SOFT 2004 Meeting Abstracts - Society of Forensic Toxicologists

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DRUG EXPOSURE PATTERN IN HAIR AND FEMORAL BLOOD IN DECEASED DRUG
ADDICTS
Henrik Druid!', Joakim Strandberg!, Ingrid Nystrom 2 , Kanar Alkassl, Fredrik Kugelberg 3 and Robert
Kronstrand 2
IDepartment of Forensic Medicine, Karolinska Institutet, SE-171 77 Stockholm, Sweden; 2Department of
Forensic Chemistry, National Board of Forensic Medicine, SE-581 85 Linkoping, Sweden; 3Departrnent of
Clinical Pharmacology, University ofLinkoping, SE-581 85 Linkoping, Sweden
Blood drug levels of illicit drugs are often not particularly high in postmortem overdose cases. This is true
for amphetamine and cocaine as well as for opiates. Thus, the postmortem investigations do not support the
use of the word "overdose", since the dose taken in these cases is probably not much larger than is usually
taken by chronic addicts. One explanation for this outcome may be reduced drug tolerance following a
period of abstinence, but - although some epidemiological reports suggest a recent interruption in drug use
in some cases -there are no firm data to confirm this hypothesis. It is difficult to estimate the degree of drug
tolerance in deceased subjects, but hair analysis of illicit drugs may at least provide a map of the past and
recent drug use pattern. In the present study, segmental hair analysis was applied on hair samples collected
from 40 deceased, supposedly drug addicts, including both cases of probable drug overdoses, and cases
with other causes of death. Portions of the hair samples were analyzed with an LC-MS-MS screening
method, which covers amphetamine and -derivatives, cocaine and metabolites, morphine, 6­
monoacetylmorphine (6-MAM), codeine, diazepam, flunitrazepam, nicotine and cotinine. Positive findings,
except nicotine and cotinine, were confirmed with GC-MS verification methods. For these analyses, the
hair was carefully aligned and cut in short segments (the first three segments 5 mm each, and additional
segments 10 mm long). The verification methods also included washing steps, and analysis of washings
was carried out to control for external contamination. Femoral blood, urine and vitreous humor were also
collected at the postmortem examinations for the routine toxicological drug screen. Twelve of the cases
were classified as heroin overdoses by the responsible forensic pathologist. In Table 1 the number of
detections of seven different drugs/metabolites in hair and blood (results for benzodiazepines not shown) in
these 12 cases are displayed. In most cases, a marked change in abuse pattern was evident. Hence, a
gradual decrease in morphine and/or 6-MAM levels was observed in 6 of 12 cases. It was also found that
the drug use at time of death, as reflected by the drugs detected in femoral blood, more often than not
differed from the drug use pattern seen in hair. Amphetamine, cocaine, benzoylecgonineand 6-MAM were
more often detected in hair than in blood. The opposite was true for codeine and morphine. In four cases,
fentanyl was found in femoral blood in concentrations that suggest that this drug most likely was the main
or a contributory factor for the demise. The results from the segmental hair analyses showed that the final
heroin dose in four cases obviously had been preceded by a period of lowered drug use, or abstinence,
whereas in other cases, a continuous drug use before death was disclosed. Thus, reduced tolerance may be
of importance in certain cases, but in the majority of the cases, other factors seem to be more important.
Interestingly, in at least four of these twelve "overdose" cases, there was evidence of a delayed death,
leading to a drop in blood morphine levels. This observation underscores the importance of considering
autopsy findings and circumstantial information when interpreting postmortem toxicological data - the
finding of low morphine levels, and/or lack of 6-MAM does not exclude an acute opiate intoxication. It is
concluded from the present study that hair analysis can assist in the toxicological evaluation of postmortem
cases, and that segmental analysis can improve the interpretation further.
Table 1. Number of detections of different drugs of abuse in hair and blood from 12 deceased heroin
addicts classified as overdoses.
L Codeine Morphine 6-MAM Amphetamine Cocaine Benzoylecgonine Fentanyl
I Hair 5 5 9 5 2 2 n.a.
I Blood 7 12 3 3 0 1 4
Key words: Hair analysis, opiates, substance abuse
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