Using medical examiner case narratives to improve opioid overdose surveillance.

BACKGROUND: Current opioid overdose mortality surveillance methods do not capture the complexity of the overdose epidemic. Most rely on death certificates, which may underestimate both opioid analgesic and heroin deaths. Categorizing deaths using other characteristics from the death record including route of drug administration may provide useful information to design and evaluate overdose prevention interventions. METHODS: We reviewed California Electronic Death Reporting System records and San Francisco Office of the Chief Medical Examiner (OCME) toxicology reports and investigative case narratives for all unintentional opioid overdose deaths in San Francisco County from 2006 to 2012. We chose this time period because it encompassed a period of evolution in local opioid use patterns and expansion of overdose prevention efforts. We created a classification system for heroin-related and injection-related opioid overdose deaths and compared demographic, death scene, and toxicology characteristics among these groups. RESULTS: We identified 816 unintentional opioid overdose deaths. One hundred fifty-two (19%) were standard heroin deaths, as designated by the OCME or by the presence of 6-monoacetylmorphine. An "expanded" classification for heroin deaths incorporating information from toxicology reports and case narratives added 20 additional heroin deaths (13% increase), accounting for 21% of all opioid deaths. Two hundred five deaths (25%) were injection-related, 60% of which were attributed to heroin. A combined classification of expanded heroin and injection-related deaths accounted for 31% of opioid overdose deaths during this period. CONCLUSIONS: Using additional sources of information to classify opioid overdose cases resulted in a modest increase in the count of heroin overdose deaths but identified a substantial number of non-heroin injection-related opioid analgesic deaths. Including the route of administration in the characterization of opioid overdose deaths can identify meaningful subgroups of opioid users to enhance surveillance efforts and inform targeted public health programming including overdose prevention programs.

Alcohol use among fatally injured victims in São Paulo, Brazil: bridging the gap between research and health services in developing countries.

BACKGROUND AND AIMS: Most studies reporting alcohol use among fatally injured victims are subject to bias, particularly those related to sample selection and to absence of injury context data. We developed a research method to estimate the prevalence of alcohol consumption and test correlates of alcohol use prior to fatal injuries. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional study based on a probability sample of fatally injured adult victims (n = 365) autopsied in São Paulo, Brazil. Victims were sampled within systematically selected 8-hour sampling blocks, generating a representative sample of fatal injuries occurring during all hours of the day for each day of the week between June 2014 and December 2015. MEASUREMENTS: The presence of alcohol and blood alcohol concentration (BAC) were the primary outcomes evaluated according to victims' socio-demographic, injury context data (type, day, time and injury place) and criminal history characteristics. FINDINGS: Alcohol was detected in 30.1% [95% confidence interval (CI) = 25.6-35.1)] of the victims, with a mean blood alcohol level (BAC) level of 0.11% w/v (95% CI = 0.09-0.13) among alcohol-positive cases. Black and mixed race victims presented a higher mean BAC than white victims (P = 0.03). Fewer than one in every six suicides tested positive for alcohol, while almost half of traffic-related casualties were alcohol-positive. Having suffered traffic-related injuries, particularly those involving vehicle crashes, and injuries occurring during weekends and at night were associated significantly with alcohol use before injury (P < 0.05). CONCLUSIONS: Nearly one-third of fatal injuries in São Paulo between June 2014 and December 2015 were alcohol-related, with traffic accidents showing a greater association with alcohol use than other injuries. The sampling methodology tested here, including the possibility of adding injury context data to improve population-based estimates of alcohol use before fatal injury, appears to be a reliable and lower-cost strategy for avoiding biases common in death investigations.

Synthetic cannabinoid drug use as a cause or contributory cause of death.

Adverse effects associated with synthetic cannabinoid use include agitation, psychosis, seizures and cardiovascular effects, all which may result in a lethal outcome. We report the collection of data from 25 medical examiner and coroner cases where the presence of synthetic cannabinoids was analytically determined. Participating offices provided case history, investigative and relevant autopsy findings and toxicology results along with the cause and manner of death determination. This information, with the agency and cause and manner of death determinations blinded, was sent to participants. Participants offered their opinions regarding the likely contribution of the toxicology findings to cause and manner of death. The results show that some deaths are being attributed to synthetic cannabinoids, with the highest risk areas being behavioral toxicity resulting in excited delirium, trauma or accidents and as contributing factors in subjects with pre-existing cardiopulmonary disease. While insufficient information exists to correlate blood synthetic cannabinoid concentrations to effect, in the absence of other reasonable causes, the drugs should be considered as a cause or contributory cause of death based on history and circumstances with supporting toxicological data.

Driving Under the Influence of Marijuana Versus Driving and Dying Under the Influence of Marijuana: A Comparison of Blood Concentrations of Δ9-Tetrahydrocannabinol, 11-Hydroxy-Δ9-Tetrahydrocannabinol, 11-Nor-9-Carboxy-Δ9-Tetrahydrocannabinol and Other Cannabinoids in Arrested Drivers Versus Deceased Drivers.

Cannabis intoxication in living and deceased drivers is an important medico-legal topic, but only a limited number of studies examine cannabinoids in living and deceased humans. This study compares cannabinoid concentrations (in ng/mL) in driving under the influence of drug (DUID) drivers with blood cannabinoids to those in drivers who died while driving with cannabinoids in their postmortem (PM) peripheral blood. From 2010 to 2013, there were 318 cannabis-positive DUID cases (mean, median THC: 4.9, 3); 88 had cannabis-only in their bloods (mean, median THC: 5.8, 4). In 23 DUID cases, Huestis' Predictive Models with 95% confidence intervals were applied and evaluated, demonstrating that the actual case time points in all 23 cases fell within the predicted time ranges. Among deceased drivers, 19 had cannabis-positive toxicology (mean, median THC: 11.7, 4.5) and 8 had cannabis-only (mean, median THC: 20.3, 19.5). Motorcyclists and bicyclists comprised the majority of deceased vehicle operators, with bicyclists averaging the highest mean and median THC concentrations overall. The analysis of variance between living and deceased drivers' cannabinoid concentrations showed that THC-OH and THC-COOH concentrations are not statistically different between the two groups, but that THC concentrations are statistically different, making it difficult to directly correlate PM with antemortem THC concentrations between living and deceased drivers.

Opioid Overdose Deaths in the City and County of San Francisco: Prevalence, Distribution, and Disparities.

Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. To better understand urban opioid overdose deaths, this paper examines geographic, demographic, and clinical differences between heroin-related decedents and prescription opioid decedents in San Francisco from 2010 to 2012. During this time period, 331 individuals died from accidental overdose caused by opioids (310 involving prescription opioids and 31 involving heroin). Deaths most commonly involved methadone (45.9%), morphine (26.9%), and oxycodone (21.8%). Most deaths also involved other substances (74.9%), most commonly cocaine (35.3%), benzodiazepines (27.5%), antidepressants (22.7%), and alcohol (19.6%). Deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African-American individuals. Decedents in high-poverty areas were significantly more likely to die from methadone and cocaine, whereas individuals from more affluent areas were more likely die from oxycodone and benzodiazepines. Heroin decedents were more likely to be within a younger age demographic, die in public spaces, and have illicit substances rather than other prescription opioids. Overall, heroin overdose death, previously common in San Francisco, is now rare. Prescription opioid overdose has emerged as a significant concern, particularly among individuals in high-poverty areas. Deaths in poor and affluent regions involve different causative opioids and co-occurring substances.

Driving under the influence of synthetic cannabinoid receptor agonist XLR-11.

The case of a 22-year-old male Caucasian driver is presented. He was involved in a traffic collision. At the roadside, he displayed blank stare and mellow speech with a barely audible voice. A DRE found low body temperature, rigid muscle tone, normal pulse, lack of horizontal and vertical gaze nystagmus, nonconvergence of the eyes, dilated pupil size, and normal Pupillary reaction to light. A standard toxicology DUID protocol was performed on the driver's whole blood including ELISA and GC-MS drug screens with negative results. Additional drug screening was undertaken for bath salts and synthetic cannabinoid receptor agonists by LC-MS/MS by a commercial laboratory and identified the synthetic cannabinoid receptor agonist XLR-11 in the driver's blood. XLR-11 was subsequently quantified at 1.34 ng/mL. This is the first documented case involving a driver operating a motor vehicle under the influence of the synthetic cannabinoid receptor agonist XLR-11.

Cannabinoids in postmortem toxicology.

Cannabinoids are often excluded from postmortem toxicology screens due to their ubiquitous nature, interpretative difficulties and unanswered questions regarding their postmortem redistribution. In this study, we review 30 postmortem cases where a drug screen gave a positive cannabinoids result and a confirmation identified Δ9-tetrahydrocannabinol (THC), 11-hydroxy-Δ9-tetrahydrocannabinol (11-OH-THC), and/or 11-nor-9-carboxy-Δ9-tetrahydrocannabinol (THC-COOH) in peripheral (BL-P) or cardiac/central blood (BL-C) and/or urine (UR). Had cannabinoids not been included in these toxicologic evaluations, incomplete or erroneous inferences would have been drawn in a substantial number of cases regarding cause/manner of death. THC was detected in 28 BL-C and in all 30 BL-P. THC and THC-COOH were confirmed present in 2 and 23 UR, respectively. 11-OH-THC was detected in 4 BL-C, 6 BL-P, and 0 UR. The mean THC concentrations in BL-C and BL-P were 8.0 and 15.8 ng/mL, respectively. The mean THC-COOH concentrations in BL-C and BL-P were 55.2 and 60.6 ng/mL, respectively. The mean 11-OH-THC concentrations in BL-C and BL-P were 17.0 and 12.5 ng/mL, respectively. Postmortem interval (PMI) for each case was determined and evaluated in relation to BL-C/BL-P concentration ratios with THC-COOH exhibiting a possible trend. This study is the first of its kind and demonstrates the usefulness of cannabinoid analyses as part of death investigations. Furthermore, it provides distribution data that will improve the ability of toxicologists and pathologists to evaluate cannabinoid concentrations in human postmortem specimens.

Methamphetamine and driving.

Methamphetamine incidence in driving under the influence cases in the City and County of San Francisco is a significant and on-going challenge. Two methamphetamine positive driving cases are presented herein demonstrating some similarities in observed signs and symptoms and drug blood concentrations but which are also characterized by very different driving styles and behaviours towards the police officers when encountered on the road.