Fagiola Michael, Hahn Timothy, Avella Joseph
Acad Forensic Pathol. 2019 Sep;9(3-4):191-199. doi: 10.1177/1925362119892005. Epub 2020 Jan 31.
A 34-year-old male was reported to be snorting a white powder that was believed to contain heroin. Toxicological analysis revealed free morphine (356 μg/L), fentanyl (34.7 μg/L), alprazolam (64.9 μg/L), and acetylfentanyl (32.9 μg/L) in femoral blood and 6-monoacetylmorphine (6-MAM, <10.0 μg/L) in vitreous fluid. Norfentanyl was only detected in stomach contents (<1.00 μg/total). Heroin, fentanyl, and acetylfentanyl were also detected in solid dose evidence submitted by law enforcement. The fentanyl and alprazolam concentrations might normally be associated with a fatal outcome and are supported with the distribution of fentanyl and alprazolam being consistent with an acute intoxication. In addition, the presence of 6-MAM and a free versus total morphine ratio of 67.9% provide supporting evidence of a rapid death following intranasal (IN) administration. However, the presence of illicit acetylfentanyl complicates toxicologic interpretation due to overlapping recreational and fatal concentrations of this compound reported in the literature as well as a potential for postmortem redistribution (PMR). Reported acetylfentanyl concentrations have also varied when presented with significant fentanyl concentrations and underscore the need to consider a wide range of illicit opioid compounds when investigating drug-related deaths. Based on our comprehensive toxicologic analysis, the results suggest an acute intoxication primarily by IN administration of acetylfentanyl and fentanyl. In addition, we suggest the presence of alprazolam, 6-MAM, and a percentage free morphine is also consistent with rapid death. The cause of death was officially attributed to an acute combined intoxication of acetylfentanyl, fentanyl, alprazolam, and heroin, with the manner of death as accidental.
据报告，一名34岁男性吸食一种据信含有海洛因的白色粉末。毒理学分析显示，股静脉血中含有游离吗啡（356μg/L）、芬太尼（34.7μg/L）、阿普唑仑（64.9μg/L）和乙酰芬太尼（32.9μg/L），玻璃体液中含有6-单乙酰吗啡（6-MAM，<10.0μg/L）。仅在胃内容物中检测到去甲芬太尼（<1.00μg/总量）。在执法部门提交的固体剂量证据中也检测到了海洛因、芬太尼和乙酰芬太尼。芬太尼和阿普唑仑的浓度通常可能与致命结果相关，且芬太尼和阿普唑仑的分布与急性中毒一致，这也支持了这一点。此外，6-MAM的存在以及游离吗啡与总吗啡的比例为67.9%，为经鼻给药后迅速死亡提供了支持证据。然而，非法乙酰芬太尼的存在使毒理学解释变得复杂，因为文献中报道该化合物的娱乐性浓度和致命浓度有重叠，且存在死后再分布（PMR）的可能性。当出现显著的芬太尼浓度时，报告的乙酰芬太尼浓度也有所不同，这突出了在调查与药物相关的死亡时需要考虑多种非法阿片类化合物的必要性。基于我们全面的毒理学分析，结果表明主要是经鼻给予乙酰芬太尼和芬太尼导致急性中毒。此外，我们认为阿普唑仑、6-MAM的存在以及游离吗啡的百分比也与迅速死亡一致。死亡原因被正式认定为乙酰芬太尼、芬太尼、阿普唑仑和海洛因急性混合中毒，死亡方式为意外。
