Death by Drug Death by Drug IntoxicationIntoxication

1995-20081995-2008

Julia Pearson, PhDJulia Pearson, PhD

Chief Forensic ToxicologistChief Forensic ToxicologistHillsborough County, FloridaHillsborough County, Florida

in lieu of Dr. Vernard Adamsin lieu of Dr. Vernard AdamsChief Medical ExaminerChief Medical Examiner

Hillsborough County, FloridaHillsborough County, Florida

Function of Medical ExaminerFunction of Medical ExaminerChapter 406, Florida StatutesChapter 406, Florida Statutes

• Determine cause of death for death by:– Criminal agency– Suicide– Accident– Suspicious circumstances– Unusual circumstances– Suddenly while in apparent good health

Investigative ToolsInvestigative Tools

• Inquiry– Scene interviews– Telephone interviews

• Inspection of scene of death• Medical records• Autopsy• Toxicology• Serology and chemistry tests

AutopsyAutopsy

• At discretion of medical examiner

• Investigative tool

• Provides information, not answer

• Permission not required

• Includes taking of specimens for testing

ToxicologyToxicology

• Testing for:– Drugs– Alcohols– Metals– Carbon monoxide

Determination of Cause of DeathDetermination of Cause of Death

• Autopsy does not reveal cause of death

• COD is from consideration of:– Circumstances– History– Autopsy findings– Toxicology tests– Other tests

Toxicology TestsToxicology Tests

• Drugs:– Thin-layer chromatography– Gas chromatography/mass spectrometry– Liquid chromatography/mass spectrometry

• Carbon monoxide:– Visible spectrometry

Accidental deathsAccidental deathsHillsborough CountyHillsborough County

Year 1995• Drug: 25• Drowning: 25• Traffic: 249

Year 2008• Drug: 223• Drowning: 20• Traffic: 268

Accidental Drug DeathsHillsborough County

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Oxycodone Associated Deaths in Oxycodone Associated Deaths in Southwestern Virginia, 2001Southwestern Virginia, 2001

The frequency of oxycodone found in postmortem cases in southwestern Virginia is increasing. In 1998 oxycodone was identified in fewer than 10 cases. In 1999, it was identified in 19 cases and in 2000, 30 cases.

James J. Kuhlman et al, Virginia Department of Forensic Science

Methadone Strikes Again, 2005Methadone Strikes Again, 2005

While certifying toxicology results at the Office of the Chief Medical Examiner in North Carolina, it appeared that there were an extraordinary number of deaths involving methadone in which the accompanying information did not suggest it should be present.

Diana Garside, North Carolina Medical Examiner’s Office

Methadone Toxicity Fatalities, 2007Methadone Toxicity Fatalities, 2007

Over the past several years, Medical Examiners in Kentucky and around the nation have observed a dramatic rise in drug intoxication deaths involving the prescription medication methadone.

Donna Stewart et al, Kentucky Medical Examiner’s Office

Most Frequently Detected Drugs in 1186 Hillsborough County Cases in 2008

(regardless of cause of death)

0

50

100

150

200

250

300

Ethan

ol

Cocain

e

Oxyco

done

Alpraz

olam

Meth

adon

e

Mor

phine

Codein

e

Hydro

codo

ne

Cariso

prod

ol

Meth

amph

etam

ine

Propo

xyph

ene

Fenta

nyl

FDLE Medical Examiners FDLE Medical Examiners Commission Drug Report 2007Commission Drug Report 2007

• Cases of drugs causing death in Florida– Cocaine 843 – Methadone 785– Benzodiazepines 743

• Alprazolam 572

– Oxycodone 705– Ethanol 466– Hydrocodone 264– Morphine (heroin) 255

FDLE Medical Examiners FDLE Medical Examiners Commission Drug Report 2007Commission Drug Report 2007

• Methadone deaths by age (total 785)

• <18 yrs (13 cases)

• 18-25 yrs (161 cases)

• 26-34 yrs (180 cases)

• 35-50 yrs (297 cases)

• >50 yrs (134 cases)

Virginia’s “Top 10 List”Virginia’s “Top 10 List”of Drugs causing Death in 2008of Drugs causing Death in 2008

1. Methadone2. Cocaine/benzoylecgonine3. Morphine/heroin4. Oxycodone5. Hydrocodone6. Alprazolam7. Fentanyl8. Diazepam9. Diphenhydramine10. Citalopram

Stimulants

Sedatives

4.7 million

0.3 million

Narcotic Pain Relievers

Anti-Anxiety Medication

1.1 million

SOURCE: 2005 National Survey on Drug Use and Health (NSDUH), published Sept 2005 by Dept of HHS / Substance Abuse and Mental Health Services Administration (SAMHSA)

1.8 million

In 2005, 6.4 million Americans Age 12+ used a In 2005, 6.4 million Americans Age 12+ used a prescription drug for non-medical purposes in prescription drug for non-medical purposes in

past monthpast month

2005 Partnership and Attitude Study 2005 Partnership and Attitude Study (PATS)*(PATS)*

Alarming number of teens have a false sense of security about the safety of abusing prescription medications

19% of teens report abusing prescription medications to get high

40% believe that prescription medicines are “much safer” to use than illegal drugs

31% believe there’s “nothing wrong” with using prescription medicines without a prescription “once in a while”

29% believe prescription pain relievers are not addictive

*18th annual study of teen drug use and attitudes Released in April 2006 by The Partnership for a Drug-Free America

PainPain

• Highly subjective

• Acute (immediate) pain-precise location

• Chronic (late) pain– Imprecise location (diffuse)– Emotional component

• Opiates produce analgesia or relief from pain

Generalization in Generalization in PharmacologyPharmacology

The more acute the use

The more naive the user

The more significant the effects

The more chronic the use-NOT Intermittent

Leads to a tolerant subject

The more subtle the effects

Psychomotor functions have adjusted to a new balance; HOWEVER, anything that can upset the new balance will result in more noticeable effects

All substances are poisons; there is All substances are poisons; there is none which is not a poison. The right none which is not a poison. The right dose differentiates a poison and a dose differentiates a poison and a remedy.remedy.

Paracelsus (1493-1541)Paracelsus (1493-1541)