Report of Increasing Overdose Deaths that include Acetyl Fentanyl in Multiple Counties of the Southwestern Region of the Commonwealth of Pennsylvania in 2015–2016

Acetyl fentanyl is a Schedule I controlled synthetic opioid that is becoming an increasingly detected “designer drug.” Routine drug screening procedures in local forensic toxicology laboratories identified a total of 41 overdose deaths associated with acetyl fentanyl within multiple counties of the southwestern region of the state of Pennsylvania. The range, median, mean, and standard deviation of blood acetyl fentanyl concentrations for these 41 cases were 0.13–2100 ng/mL, 11 ng/mL, 169.3 ng/mL, and 405.3 ng/mL, respectively. Thirty‐six individuals (88%) had a confirmed history of substance abuse, and all but one case (96%) were ruled multiple drug toxicities. This report characterizes this localized trend of overdose deaths associated with acetyl fentanyl and provides further evidence supporting an alarmingly concentrated opiate and opioid epidemic of both traditional and novel drugs within this region of the United States.     

A Rare Case of Poisoning with a Volatile Substance: Quantitative Determination of n‐Butane in Postmortem Tissue

Poisoning with volatile substances remains exceptional. Authors report the case of a married couple who were found in a car with a butane gas bottle: the woman was dead and her husband alleged it was an unsuccessful suicide pact. A specific research of volatile substances on postmortem samples with headspace gas chromatography–mass spectrometry following a quantitative determination was performed. The n‐butane concentrations detected were composed of 610 μg/L (cardiac blood), 50 μg/kg (brain), 134 μg/kg (lungs), 285 μg/kg (liver), and 4090 μg/kg (heart) and were compatible with the rare lethal concentrations evoked in the literature. The cause of death was determined to be asphyxiation through n‐butane criminal poisoning. Authors recommendation therefore is to take samples immediately and place them in properly sealed containers and hence analyzing the samples as soon as possible after collecting them or storing them under ?30°C (?22°F) if analyses cannot be performed immediately.     

Incidence of Fetal Drug Exposure in Alabama: 2004–2011

Postmortem toxicological results for neonates and stillborn fetuses were examined to determine the incidence of drug exposure in utero and the relationship to fetal mortality. From 15,600 fatalities with toxicological analyses, 39 subjects were identified; 22 had positive findings (56%). Among the general population, 10,500 had positive findings (67%). Among the subject population, 22 drugs/metabolites were identified; cocaine/benzoylecgonine was most frequent (9 of 22 cases, 41%) then methamphetamine/amphetamine (7 of 22 cases, 32%). Respective incidences among the general positive population were 12% and 6%. Fetal/neonatal concentrations overlap the general population and exceed the mother. Remaining substances, detected largely in fatalities unrelated to drug exposure, were of little toxicological significance. The variety, with exceptions, reflects the general population. That the incidence of cocaine and methamphetamine among fetuses/neonates is three‐ and fivefold greater than the general population is evidence that maternal abuse of these drugs poses greater risk to fetal viability than all other substances identified.     

Provenance Establishment of Stingless Bee Honey Using Multi‐element Analysis in Combination with Chemometrics Techniques

As consumption of stingless bee honey has been gaining popularity in many countries including Malaysia, ability to identify accurately its geographical origin proves pertinent for investigating fraudulent activities for consumer protection. Because a chemical signature can be location‐specific, multi‐element distribution patterns may prove useful for provenancing such product. Using the inductively coupled‐plasma optical emission spectrometer as well as principal component analysis (PCA) and linear discriminant analysis (LDA), the distributions of multi‐elements in stingless bee honey collected at four different geographical locations (North, West, East, and South) in Johor, Malaysia, were investigated. While cross‐validation using PCA demonstrated 87.0% correct classification rate, the same was improved (96.2%) with the use of LDA, indicating that discrimination was possible for the different geographical regions. Therefore, utilization of multi‐element analysis coupled with chemometrics techniques for assigning the provenance of stingless bee honeys for forensic applications is supported.     

Determining the Toxicological Significance of Pregabalin in Fatalities

Pregabalin has become more widely prescribed and abused in recent years but is still not always included in laboratory analysis. An LC‐MS‐MS method has been developed and applied to measure pregabalin in 93 postmortem cases, including drug‐related deaths, alternative causes of death, and fatalities where pregabalin was likely to have contributed to death. Other drugs or alcohol was detected, and the most common drug types (in decreasing frequency) were antidepressants, opioids, benzodiazepines, opiates, alcohol, antipsychotics, cocaine, cardiac drugs, amphetamines, cannabis, anticonvulsants, and antihistamines. New psychoactive substances (methoxphenidine and synthetic cannabinoids) were only found in two cases. The results provide further data to assist in evaluating the significance of postmortem pregabalin concentrations and a toxicologically significant concentration of 25 mg/L is proposed. Pregabalin, especially with concomitant use of other CNS depressant drugs, presents a significant toxicological risk and existing laboratory protocols should be reviewed for their suitability to detect pregabalin.     

The Application of Voltammetric Analysis of Δ9‐THC for the Reduction of False Positive Results in the Analysis of Suspected Marijuana Plant Matter

The development of methodologies using inexpensive, fast, and reliable instrumention is desirable in illicit drug analysis. The purpose of this study was based on cyclic voltammetry technique to differentiate the electrochemical behavior of ?⁹‐THC, the psychoactive substance in marijuana, and five different extract plants to yield false positive results after analysis protocol for cannabinoids using thin‐layer chromatography and Fast Blue B salt. After applying a deposition potential of ?0.5 V in a glassy carbon working electrode, the results indicated an anodic peak current at 0.0 V versus Ag/AgCl after addition of ?⁹‐THC solution in the electrochemical cell, and limits of detection and quantification were 1.0 ng mL^?1 and 3.5 ng mL^?1, respectively. Other interfering plants showed distinct amperometric responses. This methodology was useful to detect ?⁹‐THC even in the presence of the Fast Blue B salt, which avoided false positive results for all the studied extract plants.     

Specificity,Sensitivity, and Operability of RSID™‐Urine for Forensic Identification of Urine: Comparison with ELISA for Tamm‐Horsfall Protein

Abstract: In this study, the specificity, sensitivity, and operability of RSID?‐Urine, a new immunochromatographic test for urine identification, was evaluated and compared with ELISA detection of Tamm‐Horsfall protein (THP). Urine was successfully identified among other body fluids using RSID?‐Urine and ELISA detection of THP. The detection limit of RSID?‐Urine equated to 0.5 μL of urine; although the sensitivity of RSID?‐Urine may be lower than that of ELISA detection of THP, it is thought to be sufficient for application to casework samples. However, results from RSID?‐Urine must be interpreted with caution when the sample may have been contaminated with blood or vaginal fluid, because this might inhibit urine detection. The RSID?‐Urine assay can be performed in just 15 min by dropping the extracted sample onto the test cassette. Therefore, RSID?‐Urine should be an effective tool for the forensic identification of urine, in addition to ELISA detection of THP.     

Detection of Cutting Agents in Drug‐Positive Seized Exhibits within the United States

The following report summarizes a study performed on seized drug exhibits collected in two U.S. states to evaluate the presence and identification of cutting agents. Aliquots of seized drug materials from Kentucky (n = 200) and Vermont (n = 315) were prepared using a dilute‐and‐shoot procedure. Initial analysis was performed using gas chromatography–mass spectrometry (GC‐MS) followed by analysis using liquid chromatography quadrupole time‐of‐flight mass spectrometry (LC‐QTOF). Active compounds detected overall included caffeine (31.0%), quinine/quinidine (24.7%), levamisole (11.6%), acetaminophen, (8.2%) and procaine (8.2%). These compounds were found with several drugs of abuse, such as heroin, fentanyl, methamphetamine, and cocaine. This novel information about cutting agents used to dilute or alter drugs of abuse is important to criminal investigations and in the management of acute intoxications at health centers. However, common methodologies for analysis and standard reporting practices frequently do not include cutting agents, resulting in lacking or inadequate information regarding prevalence of these substances.     

Simultaneous Determination of 13 Anticoagulant Rodenticidesin Human Blood by Liquid Chromatography–Tandem Mass Spectrometry and its Application in Three Poisoning Cases

Anticoagulant rodenticides are widely used for rodent control around the world. A rapid and sensitive method was developed and validated for the simultaneous determination of 13 anticoagulant rodenticides (coumafuryl, pindone, valone, warfarin, coumatetralyl, coumachlor, diphacinone, dicumarol, chlorophacinone, bromadiolone, difenacoum, flocoumafen, and brodifacoum) in human blood by liquid chromatography–tandem mass spectrometry. After liquid–liquid extraction, the anticoagulant rodenticides were separated on an Eclipse Plus C18 column. Linearities were observed for each analyte in blood ranging from 0.5 to 50 ng/mL, with correlation coefficients over 0.99. The limits of detection ranged from 0.01 to 0.2 ng/mL, and the limits of quantification were 0.5 ng/mL for all analytes. The intraday and interday precisions were <15%, and accuracies ranged from 80.3% to 111.0%. This validated method with high sensitivity has been applied in three anticoagulant rodenticide poisoning cases and has been used successfully in monitoring blood concentrations for months.     

Validation of an LC–MS Method for the Detection and Quantification of BZP and TFMPP and their Hydroxylated Metabolites in Human Plasma and its Application to the Pharmacokinetic Study of TFMPP in Humans*

Abstract: An LC–MS method was developed for benzylpiperazine (BZP) and trifluoromethylphenylpiperazine (TFMPP), constituents of “party pills” or “legal herbal highs,” and their metabolites in human blood plasma. Compounds were resolved using a mixture of ammonium formate (pH 4.5, 0.01 M) and acetonitrile (flow rate of 1.0 mL/min) with a C18 column. Calibration curves were linear from 1 to 50 ng/mL (R² > 0.99); the lower limit of quantification (LLOQ) was 5 ng/mL; the accuracy was >90%; the intra‐ and interday relative standard deviations (R.S.D) were <5% and <10%, respectively. Human plasma concentrations of TFMPP were measured in blood samples taken from healthy adults (n = 6) over 24 h following a 60‐mg oral dose of TFMPP: these peaked at 24.10 ng/mL (±1.8 ng/mL) (C_max) after 90 min (T_max). Plasma concentrations of 1‐(3‐trifluoromethyl‐4‐hydroxyphenyl) piperazine peaked at 20.2 ng/mL (±4.6 ng/mL) after 90 min. TFMPP had two disposition phases (t_½ = 2.04 h (±0.19 h) and 5.95 h (±1.63 h). Apparent clearance (Cl/F) was 384 L/h (±45 L/h).     

The Identification of Ingested Dandelion Juice in Gastric Contents of a Deceased Person by Direct Sequencing and GC–MS Methods*

Abstract: DNA and chemical analysis of gastric contents of a deceased person were handled in this work. The body of the victim was discovered in his car, submerged in a lake. We were asked to determine whether or not the gastric contents of the victim harbored drugs and dandelion material. It was suspected that the victim had been murdered by poisoning with an excess amount of sleeping medication (doxylamine), which had been homogenized with dandelion. The concentrations of 11.4 and 27.5 mg/kg of doxylamine detected from spleen and liver of the victim were far higher than the assumed therapeutic concentration. Via gas chromatography–mass spectrometry (GC–MS) analysis and direct sequencing analysis of plant genetic markers such as intergenic transcribed spacer, 18S ribosomal RNA (rRNA), rbcL and trnLF, it was confirmed that the gastric contents of the victim contained taraxasterol, which is one of the marker compounds for dandelion and contained dandelion species‐specific rbcL and trnL‐trnF IGS (trnLF) sequences. The initial PCR of the genomic DNA isolated from the gastric contents showed insufficient quantity, and the second PCR, of which the template was a portion of the initial PCR products, exhibited a sufficient quantity for direct sequencing. rbcL and trnLF located in the cpDNA resulted in the successful determination of dandelion DNA in a decedent’s stomach contents. GC–MS identifies the actual presence of a taraxasterol at 28.4 min. Raw dandelion was assumed to be used as a masking vehicle for excess sleeping drug (doxylamine).     

An Objective Measure of Splitting in Parental Alienation: The Parental Acceptance–Rejection Questionnaire

Both clinicians and forensic practitioners should distinguish parental alienation (rejection of a parent without legitimate justification) from other reasons for contact refusal. Alienated children—who were not abused—often engage in splitting and lack ambivalence with respect to the rejected parent; children who were maltreated usually perceive the abusive parent in an ambivalent manner. The purpose of this study was to assess the usefulness of the Parental Acceptance–Rejection Questionnaire (PARQ) in identifying and quantifying the degree of splitting, which may assist in diagnosing parental alienation. Results showed that severely alienated children engaged in a high level of splitting, by perceiving the preferred parent in extremely positive terms and the rejected parent in extremely negative terms. Splitting was not manifested by the children in other family groups. The PARQ may be useful for both clinicians and forensic practitioners in evaluating children of divorced parents when there is a concern about the possible diagnosis of parental alienation.     

Recognition of Early Myocardial Infarction by Immunohistochemical Staining with Cardiac Troponin‐I and Complement C9*

Abstract: The diagnosis of early myocardial infarction (MI) after death, especially in the first few hours (c. 6 h) after the onset of MI, poses a challenge to the forensic pathologists. During this time, the damaged myocardium does not show grossly identifiable morphological changes and may not be recognized even with routine histological microscopic examination. However, the infarcted cardiac tissue releases certain chemicals that can be detected microscopically, two of these being cardiac troponin‐I (CT‐I) and complement C9 (C9). This study utilizes the importance of these two biomarkers immunohistochemically in an attempt to identify this early phase of MI. This study reveals that the early phase of MI of <6 h duration may be detected through immunohistochemical staining with CT‐I and C9. The ischemic/infarcted cardiac myofibers in the <6 h group display reduced/absent CT‐I staining as well as positive C9 staining.     

Distribution of ∆9‐Tetrahydrocannabinol and 11‐Nor‐9‐Carboxy‐∆9‐Tetrahydrocannabinol Acid in Postmortem Biological Fluids and Tissues From Pilots Fatally Injured in Aviation Accidents

Little is known of the postmortem distribution of ?⁹‐tetrahydrocannabinol (THC) and its major metabolite, 11‐nor‐9‐carboxy‐?⁹‐tetrahydrocannabinol (THCCOOH). Data from 55 pilots involved in fatal aviation accidents are presented in this study. Gas chromatography/mass spectrometry analysis obtained mean THC concentrations in blood from multiple sites, liver, lung, and kidney of 15.6 ng/mL, 92.4 ng/g, 766.0 ng/g, 44.1 ng/g and mean THCCOOH concentrations of 35.9 ng/mL, 322.4 ng/g, 42.6 ng/g, 138.5 ng/g, respectively. Heart THC concentrations (two cases) were 184.4 and 759.3 ng/g, and corresponding THCCOOH measured 11.0 and 95.9 ng/g, respectively. Muscle concentrations for THC (two cases) were 16.6 and 2.5 ng/g; corresponding THCCOOH, “confirmed positive” and 1.4 ng/g. The only brain tested in this study showed no THC detected and 2.9 ng/g THCCOOH, low concentrations that correlated with low values in other specimens from this case. This research emphasizes the need for postmortem cannabinoid testing and demonstrates the usefulness of a number of tissues, most notably lung, for these analyses.     

A Fatal Case of Poisoning with Fentanyl Transdermal Patches in Japan

Fentanyl transdermal patches have been used to treat cancer‐ and noncancer‐related chronic pain. However, its inappropriate or illegal application may cause fatal poisoning. We herein present the case of a Japanese woman in her 40s who was found dead with seven 25‐μg/h fentanyl transdermal patches on her body. We established a detailed toxicological analysis procedure to quantify fentanyl, and its metabolite norfentanyl, and other drugs (acetaminophen, allylisopropylacetylurea, celecoxib, estazolam, promethazine, and sertraline) in human whole blood by ultra‐high‐performance liquid chromatography–tandem mass spectrometry. The measured fentanyl and norfentanyl concentrations in the femoral and cardiac blood were 0.051 and 0.072 μg/mL and 0.033 and 0.076 μg/mL, respectively. The decedent's fentanyl concentrations were consistent with previously reported postmortem blood levels for fatal cases of poisoning by fentanyl transdermal patches. Based on the decedent's case history, autopsy findings, and toxicological analyses, the cause of death was identified as intoxication with transdermal fentanyl.     

Quantifying Uncertainty in Estimations of the Total Weight of Drugs in Groups of Complex Matrices: Using the Welch–Satterthwaite Equation

In this paper, a method is described to quantify estimations of the total amount of drugs in groups of seized items, including quantification of the precision. Previous work on this topic was based on the assumptions of normally distributed measurements and grouping of items with a common relative standard deviation. In practice, these assumptions are often violated, for example, for data with point masses at 0, or if certain items in a group have a very high standard deviation. The method described in this paper is based on work by Welch and Satterthwaite and does not assume constant relative standard deviations. Case examples are described for which the method is applied, and simulation studies are carried out for which both methods are applied. In the cases, both methods perform reasonably well. If the assumption of common relative standard deviations clearly does not apply, it is advised to use the method described.     

Effect of Substrate Interferences from High‐Density Polyethylene on Association of Simulated Ignitable Liquid Residues with the Corresponding Liquid

The effect of substrate interferences from high‐density polyethylene (HDPE) on the ability to associate an ignitable liquid residue with the corresponding liquid standard, using statistical procedures, is demonstrated. Gasoline, kerosene, and lighter fluid, at three different evaporation levels, were spiked onto HDPE and subsequently burned to generate simulated ignitable liquid residues (ILRs). Samples were extracted using a passive headspace procedure and analyzed by gas chromatography–mass spectrometry. The total ion chromatograms were subjected to data pretreatment procedures prior to principal components analysis and Pearson product moment correlation. Using the combination of these statistical procedures, simulated ILRs were successfully associated with the corresponding liquid type, despite the presence of compounds inherent to the HDPE substrate, as well as those resulting from pyrolysis of the substrate.