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ACUTE HEROIN OVERDOSES ARE DOSE RELATED
Garriott & Sturner describe the relation between dose and speed of death as follows: "The cases in the intermediate-survival range - namely, from three to 24 hours - showed values for morphine in the blood of 3 to 10 mcg per 100 ml (.03 to .1 mg per litre, ed.). ...It is of interest that the three cases in the short-survival group demonstrating the highest concentrations of morphine in the blood (50, 50, and 93 mcg per 100 ml) (0.5, 0.5, and 0.93 mg per litre, ed.) showed neither froth in the air passages nor extensive pulmonary edema, supporting the concept that a very sudden death may be due to other mechanisms after injection. Rapid central-nervous-systems and respiratory depression as a direct effect of the narcotic drug would account for this phenomenon. ...(ed. note: as of 1973) The highest observed blood morphine value in an acute heroin "overdose" is 100 mcg per 100 ml (1 mg per litre, ed.). ...relatively high concentrations of free morphine tend to indicate the importance of the final injection in producing the lethal reaction." (28). Nakamura explains "In more cases, it can be now shown that narcotic was taken and rapidly distributed by the body to the various organs, and it may now be unnecessary to explain narcotic deaths by blaming excipients or hypersensitivity responses." (63). Thus, although some rare overdoses can be attributed partially to hypersensitivity, allergic, and other reactions to adulterants in street heroin, it is now widely accepted that heroin overdoses are primarily dose related.

DEFINING THE PROCESSES OF DEATH
Some confusion exists in the literature regarding estimates of "speed" of death following intravenous heroin overdose, primarily due to two reasons. The first reason for confusion concerns the minimum lethal dose, i.e. a small blood morphine level does not rule out instant collapse or death. The second reason for confusion concerns the true nature of death, which technically involves the death of different organs over a period of time. Burgess describes this as "Death does not occur all at once. One organ or system of organs may die some time before another." (8). Thus, even in those rare cases when an addict takes a large overdose and does not immediately die, immediate incapacitation occurs via a coma, and a comatose person may continue to technically "live" for hours or even days. The variability in survival periods specifically concerns the lower doses, not the higher doses, and when it comes to "massive" doses, eg. the Cobain case, the data is remarkably clear in stating that such a dose would immediately incapacitate even a heroin addict with the highest of tolerance levels.

JAMES INQUEST LEADS TO CHANGED VERDICT
One specific case which bears special significance with regard to the Cobain case is the case of Cindy James. The James case, as described by Dinn (20), involves the tragic death of a nurse who was reported as missing for two weeks before she was found dead. The case was changed from a suicide verdict to a verdict of "undecided," and the basic point of comparison concerns the methodologies used to reach the change in verdict. Before continuing with the similarities between the James case & the Cobain case, it is important to note several differences. The James Case did not involve a gun, there was no drug paraphernalia found near the body, and there was evidence that she was mentally unstable and possibly staged her own death to appear as murder. Also, James received morphine, not heroin (heroin is significantly faster and stronger than morphine). The cases are similar in that both James and Cobain died of a massive drug overdose which appeared to police, initially at least, to be suicides, and which later, to varying degrees, were suggested to be homicides based significantly upon the massiveness of the overdoses in relation to degree of incapacitation and speed of death.

IMPORTANT PRECEDENT OF METHODOLOGY
It was conclusively determined that if the scenario of intravenous injection was indeed true, then "Following an injection, morphine at this concentration would have induced a rapid state of unconsciousness and death...Given the level of consciousness and the time required to create the scene...then the death would appear to have been a homicide." (20). Thus it is important to note that the only reason the case was not then determined to be a homicide is because there was no way to verify whether the morphine was taken orally or otherwise. The mere possibility of murder was enough to change the James verdict to "undecided," even though the case involved significant evidence of suicide. The James case establishes an important precedent of methodology, which is that the blood levels of morphine can be used to determine time of death and/or incapacitation with regards to recreating the events surrounding the death in question for the purposes of determining whether the death was due to murder or suicide. The same methodology, when applied to the Cobain case, indicates that due to death or incapacitation following the intravenous injection of a massive lethal dose of heroin (much stronger than morphine), Cobain's death would be even more certainly a homicide.

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Appendix A - Appendix B - References 1 / 2