Death by Drug Intoxication 1995-2008

Julia Pearson, PhD Chief Forensic Toxicologist Hillsborough County, Florida in lieu of Dr. Vernard Adams Chief Medical Examiner Hillsborough County, Florida

Function of Medical Examiner Chapter 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 Tools Inquiry Inspection of scene of death Scene interviews Telephone interviews Inspection of scene of death Medical records Autopsy Toxicology Serology and chemistry tests

Autopsy At discretion of medical examiner Investigative tool Provides information, not answer Permission not required Includes taking of specimens for testing

Toxicology Testing for: Drugs Alcohols Metals Carbon monoxide

Determination 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 Tests Drugs: Carbon monoxide: Thin-layer chromatography Gas chromatography/mass spectrometry Liquid chromatography/mass spectrometry Carbon monoxide: Visible spectrometry

Accidental deaths Hillsborough County Year 1995 Drug: 25 Drowning: 25 Traffic: 249 Year 2008 Drug: 223 Drowning: 20 Traffic: 268

Oxycodone Associated Deaths in Southwestern 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, 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, 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

FDLE Medical Examiners Commission 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 Commission 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” of Drugs causing Death in 2008 Methadone Cocaine/benzoylecgonine Morphine/heroin Oxycodone Hydrocodone Alprazolam Fentanyl Diazepam Diphenhydramine Citalopram

In 2005, 6.4 million Americans Age 12+ used a prescription drug for non-medical purposes in past month 0.3 million Sedatives 1.1 million Stimulants 1.8 million Anti-Anxiety Medication Narcotic Pain Relievers 4.7 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)

2005 Partnership and Attitude Study (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

Pain Highly subjective Acute (immediate) pain-precise location Chronic (late) pain Imprecise location (diffuse) Emotional component Opiates produce analgesia or relief from pain

Generalization in Pharmacology 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 Acute SOD in healthy vol “ general slowing of performance, not limited to specific skills or abilities” 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 none which is not a poison All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy. Paracelsus (1493-1541)