Michelle Torok

The comparative toxicology and major organ pathology of fatal methadone and heroin toxicity cases

In order to determine the comparative toxicology and systemic disease of cases of death due to methadone and heroin toxicity, 1193 coronial cases of opioid overdose that occurred in New South Wales, Australia between 1 January 1998 and 31 December 2007 were inspected. These comprised 193 cases in which cause of death involved methadone toxicity (METH) and 1000 cases in which cause of death involved heroin toxicity in the absence of methadone (HER). METH cases were significantly more likely to have benzodiazepines (63.7% vs. 32.2%), and less likely to have alcohol (23.6% vs. 42.7%) detected. METH cases were significantly more likely to be diagnosed with pre-existing systemic pathology (94.3% vs. 79.9%), and multiple organ system pathology (68.8% vs. 41.4%). Specifically, METH cases were more likely to have cardiac (58.9% vs. 34.5%), pulmonary (53.6% vs. 30.9%), hepatic (80.7% vs. 62.8%) and renal (25.0% vs. 9.5%) disease. Given the notable differences in toxicology and disease patterns, great caution appears warranted in prescribing benzodiazepines to methadone users, and regular physical examinations of methadone treatment patients would appear clinically warranted.

Comparative rates of violent crime among regular methamphetamine and opioid users: offending and victimization

AIMS To determine the comparative levels of violent offending and victimization among regular methamphetamine and heroin users. DESIGN Cross-sectional Setting Sydney, Australia. PARTICIPANTS A total of 400 regular methamphetamine (METH) and heroin (HER) users (118 methamphetamine users: METH; 161 regular heroin users: HER; 121 regular users of both: BOTH). FINDINGS Eighty-two per cent reported a life-time history of committing violent crime, 41% in the past 12 months. There were no group differences in life-time violence, but the METH group were significantly more likely than the HER group to have committed violence in the past 12 months (odds ratio 1.94). Nearly all (95%) reported that they had been a victim of violent crime, 46% in the preceding 12 months, with no group differences. Those who had committed a violent crime in the past 12 months were 13.23 times more likely to have been a victim in that period. The majority believed it unlikely that they would be a victim of (78%), or commit (87%), a violent crime in the next 12 months. CONCLUSIONS Regular methamphetamine use appears to be associated with an increased risk of violent offending, but not victimization, compared with heroin use.

Toxicology and Circumstances of Completed Suicide by Means Other than Overdose

Abstract:  To determine the prevalence and circumstances of psychoactive substances amongst nonoverdose completed suicide, 1436 consecutive cases autopsied at the NSW Department of Forensic Medicine over the period 1/1/1997–12/31/2006 were analyzed. Substances were detected in 67.2% of cases, and illicit drugs in 20.1%. Alcohol was present in 40.6% of cases. Males were more likely to be positive for alcohol, cannabis, and psychostimulants, and females for pharmaceuticals. Illicits were associated with younger age. Alcohol was most prominent amongst toxicity cases, as were opioids, psychostimulants amongst gunshot cases, and pharmaceuticals amongst drownings. Cases in which drug and alcohol histories were noted were more likely to have a substance detected. Alcohol was more common where a suicide note was left and where relationship problems were involved. Pharmaceuticals were more common where a previous attempt was noted. Licit and illicit substances are strongly associated with suicide, even when the method does not involve drug overdose.

Pediatric Low-Grade Ganglioglioma: Epidemiology, Treatments, and Outcome Analysis on 348 Children From the Surveillance, Epidemiology, and End Results Database

BACKGROUND Low-grade gangliogliomas/gangliocytomas (GGs) are rare tumors of the central nervous system that occur mostly in young people. Because of their rarity, large-scale, population-based studies focusing on epidemiology and outcomes are lacking. OBJECTIVE To use the Surveillance, Epidemiology, and End Results (SEER) data sets of the National Cancer Institute to study demographics, tumor location, initial treatment, and outcome data on low-grade GGs in children. METHODS SEER-STAT v8.1.2 identified all patients aged 0 to 19 years in the SEER data sets with low-grade GGs. Using the Kaplan-Meier method and Cox proportional hazard regression, we examined associations between these characteristics and survival. RESULTS There were 348 children with low-grade GGs diagnosed from 2004 to 2010, with a median follow-up of 37 months. Tumors were more prevalent in males (n = 208, 59.8%) than females (n = 140, 40.2%) (P < .001). Almost 63% occurred in children >10 years, whereas only 3.5% were found in those <1 year old. Approximately 50% were located in the temporal lobes, and only 3.7% and 3.5% were located in the brainstem and spinal cord, respectively. Surgery was performed on 91.6% of cases, with gross total resection achieved in 68.3%. Radiation was used in 3.2%. Young age (<1 year) and brainstem location were associated with worse overall survival. CONCLUSION This study shows that low-grade GGs occur in older children with a male preference. Gross total resection is achieved in the majority of cases, and radiation is rarely used. Although the majority of patients have an excellent prognosis, infants and patients with brainstem tumors have worse survival rates.

Toxicology and Characteristics of Fatal Oxycodone Toxicity Cases in New South Wales, Australia 1999–2008

Abstract:  All cases of fatal oxycodone toxicity presenting to the New South Wales Department of Forensic Medicine over the period January 1, 1999, to December 31, 2008, were retrieved. A total of 70 cases were identified. The mean age was 48.9 years, 58.6% were men, 21.4% were suicides, and in 30% oxycodone had not been prescribed to the decedent. Injecting drug users constituted 27.1% of cases, and oxycodone tablets were injected immediately prior to death by 21.4%. The mean blood oxycodone concentration was 0.40 mg/L (range 0.06–53.00 mg/L). In all cases, psychoactive substances other than oxycodone were also detected, most frequently hypnosedatives (68.6%), other opioids (54.3%), antidepressants (41.4%), and alcohol (32.9%). Preexisting systemic disease was common: cardiovascular (64.2%), pulmonary (49.3%), hepatic (66.7%), and renal (43.9%).

Sudden or Unnatural Deaths Involving Anabolic‐androgenic Steroids

Anabolic‐androgenic steroids (AASs) are frequently misused. To determine causes of death, characteristics, toxicology, and pathology of AAS positive cases, all cases (n = 24) presenting to the New South Wales Department of Forensic Medicine (1995–2012) were retrieved. All were male, and the mean age was 31.7 years. Deaths were mainly due to accidental drug toxicity (62.5%), then suicide (16.7%) and homicide (12.5%). Abnormal testosterone/epitestosterone ratios were reported in 62.5%, followed by metabolites of nandrolone (58.3%), stanozolol (33.3%), and methandienone (20.8%). In 23 of 24 cases, substances other than steroids were detected, most commonly psychostimulants (66.7%). In nearly half, testicular atrophy was noted, as was testicular fibrosis and arrested spermatogenesis. Left ventricular hypertrophy was noted in 30.4%, and moderate to severe narrowing of the coronary arteries in 26.1%. To summarize, the typical case was a male polydrug user aged in their thirties, with death due to drug toxicity. Extensive cardiovascular disease was particularly notable.

Attempted Suicide, Self-Harm, and Violent Victimization among Regular Illicit Drug Users

Relationships among attempted suicide, nonsuicidal self-harm, and physical assault were examined in 400 regular users of heroin and/or psychostimulants. Twenty-eight percent had episodes of nonsuicidal self-harm, 32% had attempted suicide, and 95% had been violently assaulted. The number of suicide attempts and nonsuicidal self-harm incidents were correlated (ρ = 0.44). There were also significant correlations between the number of assaults and nonsuicidal self-harm incidents (ρ = 0.17), and suicide attempts (ρ = 0.27). The mean age onset for non-suicidal self-harm (18.9 yrs) was significantly younger than that of initial suicide (22.3 yrs). The age at initial physical assault (16.0yrs) was significantly younger than that of nonsuicidal self-harm and initial suicide attempt. Screening for all forms of violence appears warranted when determining suicide risk for this population.

Drugs and violent death: comparative toxicology of homicide and non-substance toxicity suicide victims

AIMS To determine the comparative toxicology of death by homicide and suicide by means other than substance toxicity. DESIGN Cross-sectional (autopsy reports). SETTING Sydney, Australia. CASES A total of 1723 cases of violent death were identified, comprising 478 homicide (HOM) cases and 1245 non-substance toxicity suicide (SUI) cases. FINDINGS Substances were detected in 65.5% of cases, and multiple substances in 25.8%, with no group differences. Illicit drugs were detected in 23.9% of cases, and multiple illicit in 5.3%. HOM cases were significantly more likely to have an illicit drug [odds ratio (OR) 2.09] and multiple illicits (OR 2.94), detected, HOM cases being more likely to have cannabis (OR 2.39), opioids (OR 1.53) and psychostimulants (OR 1.59) present. HOM cases were, however, significantly less likely to have benzodiazepines (OR 0.53), antidepressants (OR 0.22) and antipsychotics (OR 0.23) present. Alcohol was present in 39.6% of cases (median blood alcohol concentration = 0.12), with no group difference in prevalence. CONCLUSIONS The role drugs play in premature death extends far beyond overdose and disease, with illicit drugs associated strongly with homicide.

Comparative patterns of cognitive performance amongst opioid maintenance patients, abstinent opioid users and non-opioid users

BACKGROUND To compare the cognitive performances of maintenance patients (MAIN), abstinent ex-users (ABST) and healthy non-heroin using controls (CON). METHODS Case control study of 125 MAIN (94 subjects maintained on methadone, 31 on buprenorphine), 50 ABST and 50 CON. Neuropsychological tests measuring executive function, working memory, information processing speed, verbal learning and non-verbal learning were administered. RESULTS There were no differences between the cognitive profiles of those maintained on methadone or buprenorphine on any administered test. After controlling for confounders, the MAIN group had poorer performance than controls in six of the 13 administered tests, and were poorer than the ABST group in five. The MAIN group exhibited poorer performance in the Haylings Sentence Completion, Matrix Reasoning, Digit Symbol, Logical Memory (immediate and delayed recall), and the Complex Figure Test (immediate recall). There were no differences between the ABST and CON groups on any of the administered tests. CONCLUSIONS Poorer cognitive performance, across a range of test and domains, was seen amongst maintenance patients, regardless of their maintenance drug. This is a group that is likely might benefit from approaches for managing individuals with cognitive and behavioural difficulties arising from brain dysfunction.

Characteristics, circumstances and toxicology of sudden or unnatural deaths involving very high range alcohol concentrations

AIMS To characterize sudden or unnatural deaths with very high-range blood alcohol concentrations (BACs) presenting to the Department of Forensic Medicine (DOFM) in Sydney between 1 January 1997 and 31 December 2011. DESIGN Case series. SETTING Sydney, Australia. CASES A total of 263 cases of sudden or unnatural death with a BAC of ≥0.300 g/100 ml. MEASUREMENTS Case characteristics, circumstances of death, quantitative toxicology, major autopsy findings and serology. FINDINGS The mean age of decedents was 46.7 years and 74.5% were male. Pre-existing alcohol problems were noted in 78.7%. Deaths were due to alcohol toxicity/chronic alcoholism (35.0%), combined alcohol/other drug toxicity (14.8%), accidents (18.6%), natural disease (13.3%), suicide (11.0%), homicide (6.8%) and one case was undetermined. Alcohol was a direct, or contributory, cause of death in 84.4% of cases. The overwhelming majority (81.4%) occurred in a home environment, and deaths did not vary by day or month. The mean BAC was 0.371 g/100 ml (range 0.300-0.820 g/100 ml), being highest in alcohol toxicity/chronic alcoholism cases (0.410 g/100 ml). The most frequently detected substances, other than alcohol, were benzodiazepines (31.9%) and opioids (12.9%). Alcohol-related disease was diagnosed in 62.9% of cases. Alcohol-related pathology was prevalent across all categories of death: severe steatosis (35.3%), cirrhosis (22.5%), chronic pancreatitis (15.3%), cardiomyopathy (9.4%) and cerebellar atrophy (9.0%). CONCLUSIONS Unnatural deaths with very high-range alcohol concentrations extend well beyond direct toxicity, and alcohol is causal in most cases. Those at greatest risk are middle-aged males, with long histories of alcohol problems.