Introduction
Drug abuse is among the common problems threatening public health around the world. The severity of care relating to drug abuse has been documented in different areas, especially when the outcome is death. As a result, drug abuse has created a significant topic in death investigations. Although drug deaths are not always obvious, overdose cases are common while other cases are detected during the autopsy. As such, these pages will evaluate death investigations by focusing on those related to drug abuse.
Background
Experts argue that while cocaine, alcohol, and opium were the primary drugs to be misused, they continue to be the commonly abused drugs around the globe. Over the decades, the societal costs associated with drug abuse are usually overwhelming. For instance, every year, the United States seizes illegal drugs worth millions of dollars and devotes billions of dollars to the enforcement of drugs (Spitz, 2006). Despite the allocation of significant amounts as a strategy of managing the issue of drug abuse in the United States, the clinical expenses for drug abuse range at hundreds of dollar billons. For example, while the documented Drug Enforcement Administration budget for 1999 was $14 billion that of agency’s banning of the primarily controlled substances like methamphetamine, cocaine, marijuana, and heroin was $24 million for 1991, while the 1998 interdictions costs were $86 million (Spitz, 2006). Further, the clinical expenses linked to drug abuse in 1995 were estimated to be $428 billion, $114 billion for drug abuse, $138 billion for smoking, and $175 billion for abuse of alcohol (Spitz, 2006).
Most abused drugs tend to be illegal, and their trade is equally prohibited. Experts associate the use and handling of the drug to violence and criminal connections, which makes substance-associated complications and deaths crucial in the legal clinical death investigation. The prevalence of substance abuse creates the need for considering it as a crucial and probable factor of contribution in death investigations (Spitz, 2006). Primarily, substance use should be involved in investigating deaths that were unexpected, sudden, and those that present situations that appear to be unnatural.
Although the substance or substances likely to have caused the death could be available at the crime scene, others could be unsuspected. More so, specific traits relating to departed, or the scene could present suspicions the death resulted from drug use contributing to the obvious observation of the drug deaths or creating the need for an autopsy for confirmation (Spitz, 2006). A general death investigation policy requires the entertainment of drug poisoning or toxicity suspicion in many clinical investigators cases, thus the need for collecting the necessary samples immediately. Considering that the costs associated with collecting and storage of samples are relatively low, investigators should ensure that valid samples are collected immediately (Spitz, 2006). The criticality of ensuring that valid specimens are collected is crucial to enhancing the solving or investigations, considering that retrieval of valid samples days later is, at times, impossible.
For example, the case of Bulgarian defector political assassination explains the need for ensuring proper collection of samples. Other than the medical and investigative characteristics that were a clear indication of poisoning, the availability of a tiny skin puncture was the only physical evidence together with ensuing subcutaneous particle recovery in the thigh soft tissue (Spitz, 2006). Basically, from the end of a particular fabricated umbrella, a tiny compass of pricked plastic had been thrust to the thigh of the victim. Despite the certain classification of the death as poisoning associated, it was not until the development of modernized analytical techniques years later when the poison was confirmed (Spitz, 2006). Upon the testing of the stored specimens, traces of ricin, which is a toxic alkaloid obtained from castor bean was established as the active agent.
A significant number of substance abuse cases have, fortunately been limitedly complex, and drug evaluates are predictable (Spitz, 2006). The availability of investigation methods and instrumentation has largely favored the detection of poisons and drugs at reduced levels. Proper collection and storage of valid specimens, as well as the appreciation of abuse/ poisoning possibility, play a significant role in facilitating investigations. For instance, realizing the possibility of substance poisoning, collection, and storage of the specimen efficiently enhanced the establishment of Ricin’s situation (Spitz, 2006). Further, the logic of collection and storage of evidence samples applies in regular clinical examiner situations.
Collecting different samples such as fluids, tissue, or hair aids in different examinations carried out by the forensic toxicologist and are therefore recommended in cases relating to different drugs. Specimen collection varies depending on the involved drug types. For example, in areas where ethyl alcohol is abused regularly, the collecting of at least two specimens from varying body areas is advised (Spitz, 2006). The specimen enables the establishment of the specific cause of death considering that the cause of death could be linked to long-term abuse of substance and not the specific substance abuse.
Chronic substance abuse could contribute to associated lifestyle long-term complications such as cardiac, neurological, pulmonary, inflammatory, and hepatic diseases. Investigations, findings, and policies of a particular case enable the establishment of whether a death is a drug linked or not. For instance, the World Health Organization organizations recommend the recognition of death resulting from chronic abuse as natural ways of death (Spitz, 2006). More so, substance-related deaths could be associated with accidents or violence resulting after abuse. For example, alcohol consumption impairs a person’s judgment, thus exacerbating risk-taking resulting in experiences of trauma on victims. Mostly, alcohol abuse is liked to domestic violence, physical injuries, and moto vehicle accidents.
In most emergency departments, alcohol is outlined together with at least one more substance, whereas over the past decade, abuse of methamphetamine and amphetamine increase has been noted (Spitz, 2006). More so, club drugs have equally been linked to abuse cases while in large cities, close to half of the homicide cases tend to be substance-related. The involvement of substances in homicide cases creates the need for involving forensic medicine in evaluating the significance included by substances in violent deaths. Although some investigations could prove the lack of notable substances in the victim’s body, the investigations could ascertain that the primary reason or death motive was linked to drugs (Spitz, 2006). Such a case could link to the killing of a retail business cashier in a robbery perpetrated by a group or person intending to support their drug behaviors.
Although heroin was the primary abused substance in the 1970s, the situation reversed in 1988 with cocaine replacing it. The increased abuse of cocaine in the United States could be linked to factors that included the ready availability, crack introduction, which is a cocaine form, and it’s reducing costs in the streets (Spitz, 2006). Currently, most deaths associating with the overdose of drugs are associated with opioids especially synthetic opioids apart from methadone. In 2017, of all the 70, 237 drug overdose deaths documented in the US, those relating to opioid overdose were 67.8 percent (47, 600) (Spitz, 2006).
Literature Review: Drug and Alcohol Abuse in Death Investigations
Drugs and alcohol intake mark some of the most common causes of accidents associated with traffic. The alcoholic content present antiseptic solutions, liquor, and food elements pose significant threats to the human body (Nakao, & Tatara, 2019). For example, the idea of driving after alcohol consumption could present severe outcomes, including death to the driver or even other people like pedestrians. More so, other drugs especially stimulant drugs and others like antiepileptics, psychotropics, anti-diabetics, and cannabis (tetrahydrocannabinol) impact individual behavior increasing death risks (Nakao, & Tatara, 2019).
Typically, the extent to which the drugs impact the operation of the automobile varies depending on the specific associated drug. For instance, some substances cause dizziness, inattention, and drowsiness, prolonging the rates of reaction, impaired concentration, and judgment, as well as consciousness disturbance (Nakao, & Tatara, 2019). Driving and operating machinery under the influence of alcohol and substances could result in accidents and collisions that threaten human life. Given the impacts of substance abuse, especially in contributing to death forensic pathology plays a critical role in determining the probable cause (Nakao, & Tatara, 2019).
According to Gill (2017), forensic pathology describes the pathology subspecialty focusing on examining both the living and the dead to gain an idea relating to the mechanism, cause, or mode of injury, disease, or death. Becoming a forensic pathologist requires one to undertake the course in anatomic/clinical pathology or anatomic and a forensic pathology fellowship. For board certification, one must pass two national examinations. The United States has two systems of investigating the death which is the coroner (C) system and the medical examiner (ME), normally varying depending on the jurisdiction specifications. For instance, while New York County has integrated ME/C system, Connecticut has a state governed medical examiner system.
Typically, medical examiners are normally forensic pathologists who are elected by governmental agencies while the coroners are appointed officials who must not hold medical degrees. According to Gill (2017), the systems tend to differ on quality levels though a forensic pathologist is required to increase the accuracy of death certification. The scholar notes the existence of a trend relating to the United States systems of medical examiners. Nevertheless, Gill (2017) notes the possibility of conflicts between medical examiners and coroners since some of the coroners tend to be funeral directors.
According to Gill (2017), the toxicological testing normally carried out in autopsy describes a series of events that must be evaluated by the consideration of the history of the deceased. The scholar notes that an autopsy normally starts with the examination of history through the review of medical records, evaluation of the crime/ investigation scene, and discussing the presenting issues with the police and family. The pathologists evaluate the history from which they create a hypothesis and undertake a physical autopsy together with the necessary laboratory tests such as toxicology and microscopy to support or refute the hypothesis (Gill, 2017).
Body examination incorporates internal and external evaluation that relates to specimen tissue removal for toxicological testing, DNA analysis, and microscopy. The process involves different participants who could include entomology, anesthesiology, odontology, medical toxicology, and anthropology, depending on the complexity of the underlying investigation. The autopsy could either be the hospital or forensic, and both targets establishing the cause of death.
Nevertheless, forensic and hospital autopsies differ in relation to toxicological analysis as it misses in hospital autopsies. Some of the forensic autopsy toxicology specimens are liver, urine, blood with peripheral being preferable, and s collected using sodium fluoride (NaF), gastric contents, and vitreous humor. According to Gill (2017), peripheral blood samples are usually opted to ensure the reduction of postmortem redistribution effects that result in various central/cardiac specimens. Sodium fluoride is preferred due to its antimicrobial and anticoagulation characteristics that inhibit the in vitro ethanol production. Equally, it is critical in preventing/ delaying impulsive cocaine hydrolysis to benzoylecgonine (BE) since the certification of death from acute cocaine intoxication requires the identification of cocaine and not BE alone.
Gill (2017) notes that a significant number of deaths relating to substance abuse/ drug intoxication, as well as automobile collisions, are explained as accidents. The authors note that forensic pathologists consider three major factors to clarify death as an outcome of intoxication. The primary factor is the medical investigation or autopsy n delayed deaths where an illness or notable injury whose severity or extent is erratic with continued life fails to present. Intoxication could be documented if the toxicology findings are within the gap of the normally experienced intoxication deaths. More so, Gill (2017) notes that intoxication could be defined if the circumstances and history match those that relate to fatal intoxication.
According to Gill (2017), the concentrations of the do not necessarily determine the death cause, and the available toxicological information does not substitute the investigation together with the medical conclusion relating to the deaths. Specifically, in a case where there has been a long-term abuse of heroin and methadone elements, factors such as tolerance tend to trigger the establishment of varying concentrations of drugs that differ among the dead and the living. Gill (2017) notes that the concentrations of drugs could equally be affected by the postmortem intervals as well as postmortem redistribution.
Postmortem redistribution describes the changes that present in concentrations of drugs following death with drugs redistribution, for instance, from the liver, myocardium, or lungs into the blood. The redistribution of a drug is affected by different factors that include the lipophilicity, pKa, and distribution volume. As a result, blood samples from peripheral sources such as the femoral vein is opted for autopsy toxicological specimens to minimize the effect of postmortem redistribution effects. Gill (2017) discourages the collection of blood samples from central areas such as the heart since they tend to be susceptible to impacts of postmortem redistribution for specific drugs like digoxin.
Application of Drug Abuse to Death Investigations
The death investigation is critical to public health. According to Gill (2017), systems of death investigation require the cooperation of authorities to be in charge of the body, undertake the postmortem short of authority, and compel the documents. Basically, the forensic pathologist determines the reason and way of death, attests to civil and criminal judgments, educates, and evaluates public health. Depending on the specific jurisdiction, certain deaths are documentable to the ME/C, such as suicides, homicides, and accidents. More so, Gill (2017) notes that deaths relating a possible threat to public health, are unexpected and sudden normally resulting from unrecognizable complications.
Ideally, the examinations incorporate a postmortem that normally involves external evaluation and dissection of the internal body intending to determine the death cause and enable in identifying the death manner. There exist multifarious ways in which the work of forensic pathologists advantages the living, including documenting specific deaths to responsible programs. For example, deaths documented to the FDA MedWatch program are evaluated further as the program investigates the negative medical impacts such as deaths that could result from related medical services and treatments.
For example, after a young female was discovered dead in bed, the autopsy did show that she was struggling with coronary artery illness, and her blood had sibutramine. Investigations confirmed that she had been using herbal medicine for weight loss that is bought over-the-counter. Upon the evaluations of the herbal medicine, sibutramine which is a derivative of amphetamine. The results of the autopsy ended up implicating the weight loss product as the poison n it and the existing heart condition were outlined as the specific death causes. Equally, death investigations to public health include the infectious disease documentation like meningitis cases that are usually documented to the Center for Disease Control and Prevention or departments of health.
More so, faulty cribs that could lead to severe infants’ entrapments are documented to the Consumer Product Safety Commission. More so, evaluation of death causes and ways of death through autopsy enables the monitoring of public health by facilitating the identification of changing and new illnesses. In relation to substance abuse, autopsies play a significant role in enabling the identification of toxic drugs. Typically, substance intoxication deaths are among the most difficult to determine the manner of death. Partly, this could be linked to the possible existence of misleading confirmation or the victim’s commitment to death, the associated risk factors like mental health complications, and abuse of substance, relating demographic groups impacted such as middle-aged men (Stone et al., 2017).
According to Stone et al. (2017), the proportion of substance intoxication deaths that are listed as undetermined differs within the United States. For instance, the authors note that recent data showered that from 2008 to 2010, proportions across states were ranging between 1% and 85%. Fortunately, the average proportions for undetermined substance-related deaths between 2011 and 2014 reduced to 6.7 percent. Even though the average is ideally minimal, most undetermined deaths are said to be correctly misclassified, thus the need for proper classification of misclassified to facilitate public health policy development, practices, and research. Over the recent past, the need for proper investigation and classification of substance abuse associated deaths has gained urgency due to the rising number of drug-related deaths, especially those relating to illicit and prescription opioids (Goldberger et al., 2013).
Investigating deaths that relate to drug abuse plays a significant role in enabling death certification. Death certificates ate important documents that outline both the manner and cause of death. The death cause explains the injury or illness that contributed to the fatality while the manner of death explains how the cause presented. Certification of an unnatural certificate of death can only be done by ME/C. the efficient certification of death has different advantages that include the enhancement of documenting critical state data relating to death causes and enabling inefficient life assurance claims. More so, proper certification offers benefits relating to estates resolution and social security. The data from certification could be utilized by authorities to procure internal administrative devotions, such as case closing.
Gill (2017) notes that investigating deaths that relate to drug abuse help in determining the manner of death that could include accidents, suicide, natural, homicide, undetermined, or therapeutic complications. The scholar notes that a significant number of intoxication deaths that result from abuse of drugs are classified as accidents depending on the findings of the toxicology, autopsy, and the circumstances. Considering the significance of investigations of deaths from drug abuse to public health surveillance, both health care providers, medical examiners, and coroners should consider developing an inclusive documentation procedure, especially for illicit and prescription opioids that are causing most distance abuse-related deaths.
Conclusion
In conclusion, abuse of drugs lists among the leading problems threatening public health at global levels. For decades, developed nations such as the United States and developing nations have continued to struggle with drug-related deaths. Recently, drug-related deaths have been exacerbated due to the increase of illicit and prescription opioids abuse. Death investigations relating to drug abuse are critical in establishing the commonly abused drugs and enabling the development of related policies. More so, investigations of deaths relating to drug abuse play a crucial role in death certification, health surveillance, and elimination of medications that are likely to harm people.
References
Gill J. R. (2017). From Death to Death Certificate: What do the Dead say?. Journal of medical toxicology : official journal of the American College of Medical Toxicology, 13(1), 111–116. doi:10.1007/s13181-016-0551-y
Goldberger, B. A., Maxwell, J. C., Campbell, A., & Wilford, B. B. (2013). Uniform standards and case definitions for classifying opioid-related deaths: recommendations by a SAMHSA consensus panel. Journal of addictive diseases, 32(3), 231–243. doi:10.1080/10550887.2013.824334
Nakao, K. I., & Tatara, Y. (2019). An analysis of alcohol and drug intake in forensic autopsy cases of traffic fatalities. IATSS research.
Spitz, W. U. (2006). Spitz and fisher’s medicolegal investigation of death : Guidelines for the application of pathology to crime investigation. Retrieved from http://ebookcentral.proquest.com Created from jsulib-ebooks on 2019-11-18 07:48:34
Stone, D. M., Holland, K. M., Bartholow, B., E. Logan, J., LiKamWa McIntosh, W., Trudeau, A., & Rockett, I. R. (2017). Deciphering suicide and other manners of death associated with drug intoxication: a Centers for Disease Control and Prevention consultation meeting summary. American journal of public health, 107(8), 1233-1239.