Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?
Could chest wall rigidity be a factor in rapid death from illicit fentanyl abuse?
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DOI：
10.3109/15563650.2016.1157722
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发表时间：
2016-01-01
影响因子：
3.3
通讯作者：
Spiller, Henry A.
中科院分区：
文献类型：
--
作者：
Burns, Glenn;DeRienz, Rebecca T.;Spiller, Henry A.
背景：通过海洛因贸易提供的非法芬太尼导致的芬太尼相关死亡人数大幅增加。过去芬太尼的使用主要是口服或通过处方芬太尼贴剂转移皮肤。可能导致死亡率增加的一个因素是给药途径的变化。快速静脉注射（IV）芬太尼可导致胸壁僵硬。我们评估了最近大量致命芬太尼中毒事件中死后芬太尼和去甲芬太尼的浓度。方法：确定了2015年1月至9月富兰克林县验尸官办公室的芬太尼相关死亡病例。假定阳性芬太尼结果通过使用液相色谱串联质谱法（LC/MS/MS）的定量分析得到证实，并且能够定量芬太尼、去甲芬太尼、阿芬太尼和舒芬太尼。结果：确定了48例芬太尼死亡。平均芬太尼浓度为12.5 ng/ml（范围为0.5 ng/ml至>40 ng/ml）。平均去甲芬太尼浓度为1.9 ng/ml（范围为未检出至8.3 ng/ml）。48例中有20例（42%）未检测到明显的去甲芬太尼浓度，25例（52%）低于1 ng/ml。芬太尼浓度升高与去甲芬太尼水平升高无关。在一些情况下，芬太尼浓度非常高（22 ng/ml和20 ng/ml），未检测到去甲芬太尼。讨论：在我们的一半病例中缺乏任何可测量的去甲芬太尼，这表明死亡非常迅速，与急性胸硬一致。另一种解释可能是剂量相关的呼吸骤停快速发作。在明显的非初次阿片类药物滥用者中，芬太尼水平在治疗范围内（1-2 ng/ml）时发生死亡。急性胸壁强直是医学界公认的并发症，但在药物滥用界尚不清楚。非法阿片类药物的普通滥用者可能不知道他们购买的非法阿片类药物中芬太尼含量的增加。结论：总之，我们认为突发性胸壁僵硬可能是一个重要的和以前未报告的因素，导致死亡率增加，从非法静脉芬太尼使用。芬太尼和去甲芬太尼的比例和浓度表明，由于在许多死亡病例中发现了芬太尼而没有去甲芬太尼，因此死亡发生得更快。与典型的阿片类药物相关过量死亡相比，胸壁僵硬可能有助于解释这些情况下的死亡原因。鉴于芬太尼替代海洛因和与海洛因结合的情况越来越普遍，应教育静脉注射海洛因使用者了解这一可能致命的并发症。
Background: There has been a significant spike in fentanyl-related deaths from illicit fentanyl supplied via the heroin trade. Past fentanyl access was primarily oral or dermal via prescription fentanyl patch diversion. One factor potentially driving this increase in fatalities is the change in route of administration. Rapid intravenous (IV) fentanyl can produce chest wall rigidity. We evaluated post-mortem fentanyl and norfentanyl concentrations in a recent surge of lethal fentanyl intoxications. Methods: Fentanyl related deaths from the Franklin County coroner's office from January to September 2015 were identified. Presumptive positive fentanyl results were confirmed by quantitative analysis using liquid chromatography tandem mass spectrometry (LC/MS/MS) and were able to quantify fentanyl, norfentanyl, alfentanyl, and sufentanyl. Results: 48 fentanyl deaths were identified. Mean fentanyl concentrations were 12.5 ng/ml, (range 0.5 ng/ml to >40 ng/ml). Mean norfentanyl concentrations were 1.9 ng/ml (range none detected to 8.3 ng/ml). No appreciable concentrations of norfentanyl could be detected in 20 of 48 cases (42%) and were less than 1 ng/ml in 25 cases (52%). Elevated fentanyl concentrations did not correlate with rises in norfentanyl levels. In several cases fentanyl concentrations were strikingly high (22 ng/ml and 20 ng/ml) with no norfentanyl detected. Discussion: The lack of any measurable norfentanyl in half of our cases suggests a very rapid death, consistent with acute chest rigidity. An alternate explanation could be a dose-related rapid onset of respiratory arrest. Deaths occurred with low levels of fentanyl in the therapeutic range (1-2 ng/ml) in apparent non-naive opiate abusers. Acute chest wall rigidity is a well-recognized complication in the medical community but unknown within the drug abuse community. The average abuser of illicit opioids may be unaware of the increasing fentanyl content of their illicit opioid purchase. Conclusion: In summary we believe sudden onset chest wall rigidity may be a significant and previously unreported factor leading to an increased mortality, from illicit IV fentanyl use. Fentanyl and norfentanyl ratios and concentrations suggest a more rapid onset of death given the finding of fentanyl without norfentanyl in many of the fatalities. Chest wall rigidity may help explain the cause of death in these instances, in contrast to the typical opioid-related overdose deaths. Intravenous heroin users should be educated regarding this potentially fatal complication given the increasingly common substitution and combination with heroin of fentanyl.