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Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?
Clin Toxicol (Phila). 2016 Jun; 54(5):420-3.CT

Abstract

BACKGROUND

There has been a significant spike in fentanyl-related deaths from illicit fentanyl supplied via the heroin trade. Past fentanyl access was primarily oral or dermal via prescription fentanyl patch diversion. One factor potentially driving this increase in fatalities is the change in route of administration. Rapid intravenous (IV) fentanyl can produce chest wall rigidity. We evaluated post-mortem fentanyl and norfentanyl concentrations in a recent surge of lethal fentanyl intoxications.

METHODS

Fentanyl related deaths from the Franklin County coroner's office from January to September 2015 were identified. Presumptive positive fentanyl results were confirmed by quantitative analysis using liquid chromatography tandem mass spectrometry (LC/MS/MS) and were able to quantify fentanyl, norfentanyl, alfentanyl, and sufentanyl.

RESULTS

48 fentanyl deaths were identified. Mean fentanyl concentrations were 12.5 ng/ml, (range 0.5 ng/ml to >40 ng/ml). Mean norfentanyl concentrations were 1.9 ng/ml (range none detected to 8.3 ng/ml). No appreciable concentrations of norfentanyl could be detected in 20 of 48 cases (42%) and were less than 1 ng/ml in 25 cases (52%). Elevated fentanyl concentrations did not correlate with rises in norfentanyl levels. In several cases fentanyl concentrations were strikingly high (22 ng/ml and 20 ng/ml) with no norfentanyl detected.

DISCUSSION

The lack of any measurable norfentanyl in half of our cases suggests a very rapid death, consistent with acute chest rigidity. An alternate explanation could be a dose-related rapid onset of respiratory arrest. Deaths occurred with low levels of fentanyl in the therapeutic range (1-2 ng/ml) in apparent non-naïve opiate abusers. Acute chest wall rigidity is a well-recognized complication in the medical community but unknown within the drug abuse community. The average abuser of illicit opioids may be unaware of the increasing fentanyl content of their illicit opioid purchase.

CONCLUSION

In summary we believe sudden onset chest wall rigidity may be a significant and previously unreported factor leading to an increased mortality, from illicit IV fentanyl use. Fentanyl and norfentanyl ratios and concentrations suggest a more rapid onset of death given the finding of fentanyl without norfentanyl in many of the fatalities. Chest wall rigidity may help explain the cause of death in these instances, in contrast to the typical opioid-related overdose deaths. Intravenous heroin users should be educated regarding this potentially fatal complication given the increasingly common substitution and combination with heroin of fentanyl.

Authors+Show Affiliations

a Central Ohio Poison Center , Ohio State University Medical Toxicology , Columbus , OH , USA ;b Office of the Franklin County Coroner , Division of Forensic Toxicology , Columbus , OH , USA ;b Office of the Franklin County Coroner , Division of Forensic Toxicology , Columbus , OH , USA ;c Department of Pediatrics, Central Ohio Poison Center , College of Medicine, Ohio State University , Columbus , OH , USA.c Department of Pediatrics, Central Ohio Poison Center , College of Medicine, Ohio State University , Columbus , OH , USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

26999038

Citation

Burns, Glenn, et al. "Could Chest Wall Rigidity Be a Factor in Rapid Death From Illicit Fentanyl Abuse?" Clinical Toxicology (Philadelphia, Pa.), vol. 54, no. 5, 2016, pp. 420-3.
Burns G, DeRienz RT, Baker DD, et al. Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse? Clin Toxicol (Phila). 2016;54(5):420-3.
Burns, G., DeRienz, R. T., Baker, D. D., Casavant, M., & Spiller, H. A. (2016). Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse? Clinical Toxicology (Philadelphia, Pa.), 54(5), 420-3. https://doi.org/10.3109/15563650.2016.1157722
Burns G, et al. Could Chest Wall Rigidity Be a Factor in Rapid Death From Illicit Fentanyl Abuse. Clin Toxicol (Phila). 2016;54(5):420-3. PubMed PMID: 26999038.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse? AU - Burns,Glenn, AU - DeRienz,Rebecca T, AU - Baker,Daniel D, AU - Casavant,Marcel, AU - Spiller,Henry A, Y1 - 2016/03/21/ PY - 2016/3/22/entrez PY - 2016/3/22/pubmed PY - 2017/3/3/medline KW - Chest wall rigidity KW - fentanyl KW - heroin KW - norfentanyl KW - opioids KW - overdose SP - 420 EP - 3 JF - Clinical toxicology (Philadelphia, Pa.) JO - Clin Toxicol (Phila) VL - 54 IS - 5 N2 - BACKGROUND: There has been a significant spike in fentanyl-related deaths from illicit fentanyl supplied via the heroin trade. Past fentanyl access was primarily oral or dermal via prescription fentanyl patch diversion. One factor potentially driving this increase in fatalities is the change in route of administration. Rapid intravenous (IV) fentanyl can produce chest wall rigidity. We evaluated post-mortem fentanyl and norfentanyl concentrations in a recent surge of lethal fentanyl intoxications. METHODS: Fentanyl related deaths from the Franklin County coroner's office from January to September 2015 were identified. Presumptive positive fentanyl results were confirmed by quantitative analysis using liquid chromatography tandem mass spectrometry (LC/MS/MS) and were able to quantify fentanyl, norfentanyl, alfentanyl, and sufentanyl. RESULTS: 48 fentanyl deaths were identified. Mean fentanyl concentrations were 12.5 ng/ml, (range 0.5 ng/ml to >40 ng/ml). Mean norfentanyl concentrations were 1.9 ng/ml (range none detected to 8.3 ng/ml). No appreciable concentrations of norfentanyl could be detected in 20 of 48 cases (42%) and were less than 1 ng/ml in 25 cases (52%). Elevated fentanyl concentrations did not correlate with rises in norfentanyl levels. In several cases fentanyl concentrations were strikingly high (22 ng/ml and 20 ng/ml) with no norfentanyl detected. DISCUSSION: The lack of any measurable norfentanyl in half of our cases suggests a very rapid death, consistent with acute chest rigidity. An alternate explanation could be a dose-related rapid onset of respiratory arrest. Deaths occurred with low levels of fentanyl in the therapeutic range (1-2 ng/ml) in apparent non-naïve opiate abusers. Acute chest wall rigidity is a well-recognized complication in the medical community but unknown within the drug abuse community. The average abuser of illicit opioids may be unaware of the increasing fentanyl content of their illicit opioid purchase. CONCLUSION: In summary we believe sudden onset chest wall rigidity may be a significant and previously unreported factor leading to an increased mortality, from illicit IV fentanyl use. Fentanyl and norfentanyl ratios and concentrations suggest a more rapid onset of death given the finding of fentanyl without norfentanyl in many of the fatalities. Chest wall rigidity may help explain the cause of death in these instances, in contrast to the typical opioid-related overdose deaths. Intravenous heroin users should be educated regarding this potentially fatal complication given the increasingly common substitution and combination with heroin of fentanyl. SN - 1556-9519 UR - https://www.unboundmedicine.com/medline/citation/26999038/Could_chest_wall_rigidity_be_a_factor_in_rapid_death_from_illicit_fentanyl_abuse L2 - https://www.tandfonline.com/doi/full/10.3109/15563650.2016.1157722 DB - PRIME DP - Unbound Medicine ER -