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Empirical data regarding dynamic alterations in illicit drug supply markets in response to the COVID-19 pandemic, including the potential for introduction of novel drug substances and/or increased poly-drug combination use at the "street" level, that is, directly proximal to the point of consumption, are currently lacking. Here, a high-throughput strategy employing ambient ionization-mass spectrometry is described for the trace residue identification, characterization, and longitudinal monitoring of illicit drug substances found within >6,600 discarded drug paraphernalia (DDP) samples collected during a pilot study of an early warning system for illicit drug use in Melbourne, Australia from August 2020 to February 2021, while significant COVID-19 lockdown conditions were imposed. The utility of this approach is demonstrated for the de novo identification and structural characterization of β-U10, a previously unreported naphthamide analog within the "U-series" of synthetic opioid drugs, including differentiation from its α-U10 isomer without need for sample preparation or chromatographic separation prior to analysis. Notably, β-U10 was observed with 23 other drug substances, most commonly in temporally distinct clusters with heroin, etizolam, and diphenhydramine, and in a total of 182 different poly-drug combinations. Longitudinal monitoring of the number and weekly "average signal intensity" (ASI) values of identified substances, developed here as a semi-quantitative proxy indicator of changes in availability, relative purity and compositions of street level drug samples, revealed that increases in the number of identifications and ASI for β-U10 and etizolam coincided with a 50% decrease in the number of positive detections and an order of magnitude decrease in the ASI for heroin., (© 2022 The Authors. Drug Testing and Analysis published by John Wiley & Sons Ltd.)

Suicide remains a global public health concern and the increased supply and use of synthetic stimulants globally may have implications for the burden of suicides attributable to substance use. This systematic review investigated any potential associations of stimulant use detected in post-mortem biological specimens and suicides. We conducted a systematic review and narrative synthesis (CRD42021237966). Medline, EMBASE, TOXLINE, and Scopus databases were searched for terms related to forensic toxicology, post-mortem toxicology, suicide and stimulants. The primary outcome was to estimate the prevalence of stimulant use in suicides. There were 26 studies whichcontributed to prevalence measures; in studies reporting at the individual compound level, suicides involved cocaine (0.1-23%), caffeine (3.2-22%), 3,4-methylenedioxymethamphetamine (0.1-17%), amphetamine (0.2-9.3%), methamphetamine (3.1-7%), and phentermine (0.9-1%). Overall, stimulant use in suicides was over-represented compared to estimates of stimulant use in the general population and has increased over time. Thirteen case reports used to contextualise suicides involving stimulants found no examples of cocaine or methamphetamine mono-intoxication of suicidal intent. This suggests mechanisms other than acute toxicity involved in stimulant-associated suicide. Future research by in-depth psychological autopsies of suicides involving stimulants, in combination with segmental hair analysis to determine the chronicity of stimulant exposure, may contribute to a better understanding of the burden of suicide attributable to stimulant use., Competing Interests: Conflict of interest The authors have no completing interest to declare., (Crown Copyright © 2022. Published by Elsevier B.V. All rights reserved.)

Background and Aim: The current phase of the North American 'opioid crisis' is characterised by illicit fentanyl use; however, the presence of illicit fentanyl in Australia is unknown. This study aimed to monitor unintentional fentanyl consumption in Australia., Design: Rapid urine drug screens (UDS) paired with surveys conducted within supervised injecting facilities (SIFs) and confirmatory laboratory testing., Setting: Sydney and Melbourne, Australia., Participants: Clients who used heroin within the past 2 days (n = 911 tests, 2017-2021). Participants were demographically similar to the overall client base (median age 43, 72% male)., Measurements: UDS were conducted using BTNX Rapid Response fentanyl urine strip tests with cross-reactivity to numerous fentanyl analogues. Positive urine samples were analysed using liquid chromatography coupled with tandem mass spectrometry. Surveys covered past 3 day drug use and lifetime report of fentanyl in heroin., Findings: Two percent of participants reported intentional use of fentanyl, mostly through fentanyl patches. Of the 911 rapid UDS conducted, 17 (1.9%) yielded positive results. Eight of these (all from Melbourne) were not explained by survey-reported fentanyl use in the past 3 days. Of these 8 unexplained positives, confirmatory laboratory analysis was conducted on 6, with 4 deemed to be false positives, and 2 confirmed for the presence of fentanyl. This represents the first confirmation of unintended use of fentanyl type substances in this population., Conclusion: There is limited evidence of unintentional fentanyl use among people in Sydney and Melbourne, Australia who regularly inject heroin, suggesting that, currently, there is very little illicit fentanyl in Australian drug markets accessed by supervised injecting facilities attendees. This study demonstrates the feasibility of quick onsite testing to cost-effectively screen large samples for fentanyl; however, the high false positive rate emphasises the need for confirmation of positive tests through advanced analytical techniques., (© 2022 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Postmortem redistribution (PMR) can result in artificial drug concentration changes following death and complicate forensic case interpretation. Currently, no accurate methods for PMR prediction exist. Hence, alternative strategies were developed investigating the time-dependent postmortem behavior of diazepam, nordiazepam, morphine, codeine, mirtazapine and citalopram. For 477 authentic postmortem cases, femoral blood samples were collected at two postmortem time-points. All samples were quantified for drugs of abuse (targeted; liquid chromatography-tandem mass spectrometry LC-MS/MS) and characterized for small endogenous molecules (untargeted; gas chromatography-high resolution MS (GC-HRMS). Trends for significant time-dependent concentration decreases (diazepam ( n = 137), nordiazepam ( n = 126)), increases (mirtazapine ( n = 55), citalopram ( n = 50)) or minimal median postmortem changes (morphine ( n = 122), codeine ( n = 92)) could be observed. Robust mathematical mixed effect models were created for the generalized postmortem behavior of diazepam and nordiazepam, which could be used to back-calculate drug concentrations towards a time-point closer to the estimated time of death (caution: inter-individual variability). Significant correlations between time-dependent concentration changes of morphine, mirtazapine and citalopram with individual endogenous molecules could be determined; no correlation was deemed strong enough for successful a posteriori estimation on the occurrence of PMR for specific cases. The current dataset did successfully lead to a significant knowledge gain in further understanding the time-dependent postmortem behavior of the studied drugs (of abuse).

Background and Aims: Prior to February 2018, codeine was available over-the-counter (OTC) in Australia as a pharmacist-only medicine (Schedule 3) in low-strength formulations when in combination with simple analgesics. In February 2018, The Advisory Committee on Medicines Scheduling (ACMS) upscheduled codeine-containing medicines (CCM) to Schedule 4 (prescription-only medicine). This study aimed to determine the impact of upscheduling on prescriptions, overdoses and deaths., Methods: This study used interrupted time series analysis, a quasi-experimental design, to retrospectively evaluate the impact of upscheduling on overdose poisoning calls to the Victorian Poisons Information Centre (VPIC), Emergency Department (ED) presentations to Austin Health, and deaths reported to the Victorian Coroner from 1 January 2013-31 December 2019., Results: There was a significant reduction in the trend of high-strength codeine poisoning calls by 0.36 (P = 0.03, 95 % CI = [-0.69, -0.04]). Low-strength codeine poisoning calls to the VPIC reduced by 13.31 (P <0.001, 95 % CI = [-16.80, 9.82]]) calls in February 2018, followed by continued reduction of 0.12 calls per month. High-strength codeine overdose ED presentations reduced in the first quarter of 2018 by 3.72 presentations (P = 0.004, 95 % CI = [-6.13, -1.31]). Low-strength codeine overdose ED presentations after the first quarter of 2018 by 0.33 (P = 0.03, 95 % CI = [-0.63, -0.03]) presentations per month. Codeine-related deaths reduced by 7.19 (P < 0.001, 95 % CI = [-9.44, -4.94]) deaths in February 2018., Conclusions: Codeine upscheduling to prescription-only medicine has reduced codeine-related poisoning calls, overdoses and unnatural death in Victoria., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Postmortem drug redistribution (PMR) is a well-known phenomenon in forensic toxicology with implications for medico-legal death investigations. Paired antemortem (AM) specimen and postmortem (PM) mortuary admission femoral blood drug concentrations from 811 coronial cases were used to construct a retrospective compilation of PM/AM drug concentration ratios for 42 parent drugs and metabolites. The median PM/AM ratios for all antidepressants were > 1 and consistent with PMR In contrast, the median PM/AM ratios of most benzodiazepines were < 1. The antipsychotics were varied (0.63-3.3) and suggest the mixed effects of PMR and drug instability. Amphetamines exhibited no trends (0.90-0.95) and are likely confounded by many factors. The PM/AM ratios of cardiovascular drugs, opioids and other drugs are also reported. This research represents an expansive retrospective compilation of paired AM and PM drug concentrations for many toxicologically relevant drugs. While the median PM/AM ratios demonstrate some drug-dependent trends, there was no obvious relationship between AM specimens and PM femoral blood taken at mortuary admission., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Driving under the influence of drugs, including alcohol, is a globally recognised risk factor for road traffic crashes. While the prevalence of alcohol and other drugs in fatal road crashes has been examined in other countries, recent data investigating drug driving in fatal Australian crashes are limited. This study aimed to examine how the presence of alcohol and other drugs in fatal road trauma in Victoria has changed over time in different road users., Methods: A population-based review of road trauma deaths was performed over the period of 01 July 2006 to 30 June 2016 in Victoria, Australia, using data from the National Coronial Information System (NCIS) and the Victorian State Trauma Registry (VSTR). Drugs were grouped according to type and analysed accordingly. Poisson regression models were used to determine change in incidence rates over the study period., Results: There were 2287 road traffic fatalities with complete toxicology data (97% of all road traffic fatalities). Alcohol (blood alcohol concentration, BAC) was the most commonly detected drug (>0.001 g/100 mL: 21.1%; >0.05 g/100 mL: 18.4%), followed by opioids (17.3%), THC (13.1%), antidepressants (9.7%), benzodiazepines (8.8%), amphetamine-type stimulants (7.1%), ketamine (3.4%), antipsychotics (0.9%) and cocaine (0.2%). Trends demonstrated changing use over time with specific drugs. Alcohol positive road fatalities declined 9% per year in passenger car/4WD drivers (IRR = 0.91, 95% CI: 0.88-0.95). The incidence of strong opioids (oxycodone, fentanyl, morphine, and methadone) increased 6% per year (IRR = 1.06; 95% CI: 1.02-1.10). Methylamphetamine was detected in 6.6% of cases and showed a yearly increase of 7% (IRR = 1.07; 95% CI: 1.01-1.13). The incidence of THC remained unchanged over the period, observed in 13.1% of cases. Stronger opioids were more commonly detected among pedal cyclists (19.0%) and pedestrians (20.9%) while THC was more commonly detected among motorcyclists (19.8%) and other light vehicle drivers (17.6%)., Conclusions: A decline in the prevalence of alcohol in fatalities suggests that law enforcement and public health strategies in Australia to address road fatalities and drink-driving may have had a positive effect. However, increases were observed in the incidence of other potentially impairing drugs including opioids and amphetamines, specifically methylamphetamine, indicating a concerning trend in road safety in Victoria that warrants further monitoring., (Crown Copyright © 2021. Published by Elsevier Ltd. All rights reserved.)

The described procedure provides a rapid technique for the detection and semi-quantitation of a large number of drugs in blood. This procedure uses a minimal sample volume and employs a one-step liquid extraction and automated data processing to yield rapid turnaround times. A total of 327 of the most commonly used medicinal and illicit drugs in Australia were selected including various amphetamines, anesthetics, antidepressants, antipsychotics, anticonvulsants, benzodiazepines, beta blockers, opioid and nonopioid analgesics, stimulants, THC and a large number of synthetic cannabinoids and other novel psychoactive substances. The extracts were subject to 5-minute chromatography using a Kinetex C18 50 × 4.6 mm 2.6 μm solid-core analytical column and analyzed using a Sciex 3200 Q-TRAP MS-MS (+ ESI, MRM mode, two transitions per analyte). The method was fully validated in accordance with international guidelines. Matrix effects and extraction efficiencies were acceptable with most analytes showing > 80% response and low variation (within 25%RSD). Cannabinoids were most affected by the matrix and yielded poorest recovery values but were still detectable. Precision, accuracy, repeatability and multipoint linearity were assessed for all analytes. The method has been used in routine practice in the forensic toxicology service at the Victorian Institute of Forensic Medicine in over 6000 coronial investigations using both postmortem and clinical blood specimens. This technique has greatly increased throughput, reduced turnaround times and allowed for rapid same-day analysis of results when needed. The method is routinely used in routine overnight testing with results reported to pathologists within 4 h of data acquisition. This rapid toxicological technique is used in conjunction with other investigative processes such as full-body CT imaging, review of case circumstances and medical histories to provide an efficient death investigation process., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Changes in the concentrations of Δ9-tetrahydrocannabinol (THC) in the postmortem period were investigated in a series of cases by comparing concentrations in blood taken on receipt of the body in the mortuary (admission specimen, AD) with the concentrations obtained in blood taken at autopsy some time later and also from blood specimens taken antemortem. Overall, the median THC concentration in AD blood was 13.7 ng/mL (n = 239, range LOQ-220), while the median concentration at autopsy was 13.8 ng/mL (n = 106, range LOQ-810) and 1.9 ng/mL (n = 147, range LOQ-48) antemortem. Fourteen cases had all three specimens taken from the same decedent. The corresponding AM, AD and PM median concentrations were 4.0 (range LOQ-48), 15.5 (range 4.0-176) and 4.4 ng/mL (LOQ-56), respectively. The median elapsed times from AM to AD and AD to PM were 33 and 97.5 h, respectively. In contrast, acetaminophen showed no change in blood concentration from AM to AD (6.8 and 6.0 mg/L, respectively). These data show large increases in THC concentration in the early postmortem period, followed by a decline, although the median blood concentrations at autopsy were similar to that obtained antemortem. In contrast, when blood was taken from the femoral region, subclavian and heart ventricles sites, in the same case, the THC concentrations, while variable, showed overall no significant difference. These dynamic changes reflect complex phenomenon occurring in deceased persons and will further serve to increase the uncertainty over any interpretation of postmortem THC concentrations., (© The Author(s) 2020. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

Culpability analysis was conducted on 5000 drivers injured as a result of a vehicular collision and in whom comprehensive toxicology testing in blood was conducted. The sample included 1000 drivers for each of 5 years from approximately 5000-6000 drivers injured and taken to hospital in the State of Victoria. Logistic regression was used to investigate differences in the odds of culpability associated with alcohol and drug use and other selected crash attributes using the drug-free driver as the reference group. Adjusted odds ratios were obtained from multivariable logistic regression models in which other potentially explanatory driver and crash attributes were included. Drivers with alcohol present showed large increases in the odds of culpability similar to that seen in other studies investigating associations between blood alcohol concentration and crash risk. Methylamphetamine also showed a large increase in the odds of culpability (OR 19) compared to the reference group at both below and above 0.1 mg/L, whereas those drivers with Δ 9 -tetrahydrocannabinol (THC) present showed only modest increase in odds when all concentrations were assessed (OR 1.9, 95 %CI 1.2-3.1). Benzodiazepines in drivers also gave an increase in odds (3.2, 95 %CI 1.6-6.1), but not other medicinal drugs such as antidepressants, antipsychotics and opioids. Drivers that had combinations of impairing drugs generally gave a large increase in odds, particularly combinations of alcohol with THC or benzodiazepines, and those drivers using both THC and methamphetamine., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The structural diversity of synthetic cannabinoids makes it a challenging task to have a comprehensive screening method for this class of drugs. The difficulty is increased by the fact that some synthetic cannabinoids undergo thermal decomposition during common routes of administration, such as smoking or vaping. CUMYL-PEGACLONE is a relatively new synthetic cannabinoid which has a structural variant from most other synthetic cannabinoids: a γ-carbolinone core. To investigate its thermal stability, CUMYL-PEGACLONE was heated in an oven at temperatures ranging from 200 to 350 o C, and a major thermal degradation product, N-pentyl-γ-carbolinone, was subsequently identified. Unlike some other synthetic cannabinoids, the thermal degradation product of CUMYL-PEGACLONE is not one of its known metabolites, nor were any known metabolites detected during the thermal stability experiments. The degradation product was formed in significant amounts at temperatures above 250°C, and has been detected (along with CUMYL-PEGACLONE) in case samples, including post-mortem blood and urine, and residue found at a scene., (© 2019 John Wiley & Sons, Ltd.)

The effectiveness of decontamination procedures used for the removal of external drug contamination in forensic hair analysis is an ongoing debate. This investigation evaluated wash methods complying with Society of Hair Testing (SoHT) guidelines and their capacity to remove cocaine (COC) and methamphetamine (MA) from artificially contaminated hair. The most effective decontamination method was determined using a systematic approach, involving (1) an initial washing solvent screen, (2) optimization of wash duration, (3) comparison of sequential wash methods, and (4) reanalysis of clinical hair samples. For analysis, hair was subjected to micro-pulverized methanolic extraction prior to quantitation by ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS). Methanol (MeOH) and 0.1 M phosphate buffer (pH 6) were the most effective organic and aqueous solvents, respectively, removing 28%-38% of COC and 16%-31% of MA. Wash durations longer than 30-60 minutes did not remove additional amounts, and a more efficient sequential wash method was subsequently developed. Despite this, the interpretation of reportable results relative to the SoHT cut-off levels was unchanged for most clinical hair samples reanalyzed after washing by agitation for 30 minutes with MeOH. These findings highlight the inability of decontamination solvents to completely remove external COC and MA contamination from hair, including wash methods adhering to SoHT guidelines., (© 2019 John Wiley & Sons, Ltd.)

In order to better understand risk factors associated with drug-facilitated sexual assault (DFSA), this study examined complainant-specific and contextual factors, as well as the toxicological profile of DFSA in Victoria, Australia. Clinical files and toxicological analysis results collected by the Victorian Institute of Forensic Medicine (VIFM) for all cases of alleged DFSA in Victoria that occurred between 1st January 2011 - 31st December 2013 were reviewed. Two hundred and four cases of alleged DFSA were identified; complainants were predominately female (93%), and their median age was 26 years (range = 18-54). Self-reported premorbid depression (21.1%) and drug and alcohol abuse (9.8%) were four and two times higher than 12-month prevalence rates in Australia, respectively. All assailants were male, half were known to the complainant and half of alleged assaults occurred in private residences. Most (93.6%) complainants reported voluntary consumption of psychoactive substances prior to the alleged DFSA. Alcohol was the most commonly self-reported substance consumed (n = 164; 64%) and concomitant use of alcohol, prescription and illicit drugs was also commonly self-reported (24%). There were 14 cases that produced a positive toxicology result where the complainant did not report voluntary consumption, which suggests these drugs may have been used covertly to facilitate sexual assault. The results of this study indicate that Females in their mid-20's who exhibit higher rates of mental health concerns represent a sub-group of the Australian population with increased vulnerability to DFSA, which typically occurs in a familiar setting in the context of voluntary alcohol and other substance use.

Synthetic cannabinoids have caused a large number of emergency presentations to hospitals for adverse cardiovascular events including numerous deaths, particularly for the more potent analogs acting on the CB 1 receptor. While smoked cannabis use is often associated with significant changes in heart rate and cardiac output, amongst other physiological changes, it has been rarely considered in the forensic literature as a significant contributory or causal factor in sudden unexpected death. A review of case reports of admissions to hospitals for cardiovascular events was undertaken together with a review of epidemiological studies, and case reports of sudden death attributed, at least in part, to use of this drug. These publications show that use of cannabis is not without its risks of occasional serious medical emergencies and sudden death, with reports of at least 35 persons presenting with significant cardiovascular emergencies who had recently smoked a cannabis preparation. At least 13 deaths from a cardiovascular mechanism have been reported from use of this drug which is very likely to be an under-estimate of the true incidence of its contribution to sudden death. In addition, many cases of stroke and vascular arteritis have also been reported with the latter often involving a limb amputation. While it is a drug with widespread usage among the community with relatively few deaths when faced with a circumstance of very recent use (within a few hours), a positive blood concentration of THC and a possible cardiac-related or cerebrovascular cause of death this drug should be considered, at least, a contributory cause of death in cases of sudden or unexpected death., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Aim: Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases., Methods: The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents., Results and Discussion: There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness., Conclusion: This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

Aims: To investigate the extent of variability in the reporting of heroin-related deaths in Victoria, Australia. Additionally, to identify opportunities to improve the accuracy and consistency of heroin-related death reporting by examining variability in the attribution, death certification, classification and coding of heroin-related death cases., Methods: Heroin-related deaths in Victoria, Australia during a 2-year period (2012-13) were identified using the National Coronial Information System (NCIS) and used as the 'gold standard' measure in this study. Heroin-related death data from the Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS) were then compared. Differences in the number of deaths reported as well as the classification and coding assigned to the identified heroin-related death cases were investigated by cross-referencing these data sets and examining the assigned ICD-10 codes., Results: A total of 243 heroin-related deaths were identified through the NCIS compared with 165 heroin-related deaths reported by the AIHW and assigned the heroin-specific ICD-10 code of T40.1. Forty per cent of all the missed heroin-related death cases resulted from either the attribution of the death to morphine toxicity or with non-specific drug toxicity certification; 30% occurred where the cases had been attributed to heroin but there were irregularities in death certification. Additional missed heroin-related death cases occurred as a result of late initial registration of these deaths to the Registry of Births, Deaths and Marriages, and where these cases were then not assessed by the ABS for classification and coding purposes., Conclusions: In Victoria, Australia, in 2012 and 2013, the overall number of heroin-related deaths was under-reported by 32% compared with the number of deaths currently identified by the Australian Bureau of Statistics and reported by the Australian Institute of Health and Welfare., (© 2018 Society for the Study of Addiction.)

An overview of the detection of benzodiazepines and their respective metabolites and target analytes in urine by LC-MS/MS is described. This overview shows substantial differences in the approach to detection using this technique including optional use of β-glucuronidase to hydrolyze conjugates present in urine. There are also significant variations in the extraction method employed from the use of direct injection, liquid-liquid extraction to solid-phase extraction options, with little apparent difference in limits of detection. Chromatography was largely based on the use of C18-bonded columns; however both C8- and phenyl-bonded columns were used to affect separation. Modern-day tandem mass spectrometers are capable of exceptional sensitivity enabling detection of sub-nanogram per milliliter amounts in urine, which provide for longer detection times in the urine of suspected drug-facilitated assaults. A method employed in the laboratory of the authors is provided by way of an example for readers wishing to establish a method in their own laboratory.

Background: The aim of this study was to investigate the safety of the management of non-fatal heroin overdose in the out-of-hospital environment; irrespective of whether or not naloxone had been administered. Heroin toxicity-related deaths as well as heroin intoxication-related traumatic deaths following patient-initiated refusal of transport were investigated. Methods: Heroin-related deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated and data linkage to pre-hospital Emergency Medical Services performed, in order to identify whether the death was related to the last episode of care by paramedics. The number of non-fatal heroin overdose events over the study period were also examined. Results and discussion: There were a total of 3921 heroin-related attendances by paramedics during the study period, including 2455 cases that involved treatment but where the patient was not transported to hospital. There were also 243 heroin-related deaths identified over the study period and 93% ( n  = 225) of those cases were matched with Ambulance Victoria electronic patient care records. Data linkage revealed 31 heroin-related deaths where there had been a recent presentation with a non-fatal heroin overdose to paramedics; however, none of these deaths were related to that episode of care, including for 11 individuals that were treated on scene by paramedics but not transported to the hospital. Conclusions: This study demonstrated that the treatment of uncomplicated heroin overdose in the out-of-hospital environment was safe in terms of mortality, irrespective of whether or not naloxone had been administered. In all of the non-fatal heroin toxicity cases attended by paramedics, whether or not transported to hospital, death occurred as a result of a subsequent and unrelated heroin overdose.

Hair is a mainstream specimen used in forensic toxicology to determine drug use and exposure. However, the interpretation of an analytical hair result can be complicated by the presence of external drug contamination. Decontamination procedures are included in hair analysis methods to remove external contamination, but the capacity of these washes to completely remove contamination for all drugs is controversial. It is evident that there is no consensus on the most effective decontamination procedure, nor can decontamination procedures consistently remove external drug contamination to less than reportable cut-offs for all analytes. ∆ 9 -tetrahydrocannabinol deposited from cannabis smoke is mostly removed by organic solvents, whereas ionizable drugs are more effectively removed by an aqueous wash. Organizations such as the Society of Hair Testing recommend a hair decontamination procedure should include both an organic and aqueous washing step, which is in accordance with the reviewed literature. Studies involving a systematic evaluation of various solvents have shown that the most effective organic solvent was methanol and the most effective aqueous solvent contained sodium dodecyl sulfate detergent. If future systematic studies can demonstrate similar findings, a consensus on the most effective decontamination procedure for forensic hair analysis may be established.

Background & Aims: Heroin use is associated with a disproportionately high level of morbidity and mortality with most deaths attributable to drug overdose. Aggregate heroin purity data has been used to examine the relationship between overdose and variability in street-level heroin, however heroin purity data alone may not be the most appropriate nor a sensitive enough measurement tool for this assessment. The aim of this study was to measure the variability in effective dose of street-level heroin seizures, accounting for variation in both purity and mass, and determine the proportion of samples with higher than expected effective dose that would not be detected using a purity-only measure., Methods: Data on Victorian heroin seizures ≤150mg in mass made between 01/01/2012 and 31/12/2013 were obtained from the Victoria Police Forensic Services Department. The effective dose of heroin in each sample was determined by multiplying the mass and purity variables. Effective dose outlier samples were considered as those containing either greater than 1.5-2 times or >2 times the median effective dose of heroin for the sample data., Results: The 983 street-level heroin samples of ≤150mg had a median mass of 92mg (IQR of 43mg), a median purity of 13% (range 3.6%-80.9%) and a median effective dose of 12.0mg of heroin (IQR 6.6mg; range 0.4mg-111mg). Approximately one in 13 samples (8%) and one in 17 samples (6%) contained between 1.5-2 times and >2 times the median effective dose of heroin respectively., Conclusion: The effective dose of heroin is a more appropriate measure than purity to identify outlier samples that containing larger than expected doses of heroin compared to typical doses that may be expected by users. Together with other identified risk factors, fluctuation in the effective dose of heroin contained in street-level samples may contribute to the potential for overdose., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: Quetiapine is misused due to its anxiolytic and hedonic effects and has been associated with deliberate self-harm. This study analyzed quetiapine-related calls to the Victorian Poisons Information Centre (VPIC), coronial data from Victorian Institute of Forensic Medicine (VIFM) and prescribed data from the Pharmaceutical Benefits Scheme (PBS) to determine current trends in overdose, misuse and mortality., Methods: This was a retrospective review of multiple databases. Calls to VPIC and coronial data from the VIFM were reviewed from 2006 to 2016. PBS prescription data from 2000 to 2015 was obtained from the Australian Statistics on Medicines website., Results: VPIC data indicated a 6-fold increase in the number of quetiapine-related calls over the 11-year period of which most were overdose-related (77%). Overdose and misuse calls increased by 6-fold and 6.6-fold, respectively. Coronial data also indicated a rise in quetiapine-related harm; a 7.4-fold increase in quetiapine-related deaths was recorded for the same period. Similarly, Australian PBS data showed that quetiapine prescriptions increased 285-fold since 2000. There was a significant positive correlation between the increase in prescribing and overdose (r = 0.75, p < 0.001), and prescribing and mortality (r = 0.82, p < 0.01)., Conclusions: This study revealed an increasing trend of misuse, non-fatal and fatal overdoses in Victoria over the last decade. The increasing rates of prescriptions in Australia and thus increased quetiapine availability are likely to have contributed to increased poisoning and mortality. Further research is warranted to explore the reasons behind increased prescribing, including off-label use., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Introduction: Accurate attribution of heroin-related deaths, as well as the differentiation from other opioid analgesic-related deaths, is essential from a public health perspective. Heroin-related deaths involve a number of complexities where heroin-specific or non-specific metabolites and indicators (6-acetylmorphine [6-AM], morphine, and codeine) may or may not be detected. The aims of this study were therefore to develop a model for improved consistency in the attribution of heroin-related deaths and to determine areas of variation in the current decision-making processes., Methods: A model was developed using different toxicological indicators of heroin use (6-AM, morphine to codeine ratio (M:C) or morphine alone) along with investigative evidence of heroin use (circumstances, scene and clinical findings) which were used to assign a weighted score. The combined scores for the toxicological and investigative evidence were used to determine the relative strength of association for the death being attributable to heroin according to three categories: suspected; likely; or strong. An expert panel was convened to validate the model and a series of test cases were provided to a cohort of forensic toxicologists and pathologists in order to identify sources of variation in decision-making within this group. The model was also evaluated for sensitivity and specificity by reviewing potential heroin-related cases and examining the evidence associated with the attribution of these cases to heroin or not., Results and Discussion: Across all potential heroin-related death cases, the use of this model enabled a greater level of consistency in the attribution of death to heroin, especially in cases where 6-AM was not detected. The largest amount of variation in the attribution of a death to heroin was observed with potential intoxication-related deaths and in toxicity cases where a M:C ratio only was reported, even more than when no toxicological evidence was available. The reviewed cases highlighted the same variation in the attribution of a death to heroin, including a large number of cases that were attributed to morphine where 6-AM was not detected., Conclusion: This model provides a useful tool for improved accuracy and consistency in the differentiation, attribution and reporting of heroin-related deaths. Previously challenging cases where death occurred after a significant period of time and either no 6-AM was detected or no samples were taken, are able to be captured using this model., (Copyright © 2017 Elsevier B.V. All rights reserved.)

A rapid LC-MS/MS method for the targeted screening of 132 NPS in hair is described. Drugs include cathinones and synthetic cannabinoids, as well as amphetamine-type stimulants, piperazines and other hallucinogenic compounds. This method utilizes hair pulverization in acidified methanol followed by analysis using liquid chromatography coupled with tandem MS. The limit of detection varied from 0.001 to 0.1ng/mg hair among the various analytes. The method was validated in terms of sensitivity, selectivity, repeatability and stability. The limit of reporting was set at 0.1ng/mg of hair. The method was successfully applied to 23 medico-legal cases where NPS were detected in blood or where NPS use was suspected. The identified NPS included acetyl fentanyl, 25C-NBOMe, MDPV, PB-22 and AB-FUBINACA, allowing hair to be used where historical or retrospective information on use of NPS is sought. This technique has proven to be efficient for the one step extraction from hair of different classes of NPS in routine toxicological investigations; from unstable and volatile compounds, such as most of the cathinones, to hydrophobic compounds such as synthetic cannabinoids., (Copyright © 2017 Elsevier B.V. All rights reserved.)

The prevalence of opioid use in therapeutic and recreational settings has steadily increased throughout the western world. The addition of fentanyl into heroin products can produce potentially dangerous consequences, even to opioid tolerant individuals who may be unaware of such additions. Following an observed spike of heroin-fentanyl related deaths in Melbourne, Australia, a study was undertaken to determine the prevalence of these cases. All reportable deaths occurring in Victoria during 2015 and submitted to the toxicology laboratory were analysed using LC-MS-MS to confirm the combination of the heroin marker 6-acetylmorphine and/or morphine, and fentanyl. Over 4,000 coronial cases in 2015 underwent toxicological analysis for these drugs, there were nine cases identified that involved fentanyl-laced heroin. There was no specific mention of fentanyl use in any of these cases. All occurred within 2 months and in two distinct locations. The first four deaths occurred within 3 days of each other, in neighboring suburbs. The ages ranged from 25 to 57 years with an average of 40 and median of 37 years, and consisted of eight males and one female. The average and median femoral blood concentration of fentanyl was 18 and 20 ng/mL (range: <1-45 ng/mL), and morphine 140 and 80 ng/mL (range: 20-400 ng/mL), respectively. All nine cases had 6-acetylmorphine detectable in blood. Urine analysis was also performed where available. A syringe, powder and spoon found at the scene of one case were also analysed and found to be positive for both heroin and fentanyl, which supported the likelihood of fentanyl-laced heroin. This is the first reported case series of fatalities involving heroin and fentanyl outside of North America in published literature. These findings may help inform public health and prevention strategies serving to decrease the potential for such fatalities in the future., (© Crown copyright 2017.)

The nature of the global drugs market has evolved rapidly and has become more complex with the emergence of new psychoactive substances (NPS), some of which have been associated with increased abuse, hospital emergency admissions and sometimes fatalities. NPS are characterized by geographic heterogeneity, with some only transient in nature and others not satisfying the criteria for harm required for international control. Consequently, a pragmatic response of the international community is to prioritize the most harmful, persistent and prevalent substances for action - an objective, which is hampered by the paucity of data on harms. The report describes a United Nations Office on Drugs and Crime (UNODC) initiative, in collaboration with the International Association of Forensic Toxicologists (TIAFT), to collect, analyze and share toxicology data at a global level to reinforce the ability of the international community in making informed decisions using a scientific evidence-based approach, in identifying the most harmful NPS., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

The number of oral fluid samples collected by the road policing authority in Victoria, Australia, requiring confirmatory laboratory analysis for drugs proscribed under Victorian legislation (methamphetamine, MDMA and Δ9-tetrahydrocannabinol) has greatly increased in recent years, driving the need for improved analysis techniques to enable expedient results. The aim of this study was to develop an LC-MS/MS-based targeted oral fluid screening technique that covers a broad range of basic and neutral drugs of abuse that can satisfy increased caseload while monitoring other compounds of interest for epidemiological purposes. By combining small sample volume, simple extraction procedure, rapid LC-MS/MS analysis and automated data processing, 40 drugs of abuse including amphetamines, benzodiazepines, cocaine and major metabolites, opioids, cannabinoids and some designer stimulants were separated over 5 min (with an additional 0.5 min re-equilibration time). The analytes were detected using a Sciex® API 4500 Q-Trap LC-MS/MS system with positive ESI in MRM mode monitoring three transitions per analyte. The method was fully validated in accordance with international guidelines and also monitored carbon-13 isotopes of MDMA and MA to reduce detector saturation effects, allowing for confirmation of large concentrations of these compounds without the need for dilution or re-analysis. The described assay has been successfully used for analysis of oral fluid collected as part of law enforcement procedures at the roadside in Victoria, providing forensic results as well as epidemiological prevalence in the population tested. The fast and reliable detection of a broad range of drugs and subsequent automated data processing gives the opportunity for high throughput and fast turnaround times for forensic toxicology.

Reduced iso-α-acids (reduced IAA) consisting of the rho-, tetrahydro- and hexahydro-IAA groups (RIAA, TIAA and HIAA, respectively) are ingredient congeners specific to beer and generally found in clear and also occasionally green bottled beer. Concentrations of reduced IAA were determined in the blood and urine of five volunteers over 6h following the consumption of small volumes of beer containing each of the reduced IAA. The reduced IAA were absorbed and bioavailable with peak concentrations at 0.5h followed by a drop of generally fivefold by 2h. Preliminary pharmacokinetics of these compounds in humans shows relatively small inter-individual differences and an estimated short half-life varying between ∼38 and 46min for the three groups. Comparison of RIAA analyte ratios within the group indicate that some analytes eliminate relatively faster than others and the formation of metabolite products was observed. Preliminary urine analysis showed only unmodified RIAA analytes were detectable throughout 6h and suggests extensive phase I metabolism of TIAA and HIAA analytes. In authentic forensic casework where clear or green bottled beers are consumed, the identification of reduced IAA groups may provide a novel method to target ingredient congeners consistent with beer ingestion and suggest the type of beer consumed., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

An understanding of tetrahydrocannabinol (THC) kinetics and residual levels after cannabis use is essential in interpreting toxicology tests in body fluids from live subjects, particularly when used in forensic settings for drug abuse, traffic and interpersonal violence cases. However the current literature is largely based on laboratory studies using controlled cannabis dosages in experienced users, with limited research investigating the kinetics of residual THC concentrations in regular high dose cannabis users. Twenty-one dependent cannabis users were recruited at admission to two residential detoxification units in Melbourne, Australia. After being provided with information about, and consenting to, the study, subjects volunteered to provide once-daily blood, urine and oral fluid (saliva) samples for seven consecutive days following admission, involving cessation and abstinence from all cannabis use. Blood and oral fluid specimens were analysed for THC and urine specimens for the metabolite THC-COOH. In some subjects THC was detectable in blood for at least 7 days and oral fluid specimens were positive for THC up to 78 h after admission to the unit. Urinary THC-COOH concentrations exceeded 1000 ng/mL for some subjects 129 h after last use. The presented blood THC levels are higher and persist longer in some individuals than previously described, our understanding and interpretation of THC levels in long term heavy cannabis users may need to be reconsidered., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Iso-α-acids (IAAs) can be used as markers for the consumption of beer. Postmortem specimens from a range of coronial cases were analyzed for IAAs in order to determine the prevalence of beer consumption and any correlation to blood alcohol concentrations (BAC). A total of 130 cases were included in this study including those where beer was mentioned in the case circumstances, cases where beer was not mentioned specifically but alcohol was detected, and cases where neither beer was mentioned nor a positive BAC was present. Available blood, serum, vitreous humour and urine specimens were analyzed. Of the 50 cases where beer was mentioned, 86% had one or more IAAs detected. In cases that only had a positive BAC (n = 60), 57% of these cases also showed the presence of these beer markers. IAAs were detected in specimens obtained from traumatized, burnt, and decomposed cases with a mention of beer consumption or where BAC was positive in blood. No IAAs were detected in cases where BAC was negative. There was little or no correlation between blood IAA concentrations and BAC. This study demonstrates the possible detection of IAAs as a marker for beer consumption., (Copyright © 2014 John Wiley & Sons, Ltd.)

Iso-α-acids (IAA) and reduced IAA can be used as beer-specific ingredient congeners to confirm beer consumption when detected in blood and other specimens using a UHPLC-MS/MS method. Recent analysis of postmortem casework demonstrated a high prevalence of beer consumption and the possibility of providing the source of alcohol in forensic casework. Research outlined in this manuscript has examined the degree to which the interval after death and quality of blood affects the concentration of IAA in postmortem cases. Postmortem whole blood and serum were analyzed in cases where natural or reduced IAA groups were detected. The trans-IAA, cis-IAA, and tetrahydro-IAA (TIAA) groups were subject to postmortem redistribution, although only weakly associated with the length of time from death to collection of specimens. Serum had threefold higher concentrations than blood for trans-IAA, cis-IAA, and TIAA. These studies confirm that although postmortem concentrations cannot be easily compared to concentrations found in living persons the presented findings do provide some understanding to assist in interpretation where the confirmation of beer consumption is required in forensic casework.

The aim of this study was to develop an LC-MS/MS based screening technique that covers a broad range of acidic and neutral drugs and poisons by combining a small sample volume and efficient extraction technique with simple automated data processing. After protein precipitation of 100μL of whole blood, 132 common acidic and neutral drugs and poisons including non-steroidal anti-inflammatory drugs, barbiturates, anticonvulsants, antidiabetics, muscle relaxants, diuretics and superwarfarin rodenticides (47 quantitated, 85 reported as detected) were separated using a Shimadzu Prominence HPLC system with a C18 separation column (Kinetex XB-C18, 4.6mm×150mm, 5μm), using gradient elution with a mobile phase of 25mM ammonium acetate buffer (pH 7.5)/acetonitrile. The drugs were detected using an ABSciex(®) API 2000 LC-MS/MS system (ESI+ and -, MRM mode, two transitions per analyte). The method was fully validated in accordance with international guidelines. Quantification data obtained using one-point calibration compared favorably to that using multiple calibrants. The presented LC-MS/MS assay has proven to be applicable for determination of the analytes in blood. The fast and reliable extraction method combined with automated processing gives the opportunity for high throughput and fast turnaround times for forensic and clinical toxicology., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Hop-derived iso-α-acid (IAA) ingredient congeners are specific to beer. Concentrations of IAAs were determined in blood of five volunteers over 6 h following the consumption of small volumes of beer containing relatively high (Pale Ale beer) or low (wheat beer) concentrations of IAAs. IAAs were quickly absorbed with peak trans-IAA concentrations at 0.5 h followed by a drop of generally 10-fold at 2 h and low or not detectable trans-IAA levels at 6 h. However, the qualitative monitoring showed that the cis-IAAs were detected at all time-points. Preliminary pharmacokinetics of these compounds in humans shows relatively small interindividual differences and an estimated short half-life of ∼30 min. Comparison of 0.5 and 2 h blood specimens demonstrated that the trans isomers were eliminated faster than the cis counterparts. Preliminary urine analysis showed only unmodified 'co' analytes detectable throughout the 6 h. In authentic forensic casework where typically large amounts of conventionally hopped beer are consumed, this approach may provide a novel method to target ingredient congeners consistent with beer ingestion., (© The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.)

The long-term stability of the iso-α-acids, and three structurally similar but chemically altered iso-α-acids (known as 'reduced iso-α-acids' and consisting of the rho-, tetrahydro- and hexahydro-iso-α-acid groups) were investigated in whole blood. Pools of blank blood spiked with the four beer-specific ingredient congener groups at two different concentration levels were stored at 20°C, 4°C and -20°C; and extracted in duplicate in weeks 1, 3, 5 and 8, using a previously published method. A loss of 15% of the initial concentration was considered to indicate possible instability and losses greater than 30% demonstrated significant losses. The individual analytes within the four iso-α-acid groups were also measured to determine which iso-α-acids were subject to greater degradation and were responsible for the overall group instability. All four iso-α-acid groups showed significant losses after 8 weeks of storage under room temperature conditions in particularly the natural iso-α-acid group where major losses were observed (96% and 85% losses for low and high concentrations, respectively). Some degradation in all iso-α-acid groups were seen at 4°C samples predominantly due to the 'n' analogs of the groups showing an increased instability in blood. The -20°C storage conditions resulted in minimal changes in concentrations of all analytes. Higher than frozen storage temperatures can result in substantial changes on the stability of the iso-α-acid type groups in blood. The aim of this study was to highlight the stabilities of the IAA analytes in order to assist in the interpretation of IAA in stored blood specimens., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Introduction: "King hits" are when a single blow to the head causes a victim to fall to the ground unconscious, either from the punch itself or the impact between the head and the ground. This can result in fatal skull fractures and subdural hematomas. This study aimed to establish the prevalence of king hit deaths in Australia and determine the involvement of drugs in these violent fatalities., Methods: The National Coronial Information System was used to retrieve all cases involving a king hit within Australia between 2000 and 2012., Results: 90 cases were identified with a median age of 33 years (range 15-78). There were 4 females. Most cases occurred in the state of New South Wales (n=28), followed by Victoria and Queensland (24 cases each), at a hotel or pub before 3a.m. Toxicology reports were available in 68 cases. Of these, 53 cases involved the use of alcohol or other drugs (other than those used in hospital treatment). Forty-nine cases (73%) involved the use of alcohol, with a median alcohol concentration of 0.144g/100mL and 0.191g/100mL in ante-mortem and post-mortem specimens, respectively. Illicit drugs were detected in 10 cases of which most involved cannabis. Other pharmaceutical drugs were detected in 3 cases., Discussion: Assaults are an ongoing problem in Australia and king hits form a large group of these substance-related and often unprovoked attacks. Importantly, this study indicated that alcohol intoxication increases the risk of victimization, not just aggressive offending. This reiterates the serious consequences of alcohol-fueled violence in Australia., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

The drug duloxetine (Cymbalta(®)) is a newer antidepressant which has been available in Australia since 2008. Duloxetine is a serotonin and noradrenaline reuptake inhibitor (SNRI), which is associated with adverse effects in the first 6 weeks of therapy, including tachycardia and worsening symptoms in people with advanced heart failure. It is also associated with serotonin toxicity in combination with certain drugs. Few reports have been published in the toxicology literature regarding duloxetine and its prevalence in coroners' cases. This study documents the prevalence of duloxetine in coronial cases between 2009 and 2012 and seeks to better understand the role of duloxetine in deaths where concomitant use with other drugs may cause adverse outcomes. Duloxetine was analyzed in blood specimens taken for the purpose of assisting the pathologist in determining a cause of death and analyzed using a validated LC-MS/MS method employed for overnight screening. There were 34 cases where duloxetine was detected of which 19 were attributed to drug toxicity. The median femoral blood concentration in the cohort was 0.14 mg/L (range 0.01-1.42 mg/L). Many deaths involved the concomitant use of numerous other medications; up to 13 other drugs were co-detected in a case. Over half of the deaths were attributed to fatal combined drug toxicity. SSRIs and venlafaxine that may have increased the risk of serotonin toxicity in combination with duloxetine were detected in five cases. Metoclopramide, contraindicated with duloxetine use, was detected in two cases. NSAIDs (n=11), antipsychotics (n=15) and benzodiazepines (n=14) were also commonly co-detected. Heart disease was observed in over 40% of the cohort, mostly in the form of coronary artery disease or cardiomegaly. Death involving duloxetine alone was uncommon (n=4); however with certain comorbidities and co-administered drugs, the risk of a fatal event is increased, particularly in the setting of other pro-serotonergic agents. In deaths where duloxetine is detected and the cause of death is believed to be natural or unascertained, it is essential that other serotonin drugs or inappropriate drug combinations be examined for their possible contribution to death., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

A method for the detection of iso-α-acid (IAA) type ingredient congeners that are derived from the hop plant (Humulus lupulus L.) was developed to detect recent consumption of beer in blood. Three structurally similar but chemically altered IAA, also used as beer-specific ingredients, are known as "reduced IAA", consisting of the rho-, tetrahydro-, and hexahydro-IAA were also targeted. The use of a simple protein precipitation extraction and ultrahigh-performance liquid chromatography system coupled with a tandem mass spectrometer system enabled detection of these analytes in both antemortem and postmortem blood. Extracts were injected onto a C18 solid-core column under gradient elution to achieve separation of isobaric analogs and isomers within a 10-min run time. Electrospray ionization in negative multiple reaction monitoring mode was used to monitor three transitions for each of the analytes that were ultimately grouped together to form a calibration curve for quantification of each of the four IAA groups. The method was fully validated according to international guidelines that included extraction efficiency, matrix effects, process efficiency, ion suppression/enhancement of co-eluting analytes, selectivity, crosstalk, accuracy and precision, stabilities, and lower limits of quantification. Finally, applicability of the method described was demonstrated by the detection of IAA ingredient congeners in the blood of a volunteer following the consumption of a relatively small amount of beer in a pilot study.

Ethyl glucuronide (EtG) quantification in hair was assessed using quality controls prepared by three methods: (a) spiking hair samples with known concentrations of EtG, (b) fortifying hair by incubation of blank hair with EtG for several days or (c) use of authentic hair samples positive for EtG. A liquid chromatography tandem mass spectrometry (LC-MS/MS) method was developed on a Shimadzu model 8030 instrument and validated for the quantification of EtG. For two concentration levels, approximately 50 and 500 pg/mg QCs, EtG concentrations were measured in duplicate (N=2) on 8 days (N=16) and intra-assay precision (repeatability) and inter-assay precision determined using one-way analysis of variance. EtG concentrations measured in authentic hair exhibited poor intra-assay precision, with coefficients of variation of 25.1 and 20.9%, compared with 17.7 and 18.5% for fortified hair and 17.4 and 11.3% for spiked hair, for the lower and higher concentrations respectively. The inter-assay precision for authentic hair was also poorer, 35.7 and 22.5%, compared with fortified (28.2 and 19.8%) and spiked (18.4 and 13.2%) hair for the lower and higher concentrations. Although spiked QCs resulted in a better repeatability and inter-assay precision, the values obtained for QCs prepared from fortified and authentic hair are likely to be more representative of case specimens. These results have implications on the interpretation of EtG concentrations when spiked QCs are used to validate methods., (Crown Copyright © 2013. Published by Elsevier Ireland Ltd. All rights reserved.)

A commercial enzyme immunoassay for the qualitative and semi-quantitative measurement of ethyl glucuronide (EtG) in urine was evaluated. Post-mortem (n=800), and clinical urine (n=200) samples were assayed using a Hitachi 902 analyzer. The determined concentrations were compared with those obtained using a previously published liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for the quantification of EtG and ethyl sulfate. Using a cut-off of 0.5 µg/ml and LC-MS/MS limit of reporting of 0.1 µg/ml, there was a sensitivity of 60.8% and a specificity of 100% for clinical samples. For post-mortem samples, sensitivity and specificity were 82.4% and 97.1%, respectively. When reducing the cut-off to 0.1 µg/ml, the sensitivity and specificity were 83.3% and 100% for clinical samples whereas for post-mortem samples the sensitivity and specificity were 90.3 % and 88.3 %, respectively. The best trade-offs between sensitivity and specificity for LC-MS/MS limits of reporting of 0.5 and 0.1 µg/ml were achieved when using immunoassay cut-offs of 0.3 and 0.092 µg/ml, respectively. There was good correlation between quantitative results obtained by both methods but analysis of samples by LC-MS/MS gave higher concentrations than by enzyme immunoassay (EIA), with a statistically significant proportional bias (P<0.0001, Deming regression) for both sample types. The immunoassay is reliable for the qualitative and semi-quantitative presumptive detection of ethyl glucuronide in urine., (Copyright © 2012 John Wiley & Sons, Ltd.)

For many decades traditional alcohol congener analysis has provided the concentrations of fermentation by-product congeners found in blood, to ascertain if the claims of an individual regarding the alcoholic beverage(s) they have consumed were feasible, assisting in cases where after-drinking is involved. However, this technique does not provide information on the exact alcoholic beverage(s) consumed. More recently, ingredient biomarker congeners specific to certain alcoholic beverages have been detected in blood, making it possible to identify the particular alcoholic beverage consumed and therefore the source of alcohol (albeit only for a limited number of beverages). This novel approach may reduce current limitations that exist with traditional methods of detecting fermentation by-product congeners, which restrict the use of alcohol congener analysis internationally and for other medico-legal scenarios. This review examines the forensic application of alcohol congener analysis in determining the source of alcohol and other techniques.

Postmortem redistribution (PMR) is an accepted toxicological phenomenon that may affect the interpretation of postmortem blood concentrations. The extent of PMR is not well understood for some drugs. This report describes the PMR of selected substances resulting from the analysis of 149 cases comparing blood specimens taken at admission of the deceased to the mortuary and then at autopsy. Blood was collected in preserved tubes containing 1 % sodium fluoride/potassium oxalate. All cases were subject to a full autopsy and blood extracts were analyzed using a targeted screen by LC-MS/MS. 30 drug or drug metabolites that were detected with an incidence of 6 or more were included in this study. The pre-autopsy interval ranged from 0.5 to 164 h (6.4 days) with an average of 64 h for the cases analyzed. The increase in drug concentration from mortuary admission to autopsy ranged from 30 % for drugs such as citalopram, mirtazapine, and sertraline to 300 % for doxylamine. Only 7 drugs of the 30 studied showed increases of greater than 20 % when comparing autopsy to mortuary admission blood irrespective of the length of the postmortem interval. Drugs including methadone, EDDP, fluoxetine, mirtazapine, and sertraline all showed statistically significant increases during the pre-autopsy interval (p < 0.05) while 6-acetylmorphine, 9-hydroxy-risperidone, and caffeine showed significant decreases (p < 0.05) from mortuary admission to autopsy. While femoral blood is thought to reduce PMR, this data shows that for some drugs significant redistribution can occur even when taking peripheral specimens irrespective of the delay in the postmortem interval.

The post mortem redistribution of ten commonly prescribed antipsychotic drugs (APs) was investigated. Femoral blood was collected from 273 cases at admission to mortuary (AD) and at post-mortem (PM). The PM samples were collected at various times up to nine days after admission and the sample pairs analysed using LC-MS/MS. The drugs included in this study were 9OH-risperidone (paliperidone), amisulpride, chlorpromazine, clozapine, haloperidol, olanzapine, promethazine, quetiapine, risperidone, and zuclopenthixol. Haloperidol, quetiapine and risperidone showed minimal changes between AD and PM specimens, whereas the majority of drugs showed significant changes between the sample pairs collected at different time points post mortem (p<0.01) in addition to an average concentration change greater than the uncertainty of measurement of the applied method. Average increases in blood concentrations after admission to the mortuary ranged up to 112% (chlorpromazine and olanzapine) but also decreases up to -43% (9OH-risperidone) were seen. There were large standard deviations between sample pairs and substantial day-to-day unpredictable changes that highlight the difficulty in the interpretation of drug concentrations post-mortem. Based on the presented data, we recommend that specimens for toxicological analysis should to be taken as soon as possible after admission of a deceased person to the mortuary in order to minimise the effects of the PM interval on the drug concentration in blood., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Inappropriate combinations of pharmaceutical drugs are often detected in deaths reported to a coroner. However, the involvement of drug combinations in the cause of death can be overlooked in cases when significant natural disease or external injury is also present. This study examined pathology reports and coroner's findings between January 2002 and December 2008. Cases that included exposure to a selection of serotonergic drugs were examined to determine the role of different death investigators in drug-associated deaths in Victoria, Australia. Of the 326 cases identified, the involvement of drugs in the death was discussed to some degree in 66% of cases. Recommendations by the coroner pertaining to death prevention were made in 12 cases (4%). In 16 cases (5%) the drugs were not mentioned in the findings, including at least 11 cases of probable major adverse drug interactions. Death investigations serve an important public health and safety role, however, the potential involvement of drugs in many cases is not always recognized.

Olanzapine (OLZ) is amongst the most commonly prescribed antipsychotic drugs and is associated with substantial instability. The aim of this study was to investigate the instability of OLZ and to identify the degradants formed from its breakdown. Three experiments were conducted to monitor the degradation of OLZ and the formation of degradants in blood (1), water (2), and post-extraction at 4 °C (3). All three sample sets were analysed in duplicate and repeated in the absence (A) and presence (B) of 0.25% ascorbic acid. One degradant was identified in sample sets 2A and 3A with m/z 329 and confirmed as 2-hydroxymethyl-OLZ (2-OH-OLZ) using LC-MS techniques. The addition of 0.25% ascorbic acid slowed the degradation of OLZ down in all three experiments and inhibited the formation of 2-OH-OLZ in sample sets 2A and 3A. To investigate the influence of oxygen on the degradation of OLZ and the formation of 2-OH-OLZ in water, an additional experiment (4) was conducted. Sample sets were prepared containing different vortexing or sonication steps in order to alter the oxygen content in the samples. Statistical analysis confirmed that degradation increased significantly following vortexing for 1 min while sonication did not affect the rate of degradation of OLZ further suggesting the involvement of oxygen in the degradative processes. 2-OH-OLZ was only identified as a degradant of OLZ in aqueous solutions. It also degrades over time but its product is currently unknown and is under investigation., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

The genetically variable CYP450 isozymes are responsible for the metabolism of up to 80% of commonly used drugs, many of which are detected in cases of unexpected or suspicious death in Australia. The aim of this study was to examine the genetic profiles of individuals in a cohort of Australian deceased individuals dying of drug toxicity (219), natural disease (150), external injury (109) or unascertained (8) causes, to determine if there was an over-representation of individuals with a genetic predisposition to altered drug metabolism in cases attributed to drug toxicity compared with other causes. Single nucleotide polymorphisms (SNP) of CYP1A2, 2C9, 2C19, 2D6, 3A4 and 3A5 were analyzed. There were 27 cases (6.1%) that were CYP2D6 poor metabolizers (PM) and an additional 8 cases (1.7 %) that were CYP2C19 PMs. Around 31% of the cases were CYP2D6 intermediate-poor metabolizers, with a number of cases exhibiting drug combinations that were likely to have caused pharmacokinetic or pharmacodynamic interactions. There was no correlation between cause of death type and CYP2D6 metabolizer status. Increased enzyme activity was also indicated by the presence of hyperinducible variants such as CYP1A2*1F, which was observed at a frequency of 48%.