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Garneau B, Roy C, Motard J, Desharnais B, Bouchard C, Mireault P. Atypical postmortem redistribution in chronic methadone consumers. J Anal Toxicol 2024:bkae016. [PMID: 38491986 DOI: 10.1093/jat/bkae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 02/09/2024] [Accepted: 02/26/2024] [Indexed: 03/18/2024] Open
Abstract
Available literature demonstrates that methadone is prone to moderate postmortem redistribution, but subject to high interindividual variability in the central to peripheral blood concentration ratios (C/P). In this case series, 10 cases of chronic methadone users displaying C/P < 1 (range 0.26-0.82) are described. Femoral, cardiac and ante-mortem blood concentrations of methadone and its metabolite 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) are reported for all cases, as well as sex, age, case history, results of the pathological investigation, other toxicological findings and cause and manner of death. EDDP blood concentrations, similar in both central and peripheral blood, as well as ante-mortem blood concentration results in Case 4, demonstrate that this atypical C/P < 1 finding is attributable to postmortem changes and not analytical or pre-analytical artifacts. Case 4 is a particularly instructive example, with femoral blood concentration (966 ng/mL) approximately twice as high as cardiac blood (499 ng/mL) and ante-mortem blood (418 ng/mL, collected 38 min prior to death)-clearly demonstrating that cardiac blood methadone concentration is more representative of the ante-mortem blood concentration in this case. In Case 4 and four others, toxicological interpretation based on femoral blood concentration alone would have been misleading. Based on these results and evidence from the literature, it is hypothesized that methadone bioaccumulates in the tissues of chronic users and redistributes from thigh tissues into femoral blood, increasing the concentration postmortem. This case series highlights how femoral blood is not always preserved from postmortem changes and that the analysis of multiple blood sources is necessary to avoid a misleading toxicological interpretation-particularly for cases of chronic methadone users.
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Affiliation(s)
- Béatrice Garneau
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais St., Montréal, Québec H2K 3S7, Canada
| | - Cynthia Roy
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais St., Montréal, Québec H2K 3S7, Canada
| | - Julie Motard
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais St., Montréal, Québec H2K 3S7, Canada
| | - Brigitte Desharnais
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais St., Montréal, Québec H2K 3S7, Canada
- Department of Environmental and Occupational Health, Université de Montréal School of Public Health, PO Box 6128, Station Centre-ville, Montréal, Québec H3C 3J7, Canada
| | - Corinne Bouchard
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais St., Montréal, Québec H2K 3S7, Canada
| | - Pascal Mireault
- Department of Toxicology, Laboratoire de sciences judiciaires et de médecine légale, 1701 Parthenais St., Montréal, Québec H2K 3S7, Canada
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Wang XM, Wang J, Fokina V, Patrikeeva S, Rytting E, Ahmed MS, La JH, Nanovskaya T. Effect of deuteration on the single dose pharmacokinetic properties and postoperative analgesic activity of methadone. Drug Metab Pharmacokinet 2022; 47:100477. [PMID: 36368298 PMCID: PMC9886271 DOI: 10.1016/j.dmpk.2022.100477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/26/2022] [Accepted: 10/04/2022] [Indexed: 02/01/2023]
Abstract
Although methadone is effective in the management of acute pain, the complexity of its absorption-distribution-metabolism-excretion profile limits its use as an opioid of choice for perioperative analgesia. Because deuteration is known to improve the pharmacokinetic, pharmacodynamic and toxicological properties of some drugs, here we characterized the single dose pharmacokinetic properties and post-operative analgesic efficacy of d9-methadone. The pharmacokinetic profiles of d9-methadone and methadone administered intravenously to CD-1 male mice revealed that deuteration leads to a 5.7- and 4.4-fold increase in the area under the time-concentration curve and maximum concentration in plasma, respectively, as well as reduction in clearance (0.9 ± 0.3 L/h/kg vs 4.7 ± 0.8 L/h/kg). The lower brain-to-plasma ratio of d9-methadone compared to that of methadone (0.35 ± 0.12 vs 2.05 ± 0.62) suggested that deuteration decreases the transfer of the drug across the blood-brain barrier. The estimated LD50 value for a single intravenous dose of d9-methadone was 2.1-fold higher than that for methadone. Moreover, d9-methadone outperformed methadone in the efficacy against postoperative pain by primarily activating peripheral opioid receptors. Collectively, these data suggest that the replacement of three hydrogen atoms in three methyl groups of methadone altered its pharmacokinetic properties, improved safety, and enhanced its analgesic efficacy.
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Affiliation(s)
- Xiao-Ming Wang
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Jigong Wang
- Department of Neuroscience, Cell Biology and Anatomy, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Valentina Fokina
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Svetlana Patrikeeva
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Erik Rytting
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Mahmoud S Ahmed
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Jun-Ho La
- Department of Neuroscience, Cell Biology and Anatomy, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Tatiana Nanovskaya
- Maternal-Fetal Pharmacology and Bio-Development Laboratories, Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, TX, 77555, USA.
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4
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Havig SM, Vindenes V, Øiestad ÅML, Rogde S, Thaulow CH. Methadone, Buprenorphine, Oxycodone, Fentanyl, and Tramadol in Multiple Postmortem Matrices. J Anal Toxicol 2021; 46:600-610. [PMID: 34115841 PMCID: PMC9282245 DOI: 10.1093/jat/bkab071] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 05/11/2021] [Accepted: 06/11/2021] [Indexed: 11/28/2022] Open
Abstract
Peripheral blood (PB) concentrations are generally preferred for postmortem toxicological interpretation, but some autopsy cases may lack blood for sampling due to decomposition or large traumas, etc. In such cases, other tissues or bodily fluids must be sampled; however, limited information exists on postmortem concentrations in matrices other than blood. Pericardial fluid (PF), muscle and vitreous humor (VH) have been suggested as alternatives to blood, but only a few studies have investigated the detection of opioids in these matrices. In this study, we aimed to investigate the detection of methadone, buprenorphine, oxycodone, fentanyl and tramadol in postmortem samples of PF, skeletal muscle and VH, in addition to PB and cardiac blood and if drug concentrations in these alternative matrices were comparable to those in PB and thereby useful for interpretation. In most of the 54 included cases, only one opioid was detected. Methadone, oxycodone, fentanyl and tramadol were detected in all of the alternative matrices in almost all cases, while buprenorphine was detected less often. For methadone, the concentrations in the alternative matrices, except in VH, were relatively similar to those in PB. Larger variations in concentrations were found for buprenorphine, oxycodone and tramadol. Quantitative analyses appeared useful for fentanyl, in all of the alternative matrices, but only four cases were included. Toxicological analyses of opioids in these alternative postmortem matrices can be useful for detection, but quantitative results must be interpreted with caution.
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Affiliation(s)
| | - Vigdis Vindenes
- Department of Forensic Sciences, Oslo University Hospital.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo
| | | | - Sidsel Rogde
- Department of Forensic Sciences, Oslo University Hospital
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Giorgetti A, Pascali J, Montisci M, Amico I, Bonvicini B, Fais P, Viero A, Giorgetti R, Cecchetto G, Viel G. The Role of Risk or Contributory Death Factors in Methadone-Related Fatalities: A Review and Pooled Analysis. Metabolites 2021; 11:metabo11030189. [PMID: 33810163 PMCID: PMC8004630 DOI: 10.3390/metabo11030189] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 12/16/2022] Open
Abstract
Methadone-related deaths are characterized by a wide range of post-mortem blood concentrations, due to the high pharmacokinetic/dynamic inter-individual variability, the potential subjective tolerance state and to other risk factors or comorbidities, which might enhance methadone acute toxicity. In the present study, the association among pre-existing and external conditions and diseases and the resultant methadone death capacity have been investigated. Beside a systematic literature review, a retrospective case-control study was done, dividing cases in which methadone was the only cause of death (controls), and those with associated clinical-circumstantial (naive/non-tolerant state), pathological (pulmonary or cardiovascular diseases) or toxicological (other drugs detected) conditions. Methadone concentrations were compared between the two groups and the association with conditions/diseases was assessed by multiple linear and binomial logistic regressions. Literature cases were 139, in house 35, consisting of 22 controls and 152 cases with associated conditions/diseases. Mean methadone concentrations were 2122 ng/mL and 715 ng/mL in controls and cases respectively, with a statistically significant difference (p < 0.05). Lower methadone concentrations (by 24, 19 and 33% respectively) were detected in association with naive/non-tolerant state, pulmonary diseases and presence of other drugs, and low levels of methadone (<600 ng/mL) might lead to death in the presence of the above conditions/diseases.
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Affiliation(s)
- Arianna Giorgetti
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Jennifer Pascali
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Massimo Montisci
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Irene Amico
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Barbara Bonvicini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Paolo Fais
- DIMEC, Department of Medical and Surgical Sciences, University of Bologna, 40126 Bologna, Italy; (A.G.); (P.F.)
| | - Alessia Viero
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Raffaele Giorgetti
- Department of Excellence of Biomedical Sciences and Public Health, University “Politecnica delle Marche” of Ancona, via Conca 71, 60126 Ancona, Italy;
| | - Giovanni Cecchetto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
| | - Guido Viel
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35121 Padova, Italy; (J.P.); (M.M.); (I.A.); (B.B.); (A.V.); (G.C.)
- Correspondence:
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Iwersen-Bergmann S, Plattner S, Hischke S, Müller A, Andresen-Streichert H, Jungen H, Erb R, Beer-Sandner B. Brain/blood ratios of methadone and ABCB1 polymorphisms in methadone-related deaths. Int J Legal Med 2021; 135:473-482. [PMID: 33454797 PMCID: PMC7870766 DOI: 10.1007/s00414-021-02502-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 01/04/2021] [Indexed: 01/16/2023]
Abstract
Methadone is an opioid that often leads to fatalities. Interpretation of toxicological findings can be challenging if no further information about the case history is available. The aims of this study were (1) to determine whether brain/blood ratios can assist in the interpretation of methadone findings in fatalities; (2) to examine whether polymorphisms in the gene encoding the P-glycoprotein (also known as multidrug resistance protein 1 (MDR1) or ATP-binding cassette sub-family B member 1 (ABCB1)), which functions as a multispecific efflux pump in the blood–brain barrier, affect brain/blood ratios of methadone. Femoral venous blood and brain tissue (medulla oblongata and cerebellum) from 107 methadone-related deaths were analysed for methadone by gas chromatography-mass spectrometry. In addition, all the samples were genotyped for three common ABCB1 single nucleotide polymorphisms (SNPs rs1045642, rs1128503, and rs2032582) using ion-pair reversed-phase high-performance liquid chromatography-electrospray ionization mass spectrometry (ICEMS). In nearly all cases, methadone concentrations were higher in the brain than in the blood. Inter-individual brain/blood ratios varied (0.6–11.6); the mean ratio was 2.85 (standard deviation 1.83, median 2.35). Moreover, significant differences in mean brain/blood ratios were detected among the synonymous genotypes of rs1045642 in ABCB1 (p = 0.001). Cases with the T/T genotype had significantly higher brain/blood ratios than cases with the other genotypes (T/T vs. T/C difference (d) = 1.54, 95% CI [1.14, 2.05], p = 0.002; T/T vs. C/C d = 1.60, 95% CI [1.13, 2.29], p = 0.004). Our results suggest that the rs1045642 polymorphisms in ABCB1 may affect methadone concentrations in the brain and its site of action and may be an additional factor influencing methadone toxicity.
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Affiliation(s)
- S Iwersen-Bergmann
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
| | - S Plattner
- Institute of Legal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - S Hischke
- Institute for Health Services Research in Dermatology and Nursing, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - A Müller
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - H Andresen-Streichert
- Institute of Legal Medicine, Faculty of Medicine, University of Cologne, Köln, Germany
| | - H Jungen
- Department of Legal Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - R Erb
- Institute of Legal Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - B Beer-Sandner
- Institute of Legal Medicine, Innsbruck Medical University, Innsbruck, Austria
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7
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Ketola RA, Kriikku P. Drug concentrations in post‐mortem specimens. Drug Test Anal 2019; 11:1338-1357. [DOI: 10.1002/dta.2662] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 06/10/2019] [Accepted: 06/11/2019] [Indexed: 01/20/2023]
Affiliation(s)
- Raimo A. Ketola
- Forensic Toxicology UnitNational Institute for Health and Welfare (THL) Mannerheimintie 166 FI‐00270 Helsinki Finland
| | - Pirkko Kriikku
- Forensic Toxicology UnitNational Institute for Health and Welfare (THL) Mannerheimintie 166 FI‐00270 Helsinki Finland
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Mikkelsen CR, Jornil JR, Andersen LV, Banner J, Hasselstrøm JB. Distribution of Eight QT-Prolonging Drugs and Their Main Metabolites Between Postmortem Cardiac Tissue and Blood Reveals Potential Pitfalls in Toxicological Interpretation. J Anal Toxicol 2019; 42:375-383. [PMID: 29579279 DOI: 10.1093/jat/bky018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/12/2018] [Indexed: 12/13/2022] Open
Abstract
Femoral blood concentrations are usually used in postmortem toxicology to assess possible toxic effects of drugs. This includes QT-prolongation and other cardiac dysrhythmia, which could have been the cause of death. However, blood concentration is only a surrogate for the active site concentration, and therefore cardiac tissue concentration may provide a more accurate toxicological interpretation. Thus, cardiac tissue and femoral and cardiac blood concentrations were examined for eight frequently used QT-prolonging drugs (QTD) and their metabolites in a mentally ill population. In total, 180 cases were included from the Danish autopsy-based forensic study SURVIVE. The concentrations were analyzed using ultra-performance liquid chromatography coupled with tandem mass spectrometry utilizing stable isotopically labeled internal standards. The results showed that the cardiac tissue concentrations were significantly higher compared to femoral and cardiac blood concentrations, with two exceptions. The median cardiac tissue-to-femoral blood concentration ratio (Kb) ranged from 2.2 (venlafaxine) to 15 (nortriptyline). The inter-individual fold difference between the minimum and maximum Kb ranged from 2.6-fold (Z-hydroxynortriptyline) to 61 (venlafaxine). For 12 compounds, postmortem redistribution appeared to be minimal, whereas four compounds displayed some degree of postmortem redistribution. Citalopram and quetiapine were selected for in-depth analysis of the relation between the toxicological interpretation and femoral blood/cardiac tissue concentrations. Within this dataset, citalopram displayed a wide overlap in cardiac tissue concentrations (~50%) between non-toxic and toxic citalopram cases, as estimated from femoral blood concentrations. In contrast, quetiapine displayed no overlap in cardiac tissue concentrations between non-toxic and toxic quetiapine cases based on femoral blood concentrations. The implication of the citalopram finding is that possible intoxications can be overlooked when only considering femoral blood concentrations. Based on the present findings, non-toxic cardiac tissue 10th-90th percentile concentration ranges were estimated for citalopram (0.93-4.4 mg/kg) and quetiapine (0.0073-0.60 mg/kg).
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Affiliation(s)
- Christian R Mikkelsen
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Jakob R Jornil
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Ljubica V Andersen
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark.,Department of Clinical Pharmacology, Aarhus University, Wilhelm Meyers Allé 4, Aarhus C, Denmark
| | - Jytte Banner
- Section of Forensic Pathology, Department of Forensic Medicine, University of Copenhagen, Frederik V's Vej 11, Copenhagen, Denmark
| | - Jørgen B Hasselstrøm
- Section of Forensic Chemistry, Department of Forensic Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
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Brockbals L, Staeheli SN, Gascho D, Ebert LC, Kraemer T, Steuer AE. Time-Dependent Postmortem Redistribution of Opioids in Blood and Alternative Matrices. J Anal Toxicol 2019; 42:365-374. [PMID: 29579266 DOI: 10.1093/jat/bky017] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 02/12/2018] [Indexed: 12/20/2022] Open
Abstract
Forensic postmortem case interpretation can be challenging, in particular due to postmortem redistribution (PMR) phenomena. Recent studies have shown that computed tomography (CT)-guided collection of biopsy samples using a robotic arm (virtobot) provides a valuable tool for systematic studies on time-dependent PMR. Utilizing this strategy, several cases involving opioid use such as methadone, fentanyl, tramadol, codeine, oxycodone and hydrocodone were evaluated for time-dependent concentration changes and potential redistribution mechanisms. Upon admission to the institute (t1), blood (femoral and right ventricle heart blood) and tissue biopsy samples (lung, kidney, liver, spleen, thigh muscle and adipose tissue) were collected utilizing CT-guided biopsy. Approximately 24 h later (t2; mean 28 ± 15 h), during the autopsy, samples from the same body regions were collected manually and in addition brain tissue, gastric content, urine and left ventricle heart blood. Analysis was conducted with liquid chromatography tandem mass spectrometry. Significant time-dependent methadone concentration increases in femoral blood (pB) indicate the occurrence of PMR, however, ultimately not relevant for forensic interpretation. The main metabolite of methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), showed a less significant trend for PMR. Redistribution by passive diffusion along the muscle-to-pB concentration gradient seems likely for methadone, but not for EDDP. Results for fentanyl suggest extensive PMR. Other opioids such as tramadol, codeine, hydrocodone and oxycodone showed no consistent trend for significant PMR. Overall, CT-guided biopsy sampling proved to be a valuable tool for the investigation of PMR mechanisms.
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Affiliation(s)
- Lana Brockbals
- Department of Forensic Pharmacology and Toxicology, Zurich Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, Zurich, Switzerland
| | - Sandra N Staeheli
- Department of Forensic Pharmacology and Toxicology, Zurich Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, Zurich, Switzerland
| | - Dominic Gascho
- Department of Forensic Medicine and Imaging, Zurich Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, Zurich, Switzerland
| | - Lars C Ebert
- Department of Forensic Medicine and Imaging, Zurich Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, Zurich, Switzerland
| | - Thomas Kraemer
- Department of Forensic Pharmacology and Toxicology, Zurich Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, Zurich, Switzerland
| | - Andrea E Steuer
- Department of Forensic Pharmacology and Toxicology, Zurich Institute of Forensic Medicine, University of Zurich, Winterthurerstrasse 190/52, Zurich, Switzerland
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Abstract
One hundred fifteen Americans die every day from opioid overdose. These overdose fatalities have been augmented by the increased availability of potent synthetic opioids, such as fentanyl and its derivatives. The death rate of synthetic opioids, other than methadone, increased by 72.2% from 2014 to 2015, and doubled from 2015 to 2016, situating the USA in the midst of an opioid overdose epidemic. The analytical identification of these opioids in postmortem samples and the correct toxicological data interpretation is critical to identify and implement preventive strategies. This article reviews the current knowledge of postmortem toxicology of synthetic opioids and the chemical and pharmacological factors that may affect drug concentrations in the different postmortem matrices and therefore, their interpretation. These factors include key chemical properties, essential pharmacokinetics parameters (metabolism), postmortem redistribution and stability data in postmortem samples. Range and ratios of concentrations reported in traditional and non-traditional postmortem specimens, blood, urine, vitreous humor, liver and brain, are summarized in tables. The review is focused on fentanyl and derivatives (e.g., acetyl fentanyl, butyryl fentanyl, carfentanil, furanyl fentanyl, 4-methoxybutyrylfentanyl, 4-fluorobutyrylfentanyl, ocfentanil) and non-traditional opioid agonists (e.g., AH-7921, MT-45, U-47700). All of these data are critically compared to postmortem data, and chemical and pharmacological properties of natural opioids (morphine), semi-synthetic (oxycodone, hydrocodone, hydromorphone, and oxymorphone), and synthetic opioids (methadone and buprenorphine). The interpretation of drug intoxication in death investigation is based on the available published literature. This review serves to facilitate the evaluation of cases where synthetic opioids may be implicated in a fatality through the critical review of peer reviewed published case reports and research articles.
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Affiliation(s)
- Marta Concheiro
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY, United States
| | - Rachel Chesser
- Department of Sciences, John Jay College of Criminal Justice, City University of New York, New York, NY, United States
| | - Justine Pardi
- Department of Forensic Toxicology, New York Office of the Chief Medical Examiner, New York, NY, United States
| | - Gail Cooper
- Department of Forensic Toxicology, New York Office of the Chief Medical Examiner, New York, NY, United States
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Montanari E, Bonasoni MP, Licata M, Salomone A, Gerace E, Vivarelli M, Giorgetti R, Tagliabracci A. Toxicological and histological analyses for a stillborn delivered by a mother under methadone maintenance therapy. Forensic Toxicol 2018. [DOI: 10.1007/s11419-017-0402-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Nedahl M, Johansen S, Linnet K. Reference Brain and Blood Concentrations of Olanzapine in Postmortem Cases. J Anal Toxicol 2018; 42:650-654. [DOI: 10.1093/jat/bky036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Michael Nedahl
- Department of Forensic Medicine, University of Copenhagen, Frederik V’s vej 11, 3. Floor, 2100 Copenhagen Ø, Denmark
| | - Sys Johansen
- Department of Forensic Medicine, University of Copenhagen, Frederik V’s vej 11, 3. Floor, 2100 Copenhagen Ø, Denmark
| | - Kristian Linnet
- Department of Forensic Medicine, University of Copenhagen, Frederik V’s vej 11, 3. Floor, 2100 Copenhagen Ø, Denmark
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Christensen MR, Bugge A, Malik ME, Thomsen JL, Lynnerup N, Rungby J, Banner J. Establishing post mortem criteria for the metabolic syndrome: an autopsy based cross-sectional study. Diabetol Metab Syndr 2018; 10:36. [PMID: 29713389 PMCID: PMC5918842 DOI: 10.1186/s13098-018-0339-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/18/2018] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Individuals who suffer from mental illness are more prone to obesity and related co-morbidities, including the metabolic syndrome. Autopsies provide an outstanding platform for the macroscopic, microscopic and molecular-biological investigation of diseases. Autopsy-based findings may assist in the investigation of the metabolic syndrome. To utilise the vast information that an autopsy encompasses to elucidate the pathophysiology behind the syndrome further, we aimed to both develop and evaluate a method for the post mortem definition of the metabolic syndrome. METHODS Based on the nationwide Danish SURVIVE study of deceased mentally ill, we established a set of post mortem criteria for each of the harmonized criteria of the metabolic syndrome. We based the post mortem (PM) evaluation on information from the police reports and the data collected at autopsy, such as anthropometric measurements and biochemical and toxicological analyses (PM information). We compared our PM evaluation with the data from the Danish health registries [ante mortem (AM) information, considered the gold standard] from each individual. RESULTS The study included 443 deceased individuals (272 male and 171 female) with a mean age of 50.4 (± 15.5) years and a median (interquartile range) post mortem interval of 114 (84-156) hours. We found no significant difference when defining the metabolic syndrome from the PM information in comparison to the AM information (P = 0.175). The PM evaluation yielded a high specificity (0.93) and a moderate sensitivity (0.63) with a moderate level of agreement compared to the AM evaluation (Cohen's κ = 0.51). Neither age nor post mortem interval affected the final results. CONCLUSIONS Our model of a PM definition of the metabolic syndrome proved reliable when compared to the AM information. We believe that an appropriate estimate of the prevalence of the metabolic syndrome can be established post mortem. However, while neither the PM nor the AM information is exhaustive in terms of defining an individual's health status, a superlative estimate may be obtained by combining the PM and the AM information. With this model, we open up the possibility of utilising autopsy data for future studies of the metabolic syndrome.
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Affiliation(s)
| | - Anne Bugge
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Forensic Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Jørgen Lange Thomsen
- Department of Forensic Medicine, University of Southern Denmark, Odense, Denmark
| | - Niels Lynnerup
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen Rungby
- Department of Endocrinology, Bispebjerg Hospital, Copenhagen, Denmark
| | - Jytte Banner
- Department of Forensic Medicine, University of Copenhagen, Copenhagen, Denmark
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Lemaire E, Schmidt C, Dubois N, Denooz R, Charlier C, Boxho P. Site-, Technique-, and Time-Related Aspects of the Postmortem Redistribution of Diazepam, Methadone, Morphine, and their Metabolites: Interest of Popliteal Vein Blood Sampling. J Forensic Sci 2017; 62:1559-1574. [DOI: 10.1111/1556-4029.13404] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 11/06/2016] [Accepted: 11/09/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Eric Lemaire
- Department of Pathology; University Hospital - CHU Sart Tilman; Domaine Universitaire du Sart Tilman - B.35; Liège B-4000 Belgium
- Department of Forensic Medicine; Medico-legal Institute of the University of Liège; Rue Dos-Fanchon 37; B-4020 Liège Belgium
| | - Carl Schmidt
- Department of Pathology; University of Michigan; 300 N. Ingalls, NI2D22, SPC 5452 Ann Arbor Michigan 48109 USA
| | - Nathalie Dubois
- Medico-legal Toxicology Laboratory; University Hospital - CHU Sart Tilman; Domaine Universitaire du Sart-Tilman - B.35; Liège B-4000 Belgium
| | - Raphael Denooz
- Medico-legal Toxicology Laboratory; University Hospital - CHU Sart Tilman; Domaine Universitaire du Sart-Tilman - B.35; Liège B-4000 Belgium
| | - Corinne Charlier
- Medico-legal Toxicology Laboratory; University Hospital - CHU Sart Tilman; Domaine Universitaire du Sart-Tilman - B.35; Liège B-4000 Belgium
| | - Philippe Boxho
- Department of Forensic Medicine; Medico-legal Institute of the University of Liège; Rue Dos-Fanchon 37; B-4020 Liège Belgium
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15
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Skov L, Holm KMD, Linnet K. Nitrobenzodiazepines: Postmortem brain and blood reference concentrations. Forensic Sci Int 2016; 268:39-45. [DOI: 10.1016/j.forsciint.2016.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 08/20/2016] [Accepted: 09/02/2016] [Indexed: 10/21/2022]
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16
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Skov L, Holm KMD, Johansen SS, Linnet K. Postmortem Brain and Blood Reference Concentrations of Alprazolam, Bromazepam, Chlordiazepoxide, Diazepam, and their Metabolites and a Review of the Literature. J Anal Toxicol 2016; 40:529-36. [DOI: 10.1093/jat/bkw059] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 04/24/2016] [Indexed: 12/20/2022] Open
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17
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Holm KMD, Linnet K. Determination of the unbound fraction of R- and S-methadone in human brain. Int J Legal Med 2016; 130:1519-1526. [DOI: 10.1007/s00414-016-1365-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 03/29/2016] [Indexed: 10/22/2022]
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18
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Lusetti M, Licata M, Silingardi E, Reggiani Bonetti L, Palmiere C. Therapeutic and recreational methadone cardiotoxicity. J Forensic Leg Med 2016; 39:80-4. [PMID: 26859696 DOI: 10.1016/j.jflm.2016.01.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2015] [Revised: 12/07/2015] [Accepted: 01/18/2016] [Indexed: 11/30/2022]
Abstract
Several classes of drugs have been associated with an increased risk of cardiovascular disease and occurrence of arrhythmias potentially involved in sudden deaths in chronic users even at therapeutic doses. The study presented herein focuses on pathological changes involving the heart possibly due to methadone use. 60 cases were included in the study in total and were divided into three groups (therapeutic methadone users: 20 cases, recreational methadone users: 20 cases, and sudden death group in subjects who had never taken methadone: 20 cases). Autopsies, histology, biochemistry and toxicology were performed in all cases. Macroscopic and microscopic investigation results in therapeutic methadone users were similar to those observed in sudden, unexpected deaths in non-methadone users. In recreational methadone consumers, macroscopic and microscopic examination of the heart failed to provide results consistent with acute or chronic myocardial or coronary damage, thereby corroborating the hypothesis of death most likely following respiratory depression.
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Affiliation(s)
- Monia Lusetti
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Manuela Licata
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Enrico Silingardi
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Legal Medicine, Modena, Italy
| | - Luca Reggiani Bonetti
- Department of Diagnostic Medicine, Clinical and Public Health, University of Modena and Reggio Emilia - Section of Clinical Pathology, Modena, Italy
| | - Cristian Palmiere
- University Center of Legal Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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