Table IX.
NPS Opioids Case Histories with Clinical Symptoms, Autopsy Findings and Primary Drug and Additional Drug Concentrations
| Drug | History | Clinical symptoms/Autopsy findings | Drug results (ng/mL unless specified) | Reference |
|---|---|---|---|---|
| 3-Methylfentanyl | 80 y/o M died at hospital after 3-methylfentanyl OD | N/A | Antemortem blood: 1.1 | (222) |
| 30 y/o M found supine in bed with drug paraphernalia (blue wax baggies and capped syringe) nearby. Last known alive ∼24 h prior | Severe pulmonary and cerebral edema and urine retention. No injection sites observed | Blood: (±)-cis-3-MF 1.2, (±)-trans-3-MF 0.7 Morphine (free) 8.3, fentanyl 1.8, norfentanyl 0.2 Vitreous: 6-AM (free) 1.0 |
(223) | |
| 54 y/o M with hx of depression, anxiety and alcohol abuse | N/A | Blood: (±)-cis-3-MF 0.78, (±)-trans-3-MF 0.39 Fentanyl 0.54, norfentanyl 0.63, oxymorphone (free) 1.7, diazepam 850, nordiazepam 800, oxazepam 23, temazepam 27, alprazolam 55 |
(223) | |
| 36 y/o M found dead in residence with needle in arm | Autopsy findings included pulmonary edema | Blood: (±)-cis-3-MF 0.34, (±)-trans-3-MF 0.23 ethanol 188 mg/dL, +naloxone, diazepam 22, nordiazepam 69, chlordiazepoxide 110, morphine (free) 12, THC 0.7 Urine: +6-AM |
(223) | |
| 50 y/o M with remote hx of drug and alcohol abuse gurgling in sleep, stopped breathing. EMS unable to revive | Pulmonary and cerebral edema | Blood: (±)-cis-3-MF 1.34, (±)-trans-3-MF 0.69 Oxycodone (free) 6.2, BZE 56, 7-AMC 22, lamotrigine 4.6, quetiapine 710 Urine: +6-AM |
(223) | |
| 33 y/o M with hx of seizures, bipolar disorder and heroin abuse found dead with four stamp bags in pants | N/A | Blood: (±)-cis-3-MF 1.6, (±)-trans-3-MF 0.71 | (223) | |
| 22 y/o M found in girlfriend’s apartment hallway, transported by EMS to hospital, pronounced dead. Subject recently released from prison for driving without license and drug possession. Girlfriend stated he took two clonazepam and one oxycodone that night | Pulmonary and cerebral edema and urine retention. Injection sites observed | Blood: (±)-cis-3-MF 0.84, (±)-trans-3-MF 0.37 Oxycodone 62, oxymorphone (free) 1.1, 7-AMC 120, +naloxone |
(223) | |
| 22 y/o M unresponsive after insufflating what he believed was cocaine. Unmarked blue plastic baggies found by decedent’s feet consistent with heroin | Pulmonary and cerebral edema | Blood: (±)-cis-3-MF 0.18, (±)-trans-3-MF <0.10; ethanol 30 mg/dL, BZE 1100, +naloxone, THC 1.8 | (223) | |
| 46 y/o M with hx of heroin abuse, recently released from prison, found unresponsive in brother’s basement. EMS administered three doses of epinephrine, naloxone and intubated decedent. Two empty bags heroin found at scene | Pulmonary and cerebral edema | Blood: (±)-cis-3-MF 0.51, (±)-trans-3-MF 0.26 6-AM 33, morphine (free) 40, cocaine 100, cocaethylene 32, BZE 1600, oxycodone (free) 81, oxymorphone (free) 1.2, quetiapine 230 | (223) | |
| 55 y/o M with MVC, hx of chronic pain led to heroin and prescription opioids use. Found unresponsive at another residence. EMS administered 0.4 mg naloxone and started OD protocol. Unable to revive | Mild pulmonary edema | Blood: (±)-cis-3-MF 3.28, (±)-trans-3-MF 1.9 Cocaine 140, BZE 420, amitriptyline 420, nortriptyline 890, clonazepam 8.1, 7-AMC 180, +naloxone, ethanol 13 mg/dL |
(223) | |
| 26 y/o F with hx of opioid abuse and rehab. Witnessed insufflating white substance she believed was fentanyl. Boyfriend administered naloxone and second dose administered by police | Visceral congestion and mild pulmonary edema | Blood: (±)-cis-3-MF 0.33, (±)-trans-3-MF 0.25 Citalopram/escitalopram 370 | (223) | |
| 31 y/o M with hx of opioid addiction found unresponsive in bedroom with vomit around nose and mouth. Decedent insufflated drugs. 3 orange glassine baggies and straw found on desk | Pulmonary edema | Blood: (±)-cis-3-MF 0.35, (±)-trans-3-MF 0.19 | (223) | |
| 32 y/o M with hx of heroin abuse and outpatient rehab found unresponsive in kitchen with syringe in hand and three blue wax baggies and one clear baggie in shorts. Decedent’s spouse stated he relapsed | Pulmonary edema and IV injection site in antecubital fossa | Blood: (±)-cis-3-MF 0.71, (±)-trans-3-MF 0.38 Morphine (free) 14, fentanyl 1.5, norfentanyl 0.27 Urine: +6-AM |
(223) | |
| 32 y/o F with hx of heroin abuse currently in rehab found unresponsive after recently released from jail. Decedent found with zolpidem, quetiapine and lansoprazole, with syringe in package and plastic straw. Clear plastic bag with white powder found in bra at autopsy | Pulmonary edema, moderate cerebral edema and IV injection sites observed | Blood: (±)-cis-3-MF 0.74, (±)-trans-3-MF 0.69 p-FIBF 1.4, 4-ANPP 0.53, alprazolam 14, morphine (free) 14, quetiapine 370, zolpidem 17, THC 5, fentanyl 1.2, norfentanyl 0.2 Urine: +6-AM |
(223) | |
| 28 y/o M with hx of heroin abuse and rehab found dead in bathroom. Blue wax paper substance found on toilet seat and half straw near decedent | Pulmonary edema, moderate cerebral edema and urine retention | Blood: (±)-cis-3-MF 1.4, (±)-trans-3-MF 0.77; alprazolam 16, morphine (free) 25, dextro/levomethorphan 38, fentanyl 0.7 Urine: +6-AM |
(223) | |
| 36 y/o M with hx of asthma, heroin abuse and suicidal tendencies, recently released from prison, found unresponsive | Pulmonary and cerebral edema | Blood: (±)-cis-3-MF 0.38, (±)-trans-3-MF 0.19 | (223) | |
| 22 y/o M with hx of heroin abuse and rehab found unresponsive in bedroom. Unmarked baggie and syringe and empty blue paper wrapper from jean pocket found on scene. Decedent revived with naloxone twice previously | Pulmonary edema, moderate cerebral edema and IV injection sites observed | Blood: (±)-cis-3-MF 0.79, (±)-trans-3-MF 0.54 Alprazolam 6.5, morphine (free) 10, fentanyl 0.79, THC 1.0 |
(223) | |
| 30 y/o F with hx of drug abuse recently released from prison on drug charges, found unresponsive in room littered with syringes and empty blue and clear baggies. One baggie imprinted with word ‘OWL’ | Pulmonary edema. Injection sites observed on antecubital fossa, right hand and& neck | Blood: (±)-cis-3-MF 0.35, (±)-trans-3-MF 0.19 Clonazepam 7.7, 7-AMC 100, cocaine 160, BZE 1,100, morphine (free) 20, lamotrigine 0.21, dextro/levomethorphan 44 |
(223) | |
| Unknown gender and age DUID | N/A | Blood: (±)-cis-3-MF 0.21, (±)-trans-3-MF 0.13 +Caffeine |
(223) | |
| 29 y/o M DUID | N/A | Blood: (±)-cis-3-MF 0.79, (±)-trans-3-MF 0.19 Clonazepam 48, 7-AMC 64, cocaine 60, BZE 1700, fentanyl 1.0, norfentanyl 0.53 |
(223) | |
| Carfentanil | 33 y/o M with hx of ethanol, cannabis and cocaine use found bradypneic by EMS following insufflating white powder, admitted to hospital | RR 9 breaths/min, EMS 2 mg IV naloxone, assisted ventilation. At ED, another 2 mg IV naloxone without improvement. Subject comatose with pupillary miosis fixed at 2 mm, diaphoretic and warm. HR 113 bpm, BP 165/84 mmHg. Awoke 31 h post admission and discharged 3 days after admission | Venous blood: 22.4 (at admission), 1.0 (25.5 h post admission), 0.52 (31 h post admission; interpolated) Ethanol 99 mg/dL, norcarfentanil 3.95 (at admission), 0.93 (25.5 h post admission) Urine: +THC-COOH, +cocaine |
(224) |
| 41 y/o M insufflated white powder purported to be cocaine at private party. Comatose within minutes | Patient presented with myosis and bradypnea and subsequently hospitalized in ICU. Patient recovered and returned home after few days | Plasma: <0.01 Norcarfentanil <0.05 Urine (+1 h): 2.88 Norcarfentanil 8.8, cocaine 570, BZE 1,230, EME 367 |
(225) | |
| 48 y/o F with hx of depression and drug use, found unconscious at home after use of fentanyl purchased over internet. Empty boxes pregabalin and buprenorphine on scene. EMS medical care included sufentanil delivery. Admitted to hospital comatose | Patient miotic and naloxone administered without success. Hospitalized, intubated, ventilated and treated with lidocaine, etomidate and propofol. Recovery completed after 8 days in ICU and 12 days in internal medicine ward | Plasma: 32.4 Norcarfentanil 15.8, <0.04 fentanyl, sufentanil <0.05, buprenorphine 0.48, norbuprenorphine <0.5 Urine: 1,430 Norcarfentanil 1,820, fentanyl 1.7, sufentanil <0.05, buprenorphine 6.0, norbuprenorphine 19.4 |
(225) | |
| 41 y/o M with hx of opioids and benzodiazepines use found unconscious by family. When conscious, subject stated he took 0.025 mg (nasally) and 0.025 mg (IV) carfentanil with 0.5 g heroin 5 h prior | EMS found in respiratory depression (2 breaths/min), GCS 3. EMS administered three doses 0.4 mg naloxone. At ED subject lost consciousness again, given two more 0.4 mg naloxone and admitted to ICU with naloxone infusion | Urine: 457 +Norcarfentanil, +morphine-3-glucuronide, +codeine-6-glucuronide, +buprenorphine, +methadone, +benzodiazepines, +ethyl glucuronide, +ethyl sulfate |
(226) | |
| 16 y/o M found unconscious after taking unknown substance. Intubated, airlifted to hospital, regained consciousness after IV naloxone and flumazenil. White powder discovered in patient’s belongings was carfentanil. Patient was also prescribed atomoxetine | Patient hypotensive (71/58 mmHg), tachycardic (128 bpm), hypopneic and cyanotic (pO2 saturation 70%). Temp normal and normal pupils responded to light | Serum (1 h after use): 0.6 Norcarfentanil 0.2 Urine: 1.3 Norcarfentanil 0.5 |
(227) | |
| 31 y/o M with hx of heroin use. Last seen asking for money to buy drugs. Found deceased with drug paraphernalia, white powder and rock-like substance | Pulmonary edema, urinary retention, acute needle puncture marks, no significant natural disease. COD ruled carfentanil and ethanol toxicity | Blood: 0.13 Ethanol 226 mg/dL |
(228) | |
| 33 y/o F with hx of heroin use, last seen highly intoxicated while mixing heroin and fentanyl. Found deceased on mattress on her floor with drug paraphernalia nearby | Pulmonary edema and airway foam, urinary retention. No significant natural disease. COD ruled acute carfentanil and ethanol toxicity | Blood: 0.64 Ethanol 177 mg/dL, quinine 430 |
(228) | |
| 26 y/o F with hx of drug use found unresponsive after reportedly insufflating heroin. Drug paraphernalia on scene | Foam in airway, no significant natural disease. COD ruled carfentanil, methamphetamine, alprazolam and diazepam toxicity | Blood: 0.12 Methamphetamine 90, alprazolam 14, diazepam 57, nordiazepam 100 |
(228) | |
| 43 y/o F with hx of recent drug OD, found deceased with tourniquet on arm, drug paraphernalia and white powder present | Pulmonary edema, obesity, focally severe atherosclerosis of left circumflex artery. COD carfentanil, methamphetamine, alprazolam and opiate | Blood: 0.27 Morphine 30, methamphetamine 20, alprazolam 15 |
(228) | |
| 34 y/o F with hx of drug use, including heroin, found deceased in shed with syringes nearby | Drug bindle in axilla, track marks, pulmonary edema with foam, no significant natural disease. COD mixed drug toxicity (carfentanil, opiate and methamphetamine) | Blood: 0.44 Morphine 60, methamphetamine 180, BZE 150, clonazepam 2.7, 7-AMC 160 |
(228) | |
| 23 y/o M with hx of heroin use, found deceased slumped in bathroom with syringe in hand. Syringe analysis indicated heroin, fentanyl and methamphetamine | Pulmonary edema, acute needle puncture mark. COD ruled acute carfentanil toxicity | Blood: 0.14 Urine: 6-AM 6 |
(228) | |
| 43 y/o M with hx of opiate dependence from chronic pain, found deceased with syringe in antecubital fossa. Family denied hx of drug abuse; syringes reportedly for testosterone | Acute and chronic needle punctures; pulmonary edema with microscopy consistent with IV drug use; cardiomegaly and left ventricular hypertrophy. COD mixed carfentanil and mitragynine toxicity | Blood: 0.26 Alprazolam 27, mitragynine 160, citalopram 400 |
(228) | |
| 39 y/o M with hx of heroin dependence on methadone, found in alley and initially responded to naloxone. Pronounced dead at hospital | Pulmonary edema, anoxic brain injury. COD anoxic brain injury after resuscitated cardiopulmonary arrest due to carfentanil and cocaine toxicity | Blood: 0.19 Cocaine 30, BZE 580 |
(228) | |
| 23 y/o M with hx of heroin use, reportedly insufflated cocaine, found slumped in bathroom with spoon and a syringe in pants | Acute needle puncture, no significant natural disease. COD acute carfentanil toxicity | Blood: 0.16 | (228) | |
| 32 y/o M with hx of heroin dependence, found dead prone with drug paraphernalia present | Pulmonary edema, no significant natural disease. COD mixed carfentanil, fentanyl and methamphetamine toxicity | Blood: 0.12 Methamphetamine 410, amphetamine 80, 7-AMC 13 Liver: fentanyl 7.4 mcg/kg Urine: 6-AM 7 |
(228) | |
| 63 y/o M with hx of heroin use, reportedly insufflating heroin with someone else and both found unresponsive. Other person revived with naloxone | Pulmonary edema with mucus plugging. COD carfentanil and trazodone toxicity | Serum: 0.10 BZE 30, trazodone 0.21 mcg/mL |
(228) | |
| Cyclopropylfentanyl | 39 y/o M with hx of chronic pain treated with insufflated ground oxycodone. Discovered on couch in crouched position with small plastic bag with an unknown white powder | Autopsy findings included weak brain edema and blood congested lungs. Frothy fluid found in larynx and respiratory tract | Heart blood (at autopsy): 52.4 Femoral blood (collected 11 h post death): 15.7 Femoral blood (collected 29 h post death at autopsy): 19.8 Ethanol 127 mg/dL, codeine 480, diphenhydramine 1000, morphine 14, oxycodone 6, zolmitriptan 4.5 |
(229) |
| 27 y/o M with hx of recreational drug use found deceased at home with 18 rectangular white pills marked ‘XANAX’ but identified as cyclopropylfentanyl | COD mixed drug intoxication | Blood: 29 Pregabalin 10 mcg/mL, morphine 49, amphetamine 365, MDMA 460, MDA 48, BZE 5.2, 7-AMC 250, buprenorphine 0.89, norbuprenorphine 6.2, THC 4.7 Urine: 610 |
(230) | |
| 25 y/o M developed nausea, profuse sweating and dyspnea 10 min after using a ‘fentanyl research chemical’ nasal spray from a local drug trafficker. He also used cannabis the same day. Symptoms progressed to coma, respiratory depression and admitted to hospital | Coma, miosis, RR 14/min. BP 127/70 mmHg and HR 65 bpm. Given 0.8 mg naloxone and breathing stabilized. Patient had decreased pO2 for 12 h, discharged after 1 day | Urine: 7 Cyclopropylnorfentanyl 220, THC-COOH 9.2, BZE 23, EME 9.2 |
(231) | |
| 25 y/o M with hx of oxycodone drug abuse after sports injury 5 years prior, found unresponsive in bed at home | Dry white foam purge on decedent’s mouth. COD alcohol, cocaine, oxycodone and cyclopropylfentanyl | Heart blood: 14 Oxycodone (free) 60, oxymorphone (free) 30, BZE 100 ng/mL, cocaethylene 70, ethanol 26 mg/dL |
(232) | |
| 24 y/o M found dead at home | Lung congestion with fluid and dark blood. Suspected COD polydrug intoxication | Blood: 20.4 +Heroin, +cocaine, +amphetamine (other stimulants), +therapeutic drugs |
(233) | |
| Furanylfentanyl | 53 y/o M with hx of heroin and other drugs use and depression found unresponsive at home, sitting on chair with head and chest collapsed on desk and butterfly needle inserted into left-hand vein. EMS noted rigor mortis and decedent was declared dead. White powder on scene was furanylfentanyl | Multivisceral congestion, pulmonary and cerebral edema, with no evidence of disease or physical injury. Petechia on lower limb surface. Recent needle punctures on back of hands and track marks on forearms | Femoral blood: 2.7 Cardiac blood: 11.8 Urine: 71.3 Bile: 7.7 Cerebrospinal fluid: 2.6 Gastric content: 40.1 ng/g |
(234) |
| 44 y/o M with hx of IV drug use found unresponsive at home. Attempted revival unsuccessful. Drug paraphernalia on scene, plastic bag containing white powder and two small plastic tubes containing colored liquid. White powder was furanylfentanyl and other crystalline powders contained MMMP. Two liquids for vaping contained glycerin, nicotine and furanylfentanyl | Coarse white froth in distal trachea and main bronchi and pulmonary edema and congestion | Blood: 1.6 MMMP 6.7, THC 10, THC-COOH 23, mirtazapine 200, paliperidone 30 quetiapine 200 |
(235) | |
| 19 y/o F insufflated a fentanyl powder called ‘China White’ and developed apnea. Found unresponsive, normotensive and bradypneic. Treated with supplemental oxygen and 3 mg IV naloxone, some mental status improvement. Powder identified as furanylfentanyl | In ED, lethargic, minimally responsive, cyanotic and coughing, acute respiratory distress and aspiration. Hypertensive 149/112 mmHg, tachycardic 143 bpm and hypoxic 80% pulse oximeter. Pupils 2 mm and reactive to light. Normal muscle tone, but acute lung injury due to aspiration. Extubated after 30 h and symptoms resolved | Serum: 3.6 Urine: 17.6 |
(236) | |
| 46 y/o F with hx of alcoholism, found dead in unsanitary apartment. Decomposition noted | No traumatic or preexisting lesions considered as COD | Cardiac blood: 14 U-47700 54, 4-ANPP 33, methadone 154, EDDP 27, methamphetamine 664, amphetamine 103, cocaine 12, BZE 840 |
(237) | |
| 30 y/o M with hx of drug and alcohol addiction found in father’s kitchen in cardiorespiratory arrest. Unable to revive. Recently released from jail and oxycodone dependent. Decedent had prescription for pregabalin, methylphenidate and clonazepam | Coronary artery presented moderate to severe atherosclerosis | Femoral blood: 0.89 U-47700 26, 4-ANPP 18, clonazepam 94, methylphenidate 15, pregabalin 5,571, THC 18, THC-COOH 32, THC-OH 3.3, naproxen 2,118, nortriptyline 14, diazepam 11 Cardiac blood: 2.4 U-47700 45 |
(237) | |
| beta-Hydroxyfentanyl | 22 y/o touched tongue to powdered ‘fentanyl’ to treat migraine headache, unresponsive and apneic. EMS gave 2 mg IM naloxone on arrival. Powder chemically verified as beta-hydroxyfentanyl | At ED, patient conscious, alert with tachycardia (141 bpm), hypertension (149/95 mmHg) and pO2 saturation 100%. Observed for 4 h | Serum: 6.5 +Alprazolam |
(236) |
| p-FIBF | 35 y/o M found dead in bathroom. Glass pipe with brown color contamination found at scene | COD circulatory failure associated with NPS | Blood: 74 Despropionyl p-fluorofentanyl 6.5, alpha-PiHP 5.6, THC-COOH 16 |
(238) |
| 29 y/o M with hx of drug use and rehab found dead with syringe in hand and empty bottles of steroids nearby. Decomposition noted | No traumatic or preexisting lesions noted during autopsy | Femoral blood: 27 Methoxyacetylfentanyl 14, cyclopropylfentanyl 0.10, 4-ANPP 9.7, alprazolam 12, quetiapine 58, gabapentin 15, +duloxetine, +U-47700, +acetylfentanyl, +despropionyl fluorofentanyl Cardiac blood: 31 Methoxyacetylfentanyl 70, cyclopropylfentanyl 0.15, 4-ANPP 3.1, +U-47700, +acetylfentanyl, +despropionyl fluorofentanyl, +N-methyl U-47931E |
(237) | |
| U-48800 | 41 y/o M with hx of cocaine and heroin use collapsed in hotel room bathroom. Decedent vomited all day and injected four bags of heroin. Stamp bags labeled ‘Stranger Danger’ with blue skull wearing hat and needle recovered at scene | Peripheral blood: 0.27 4-ANPP 0.4, cocaine 95, BZE 120, fentanyl 7.2, norfentanyl 11.3 |
(239) | |
| 46 y/o F found in supine position on bedroom floor with livor mortis. 13 stamped bags of ‘Stranger Danger’ with blue skull wearing hat recovered at scene | Peripheral blood: 5.3 4-ANPP 7, p-FIBF 0.13, cocaine 530, BZE 960, morphine 12, fentanyl 58, norfentanyl 8.3, acetylfentanyl 0.93 |
(239) | ||
| 58 y/o M with hx of IV heroin for past 5 days collapsed in front of mother. EMS transferred decedent to hospital, resuscitation efforts were unsuccessful | Peripheral blood: 2.8 Ethanol 203 mg/dL, 7-AMC 9, codeine 14, morphine 210, 6-AM 12, THC 0.62, +naloxone, +caffeine |
(239) | ||
| 39 y/o F with hx of drug abuse recently released from prison for drug charge. Text messages about illicit substances to ‘celebrate’. Drug paraphernalia found on scene included clean baggies with brown-white powder, spoon and loaded syringe | Peripheral blood: 6.2 4-ANPP 0.66, cocaine 140, BZE 3,300, morphine (free) 24, hydroxyzine 24, fentanyl 9.7, norfentanyl 1.7, acetylfentanyl 0.64, +caffeine, +cotinine, +levamisole |
(239) | ||
| 42 y/o M with hx of drug abuse last seen alive with withdrawal symptoms, including seizures and vomiting | Needle marks in antecubital fosse. Hypertensive cardiovascular disease | Peripheral blood: 1.9 Amphetamine 33, methamphetamine 61, +naloxone |
(239) | |
| 45 y/o M suspected OD | N/A | Femoral blood: 0.8 Cyclopropylfentanyl 2.5, ethanol 144 mg/dL, +cotinine |
(239) | |
| 33 y/o F with hx of heroin abuse, suspected OD | N/A | Iliac blood: 1.0 Cocaine 69, BZE 530, morphine 14, THC 7.3, dextromethorphan 26, fentanyl 7.5, norfentanyl 2.1, acetylfentanyl 0.18, 4-ANPP 0.13, U-47700 1.8, morphine 10, 6-AM 1.1, +caffeine, +levamisole, +naloxone |
(239) | |
| 36 y/o F unknown circumstances | N/A | Cardiac blood: 1.8 Methoxyacetylfentanyl 32, +4-ANPP, +caffeine |
(239) | |
| Isotonitazene | 27 y/o F with hx of heroin use found deceased in car with head in a bucket of water | N/A | Blood: 1.0 Fentanyl 5.7, norfentanyl 2.4, 4-ANPP 1.4, etizolam 6.2, diazepam 120, nordiazepam 210, oxazepam 22, THC 1.3, THC-COOH 64, +caffeine, +cotinine, +naloxone, +diphenhydramine, +quinine |
(9) |
| 27 y/o M with hx of heroin use found unresponsive at home with needles and substance believed to be heroin | Multiple track marks noted on body | Cardiac blood: 1.9 Etizolam 15, +caffeine, +acetaminophen, +diphenhydramine Vitreous: 0.1 Urine: 2.6 |
(9) | |
| 66 y/o M with hx of heroin use, hypertension and seizures found deceased in bed by family | Heart weighed 483 g with signs of stenosis. Right lung 832 g, left lung 667 g. Pulmonary edema, hypertensive, cardiovascular disease | Peripheral blood: 1.5 Fentanyl 2.9, norfentanyl 1.0, etizolam 13, levetiracetam 14 µg/mL, diphenhydramine 200, +cotinine, +quinine Urine: +morphine |
(9) | |
| 41 y/o F with hx of heroin use found unresponsive. 1.5 days prior visited ED at hospital for suspected drug OD and 5 days prior released from drug rehabilitation program. White powder found in pocket | N/A | Subclavian blood: 0.9 Fentanyl 5.8, norfentanyl 0.61, acetylfentanyl 0.69, 4-ANPP 1.6, morphine (free) 12, cocaine 89, BZE 800, +naloxone, +tramadol, +O-desmethyltramadol, +acetaminophen, +cotinine, +caffeine, +levamisole, +quinine Urine: 3.5 +Xylazine |
(9) | |
| 53 y/o M found unresponsive on back on floor of friend’s apartment. Showed friend white powdery substance night before | Pulmonary and cerebral edema, moderate atherosclerosis of left descending artery | Peripheral blood: 2.7 +4-ANPP, BZE 370, U-47700 0.34, +phenacetin, +levamisole, +diphenhydramine Urine: 4.0 |
(9) | |
| 27 y/o M found lifeless in cemetery | Linear puncture marks on right and left thighs. Pulmonary edema; right lung weighed 976 g and left 992 g. Kidneys red-brown and slightly granular | Peripheral blood: 1.8 Etizolam 30, THC-COOH 7.7, THC 1.2, diphenhydramine 190, +caffeine, +cotinine, +quinine +piperidylthiambutene Urine: 2.8 +piperidylthiambutene |
(9) | |
| 56 y/o F with hx of opiate use disorder, pain symptoms and previous suicide attempt by drug OD, found deceased slumped over toilet. Known suboxone user | Mild cardiomegaly (470 g) with focal histologic changes from hypertension. Pulmonary edema: right lung 930 g and left 800 g. Vascular congestion and kidney glomerulosclerosis and arteriolosclerosis | Iliac blood: 0.4 Flualprazolam 4.0, +naloxone, +hydroxyzine, +etizolam, +cotinine, +caffeine, +O-desmethylvenlafaxine, venlafaxine, norfluoxetine, +fluoxetine, +quetiapine |
(9) | |
| 41 y/o M with hx of heroin use and prior OD found deceased by hotel staff. White powdery substance found on scene | Red purge extruding from oral and nasal cavities. No foam cone noted. Distended bladder and organs congested | Subclavian blood: 1.7 Flualprazolam 6.4, +caffeine, +cotinine |
(9) | |
| Hx of depression and drug abuse, including fentanyl. White powder at scene chemically verified as isotonitazene | Blood organ congestion, gastric material in upper and lower respiratory tract, heavy lungs (lung weights 840 and 640 g) | Femoral blood: 2.28 Diazepam 29, nordiazepam 71, oxazepam 4.8, mefenamic acid <5.0 µg/mL, domperidone 6.0, acetaminophen 4.8 µg/mL Cardiac blood: 1.70 Urine: 1.88 Vitreous humor: 0.36 Liver: <0.05 ng/g Heart: 7.74 ng/g Brain: 18.6 ng/g |
(240) | |
| M with hx of isotonitazene use, including hospitalization for isotonitazene detoxication 2 months prior to death. White powder and pipe discovered at scene. Night of death decedent took lorazepam too | Blood organ congestion, gastric material in upper and lower respiratory tract, heavy lungs 1,260 and 900 g | Femoral blood: 0.59 Lorazepam 12, THC 56, THC-OH 1.8, THC-COOH 6.5, CBN 2.9 Cardiac blood: 1.13 Urine: 3.37 Vitreous humor: 0.12 Liver: <0.05 ng/g Heart: 2.17 ng/g Brain: 2.72 ng/g |
(240) | |
| Hx of depression | Blood organ congestion, gastric material in upper and lower respiratory tract, heavy lungs 610 and 580 g | Femoral blood: 0.74 Ethanol 57 mg/dL Cardiac blood: 0.70 Urine: 0.19 Vitreous humor: 0.65 Liver: <0.05 ng/g Brain: 4.45 ng/g |
(240) | |
| Brorphine | 24 y/o M with hx of opioid use, withdrawal symptoms in ED. Generalized pain in chest, abdomen and muscles, weakness, cramping, confusion and bradyphrenia. 1–2 months prior, started brorphine orally 4×/day and etizolam and prescribed sertraline and mirtazapine | Normal BP with tachycardia 114 bpm, O2 saturation 98% and Temp 37.3°C. Clammy and sweaty. Treatment with trazodone and nordiazepam | Serum: 69.4 +sertraline, +mirtazapine, +risperidone Serum (+60 h): 7.9 +trazodone, +nordiazepam |
(241) |
| 53 y/o M with hx of opioid use, suspected drug OD. ‘Heroin’ recovered at scene | N/A | Femoral blood: 10 Flualprazolam 50, +4-ANPP, +caffeine, +cotinine, +quinine, codeine 6.6, morphine 66, 6-AM 1.5, citalopram/escitalopram 76, fentanyl 3.4, norfentanyl, +isotonitazene Urine: 23 |
(10) | |
| 60 y/o M with unknown hx | N/A | Femoral blood: 0.9 +4-ANPP, +caffeine, methadone 160, EDDP 45, morphine 42, bupropion 18, hydroxybupropion 380, duloxetine 520, lamotrigine 6.8 µg/mL, gabapentin 15 µg/mL, fentanyl 14, norfentanyl 11, +flualprazolam Urine: 0.4 |
(10) | |
| 45 y/o M suspected drug OD | N/A | Femoral blood: 1.0 Flualprazolam 2.5, +4-ANPP, +caffeine, +cotinine, tramadol 33, THC 0.62, fentanyl 5.0 Urine: 1.9 |
(10) | |
| 57 y/o F suspected drug OD with drug paraphernalia at scene | N/A | Peripheral blood: + +4-ANPP, +caffeine, +cotinine, +naloxone, cocaine 110, BZE 1,300, THC 0.88, diphenhydramine 61, fentanyl 31, norfentanyl 5.5, acetyl fentanyl 0.13 |
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| 42 y/o M suspected drug OD | N/A | Peripheral blood: 1.1 +4-ANPP, +caffeine, +cotinine, +naloxone, diphenhydramine 620, fentanyl 36, norfentanyl 1.4, morphine 110, 6-AM 7.3, +flualprazolam Urine: 3.3 |
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| 60 y/o M suspected drug OD | N/A | Peripheral blood: 8.1 +Cotinine, sertraline 26, desmethylsertraline 110, verapamil 42, diphenhydramine 960, fentanyl 3.1, morphine 79, 6-AM 2.5, +flualprazolam Urine: 21 |
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| 47 y/o M experienced sudden suspected drug OD death. Counterfeit pills identified as brorphine | N/A | Femoral blood: 2.5 +4-ANPP, +naloxone, oxycodone 22, sildenafil 35, n-desmethylsildenafil 10, fentanyl 16, norfentanyl 1.1 |
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| 39 y/o M suspected drug OD | N/A | Peripheral blood: 6.7 +4-ANPP, +caffeine, +cotinine, +nicotine, alprazolam 14, tramadol 70, gabapentin 10 µg/mL, diphenhydramine 1,200, fentanyl 45, norfentanyl 2.1, codeine 6.5, morphine 290, hydromorphone 4.7, +flualprazolam Urine: 7.3 |
(10) | |
| 37 y/o F suspected drug OD | N/A | Peripheral blood: 0.7 Ethanol 138 mg/dL, +4-ANPP, +cotinine, +naloxone, THC-COOH 85, THC 18, diphenhydramine 110, fentanyl 22, +flualprazolam |
(10) | |
| 48 y/o M suspected drug OD | Puncture marks | Iliac blood: 0.1 Flualprazolam 5.4, +4-ANPP, +caffeine, +naloxone, morphine 8.0, diphenhydramine 190, fentanyl 4.7, norfentanyl 1.6, acetyl fentanyl 1.2, +clonazolam Hospital blood: 0.6 Urine: 0.2 |
(10) | |
| 47 y/o F suspected heroin OD | N/A | Femoral blood: 6.7 Flualprazolam 13, +4-ANPP, +cotinine, +naloxone, codeine 7.0, morphine 85, 6-AM 12, xylazine 170, amphetamine 55, methamphetamine 580, fentanyl 190, norfentanyl 5.4, acetyl fentanyl 0.15 Urine: 2.1 |
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| 30 y/o F suspected drug OD. Died at hospital | N/A | Hospital blood: 0.3 +Caffeine, +naloxone, midazolam 20, amphetamine 110, methamphetamine 1900, MDA 9.8, MDMA 75, fentanyl 0.37, norfentanyl 0.97 Urine: 1.4 |
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| 53 y/o M suspected drug OD | N/A | Hospital blood: Negative Flualprazolam 20, +4-ANPP, +caffeine, +naloxone, morphine 15, xylazine 30, fentanyl 19, norfentanyl 4.2 |
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| 54 y/o F suspected drug OD | Pulmonary and cerebral edema noted at autopsy | Iliac blood: 0.1 EtOH 19 mg/dL, codeine 21, morphine 290, 6-AM 34, lamotrigine 0.60 µg/mL, topiramate 9,400, cyclobenzaprine 38, amphetamine 140, methamphetamine 730, fentanyl 17 |
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| M unknown age suspected drug OD | N/A | Peripheral blood: 0.7 Ethanol 100 mg/dL, +4-ANPP, +caffeine, +cotinine, +naloxone, +nicotine, nordiazepam 130, chlordiazepoxide 66, lorazepam 9.4, THC 0.70, diphenhydramine 53, fentanyl 32, +flualprazolam |
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| 51 y/o M suspected drug OD | N/A | Peripheral blood: 1.1 Ethanol 60 mg/dL, +4-ANPP, +caffeine, +cotinine, +naloxone, +nicotine, cocaine 71, BZE 1,600, diphenhydramine 98, fentanyl 9.3, norfentanyl 5.6, morphine 19, +flualprazolam Urine: 0.4 |
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| 49 y/o F suspected drug OD | N/A | Peripheral blood: 3.8 +4-ANPP, +caffeine, +naloxone, diphenhydramine 260, fentanyl 21, norfentanyl 12, acetyl fentanyl 2.0, morphine 70, +flualprazolam Urine: 1.8 |
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| 29 y/o M with hx of drug use, suspected drug OD. Illicit drugs found at scene | N/A | Peripheral blood: 1.1 Flualprazolam 3.6, +4-ANPP, +caffeine, +cotinine, +naloxone, +nicotine, +quinine, acetaminophen 16 µg/mL, 7-AMC 5.2, tramadol 70, diphenhydramine 490, amphetamine 10, methamphetamine 42, fentanyl 37, norfentanyl 1.3 Urine: 0.8 |
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| 61 y/o F suspected drug OD | N/A | Peripheral blood: 0.4 Ethanol 57 mg/dL, +4-ANPP, +cotinine, +naloxone, +nicotine, alprazolam 65, BZE 330, morphine 33, 6-AM 2.3, gabapentin 9.9, fentanyl 21, norfentanyl 1.9 Urine: 0.2 |
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| 61 y/o F with hx of obesity, tobacco use, hypertension, chronic obstructive pulmonary disease, schizophrenia, hyperlipidemia, found deceased at home following OD. Last seen alive 5 days prior, advanced decomposition | COD toxic effects of multiple substances, including brorphine and fentanyl | Cardiac blood: 2.0 Fentanyl 0.32, ethanol 27 mg/dL, chlorpromazine 82, gabapentin 6.8 mcg/mL |
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| Tianeptine | 24 y/o M with 2-year hx of tianeptine and phenibut misuse, lethargic, slurred speech and found unresponsive. Transported to ED where he died 19 days after initial submission | Patient comatose with intact brainstem reflexes, intubated due to low respiratory rate. 2 days after admission, brain MRI indicated diffuse white matter damage characteristic of toxic leukoencephalopathy | Serum: 3,000 +Clonazepam, +7-AMC, +midazolam, +alpha-hydroxymidazolam, +THC, +THC-OH, +methylphenidate |
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| 36 y/o M IV tianeptine powder to ‘help him see into the future’. Became unresponsive, EMS called, naloxone administered and patient discharged 13 h after admission | Upon arrival at ED, excessive pupil constriction, sedation and RR 6/min noted | Urine: 2 Serum: Ethanol 133 mg/dL |
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| 51 y/o M found deceased in hotel room with syringes beside bed | Cerebral and pulmonary edema, tracheal lumen edema, unilateral inguinal lesion to facilitate IV drug injection. Granulomatous inflammation foci and focal necrotic foci in lungs. Chronic liver inflammation and mild perivascular fibrosis of heart | Femoral blood: 4,401 Citalopram 288, +7-AMC |
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| 38 y/o M with hx of drug abuse suddenly fainted and died in kitchen of his workplace. Syringes discovered in refrigerator. Tianeptine tablets located in pocket | Cerebral and pulmonary edema, tracheal lumen edema. Bilateral inguinal lesions for IV drug injections. Diffuse granulomatous inflammation loci as foreign body in lungs and chronic liver inflammation | Femoral blood: 538 +Nordiazepam |
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| 28 y/o M with hx of alcohol, tobacco and illicit drug use, depression and anxiety, found lying on floor of home. Capsules and powders on scene, foil pouch labeled ‘Powder City Tianeptine 12.5 mg’ | Pulmonary edema, urinary retention, modest cardiomegaly and evidence of remote surgical closure of ductus arteriosus | Postmortem blood: 2,000 + 8-aminoclonazolam (presumptive) |
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| 30 y/o M with hx of remote head injury found deceased in residence. Prescribed alprazolam for adjustment disorder, generalized anxiety disorder and paranoia. Drug paraphernalia at scene, included tianeptine powder ordered from internet | Recent puncture mark on right antecubital fossa. Hypertensive cardiovascular disease, pulmonary edema and pulmonary congestion | Postmortem blood: 8,400 Ethanol 12 mg/dL, alprazolam 33 |
(246) |
3-MF = 3-methyl fentanyl, 4-ANPP = N-phenethyl-4-piperidinone, 7-AMC = 7-aminoclonazolam, CBN = cannabinol, IM, intramuscular, MMMP = 2-methyl-4ʹ(methylthio)-2-morpholinopropiophenone, MRI = magnetic resonance imaging, THC-OH = 11-Hydroxy-delta-9-tetrahydrocannabinol.