A critical review of the causes of death among post-mortem toxicological investigations: analysis of 34 buprenorphine-associated and 35 methadone-associated deaths

AIMS

To assess the trends in the number, mortality and the nature of forensic cases involving toxicological detection of buprenorphine or methadone among toxicological investigations performed in Paris from June 1997 to June 2002.

DESIGN

Retrospective, 5 year study with review of premortem data, autopsy, police reports, hospital data, and post-mortem toxicological analyses.

SETTING AND PARTICIPANTS

34 forensic cases of buprenorphine and 35 forensic cases of methadone detection among 1600 toxicological investigations performed at the Laboratory of Toxicology in the Medical Examiner's Office in Paris.

MEASUREMENTS AND RESULTS

Therapeutic, toxic or lethal drug concentrations were defined based upon the results of blood analyses and the published literature. Drug concentrations were cross-referenced with other available ante- and post-mortem data. Subsequently, we classified a 'clear responsibility', 'possible responsibility' or 'not causative' role for buprenorphine or methadone in the death process, or 'no explanation of death'. Buprenorphine and methadone can be regarded as being directly implicated in, respectively, four of 34 death cases (12%) and three of 35 death cases (9%), and their participation in the lethal process is strongly plausible in eight (buprenorphine) and 11 (methadone) additional deaths.

CONCLUSIONS

Analysis of causes of death reveals the difficulties in determining the role of substitution drugs in the death process, as many other factors may be involved, including circumstances surrounding death, past history, differential selection of subjects into either substitution modality and concomitant intake of other drugs (especially benzodiazepines and neuroleptics). The potential for synergistic or additive actions by other isolated molecules-particularly opioids, benzodiazepines, other psychotropes and alcohol-must be also considered.

[Eosinophilia and renal pathology]

Although rare, renal involvement during hypereosinophilic syndromes can lead to life-threatening situations. Since eosinophilic renal lesions can occur in a wide range of primary or secondary diseases, diagnosis can pose difficult clinical dilemmas. In some settings, renal lesions may be a predictable complication as in essential hypereosinophilic syndrome or angiolymphoid hyperplasia with eosinophilia. In other cases, renal lesions may be a highly unusual event secondary to cholesterol embolization, drug-induced reactions, immunoallergic responses, eosinophilic helminthic infection, or maintenance hemodialysis. The mechanisms of renal involvement are complex. In hypereosinophilic syndromes, renal involvement has been attributed to the deleterious effects of eosinophil granules and possibly to micro-emboli from the heart in patients presenting fibroplastic endocarditis or eosinophilic myocarditis. Most secondary forms are usually due to an immuno-allergic process leading to deposit of immune complexes in glomeruli. The effects of polynuclear eosinophils could also be due to release of cytokines and other mediators such as leukotriens. Cholesterol embolization involves a different mechanism in which hypereosinophilia is often moderate and accessory to arteriolar lesions. Eosinophiluria may be observed in any setting but the prognostic value of this finding as well as the mechanism underlying remain unclear.

[Electrocardiographic changes due to halofantrine in the treatment of malaria: therapeutic implications]

Electrocardiographic changes and their relationship with profiles of halofantrine (H) and desbutylhalofantrine (DBH) were assessed in a prospective study of 34 male patients with an uncomplicated falciparum malaria. H. was delivered in a one day in three intakes, 24 mg/kg/day. Seven days later the same regimen was administered. This study included a twelve-lead-electrocardiogram (to measure QTc interval), an ambulatory ECG monitoring a signal-averaged-electrocardiogram (to detect late ventricular potentials), and a kinetic-time profile of H. and DBH with high performance liquid chromatography. Data were obtained as follows: day 1 just prior to drug intake, 6 hours (H6), 12 hours (H12) after to drug delivery on day 1 and 8. There after on days 2, 3, 4, 9, 10, 11. Ambulatory ECG monitoring was recorded on day 1 and 8. QTc lengthening was noted in 10 patients with a mean QTc interval of 451 msec (range: 440-469 msec). Maximum QTc interval was obtained at H12 on day 1 (p < 0.0002) and 8 (p < 0.03). Signal-averaged electrocardiogram performed in 8 cases disclosed late potential in 4 cases (day 4: one case, day 9: 3 cases). No ventricular arrhythmia was observed on day 1 and 8. Plasma concentration time profile of H. showed a significant increase at day 8 H12 with a time effect (p < 0.0008) and a significant time-intake interaction (p < 0.02). QTc interval was significantly correlated with H. plasma level (p < 0.01) but not with D.B.H.. Late potentials were associated in 3 cases with a maximum plasma concentration level of H. These data showed that H. is potentially deleterious with a cardiac toxicity which appears dose-related, particularly during the second cure. Following this study, new prescription rules has been proposed before H. therapy.

[Drinking water for troops in the field]

To provide for Armed Forces' water wants, drinking water is only used. Its production is not an easy thing in military operations. Armed Forces must use their own production means. Four new individual and collective field purification systems adapted to manpower, will been soon in use in the French Army. Filtration or distillation processes always with chlorine addition are used. The results give satisfaction in bacterial epuration; nevertheless chemical and nuclear risks are not controlled except in case of distillation mechanism associated with ion resins exchanging and charcoal filtration.

[Aluminum, hypothetic cause of Alzheimer disease]

A great deal of research has focused on aluminium as a putative causative factor in Alzheimer's disease. We measured by atomic absorption spectrophotometry aluminium levels in blood, urine and cerebrospinal fluid from 15 patients with Alzheimer's disease, compared with 20 control individuals. There were no statistically significant differences between the two groups. This suggests that aluminium is not a causative factor for Alzheimer's disease.

Acute renal failure following collective intoxication by Cortinarius orellanus

Twenty-six young men with no previous medical history all ingested mushroom soup, exclusively made with Cortinarius orellanus. They were hospitalized 10-12 days after the incident. On admission, 12 patients presented with acute tubulointerstitial nephritis with acute renal failure; 8 required haemodialysis. In addition to symptomatic treatment, 9 patients were given corticosteroids. In this group of 12 patients, 8 recovered rapidly, and the other 4 suffered from chronic renal failure for several months. In the other group of 14 patients, initial leukocyturia was observed in 12 cases, although renal function remained normal during a one-year follow-up. Hepatic acetylation and hydroxylation tests performed after 6 months in 22 patients did not provide any explanation for the strong individual sensitivity to the renal toxicity of this fungus.

[Borderline arterial hypertension in young adults: contribution of paraclinical investigations]

The comparison of 106 young adults with borderline hypertension to 85 controls allow to specify the contribution of paraclinic investigations in the diagnosis. Ambulatory blood pressure monitoring reveal the lack of lability of borderline hypertensives and cannot find predictive index of subsequent established hypertension. Results of exercise testing disclose correlation only with overweight. It is the same for increased left ventricular mass assessed by echography. Pulse wave velocity measurement display early arterial modifications.

[Renal risk of vaccinations. Prospective survey and retrospective study]

The risk of renal damage from diphtheria, tetanus and typho-paratyphoid vaccination was assessed by means of a prospective and a retrospective study. The prospective study involved 817 young adults without history nor signs of urinary disease and therefore, with presumably healthy kidneys. Urine samples were taken before and after each injection and examined for proteinuria and microscopic haematuria. After a total of 1712 doses there was no evidence of post-vaccination nephropathy. In a retrospective study of 63 patients with various forms of glomerulonephritis vaccination was found to be responsible for one case of acute renal failure consecutive to proliferative lesions and one case of syndromic reaction in an asymptomatic Berger's disease. These two complementary studies show that post-vaccination nephropathy may occur, albeit rarely, and that current preventive measures should be pursued.

[Electron microprobe ultrastructural localization of aluminium in hepatocytes (authors' transl)]

Liver tissue of a female patient who died of dialysis encephalopathy with aluminium intoxication was studied by electron microscopy and X-ray microprobe analysis. Aluminium was present in high concentrations in lipofuscin granules of hepatocytes and associated with severe lesions of most hepatic cells. The Küpffer cells, however, were normal. A similar study conducted in rats intoxicated by soluble aluminium salts showed that aluminium begins to concentrate in the lysosomes of hepatocytes, where it combines with phosphorus to form an insoluble salt.

Ten years' experience with benzbromarone in the management of gout and hyperuricaemia

The results over 10 years in 200 patients (103 with gout and 97 with hyperuricaemia) treated with benzbromarone 75 - 120 mg/d are reported. The average stable decrease in the serum uric acid level was 54%. The severity and incidence of articular manifestations in the patients with gout were reduced by 75% before the end of the 1st year of treatment; relapses were very uncommon in the following years. In all cases tophaceous deposits disappeared within 6 - 18 months. Adequate fluid intake and alkalinization of urine effectively contributed to a low incidence of urinary incidents (3%), although 35% of the patients were overexcretors of urate before treatment and 33% had a previous history of urolithiasis or associated urinary problems. The drug was well tolerated by 96% of the patients. Renal tolerance has been demonstrated by routine urinalysis and functional tests, as has the long-term safety of the drug with regard to the liver, nervous system and eyes. The biological and clinical results suggest that benzbromarone should be considered as the drug of choice in the majority of gouty and hyperuricaemic patients.