Hair Morphine Concentrations of Fatal Heroin Overdose

7/29/2019 Hair Morphine Concentrations of Fatal Heroin Overdose

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2002 Society for the Study of Addiction to Alcohol and Other Drugs Addiction, 97, 977984

INTRODUCTION

The rate of fatal opioid overdoses among 1544-year-

olds in Australia increased from 1.3 in 1964 to 71.5 per

million in 1997, with the greatest increase occurring

among older heroin users (Hall et al. 1999). Similarly

large increases have been reported in other countries

(Davoli et al. 1997; Neeleman & Farrell 1997; Risser et al.

2000). The typical overdose fatality, in Australia and

elsewhere, is a 30-year-old-male with a long history of

heroin use, who was not in treatment at the time of death

(Darke & Zador 1996; Darke et al. 2000b). In the major-

ity of cases, central nervous system (CNS) depressant

drugs other than heroin are also detected, most com-

monly alcohol and benzodiazepines (Monforte 1977;

Kintz et al. 1989; Darke & Zador 1996; Zador et al. 1996;

Darke et al. 2000b). It should be noted that heroin over-

whelmingly predominates illicit opiate use in New South

Wales (NSW), and in Australia generally, rather than

other opiate preparations (Darke et al. 2000a).

Despite the predominance of experienced, long-term

heroin users among fatalities, a large proportion of fatal-

Hair morphine concentrations of fatal heroin overdose

cases and living heroin users

Shane Darke1, Wayne Hall1, Sharlene Kaye1, Joanne Ross1 & Johan Duflou2

National Drug and Alcohol Research Centre, University of New South Wales, NSW1 and Institute of Forensic Medicine,

University of Sydney, NSW, Australia2

ABSTRACT

Aims To compare heroin and other opiate use of heroin overdose fatalities,

current street heroin users and drug-free therapeutic community clients.

Design Hair morphine concentrations that assess heroin use and other opiate

use in the 2 months preceding interview or death were compared between

heroin overdose fatalities diagnosed by forensic pathologists (FOD) (n = 42),

current street heroin users (CU) (n = 100) and presumably abstinent heroin

users in a drug-free therapeutic community (TC) (n = 50).

Setting Sydney, Australia.

Findings The mean age and gender breakdown of the three samples were

32.3 years, 83% male (FOD), 28.7 years, 58% male (CU) and 28.6 years, 60%

male (TC). The median blood morphine concentration among the FOD cases

was 0.35mg/l, and 82% also had other drugs detected. There were large dif-

ferences between the three groups in hair morphine concentrations, with the

CU group (2.10 ng/mg) having concentration approximately four times that of

the FOD group (0.53 ng/mg), which in turn had a concentration approximately

six times that of the TC group (0.09ng/mg). There were no significant differ-

ences between males and females in hair concentrations within any of thegroups. Hair morphine concentrations were correlated significantly with blood

morphine concentrations among FOD cases (r= 0.54), and self-reported heroin

use among living participants (r= 0.57).

Conclusions The results indicate that fatal cases had a lower degree of

chronic opiate intake than the active street users, but they were not abstinent

during this period.

KEYWORDS Hair, heroin, morphine, overdose.

RESEARCH REPORT

Correspondence to:

A/Prof Shane Darke

National Drug and Alcohol Research Centre

University of New South Wales

NSW

Australia

E-mail: [email protected]

Submitted 30 April 2001;initial review completed 19 July 2001;

final version accepted 11 January 2002


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978 Shane Darke et al.


ities have low blood morphine concentrations (heroin is

rapidly metabolized into morphine once administered)

(Monforte 1977; Kintz et al. 1989; Darke & Zador 1996;

Zador et al. 1996; Darke et al. 2000b). Studies have

demonstrated that, in many cases, blood morphine con-

centrations are below, or similar to, those of living intox-

icated heroin users (Darke et al. 1997), or of heroin users

who died of causes other than overdose (Monforte 1977).

This is puzzling, as high blood levels of morphine at

autopsy would be expected in long-term users, who

would presumably have a high tolerance to the CNS

depressant effects of opioids. Lower morphine concen-

trations may, in part, relate to the use of other drugs in

combination with heroin. There is a negative correlation

between blood morphine and alcohol concentrations

among fatal overdose cases (Steentoft et al. 1988;

Ruttenber et al. 1990; Zador et al. 1996; Darke et al.

2000b), suggesting that lower doses of heroin are fatal

when combined with alcohol. Other life-style factors,such as levels of recent drug use, however, may also

contribute to this pattern.

Until recently, it was difficult to measure recent drug

use accurately, as researchers have had to rely solely

upon toxicological and other data contained in coronial

files. The toxicological data have consisted of blood con-

centrations of drugs, which provide a window on drug

use only in the past 2448 hours. The development of

drug detection techniques for hair samples has enabled

more detailed analysis of recent drug use (Magura et al.

1992; Kintz & Mangin 1993). A recent study compared

morphine concentrations detected in hair samples offatal overdose cases, heroin users entering detoxication

and incompletely abstinent former users (Tagliaro et al.

1998). Morphine concentrations in the fatal cases were

significantly lower than those of current users, but were

not significantly different from the group of incompletely

abstinent former users. The authors argued that most

fatalities had recommenced heroin use after a period of

abstinence, and so had a lower tolerance to opioids than

the active heroin-using group.

The current study compared heroin and other opiate

use, as assessed by morphine and 6-monoacetyl mor-

phine (6-MAM, the specific metabolite of heroin) con-centrations in hair, in the 2 months preceding either

interview or death in three groups of heroin users: (1)

heroin overdose fatalities (FOD); (2) current street heroin

users (CU); and (3) drug free therapeutic community

clients (TC). The aim was to replicate and extend the find-

ings of Tagliaro et al. (1998). While all overdose cases

were certified by police investigation as having used

heroin prior to death, and heroin is overwhelmingly the

predominant opioid in NSW, opiates other than heroin

may well have also been consumed in this period and con-

tributed to hair morphine concentrations.

METHODS

Cases

Fatal overdose cases

Permission was obtained from the NSW State Coroner

to collect hair samples from suspected heroin overdose

fatalities upon which autopsies were conducted at the

Institute of Forensic Medicine in inner-city Sydney.

All suspected heroin overdose cases presenting to the

Institute of Forensic Medicine between February 1999

and October 1999 had hair samples taken at autopsy. A

total of 68 cases were identified as suspected heroin over-

dose cases. Final autopsy reports and coronial files were

then inspected for cause of death. Eligibility for inclusion

as a FOD case was identical to that used in previous work

by the authors: forensic pathology conclusion that death

was from narcotism, circumstances of death (e.g. pres-

ence of injecting equipment) and evidence from policeinvestigations (Darke et al. 2000b). Eight cases were

rejected from the study, as forensic pathology indicated

causes of death unrelated to heroin use. This left a total

of 60 cases in which death was attributed to narcosis.

In 18 of these cases, equipment failure at the analytical

laboratory prevented analysis, leaving 42 cases in which

a hair analysis was possible.

Therapeutic community clients

Fifty clients from the two largest Sydney therapeutic com-

munities were interviewed between February and August1999, and had head hair samples taken for analysis. All

living subjects were volunteers who were paid A$20 for

participation in the study. It was a requirement of entry

into the study that clients had been enrolled in treatment

for at least 1 month prior to interview and to have at least

2 cm of head hair. All respondents were guaranteed, both

at the time of screening and interview, that any infor-

mation they provided would be kept strictly confidential,

as would the results of the individuals hair analysis.

Interviews were conducted by one of the research team

and took approximately 30 minutes to complete.

Current heroin users

One hundred current heroin users were recruited and

interviewed between May and August 1999, by means

of advertisements placed in rock magazines, needle

exchanges and by word of mouth. Respondents con-

tacted the researchers, either by telephone or in person,

and were screened for suitability for the study. To be eli-

gible respondents had to have injected heroin at least six

times in the preceding 6 months and at least once in the

preceding month, and to have at least 2cm of head hair.


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Opiate overdose 979


Data collection forms

Fatal cases

The coronial files of all suspected overdose fatalities

were inspected to confirm heroin overdose as the cause

of death, and to record relevant case data. The standard-

ized data collection form devised by Zadoret al

. (1996)was employed to record data. Information on the

demographic characteristics, drug use history, circum-

stances of death and toxicological findings were retrieved

from the coronial files. Documents of particular rele-

vance contained in the files were police reports, ambu-

lance officers statements, witness statements, autopsy

reports, transcripts of coronial inquests (where con-

ducted) and results of toxicological analyses. Data on

drug use history are not collected systematically in coro-

nial files, although they are generally present. In NSW,

all overdose cases have blood and bile samples taken at

autopsy that are analysed for total morphine concentra-tions at the Division of Analytical Laboratories, NSW

Health.

Structured interview

Therapeutic community clients and current heroin users

were administered a structured interview. Areas covered

by the structured interview included demographics, drug

use history, overdose history and heroin use in the pre-

ceding month. Heroin use in the preceding month was

measured using the opiate treatment index (OTI) (Darke

et al. 1992). The OTI use a recent use episodes method-ology. Estimates of heroin consumption are based upon

a ratio of the number of use episodes on the two most

recent use days and the two intervals between the three

most recent use days. Two estimates of quantity con-

sumed and two estimates of intervals between use are

thus obtained. All interviews were conducted by two of

the authors (S.K., J.R.).

Hair sampling

A sample of 50100 hairs were taken from the posterior

vertex (crown of head) of each living volunteer at theconclusion of the structured interview, with the hair

being cut as close to the scalp as possible. Hair samples

from the posterior vertex of overdose cases were taken

at the time of autopsy. Samples were stored in plastic

bags at room temperature until sent for analysis at the

Victorian Institute of Forensic Medicine. Hair analyses

were conducted on the 2cm of hair closest to the scalp.

Hair grows at a rate of approximately 1cm per month

(Magura et al. 1992). The current study thus analysed

heroin and other opiate use over the 2 months preceding

interview or death. The hair morphine concentrations

obtained reflect the overall exposure to heroin in the 2

months preceding interview or death.

The mean weight of analysed samples was 23.3mg

(SD 13.9, range 4127). Mean sample weights for the

three groups were: TC = 28.8mg, CU = 20.8mg,

FOD = 22.9mg. There were no systematic differences

between groups in hair colour or treatments

Analyses

Hair analysis

Procedures followed by the Victorian Institute of Forensic

Medicine for analysis of hair morphine concentrations

were identical to those employed by Tagliaro et al. (1998).

Statistical analyses

Students t-tests were used for continuous data, and the

c2 statistic used for the analysis of categorical data.

Where distributions were skewed, log transformations

were performed to allow the use of parametric statistics,

including t-tests and Pearsons product moment

correlations.

Bile morphine concentrations were categorized into

20 mg/l range categories. Spearmans rank order cor-

relations were conducted in correlating bile morphine

concentration to other variables. All analyses were

conducted using SPSS (release 9.0) (SPSS 1999).

RESULTS

Sample characteristics

The FOD group had a mean age of 32.3 years (SD 7.7,

1746), were overwhelmingly male, unemployed and not

in treatment at the time of death (Table 1). Eighty-eight

per cent of fatal cases were known heroin users, 81%

were classified as dependent (i.e. having long-term heavy

Table 1 Demographic characteristics of samples.

FOD CU TC

Variable ( n = 42) ( n = 100) ( n = 50)

Mean age (years) 32.3 28.7 28.6

(range) (1746) (1848) (1952)

% Male 83 58 60

Unemployed (%) 59 88 98

Treatment status (%)

Not in treatment 93 80 0

Therapeutic community 2 0 100

Methadone maintenance 5 20 0


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involvement in the heroin life-style) and 19% as re-

creational users. In all cases, the route of heroin admin-

istration was by injection. One case was a death in

custody, one case was in periodic detention at the time of

death, and two cases were suicides. The median blood

morphine concentration of cases was 0.35 mg/l (range

0.1012.0 mg/l), and 66% had bile morphine concen-

trations greater than 20 mg/l (range 0- >100 mg/l). In

82% of cases drugs other than morphine were also

detected. The most common drugs detected in addition

to morphine were alcohol (50%, median BAC =

0.12 g/100ml), benzodiazepines (28%) and cocaine

(18%). Fifty-six per cent of cases were known to be heavy

alcohol users. There was a significant negative correla-

tion between log blood morphine and log blood alcohol

concentrations (r= 0.29, P < 0.05).

In terms of key demographic and toxicological vari-

ables, the FOD group were similar to people in NSW who

died of heroin overdose between 1992 and 1996 (Darkeet al. 2000).

There were no significant differences between FOD

cases and overdose cases in which equipment failure

prevented analysis being conducted in: age (32.3 versus

33.4 years), percentage male (83 versus 82%) or per-

centage classified as a dependent heroin user (81 versus

92%).

The average age in both the CU and TC groups was in

the late twenties, and both groups consisted predomi-

nantly of unemployed males. Eighty per cent of the CU

group were not in treatment at the time of interview. The

remaining 20% were enrolled in methadone mainte-nance, but were active heroin users and met criteria for

inclusion in the study. Among the CU group, 79% were

daily heroin users, 16% used more than weekly but less

than daily, and 5% used less than weekly. Among TC

subjects, 88% reported no heroin use in the preceding

month, with the remainder reporting sporadic use over

that period.

Both the CU and TC groups had high levels of poly-

drug use. The CU group had used a mean of 9.0 drug

classes in their life-time (SD 1.7, range 411) and 6.1 (SD

2.0, range 210) in the preceding 6 months. Similarly,

the TC group had used a mean of 9.7 drug classes in theirlife-time (SD 1.2, range 711) and 5.4 (SD 2.1, range

19) in the preceding 6 months. Opiates other than

heroin had been used sporadically in the preceding 6

months: CU (41% used, median used days = 6), TC (44%

used, median used days = 17). Sixty per cent of the CU

and TC groups reported no alcohol use in the preceding

6 months, with l% reporting daily use and 16% more

than weekly use. A history of at least one non-fatal over-

dose was reported by 68% of the TC group and 54% of

the CU group. The demographic and drug use character-

istics of these groups were consistent with other recent

Australian studies of heroin users (Swift et al. 1999;

Darke et al. 2002).

The FOD group was significantly older than both the

CU (32.3 versus 28.7, t140 = 2.8, P < 0.01) and TC (32.3

versus 28.6, t88 = 2.3, P < 0.05) groups. The CU and TC

groups did not differ significantly in age. There were sig-

nificantly more males in the FOD group than in either theCU (83 versus 58%, 2, 1 df = 8.4, P < 0.01) or TC (83

versus 60%, 2, 1 df = 6.0, P < 0.05) groups. There was

no significant gender difference between the CU and TC

groups. The FOD group were less likely than either the

CU (59 versus 88%, 2, 1df = 15.5, P < 0.001) or TC (59

versus 98%, 2, 1df = 22.1, P < 0.001) groups to be

unemployed. The latter two groups did not differ signifi-

cantly in employment status.

Hair morphine concentrations

Median group hair morphine and 6-MAM concentra-tions are presented in Table 2. Morphine was detected in

the hair of 98% of the CU group, 100% of the FOD group

and 72% of the TC group. 6-MAM was detected in 71%

of the CU group, 26% of the FOD group and 26% of the

TC group.

There were large differences between the three

groups, with the CU group having a median hair mor-

phine concentration approximately four times that of the

FOD group, who in turn had a concentration approxi-

mately six times that of the TC group. Due to the skew-

ness of the hair morphine concentration distributions,

log transformations were conducted, and t-tests per-formed between the group mean log hair concentrations.

The CU group had a significantly higher mean log hair

concentration than both the FOD (t140 = 4.1, P < 0.001)

and TC (t148 = 7.9, P < 0.001) groups, while the FOD

group had a significantly higher mean log hair concen-

tration than the TC group (t90 = 3.3, P < 0.001).

When analyses are restricted solely to cases in which

6-MAM was detected, a similar patten emerged. The CU

group had a significantly higher mean log 6-MAM hair

concentration than both the FOD (t80 = 2.27, P < 0.05)

and TC (t82 = 2.87, P < 0.05) groups, while the FOD and

TC groups did not differ significantly. The small numbersinvolved in the last analyses should be borne in mind.

The distributions of hair morphine concentrations

among the three groups are presented in Fig. 1. The large

difference between the CU and other groups is illustrated

by the 22% of the CU group who had hair morphine con-

centrations over 5 ng/mg, compared to only 2% of both

the FOD and TC groups.

There were no significant differences between males

and females in mean log hair concentrations in the TC,

CU or FOD groups. Age and log hair morphine concen-

trations were not significantly correlated in any of the


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Opiate overdose 981


three groups: TC (r = 0.08), CU (r = 0.03) and FOD

(r= 0.02).

There was a significant positive correlation among the

FOD group between log hair and log blood morphine con-

centrations (r=0.54,P < 0.001). There was no significant

correlation between hair morphine concentration and

bile morphine concentration (rs = 0.08) or between blood

morphine and bile morphine concentrations (rs = 0.23).

There was a significant positive correlation among

living users (i.e. CU and TC) between self-reported heroin

use and log hair morphine concentrations (r = 0.57,

P < 0.001), and between self-reported heroin use and log

6-MAM hair morphine concentrations (r = 0.54,

P < 0.001).

DISCUSSION

The major finding of the current study was the large dif-

ference between the three groups in recent heroin and

other opiate consumption levels, as indicated by hair

morphine concentrations. Current heroin users had a

Median hair morphine concentration (ng/mg)

Group Males Females Persons

CU

Morphine (n = 100) 2.10 2.10 2.10

(0.0023.00) (0.0021.00) (0.0023.00)

6-MAM (n = 71)a 0.47 0.42 0.42

(0.102.30) (0.103.30) (0.103.30)

FOD

Morphine (n = 42) 0.53 1.00 0.53

(0.0931.00) (0.224.10) (0.0931.00)

6-MAM (n = 11)a 0.16 0.51 0.33

(0.051.20) (0.070.63) (0.051.20)

TC

Morphine (n = 50) 0.14 0.08 0.09

(0.004.00) (0.005.10) (0.005.10)

6-MAM (n = 13)a 0.15 0.23 0.15

(0.120.45) (0.085.10) (0.085.10)

aCases in which 6-MAM was detected.

Table 2 Median hair morphine concen-

trations (range in brackets).

Figure 1 Distribution of hair morphine

concentration among fatal overdose cases,

current heroin users and therapeutic com-

munity clients


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median hair morphine concentration four times that of

the fatal overdose cases, indicating substantially heavier

recent opiate use. The fatal cases, however, were not

abstinent in the period prior to death, as the median mor-

phine concentration of this group was in turn six times

that of the therapeutic community clients, but they had

used considerably less heroin and other opiates than

active street users. As noted previously, the hair mor-

phine concentrations cannot be used to indicate which

specific opiates had been used by participants in the pre-

ceding 2 months. This, however, is not important. It is

exposure to opiates per se that is of relevance here.

However, it should be noted that even when the analyses

are restricted to 6-MAM, the specific metabolite of

heroin, the current user group had significantly higher

concentrations of 6-MAM than the fatal overdose cases.

It is important to note that the demographic charac-

teristics and toxicological findings of the fatal overdose

cases were similar to those of NSW overdose casesreported in other studies (Darke et al. 2000b). In terms of

key variables such as age, sex, employment, treatment

status, prison status and blood toxicology, this was a

typical group of NSW overdose cases. Similarly, the

demographics and drug use of the living heroin users

were consistent with other studies of NSW heroin users

(Swift et al. 1999; Darke et al. 2002). Consistent with the

epidemiological data on opiate use in NSW, the use of

opiates other than heroin among current users was

sporadic, having been used by less than half of the group,

and with median frequency monthly use. In contrast,

79% were daily heroin users.The results of the study are similar to those reported

by Tagliaro et al. (1998), but with some important differ-

ences. In the Tagliaro study, there was no significant dif-

ference between the hair morphine concentrations of the

fatal overdose cases and incompletely abstinent controls,

leading the authors to conclude that most fatalities had

recommenced heroin use after a period of virtual absti-

nence, and so had a lower tolerance to opioids than the

active heroin using group. The current results do not

support the conclusion that these cases were abstinent

from heroin and other opiates. Rather, they suggest that

the fatal cases were still using heroin and other opiates,but at a lower degree of chronic intake. It should also be

noted that the incompletely abstinent controls in the

Tagliaro et al. (1998) study had a mean hair morphine

concentration of 0.74ng/mg, compared to the median

value of 0.09ng/mg reported among the TC group in the

current study. The control group of incompletely absti-

nent controls in the Tagliaro et al. (1998) study thus

appeared to be using more heroin and other opiates than

the control group of TC clients from the current study.

In comparing the two studies, however, there are

methodological differences which should be borne in

mind. The analytical methods employed for hair analysis

were identical in the two studies. However, hair samples

in the Tagliaro et al. study varied from 3 to 5 cm in length,

meaning that morphine concentrations related to heroin

and other opiate use over different times for different indi-

viduals. No group data were presented, so it is unclear

whether there were systematic differences in measuredhair length between groups. The current study restricted

measurements to 2 cm of hair for all subjects, so heroin

and other opiate use for all groups and individuals was

measured over an equivalent period. It is thus not pos-

sible to directly compare morphine concentrations from

the two studies.

The fact that the FOD group of long-term users did

not appear to be using as much heroin and other opiates

as the current users may reflect the natural history of

heroin use. The rigours of the heroin life-style may mean

that after a decade or more of heroin use, many users cut

down their use, although remaining regular, dependentusers of heroin and other opiates. The low blood mor-

phine concentrations detected in many fatal overdose

cases may thus reflect less frequent use, and correspond-

ingly lower and less stable tolerance to opioids.

The potential role of alcohol in these fatal heroin

overdose cases should not be ignored. While not strictly

comparable, the comparative figures on alcohol con-

sumption suggest a much higher prevalence of alcohol

use among fatal cases than the broader heroin using

population. A recent comparative study of the blood toxi-

cology of fatal overdose cases and current street heroin

users provides support for this assertion (Darke et al.1997). It is possible that many of the overdose cases in

these two studies were compensating for their reduced

heroin and other opiate use by increasing their alcohol

use. The lower heroin and other opiate use of the fatal

cases in the current study, and the associated lower tol-

erance, would increase the risk of an overdose in the pres-

ence of alcohol. It is important to note the negative

correlation between blood alcohol and morphine con-

centrations among fatal cases, which is consistent with

earlier research (Steentoft et al. 1988; Ruttenber et al.

1990; Zador et al. 1996; Darke et al. 2000b).

It is worthy of note that there were no sex differencesin hair morphine concentration in any of the three

groups. The use patterns of males and females appeared

comparable. If this is so, why are males so heavily over-

represented among fatal overdose cases? It would appear

that male and female overdose cases were using at the

same lower levels compared to current users, and so

would be at a similar level of risk due to reduced toler-

ance. However, it has been demonstrated repeatedly that

substantially higher proportions of male overdose fatal-

ities have alcohol detected (Darke & Zador 1996; Darke

et al. 1997; Darke et al. 2000b). In the current study, 58%


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Opiate overdose 983


of male overdose cases had alcohol detected, compared to

14% of the females. A combination of low tolerance and

alcohol use may expose older male heroin users to sub-

stantially greater risk of overdose than females. The role

of alcohol among male heroin users, and its relationship

to overdose, is clearly one of significance to clinicians.

Further research on the nature of the relationshipbetween alcohol, heroin overdose and gender is clearly

warranted.

The study by Tagliaro et al. (1998) did not find a sig-

nificant correlation between blood and hair morphine

concentrations, which may reflect the fact that the time

frame over which heroin and other opiate use was

measured varied from individual to individual. The cur-

rent study found a 0.54 correlation between these two

variables. Heroin and other opiate consumption prior to

death in the current study was thus associated with blood

morphine concentration detected upon death.

Finally, the results of the current study are also rel-evant to the validity of self-reported drug use among

heroin users in research studies. There was a strong cor-

relation between hair morphine concentrations and self-

reported heroin use in the preceding month (the period

covered by the OTI), and between 6-MAM hair concen-

trations and self-reported heroin use. The literature on

the validity of self-reported drug use among IDU has

shown self-reported drug use to have high degrees of con-

current reliability and validity (Darke 1998). The current

study is consistent with these studies.

The correlation between hair and bile morphine

concentrations, however, was not significant. Bile mor-phine concentration is routinely reported in toxico-

logical reports of NSW overdose fatalities. Higher bile

morphine concentrations are assumed to indicate long-

term, chronic opiate use (Hepler & Isenschmid 1998).

The current study indicates that bile morphine concen-

trations should be treated cautiously, a point made by

other authors (Agarwal & Lemos 1996). The absence of

a significant statistical relationship between heroin and

other opiate consumption in the preceding two months

and bile readings suggests that bile may be a poor marker

for morphine consumption, and a poor diagnostic indi-

cator of dependent opiate use. For coronial mattersinvolving the determination of recent opiate consump-

tion, hair analysis would appear to provide a more accu-

rate measure than reliance upon bile concentration.

The profile of overdose cases as typically older,

untreated heroin users who are using less opiates than

current street users poses the question of how to reduce

overdose mortality among this group. As the current

data illustrates, it is unusual for fatal heroin overdose

cases to be enrolled in a treatment programme. In fact,

one previous study of overdose fatalities reported that

three-quarters of cases had never been enrolled in

methadone maintenance, the primary treatment modal-

ity in Australia (Zador et al. 1996). The recruitment to

treatment of at risk older heroin users may substantially

reduce overdose mortality and morbidity. While public

attention tends to focus on younger heroin users it is

older heroin users, who are using less heroin and other

opiates, that are at greatest risk. Targeted educationabout the role of alcohol in overdose may also help

reduce morbidity, particularly among male heroin users.

In summary, the current study found that fatal over-

dose cases were not abstinent from opiates in the period

prior to death, but were using considerably less heroin

and other opiates than active street users. Fatal overdose

cases appeared to have been at risk from a lower tolerance

to opiates and a higher level of alcohol consumption. This

group represents a high priority for recruitment into

treatment if overdose mortality is to be substantially

reduced.

ACKNOWLEDGEMENTS

This research was funded by the Commonwealth

Department of Health and Aged Care and the NSW

Department of Health. The authors wish to thank the

staff at WHOS, Odyssey House, the Kirketon Road

Centres, the Glebe Coroners Court, the NSW Institute of

Forensic Medicine and the Victorian Institute of Forensic

Medicine and the Drug Intervention Service Cabramatta.

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