Tissue distribution of tramadol and metabolites in an overdose fatality

Tramadol (Ultram) is a centrally acting, synthetic analgesic agent. Although it has some affinity for the opiate receptors, tramadol is believed to exert its analgesic effect by inhibiting the re-uptake of norepinephrine and serotonin. There are several published cases of tramadol's involvement in drug-related deaths and impairment. Reports of deaths involving tramadol alone with associated tissue concentrations are rare. This report documents a case in which tramadol overdose was identified as the cause of death. The following tramadol concentrations were found in various tissues: blood, 20 mg/L; urine, 110.2 mg/L; liver, 68.9 mg/kg; and kidney, 37.5 mg/kg. Tissue distributions of the two primary metabolites, N-desmethyl and O-desmethyl tramadol, are also reported. In each tissue or fluid except urine, the tramadol concentration was greater than either metabolite, consistent with other reports of drug-impaired drivers and postmortem cases. The O-desmethyl metabolite concentration was greater than the N-desmethyl metabolite concentration in all tissues; this is in contrast to other postmortem reports, in which the majority of cases report concentrations of O-desmethyl as less than those of N-desmethyl. This may be useful as an indicator of time lapse between ingestion and death.     

Reviews

Terrorism in Mozambique by Alex Vines. Centre for Southern African Studies, University of York, in association with James Currey, London, 1991. xiv plus 176pp. including maps, figures, tables, appendices, bibliography and index. R47.25. Paperback.

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La France et l'Afrique du Sud: Histoire, Mythes et Enjeux Contemporains edited by Daniel C. Bach. Karthala, Paris, 1990.432pp. Paperback.     

Hmong folk remedies: limited acetylation of opium by aspirin and acetaminophen.

The traditional folk medicine of the Hmong and other Southeast Asian refugees has accompanied them during their immigration in this country over the past two decades. In two recent cases involving Hmong defendants, unknown solids, resembling charcoal in consistency and purported to be "backache remedies," were analyzed and found to be complex mixtures of aspirin, acetaminophen, caffeine and partly acetylated opium. In particular, significant amounts of acetylacetaminophen, 3-O-acetylmorphine, 6-O-acetylcodeine, 6-O-acetylmorphine, and heroin were identified by gas chromatography/mass spectrometry. Heating approximately equal weights of solid opium, aspirin, and acetaminophen at 130 degrees C for several hours produced a mixture of compounds showing a similar acetylation pattern.     

Teaching "street law" to the criminally insane

A course in "Street Law" was taught to forensic patients by law students, following a format used by Georgetown University Law Center. Although the course has been taught to high school students and inmates of correctional facilities, this was the first time it has been extended to mental patients found not guilty of crimes by reason of insanity. An outstanding feature of the course was marked enthusiasm shown by patients who, through long institutionalization, had become apathetic, indifferent, and despairing. Their readiness and ability to learn brought to mind a couple of old sayings often heard around mental hospitals, "I may be crazy but I'm not stupid," and "Sometimes you can't tell the patients from the staff." The staff of at least one ward has picked up "teaching and learning to use as a central theme in treatment of patients, not abandoning traditional methods, but shifting the emphasis from therapy to teaching as a way of getting the patient's interest in his own rehabilitation. Judges, reviewing cases for release, have looked quizzical when the patients' active participation in a "law course" has been used as evidence of satisfactory progress.