Hilde Erøy Edvardsen1, Torill Tverborgvik2, Joachim Frost3, Sidsel Rogde4, Inge Morild5, Helge Waal6, Thomas Clausen6, Lars Slørdal7, Vigdis Vindenes8. 1. Department of Forensic Sciences, Oslo University Hospital, Post Box 4950, Nydalen, N-0424 Oslo, Norway. Electronic address: himlun@ous-hf.no. 2. Department of Forensic Sciences, Oslo University Hospital, Post Box 4950, Nydalen, N-0424 Oslo, Norway. 3. Department of Clinical Pharmacology, St. Olavs Hospital - Trondheim University Hospital, Post Box 3250 Sluppen, N-7006 Trondheim, Norway. 4. Department of Forensic Sciences, Oslo University Hospital, Post Box 4950, Nydalen, N-0424 Oslo, Norway; Department of Forensic Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Post Box 4950, Nydalen, 0424 Oslo, Norway. 5. The Gade Laboratory for Pathology, Department of Clinical Medicine, University of Bergen, Haukeland University Hospital, N-5021 Bergen, Norway. 6. Norwegian Centre of Addiction Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Post Box 1039, Blindern, N-0315 Oslo, Norway. 7. Department of Clinical Pharmacology, St. Olavs Hospital - Trondheim University Hospital, Post Box 3250 Sluppen, N-7006 Trondheim, Norway; Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Post Box 8905 MTFS, N-7491 Trondheim, Norway. 8. Department of Forensic Sciences, Oslo University Hospital, Post Box 4950, Nydalen, N-0424 Oslo, Norway; Norwegian Centre of Addiction Medicine, Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Post Box 1039, Blindern, N-0315 Oslo, Norway.
Abstract
BACKGROUND: In toxicology, international classification systems focus on single intoxicants as the cause of death. It is, however, well known that very few drug related deaths are caused by a single substance and that information concerning the drug concentrations as well as the combinations of drugs are essential in order to ascertain the cause of death. The aim of the study was to assess whether those prone to fatal intoxications differ significantly from chronic drug users - in terms of demographics and drug exposure patterns. MATERIAL AND METHODS: Fatal psychoactive drug intoxications in Norway during 2012, where a forensic autopsy including toxicological analysis were performed, were included. Analytical findings in blood were compared with concentrations in blood from apprehended drivers under the influence of drugs and ethanol (DUID) during the same time period. The opioid and benzodiazepine concentrations were assessed as morphine and diazepam equivalents, respectively, in order to compare concentrations across the different groups. RESULTS: A total of 194 autopsy cases and 4811 DUID cases were included. Opioids were detected in around 90% of the drug intoxication cases, but in only 16% of the DUID cases. The number of substances detected in fatal intoxications was 4.9 compared to 2.6 in the DUID cases. The total opioid concentrations were significantly higher in the fatal intoxication cases compared to DUID cases (229ng/mL versus 56.9ng/mL morphine equivalents, respectively). Benzodiazepines were detected in 90% of the fatal cases. Only one fatal opioid mono-intoxication was found; a case with a very high methadone concentration (1238ng/mL). DISCUSSION: Mono-intoxication with heroin was not seen in any of the fatal intoxications in Norway, and single drug intoxications were rare (1.5%). Fatal intoxications were caused by a combination of drugs with significantly more substances as well as higher total drug concentrations among the fatal cases compared to the DUID cases. The combination of opioids and benzodiazepines seemed to represent an increased risk of death. CONCLUSION: The total load of drugs influence the degree of intoxication and the total concentration level must be considered, including the total number of substances. Our findings imply that international statistics regarding an opioid being the main intoxicant should have a shift in focus towards combinations of drugs (especially opioids and benzodiazepines) as a major risk factor for fatal drug overdoses.
BACKGROUND: In toxicology, international classification systems focus on single intoxicants as the cause of death. It is, however, well known that very few drug related deaths are caused by a single substance and that information concerning the drug concentrations as well as the combinations of drugs are essential in order to ascertain the cause of death. The aim of the study was to assess whether those prone to fatal intoxications differ significantly from chronic drug users - in terms of demographics and drug exposure patterns. MATERIAL AND METHODS: Fatal psychoactive drug intoxications in Norway during 2012, where a forensic autopsy including toxicological analysis were performed, were included. Analytical findings in blood were compared with concentrations in blood from apprehended drivers under the influence of drugs and ethanol (DUID) during the same time period. The opioid and benzodiazepine concentrations were assessed as morphine and diazepam equivalents, respectively, in order to compare concentrations across the different groups. RESULTS: A total of 194 autopsy cases and 4811 DUID cases were included. Opioids were detected in around 90% of the drug intoxication cases, but in only 16% of the DUID cases. The number of substances detected in fatal intoxications was 4.9 compared to 2.6 in the DUID cases. The total opioid concentrations were significantly higher in the fatal intoxication cases compared to DUID cases (229ng/mL versus 56.9ng/mL morphine equivalents, respectively). Benzodiazepines were detected in 90% of the fatal cases. Only one fatal opioid mono-intoxication was found; a case with a very high methadone concentration (1238ng/mL). DISCUSSION: Mono-intoxication with heroin was not seen in any of the fatal intoxications in Norway, and single drug intoxications were rare (1.5%). Fatal intoxications were caused by a combination of drugs with significantly more substances as well as higher total drug concentrations among the fatal cases compared to the DUID cases. The combination of opioids and benzodiazepines seemed to represent an increased risk of death. CONCLUSION: The total load of drugs influence the degree of intoxication and the total concentration level must be considered, including the total number of substances. Our findings imply that international statistics regarding an opioid being the main intoxicant should have a shift in focus towards combinations of drugs (especially opioids and benzodiazepines) as a major risk factor for fatal drug overdoses.
Authors: Zheng Dai; Marie A Abate; D Leann Long; Gordon S Smith; Theresa M Halki; James C Kraner; Allen R Mock Journal: Forensic Sci Int Date: 2020-05-31 Impact factor: 2.395