Heroin poisoning deaths with 6-acetylmorphine in blood: demographics of the victims, previous drug-related offences, polydrug use, and free morphine concentrations in femoral blood

Abstract

This article discusses cases of drug-poisoning death in which 6-acetylmorphine (6-AM) was identified in blood as evidence for recent use of heroin. We report the demographics of the victims, previous drug-related offences, polydrug use, and the concentrations of free morphine in peripheral blood. After solid-phase extraction, morphine, codeine, and 6-AM were determined in blood samples by isotope-dilution gas chromatography-mass spectrometry (GC-MS) using limits of quantitation of 0.005 mg/l for each opiate. The victims of heroin poisoning were mainly men (88%), with a mean age of 35.4 ± 8.4 years (±SD) and no significant gender difference in age (men 35 ± 8.4 years; women 35 ± 8.6 years). The median concentration of free morphine in blood (n = 671) was 0.25 mg/l (66% [ 0.20 mg/l) and women had a higher concentration (0.30 mg/l) than men (0.24 mg/l) (P \ 0.05). No significant difference (P [ 0.05) was found for the concentration of free morphine in blood when heroin was the only drug taken (median 0.26 mg/l, n = 53) compared with multidrug deaths (median 0.24 mg/l, n = 618) (P [ 0.05). The coingested drugs most commonly identified in heroin-related deaths were ethanol (44%), diazepam (27%), cannabis (20%), and flunitrazepam (19%). We found that 61% of victims had previous drugrelated offences ranging from 1 to 48 times. The close agreement between the concentrations of free morphine in blood when heroin was the only drug taken and multidrug deaths suggests that differences in tolerance to opiates is more important in causing death than adverse drug-drug interactions.

Can measurements of heroin metabolites in post-mortem matrices other than peripheral blood indicate if death was rapid or delayed?

“…This simplification implies that in some cases, heroin could have been less important in causing death, compared with the other drugs detected. However, because additional drugs are detected in the majority of heroin-related deaths [9,40,41] our results are expected to be relevant for heroin-intake cases in general. It is also worth mentioning that some of the 15 excluded morphine-positive cases could be a result of a "very delayed" heroin death, even though 6-AM was not detected, since intake of heroin is more common than intake of morphine among illicit drug users in Europe [1].…”

“…When interpreting toxicological findings in heroin-related deaths, it may be of great importance to assess the time span between administration of heroin and death [6]. Detection of 6-AM in blood has been suggested to indicate a rapid death [6][7][8][9], most likely within 1-2 h [9,10], or even as short as within 20-30 min [6], after intake of heroin. When 6-AM is detected in another matrix (e.g.…”

Drug-related causes of death: Socioeconomic and demographic characteristics of the deceased

“…Longitudinal studies of risk of death mostly employ treatment samples or notified addicts, while studies of the deceased mainly employ coroner notifications. Cause of death has often been restricted to heroin, opioids, and cocaine [3,4,[7][8][9][10][11][12]. A study of all drug-related deaths in Oslo from 2006 to 2008 included information on contacts with health and social services prior to death.…”

“…So are studies of drug-related deaths or fatal overdoses selected from coroners (forensic autopsy) and police files as well as agencies for problem and dependent users and the homeless, including recent background information [7][8][9][10]. Very few of these studies, however, have a retrospective design including information about status several years prior to death [11,12].…”

“…There are, to our knowledge, no studies mapping the heterogeneity of the economic and social situations several years prior to death for all those with a drug-related death. Longitudinal studies of risk of death and overdose among selected high-risk problem drug users are numerous [3,4], as are studies of drug-related deaths or fatal overdoses selected from coroners (forensic autopsy) and police files as well as agencies for problem and dependent users and the homeless, including recent background information [7][8][9][10]. Very few of these studies, however, have a retrospective design including information about status several years prior to death [11,12].…”