A Cocaine and Heroin-Related Sudden Death in Sri Lanka: Toxicological Evaluation

Cocaine is a prominent illicit substance associated with sudden mortality in individuals engaging in poly-drug use. We are presenting a case of a sudden death of a 37-year-old male. The autopsy failed to reveal the pathological cause of death, and the toxicological analysis of post-mortem samples was carried out. Quantitative analysis of ethanol was carried out by headspace gas chromatography with a flame ionization detector (FID). Solid-phase extraction was carried out to extract drugs and their metabolites from biological samples. After derivatization, these drugs and metabolites were then quantitatively analysed using gas chromatography-mass spectrometry. The analytical methods were validated before analysing the samples.
In the toxicology results, all biological samples, including blood, bile urine, and stomach contents, contained morphine, with concentrations ranging from 12 μg/mL to 55 μg/mL. 6-Monoacetylmorphine was detected in urine at a concentration of 8 μg/mL and in stomach contents at a concentration of 60 μg/mL. The concentrations of cocaine were detected in bile, urine, and stomach contents at 727 μg/mL, 202 μg/mL, and 39 μg/mL, respectively. Benzoylecgonine was detected in blood, urine, and stomach contents at concentrations of 6 μg/mL, 227 μg/mL, and 7 μg/mL, respectively. Additionally, ecgonine methyl ester was identified in urine at a concentration of 123 μg/mL. Furthermore, ethanol concentrations of 109 mg/100 mL in blood and 102 mg/100 mL in urine were also detected.
The presence of cocaethylene in the stomach contents and urine samples confirmed that cocaine and ethanol were co-administered, leading to a more pronounced effect. The presence of cocaine, its metabolites, ethanol, cocaethylene, and heroin metabolites in the biological samples reveals the simultaneous use of cocaine, heroin, and ethanol. This drug combination likely led to acute toxicity. Therefore, these findings provide a well-defined outline for the cause of death.