Please help me understand this toxicology report
March 22, 2021 6:02 AM Subscribe
My daughter died 1/2/21 from an overdose of fentanyl and meth (source, death cert). The tox report was 7 pages and indicted that she tested positive for a dozen substances. I met with the coroner to ask for clarification, but retained little of her patient explanations and forgot most of my questions. (I still can't believe my daughter is gone. The meeting was as surreal as a Dali painting.) I'm hoping you all can minimize/eliminate the need for me to bother this poor woman again.
(All common sense disclaimers regarding IANAD, IANYD, etc are assumed. Specific questions are at the end.)
When I first saw her autopsy, I was too intimidated by the sheer number of drugs in her system to focus on details. After I dropped the ball at the meeting with the coroner, I forced myself to thoroughly read the tox report. It begins with a chart of positive blood test result for 12 substances, measured as ng/mL, followed by pages of info about the items on the list. Based on that, I'm guessing the first 9 of the 12 were not contributing factors in her death, in fact, they probably had minimal effect on her behavior.
Blood concentrations not given for these 2
1. 4-ANPP Used in the production of fentanyl, it is considered to be pharmacologically weak.
2. Caffeine (No Doz)
Inactive metabolites
3. Delta-9 Carboxy THC 19 ng/mL
4. Norfentanyl 15ng/mL
Weed
5. Delta-9 THC 1.3ng/mL. Based on this example from report: 50- 270 ng/mL at 6 to 9 minutes after beginning smoking, decreasing to less than 5 ng/mL by 2 hrs, 1.3ng/mL appears to indicate it had been several hours since she last smoked.
Pharmaceuticals
7. Lorazepam 6.2 ng/mL A benzodiazepine, amount detected is consistent with her prescribed dose.
8. Clonazepam 2.5 ng/mL A benzodiazepine, amount detected is less than a therapeutic dose. (Perhaps given at the hospital; half-life of 20-80 hours.)
9. 7-Amino Clonazepam 120ng/mL Metabolite of clonazepam....
Unknown
10. Amphetamine 120ng/mL Average peak plasma level of a 30 mg dose is about 100 ng/mL at 2.5 hr, so 120ng/mL is not alarming. However, amphetamine is also a metabolite of methamphetamine, benzphetamine and selegiline. I have no idea if this refers to the metabolite or if it means she was also taking amphetamines.
Assumed cause of death: methamphetamine laced with fentanyl
11. Methamphetamine 67ng/mL Blood levels of 200-600 ng/mL have been reported in meth users who exhibited violent/irrational behavior, which leads me to believe 67ng/mL indicates meth was a secondary factor.
12. Fentanyl 10 ng/mL Fatal Overdoses: blood 3–28ng/ml (average 8.3)
Specific questions
Thank you for any help. I know I can't change anything - I'm just trying to better understand the last hours of my beautiful daughter's life.
(All common sense disclaimers regarding IANAD, IANYD, etc are assumed. Specific questions are at the end.)
When I first saw her autopsy, I was too intimidated by the sheer number of drugs in her system to focus on details. After I dropped the ball at the meeting with the coroner, I forced myself to thoroughly read the tox report. It begins with a chart of positive blood test result for 12 substances, measured as ng/mL, followed by pages of info about the items on the list. Based on that, I'm guessing the first 9 of the 12 were not contributing factors in her death, in fact, they probably had minimal effect on her behavior.
Blood concentrations not given for these 2
1. 4-ANPP Used in the production of fentanyl, it is considered to be pharmacologically weak.
2. Caffeine (No Doz)
Inactive metabolites
3. Delta-9 Carboxy THC 19 ng/mL
4. Norfentanyl 15ng/mL
Weed
5. Delta-9 THC 1.3ng/mL. Based on this example from report: 50- 270 ng/mL at 6 to 9 minutes after beginning smoking, decreasing to less than 5 ng/mL by 2 hrs, 1.3ng/mL appears to indicate it had been several hours since she last smoked.
Pharmaceuticals
Background: my daughter was hospitalized from 12/21-12/28. Before she was hospitalized, she had a prescription for Lorazepam and Provigil, but she was out of the latter. I don’t know what drugs she was given at the hospital, but it’s a safe bet that she received at least a benzodiazepine and an antipsychotic.6. Olanzapine 4.8ng/mL An antipsychotic, amount detected is less than a therapeutic dose. (Perhaps given at the hospital; half-life of 21-54 hours.)
7. Lorazepam 6.2 ng/mL A benzodiazepine, amount detected is consistent with her prescribed dose.
8. Clonazepam 2.5 ng/mL A benzodiazepine, amount detected is less than a therapeutic dose. (Perhaps given at the hospital; half-life of 20-80 hours.)
9. 7-Amino Clonazepam 120ng/mL Metabolite of clonazepam....
Unknown
10. Amphetamine 120ng/mL Average peak plasma level of a 30 mg dose is about 100 ng/mL at 2.5 hr, so 120ng/mL is not alarming. However, amphetamine is also a metabolite of methamphetamine, benzphetamine and selegiline. I have no idea if this refers to the metabolite or if it means she was also taking amphetamines.
Assumed cause of death: methamphetamine laced with fentanyl
11. Methamphetamine 67ng/mL Blood levels of 200-600 ng/mL have been reported in meth users who exhibited violent/irrational behavior, which leads me to believe 67ng/mL indicates meth was a secondary factor.
12. Fentanyl 10 ng/mL Fatal Overdoses: blood 3–28ng/ml (average 8.3)
Specific questions
- Do my assumptions about the first 9 seem true?
- What is the more likely explanation for the amphetamine in her system?
- As I understood things, the coroner said meth was primarily responsible for her death, i.e., Narcan would have made little/no difference in her chance of survival. But the above info seems to contradict this.
Thank you for any help. I know I can't change anything - I'm just trying to better understand the last hours of my beautiful daughter's life.
I can't help you with your question, but I want to express my condolences and tell you how sorry I am. I hope you have loving support.
posted by Dolley at 6:36 AM on March 22, 2021 [9 favorites]
posted by Dolley at 6:36 AM on March 22, 2021 [9 favorites]
Sorry for your loss.
The metabolite is basically the "result" of the body metabolizes something. By measuring the metabolites, we can make a reasonable guess at what had the body metabolized prior to the event.
Methamphetamine is metabolized into amphetamine.
Here's a short from Mayo Clinic on these reactions
Similarly, fentanyl is metabolized into norfentanyl
Anything with THC is probably a metabolite from smoking MJ.
So my very amateur conclusion would be a mix of weed, fentanyl, and meth, plus caffeine.
Fentanyl is often found as a part of the drug trade now, to enhance the addictive qualities of the narcotics, as fentanyl itself is a synthetic opioid, and it is extremely potent. Nalaxone (generic name of Narcan) may or may not have made a difference depending on the amount of fentanyl that was laced into that last dose. Sometimes, according to the link below, MULTIPLE doses of Nalaxone may be needed to counteract fentanyl. Overdose is far more likely to occur if the narcotics have been laced with other narcotics such as fentanyl.
Here's a little more about Fentanyl
posted by kschang at 6:44 AM on March 22, 2021 [6 favorites]
The metabolite is basically the "result" of the body metabolizes something. By measuring the metabolites, we can make a reasonable guess at what had the body metabolized prior to the event.
Methamphetamine is metabolized into amphetamine.
Here's a short from Mayo Clinic on these reactions
Similarly, fentanyl is metabolized into norfentanyl
Anything with THC is probably a metabolite from smoking MJ.
So my very amateur conclusion would be a mix of weed, fentanyl, and meth, plus caffeine.
Fentanyl is often found as a part of the drug trade now, to enhance the addictive qualities of the narcotics, as fentanyl itself is a synthetic opioid, and it is extremely potent. Nalaxone (generic name of Narcan) may or may not have made a difference depending on the amount of fentanyl that was laced into that last dose. Sometimes, according to the link below, MULTIPLE doses of Nalaxone may be needed to counteract fentanyl. Overdose is far more likely to occur if the narcotics have been laced with other narcotics such as fentanyl.
Here's a little more about Fentanyl
posted by kschang at 6:44 AM on March 22, 2021 [6 favorites]
Like Dolley, I can't help you with your question, but wanted to express my deepest sympathies and hopes that you find peace and comfort after your time of grief.
posted by Gelatin at 7:13 AM on March 22, 2021 [2 favorites]
posted by Gelatin at 7:13 AM on March 22, 2021 [2 favorites]
I am so sorry.
My first instinct was the same as wenestvedt - that if you thought visiting the coroner again would help you, I think you should ask. You could ask if you could take someone else with you, if you have a friend who would make a good note taker and second pair of ears (or ask if you might be able to record what she tells you this time) - which might reassure her that this isn’t going to be a recurring visit, you just need to hear it once more.
posted by penguin pie at 7:17 AM on March 22, 2021 [12 favorites]
My first instinct was the same as wenestvedt - that if you thought visiting the coroner again would help you, I think you should ask. You could ask if you could take someone else with you, if you have a friend who would make a good note taker and second pair of ears (or ask if you might be able to record what she tells you this time) - which might reassure her that this isn’t going to be a recurring visit, you just need to hear it once more.
posted by penguin pie at 7:17 AM on March 22, 2021 [12 favorites]
I am so sorry.
If you ever want to talk with someone who has been there, please feel free to memail.
posted by InkaLomax at 7:28 AM on March 22, 2021 [5 favorites]
If you ever want to talk with someone who has been there, please feel free to memail.
posted by InkaLomax at 7:28 AM on March 22, 2021 [5 favorites]
Best answer: I'm sorry for your loss.
I'm an emergency doc, and not an expert on polysubstance toxicology, but I treat polysubstance overdoses all the time, so I'll speculate a little.
The multiple respiratory depressants your daughter had on board (fentanyl and benzodiazepines, and to a lesser extent the traces of olanzapine probably left over from her recent hospitalization) are by far the most likely proximate cause for her death.
That said, polysubstance overdoses can cause death in a variety of ways, and because of that it's impossible to reconstruct exactly what happened. Meth, benzos, fentanyl, antipsychotics from her recent hospitalization, THC, even caffeine; I don't know exactly how all of these interact with one another, but all of them together could have led, for example, to cardiac conduction problems that caused a fatal heart arrythmia. I've seen deadly arrythmias from meth use alone, and from antipsychotics like olanzapine (Zyprexa), when taken in overdose.
Amphetamine and methamphetamine are pretty much the same substance; meth just has an extra methyl group sticking off one end of its chemical structure. There is some cross-reactivity between the toxicology assays for meth and amphetamine, meaning that taking meth will often make you test positive for amphetamine. When I see that someone is amphetamine-positive, I assume meth unless they are on Adderall or a related drug, or unless they tell me they took a friend's ADHD meds.
Because respiratory failure from fentanyl, benzos and other meds seems to me to be most likely to have caused your daughter's death, Narcan might have helped to prevent it if given in time, but there's no way to be sure. I'm sure emergency workers responding to the scene would have given it to her if she was down but still alive. I know I would have.
posted by killdevil at 7:39 AM on March 22, 2021 [35 favorites]
I'm an emergency doc, and not an expert on polysubstance toxicology, but I treat polysubstance overdoses all the time, so I'll speculate a little.
The multiple respiratory depressants your daughter had on board (fentanyl and benzodiazepines, and to a lesser extent the traces of olanzapine probably left over from her recent hospitalization) are by far the most likely proximate cause for her death.
That said, polysubstance overdoses can cause death in a variety of ways, and because of that it's impossible to reconstruct exactly what happened. Meth, benzos, fentanyl, antipsychotics from her recent hospitalization, THC, even caffeine; I don't know exactly how all of these interact with one another, but all of them together could have led, for example, to cardiac conduction problems that caused a fatal heart arrythmia. I've seen deadly arrythmias from meth use alone, and from antipsychotics like olanzapine (Zyprexa), when taken in overdose.
Amphetamine and methamphetamine are pretty much the same substance; meth just has an extra methyl group sticking off one end of its chemical structure. There is some cross-reactivity between the toxicology assays for meth and amphetamine, meaning that taking meth will often make you test positive for amphetamine. When I see that someone is amphetamine-positive, I assume meth unless they are on Adderall or a related drug, or unless they tell me they took a friend's ADHD meds.
Because respiratory failure from fentanyl, benzos and other meds seems to me to be most likely to have caused your daughter's death, Narcan might have helped to prevent it if given in time, but there's no way to be sure. I'm sure emergency workers responding to the scene would have given it to her if she was down but still alive. I know I would have.
posted by killdevil at 7:39 AM on March 22, 2021 [35 favorites]
You have my deepest condolences.
One other thing to keep in mind, that you probably already know: doing drugs just plain wears out your body. 25 years ago, my loved one died at age 29 not from an overdose, but from a medium dose. He had taken much more in the past, and had been totally clean for short periods, and the ups and downs were just too much for his heart, as killdevil discusses. When I saw the report my first thought was "hey, that wasn't an overdose!" And then they pointed out that his system was just too weak by that point to handle it.
<3
posted by Melismata at 8:32 AM on March 22, 2021 [5 favorites]
One other thing to keep in mind, that you probably already know: doing drugs just plain wears out your body. 25 years ago, my loved one died at age 29 not from an overdose, but from a medium dose. He had taken much more in the past, and had been totally clean for short periods, and the ups and downs were just too much for his heart, as killdevil discusses. When I saw the report my first thought was "hey, that wasn't an overdose!" And then they pointed out that his system was just too weak by that point to handle it.
<3
posted by Melismata at 8:32 AM on March 22, 2021 [5 favorites]
<3
a few sweet children i have known in my addict son's circle have gone as well.
posted by j_curiouser at 8:36 AM on March 22, 2021 [2 favorites]
a few sweet children i have known in my addict son's circle have gone as well.
posted by j_curiouser at 8:36 AM on March 22, 2021 [2 favorites]
Very sorry to hear about your loss
posted by olopua at 8:48 AM on March 22, 2021 [1 favorite]
posted by olopua at 8:48 AM on March 22, 2021 [1 favorite]
I'm so sorry for your loss.
posted by heathrowga at 8:49 AM on March 22, 2021 [1 favorite]
posted by heathrowga at 8:49 AM on March 22, 2021 [1 favorite]
Perspective here from a public health/narcotic recovery point of view. The impulse on the street by drug-recovery street outreach workers is to give more than one dose of Narcan if the first one appears to be insufficient, or if a person wakes up for a moment and then falls back into their unresponsiveness. Part of the terrible problem with fentanyl is that it is much, much stronger than heroin or most oral opiates and attaches more strongly to opiate receptors. Outreach workers tell me it sometimes takes two, three, or even four Narcan doses to revive someone who has taken fentanyl. And it doesn't always work even if drug use was witnessed and Narcan given immediately.
It's unlikely that a person with only one dose at hand, considered typical for worried families who are aware their family member is using opiates or meth, could have successfully revived a person with fentanyl on board. Much, if not most meth and heroin is now laced with fentanyl, which is spreading from one drug-using community to another across the country. Some drug-outreach organizations and needle-exchange programs are distributing both multiple doses of Narcan and fentanyl-detection strips to their clients so they can test their drugs before use, which is how they know how widespread fentanly-adulteration of heroin and meth is. They also advise clients to NOT USE ALONE. It's just too easy to overdose with the drug supply that's out there.
I'm so sorry this happened to your daughter, and you.
posted by citygirl at 8:50 AM on March 22, 2021 [10 favorites]
It's unlikely that a person with only one dose at hand, considered typical for worried families who are aware their family member is using opiates or meth, could have successfully revived a person with fentanyl on board. Much, if not most meth and heroin is now laced with fentanyl, which is spreading from one drug-using community to another across the country. Some drug-outreach organizations and needle-exchange programs are distributing both multiple doses of Narcan and fentanyl-detection strips to their clients so they can test their drugs before use, which is how they know how widespread fentanly-adulteration of heroin and meth is. They also advise clients to NOT USE ALONE. It's just too easy to overdose with the drug supply that's out there.
I'm so sorry this happened to your daughter, and you.
posted by citygirl at 8:50 AM on March 22, 2021 [10 favorites]
Response by poster: I so appreciate the information and your kind words. While I'm sure the coroner would graciously meet with me again, gathering around a table to casually discuss the details of my daughter's death was a surreal experience that I don't want to repeat.
A couple of quick follow-up questions:
I thought her snobbish attitude toward everything "small-town", which is what she considered meth, offered some measure of protection. Recently, a trusted friend told me she did use it briefly in 2019, would not have actively sought it now, but wouldn't have necessarily passed on an opportunity to do it again. The same friend is adamant that she would not have knowingly done fentanyl.
She died at the house across the street from my place in my hometown (I spend about 75% of my time in Chicago.) I have never met that neighbor and I'm sure my daughter didn't know him before 12/31, when he apparently decided to party with an obviously unstable young woman. I have since learned (via an hour or so with Google), his name, age (approx 41), and extensive arrest record, including multiple meth-related charges, at least 2 of which are still open. Regardless, he's not shy about posting pro-drug messages on Facebook.
posted by she's not there at 8:22 PM on March 23, 2021
A couple of quick follow-up questions:
- Re active metabolites, should they be basically considered more of the original drug, i.e., does 67 ng/mL for meth and 120 ng/mL, for amphetamine essentially amount to 187 ng/mL for meth? Similarly, is Clonazepam 2.5 ng/mL + 7-Amino Clonazepam 120ng/mL the same as Clonazepam 122.5ng/mL in terms of effects?
- Is it safe to assume (or would the coroner know) that the meth was laced with fentanyl, rather than that she took them separately?
I thought her snobbish attitude toward everything "small-town", which is what she considered meth, offered some measure of protection. Recently, a trusted friend told me she did use it briefly in 2019, would not have actively sought it now, but wouldn't have necessarily passed on an opportunity to do it again. The same friend is adamant that she would not have knowingly done fentanyl.
She died at the house across the street from my place in my hometown (I spend about 75% of my time in Chicago.) I have never met that neighbor and I'm sure my daughter didn't know him before 12/31, when he apparently decided to party with an obviously unstable young woman. I have since learned (via an hour or so with Google), his name, age (approx 41), and extensive arrest record, including multiple meth-related charges, at least 2 of which are still open. Regardless, he's not shy about posting pro-drug messages on Facebook.
posted by she's not there at 8:22 PM on March 23, 2021
Not a medical professional but...
a) I do not believe you can estimate original dose via the metabolites alone, as this would also have to cover amount where were not absorbed by the body (technical word: bio-available). Any such guesswork would be too error prone to be useful as pointed out by this research paper:
I understand this is a part of your grieving process, but I believe you need to talk to someone who can offer guidance on grief as soon as possible.
posted by kschang at 12:04 AM on March 24, 2021 [1 favorite]
a) I do not believe you can estimate original dose via the metabolites alone, as this would also have to cover amount where were not absorbed by the body (technical word: bio-available). Any such guesswork would be too error prone to be useful as pointed out by this research paper:
Conclusions—A large degree of error can arise from attempting to estimate antemortem drug concentrations and the ingested dose from postmortem measurements. The chosen site and technique for postmortem blood sampling can greatly influence the concentration of drug measured.b) It is a reasonable guess, that the meth is laced with fentanyl, as that is the most common way to get fentanyl nowadays. Fentanyl itself is VERY tightly controlled in the US, and the actual drugs being abused are probably exported from China and ended up in the hands of the drug cartels who laced it in their own drugs. Here's an NPR article about an author who actually visited two of the factories in China, and wrote a book about this deadly pipeline.
I understand this is a part of your grieving process, but I believe you need to talk to someone who can offer guidance on grief as soon as possible.
posted by kschang at 12:04 AM on March 24, 2021 [1 favorite]
I hate to bring this to your attention but I have had friends and relatives in those lifestyles and the rumor in meth addicts is there is more users going to the intravenous method of ingesting and that has made drug dealers lace meth with fentanyl to get the user more addicted than by the meth alone. The depressants in the hospital also may have made a contribution but if your daughter had a meth habit that was primarily IV dependent she could have very easily overdosed without knowing she was even using Fentanyl
posted by The_imp_inimpossible at 4:01 AM on March 24, 2021
posted by The_imp_inimpossible at 4:01 AM on March 24, 2021
This thread is closed to new comments.
I would encourage you to call the coroner again: they will understand your difficulty, having seen grief before, and they shouldn't give you a hard time.
What you're processing is enormous, and they can certainly give some time to help you.
posted by wenestvedt at 6:36 AM on March 22, 2021 [35 favorites]