Fatal alfentanil/morphine mixture: A case report

A 23 year-old man, health care professional, was found dead in the toilets of a local hospital. Medical supplies for injection (syringe, needles) were found near the body at the scene, in a waste. External body examination revealed a single point of injection located at the left elbow crease and the lack of any traumatic injury. During examination, the pathologist collected cardiac blood and urine. These specimens were tested for ethanol, volatiles, pharmaceuticals and drugs of abuse, using headFspace GC/FID and GC/MS, Elisa, LC-DAD, GC/MS and LC/MS/MS. Ethanol tested positive in blood (0.99 g/L) and urine (0.19 g/L). Using a dedicated LC/MS/MS procedure, alfentanil was identified in both blood (19 ng/mL) and urine (25 ng/mL). Morphine was identified in blood, at 36 ng/mL (free morphine) and 39 ng/mL (total morphine). In urine, total morphine concentration was 81 ng/mL. No other drug was detected. Given the ratio (0.92) free morphine to total morphine in blood and the low concentrations of both alfentanil and morphine in urine, it was considered that the death occurred rapidly after drugs administration. The manner of death was considered as acute intoxication of both alfentanil and morphine, in presence of ethanol.