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•Synthetic cannabinoid use has been associated with lethal outcomes.•Pre-existing conditions may produce greater risk for a fatal case outcome.•Differences of opinion exist regarding cause and manner of death determination. Adverse effects associated with synthetic cannabinoid use include agitation, psychosis, seizures and cardiovascular effects, all which may result in a lethal outcome. We report the collection of data from 25 medical examiner and coroner cases where the presence of synthetic cannabinoids was analytically determined. Participating offices provided case history, investigative and relevant autopsy findings and toxicology results along with the cause and manner of death determination. This information, with the agency and cause and manner of death determinations blinded, was sent to participants. Participants offered their opinions regarding the likely contribution of the toxicology findings to cause and manner of death. The results show that some deaths are being attributed to synthetic cannabinoids, with the highest risk areas being behavioral toxicity resulting in excited delirium, trauma or accidents and as contributing factors in subjects with pre-existing cardiopulmonary disease. While insufficient information exists to correlate blood synthetic cannabinoid concentrations to effect, in the absence of other reasonable causes, the drugs should be considered as a cause or contributory cause of death based on history and circumstances with supporting toxicological data.

Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. To better understand urban opioid overdose deaths, this paper examines geographic, demographic, and clinical differences between heroin-related decedents and prescription opioid decedents in San Francisco from 2010 to 2012. During this time period, 331 individuals died from accidental overdose caused by opioids (310 involving prescription opioids and 31 involving heroin). Deaths most commonly involved methadone (45.9 %), morphine (26.9 %), and oxycodone (21.8 %). Most deaths also involved other substances (74.9 %), most commonly cocaine (35.3 %), benzodiazepines (27.5 %), antidepressants (22.7 %), and alcohol (19.6 %). Deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African-American individuals. Decedents in high-poverty areas were significantly more likely to die from methadone and cocaine, whereas individuals from more affluent areas were more likely die from oxycodone and benzodiazepines. Heroin decedents were more likely to be within a younger age demographic, die in public spaces, and have illicit substances rather than other prescription opioids. Overall, heroin overdose death, previously common in San Francisco, is now rare. Prescription opioid overdose has emerged as a significant concern, particularly among individuals in high-poverty areas. Deaths in poor and affluent regions involve different causative opioids and co-occurring substances.

We reviewed postmortem fentanyl cases to compare peripheral blood (PB) concentrations between deaths caused by fentanyl and deaths in which fentanyl was incidental. Furthermore, we describe PB concentrations in fentanyl-caused deaths with and without transdermal (TD) fentanyl use. Our review produced 20 cases with PB fentanyl. Of these, 13 were determined to be fentanyl-caused deaths. Eight of the 13 involved TD fentanyl. The remaining 7 cases were decedents undergoing therapy with fentanyl (TD, n  = 3; intravenous, n  = 4). In the 13 fentanyl-caused deaths, the mean PB fentanyl level was 30.1 ng/ml. In the deaths involving TD fentanyl use, the mean fentanyl level was 41.7 ng/ml. Deaths without TD fentanyl use had a mean fentanyl level of 21.3 ng/ml. There were 7 other cases with incidental fentanyl. In 3 of these, therapeutic TD fentanyl was used and the mean PB concentration was 16.6 ng/ml. In the remaining 4 deaths in which therapeutic intravenous fentanyl was employed, the mean PB fentanyl level was 8.1 ng/ml. Our review suggests that a PB fentanyl concentration equal to or greater than 25 ng/ml indicates that fentanyl should be considered as being contributory to or the cause of death. However, ranges of measured PB concentrations are once again shown to overlap between subjects who overdose and those who use fentanyl as prescribed. In addition, fentanyl-caused deaths involving TD fentanyl exposure have higher PB fentanyl concentrations than those who did not use transdermal patches. Although enlightening, our study suggests that further evaluation of fentanyl concentration variability among different postmortem blood specimens is needed.

New designer drugs, access to databases, and changing availability of samples for analysis have changed the face of modern forensic toxicology in recent years. Forensic Toxicology: Drug Use and Misuse brings together the latest information direct from experts in each sub-field of the discipline providing a broad overview of current thinking and the most innovative approaches to case studies.The text begins with an in-depth discussion of pharmaco­epidemiology, including information on the value of nationwide databases in forensic toxicology. The use and abuse of drugs in driving, sport and the workplace are then discussed by industry experts who are conducting case work in their field. Not only are new drug groups discussed (NPS), but also their constantly changing impact on drug legislation. Synthetic cannabinoids, khat and mephodrone are discussed in detail. Following a section devoted to legislation and defence, readers will find comprehensive chapters covering sample choice reflecting the increasing use of hair and oral fluid, and also the less commonly used sweat and nail analysis. New and old case examples are compared and contrasted in the final part of the book, which will enable readers to understand how drugs impact on each other and how the interpretative outcome of a case are dependent on many aspects.From use of pharmaceutical drugs in a clinical setting, through smart drugs to new psychoactive drugs, this book documents the wide range in which drugs today are abused. This book will be an essential resource for postgraduate students in forensic toxicology, and for researchers in forensic toxicology laboratories who need the latest data and knowledge.