Table 1:

Summary of Carfentanil-Related Deaths

	Date of Death		Demographics	History and Scene Findings	Autopsy Findings	Drug Screen		Drug Concentration		Carfentanil (ng/mL)	Cause of Death
1	1/30/17		31 W/M	History of heroin abuse; last known alive asking for money to buy drugs; found deceased with drug paraphernalia including white powder and rock-like substance	Pulmonary edema, urinary retention, acute needle puncture mark; no significant natural disease	IA negative; MS cocaine, cocaine metabolites, mirtazapine, nicotine, cotinine (urine); IA benzodiazepine; MS mirtazapine, quinine/ quinidine (blood)		Ethanol 0.226 g/dL; cocaine - ND		0.13	Mixed carfentanil and ethanol toxicity
2	2/4/17		33 W/F	History of heroin abuse reportedly injecting heroin and fentanyl; found deceased on bed with drug paraphernalia	Pulmonary edema and airway foam, urinary retention; no significant natural disease	IA negative; MS morphine, quinine/quinidine, nicotine, cotinine (urine); IA negative; MS quinine/ quinidine (blood)		Ethanol 0.177 g/dL; opiates - ND; 6-MAM (vitreous and urine) ND; quinine 430 ng/mL		0.64	Acute carfentanil and ethanol toxicity
3	2/8/17		26 W/F	History of substance abuse; found unresponsive after reportedly insufflating heroin with drug paraphernalia present	Foam in airway; no significant natural disease	IA amphetamine, benzodiazepine, and opiate; MS 6-MAM, morphine, amphetamine, methamphetamine, diphenhydramine, quinine/ quinidine (urine)		Methamphetamine 0.09 mg/L; alprazolam 14 ng/mL; diazepam 57 ng/mL with nordiazepam 100 ng/mL; opiate - ND		0.12	Mixed carfentanil, methamphetamine, alprazolam and diazepam toxicity; OSC recent heroin use
4	2/14/17		43 W/F	History of recent drug overdose found deceased with tourniquet on arm, drug paraphernalia and white powder present	Pulmonary edema; obesity; focally severe atherosclerosis of left circumflex artery	IA amphetamine, benzodiazepine, fentanyl, opiate; MS alprazolam, amphetamine, methamphetamine, amitriptyline, nortriptyline, morphine, quinine/quinidine, ranitidine, nicotine, cotinine (urine)		Morphine 0.03 mg/L; fentanyl (blood and liver) - ND; methamphetamine 0.02 mg/L; alprazolam 15 ng/mL		0.27	Recommendation to coroner: mixed drug toxicity (carfentanil, methamphetamine, alprazolam, opiate)
5	2/16/17		34 W/F	History of heroin and drug abuse found deceased in a shed with syringes nearby	Drug bindle in the axilla; track marks, pulmonary edema with foam; no significant natural disease	IA amphetamine, benzodiazepine, cocaine, fentanyl, opiate; MS amphetamine, methamphetamine, clonazepam metabolite, cocaine, cocaine metabolites, morphine, ibuprofen, gabapentin, levamisole, quinine/quinidine, nicotine, cotinine (urine)		Morphine 0.06 mg/L; methamphetamine 0.18 mg/L; benzoylecgonine 0.15 mg/L; cocaine - ND; fentanyl (liver and blood) - ND; MAM (vit) - ND; clonazepam 2.7 ng/mL amino clonazepam 160 ng/mL		0.44	Mixed drug toxicity (carfentanil, opiate, methamphetamine); OSC recent cocaine and clonazepam use
6	2/17/17		23 W/M	History of heroin abuse with possible recent use found deceased slumped in bathroom grasping a syringe	Pulmonary edema; acute needle puncture mark	IA negative; MS quinine/quinidine (urine and blood)		Urine 6-MAM 0.006 mg/L; opiate - ND; syringe analysis diacetylmorphine, 6-MAM, morphine, 6-diacetylcodeine, codeine, fentanyl, methamphetamine, noscapine, papaverine, quinine/ quinidine		0.14	Acute carfentanil toxicity; OSC recent heroin use
7	3/8/17		43 W/M	History of opiate dependence for chronic pain; found deceased with syringe in antecubital fossa; family denies history of drug abuse (syringe reportedly for testosterone)	Acute and chronic needle punctures; pulmonary edema with microscopy consistent with intravenous drug use; cardiomegaly and left ventricular hypertrophy	IA benzodiazepine; MS alprazolam, citalopram and metabolite, diphenhydramine (urine); additional referral lab screen positive for mitragynine		Alprazolam 27 ng/mL; mitragynine 160 ng/mL; citalopram 400 ng/mL; diphenhydramine - ND		0.26	Mixed carfentanil and mitragynine toxicity
8		3/21/17	39 B/M	History of heroin dependency on methadone therapy; found in an alleyway and responded to Narcan, but later pronounced deceased in a hospital	Pulmonary edema, anoxic brain injury	IA cocaine metabolite; MS tramadol, cocaine and metabolites, quinine (admit urine), and naloxone (blood)		Cocaine 0.03 mg/L; benzoylecgonine 0.58 mg/L; tramadol - ND		0.19	Anoxic brain injury due to resuscitated cardiopulmonary arrest due to mixed carfentanil and cocaine toxicity
9		3/30/17	23 W/M	History of heroin abuse reportedly insufflating cocaine; found slumped in the bathroom with a spoon and a syringe in pants pockets	Acute needle puncture; no significant natural disease	IA amphetamine, opiate; MS methamphetamine, morphine, quinine/quinidine (urine)		Opiate - ND; 6-MAM (vit) - ND; amphetamine/methamphetamine - ND		0.16	Acute carfentanil toxicity
10		4/17/17	32 W/M	History of heroin dependence; found deceased prone with drug paraphernalia present (needles); linked to case 8 through police investigation	Pulmonary edema; no significant natural disease	IA amphetamine, benzodiazepine, fentanyl and opiate; MS alprazolam, amphetamine, methamphetamine, fentanyl, norfentanyl, morphine and paroxetine present (urine)		Amphetamine 0.08 mg/L; methamphetamine 0.41 mg/L; fentanyl (liver) 7.4 μg/kg; opiates - ND; 6-MAM (vit) - ND; MAM (urine) 0.007 mg/L; amino clonazepam 13 ng/mL		0.12	Mixed drug toxicity (carfentanil, fentanyl and methamphetamine)
11		4/26/17	63 NA/M	History of heroin abuse; reportedly insufflating heroin with another individual and both found unresponsive (other individual revived with Narcan)	Pulmonary edema with mucus plugging		IA cocaine; MS cocaine metabolites, naloxone and trazodone (admit blood)	Cocaine - ND; benzoylecgonine 0.03 mg/L; trazodone 0.21 μg/mL		0.10 (se- rum)	Mixed drug toxicity (carfentanil and trazodone)

W - White; B - Black; NA - Native American; M - Male; F - Female; IA - Immunoassay; MS - Mass spectrometry; ND - none detected; 6-MAM - 6-monoacetyl morphine; OSC - other significant conditions; vit - vitreous