Barry Levine

The role of ethanol in heroin deaths.

The purpose of this study was to evaluate the role of ethanol in deaths due to heroin intoxication. Over a 12 month period, all cases investigated by the Office of the Chief Medical Examiner, State of Maryland where a blood screen by Roche Abuscreen radioimmunoassay (RIA) was positive at a cutoff of 100 ng/mL were included in the study. Free morphine was quantitated using the Coat-A-Count RIA and ethanol was quantitated by head space gas chromatography. All presumptive morphine positive cases were confirmed by gas chromatography/mass spectrometry. Seventy of the 119 cases where death was attributed to narcotic or alcohol and narcotic intoxication had blood ethanol concentrations (BAC) greater than or equal to 0.02 g/dL; 48 had BAC > or = 0.10 g/dL. Only 3 of 45 cases where morphine was identified but was unrelated to death had BAC > or = 0.02 g/dL. At all ranges of free morphine concentrations, there was a greater percentage of narcotic deaths when ethanol was present. From the data, we conclude that 1) the use of even small amounts of ethanol with heroin is clearly a risk factor in deaths due to heroin, 2) there are some heroin deaths where no free morphine is identified in the blood. In these deaths, ethanol is unlikely to be present, 3) at blood ethanol concentrations between 0.20 and 0.29 g/dL, the morphine concentrations in heroin deaths increased significantly, 4) at blood ethanol concentrations greater than 0.30 g/dL, morphine became less of a factor than the ethanol in causing death.

A Fentanyl Epidemic in Maryland 1992

In early 1992, the Office of the Chief Medical Examiner, State of Maryland, encountered 30 cases where fentanyl was identified in the postmortem specimens. Twenty-five of the decedents were found in Baltimore City and five were found in the surrounding counties. Four of the decedents were female and eight of the victims were white. The blood fentanyl concentrations ranged from 2.2 to 100 micrograms/L. Ethanol and other abused drugs were detected in 28 of these cases. The cause of death in all cases was ethanol-, drug intoxication, or both.

The interpretation of cocaine and benzoylecgonine concentrations in postmortem cases

This study examined cocaine and benzoylecgonine concentrations in 100 consecutive deaths where either compound was identified in blood or urine specimens to determine whether any relationship between these concentrations and cause of death can be found. Forty-seven of the 100 cases were deaths attributed to cocaine, narcotic or combined cocaine and narcotic intoxication. There were 13 cases of cocaine intoxication where no psychoactive substance other than ethanol was detected. The mean cocaine concentration in these deaths was 908 ng/ml; three cases had cocaine concentrations greater than 2000 ng/ml, while the other ten cases had cocaine concentrations less than or equal to 700 ng/ml. The mean cocaine concentration in non-cocaine deaths where no psychoactive substance other than ethanol was detected was 146 ng/ml. This difference was not statistically significant. However, the average blood benzoylecgonine concentration in the 13 cocaine deaths was significantly higher than in the 19 non-cocaine deaths. A review of combined cocaine and narcotic deaths suggest that the narcotic is the main causative agent in these deaths.

Status of Alcohol Absorption in Drinking Drivers Killed in Traffic Accidents

One issue which constantly confronts the forensic toxicologist in drinking driver cases is the relationship between the breath or blood alcohol concentration (AC) of the driver at the time of an event such as a traffic stop or an accident and the AC measured at a time subsequent to the event. In theory, the AC can be rising, on a plateau or declining at the time of the event. Several studies have indicated that the overwhelming majority of drinking drivers are on a plateau or are post-absorptive at the time of the event. In this study, driver fatality cases investigated by the Office of the Chief Medical Examiner, State of Maryland during a three-year period were reviewed. Included in this study were cases positive for alcohol in the blood at a cutoff of 0.01 g/dL and death occurring within 15 min of the accident. In fact, many of these deaths were instantaneous or near instantaneous based on the injuries documented by the medical examiner at autopsy. The blood and urine were analyzed for alcohol by head-space gas chromatography and urine AC to blood AC ratios were calculated. A total of 129 cases were included in this study. Eleven of the 129 cases (8.5%) had urine to blood AC ratio less than 1.0. It is likely that these individuals were in the absorptive phase at the time that the accident occurred. Thirty-two cases had a urine to blood AC ratio between 1.0 and 1.2 inclusive. In these cases, the subject could be viewed as in the plateau phase of the blood AC versus time curve. The remaining 86 cases had a urine to blood AC ratio greater than 1.2. This suggests that these individuals were in the post-absorptive state at the time of the accident. The information acquired from this study provides additional evidence to support the notion that the vast majority of individuals are not in the absorptive phase at the time of a traffic stop or an accident.

Zolpidem Distribution in Postmortem Cases

Zolpidem is the prototype of a class of sedative hypnotic drugs that are derivatives of imidazopyridine and is sold in the United States under the trade name Ambien. Over a four-year period, zolpidem was identified in eight cases investigated by the Office of the Chief Medical Examiner, State of Maryland. Zolpidem was identified by gas chromatography-nitrogen-phosphorus detection (GC-NPD) following an alkaline extraction and was confirmed by full-scan electron impact gas chromatography/mass spectrometry. Zolpidem was quantitated by GC-NPD in all specimens received. Five of the cases presented were deaths due to drug intoxication. In three of these cases, zolpidem was an incidental finding because the drug fatalities resulted from other drugs. In the other two cases of drug intoxication, zolpidem was present in elevated concentrations and was a contributing, but not exclusive cause of the drug intoxication. The remaining three cases were deaths that were not caused by drugs. The blood zolpidem concentrations in these cases were therapeutic (0.28, 0.12 and 0.19 mg/L, respectively). In six of the eight cases where both blood and urine were analyzed, the blood concentration was higher than the urine concentration. The distribution of zolpidem into the liver and kidney failed to identify any sequestration of the drug into either specimen.

Postmortem stability of barbiturates in blood and tissues.

The stability of five commonly prescribed barbiturates and thiopental in blood and liver at room temperature and at 4 degrees C was studied. Gas chromatography was used for oxybarbiturate analysis while liquid chromatography was used to quantitate thiopental. In blood and liver, greater than 75% of the drugs were detected at the end of the two- to three-month period. These changes were not considered significant; therefore, barbiturates appear to be stable in blood and liver under the conditions of these experiments.

Accidental Poisonings Involving Carbon Monoxide, Heating Systems, and Confined Spaces

Eleven incidents of carbon monoxide (CO) intoxication resulting in sixteen fatalities are reported. All of the cases involved heating systems as either the source or the means of distributing the CO. Blood samples were analyzed for ethanol and CO. Elevated blood CO saturations were found in 14 of the 16 victims while none of the victims had a blood ethanol concentration greater than 0.10% (w/v).

Distribution of Ethanol in Postmortem Liver

The analysis of multiple specimens for ethanol has become a necessary and accepted practice in postmortem forensic toxicology. The correlation between blood and various body fluids has been well documented. However, there is little data on the distribution of ethanol in specimens such as the liver. In postmortem cases where blood is unavailable or contaminated, liver may be used for alcohol and drug analyses. This study reports the analysis, by head space gas chromatography, of heart blood and liver specimens for ethanol from 103 postmortem cases. The average liver/heart blood ratio in cases with a blood alcohol level (BAC) > or = 0.04 g/dL was 0.56, SD = 0.30, with a range of 0-1.40.

A multiple drug intoxication involving cyclobenzaprine and ibuprofen

A 19-year-old black man presented to the emergency room with superficial cuts on the anterior wrists, lethargy, tachycardia, and metabolic acidosis. Multiple containers of medication were found at the scene. Dysrhythmias developed and the patient died 7 h after admission. No anatomic cause of death was identifiable at autopsy. Toxicologic analysis identified the following drugs in the blood (mg/L): cyclobenzaprine (0.3), phenylpropanolamine (2.5), chlorpheniramine (0.2), lidocaine (6.6), phenytoin (19), and ibuprofen (130). Lidocaine and phenytoin had been administered therapeutically. The major symptoms displayed by the patient were tachycardia and metabolic acidosis, symptoms consistent with cyclobenzaprine and ibuprofen intoxication, respectively. Therefore, the medical examiner ruled that the cause of death was multiple drug intoxication and that the manner of death was suicide.

Benzoylecgonine and Ecgonine Methyl Ester Concentrations in Urine Specimens

The two major urinary metabolites of cocaine are benzoylecgonine (BE) and ecgonine methyl ester (EME). The major advantage of BE screening is that many commercial immunoassays are designed to detect BE. On the other hand, EME is more amenable to gas chromatographic screening. To ascertain the merits of screening BE versus EME for identifying cocaine use, 380 consecutive urine specimens presented to the Office of the Chief Medical Examiner-State of Maryland were tested for BE by EMIT (cutoff 0.3 mg/L) and for EME by gas chromatography-nitrogen-phosphorus detection (cutoff 0.05 mg/L). Each presumptive positive was confirmed by gas chromatography-mass spectrometry. One hundred four specimens tested positive for BE or EME. Ninety three specimens were positive for both BE and EME, seven were positive for BE (cutoff 0.05 mg/L) only and four were positive for EME only. BE concentrations ranged from 0.08-386 mg/L while EME concentrations ranged from 0.06-72 mg/L. The BE concentration was greater than or equal to the EME concentration in 73% of the cases. Using BE as a sole screen, 96% of the cases of cocaine use were identified while EME screening identified 93% of the cases.