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International Journal of Legal Medicine

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Open Access 01-11-2020 | Nausea | Original Article

Aspiration in lethal drug abuse—a consequence of opioid intoxication

Authors: Johannes Nicolakis, Günter Gmeiner, Christian Reiter, Monika Heidemarie Seltenhammer

Published in: International Journal of Legal Medicine | Issue 6/2020

Abstract

Aims

The primary objective of this study was to investigate whether the fatalities of opioid abuse are not only related to respiratory depression but also as a result of other side effects such as emesis, delayed gastric emptying, a reduction of the cough reflex, and impaired consciousness leading to the aspiration of gastric contents, a finding regularly observed in drug-related deaths.

Design

A retrospective exploratory study analyzing heroin/morphine/methadone-related deaths submitted to court-ordered autopsy.

Setting

Center for Forensic Medicine, Medical University of Vienna, Austria (2010–2015).

Participants

Two hundred thirty-four autopsy cases were included in the study: morphine (n = 200), heroin (n = 11), and methadone (n = 23) intoxication.

Findings

Analyses revealed that 41.88% of all deceased showed aspiration of gastric contents with equal gender distribution (p = 0.59). Aspiration was more frequent in younger deceased (χ² = 8.7936; p = 0.012) and in deceased with higher body mass index (BMI) (χ² = 6.2441; p = 0.044). Blood opioid concentration was lower in deceased with signs of aspiration than in non-aspirators (p = 0.013). Toxicological evaluation revealed a high degree of concomitant substance abuse (91%)—benzodiazepines (61.6%) and/or alcohol (21.8%).

Conclusions

There are lower opioid concentrations in deceased with signs of aspiration, a fact which strongly points to aspiration as alternative cause of death in opioid-related fatalities. Furthermore, this study highlights the common abuse of slow-release oral morphine in Vienna and discusses alternative medications in substitution programs (buprenorphine/naloxone or tamper-resistant slow-release oral morphine preparations), as they might reduce intravenous abuse and opioid-related deaths.

United Nations Office on Drugs and Crime (2018) World drug report 2018

Risser D, Honigschnabl S, Stichenwirth M et al (2001) Drug-related emergencies and drug-related deaths in Vienna, 1995-1997. Drug Alcohol Depend 61:307–313PubMed

Risser D, Schneider B (1994) Drug-related deaths between 1985 and 1992 examined at the Institute of Forensic Medicine in Vienna, Austria. Addiction 89:851–857PubMed

White JM, Irvine RJ (1999) Mechanisms of fatal opioid overdose. Addiction 94:961–972PubMed

Darke S, Zador D (1996) Fatal heroin ‘overdose’: a review. Addiction 91:1765–1772PubMed

Warner-Smith M, Darke S, Lynskey M, Hall W (2001) Heroin overdose: causes and consequences. Addiction 96:1113–1125. https://doi.org/10.1080/09652140120060716CrossRefPubMed

Saba GP 2nd, James AE Jr, Johnson BA, Stitik FP, Burns B (1974) Pulmonary complications of narcotic abuse. Am J Roentgenol Radium Therapy Nucl Med 122:733–739

Gottlieb LS, Boylen TC (1974) Pulmonary complications of drug abuse. Western J Med 120:8–16

Joseph WL, Fletcher HS, Giordano JM, Adkins PC (1973) Pulmonary and cardiovascular implications of drug addiction. Ann Thorac Surg 15:263–274PubMed

10.

Siegel H (1972) Human pulmonary pathology associated with narcotic and other addictive drugs. Hum Pathol 3:55–66PubMed

11.

Glassroth J, Adams GD, Schnoll S (1987) The impact of substance abuse on the respiratory system. Chest 91:596–602PubMed

12.

Kringsholm B, Christoffersen P (1987) Lung and heart pathology in fatal drug addiction. A consecutive autopsy study. Forensic Sci Int 34:39–51PubMed

13.

Mukhopadhyay S, Katzenstein AL (2007) Pulmonary disease due to aspiration of food and other particulate matter: a clinicopathologic study of 59 cases diagnosed on biopsy or resection specimens. Am J Surg Pathol 31:752–759. https://doi.org/10.1097/01.pas.0000213418.08009.f9CrossRefPubMed

14.

Warnock ML, Ghahremani GG, Rattenborg C, Ginsberg M, Valenzuela J (1972) Pulmonary complication of heroin intoxication. Aspiration pneumonia and diffuse bronchiectasis. JAMA 219:1051–1053PubMed

15.

Megarbane B, Chevillard L (2013) The large spectrum of pulmonary complications following illicit drug use: features and mechanisms. Chem Biol Interact 206:444–451. https://doi.org/10.1016/j.cbi.2013.10.011CrossRefPubMed

16.

Passarino G, Ciccone G, Siragusa R, Tappero P, Mollo F (2005) Histopathological findings in 851 autopsies of drug addicts, with toxicologic and virologic correlations. Am J Forensic Med Pathol 26:106–116PubMed

17.

Winklhofer S, Surer E, Ampanozi G, Ruder T, Stolzmann P, Elliott M, Oestreich A, Kraemer T, Thali M, Alkadhi H, Schweitzer W (2014) Post-mortem whole body computed tomography of opioid (heroin and methadone) fatalities: frequent findings and comparison to autopsy. Eur Radiol 24:1276–1282. https://doi.org/10.1007/s00330-014-3128-7CrossRefPubMed

18.

Schug SA, Zech D, Grond S (1992) Adverse effects of systemic opioid analgesics. Drug Saf 7:200–213PubMed

19.

Campora E, Merlini L, Pace M, Bruzzone M, Luzzani M, Gottlieb A, Rosso R (1991) The incidence of narcotic-induced emesis. J Pain Symptom Manag 6:428–430

20.

Aparasu R, McCoy RA, Weber C, Mair D, Parasuraman TV (1999) Opioid-induced emesis among hospitalized nonsurgical patients: effect on pain and quality of life. J Pain Symptom Manag 18:280–288

21.

Breitfeld C, Peters J, Vockel T, Lorenz C, Eikermann M (2003) Emetic effects of morphine and piritramide. Br J Anaesth 91:218–223PubMed

22.

Wirz S, Wartenberg HC, Nadstawek J (2008) Less nausea, emesis, and constipation comparing hydromorphone and morphine? A prospective open-labeled investigation on cancer pain. Support Care Cancer 16:999–1009. https://doi.org/10.1007/s00520-007-0368-yCrossRefPubMed

23.

Liakoni E, Dolder PC, Rentsch KM, Liechti ME (2016) Presentations due to acute toxicity of psychoactive substances in an urban emergency department in Switzerland: a case series. BMC Pharmacol Toxicol 17:25. https://doi.org/10.1186/s40360-016-0068-7CrossRefPubMedPubMedCentral

24.

Zun LS, Downey LV, Gossman W, Rosenbaumdagger J, Sussman G (2002) Gender differences in narcotic-induced emesis in the ED. Am J Emerg Med 20:151–154PubMed

25.

Bijur PE, Esses D, Birnbaum A, Chang AK, Schechter C, Gallagher EJ (2008) Response to morphine in male and female patients: analgesia and adverse events. Clin J Pain 24:192–198. https://doi.org/10.1097/AJP.0b013e31815d3619CrossRefPubMed

26.

Cepeda MS, Farrar JT, Baumgarten M, Boston R, Carr DB, Strom BL (2003) Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther 74:102–112. https://doi.org/10.1016/S0009-9236(03)00152-8CrossRefPubMed

27.

Daoust R, Paquet J, Lavigne G, Piette E, Chauny JM (2015) Impact of age, sex and route of administration on adverse events after opioid treatment in the emergency department: a retrospective study. Pain Res Manag 20:23–28PubMedPubMedCentral

28.

Risser D, Bonsch A, Schneider B, Vycudilik W, Bauer G (1994) Drug fatalities from the forensic medicine viewpoint. 10 years experiences of the Vienna Institute of Forensic Medicine. Wien Klin Wochenschr 106:677–680PubMed

29.

Eisenbach-Stangl I (2013) Deviance or innovation? Recent changes of drug substitution treatment policy in Austria. Subst Use Misuse 48:1010–1021. https://doi.org/10.3109/10826084.2013.797842CrossRefPubMed

30.

Beer B, Rabl W, Libiseller K, Giacomuzzi S, Riemer Y, Pavlic M (2010) Impact of slow-release oral morphine on drug abusing habits in Austria. Neuropsychiatr 24:108–117PubMed

31.

Schwarzenbrunner T (2014) Prescribed drugs - a new crime field? Psychiatr Danub 26:364–367PubMed

32.

Zeidler R (2010) [Verschreibungspraxis von Wiener ÄrztInnen]. Fakultät für Psychologie, Universität Wien

33.

Crews JC, Denson DD (1990) Recovery of morphine from a controlled-release preparation. A source of opioid abuse. Cancer 66:2642–2644PubMed

34.

Peyriere H, Eiden C, Micallef J, Lapeyre-Mestre M, Faillie JL, Blayac JP (2013) Slow-release oral morphine sulfate abuse: results of the postmarketing surveillance systems for psychoactive prescription drug abuse in France. Eur Addict Res 19:235–244. https://doi.org/10.1159/000346179CrossRefPubMed

35.

Peyriere H, Nogue E, Eiden C, Frauger E, Charra M, Picot MC, List of investigators (2016) Evidence of slow-release morphine sulfate abuse and diversion: epidemiological approaches in a French administrative area. Fundam Clin Pharmacol 30:466–475. https://doi.org/10.1111/fcp.12210CrossRefPubMed

36.

McLean S, Bruno R, Brandon S, de Graaff B (2009) Effect of filtration on morphine and particle content of injections prepared from slow-release oral morphine tablets. Harm Reduct J 6:37. https://doi.org/10.1186/1477-7517-6-37CrossRefPubMedPubMedCentral

37.

McLean S, Patel R, Bruno R (2017) Injection of pharmaceuticals designed for oral use: harms experienced and effective harm reduction through filtration. Curr Top Behav Neurosci. https://doi.org/10.1007/7854_2016_470

38.

Bauer SM, Loipl R, Jagsch R, Gruber D, Risser D, Thau K, Fischer G (2008) Mortality in opioid-maintained patients after release from an addiction clinic. Eur Addict Res 14:82–91. https://doi.org/10.1159/000113722CrossRefPubMed

39.

Monforte JR (1977) Some observations concerning blood morphine concentrations in narcotic addicts. J Forensic Sci 22:718–724PubMed

40.

Darke S, Hall W (1995) Levels and correlates of polydrug use among heroin users and regular amphetamine users. Drug Alcohol Depend 39:231–235PubMed

41.

Jones JD, Mogali S, Comer SD (2012) Polydrug abuse: a review of opioid and benzodiazepine combination use. Drug Alcohol Depend 125:8–18. https://doi.org/10.1016/j.drugalcdep.2012.07.004CrossRefPubMedPubMedCentral

42.

Aeschbach Jachmann C, Jagsch R, Winklbaur B, Matzenauer C, Fischer G (2008) Office-based treatment in opioid dependence: a critical survey of prescription practices for opioid maintenance medications and concomitant benzodiazepines in Vienna, Austria. Eur Addict Res 14:206–212. https://doi.org/10.1159/000141645CrossRefPubMed

43.

Vycudilik W (1988) Comparative morphine determination in parts of the brain using combined gas chromatography/mass spectrometry. A possibility for assessing survival time. Z Rechtsmed 99:263–272PubMed

44.

Krabseth H, Morland J, Hoiseth G (2014) Assistance of ethyl glucuronide and ethyl sulfate in the interpretation of postmortem ethanol findings. Int J Legal Med 128:765–770. https://doi.org/10.1007/s00414-014-1031-zCrossRefPubMed

45.

Navaratnam V, Foong K (1990) Adjunctive drug use among opiate addicts. Curr Med Res Opin 11:611–619. https://doi.org/10.1185/03007999009112687CrossRefPubMed

46.

Hickman M, Lingford-Hughes A, Bailey C, Macleod J, Nutt D, Henderson G (2008) Does alcohol increase the risk of overdose death: the need for a translational approach. Addiction 103:1060–1062. https://doi.org/10.1111/j.1360-0443.2008.02134.xCrossRefPubMed

47.

Bender R, Lange S (2001) Adjusting for multiple testing--when and how? J Clin Epidemiol 54:343–349PubMed

48.

Albuquerque AF, Queiroz SI, Germano AR, da Silva JS (2017) Factors associated to post-operative nausea and vomiting following oral and maxillofacial surgery: a prospective study. Oral Maxillofac Surg 21:49–54. https://doi.org/10.1007/s10006-016-0598-6CrossRefPubMed

49.

Liu FL, Cherng YG, Chen SY et al (2015) Postoperative recovery after anesthesia in morbidly obese patients: a systematic review and meta-analysis of randomized controlled trials. Can J Anaesth 62:907–917. https://doi.org/10.1007/s12630-015-0405-0CrossRefPubMed

50.

Kreek MJ (1984) Opioid interactions with alcohol. Adv Alcohol Subst Abus 3:35–46. https://doi.org/10.1300/J251v03n04_04CrossRef

51.

Johnstone RE, Reier CE (1973) Acute respiratory effects of ethanol in man. Clin Pharmacol Ther 14:501–508PubMed

52.

Eder H, Jagsch R, Kraigher D, Primorac A, Ebner N, Fischer G (2005) Comparative study of the effectiveness of slow-release morphine and methadone for opioid maintenance therapy. Addiction 100:1101–1109. https://doi.org/10.1111/j.1360-0443.2005.001128.xCrossRefPubMed

53.

Ellis AD, McGwin G, Davis GG, Dye DW (2016) Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses. Forensic Sci Med Pathol 12:243–247. https://doi.org/10.1007/s12024-016-9780-2CrossRefPubMedPubMedCentral

54.

Scott KS, Oliver JS (1999) Vitreous humor as an alternative sample to blood for the supercritical fluid extraction of morphine and 6-monoacetylmorphine. Med Sci Law 39:77–81. https://doi.org/10.1177/002580249903900114CrossRefPubMed

55.

Wyman J, Bultman S (2004) Postmortem distribution of heroin metabolites in femoral blood, liver, cerebrospinal fluid, and vitreous humor. J Anal Toxicol 28:260–263PubMed

Title: Aspiration in lethal drug abuse—a consequence of opioid intoxication
Authors: Johannes Nicolakis
Günter Gmeiner
Christian Reiter
Monika Heidemarie Seltenhammer
Publication date: 01-11-2020
Publisher: Springer Berlin Heidelberg
Keywords: Nausea
Affective Disorder
Opioids
Foreign Body Aspiration
Intoxication
Opioids
Foreign Body Aspiration
Aspiration
Morphine
Affective Disorder
Methadone
Benzodiazepine
Published in: International Journal of Legal Medicine / Issue 6/2020
Print ISSN: 0937-9827
Electronic ISSN: 1437-1596
DOI: https://doi.org/10.1007/s00414-020-02412-y

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Aspiration in lethal drug abuse—a consequence of opioid intoxication

Abstract

Aims

Design

Setting

Participants

Findings

Conclusions

At a glance: The ONWARDS insulin icodec trials

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Abstract

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Participants

Findings

Conclusions

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