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ForensicToxicologyDrugsandChemicals:Overview,Definitions,SceneFindings

ForensicToxicologyDrugsandChemicals
Author:GregoryGDavis,MD,MSPHChiefEditor:JScottDenton,MDmore...
Updated:May01,2014

Overview
In2006,deathscausedbypoisoningaccountedfor20.8%ofalldeathscausedby
injuryintheUnitedStates,surpassingthepercentageofdeathscausedbyfirearms
(17.3%)andsecondonlytodeathscausedbymotorvehiclecollisions(24.4%). [1]
Giventhatanelementofintoxicationisinvolvedinmanymotorvehiclecollisions,
thevitalroletoxicologicanalysisplaysinmoderndeathinvestigationbecomesclear.
Deathsrelatedtodrugoverdosesincelebritieshavebroughtmassmediaattention
tothedrugabusepandemic.Whereashistoricallydrugssuchasheroinandcocaine
havebeenconsideredthe"dangerous"drugs,inrecentyears,prescriptiondrug
abusehasfarsurpassed"illegal"drugsasagentsoflethaldrugtoxicity.Thistrend
isexpectedtocontinue.
Entiretextbookshavebeenwrittenonforensictoxicologyandindividualdrugsand
chemicalsthatcancausedeath.Thisarticlehighlightsaspectsnotnecessarilyfound
ingeneraltextbooks.Discussionsofcommonclassesofdrugsandotherpoisonous
substancescanbefoundatMedscapeReference,aslistedintheFurtherReading
section.
Theimagebelowdepictsthesceneofadeathcausedbydrugoverdose.

Kitchencounterwithparaphernaliausedinintravenousdrugabuse.Spoons,syringes,and
lighterarepresentonthecounter.Thedecedentwasdeadatthekitchentable.

History
Toxicologicanalysisisappliedanalyticalchemistrymoderntoxicologicanalysis
dependsuponscreeningandconfirmatorytests.Screeningtestsaretypically
performedwithcommercialkitsthatcontainantibodiesdirectedtowardcommon
drugsofabuse.Ifthisscreeningtestisnegative,thenthedecedentisusually
considerednegativeforanintoxicatingsubstance.Ifthescreeningtestispositive,
thenthatpositiveresultmustbeconfirmed,typicallywithgaschromatography/mass
spectrometry(GC/MS).
GC/MSanalysisallowsseparationofcompoundsbasedontheirretentiontime
withinachromatographycolumnandidentificationofeachcompoundbythe
characteristicfragmentsintowhichagivenchemicalisbrokenfollowingionizationof
thecompound.(AconciseaccountofthetechniqueofGC/MSisavailablehere.)
Overtheyears,technologicadvancesinelectronicsanddetectorshaveallowed
GC/MStodetecteversmallerconcentrationsofcompounds,ashastheadditionof
otheranalyticaltechniques,suchasliquidchromatography.
Ingeneral,screeningtestscanbeperformedquickly,buttheyprovideonlya
qualitativeresult(eg,asubstanceisorisnotpresent).Confirmatorytestingusually
takeslonger,butitprovidesanactualconcentrationofthesubstanceinthebody
fluidanalyzed.

Epidemiology
AsmentionedintheIntroductionsection,poisoningsaccountforsome20%ofall
deathscausedbyinjuryintheUnitedStatestheseincludebothintoxicationfrom
abuseofillicitdrugsanddeathsresultingfromaconsequenceofmedicationtaken
asmedicaltherapy. [1]The2021%figureonlyaccountsfordeathscausedby
intoxicationanddoesnotincludecasesinwhichanintoxicantwasfoundthatdid
notcausedeath.Severalmedicalexaminers'officesthatroutinelytestforalcohol
anddrugsofabusereportfindingsomesubstanceontoxicologicanalysisinatleast
50%oftheircases. [2]

OverviewoftheEntity
TheIntroductionandEpidemiologysectionshavebothmentionedthatdrugsare
foundin50%offorensicautopsies(whentested)andthatdrugsormedicationsare
responsibleforcausingorcontributingtodeathinover20%ofdeathsunrelatedto
naturalcausesintheUnitedStates.Theprevalenceofdruguseisreiteratedhereto

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emphasizethevitalrolethattoxicologicanalysisplaysinautopsypathology.
Blood,urine,bile,ocularfluid,gastriccontents,liver,andbraintissuecanallbe
usefulspecimens.Peripheralblood(femoralorsubclavian)specimensareoptimal
forpostmortemtoxicologicquantificationurineistheprimarybodyfluidusedfor
drugscreening.Specimensneednotnecessarilybetestedautomatically,butthe
bestpracticeistoatleastcollectandholdthespecimensuntilcompletionofthe
autopsyreportanddeathcertificate.Sometimes,additionalhistorydoesnot
becomeknownuntilafterthebodyisreleased,whichisthentoolatetocollect
samples.

IndicationsfortheProcedure
Basedontheprevalenceofsubstanceswithinthepopulationofdecedents
examinedbyforensicpathologists,simplydyingincircumstancesthatwouldbring
one'sbodytothemedicalexaminer'sofficeforinvestigationissufficientindication
towarranttoxicologicanalysis. [2]Nevertheless,factorssuchascostoraprolonged
laginreceivingtoxicologicresultscanmakeitimpracticaltoperformathorough
analysisoneverycase.Historythenbecomesthebestguidetodeterminingwhen
andwhatteststoorder.
Casesinwhichahistoryorevidenceofalcoholordrugabuseexistscertainlymerit
toxicologicanalysis,asdocasesforwhichnovisiblecauseofdeathcanbefoundat
autopsy.Orderingtoxicologicanalysisinallhomicidesandaccidentsisalsowise,as
questionsconcerningthepresenceorabsenceofintoxicatingsubstancesarelikely,
notonlyfromrelativesofthedecedentbutinanylegalproceedingthatmaylater
arise.Suchquestionsmayariseinsuicidesaswell,and3separatestudieswithin
theUnitedStateshavereportedthat6873%ofsuicideshavesomesubstance
detectedinthebodyontoxicologicanalysis. [3]
Theonlymannerofdeathnotyetdiscussediscasesinwhichdeathappearstobe
duetosomenaturalcause.Certainlysomeofthesecasesdonotseemtoneed
toxicologicanalysis,butevenhereapathologistcannotalwaysanticipatequestions
thatmaylaterarise,particularlywhenanunexpectedcivilsuitisbroughttothe
pathologist'sattention.Oneapproachistoperformsimplescreeningassayson
apparentlynaturaldeathstoquicklyruleoutthepresenceofsubstancesthatmay
havecontributedtodeath(eg,cocainemaytriggeramyocardialinfarctor
cerebrovascularaccident).Pathologistsrarelyregretorderingtoxicologicanalysison
acaseregretusuallycomesfromcasesinwhichnotoxicologictestingwas
performed,thespecimenshavebeendiscarded,andonlythendoquestionscome
fromfamilyandtheirattorneys.
Historyandsceneinvestigation,powerfulastheyare,arenotinfallibleguidesin
orderingtoxicologicanalysisinamedicalexaminerpopulation(seeSceneFindings,
below).(Sceneinvestigationisdiscussedindetailinaseparatearticle.)Gruszecki
etalreportedthathistoryandscenefindingsdetectedonly63%ofallcasesin
whichintoxicatingsubstanceswerefoundhence,theauthors'suggestionthatdying
incircumstancesthatbringabodytothemedicalexaminerforinvestigationis
sufficientinandofitselftowarranttoxicologicanalysis. [2]

Definitions
Benzodiazepines
Theseagentsareafamily(orclass)ofdrugsusedasantianxietyagents.Often
abusedinconjunctionwithopiates,benzodiazepinescanpotentiatetheeffectsof
opiates.Diazepam(Valium)andalprazolam(Xanax)aremembersofthisfamily.

Cookerspoon
Cookerspoonsarespoonsusedformeltingasubstanceforinjecting.Thebottomof
thebowlisheated,usuallywithalighter,untilthesubstanceinthebowlmeltsasa
result,thebottomofthebowlisusuallycoatedwithsoot.

Crackpipe
Thisisadeviceusedforsmokingcrackcocaine.Crackpipesaregenerallyashort
lengthofahollowcylinder,suchasaglassormetaltube.Theendsarecharred,
andoneendoftencontainsatuftofcoppermesh(Seetheimagebelow).Theends
maybewrappedinelectricaltapetoinsulatethefingersandlipsfromthehotpipe.

Photographofacrackpipefoundinthepocketofclothing.Noticethattheendsarebrokenand
couldcutanindividualcarelesslyexaminingthepockets.

Daterapedrugs
Thesedrugsincludeanyofseveralsedativehypnotics,suchasgamma
hydroxybutyrate(GHB)orflunitrazepamRohypnol),thatcaninducehypotoniaand
amnesiawheningested.GHBisendogenousinmammalsatnanomolar
concentrations.

Depressant
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Anysubstancethatdepressesorsuppressesthenormalfunctionofthecentral
nervoussystemisadepressant(eg,alcohol,opiates,andbenzodiazepines).

Designerdrugs
Drugsthathavebeenalteredchemicallysothatthesubstancefallsoutsideofalist
ofsubstancesthatarelegallyproscribedareknownasdesignerdrugs.Thechemical
sidegroupsofamphetamines,forexample,canbealteredslightlywhileretaining
thestimulantpropertiescharacteristicofamphetamines.Similarchemicalchanges
canbemadetocannabinoids.

Drugscreen
Thisisaninitialtestonabodyfluidthatisperformedtolookforthepresenceof
classesofcommonlyabuseddrugs.Screensoftenrelyuponantibodiesdirected
againstspecificdrugclassesandsomespecificdrugs.Adrugscreenisqualitative
onlyandissubjecttofalsepositives.

Exciteddelirium
Exciteddeliriumreferstoanagitatedstatethatmayormaynotbeassociatedwith
theuseofstimulantdrugs.Thisconditionistypicallymanifestedasrash,abnormal
behavior,oftenassociatedwithdelusionorparanoiaandextraordinarystrength.
Hyperthermiaiscommon.

Huffing
Thisisthepracticeofinhalingvolatilecompoundstoexperiencea"high."

Needletrack
Aneedletrackisalineofneedlemarksorscarsleftontheskinalongthecourseof
avein.Suchtracksareoftenonthearmsbutcanalsobefoundinsitesgenerally
hiddenfrompublicview,asseenintheimagesbelow.

Aneedletrackmarkinthearmofanindividualwhodiedasaresultofintravenousdrugabuse.

Needlemarksintheleftsideofthegroinofamanwhodiedofintravenousdrugabuse.The
arrowpointstowardascarredtrackthatformedbecauseofrepeatedinjectioninthesamesite.
Thedecedent'sarmswerefreeofneedlemarksheworkedasasalesman.

Opioids
Opioidsarealsoknownasnarcotics,thefamilyorclassofdrugsthatarenarcotic
analgesics,exemplifiedbytheprototypemorphine.Naturalandsyntheticanalogues
ofmorphineexist,andallhavethepotentialforabuse.Heroin,oxycodone,

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methadone,andfentanylaremembersofthisfamily.

Sedative
Anydrugusedtoinducerelaxationoranesthesiaisasedativetheseagents
depressthecentralnervoussystem.Benzodiazepines,opiates,andalcoholallhave
sedativeproperties.

Stimulant
Anysubstancethatstimulatesorincreasethenormalfunctionofthecentralnervous
systemisastimulant(eg,cocaineandamphetamines).Caffeineisamildstimulant.
(SeealsothePillIdentifiertool.)

SceneFindings
Thepresenceofdrugsordrugparaphernaliaatascenealertsthedeath
investigationteamtothepossibilityofanoverdose.Drugevidencemaybe
marijuana,pills,crackcocaine(asintheimagebelow),orpowderymaterial,orthe
containersthesedrugswerepackagedin,suchasplasticbaggies,medication
containers,orbottlesforliquids.

Crackcocainefoundwrappedinapapertowelintheinterglutealcleft.

Paraphernaliaincludesarticlesusedforselling(eg,pocketscale),injecting(eg,
syringes,lighters,cookerspoonwithsootonbottomofbowlseethefirstimage
below),smoking(eg,roachclips,bong,lighter,crackpipe(asshowninthesecond
imagebelow),orsnorting(eg,razorblade,card,mirror)drugs.Ofcourse,familyor
friendsmayhideordisposeofthisevidencebeforethearrivalofthedeath
investigator.Likewise,thedecedentmayhavehiddenhisstashforexample,by
placingarockofcrackcocaineinsideapartiallyemptypackofcigarettes.

Kitchencounterwithparaphernaliausedinintravenousdrugabuse.Spoons,syringes,and
lighterarepresentonthecounter.Thedecedentwasdeadatthekitchentable.

Photographofacrackpipefoundinthepocketofclothing.Noticethattheendsarebrokenand
couldcutanindividualcarelesslyexaminingthepockets.

Additionalhistorymaycomefromexaminationofwritingsofthedecedentinadiary
orcalendar,fromexaminationofwebsitesvisitedonthedecedent'scomputer,or
fromexaminationofemailmessages,textmessages,orinformationwithinasocial

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networkingsite.Whencomputerevidenceisfound,itshouldberecordedinsome
waysuchthatifthesiteislaterchanged,theinformationwillnotbelosttothe
forensicpathologist.
Giventhewidespreadnatureofprescriptiondrugabuse,allmedicationsfoundon
sceneshouldbecarefullydocumented. [4]Pillsshouldbecountedtoestablish
appropriateusagepatterns.Overthecounter(OTC)medicationspresentatthe
sceneshouldalsoberecordedsomeofthesemedications,suchas
acetaminophen,canhavepotentiallylethalconsequencesiftakeninappropriately.

TraceEvidence
Traceevidencemaybefoundatthesceneorwhenexaminingthebodyinthe
morgue.ParaphernaliadescribedintheSceneFindingssectioncanbefoundwithin
pocketsofadecedent'sclothingorinbelongings.Paraphernaliaordrugsareoften
hidden,andwhoeverlooksthroughpocketsmustbecarefultoavoidastabfroma
needleonasyringeoracutfromabrokencrackpipe.Longforcepsorsurgical
clampsareusefultoolsforlookingthroughpocketsratherthanusingahandto
reachintothepocket.Evidencecanbehiddeninanysignificantcreaseintheskin
includingunderabreast,intheinterglutealcleft(suchasintheimagebelow),or
simplywithinafoldoffat.Evidencemayalsobefoundinanybodycavity(eg,
withinthevaginaorrectum).

Crackcocainefoundwrappedinapapertowelintheinterglutealcleft.

Acrackpipeorasyringelikelycontainsresiduefromthedrugsused.Ifdeemed
necessary,washingsofparaphernaliacanbetestedfordrugsviagas
chromatography/massspectrometry(GC/MS),butitisimportanttorememberthat
theamountofdruginsuchwashingsmaybemuchgreaterthantheamountofdrug
extractedfromabloodsample.Thisresultsinapotentialtechnicalhazardforthe
laboratory.Ifenoughdrugispresent,itcanoverwhelmthebindingsitesona
chromatographycolumn,andsubsequentslowelutionofdrugfromthecolumncan
thencontaminatesubsequentsamples.Thecolumnmustbewasheduntilclean
afterconfirmingthepresenceofanydrugs.

GrossExaminationandFindings
Grossexaminationmayrevealevidenceofdrugabuseoneitherexternalorinternal
examination.Drugsordrugparaphernaliamaybefoundduringexaminationofthe
clothingortuckedbetweenclothingandthebody,suchasinunderwearorwithin
thecupofabra.Examinationofthebodyitselfmayrevealneedlemarksorscarred
needletracks,asinthefirstimagebelow.Thesemarksareoftenonthearmsbut
maybefoundelsewhere.Inrarecases,theneedlemarkisinaspecificlocation,
generallyhiddenfrompublicview,wherethedecedenthabituallyinjecteddrugs,as
inthesecondimagebelow.

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Aneedletrackmarkinthearmofanindividualwhodiedasaresultofintravenousdrugabuse.

Needlemarksintheleftsideofthegroinofamanwhodiedofintravenousdrugabuse.The
arrowpointstowardascarredtrackthatformedbecauseofrepeatedinjectioninthesamesite.
Thedecedent'sarmswerefreeofneedlemarksheworkedasasalesman.

Internalexaminationmayrevealpillsorchalkywhitematerialwithinthestomach,
particularlyinasuicidaloverdose.Usually,however,thepillshavedissolved
completelyandarenolongerevident,evenwhentoxicologicanalysisrevealsa
lethalconcentrationofsomedrugtakenbymouth.Inotherwords,theabsenceof
pillsinthestomachdoesnotruleoutasuicidaldrugoverdose.
Variousorgansystemscanbeaffectedbydrugabuseatthegrosslevel.For
example,massivehepaticnecrosisiscommonlyseenfollowingacetaminophen
toxicity(seetheimagesbelow),endocarditismayinvolvecardiacvalvesif
intravenousdrugabusersarenotusingsteriletechnique,andcerebrovascular
accidentsandmyocardialinfarctsmaybeseeninthesettingofstimulantuse.Other
changesmaybeseenatthemicroscopiclevelinthebrain,lungs,heart,kidney,
liver,andskin.

Hepaticnecrosisthatdevelopedfollowingingestionofanoverdoseofacetaminophen.Necrosis
canbeglobalorfocal.Noticethelackofinflammation,whichmaybetrueearlyintheprocessof
necrosis.Magnification100.

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Hepaticnecrosisthatdevelopedfollowingingestionofanoverdoseofacetaminophen.Necrosis
canbeglobalorfocal.Noticethelackofinflammation,whichmaybetrueearlyintheprocessof
necrosis.Thishigherpowerviewshowsmicrosteatosisofhepatocytesattheedgeofnecrosis.
Magnification400.

Forensicpathologistsarefamiliarwiththepracticeofsmugglingdrugswithinthe
bodiesofpeopleenteringtheUnitedStates,aprocessreportedasearlyas1975. [5]
Thosewhosmuggledrugsinthiswayarecalledbodypackersormules,andthese
peopleareatriskforsuddendeathfromamassiveoverdoseifoneormorepackets
shouldthedrugsleak. [6]
Avariantofthissortofdeathcanoccurwhenanindividualswallowsdrugs,package
andall,totrytoavoiddiscoveryofthedrugswhenconfrontedbythepolice.Death
canoccurfrommassiveintoxication,butitcanalsooccurifthedecedentaspirates
theevidenceratherthanswallowingit(seetheimagebelow).Thefindingsinsucha
casecanbesubtleifthedrugwaswrappedinasmallportionofplasticwrap,only
adiligentsearchofgastriccontentswillrevealthecolorlesspieceofplastic.

Abagofmarijuanawasaspiratedbyanindividualwhotriedtoswallowhisdrugevidencewhen
pulledoverbythepolice.Thedecedentsuddenlybecameunresponsivewhileinpolicecustody.

Vomitingandaspiratinggastriccontentsintotheairwaysorlungsisnotuncommon
forpersonsdyingofdrugtoxicity.Rememberthatalthoughterminalaspirationmay
haveoccurred,theunderlyingcauseofdeathisdrugtoxicityand,inmostcases,
thiswillbeanaccidentalmannerofdeath.Similarly,pulmonaryedemaandanoxic
encephalopathyarecommonlyseenfollowingdrugintoxication.Thesefindingsare
nottheunderlyingcauseofdeathanddonotresultinanaturalmannerofdeath.

SpecialDissections
Ifthepathologistwishestodocumentaneedletrackmarkmicroscopicallyaswellas
grossly,thenanincisionismadeimmediatelytoonesideoftheveinwiththetrack
mark.Extravasatedbloodfromthevenipuncturemaybevisibleinthesofttissue
adjacenttothevein.Aportionoftheveinmaythenbedissectedoutofthebody,
fixed,andsubmittedforhistologicexamination.Thebestviewcomesfromasection
takenperpendiculartothelongaxisofthevein.Microscopicexaminationtypically
showsscarringaroundthevein,foreignbodygiantcells,and,uponpolarization,
birefringentmaterialsuchascrystalsorfibers(seetheimagebelow).

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Crosspolarizationofthewallofaveinfromtheantecubitalfossainanindividualwithahistory
ofintravenousdrugabuse.Noticethebirefringentcrystallinematerialwithinforeignbodygiant
cells.Originalmagnifications100and400.

SpecialAutopsyProcedures
Fromamedicalpointofview,collectingandretainingspecimensforpotential
toxicologicanalysisisalwaysappropriateineveryautopsythatisundertakento
determinethecauseofaperson'sdeath.Thoroughspecimencollectionispossible
inexaminationsmandatedbylaw,buthospitalautopsiesareauthorizedbythe
permissionofthedecedent'snextofkin.Therefore,thediscussionbelowmustbe
tempered,inhospitalpractice,byabidingbytherestrictionsstatedintheautopsy
permit.
Bloodobtainedfromaperipheralvesselisthepreferredbloodspecimenfor
toxicologicanalysis,astheconcentrationofcompoundsinbloodfromtheheartmay
bealteredafterdeathbyredistributionofbloodfromthelungsorliver. [7]Some
authorsclaimthatbloodfromafemoraloriliacveinisleastsusceptibleto
contaminationfromtheliverwhentheveinisfirstoccludedbyatieorclamp, [7]but
othersreportthatligationoftheveinhasnosignificanteffectonthebloodsample.
[8]Evenauthorswhoadvocateligationoftheperipheralveinbeforeobtainingblood
acknowledgethatsuchproceduresaresometimesimpractical. [7]Theworstmistake,
ofcourse,istohavenosampleatall.Atleastsomeofthecollectedbloodshould
bestoredinagraytoptubecontainingsodiumfluoride.
Whenavailable,urineshouldbeobtainedfromeveryautopsy,becauseitisideally
suitedforrapidscreeningassays.Vitreousfluidcanbescreenedfordrugsand
ethanolascancerebrospinalfluidandbile.Dependingonthecase,vitreousfluid
maybestoredinaredtoptube(ifanalysisforelectrolytesisbeingconsidered)ora
graytoptube(ifdrugscreeningmaybeperformed)(forensicvitreousanalysisis
discussedindetailinaseparatearticle.)Manymedicalexaminerofficesalso
routinelyretainliver,brain,bile,andgastriccontentsfortoxicologicanalysisif
needed.Splenictissueandskeletalmusclemaybeusedindecomposedbodies.
Subduralhematomasshouldbesampledifpresenttheymaycontaindrugsor
alcoholsthathavesincebeenmetabolizedintheperipheralblood.
Ifanindividualwasevaluatedatahospitalbeforedeath,thentheylikelyhadblood
drawnfortests.Thisperimortembloodisaprecious,irreplaceableresourcefor
toxicologicanalysisandshouldberoutinelyobtainedaspartofthedeath
investigation. [4]Bloodobtainedatthehospitalwouldnotbesubjecttopostmortem
redistributionthewaythatbloodobtainedatautopsyis.Hospitalpathology
laboratoriesholdbloodonlyforseveraldays,sorequestingthatthelaboratoryhold
thesampleassoonasinvestigationofthedeathbeginsisimportant.Asampleof
bloodmayberetainedinthebloodbanklongerthanelsewhereinthelaboratory.
Thebraincanbeanespeciallyusefulmatrixfortoxicologicanalysisthisorganis
littleaffectedbypostmortemredistributionofdrugs. [7]Furthermore,thebrain,which
isfattyandsequesteredbothbyitsanatomiclocationandbythebloodbrainbarrier,
canharboradruglongerthanothermatrices. [9]Thus,thebrainmaybetheonly
matrixpositiveforcocaineinacaseinwhichapathologistsuspectsadrugof
abuse,suchascocaineinayoungpersonwhohasdiedfromahypertensivebleed
inthebasalganglia.Hairanalysiscanbeusedinthesamesortofway. [10]The
braincanalsobeusedformolecularanalysisincasesofexciteddelirium. [11]

SpecialHandling
Somesubstances,suchasethanol,arestableafterdeathandrequirenospecial
handling.Cocaine,ontheotherhand,isnotoriouslyunstable,undergoingboth
enzymemediatedandspontaneoushydrolysisevenafterdeath.Theenzyme
mediatedhydrolysisofcocaineisinhibitedbyfluorideandbycold. [12]Giventhe
frequentpresenceofcocaineinforensicpractice,forensicpathologistsusefluoride
asananticoagulantandrefrigeratetoxicologicsamples.(Sodiumfluorideisingray
toptubesitalsoinhibitsinvitroglycolysisinbloodsamples.)Refrigerationretards
otherunwantedchemicalreactionsaswell.Althoughethanolisstableafterdeath,
onedoesnotwantsamplestoputrefy,allowingbacteriatoproduceadditional
ethanol.
Someindividualsenjoytheintoxicationbroughtonbyinhalingvolatilefumes,such
asgasoline,toluene,orhalogenatedhydrocarbons,aprocesscommonlycalled
huffing.Whenconfrontedwithsuchacase,thepathologistmustmakecertainto
obtainandsavespecimensinawaythatminimizeslossofthesevolatile
compoundstoevaporationbeforeanalysis.Samplesoftheusualmatrices(blood,
urine,vitreoushumor,bile,liver,andbrain,ifavailable)shouldbesaved,and,if
desired,samplesoflungtissueorgasaspiratedfromthetracheacanalsobesaved
andanalyzed.

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Thesolidandliquidsamplesshouldbeplacedinairtight,nonreactivecontainers,
andthecontainersshouldbeasfullaspossibletoreducetheheadspaceavailable
withinthespecimencontainer,thusminimizinglossofthevolatilecompoundwhen
thecontainerisopenedforanalysis. [13]Glassspecimentubesarenonreactiveand
readilyavailable,buttoluenecanbeabsorbedbyrubberso,ifpossible,inserta
sheetofaluminumfoilbetweenthespecimenandthestopperbeforestoppingthe
tube,especiallyforsamplesofsolidtissuethatrequireremovalofthestopper. [14]
(Thisiseasierthanitmightseemfirst,fitthefoiltightlyaroundthebaseofthe
stopper,andtheninsertthestopperintothetube.)
Volatilecompoundsarelessvolatileatlowertemperaturesthus,thespecimens
shouldberefrigeratedpromptlyandkeptcooluntilanalysis. [13]Foranycasein
whichunusualstepsarenecessary,personalcommunicationwiththetoxicology
laboratorythatwillperformtheanalysiswillhelpassurethatthespecimensare
collected,stored,transferred,andanalyzedcorrectly. [15]
Actualdrugsfoundatpostmortemexamination,whetherinpropertyorduring
internalexamination,requirespecialhandling.Withillicitdrugs,thehandlingmay
betotransfertheevidencetoapoliceofficerortoapolicedruglaboratory,withan
appropriateformdocumentingtransferofthisevidence.Somedrugs,suchas
opioids,havepotentialforabuseeventhoughtheymaybelicit.Ifsuchdrugsare
heldatthecoroner'sormedicalexaminer'soffice,theyshouldbeheldassecurely
asanyotherevidence,suchthattamperingwouldbeevident.Whenthetimecomes
todisposeofsuchdrugs,disposalisbestdoneinsomewaythatisabovereproach
forexample,inthepresenceofwitnessesintheofficeandthedisposalshould
bedocumentedintheofficerecords.
Iftheexaminationandanalysisofdrugsorotherevidencemayhaveeventual
importanceinalegalproceeding,thenthetransferofitemsfromthecustodyofone
persontoanothermustbedocumentedinawaythatisacceptableincourt.This
documentationiscalledthechainofevidenceorchainofcustody.Achainof
evidenceisusedincourttoshowwhohadcontroloftheitemorspecimenin
questionatalltimes.Thisisnecessary,becauseUnitedStateslawstatesthat
anyoneontrialhastheconstitutionalrighttoquestionhisorheraccusersaboutthe
circumstancesofthetrial.
Ifnochainofcustodyisdocumented,orifalinkinthechainismissing,thenitmay
notbepossibletosatisfyajurythatthespecimenwashandledproperly,andthus
theitemmaybeexcludedasevidenceinatrial.Thechainofcustodypapertrail
describestheitemandliststhenames(withsignatures),dates,times,andplaces
whentheitemchangedhands.AfullerdiscussionisavailableinthebookPathology
andLaw. [16]

HistologyandMicroscopicExaminationand
Findings
Inadditiontothefindingsseeninassociationwithneedletrackmarks,asdiscussed
intheSpecialDissectionssection,microscopicexaminationcanshowfeaturesof
intravenousdrugabuseininternalorgans.Thelungsareparticularlyapttocontain
birefringentcrystallinematerial,asdrugsandinsolublematerialinjected
intravenouslymustpassfirstthroughthepulmonarycircuit,wherethepulmonary
capillariesactasafilterfordebris(seethefirstimagebelow).Insomecases,
crystalsmaybeseenintheliverinadditiontothelungs.Whenpresent,crystalsin
theliverareintheconnectivetissueofthetriads(seethesecondimagebelow).Not
everyonewhoabusesdrugsintravenously,however,hasbirefringentmaterialin
eitheroftheseorgans.

Crosspolarizationofasectionoflunginanindividualwithahistoryofintravenousdrugabuse.
Noticethebirefringentcrystallinematerialwithinforeignbodygiantcells.Original
magnifications100and200.

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Crosspolarizationofasectionofliverinanindividualwithahistoryofintravenousdrugabuse.
Noticethebirefringentcrystallinematerialwithintriads,aswellasevidenceofhepatitis.Original
magnifications100and400.

Alcoholicssometimesconsumeethyleneglycol,whichproducesananiongap.
Ethyleneglycolisconvertedtooxalicacidinthebody,andwithtime,thisacidis
depositedasbirefringentoxalatecrystalsintherenaltubules(seetheimagebelow).
Aforensicpathologistshouldroutinelyscreenforthesecrystalswhenexamining
histologicsectionsofakidney,especiallyifnovitreouschemistryhasbeen
performed.Theyieldislow,butwhenpresent,theseoxalatecrystalsmaybethe
onlysignalertingthepathologisttotellthetoxicologylaboratorytotestspecifically
forethyleneglycol.Ethyleneglycolisnotveryvolatile,henceitsusefulnessas
antifreeze,butasaconsequenceofitslowvolatility,ethyleneglycolisnotfoundin
routinetoxicologicscreensforvolatilecompounds,suchasethanoloracetone.
Ethyleneglycolmustbespecificallysought.

Crosspolarizationofasectionofakidneyinanalcoholicfounddeadonastoop.Calcium
oxalatecrystalsintubulesledtoanalysisforethyleneglycolanddeterminationofthecauseof
death.Originalmagnifications100and200.

Otherhistologicfindingsseenindrugabusersincludesaggregatesofhemosiderin
aroundcerebralvesselsandfibrointimalhyperplasiaofcoronaryarteriolesinchronic
stimulantusers,bacterialendocarditisinintravenousdrugabusers,hepaticnecrosis
andsteatosisfollowingtoxicitywithacetaminophenandothersubstances(seethe
imagesbelow),anddeeptissueabscessformationatinjectionsites.

Hepaticnecrosisthatdevelopedfollowingingestionofanoverdoseofacetaminophen.Necrosis
canbeglobalorfocal.Noticethelackofinflammation,whichmaybetrueearlyintheprocessof
necrosis.Magnification100.

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Hepaticnecrosisthatdevelopedfollowingingestionofanoverdoseofacetaminophen.Necrosis
canbeglobalorfocal.Noticethelackofinflammation,whichmaybetrueearlyintheprocessof
necrosis.Thishigherpowerviewshowsmicrosteatosisofhepatocytesattheedgeofnecrosis.
Magnification400.

PhotographyandDocumentation
Needlemarks,trackmarks,andillicitsubstancesfoundduringexaminationall
deservephotographs.Weighingillicitdrugsisalsowise,asthisweightboth
quantifiestheamountofdrugandrecordshowmuchdrugwaspresentshould
questionslaterariseabouttheamountofdrugremaining.Incasesofingesteddrug
overdoses,thegastriccontentsshouldbemeasuredandcollectedtofacilitate
calculationoftheamountofdrugsswallowed.

AncillaryandAdjunctiveStudies
Toxicologictestsforsubstancescommonlyfoundareeasilyperformed,assuch
testsareroutine.Sometimes,however,anunusualsubstancerequiresunusual
measures.Sendingsamplesofasubstancerarelyabusedinagivenregiontoa
referencelaboratorytwiceayearmaybemoreeconomicalthanforalocal
toxicologylaboratorytobuyamachinededicatedsolelytoatestthatisseldom
needed.
Morerarelystill,thepathologistandtoxicologistmayneedtocreateanewmeans
totestforasubstancethatissuspectedinagivencase.Forexample,thebook
FinalExitofferstechniquesforcommittingsuicide,oneofwhichistoplaceone's
headintoanairtightbagfilledwithheliumfromahoseconnectedtoahelium
canister. [17]Recognitionofthecauseofdeathinsuchacaseissimpleenough,if
thebag,hose,andcanisterremaininplace,buttoxicologicanalysisforhelium
requiresalterationofthenormalprocedureforgaschromatography,becausehelium
istypicallyusedasthecarriergas.Auwaerteretalhavereportedaprocedurefor
detectingheliuminsuchacasebyusingnitrogenasthecarriergas. [18]
Othercaseshavebeenreportedregardingthedevelopmentofanewanalytical
proceduretoassessagivencase. [19]Whenfacedwithauniquecompound,
communicationbetweenthepathologistandthetoxicologistiscriticallyimportantso
thatbothpartiesknowwhatispossibleandcanplanhowtoproceedtobest
evaluateagivencase.
SeealsoAdjunctstotheForensicAutopsy.

DiagnosticCriteria
Interpretationofconcentrationsofdrugs,whetherlicitorillicit,isproperlymade
frombloodorsolidorganconcentrationsdeterminedandconfirmedbygas
chromatography/massspectrometry(GC/MS)withinthecontextofthe
circumstancesthatsurroundeddeath. [4]Byitself,apositivescreeningtestofurine,
oranyothermatrixforthatmatter,isinsufficienttoconclusivelyproveuseofadrug
bythedecedent,althoughitmaystronglysuggestrecentuseandcanprovide
valuableinformationwhentakeninconcertwiththecircumstancesofdeath.
Further,screeningtests(suchasimmunoassays)donotprovideconcentrationsfor
anyclassofcompoundstheydetecttheyarepurelyqualitative.Sometimes,
however,nospecimenisavailableforconfirmationofscreeningresults,and
quantificationofdrugconcentrationsinthebloodatthetimethataninjuryor
overdosehappenedisnotpossible.Anexampleofsuchascenariooccurswhenan
individualwithapositivedrugscreenuponadmissionlingersinacomaforover1
weekinahospitalorextendedcarefacilitybeforedying.Inthesecases,althougha
drugscreenperformedonurinedetectedsomeintoxicatingsubstance,noblood
remainsfromthetimeofadmissionforquantificationand,ofcourse,thesubstance
wasmetabolizedandexcretedbythebodylongbeforedeath.
Insuchacase,theresultsofascreeningtestmustbeacceptedforwhattheyare
ascreenandnomore.Coupledwithadditionalevidence,however,suchasacrack
pipeinapocketandwitnessreportsthatthedecedenthadbeensmokingcrack
cocainebeforesuddenlycollapsing,thenascreeningtestthatdetectedcocaine
metabolitesintheurineisprobablyaccurate,anditwouldbeappropriatetoopine
thatevidenceexiststhatcocainewasinthedecedent'ssystematthetimeof
admission.
Notethatsomescreeningtestsaresubjecttofalsepositiveresults,sometimesby
crossreactivityoftheantibodieswithprescribedmedications. [20]Quitecommonly,
decomposedbodiestestpositiveonamphetaminescreens,becausetheproduction
ofphenylethylamineispartoftheputrefactionprocess.Goodmedicalpractice
alwayscallsforcorrelationofthehistorywiththephysicalfindings.Ifascreening

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testresultcannotbevalidatedbysomeothermeans,thenitmustbeconsidered
possiblethatthescreeningtestresultisafalsepositive.
Thedeterminationthatdeathwascausedbyintoxicationwithasinglesubstanceor
withamixtureofsubstancesisthebusinessofforensicpathology,sometimesa
fiendishlytrickybusiness.Findingarangeofconcentrationsofagivensubstance
thathavebeenreportedasthecauseofdeathinthemedicalliteratureisusually
possible.Biologicsystemsknownothingofcutoffs,however,andstudiesabound
thatshowthatadrugconcentrationthatcauseddeathinonecasewasanincidental
findinginanother.
Forexample,Darkeetalreportednosignificantdifferenceinmorphine
concentrationsinindividualsdyingofadrugoverdosewhencomparedwith
individualskilledbyhomicidalviolence,suchasshootingorstabbing. [21]Sucha
findingshouldcomeasnosurprisewhenoneremembersthepharmacologic
conceptoftheLD50,thedoseofagivendrugthatwillkill50%oftheratsexposed
tothatdose.Ifagivendosekills50%oftherats,thenasmallerdosepresumably
wouldkill10%oftheratsoralargerdose90%oftherats.Thevariabilityinbiologic
systemsmeansthatthesameconcentrationofdrugmaykilloneindividualbut
leaveanotherunscathed,evenifoneignorestheeffectofdrugtolerance.
How,then,doesapathologistmakeadeterminationoftheroleadrugplaysin
causingdeathbasedonreproduciblecriteriaandnotintuition?Ireysuggesteda
usefulschemeinthebookPathologyofDrugInducedandToxicDiseases. [22]In
brief,Ireyprovidedseveralcategoriesofsignificancethatanysubstancefoundina
decedentmayhave,includingthefollowing[22]:
Causative:Thesubstanceisunequivocallyresponsibleforillnessordeath.
Probablecauseofdeath:Deathisaknowncomplicationofthatsubstance
andtheclinicalpictureisinkeepingwithpreviousexperienceandreports,
providedothercausesofdeathhavebeenreasonablyeliminated.
Possiblecauseofdeath:Theclinicopathologicpicturecouldbecausedby
thedruginquestion,butitcouldjustaseasilybecausedbysomeother
processfoundinthedecedentassigningthedruginquestionasthecause
ofdeathwouldbeuniqueandwarrantpublicationinthemedicalliterature.
Coincidental:Thesubstancehappenstobepresentbuthasnobearingon
illnessordeath.
Negative:Thesubstanceisnotdetected.
ApplicationofIrey'scriteriaisreproducible,asproperlyappliedscienceshouldbe.
Thedecisionofwhetherdeathwascausedbyagivendrugorcombinationofdrugs
inagivencaseremainsdifficultsometimes,butIrey'scriteriaprovideauseful
conceptualframeworkformakingaccurate,defendablediagnoses.

CommonMisconceptions
Misconceptionsconcerningdrugsareheldbythosewhoabusedrugsandhealth
practitioners.Duetothepopularityofforensicthemedtelevisionseries,many
laypeopleassumethatthoroughtoxicologicanalysistakesaslongasacommercial
break.Evenunderthebestofcircumstances,conductingtoxicologicanalyses
correctlymaytakedaystoweeks,anditmaytakemuchlongerthanthatinsome
busyjurisdictions.Peoplealsotendtothinkthatlaboratoriesareinterchangeable,
whichisacredittotheuniformityofgoodpracticefollowedbyaccredited
laboratories.Notalllaboratoriesareaccredited,however,aspointedoutinthe
NationalAcademyofSciences2009reportonforensicscienceintheUnitedStates.
[23]Variationinqualityofworkisbutonereasonthatlaboratoryresultsaresubject
tochallengeincourt,apointdiscussedinmoredetailbelowinIssuesArisingin
Court.
Drugusersalsofallvictimtofallaciespertainingtotheirdrugofchoice.Theyoften
thinkofthedrugsthattheychoosetouseassafe,ignoringtheoverlapthatexists
betweenthetherapeuticandlethalrangesforcontrolledsubstancesandillicitdrugs.
Further,druguserswhohavebeenincarceratedforatimeoftenresumedruguse
againuponreleasefromprisonbutfailtotakeintoaccountthelossoftolerance
thatoccurredduringtheirinternment.Therefore,theyareatriskofdyingwhenthey
usethesameamountofdrugthattheyhadbeenusingbeforetheirimprisonment.
Moreover,noagencyoverseesdrugpurityforstreetdrugs,andthepurityofthe
substancebeingabusedmayhavechangedwhileanindividualwasinjail.
Misinterpretationofpublichealthadvisorieshasalsoresultedinfatalities.Inthe
interestofpromotingpublichealth,officialshaveoccasionallyissuedwarningsto
thepublictoavoidcertainneighborhoodsbecauseadrugbeingsoldtherewas
unusuallypowerfulandlikelytocausedeath.Paradoxically,thesewarningshaveled
toincreasedtrafficanddeathsinthearea,becausesomedruguserstookthe
informationasanadvertisementratherthanasawarning.
Practitionersmayalsobedupedbydrugusersbyfailingtoacknowledgethat
addictsaredistributedacrosseverysocioeconomiccohort.Asdescribedearlierin
thesectionIndicationsfortheProcedure,somedruguserstakegreatcarenottobe
detected.Assumingthataspecificpersoncouldnotpossiblyabusedrugsisnave.
Blindlystickingtoapublished"lethal"rangeforadrug,asdescribedaboveinthe
sectionDiagnosticCriteria,isalsonave.Certainlyapublishedlethalrangeisuseful
andmustbeconsidered,buttodismisssomedrugascausingdeathbecauseits
concentrationis0.01mg/Lbelowthereportedlethalrangeistoignorethetruth,if
thecircumstancesindicatethatthedeathiscausedbyadrugoverdose.Sufficeitto
saythatifapersondiedduetotheeffectsofadrugonthatperson,thelevelis
lethalregardlessofwherethebloodconcentrationfallsonatable.
Finally,overdoseasaconceptmaybemisunderstoodbybothdrugusersandhealth
practitioners.Somedeathscertainlyoccurbecausealethalconcentrationofdrugis
inthebody,but,inothercases,drugscanleadtodeathbyalternatemechanisms
irrespectiveoftheconcentrationofthedruginthebody.Cocaine,forexample,can
causedeathatanyconcentration. [9]Mechanismsbywhichadrugcancausedeath
atlowconcentrationarebeingelucidated,asdescribedbelowinFuture

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Developments.

IssuesArisinginCourt
Forensicpathologistsmostoftentestifyinmurdertrials,andthosetrialsoften
includediscussionofthedegreetowhichthedecedent'sbehaviorwasalteredby
intoxicatingcompoundsfoundinthebody.Foralcohol,dataexistthatprovidesome
degreeofconfidenceinansweringaquestionaboutthedecedent'sbehaviorin
generaltermsbasedonagivenbloodethanolconcentration.
Forotherdrugs,suchascocaine,nosuchdataexist.Furthermore,forcocaineand
otherdrugs,thebehavioroftheindividualdependsnotonlyontheconcentrationof
thedruginthebloodbutalsoonwhethertheconcentrationisincreasingor
decreasing. [9]Thehonestforensicexpertlimitsspeculationconcerningthebehavior
ofanindividualbasedondrugsfoundinthesystemtogeneralities,forexample,
sayingthatcocainedoesalterbehavior,thatithasstimulantproperties,butthat
predictingfromthebloodconcentrationalonewhatagivenperson'sbehaviorwould
havebeenisnotpossible.
Partofpreparingforcourtisanticipatingquestionsthatmayarise.Thisprocess
beginsattheautopsyandincludespreservationofevidence.Forexample,saving
fentanylpatchesinbottlelabeledwiththeappropriatecasenumberisprudent
practiceincasesofunexpecteddeath. [15]Intheeventthatalegalsuitlateralleges
thatthepatchwasdefective,thepatchisavailableforexaminationandtesting.
Rememberthatthepurposeofcourtistoresolvedisputes,sowhenevera
pathologistisabletoproduceevidencethatsettlesadispute,thenthepathologist
hasservedthecourtwell.
Thewisepathologistactstoresolvedisputesaboutafindingordiagnosisbeforethe
disputesreachcourt.Asanexample,thefollowingscenariorecursperiodically:
Toxicologicanalysisdetectsanillicitsubstanceinanindividualwho,thedecedent's
familyadamantlymaintains,neveruseddrugs.Oncethepathologistrealizesthat
thefamilydoubtstheresultsoftheinitialtoxicologytest,sendingasamplefor
toxicologicanalysistoasecondtoxicologylaboratoryotherthantheinitialfacility
mayheadofflitigation.
Thepathologisttellsthefamilyitisonlypropertodoublecheckincasesofsuch
vehementdisagreement,becausemistakesdosometimesoccur,butmakesno
promiseofwhatthesecondlaboratorywillfind.Ifthetoxicologyresultsfromthe
secondfacilitydisagreewiththoseofthefirstthatis,iftheoffendingsubstanceis
notfoundinarepeattestthenevaluationofwhatwentwronginthefirst
laboratorytestisappropriate,asisanapologytothefamilyforanydistresscaused.
If,however,thesecondlaboratoryconfirmsthepresenceoftheoffending
substance,thenthepathologisthasalreadytakenthestepthatanycourtwillfirst
orderifthefamilysues.
Thefamilymayormaynotacceptthetruthoftheirlovedone'sintoxication,but
otherswithouttheblindersofvestedinterestwillbeconvinced,andthepathologist's
partinthedisputeisessentiallydone.Thefamilymaynotbedone,however,and
maydemandDNAtestingtoprovethebloodisfromtheirlovedone.The
pathologistmayperformsuchtesting,buttellingthefamilythatthepathologistis
satisfiedisalsopossible,andanyfurthertestingwillbedoneatthefamily's
expense.IfthefamilychoosesalaboratoryforDNAanalysis,thenthepathologist
transmitsthebloodsampleforDNAtestingdirectlytothelaboratorywith
appropriatechainofcustody.Thesamplemustnotbegiventothefamilyunlessso
orderedbyacourt.
OnJune25,2009,theUSSupremeCourtruledthatpathologylaboratoriesarenot
exemptfromUSlawsthatrequirethatevidenceagainstapersonaccusedincourt
issubjecttochallengeintheformofcrossexamination.Thismeansthata
laboratoryreportalonemaynolongerbesufficientasevidenceinatrialtheanalyst
whoperformedthetestmayalsobesubpoenaedandmayhavetotestifyincourt.
TheSupremeCourtrulingrunscountertotheexperienceofpathologylaboratories,
whichareaccustomedtodispensingmanyreportsadaythatarealmostalways
acceptedastrueandaccuratewithoutquestion.Someonecallingandquestioning
theresultsofalaboratorytestisnotunheardofmedicalpractitionerscalltodouble
checkandchallengeunexpectedresultsdaily.
WhatmakestheSupremeCourt'srulingdifferentisthatroutinelaboratoryresults
thatareseldomquestionedinclinicalpracticewillrequirethepresenceofa
pathologistortechnicianincourttoexplainandjustifytheresultsconcerningany
givenlaboratorytestrelevanttoacriminaltrial.Pathologylaboratoriesarenot
staffedtoprovidesuchservicetocourts,andhowthismatterwillimpactupon
laboratorieswhenallissettledremainstobeseen.Despitetheinconvenienceof
theSupremeCourt'srulingtopathologylaboratories,thisdoesaffordpathologists
anopportunitytogetoutofthelaboratory,placethemselvesinthepubliceye,and
demonstratetheimportanceandworthofpathologytestingandpathologiststothe
community.

FutureDevelopments
Enterprisingindividualswithsophisticatedknowledgeofchemistryhavesynthesized
chemicalanalogsofcommondrugsofabuse,suchasamphetamines,opiates,and
marijuana.Thesechemicalanalogsarepharmacologicallyactive,butbecauseof
theirnovelstructuretheytechnicallyescapelegalrestrictionsontheirsaleanduse.
[24]Thesesubstancesaremarketedandsoldundermanynames,suchasbath
salts,K2,orspice. [25]TheycanbeboughtatstoresorovertheInternet.Often,the
substancesbearalabelstatingthattheyarenotintendedforhumanconsumption,
anotherploytoavoidlegalrepercussionsforsellingthematerial.Othernewdrugs
availableforpurchasearetheopiateagonistsSalviaandKratom,bothderivedfrom
plants. [24]ThesaleanduseofSalviaandKratomarealsolargelyunrestrictedby
law.
Thecompoundsandlawscontinuetochangeinaneverendinggameofcatand

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mousefasterthanpublicationscankeepupwiththelatestfad.Internetpostingsare
thebestsourceofinformationonthisrapidlychangingprocess.Perhapsmost
importantistorememberthatthesesubstancesarelikelytobemissedbya
standardtoxicologicalscreendirectedagainsttheusualdrugsofabuse.Therefore,
ifreasonexiststohaveahighindexofsuspicionfordruguseorintoxication,butno
substanceisdetectedonstandardscreens,oneofthesechemicalanalogsmaybe
present.Testingforthechemicalcouldbeexpensive,however.
Researchinbasicscienceswillimprovetheunderstandingandpracticeofforensic
pathologyintheyearsaheadregardingdeathscausedbyintoxication.Forexample,
cocaineandmethadonecancausedeathatconcentrationsoftenperceivedastoo
lowtobe"overdoses."Researchindicatesthatcocaine[26]andmethadone[27]both
alterproperrepolarizationoftheheart,helpingtoexplainhowdeathcanoccurat
lowconcentrationsofthesedrugs.Othersareworkinginpharmacogenomics,which
hasthepotentialtohelpforensicpathologistsunderstandthemechanismofdeath
forcertainindividualswhomaymetabolizeadrugmoreslowlythanothers,thus
overdosingmoreeasily. [28]Thesefieldsareinterrelated,astheabsenceofagene
orgenecopynecessaryforproperrepolarizationoftheheartcancausedeathjust
assurelyastheabsenceofageneorgenecopyforpropermetabolismofadrug.

ContributorInformationandDisclosures
Author
GregoryGDavis,MD,MSPHProfessorofPathology,Director,ForensicDivision,DepartmentofPathology,
UniversityofAlabamaatBirminghamSchoolofMedicineChiefCoroner/MedicalExaminer,JeffersonCounty,
Alabama
GregoryGDavis,MD,MSPHisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,
AmericanSocietyforClinicalPathology,CollegeofAmericanPathologists,NationalAssociationofMedical
Examiners,UnitedStatesandCanadianAcademyofPathology,AmericanAcademyofForensicSciences
Disclosure:Nothingtodisclose.
ChiefEditor
JScottDenton,MDClinicalAssistantProfessorofPathology,UniversityofIllinoisCollegeofMedicineat
PeoriaForensicPathologistandIllinoisCoronersPhysician
JScottDenton,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanMedical
Association,AmericanMedicalAssociation,AmericanSocietyforClinicalPathology,CollegeofAmerican
Pathologists,IllinoisStateMedicalSociety,NationalAssociationofMedicalExaminers,AmericanAcademyof
ForensicSciences,IllinoisSocietyofPathology,PeoriaMedicalSociety
Disclosure:Nothingtodisclose.
Acknowledgements
ThankstoGeneP.SiegalforhistimeandhelpwithphotomicrographsandtoStephenJ.Cinaforsupplying
photographsandcogenteditorialsuggestions.

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