Hydromorphone-Related Fatalities in Ontario

Abstract

The interpretation of drug intoxication in death investigations is based on the available published literature. In the case of hydromorphone, the literature is limited. This report serves to facilitate the evaluation of cases where hydromorphone may be implicated in a fatality through the examination of 251 hydromorphone-positive cases in the province of Ontario from 1985 to 2003. Thirty-three of these cases were selected for review in greater detail. In four cases in which hydromorphone was the sole drug detected and death was attributed to hydromorphone toxicity, concentrations ranged from 77 to 2684 ng/mL. Hydromorphone concentrations ranged from 21 to 441 ng/mL in 28 cases in which at least one other drug was detected. In five deaths attributed to natural causes, blood hydromorphone concentrations ranged from 75 to 423 ng/mL. The results of this study emphasize the importance of case specific information. Fatalities due to hydromorphone occurred at 51 ng/mL and greater; however, tolerant users of this drug, as seen in the deaths attributed to natural causes, may achieve incidental concentrations that would otherwise be considered fatal. Hydromorphone was detected and quantitated using gas chromatography-mass spectrometry.

Effect of Ethanol on Opioid Drug Permeability Through Caco-2 Cell Monolayers

“…Co-ingestion of alcoholic beverages with certain extended-release drug product formulations may accelerate drug release and affect the rate of its gastrointestinal absorption (9). Also, ethanol may enhance the adverse effects of opioids (10).…”

Accidental Death from Hydromorphone Ingestion

“…The minimum lethal concentration in an opiate naïve individual would appear to be in the vicinity of 60 ng/mL. Higher postmortem blood concentrations appeared in opiate‐tolerant subjects (10). Patients dying from cancer, not hydromorphone administration, had blood hydromorphone concentrations in the 75–423 ng/mL range.…”

“…Wallage and Palmentier (10) reviewed 251 hydromorphone‐related fatalities within a 19‐year span, in which postmortem blood hydromorphone measurements were performed at their facility. In four cases, hydromorphone was the sole cause of death.…”

Fatal overdoses involving hydromorphone and morphine among inpatients: a case series

“…This case series provides detailed descriptions of the circumstances leading to unintentional (or accidental) opioid overdoses and complements several population-based studies that show the substantial incidence of opioid overdose, many of which are related to medication misuse. 4,9,10 Adverse drug events are often related to ordering or administration, and serious adverse drug events are often (42%) preventable. 8 The cases presented here show that fatal opioid overdoses occur even when opioids are used in medically supervised settings and show the need for a comprehensive approach to reducing harms from opioids among patients admitted to hospital.…”