REVIEW
OF RARE OVERDOSE CASES IN COBAIN'S RANGE
Remarkably, 8 studies out of 19 reported on at least one
of the 26 rare blood morphine levels in Cobain's range.
Staubb, et.
al., listed 12 cases in particular out of the 52 cases studied
which showed total blood morphine levels equal or above Cobain's
level. (90). However, it is vital to note that all these
cases involved abrupt death immediately following injection,
and
none of any of the 52 cases studies was reported to have
committed suicide with a gun of any kind. Basically,
their study showed
a remarkable consistency in abrupt reactions, indicating
an 85% probability of instant death, and 15% chance
of instantaneous
collapse into a comatose state. Still, it is worth pointing
out that this is the single largest group of cases at or
above Cobain's range. Coumbis & Balkrishena (16) show four high
level cases, while Gottschalk & Cravey (33) and Hine,
et. al. (42) each show 3 such cases. Studies which found
only one
such level are Richards, et. al. (77), Paterson (70), and
Monforte (62). Finally, Nakamura (63), mentioned previously,
also found
only one very high level case, with 1.8 mg/L, and the manner
of death was known to be instantaneous.
WASHINGTON STATE HEROIN OVERDOSES
Regarding Washington State heroin overdose deaths, including Seattle,
a 1996 report by Logan & Smirnow in a study of 32 cases of "...deaths
involving morphine." (58). The focus of their research basically
concerned testing the reliability of postmortem blood samples over
time, and the variabilities between morphine levels when collected
from different tissues, including different "sites" of
blood collection, eg. femoral, iliac, and ventricular sites. Also
of specific relevance to the Cobain case is the authors noted "...the
pattern of opiate use in this population is almost exclusively one
of Mexican black tar heroin." (58). Generally, they conclude
that "Although both site dependant differences and time dependant
changes have been shown to affect the concentration of some drugs
in postmortem samples, neither appears to be the case with morphine." (58).
The main point is that the Cobain blood data is generally regarded
as reliable, despite the fact that the body was discovered at least
three days after death. More importantly, note that only one case
of 32 was suicide, with the remainder listed as accidents or probable
accidents. The highest total blood morphine level, collected initially
from the iliac site, is 0.4 mg/L, shows black tar heroin use among
a population of addicts does not appear to necessarily lead to
significantly higher blood morphine levels than those found in
addict populations
where black tar heroin is uncommon.
BLACK TAR HEROIN DEATHS IN NEW MEXICO
The high lethality of black tar heroin due to increased purity
levels is discussed in Sperry's 1988 paper (90). Most of the 129
deaths
involved "...very high (greater than 1 mg/L) concentrations
of opiates in the blood..." (89). Sperry also discovered the
highest level of purity in black tar heroin ever reported, 93 % in
some rare cases. No case involved "...the so-called acute idiosyncratic
reaction...," further supporting the findings that acute heroin
overdoses are dose-related primarily. While it is obvious that many
adulterants can increase lethality, it would be completely mistaken
to think that pure heroin lacks toxicity as a result of it's purity
or the lack of toxic adulterants. None of the cases studied by Sperry
showed evidence of other drugs, and no case was reported to involve
a gun or trauma. While it is unfortunate that Sperry does not provide
a detailed list of blood morphine levels and other data, it is important
to note that even in a population of addicts overdosing on black
tar heroin, levels over 1 mg/L are considered "...very high..." (89)
This contrasts with Cobain's level, which registers 50% higher.
Due to lack of specific blood data, Sperry's report is excluded
from
Appendix A.
PREPONDERANCE OF EVIDENCE
Further confirmation of these findings is seen ubiquitously throughout
the scientific literature, creating a preponderance of evidence.
Gottschalk & Cravey's study of 128 heroin-related deaths showed
only 3 cases in Cobain's range. (33). Only one of the 128 deaths
involved secondary self-inflicted trauma of any kind, in which
one person committed suicide by hanging. Notably, despite evidence
of
intravenous heroin and/or morphine use, and despite the fact that
morphine levels in other tissues confirmed death by overdose, there
was no morphine detectable in the blood at all, which helps explain
how the individual had time to hang himself. The individual in
question tested positive for several drugs, as is common in cases
of self-poisoning,
and this accounts for the lethality of the otherwise low dose of
opiates. Specifically, oral methadone was also consumed, thus there
would be a moderately delayed reaction before the combined effects
of the drugs took effect and killed the victim before he died from
the hanging itself. None of the 128 deaths involved a gun of any
kind.
DECONSTRUCTING THE MYTH OF THE SUICIDAL HEROIN
ADDICT
Paterson (70) discusses 189 cases of fatal self-poisoning
in North and West London between 1975 and 1984. These cases
involved
only one drug each, and each case was determined to be the
direct result of an overdose of that specific drug, with no
other contributing causes. The study further confirms that
the myth of the suicidal heroin addict is indeed a myth, with
only seven cases involving morphine, i.e. less than 0.04% of
the cases studied. The average, or "mean," blood
morphine level was high, at 1 mg/L, with a range of 0.19 mg/L
to 1.9 mg/L, indicating at least one case in which the concentration
was at or above Cobain's range (probably only one, which would
raise the mean beyond normally seen mean levels). No other
details are provided concerning the route of administration,
i.e. whether or not the morphine or heroin were administered
orally or intravenously. Intravenous administration is a significant
possibility, and since Paterson's study includes at least one
case in seven in Cobain's range, the data is used in this study
to determine the specific probability and/or possibility of
an individual attaining such a high blood level. Note that
if the data is interpreted as 1 case in 189, then the chances
of an individual attaining such a blood morphine level via
self-poisoning, during a nine year period, is less than 0.0054%,
i.e. extremely remote.
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Appendix A - Appendix
B - References 1 / 2
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