Relation of postmortem blood alcohol and drug concentrations in fatal poisonings involving amitriptyline, propoxyphene and promazine

Ethanol and Medical Psychotropics Co-Consumption in European Countries: Results from a Three-Year Retrospective Study of Forensic Samples in Spain

Ethanol and medical psychotropics (MPs) are legal psychoactive substances widely consumed in Western countries that are routinely detected in standard toxicological analyses at compulsory autopsies, and toxicokinetic interactions between these drugs have been described. However, studies assessing the consequences of this co-consumption are scarce in Europe. We performed a retrospective study on toxicological results from compulsory autopsies in Spain. Thirty-five legal psychotropics, including ethanol, were measured in blood samples from 380 decedents to assess the determinants of such co-consumption. MPs were detected in 42.4% of the subjects. Polypharmacy was frequent in our series (25%), being more frequent in men than in women. More than one-third of the decedents had detectable levels of ethanol, and a significant positive association between ethanol levels and age was evident. About one-third of MPs consumers were also co-consumers of ethanol. The simultaneous consumption of ethanol and MPs was higher in men than in women. Blood alcohol concentrations (BAC) were lower in men who consumed MPs. In polypharmacy deaths, there was a significant negative association between the number of MPs consumed and BAC in men (r = -0.097; p = 0.029). Our results showed a high prevalence of co-consumption of MPs and ethanol in the European population involved in medico-legal issues and suggest that toxicokinetic interactions may be lowering BAC in men. This is a very worrying result, as it could indicate that the legal blood ethanol limits set by legislation would not be appropriate for men on MPs treatment.

Potential drug-drug interactions in acute poisonings managed in the intensive care unit: Occurrence, risk factors and relationship to patient severity on admission

Beyond the direct toxicity resulting from each drug in the poisoned patient, additional toxicities may result from drug-drug interactions (DDIs). We aimed to determine the frequency of potential DDIs in the poisoned patient and investigate whether DDIs are associated with severity. We conducted a 1-year cohort study in a toxicological ICU. DDIs were identified using an electronic interaction-checker tool. Among our 354 ICU poisoned patients, 134 (38%) presented at least one potential DDI between acute poisoning drugs and 180 (51%) at least one potential DDI between acute poisoning and long-term treatment drugs. Using multivariate analyses, previous suicide attempt was associated with the presence of potential DDIs between acute poisoning drugs in suicide attempt patients (P = 0.014). Chronic alcoholism (P = 0.005) and tobacco smoking (P = 0.022) were associated with the presence of potential DDIs between acute poisoning and long-term treatment drugs in recreational drug users. Presence of potential DDIs between acute poisoning and long-term treatment drugs was associated with catecholamine infusion (P = 0.022) in suicidal self-exposure patients. Presence of potential pharmacodynamic DDIs between acute poisoning and long-term treatment drugs was associated with aspiration pneumonia onset in recreational drug users (P = 0.03). ICU poisoned patients present a high rate of potential DDIs that may influence the outcome.

Promazine Detection in Human Hair: Presentation of a LC-MS/MS Method and Pattern of Drug Discontinuation

Promazine is one of the oldest phenothiazine derivatives that have been proposed for the treatment of various psychiatric disorders. The drug is available as tablets, syrups and in injectable forms. Despite its prescription to millions of subjects, its detection in human hair has seldom been reported. The aim of the present work was to develop a specific method to identify promazine in human hair by LC-MS/MS and to apply it to a patient who was self-medicating. The method involves overnight incubation of 20 mg of cut hair in 1 mL of pH 9.5 borate buffer in presence of amitriptyline-d3 at 40 °C. The chromatographic separation was performed using a reverse phase column HSS C18 with a gradient elution for 15 min. Linearity was verified from 0.5 to 500 pg/mg (r² = 0.9996), after spiking blank hair with the corresponding amounts of promazine. The limit of detection was estimated at 0.1 pg/mg. The precision was lower than 20 %. Promazine tested positive in the hair of a psychotic subject at 228 to 270 pg/mg in 3 x 1 cm segment. Given this was a patient who was self-medicating, her physician requested an immediate drug discontinuation. In a fresh hair specimen collected 3 months later, the proximal segment (0 to 1 cm) tested positive at 0.9 pg/mg, clearly indicating that the time to obtain a negative result after promazine discontinuation is about 3 to 4 months.

Amitriptyline functionally antagonizes cardiac H2 histamine receptors in transgenic mice and human atria

We have previously shown that histamine (2-(1H-imidazol-4-yl)ethanamine) exerted concentration-dependent positive inotropic effects (PIE) or positive chronotropic effects (PCE) on isolated left and right atria, respectively, of transgenic (H₂R-TG) mice that overexpress the human H₂ histamine receptor (H₂R) in the heart; however, the effects were not seen in their wild-type (WT) littermates. Amitriptyline, which is still a highly prescribed antidepressant drug, was reported to act as antagonist on H₂Rs. Here, we wanted to determine whether the histamine effects in H₂R-TG were antagonized by amitriptyline. Contractile studies were performed on isolated left and right atrial preparations, isolated perfused hearts from H₂R-TG and WT mice and human atrial preparations. Amitriptyline shifted the concentration-dependent PIE of histamine (1 nM-10 μM) to higher concentrations (rightward shift) in left atrial preparations from H₂R-TG. Similarly, in isolated perfused hearts from H₂R-TG and WT mice, histamine increased the contractile parameters and the phosphorylation state of phospholamban (PLB) at serine 16 in the H₂R-TG mice, but not in the WT mice. However, the increases in contractility and PLB phosphorylation were attenuated by the addition of amitriptyline in perfused hearts from H₂R-TG. In isolated electrically stimulated human atria, the PIE of histamine that was applied in increasing concentrations from 1 nM to 10 μM was reduced by 10-μM amitriptyline. In summary, we present functional evidence that amitriptyline also acts as an antagonist of contractility at H₂Rs in H₂R-TG mouse hearts and in the human heart which might in part explain the side effects of amitriptyline.

Quantifying enhanced risk from alcohol and other factors in polysubstance-related deaths

BACKGROUND

To quantify how alcohol, polysubstance use and other factors influence opioid concentrations in drug-related deaths in West Virginia (WV), United States.

METHODS

Multiple linear regression models were employed to identify relationships among alcohol, other factors, and the concentrations of four commonly identified opioids (fentanyl, hydrocodone, oxycodone, methadone), accounting for demographic, toxicological and comorbid characteristics in WV drug-related deaths from 2005 to 2018.

RESULTS

Alcohol concentrations of 0.08% or above were associated with significant reductions in blood concentrations of fentanyl (27.5%), hydrocodone (30.5%) and methadone (32.4%). Significantly lower predicted concentrations of all opioids studied were associated with multiple opioid vs. single opioid presence, with predicted concentration reductions ranging from 13.7% for fentanyl to 65-66% for hydrocodone and oxycodone. Benzodiazepine presence was associated with small, non-statistically significant changes in opioid concentrations, while stimulant presence was associated with statistically significant reductions in hydrocodone and oxycodone concentrations.

CONCLUSIONS

Co-ingestion of alcohol, multiple opioids or stimulants were associated with significantly decreased predicted concentrations of commonly identified opioids in drug deaths. Further evidence is provided for enhanced risks from polysubstance use with opioids, which has important public health implications.

A drink before suicide: analysis of the Queensland Suicide Register in Australia

AIMS

Previous studies analysing blood alcohol concentration (BAC) at the time of suicide have primarily focused on sociodemographic factors. Limited research has focused on psychosocial factors and co-ingestion of other substances to understand the mechanisms of how alcohol contributes to death by suicide. The aim was to examine time trends, psychosocial factors related to acute alcohol use and co-ingestion of alcohol and other substances before suicide.

METHODS

The Queensland Suicide Register in 2004-2015 was utilised and analysed in 2019. The cut-off point for positive BAC was set at ⩾0.05 g/dl. Substances were categorised as medicines, illegal drugs and other. Medicines were coded by the Anatomical Therapeutic Chemical (ATC) classification system. Joinpoint regression, univariate odds ratios, age and sex-adjusted odds ratios and Forward Stepwise logistic regression were performed.

RESULTS

BAC information was available for 6744 suicides, 92% of all cases in 2004-2015. The final model showed that independent factors distinguishing BAC+ from BAC- were: age group 25-44 years, Australian Indigenous background, being separated or divorced, hanging, diagnosis of substance use, lifetime suicidal ideation, relationship and interpersonal conflict, not having psychotic and other psychiatric disorder, and no nervous system drugs or any other substances in blood at the time of suicide.

CONCLUSIONS

Our findings suggest that people who die by suicide while under the influence of alcohol are more likely to be under acute stress (e.g. separation) and not have earlier psychiatric conditions, except substance use. This highlights the importance of more strict alcohol policies, but also the need to improve substance use treatment.

Can Lipoic Acid Attenuate Cardiovascular Disturbances Induced by Ethanol and Disulfiram Administration Separately or Jointly in Rats?

The exogenous lipoic acid (LA) is successfully used as a drug in the treatment of many diseases. It is assumed that after administration, LA is transported to the intracellular compartments and reduced to dihydrolipoic acid (DHLA) which is catalyzed by NAD(P)H-dependent enzymes. The purpose of this study was to investigate whether LA can attenuate cardiovascular disturbances induced by ethanol (EtOH) and disulfiram (DSF) administration separately or jointly in rats. For this purpose, we measured systolic and diastolic blood pressure, recorded electrocardiogram (ECG), and estimated mortality of rats. We also studied the activity of aldehyde dehydrogenase (ALDH) in the rat liver. It was shown for the first time that LA partially attenuated the cardiac arrhythmia (extrasystoles and atrioventricular blocks) induced by EtOH and reduced the EtOH-induced mortality of animals, which suggests that LA may have a potential for use in cardiac disturbance in conditions of acute EtOH intoxication. The administration of EtOH, LA, and DSF separately or jointly affected the ALDH activity in the rat liver since a significant decrease in the activity of the enzyme was observed in all treatment groups. The results indicating that LA is an inhibitor of ALDH activity are very surprising.

How Postmortem Redistribution of MDMA in Acute Alcohol-MDMA Combined-Use Rats Change under Effects of Alcohol

MDMA is often taken recreationally with alcohol as combined-use. The objective was to determine MDMA postmortem redistribution (PMR) and corresponding effects in combined-style under different storage conditions. Steps were 20%-mixture of alcohol-water for initial 4 weeks to Group-A&B and intragastric infusions of MDMA (150 mg/kg) to Group-A later; in the same time, drinking pure water to Group-C&D first and then MDMA-fed to Group-C. The sacrificed rats were kept under different conditions for 10-d, during which the body fluids and tissues were collected on 15 continuous time-points and then detected. The MDMA concentrations were quite different along with postmortem interval (PMI) went by; the area under concentration-PMI curve significantly increased with combined-alcohol in comparison to MDMA alone, while that significantly decreased by lowering preservation temperature, allied with corresponding humidity. Combined-alcohol could exacerbate PMR of MDMA, as concentrations of combined-use rats’ samples were quite higher than mono-MDMA ones under any conditions, while different for body fluids and tissues; meanwhile lowering storage temperature could alleviate effects of alcohol. The study implies that in case of combined-use, the changes of concentrations are probably effected by some combined component, especially when come to identification of toxic level or even death.

Additive Effects of Cointoxicants in Single-Opioid Induced Deaths

A forensic drug database (FDD) was used to capture comprehensive data from all drug-related deaths in West Virginia, with deaths also included from the northern New England states of Maine, Vermont, and New Hampshire. All four states serve predominantly rural populations under two million and all have similar state medical examiner systems that employ statewide uniform death certification policies and practices. This study focused on 1482 single opioid deaths (fentanyl, hydrocodone, methadone, and oxycodone) in the FDD from 2007-2011. We modeled relationships between the opioid concentrations and the presence or absence of the following commonly occurring non-opioid cointoxicants: benzodiazepines (alprazolam and diazepam), alcohol, tricyclic antidepressants, selective serotonin reuptake inhibitors, and diphenhydramine. Additional covariates of state, age, body mass index, and sex were included. Results showed that the presence of alcohol, benzodiazepines, and antidepressants were each associated with statistically significant lower concentrations of some but not all of the opioids studied, which may obscure the interpretation of postmortem toxicology results alone. Fentanyl concentrations appeared to be the least associated with the presence or absence of the variables studied, and cointoxicant alcohol appeared to be associated with lower concentrations in opioid concentrations than were most of the other factors in the model studied. These findings underscore the importance of documenting all potential cointoxicants in opioid-related deaths.

The relationship between observed signs of impairment and THC concentration in oral fluid

BACKGROUND

Studies have shown that cannabis intake increases the risk of traffic accidents. Controlled experiments support these findings and have shown a positive dose-effect relationship.

METHODS

In this retrospective cross-sectional study of data from a roadside survey, we investigated whether a police officer's judgment regarding signs of impairment is related to the concentration of delta-9-tetrahydrocannabinol (THC) in the oral fluid (OF). We investigated 2,632 cases from a representative sample of 3,302 Spanish drivers: 253 drivers positive for THC only, 32 positive for THC and ethanol, 201 with only ethanol detected in their breath, and 2,146 drivers who tested negative for ethanol in breath and drugs in OF. Recorded data comprised breath alcohol concentrations, THC concentrations in the OF, and the 31 observed signs of impairment. Subject groups were compared using the chi-square test, and logistic regression was used to examine the risk of being categorized as exhibiting signs of impairment.

RESULTS

A relationship was found between the OF THC concentration and some observed signs of impairment. Eye signs were noticeable from a THC concentration >3.0 ng/ml in OF, and >25 ng/ml was related to behavior, facial expression, and speech signs. Alcohol and THC contribute to impairment independently and, when taken simultaneously, the effects are comparable to the sum of the effects when consumed separately.

CONCLUSIONS

The observation of signs of impairment due to cannabis occurs in an OF concentration-related manner but, as a clinical test, OF has low sensitivity and specificity in a random roadside survey.

Unintentional alcohol and drug poisoning in association with substance use disorders and mood and anxiety disorders: results from the 2010 Nationwide Inpatient Sample

OBJECTIVE

To examine unintentional alcohol and drug poisoning in association with substance use disorders (SUDs) and mood and anxiety disorders.

METHOD

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) external-cause-of-injury codes on discharge records of patients ages 12+ years from the 2010 Nationwide Inpatient Sample were examined to identify cases with unintentional alcohol poisoning (E860) and/or drug poisoning (E850-E858). ICD-9-CM diagnosis codes were examined to identify comorbid alcohol dependence, drug dependence, tobacco use disorder, and mood/anxiety disorders. Poisson regression was used to derive risk ratios to assess the associations between these comorbid conditions and alcohol/drug poisoning.

RESULTS

Estimated numbers of hospitalisations related to unintentional alcohol and drug poisoning were, respectively, 5623 and 60 423 in men, and 3147 and 68 568 in women. For both sexes, the proportion with SUDs or mood/anxiety disorders was significantly higher among inpatients with alcohol and drug poisoning than among all inpatients. Estimated risk ratios indicated strong relationships of SUDs and mood/ anxiety disorders with unintentional poisoning from alcohol and drugs. The strongest association was between alcohol dependence and alcohol poisoning for both sexes. Significant associations also existed between drug dependence and drug poisoning, and mood/anxiety disorders and poisoning from alcohol and drugs.

CONCLUSIONS

SUDs and mood/anxiety disorders are key risk factors for unintentional poisoning by alcohol and drugs among inpatients in the USA. Effective treatments of these disorders should be targeted as poisoning prevention efforts. Future studies are needed to clarify a potential bias in the data due to differential inpatient mental condition screening practices.

Hospitalizations for alcohol and drug overdoses in young adults ages 18-24 in the United States, 1999-2008: results from the Nationwide Inpatient Sample

OBJECTIVE

Recent reports indicate an increase in rates of hospitalizations for drug overdoses in the United States. The role of alcohol in hospitalizations for drug overdoses remains unclear. Excessive consumption of alcohol and drugs is prevalent in young adults ages 18-24. The present study explores rates and costs of inpatient hospital stays for alcohol overdoses, drug overdoses, and their co-occurrence in young adults ages 18-24 and changes in these rates between 1999 and 2008.

METHOD

Data from the Nationwide Inpatient Sample were used to estimate numbers, rates, and costs of inpatient hospital stays stemming from alcohol overdoses (and their subcategories, alcohol poisonings and excessive consumption of alcohol), drug overdoses (and their subcategories, drug poisonings and nondependent abuse of drugs), and their co-occurrence in 18- to 24-year-olds.

RESULTS

Hospitalization rates for alcohol overdoses alone increased 25% from 1999 to 2008, reaching 29,412 cases in 2008 at a cost of $266 million. Hospitalization rates for drug overdoses alone increased 55%, totaling 113,907 cases in 2008 at a cost of $737 million. Hospitalization rates for combined alcohol and drug overdoses increased 76%, with 29,202 cases in 2008 at a cost of $198 million.

CONCLUSIONS

Rates of hospitalizations for alcohol overdoses, drug overdoses, and their combination all increased from 1999 to 2008 among 18- to 24-year-olds. The cost of such hospitalizations now exceeds $1.2 billion annually. The steepest increase occurred among cases of combined alcohol and drug overdoses. Stronger efforts are needed to educate medical practitioners and the public about the risk of overdoses, particularly when alcohol is combined with other drugs.

Neuroimaging insights into the role of cortical GABA systems and the influence of nicotine on the recovery from alcohol dependence

This paper reviews evidence suggesting that nicotine and tobacco smoke profoundly modulate the effects of alcohol on γ-aminobutyric acid (GABA) neuronal function, specifically at the GABA(A)-benzodiazepine receptor (GABA(A)-BZR). The focus of this paper is on recent neuroimaging evidence in preclinical models as well as clinical experiments. First, we review findings implicating the role of alcohol at the GABA(A)-BZR and discuss the changes in GABA(A)-BZR availability during acute and prolonged alcohol withdrawal. Second, we discuss preclinical evidence that suggests nicotine affects GABA neuronal function indirectly by a primary action at neuronal nicotinic acetylcholine receptors. Third, we show how this evidence converges in studies that examine GABA levels and GABA(A)-BZRs in alcohol-dependent smokers and nonsmokers, suggesting that tobacco smoking attenuates the chemical changes that occur during alcohol withdrawal. Based on a comprehensive review of literature, we hypothesize that tobacco smoking minimizes the changes in GABA levels that typically occur during the acute cycles of drinking in alcohol-dependent individuals. Thus, during alcohol withdrawal, the continued tobacco smoking decreases the severity of the withdrawal-related changes in GABA chemistry. This article is part of a Special Issue entitled 'Trends in neuropharmacology: in memory of Erminio Costa'.

Impairment due to cannabis and ethanol: clinical signs and additive effects

AIMS

Studies have shown that the impairing effects of Delta-9-tetrahydrocannabinol (THC) are dose-related. Cannabis intake increases the risk of traffic accidents. The purpose of this study was to see how different clinical tests and observations were related to blood THC concentrations and to determine whether the combined influence of THC and ethanol was different from either drug alone.

DESIGN

A retrospective cross-sectional forensic database study.

SETTING

Drivers apprehended by the police suspected of driving under the influence of alcohol and other drugs.

PARTICIPANTS

We investigated 589 cases positive for THC only. In addition, 894 cases with THC and ethanol were included. A comparison was made with 3480 drivers with only ethanol in their blood and 79 drivers who tested negative.

MEASUREMENTS

Data were analytical results of blood samples and the 27 clinical tests and observations included in the Norwegian clinical test for impairment (CTI).

FINDINGS

No relationship was found between blood THC concentration and most of the CTI tests. Blood THC concentration was, however, related to conjunctival injection, pupil dilation and reaction to light and to the overall risk of being judged impaired. When THC and ethanol were detected together the risk of being judged impaired was increased markedly.

CONCLUSIONS

This study demonstrates that cannabis impairs driving ability in a concentration-related manner. The effect is smaller than for ethanol. The effect of ethanol and cannabis taken simultaneously is additive. Conjunctival injection, dilated pupils and slow pupil reaction are among the few signs to reveal THC influence.

Prevalence of adverse drug combinations in a large post-mortem toxicology database

The prevalence of important adverse drug combinations was studied among the 37,367 cases included in the Finnish post-mortem toxicology database during 2000-2006. The new SFINX interaction database (Swedish, Finnish, INteraction X-referencing) was utilised to identify adverse drug combinations. Consequently, the 24 drugs chosen for the study generated 96 two-compound combinations possessing potentially severe interactions. The total number of hits for the combinations found in the post-mortem database was 267, which accounts for approximately 0.71% of all cases. The potential role of adverse drug interaction (ADI) in these cases was evaluated from the background information and death certificate. The possible ADI cases comprised 23% of all hits and 0.17% of all cases analysed. In cases with a pharmacodynamic mechanism, the most prominent combinations were medicines causing serotonin syndrome or a beta(1)-blocker with verapamil or diltiazem. In cases with a pharmacokinetic mechanism, half of the cases involved digoxin in combination with verapamil. In one third of the possible ADI cases, a forensic pathologist had noted the studied compounds as an underlying or contributing cause of death, although the agents' specific role in ADIs was rarely recognised.

Classes of drugs and their prevalence in multiple drug intoxication in suicides and accidents

In autopsy cases of multiple drug intoxication (MDI), the drugs identified may seem inadequate to cause death, especially when no drug is present in a concentration that is considered lethal. We sought to describe the combinations of drugs in MDI and to discern trends that could aid in the investigation of these deaths. Medical examiner autopsy cases were surveyed. MDI was established by postmortem blood screening. Of 24 cases, 13 were determined to be suicides, 9 were accidents, and 2 were indeterminate. The mean age was 37 years. Men were more likely to die from MDI by accident while women were more likely to die from suicide. The mean number of drugs found in suicides was 4, compared to 2 in accidents (p=0.0274). Opiates, antidepressants, benzodiazepines, ethanol, and cocaine were equally likely to be present in either group. Other legal drugs were more likely to be found in the suicides (p=0.0115). Ethanol was considerably less common in fatal MDI than controlled prescription drugs such as opiates and benzodiazepines, and also less common than other prescription drugs. These data suggest profiles that may help elucidate manner of death in indeterminate cases of death from MDI.

Massive intoxication involving unusual high concentration of amitriptyline

Amitriptyline is a tricyclic antidepressant widely used in the treatment of depression. Antidepressant drugs are among the most commonly encountered causes of self-poisoning, as illustrated by several published cases in the literature. This investigation reports a case of massive amitriptyline intoxication, involving a 44-year old female found dead in bed. The presence of this tricyclic antidepressant was revealed by a routine screening procedure. The concentration was calculated by gas chromatography/ electron ionization-mass spectrometry in the selected ion monitoring mode after solid-phase extraction using proadifen as internal standard and was in the post-mortem whole blood sample 85.9 mug/mL. This value was much higher than the reported toxic values ever found in the literature, and may therefore have caused the victim's death. Nortriptyline was also detected in the toxic concentration range, as well as therapeutic levels of diazepam and nor-diazepam. Taking into account both the available circumstantial information and toxicological results, it is very likely that death was caused by self-poisoning. Human & Experimental Toxicology (2007) 26, 667-670.