Fatal oral heroin overdose. A case report

Abstract

Overdose by heroin injection is well-known but overdose by swallowing is poorly described. A case of lethal overdose by heroin ingestion is presented. A 25-year-old man prisoner was found hanged in his retention unit, he occupied alone, with feet based on the floor. He was seen alive 90 minutes before death. An autopsy was performed four days later and initially, concluded by mechanical asphixya death, without fight or injection marks. Toxicology analysis were realized on peripheral blood, bile and gastrointestinal contents and results are described. Alcohol dosage was realized by GC-FID on all samples. Blood and gastric liquid screening was realized by GC-MS and LC-MS/MS, after liquid/liquid extraction in acidic and basic conditions. Specific methods by GC-MS or LC-MS/MS were done for cannabinoids, amphetamines, cocaine and opiates determination. Other identified substances were quantified by LC-MS/MS or immunoassay. Alcohol was not found in any sample. Concerning drugs of abuse, only opiates were detected in blood and liquid gastric. Morphine, 6-MAM and codeine were measured in concentration of 996 μg/L, 366 μg/L and 84 μg/L in peripheral blood and 45 μg/g, 152 μg/g and 25 μg/g in liquid gastric respectively. Heroin was also detected at 25 μg/g in liquid gastric in association with papaverine and noscapine (opium alkaloids). Some prescribed drugs as tramadol and paracetamol were also identified at 472 μg/L and 42 mg/L in blood. The presence of heroin intact in liquid gastric, without injection marks on the body, suggest oral absorption. After the present first toxicologic results, the food found in the unit was analyzed by the Forensic Police National Institute (INPS) and heroin was detected in a piece of cake, confirming the route of administration. The prisoner was not known to consume heroin. The presence of 6-MAM in blood after oral administration of heroin suggests a massive and recent absorption before the death, probably greater than 1 gram [1]. Indeed, several publications showed that after an ingested dose lower than 1 gram, neither heroin nor 6-MAM could be detected in blood due to a very high activity of deacetylation systems in either the gut or the liver or both [1]. Blood concentrations of morphine and 6-MAM measured were potentially lethal, in particular for a naive subject, by inducing a respiratory depression. However, it was not possible to conclude if the death was related to the heroin overdose or to the hanging, probably a mixed process.