Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses
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LETTER TO THE EDITOR
Identifying cases of heroin toxicity where 6-acetylmorphine (6-AM) is not detected by toxicological analyses Xiulu Ruan1 • Srinivas Chiravuri2 • Alan D. Kaye1
Accepted: 11 May 2016 / Published online: 26 May 2016 Ó Springer Science+Business Media New York 2016
The study by Ellis et al. [1] is both informative and pragmatic. Based on the fact that heroin has a very short halflife (2–6 min) and its immediate metabolite, 6-acetylmorphine (6-AM), also has a rather short half-life of 6–25 min before it is hydrolyzed to morphine, 6-AM and therefore heroin, may not be detected in many postmortem samples associated with heroin fatalities. Since codeine is often present in heroin preparations as an impurity and is not a metabolite of heroin, Ellis et al. [1] hypothesized that in known intravenous (IV) drug users, the ratio of morphine to codeine (M/C ratio), when[1, may be used to identify a heroin fatality. In their study, Ellis et al. found that, of 103 IV drug users with quantifiable morphine and codeine in a postmortem sample, the M/C ratio was greater than 1 in 98 % of decedents. The M/C ratio in IV drug users, if greater than 1, is seen in deaths related to heroin toxicity where 6-AM is detected in a postmortem sample. When controlling for the absence or presence of 6-AM, there was no statistically significant difference in the proportion of IV drug users when compared to non IV drug users with an M/C ratio of greater than 1. Thus, Ellis et al. suggest that
& Xiulu Ruan [email protected] Srinivas Chiravuri [email protected] Alan D. Kaye [email protected] 1
Department of Anesthesiology, Louisiana State University Health Science Center, 1542 Tulane Ave., New Orleans, LA 70112, USA
2
Department of Anesthesiology, University of Michigan Health System Back and Pain Center, 325 E. Eisenhower Parkway, Suite 100 SPC 5721, Ann Arbor, MI 48108, USA
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their study provides evidence that a M/C ratio greater than one in an IV drug user is evidence of a death related to heroin toxicity, even if 6-AM is not detected in the blood. They conclude that using the M/C ratio, in addition to scene and autopsy findings, provides sufficient evidence to show heroin is the source of the morphine and codeine [1]. We would like to commend the authors’ novel work and we further believe their methodology may potentially have a significant impact on the reporting accuracy of heroin fatalities. The United States of America is experiencing a rampant heroin epidemic [2]. According to the CDC, the rate of heroin-related drug overdose deaths had gradually increased until 2009, when the rate was 1.1 per 100,000. Beginning in 2011, the overdose death rate increased sharply, from 1.4 to 2.7 per 100,000 by 2013, a rate that represents a more than 286 % increase since 2002 [3]. Heroin over- dose death rates increased by 26 % from 2013 to 2014 and have more than tripled since 2010, from 1.0 per 100,000 in 2010 to 3.4 per 100,000 in 2014 [4]. The heroin mortality rate is still underestimated in the Multiple Cause of Deat
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