Toxicologic Assessments in Acute Heroin Fatalities

Abstract

The recent improvements in analytic methods enable routine morphine detection in blood in microgram or nanogram quantities. It is now possible to assess acute death from heroin use by toxicologic analyses. A review of available data indicates a rapid distribution of morphine even in sudden fatalities, to the various organs of the body. Blood morphine levels in most acute heroin-involved deaths range from 0.1 to 1.0 microgram/ml, while morphine concentration in liver ranges from 0.1 to 10.0 microgram/gm. In rapid death, the blood to liver ratio is approximately 1:5. Blood and liver appear to be the specimens of choice in determining fatality due to heroin; however a distribution study that included other tissues such as brain, bile, and urine would afford a more meaningful evaluation in forensic investigation. The correlation of the survival periods of decedents to concentrations of morphine in tissues is discussed. Since morphine concentration decreases precipitously in antemortem blood immediately after administration of heroin, the assurance of detecting and determining morphine is greater in blood specimens from decedents who died within 1 hr after drug taking than from those who survived for a longer period. Blood levels of morphine also appear to be regulated by dosage. The role of ethanol and other drugs, including excipients in illicit heroin preparations, in acute narcotism is still poorly understood. Morphine is produced in the antemortem metabolism of codeine. A close evaluation of toxicologic data is necessary to determine whether the morphine detected, if a metabolite, is a conversion product of codeine, heroin, or both. In any event, the cause of death involving heroin is determined only after information from history and pathology, as well as toxicology, are carefully correlated.

Heroin Overdose: Research and Evidence-Based Intervention

“…15,18,22,26,70,71 Second, instantaneous death appears to be unusual. 22,26,34,[71][72][73] These data indicate that there is time to intervene in the majority of heroin overdose deaths, and that in most cases, people are present who could intervene.…”

Heroin overdose: causes and consequences

“…Recent studies have also dispelled the notion that death may be related to contaminants in heroin. 6,22,37,49,50 The demographic and toxicological characteristics of heroin overdose fatalities are puzzling.…”

“…This is consistent with evidence that the majority of overdoses do not occur immediately after administration. 22,45,49,74,75 For example, Zador et al 22 estimated that 22% of fatalities died over a period of time longer than 3 hours, as did over half (52%) of cases studied by Garriot & Sturner, 74 while Nakamura 49 reported that in 44% of cases the interval was greater than 2 hours. Further research is required to establish whether an association exists between hepatic disease and overdose and, if so, the nature and extent of this association.…”

Heroin-Related Deaths: New Epidemiologic Insights

“…Of the studies of heroin-related mortality in U.S. cities (2)(3)(4)(5)(6)(7)(16)(17)(18)(19)(20), some do not clearly differentiate between deaths due exclusively to heroin and those due to narcotics in general or to specific combinations of heroin and other drugs.…”

“…Blood ethanol concentrations from autopsy samples reflect only minimum levels because concentrations in the living decrease by about 100 to 200 mg/liter per hour (26). Many reports have noted that ethanol is commonly found in the blood of heroin overdose victims (2,7,20,21,23), but no data have specifically shown ethanol to be a risk factor or ethanol abusers to be a high-risk group.…”