Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, 58758 Linköping, Sweden. Electronic address: davide.guerrieri@rmv.se.
The European Nordic Countries are the most exposed to opioid-related deaths. Between April and October 2016, a series of forty lethal intoxications occurred in Sweden, in which the presence of the synthetic opioid acrylfentanyl was determined to be the main - or a contributing - cause of death. In the reported cases, the blood concentration of acrylfentanyl - mostly detected in combination with other drugs - ranged from 0.01ng/g to 5ng/g; victims were predominantly males (34 males and 6 females), and their age varied between 18 and 53 years. We further describe five cases, representative of the different drug administration route (nasal spray, tablets) and intentions (accidental or voluntary intoxication). Moreover, we address nine cases of non-lethal intoxication, in single (8 cases) or polydrug scenario (1 case). We discuss the present characteristics of the Swedish drug market for fentanyl-analogs in general and acrylfentanyl in particular, reporting a structural difficulty to effectively counteracting the appearance of unscheduled substances due to the constant turnover of new molecules on the recreational drug market.
Alcohol and substance abuse in general is a risk factor for suicide, but very little is known about the acute effect in relation to suicide method. Based on information from 18,894 medico-legal death investigations, including toxicological findings and manner of death, did the present study investigate whether acute influence of alcohol, tetrahydrocannabinol (THC), or central stimulants (amphetamine and cocaine) was related to the use of a violent suicide method, in comparison with the nonviolent method self-poisoning and alcohol-/illicit drug-negative suicide decedents. Multivariate analysis was conducted, and the results revealed that acute influence of THC was related to using the violent suicide method–– jumping from a height (RR 1.62; 95% CI 1.01–2.41). Alcohol intoxication was not related to any violent method, while the central stimulant-positive suicide decedent had a higher, albeit not significant, risk of several violent methods. The study contributes with elucidating suicide methods in relation to acute intoxication.
Carisoprodol is a drug frequently prescribed for lower back pain. Several case reports on the toxic potential have been published. Larger autopsy materials have supported the high toxicity of the drug, but have also shown that carisoprodol most often appears in mixed intoxications. The present study reports on contacts concerning possible intoxications with carisoprodol to the Norwegian Poisons Information Department. From 1992 to 2003, the number of contacts concerning carisoprodol rose heavily, also when adjusting for increasing total number of contacts. There was a relationship between the whole sales figure of carisoprodol and the number of contacts. Of the cases classified as "serious intoxications", carisoprodol was the second most frequent drug, only surpassed by acetaminophen (paracetamol). Despite the potential weaknesses of the present material, this study gave an additional indication of a high toxicity of carisoprodol.
Blood samples from 733 drivers suspected of driving under the influence of alcohol in the province of Ontario from 2001 to 2005 were retrospectively examined.
Samples were analyzed for alcohol content by headspace gas chromatography with flame ionization detection. Drivers ranged in age from 15 to 83 years old with the majority of blood samples obtained from males (n=623, 85%). Of the 704 cases where quantifiable numerical values were obtained, blood alcohol concentrations ranged from 13 to 414 mg/100 mL (mean 172 mg/100 mL) for males and 10 to 425 mg/100 mL (mean 173 mg/100 mL) for females. The majority of these drivers (n=640/704, 90.9%) had blood alcohol concentrations of 80 mg/100 mL and greater at the time of sampling. Analysis for alcohol was undertaken in all cases. However, additional toxicological examinations for drugs was conducted on a case-by-case basis based on the submitted case history and/or where there were requests for additional drug analysis, or where such analysis would be probative in the absence of the detection of alcohol at a concentration that could cause impairment.
Therefore, analyses for drugs were only performed in a small subset of 42 cases (6%). Thirty-four of these cases had positive drug findings, with Delta(9)-tetrahydrocannabinol being the most frequently encountered drug (n=18), followed by benzoylecgonine/cocaine (n=8), morphine (n=6), lorazepam (n=5) and diphenhydramine (n=4). The majority of individuals were involved in some type of motor vehicle accident (n=658, 89.8%), with single motor vehicle accidents (n=412, 56.2%) being the most common, followed by multiple motor vehicle accidents (n=169, 23%). Injuries (n=309, 42.1%) were the main cause of individuals not being able to provide breath samples with specific, non-life threatening injuries (n=178, 24.3%) representing the highest percentage of cases. The majority of incidents (n=449, 61.3%) occurred between Friday and Sunday reaching a peak on Saturday (n=174, 23.7%). Incidents occurred throughout the day, with the majority of events (n=449/705, 63.7%) for which a time was provided occurring between 6:01 pm and 3:00 am, and the peak number of incidents occurring between 9:01 pm and midnight (n=168/705, 23.8%).
However, these data demonstrate that ''drugged driving" does occur and that further, comprehensive investigation is needed to determine the frequency and type of drug use by Ontario drivers.
The objective of the present study was to evaluate the frequency of alcoholic drunkenness documented during forensic medical expertises (investigations) of the corpses carried out in this country throughout the period from 2011 till 2016. The investigations were conducted with the use of medical statistics methods by calculating the fractional difference, dynamics, and rates of detection of the cases of alcoholic intoxication depending on the cause of death. The study has demonstrated the high frequency of the cases of alcoholic drunkenness revealed during forensic medical expertises (investigations) of the corpses that amounted to 30.5% [15, 16]. The total number of the corpses examined in 2016 was 8.6% higher than in 2011. The frequency of the documented cases of alcoholic drunkenness during the same period decreased by 19.7%. The frequency of the documented cases of alcoholic drunkenness in the cases of violent death was 2.8 times that in the cases of death from various diseases (52.8 and 19.0% respectively). The enhanced frequency of alcoholic drunkenness in relation to the number of the conducted forensic medical expertises was documented in the cases of death by drowning and from hypothermia whereas the lowest frequency of alcoholic intoxication was recorded for the corpses of the people who had died from malignant tumours and diseases of the nervous system. Various regions of Russia differed in terms of the frequency of alcoholic drunkenness recorded among the recently deceased people.
Amphetamine is a major drug of abuse in Sweden and in the other Nordic countries. The demographics of amphetamine abusers in Sweden and the concentrations of this stimulant in blood are reported for 10 years of forensic blood samples (2001-2010). Using a forensic toxicology database (TOXBASE), we studied 1183 amphetamine-related deaths, 20,452 users of illicit drugs, and 47,366 people arrested for driving under the influence of drugs (DUID). Most amphetamine abusers were male (82%-87%), and their average age was 33 to 39 years with males being 2 to 3 years older than females (P
Department of Oncology-Pathology, Karolinska Institutet, Retzius v. 3, KI Campus Solna, 171 77 Stockholm, Sweden; Department of Forensic Medicine, National Board of Forensic Medicine, Artillerigatan 12, 587 58 Linköping, Sweden. Electronic address: carl.soderberg@ki.se.
Making the diagnosis fatal intoxication is a challenging task for the forensic pathologist and toxicologist, particularly when the cases involve substances where reference information is scarce or not at all available. This study presents postmortem femoral blood concentrations for 24 antipsychotic substances, based on samples collected and analyzed from 4949 autopsy cases in Sweden during 1992-2010. In addition our study provides information about the prevalence of different antipsychotics in accidental, suicidal, homicidal and uncertain deaths. The data have been selected and evaluated according to strict inclusion and exclusion criteria as well as a manual, multi-reviewer, case-by-case evaluation. The reference information is subdivided into intoxications by one specific substance only (group A, n=259), multi-substance intoxications (group B, n=614) and postmortem controls, consisting of deaths not involving incapacitation by substances (group C, n=507). Moreover, the results are compared with data based on therapeutic drug monitoring, and data collected from driving under the influence cases. Median concentrations in group A were significantly higher than in group C for all substances evaluated. For 17 of 24 substances, the median concentrations in group B were significantly higher than in group C. In general, the therapeutic drug monitoring and driving under the influence concentrations were similar to, or lower than, the concentrations in group C.
The nongenotoxic classification for the ubiquitous environmental contaminants polychlorinated dibenzodioxins (PCDDs) and polychlorinated dibenzofurans (PCDFs) implies that a toxicity threshold may exist. Therefore, a minimal risk level or tolerable daily intake (TDI) value can be estimated by identifying no observable adverse effect levels (NOAELs) from animal toxicological investigations and extrapolating this dose to humans by the use of safety factors. When available, data from epidemiological investigations are utilized and carry a larger "weighting" than the animal studies (i.e., smaller safety factors required). A complete database review for the most toxic congener of this class of halogenated aromatic hydrocarbons, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD), yields a NOAEL of 1.0 ng/kg body wt/day for rat carcinogenicity (Kociba et al., Toxicol. Appl. Pharmacol. 46, 279-303, 1978) and reproductive toxicity (Murray et al., Toxicol. Appl. Pharmacol. 50, 241-252, 1979) effects. By employing a 100-fold safety factor to compensate for inter- and intraspecies variability, a tentative TDI value can be estimated at 10 pg/kg body wt/day. For food intake purposes, a total of 17 2,3,7,8-substituted PCDD/PCDF congeners are included in this estimate by using an additive toxic equivalency (TEQ) approach based on international toxic equivalency factors (I-TEFs) developed by NATO (NATO Report No. 178, 1988). This implies that averaged over an individual's total lifespan (estimated at 70 years), 600 pg TCDD TEQs can be taken in daily (60 kg average body weight) without appreciable risk of deleterious effects. The current estimated Canadian daily intake for PCDDs and PCDFs from all sources is 2.0-4.2 pg TCDD TEQs/kg body wt/day (Gilman et al., Chemosphere 23, 1661-1667, 1990). Recent comprehensive epidemiological studies involving industrial/occupational scenarios suggest an increased cancer risk for workers exposed to TCDD-contaminated processes (products contaminated with TCDD) but only at relatively high exposure levels with long latency periods when compared to the background population. To date, the only sustained toxic effect in humans associated with PCDD/PCDF exposure has been chloracne and related dermatological lesions.
