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.


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?

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...


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??


Dr. Richard Keller said...

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




HGB ALC 5.6%



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.

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.

Anonymous said...

Reviewing an autopsy report with the following "postmortem iliac blood toxicology" results:benzoylecgonine: 686 ng/ml;morphine: 72.8 ng/ml." The autopsy was the morning after a death from a fall @ 5 p.m. the prior date (8:20 a.m. autopsy). postmortem urine tox positive for benzoylecgonine, 6-monoacetylmorphine, morphine, codeine, & hydromorphone. Curious as to your comments. Thanks!

Dr. Richard Keller said...

Poly-substance use some hours before death. There is evidence of use of heroin (6-MAM in urine) and oxycodone (metabolite in urine), as well as cocaine (reduced to its metabolites, so the time frame-couple/few hours?).

Not at all unusual for an individual to mix there drugs.

Whether these drugs contributed to the fall would be left up to the investigation.

carolhrtmn said...

My 34 year old sons official cause of death was Hypertensive and Atherosclerotic Cardiovasclar Disease. However on the toxicology report he showed 0.09 mg/L of Benzoylecgoine presant. they did not mention this at all as a possible factor. Can you tell me what this could mean? And how long before his death he may have consumed Cocaine?

Dr. Richard Keller said...

It is likely that your son used cocaine sometime within a day of his death, likely a 6 to 24 hour window not knowing how much he used. It is also very possible that his cocaine use contributed to both his death and the heart disease seen at his death. The cardiac changes are very similar for both hypertension and cocaine, and difficult to differentiate between them.

Drug use contributes to so many of the deaths that occur in our young individuals. My condolences.

Anonymous said...

I am looking for some clarity regarding the interpretation with my loved ones autopsy report. There will be several questions.
Summary is as follows...
A 20 year old male about 120 pds was with 3 individuals and his cause of death on death cert. was reported as Heroin Toxicity, onset interval 3 hours. However, the EMT and Hospital reports say full cardiac arrest and he was asitole when EMTs arrived to house he was at. the hospital reports a xray was taken and he had fluid and edema around it. So my first question is this.. is there two causes of death reported here? Second question is once I share the toxicology levels.. is it humanly possible for the individual to give himself 16 injections of Heroin. The autopsy report shows 16 crusted, recent injections around ankles and top of feet. The three individuals stories don't add up but all say around 530 am two carried him in unresponsive with blue lips and fingertips from a car he had been riding in to sleep it all off... but at 1000 am they decided to call 911 since he was not breathing and vomit in his mouth. no evidence of drugs or syringes found... I want to know if he was dead when they carried him from the car... with the assumption prior to he had already had the heroin injections in him.... the levels are as follows:
Morphine: 86.4 ng/mL
Oxycodone: 37.5 ng/mL

Morphine : 10000 ng/mL
6-Monoacetylmorphine 744 ng/mL
Codeine 244 ng/mL
Hydrocodone 750 ng/mL
Oxycodone 6566 ng/mL
0xymorphone 1813 ng/mL

Scene Investigation is as follows, subject was discovered unresponsive at residence of a friend, resuscitation was intitiated and continued at hospital. Death was pronounced shortly after arrival.

I also would like to know please what the below terminology actually means on autopsy report...

subject died several hours after injection, based on 6- monoacetylmorphine level in ER urine. none in the blood and low blood morphine.

I see this pattern more frequently then death within minutes of injection.

If you can give any clarity or straight forward answers... I would be appreciative so to be able to attempt to find some peace with all this.

Thank you.

Anonymous said...

Can an autopsy reveal if a person that died of a heart attack and never used cocaine only marijuana, rather or not someone slipped cocaine in their alcohol. Are they able to provide factual information with there findings? If so, what would the coroner test or look for to prove this theory?

Dr. Richard Keller said...

My condolences. Your loved one apparently died of a poly-substance use of drugs (heroin and oxycontin, at least). From the story you relate it appears accidental. Your loved one was very likely dead at 5:30, when he was removed from the car, having used the drugs a few hours (3-4 maybe) earlier judging from the drug level results. In particular, the 6-MAM (a metabolite specific to heroin) found in the urine and not the blood is consistent with that time frame. 6-MAM is cleared from the blood within a few hours as the body breaks down the heroin that was taken in.

16 injection sites (track marks) are not unusual to see in an individual. It is difficult to know the age of those punctures with any accuracy, so they likely occurred over some time.

Indeed it is pretty common for an opiate-related death to occur hours after use due to respiratory and cardiac depression. Decreasing respiratory function and cardiac pumping action lead to the development of edema and fluid in the lungs (seen on X-ray) and airways, resulting in a picture common in opiate overdose deaths. A death that occurs within minutes, most often due to using an amount or a strength that the user is unaccustomed to, presents a different picture.

I hope this helps a bit.

Dr. Richard Keller said...

There, unfortunately, are no real tests to tell if someone has used cocaine in the past, only tests for recent use.

A swab of the nose is useful for recent snorting, but there are no other real tests to check for route of administration.

As to your question about "slipping" someone cocaine in a drink: cocaine is poorly absorbed from the stomach, so that premise is unlikely. Now a baggy of it rupturing in the intestine can be fatal, but that is a much larger amount emptying well after the stomach.

Kelly Hocutt said...

Please help me with this. My mother died 5 years ago and the official autopsy report said it was acute cocaine toxicity. The level was 1 ml. But even higher levels of a cow, pig, sheep dewormer. I'm guessing that is what it was cut down with???? She also had cancer and was going through chemo but they did not list that as a factor. So basically I'm asking was she poisoned and did not know it???? Is that a high level of cocaine? ???

Dr. Richard Keller said...

My condolences.

That is indeed enough cocaine to contribute to her death. Cocaine bought off the streets can be cut with any number of things and it is possible that the de-wormer was a part of the cutting process in this case. The de-wormer in and of itself is not likely to have contributed to your mother's death.

if your mother was undergoing chemotherapy, it is likely that her run-down physical condition contributed to her death, but it is impossible to say to what extent.

I would consider this an accidental death from cocaine use.


PLEASE HELP ME, my mom passed away 3 yrs ago & a friend just confessed to me that my mom was using crack cocaine occasionally before her death. Her autopsy report says cocaine 20 ng/mL. Can you guesstimate how long it'd been since she used. It says "Analysis by High Performance Liquid Chromatography/Time of Flight-Mass Spectrometry. (LC/TOF-MS)......I hope you can tell better with type of test performed. Thank you

Dr. Richard Keller said...

My condolences.

If only cocaine was found (no metabolites), likely her death occurred less than a couple hours after her use of cocaine. She likely went quite quickly after her use.

Iulia Taranu said...

Dr. Keller,

I am working on a homicide case and was hoping you could tell me what the analysis means on the cocaine found in the whole blood. The autopsy lab reports the screening threshold was 25 ng/ml and the confirmation threshold was 30 ng/ml. The benzoylecgonine result was 34 ng/ml. I am not sure if those numbers mean the victim was very high on cocaine or barely at all. He had definitely ingested cocaine a few hours prior, but not sure how many hours prior to his death. Any help would be greatly appreciated.

Dr. Richard Keller said...

Unfortunately, you can not back calculate the amount of cocaine that was used from any post-mortem (or other post-use) levels, the metabolism kinetics are just not linear enough for that. That lab result would be consistent with use within hours of the death, but you can't say much else with certainty from the value alone. You could surmise that they used more than "barely at all", otherwise the metabolite result wouldn't be at that level, hours after use.

Anonymous said...

Dr. Keller, in your opinion considering that there are no safe levels of cocaine, do you believe a person could still be alive after testing positive for 54000ng/ml of cocaine in a urine sample?

Dr. Richard Keller said...

If the units are right that is indeed a very large amount. Survivable? There are no absolutes in medicine, but that would be reflective of taking a huge amount and would only be very rarely survivable. I'd have rechecked the specimen.

Unknown said...

Dear Doc,

I realize it has been about 10 years since you wrote this article but if you are still answering questions, I have one for.
I found my husband (we were seperated) 53 yr old white male dead on the living room couch in a slumped(left) but sitting. Before he passed he was complaining of abdominal pain. I found out later he was buying a bottle of jim bean a day for a while. The coroner is saying he died from diabetic ketoacidosis but he was not diabetic. The day before he passed he texted me& called me& was asking me questions like we were in the middle of a conversation. I just told him I have no idea what you are talking about then when he called I couldn't understand him. The following day is when I found him dead. I picked up the coroners report today and it is throwing me it shows his toxicology results as:
Benzodiazepines 100ng/ml
Buprenorphine/metabolite .50 ng/ml
Cannabinoids 10ng/ml
Cocaine/ metabolites 20ng/ml
Fentanyl/metabolite .50 ng/ml
Methadone/metabolite 25 ng/ml
Methamphetamine/ mdma 20 ng/ml
Opiates 20ng/ml
Oxycodone/ oxymorphine 10 ng/ml
Phencyclidine 10ng/ml
Acetone 5.0 mg/dl
Ethanol 10mg/dl
Isopropanol 5.0 mg/dl
Methanol 5.0 mg/dl

I know he had been taking xanax, ambien, and something for cholesterol. But does this mean he was doing each one of these drugs cuz he had been addicted to opiates but he got clean in 2010. Would you come to the conclusion he relapsed and was trying anything or would there be another explanation? Please help I have a 15 year old that somehow I need to explain all these results to. THANK YOU SO VERY MUCH IN ADVANCE! it's amazing how you are helping everyone try to get answers to this senseless thing!

Dr. Richard Keller said...

I am still here, answering questions.

While I don't have all of the investigative data, it would appear that these toxicology results are consistent with a poly-substance intoxication causing his death. I would say that it is quite apparent that he relapsed in his drug use and was using a large number of different drugs in his self-medication. This mixture would work together in their lethality.

The acidosis (likely misdiagnosed as diabetic) was likely related to the mix of drugs, as well as related to his alcohol use (apparently including isopropyl alcohol and methanol).

It is unfortunate, my condolences.

Anonymous said...

My mom passed and the coroner determined she died from a mix of oxy and xanax. She tested positive for 7.3 ng/mL and 420 ng/mL along with another detectible 7 drugs with no numbers. Those were the numbers from the comprehensive blood screen and Zolpideim at 40 ng/mL Blood Drug Quantitation. She had been an addict for probably 20 years. I am curious in layman's terms how high is this? Is this super high? Dumb luck? I understand a tolerance is developed but I feel I need more information. We know she had too much for several days leading to her passing. Can you tell me anything else about why she died?

Anonymous said...

Also this autopsy report was done about 26 hours after death if that affect numbers

Dr. Richard Keller said...

My condolences.

While the zolpidem level is not all that high, likely all of the drugs contributed to her death. Her cause of death would appear to be due to polysubstance use (and likely an accident). Each of the drugs you mentioned: oxycodone, alprazolam (Xanax), and zolpidem (Ambient) have a side effects respiratory depression. In particular, the combination decreases respiratory rate and depth leading to the death of the individual who has consumed them. The combination is much more deadly than any of them alone. The drugs consumed can also depress the heart's ability to pump contributing to the underlying cause of death.

Crystal Johnson said...

Hello, my husband was arrested for public intoxication and found 7 hrs later dead in his jail cell. It took 3 months for the autopsy to come bk. The police report says pending.he was beaten badly. But that was left out of all reports. He definetly was a victim to police brutality. He had a busted rt eye, lip, his rt temple was pushed in and bruised.his entire lf side of his face appeared as if he was struck with a hard object. The autopsy says accident and cause of death cocaine plus cocaethylene. He did use cocaine regularly but im not buying that he overdose. Do you think that if he did coke plus alcohol at 1230 am, he would just suddenly die at 930am. The jail staff said that he was seen drinking orange juice an appeared fine at 900am it just sounds suspect that he just died 30 mins after. What do you think is that possible?

Dr. Richard Keller said...

I'd say you need more information on the trauma your husband endured

My condolences.

Charity Long said...

My daughter was found dead then resuscitated by ems lived 5days.they said cause of death was brain injurie respiratory arrest now that's been changed by coroner & medical examiner who never seen her after autopsy no tox screen just urine test from er saying trace of cocaine & diazepam & antidepressant but changed her cause of death to cocaine overdose I don't see how this is being assumed.could you explain this to me thank you &God bless

Dr. Richard Keller said...

My condolences

Likely her proximate cause of death was anoxic brain damage due to her respiratory arrest (damage to the brain from lack of oxygen delivery). If what you tell me is correct, and I have no reason to doubt it, it seems they are grasping at straws to come up with the cocaine overdose/overuse as her cause of death. I don't see enough information to come to that conclusion.

Anonymous said...

My husbands tox report revealed the following:
28ng/mL femoral blood cocaethylene
140ng/mL femoral blood benzoylecgonine

His time of death was 11:44am and blood for the autopsy was not drawn until 7pm. He was 6'1 203lbs. Could these levels be consistent with usuage within the last 12hrs (midnight the night before and 11:44am next day?) or at least 24hrs?

His BAC was .286 and vitreous 305

Dr. Richard Keller said...

Considering a half-life for benzoylecgonine of 6 hours (i.e. level drops by half each 6 hours) it is very likely that the most recent use of cocaine was more likely in the "last 12 hours" range than in the over 24 hour range (although it does not rule-out use then as well).

Although do keep in mind that there really is no reliable way to back calculate time of use based on one level.

My condolences.

Unknown said...
This comment has been removed by the author.
Dr. Richard Keller said...

While you can back-calculate from a a blood alcohol result to the amount ingested, the same is not true with cocaine and other drugs. the way cocaine is metabolized in the body can result in a wide range of metabolites after ingestion/use. The results that your friend got in no way speaks to how much he used.

Keep in mind also that there is no safe amount of cocaine. It can thrill you and it can kill you.

Those urine drug tests are a pesky thing for those who choose to use.

Unknown said...

My sisters toxicology report says she was positive for cocaine metabolite but not cocaine. She also had pulmonary Anthea cos is listed as a contributing death factor. She did use crack cocaine could this have caused the anthracosis? Also us there any way to tell when she last used if only metabolite was found most likely four hours prior correct? She passed in a car crash but we don't know why she didn't stop or brake...could the crack have caused her to have a seizure or heart attack and passed out?? I'm going insane and need closure!!

Dr. Richard Keller said...

My condolences, time will diminish but not resolve your feelings.

The anthracosis would have been from some other cause other than the crack. An unusual diagnosis.

From what you say about the metabolite and no cocaine, a 4 hour timeframe would be likely.

Cocaine, at any amount, can indeed cause seizure, heart attack, or heart rhythm problems contributing to death or, indeed, a car crash. A very possible event in your sister's death.

DatBMe said...

Hi Dr. Keller! I 21st wondering if you could help me out here! My friend died... I always knew he used Cocaine periodically but I wasn't aware of all these other things... Can you tell me what killed him? He has .10% ethanol, 227 ng/ml morphine, 57 ng/ml cocaine, 12 ng/ml cocaethylene, 82 ng/ml benzolecgonine, and 10 ng/ml 6 monoacetylmorphine in his femoral blood... there was .11% ethanol in his heart blood, and no 6 monoacetylmorphine in his urine... I'm just curious to clear up outstanding questions about my friend, I'm wondering how much I never knew about him! Thank you in advance.

Dr. Richard Keller said...

My condolences.

Your friend looks to have died from a heroin overdose. 6 MAM (monoacetylmorphine, which only comes from heroin) in his blood points to death quite quickly after his use (probably injection) of the heroin.

He had been drinking prior to his death, difficult to say when. The cocaine he used may have been at the same time as the heroin or within a few hours of the heroin.

Remember drug users have many reasons for their use, many times known only to themselves.

tonja gee said...

My dad had 29 units of fentanyl in his toxicology report..which was obviously too much he over dosed. I don't even really know what that substance is.

Dr. Richard Keller said...

My condolences.

Fentanyl is a very powerful synthetic opioid narcotic. It is primarily used in cases of severe, intractable pain. It comes in several forms, most notably in a skin patch. It is many times as potent as heroin. For several years, beyond the use and abuse of fentanyl primarily, we are seeing fentanyl mixed with or substituted for heroin bought "on the streets". Those later cases is where we most often see overdose deaths. It is quite often, likely, taken unknowingly, mistaken for the heroin the user is more used to and fatal use occurs with the addition or substitution.

As you put in your other note to me, likely your dad's heart disease and kidney disease contributed to his succumbing to the drug use.

Unknown said...

My brother in law's autopsy report said he died from acute cocaine toxicity. He was dead at least three days before he was found. Does this mean he died from an overdose?

Dr. Richard Keller said...

Because there is no safe dose of cocaine, any amount can be lethal depending on the circumstance and the individual, the amount taken by your brother-in-law may not have been an overdose per se, but could have nonetheless been a lethal amount for him at that time and place.

My condolences

Anonymous said...

hello.. seeking some sort of closure. my brother passed away a few months ago, we obtained autopsy results which showed: (from blood samples): cocaine <0.01mg/L, benzoylecgonine 0.048mg/L, xanax 0.1mg/L, buprenorphine 0.8mg/L & norpuprenophine 0.96mg/L, ethanol 60mg/dl..
my question: cause of death was determined to be cocaine toxicity. these levels seem to be rather low-would the other drug levels have been more likely to have caused his death? other significant information would be the autopsy revealing he had a mild cardiomegaly with left ventricular hypertrophy and severe fatty liver. was the cocaine lethal because of his heart? any insight would be helpful, he was only 33.

Dr. Richard Keller said...

My condolences

Two things to keep in mind 1) there is no safe amount of cocaine to ingest/use, any dose can be lethal in a given individual; 2) cocaine continues to be metabolized/broken-down by red blood cells even for awhile after death, making calculation of amount ingested/used impossible, also there is no way to know what his blood level was at death.

It is likely that all of the substances had some contribution in his death, complicated by his underlying medical condition. Nonetheless, cocaine was likely a considerable contribution to his death.

Anonymous said...

Can you tell me from the levels below when the drug was consumed? Autopsy was done about 13 hours after death. thank you Blood samples are from the heart.

Cocaine 1.664 mg/l
Benzoylecgonine 3.640mg/l
Ecgonine methyl ester 2.060mg/l

Anonymous said...

Dr. Richard Keller said...

Because the cocaine "parent compound" is still present in the blood, death likely occurred soon after use of cocaine, i.e. within a couple of hours at most.

Anonymous said...

my daughters urine tests came back.
her urine showed 253,000 ng of cocaine and 5600 ng methamphetamines.

what does this look like in layman terms?

Dr. Richard Keller said...

I seem to have lost an Anonymous post with questions about an individual died with fentanyl in urine and cocaine metabolites in blood an urine. The poster should recognize their questions.

I'll answer their questions:

The fentanyl use was some time before death allowing for it clearing from the blood. It would be present in the urine a day or 2 depending on the amount taken.

The benzoylecgonine live is indeed high, but different people metabolize differently. There is no way to back-calculate to the amount of cocaine used.

Their death would not have been painful. It would likely have proceeded with a loss of consciousness first and then stoppage of breathing and/or the heart.

My condolences

Dr. Richard Keller said...

the missing comment post answered above:

Hi Dr. Richard Keller,

My fiancé just passed in September..

The toxicology report states cause of death to be complications of acute cocaine intoxication

Ethanol .10%
Fentanyl screen positive
cocaine metabolite screen positive
Levamisole, Fentanyl, Cocaine and Metabolites detected

Ethanol .03G%
Cocaethylene present less than 25 NG/ML
Benzoylecgonine 921 NG/ML

Congested, Edematous, Lungs, Bilaterally

I have a few questions…

1) Why is there fentanyl detected in the urine and not the blood?
2) Isn't a 921 NG/ML level of Benzoylecgonine extremely high?
3) Did he experience a painful death?

Thank you so much

Dr. Richard Keller said...

To Anonymous above who wrote:

my daughters urine tests came back.
her urine showed 253,000 ng of cocaine and 5600 ng methamphetamines.

what does this look like in layman terms?

Your daughter died of a polysubstance overdose/usage. The usage of cocaine and methamphetamines are each potentially lethal on their own and, in particular, make a lethal combination. There is no way of knowing just how much of either of the substance was taken, but that was likely her cause of death.

My condolences

Anonymous said...

my mother had 0.006mg/l of cocaine is that a large amount ???

Dr. Richard Keller said...

As I have said before, there is no safe amount of cocaine, it can kill at any amount. That being said that level is certainly a significant amount and would be consistent with causing/contributing to her death.

My condolences.

Anonymous said...

My husband was a veteran that snorted tons of 10 and 5 mg oxycodone. He died at 0500. Autopsy wasn t completed til at least 18 hours later wasn t found fir at least 12hrs. Oxycodone at time of autopsy was .50/ml his lungs weighed 1400 grams. Pulmonary edema cardiomegely coronary artery disease supposedly was the caused.could the am of oxycodone in his bld 18 hrs later enough to cause his death.
Thank you

Dr. Richard Keller said...

My condolences

I would agree with the oxycodone being the cause of death, with a contributing factor being his heart disease. The significant pulmonary edema is very consistent with and over-use/overdose death. Likely he also had fluid in his upper airway.

Josh Ashbrook said...

Recently received my fathers autopsy/toxicology report. I wanted some clarification on the levels found in his blood.

Cocaine: .392
Cocaine metabolite: benzoglyconine: 5.46
Cocaine metabolite: ecgonine methyl ester: 1.30
Cocoaethylene: .010

Fentanyl: .005

Alprazolam: .022

Thanks for your help.

Dr. Richard Keller said...

My Condolences

These results are consistent with a poly- substance use related death.

The fentanyl, by itself and in combination with Xanax, would contribute to respiratory and cardiac depression. Neither his lungs nor his heart would work as well as they ought, contributing to death. The fentanyl has a particularly lethal potential, even at that level and in combination.

The I have said there is no safe amount of cocaine. It can kill at any level. Also, I have noted that you can't back-calculate to the amount consumed from post-mortem levels. That being said, the amount of cocaine and its metabolites would likely indicate a significant amount was consumed. The amount of parent compound, the cocaine itself, present also speaks to the fact that your father's death occurred within a short time of that consumption (certainly way less that 2 hours). The fact that breakdown of cocaine continues even after death, though slower than in life, also would go along with significant use contributing to his death.

Anonymous said...

Hi Doc!

My friend was in an accident as a truck driver. He was required to take a post-accident drug test (urinalysis). He tested positive for cocaine. The report isn't clear. It just says "positive" and has cocaine metabolites 1110.000. He was fired for testing positive but claims he used three days prior. Is this a high amount? Could he have been under the influence or still coming down?

Thanks for any help!

Dr. Richard Keller said...

There in lies the problem of using urine drug levels to test for current impairment. Drugs and their metabolites are often detectable in the urine well past the time they are in the brain and blood causing intoxication. For example, cocaine metabolite can remain detectable in the urine 3-4 days after use, even though the intoxication is long gone. (A more significant example is marijuana ingredients and metabolites detectable out to 30-40 days after use).

To your other question, unlike alcohol, there is no way to back calculate from detectable levels of cocaine and its metabolites to the amount used. The metabolism is not a staring line, so the measured urine level is of little value other than testifying to use.

Anonymous said...

Hi - my husband committed suicide and I am wondering if you could help me understand what the following results means he took and what the levels mean - i.e. high or low. There is a lot of items on the list.

MDA 5.0 ng/mL
MDEA 10 ng/ML
MDMA 5.0 ng/ML
Methamphetamine 5.0 ng/ML
Norpseudoephedrine 5.0 ng/ML
Phenylpropanolamine 5.0 ng/ML
Amphetamines 20 ng/ML
Barbiturates 0.040 mcg/ML
Benzodiazepines100 ng/ML
Buprenorphne/Metabolye 0.50 ng/ML
Cannabinoids 10 ng/ML
Cocaine /Mateabolites 20 ng/ML
Fenatnyl/Acetyl Fentanyl 0.50 ng/ML
Metahdone/Metabolte 25 ng/mL
Methamphetamine/MDMA 20 ng/mL
OPiates 20 ng/ML
Ocycodeone/Oxymorhone 10 ng/ML
Phencyclidine 10 ng/ML
Acetone 5.0 mg/DL
Ethanol 10 mg/dl
Isopropanol 5.0 mg/dL
Methanol 5.0 mg/dL

Thank you for your help

Dr. Richard Keller said...

My condolences.

His intentions seem apparent. His is a considerable/considered polysubstance use/overdose. It is more likely the combinations of the substances causing his death than necessarily any of the drugs he consumed individually.

He mixed multiple respiratory and cardiac suppressants (fentanyl, oxycodone, methadone, buprenorphine, benzodiazepines, barbiturates, and alcohol) with several other drugs (cocaine, Ecstasy, PCP, methamphetamines, and marijuana). This large mixture/combination would have only one apparent intent, death by suicide.

The respiratory and heart suppression would have put him to sleep and to death.

Anonymous said...

Thanks. He actually parked his car on the railroad tracks and the cause of death is listed as multiple traumatic injuries. How long do you think it would take to knock him out from these drugs. Wondering if he was conscious when the train hit him. The coroners report says 'examination of the specimens submitted did not reveal any positive findings of toxicological significance'. What does that mean given that there were so many substances with a reading? Thanks!

Dr. Richard Keller said...

The mixture with overlapping effects gives the group "toxicological significance". It is very likely that without the trauma, the poly substance use/ingestion would have killed him, no matter what the coroner reported. A large number of drug-related deaths are poly-substance. None individually lethal, but the combination with overlapping and synergistic effects, result in lethality.

It is also very likely that your husband was rendered unconscious by the combination of substances, insensate at the time of the trauma.

Anonymous said...

Hi, hoping you can answer a couple of questions for me. How likely is it that blood would be negative for cocaine and its metabolites but urine be positive for both? Also, what are the chances of a false positive for the cocaine/metabolites in the urine? Is there a way to tell if someone was a chronic user? Thank you very much for your help!

Dr. Richard Keller said...

For your first question I will assume the blood and urine specimen were collected nearly simultaneously, otherwise all bets are off. Frequently the blood is clear of cocaine itself while their is still some cocaine detectable in the urine along with its metabolites, because cocaine is metabolized quickly in the blood and continues after death for awhile. There is no way that there would be no metabolites in the blood when the cocaine parent compound is found in the urine, its metabolism and urine clearance just doesn't work out that way.

If a respectable test is used for the urine, not some outdated or poorly stored dip-card, there is only a very small risk of a urine false positive. If there is a question it should be confirmed in a licensed laboratory.

There is no test for the chronicity of cocaine use in individuals, although testing different lengths of hair might point to it. "old" use further out, "newer use closer to the scalp. But I wouldn't trust it.

Anonymous said...

I had a very dear friend pass away from cocaine and heroine POISENING,why not accidental overdose? Just curious as to the poison part. Exficiation due to lungs completely filled was on there too.

Dr. Richard Keller said...

my condolences.

I can't imagine why any professional would use "poisoning" as a cause of death related to licit or illicit drugs. Indeed, accidental overdose would be more appropriate.

In many drug overdose or use related deaths the lungs and upper airways are filled with liquid. As their respiratory and cardiac depression/suppression progresses that fluid collects. By the time that is occurring the individual is no longer aware.

Anonymous said...

My son passed away in April in his sleep. He was 30 years old. I found him laying in his bed and he looked like he just drifted away - his arms were behind his head. When they did the autopsy, the toxicology report showed 69.6 mcg/L of monocetyl morphine in urine, 23.0 mcg/L of fentanyl in the blood and 56.8 mcg/kg in the brain, .10 mg/L of morphine in the blood. The cause of death was mixed drug intoxication (heroin and fentanyl). We know that he had used cocaine, but never heroin. Upper airway contained pink-white frothy foam. Lungs had congestion and edema.The rapid urine drug of abuse screen was positive for cocaine. We believe he got a tainted batch of cocaine and that killed him. Can you tell me what these results mean? I would appreciate any help, this is all I think about!

Dr. Richard Keller said...


Your son may have used cocaine some time before his death, hence the positive screen, but it would appear any levels were negligible at the time of his death.

Nothing would give the heroin and fentanyl results you list other than use of those drugs (unfortunately, incredibly common these days), with heroin confirmed by the MAM in his urine. Those levels would have caused his death and the autopsy results are consistent with that cause of death (froth/purge and lung edema). A very quick death is also very likely, with him found in repose as you mention.

My condolences

Anonymous said...

Dr. Can you help explain cause of death on the following
20YO Female Diphenhydramine 168 NG/ML, Delta 9 THC 1.4NG/ML, Delta 9 Carboxy THC 3.9 NG/ML, Benzoylecogonine <25NG/ML (Iliac Blood) Patient had a history of Opiate drug use but had been "clean" for 3 months. Patient had been out night before, up early in the morning, got coffee then found unconscious 10 min later.

Dr. Richard Keller said...

It is quite likely that cocaine consumption contributed to her death (the benzoylecgonine, cocaine metabolite, in her blood). There is no evidence of heroin in these results. Keep in mind that the THC does not contribute to death, although she had used marijuana that morning.

Anonymous said...

Hi Dr. Keller,

If you are still here and reading this i would like your opinion on the death of my brother. We received his autopsy report today and these are the toxicology findings:
Ethanol .01g% (HSCG)
Cocaine 378 ng/ml (LC/MS)
Benzoylecognine >1500 Ng/ml (LC/MS)
Lamotrigine .91 mg/l (GC)
Cotinine detected

These are from blood tests taken one day after his body was found. What does this mean?

Dr. Richard Keller said...

My condolences.

Your brother's death is very likely related to his significant cocaine use (considering the levels of it and its metabolite). He had also been drinking alcohol and smoking tobacco (cotinine) and was taking Lamictal (lamotrigine), which was not likely related to his death.

Anonymous said...

hi dr. keller

my brother was found in a canal recently with only a gasp of water as the ME said that essentially caused him to drown in only 6 inches of water. listed as accidental drowning He was an addict of opiates but was off them but smoking what he thought was meth? and im assuming because the only thing that came up in tox was cocaine 169ng/ml and Benzoylecgonine 1247ng/ml taken from blood of the heart.. nothing else no synthetics no fentynal no alcohol no benzos opiates etc. There was one person to see him alive and it was not a pleasant encounter from what i was told by this said person. what do these levels mean and could he have passed out and have been put in this extremely steep canal ? I ask because he had not one injury on him and my assumption is the person he was with thought he died so they took him into the 6 inch deep canal. again my assumption and he had use cocaine for years do the amounts make difference for how long he was a user and that the blood was taken form the heart?

Dr. Richard Keller said...

Most likely cocaine use caused your brother's death, the levels found are quite high. The "drowning" would seem to be incidental. It is possible he passed out and fell into the water or he might have been placed into the water--a common "street" "cure" for overdose.

With the level of cocaine that he had in his blood it would seem that he died quite soon after using. Years of cocaine use may indeed have caused heart effects that contributed to his death as well.

My condolences