Segmental hair analysis in order to evaluate driving performance

On the 31st of July 2002 the Lombardy local government issued a memorandum, C.R. 35/SAN, providing "guidelines to investigate drugs of abuse addiction in order to judge driving performance". About hair samples, this memorandum advises that the proximal lock of 6 cm-length would be analysed for opiates, cocaine, cannabinoids, amphetamine and derivatives, divided into two segments of 3 cm, each. The Local Medical Driving Licence Commissions (CML) can decide whether or not to enforce these instructions; from our survey it resulted that most CMLs do not abide by the memorandum, not requiring segmental analysis. The purpose of our study was to verify whether this procedural discordance could affect analytical results and, consequently, the evaluation of the subject's driving performance. We analysed hair samples taken from subjects who were requesting the renewal of their driving licence in our Laboratory during the period from 1 August 2002 to 31 December 2006. We divided samples into two groups: (1) samples previously analysed in one single segment which resulted positive for at least one analyte, but under the cut-off (0.5 ng/mg), were re-analysed in accordance with the guidelines; (2) samples previously processed following guidelines which resulted positive in one of the segments were newly analysed in a single segment. Comparing the new results with the original ones, an increase of positive results emerged in the first group. The second set of results fully supported the first ones. These results underscore the importance of the 35/SAN memorandum, so if the guidelines had been followed there would have been a larger amount of driving licence renewal denie

Alcohol and drugs fatal road accidents between 1999 and 2009

Introduction: The Italian National Institute of Statistics recorded 5.131 fatal road accidents in 2007. One of the main causes of traffic crashes is driving under the effects of alcohol and/or psychoactive substances (illicit drugs or some medication). In Italy the legal limit of blood alcohol concentration passed from 0.8 g/L to 0.5 g/L in 2007 and the Court can decide if also psycoactive substances have to analysed in blood in fatal accidents. Aims: A retrospective study was carried out to produce epidemiological data concerning the role played by alcohol and psychoactive substances in fatal road accidents. The focus of this study was to establish the dimension of this problem and to describe the characteristics of people involved in road fatalities under psychoactive substance effects. Methods: The material studied is made up of 487 subjects deceased in consequence of road accidents and examined at the Department of Legal Medicine, University of Pavia, during the period from 01-01-1999 to 30-06-2009. More than 70% of people involved in traffic accident were mothorvehicle driver, while pedestrian and cyclist are equally represented. Blood specimens were analyzed for alcohol and in 262 cases also for illicit and therapeutic drugs. Drugs when present were quantitated. Urine, when available, was submitted to immunochemical screening of drugs of abuse and confirmation of positive results by GC-MS. Results:. Alcohol above 0.1 g/L was detected in 205 cases (42.2%) and the concentration measured was above the legal limit (0.5 g/L) in the 70.7% of these cases. A blood alcohol concentration (BAC) between 1.5 g/L e 2.5 g/L was mesured in 55 cases (27%) while 28 subjects (14%) had a BAC higher than 2,5 g/l. Central nervous system active drugs were detected in 23.3% (62 cases). Cocaine and metabolites (29%) and cannabinoids (25%) are the most represented drugs of abuse; opioids were detected in 24 cases, morphine was detected in 9 cases and methadone in 15 ones, and no amfetamine and derivatives are founded. Association with alcohol was found in 25.4% of positive cases for illicit drugs. Conclusions: The incidence of alcohol and drugs among the population involved in fatal traffic accidents highlight the importance of performing qualitative and quantitative blood analyses to assess the effective role of alcohol and drugs in driving impairment

Methadone-related deaths: a worrying increase

Objectives. Methadone has been used in Italy in maintenance programs for heroin addicts since the early 1980s. Its use requires a careful evaluation of the dosage, in relation with the opioid tolerance developed by the patient under treatment. The number of methadone-related deaths observed by our Laboratory has been increasing during the last five years: the aim of this work is to discuss the causes of such an increment, whether there has been an increase in methadone use without medical prescription, an incorrect use of the drug when take-home doses were prescribed, simultaneous consumption of alcohol or drugs, or even doctor’s carelessness at the Addiction Units when judging the appropriate methadone dosage. Materials and Methods. Between 2006 and 2010 we observed twenty cases of lethal poisoning related to methadone administration, seven of those in the year 2010 alone. Fifteen were males and five females, the average age being 32 (min 2 - max 54). The following toxicological analyses were carried out on postmortem samples: HS-GC quantitative analysis of ethanol in blood; GC-MS systematic toxicological analysis (STA) in blood followed by quantitative determination of identified drugs; GC-NPD determination of methadone in blood and in urine when available. Whenever possible (12 cases) GC-MS quantitative determination of methadone and morphine in hair (2 cm closest to the scalp) was performed. Results. It has been established that half of the deaths had been caused by methadone only, while in the other ten there had been contribution, besides methadone, of other substances (especially ethanol). The evaluation of the anamnestic data has allowed to observe that six of the deceased subjects were not following any methadone therapy, five had take-home methadone doses, while three other subjects had started methadone therapy just a few days earlier. In three of the remaining six cases, all involving subjects with supervised methadone consumption, blood alcohol concentration was over 200 mg/100 ml, and in one case there were high concentrations of Promethazine and Levomepromazine, the only medications found besides methadone. Highest blood methadone average concentrations (891 ng/ml) were surprisingly those related to subjects who had just started methadone treatment, followed by those of subjects with take-home doses (720 ng/ml). Lowest concentrations (455 ng/ml) were, conversely, those of subjects who had taken methadone without a doctor’s prescription and those of patients with supervised consumption by a drug treatment service (695 ng/ml). Conclusion. By evaluating the results we came to the following conclusions: 1) the death of three patients during induction into methadone treatment have been caused by administration of excessive starting doses; 2) when take-home doses are prescribed, sometimes patients display a tendency to irregular assumption of the drug, this being documented through the occasional findings of unconsumed syrup bottles at the patient’s domicile and through hair analysis, subsequently increasing the risk of overdosing; 3) in one single case, take-home methadone has indirectly lead to the death of a two years old girl who has drunk the syrup left unattended by her father; 4) among subjects with supervised consumption, high blood concentrations have generally not been observed, but there has been simultaneous alcohol or psychotropic drugs intake; 5) the abuse of methadone illegally obtained, often through patients allowed to carry it home, is rather common. Special caution has to be exercised in prescribing take-home doses, together with a more careful evaluation during induction into methadone treatment when tolerance is unclear. Key Words: Methadone, intoxication, blood level

Fatal intoxication due to dichloromethane exposure: a case report

Introduction. Dicholomethane (DCM) is a solvent, industrially used also as component of paint and varnish removers. Due to its high volatility, its use in confined spaces can cause a serious health hazard as a result of accumulation of the solvent vapour. At high levels, DCM acts on the central nervous system, major toxic effect being narcosis, depression and at last death. A case of accidental death in working place is described. Materials and Methods. A 50-year-old white male was found dead at his working place. He was found on one's back on tank border he was cleaning without using a gas mask.The tank contained paint residuals. The following toxicological analyses were carried out on post-mortem samples: at first sistematic toxicological analysis (STA) by GC-MS, ethanol and volatile substances detection by headspace gas chromatography (HS-GC) were performed in blood. A positive result for dichloromethane emerged and so quantitation in biological fluids, organs and viscera was performed after optimization of the headspace gas chromatography-flame ionization detection technique (GC-HS-FID). Carboxyhemoglobin levels were also measured by spectrophotometric tecnique. Results. No drugs neither ethanol were found in blood sample. The following concentrations of DCM were measured: cardiac blood (220 mg/L), urine (25 mg/L), gastric content (22 mg/L), brain (170 mg/kg), fat (170 mg/kg), liver (250 mg/kg), lung (330 mg/kg), and kidney (160 mg/kg). Carboxyhemoglobin resulted at a level of 8%. Conclusion.The cause of death was an accidental poisoning due to dichloromethane. The normal range of carboxyhemoglobin and the very high levels of DCM in biological samples indicated that the death was the consquence of the direct effect of dichloromethane on the central nervous system