The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths
The attribution of a death to heroin: A model to help improve the consistent and transparent classification and reporting of heroin-related deaths
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DOI：
10.1016/j.forsciint.2017.10.012
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发表时间：
2017-12-01
影响因子：
2.2
通讯作者：
Pilgrim, Jennifer L.
中科院分区：
文献类型：
--
作者：
Stam, Nathan C.;Gerostamoulos, Dimitri;Pilgrim, Jennifer L.
导言：从公共卫生的角度来看，海洛因相关死亡的准确归因以及与其他阿片类镇痛相关死亡的区分是至关重要的。海洛因相关死亡涉及许多复杂性，其中海洛因特异性或非特异性代谢物和指标（6-乙酰吗啡[6-AM]、吗啡和可待因）可能被检测到，也可能不被检测到。因此，这项研究的目的是建立一个模型，以提高海洛因相关死亡归因的一致性，并确定当前决策过程中的差异领域。方法：采用海洛因使用的不同毒理学指标（6-AM、吗啡与可待因比（M: C）或单独使用吗啡）和海洛因使用的调查证据（情况、现场和临床表现）建立模型，并利用这些指标进行加权评分。毒理学和调查证据的综合得分被用来根据三个类别确定海洛因可归因于死亡的相对关联强度：疑似；可能;或强。召集了一个专家小组来验证该模型，并向一群法医毒理学家和病理学家提供了一系列测试案例，以确定这一群体中决策变化的来源。该模型还通过审查潜在的海洛因相关病例和检查与这些病例是否属于海洛因相关的证据来评估其敏感性和特异性。结果和讨论：在所有可能与海洛因有关的死亡病例中，使用该模型使死亡归因于海洛因的一致性更高，特别是在未检测到6-AM的情况下。在可能与中毒有关的死亡和仅报告了M: C比率的中毒病例中，将死亡归因于海洛因的差异最大，甚至超过没有毒理学证据的情况。审查的病例强调了将死亡归因于海洛因的相同差异，包括大量归因于吗啡的病例，其中未检测到6-AM。结论：该模型为提高海洛因相关死亡的鉴别、归因和报告的准确性和一致性提供了一个有用的工具。以前具有挑战性的病例发生在相当长的一段时间后，没有检测到6-AM或没有采集样本，使用该模型可以捕获。(C) 2017 Elsevier B.V.版权所有
Introduction: Accurate attribution of heroin-related deaths, as well as the differentiation from other opioid analgesic-related deaths, is essential from a public health perspective. Heroin-related deaths involve a number of complexities where heroin-specific or non-specific metabolites and indicators (6-acetylmorphine [6-AM], morphine, and codeine) may or may not be detected. The aims of this study were therefore to develop a model for improved consistency in the attribution of heroin-related deaths and to determine areas of variation in the current decision-making processes.Methods: A model was developed using different toxicological indicators of heroin use (6-AM, morphine to codeine ratio (M: C) or morphine alone) along with investigative evidence of heroin use (circumstances, scene and clinical findings) which were used to assign a weighted score. The combined scores for the toxicological and investigative evidence were used to determine the relative strength of association for the death being attributable to heroin according to three categories: suspected; likely; or strong. An expert panel was convened to validate the model and a series of test cases were provided to a cohort of forensic toxicologists and pathologists in order to identify sources of variation in decision-making within this group. The model was also evaluated for sensitivity and specificity by reviewing potential heroin-related cases and examining the evidence associated with the attribution of these cases to heroin or not.Results and Discussion: Across all potential heroin-related death cases, the use of this model enabled a greater level of consistency in the attribution of death to heroin, especially in cases where 6-AM was not detected. The largest amount of variation in the attribution of a death to heroin was observed with potential intoxication-related deaths and in toxicity cases where a M: C ratio only was reported, even more than when no toxicological evidence was available. The reviewed cases highlighted the same variation in the attribution of a death to heroin, including a large number of cases that were attributed to morphine where 6-AM was not detected.Conclusion: This model provides a useful tool for improved accuracy and consistency in the differentiation, attribution and reporting of heroin-related deaths. Previously challenging cases where death occurred after a significant period of time and either no 6-AM was detected or no samples were taken, are able to be captured using this model. (C) 2017 Elsevier B.V. All rights reserved.