Friday, January 13, 2006

Intro to toxicology testing

Toxicology testing: checking body fluids for drugs (including alcohol) and other toxins (e.g. carbon monoxide).

Drugs and alcohol cause or contribute to a large percentage of the deaths we investigate. They are involved in accidental overdoses, suicides, vehicular related accidents (driver, passenger or pedestrian), or can kill in concert with other “pathology” (e.g. an overly sedated individual with sleep apnea can/will die). Drug-drug interactions can be even deadlier than the use of a single substance, e.g. the use of benzodiazepines (like Valium) is most often only deadly when combined with alcohol. We do toxicology testing on every decedent in whom drugs, alcohol and/or toxins could be a consideration. It is easier for us than some Coroner’s offices, because we have our own in-house toxicology lab.

We test various body fluids. Vitreous, the fluid inside the eyeball, gives an excellent reflection of what was bathing the brain at the time of death. Blood, the most considered body fluid for testing, gives important results, but does have some limitations. The finding of drugs and alcohol in blood most often are used as proof of impairment, depending on the level. A finding of cocaine in the blood reflects use within a couple hours of death, but because there are enzymes in blood cells that can continue to break down cocaine after death and even in the blood draw tube the level found in the blood may not reflect that at the time of death. Delta-9-THC in the blood reflects marijuana use within about an hour of death, while Carboxy THC can be found in the urine out to about a week depending on chronicity of use. The finding in urine does not reflect impairment. There is also a distribution problem with blood testing as the drug moves about the body and in and out of various body compartments. We also test bile in some individuals, but a finding here only tells us that the use has been with about the last 2-3 weeks.

This will serve as a bit of an introduction to tox testing that I will build on in the future.

52 comments:

Anonymous said...

I found this post only after posting a question awhile back. I had asked if a coroner finds 2mg per liter in a decedent if it could make him commit suicide (jump off of a bridge) from just the cocaine. I was asking if he had that test post-mortem could that level have been so toxic could have made him kill himself. He did coke and from what I heard a half an hour later jumped from a bridge. Is there one core thing that could have made his suicide happpen with that much cocaine. He had absoulutely no signs of suicide ever that I noticed and I'm a mental health worker (25 years in the business, Masters). I hope that clarifies what I was asking. Your articles are so interesting

Dr. Richard Keller said...

Cocaine can contribute to suicidal action in 2 ways: 1) significant levels in the blood and brain can cause a drug-induced psychosis and/or 2) dropping levels or withdrawal after use can cause a deep depression with neurotransmitter depletion, or worsen an existing depression, both of these can result in self-harm or suicide.
Also, many using cocaine and other drugs are self-medicating, and the underlying condition/problem may have more to do with the death than the drugs.

John Donnelly PA-C said...

In a toxicology post mortem exam the lab reports cocaine/metabolites at 300 mg and Benzoylecgonine at 150 mg. Doe sthis indicate recent use? Would the use be heavy? The person entered the ER with acute laryngeospasm and died after they were unable to intubate or to place a trach in a timely manner.

Dr. Richard Keller said...

If those results are blood sample, the positive cocaine parent compund would point to recent use, i.e. within a couple of hours.
If they are urine results, the time frame could stretch out further to 10 or more.
Either result demonstrates significant consumption and while I have seen higher levels, could certainly point to lethal ingestion.
Laryngospasm (and even trismus) does occur with acute cocaine overdose and would be consistent with a significant ingestion and shorter time frame since ingestion.

Anonymous said...

My brother just recentlydied. There running the toxicology test on him. What I want to know is how long does this take? When will we know how he died?

Dr. Richard Keller said...

Unfortunately, it can take 3-5 weeks when tox testing is sent out to a reference lab for testing and interpretation. That is why I am glad we have our own in-house tox lab.

Anonymous said...

question: in a postmortem exam there was cocaine traces found in the vitreous body, but not found in the urine or blood. how long ago might have the person used cocaine, months, years?

Dr. Richard Keller said...

Still within a day of use, it doesn't stay very long in the vitreous, but longer than the blood

Anonymous said...

A friends's wife died and the her death is unexplained at present. She was suffering from headaches, muscle weakness, and on the night of her death she was suffering from a sever headache and double vision. She was given several drugs to control the pain and was told it was just a headache. Later she slipped into a coma and died. The family have been told that you can't test for a drug overdose after to death?

Dr. Richard Keller said...

Testing can and should be done. It is most often submoitted to a national reference lab by the Coroner/ME office. Testing can be done on blood (best), urine, vitreous, bile, the liver, and other specimens, including decomp fluids.

Scott Wolfinger said...

Would an autopsy uncover stage 4 lung cancer, which spread to the brain, causing tumors?

Dr. Richard Keller said...

Most definitely

Anonymous said...

My mother committed suicide and they only did an ethenal test. They did not do an autopsy. The lab has 16cc of blood left and I wanted to know what test I should order. 16cc isn't much to work with, but I do know that I want to see what her level of xanax were at the time. We had called 911 for an attempted overdose. The police and medics did not see a threat at the time and left the scene. She was found 8hrs later with both femorals cut. She was suffering an infection she contracted after having jaw surgery at the mayo clinic. Can any blood test be done to see if that may have had anything to do with her choice to leave us?

Dr. Richard Keller said...

There would be enough of a sample to check a Xanax level.

While it is obvious that your mother was suffering, there is no way to measure that suffering in a blood test, whether from the infection or not.

My condolences, make sure you have some support going forward

Jennifer Angel said...

Hello,
My brother committed suicide about 3 months ago. Blood was drawn for a toxicology report but the report came back negative for anything except caffeine. My family and I find this report to be unusual because my brother had a prescription for medical cannabis and he had been smoking cannabis regularly, so we find it odd that no THC showed up on the report.
Does this sound unusual to you?
Thanks.

Dr. Richard Keller said...

THC is detected in the blood for a much shorter time that it is detectable in the urine, so it is not at all odd that his blood was "negative", that is below the level of the test's lower limit of detection. There likely was some just not much, not enough for the test to be "positive". Had urine been tested you would have seen his use documented.

Anonymous said...

mom had stage 4 lung cancer
have concerns my mother was overdosed on morphine at a palliative care facility on Oct.5 it is now the 15th . can we have an accurate toxicology done at this point to find out if it was the morphine that killed her

Dr. Richard Keller said...

If blood was drawn at or near her time of death and those specimens are still being held levels could be run and may answer some of your questions. Otherwise, there is no way to get levels that would answer the question at this time.

My condolences.

angel mom said...

My son died 7 weeks ago at home, he was 17. He was found when we went to wake him for school. Autopsy was unremarkable. I called the medical examiners office and they said that they sent out for further toxicology and microscopic specimens, but the lady could not tell me what the specimens were or why they sent out for further toxicology. They say results will not be in for a few more weeks. Why would they need to do this?

Dr. Richard Keller said...

Unfortunately, many ME offices don't have the capability to do toxicology testing "in house". That necessitates that they send out the testing to one of the large reference labs and they are then at the mercy of the lab for result turn around time. It is not unusual for the results to take 3-4 weeks to get back.

My condolences. With a death like your son's death it is critical to examine toxicology testing before any formal pronouncement on cause and manner of death. All possibilities must be checked and ruled out, if possible. Hang in there, your answers will come.

Anonymous said...

My Brother in law recently dies and some of my family, including myself believe it was a suicide. He was found in his car along with a bottle of unisom. He didn't have sleeping problems. When the toxicology reports came back, they said that they found traces of the unisom but not enough to kill him. My question is, after you die, do all the drugs stay in your system or can they go away?

Dr. Richard Keller said...

Some drugs do indeed continue to be metabolized after death, most notably cocaine.

Diphenhydramine (Unisom) has not been well studied in overdose and death, so it is difficult to know whether how much post-mortem metabolism might occur. The amount of Diphenhydramine that might be lethal in an individual is going to depend on their overall health, what other meds they are taking, and if any other respiratory depressant was taken with it.

My condolences

Unknown said...

I'm a paramedic and recently have been called to court for call I was on. Long story short we found a male patient deceased, he was found weeks after his death, decomposing and such signs. Witness say he was a drug user and the were large amounts of drugs on scene. Toxicology reports came back negative for any drugs in his system, my question is how long will drugs stay in your body? Is it possible to still find traces after being dead this long?

Dr. Richard Keller said...

Decomposition decomposes/destroys everything. A specimen drawn weeks after a death will be negative, no matter how much was in the system at the time of death. Blood must be drawn with a few hours of death to be of value in finding drugs, the exception is cocaine which will continue to be metabolized in blood after death. Urine and vitreous will hold results hours to a day. Sometimes bile can be used later, but it reflects use within weeks of the time of death, not just near the time of death

Mel34 said...

My brother was found deceased no signs of foul play also was badly decomposed no drugs in system he used heroine and was a alcoholic would either one of those be able to be found if it was an overdose. Also if you overdose how long after using does it take to overdose is it immediate or can it take 10-30min. etc.

Dr. Richard Keller said...

My condolences.

It is no way to do testing for drug overdose in individuals who have become badly decomposed. The decomposition fluids are just not testable.

Depending on the amount or concentration of the drugs used/consumed overdose death can occur essentially instantaneously (I have seen those who have died with the needle still in their vein), but it can take up to an hour for their death to occur from respiratory and circulatory collapse.

Anonymous said...

Is it a painful death if its not instantaneous? What things would you look for to know if it happened pretty fast or not?

Dr. Richard Keller said...

It does not appear to be painful, there brain is very suppressed (shut down, as it were) as well making it unlikely they experience anything during that timeframe.

We look at the amount of drug found in their bloodstream, urine and vitreous in their eyes, the distribution of the drug (it takes time to move through the body and into the urine), presence of metabolites, fluid backed-up into their lungs and airways from not breathing effectively, and their heart not circulating as it should. All of that is taken into account in the determination.

Anonymous said...

My brother passed away toxicology is as follows
Volatiles Blood: Ethanol Positive 96 mg/dl
Volatiles Urine: Ethanol Positive 126 mg/dl

Comprehensive Blood Screen
Cocaine Positive 116 ng/ml
Cocaethylene Positive 101 ng/ml
Benzoylecgonine Positive 1885 ng/ml
Levamisole Positive

Comprehensive Urine Screen was positive for all of the above

His cause of death is overdose.. Ng is a nanogram that doesn't seem like a lot. He was 6'6 287 pounds. Do you agree with this determination?

Dr. Richard Keller said...

My condolences.

While a nanogram by itself is small, the units here are ng/ml, that is for every milliliter of blood there was that much cocaine. That is, indeed, enough of the toxic cocaine to result in his death. Also keep in mind , as I have said before, there is no safe level of cocaine. Even small amounts in the "right place" can cause the heart rhythm to become erratic, cause spasm/closing of blood vessels in critical areas of the heart and brain. Any or all of this can result in death for the consumer of cocaine.

Anonymous said...

In March 2016 we found out that my dad passed away of a suspected overdose. He had bipolar and had been very unstable for a while. We lost contact with him a while before his death with the last known person to have spoken to him in August 2015 (6/7 months before he was found). Through various pieces of information we found out that he only had vodka in the fridge in his apartment and some other signs pointed to suicide. The person who found him told us that it looked like "he had been there for a long time" and that there was a noticeable smell and flies around. 8 months on and we are still waiting for the post mortem results but we have recently found out from toxicology results that there was alcohol intoxication. If he had been dead for 6 months before he was found would there still be traces of alcohol/drugs in his system? And will the coroner be able to give us an estimated time of death?

kelly k said...

My brother died 2 weeks ago. About 5 weeks before his death he told me he did a small amount of cocaine. About a week after using cocaine, he had to get a couple of blood transfusions. He was a bigger guy, about 280lbs. My question is, with the time passed between use, and death, his size, and his transfusions, will his toxicology test show positive for cocaine? I ask because I want to kniw if he had done more closer to death. Thanks.

Unknown said...

Why would a cause of death report take 16 weeks?

Dr. Richard Keller said...

My condolences

If your father had been dead for 6 months, standard toxicology would be impossible. More likely death occurred within days of his body being found.

The coroner should indeed have an estimated time window of his death.

It is time for you to get pushier about getting his autopsy results.

Dr. Richard Keller said...

The order of these posts is somewhat out of sync and I apologize. Nonetheless to kelly k:

Any cocaine in your brother's system would have been used by him much closer to his time of death than 5 weeks before his death. Cocaine itself in his blog means use within hours. Metabolites in his urine could mean use up to a few days of his death.

Dr. Richard Keller said...

To "Unknown" above:

It shouldn't take that long, get pushy and demand results.

Brooke Deaton said...

Will steroid and testosterone use show up on a toxicology report from autopsy?

Dr. Richard Keller said...

These and many other drugs are not picked up on a routine post-mortem screening. The routine screen concentrates on frequently used/abused drugs. Many other drugs/medications can be "special ordered", but they must be suspected to be ordered.

Anonymous said...

My friend's ex-husband was recently found dead in a lake 6 weeks after he went missing. The body shows no signs of injury. He was drunk the day he went missing. Would they be able to tell if he was drunk at the time of his death or if he could of possibly been alive for a few days before he was killed? Originally one of his room mates said he came home late Friday night/ Early Saturday morning, and then left around 6pm Saturday night to go get his phone and jacket from the bar he left, now supposedly they are saying he never made it home. It's just weird to me that that room mate knew he was missing his cell phone and jacket before that information was released by the police. We are suspecting foul play so we are hoping his BAC could show if he died that night or another night. We are still awaiting his toxicology results but she was hoping you might be able to answer if it can show if he was drunk or not after his body was dead for 6 weeks or so.

Dr. Richard Keller said...

Any measure of blood alcohol at this point (6 weeks after death) would not accurately reflect alcohol that he may have consumed, unfortunately.

Unknown said...

My daughters ex boyfriend and father of her son just died, he was 25 and had a history of herion use. His autopsy was 2 days ago and the family tells her the medical examiner stated it was absolutely not a drug overdose...would they be able to determine that this soon

Dr. Richard Keller said...

Likely not, unless they have in office toxicology testing which is rather rare to have these days. Most of the time blood and urine or other body fluids have to be sent out and it takes weeks for results.

Amber Stoneberger said...

My sister was found deceased in a December. She was 32 and has no major health issues. She did have a prescription drug problem for many years. The tox screening came back and the only thing present in her system was Zoloft (.35). I'm very confused as I know she had taken a lot of xanax and other pain medications with in 24 hours of dying. Her cause of death was drug induced cardiac arrhythmia (Zoloft). No autopsy was done. Only tox screens. I'm very confused by this all. The prescription she had for Zoloft had not been filled since July and she had taken 27 of the pills in a 5 month period. She was in a bad place and was very down. She had basically hit bottom. I had assumed she had taken something off the street and overdosed. Is a level of 0.35 a leathal dose of Zoloft? The coroner had told me that he knew she died from a cardiac event and suspected it was cause by a drug or medication. He didn't feel an autopsy was needed. How would he have know that? I don't think she would have accidentally taken too much Zoloft as it didn't give her that buzz she wanted. I can only see her taking too much to end her life. I just need answers. I don't know what else to ask for.

Dr. Richard Keller said...

My condolences

It is possible for a Zoloft overdose to cause a cardiac rhythm problem related death, but it is infrequent. To get enough Zoloft into the system for a lethal overdose requires an intentional act.

It would be surprising that if she was known to have taken that none was found. Hopefully both her urine and blood were tested, because the results can be quite different. Ask if both were tested. That is really all I can add for you.

Anonymous said...

A few weeks ago my older brother commited suicide.. 5 days prior he went to a music festival with his friends, afterwards he admitted to me that he did a small amount of a drug called cat. I just want to know if that could be the cause for him leaving us, and if it would come up on his toxicology report

Dr. Richard Keller said...

Cat/Khat/Methcathinone taken 5 days before his death is unlikely to have contributed to his death, it would have been cleared from his system. Detection would require a specially ordered urine test. It is not routinely tested for.

My condolences.

Anonymous said...

Hi. My mother passed away on 11 April 2017. We found 2 empty bottles of whiskey on her dressing table. She was 61 years old and not a drinker at all. She was addicted to anti-depressants and sleeping pills. We are not sure whether it was suicide or not. She complained not sleeping well the last couple of months. I think she drank the alcohol to get some sleep. Blood were send to toxicology. Her autopsy was done about 36 hrs after death. Will her blood show her alcohol levels? I read up that the alcohol levels in blood decline after death? If this is the case how will we know what caused her death? Thank you

Linda s said...

my daughter was found unresponsive and sort of a blueish color and ice cold I found her about 11:15am that morning. when the medical examiners office called me the next day I was told there were no signs of a normal trama which would be like heart attack, seizure, whichever BUt i would not get the toxicology report for 2-3 months i did not find anything out of the ordinary like empty pill bottles laying around or packages. my daughter was on many medications for depression, OCD anxiety. she had blood not a lot sort of watery on her face around her mouth can you tell me if i would get the reading of this report in the mail or they would call me?

Dr. Richard Keller said...

Dear anonymous, My condolences regarding your mother's death.

The blood alcohol level will give some information, but will not be totally accurate because it does decline slowly after death, as you mention.

Likely, the levels that were drawn for her other meds will also contribute information. An autopsy, if done, would also contribute

The death investigation along with the post-mortem drug.med/alcohol levels and the autopsy are considered when arriving at the cause of death.

I would also mention that many people who overuse alcohol are secret drinkers and function well for an extended period of time, until they can't any longer.

Dr. Richard Keller said...

Linda s

My condolences.

The toxicological report will most likely give you the answers you need [they should call you with the results, not send them in the mail. I'd complain if they do the latter]. The material you mention around her mouth at death is called "purge" and is consistent with a drug/med induced death.

amy melissa said...

My 16 yr old son has been deceased for almost 6 months we don't know the cause of death yet and have heard nothing about his toxicology report . I found him in his room when he died . The medical eximainer said she had seen cases like his but it was highly unusual . I asked her was there any way it was drug related and she said no . When the EMT 's worked on him they pulled a lot of blood and fluid off of his lungs . He was fine that night when I went to bed we had gone to the mall earlier went shopping etc . Why would the results take so long to get back ?

Dr. Richard Keller said...

Actually, it sounds very consistent with a drug overdose induced death. The blood and fluid in lungs and airways occurs frequently
in overdose deaths.

Toxicology results should not take 6 months to be reported out. You will, apparently, need to really push to get the results (demand them) and you may need to go over the head of the medical examiner (everyone reports to someone).

My condolences