Assisted suicide by fentanyl intoxication due to excessive transdermal application

Abstract

Herein, we report a case of an assisted suicide committed by application of 34 matrix-based fentanyl-containing transdermal therapeutic systems (TTS) with different release rates. The TTS were supplied by the husband but administered by the deceased herself. Besides routine systematic toxicological analysis (STA), the concentrations of fentanyl and norfentanyl were determined in the blood (femoral and heart), urine, stomach content, brain, lung tissue, musculus iliopsoas, liver, kidney, bile and in some of the used TTS by LC-MS/MS. Blood levels of fentanyl were 60.6 μg/L in femoral blood and 94.1 μg/L in heart blood. These concentrations are in good concordance with levels described in cases with accidental or lethal suicidal fentanyl patch application. The organ distribution indicates an influence of post-mortem redistribution. The levels of residual fentanyl in the TTS were also determined. STA furthermore revealed supratherapeutic levels of bromazepam. Thus, the cause of death was a combination of fentanyl and bromazepam intoxication. However, considering the determined levels of fentanyl and norfentanyl in the entire set of specimens and the high toxicity in comparison to bromazepam, fentanyl was the leading toxic noxa.

Not so patchy story of attempted suicide…leading to 24 hours of deep sleep and survival!

“…However, a literature search highlighted three other case reports of suicide by fentanyl patches in adults; in a woman aged 42 years with 11 100 µg patches,7 an assisted suicide of a woman aged 46 years with 34 mixed dose patches,8 and suicide of a woman aged 78 years with 10 100 µg patches 9. These cases are a testament to the lethality of fentanyl dose presented here, and how remarkable it was that the patient was able to survive.…”

A Fatal Case of Poisoning with Fentanyl Transdermal Patches in Japan

“…Juebner et al. reported on a German woman with a history of cancer committed suicide using 34 transdermal fentanyl matrix patches on her body, with release rates ranging from 25 to 100‐μg/h . In Croatia, there was an autopsy case involving a small child who died by the misuse of a fentanyl transdermal patch instead of band‐aid .…”

Fentanyl novel derivative‐related deaths

“…When not directly prescribed, patches could be obtained from relatives (Flannagan, Butts, & Anderson, ; Thomas, Winecker, & Pestaner, ; Wiesbrock, Rochholz, Franzelius, Schwark, & Grellner, ). The number of patches applied ranged from 34 (Juebner et al, ), to just one lethal one (Anderson & Muto, ; Jumbelic, ; Kuhlman et al, ). Application to atypical areas, for example, bruised skin (Bakovic, Nestic, & Mayer, ) or oral cavities (Hull, Juhascik, Mazur, Flomenbaum, & Behonick, ; Kramer & Tawney, ; Martin et al, ; Moore, Palmer, & Donovan, ), as well as licking, chewing, swallowing, or injecting the contents of prescription FEN patches, all resulting in enhanced absorption and a quick high (Anderson & Muto, ; Kuhlman et al, ; Thomas et al, ; Palamalai et al, ), were reported.…”

“…With regard to pathological findings, visceral and especially pulmonary oedema and congestion were invariably described, with just a few exceptions (Juebner, Fietzke, Beike, Rothschild, & Bender, 2014). Cardiac and liver abnormalities (organomegaly, fatty infiltration, or fibrosis) and gastric content aspiration were reported.…”

“…When not directly prescribed, patches could be obtained from relatives (Flannagan, Butts, & Anderson, 1996;Thomas, Winecker, & Pestaner, 2008;Wiesbrock, Rochholz, Franzelius, Schwark, & Grellner, 2008). The number of patches applied ranged from 34 (Juebner et al, 2014), to just one lethal one (Anderson & Muto, 2000;Jumbelic, 2010;Kuhlman et al, 2003).…”