Fatal Fentanyl Intoxication Following Excessive Transdermal Application

Abstract

The case history and toxicological findings of a fatal fentanyl intoxication due to the application of multiple transdermal patches are presented. An 83 year-old white female with terminal cancer was found dead with three 100 mg/h fentanyl patches on her chest. The autopsy and subsequent histological studies revealed extensive areas of gastric carcinoma, a large atrial tumor, ulceration of esophagus, metastasis of peripancreatic lymph nodes and a recent surgical removal of part of the lower lobe of the left lung. Toxicological analysis by GC/MS yielded fentanyl concentrations of blood, 25 ng/mL; brain, 54 ng/g; heart 94 ng/g; kidney 69 ng/g; and liver 104 ng/g. The cause of death was determined to be fentanyl overdose and the manner of death was ruled undetermined as the investigation was unable to conclusively establish whether this was an accidental overdose, a suicide, an assisted suicide, or possibly a homicide. This case demonstrates the need for caution in self-administration of transdermal fentanyl patches, in particular, the dangers inherent in the application of multiple patches which can result in the release of potentially toxic or lethal doses.

Fentanyl, fentanyl analogs and novel synthetic opioids: A comprehensive review

“…In the 1990s fentanyl transdermal patches were introduced for widespread palliative use and access extended from clinicians to include patients. As a result, reports of overdoses caused by the misuse of fentanyl transdermal patches emerged in the 1990s and continued into the early 2000s (Rose et al, 1993;Marquardt and Tharratt, 1994;Flannagan et al, 1996;Edinboro et al, 1997;Kramer and Tawney, 1998;Frolich et al, 2001;Reeves and Ginifer, 2002;Tharp et al, 2004;Coon et al, 2005;Teske et al, 2007). In 1994, the FDA issued a warning regarding the dangers associated with fentanyl patches, expressing that it should only be prescribed to those with severe pain that cannot be managed by less potent opioids (Wyman, 1994).…”

Transdermal fentanyl: Pharmacology and toxicology

“…Although the latter data are fatality related, they often inadequately distinguish between misuse and abuse, and generally fail to specify the form and/or route by which fentanyl was utilized. A more obvious association from the medical examiner literature is the utilization of the transdermal fentanyl delivery systems as a method of suicide [27,35,36]. While in many cases the cause of death may be confirmed objectively, deciphering the manner of death to determine who died from fentanyl abuse rather than suicide is often difficult.…”

“…Corresponding norfentanyl concentrations were <2 ng/mL, 4.2 ng/mL, and 4.4 ng/mL, respectively [29]. An 83-year-old woman who had three 100 μg/hour transdermal devices on her skin had a blood fentanyl concentration of 25 ng/mL [36]. Injection administration from a transdermal fentanyl device resulted in blood fentanyl concentrations of 2.7 ng/mL and 13.8 ng/mL in 2 decedents who extracted the drug from a 100 μg/hour transdermal device [94].…”

Akzidentelle Intoxikation durch unbeschriftete, generische transdermale Fentanylpflaster nach unzureichender Aufklärung

“…Der alarmierte Notarzt fand einen soporösen Patienten mit einem Glasgow-Coma-ScaleWert von 6 Am Abend des gleichen Tages klebte der Patient sich je eines der Schmerzpflaster auf eine schmerzende Körperregion. Jeweils ein Pflaster klebte auf dem linken oberen Sprunggelenk, auf der Narbe der Bypassoperation am linken Unterschenkel, in der linken Leiste, auf dem linken Hüftgelenk und der Lendenwirbelsäule.…”

“…Es handelt sich dabei sowohl um akzidentelle als auch um suizidale bzw. missbräuchliche (Abusus) Intoxikationen [2,6,7,8,9,10,11,12]. So konnte ein Bericht zeigen, dass durch Zerschneiden eines 50-μg/ h-Pflasters lebensbedrohliche Komplikationen entstehen können, wenn Fentanyl unkontrolliert perkutan aufgenommen wird [2].…”