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Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses.
Forensic Sci Med Pathol. 2016 Sep; 12(3):243-7.FS

Abstract

PURPOSE

Heroin has a half-life of 2-6 min and is metabolized too quickly to be detected in autopsy samples. The presence of 6-acetylmophine (6-AM) in urine, blood, or other samples is convincing evidence of heroin use by a decedent, but 6-AM itself has a half-life of 6-25 min before it is hydrolyzed to morphine, so 6-AM may not be present in sufficient concentration to detect in postmortem samples. Codeine is often present in heroin preparations as an impurity and is not a metabolite of heroin. Studies report that a ratio of morphine to codeine greater than one indicates heroin use. We hypothesize that the ratio of morphine to codeine in our decedents abusing drugs intravenously will be no different in individuals with 6-AM present than in individuals where no 6-AM is detected, and we report our study of this hypothesis.

METHODS

All accidental deaths investigated by the Jefferson County Coroner/Medical Examiner Office from 2010 to 2013 with morphine detected in blood samples collected at autopsy were reviewed. Five deaths where trauma caused or contributed to death were excluded from the review. The presence or absence of 6-AM and the concentrations of morphine and codeine were recorded for each case. The ratio of morphine to codeine was calculated for all decedents. Any individual in whom no morphine or codeine was detected in a postmortem sample was excluded from further study. Absence or presence of drug paraphernalia or evidence of intravascular (IV) drug use was documented in each case to identify IV drug users. The proportion of the IV drug users with and without 6-AM present in a postmortem sample was compared to the M/C ratio for the individuals.

RESULTS

Of the 230 deaths included in the analysis, 103 IV drug users with quantifiable morphine and codeine in a postmortem sample were identified allowing for calculation of an M/C ratio. In these IV drug users, the M/C ratio was greater than 1 in 98 % of decedents. When controlling for the absence or presence of 6-AM there was no statistically significant difference in the proportion of IV drug users when compared to non IV drug users with an M/C ratio of greater than 1 (p = 1.000).

CONCLUSION

The M/C ratio in IV drug users, if greater than 1, is seen in deaths due to heroin toxicity where 6-AM is detected in a postmortem sample. This study provides evidence that a M/C ratio greater than one in an IV drug user is evidence of a death due to heroin toxicity even if 6-AM is not detected in the blood. Using the M/C ratio, in addition to scene and autopsy findings, provides sufficient evidence to show heroin is the source of the morphine and codeine. Listing heroin as a cause or contributing factor in deaths with evidence of IV drug abuse and where the M/C ratio exceeds 1 will improve identification of heroin fatalities, which will allow better allocation of resources for public health initiatives.

Authors+Show Affiliations

Virginia Commonwealth University School of Medicine, 1101 E. Marshall Street, PO Box 980662, Richmond, VA, 23298, USA.University of Alabama at Birmingham, 1515 6th Ave. S, Birmingham, AL, 35233, USA.University of Alabama at Birmingham, 1515 6th Ave. S, Birmingham, AL, 35233, USA.University of Alabama at Birmingham, 1515 6th Ave. S, Birmingham, AL, 35233, USA. dwdye@uab.edu.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

27114260

Citation

Ellis, Ashley D., et al. "Identifying Cases of Heroin Toxicity Where 6-acetylmorphine (6-AM) Is Not Detected By Toxicological Analyses." Forensic Science, Medicine, and Pathology, vol. 12, no. 3, 2016, pp. 243-7.
Ellis AD, McGwin G, Davis GG, et al. Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses. Forensic Sci Med Pathol. 2016;12(3):243-7.
Ellis, A. D., McGwin, G., Davis, G. G., & Dye, D. W. (2016). Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses. Forensic Science, Medicine, and Pathology, 12(3), 243-7. https://doi.org/10.1007/s12024-016-9780-2
Ellis AD, et al. Identifying Cases of Heroin Toxicity Where 6-acetylmorphine (6-AM) Is Not Detected By Toxicological Analyses. Forensic Sci Med Pathol. 2016;12(3):243-7. PubMed PMID: 27114260.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses. AU - Ellis,Ashley D, AU - McGwin,Gerald, AU - Davis,Gregory G, AU - Dye,Daniel W, Y1 - 2016/04/25/ PY - 2016/03/31/accepted PY - 2016/4/27/entrez PY - 2016/4/27/pubmed PY - 2017/3/1/medline KW - Codeine toxicity KW - Death certification KW - Drug abuse KW - Forensic pathology KW - Forensic toxicology KW - Heroin toxicity KW - Morphine toxicity SP - 243 EP - 7 JF - Forensic science, medicine, and pathology JO - Forensic Sci Med Pathol VL - 12 IS - 3 N2 - PURPOSE: Heroin has a half-life of 2-6 min and is metabolized too quickly to be detected in autopsy samples. The presence of 6-acetylmophine (6-AM) in urine, blood, or other samples is convincing evidence of heroin use by a decedent, but 6-AM itself has a half-life of 6-25 min before it is hydrolyzed to morphine, so 6-AM may not be present in sufficient concentration to detect in postmortem samples. Codeine is often present in heroin preparations as an impurity and is not a metabolite of heroin. Studies report that a ratio of morphine to codeine greater than one indicates heroin use. We hypothesize that the ratio of morphine to codeine in our decedents abusing drugs intravenously will be no different in individuals with 6-AM present than in individuals where no 6-AM is detected, and we report our study of this hypothesis. METHODS: All accidental deaths investigated by the Jefferson County Coroner/Medical Examiner Office from 2010 to 2013 with morphine detected in blood samples collected at autopsy were reviewed. Five deaths where trauma caused or contributed to death were excluded from the review. The presence or absence of 6-AM and the concentrations of morphine and codeine were recorded for each case. The ratio of morphine to codeine was calculated for all decedents. Any individual in whom no morphine or codeine was detected in a postmortem sample was excluded from further study. Absence or presence of drug paraphernalia or evidence of intravascular (IV) drug use was documented in each case to identify IV drug users. The proportion of the IV drug users with and without 6-AM present in a postmortem sample was compared to the M/C ratio for the individuals. RESULTS: Of the 230 deaths included in the analysis, 103 IV drug users with quantifiable morphine and codeine in a postmortem sample were identified allowing for calculation of an M/C ratio. In these IV drug users, the M/C ratio was greater than 1 in 98 % of decedents. When controlling for the absence or presence of 6-AM there was no statistically significant difference in the proportion of IV drug users when compared to non IV drug users with an M/C ratio of greater than 1 (p = 1.000). CONCLUSION: The M/C ratio in IV drug users, if greater than 1, is seen in deaths due to heroin toxicity where 6-AM is detected in a postmortem sample. This study provides evidence that a M/C ratio greater than one in an IV drug user is evidence of a death due to heroin toxicity even if 6-AM is not detected in the blood. Using the M/C ratio, in addition to scene and autopsy findings, provides sufficient evidence to show heroin is the source of the morphine and codeine. Listing heroin as a cause or contributing factor in deaths with evidence of IV drug abuse and where the M/C ratio exceeds 1 will improve identification of heroin fatalities, which will allow better allocation of resources for public health initiatives. SN - 1556-2891 UR - https://www.unboundmedicine.com/medline/citation/27114260/Identifying_cases_of_heroin_toxicity_where_6_acetylmorphine__6_AM__is_not_detected_by_toxicological_analyses_ L2 - https://dx.doi.org/10.1007/s12024-016-9780-2 DB - PRIME DP - Unbound Medicine ER -