Death caused by drug addiction: A review of the experiences in Hamburg and the situation in the Federal Republic of Germany in comparison with the literature

Forensic Science International, 43 (19891223-237 Elsevier Scientific Publishers Ireland Ltd.

223

DEATH CAUSED BY DRUG ADDICTION: A REVIEW OF THE EXPERIENCES IN HAMBURG AND THE SITUATION IN THE FEDERAL REPUBLIC OF GERMANY IN COMPARISON WITH THE LITERATURE

W. JANSSEN, Institute

K. TRÜBNER

of Forensic

Medicine,

and K. PÜSCHEL University

of Hamburg,

Butenfeld

31, 2000 Hamburg

61 IF.R.G.1

(Received October 17th, 19881 (Revision received February 8th, 1989) (Accepted February lOth, 1989)

Summary Based on criminologieal experiences and pathomorphological, serological and toxicologieal studies of more than 300 fatalities, an overview is given of drugs, their intravenous abuse and drug deaths in Hamburg and the Federal Republic of Germany. The number of drug deaths has increased dramatically in Hamburg, where there were more than 50 cases each year in 1987 and 1988. In the F.R.G. approximately 400 cases are registered per annum. The percentage of female intravenous drug abusers is growing and the age of the decedents is increasing. The mean was formerly 25 years, but is now 30 years. Among the histopathological findings, foreign-body granulomas are of special value; infectieus diseases, especially hepatitis B and HIV-infection, have to be investigated serologically and morphologically. The prevalente of HIV-1 antibodies among drug deaths in Hamburg is approximately 15%, in comparison with approximately 50°/o in Berlin. The %upply” of heroin has apparently become so copieus that nearly al1 deaths are caused by overdosage with this substance. An international agreement about a definition of a drug death is a prerequisite for nationwide analyses. Key words: Drug death; Narcotics; Heroin; Criminology of intravenous granulomas; Hepatitis; HIV-1 infection

drug abuse; Foreign-body

Introduction

Death as a result of drug addiction is of enormous medical, legal and social significante. Drug addiction is of great concern to the individuals involved and for society as a whole [l-81. Crime connected with death caused by drug addiction poses special problems for forensic scientists. The increase in the number of drug deaths reflects the extent of, and the changes in drug addiction. Leading experts representing the judiciary and police estimate that the negative effects of drug-connected crime are more serious than the effects of terrorism for the community in the Federa .l Republic of Germany. 0379-0738/89/%03.50 0 1989 Elsevier Scientific Publishers Printed and Published in Ireland

Ireland Ltd.

224

Definition

of Drug Death

For epidemiological analyses, a standardized definition of the term “drug death” is essential. In practice, however, different criteria are used. Deaths caused immediately by an overdose of illicit drugs are registered everywhere. The differences relate especially to the interpretation of the causa1 connection between drug addiction and death. In the F.R.G. the following definition has been produced by a special Working Group of the criminal police and is designed to record al1 deaths where a causa1 connection to drug addiction (illicit drugs or substitutes) is evident: (1) Death due to intentional or accidental overdose. (21 Death due to long-term abuse of drugs. (31 Suicides connected with dependence on drugs. (4) Fata1 accidents influenced by drugs [9]. Group 1, the so-called “golden shot”, represents approximately two-thirds of al1 drug deaths. Groups 2, 3 and 4 together contain one-third of the registered cases. The Federal Criminal Police Office of the F.R.G. in Wiesbaden has been registering drug deaths for approximately 20 years. The same or similar definitions can be found in Denmark, Ireland, Monaco and Norway. An accepted worldwide definition of drug death is imperative for nationwide investigations and comparisons, because the problem of drug addiction does not stop at national borders. Consumed

and Confiscated

Drugs

In ancient civilized nations the use of drugs was connected with certain ritual acts, many of them with religious character. This is not comparable with drug consumption nowadays. The drugs, their dose and the kind of application have changed rapidly. In the F.R.G. a drug is defined by the Narcotics Act (“ Betäubungsmittelgesetz”). The term “narcotic” is purely a nomen jutis. It is not identical with pharmacological or medical terminology and can be changed by decrees to bring it up-to-date. In this Act not only drugs are registered (i.e. heroin, morphine, codeine, methadone, amphetamine, cocaine, mescaline, LSD, cannabis) but also many substances that are taken as an alternative to or as substitutes for drugs (i.e. benzodiazepines, barbiturates - apart from medical prescription - and methaqualonl. However, the so-called designer drugs are not registered. These are new synthetic substitute drugs derived from amphetamine, fentanyl or meperidine. They can produce many problems in To some extent they have qualities that have toxicological analysis. remained unknown til1 now [5]. The importante of drugs can easily be demonstrated with the amounts

225

confisticated by the police. The figures published in Hamburg show that (11 the confiscated amounts of heroin were especially large; (2) seizure of products of cannabis was extremely high; (31 the use of cocaine is increasing; (41 the amount of confiscated amphetamine is changing; and (51 LSD-trips show a decreasing tendency. in the F.R.G. are tending increasingly towards Drug addicts polytoxicomania. Stimulants and sedatives are taken within a short time, or even simultaneously. The number of patients in hospita1 who have to be detoxicated from many drugs simultaneously, e.g. heroin, alcohol and pharmaceutical products, is increasing. The classification of drugs by the WHO distinguishes psychic and physical dependence on the one hand and the habituation to drugs on the other hand. The most severe consequences are attributed to heroin. Epidemiology

and Criminology

Statistics It is estimated that 70 000-80 000 people in the F.R.G. inject narcotics intravenously; 300 000 - 500 000 people are dependent on prescribed psychoactive drugs. Figure 1 shows the development of the scene concerning narcotics since 1974. Since 1970 the drug deaths are centrally registered in the Federal Criminal Police Office and the number of drug deaths shows a steady increase until 1979 when over 600 drug victims were counted [9]. After 1979 the number of drug deaths decreased to 300- 500 annually (Fig. 21. A similar development can be registered for Hamburg except for the last 2 years (Fig. 31, when the number of deaths caused by drug addiction increased dramatically. Fifty-one drug deaths were registered in 1987. This puts Hamburg in second place in the F.R.G. - after Frankfurt and before Berlin. This development continued in 1988. Until September there were

80.000~70.000-60.000-50.000-40.000-30.000-20.000-10.000 --

Fig. 1. Number

of intravenous

drug abusers

in the F.R.G.; development

since 1974.

226

n tìoo--

500-400-300-ZOO-lOO--

Fig. 2. Number of registered

drug-deaths

in the F.R.G. since 1970; sex distribution.

48-1 45-1 42-1 39-1 36-1 33-1 30-1 27-1 24-1 21-1 EI-: 15-1 12-1 9-1 6-1

70 72 74 76 78 80 EI284 86 88 Fig. 3. Drug deaths in Hamburg since 1970; sex distribution.

227 TABLE

1

MORTALITY:

DRUG DEATHS

Federal Republic of Germany Italy France Denmark Switzerland

PER MILLION

INHABITANTS

6.5 3.8 2.9 27.9 15.6

more than 50 drug deaths in the city state of Hamburg. Compared with other European countries the F.R.G. had the highest absolute number of drug deaths in the years 1980- 1986 (approx. 400 yearlyl followed by Italy (approx. 3001 and France (approx. 2001. However, in Denmark and Switzerland the drug mortality was higher (Table 11. During the whole period of investigation, male drug addicts predominate in Germany, but it must be mentioned that in comparison with earlier times, more women are counted among drug deaths. The sex distribution has changed from 4.9 : 1 to 2.6 : 1 between 1975 and 1985. The average age of drug victims increased during the last two decades from 25 years to approximately 30 years. A comparison between different regions in the F.R.G. shows that the rate of drug deaths per million people differ widely. Especially high rates can be found in the city states of Hamburg and Bremen and in Berlin. The official statistics concerning drug deaths suffer from a serious disadvantage - the causa1 connection between drug abuse and death is not determined according to the same standards everywhere. Only in some areas statistics are based on results of regular autopsies and toxicological investigations. Drug-career

and tendenties

In Hamburg it takes on average 1-2 years until a drug addict is registered by the police for the first time. On average 6-8 years pass from the start of the drug-career until death. Sometimes the survival period is only some months - on the other hand, some drug victims survived 19 years. In 1986 the statistics of the F.R.G. estimated the mean time of survival of the male drug addicts at 8.1 years. The time of survival of the female drug victims is much shorter, being only 6.5 years. After 10 years lO-15% of the “fixers” registered by the police are dead. Not al1 drug addicts die! Approximately 40-50% of the consumers of hard drugs (especially the older onesl break free from the habit, the reason being unknown. Therapeutic success is comparably poor. A quarter of the drug deaths in Hamburg investigated by autopsy and toxicological examinations were not registered as drug addicts by the police before death. It has to be presumed that the number of unreported drugrelated fatalities is even higher.

TABLE

2

DRUG DEATHS:

PLACE

Own flat Other flat Public buildinglopen Hospita1 Hotel room Prison

WHERE

THE CORPSE

area”

footpath,

FOUND

36% 22% 16% 16% 5% 3% 2%

Place of work “e.g. Train station,

WAS

restaurant,

water,

ambulance.

Investigations in Hamburg

It has to be emphasized that conditions for our investigations are wel1 organised in Hamburg. There is close cooperation between the Drug Squad of the police and the Institute of Forensic Medicine of the University. The frequency of autopsies of those registered as drug addicts is almost 100%. However, we are not sure about the number of unreported cases. Our own experiences are based on more than 300 examined cases from Hamburg and surrounding areas. Place where

the corpse

was found

-

extemal

findings

Drug deaths mostly occurred in the inner city-areas of Hamburg. However decentralization of drug traffic and consumption has lead to a shift of the drug scene to the suburbs. TABLE

3

CAUSES

OF DRUG DEATHS 70%

Intoxication Natura1 death Pneumonia Myocarditis Liver cirrhosis Coma hepaticum

10%

External violente Hanging Suffocation Drowning Carbon monoxide Burning Fa11 from height Traffic-accident Exsanguination

20%

)

229

Most drug deaths are found in private homes. Other places are hospitals, toilets, public places, hotel rooms (Table 2). The surrounding circumstances of the death can be clear: e.g. the syringe in the vein and the fixer utensils near the corpse. Otherwise friends or relatives of the addict systematically remove al1 traces. Needle marks are the most important signs for an intravenous drug addiction and must be recognized during the external examination of the corpse. Sometimes the drug addicts inject themselves in areas that are difficult to recognize, e.g. the mouth, the feet, the lower legs and the neck. Sometimes we find drugspecific tattoos as hints of the addiction. Autopsies - Histology, SQTOdOg?J, Toxicology /aS Causes of death. The following causes

of death of drug victims were diagnosed during the last 10 years: intoxication, 70%; natura1 death, 10%; external violente, 20%. Fata1 intoxication with heroin alone dominates. The most common infections in drug addicts are hepatitis, myocarditis and pneumonia. External violente includes suicides, e.g. by hanging, drowning or accidents involving a fa11 from a height or fire in the flat (Table 3). The so-called “body-packers” or drug-couriers who died because of the rupture of cocaine or heroin-filled condoms in the intestine are not drug deaths according to the official definition in the F.R.G. Body-packers are

Fig. 4. Subcutaneous

( x 150).

foreign-body

granuloma;

multinucleated

giant cells containing

talc particles

230

mostly not dependent on drugs themselves and do not take drugs intravenously [lol. fbl Histology. The most important organs in the histological investigations of drug deaths are the liver, the lungs and the heart. A great deal of literature about the features is available [3,11-221. The histomorphological findings in these organs correspond either to direct effects of the drug addiction or to concomitant infections, hypoxia or bleeding. The demonstration of foreign-body granulomas is of special diagnostic importante in the histological investigation, being traces of intravenous drug abuse [22]. These granulomas were found in the lungs of 60% of drug deaths. Other places where granulomas can be detected are the skin around the needle marks (sec Fig. 41, the liver and also other organs. Mostly talc or starch, but sometimes other unidentified substances were found in the granulomas. These are auxiliary substances for the production of tablets or for “stretching” the drugs. Püschel et al. in Germany and Kringsholm and Christoffersen in Denmark have reported in great detail on the pathogenesis of the foreign-body granulomas and the various filler materials [14,15,19,20]. Oedema, haemorrhage and many macrophages can be found histologically in the alveolar spaces [6,14,16]. In our material, siderophages as described by Rajs et al. were distinguished in 20% of the cases [22]. The pattern of distribution shows typical smal1 foei (sec Fig. 51. Presumably these are the residues of intra-alveolar hemorrhages during episodes of intoxication, lung oedema and coma.

Fig. 5. Intra-alveolar ( x 250).

siderophages

in the lung of 30.year-old

fixer,

who died of heroin overdosage

231

In relation to the findings in the heart, the detailed investigations of Rajs and Falconer [21] and Kringsholm and Christoffersen [14] are of basic significance. We found similar degenerative and inflammatory changes in the heart, in 5-10% of the cases, mostly with unspecific scattered mononuclear infiltrates and focal myocardial fibrosis (so called “borderline” myocarditis according to the Dallas classificationl. Alterations of liver cells, i.e. lipofuscinosis and cytoplasmatic granules, can be caused by a long-term abuse of medical drugs [3,23]. The inflammatory diseases found in 70-80% of our cases [11,24] are mostly due to unsterile techniques of injection. These were mostly of unspecific reactive or chronic persistent types. Chronic aggressive hepatitis, liver cirrhosis and acute viral hepatitis make up approximately 10% of al1 cases. Morphologically the HBs-Ag can be visualized with aldehyde-fuchsine or orcein-stain, by in situ hybridisation or immunocytologically. It would be a considerable advantage if the drug could be made visible directly in the cells of the target organ. The Japanese team of Ishiyama and co-workers have reported preliminary results - especially concerning barbiturates - with immunohistological methods [25]. (cl Postmortem serology. For the investigation of the aetiology of the inflammatory liver changes, immunocytological and postmortem serological investigations have proved to be of great help. In more than 50% of 93 serologically-investigated drug deaths, antibodies against the hepatitis-core

Fig. 6. Intravenous

drug abuse and AIDS; cutaneous

Kaposi-sarcoma

(x

380).

232

Fig. 7. Infiltration ( x 100).

Fig. 8. Opportunistic

of cardiac

muscle by Kaposi-sarcoma;

Pneumocystis

carinii pneumonia

34-year-old intravenous

in a HIV-1-positive

drug addict

drug addict ( x 380).

233 A %

............... .~.-.','.'.'.~.'.'.~.~.~.'.'.~ :::_ .~.'.'_'.'.'.'.'.'.'_' .............. ............................ ............... ............. .:.:...:.:::.::.:.:.:.: .. ............................ ............................................... .1:~1::::'~.1::1 _((;;~~~~,.~; -~~:.:.:.:::.:.~.~:::............................................. .............................................. ............... .......................................................................... __, ., ., ,.,.(,.__,.,.,.,._.~.~(; .'.'.'.'.-.'.'_'.'.~.'.'.'.'.' ............... ............... ........................... ............... ..:.:.:.:.:.'~.:.":.:.: .. ........................................... .............. :.:;:::.:::.:;:.: .............. ............... .............. ... . . .. ..I..I..... .. ............. : ................ ............................ ......................... ':::: '.'.'.'.'.'.~.'.'.', ............................. ............... .,.,.,._,~,.,.,., ,.,_.~,., .'.'.'.'.z:' '.'.:'.I'.'z .............. ..:.::.:.:-~:.~':.::I'. ... .......... ............... ............... ........................................... ........ .................................... .................. ........ .(,.,.,.,.( ...................... ..(_ .................................

50 40 30 20 10 -

HBe-Ag

anti-HBe

Fig. 9. Serological hepatitis

HBs-Ag

B markers

anti-HBs

anti-HBc antigen antibody

in 93 drug deaths.

antigen could be demonstrated. More than half of the victims had had contact with hepatitis-B-viruses during their life. The antibodies against HBsantigen that are responsible for immunity protection were present in 42% of the cases (sec Fig. 91. The HBs-Ag was detected in five cases [24]. Drug addicts are a risk group for HIV-infection and AIDS [26-281. Therefore the drug death, too, is increasingly connected with the problem of AIDS [28,29]. In Hamburg, since 1985, we have examined al1 drug deaths serologically. The findings of Elisa, IFT and Westernblot are very reliable and reproducible in postmortem samples (sec Fig. 101. Among the drug deaths in Hamburg in recent years approximately lO20% were HIV-infected [28]. With the advent of HIV-infections, the morphological findings in drug deaths have widened enormously [29,30]. The final stage of AIDS can be characterised by a lymphadenopathy-syndrome, Kaposi-sarcoma or Pneumocystis cdnii pneumonia, etc (sec Figs. 6-81.

1985

1986

Fig. 10. Drug deaths: development

1987

of HIV-1-prevalente

in Hamburg and Berlin.

234

(al Toxicology. Toxicological investigations in al1 suspected drug deaths are indispensable and mostly decisive for the evaluation of the cause of death. In the F.R.G. the forensic toxicological investigations are not centralized. They are conducted by regional laboratories. Toxicological investigations in Hamburg are carried out only in the laboratories of the Institute for Forensic Medicine of the University. The evaluation of every single drug death should be established by close cooperation between the forensic pathologist and the toxicologist. The spectrum of lethal morphine concentrations in the blood of the corpse is quite wide. The lethal concentration depends on the individual disposition of the drug addict. Quite often relatively low doses are found in the blood and urine of the dead drug addict. The term “overdose” is very relative and depends on actual susceptibility. Death sometimes occurs in spite of low doses in the blood and urine after periods of longer abstinente, e.g. in prison, or by interaction with other substances, e.g. alcohol or drugs or after surviva1 periods in a comatose stage. When the drug victims were “clean” before their death, a smal1 amount can be lethal even if the same dose had been tolerated earlier. The percentage of acute intoxications by heroin in Hamburg has been steadily increasing. In 1987 approximately 70-800/6 of the drug deaths died of intoxication with heroin. Mixed intoxication, especially with alcohol, barbiturates and benzodiazepines, form the next largest group. The situation in Hamburg reflects the situation for the F.R.G. as a whole. Deaths from cocaine - mostly after intravenous injections - are relatively rare (sec Fig. 111. Special investigations are required for the proof of opiates in the mucous

100% m Heroin EB Cocaine lZ3 Barbiturates m Polytoxicomania EZ Heroin-alcohol 0 Suicide/accident Other

1983 Fig.

1984

1985

. Drug deaths in Hamburg (1983- 1987); toxica logica1 findings.

235

membrane of the nose in case of “snorting” and in the hair to prove longtime abuse. The mucous membrane of the nose should be examined for a chronic granulomatous rhinitis and for traces of heroin [31]. The hair wil1 be subjected to toxicological investigations for heroin from the root to the tip of the hair. From these investigations certain conclusions can be drawn concerning the drug career and the drugs consumed [32]. Conclusions

(11 Every questionable drug death should be subjected to an autopsy and detailed micromorphological, toxicological and serological investigations, which should be performed in close cooperation between morphologists and toxicologists. (21 The corpse is the most important evidente in establishing the cause of death. The investigation of the corpse provides early investigative evidente to assist in tracing the dealer. (31 Detecting the cause of death and the source of the drug are important steps towards the prevention of the drug abuse. (41 Even when the quality of the statistics of drug deaths is questionable, indications of the extent of drug abuse can be found, as wel1 as changing trends in the drug scene. Serological screening can also be useful for the epidemiology of hepatitis and HIV-infections. (51 Drug deaths are, to a certain extent, a parameter of the effectivity of the control programs for drugs, for therapeutic measures and preventive prescribing of drugs. (61 Toxicological investigations very quickly reflect the change of illicit substances in the drug scene. (71 “Supply” for heroin has apparently become so copieus that almost al1 deaths in Hamburg within the last 2 years are caused by heroin intoxication. (81 It is evident that it is difficult to distinguish between drug-induced deaths and deaths among drug addicts. An international agreement about a definition of a drug death is absolutely necessary for nationwide analysis. References 1

2 3 4 5

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