Forensic Toxicology

, Volume 30, Issue 1, pp 19–24 | Cite as

Heroin poisoning deaths with 6-acetylmorphine in blood: demographics of the victims, previous drug-related offences, polydrug use, and free morphine concentrations in femoral blood

Original Article


This article discusses cases of drug-poisoning death in which 6-acetylmorphine (6-AM) was identified in blood as evidence for recent use of heroin. We report the demographics of the victims, previous drug-related offences, polydrug use, and the concentrations of free morphine in peripheral blood. After solid-phase extraction, morphine, codeine, and 6-AM were determined in blood samples by isotope-dilution gas chromatography–mass spectrometry (GC–MS) using limits of quantitation of 0.005 mg/l for each opiate. The victims of heroin poisoning were mainly men (88%), with a mean age of 35.4 ± 8.4 years (±SD) and no significant gender difference in age (men 35 ± 8.4 years; women 35 ± 8.6 years). The median concentration of free morphine in blood (n = 671) was 0.25 mg/l (66% > 0.20 mg/l) and women had a higher concentration (0.30 mg/l) than men (0.24 mg/l) (P < 0.05). No significant difference (P > 0.05) was found for the concentration of free morphine in blood when heroin was the only drug taken (median 0.26 mg/l, n = 53) compared with multidrug deaths (median 0.24 mg/l, n = 618) (P > 0.05). The coingested drugs most commonly identified in heroin-related deaths were ethanol (44%), diazepam (27%), cannabis (20%), and flunitrazepam (19%). We found that 61% of victims had previous drug-related offences ranging from 1 to 48 times. The close agreement between the concentrations of free morphine in blood when heroin was the only drug taken and multidrug deaths suggests that differences in tolerance to opiates is more important in causing death than adverse drug–drug interactions.


Drug abuse Heroin Morphine Poisoning deaths Polydrug use Tolerance 


Conflict of interest



  1. 1.
    Warner-Smith M, Darke S, Lynskey M, Hall W (2001) Heroin overdose: causes and consequences. Addiction 96:1113–1125PubMedCrossRefGoogle Scholar
  2. 2.
    Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K (2003) Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990–98. Addiction 98:739–747PubMedCrossRefGoogle Scholar
  3. 3.
    Toprak S, Cetin I (2009) Heroin overdose deaths and heroin purity between 1990 and 2000 in Istanbul, Turkey*. J Forensic Sci 54:1185–1188PubMedCrossRefGoogle Scholar
  4. 4.
    Quaglio G, Talamini G, Lechi A, Venturini L, Lugoboni F, Mezzelani P (2001) Study of 2708 heroin-related deaths in north-eastern Italy 1985–98 to establish the main causes of death. Addiction 96:1127–1137PubMedCrossRefGoogle Scholar
  5. 5.
    Nutt D, King LA, Saulsbury W, Blakemore C (2007) Development of a rational scale to assess the harm of drugs of potential misuse. Lancet 369:1047–1053PubMedCrossRefGoogle Scholar
  6. 6.
    Degenhardt L, Mathers B, Vickerman P, Rhodes T, Latkin C, Hickman M (2010) Prevention of HIV infection for people who inject drugs: why individual, structural, and combination approaches are needed. Lancet 376:285–301PubMedCrossRefGoogle Scholar
  7. 7.
    Meissner C, Recker S, Reiter A, Friedrich HJ, Oehmichen M (2002) Fatal versus non-fatal heroin “overdose”: blood morphine concentrations with fatal outcome in comparison to those of intoxicated drivers. Forensic Sci Int 130:49–54PubMedCrossRefGoogle Scholar
  8. 8.
    Burt MJ, Kloss J, Apple FS (2001) Postmortem blood free and total morphine concentrations in medical examiner cases. J Forensic Sci 46:1138–1142PubMedGoogle Scholar
  9. 9.
    Fugelstad A, Ahlner J, Brandt L, Ceder G, Eksborg S, Rajs J, Beck O (2003) Use of morphine and 6-monoacetylmorphine in blood for the evaluation of possible risk factors for sudden death in 192 heroin users. Addiction 98:463–470PubMedCrossRefGoogle Scholar
  10. 10.
    Ceder G, Jones AW (2001) Concentration ratios of morphine to codeine in blood of impaired drivers as evidence of heroin use and not medication with codeine. Clin Chem 47:1980–1984PubMedGoogle Scholar
  11. 11.
    Romberg RW, Lee L (1995) Comparison of the hydrolysis rates of morphine-3-glucuronide and morphine-6-glucuronide with acid and beta-glucuronidase. J Anal Toxicol 19:157–162PubMedGoogle Scholar
  12. 12.
    Jung BF, Reidenberg MM (2005) Interpretation of opioid levels: comparison of levels during chronic pain therapy to levels from forensic autopsies. Clin Pharmacol Ther 77:324–334PubMedCrossRefGoogle Scholar
  13. 13.
    Schuberth J, Schuberth J (1989) Gas chromatographic-mass spectrometric determination of morphine, codeine and 6-monoacetylmorphine in blood extracted by solid phase. J Chromatogr 490:444–449PubMedCrossRefGoogle Scholar
  14. 14.
    Bloor M, Gannon M, Hay G, Jackson G, Leyland AH, McKeganey N (2008) Contribution of problem drug users’ deaths to excess mortality in Scotland: secondary analysis of cohort study. BMJ 337:a478PubMedCrossRefGoogle Scholar
  15. 15.
    Romelsjo A, Engdahl B, Stenbacka M, Fugelstad A, Davstad I, Leifman A, Thiblin I (2010) Were the changes to Sweden’s maintenance treatment policy 2000–06 related to changes in opiate-related mortality and morbidity? Addiction 105:1625–1632PubMedCrossRefGoogle Scholar
  16. 16.
    Oviedo-Joekes E, Brissette S, Marsh DC, Lauzon P, Guh D, Anis A, Schechter MT (2009) Diacetylmorphine versus methadone for the treatment of opioid addiction. N Engl J Med 361:777–786PubMedCrossRefGoogle Scholar
  17. 17.
    Hickman M, Carrivick S, Paterson S, Hunt N, Zador D, Cusick L, Henry J (2007) London audit of drug-related overdose deaths: characteristics and typology, and implications for prevention and monitoring. Addiction 102:317–323PubMedCrossRefGoogle Scholar
  18. 18.
    Risser D, Uhl A, Oberndorfer F, Honigschnabl S, Stichenwirth M, Hirz R, Seblad D (2007) Is there a relationship between street heroin purity and drug-related emergencies and/or drug-related deaths? An analysis from Vienna, Austria. J Forensic Sci 52:1171–1176PubMedCrossRefGoogle Scholar
  19. 19.
    O’Neal CL, Poklis A (1998) The detection of acetylcodeine and 6-acetylmorphine in opiate positive urines. Forensic Sci Int 95:1–10PubMedCrossRefGoogle Scholar
  20. 20.
    Logan BK, Smirnow D (1996) Postmortem distribution and redistribution of morphine in man. J Forensic Sci 41:221–229PubMedGoogle Scholar
  21. 21.
    Dalpe-Scott M, Degouffe M, Garbutt D, Drost M (1995) A comparison of drug concentrations in postmortem cardiac and peripheral blood in 320 cases. Can Soc Forensic Sci J 28:113–121Google Scholar
  22. 22.
    Crandall CS, Kerrigan S, Blau RL, Lavalley J, Zumwalt R, McKinney PE (2006) The influence of site of collection on postmortem morphine concentrations in heroin overdose victims. J Forensic Sci 51:413–420PubMedCrossRefGoogle Scholar
  23. 23.
    Pelissier-Alicot AL, Gaulier JM, Champsaur P, Marquet P (2003) Mechanisms underlying postmortem redistribution of drugs: a review. J Anal Toxicol 27:533–544PubMedGoogle Scholar
  24. 24.
    Goldberger BA, Cone EJ, Grant TM, Caplan YH, Levine BS, Smialek JE (1994) Disposition of heroin and its metabolites in heroin-related deaths. J Anal Toxicol 18:22–28PubMedGoogle Scholar
  25. 25.
    Merrall EL, Kariminia A, Binswanger IA, Hobbs MS, Farrell M, Marsden J, Hutchinson SJ, Bird SM (2010) Meta-analysis of drug-related deaths soon after release from prison. Addiction 105:1545–1554PubMedCrossRefGoogle Scholar
  26. 26.
    Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG et al (2007) Release from prison—a high risk of death for former inmates. N Engl J Med 356:157–165PubMedCrossRefGoogle Scholar
  27. 27.
    Spiehler VR (1989) Computer-assisted interpretation in forensic toxicology: morphine-involved deaths. J Forensic Sci 34:1104–1115PubMedGoogle Scholar
  28. 28.
    Stenhouse G, Stephen D, Grieve JH (2004) Blood free morphine levels vary with concomitant alcohol and benzodiazepine use. J Clin Forensic Med 11:285–288PubMedCrossRefGoogle Scholar
  29. 29.
    Kumar S, Porcu P, Werner DF, Matthews DB, Diaz-Granados JL, Helfand RS, Morrow AL (2009) The role of GABA(A) receptors in the acute and chronic effects of ethanol: a decade of progress. Psychopharmacology (Berl) 205:529–564CrossRefGoogle Scholar
  30. 30.
    Druid H, Strandberg JJ, Alkass K, Nystrom I, Kugelberg FC, Kronstrand R (2007) Evaluation of the role of abstinence in heroin overdose deaths using segmental hair analysis. Forensic Sci Int 168:223–226PubMedCrossRefGoogle Scholar
  31. 31.
    Hand CW, Moore RA, Sear JW (1988) Comparison of whole blood and plasma morphine. J Anal Toxicol 12:234–235PubMedGoogle Scholar

Copyright information

© Japanese Association of Forensic Toxicology and Springer 2011

Authors and Affiliations

  • Alan Wayne Jones
    • 1
  • Anita Holmgren
    • 1
  • Johan Ahlner
    • 1
  1. 1.Department of Forensic Genetics and Forensic ToxicologyNational Board of Forensic MedicineLinköpingSweden

Personalised recommendations