Antemortem and Postmortem Methamphetamine Blood Concentrations: Three Case Reports

Journal of Analytical Toxicology 2013;37:386 –389 doi:10.1093/jat/bkt040 Advance Access publication May 29, 2013 Case Report Antemortem and Postmortem Methamphetamine Blood Concentrations: Three Case Reports Iain M. McIntyre1*, Craig L. Nelson2, Bethann Schaber2 and Catherine E. Hamm1 1 Forensic Toxicology Laboratory, County of San Diego Medical Examiner’s Office, 5570 Overland Ave., Suite 101, San Diego, CA 92123, USA, and 2Department of Forensic Pathology, County of San Diego Medical Examiner’s Office, 5570 Overland Ave., Suite 101, San Diego, CA 92123, USA *Author to whom correspondence should be addressed. Email: We compare antemortem whole-blood to postmortem peripheral blood concentrations of methamphetamine and its metabolite amphetamine in three medical examiner cases. Antemortem specimens, initially screened positive for methamphetamine by ELISA, were subsequently confirmed, together with the postmortem specimens, by GC-MS analysis following solid-phase extraction. Methamphetamine peripheral blood to antemortem blood ratios averaged 1.51 (+ + 0.049; n 5 3) and amphetamine peripheral blood to antemortem blood ratios averaged 1.50 (n 5 2). These data show that postmortem redistribution occurs for both methamphetamine and amphetamine, revealing that postmortem blood concentrations are ∼1.5 times greater than antemortem concentrations. Furthermore, as both methamphetamine and amphetamine have previously been shown to have liver/peripheral blood (L/P) ratios of 5–8, it can be proposed that drugs displaying L/P ratios ranging from 5 to 10 may exhibit postmortem concentrations up to twice those concentrations circulating in blood before death. blood-to-peripheral blood (C/P) ratios were found to average 1.61 (+0.48), and liver to peripheral blood (L/P) ratios averaged 5.68 (+2.32). Comparable data were found for amphetamine. These data showed a smaller average C/P ratio than that previously reported by Barnhart et al. (11), but established that methamphetamine and amphetamine were most likely prone to some degree of postmortem redistribution (PMR). However, since there was no opportunity for analyses in both antemortem and postmortem specimens from the same individuals, a direct assessment of the degree of PMR could not be determined. The study reported here examines three cases in which antemortem specimens were collected and postmortem peripheral blood specimens were also available. This study presents an investigation of PMR, and provides better insight on the extent to which methamphetamine and amphetamine concentrations may be expected to increase after death as a result of PMR. Introduction Methamphetamine is a highly addictive central nervous system stimulant that can be injected, snorted, smoked or ingested orally. Although available by prescription for the treatment of attention-deficit disorder (1), the major use (abuse) of methamphetamine remains illicit—generally synthesized in clandestine laboratories. It is metabolized by N-demethylation to amphetamine, which is also a pharmacologically active drug (2). Single oral doses of methamphetamine have been reported to produce peak plasma concentrations up to 0.02 mg/L with a 12.5 mg dose (3). A 30 mg oral dose resulted in an average peak serum methamphetamine concentration of 0.094 mg/L (range 0.062 –0.291 mg/L) (4). Single intravenous doses (0.50 mg/kg) have resulted in an average peak plasma methamphetamine concentration of 0.132 mg/L, with amphetamine at 0.0092 mg/L (5). Half-life of elimination is pH dependent, ranging from 6 to 15 h for methamphetamine and 7 to 34 h for amphetamine (2). Blood concentrations ranging from 0.15 to 0.56 mg/L have been reported in methamphetamine abusers showing violent and irrational behavior (6) and from 0.05 to 2.6 mg/L in individuals arrested for erratic driving (7). Postmortem blood concentrations have been described to range from 1.4 to 13 mg/L in abusers who died of traumatic injury by violent means (8). Deaths resulting from overdose have been shown with methamphetamine concentrations ranging from 0.09 to 18 mg/L, with an average of 1.0 mg/L (9). When attempting to compare blood and clinical plasma/serum concentrations, it is important to be aware that the blood/plasma ratio for methamphetamine is 0.6–0.7 (2). The distribution of methamphetamine and amphetamine in postmortem peripheral blood, central blood and liver has been recently reported (10). Methamphetamine central Methods Cases Case 1 This 44-year-old man had no reported medical history. On the day of his death, he was with his girlfriend playing video games when he suddenly grabbed his chest and became unresponsive. Bystander cardiopulmonary resuscitation (CPR) was initiated. He was transported by ground ambulance to a nearby hospital with an estimated down time of 35 min. He arrived in the emergency room with CPR in progress with ventricular fibrillation. Despite administration of multiple cardiac medications, including epinephrine, lidocaine and amiodarone, and defibrillation attempts, he died in the emergency room. His girlfriend later admitted that they had been using methamphetamine. The autopsy documented findings of hypertensive and atherosclerotic cardiovascular disease. The heart was enlarged (580 g) with concentric left ventricular hypertrophy. The coronary arteries demonstrated focal, moderate to marked calcific atherosclerotic stenosis of the vessel lumens. Microscopic examination of the heart muscle documented both acute cardiomyocyte necrosis and extensive areas of older fibrosis. Toxicology testing confirmed only methamphetamine. The cause of death was listed as hypertensive and atherosclerotic cardiovascular disease with acute methamphetamine intoxication contributing. Autopsy was performed 30.5 h after death. Antemortem blood specimens were drawn 22 min prior to pronouncement of death. Case 2 This 46-year-old man was the unrestrained rear seat passenger of a pickup truck traveling on an interstate when it veered off the # The Author [2013]. Published by Oxford University Press. All rights reserved. For Permissions, please email: road and went down a center embankment, rolling over. He was partially ejected. Witnesses found him initially responsive and yelling. He was transported by ground to a nearby location for airlift, but lost his pulse while being loaded onto the helicopter. He arrived at a regional trauma center with resuscitative efforts still underway. Despite resuscitative efforts, death was pronounced almost 2 h following the initial report of the incident. The decedent’s medical history included fibromyalgia, chronic fatigue and methamphetamine use. Toxicology testing confirmed methamphetamine and cannabinoids (which were not quantified). The autopsy documented multiple bone fractures and visceral lacerations, and the cause of death was listed as multiple blunt force injuries. Autopsy was performed 22.5 h after death. Antemortem blood specimens were drawn 7 min prior to pronounc (...truncated)