Cocaine-related Deaths Research Articles

Hospitalized cocaine detoxification patients in Paris, France: Increased patient levels and changing population characteristics since 2011

The past twenty years have seen a rise in cocaine-related statistics in France, including cocaine use in the general population, emergency ward presentations of acute cocaine intoxication, cocaine use disorders related outpatient appointments and cocaine-related deaths. This study's objectives were to describe trends in patients' admission for specific cocaine detoxification as well as changes in patients' characteristics in the Assistance publique-Hôpitaux de Paris (AP-HP) hospitals group located in Paris region, France. We reviewed the international classification of diseases 10th edition (ICD-10) discharge codes of the AP-HP hospitals group between 2011 and 2021. In addition, medical reports of the largest addiction medicine ward were also analysed for changes across the years 2009, 2014, 2019 and 2022. The regional database showed an almost 3-fold increase in cocaine-related disorders discharge codes between 2011 and 2019. This occurred due to a rise in hospital stays for cocaine dependence or cocaine acute intoxication prior to the fall in levels of inpatient stays associated with the coronavirus disease 2019 (COVID-19) pandemic. The in-depth analysis of inpatients' stays in the specialized addiction medicine ward also showed an increase in admissions for cocaine detoxification programs, with a prevalence of 1.19% in 2009 to 15.73% in 2022 (P=1.44×10-20). Inpatient characteristics showed significant changes, especially in 2022, namely: more daily users, less intravenous administration and less comorbid illicit substances use disorders, with heightened levels of cured hepatitis C patients (P<0.05). Inpatient prescriptions were primarily dopaminergic antagonists with sedatives properties (cyamemazine, loxapine and chlorpromazine), dopamine-receptors partial agonist (aripiprazole) and serotonin reuptake inhibitors. The referral to hospital care for cocaine detoxification has increased in Paris region since 2011, coupled with changes in inpatients' characteristics. This trend has significant implications for the management of inpatient hospital services.

Drug poisoning deaths by occupation and drug type, Massachusetts 2010-2019.

To investigate variation in drug poisoning mortality rates by drug type and occupation in Massachusetts. Death certificates for deaths by drug poisonings occurring between 2010 and 2019 in Massachusetts were coded based on the decedent's occupation. Mortality rates and rate ratios (with all other occupations as the reference group) were calculated based on the occupation of the workers according to drug type. Poisson regression was used to determine significantly elevated mortality rates and trends in drug poisoning deaths by occupation and drug type. The rate of drug poisoning deaths increased from 2010 to 2016 after which they plateaued. With respect to specific substances, fentanyl- and cocaine-related deaths increased throughout the surveillance period. For drug poisoning deaths overall, workers in construction trades (3,017); food preparation and serving (1,116); transportation and material moving (1,062) occupations had the highest number of drug poisoning deaths. When adjusting for age, sex, race/ethnicity, and educational attainment, workers in 7 occupations had significantly elevated mortality rate ratios for drug poisonings overall: farming, fishing, and forestry (3.42, P < 0.001); construction trades (2.58, P < 0.001); health care support (1.61, P < 0.001); community and social service (1.60, P < 0.001); food preparation and serving related (1.54, P < 0.001); personal care and service (1.37, P < 0.001); and arts, design, entertainment, sports, and media (1.21, P = 0.010). In many cases, workers in these same occupations had elevated mortality rate ratios for poisonings from specific substances. Health care practitioners and technical occupation workers only had elevated rates for methadone-related poisonings (1.73, P = 0.010). These findings highlight that workers in certain occupations have an elevated risk for drug poisonings and that the patterns differ with respect to the drug type. These findings can be useful for providing services to workers in high-risk occupations and in identifying occupational factors that may be related to the risk of drug poisoning death. While previous research has begun to uncover work-related factors that may contribute to opioid use, further work is needed to identify occupational factors that may contribute to psychostimulant and benzodiazepine use.

Abstract WP107: Temporal Trends in Ischemic Stroke-Related Mortality With Concomitant Cocaine Drug Abuse in Age Group of 15-55 Years From 1999-2020 in US

Objectives: The purpose of this study was to assess the trends in mortality rate after ischemic stroke and cocaine drug abuse in different demographics in the United States, compared to non-cocaine users. Introduction: Cocaine misuse has been linked to a higher risk of stroke. This has been observed in the US over the last decade and requires further investigation. Methods: Death certificates from Centers for Disease Control and Prevention Wide-Ranging On Line Data for Epidemiologic Research database were examined from 1999 to 2020 for multiple causes of death MCD-ICD 10 Codes (F14.0-14.9 and T40.5). Age-adjusted mortality rates (AAMRs) per 1000,000 persons and annual percent change (APC) were calculated and stratified by ten-year age group, sex, race/ethnicity, and urbanization. Results: From 1999 to 2020, adults aged 15-55 had 307,615 stroke-related deaths and cocaine-related death were 180,155 and combined stroke plus cocaine-related deaths were 6392.. The AAMR inclined from 1.7 in 1999 to 2.6 in 2007 (APC: 5.4; 95% CI: 3.6 to 8.2), after which it declined to 1.5 in 2010 (APC: -21.32; 95% CI: -25.8 to 12.6), then steadily inclined to 1.6 in 2020 (APC: 2.50, CI: 0.57 to 6.4). Men had consistently higher AAMR than women from 1999 (AAMR men: 1.9 vs women: 1.6) to 2020 (AAMR men: 2.3 vs. women: 0.9). Non-Hispanic (NH) Black or African American adults had the highest overall AAMR (7.8), followed by Hispanic or Latino (2.8), followed by NH White (1.8). AAMR also varied substantially by Urbanization. Conclusions: Deaths from cocaine-related stroke rose from 2007-2010, then declined until 2020. African American adults and men in large cities had high mortality rates. Preventing stroke related to drug abuse is crucial..

Heat shock protein (HSP) and its correlation to cocaine-related death: a systematic review.

Investigating deaths related to chronic cocaine abuse can be a difficult task, particularly when they occur suddenly and without explanation. Cocaine abuse can trigger biological effects similar to physiological stressors, causing the body to produce heat-shock proteins (HSPs). However, there is still limited information on the specific levels of each HSP type. This systematic review aims to comprehensively collect and analyze all existing literature data regar-ding the relationship between HSPs and cocaine abuse to investigate whether HSPs can be utilized as forensic markers for accurately dia-gnosing cocaine-related deaths. The Authors conducted the literature search using PubMed and Scopus databases, searching for articles published between 1 January 1992 and 1 April 2024 using the text string: "heat shock protein" AND "cocaine". Twenty articles were collected, but only nine were included in the systematic review. The data gathered pertained to both human and murine species. The majority of the analyzed articles revealed an elevation in HSP25, HSP27, HSP60, HSP70, HSP72, and HSP73 levels in the brain, cerebellum, and liver, indicating cocaine-induced stress. The relationship between HSP and cocaine has been unclear over time. However, recent studies have shown that cocaine consumption leads to an increase in HSP levels, particularly in the central nervous system. This correlation can also be observed in certain types of liver cells that are capable of binding cocaine metabolites. In conclusion, HSP brain levels, along with other biomarkers, may be used to diagnose sudden, unexpected death related to cocaine abuse.

Polysubstance mortality trends in White and Black Americans during the opioid epidemic, 1999–2018

BackgroundPsychoactive drug combinations are increasingly contributing to overdose deaths among White and Black Americans. To understand the evolving nature of overdose crisis, inform policies, and develop tailored and equitable interventions, this study provides a comprehensive assessment of polysubstance mortality trends by race and sex during the opioid epidemic.MethodsWe used serial cross-sectional US mortality data for White and Black populations from 1999 through 2018 to calculate annual age-adjusted death rates (AADR) involving any opioid, opioid subtypes, benzodiazepines, cocaine, psychostimulants, or combinations of these drugs, stratified by race and sex. Trend changes in AADR were analyzed using joinpoint regression models and expressed as average annual percent change (AAPC) during each period of the three waves of the opioid epidemic: 1999–2010 (wave 1), 2010–2013 (wave 2), and 2013–2018 (wave 3). Prevalence measures assessed the percent co-involvement of an investigated drug in the overall death from another drug.ResultsPolysubstance mortality has shifted from a modest rise in death rates due to benzodiazepine-opioid overdoses among White persons (wave 1) to a substantial increase in death rates due to illicit drug combinations impacting both White and Black populations (wave 3). Concurrent cocaine-opioid use had the highest polysubstance mortality rates in 2018 among Black (5.28 per 100,000) and White (3.53 per 100,000) persons. The steepest increase in death rates during wave 3 was observed across all psychoactive drugs when combined with synthetic opioids in both racial groups. Since 2013, Black persons have died faster from cocaine-opioid and psychostimulant-opioid overdoses. Between 2013 and 2018, opioids were highly prevalent in cocaine-related deaths, increasing by 33% in White persons compared to 135% in Blacks. By 2018, opioids contributed to approximately half of psychostimulant and 85% of benzodiazepine fatal overdoses in both groups. The magnitude and type of drug combinations with the highest death rates differed by race and sex, with Black men exhibiting the highest overdose burden beginning in 2013.ConclusionsThe current drug crisis should be considered in the context of polysubstance use. Effective measures and policies are needed to curb synthetic opioid-involved deaths and address disparate mortality rates in Black communities.

From Bumps to Binges: Overview of Deaths Associated with Cocaine in England, Wales and Northern Ireland (2000-2019).

The UK, as the "cocaine capital of Europe," currently accounts for ∼75% of all cocaine-related hospital admissions in Europe. This study aims to analyze the trends in cocaine-related deaths in England, Wales and Northern Ireland over 20 years (2000-2019). Cases reported to the National Programme on Substance Abuse Deaths (NPSAD) occurring between 2000 and 2019 where cocaine was detected at post-mortem (PM) were extracted for analysis. A total of 5,339 cases were retrieved, with an increase in the rate of reporting over time. Cocaine was deemed a cause of death and quantified in PM blood samples along with its major metabolite benzoylecgonine in 685 cases. Of these 685 cases, 25% (n = 170/685) occurred following acute use, 22% (n = 154/685) following chronic/binge use, 40% (n = 271/685) in combination with morphine, 4% (n = 29/685) in drug packer/swallower circumstances and 9% (n = 61/685) in a suicide context. Cardiac complications were evident in 22% of cases (n = 154/685). The average concentration of cocaine detected in cardiac cases (900 ng/mL) was considerably lower than that detected in cases where acute (19,100 ng/mL) or chronic/binge (6,200 ng/mL) dosing was evident. This is the first cocaine-related mortality study in these geographical areas. Deaths following cocaine use continue to rise despite its Class A drug listing in the UK. While underlying and external risk factors including polydrug use, cardiac complications and mental health can all contribute to the incidence of fatal drug toxicity following cocaine use, this study demonstrates that the risk of a cocaine overdose cannot be attributed to a specific blood concentration range.

Exploring Potential Bellwethers for Drug-Related Mortality in the General Population: A Case for Sentinel Surveillance of Trends in Drug Use among Nightclub/Festival Attendees

Background : Drug-related deaths in the US continue to increase. Sentinel surveillance of high-risk populations can provide early warning for shifts in trends. Nightclub/festival attendees have high levels of drug use, so we explored whether use among this population can serve as a potential bellwether or indicator for use-related mortality in the general population. Methods : Trends in past-year cocaine and methamphetamine use were estimated from nightclub/festival attendees in New York City (NYC) and among NY residents, and trends were estimated for related death rates in NYC (2014/15–2019/20). Using national data from England and Wales (2010–2019), trends in past-year cocaine and ecstasy use (among the full population and among nightclub attendees) and related deaths were also estimated. Results : In NY/NYC, cocaine use remained stable in the general population, but use among nightclub/festival attendees and cocaine-related deaths doubled. Methamphetamine use among nightclub/festival attendees and death rates also more than doubled while use among the general population remained stable. In UK countries, increases in cocaine and ecstasy use were larger for infrequent/frequent nightclub attendees than in the general population, with 3.6- and 8-fold increases in related deaths, respectively. In UK countries, the association between nightclub attendance and death rates increased in a dose-response-like manner with larger associations detected when death rates were lagged by one year. Conclusions : Patterns of use among nightclub/festival attendees, more so than patterns in the general population, were similar to patterns of drug-related deaths. Use among this subpopulation could possibly serve as a bellwether for use-related outcomes. Continued surveillance is recommended.

Clinical characteristics of fatal cocaine toxicity in Australia, 2000-2021.

With increased use, the number of cocaine-related deaths has increased. We aimed to determine: (i) the toxicological profile of cocaine, metabolites and adulterants amongst three groups of cocaine-related fatalities in which cocaine and/or metabolites were present in blood: (a) fatal toxicity, where cocaine only (CO) was present (n=48), (b) multiple drug toxicity (MDT) where other drugs were present (n=604), and (c) a comparison group of death from traumatic injury (TI, n=232); (ii) the acute clinical presentation by group; and (iii) cardiovascular disease by group. Retrospective study of cocaine-related deaths in Australia, 2000-2021, from the National Coronial Information System. The parent drug cocaine was significantly more common, and had a higher median concentration, amongst the CO group (97.9%, 1.550 mg/L) than the MDT (68.9%, 0.09 mg/L) and TI (70.7%, 0.05 mg/L) groups respectively. Similarly large ratios between CO, MDT and TI were seen for benzoylecgonine (2.100, 0.510, 0.240 mg/L), methylecgonine (1.350, 0.140, 0.070 mg/L), lignocaine (1.200, 0.200, 0.150 mg/L) and levamisole (0.230, 0.045, 0.025 mg/L). The two toxicity groups had significantly higher proportions than the TI group for reports of sudden collapse, seizure, acute psychosis, hyperthermia and vomiting. In addition, CO had higher proportions than MDT and TI of sudden collapse. CO had significantly higher proportions of cardiomegaly and coronary artery disease than the TI group. Compared to MDT and TI cases, CO cases had higher cocaine concentrations, higher concentrations of adulterants, higher levels of cardiovascular disease and were more likely to suddenly collapse.

Rates, characteristics and toxicology of cocaine-related deaths in Australia, 2000-2021.

To (i) assess the population mortality rates of cocaine-related deaths in Australia, 2000 to 2021; (ii) determine the circumstances of death and case characteristics; and (iii) determine their toxicological profile. Retrospective study of cocaine-related deaths in Australia, 2000 to 2021, retrieved from the National Coronial Information System. Australia-wide. A total of 884 cases, mean age = 33.8 (SD, 10.0) years and 86.5% (n = 765) male. Information was collected on characteristics, manner of death and toxicology. Only cases in which the presence of blood cocaine and/or metabolites were included. Population rates did not significantly increase during 2001-2011 (annual percentage change [APC] = 1.5; CI, -3.2, 6.5), but from 2012, there was a marked acceleration (APC = 20.0, 95% CI, 15.5, 25.3). Circumstances of death were unintentional drug toxicity (70.7%, n = 625), intentional self-harm (17.8%, n = 157), traumatic accident (11.5%, n = 102). The proportion of cases constituted by unintentional toxicity declined across the study period (APC = -2.6; CI, -3.1, -2.1). There was a substantial decline in the proportion of cases with a history of injecting drug use (APC = -5.7; CI, -6.5, -4.9) and with a history of substance use problems (APC = -3.2; CI, -3.9, -2.5). Both cocaine (0.100 vs 0.050 mg/L, P < 0.001) and benzoylecgonine (0.590 vs 0.240 mg/L, P < 0.001) concentrations were higher amongst toxicity cases than in cases of death from traumatic injury. Cocaethylene was present in 26.4% (n = 233), levamisole in 18.6% (n = 164) and lignocaine in 11.5% (n = 102). Psychoactive drugs in addition to cocaine were present in 92.9% (n = 821), most commonly opioids (50.5%, n = 446), alcohol (47.1%, n = 416), hypnosedatives (43.2%, n = 382) and psychostimulants (30.3%, n = 268). There was a steady decline in the proportion of opioid positive cases (APC = -5.4; CI, -6.3, -4.5). There was a large increase in cocaine-related deaths across Australia from 2000 to 2021. This was accompanied by changes in case profiles, with histories of injecting drug use and substance use problems, as well as recent opioid use, becoming less prominent.

Trends in cocaine use, markets and harms in Australia, 2003-2019.

This paper aims to describe cocaine use, markets and harms in Australia from 2003 to 2019. Outcome indicators comprised prevalence of use from triennial household surveys; patterns of use from annual surveys of sentinel samples who use stimulants; and cocaine-related seizures, arrests, hospitalisations, deaths and treatment episodes. Bayesian autoregressive time-series analyses were conducted to estimate trend over time: Model 1, no change; Model 2, constant rate of change; and Model 3, change over time differing in rate after one change point. Past-year population prevalence of use increased over time. The percentage reporting recent use in sentinel samples increased by 6.1% (95% credible interval [CrI95% ] 1.2%,16.9%; Model 3) per year from around 2017 (48%) until the end of the series (2019: 67%). There was a constant annual increase in number of seizures (count ratio: 1.1, CrI95% 1.1,1.2) and arrests (1.2, CrI95% 1.1,1.2), and percentage reporting cocaine as easy to obtain in the sentinel samples (percent increase 1.2%, CrI95% 0.5%,1.8%; Model 2). Cocaine-related hospitalisation rate increased from 5.1 to 15.6 per 100 000 people from around 2011-2012 to 2017-2018: an annual increase of 1.3 per 100 000 people (CrI95% 0.8,1.8; Model 3). While the death rate was low (0.23 cocaine-related deaths per 100 000 people in 2018; Model 2), treatment episodes increased from 3.2 to 5.9 per 100 000 people from around 2016-2017 to 2017-2018: an annual increase of 2.9 per 100 000 people (CrI95% 1.6,3.7; Model 3). Cocaine use, availability and harm have increased, concentrated in recent years, and accompanied by increased treatment engagement.

Health consequences of cocaine use in France: data from the French Addictovigilance Network

As the number and severity of complications related to cocaine use reported to the French Addictovigilance Network have increased, the French health authorities requested a national epidemiologic study of the data collected by this network from 2010 to 2016. For this purpose, the spontaneous reports (SRs) linked to cocaine notified by health professionals were analyzed as well as the data from the pharmacoepidemiological surveys OPPIDUM (observation of illegal drugs and misuse of psychotropic medications) and DRAMES (deaths related to the abuse of licit and illicit psychoactive substances). In total, 1265 SRs were analyzed (510% increase from 2010 to 2016). Users were mainly men (952/1261; 75%), with a median age of 35.0years [IQ25-75 : 28-42]. Cocaine was consumed through the intranasal route by 52% of users (416/797), followed by intravenous administration (32%, 253/797) and inhalation (24%, 190/797). The use of cocaine powder and crack cocaine was reported in 70% (475/674) and 23% (154/674) of SRs, respectively. Cocaine was consumed with other psychoactive substances and alcohol in 47% (603/1265) and 60% (387/649) of cases, respectively. The main cocaine-related complications were psychiatric complications (29%), neurologic complications (24%) and cardiovascular complications (23%). Analysis of the OPPIDUM survey data showed that in 2016, 15.9 and 2.4% of the included subjects consumed cocaine or crack cocaine the week preceding the survey, the highest rate for the 2006-2016 period. The DRAMES survey indicated that cocaine-related deaths increased by threefold from 2014 to 2016. These data confirm that cocaine use in France is worrying with an increase in the number of severe complications and deaths.

Increase in cocaine-related deaths in Slovenia

Abstract Background In 2016, sudden increase in cocaine related deaths was reported in Slovenia. Study aims to provide data for understanding this new trend and results will serve to create responds to prevent those deaths in the future. Methods We used a trendspotter study methodology. Data from General Mortality Register with forensic autopsies and toxicological analysis were overviewed. For further analysis we linked mortality data with the treatment database for the history of treatment. Data from Early Warning System and national Police service were used. Results All 18 cocaine deaths in 2016 were men with average age 38.9 years. The highest number of deaths occurred in the 30-34 age group. Deaths in time periods can not be linked with seizures of cocaine with certainty. An autopsy was performed in 17 people. Cocaine with benzodiazepines was found in 7 deaths or with opiates in five deaths. Followed are combinations with amphetamines, alcohol and cannabis. 33% were included in the treatment programs. Conclusions No detailed data on cocaine related deaths was available in Slovenia until now. With analysis we got an important inside on this problem and the basis for setting trends regarding cocaine deaths in Slovenia. Key messages Sudden increase in cocaine related deaths was reported in Slovenia. Study aims to provide data for understanding new trend in cocaine related deaths.

Effects of cocaine and levamisole (as adulterant) on the isolated perfused Langendorff heart

Cocaine-related deaths occur regularly in forensic routine work. In cases in which the detected concentration of cocaine is rather low and other causes of death apart from intoxication can be ruled out, the question arises if adulterants of cocaine might have played a crucial role. In the present study, cardiac effects of cocaine, of the adulterant levamisole and of mixtures of both were evaluated using the isolated perfused Langendorff heart. While exposed to the substances, functional parameters heart rate, left ventricular pressure and coronary flow were documented. Relevant alterations of these parameters were found for cocaine as well as for levamisole. Exposing the hearts to a mixture of both resulted in a combination of these effects; the emergence of new alterations or an obvious aggravation were not detected. Nevertheless, the results imply that the consumption of cocaine adulterated with levamisole bares an increased risk for cardiac complications, especially in the presence of preexisting cardiac pathologies.

Treatment versus Punishment: Understanding Racial Inequalities in Drug Policy.

Many observers believe that the policy response to the opioid crisis is less punitive than the crack scare and that the reason is that victims are (stereotypically) white. To assess this conjecture, we compile new longitudinal data on district-level drug-related deaths and (co)sponsorship of legislation on drug abuse in the House of Representatives over the past four decades. Using legislator fixed effects models, we then test how changes in drug-related death rates in legislators' districts predict changes in (co)sponsorship of treatment-oriented or punitive legislation in the subsequent year and assess whether these relationships vary by race of victim or drug type. Policy makers were more likely to introduce punitive drug-related bills during the crack scare and are more likely to introduce treatment-oriented bills during the current opioid crisis. The relationship between district-level drug deaths and subsequent sponsorship of treatment-oriented legislation is greater for opioid deaths than for cocaine-related deaths and for white victims than for black victims. By contrast, district-level drug deaths are not significantly related to sponsorship of punishment-oriented bills. These results suggest that the racial inequalities and double standards of drug policy still persist but in different forms.

An exploratory study of information sources and key findings on UK cocaine-related deaths.

Cocaine-related deaths have increased since the early 1990s in Europe, including the UK. Being multi-factorial, they are difficult to define, detect and record. The European Monitoring Centre for Drugs and Drug Addiction commissioned research to: describe trends reported to Special Mortality Registries and General Mortality Registers; provide demographic and drug-use characteristic information of cases; and establish how deaths are identified and classified. A questionnaire was developed and piloted amongst all European Monitoring Centre for Drugs and Drug Addiction Focal Point experts/Special Mortality Registries: 19 (63%) responded; nine countries provided aggregated data. UK General Mortality Registers use cause of death and toxicology to identify cocaine-related deaths. Categorisation is based on International Classification of Diseases codes. Special Mortality Registries use toxicology, autopsy, evidence and cause of death. The cocaine metabolites commonly screened for are: benzoylecgonine, ecgonine methyl ester, cocaethylene and ecgonine. The 2000s saw a generally accelerating upward trend in cases, followed by a decline in 2009. The UK recorded 2700-2900 deaths during 1998-2012. UK Special Mortality Registry data (2005-2009) indicate: 25-44 year-olds account for 74% of deaths; mean age=34 (range 15-81) years; 84% male. Cocaine overdoses account for two-thirds of cases; cocaine alone being mentioned/implicated in 23% in the UK. Opioids are involved in most (58%) cocaine overdose cases.

Levamisole adulterated cocaine and pulmonary vasculitis: Presentation of two lethal cases and brief literature review

The first case reports of levamisole-related disease in cocaine users were published in 2010, although levamisole adulteration of cocaine was first recognized several years earlier. Currently, more than 70% of street cocaine seizures, in the US and the EU, contain levamisole, which could potentially be converted to aminorex, though the reasons for this practice still remain obscure. Here we report two fatal cases of isolated pulmonary vasculitis in abusers of levamisole-adulterated cocaine, where a complete autopsy, full toxicological analysis by gas chromatography–mass spectrometry (GC–MS) using a previously published method of Karch et al. and histological examination were performed. A control group composed of 11 cases of cocaine related deaths, where the presence of levamisole was excluded in blood, urine and hair, was used. Recent literature on the human pharmacokinetics of levamisole and aminorex is also reviewed.The toxicological analysis revealed positive qualitative and quantitative results for cocaine, benzoylecgonine and levamisole in both cases. In case 1 levamisole was found at the concentration of 13.5 and 61.3mg/L in blood and urine respectively, whereas in case 2 at 17.9 and 70.2mg/L. The histological examination highlighted in case 1 in heart samples microscopic evidence of the typical remodeling changes associated with chronic stimulant abuse, whereas lungs showed numerous lymphocytes surrounding and infiltrating the wall of small pulmonary vessels and a perivascular fibrosis with transforming fibroblasts. In case 2, the myocardial samples showed wide fields of myocardial necrosis characterized by hypercontraction of the myocytes with thickened Z-lines and short sarcomeres, whereas lung samples showed a significant intimal thickening of arteriole walls and lymphocytic infiltration of the wall and edema. Moreover, there were also numerous perivascular lymphocytic infiltrates.Although the pathological cardiac findings have allowed us to establish the cause of death in both cases, the presence of pulmonary vasculitis in the lungs represent a further complication. If the disease had progressed to hemorrhage, it certainly would have been a contributory cause of death.The two cases here reported allow us to advance a hypothesis about the possible correlation between the consumption of levamisole adulterated cocaine and pulmonary vasculitis and the comparison of these findings with the control group support this hypothesis.However, this hypothesis is still weak, taking into consideration the fact that pulmonary vasculitis was detected in 2 cases only, making it impossible to exclude a different etiology of this finding.Only through careful histological lung examinations of further cases of fatalities, related to levamisole adulterated cocaine, can this hypothesis be confirmed or refuted.

Retrospective Analysis of Oxycodone- and Cocaine-Related Deaths in Southwestern Ontario during 2003–2010

Oxycodone hydrochloride is a potent semisynthetic opioid analgesic with a primary role in moderate to severe chronic pain management. It was approved by Health Canada in 1996 for that purpose and added to the Ontario provincial drug formulary in 2000. Increases in oxycodone abuse and oxycodone-related deaths have been noted in both Canada and the USA since oxycodone's introduction to the pharmaceutical market. A retrospective analysis was conducted, reviewing all of the medicolegal autopsies performed at a regional Ontario Forensic Pathology Unit, from 2003–2010. All cases that listed oxycodone and/or cocaine as cause of death were reviewed to ascertain trends in demographic data, preexisting prescription medication use, and concomitant drug use. Cocaine-related deaths were analyzed in order to contextualize oxycodone-related deaths in the setting of drug abuse. Oxycodone-related deaths were observed to increase from 2003–2010 and surpassed cocaine-related deaths in 2010. The proportion of female to male oxycodone-related deaths did not statistically differ during the study years. The proportion of female deaths was constant over the study period, however, male deaths showed a statistically significant increase by 23% from 2009–2010. Females were more likely to die from oxycodone rather than cocaine use, and the converse was seen in males. Among all oxycodone-related deaths over half of the decedents (53%) had a prescription for oxycodone. Oxycodone was also more likely to be reported with polysubstance use. This study illustrates how an abused prescription analgesic can be an ever-increasing burden on society even ten years after its release onto the market.

Concentrations of Cocaine and Benzoylecgonine in Femoral Blood from Cocaine-Related Deaths Compared with Venous Blood from Impaired Drivers

The concentrations of cocaine and its major metabolite benzoylecgonine (BZE) were determined in femoral blood from 132 cocaine-related deaths and compared with venous blood from 988 apprehended drivers. Cocaine and BZE were determined by solid-phase extraction and isotope dilution gas chromatography-mass spectrometry with limits of quantitation of 0.02 mg/L for both substances. Significantly more men (95-98%) than women (2-5%) abused cocaine, although their mean age was about the same (29-30 years). Mean age (±SD) of cocaine-related deaths was 29 ± 7 years, which was not significantly different from 30 ± 8 years in traffic cases (P > 0.05). The median concentration of cocaine in blood in 61 fatalities was 0.10 mg/L compared with 0.06 mg/L in traffic cases (P < 0.001). In drug intoxication deaths, the median concentration of cocaine was 0.13 mg/L (N = 25), which was not significantly different from 0.09 mg/L (N = 36) in other causes of death. Cocaine-related deaths mostly involved mixed drug intoxications including co-ingestion of heroin, cannabis, amphetamines as well as legal drugs, such as benzodiazepines and/or ethanol. The concentrations of cocaine in blood from living and deceased persons overlapped, which makes it infeasible to predict toxicity from the analytical toxicology results alone.

Analysis of skeletal muscle has potential value in the assessment of cocaine-related deaths

This study assesses the interpretive value of cocaine, benzoylecgonine (BZE) and cocaethylene (COET) in skeletal muscle (rectus femoris) in cocaine-using decedents. The distribution of these analytes in cardiac muscle (CM), vitreous humour (VH), femoral blood (FB) and cardiac blood (CB) is also reported. In rectus femoris muscle, the spatial distribution of the analytes was examined across the whole rectus femoris muscle collected from seven fatalities in which cocaine was detected. In six of these cases, death was attributed to trauma and in one case the cause of death was undetermined but suspected to be drug related. In two additional cases analytes were detected in the blood and/or VH but not in the muscle. The muscle was sectioned into 12–15 approximately equal segments, each of which was analysed after homogenisation. Tissue and bio-fluid samples were extracted by solid phase extraction with confirmation and quantification by GC–ion trap-MS/MS. No significant variation was observed in the concentration of any analyte throughout the muscle in the 7 cases analysed. The results reported here are in contrast to a previous study in which great variation in the concentration of some basic drugs (mainly tricyclic antidepressants and benzodiazepines) was observed throughout the thigh muscle bulk (Williams and Pounder, 1997). Analyte concentrations in skeletal muscle (SM) correlated well with those in FB (p<0.01). In general, the concentration of cocaine and COET followed the order VH>CM>SM>FB≥CB. Cocaine concentrations measured in VH were significantly higher than in blood and muscle. Inter-matrix variations in the concentrations of BZE and COET were less marked. The concentration of BZE exceeded that of cocaine in all matrices and in all cases except one where the time between death and drug intake was suspected to be short. In this case, the cocaine to BZE ratio measured in SM (2.66), CM (2.91) and VH (2.19) was higher than that measured in FB (0.97). Given that the concentrations of cocaine and its metabolites were uniformly distributed throughout the muscle and considering the good correlation observed between muscle and blood, muscle could be of interpretive value in cocaine related deaths. Further, since cocaine is known to have greater post-mortem stability in muscle than blood, concentrations measured in muscle may reflect more closely those at the time of death and might be of particular value in cases with an extended period between death and tissue sampling.

‘Opioid Drought’, Canadian-style? Potential implications of the ‘natural experiment’ of delisting Oxycontin in Canada

Non-medical prescription opioid use (NMPOU) and related arms – e.g., morbidity and mortality – have become a major pubic health challenge in North America (i.e., the US and Canada). here, some 5% of the general population report NMPOU; these ates are substantially higher among vulnerable groups (e.g., highchool students; Brands, Paglia-Boak, Sproule, Leslie, & Adlaf, 2010; alomiteanu, Boak, Fischer, Mann, & Rehm, 2012; Manchikanti, ellows, Ailinani, & Pampati, 2010). In recent years, prescripion opioids (POs) have replaced heroin as the primary opioid mong street drug users, which has vanished from street marets in many cities (Davis & Johnson, 2008; Fischer, Rehm, Patra, Firestone Cruz, 2006). Treatment demand for PO dependence has ubstantively increased across North America (Fischer, Nakamura, aolomiteanu, Boak, & Rehm, 2010; Manchikanti et al., 2010). In 008, 14,800 PO-related accidental poisoning deaths occurred in he US, more than heroinand cocaine-related deaths combined Centers for Disease Control and Prevention, 2011). In Canada, POelated death rates have also sharply risen, and are estimated to onstitute up to 50% of annual drug deaths (Fischer & Rehm, 2011). The extent of the PO problem in North America appears to e correlated with the extensive volume of POs dispensed. The S and Canada feature the world’s highest PO consumption rates ith 47,809 Standardized Defined Daily Doses (S-DDD) and 26,380 -DDD per million inhabitants/day, respectively (International arcotics Control Board, 2011). While the PO problem involves a ariety of different PO drugs, the oxycodone-based formulation Oxycontin’ has in exceptional ways contributed to – and come o epitomize – this crisis phenomenon in North America (Cicero, nciardi, & Munoz, 2005; Dhalla et al., 2009; Kuehn, 2007; Paulozzi, udnitz, & Xi, 2006). Oxycontin was approved in North America n 1996; however its medical dispensing and use – propelled by ggressive advertising and promotion strategies – rapidly increased MacIntyre & Karp, 2012; van Zee, 2009).