Death in police custody or negligence, or body packing and self administration

(Accepted for presentation to the Last Word Society of the American Academy of Forensic Sciences for presentation in February of 2015)

Learning objectives: Review the metabolism of heroin; recognize how the route of the administration of heroin leads to differences in the formation of 6-monoacetyl morphine (6-MAM); examine how the onset of the signs of heroin overdose can lead to determining the approximate time at which heroin was used.

Police officers arrested Mr. X for possession of illicit drugs with intent to distribute. At the time of the arrest, police officers alleged that they saw Mr. X swallow several marble sized bags of contraband containing an unidentified white powder. Police officers believed this powder to be cocaine, but no field tests or laboratory tests were ever performed on the samples in question.

Mr. X was taken into custody and assigned to a single cell, which was equipped with video monitoring. In addition, police officers were supposed to come by Mr. X’s cell and monitor him for safety, every 15 minutes. A review of the monitoring checklist indicated that monitoring visits were not conducted according to the 15 minute schedule.

On the day of Mr. X’s death, Mr. X appeared in good health between 8-9 AM, when breakfast was served. However, when police officers came by to serve lunch between 11 AM and noon, Mr. X was found to be unresponsive with a great deal of blood-tinged, frothy, white fluid emanating from his mouth and nose.

His family filed a wrongful death civil suit against the police department and the city that employed the police officers, alleging negligence and failure to adequately monitor Mr. X’s condition while in their care. This author was retained as a forensic expert on the toxicity of heroin, on behalf of the police department and the municipality in question.

The metabolism of heroin involves several steps and differs depending upon the route of administration. Following Intranasal (IN), intramuscular (IM), or intravenous (IV) administration of heroin, heroin is almost immediately hydrolyzed to 6-monoacetylmorphine (6-MAM) in the blood and then travels to the liver where the 2nd acetyl group is removed liberating morphine. 6-MAM and morphine are the active ingredients which actually manifest the psychopharmacological effects of heroin in the brain. In contrast to IN, IM or IV administration, orally-administered heroin is rapidly converted to morphine in the stomach and virtually no 6-MAM is formed, or found in blood or urine.

Findings at autopsy:

At autopsy, three small bags (less than 1 inch in diameter) of white powder were removed from the decedent’s stomach. The contents of the bags were never analyzed, but the presence of BE and 6-MAM in the decedent’s urine indicated that both cocaine and heroin were present to some extent. The codeine is an impurity extracted from the opium poppy during the processing of the morphine into heroin.

Major Laboratory Toxicology Findings (specimen: postmortem fluoridated femoral blood)

Free codeine: 56 ng/ml; Free morphine: 987 ng/ml.

In urine:

Cocaine metabolite, benzoylecgonine, (BE): 666 ng/ml.

6-monoacetylmorphine (6-MAM): Present – less than 40 ng/ml.

Free morphine: greater than 2,000 ng/ml; Free codeine: greater than 2,000 ng/ml.

Plaintiff’s theory of the case

Plaintiffs alleged that the decedent died as a result of swallowing several bags of heroin and that the heroin slowly leached out of the bags over several days, accumulating to a toxic level, which ultimately caused the decedent to experience respiratory depression and pulmonary edema, which led to his death.

Defendant’s theory of the case

Mr. X appeared in good health during the first few days of his incarceration and never showed any signs of drug ingestion until he was found in pulmonary edema around noon time on the day of his death. Following a heroin overdose, pulmonary edema occurs either immediately or within 4 hours of the overdose. Since Mr. X appeared healthy at breakfast time (8-9 AM), the heroin must have been ingested between 8 AM and noon. Because 6-MAM was detected in urine at autopsy, the heroin must have been ingested by a route other than absorption from the stomach, implying that they heroin was probably “body-packed” into the facility and self-administered by “snorting.”


Key terms: Heroin; 6-monoacetylmorphine; pulmonary edema