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To compare the characteristics of dextropropoxyphene (DXP) poisoning victims with those of victims of poisonings by antidepressants and sedatives, we examined all fatal poisonings due to DXP, antidepressants or sedatives among autopsies performed at one department of forensic medicine in Sweden during the six-year period from 1992 to 1997. In 202 cases, death was classified as fatal poisonings by DXP, antidepressants or sedatives. DXP caused death in 78 cases (39%), antidepressants in 49 (24%), and sedatives in 75 (37%). DXP as a single preparation was predominant in causing death. The second compound, flunitrazepam, caused death in 30 cases (15%). The victims of poisonings by DXP, antidepressants, or sedatives shared a similar history of alcohol/drug abuse, depression and somatic illness. They were mostly living alone at the time of death (>60%), the majority died at home (81%), and suicide was the most frequent manner of death (73%). Age seemed to be an important characteristic regarding the choice of drug. Younger people predominantly died of DXP (mean age 43 years, 95% confidence interval, CI 39-47), and elderly people of sedatives (mean age 59 years, CI 55-63). Antidepressants were found mainly in middle-aged victims (mean age 51 years, CI 48-54). The predominance of sedatives among the elderly might be explained by a very high prescription rate of such drugs in older age groups, but prescription rate could not explain the DXP predominance among younger people. We hypothesize that younger people are more prone to abuse therapeutic drugs for euphoric reasons than elderly people, and that because of its high toxicity, DXP leads to accidental deaths more often than sedatives.

Among prescribed drugs in Sweden dextropropoxyphene (DXP) is the medical compound most frequently responsible for self-inflicted fatal poisonings. To analyze the process leading to the classification of the manner of death in cases of fatalities where DXP caused or contributed to death, a set of explicit and implicit operational criteria was applied retrospectively to fatal DXP poisonings among autopsy cases performed at one department of forensic medicine in Sweden during the six-year period from 1992 to 1997. DXP fatality was found in 113 (2.6%) of the total 4306 autopsy cases. Suicide was recorded in 84 (74%) of these cases, and an undetermined manner of death in 24 (21%). Explicit unambiguous expressions of the intent of the decedent were found in 29 (26%) of the 109 analyzed cases. (In four cases no analysis could be performed). In 46 cases only implicit and no explicit criteria were found. The total number of implicit criteria in individual cases without explicit criteria never exceeded three and in 34 cases no criteria of any type were documented. It is concluded that the classification of the manner of death at DXP fatalities was often based on very limited grounds when the operational criteria were used as a standard for comparison. Information from relatives, friends and others concerning the decedent was rarely accessible. The shortage of information probably led to deficiencies in the death statistics concerning DXP fatalities. Considerable underreporting of accidents and probable overreporting of suicides were found. Failure to report DXP deaths as accidents may delay discovery of the high toxicity of this drug. This might be one of the reasons why the DXP fatality rate is still constantly high in Sweden, while both Denmark and Norway have managed to decrease their DXP death rates by vast restrictions, based on alarming reports of accidental DXP fatalities. In order to guarantee valid death statistics concerning self-inflicted poisoning, the information base leading to classification of the manner of death has to be enlarged. This requires implementation of new routines, including interviews of relatives, acquaintances and significant others to get the information needed to assess the decedent's intention to die. Operational criteria may facilitate the difficult classification process by providing a structured standard, and the set of explicit and implicit criteria applied in this study is recommended.

We evaluated postmortem diffusion of gastric drug residue into tissues and blood in eight suicidal overdoses. Analyses were performed on liver (five sites), lung (four sites), spleen, psoas muscle and kidney (left and right), blood (peripheral and torso), vitreous, pericardial fluid, bile and, urine as well as residual gastric contents. Standard analytical techniques and instrumentation gas chromatograph/mass spectrometer and high performance liquid chromatography (GC-MS and HPLC) were used throughout. These case studies confirm previous studies of an animal and human cadaver model of gastric diffusion, in that in several instances there was drug accumulation in the left posterior margin of the liver and, to a lesser extent, the left basal lobe of the lung. Uncontrollable variables, such as postmortem interval, refrigeration before autopsy, and position of the body appear to influence significantly drug accumulation in a specific site. We suggest that autopsy sampling techniques should be standardized on blood taken from a ligated peripheral (preferably femoral or external iliac) vein, and liver from deep within the right lobe.

A total of 1859 cases provides the basis for this study in which propoxyphene, and often its major metabolite, was demonstrated by toxicological analysis in the blood or tissues of the deceased at 27 medical examiner or coroner's offices across the United States and Canada. The study period includes the last five months of 1975 through December 1978. The cases describe a clearly defined adult population with a marked tendency toward hypochondria, chronic minor illness, and severe psychiatric problems. The high proportion of suicides (44.1% of the total cases and 54.0% of the drug-caused deaths) and multiple-drug toxicities (88.6%) suggests that the involvement of propoxyphene in many of these fatalities may be of less significance than the phenomenon of "polypharmacy" and self-medication without appropriate medical supervision. This evaluation of propoxyphene provides no evidence that propoxyphene is responsible for "street-drug" fatalities. Its appearance in postmortem toxicological examinations has been declining sharply since 1977, but it continues to be dangerous when used excessively, particularly in combination with alcohol and other central nervous system depressant drugs.

From 1971 through 1980, 1115 deaths were ascribed by the Dallas County Medical Examiner's Office to poisoning of some type. An analysis of these deaths, with emphasis on the substances involved, is the purpose of this study. Relatively few agents or groups of agents accounted for 87% of these deaths: carbon monoxide, barbiturates, propoxyphene, narcotics, tricyclic antidepressants, ethyl alcohol, and inhalants (gases and solvents). Twenty-five percent of the deaths were classified as mixed intoxications, resulting from combinations of agents. Two major trends were observed: in the second five-year period, barbiturate-induced deaths decreased considerably (58%) and deaths from tricyclic antidepressants increased more than four times as compared with the first five-year period. Yearly statistics have been compiled for deaths from each agent.

The incidence of acute, fatal narcotism in San Francisco was determined to be 3.2% of all deaths (10 882) subject to medical examiner's inquiry in a five-year period. Heroin was responsible for the greatest number of these cases, usually accompanied by alcohol or other abused drugs. The median concentration of the heroin metabolite, morphine, in the blood in fatal cases was 20 microgram/dL. Death from propoxyphene, the second most frequently encountered narcotic, was generally determined to be suicidal, while death from heroin was judged to be accidental. The highest rate occurred in black males between the ages of 21 and 30 years. The three most consistent findings were positive identification of the drug in the body (100% of the cases), pulmonary edema (90.4% of the cases), and microscopic liver changes (71.1% of the cases).

Ninety-nine deaths involving propoxyphene or codeine or both were investigated through interviews with surviving relatives and associates. The criterion for admission to this study was the presence of propoxyphene or codeine in the body fluids or tissues, determined analytically. The codeine-related group included more ethnic minority persons, more histories of primary drug addiction, more users of street drugs, and more accidental deaths. In the propoxyphene-related group there were fewer histories of drug addiction and more persons with mental illness and more suicides. Most victims had considerable past experience with one or both of the drugs and other drugs as well. Propoxyphene was usually obtained by physician prescription. Codeine was often obtained illegally.

Eighteen medical examiners, coroners, and forensic science laboratories and offices, representing a total jurisdictional population of 52.6 million, were visited during November 1975, and more than 1200 cases occurring in the four years from 1972 through 31 July 1975 were evaluated for inclusion in the study. The sites were distributed across the United States and Ontario, Canada, and included urban and rural, states, city, and county jurisdictions. Scientific data and circumstantial information was gathered consistently for each case and site by means of five questionnaires. Finally, 1022 cases were compiled and examined, and the data were analyzed to form the body of data from which this report is written. The following conclusions may be drawn. 1. The number of deaths involving propoxyphene is increasing each year, and at a faster rate than total drug deaths. The absolute numbers and rate are different in urban and rural areas, but the frequency reached 6.0 deaths per million population in 1974. Deaths attributed to suicide as well as those determined to be accidental deaths and undetermined have increased. 2. Approximately 66% of all the cases studied had the word propoxyphene included in the cause of death statement on the death certificate. Approximately 46% of the cases were classified as suicide (64% of them female and 36% male), 26% as accidents, and 21% as undetermined. 3. The deceased were mainly middle-class, Caucasian, urban dwellers, with male and female evenly distributed. Their ages were from 20 to 50 years, with few outside this range. Female ages were uniformly distributed, but males in their early twenties were very prominent. This is different from the U.S. population age distribution, which is currently dominated by teenagers. Propoxyphene does not appear to be a pediatric problem, as seen in the study. 4. The deceased were not part of the illegal drug abuse population and had no particular propensity for the use of heroin or narcotics, but rather they were a particular medical population of those who misuse prescription drugs and alcohol. 5. The deceased did have a marked tendency to hypochondria, chronic minor illnesses and emotional problems. Some 43% had recent medical histories, and 82% had a documented psychiatric history which often included (51%) self-destructuve behavior such as suicide attempts. Almost all received a wide range of prescription drugs, particularly tranquilizers, which they often misused in the sense of self-medicating, multiple drug ingestion, and combining alcohol with their medication. Approximately 34% had a history of misusing some drug, and 20% could be defined as abusers in that they were prone to excessive use of their medications; 44% had diazepam available to them, and 17% were either problem drinkers or alcoholics.