Fatal Intravenous Fentanyl: Abuse Four Cases Involving Extraction of Fentanyl From Transdermal Patches
Amy M. Tharp, MD, Ruth E. Winecker, PhD, and David C. Winston, MD, PhD
(Am J Forensic Med Pathol 2004;25:#2 pp:178-181) DOI: 10.1097/01.paf.0000127398.67081.11
Case 1
A 35-year-old Caucasian man with no known history of drug use was working in his workshop at home one evening. His wife reported that at approximately 12:30 AM, she asked him to come into the house, but that he stated that he would probably continue building porch swings through the night. His father, who stated that he "appeared OK," last saw him alive at 2:30 AM. At approximately 5:00 AM, the decedent’s wife found him lying on the floor of his workshop. Paramedics were unable to resuscitate him. Police investigating the scene found a fentanyl patch, a needle, and syringe in the workshop. External examination of the body revealed no evidence of trauma, except for a 3/4-inch recent contusion with some yellow discoloration at its margins in the left antecubital fossa and a faint petechial-like contusion along a vein on the right forearm. Pulmonary congestion and edema, with a combined lung weight of 920 g, were the only other significant autopsy findings. Toxicological analysis of aortic blood was remarkable for a fentanyl concentration of 5 ug/L, as well as a concentration of 0.8 mg/L of propoxyphene (generally considered to be a nontoxic concentration), and therapeutic concentrations of amitriptyline (0.08 mg/L) and its metabolite nortriptyline (0.33 mg/L). No other organic bases were detected, and testing for norpropoxyphene was not performed. The cause of death was attributed to "fentanyl poisoning," with the manner of death listed as accident.
Case 2
A 38-year-old Caucasian man with a history of drug use was living with his relatives. His family claimed that he had begun a treatment of his drug use in a program that used "morphine patches" for unknown therapeutic purposes. He was last seen alive at 10:00 PM, at which time he complained of nausea. His brother found him dead in bed the following morning at 8:15 AM. Resuscitative efforts were attempted but were unsuccessful. Law officers found a hypodermic needle in the bed beside the body and a ligature on his left hand, with apparent needle marks between the thumb and forefinger. On external examination at the time of autopsy, scars were noted in the right antecubital fossa as well as over each wrist, including a relatively recent puncture site over the dorsum of the left hand, between the thumb and second digit. Internal examination revealed pulmonary congestion and edema, with a combined lung weight of 1500 g, and cardiomegaly (450 g). A focus of granulomatous inflammation was present within the left lung with caseous necrosis, which was found to be due to Coccidioides immitis on silver stains. Focal chronic hepatitis and moderate coronary atherosclerosis were also identified. Toxicologic studies of aortic blood were positive for a 27 ug/L concentration of fentanyl, with no other substances identified. The cause of death was listed as "fentanyl poisoning" with the manner of death as accident.
Case 3
A 42-year-old Caucasian man was found dead in his home, lying prone in the hallway, with his eyeglasses broken and hanging from his face. He had last been known to be alive on the previous day at 10:30 PM, when he had answered a phone call. At the scene, a bottle of diazepam with 11 pills missing from the prescribed number, a methylphenidate tablet, and 2 syringes (1 empty and 1 filled with a clear liquid), as well as an empty box of fentanyl patches were recovered. He had a history of ethanol and multisubstance abuse and was seen in his local emergency room the week prior to his death for treatment of an attempted suicide by Percocet and Restoril overdose, as well as self-inflicted abrasions and lacerations, and ethanol intoxication. Following a work-up, gastric decontamination, and observation, he was sent to a psychiatric hospital for involuntary commitment. It was not determined how he came to be at his home on the day of his death. External examination was unremarkable, with the exception of abundant healed apparently self-inflicted incised wounds on the wrists, abdomen, and forearms. No fentanyl patches were found on the body. Pulmonary congestion and edema, with a combined lung weight of 1920 g, cardiomegaly (450 g), with mild coronary atherosclerosis, and mild hepatic steatosis were found at autopsy. Aortic blood was sent for toxicologic analyses and was positive for 17 ug/L of fentanyl, 0.49 mg/L of paroxetine, low concentrations of cocaine (0.061 mg/L) and its metabolite, benzoylecgonine (0.36 mg/ L), and diazepam (0.15 mg/L). Fentanyl overdose was listed as the cause of death and the manner of death was classified as suicide.
Case 4
A 39-year-old Caucasian man complained of a fever, sore throat, and malaise. He was seen in his local urgent care facility and given hydrocodone cough syrup. Two weeks later, he was found unresponsive in the bathroom of his home by his mother, who admitted removing a needle with attached syringe from his arm. Also found at the scene were 2 empty bottles of hydrocodone, a one-third full bottle of hydrocodone syrup, empty bottles of alprazolam and zolpidem, 2 additional syringes, and 2 empty wrappers from fentanyl patches. He was taken to the local emergency room, where he was pronounced dead. Further investigation revealed a history of drug use, asthma, depression, and psychosis. At the time of autopsy, old needle puncture sites were found within bilateral antecubital fossae, with a relatively recent needle puncture in the left antecubital fossa. Microscopic examination of these sites revealed dermal foreign body giant cells with polarizable material. Internal findings included cardiomegaly (510 g) with left ventricular hypertrophy and hepatosplenomegaly. Numerous foreign body giant cells with polarizable material were present within the lungs, surrounding the pulmonary blood vessels. Toxicologic analysis of femoral blood was positive for 13 ug/L of fentanyl, 0.083 mg/L of hydrocodone, and 0.076 mg/L of oxycodone. Testing of the syringe found at the scene was positive for fentanyl. The cause of death was determined to be fentanyl toxicity, with hydrocodone and oxycodone listed as significant contributing factors. The manner of death was determined to be accident.