FORENSIC TOXICOLOGY - Bio Medical Forensics

Conversations with two MDMA / MDA clandestine lab operators
indicated that they perceived that the preparation of MDA is simpler
than that of MDMA. In addition, they believed that the chemicals needed
to synthesize MDA were easier to obtain and were not monitored (by the
authorities) as closely as those for the synthesis of MDMA. While
neither of these statements is necessarily true, it is the underground
chemist’s perception that is important. It is also possible that MDA is
included in some ecstasy preparations because of its reputed higher
potency and longer half-life. Methamphetamine might be included in
ecstasy tablets to provide enhanced stimulant effects and to maintain and
increase market size because of the addiction potential of the drug.
Finally, our observations confirm that studies designed to determine
whether ecstasy alone might cause brain damage need to confirm by
forensic drug testing whether ecstasy was the only illicit drug used by
the subject.
The opinions and assertions contained herein are the private views
of the authors and are not to be construed as official or as reflecting
views of the United States Departments of Army or Defense, or of
Health Canada.
Ecstasy, MDA, Methamphetamine
K35 Postmortem Morphine Concentrations –
Are They Meaningful?
Christena L. Langee, MD* and Bruce A. Goldberger, PhD, University
of Florida, Department of Pathology, Immunology and Laboratory
Medicine, PO Box 100275, Gainesville, FL 32610-0275; Julia V.
Martin, MD, District Five Medical Examiner’s Office, 809 Pine Street,
Leesburg, FL 34748
The goals of this presentation are to review factors influencing
postmortem morphine concentrations and to compare concentrations in
terminally ill patients to a varied population. The presentation will
provide recommendations for interpretation of postmortem morphine
concentrations, as well as, describe how these factors can influence the
cause and manner of death.
Introduction: Morphine is a strong opioid agonist that has become
the drug of choice for the treatment of moderate to severe pain associated
with cancer and in palliative and terminal care. One of the most
daunting tasks for forensic pathologists is interpretation of the toxicological
findings. This is especially difficult in decedents with multiple
medical problems who receive morphine and other opioids for comfort
care in the terminal stages of disease, in which high concentrations may
be suspicious for euthanasia. Many factors will alter postmortem morphine
concentrations. Intrinsic factors include general health, disease
processes, renal failure and hepatic function. Postmortem factors include
the postmortem interval, site of specimen collection, and postmortem
redistribution. Medication factors include dosing, frequency, duration of
exposure to opioids and tolerance to opioids. Published therapeutic and
toxic values of morphine are typically based on measures in living, nonchronic
users, and postmortem data obtained from terminal patients
receiving morphine for comfort measures is lacking.
Methods: We conducted a retrospective review of medical
examiner cases with morphine identified in the toxicological evaluation.
More than 50 cases from the District 5 Medical Examiners Office in
Leesburg, Florida from the years 2001, 2002 and 2003 were identified.
Included were deaths that occurred at home, with and without hospice
care; in nursing homes and assisted living facilities, with and without
hospice care; and deaths that occurred in a hospital, inpatient setting.
Cases involving heroin use, those with incomplete medical records, or
decedents who were embalmed were excluded from the study. Antemortem
medical records were reviewed for age, general health status,
and disease processes with special attention to evidence of renal and
hepatic failure. In addition, medication schedules and dosing were
reviewed, as well as, length of time receiving morphine and previous
* Presenting Author
exposure to opioids. The autopsy files were reviewed for cause and
manner of death, confirmation of disease processes, site of specimen
collection and the time interval from death to acquisition of specimens
(postmortem interval).Toxicological analyses were performed according
to standard laboratory protocol using gas chromatography-mass spectrometry
for identification and quantitation of morphine. Morphine concentrations
in blood were measured as free and total morphine.
Results: Evaluation of the data revealed an age range from mid 40s
to early 90s. Disease processes were highly varied including cancer,
dementia, acute injury and chronic pain due to injury and other causes.
The data showed a wide range of morphine concentrations from less than
the defined therapeutic values to more than 20 times the therapeutic
value (as compared to non-chronic users). The reported cause and
manner of death varied from natural death resulting from end-stage
disease processes to accidental deaths from injury and morphine toxicity.
The results of our study mirror previous studies with elevated postmortem
morphine concentrations in decedents with renal failure, chronic
use of opioids and collection of specimens from central sites. Morphine
concentrations were highly variable in decedents who were terminally ill
and receiving morphine for comfort measures.
Conclusion: It is important for forensic pathologists to be aware of
all factors that influence postmortem morphine concentrations before
deciding how these values influence the determination of cause and
manner of death. Postmortem morphine concentrations were elevated in
decedents with renal failure because of a decreased ability to excrete the
drug. Decedents with chronic illness, cancer, and liver failure had a
decreased ability to metabolize the drug. Decedents with tolerance to
opioids had higher postmortem concentrations beyond the defined therapeutic
range. Specimen site must also be considered, as concentrations
are higher when collected from a central site versus a peripheral site.
Special attention to these variables is required when the decedent was
terminally ill and receiving morphine for comfort measures, as the concentrations
are highly variable. The significance of a prolonged postmortem
interval in these cases is unknown.
In summary, when an elevated postmortem concentration of morphine
is reported, an exhaustive search of the medical records must be
conducted. Information obtained should include underlying disease
processes, medication schedules and dosing and evidence of length of
time on morphine, previous exposure to opioids and development of tolerance.
Postmortem interval should be noted and communicated to the
forensic toxicologist. This information, when considered, will be
important when declaring the cause and manner of death.
Morphine, Postmortem, Interpretation
K36 A Review of Succinylmonocholine
Concentrations in Body Fluids and
Tissues Analyzed by LC-MS/MS
Michael F. Rieders, PhD*, Kevin D. Ballard, MD, PhD, Francis X.
Diamond, Loan T. Nguyen, Eric F. Rieders, PhD, and William E.
Vickery, National Medical Services, Inc., 3701 Welsh Road, Willow
Grove, PA 19090; Fredric Rieders, PhD, Fredric Rieders Family
Renaissance Foundation, 2300 Stratford Avenue, Willow Grove,
PA 19090
The objective of this data compilation was to summarize analytical
findings for succinylmonocholine from a wide variety of forensic and
clinical specimen types obtained over a period spanning four years,
along with a statistical analysis of the data set; also, the identification of
basal levels of succinylmonocholine in normal postmortem mammalian
tissues.
Demonstration of presence of succinylmonocholine in postmortem
tissue samples known not to have been exposed to succinylcholine, and
presentation of levels of this compound in a variety of postmortem
samples.
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