Aspiration in lethal drug abuse\u2014a consequence of opioid intoxication

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

doi:10.1007/s00414-020-02412-y

Abstract

AimsThe 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.DesignA retrospective exploratory study analyzing heroin/morphine/methadone-related deaths submitted to court-ordered autopsy.SettingCenter for Forensic Medicine, Medical University of Vienna, Austria (2010–2015).ParticipantsTwo hundred thirty-four autopsy cases were included in the study: morphine (n = 200), heroin (n = 11), and methadone (n = 23) intoxication.FindingsAnalyses 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%).ConclusionsThere 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.

Highlights

Illicit substance abuse still continues to represent a widespread public health problem with the likelihood of a fatal outcome [1]
While respiratory depression is the primary mechanism of death in opioid overdoses [4], previous studies frequently identified opioid concentrations generally considered to be non-lethal in a non-tolerant population, providing a strong indication of a different cause of death [5, 6]
Clinical expertise suggests that asphyxiation through aspiration is a considerable factor in drug-related deaths, as aspiration of gastric contents is a common complication of drug use [7,8,9,10,11,12,13,14,15]

Summary

Introduction

Illicit substance abuse still continues to represent a widespread public health problem with the likelihood of a fatal outcome [1]. Opioid intoxication is the major cause of illegal-drugassociated deaths in Austria [2, 3]. While respiratory depression is the primary mechanism of death in opioid overdoses [4], previous studies frequently identified opioid concentrations generally considered to be non-lethal in a non-tolerant population, providing a strong indication of a different cause of death [5, 6]. Previous studies have found aspiration rates between 8.5 and 66% in deceased drug users [16, 17]. In terms of opioid-induced aspiration, this phenomenon is attributable due to 4 major mechanisms: (i) emesis, (ii) delayed gastric emptying, (iii) reduction of the cough reflex, and (iv) impaired consciousness

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Results

Conclusion