Interpretation of Autopsy Report
Category: Health > Medicine
Asked by: physiologyphd-ga
List Price: $20.00
05 Dec 2005 08:30 PST
Expires: 04 Jan 2006 08:30 PST
Question ID: 601659
I'm trying to interpret the results of my mother's autopsy. The final conclusion for cause of death was "intoxication by morphine and alprazolam" and the manner of death was "Undetermined-ingested unprescribed narcotic and prescribed sedative". She was 52 y/o, 90lbs, and the autopsy was performed 24hrs following the approximate time of death. Heart blood samples yielded the following results: (FREE) Alpha-hydroxyalprazolam 0.057 mg/l, alprazolam 0.518 mg/l; (TOTAL) alpha-hydroxyalprazolam 0.213 mg/l, alprazolam 0.518 mg/l; (FREE) morphine 0.34 mg/l; (TOTAL) 3.2 mg/l. She had a Rx for the Xanax, however the morphine was not Rx, and was probably left over from my father's terminal bout of cancer. I'm fairly certain this is suicide, as she died 2 years to the day that my father did, in bed, holding his urn, with both these drugs in her system. However, in an effort to explain this very objectively to family I was trying to back calculate the approximate oral dose of each she would have had to ingest to yield these blood values. I have looked for the information I need to do the calculations on the web, to no avail, so I'll happily pay for a full explanation ($20-40).
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Re: Interpretation of Autopsy Report
From: markvmd-ga on 05 Dec 2005 13:14 PST
Physiologyphd, please accept my condolences for the loss of you parents to such circumstances. I hope you and any siblings will give serious consideration to seeing a therapist to deal with the complex issues of such an experience. I am not an expert in this field. Please familiarize yourself with the disclaimer provided by Google. I will not be answering this question in its entirety-- that is up to a Researcher-- but would like to give a relatively simple analysis of the part the alprazolam played. The pharmacokinetics of any drug can be dicey to follow. Calculating serum concentrations and backtracking to determine initial doses is even more complex and may change based on how the drug is taken and a host of other factors. Some medications stop metabolizing if a patient dies while others may break down into different components than if the patient was alive. Such details, should you want them, can be obtained from the drug manufacturer. "Therapeutic plasma levels of alprazolam range from 5 to 50 µg/L, toxic concentrations are between 100 and 400 µg/L." Schulz M, Schmoldt A. Therapeutic and toxic blood concentrations of more than 500 drugs. Pharmazie 1997; 52 : 895-910. If you are correct in your statement that the blood values given were in mg/L (milligrams per litre) then you must multiply those numbers by 1000 to get µg/L (micrograms per litre). This does seem to be the case. The common oral therapeutic dose of 1 to 6 mg/day results in a serum level of 0.019 to 0.055 µg/L (average peak at 1.3 hours post). Thus, the low range for toxicity can be reached with just 12mg of the drug. Benzodiazepines, a group of drugs to which alprazolam belongs, are remarkably benign when taken alone. There is a case study example of a 36 year old man with a serum level of 527 µg/L recorded 12 hours after an attempted suicide who recovered well (this can be seen at http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijpharm/vol1n2/bis.xml). It is in combination with other drugs or alcohol that they contribute to a fatal outcome. Morphine uptake rates are dependent on the formulation of the drug and I am unfamiliar with the conversions for oral versions as I only studied IV and IM rates. There is this citation: "Following single-dose oral administration of a 60 mg dose of AVINZA (morphine sulfate extended-release capsules) under fasting conditions, morphine concentrations of approximately 0.033 to 0.066 mg/L were achieved within 30 minutes" per rxlist.com. Other formulations may have other rates. The theraputic serum level starts at about 0.02mg/L The fatal range for morphine begins at 0.2 mg/L and runs up to 2.3 mg/L. Please look into therapy for yourself. You are quite likely to be at increased risk of suicide yourself. I extend my best wishes and trust that you can work through this terrible experience.
Re: Interpretation of Autopsy Report
From: baz2121-ga on 05 Dec 2005 20:19 PST
I am sorry for your loss, and the previous post by markvmd explains most of it, but what you need to know, is that an autopsy explains aetiology of death to the best of the medical and scientific evidence discovered through the procedure. If the conclusion was "intoxication by morphine and alprazolam" then that is what was found. Whether or not this was intentional, accidental or suicidal, the autopsy cannot tell you. The autopsy can only tell you how she died, not why. Unless there was a sepcific point of investigation, then you'd have to find out for yourself. Your calculations to determine the dose, need to include the half-lives of the drugs, which will tell you how long they were in here system. But considering the way your mother passed, your opinon is very likely. And please follow the advice given by markvmd, it's very good advice and will help as time goes on. Baz
Re: Interpretation of Autopsy Report
From: physiologyphd-ga on 06 Dec 2005 05:44 PST
I appreciate the feedback and concern. The intent was not to 'prove' anything as much as it was to put all the information on the table so that people can draw their own conclusions, since the autopsy was inconclusive as to intent. The point I was attempting to address was how likely this was an accidental overdose. So, a ballpark estimate of what was ingested would help address that point. She was a small woman, and the combination of the two drugs could have had unintended side effects. She was suffering grand mal seizures as a byproduct of silicon poisoning (implants) and annorexia. She was both clinically depressed as well as anxious (thus the 2mg tid Rx for Xanax). In addition to the Xanax RX where two antidepressants, two anti-seizures, a muslce relaxor, and a potent anti-inflammatory. However, none of these drugs were found in her system, nor were any of the 30+ Rx she had stockpiled from misdiagnonses over the years (she horded Rx drugs), suggesting that she was not being compliant with her treatment. So, the non-Rx morphine was either a sign of intent, or a last ditch effort at pain modulation. However, taking the context (date, position, decline in mental health, weight loss, etc) into account it is difficult to assert that this was not intentional. As I said before, I appreciate the concern, but my point was to compile all the objective evidence, so that family members who knew less of the interpersonal information, and do not have a PhD in physiology could at least have the facts appropriately framed. The information that markvmd sent was similar to what I had found on my own, so it was not surprising. Given that the upper end of the fatal range listed was 2.3 mg/L, the fact that she had a TOTAL blood value of 3.2 mg/L makes it difficult to conclude that this was the result of an unintended synergy between the two drugs, especially when you consider that she had a fatal dose of Xanax alone (518ug/L). If anyone disagrees with markvmd's information, please pipe in. I'll withold final conclusion for a couple more days in case anyone else has some insight. I also really appreciate the gesture of posting comments instead of answers. It is refreshing to be reminded that not everyone is motivated by money alone. Thanks
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