title: A critical review of the causes of death among post-mortem toxicological investigations: analysis of 34 buprenorphine-associated and 35 methadone-associated deaths.
abstract: OBJECTIVE
  To assess the trends in the number, mortality and the nature of forensic cases involving toxicological detection of buprenorphine or methadone among toxicological investigations performed in Paris from June 1997 to June 2002.
  
  
  METHODS
  Retrospective, 5 year study with review of premortem data, autopsy, police reports, hospital data, and post-mortem toxicological analyses.
  
  
  METHODS
  34 forensic cases of buprenorphine and 35 forensic cases of methadone detection among 1600 toxicological investigations performed at the Laboratory of Toxicology in the Medical Examiner's Office in Paris.
  
  
  RESULTS
  Therapeutic, toxic or lethal drug concentrations were defined based upon the results of blood analyses and the published literature. Drug concentrations were cross-referenced with other available ante- and post-mortem data. Subsequently, we classified a 'clear responsibility', 'possible responsibility' or 'not causative' role for buprenorphine or methadone in the death process, or 'no explanation of death'. Buprenorphine and methadone can be regarded as being directly implicated in, respectively, four of 34 death cases (12%) and three of 35 death cases (9%), and their participation in the lethal process is strongly plausible in eight (buprenorphine) and 11 (methadone) additional deaths.
  
  
  CONCLUSIONS
  Analysis of causes of death reveals the difficulties in determining the role of substitution drugs in the death process, as many other factors may be involved, including circumstances surrounding death, past history, differential selection of subjects into either substitution modality and concomitant intake of other drugs (especially benzodiazepines and neuroleptics). The potential for synergistic or additive actions by other isolated molecules-particularly opioids, benzodiazepines, other psychotropes and alcohol-must be also considered.
authors.affiliation: Laboratoire de Toxicologie de la Préfecture de Police, Paris, France. docteur-stephane.pirnay@laposte.net
authors.forename: S
authors.initials: S
authors.lastname: Pirnay
authors.forename: S W
authors.initials: SW
authors.lastname: Borron
authors.forename: C P
authors.initials: CP
authors.lastname: Giudicelli
authors.forename: J
authors.initials: J
authors.lastname: Tourneau
authors.forename: F J
authors.initials: FJ
authors.lastname: Baud
authors.forename: I
authors.initials: I
authors.lastname: Ricordel
mesh_terms: D000328:Adult; D001344:Autopsy; D002047:Buprenorphine / Q000097:blood / Q000506:poisoning*; D002423:Cause of Death; D062787:Drug Overdose / Q000401:mortality; D005260:Female; D006801:Humans; D008297:Male; D008691:Methadone / Q000097:blood / Q000506:poisoning*; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D009294:Narcotics / Q000097:blood / Q000506:poisoning*; D012189:Retrospective Studies; D019966:Substance-Related Disorders / Q000401:mortality / Q000534:rehabilitation
chemical_list: D009294:Narcotics; D002047:Buprenorphine; D008691:Methadone