North Carolina Office of the Chief Medical Examiner

Toxicology

The Toxicology Laboratory located at the Office of the Chief Medical Examiner in Raleigh is nationally accredited by the American Board of Forensic Toxicology, Inc. and serves all 100 counties of the North Carolina Medical Examiner System by providing forensic analytical testing of specimens and evidence from medical examiner cases. The laboratory is responsible for analytical testing, records maintenance and review of analytical testing and interpretation of results for more than 10,000 medical examiner cases annually. The staff which consists of toxicologists, chemists, laboratory technicians and administrative technicians performs more than 36,000 analytical tests each year.

Note: Toxicologists at the North Carolina Office of the Chief Medical Examiner (NC-OCME) are limited to interpreting information for our own cases.

Interpretation of Toxicology Results

The following table is provided only as a guide. The data have been compiled from previously published scientific literature and from prior OCME experience; hence these concentrations cannot be regarded as complete for all therapeutic and poisoning situations. When available, references are included for a drug. Also, the appropriate screening assay is designated for each drug. Average concentrations are given in parenthetical form when available. Many of the concentrations listed as toxic are from driving under the influence of drugs (DUID) data and are referenced as such in the comments column. The proper interpretation of postmortem drug concentrations is complex and complicated by many factors including individual variations in response to drugs, tolerance, physical stature, and disease states; the presence of other drugs, and the potential for postmortem changes in blood-drug concentrations. If a toxicological agent is suspected in a case, additional specimens including peripheral blood (PB) and liver (LVR) should be submitted for a more complete investigation. Normal and lethal liver concentrations where available have been added for clarity.

Last Revision: June 30, 2017

Drug (Reference) Assay Therapeutic (mg/L) Toxic (mg/L) Lethal (mg/L) Additional Information
Acetaminophen (1,4,23,24) A 1-52 30-300 90-320 (170) The toxic effects of acetaminophen are often seen 2-4 days after ingestion and blood levels may not be extremely high at time of death.
Acetyl fentanyl (27,28) L/B N/A Unknown 0.47*  (0.089-0.945)
0.008**
*Average peripheral concentrations not involving fentanyl or heroin combination
** Average peripheral concentration when combined with fentanyl and heroin
Acrylfentanyl (47) L/B N/A Unknown 3.2 (0.42-8.5) ng/mL* *Based on 5 patient cases, also called Acryloylfentanyl
AH-7921 (30,35) L/B N/A 0.03-0.99 µg/g* Unknown *Concentration of AH-7921 in combination with other drugs
Alprazolam (1,4,21,23) L/B 0.005-0.11 0.008-0.64 0.12-2.1 (0.55) The concentrations listed as toxic are from driving under the influence (DUID) cases. Only 30% of those arrested had concentrations greater than 0.10 mg/L.
Amantadine (1,23,24) B 0.1-1.0 1-5 21-48 (34)  
Amitriptyline (1,4,7,13,23,24) B 0.01-0.50;

Liver: 0.4-17 mg/kg
>0.5;

Liver:
> 50 mg/kg
0.6-27;

Liver: 50-420 mg/kg
Postmortem normal concentrations often exceed 0.5 mg/L. Significant postmortem redistribution (PMRD) can occur with all tricyclics. PB and LVR may be required to resolve difficult cases.
Amlodipine (1,14,23) B 0.001-0.024 0.067-0.39 0.9-2.7 Significant PMRD can occur with this drug. PB and LVR may be required to resolve difficult cases.
Amoxapine (1,7,23) B 0.01-0.6 0.31-2.90 0.9-20 (6.9);

Liver: 50-348 mg/kg
Significant PMRD can occur with this drug. PB and LVR may be required to resolve difficult cases.
Amphetamine (1,7,21,23,24) B/L 0.02-0.2 0.2-3 0.5-41 (8.6) Tolerance is important to consider when evaluating the toxicity of this drug. Cardiotoxic with ethanol consumption.
Aripiprazole (1,23,38) B/L 0.039 - 0.5 0.063-1.42 Unavailable* *Fatalities have occurred but information is limited as deaths may not have been attributed to the drug alone
Arsenic (1,7,23,24) S 0.002-0.07; 0.27 (herbicide workers) 0.05-12.7* 0.6-9.3 (3.3) oral;
0.1-0.6 (0.4) arsine fumes
Detection of chronic arsenic poisoning is complex. Blood specimens alone are insufficient. Tissues and/or hair are usually required. *Subacute poisoning incident from contaminated well water (nausea, emesis, diarrhea, abdominal pain).
Asenapine  (15,23,31) B 0.002-0.005 >0.01 700 ng/mL* *n=1,  Stomach contents contained 176 mg of unabsorbed asenapine.
Baclofen (23,42) L 0.08-0.4 (-0.6) 1.1-3.5 6-9.6  
Benztropine (1,7,23) B 0.005-0.18 >0.05 0.2-1.1 (0.5)  
Buprenorphine (1,10,23,28) L 0.5-5 ng/mL* 2.2-4.1 ng/mL** 1-29 ng/mL (8)***
52 ng/mL****
1-15 ng/mL*****
*Note units change. Tolerance and route of administration is important to consider when evaluating the toxicity of this drug. Significant PMRD can occur.
** Toxic levels found in MVA or DI arrests
***Postmortem blood concentrations following intravenous administration.
****13 month old fatality, only drug present.
*****Postmortem blood concentrations  following oral administration
Brivaracetam (28) A 1.0-4.2 Unknown Unknown  
Bupropion (1,3,13,23) B 0.01-0.4 1.2-2 4-13 (6.6);

Liver: 8.7-14 mg/kg
PMRD can occur with this drug. PB may be required to resolve difficult cases. Bupropion is unstable in whole blood and liver at room temperature.
Buspirone (1,21,23) B 0.0005-0.004 >0.008 0.44  
Butalbital (1,7,21,23,24) A 1-10 0.1-28 (8.5) 13-30 The concentrations listed as toxic are from DUID cases.
Butylone (28) B N/A 0.1* 1.2-20** *Based on one patient (living)
**Based on 3 patients
Caffeine (1,4,13,21,23,24) B 4-36 50-400 79-567 (204)  
Carbamazepine (1,4,13,23,24) A/B 2-12 3-77 35-70 (45)  
Carbon Monoxide (1,7,23,24) S <10 % SAT 15-25 % SAT 48-93% (72) Smokers: 5-6%
Carfentanil (47) L N/A Unknown 0.43 (0.15 -0.75) ng/mL* *Based on 6 patient cases
Carisoprodol (1,4,7,23,24) A/B/L 2.6-30 2.6-40 >30; 39,110 Tolerance is important to consider when evaluating the toxicity of this drug. The concentrations listed as toxic are from DUID cases.
Chlordiazepoxide (1,6,7,10,19,21,24) B/L 0.1-3.0 1.1* 26**
20***
*average for DUID cases
**Death attributed solely to chlordiazepoxide
***Death attributed to chlordiazepoxide and amitriptyline
Chlorpheniramine (1,23) B 0.003-0.017 0.5 >0.5; 0.069 and 0.08* Postmortem normal concentrations often exceed 0.25 mg/L. Significant PMRD can occur with this drug. PB and LVR may be required to resolve difficult cases. *Observed in two infant deaths.
Chlorpromazine (1,4,13,23,24) B 0.02-0.30 low dose; 0.75 high dose 0.5-3.0 1-35 (17) Liver levels can usually differentiate high chronic vs. fatal cases. Significant PMRD can occur with this drug. PB and LVR may be required to resolve difficult cases.
Citalopram (1,4,23) B 0.05- 0.11;

LVR: 1.0-5.7 mg/kg
1.0-4.0 3.4-49;

LVR: 24-55 mg/kg
Postmortem normal concentrations often exceed 0.5 mg/L. Significant PMRD can occur with all SSRI's. PB and LVR may be required to resolve difficult cases. The concentrations listed as toxic are from DUID cases.
Clobazam (1,23) B 0.03-0.3 >0.5 1.5*
3.9**
*Intentional overdose of clobazam and diazepam.
**Only significant finding at autopsy.
Clomipramine (1,4,23,24) B 0.09-0.25;

LVR: 7-20 mg/kg
>0.4-0.6 0.54-3.3;

LVR: 90-320 mg/kg
Significant PMRD can occur with all tricyclics. PB and LVR may be required to resolve difficult cases.
Clonazepam
(1,13, 21,23,24)
L/B 0.02-0.2 >0.08 >0.3-10 (+mtb)
Acute OD: 1.4*
Clonazepam is unstable in whole blood. Usually present as metabolite (mtb) only. The concentrations listed as toxic are from DUID cases. *With 0.6 of oxycodone present.
Clonidine (1,11,23) L/B 0.001-0.002 >0.025-0.05 0.023*; 0.047** Significant PMRD can occur with clonidine. *43 year old woman who died from OD. **death of a 23 month old.
Clozapine (1,4,13,21,23) B 0.06-1.0;

Liver <10 mg/kg
0.6-9.5 1.2-13 (5.2);

LVR: 19-85 mg/kg
Significant PMRD can occur with this drug. PB and LVR may be required to resolve difficult cases.
Cocaine (1,13,21,23,24) L/B 0.05-1 0.1-5 >0.9 Concentrations listed include the cocaine metabolites benzoylecgonine and ecgonine methyl ester.
Concentrations vary greatly depending on the dosage, route of administration, period of survival and manner of storage of the specimens.
Codeine (1,4,21,23,24) L/B 0.03-0.4 0.2 1-8.8 (2.8); 0.49* The concentrations listed as toxic are from impaired driving cases. *Postmortem concentration found in 3 year old.
Cyanide (1,7,23,24) S <0.06 0.02-5.9 1.1-53 (oral); 1-15 (inhalation); seen as low as 0.17 in fire victims Includes both smokers and non-smokers.
Cyclizine (1,21,24) B 0.01-0.3 0.75-1 15-80 (oral); 1.5* *Postmortem overdose concomitantly with dipipanone.
Cyclobenzaprine (1) B 0.003-0.04 0.03-0.35 >0.3 with other drugs present;
LVR: >25mg/kg
Postmortem normal concentrations often exceed 0.25 mg/L. Significant PMRD can occur with all tricyclics. PB and LVR may be required to resolve difficult cases. Toxic liver concentrations >25 mg/kg
Desipramine (1,3,4,7,23,24) B 0.01-0.8 0.3-2.0 3-15 (9.8);

LVR: 50-294 mg/kg
Significant PMRD can occur with all tricyclics. PB and LVR may be required to resolve difficult cases.
Dextromethorphan (1,21,23) B 0.01-0.04 0.13-2.8*
0.5-1.2**
1-18;

LVR: 31-230 mg/kg
*ED concentrations in non-lethal overdose, ** DUID cases
May exhibit PMRD; PB and LVR may be required to resolve difficult cases.
Diazepam (1,4,7,13,21,23.24) B/L 0.1-2 (low dose); 2-4 (high dose) 2-5 >5 Diazepam only deaths are infrequent. Toxic concentrations include DUID.
Diethylpropion (1,24) B 0.003-0.007 2 5  
Difluoroethane V N/A 9 3-380 Concentrations in deaths many be lower than expected due to volatility of the gas.
Diltiazem (1,4,7,21,23) B 0.03-0.4 >0.8 2-33 (15);

LVR: 41-380 mg/kg
Not stable in whole blood. PMRD may occur, PB and LVR excellent complementary specimens to resolve difficult cases.
Diphenhydramine (1,3,7,23,24) B 0.02-1 >1-2 1.1-31 Lethal concentrations include infant reported deaths. Significant PMRD can occur. PB and LVR excellent complementary specimens to resolve difficult cases.
Donepezil (1) B appr. 0.03-0.075 >0.075 0.210* * Level is from an OD and is from when patient was still alive.
Doxepin (1,3,7,13,23,24) B 0.01-0.25 >0.5-1

0.7-29 (9.3);

LVR: 50-320 mg/kg

Postmortem normal concentrations often exceed 0.5 mg/L. Significant PMRD can occur with all tricyclics. PB and LVR excellent complementary specimens to resolve difficult cases. Toxic liver concentrations > 50 mg/kg
Doxylamine (1,23) B 0.05-0.8 0.2-7.5

0.7-140;

LVR: 80-300 mg/kg

Significant PMRD can occur.
Duloxetine (1) B 0.03-0.12 >0.24 >1; 0.910; 2.5* Significant PMRD can occur. *OD concomitantly with baclofen.
Ephedrine (1,4,23) L/B 0.018-0.6 >1 >2.7  
Eszopiclone (1,9) L <0.07 0.07 0.20-3.9 This analyte is unstable. Please ship specimens frozen. The concentrations listed as toxic are from impaired driving cases.
Ethchlorvynol (1,3,7,13,23,24) S 0.5-20 18-280 14-400 (119)  
Ethylene glycol (1,3,7,13,23,24) S N/A 94-500 300-4300 (2400)  
Etizolam (23,28) L/B  0.008-0.02 0.03 0.086*, 0.264 *Concentration found in an overdose case involving 4 other psychotropic drugs
Fenfluramine
(1,13, 21,23,24)
B 0.03-0.3 0.5-2.5 6.5-16* *Data is includes children aged 2-6 and a 13 year old, as well as a 36 and 25 year old woman.
Fentanyl (1,7,21,23) L/B 1-5 ng/mL* 3 ng/mL

2(IV); >7(patch)
Oral abuse of patch: 6.1-97; IV: 3-383; Patch: 12-41;

LVR:
IV: 5.9-78 ng/g
Patch: 79-203 ng/g

*Note units change. Tolerance and route of administration is important to consider when evaluating the toxicity of this drug. Significant PMRD can occur. Peripheral blood and liver should be collected in cases suspicious for fentanyl patch toxicity.
Flunitrazepam (1,23) S 0.005-0.015 >0.01-0.05 0.01-1.6 Toxic concentrations listed are for DUID. Parent drug is rarely detected. Values given are for the 7-amino flunitrazepam metabolite.
2- Fluorofentanyl (47) L/B N/A Unknown 7.7 (1.2-18) ng/mL* *Based on 11 patient cases
Fluoroisobutyrylfentanyl (47) L/B N/A Unknown 11.5 (0.3-75) ng/mL* * Based on 23 patient cases
3- Fluorophenmetrazine (41) B N/A Unknown 0.003-1.4* *Based on 15 cases
Furanylfentanyl (29) L/B N/A Unknown 12.9 ng/ml (0.2-76)  
Fluoxetine
 (1,3,7,13,22,24)
B <0.12-0.8 0.2-3 (parent + mtb)

1.3-6.8 (3.8);

LVR: 50-360 mg/kg

Postmortem normal concentrations often exceed 1 mg/L. Significant PMRD can occur with all SSRIs. PB and LVR excellent complementary specimens to resolve difficult cases. The concentrations listed as toxic are from DUID cases.
Fluphenazine (1,3,13,24) S 0.0003-0.02 0.05-0.1 0.1  
Fluvoxamine (1,4,24) B 0.06-0.23 0.3-0.75 2.8-16;
3.4-11 (5.0)
Significant PMRD can occur with all SSRIs. PB and LVR excellent complementary specimen to resolve difficult cases. The concentration listed as toxic is from a DUID case.
Gabapentin (1,16,22,23) L 0.5-6 <2.0-25 (8.4) >80* Toxic concentrations are from impaired driving cases. Concentrations > 6.0 may be necessary to control seizures in refractory patients. Tolerance and indication for use (e.g. chronic pain vs. seizure) should be considered when evaluating the toxicity of this drug. *Lethal concentrations may be lower if used with other CNS depressants.
Gabapentin enacarbil (28) S 1.9-7.5 Unknown Unknown  
Gamma-hydroxybutyrate (1,3,23) S 20-120 8-551 27-4400 Lethal levels lower with concomitant use of ethanol. The concentrations listed as toxic are from impaired driving cases.
Guaifenesin (1,23) B/A 0.3-1.5 Unknown 14*
27**
*A lethal conc. of hydrocodone was also detected.
**In combination with diphenhydramine and chlorpheniramine.
Haloperidol (1,3,7,13,23,24) S/B 0.005-0.017 0.04-0.5 0.2-1 PMRD can occur.  
Heroin (1,24) L 0.1 (morphine in chronic user) Unknown >0.1 (morphine); 0.05-2.1*; No recent usage: 0.38-0.41 Tolerance is important to consider when evaluating the toxicity of this drug and survival time of victims. Urine, bile or vitreous are excellent complimentary specimens to use in distinguishing between morphine and heroin use. Concentrations reported as morphine. *Postmortem concentrations from 42 young adults dying rapidly after injection.
Hydrocodone (1,7,21,23,24) L/B 0.01-0.05 0.1-0.2 0.12-7 Tolerance and route of administration is important to consider when evaluating the toxicity of this drug. May exhibit PMRD.
Hydromorphone (1,7,21,23,24) L 0.005-0.015 >0.1 0.07-2.7 Tolerance is important to consider when evaluating the toxicity of this drug.
Hydroxyzine (1,4,7,23,24) B 0.01-1 >0.17 1.1-39 The concentrations listed as toxic are from impaired driving cases. Significant PMRD can occur. Peripheral blood is required for accurate interpretation.
Ibuprofen (1,7,13,23,24) S/A 15-30 100-400 185-680; 518  
Imipramine (1,5,6,7,10,21,24) B 0.05-0.35 0.25-4.9

0.3-30;

LVR: 33-381 mg/kg

Significant PMRD can occur with all tricyclics. PB and LVR excellent complementary specimen to resolve difficult cases. It is not uncommon for normal postmortem concentrations to exceed 0.5.
Ketamine (1,4,23,24) B/L 1-6 >7 (abuse) 7-10; 3.8, 6.9 Nonmedical IV use can be lethal at conc. as low as 2.0 mg/L. May exhibit PMRD.
Lacosomide (23) A 1-12 >20 120* *High levels of guaifenesin and topiramate present.
Lamotrigine (1,3,23) A/B 1-5 (monotherapy) 3-9.1 (combo therapy) 15-30 20-60*; 20-38** *5 victims of overdose ranging from 2 wks old to 42.
**2 patients concomitantly with valproic acid.
Levetiracetam (1,2,23) A 10-40 70 35*, 190** *multi-drug intoxication. ** single drug intoxication
Tolerance should be considered when evaluating the toxicity of this drug.
Lidocaine (1,4,7,13,23) B 0.08-6 1.5-19 6-92 Route of administration is important to consider when evaluating the toxicity of this drug.
Lithium (1,7,13,23,24) S <1.3 mEq/L >1.5 mEq/L 2.4-14.0; 0.3-4.6 mEq/L  
Loperamide (1,48) B/L 0.0002-0.003 Unknown 0.054-1.2 May exhibit PMRD.
Lorazepam (1,3,7,13,23) L 0.05-0.24 0.3-0.6 71 year old woman: 0.52; 6 year old: 2.8; 0.28-1.0* Lower toxic concentrations are found in cases of ingestion of multiple respiratory depressants. Apparently does not exhibit PMRD. *3 adult victims with at least one other depressant drug.
Lorcaserin (28) B 46 µg/L Unknown Unknown  
Loxapine (1,7,23,24) B 0.01-0.03 0.2-0.72 2-9.5 (heart blood) Significant PMRD can occur. PB and LVR excellent complementary specimens to resolve difficult cases.
Memantine (1,20) B 0.039-0.15 >0.3 >1  
Meperidine (1,3,7,21,23) B/L 0.06-1.84 >1 8-20 (oral); 1-8 (IV) May exhibit PMRD.
Meprobamate (1,3,4,7,13,21,23,24) A/B 5-12 >10-25 35-240 Tolerance is important to consider when evaluating the toxicity of this drug. DUID cases reported to have meprobamate concentrations of 35-96 mg/L.
Metaxalone (1,25) A/B <2.0-8.6 20 20-63* The concentration listed as toxic is from an impaired driving case. *Most deaths attributed to metaxalone are multiple drug intoxications.
Methadone (1,3,4,7,13,21,23,24) L/B 0.01-1.06 >0.2

0.06-3.1 (0.28); Maintenance patients OD: 0.18-4.0 (1.3);

LVR: 1.8 - 9 mg/kg

Significant PMRD can occur. Liver is an excellent complementary specimen to resolve difficult cases. Tolerance is important to consider when evaluating the toxicity of this drug. Toxic concentration listed reflects DUID.  
Methamphetamine (1,7,23,24) B/L 0.01-0.3 0.12-5 0.09-64 DUID cases reported to have methamphetamine concentrations of 0.05-2.6 mg/L. May exhibit PMRD.
Methanol (1,3,7,23,24) V N/A >25 50-5430  
Methylenedioxy-methamphetamine (MDMA) (1,3,21) B 0.02-0.35 0.05-1.9 0.5-7.3 (2.7) The concentration listed as toxic is an average value from DUID cases. May exhibit PMRD.
3,4-methylenedioxypyrovalerone (MDPV) (28) B N/A 0.016-8.4 * 0.039– 1.1** *Based on blood samples from impaired drivers
**Range is patient variable
Mephedrone (28, 32, 43) B N/A 0.15-0.28 4.5* (0.1-22) *Average based on 10 patients
Methylone (32, 43) B N/A 0.07-3.4* 0.56-3.3** * Based on two cases where methylone was only drug found
**Based on three cases
Metoprolol (1,7,21,23,24) B 0.035-0.5 0.65-18 4.7-142 May exhibit PMRD.
Midazolam
(1,4,7,21,23)
L/B 0.008-0.6 0.03-1.5 0.07-2.8 May exhibit PMRD.
Mirtazapine (1,23) B 0.03-0.3 0.1-2

1-12;

LVR: >14mg/kg*

The concentrations listed as toxic are from DUID cases. * Seen with other drugs concomitantly
Mitragynine (1,17) B/L Unknown Unknown 0.60** Ingredient of Kratom. **Death was deemed “possible kratom toxicity.”
Morphine (1,3,7,21,23,24) L 0.01-0.3* 0.04-5 0.1-4 Tolerance is important to consider when evaluating the toxicity of this drug. *Higher doses in cancer patients. May exhibit PMRD. 
MT-45 (34, 36) B/L Unknown 0.520* 0.006-1.9 ** *Based on one case report
**Concentrations from femoral postmortem blood
Naproxen (1,21,23,24) A/S 20-50 200-840 Unknown May exhibit PMRD.
25B-NBOMe (33) S N/A   0.180 ng/ml* *Based on one patient case
25C-NBOMe (44) S N/A   0.60 µg/kg* *Peripheral whole blood from one case report
25H-NBOMe (33) S N/A   0.9 ng/mL  
25I-NBOMe (33) S N/A   0.34-7.5 ng/mL  
O-desmethylvenlafaxine* (1,23) B 0.069-0.3 1-5.1 Unknown *also called desvenlafaxine (Pristiq®). Significant PMRD can occur. Liver is excellent complementary specimen to resolve difficult cases.
Olanzapine (1,23) B 0.02-0.4 0.01-1.0 0.8-4.9 Freeze specimen to prevent analyte degradation. May exhibit PMRD.
Oxazepam
 (1,3,4,7,21,23,24)
L 0.1-1.5 0.2-8.0 3-6.1 The concentrations listed as toxic are from DUID cases. May exhibit PMRD.
Oxcarbazepine (1,23) A/B 8-12 (mtb) >45 2.5 (parent) 92 (mtb) 10-OH carbazepine metabolite accumulates with chronic dosing, whereas, parent analyte does not.
Oxycodone (1,7,21,23,24) B/L 0.005-0.1 0.01-0.5 (0.24) 0.12-14 Tolerance is important to consider when evaluating the toxicity of this drug. The concentrations listed as toxic are from DUID cases. May exhibit PMRD.
Oxymorphone (1,8) L 0.003-0.005 Unknown 0.010-0.15 Tolerance is important to consider when evaluating the toxicity of this drug. May exhibit significant PMRD.
Paroxetine (1,4,23) B 0.1-0.6 >0.35-0.4

0.7-4.6;

LVR: 15-113 mg/kg*

Significant PMRD can occur with all SSRIs. Liver is an excellent complementary specimen to resolve difficult cases. *With co-ingestion of other drugs.
Pentobarbital (1,3,4,7,13,21,23,24) A Sedation Target 1-5; Coma or ICP Target: 30-40 >10-19 5-169  
Phencyclidine (1,7,23,24) B/L 0.01-0.2 0.007-0.8 0.3-25 May exhibit PMRD.
Phenibut (39) L N /A 29.7-36.5 * Unknown *Based on two nonfatal overdose cases
Phenobarbital (1,6,7,10,19,21) A 6-48 >30-40 >50  
Phentermine (1,21,23,24) B/L 0.03-0.51 0.2 1-7.6 May exhibit PMRD.
Phenylpropanolamine (1,4,23,24) B 0.1-0.5 0.3-2 >2 May exhibit PMRD.
Phenytoin (1,4,13,23,24) A 5-20 >20-50 43-94 May exhibit PMRD.
Pregabalin (1) L 1.3-4.9 >10 25 and 180*
50**
*Found in 2 deaths with at least one other drug.
**Found with other drugs with suspected heroin suicide.
Primidone (1,3,7,13,23,24) A <5 y/o: 7-10; Adults: 5-12 9-50 65  
Procainamide (1,7,13,23,24) B 4-10 10-16 17-260 (100)  
Promethazine (1,4,7,21,23) B 0.05-0.2 0.17-1

0.16-12;

LVR: 23-180 mg/kg

Will exhibit PMRD, peripheral blood and liver should be collected in cases suspicious for promethazine OD.
Propoxyphene (1,3,4,7) B 0.13-1.0 >0.5 1.0-17 Will exhibit PMRD, peripheral blood and liver should be collected in cases suspicious for propoxyphene OD.
Propranolol
 (1-7,13,21,23)
B 0.02-0.3 1-4.5 2-29 May exhibit PMRD.
Pseudoephedrine (1,23,24) B/L 0.5-0.8 Unknown 10-66 May exhibit PMRD.
Quetiapine (1) B 0.1-1 1.1-8.8 5-49;
Acute OD: 7.2-25; Psychiatric patient OD: 170
LVR: 34-200 mg/kg
PMRD may occur, PB and LVR excellent complementary specimens to resolve difficult cases.
Quinidine (1,7,13,21,23,24) B Naïve: 2-5
Dependent: 3-6
6-10 10-45  
Quinine (1,3,23,24) B 0.22-15 >10 6-24 (13)  
Risperidone (1,23) S 0.006-0.11 >0.12 1.8 May exhibit PMRD.
Rufinamide (1,23) A 3.0-30 >40 Unknown  
Salicylate (1,3,4,7,13,23,24) S 10-300 >200 400-7300 (600) Higher conc. are with arthritic patients that have been titrated to this level (44-330).
Sertraline (1,23) B 0.05-0.25 >0.2 >1.5 (parent only) Normal postmortem concentration often exceeds 0.75 mg/L. PMRD may occur, PB and LVR excellent complementary specimens to resolve difficult cases.
Suvorexant (40, 45) S Unknown 0.156 (0.075-0.303)*
2.33 (0.135-0.465)**
Unknown *Plasma concentrations 11 hours after 20 mg dose for driving impairment on two separate days
**Plasma concentrations 11 hours after 40 mg dose for driving impairment on two separate days
Tapentadol (1,15,23,26) B/L 0.05-0.13 >1 >2*; 0.3** Tolerance is important to consider when evaluating the toxicity of this drug. *Without the presence of other significant CNS depressant drugs. ** With ethanol and several other drugs.
Temazepam (1,3,21,23,24) L 0.02-1.1 >1 0.9-14*; 3.8-10.0** May exhibit PMRD. *With other drugs present. **Only temazepam.
Theophylline (1,4,7,13,23,24) A Children: 5-10; Adults 5-15 >20 25-250  
Thioridazine (1,4,7,13,23) B

0.14-2.6;

LVR: 1-12 mg/kg

1.1-14

1-18 (5.4);

LVR: 25-513 mg/kg

PMRD may occur, PB and LVR excellent complementary specimen to resolve difficult cases.
Tianeptine (28) L 0.322*
0.353-0.405**
Not Available 4.0-18***
23 mg/kg (liver)****
2.0 (urine) ****
*Based on 12 healthy male patients
** Based on elderly patients
***Blood concentrations
****Concentrations based from same patient
Topiramate (1,21) A 2-10 >5.9-16 >49
43*
The concentrations listed as toxic are from DUID cases.   *With 2 other drugs present.
Tramadol (1,3,13,23) B/L 0.1-1 0.01-5.3 1.1*-23; Avg 6.1** The concentrations listed as toxic are from DUID cases. *With other drugs present. **Only tramadol.
Trazodone (1,7,13,23,24) B 0.5-2.5 >4-26

9.4-34;

LVR: 57-82 mg/kg

PMRD may occur, PB and LVR excellent complementary specimens to resolve difficult case. The concentrations listed as toxic are from overdose cases in which the patient survived with supportive therapy.
Triazolam (1,7,23,24) L 0.002-0.02 >0.004-0.04 0.01-0.22 The concentrations listed as toxic are from DUID cases. May exhibit PMRD.
Trichlorethanol (1,4,23) S 2-27 >40-330 20-640 (250) Mtb. of chloral hydrate. Significant PMRD can occur. PB and LVR may be required to resolve difficult cases.
Trimipramine (1,4,23,24) B 0.011-0.3 0.5-1.0

0.4-12;

LVR: 42-544 mg/kg

PMRD may occur, PB and LVR excellent complementary specimens to resolve difficult cases.
U-47700 (29,37) B/L N/A   0.253 (0.017-0.490)  
Valproic acid (1,3,7,13,23,24) S/A 40-125 (plasma); 27-50 (whole blood);
Epilepsy: 50-100; Mania: 50-125
52-148 (hepatotoxic)  482-2120 (coma) 166*; 269**;2204 * 3 pediatric patients who developed fatal hepatitis.
**OD in a one month old.
Venlafaxine (1,23) B 0.1-0.4 1-24

6.6-95 (61);

LVR: 21-430 mg/kg

PMRD may occur, PB and LVR excellent complementary specimens to resolve difficult cases.
Verapamil
 (1,3,4,7,21, 23
B 0.02-1 >1-4

0.9-85 (11);

LVR: 3-280 mg/kg

May exhibit PMRD.
Vilazodone (1,28) S 0.028-0.063 0.360* Unknown *Concentration found in pediatric patient that experienced seizures (lived)
Vortioxetine (28) B 19-53 µg/L* Unknown Unknown *Steady state plasma concentrations in living patients
Zaleplon (1,23) L 0.001-0.03 0.037-0.13 >2.2; 0.870* The concentrations listed as toxic are from DUID cases. May exhibit PMRD. *With other drugs present.
Ziprasidone (1,6) S 0.045-0.2 >0.4 2.0  
Zolpidem (1,3,4,9,21,23) B/L 0.08-0.15 0.07-0.7 >1; >0.8*; Avg 1.9** The concentrations listed as toxic are from DUID cases. Tolerance should be considered when evaluating the toxicity of this drug. *With ethanol. **11 adults following acute OD with only zolpidem.
Zonisamide (1,12,18,23) A 10--40 >30-70 44* *Blood specimen at time of death from ingesting 4.8g

 

Assay Key-many compounds are detected by more than one screening test.

A=Acids/Neutrals
B=Bases/Neutrals
L=LCMS
S=Special
V=Volatiles

References:

  1. Baselt RC. Disposition of Toxic Drugs and Chemical in Man, 9th ed. Biomedical Publications, Seal Beach, CA 2011.
  2. Bishop-Freeman SC, Kornegay NC, Winecker RE. Postmortem Levtiracetam (Keppra®) from North Carolina. J Anal. Toxicol. 36:422-428 (2012).
  3. Drug Monograph. Lexi-Comp Online, Lexi-Drugs Online. Lexi-Comp Inc. Hudson, OH. Available at: http://www.crlonline.com/crlonline. Accessed between March 25,2009 and April 6,2009.
  4. Druid H, Holmgren P. A Compilation of Fatal and Control Concentrations of Drugs in Postmortem Femoral Blood. J Forensic Sci 1997;42:79-87.
  5. Druid H, Holmgren P, Hallander S, Ahlner J. Interpretation of postmortem femoral blood concentrations of newer antidepressants and hypnotics. American Academy of Forensic Sciences, February, 2001.
  6. Fasano CJ, O’Malley GF, Larse C and Rowdon AK. Pediatric Ziprasidone Overdose. Pediatric Emergency Care. 25 (4): 258-259 (2009).
  7. Ford M D, Delaney K A, Ling L J, Erickson T. Clinical Toxicology, 1st ed. W.B. Saunders Company, Philadelphia,PA, 2001.
  8. Garside D, Hargrove RL, Winecker RE. Concentration of Oxymorphone in Postmortem Fluids and Tissue. J Anal. Toxicol. 33:121-128 (2009).
  9. Jones AW and Holmgren A. Concentrations of zolpidem and zopiclone in venous blood samples from impaired drivers compared with femoral blood from forensic autopsies. Forensic Science International 222: 118-123 (2012).
  10. Kim HK, Smiddy M, Hoffman RS, Nelson LS. Buprenorphine May Not Be as Safe as You Think: A Pediatrick Fatality From Unintentional Exposure. Pediatrics 2012; 130;31700; originially published online Nov 5 2012; DOI: 10.1542/peds.2012-1342. Apr 1 2014 <http://pediatrics.aappublications.org/content/130/6/e1700.full.html>.
  11. W Klein-Shwartz. Trends and Toxic Effects from Pediatric Clonidine Exposures. Arch Pediatr Adolesc Med. 2002;156:392-396. Accessed 9 Apr 2014 from: <http://archpedi.jamanetwork.com/>.
  12. Leppik IE. Zonisamide. Epilepsia 1999; 40 (Suppl 5): S23-9.
  13. Lexi-Comp Online, Lexi-Drugs Online. Specific drug search. Accessed between March 24, 2014 and April 4, 2014.
  14. Linnett K, Lang LM, Johansen SS. Postmortem Femoral Blood Concentrations of Amlodipine. J Anal. Toxicol, 35: 227-231 (2011).
  15. Micromedex 2.0. Accessed between March 24, 2014 and April 4, 2014.
  16. Middleton O. Suicide by Gabapentin Overdose. J Foresnic Sci 2011 Sep;56(5):1373-1375.
  17. Neerman MF, Frost RA, and Deking J. A Drug Fatality Involving Kratom. J Foresnic Sci 2013 Jan;58 (S1):S278-279.
  18. Oommen KJ, Matthews S. Zonisamide: A new Antiepileptic Drug. Clinical Neuropharmacology 1999; 22(4): 192-200.
  19. Peterson BL. Prevalence of Gabapentin in Impaired Driving Cases in Washington State in 2003–2007. J Anal. Toxicol 33: 545-549 (2009).
  20. Periclou A, Ventura D, Rao N, and Abramowitz W. Pharmacokinetic study of Memantine in healthy and Renally Impaired Subjects. Clin. Pharmacol. Ther. 2006; 79 (1): 134-143.
  21. Repetto MR, Repetto M. Habitual, Toxic, and Lethal Concentrations of 103 Drugs of Abuse in Humans. Clin Toxicol 1997;35:1-9.
  22. Schauer SG and Varney SM. Gabapentin overdose in a military beneficiary. Mil Med 2013 Jan; 178(1):e133-135.
  23. Schulz M, Iwersen-Bergmann S, Andresen H, Schmoldt A. Therapeutic and toxic blood concentrations of nearly 1,000 drugs and other xenobiotics. Crit Care. 2012; 16(4): R136. Published online 26 Jul 2012. Accessed 1 Apr 2014 < http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3580721/#S1>.
  24. Stead AH, Moffat AC. A Collection of Therapeutic, Toxic and Fatal Blood Drug Concentrations in Man. Human Toxicol 1983;3:437-464.
  25. Bishop-Freeman, Sandra C.; Miller, Allison; Hensel, Erin; Winecker, Ruth E. Postmortem Metaxalone (Skelaxin®) Data from North Carolina.  J Anal Toxicol. 2015 Oct; 39(8):629-36. doi: 10.1093/jat/bkv066).RE Winecker, JO Brower and LA Friedrich. Tapentadol in Twelve Postmortem Cases from North Carolina and Proceedings: The International Association of Toxicologists, Hamamatsu, Japan, June 4, 2012.
  26. Poklis J, Poklis A, Wolf C, Mainland M, Hair L, Devers K, Chrostowski L, Arbefeville E, Merves M, Pearson J.  Postmortem tissue distribution of acetyl fentanyl, fentanyl and their respective nor-metabolites analyzed by ultrahigh performance liquid chromatography with tandem mass spectrometry. Forensic Sci Int 257: 435-41 (2015).
  27. Baselt RC. Disposition of Toxic Drugs and Chemical in Man, 10th ed. Biomedical Publications, Seal Beach, CA 2014.
  28. Mohr AL, Friscia M, Papsun D, Kacinko SL, Buzby D, Logan BK. Analysis of Novel Synthetic Opioids U-47700, U-50488 and Furanyl Fentanyl by LC-MS/MS in Postmortem Casework. J. Anal. Toxicol. 40(9):709-717 (2016).
  29. Kronstrand R, Thelander G, Lindstedt D, Roman M, Kugelberg FC. Fatal intoxications associated with the designer opioid AH-7921.  J Anal Toxicol 38(8):599-604 (2014).
  30. Miller C, Pleitez O, Anderson D, Mertens-Maxham D, Wade N. Asenapine (Saphris®): GC–MS Method Validation and the Postmortem Distribution of a New Atypical Antipsychotic Medication. J Anal Toxicol 37(8):559-564 (2013)
  31. Prosser JM, Nelson LS. The Toxicology of Bath Salts: A review of Synthetic Cathinones. J Med Toxicol 8(1): 33-42 (2012)
  32. Kyriakou C, Marinelli E, Frati P, Santurro A, Afxentiou M, Zaami S, Busardo FP. NBOMe: new potent hallucinogens--pharmacology, analytical methods, toxicities, fatalities: a review. Eur Rev Med Pharmacol Sci. 19(17):3270-81. (2015)
  33. Papsun D, Krywanczyk A, Vose JC, Bundock EA, Logan BK. Analysis of MT-45, a Novel Synthetic Opioid, in Human Whole Blood by LC–MS-MS and Its Identification in a Drug-Related Death. J Anal Toxicol 40 (4): 313-317. (2016)
  34. Karinen R, Tuv SS, Rogde S, Peres MD, Johansen U, Frost J, Vindenes V, Oiestad AML. Lethal poisonings with AH-7921 in combination with other substances. For Sci Int. 244: e21-e24 (2014).
  35. EMCDDA Europol Joint Report on a new psychoactive substance: 1-cyclohexyl-4-(1,2- diphenylethyl) piprazine (‘MT-45’). 2005
  36. Elliott, S. P., Brandt, S. D., & Smith, C. (2016). The first reported fatality associated with the synthetic opioid 3, 4-dichloro-N-[2-(dimethylamino) cyclohexyl]-N-methylbenzamide (U-47700) and implications for forensic analysis. Drug Test Anal, 8(8), 875-879.
  37. El-Sayeh HG, Morganti C, Adams CE. Aripiprazole for schizophrenia systematic review. The British Journal of Psychiatry 189(2): 102-108. 2006
  38. Li, C., & Sundararajan, K. (2015). An uncommon case of phenibut toxicity in an intensive care unit. Int J Med Pharm Case Rep, 5, 1-6.
  39. Vermeeren, A., Sun, H., Vuurman, E. F., Jongen, S., Van Leeuwen, C. J., Van Oers, A. C., ... & Bautmans, A. (2015). On-the-road driving performance the morning after bedtime use of suvorexant 20 and 40 mg: a study in non-elderly healthy volunteers. Sleep, 38(11), 1803.
  40. Bäckberg, M., Westerbergh, J., Beck, O., & Helander, A. (2016). Adverse events related to the new psychoactive substance 3-fluorophenmetrazine–results from the Swedish STRIDA project. Clinical toxicology, 54(9), 819-825.
  41. Sørensen, L. K., & Hasselstrøm, J. B. (2014). Determination of Therapeutic γ-Aminobutyric Acid Analogs in Forensic Whole Blood by Hydrophilic Interaction Liquid Chromatography–Electrospray Tandem Mass Spectrometry. Journal of analytical toxicology, bku010.
  42. Karch, S. B. (2015). Cathinone Neurotoxicity (“The “3Ms”). Current Neuropharmacology, 13(1), 21–25. http://doi.org/10.2174/1570159X13666141210225009
  43. Zuba, D., Sekuła, K., & Buczek, A. (2013). 25C-NBOMe–new potent hallucinogenic substance identified on the drug market. Forensic science international, 227(1), 7-14.
  44. National Center for Biotechnology Information. PubChem Compound Database; CID=24965990, https://pubchem.ncbi.nlm.nih.gov/compound/24965990 (accessed May 31, 2017).
  45. Bennett, J. T. (2010). Search form. AMC, 10, 12. https://www.ptcommunity.com/journal/article/full/2014/4/264/suvorexant-dual-orexin-receptor-antagonist-management-insomnia
  46. NC-OCME unpublished data
  47. Bishop-Freeman, Sandra C.; Brower, Justin O, Feaster, Marc S, Miller, Allison; Hargrove, Robert L, Winecker, Ruth E. Loperamide-Related Deaths in North Carolina. J Anal Toxicol. 2016 Oct;40(8):677-686.

 

Last Modified: June 30, 2017