Saturday, March 04, 2006

Cocaine and Death

As I have mentioned before, Cocaine is the #1 killer drug in Lake County. It is a very potent nervous system stimulant, which explains its euphoric and its lethal effects (in combination with its vascular effects). For some reason we have seen a bit of an up-tick in its lethal consequences recently. I don't know why and I don't know if it's a trend.

Cocaine is rapidly metabolized in the body, which makes it a bit tricky to catch in the bloodstream of a live individual. Usually, however, levels of Cocaine and/or its metabolites measured in bodily fluids after death give us the information we need to arrive at a determination of Cocaine-induced death. Most of the Cocaine consumed (inspired, injected, ingested) is metabolized in the liver, but Cocaine is relatively unique in that enzymes in blood cells also break it down, so Cocaine levels in the blood can drop after death and can even drop after blood is drawn and is in the lab tube. Cocaine's various metabolites are more stable in the blood and cocaine is relatively stable in the urine and vitreous (eyeball) fluid. Vitreous levels can be particularly helpful in reflecting brain levels.

We can get one bit of information if we find Cocaine in the blood we draw (or blood drawn in an ER before the individual dies). We then know that the individual likely consumed the cocaine a short time (at most, a few hours) before their death, because the half-life in the bloodstream (amount of time for one half of the substance to be cleared/metabolized) is thirty minutes. Through its vascular effects, primarily, Cocaine can kill several hours after consumption.

As our toxicology reports state "there are no safe levels of Cocaine". There is little doubt as to the cause/contribution to death when very high levels are found in the blood, urine, and/or vitreous fluid. But even lesser amounts kill individuals with heart electrical problems or vascular/circulatory abnormalities, or with risk of seizure or other neurologic abnormalities. Chronic Cocaine use can actually contribute to the development of these abnormalities, placing the user at increased risk of death.

72 comments:

Anonymous said...

This is the closest site I can find that may help me. My son committed suicide by cocaine. The coroner said his cocaine level in his blood aobut 4 hours after his death was 2 mg. per liter. Is this toxic enough to make one commit suicide? Your "Live from the coroner's Office" ios interesting in what I am now going through

Dr. Richard Keller said...

That Cocaine level is certainly a toxic/lethal amount and consistent with consumption of a large amount of Cocaine.

We have also seen that level in accidental overdoses, because a user at times does not know "when to quit" and will use every bit "on hand".

beckr2 said...

My sister was killed in an auto accident, she did not cause the crash. However, the post-mortem blood test showed
cocaine less than o.o5mcg/ml
benzoylecgonine 0.24mcg/ml
methylecgonine 0.10 mcg/ml
I need to know does this mean she was doing cocaine the night of the crash.Her blood ethanol was also 173mg/dl. Thanks in advance

Dr. Richard Keller said...

While it is very difficult to predict based on one-time measurement, it is likely that her cocaine use was a few to several hours prior to the crash. the half-lives of the various compounds (4 hrs for methylecgonine and 6 hrs for benzylecgonine) would likely put it in the 4-6 hr range. Again just a guess.

Anonymous said...

In an autopsy report, is 1.5 mg/L of Benzoylecgonine and Less than0.10 mg/L high levels?
what does this amount concur with?
high does before death or low.
the death occurred on November 19th
the evidence was submitted on November 21st.

Dr. Richard Keller said...

The finding of the benzoylecgonine would be consistent with use of cocaine within a few days, probably less than about 4 days depending on chronic use, and greater than an hour or 2.

Cocaine pharmacokinetics do not allow for back calculation to an amount used, metabolism is not linear like alcohol.

So while likely a significant dose was "ingested", there is no telling how much.

Anonymous said...

HI thanks for the answer.
I just realized I left out a word.
so I am re - asking the question.
Here is what I meant to write:
In an autopsy report, is 1.5 mg/L of Benzoylecgonine and Less than0.10 mg/L of cocaine levels?
what does this amount concur with?
high does before death or low.
the death occurred on November 19th
the evidence was submitted on November 21st.

Dr. Richard Keller said...

My answer would be pretty much the same, although the low cocaine level may point to the shortest time frame being a bit longer. Cocaine half-life in blood is very short, i.e. half an hour.

The other thing to keep in mind is that red cell enzymes can continue to break down cocaine in the blood stream even after death. Another confounding factor.

Anonymous said...

Thank you again. Just one more question please.

The autopsy revealed this:

Blood (Chest) Less Than 0.10 mg/L cocaine.

Blood (Chest)1.5 mg/L Benzoylecgonine.

Body found 4:49 a.m. November 19th

Autopsy began on 11:20 a.m. November 20th.

Is the amount of "actual" cocaine found in the blood in the chest a lethal amount, or at least a large amount? Because(red cell enzymes can continue to break down cocaine in the blood stream even after death) could the amount have been higher?
sincerely,

Dr. Richard Keller said...

Keep in mind as we put in our tox reports:
"There is no safe level of cocaine"

The total of the cocaine and its metabolite would certainly be consistent with a cocaine intoxication death (whether the cocaine itself is at a lethal level would certainly be debatable), but, as your case is laid out, the cocaine level was likely higher and dropped over time.

Carlos said...

Doc-

A guy was killed by multiple stab wounds. The body was found cool to the touch on Monday morning.

The samples for toxicology testing were taken 24 hours later during the autopsly.

The tox. tests were performed 24 hours after that, on Wednesday, and the results were:

Cocaine - 0.02 mg/L.

From that information, can you give me an educated guess as to roughly when that guy last used cocaine??

Thanks.

Dr. Richard Keller said...

Guessing within a very few hours (minutes?) of death

Vincenzo4@hotmail.com said...

My brother was found dead on 9/27/07 at about 08:00; autopsy was started at around 09:50; Tox results follows: Blood: Ethanol, 0.261%, Cocaine 0.043 mg/L, Cocaethylene 0.092 mg/L, Benzoylecgonine 2.422 mg/L and Acetaminophen 43.38 mg/L; Urine: Ethanol, 0.241%, Cocaine 7.549 mg/L, Cocaethylene 7.749 mg/L, Benzoylecgonine 66.501 mg/L and Acetaminophen 20.30 mg/L and Oxycodone 7.222 mg/L. Bile had Ethanol 0.270 and Nasal Swab Analysis EME, PTROPINE, COC; Microscopic Findings Pulmonary Edema and Congestion; Focal Acute Bronchail Pneumonia; Moderate Fathhy Metmorphosis of the liver and Diffuse Visceral Congestion. "Mucosal surfaces of the larnyx and trachea are partially covered by a red tan foamy liquid material...trachail-bronchail tree..."

Dr. Richard Keller said...

All too typical of mixed overdose/intoxication death: cocaine, alcohol and OxyContin (with acetaminophen in the mix). Nasal inhalation of the 1st and ingestion of the others. Cocaine used within a short period before death.

Anonymous said...

My friend died last year and the autopsy listed Acute fulminant pulmonary edema & congestion, Acute visceral congestion,Moderate hepatomegaly, early CAD under findings. Under Toxicology, there were several drugs listed under Comprehensive Blood Drug Screen; Alprazolam: 15 ng/mL, Citalopram(trace)Cocaine(trace)Benzoylecgonine: 1760 ng/mL & Metoclopramide(trace). Under Comprehensive Urine Drug Screen, there were Alphahydroxyalprazolam, Citalopram, Cocaine, Cocaethylene, Benzoylecgonine, Hydrocodone, Metoclopramide, & Oxazepam. The cause of Death is listed under Accident(Acute Cocaine Toxicity). What is the signifigance of such a large amt of Benzoylecgonine? and it says there is only a trace of cocaine so why is death listed as cocaine toxicity? Some friends have said he wanted to die but I never got that impression from statements he made. He had recently been hosptitalized w/pneumnia and was on a respirator for 2 weeks two weeks before his death. Does it sound like the a high level of the Benzoylecgonine caused his death or the combination of all of the drugs?

Dr. Richard Keller said...

Benzoylecgonine is the primary metabolic product from cocaine. It has a longer half-life (the time in which ½ of the substance is cleared from the body) than the parent compound, cocaine, 6 hours as opposed to half an hour. Cocaine also continues to be metabolized by blood cells even after death.

These results are consistent with cocaine-induced death. It is not unusual to find a “trace” of cocaine in the blood in such a situation. Most of those types of death are accidental in that folks tend to consume all of the cocaine they have available, not saving some for later.

Anonymous said...

Thank you for your response!I would like to ask a couple of more questions as there has been so many unanswered questions and I have had a hard time dealing with his death. He had struggled with his addictions the past couple of years;I think what got him started was the prescription narcotic pain medication he received for legitimate back & shoulder pain. When he ran out and couldn't get more, he would get cocaine or other drugs like oxycontin from "friends". I don't do drugs so it was hard to deal with but we had been in a relationship for several years so it's hard to just leave. I finally had enough and left a week before he died but I was still stopping by every day and he had a Drs appt scheduled the day after he died to try and get into a rehab program. I came home and found him sitting up slumped to the side with a pillow with uneaten food on it. I just thought he was sleeping so didn't try to "wake" him up right away. Our dog was sleeping on his feet. I finally tried to arouse him unsuccessfully and took his blood pressure with the machine his Dr had given him and it said -0- so i called 911. They told me to get him on the floor and try CPR. When I tried to move him, he fell on the floor and hot water squirted out from under his arms and there was really a bad smell all at once. They came really fast and worked on him in the ambulance for quite awhile unsuccessfully before they took him to the hospital but I found out later he was already dead when they got there and most likely had been dead when I got there. He was only 44 so I have been haunted by the vision of him sitting there ever since. He was depressed that I had left but he wanted me to come back and he told me on the phone that morning that he felt pretty good so I really don't think that he committed suicide but some of his friends seem to think he did because of the high levels of drugs. Everyone has their own theory and there has been so many ugly rumors since then, it has caused me alot of grief. One of his friends said he brought him over a 72 hour morphine patch which he sucked all of the juice out of;Another rumor is that he went into a seizure and his friends got scared and set him up the way I found him and left. I think everyone was afraid there would be a Police investigation but there wasn't much of an investigation. They made us leave(the dog too) for 4 hrs. The CSI team came and took some pictures and took all of his medicine and left. It definitely wasn't like the TV show. One of his aunts said there was rat poision in his system. I am having a hard time dealing with his death even though it's been a year now as I feel guilty because I left and wonder if he did, in fact committ suicide even though there wasn't a note.I am confused about the amt of benzoylecgonine. It is in the form ng/mL. How is that in relation to mg/ML? Is 1760 ng/mL really an abnormally large amt? Also, did he most likely smoke it or snort it? The last time I talked to him was 10:30am. I found him @ 2:30 pm when I thought he was sleeping. What was the most likely time of death? The medical examiner put the time he arrived at the hospital but from what the firemen and ems guys said, he was dead when they got to my house because he flat-lined on the machine and didn't have any blood pressure. Even though, the autopsy says accident, I still wonder if he took his own life. He always told me he would never do that, that only cowards would do that plus he had food on his lap and I don't think a person trying to kill theirself would bother to eat but I really don't know. To sum it up, based on this post and my previous post, do you think he committed suicide? What is the most likely time of death? Do you think he suffered? and is the amt of benzoylecgonine a lethal amt? also, how does the ng/mL convert to milligrams per Liter? I have been trying to move on but it has been very difficult. It would put my mind at ease if you could answer these questions even if they are not the answers I want to hear. Thank you so much for your help!

Dr. Richard Keller said...

The morphine (or possibly fentanyl) from the patch would have shown up in the tox testing. There are several ways to extract drug from those transdermal patches, sucking on it being just one. It would appear that if it did occur, he didn’t receive a significant amount.

Seizure activity certainly can occur at the time of death and has scared away “friends” in other cases, especially if the death involves some illicit activities.

“Rat Poison” most often involves a blood thinner; signs of its overdose would have been present at autopsy. Arsenic requires special testing, but considering the other tox results I would think it is unlikely.

Cocaine is not a “usual” means of suicide, it is used recreationally and, as I have mentioned, often overused. He tox results are very consistent with any number of cocaine-related deaths. There is really no way, now, of knowing how he took in the cocaine. We often swab the nostrils and screen for the presence of cocaine to discern “snorting”.

I doubt he committed suicide, he likely over-used accidentally, likely died within a few hours of getting to the ER, likely did not suffer (died quickly), and died as result of cocaine intoxication with lethal levels found in his system (remembering, too, that there are no “safe” levels of cocaine).

[Google can help you with the units conversions]

Hang in there, death of friend (particularly a close friend) is often devastating, you will not “get over it”, but the pieces can come back together and your life will continue with the memory and the grief. You can handle it.

Anonymous said...

DR KELLER. I HAVE BEEN READING YOUR INFORMATION REGARDING COCAINE AND OVERDOSE. I TOO HAVE A QUESTION..ANY HELP WOULD BE SINCERLY APPRECIATED...
25 YEAR OLD MALE GOT INTO A FIGHT..
RECIEVED A STAB WOUND TO CHEST.
WOUND WAS 1.8 -BY 0.5 IN WOUND.
PENETRATES THE PERICARDIUM AND THEN THE HEART, NEAR APEX INTO THE RIGHT VENTRICLE. WOUND OF HEART IS 1.3 CENT ACROSS. WOUND DOES COMMUNICATE WITH THE VENTRICLE CHAMBER. ASSOCIATED WITH WOUND WAS A 300 MILLITER HEMOPERICARDIUM.

ONE LUNG IS 420 AND THE OTHER IS 380.GRAMS
HEART 350 GRAMS.
STOMACH CONTAINED 800 MILLI OF FOOD AND NOTED WAS A MALTED BEVERAGE ODOR.

TOX REPORTS STATES
PERIPHERAL BLOOD ETHYL ALCOHOL 0.068 G/100ML
BENZODIAZEPINES POSTIVE
CANNABINOIDS POSTIVE
COCAINE/METABOLITES POSTIIVE
TRICYCLIC ANTIDEPRESSANT POSTIVE
CARISOPRODOL POSTIVE
OPIATES POSTIVE

MARIHUANA [THC] 0.004 MG/L
MARIHUANA METABOLITE [THC-COOH] 0.005 MG/L
COCAINE 0.059MG/L
COCAINE METABOLITE [BENZOYLECGONINE 0.958MG/L
MEPROBAMATE 0.869MG/L
HYDROCODONE 0.035MG/L
HGB ALC 5.6%

AFTER HE WAS INJURIED HE WENT BACK INTO THE HOUSE AND DID MORE COCAINE.. THEN CALLED FOR 911. HE WAS ON THE 911 TAPE SNORING AND THEN PASSED OUT. YOU CAN HEAR WHAT SEEMS LIKE BUBBLING SOUNDS IN THE BREATHING.THE AUTPOSY REPORT SHOWED GASTRIC CONTENTS IN THE BRONCOHOLS. HE WAS REPORTED SHALLOW BREATHING AND PULSE RATE OF 46. ON THE WAY TO THE HOSPITAL HE DIED. WHAT IS THE POSSIBILTY THAT HE SUFFOCATED ON THE GASTRIC CONTENTS OR OVERDOSED ON THE DRUGS?? THE 300 MIL BLOOD IN THE PERICARDIUM SAC BEING DELAYED [ CONTINUING AFTER DEATH]
TIME SPAN WOULD HAVE BEEN APPOX 10MIN AFTER EMS ARRIVED BP DROPPED.
ARRIVED AT HOSP 15 MIN LATER UNDER TOTAL CPR. TOTAL TIME APPOX 28-30 MIN.
MY QUESTION IS COCAINE / DRUG OVERDOSE CONSISTANT WITH THE GASTRIC ASPIRATION. AND WOULD THE DEATH HAVE OCCURED BY THIS BEFORE THE INJURY CREATED THE 300 MILL.
BLOOD IN THE SAC??
THEY DID ALSO ADMISTER EPINEPHRINE 3X AND ATROPINE 3X .

PLEASE HELP SHINE SOME LIGHT. THANK YOU

Dr. Richard Keller said...

It would seem most likely that he died of the stab wound. The wound into the ventricle will send blood into the pericardial sac. As the pericardium fills, blood return to the heart stops with tamponade and continued filling stops. In addition, as the heart stops beating no more blood flows into the pericardium, because of the loss of pressure in the ventricle.

The aspiration of stomach contents may have occurred just before death, but is just as likely with resuscitative efforts in this case.

Certainly the cocaine didn’t help him, but was likely more a confounder in this case than anything. Cocaine (with his Soma and hydocodone) may have contributed some, but vomiting due to them at these levels would be somewhat unusual.

Anonymous said...

We have a homicide victim who was strangled and then hidden, so her body was not discovered for a month. The killer claims that he and the victim were on a crack cocaine binge the night before, and he "accidentally" killed her when she attacked him the next morning because he refused to go out and get her more crack. Toxicology tests of her cardiac blood found no measurable cocaine or benzoylecgonine, or any other drugs for that matter, except a trace of ethanol. I haven't found much literature on the length of time that cocaine byproducts will remain in blood after death, but it seems to me that their total absence indicates that the defendant is lying about the victim using cocaine the night before she died. Can you shed any light or direct me to any studies?

Dr. Richard Keller said...

While the parent compound (Cocaine) could likely be broken down and gone the lack of metabolites certainly casts doubt on his statement.

Anonymous said...

I really hope you can help me. My dad died right before Christmas; he was 60. We were originally told he had a heart attack yet when we received the death certificate, the cause of death is listed as cocaine intoxication with a contributing factor of cocaine ingestion. I received the autopsy report today and it seems he did have some signifcant heart issues. However, I am trying to figure out the cocaine. The toxicology report states: Blood Levels:
Cocaine = 57 ng/mL
benzoylecgonine = 652 ng/mL (what is this?)
Are those levels high? Any ideas of the time frame between use and death? Does this mean he overdosed? Does the "ingestion" mean anything? Does any of this mean he used regulary or occasionaly? The time of death is listed at 8:40am and the autopsy began at 10:30am. Thank you for any help you can give me...I am searching for answers!

Dr. Richard Keller said...

I have certainly seen higher levels, but there is no safe level of cocaine, particularly in a 60 year old man with heart disease

With cocaine still in the blood, death would have have to occured within a few hours of use

Ingestion is just the term used for taking in a drug other than by injection, so would include snorting, eating, drinking, etc

There is no way of knowing whether he used once or more than once

I hope that gives you a few answers. Certain questions (not neccesarily asked) have no answers

Anonymous said...

Thank you so much for your help on my seach for answers with my dad's death. I do understand that sometimes there are no answers and the best I can hope for is peace...and time will help with that.

I do have one more question~~or maybe two more. You said the cocaine use would have been within hours of his death; the death certificate states "the interval between onset and death was: minutes". Does this mean minutes between when he used cocaine, or could it mean minutes between the "Atherosclerotic cardiovascular disease (There are 6items listed in A,B,C order under this). He was found in a parking lot in his vehicle early one morning about 5 minutes from home; he had left for work. I don't why it matters...but I would like to know if he used the night before or that morning.

Again, thank you for your help. I don't know where else to look for information.

Dr. Richard Keller said...

Glad I can help some

He likely used that morning

The "minutes" they listed on the death certificate would be their estimate of cocaine use to death (the choices are minutes, hours, days, etc). Again, most likely minutes to a couple of hours and just as likely on the short end of that

He worked on the atherosclerotic cariovascular disease for many years

Anonymous said...

Dr. Keller,
My brother passed away recently and I have lots and lots of questions. Maybe you could help with a few of them.
1. On the toxicology report there is no "dosage" listed on the cocaine and heroin results, nor with the morphine, codeine, amphetamine, methamphetamine, yet on the drugs such as Diazepam, Temazepam, Oxazepam and Citalopram (which were prescribed meds) have a dosage listed on them... why is that?

2. How and why is it that he tested negative on the following:
morphine, codeine,6 mam, cocaine, amphetamine, methamphetamine, ephedrine (which was tested on femoral blood), yet he tested postive for the above on urine?

3. on Benzolyecgonine the toxicology reports has a dosage of 73NG/ML - I know that there is "no safe amount", but is that a large amount, or only a small amount.

4. his time of death is being based on the 911 phone call, are liver temps no longer done? why would they use the 911 call as time of death?

according to the autopsy report he had severe pulmonary edema and congestion, is this in direct relation the drugs he took?

He died 2/25/09
autopsy done 2/26/09 at 9:44 am

he also had surgery to remove a grade 2 astrocytoma, in which the roots of the tumor were still there, he had depression, anxiety and was also diagnosed with bipolar.

Any information you could give me would be very helpful.

thank you, CP

Dr. Richard Keller said...

1) I don't know why the levels wouldn't have been listed, unless they were "dip test" results without levels measured

2) These pass into the urine and are cleared from the blood over time (while alive)

3) This is not a large amount, as these results go

4) liver temps are not done very often due to equipment constraints and the need to open the body to measure appropriately

Many drugs that cause death cause pulmonary edema as death arrives

Anonymous said...

I realize this is an ancient blog post, but I'll give it a whirl.

What would you make of a 41 yo male, known to have been using cocaine in the past, who is found dead (laying on floor, not "slumped") with red pinprick spots on his fingertips.

Toxicology found *nothing* in blood (and veins were all stripped searching). In urine, however, was found Cocaine and Valium. This was '79 - no one was discussing metabolites.

Apparently, an aortic valve was also ruptured.

Only other significant item was a "leak" the size of a needle puncture found behind one arm by the embalmer.

Is it possible to OD w/o having anything at all in one's blood? If not, what is a reasonable explanation? Insulin?

Thank you in advance

Dr. Richard Keller said...

Cocaine (the parent compound) rapidly metabolizes in the blood and if metabolites are not looked for (only cocaine itself), it can be “clean”. Also many of cocaine’s effects can have delayed onset, e.g. heart effects with damaged arteries and small vessels, valves and heart muscle.

The red spots on the fingertips may represent end blood vessel/capillary damage and rupture.

Insulin is an incredibly difficult substance to pick up as a cause of death on tox testing.

I don’t know what the “leak” would be.

bisected soul said...

Dear Dr. Keller,
Thank you for this very helpful blog. I have a question relating to this cocaine post. My husband committed suicide in September during the middle of a running relay race. He left the race course, entered a vacant house, and stabbed himself 29 times. I know he had consumed several energy drinks prior to the race. I just got the autopsy report. He had been dead for over an hour by the time we found him. The blood sample was taken a few days later. I don't know when the analysis was performed. He was found to have a level of cocaine in his blood above the LOD and below the LOQ. It was reported as less than 0.02mg/L. In talking to the toxicologist, she said the level was 0.012 mg/L by GC-MS.

Is there any chance that trace amounts of cocaine in the energy drinks could be responsible for a blood level in this neighborhood? I am finding it very hard to believe he intentionally ingested cocaine. I know that Red Bull was found to have cocaine in it, which is why I ask.

Thank you!

Dr. Richard Keller said...

There is no cocaine, per se, in energy drinks sold in this country. That would be illegal. Tests have demonstrated trace amounts of a biologically inactive cocaine metabolite. I don’t know, depending on the actual test results (cocaine itself vs. cocaine metabolites), but I suppose it is possible that that is what was measured in your husband’s case.

Caffeine is Red Bull’s active ingredient, one of the most psychoactive substances used by people.

Anonymous said...

Can you please help with interpretation of my brother's toxicology report? I just received his medical examiner's report and I need to try to explain the results to my parents, however, I do not understand them myself. What I can find on the internet is very confusing to me.

The official cause of death is "hypertensive cardiovascular disease. Toxic effects of cocaine contribution". He had a blood level of 0.10mg/L of benzoylecgonine. I know this is an indicator of cocaine. Is this a high level? He was mentally ill and on other psychotropic medications, as well as having taken benadryl for allergies (tox result .015mg/L of diphenhydramine), which were probably also additional contributing factors.

I deeply appreciate any help.

Dr. Richard Keller said...

The benzoylecgonine level is not high, although relating that to amount used is still a bit of a guess.

Any cocaine use in someone with hypertensive cardiovascular disease is a potentially deadly stressor on the system and can contribute to their death from the underlying disese process.

Anonymous said...

My son recently committed suicide by hanging himself. The coroner said his blood level for Cocane, Quant was positive 267 ng/mL and Benzoylecgonine, Quant was 858 ng/mL. We beleive he was dead for over 24 hours before he was found. The test was done 3 days after he died. Is this a high level of Cocaine and doesn't the level of Cocaine get lower after you are dead? Would this be high enough level to make you commit suicide?

Dr. Richard Keller said...

Yes it is high, yes it does metabolize even after death just being in the blood, and yes (although most cocaine deaths are more accidental than suicide, most often once a user gets started they will use all they have in the house or until death)

It is the hardest drug addiction to kick

bobbyd said...

Dr. Keller,

I need your help reading my fathers toxicology report.
He died from a drug overdose at the age of 40. I am having trouble reading and trying to figure out what killed him and if this was a routine high. He was also found to be fairly healthy at the time of his death.

Benzoylecgonine- .81 MCG/ML

Ethanol- 57 MG/DL

Codine- 33 NG/DL

Morphine- 144 NG/ML

Diazepam- .10 MCG/ML

Nordiazepam- .22 MCG/ML

Thank you any help is appreciated.

Dr. Richard Keller said...

Not knowing if these are blood/serum levels is somewhat restricting on my opinion. Nonetheless, to answer your question of whether this is a routine high, I would opine that it is a "normal" use of an unfortunate combination that this time resulted in his death. There is no safe amount of cocaine to use and opiates + benzos are a deadly combination. Can you get away with it sometimes? Maybe, but keep tempting the fates and at some point they will trim your skein of life.

Anonymous said...

Hi could you help?
My partner was killed in a car accident in march 1.30am sat morning,and in the blood test results shows that the benzoylecgonine was medium to high.
He had been taking cocaine and drinking alcohol till 5am on the thursday would this make it medium to high,or does it mean he wouldof took it on the friday night?

Dr. Richard Keller said...

Those kind of levels would be most consistent with use on Friday.

E.M.T said...

sorry i ment hed been drinking and taking cocaine ill 5am friday morning not thursday. would this make it medium to high,or does it mean he wouldof took it on the friday night?
sorry to confuse you.
thanks

Dr. Richard Keller said...

That does make a difference, morning use would be a possibility.

CMA said...

My Mother died from a stab wound to the neck severing her jugular vein. The tox screen through the blood states negative for TLC drugs, cocaine / metabolic levels are 0.86 UG/ML, salicylate screen is negative, ethanol level is 0.224 G/DL. Tox screen through vitreous states ethanol levels are 0.191
Tox screen through bladder washing states TLC drugs not detected, cocaine/metabolic levels are 0.17 UG/ML and ethanol levels are 0.024 G/DL. Does the mean my mother used drug at the time of her death? If she did use drugs was it a large amount? I need to understand and thank you for you help.

Dr. Richard Keller said...

It would appear that she consumed a fair amount of alcohol and at least some cocaine shortly before her death. The alcohol is an easier call as to amount than the cocaine amount because of how the levels develop. The blood to urine amounts speak to use shortly before death.

amedbery said...

A family member died while incarcerated - he had missed dialysis do to a problem with the access shunt and his potassium levels were not checked for the two days before he went to have the shunt fixed. He went to the hospital via EMS with a potassium level of 10.3 and died. The first autopsy report said that he died of cardiac arrest due to complications from chronic renal failure. Later, it was amended to say the cause of death was cardiac arrest due to cocaine toxicity. His toxicology reports are negative for ethanol, methanol, acetone and isopropanol. The results were also negative for amphetamine (threshold of .15 mg/L), benzodiazepines (t/h .o5 mg/L), methamphetamine (t/h at .15 mg/L), oxycodone (t/h .10 mg/L), cannabinoids, and opiates(t/h .o3 mg/L). However, the test was positive for cocaine metabolite, and it showed that benzoylecgonine was at .15 mg/L. He had been in his cell complaining of fainting and illness as of 6:20 that morning and was in constant supervision until EMS arrived at 6:40 am. He was taken to the emergency room and arrived unresponsive. He was pronounced dead at 9:30 am. Would it have really been possible that he died from a cocaine overdose?

Dr. Richard Keller said...

The thing to keep in mind here is that in chronic renal failure there is a fair possibility of false positive benzoylecgonine results. So it is certainly possible that cocaine was not the culprit.
A potassium of greater than 10, and other associated problems related to his lack of dialysis, could explain his death.

Heather Nye said...

Dr. Keller,

I appreciate the time you take to answer all of these questions! My question is this: we have a 32 yr old gunshot victim. Autopsy is performed about 10 hours later. On the official ME's report, no drugs are detected. On a different report to the sheriff's office, the tox results show negative blood results, positive urine results for cocaine, metabolite, and cannabinoids. I've read that cocaine will metabolize very quickly in the blood stream, but wouldn't the metabolites still be there? And the marijuana? Also, is it unusual for a memo from the ME's office to be included in a police homicide report rather than the official examination report and for them to have conflicting information? Hope you still answer these questions! Thank you sir.

Dr. Richard Keller said...

Cocaine, itself, will clear from the blood even after death.

I would have expected metabolites to be present, but without knowing when the cocaine was consumed (possibly well before death?) they may have cleared before death. It is possible that there were 2 drug uses, the first well before death explaining the cannabinoids (which remain in the urine long after gone from the blood) and the cocaine metabolites in the urine. A very recent cocaine ingestion could have also occurred and that cocaine cleared from the blood post-mortem, by a different pathway and not resulting in measured metabolites. Or the blood values may be wrong.

Indeed there should have been an official ME report in the record, not merely a memo.

Anonymous said...

Dr Keller can you tell me is a a cocaine level of 0.24mg/L a high level?

Dr. Richard Keller said...

While, as I have mentioned before, there is no way to back extrapolate to how much cocaine was consumed from a blood level, yes that would be considered a significantly high level.

Remember, too, that there is no safe level of cocaine in the body.

Anonymous said...

Hi Dr.Keller my brother was fatally injured while we were riding 4 wheelers a few months ago this was a 25 year Saturday morning tradition we and 2 of our friends did we were a year apart so we were very close always (best friends)and our other friends were each others so we were a tight group that all went to school together and stayed close despite that we all grew up and had families anyhow my brothers biggest fault was he was obsessed with his health and health food and organic food he wouldn't even eat at fast food or skillet meals or anything processed he went to the gym every day for the past 35 years also he was strong against drugs and alcohol even OTC drugs and caffeine while we were always drinking coffee in the mornings he always had his tea with no caffeine we used to make fun of him and tease him about his tea just playing but I never really knew what it consisted of other then he said it was made out of one of the healthiest things in the world, kind of a cure all herbal tea called mata de coca he bought it at the health food place at the mall he convinced me to drink it a few times when I was having stomach problems it did seem to help and it tasted better than I thought it would.anyhow in the post mortem tox report it said something about benzoylecgonine and if I remember right the level was maybe 40000 mg I think. I have never heard of benzoylecgonine my niece is going to school for forensics and she said it is cocaine but we cant figure out why wouldn't it just say cocaine? I guess my questions are this well the first one I can answer myself there is no possible way he could be doing cocaine there would be some sort of signs wouldn't there? we spend way to much time together and plus it goes against everything he stood for. or could that mate da coca tea he got at the mall here in ohio have cocaine in it? is my niece right about benzoylecgonine being the scientific name for cocaine? and if it is cocaine 40000 mg would be a huge amount right so how in the would could someone be doing that much and lead a normal life with out anybody knowing? did I mention he was 55 and Im 54 he was more like our kids ages than our ages Thanks in advance

Dr. Richard Keller said...

Benzoylecgonine is produced by the body as it breaks down cocaine. There are teas that contain coca leaf and small amounts of cocaine, but they are not really available in the

Dr. Richard Keller said...

(Oops) the tea is not really available in the US, although things happen. So your brother either got some real coca tea or had used cocaine. Let's go with the coca tea not, not supposedly sold in this country.

Anonymous said...

Can you tell me how a person could have autopsy readings of:
Cocaine, Quant 624 ng/ML
Benzoylecgonine, quant 607ng/ml
cocaethylene, quant 51.5 ng/ml
morphine, quant 262 ng/ml
6-Momoacetylmorphine, quant 68.8ng/ml, codeine, quant 15.6,ethanol .05%
What did he do and is this a lot of everything? Could this have been accidental or was it something that was done knowingly?

Dr. Richard Keller said...

The person with these results would have done cocaine, heroin, and alcohol shortly before their death. The cause of death could certainly be related to this polysubstance use, not knowing what else might have been involved, e.g.trauma. As I have said, there is really no way to back-calculate the amounts consumed, other than the alcohol. However, the alcohol seems incidental, while likely significant amounts of cocaine and heroin were consumed. The use was likely intentional, although the amounts consumed are difficult to control while the drugs are being used, and it is difficult to control for purity of the drugs used.

Anonymous said...

Have several questions . If you could help me please I would appreciate it greatly. My son died 4/12/03 . The autopsy report was done 4/17/03. According to the tox report his blood contained 10 mg/L cocaine, 23 mg/L Benzoylecgonine only.He had plastic (saran wrap) pieces that were in his throat that had cocaine traces on them. His stomach contents was 710 mg/L cocaine, greater than 5000 mg/L Benzoylecgonine only. The police report was a homicide investigation but was dropped because the med examiner's report said cause of death : cocaine toxicity manner of death : suicide. Time of death 11:30 am. There was a note on police report ; description of trauma - possible scar to the right side of neck. The actual autopsy report stated : cocaine toxicity, abrasion-contusion band on the anterior lateral right neck, contusion and abrasion of the submental region of the head. Metal stabilizing pins in the lower lumbar spine , projectile fragments in the lower left retroperitoneal space (remote gunshot wound) the hospital er report said med history parapolegic; depression. To my knowledge hecwas not depressed and was not on any meds for that. The er report states he was admitted for cardio pulmonary arrest. My questions are: were the amts of cocaine and Benzolylecgonine found in his blood, stomach enuf to give him a heart attact, or toxic enuf to kill him. I thot the death cert (which I don't hv) stated the cause of death was affixiation because of the plastic stuck in his throat. My other question is in your opinion, do u think his death was accidental or suicide. He was a parapeligec from a gunshot wound he recd 2/28/02. Was known to do cocaine recreational at first and then got hooked, he was otherwise a very healthy young man. Very strong upper body. Played football since he was 6. I want to reopen this case because I think there was foul play involved but I need a professional opinion to proceed. Thanking you in advance for you help.

Dr. Richard Keller said...

To answer your questions:

The drug levels in his blood and stomach are indeed consistent with death due to cocaine. Cocaine is most toxic to the heart and brain in causing death.

In my experience, suicide by cocaine is very rare. Accidental overuse is most likely.

Without seeing the marks on his neck and under his chin (sub-mental), I wonder what they were attributed to and if they were pre-mortem, post-mortem, or related to his death. With his physical strength, as you described, it is very unlikely someone could forcibly put saran wrapped cocaine down his throat without other evidence of significant trauma. It is more likely he ingested the cocaine package--maybe thinking he was going to be caught with the goods.

Homicide would only seem to hinge on charging whoever supplied/sold him the drugs with "drug induced homicide".

My condolences, I hope this is of some help to you.

Anonymous said...

Father died...on the autopsy it had ingested cocaine can i know more about it

Dr. Richard Keller said...

My condolences regarding your father's death.

There is a wealth of information in this post and discussion, take a read.

One thing, keep in mind that "ingested" is medical-speak for "used".

Anonymous said...

My mother's official cause of death was suicide. Could you please explain these results.

Cocaine Quantization:
Cocaine: Negative
Cocaine Metabolite (Benzoylecgonine): 0.05micrograms/ml
Cocaine Metabolite (Methylecgonine): Negative

Vitreous Cocaine Quantitation:
Cocaine: less than 0.05 Micrograms/ml
Cocaine Metabolite (Benzoylecgonine): 0.28 Micrograms/ml
Cocaine Metabolite (Methylecgonine): Negative
Cocaethylene: Negative

Could you please explain these numbers for me. Are they large amounts? I saw my mother within 2 hours of her death and she seemed normal. Worried about possible foul play.

Thank you kindly for your response.

Anonymous said...

My father died on January 27th and the autopsy was performed on Jan 29th at 1000 hours. Cause of death was acute cocaine toxicity. blood toxicologic testing results:
cocaine level:0.20 mg/L
Benzoylecgonine: 0.83 mg/L
cocaethylene: lower than the lowest calibrator of 12.5 ug/L
Ethanol: negative
DIAGNOSTIC AND THERAPEUTIC MARKINGS(?) needle puncture site on upper right anterior arm and dorsum of left hand covered by gauze and paper tape.
Missing shoes, one sock, coat and shirt. Was seen at hotel having seizure with two unknown individuals who took off in his car. An ambulance was called but he still passed away. I am wondering based on these numbers if it is possible to tell if he was a long term user, how bad of a habit he had and if the levels found would indicate deliberate or accidental death. Also if the needle marks are likely from drug use, the autopsy itself or something else. His death is still unexplained and also why he was in the place found at the time or who the people were. Is there anything that would indicate forced drug overdose by someone else? His death is suspicious and not easy to clarify. It seems that the toxicologist treated him as just another drug overdose / end of story but his family is left with no answers. Im hoping you can help me make sense of these results. Thank you.

Dr. Richard Keller said...

My condolences.

There is no way to go from the lab results to knowing how much your mother used, but she did use cocaine. I would mention that in my experience people rarely use cocaine for suicide nor for murder. Most likely hers was an accidental death due to cocaine use.

The fact that she had some cocaine in her vitreous along with benzoylecgonine in both specimens means she likely used before the visit you had with her 2 hours before she died, but likely within a few hours of her death.

Death from cocaine can occur hours after use, so death due to cocaine is still highly likely.

Dr. Richard Keller said...

My condolences.

There is no way to go from lab values to how much cocaine was ingested/used nor to know how chronic was the use. His levels are certainly consistent with many accidental over-uses that I have seen. Cocaine users tend to use all of the cocaine they have at the time, they don't usually save some for later. Cocaine users often can't self-regulate their use.

As to the needle punctures: Cocaine is not usually injected. Injecting it into the back of the hand would not likely reach the general circulation because of local blood vessel effects (constriction, clamping down). These punctures are very possibly due to blood draws by medical personnel or coroner/medical examiner personnel, those records should be available to find that out.

The 2 guys who left may have been using with your father when thing went bad, so they hit the road, but local police investigation will give you more information.

I can't be sure, but nothing in what you have shared makes me think anything other than an accidental death related to use of cocaine.

Dr. Richard Keller said...

Sorry I inadvertently deleted your comment but here it is:
Anonymous has left a new comment on your post "Cocaine and Death":

Autopsy report shows
cocaine 138 ng/mL
benzoylecgonine 1712 ng/mL
methylecgonine 231 ng/mL
Time of death was 1:00 p.m.
Is this a significant amount of cocaine. And does it signify that cocaine would have been taken shortly before death (1:00 p.m.)?
Cause of death was hanging and the individual suffered from mental illness. Thank you for your help

My reply:
Those are indeed very significant post-mortem levels (cocaine and its metabolites), but, of course, there is no way to know how much was used to yield these levels. Because of the cocaine itself being found it is apparent that the cocaine use was likely within a couple of hours of the time of death. These levels could very easily have been toxic in and of themselves.

Death by suicide is unfortunately more frequent in individuals with both mental illness and substance use/abuse. Unfortunately, these individuals are usually in so much psyche pain and/or become convinced that they or others would be better off off this Earth, that this becomes their choice. My condolences.

Chrsitina said...

oh my goodness this is the only page i can find.. please help me.. I am trying to find out how many pills of each my father took to commit suicide.

acetamininophen formal blood: 68.2 mg/L

Diazepam femoral blood:0.54 mg/L

Hydrocodone: femoral blood: 0.23 mg/L
brain 0.44 mg/kg
gastric contents 14.8 mg/total
small bowel contains5.64 mg total

Nordiazepam:femoral blood: 0.28 mg/L

Oxycodone femoral blood 36.1mg/L
Urine: 0.36 mg/L

PLEASESEEE how many pills of each did he take.. Thank you so much!!!!!

Dr. Richard Keller said...

Not knowing how long after he ingested the various pills it is difficult to say with certainty how many pills he took.

Considering how much was still in his stomach, realizing that these meds will slow stomach emptying, he would seem to have taken quite a few. The oxycodone is at a likely toxic level and certainly with the additive effects of the hydocodone and the benzodiazepines death is no doubt related to the ingestion. No one could have secretly given him these meds considering the amount (taken) in his system.

I wish I could answer your question more specifically, but there are too many variables (time since ingestion, not knowing whether they were taken all at one tim or over a period of time, and the gastric emptying effects) to be able to give you a number.

My condolences.

Christina Bosch said...

Ohh Thank you so much for talking with me. He took all the pills those pills at once. With that mixture was he in any pain.. or just fall asleep?? :( could he feel anything?

Dr. Richard Keller said...

He would have been insensate, "asleep", without pain. He did not suffer during his death. Again, my condolences.

Anonymous said...

One of the causes of death listed for my brother was ischemic bowel. The coroner also mentioned that a heart attack was the main cause of death. Cocaine was found in his system, but I was not given an exact amount. The coroner thought it would have been a short time before the ischemic bowel issue killed him anyway. With all of this going on how recent would cocaine use have been for it to be detected in the autopsy? My brother was an addict but was too sick to have left his house for at least 48 hours before his death. I believe he took cocaine 3 to 4 days before, but I doubt he would have saved any. He was also acting very distraught the day or two before his body was found. Screaming and out of his mind but refused to go to the hospital.

Dr. Richard Keller said...

My condolences.

If the cocaine metabolites were found in his urine, 3-4 days since use is indeed possible. If the cocaine was in his blood, less likely, but it depends on which metabolites were found.

The confusion and agitation you describe is a possible symptom of his dying bowel, but nonetheless it is not likely there was much you could have done by that time to change the fact that he was dying.

sharee said...

Please could you tell me if 9mg of crack cocaine is a lethal amount, and also, how many rocks of crack would that equate to?

Thanks so much.

Dr. Richard Keller said...

9 mg is a fair amount of crack and using that in one session could very well be lethal. Keep in mind, as well, my previous comment that there is no safe amount of cocaine is safe, any can be lethal. 9 mg of crack would translate to about 10 grams of cocaine

Each rock of crack tends to weigh somewhat less than half a gram. As I said that is a tai amount of crack.