, SD), controls 22.23 +/- 5.08%, p = 0.434; Tb.Th: 172.67 +/- 36.83 mcm, controls 169.73 +/- 36.13 mcm, p = 0.764). Only the eroded surface was significantly different to the controls (ES/BS: 8.16 +/- 2.04%, controls 6.96 +/- 2.17%, p = 0.038). We conclude that the incidence of metabolic bone disease in drug addicts is low.     

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.     

30例吸毒者猝死分析

本文收集的30例吸毒者猝死资料均证实有吸毒史,排除损伤、机械性窒息、常见毒物中毒,全部作了尸体解剖检验和病理组织切片检查,发现脑、心、肺、肝、肾等多脏器损害,现报道如下。资料该30例系收集1996-2003年重庆市刑事科学技术研究所的尸检案例。结果一、一般情况男性28例(87.5%),女性2例(12.5%);最大的37岁,最小的16岁,平均24.63岁,20～28岁占绝大多数(70%),青少年已占总数的近80%;文化程度均为高初中;职业分布:机关工作人员1例,工人2例,待业、无业人员及无正当职业27例。二、吸毒史及体型30例资料中,青少年24名,吸毒时间2～3年的法律与医…     

30例吸毒者猝死分析

本文收集的30例吸毒者猝死资料均证实有吸毒史，排除损伤、机械性窒息、常见毒物中毒，全部作了尸体解剖检验和病理组织切片检查，发现脑、心、肺、肝、肾等多脏器损害，现报道如下。     

Cause of death and drug use pattern in deceased drug addicts in Sweden, 2002-2003

Compared with their contemporaries, individuals abusing illicit drugs suffer a higher risk of premature death. In Sweden, a simple protocol for registration of fatalities among abusers of alcohol, pharmaceuticals, illicit drugs, or other substances, has been used by the forensic pathologists since 2001. This routine was introduced to allow for an evaluation of the cause and manner of death, and patterns of abuse among different groups of abusers. We explored the data on drug abusers (i.e. abusers of illicit drugs) subjected to a forensic autopsy 2002-2003. The Swedish forensic pathologists examined 10,273 dead victims during the study period and 7% (743/10,273) of the cases were classified as drug abusers. Toxicological analyses were carried out in 99% (736/743) and illicit drugs were detected in 70% (514/736) of these. On average, 3.8 substances (legal or illegal) were found per case. The most common substances were ethanol and morphine, detected in 43 and 35% of the cases, respectively. When exploring the importance of the different substances for the cause of death, we found that the detection of some substances, such as fentanyl and morphine, strongly indicated a poisoning, whereas certain other substances, such as benzodiazepines more often were incidental findings. In total, 50% (372/743) died of poisoning, whereas only 22% (161/743) died of natural causes. Death was considered to be directly or indirectly due to drug abuse in 47% (346/743), whereas evidence of drug abuse was an incidental finding in 21% (153/743) or based on case history alone in 33% (244/743). We believe that this strategy to prospectively categorize deaths among drug addicts constitutes a simple means of standardizing the surveillance of the death toll among drug addicts that could allow for comparisons over time and between countries.     

Histopathological findings in 851 autopsies of drug addicts, with toxicologic and virologic correlations

This investigation was carried out on 851 consecutive judicial autopsies of drug addicts who died mostly of heroin overdose from 1977 to 1996. Research of anti-HIV/HBV/HCV antibodies was performed, and histologic sections were retrospectively reviewed. More than 65% were HBV/HCV-positive and about 17% HIV-positive; females were HIV-positive more often than males. Intracranial microhemorrhages were frequently found; cerebral infectious diseases were rare. Inflammatory heart lesions, myocardial fibrosis, and acute ischemia were common. Interstitial nephritis (found in about 8%) was more frequent in females, in older patients, and in those carrying HIV infection; glomerular sclerosis was detected in about 12%. Acute bronchitis and/or pneumonia was demonstrated in 12%, without significant association with HIV infection; pulmonary hemorrhages, foreign body granulomas, and food aspiration were also commonly seen; hyperplasia of pulmonary perivascular lymphatic tissue was rather characteristic. Liver was carrying steatosis in 66.3% and/or hepatitis in 64.5%; acute hepatitis was more frequent in females, chronic hepatitis in older subjects and in those proven positive for hepatotropic viruses; cirrhosis occurred more often in older patients, in those carrying virus infection, and in consumers of nonnarcotics drugs such as ethanol. No pathologic finding was clearly related to drug abuse; therefore, during autopsy, drug addiction can be suspected, but anamnestic and circumstantial data are needed to lead pathologists to request toxicologic analysis to ascertain the cause of death. The present investigation emphasizes that, in addition to the risk of death by overdose, the high incidence of acute and chronic diseases could seriously undermine the health status of heroin and/or other drug consumers.     

Nutritional status of deceased illicit drug addicts in Stockholm, Sweden--a longitudinal medicolegal study

Autopsy investigations, toxicological analyses, and calculation of body mass index were performed in 1180 deceased illicit drug addicts (IDAs) in Stockholm. Sweden during 1988-2000, i.e., during a period of time when the general population in numerous countries showed a dramatic increase in the prevalence of overweight. Nutritional deficit in IDAs has been pointed out as a threat to their health as well as to their quality of life. The prevalence of overweight in deceased IDAs increased from 27.4% in 1988 to 45.5% in 2000. The prevalence of overweight among all heroin users, heroin injectors, methadone, cocaine, and amphetamine users was 36.0, 38.4, 43.1, 45.0 and 50.9%, respectively, the lowest prevalence being among users of cannabis alone and HIV-positive IDAs (22.0 and 16.1%, respectively). In conclusion, Stockholm's IDAs are affected by the past decade's dramatically increased prevalence of overweight, at least to the same degree as the general population. The increased body weight seems not to influence the danger of dying upon heroin administration.     

The problem of interviewing drug addicts in custody: A study of interrogative suggestibility and compliance

Abstract

The interrogation of drug addicts in custody presents a problem. The reliability of confessions made either under the influence of drugs or during drug withdrawal may be adversely affected. This study explores the effect of drug use and drug withdrawal on interrogative suggestibility and compliance. These two psychological factors are relevant to erroneous testimony. The interrogative suggestibility and compliance of heroin addicts on an inpatient drug unit were measured on opiates, whilst withdrawing from opiates and drug free. The interrogative suggestibility and compliance of the group of subjects as a whole did not differ significantly in these three conditions. However the results did suggest that a subgroup of vulnerable individuals may have been more suggestible when under the influence of opiates. Further work is needed to clarify these results and to aid professionals assessing fitness for interview and cases of retracted confessions.     

Family role in the reintegration process of recovering drug addicts: a qualitative review of Israeli offenders

In an outcome evaluation of recovering addicts who participated in a prison-based therapeutic community, 39 clients, a nonrandomized subsample, are interviewed about their rehabilitation and reintegration experience. This study focuses on the family as the main source of support and as an agent of change for the recovering drug addict. Although many studies show marriage and family to be positively related to successful reintegration and rehabilitation, clients in this study report families as having a negative effect on the rehabilitation and reintegration process. This is especially true among those who reunite with their spouse. The findings are discussed in regard to role expectations and support mechanisms, and suggestions are made for further research.     

Fatal intoxications in the Nordic countries. A forensic toxicological study with special reference to young drug addicts

Fatal intoxications in the 15-34 age group in the five Nordic countries during the years 1984 and 1985 (Sweden only in 1984) were investigated. The known drug addicts were studied separately. The highest incidence of intoxications, calculated per 10(5) population, was found in Finland (11.3), followed by Denmark (10.3), Sweden (8.5), Iceland (7.2) and Norway (6.6). The percentage of intoxications caused by drugs was 92 in Denmark, 71 in Norway, 66 in Sweden, 50 in Finland and 17 in Iceland. Ethanol intoxications were seen 5-7 and 2-3 times as frequently in Finland and in Iceland, respectively, than in the other three countries. Carbon monoxide intoxications accounted for two-thirds of all fatal intoxications in Iceland. Drug addicts accounted for 62% of all fatal intoxications in the Danish material. The corresponding figures were 33% in the Norwegian, 16% in the Swedish and 5% in the Finnish material. No deaths in drug addicts were found in Iceland. Most drug addicts in Denmark, Norway and Sweden died of hard drugs and most in Norway and Sweden, from heroin or morphine, whereas in Denmark other strong analgesics, such as methadone, dextropropoxyphene and ketobemidone, accounted for 40% of all hard-drug-related fatal intoxications. To a certain extent the results reflect differences in the legal autopsy routines in the various Nordic countries. However, the ascertainment of drug addicts is assumed to be near-complete in each country.     

The occurrence of HIV antibodies in drug addicts autopsied at the University Institute of Forensic Medicine in Copenhagen in 1987

In 1987 a total of 89 intravenous drug addicts were admitted to medico-legal autopsy at the University Institute of Forensic Medicine in Copenhagen. Totally 10 cases were reactive by the Elisa test and five of these, or 7% of the total material tested, could be confirmed by the immuno-blotting test. The other five cases must be considered as false positive, possibly due to antibodies against cellular antigens. Among the five real positive cases, four were known before-hand while in one case the HIV-positivity was not known. These findings - together with the possibility of false negative reactions - especially regarding persons with acute HIV-infection, requires special precautionary measures when autopsies of drug addicts are performed.     

Prevalence of HIV-1 antibodies in drug addicts autopsied at the University Institute of Forensic Pathology in Copenhagen 1988-1991.

In the period 1988-1991 the HIV-1 antibody test was performed in a total of 389 autopsied drug addicts. The HIV-1 incidence rose from 6% in 1988 to 14% in 1990 and 14% in 1991. There was no significant difference between the cumulated incidence in males and females. The HIV-1-positive addicts were compared to the HIV-1 negative addicts as regards mean age, duration of abuse, residence and cause and manner of death. Except for residence, where significantly more HIV-1-positive than negative addicts lived in Copenhagen, there were no significant differences between the two groups. In about one-third of the HIV-1-positive cases, equal both for males and females, the HIV-1-positivity was not known beforehand. The results are discussed in relation to the findings in other countries and to the findings in selected groups of living addicts in Copenhagen. It is concluded, that the diagnosis of HIV-1 infection in autopsied drug addicts is important from epidemiologic and hygienic points of view.     

Some observations concerning blood morphine concentrations in narcotic addicts

Blood samples from deceased narcotic addicts were analyzed for morphine, and the results form persons who died from narcotic addiction were compared with those from homicide victims. In most instances morphine was detectable in both types of death, and usually the values obtained were less than 30 microgram/dl. Narcotic addiction deaths involving only morphine, or morphine plus a combination of ethanol, quinine, or diazepam (Valium), were also evaluated. In some cases high quantities of ethanol were present, and death could be attributed to the combined CNS depressant effects of morphine and ethanol. The quinine levels would not normally be considered toxic, however, and it could not be ascertained that the quantity of this drug present contributed to death. Diazepam was present in elevated concentrations, and its depressant effect may have been a factor in some narcotic addiction deaths.