Heroin-Related Fatalities in Jeddah, Saudi Arabia, between 2008 and 2018

Abstract

To date, epidemiological studies have not evaluated heroin-related deaths in the Middle East and North African regions, especially Saudi Arabia. All heroin-related postmortem cases reported at the Jeddah Poison Control Center (JPCC) over a 10-year period (21 January 2008 to 31 July 2018) were reviewed. In addition, liquid chromatography electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) was utilized to determine the 6-monoacetylmorphine (6-MAM), 6-acetylcodeine (6-AC), morphine (MOR), and codeine contents in unhydrolyzed postmortem specimens. Ninety-seven heroin-related deaths were assessed in this study, and they represented 2% of the total postmortem cases at the JPCC (median age, 38; 98% male). In the blood, urine, vitreous humor, and bile samples, the median morphine concentrations were 280 ng/mL, 1400 ng/mL, 90 ng/mL, and 2200 ng/mL, respectively; 6-MAM was detected in 60%, 100%, 99%, and 59% of the samples, respectively; and 6-AC was detected in 24%, 68%, 50%, and 30% of the samples, respectively. The highest number of deaths (33% of total cases) was observed in the 21-30 age group. In addition, 61% of cases were classified as "rapid deaths," while 24% were classified as "delayed deaths." The majority (76%) of deaths were accidental; 7% were from suicide; 5% were from homicide; and 11% were undetermined. This is the first epidemiological study to investigate heroin-related fatalities in Saudi Arabia and the Middle East and North African region. The rate of heroin-related deaths in Jeddah remained stable but increased slightly at the end of the study period. Most patients were heroin-dependent abusers and from the middle-aged group. The availability of urine, vitreous humor, and bile specimens provided valuable information regarding the opioids that were administered and the survival time following heroin injection.

Keywords: LC-MS/MS; forensic toxicology; opiates; opioids; postmortem.

Figure 1

The total number of heroin-related deaths cases over the 10-year period in Jeddah, Saudi Arabia (2008–2018).

Figure 2

Variation in median concentration of morphine in blood with sodium fluoride in heroin-related deaths cases over a 10-year period. The horizontal boxes correspond to the median concentration ratio, and the box lengths correspond to the 25–75th percentile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range.

Figure 3

Variation of morphine concentration in the 97 heroin-related fatality cases according to age group (a) blood with sodium fluoride (ng/mL), (b) urine (ng/mL), (c) vitreous humor and (d) bile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range (this description is applied to the remaining box-plot figures).

Figure 3

Variation of morphine concentration in the 97 heroin-related fatality cases according to age group (a) blood with sodium fluoride (ng/mL), (b) urine (ng/mL), (c) vitreous humor and (d) bile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range (this description is applied to the remaining box-plot figures).

Figure 4

Distribution of 6-AC in the 97 heroin-related fatality cases according to postmortem interval time group (a) blood with sodium fluoride (ng/mL), (b) urine (ng/mL), (c) vitreous humor and (d) bile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range (this description is applied to the remaining box-plot figures).

Figure 4

Distribution of 6-AC in the 97 heroin-related fatality cases according to postmortem interval time group (a) blood with sodium fluoride (ng/mL), (b) urine (ng/mL), (c) vitreous humor and (d) bile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range (this description is applied to the remaining box-plot figures).

Figure 5

Variation of median morphine concentration in the 97 heroin-related fatalities cases according to survival time before death; (a) blood with sodium fluoride (ng/mL), (b) urine (ng/mL), (c) vitreous humor and (d) bile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range (this description is applied to the remaining box-plot figures).

Figure 5

Variation of median morphine concentration in the 97 heroin-related fatalities cases according to survival time before death; (a) blood with sodium fluoride (ng/mL), (b) urine (ng/mL), (c) vitreous humor and (d) bile. The whiskers correspond to the smallest and largest value within 1.5 times the interquartile range, and circles (outlier) symbolize values exceeding at least 1.5 times the interquartile range and extremes (asterisks) correspond to values exceeding at least 3.0 times the interquartile range (this description is applied to the remaining box-plot figures).