- Email: [email protected]
Hair testing in postmortem diagnosis of substance abuse: An unusual case of slow-release oral morphine abuse in an adolescent
Journal of Forensic and Legal Medicine 36 (2015) 172e176
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Case report
Hair testing in postmortem diagnosis of substance abuse: An unusual case of slow-release oral morphine abuse in an adolescent rie Baillif-Couniou a, *, Pascal Kintz b, Caroline Sastre a, Phak-Rop Pos Pok c, Vale pin d, Georges Leonetti a, e, Anne-Laure Pelissier-Alicot a, e ze d, Gilbert Pe Marjorie Che ^pital de la Timone, Institut de M AP-HM, Ho edecine L egale, 13385 Marseille, France X-Pertise Consulting, 67205 Oberhausbergen, France c INPS, Laboratoire de Police Scientifique, 13245 Marseille, France d Laboratoire TOXLAB, 75018 Paris, France e Aix-Marseille Universit e, 13284 Marseille, France a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2015 Received in revised form 24 August 2015 Accepted 27 August 2015 Available online 4 September 2015
Morphine sulfate misuse is essentially observed among regular heroin injectors. To our knowledge, primary addiction to morphine sulfate is exceptional, especially among young adolescents. A 13-year-old girl, with no history of addiction, was found dead with three empty blisters of Skenan® LP 30 mg at her side. Opiates were detected in biological fluids and hair by chromatographic methods. Blood analyses confirmed morphine overdose (free morphine: 428 ng/mL; total morphine: 584 ng/mL) and segmental hair analysis confirmed regular exposure over several months (maximum morphine concentration 250 pg/mg). Suspecting the victim's mother of recreational use of Skenan®, the magistrate ordered analysis of her hair, with negative results. From an epidemiological viewpoint, this case of oral morphine sulfate abuse in an adolescent with no previous history suggests the emergence of a new trend of morphine sulfate consumption. From a toxicological viewpoint, it demonstrates the value of hair testing, which documented the victim's regular exposure and made an important contribution to the police investigation. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Slow-release oral morphine Overdose Adolescent Addictions Hair analysis
1. Introduction Morphine sulfate is a schedule II opioid under the most recent Controlled Substances Act.1 In France, morphine sulfate is regulated as a narcotic and prescribed using a special form for a maximum period of 28 days.2 It is marketed under parenteral forms, immediate-release oral forms and slow-release oral forms (slow-release oral morphine or SROM), which are all indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. As SROM appears to reduce craving and depressive symptoms, its effectiveness as maintenance therapy for opioid dependence is under debate.2,3 In some European countries and Australia, SROM is prescribed as an alternative to methadone maintenance treatment in patients who do not tolerate methadone or with inadequate withdrawal
* Corresponding author. Tel.: þ33 04 91 32 45 16; fax: þ33 04 91 32 45 12. E-mail address: [email protected] (V. Baillif-Couniou).
suppression.4e6 In France, SROM can be prescribed in cases of methadone and buprenorphine failure or contra-indications to these substances, when authorized by the medical officer of the health insurance system.7 But according to the recent Cochrane systematic review, evidence of the effectiveness of SROM for opioid maintenance is insufficient.3 While the quality of life of patients treated with SROM does not significantly differ from that of those treated with methadone or buprenorphine, side effects (nausea, headache, constipation, insomnia) are more frequent with SROM. Morphine misuse or abuse is a well-known problem. The effects sought are close to those of heroin: to obtain a high and a sensation of wellbeing.8 Intravenous and nasal routes are the most common ways of administration.8 In most cases, morphine sulfate is consumed by heroin injectors and polydrug users with a long history of drug abuse.6,8 Primary consumption is uncommon. Most users are adults who were prescribed SROM for long periods, or healthcare professionals.9,10 Cases involving very young adolescents appear to be exceptional.
http://dx.doi.org/10.1016/j.jflm.2015.08.014 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
In addition, in this case hair testing had a particularly important impact on the course of the police investigation, as it both established the innocence of the victim's mother and led to the dismantling of a drug-trafficking ring. 2. Case report A 13-year-old girl was found unconscious on the living room sofa by her mother, who called the emergency services at 6.30 pm. The emergency services found the girl in cardiopulmonary arrest. Resuscitation attempts were unsuccessful and death was pronounced at 7.00 pm. According to the mother, the girl had complained of abdominal pain in the morning and had taken a tablet, of which the mother knew neither the name nor the source, in the early afternoon. She then fell deeply asleep and her mother tried to wake her at 6.15 pm. The victim was not receiving any treatment, and according to the mother she had no known history of addictive disorder or suicidal intent. One capsule and three empty blisters of Skenan LP® 30 mg were found at the girl's side. Careful search of the apartment revealed no other blisters of Skenan LP® or any other opioid. The mother stated that no family member was treated with the drug, and this was confirmed by the family doctor when questioned by police. The autopsy was carried out the next day and revealed only pulmonary and brain edema. There were no visible injection sites. Specimens were taken for conventional toxicological analysis: heart and femoral blood with NaF 1% as preservative, gastric content, vitreous humor and urine. At the beginning of autopsy, four 32-cm brown hair strands were collected from the posterior vertex region of the scalp. Specimens were stored at þ4 C until analysis, except the hair strands which were stored at room temperature. Suspecting the mother of consuming Skenan® for recreational purposes, the magistrate ordered analysis of her hair. A 30-cm brown hair strand was collected from the posterior vertex region. 3. Materials and methods Alcohols (ethanol, 1-propanol, acetone, isopropanol, butanol) were analyzed by gas chromatography with head space injection and flame ionization detector (HS-GC/FID) in femoral blood, urine and vitreous humor. Urinary screening was done by immunochromatography (Nal Von Minden GmbH, Regensburg, Germany) for opioids, amphetamines, cannabinoids, cocaine, methadone, benzodiazepines, antidepressants and barbiturates. Cardiac blood was screened for drugs of abuse (including opioids, amphetamines and other hallucinogens, cannabinoids, cocaine, GHB/GBL, solvents and benzodiazepines) and pharmaceuticals by routine procedures including liquid chromatography coupled with a diode array detector (HPLC-DAD) and gas chromatography coupled with mass spectrometry (GC-MS). 3.1. Determination of opiates in biological fluids Opiates (morphine, codeine, diacetylmorphine, 6monoacetylmorphine, pholcodine and ethylmorphine) were measured in femoral blood, gastric content and urine by GC-MS. Morphine and morphine-d3 (as internal standard, IS) were obtained from LGC Standards (Molsheim, France). b-Glucuronidase from bovine liver, type B-1, was obtained from SigmaeAldrich (Saint-Quentin-Fallavier, France). Stock solutions of morphine and morphine-d3 were prepared in methanol at 1 mg/mL and stored at 20 C. The working solutions were diluted with methanol before use for preparation of calibration standards.
173
For determination of free morphine, 50 mL of IS at 1 ng/mL, 1 mL of dipotassium phosphate 1 M (pH 8.4) and 3 mL of chloroform/ isopropanol (95:5, v/v) were added to 1 mL of the specimen to be analyzed. The mixture was shaken for 10 min and centrifuged at 3000 rpm for 3 min. The organic phase was removed and evaporated to dryness under nitrogen. The residue was dissolved in 50 mL of trimethylsilyl (TMS) and heated for 20 min at 70 C. After cooling, an aliquot of this solution (1 mL) was injected into the GC-MS. For determination of total morphine, 1 mL of the specimen to be analyzed was incubated at 60 C for 24 h with 1 mL of acetate buffer (pH 5) containing 30,000 U of b-glucuronidase, and then treated as described for the free fraction. The amount of conjugated morphine (morphine glucuronide) was evaluated by calculating the difference between total and free morphine. The chromatographic conditions have been previously described.11 The retention time (rt) and fragment ions for identification (m/z) were as follows: morphine (rt: 12.45 min, m/z: 429, 414, 401) and morphine-d3 (rt: 12.42 min, m/z: 432, 417, 404). 3.2. Determination of opiates in hair The 32-cm hair strands of the victim were cut into five segments. The first four segments measured 6 cm each, the last 8 cm. The period analyzed extended from June 2008 to January 2011. The hair strand of the mother was cut into three segments of 3 cm each. The period analyzed extended from April 2009 to October 2011. The distal segment (21 cm) was not analyzed. Opiates were determined in hair by liquid chromatographytandem mass spectrometry (LC-MS/MS) after triple liquideliquid extraction as follows: each hair segment was washed in methanol and then in dichloromethane. Twenty mg of finely cut hair was weighed. IS was added together with 1 mL of HCl 0.1 M for incubation overnight at 56 C. Phosphate buffer pH 8.4 was added for neutralization and alkaline extraction with dichloromethane-isopropanol-heptane. The organic phase was then acidified with HCl 0.2 M for a second extraction. The aqueous phase was isolated and NaOH 1 M and saturated phosphate buffer pH 8.4 were added for a third extraction with dichloromethane. The final organic phase was evaporated and diluted with formiate buffer 2 mM pH 3.0 for injection onto LC-MS/MS apparatus (TSQ Quantum, Thermo Fisher Scientific Inc., Villebon-sur-Yvette, Courtaboeuf, France). The following ions were used: morphine: parent ion m/z 286.1 and daughter ions m/z 152, 153, 181; morphine-d3: parent ion m/z 289.1 and daughter ions m/z 152, 153, 181. 4. Results 4.1. Toxicological analysis Toxicological analysis showed the presence of morphine in all specimens. Morphine concentrations in the victim's biological fluids are shown in Table 1. It is important to note that only morphine was identified in these specimens, and testing for other
Table 1 Morphine concentrations in the victim's biological fluids.
Unconjugated morphine Total morphine Conjugated morphine
Femoral blood (ng/mL)
Urine (ng/mL)
Gastric content (ng/mL)
428 584 156
11,500 13,800 2330
87,750 Unavailable Unavailable
174
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
opioids, codeine in particular, was negative. Other analyses (testing for alcohols, other drugs and medications) were also negative. Hair analysis (Table 2) demonstrated low but regular morphine consumption for two and a half years. All three segments of the mother's hair tested negative for opiates. 4.2. Police investigations As hair testing had exonerated the mother, further investigations were carried out by the police. Firstly, neighborhood and school friends were questioned, with negative results. Secondly, the company (Bristol Myers) that markets the drug involved identified the wholesaler (Alliance Healthcare) from batch numbers and barcodes of tablets seized at the victim's home. This in turn led to identification of the dispensing pharmacists and prescriptions. The batches concerned had been commercialized between March 2009 and February 2011. A total of 40 boxes had been delivered by 3 pharmacies near where the victim lived. The prescriptions were identified and had been issued to 5 patients treated in the local cancer center. They were regular and not falsified or stolen, but were delivered to patients living in the same apartment blocks as the victim. Further police investigation ascertained that children of these patients had taken the pills to supply their friends since the beginning of 2009. The perpetrators of the drug trafficking had confirmed that the victim had occasionally consumed SROM for several months. However, in view of the results of the hair testing, it is highly probable that the victim had used other sources of supply before 2009 (repeated dealing, gifts etc). Statements by persons close to the victim indicated that her behavior had changed since the death of her father a few years previously. Finally, these investigations led to the dismantling of a Skenan LP® trafficking ring organized by teenagers in the victim's neighborhood, and confirmed her regular consumption of SROM. 5. Discussion Free and total morphine concentrations were high in the victim's femoral blood, suggesting a morphine overdose.12 The femoral blood free/total morphine ratio was higher than 0.5, which supports the view of a short agony, less than 4 h.12e14 Free morphine concentration in the gastric content was high. As the gastric content volume measured during the autopsy was 200 mL, the absolute amount of free morphine was 17.55 mg. These results are in favor of an absorption by an oral route, as the concentration seems to be too high to be attributed to a postmortem redistribution phenomenon, and confirms the short agony. The absence of codeine, a degradation product of morphine, confirms this notion. Hair analysis demonstrated that morphine consumption had been low but regular for two and a half years. Even if morphine tolerance cannot be excluded as the victim had consumed the drug for several months, the death was officially attributed to morphine overdose. Morphine abuse is an old problem, but strict control of prescriptions and the emergence of sustained-release forms have changed the consumer profile. In France, slow-release formulations
seem to be more commonly diverted than the immediate-release forms,6,8 probably because of their high drug load,15 while in the United States the immediate-release oral forms seem to be in greater demand, after oxycodone and hydrocodone.15e17 In France, two different formulations are available; one (Skenan LP®), formulated in easily soluble capsules, is more commonly diverted than the other (Moscontin®), which is formulated as coated tablets.6 Intravenous injection is the predominant route of administration, followed by the oral and intranasal routes.6,8 The availability of the product on the street market is low, due to strict application of the narcotics regulations. Morphine sulfate is acquired by doctor's prescription, drug dealing, as a gift, by “doctor shopping” and forged prescriptions.6 Most often, consumers are former heroin injectors, aged over 30 years, polydrug users, with a long history of drug abuse, and living in an urban environment. The most frequently coingested drugs are benzodiazepines, cannabis and cocaine.6 SROM abuse is also described in buprenorphine injectors, younger than the previous group (18e35 years old) and living in precarious circumstances.8 Morphine sulfate abuse in subjects without a history of addiction is far less common and generally concerns adults treated with analgesic opioids, or health professionals with easy access to the product.8,10 To the best of our knowledge, SROM misuse by young adolescent population has not been previously described. In an American series of 16,209 adolescents aged 13 to 18 who abused prescription drugs, opioids accounted for 68% and stimulants for 32%. The most commonly consumed drug was hydrocodone, with immediaterelease morphine coming only in sixth position. The molecules most frequently involved in fatal cases were methadone and oxycodone, no deaths being reported with morphine. The average age of consumers was 16.6 ± 1.7 years and median age was 17 years. Girls outnumbered boys (52.5% vs 47.5%). In 51.6% of cases, several substances were taken in combination. In 86.3% of cases, drugs were consumed at the teenager's home. Age at onset of consumption or modalities and motivations of consumption were not specified in this study. Friends and family members appeared to be the most common source of drugs.18 According to McCabe et al., most prescription opioid use among adolescents was associated with pain relief.19 In the case reported here, the young victim consumed only SROM. Her drug misuse did not begin with a personal prescription, but she was introduced to recreational use by other teenagers. Her young age supports the hypothesis of a recreational use. Hair analysis was of great value in this case, as segmental analysis of the victim's hair established the regular misuse or abuse of morphine. The major advantage of hair testing compared with blood or urine testing is a larger detection window (weeks to months), depending on the length of the hair shaft.20 Hair is a unique material for retrospective investigation of chronic drug use. It is useful in addictology for diagnosis of history of drug abuse or relapse. It is used for monitoring patients in maintenance programs.21e23 It can demonstrate addictive behaviors among anesthesiologists abusing opioids, fentanyl, sufentanyl, propofol, midazolam or ketamine at low concentrations, for which it is extremely difficult to obtain positive blood and/or urine specimens.24,25 It can validate or invalidate self-reported drug use, especially in prison inmates or suspects.26 It has also been used to
Table 2 Morphine concentrations in the victim's hair segments.
Morphine (pg/mg)
Segment 1 01/2011 to 08/2010 (6 cm)
Segment 2 07/2010 to 02/2010 (6 cm)
Segment 3 01/2010 to 08/2009 (6 cm)
Segment 4 07/2009 to 02/2009 (6 cm)
Segment 5 02/2009 to 06/2008 (8 cm)
131
187
163
250
186
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
ascertain in utero drug exposure and in workplace drug testing.27e29 In postmortem cases, it is the only way to determine a history of drug abuse, since the family environment is often unaware of the victim's addictive behavior, as in this case. Hair analysis can be useful in understanding the circumstances of death30 and can also help in interpretation of blood concentrations when the naive or tolerant status of the victim is not known.20,29 However, it is important to be aware that the interpretation of concentrations in hair has some limitations. Drug incorporation in hair presents interindividual variations related to ethnicity,31 melanin affinity,32 growth rate33 and length of the quiescent period.34 Cosmetic treatments should also be considered. Whereas shampooing causes only a slight decrease in drug concentrations, perming, bleaching and dyeing can cause a partial loss of drug substances from the hair.35 For these reasons, ingested doses cannot be correlated with hair concentrations with certainty. Contamination from environmental pollution or after drug incorporation into the hair from individual body fluids, such as sweat during agony or putrefactive fluids after death, has to be taken into account.36 These contaminations appear to be difficult to remove, even after standard decontamination procedures. The best indicator to discriminate between external contamination and long-term exposure seems to be the concentration profile in the different segments that could have been contaminated by this way. Very homogeneous results after segmental analyses may be an indicator of external contamination.36 In our case, this possibility can be excluded: autopsy was performed the next day and the hairs were sampled at the beginning of the autopsy in order to avoid contamination by biological fluids. It is very unlikely that the hair was contaminated. Although the hair root could have been contaminated by sweat, morphine was detected even in segments far from the root. Also, the concentrations measured differed between segments. From an analytical point of view, the technique used (LC/MS-MS), which is currently the gold standard for hair testing, yields excellent performances in terms of sensitivity and specificity. However, the procedures are time-consuming, complex and require a certain number of specimens, which can raise difficulties in postmortem analyses. New screening techniques with excellent specificity and satisfactory sensitivity (and which allow re-use of the extraction solution for confirmation, thus requiring fewer specimens) could be used subject to improvement where certain molecules such as amphetamine or cocaine derivatives are concerned.37 Further police investigations led to the dismantling of morphine sulfate trafficking among acquaintances of the victim and confirmed the results of hair analysis. Lastly, hair analysis exonerated the mother who had been suspected of using Skenan LP® at home for her own consumption. In conclusion, this report underlines the value of hair testing in medicolegal investigation and retrospective diagnosis of substance misuse and abuse. Conflict of interest The authors declare « Conflicts of interest: none ». Funding None. Ethical approval None required. Competing interests The authors declare that they have no competing interests.
175
References 1. http://www.justice.gov/dea/pr/multimedia-library/publications/drug_of_abuse. pdf [accessed 10.04.15]. 2. Jegu J, Gallini A, Soler P, Montastruc JL, Lapeyre-Mestre M. Slow-release oral morphine for opioid maintenance treatment: a systematic review. Br J Clin Pharmacol 2011;71:832e43. 3. Ferri M, Minozzi S, Bo A, Amato L. Slow-release oral morphine as maintenance therapy for opioid dependence (review). Cochrane Database Syst Rev 2013;6:1e28. 4. Kastelic A, Dubajic G, Strbad E. Slow-release oral morphine for maintenance treatment of opioid addicts intolerant to methadone or with inadequate withdrawal suppression. Addiction 2008;103:1837e46. 5. Bond AJ, Reed KD, Beavan P, Strang J. After the randomised injectable opiate treatment trial: post-trial investigation of slow-release oral morphine as an alternative opiate maintenance medication. Drug Alcohol Rev 2012;31: 492e8. 6. Peyriere H, Eiden C, Micallef J, Lapeyre-Mestre M. Slow-release oral morphine sulfate abuse: results of the postmarketing surveillance systems for psychoactive prescription drug abuse in France. Eur Addict Res 2013;19:235e44. 7. pmb.ofdt.fr/pmb_documents/LEGI/224.pdf [accessed 10.04.15]. 8. http://www.ofdt.fr/ofdtdev/live/publi/rapports/rap10/epfxacq1.html [accessed 10.04.15]. 9. Pauly V, Pradel V, Pourcel L, Nordmann S, Frauger E, Lapeyre-Mestre M, et al. Estimated magnitude of diversion and abuse of opioids relative to benzodiazepines in France. Drug Alcohol Depend 2012;126:13e20. 10. Merlo LJ, Trejo-Lopez J, Conwell T, Rivenbark J. Patterns of substance use initiation among healthcare professionals in recovery. Am J Addict 2013;22: 605e12. ger MN, Kuhlmann E, Charpenel-Durat C, 11. Pok PR, Mauras M, De Saint Le Navarette C, et al. Blood concentrations of clobazam and norclobazam in a lethal case involving clobazam, meprobamate and clorazepate. Leg Med (Tokyo) 2010;12:300e4. 12. Rees KA, Pounder DJ, Osselton MD. Distribution of opiates in femoral blood and vitreous humour after heroin/morphine-related deaths. Forensic Sci Int 2013;226:152e9. 13. Staub C, Jeanmonod R, Fryc O. Morphine in postmortem blood: its importance for the diagnosis of deaths associated with opiate addiction. Int J Leg Med 1990;104:39e42. 14. Burt MJ, Kloss J, Apple FS. Post-mortem blood free and total morphine concentrations in medical examiner cases. J Forensic Sci 2001;46:1138e42. 15. Kirsh K, Peppin J, Coleman J. Characterization of prescription opioid abuse in the United States: focus on route of administration. J Pain Palliat Care Pharmacother 2012;26:348e61. 16. Butler SF, Black RA, Cassidy TA, Dailey TM, Budman SH. Abuse risks and routes of administration of different prescription opioid compounds and formulations. Harm Reduct J 2011;8:29e46. 17. Lankenau SE, Teti M, Silva K, Jackson Bloom J, Harocopos A, Treese M. Initiation into prescription opioid misuse among young injection drug users. Int J Drug Policy 2012;23:37e44. 18. Zosel A, Bartelson BB, Bailey E, Lowenstein S, Dart R. Characterization of adolescent prescription drug abuse and misuse using the Researched Abuse Diversion and Addiction-related Surveillance (RADARS®) System. J Am Acad Child Adolesc Psychiatry 2013;52:196e204. 19. McCabe SE, West BT, Boyd CJ. Motives for medical misuse of prescription opioids among adolescents. J Pain 2013;14:1208e16. 20. Kintz P. Value of hair analysis in postmortem toxicology. Forensic Sci Int 2004;142:127e34. 21. Koster RA, Alffenaar JW, Greijdanus B, VanDernagel JE, Uges DR. Fast and highly selective LC-MS/MS screening for THC and 16 other abused drugs and metabolites in human hair to monitor patients for drug abuse. Ther Drug Monit 2014;36:234e43. 22. Musshoff F, Lachenmeier K, Wollersen H, Lichtermann D, Madea B. Opiate concentrations in hair from subjects in a controlled heroin-maintenance program and from opiate-associated fatalities. J Anal Toxicol 2005;29:345e52. 23. Musshoff F, Lachenmeier K, Lichtermann D, Madea B. Cocaine and opiate concentrations in hair from subjects in a heroin maintenance program in comparison to a methadone substituted group. Int J Leg Med 2009;123:363e9. 24. Kintz P, Villain M, Dumestre V, Cirimele V. Evidence of addiction by anesthesiologists as documented by hair analysis. Forensic Sci Int 2005;153:81e4. 25. Gold MS, Melker RJ, Dennis DM, Morey TE, Bajpai LK, Pomm R, et al. Fentanyl abuse and dependence: further evidence for second hand exposure hypothesis. J Addict Dis 2006;5:15e21. 26. Vignali C, Stramesi C, Vecchio B, Groppi A. Hair testing and self-report of cocaine use. Forensic Sci Int 2012;215:77e80. mez-Culebras M, Pichini S, Martinez S, et al. 27. Friguls B, Joya X, Garcia-Serra J, Go Assessment of exposure to drugs of abuse during pregnancy by hair analysis in a Mediterranean island. Addiction 2012;107:1471e91. lez-Colmenero E, Lendoiro E, Concheiro-Guisa n A, de 28. Concheiro M, Gonza Castro A, Cruz-Landeira A, et al. Alternative matrices for cocaine, heroin, and methadone in utero drug exposure detection. Ther Drug Monit 2013;35:502e9. 29. Tsanaclis LM, Wicks JF, Chasin AA. Workplace drug testing, different matrices different objectives. Drug Test Anal 2012;4:83e8. 30. Paterson S, Cordero R, Stearns E. Chronic drug use confirmed by hair analysis: its role in understanding both the medical cause of death and
176
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
the circumstances surrounding the death. J Forensic Leg Med 2009;16: 143e7. 31. Henderson GL, Harkey MR, Zhou C, Jones RT, Jacob P. Incorporation of isotopically labeled cocaine into human hair: race as a factor. J Anal Toxicol 1998;22:156e65. 32. Nakahara Y, Takahashi K, Kikura R. Hair analysis for drugs of abuse. X. Effect of physicochemical properties of drugs on the incorporation rates into hair. Biol Pharm Bull 1995;18:1223e7. 33. LeBeau MA, Montgomery MA, Brewer JD. The role of variations in growth rate and sample collection on interpreting results of segmental analyses of hair. Forensic Sci Int 2011;210:110e6.
34. Kronstrand R, Scott K. Drug incorporation into hair. In: Kintz P, editor. Analytical and practical aspects of drug testing in hair. Boca Raton: CRC Press, Taylor & Francis Group; 2007. p. 1e24. 35. Yegles M. Pitfalls in hair analysis: cosmetic treatment. Ann Tox Anal 2005;17: 275e8. 36. Kintz P. Segmental hair analysis can demonstrate external contamination in postmortem cases. Forensic Sci Int 2012;215:73e6. 37. Baumgartner MR, Guglielmello R, Fanger M, Kraemer T. Analysis of drugs of abuse in hair: evaluation of the immunochemical method VMA-T vs. LC-MS/MS or GC-MS. Forensic Sci Int 2012;215:56e9.
Contents lists available at ScienceDirect
Journal of Forensic and Legal Medicine j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / j fl m
Case report
Hair testing in postmortem diagnosis of substance abuse: An unusual case of slow-release oral morphine abuse in an adolescent rie Baillif-Couniou a, *, Pascal Kintz b, Caroline Sastre a, Phak-Rop Pos Pok c, Vale pin d, Georges Leonetti a, e, Anne-Laure Pelissier-Alicot a, e ze d, Gilbert Pe Marjorie Che ^pital de la Timone, Institut de M AP-HM, Ho edecine L egale, 13385 Marseille, France X-Pertise Consulting, 67205 Oberhausbergen, France c INPS, Laboratoire de Police Scientifique, 13245 Marseille, France d Laboratoire TOXLAB, 75018 Paris, France e Aix-Marseille Universit e, 13284 Marseille, France a
b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 24 April 2015 Received in revised form 24 August 2015 Accepted 27 August 2015 Available online 4 September 2015
Morphine sulfate misuse is essentially observed among regular heroin injectors. To our knowledge, primary addiction to morphine sulfate is exceptional, especially among young adolescents. A 13-year-old girl, with no history of addiction, was found dead with three empty blisters of Skenan® LP 30 mg at her side. Opiates were detected in biological fluids and hair by chromatographic methods. Blood analyses confirmed morphine overdose (free morphine: 428 ng/mL; total morphine: 584 ng/mL) and segmental hair analysis confirmed regular exposure over several months (maximum morphine concentration 250 pg/mg). Suspecting the victim's mother of recreational use of Skenan®, the magistrate ordered analysis of her hair, with negative results. From an epidemiological viewpoint, this case of oral morphine sulfate abuse in an adolescent with no previous history suggests the emergence of a new trend of morphine sulfate consumption. From a toxicological viewpoint, it demonstrates the value of hair testing, which documented the victim's regular exposure and made an important contribution to the police investigation. © 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
Keywords: Slow-release oral morphine Overdose Adolescent Addictions Hair analysis
1. Introduction Morphine sulfate is a schedule II opioid under the most recent Controlled Substances Act.1 In France, morphine sulfate is regulated as a narcotic and prescribed using a special form for a maximum period of 28 days.2 It is marketed under parenteral forms, immediate-release oral forms and slow-release oral forms (slow-release oral morphine or SROM), which are all indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. As SROM appears to reduce craving and depressive symptoms, its effectiveness as maintenance therapy for opioid dependence is under debate.2,3 In some European countries and Australia, SROM is prescribed as an alternative to methadone maintenance treatment in patients who do not tolerate methadone or with inadequate withdrawal
* Corresponding author. Tel.: þ33 04 91 32 45 16; fax: þ33 04 91 32 45 12. E-mail address: [email protected] (V. Baillif-Couniou).
suppression.4e6 In France, SROM can be prescribed in cases of methadone and buprenorphine failure or contra-indications to these substances, when authorized by the medical officer of the health insurance system.7 But according to the recent Cochrane systematic review, evidence of the effectiveness of SROM for opioid maintenance is insufficient.3 While the quality of life of patients treated with SROM does not significantly differ from that of those treated with methadone or buprenorphine, side effects (nausea, headache, constipation, insomnia) are more frequent with SROM. Morphine misuse or abuse is a well-known problem. The effects sought are close to those of heroin: to obtain a high and a sensation of wellbeing.8 Intravenous and nasal routes are the most common ways of administration.8 In most cases, morphine sulfate is consumed by heroin injectors and polydrug users with a long history of drug abuse.6,8 Primary consumption is uncommon. Most users are adults who were prescribed SROM for long periods, or healthcare professionals.9,10 Cases involving very young adolescents appear to be exceptional.
http://dx.doi.org/10.1016/j.jflm.2015.08.014 1752-928X/© 2015 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
In addition, in this case hair testing had a particularly important impact on the course of the police investigation, as it both established the innocence of the victim's mother and led to the dismantling of a drug-trafficking ring. 2. Case report A 13-year-old girl was found unconscious on the living room sofa by her mother, who called the emergency services at 6.30 pm. The emergency services found the girl in cardiopulmonary arrest. Resuscitation attempts were unsuccessful and death was pronounced at 7.00 pm. According to the mother, the girl had complained of abdominal pain in the morning and had taken a tablet, of which the mother knew neither the name nor the source, in the early afternoon. She then fell deeply asleep and her mother tried to wake her at 6.15 pm. The victim was not receiving any treatment, and according to the mother she had no known history of addictive disorder or suicidal intent. One capsule and three empty blisters of Skenan LP® 30 mg were found at the girl's side. Careful search of the apartment revealed no other blisters of Skenan LP® or any other opioid. The mother stated that no family member was treated with the drug, and this was confirmed by the family doctor when questioned by police. The autopsy was carried out the next day and revealed only pulmonary and brain edema. There were no visible injection sites. Specimens were taken for conventional toxicological analysis: heart and femoral blood with NaF 1% as preservative, gastric content, vitreous humor and urine. At the beginning of autopsy, four 32-cm brown hair strands were collected from the posterior vertex region of the scalp. Specimens were stored at þ4 C until analysis, except the hair strands which were stored at room temperature. Suspecting the mother of consuming Skenan® for recreational purposes, the magistrate ordered analysis of her hair. A 30-cm brown hair strand was collected from the posterior vertex region. 3. Materials and methods Alcohols (ethanol, 1-propanol, acetone, isopropanol, butanol) were analyzed by gas chromatography with head space injection and flame ionization detector (HS-GC/FID) in femoral blood, urine and vitreous humor. Urinary screening was done by immunochromatography (Nal Von Minden GmbH, Regensburg, Germany) for opioids, amphetamines, cannabinoids, cocaine, methadone, benzodiazepines, antidepressants and barbiturates. Cardiac blood was screened for drugs of abuse (including opioids, amphetamines and other hallucinogens, cannabinoids, cocaine, GHB/GBL, solvents and benzodiazepines) and pharmaceuticals by routine procedures including liquid chromatography coupled with a diode array detector (HPLC-DAD) and gas chromatography coupled with mass spectrometry (GC-MS). 3.1. Determination of opiates in biological fluids Opiates (morphine, codeine, diacetylmorphine, 6monoacetylmorphine, pholcodine and ethylmorphine) were measured in femoral blood, gastric content and urine by GC-MS. Morphine and morphine-d3 (as internal standard, IS) were obtained from LGC Standards (Molsheim, France). b-Glucuronidase from bovine liver, type B-1, was obtained from SigmaeAldrich (Saint-Quentin-Fallavier, France). Stock solutions of morphine and morphine-d3 were prepared in methanol at 1 mg/mL and stored at 20 C. The working solutions were diluted with methanol before use for preparation of calibration standards.
173
For determination of free morphine, 50 mL of IS at 1 ng/mL, 1 mL of dipotassium phosphate 1 M (pH 8.4) and 3 mL of chloroform/ isopropanol (95:5, v/v) were added to 1 mL of the specimen to be analyzed. The mixture was shaken for 10 min and centrifuged at 3000 rpm for 3 min. The organic phase was removed and evaporated to dryness under nitrogen. The residue was dissolved in 50 mL of trimethylsilyl (TMS) and heated for 20 min at 70 C. After cooling, an aliquot of this solution (1 mL) was injected into the GC-MS. For determination of total morphine, 1 mL of the specimen to be analyzed was incubated at 60 C for 24 h with 1 mL of acetate buffer (pH 5) containing 30,000 U of b-glucuronidase, and then treated as described for the free fraction. The amount of conjugated morphine (morphine glucuronide) was evaluated by calculating the difference between total and free morphine. The chromatographic conditions have been previously described.11 The retention time (rt) and fragment ions for identification (m/z) were as follows: morphine (rt: 12.45 min, m/z: 429, 414, 401) and morphine-d3 (rt: 12.42 min, m/z: 432, 417, 404). 3.2. Determination of opiates in hair The 32-cm hair strands of the victim were cut into five segments. The first four segments measured 6 cm each, the last 8 cm. The period analyzed extended from June 2008 to January 2011. The hair strand of the mother was cut into three segments of 3 cm each. The period analyzed extended from April 2009 to October 2011. The distal segment (21 cm) was not analyzed. Opiates were determined in hair by liquid chromatographytandem mass spectrometry (LC-MS/MS) after triple liquideliquid extraction as follows: each hair segment was washed in methanol and then in dichloromethane. Twenty mg of finely cut hair was weighed. IS was added together with 1 mL of HCl 0.1 M for incubation overnight at 56 C. Phosphate buffer pH 8.4 was added for neutralization and alkaline extraction with dichloromethane-isopropanol-heptane. The organic phase was then acidified with HCl 0.2 M for a second extraction. The aqueous phase was isolated and NaOH 1 M and saturated phosphate buffer pH 8.4 were added for a third extraction with dichloromethane. The final organic phase was evaporated and diluted with formiate buffer 2 mM pH 3.0 for injection onto LC-MS/MS apparatus (TSQ Quantum, Thermo Fisher Scientific Inc., Villebon-sur-Yvette, Courtaboeuf, France). The following ions were used: morphine: parent ion m/z 286.1 and daughter ions m/z 152, 153, 181; morphine-d3: parent ion m/z 289.1 and daughter ions m/z 152, 153, 181. 4. Results 4.1. Toxicological analysis Toxicological analysis showed the presence of morphine in all specimens. Morphine concentrations in the victim's biological fluids are shown in Table 1. It is important to note that only morphine was identified in these specimens, and testing for other
Table 1 Morphine concentrations in the victim's biological fluids.
Unconjugated morphine Total morphine Conjugated morphine
Femoral blood (ng/mL)
Urine (ng/mL)
Gastric content (ng/mL)
428 584 156
11,500 13,800 2330
87,750 Unavailable Unavailable
174
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
opioids, codeine in particular, was negative. Other analyses (testing for alcohols, other drugs and medications) were also negative. Hair analysis (Table 2) demonstrated low but regular morphine consumption for two and a half years. All three segments of the mother's hair tested negative for opiates. 4.2. Police investigations As hair testing had exonerated the mother, further investigations were carried out by the police. Firstly, neighborhood and school friends were questioned, with negative results. Secondly, the company (Bristol Myers) that markets the drug involved identified the wholesaler (Alliance Healthcare) from batch numbers and barcodes of tablets seized at the victim's home. This in turn led to identification of the dispensing pharmacists and prescriptions. The batches concerned had been commercialized between March 2009 and February 2011. A total of 40 boxes had been delivered by 3 pharmacies near where the victim lived. The prescriptions were identified and had been issued to 5 patients treated in the local cancer center. They were regular and not falsified or stolen, but were delivered to patients living in the same apartment blocks as the victim. Further police investigation ascertained that children of these patients had taken the pills to supply their friends since the beginning of 2009. The perpetrators of the drug trafficking had confirmed that the victim had occasionally consumed SROM for several months. However, in view of the results of the hair testing, it is highly probable that the victim had used other sources of supply before 2009 (repeated dealing, gifts etc). Statements by persons close to the victim indicated that her behavior had changed since the death of her father a few years previously. Finally, these investigations led to the dismantling of a Skenan LP® trafficking ring organized by teenagers in the victim's neighborhood, and confirmed her regular consumption of SROM. 5. Discussion Free and total morphine concentrations were high in the victim's femoral blood, suggesting a morphine overdose.12 The femoral blood free/total morphine ratio was higher than 0.5, which supports the view of a short agony, less than 4 h.12e14 Free morphine concentration in the gastric content was high. As the gastric content volume measured during the autopsy was 200 mL, the absolute amount of free morphine was 17.55 mg. These results are in favor of an absorption by an oral route, as the concentration seems to be too high to be attributed to a postmortem redistribution phenomenon, and confirms the short agony. The absence of codeine, a degradation product of morphine, confirms this notion. Hair analysis demonstrated that morphine consumption had been low but regular for two and a half years. Even if morphine tolerance cannot be excluded as the victim had consumed the drug for several months, the death was officially attributed to morphine overdose. Morphine abuse is an old problem, but strict control of prescriptions and the emergence of sustained-release forms have changed the consumer profile. In France, slow-release formulations
seem to be more commonly diverted than the immediate-release forms,6,8 probably because of their high drug load,15 while in the United States the immediate-release oral forms seem to be in greater demand, after oxycodone and hydrocodone.15e17 In France, two different formulations are available; one (Skenan LP®), formulated in easily soluble capsules, is more commonly diverted than the other (Moscontin®), which is formulated as coated tablets.6 Intravenous injection is the predominant route of administration, followed by the oral and intranasal routes.6,8 The availability of the product on the street market is low, due to strict application of the narcotics regulations. Morphine sulfate is acquired by doctor's prescription, drug dealing, as a gift, by “doctor shopping” and forged prescriptions.6 Most often, consumers are former heroin injectors, aged over 30 years, polydrug users, with a long history of drug abuse, and living in an urban environment. The most frequently coingested drugs are benzodiazepines, cannabis and cocaine.6 SROM abuse is also described in buprenorphine injectors, younger than the previous group (18e35 years old) and living in precarious circumstances.8 Morphine sulfate abuse in subjects without a history of addiction is far less common and generally concerns adults treated with analgesic opioids, or health professionals with easy access to the product.8,10 To the best of our knowledge, SROM misuse by young adolescent population has not been previously described. In an American series of 16,209 adolescents aged 13 to 18 who abused prescription drugs, opioids accounted for 68% and stimulants for 32%. The most commonly consumed drug was hydrocodone, with immediaterelease morphine coming only in sixth position. The molecules most frequently involved in fatal cases were methadone and oxycodone, no deaths being reported with morphine. The average age of consumers was 16.6 ± 1.7 years and median age was 17 years. Girls outnumbered boys (52.5% vs 47.5%). In 51.6% of cases, several substances were taken in combination. In 86.3% of cases, drugs were consumed at the teenager's home. Age at onset of consumption or modalities and motivations of consumption were not specified in this study. Friends and family members appeared to be the most common source of drugs.18 According to McCabe et al., most prescription opioid use among adolescents was associated with pain relief.19 In the case reported here, the young victim consumed only SROM. Her drug misuse did not begin with a personal prescription, but she was introduced to recreational use by other teenagers. Her young age supports the hypothesis of a recreational use. Hair analysis was of great value in this case, as segmental analysis of the victim's hair established the regular misuse or abuse of morphine. The major advantage of hair testing compared with blood or urine testing is a larger detection window (weeks to months), depending on the length of the hair shaft.20 Hair is a unique material for retrospective investigation of chronic drug use. It is useful in addictology for diagnosis of history of drug abuse or relapse. It is used for monitoring patients in maintenance programs.21e23 It can demonstrate addictive behaviors among anesthesiologists abusing opioids, fentanyl, sufentanyl, propofol, midazolam or ketamine at low concentrations, for which it is extremely difficult to obtain positive blood and/or urine specimens.24,25 It can validate or invalidate self-reported drug use, especially in prison inmates or suspects.26 It has also been used to
Table 2 Morphine concentrations in the victim's hair segments.
Morphine (pg/mg)
Segment 1 01/2011 to 08/2010 (6 cm)
Segment 2 07/2010 to 02/2010 (6 cm)
Segment 3 01/2010 to 08/2009 (6 cm)
Segment 4 07/2009 to 02/2009 (6 cm)
Segment 5 02/2009 to 06/2008 (8 cm)
131
187
163
250
186
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
ascertain in utero drug exposure and in workplace drug testing.27e29 In postmortem cases, it is the only way to determine a history of drug abuse, since the family environment is often unaware of the victim's addictive behavior, as in this case. Hair analysis can be useful in understanding the circumstances of death30 and can also help in interpretation of blood concentrations when the naive or tolerant status of the victim is not known.20,29 However, it is important to be aware that the interpretation of concentrations in hair has some limitations. Drug incorporation in hair presents interindividual variations related to ethnicity,31 melanin affinity,32 growth rate33 and length of the quiescent period.34 Cosmetic treatments should also be considered. Whereas shampooing causes only a slight decrease in drug concentrations, perming, bleaching and dyeing can cause a partial loss of drug substances from the hair.35 For these reasons, ingested doses cannot be correlated with hair concentrations with certainty. Contamination from environmental pollution or after drug incorporation into the hair from individual body fluids, such as sweat during agony or putrefactive fluids after death, has to be taken into account.36 These contaminations appear to be difficult to remove, even after standard decontamination procedures. The best indicator to discriminate between external contamination and long-term exposure seems to be the concentration profile in the different segments that could have been contaminated by this way. Very homogeneous results after segmental analyses may be an indicator of external contamination.36 In our case, this possibility can be excluded: autopsy was performed the next day and the hairs were sampled at the beginning of the autopsy in order to avoid contamination by biological fluids. It is very unlikely that the hair was contaminated. Although the hair root could have been contaminated by sweat, morphine was detected even in segments far from the root. Also, the concentrations measured differed between segments. From an analytical point of view, the technique used (LC/MS-MS), which is currently the gold standard for hair testing, yields excellent performances in terms of sensitivity and specificity. However, the procedures are time-consuming, complex and require a certain number of specimens, which can raise difficulties in postmortem analyses. New screening techniques with excellent specificity and satisfactory sensitivity (and which allow re-use of the extraction solution for confirmation, thus requiring fewer specimens) could be used subject to improvement where certain molecules such as amphetamine or cocaine derivatives are concerned.37 Further police investigations led to the dismantling of morphine sulfate trafficking among acquaintances of the victim and confirmed the results of hair analysis. Lastly, hair analysis exonerated the mother who had been suspected of using Skenan LP® at home for her own consumption. In conclusion, this report underlines the value of hair testing in medicolegal investigation and retrospective diagnosis of substance misuse and abuse. Conflict of interest The authors declare « Conflicts of interest: none ». Funding None. Ethical approval None required. Competing interests The authors declare that they have no competing interests.
175
References 1. http://www.justice.gov/dea/pr/multimedia-library/publications/drug_of_abuse. pdf [accessed 10.04.15]. 2. Jegu J, Gallini A, Soler P, Montastruc JL, Lapeyre-Mestre M. Slow-release oral morphine for opioid maintenance treatment: a systematic review. Br J Clin Pharmacol 2011;71:832e43. 3. Ferri M, Minozzi S, Bo A, Amato L. Slow-release oral morphine as maintenance therapy for opioid dependence (review). Cochrane Database Syst Rev 2013;6:1e28. 4. Kastelic A, Dubajic G, Strbad E. Slow-release oral morphine for maintenance treatment of opioid addicts intolerant to methadone or with inadequate withdrawal suppression. Addiction 2008;103:1837e46. 5. Bond AJ, Reed KD, Beavan P, Strang J. After the randomised injectable opiate treatment trial: post-trial investigation of slow-release oral morphine as an alternative opiate maintenance medication. Drug Alcohol Rev 2012;31: 492e8. 6. Peyriere H, Eiden C, Micallef J, Lapeyre-Mestre M. Slow-release oral morphine sulfate abuse: results of the postmarketing surveillance systems for psychoactive prescription drug abuse in France. Eur Addict Res 2013;19:235e44. 7. pmb.ofdt.fr/pmb_documents/LEGI/224.pdf [accessed 10.04.15]. 8. http://www.ofdt.fr/ofdtdev/live/publi/rapports/rap10/epfxacq1.html [accessed 10.04.15]. 9. Pauly V, Pradel V, Pourcel L, Nordmann S, Frauger E, Lapeyre-Mestre M, et al. Estimated magnitude of diversion and abuse of opioids relative to benzodiazepines in France. Drug Alcohol Depend 2012;126:13e20. 10. Merlo LJ, Trejo-Lopez J, Conwell T, Rivenbark J. Patterns of substance use initiation among healthcare professionals in recovery. Am J Addict 2013;22: 605e12. ger MN, Kuhlmann E, Charpenel-Durat C, 11. Pok PR, Mauras M, De Saint Le Navarette C, et al. Blood concentrations of clobazam and norclobazam in a lethal case involving clobazam, meprobamate and clorazepate. Leg Med (Tokyo) 2010;12:300e4. 12. Rees KA, Pounder DJ, Osselton MD. Distribution of opiates in femoral blood and vitreous humour after heroin/morphine-related deaths. Forensic Sci Int 2013;226:152e9. 13. Staub C, Jeanmonod R, Fryc O. Morphine in postmortem blood: its importance for the diagnosis of deaths associated with opiate addiction. Int J Leg Med 1990;104:39e42. 14. Burt MJ, Kloss J, Apple FS. Post-mortem blood free and total morphine concentrations in medical examiner cases. J Forensic Sci 2001;46:1138e42. 15. Kirsh K, Peppin J, Coleman J. Characterization of prescription opioid abuse in the United States: focus on route of administration. J Pain Palliat Care Pharmacother 2012;26:348e61. 16. Butler SF, Black RA, Cassidy TA, Dailey TM, Budman SH. Abuse risks and routes of administration of different prescription opioid compounds and formulations. Harm Reduct J 2011;8:29e46. 17. Lankenau SE, Teti M, Silva K, Jackson Bloom J, Harocopos A, Treese M. Initiation into prescription opioid misuse among young injection drug users. Int J Drug Policy 2012;23:37e44. 18. Zosel A, Bartelson BB, Bailey E, Lowenstein S, Dart R. Characterization of adolescent prescription drug abuse and misuse using the Researched Abuse Diversion and Addiction-related Surveillance (RADARS®) System. J Am Acad Child Adolesc Psychiatry 2013;52:196e204. 19. McCabe SE, West BT, Boyd CJ. Motives for medical misuse of prescription opioids among adolescents. J Pain 2013;14:1208e16. 20. Kintz P. Value of hair analysis in postmortem toxicology. Forensic Sci Int 2004;142:127e34. 21. Koster RA, Alffenaar JW, Greijdanus B, VanDernagel JE, Uges DR. Fast and highly selective LC-MS/MS screening for THC and 16 other abused drugs and metabolites in human hair to monitor patients for drug abuse. Ther Drug Monit 2014;36:234e43. 22. Musshoff F, Lachenmeier K, Wollersen H, Lichtermann D, Madea B. Opiate concentrations in hair from subjects in a controlled heroin-maintenance program and from opiate-associated fatalities. J Anal Toxicol 2005;29:345e52. 23. Musshoff F, Lachenmeier K, Lichtermann D, Madea B. Cocaine and opiate concentrations in hair from subjects in a heroin maintenance program in comparison to a methadone substituted group. Int J Leg Med 2009;123:363e9. 24. Kintz P, Villain M, Dumestre V, Cirimele V. Evidence of addiction by anesthesiologists as documented by hair analysis. Forensic Sci Int 2005;153:81e4. 25. Gold MS, Melker RJ, Dennis DM, Morey TE, Bajpai LK, Pomm R, et al. Fentanyl abuse and dependence: further evidence for second hand exposure hypothesis. J Addict Dis 2006;5:15e21. 26. Vignali C, Stramesi C, Vecchio B, Groppi A. Hair testing and self-report of cocaine use. Forensic Sci Int 2012;215:77e80. mez-Culebras M, Pichini S, Martinez S, et al. 27. Friguls B, Joya X, Garcia-Serra J, Go Assessment of exposure to drugs of abuse during pregnancy by hair analysis in a Mediterranean island. Addiction 2012;107:1471e91. lez-Colmenero E, Lendoiro E, Concheiro-Guisa n A, de 28. Concheiro M, Gonza Castro A, Cruz-Landeira A, et al. Alternative matrices for cocaine, heroin, and methadone in utero drug exposure detection. Ther Drug Monit 2013;35:502e9. 29. Tsanaclis LM, Wicks JF, Chasin AA. Workplace drug testing, different matrices different objectives. Drug Test Anal 2012;4:83e8. 30. Paterson S, Cordero R, Stearns E. Chronic drug use confirmed by hair analysis: its role in understanding both the medical cause of death and
176
V. Baillif-Couniou et al. / Journal of Forensic and Legal Medicine 36 (2015) 172e176
the circumstances surrounding the death. J Forensic Leg Med 2009;16: 143e7. 31. Henderson GL, Harkey MR, Zhou C, Jones RT, Jacob P. Incorporation of isotopically labeled cocaine into human hair: race as a factor. J Anal Toxicol 1998;22:156e65. 32. Nakahara Y, Takahashi K, Kikura R. Hair analysis for drugs of abuse. X. Effect of physicochemical properties of drugs on the incorporation rates into hair. Biol Pharm Bull 1995;18:1223e7. 33. LeBeau MA, Montgomery MA, Brewer JD. The role of variations in growth rate and sample collection on interpreting results of segmental analyses of hair. Forensic Sci Int 2011;210:110e6.
34. Kronstrand R, Scott K. Drug incorporation into hair. In: Kintz P, editor. Analytical and practical aspects of drug testing in hair. Boca Raton: CRC Press, Taylor & Francis Group; 2007. p. 1e24. 35. Yegles M. Pitfalls in hair analysis: cosmetic treatment. Ann Tox Anal 2005;17: 275e8. 36. Kintz P. Segmental hair analysis can demonstrate external contamination in postmortem cases. Forensic Sci Int 2012;215:73e6. 37. Baumgartner MR, Guglielmello R, Fanger M, Kraemer T. Analysis of drugs of abuse in hair: evaluation of the immunochemical method VMA-T vs. LC-MS/MS or GC-MS. Forensic Sci Int 2012;215:56e9.