Hair testing in postmortem diagnosis of substance abuse: An unusual case of slow-release oral morphine abuse in an adolescent

Highlights

• Oral morphine misuse is exceptional among young adolescents without history of addiction.

• Hair testing is useful to document an unsuspected misuse.

• Hair testing can contribute to police investigations.

Abstract

Morphine sulfate misuse is essentially observed among regular heroin injectors. To our knowledge, primary addiction to morphine sulfate is exceptional, especially among young adolescents. A 13-year-old girl, with no history of addiction, was found dead with three empty blisters of Skenan^® LP 30 mg at her side. Opiates were detected in biological fluids and hair by chromatographic methods. Blood analyses confirmed morphine overdose (free morphine: 428 ng/mL; total morphine: 584 ng/mL) and segmental hair analysis confirmed regular exposure over several months (maximum morphine concentration 250 pg/mg). Suspecting the victim's mother of recreational use of Skenan^®, the magistrate ordered analysis of her hair, with negative results. From an epidemiological viewpoint, this case of oral morphine sulfate abuse in an adolescent with no previous history suggests the emergence of a new trend of morphine sulfate consumption. From a toxicological viewpoint, it demonstrates the value of hair testing, which documented the victim's regular exposure and made an important contribution to the police investigation.

Introduction

Morphine sulfate is a schedule II opioid under the most recent Controlled Substances Act.¹ In France, morphine sulfate is regulated as a narcotic and prescribed using a special form for a maximum period of 28 days.² It is marketed under parenteral forms, immediate-release oral forms and slow-release oral forms (slow-release oral morphine or SROM), which are all indicated for the relief of moderate to severe acute and chronic pain where an opioid analgesic is appropriate. As SROM appears to reduce craving and depressive symptoms, its effectiveness as maintenance therapy for opioid dependence is under debate.2, 3 In some European countries and Australia, SROM is prescribed as an alternative to methadone maintenance treatment in patients who do not tolerate methadone or with inadequate withdrawal suppression.4, 5, 6 In France, SROM can be prescribed in cases of methadone and buprenorphine failure or contra-indications to these substances, when authorized by the medical officer of the health insurance system.⁷ But according to the recent Cochrane systematic review, evidence of the effectiveness of SROM for opioid maintenance is insufficient.³ While the quality of life of patients treated with SROM does not significantly differ from that of those treated with methadone or buprenorphine, side effects (nausea, headache, constipation, insomnia) are more frequent with SROM.

Morphine misuse or abuse is a well-known problem. The effects sought are close to those of heroin: to obtain a high and a sensation of wellbeing.⁸ Intravenous and nasal routes are the most common ways of administration.⁸ In most cases, morphine sulfate is consumed by heroin injectors and polydrug users with a long history of drug abuse.6, 8 Primary consumption is uncommon. Most users are adults who were prescribed SROM for long periods, or healthcare professionals.9, 10 Cases involving very young adolescents appear to be exceptional.

In addition, in this case hair testing had a particularly important impact on the course of the police investigation, as it both established the innocence of the victim's mother and led to the dismantling of a drug-trafficking ring.