Under The Microscope: Hallucinogenic Drugs

Drugs of dependence may be absorbed orally, by intravenous, subcutaneous or - rarely intramuscular injection, by smoking, or by nasal sniffing. The routine at autopsy, in respect of obtaining samples for toxicological analysis, is altered according to the route of administration. As mixing of drugs and addition of non-narcotic drugs is common, itis the usual practice to take a wide range of samples even if the primary route is known with some degree of certainty For example, an addict dying 'on the needle' where intravenous injection is obvious, will still have stomach contents taken for investigation. The standard samples should be taken, as described in a previous chapter, comprising several samples of venous blood (one with fluoride), stomach and contents, liver and urine. In some circumstances, additional samples such as bile, cerebrospinal fluid and vitreous humour may be taken, as well as brain or kidney. The great advances in the analytical techniques allow the analysis of drugs also in other biological samples, such as saliva, sweat and hair. Hair analysis can also provide evidence of long-term exposure to drugs (weeks, months or years), because most drugs, if not all, incorporate in hair and are relatively stable. At least 50 mg of hair should be collected, cutting about a pencil thickness of strands of hair as close to the skin as possible from the back of the head, dried and stored in a sealed plastic bag or tube at room temperature. When the drug has been injected, then an ellipse of skin around the injection mark, extending down through the subcutaneous tissue to the muscle, should be excised, along with a control area of skin from another non-injected site. These should be refrigerated, not fixed in formalin, until delivery to the laboratory can be arranged. Full histology should always be taken, especially if drugs have been injected, as foreign substances may be discovered as embolic particles, especially in the lungs. Pulmonary granulomata are well-known histological features of 'mainlining' addicts taking impure drugs intravenously, as the lung capillaries filter out coarse particulate matter used to dilute the active narcotic. Talc is particularly prone to form granulomata, sometimes with foreign body giant cells. Under polarized light, doubly refractile particles may be seen in the centre of the reactive nodules. Sometimes, strands of cotton may form foreign bodies, derived from the cloth strainer used to filter particles crudely from the drug solution before injection.

Morphine is the major representative of the general group of opioids, which comprise natural opium and a whole series of chemically related derivatives. They may be taken orally or injected and several, such as crude opium and heroin - may be absorbed by inhaling smoke. Morphine itself is poorly absorbed from the gastrointestinal tract; heroin can be taken via the nasal mucosa.

The group consists of opium, morphine, heroin (diacetyl morphine), codeine (dimethyl morphine), dihydrocodeine (DF 1 18), etorphine (Immobilon), methadone, papaverine, pethidine, dipipanone, dextrornoramide, dextropropoxyphene, pentazocine, cyclazocine, diphenoxylate,buprenorphine, tramadol, fentanyl and many more.

The autopsy findings in deaths from all these drugs are relatively non-specific. Toxicological analysis and expert interpretation of the results are necessary for the proper elucidation of the deaths, but certain features can be useful pointers. The first is the presence of injection marks. When fresh, they look just like any other needle mark commonly seen from therapeutic or diagnostic procedures. They are commonly on the arms, either in the classical position in the antecubital fossa on the front of the elbow, or into one of the prominent veins of the forearms or dorsum of the hand. The left side is favourite as most people are right-handed, but in habitual users, sclerosis of the veins may lead to the arms being used randomly. The veins of the dorsum of the foot may be used when the hands and arms have become unusable because of thrombosis and scarring. Less common sites are in the thighs but here, as with the abdominal wall, the injections may be subcutaneous, rather than intravenous. This mode of injection is known as 'skin-popping' and can lead to areas of subcutaneous sclerosis, fat necrosis, abscesses and, if the injections are deeper into the muscle, to chronic myositis.

Other external signs may be tattoos, often bizarre and connected with the drug subculture. One specific type is tattooing, often of numerals, such as '13', on the buccal (inner) surface of the lower lip. Where chronic addiction has taken its toll, the body may be emaciated, dirty and show signs of infection, especially in the form of skin ulceration. Rarely, there may be necrosis or even loss of phalanges from thrombotic or septic emboli. Old injection marks, sometimes with associated bruising, may be found, the bruising undergoing the usual spectrum of colour changes if not recent. The veins may show overlying fibrosis where phlebitis has occurred, or old venous thrombosis with firm cord-like vessels under the skin.

Where sudden death has occurred in habituated addicts, there may be gross pulmonary oedema, with a plume of froth exuding from the mouth or nostrils, suggestive of drowning. This pulmonary oedema is sometimes a striking feature of rapid death in those who are habituated to opioid drugs, especially heroin. It does not seem to occur in novices to the habit, who tend to die in a different way, from a sudden primary cardiac arrest. The oedema may be blood tinged, again causing confusion with drowning.

As with all deaths from toxic substances, the interpretation of laboratory analytical results may present considerable difficulties. There may be a long delay between the administration of the drug and death, during which time the blood, urine and even tissue levels may decline, or even disappear. Many drugs break down rapidly in the body and their metabolites may be the only recognizable products of their administration. In some cases, data on lethal blood levels may be imperfectly known and great variations in personal susceptibility may make the range of concentrations found in a series of deaths so wide as to be rather unhelpful. As mentioned above, some persons die rapidly after the first episode of taking a 'normal' dose of a drug because of some ill-understood personal idiosyncrasy and here quantitative analysis may not assist. Where habituation and tolerance has developed, drug users may have concentrations in their body fluids and tissues far higher than lethal levels published for non-habitues. In general, the great usefulness of toxicological analysis is both qualitative and quantitative. The former will show what drugs have been taken in the recent past; the length of time that drugs or their metabolites - persist in different fluids and tissues varies widely.

The quantitative analysis can be useful, especially when the results reveal high levels - into the toxic or lethal ranges. These ranges are usually obtained anecdotally from surveys of large numbers of deaths but, as stated, can differ in terms of - minimum and maximum values from different laboratories. The problems of idiosyncratic sensitivity and tolerance cause such published ranges to act only as a general yardstick and deaths that occur outside the ranges (usually off the lower end) cannot be excluded from having been caused by the drug in question if other factors may have been involved.

Such factors include the presence of other drugs or alcohol, or both, delayed death and abnormal sensitivity. Thus the analysis is not the final arbiter of the cause of death, although it is a highly important component of the whole range of investigation. The pathologist has the duty to correlate and interpret all known facts. He must fit the circumstances, the presence of natural disease, trauma and other toxic substances with the laboratory findings, to arrive at the most reasonable cause of death. The advice of the toxicology laboratory is vital in this process, especially in relation to known lethal ranges and the significance of metabolites, but the analysts should not become the sole arbiter of the cause of death.

Acknowledgements:

www.aived.nl    AIVD – @Erik Akerboom ©

www.politie.nl  Politiekorpschef  @Janny Knol©

www.politie.nl WEB Politie - @Henk van Essen©

 

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