Eileen said:

benni said:

I'm not sure about how you're parsing this overall, nor dividing toxicity from overdose... I'm not convinced.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3805449/

Documenting Causality on the Death Certificate: The ME/C must determine which one, or more, of the drugs detected is present in a concentration that is sufficient—by itself or in combination—to be toxic and to be listed as a the cause of death.10,11 All drugs that are deemed physiologically significant in causing death should be listed individually in Part 1 of the cause of death portion of the death certificate.

In drug-caused deaths that result from the combined effects of multiple drugs on the central nervous system, all drugs that contributed to the underlying cause of death should be listed in Part I of the death certificate.

Specifying individual drug names on the death certificate is important because death certificates are the source documents for national mortality statistics.

when reporting a death due to the acute toxic effects of a drug, use toxicity, toxic effects, intoxication, or poisoning in the Cause of Death portion of the death certificate

It is best to avoid the term overdose because it lacks a specific meaning.

You neglected a part of that article:

In general, it is better to record the parent drug than the drug metabolite whenever that information can be determined. For example, where morphine is detected on postmortem toxicology, and depending on the results of additional toxicologic testing (e.g., 6-AM) or the circumstantial information from the death investigation, the ME/C should specify morphine if it appears that prescription morphine was involved and heroin if it appears that the morphine was a metabolite of heroin (e.g., 6-AM). Otherwise, it is impossible to use death certificate information to determine how many deaths involved prescription agents rather than illicit substances.

Caution should be exercised in selecting the words used to describe the cause of death because such wording determines whether the death is categorized as an acute poisoning injury or a chronic condition in vital statistics (Appendix B).¹⁴ The coding rules specify the wording that qualifies for each code assigned to the underlying cause of death and each contributing cause of death on the death certificate.⁹ For example, the following phrases would be coded with the same ICD-10 category “poisoning (X42) with nature of injury specifying the cocaine involvement (T40.5)”: acute cocaine intoxication, acute cocaine toxicity, toxic effects of cocaine, cocaine poisoning, and cocaine overdose. In contrast, the following phrases would be coded to the ICD-10 F14 category “Mental and Behavioral Disorders Due to Use of Cocaine”: cocaine use, cocaine abuse, cocaine snorting, and cocaine addiction.

Thus, when reporting a death due to the acute toxic effects of a drug, use toxicity, toxic effects, intoxication, or poisoning in the Cause of Death portion of the death certificate and avoid the words use or abuse, which—along with terms such as dependence and disorder—would be appropriate to use only if the intent is to implicate substance use as the cause of death.

Terms such as such as addiction and disorder are appropriately used to describe long-term drug dependence or drug addiction that has caused physiological damage to a point at which a natural death occurred (as through organ failure). It is best to avoid the term overdose because it lacks a specific meaning.

[Edited 6/5/16 22:53pm]

Here is an interesting article:

http://content.time.com/t...31,00.html

"In a study published in March in the American Journal of Clinical Pathology, Apple and colleagues measured fentanyl levels in bodies immediately after death and again several hours later at autopsy. The researchers found that some bodies had no detectable levels of the drug at the first measurement but showed significant levels at the second — and that these levels varied widely depending on which part of the body was sampled. Since it is not always clear when exactly a person died, or how long redistribution takes, the variance could make a therapeutic level of a drug appear toxic, or vice versa."

benni said:

You neglected a part of that article:

I neglected a lot of the article because I didn't think it applied to the points at hand, and still don't understand how the parts you pasted applied. Maybe we aren't having the same discussion due to jargon misinterpretation or something.

My position was/is regarding whether or not the ME can avoid listing drugs that the ME believes contributed to toxicity/death occurring. My position is no they cannot, the ME is supposed to list those drugs. I'm presuming the ME in this case followed the proper procedures and standards in this regard (although I have sliver of doubt due to the minimalism of the data).

I understood you to be arguing (as in presenting your case) that another drug such as Percocet could still have set in motion the physiological condition, at that moment, that resulted in Fentanyl then being toxic even if it wouldn't have been toxic on its own, and that it would be okay for the ME to believe that, without listing Percocet or that other drug as a cause.

benni said:

Here is an interesting article:

http://content.time.com/t...31,00.html

"In a study published in March in the American Journal of Clinical Pathology, Apple and colleagues measured fentanyl levels in bodies immediately after death and again several hours later at autopsy. The researchers found that some bodies had no detectable levels of the drug at the first measurement but showed significant levels at the second — and that these levels varied widely depending on which part of the body was sampled. Since it is not always clear when exactly a person died, or how long redistribution takes, the variance could make a therapeutic level of a drug appear toxic, or vice versa."

** Very interesting, thanks!

Much of what scientists do know about drug-related death comes from the 25 years of research by Dr. Steven Karch, a cardiac pathologist based in Berkeley, Calif., who has written two widely respected texts on the topic.

** Most everything about that paragraph is scary. Much of the current science relies on work by ONE person? Who has written TWO books?

On June 7, he testified for the defense in the Wichita case, stating that in most instances of drug overdose, the currently available medical technology cannot accurately determine whether or which drugs caused death.

the medical examiner testified that a person's drug history is "not something that I usually consider or go into" when drugs are detected in the body and no other cause of death is apparent.

What is clear, however, is that juries across the country are in some cases hearing evidence based on shaky forensic science or from forensics professionals who lack the necessary expertise.

** For all the above - society thinks the problem is that we aren't putting enough doctors and neighbors and family members and etc. in jail over this? Doesn't exactly inspire confidence...

Eileen said:

benni said:

You neglected a part of that article:

I neglected a lot of the article because I didn't think it applied to the points at hand, and still don't understand how the parts you pasted applied. Maybe we aren't having the same discussion due to jargon misinterpretation or something.

My position was/is regarding whether or not the ME can avoid listing drugs that the ME believes contributed to toxicity/death occurring. My position is no they cannot, the ME is supposed to list those drugs. I'm presuming the ME in this case followed the proper procedures and standards in this regard (although I have sliver of doubt due to the minimalism of the data).

I understood you to be arguing (as in presenting your case) that another drug such as Percocet could still have set in motion the physiological condition, at that moment, that resulted in Fentanyl then being toxic even if it wouldn't have been toxic on its own, and that it would be okay for the ME to believe that, without listing Percocet or that other drug as a cause.

Yes, you understand correctly. The percocet could have increased the toxicity level of the fentanyl and therefore would not have to be listed, as it in itself, was not considered to be fatal. However, due to the toxicity level then of fentanyl, that would be the cause of the death. I had found another journal article (which I've been searching for again) that stated that a second drug would not have to be listed if it was not at toxic or fatal levels in the system. However, I cannot remember the search items I had used in finding it before, but will post it when I find it.

Also, the rest of the article is pertinent in establishing whether there was "abuse" involved or not. According to the article, words such as "use" or "abuse" along with "dependence" or "disorder" are more appropriate to use if they are wanting to implicate substance use as the cause of the death. Toxicity is used to indicate "acute toxic events" which is very different from chronic drug use. Acute toxicity is defined as: 1. Acute toxicity refers to those adverse effects occurring following oral or dermal administration of a single dose of a substance, or multiple doses given within 24 hours, or an inhalation exposure of 4 hours.

I also found this: The words and terms used on the death certificate can influence the underlying cause assigned to the death. For example, the words “intoxication” or “toxicity” will result in the assignment of drug overdose as the underlying cause, while the words “abuse” or “use” will result in the assignment of an underlying cause related to mental health or behavior (i.e., an ICD-10 “F” coderather than an “X” or “Y” code).

Eileen said:

benni said:

Here is an interesting article:

http://content.time.com/t...31,00.html

"In a study published in March in the American Journal of Clinical Pathology, Apple and colleagues measured fentanyl levels in bodies immediately after death and again several hours later at autopsy. The researchers found that some bodies had no detectable levels of the drug at the first measurement but showed significant levels at the second — and that these levels varied widely depending on which part of the body was sampled. Since it is not always clear when exactly a person died, or how long redistribution takes, the variance could make a therapeutic level of a drug appear toxic, or vice versa."

** Very interesting, thanks!

Much of what scientists do know about drug-related death comes from the 25 years of research by Dr. Steven Karch, a cardiac pathologist based in Berkeley, Calif., who has written two widely respected texts on the topic.

** Most everything about that paragraph is scary. Much of the current science relies on work by ONE person? Who has written TWO books?

On June 7, he testified for the defense in the Wichita case, stating that in most instances of drug overdose, the currently available medical technology cannot accurately determine whether or which drugs caused death.

the medical examiner testified that a person's drug history is "not something that I usually consider or go into" when drugs are detected in the body and no other cause of death is apparent.

What is clear, however, is that juries across the country are in some cases hearing evidence based on shaky forensic science or from forensics professionals who lack the necessary expertise.

** For all the above - society thinks the problem is that we aren't putting enough doctors and neighbors and family members and etc. in jail over this? Doesn't exactly inspire confidence...

No it doesn't inspire confidence at all. And it is surprising to see that most of what we know about drug-related deaths comes from one person. It seems that this is not an exact science yet.

If we put aside all conjecture, the only thing we know is Prince died from fentanyl intoxication, and a few days before he was given a "save shot" because he was not conscious. That is all we know for certain.

What we do not know:

If Prince was suffering chronic pain.

If Prince was found with Percocet on his person

If the plane incident was an OD

If Prince had any underlying illness

How long Prince had been taking fentanyl

If Prince had ever taken percocet

If Prince was long/short term user of fentanyl

If fentanyl was prescribed or not

Why he was at Walgreens

What his doctors visits were about

Whether anyone around him knew anything

We do not kno any of the above. Anything regarding those points has come from the media or our own speculation.

The truth is, I dont think we will ever know unless there is a trial. If someone is charged and it goes to court, then I think all of this will be revealed.

benni said:

Eileen said:

** Very interesting, thanks!

Much of what scientists do know about drug-related death comes from the 25 years of research by Dr. Steven Karch, a cardiac pathologist based in Berkeley, Calif., who has written two widely respected texts on the topic.

** Most everything about that paragraph is scary. Much of the current science relies on work by ONE person? Who has written TWO books?

On June 7, he testified for the defense in the Wichita case, stating that in most instances of drug overdose, the currently available medical technology cannot accurately determine whether or which drugs caused death.

the medical examiner testified that a person's drug history is "not something that I usually consider or go into" when drugs are detected in the body and no other cause of death is apparent.

What is clear, however, is that juries across the country are in some cases hearing evidence based on shaky forensic science or from forensics professionals who lack the necessary expertise.

** For all the above - society thinks the problem is that we aren't putting enough doctors and neighbors and family members and etc. in jail over this? Doesn't exactly inspire confidence...

No it doesn't inspire confidence at all. And it is surprising to see that most of what we know about drug-related deaths comes from one person. It seems that this is not an exact science yet.

.

You are completely wrong. It does not come from one person, and it is a very exact science.

EmancipationLover said:

You are completely wrong. It does not come from one person, and it is a very exact science.

Okay, that's hilarious. Feel free to seek out the authors of the linked article and study we were quoting/discussing and argue with those people. Or post another resource that has a different take on the subject.

EmancipationLover said:

benni said:

No it doesn't inspire confidence at all. And it is surprising to see that most of what we know about drug-related deaths comes from one person. It seems that this is not an exact science yet.

.

You are completely wrong. It does not come from one person, and it is a very exact science.

Much of what scientists do know about drug-related death comes from the 25 years of research by Dr. Steven Karch, a cardiac pathologist based in Berkeley, Calif., who has written two widely respected texts on the topic.

What is clear, however, is that juries across the country are in some cases hearing evidence based on shaky forensic science or from forensics professionals who lack the necessary expertise. According to a 2009 report by the National Research Council of the National Academy of Sciences: "Rigorous and mandatory certification programs for forensic scientists are currently lacking...as are strong standards and protocols for analyzing and reporting on evidence. And there is a dearth of peer-reviewed, published studies establishing the scientific bases and reliability of many forensic methods. Moreover, many forensic science labs are underfunded, understaffed, and have no effective oversight."

Given the state of the science, then, should it be used in court? Ed Cheng, a professor of law at Brooklyn Law School and expert on scientific testimony, says, yes, noting that more research is still needed. "If we were to require studies and statistical assessment on every assertion, almost nothing would be able to be used in court. My view on this is that the question here is not throwing the baby out with the bathwater," says Cheng. "It's clear that the forensic sciences do not have as much of an empirical basis as we would like them to have. The question becomes how do we motivate them sufficiently to come up with the empirical basis that we want?"

Some experts do agree with Cheng. "The evidence base is improving," says Apple, who is currently conducting a study of blood and tissue samples taken postmortem, in order to build up a usable database of drug information. "So when people have to make death determinations from smaller jurisdictions where they don't have [an expert on staff] like me, they can make them with some assurance."

But Karch is less sanguine about the reliability of such data and thinks that as long as the reliability of forensic evidence is still evolving, it has no place in court. "It's a giant miscarriage of justice," he says. He recalls the malpractice and murder convictions that were won many years ago against doctors who were thought to have killed patients by administering digoxin, a drug for arrhythmia and other heart problems. It turned out that the drug collected in the heart muscle in live patients and was released into the body after death, making safe doses of the drug look deceptively high — a result similar to those seen in current studies of fentanyl and methadone.

In the Schneider case, which entered jury deliberations on Wednesday, the defense team sought and failed to prevent the jury from hearing testimony that it believed did not have sufficient scientific foundations. But according to Cheng, it may be preferable to let the jury hear both sides of the scientific dispute and make up their own minds. "I myself have floated between the poles on this," he says. "I'm currently more on the 'Let the jury hear it' side. I'm not convinced that good science and bad science is always cut and dried."

Rebeljuice said:

If we put aside all conjecture, the only thing we know is Prince died from fentanyl intoxication, and a few days before he was given a "save shot" because he was not conscious. That is all we know for certain.

What we do not know:

If Prince was suffering chronic pain.

If Prince was found with Percocet on his person

If the plane incident was an OD

If Prince had any underlying illness

How long Prince had been taking fentanyl

If Prince had ever taken percocet

If Prince was long/short term user of fentanyl

If fentanyl was prescribed or not

Why he was at Walgreens

What his doctors visits were about

Whether anyone around him knew anything

We do not kno any of the above. Anything regarding those points has come from the media or our own speculation.

The truth is, I dont think we will ever know unless there is a trial. If someone is charged and it goes to court, then I think all of this will be revealed.

The chronic pain has been reported on by several of those that worked closely with Prince.

True, about the percocets. It was just reported that law enforcement were stating opiods had been found on Prince, and that could have been fentanyl or could have been hogwash.

And true regarding the plane incident.

Also true about underlying medical illnesses.

No, we don't know how long he had been taking fentanyl, but since the official cause of death is listed as accidental fentanyl toxicity, and from what I have read tonight, I don't think he was using that long-term. From an earlier post: Also, the rest of the article is pertinent in establishing whether there was "abuse" involved or not. According to the article, words such as "use" or "abuse" along with "dependence" or "disorder" are more appropriate to use if they are wanting to implicate substance use as the cause of the death. Toxicity is used to indicate "acute toxic events" which is very different from chronic drug use. Acute toxicity is defined as: 1. Acute toxicity refers to those adverse effects occurring following oral or dermal administration of a single dose of a substance, or multiple doses given within 24 hours, or an inhalation exposure of 4 hours. I also found this: The words and terms used on the death certificate can influence the underlying cause assigned to the death. For example, the words “intoxication” or “toxicity” will result in the assignment of drug overdose as the underlying cause, while the words “abuse” or “use” will result in the assignment of an underlying cause related to mental health or behavior (i.e., an ICD-10 “F” coderather than an “X” or “Y” code). ---- So the terminology the ME used as the cause of death at least gives us a clue that she is indicating an "acute toxic event", not substance use, per say.

True, we don't know if he had taken percocets except as reported in news stories which may or may not be true.

Regarding the long term/short term user, see my response to "how long Prince had been taking fentanyl".

Again, no we don't know if it was prescribed. However, I have a hard time imagining Prince buying drugs on the black market. But that doesn't mean he didn't.

Regarding Walgreens, we know from the reports of the pharmacist staff that Prince bought his prescriptions there. But we do not know if he was there at that time to purchase prescriptions.

Regarding the doctor visits, all we know for certain is that he was seen on the 7th and 20th and that the tests had been done, which the doctor stated he was delivering, as well as the doctor having prescribed him medication. What medication? We also know that a pain management doctor / addiction specialist was called in by those closest to Prince. Whether he was called for his pain management expertise or addiction still remains to be seen. The doctor's son is talking addiction, and they are reporting it as a "life saving mission".

Regarding those close to him knowing, for the pain management / addiction specialist to be called in, it states that someone close to Prince knew what was going on.

Also, if none of this were true, the DEA would not have been called in to help investigate.

benni said:

Yes, you understand correctly. The percocet could have increased the toxicity level of the fentanyl and therefore would not have to be listed, as it in itself, was not considered to be fatal. However, due to the toxicity level then of fentanyl, that would be the cause of the death. I had found another journal article (which I've been searching for again) that stated that a second drug would not have to be listed if it was not at toxic or fatal levels in the system. However, I cannot remember the search items I had used in finding it before, but will post it when I find it.

Also, the rest of the article is pertinent in establishing whether there was "abuse" involved or not...

If you do run across that other piece or other pertinent info yes post, I'll read.

So far as the use/abuse jargon, yes I caught that in my first pass. But the ME had already judged it Toxicity (acute I presumed) so I was stopping there. Goes back to the minimalism of the report... I have no idea how much use (history) they might have evidence of or are concerned with, but I can't imagine the ME would have including any 'editorializing' type diagnosis in this case unless there was no other cause of death to list. They had an acute event responsible, they were good to go. This is still MN and he's still Prince and it wasn't even Hennepin County ME (the city), it's suburban/rural. Plus I think the original CC Sheriff's statement was a warning shot across the bow to other offices as to the degree of discretion expected.

The issues we're discussing are probably why they handled the announcement the way they did, even. Have the world download the document attached to a statement that says, we aren't answering any questions so don't even try. They didn't want to have to address queries like, "Does this mean no other narcotics were present in the body? Is that what you're saying here?"

I'm not agreeing or disagreeing with the minimalism in the report, I accept it as is. However the issues and learnings involved are still very interesting to consider.

Eileen said:

EmancipationLover said:

You are completely wrong. It does not come from one person, and it is a very exact science.

Okay, that's hilarious. Feel free to seek out the authors of the linked article and study we were quoting/discussing and argue with those people. Or post another resource that has a different take on the subject.

.

I work in an academic Pharmacy department. The pharmacology of opioid drugs, including metabolism, drug-drug interactions etc., has been studied in detail by many researchers worldwide. This is not some voodoo stuff that only a small group of people (let alone a single scientist) has worked on, it is a well-established field of research activity. You can try to argue with me about that, but I'm not going to collect all these research papers via SciFinder, PubMed or any other scientific databank for you.

.

Prince died from fentanyl intoxication, period - the certificate clearly states that. There is no interaction with another drug involved, that would have been listed. I don't see a point in arguing about that, these tests have been performed by qualified professionals with sound scientific training.

EmancipationLover said:

Eileen said:

Okay, that's hilarious. Feel free to seek out the authors of the linked article and study we were quoting/discussing and argue with those people. Or post another resource that has a different take on the subject.

.

I work in an academic Pharmacy department. The pharmacology of opioid drugs, including metabolism, drug-drug interactions etc., has been studied in detail by many researchers worldwide. This is not some voodoo stuff that only a small group of people (let alone a single scientist) has worked on, it is a well-established field of research activity. You can try to argue with me about that, but I'm not going to collect all these research papers via SciFinder, PubMed or any other scientific databank for you.

.

Prince died from fentanyl intoxication, period - the certificate clearly states that. There is no interaction with another drug involved, that would have been listed. I don't see a point in arguing about that, these tests have been performed by qualified professionals with sound scientific training.

Still don't know why you are (now intently) projecting others opinions or beliefs onto me. There's nothing to discuss on such a basis.

Eileen said:

EmancipationLover said:

.

I work in an academic Pharmacy department. The pharmacology of opioid drugs, including metabolism, drug-drug interactions etc., has been studied in detail by many researchers worldwide. This is not some voodoo stuff that only a small group of people (let alone a single scientist) has worked on, it is a well-established field of research activity. You can try to argue with me about that, but I'm not going to collect all these research papers via SciFinder, PubMed or any other scientific databank for you.

.

Prince died from fentanyl intoxication, period - the certificate clearly states that. There is no interaction with another drug involved, that would have been listed. I don't see a point in arguing about that, these tests have been performed by qualified professionals with sound scientific training.

Still don't know why you are (now intently) projecting others opinions or beliefs onto me. There's nothing to discuss on such a basis.

.

My first reply was to benni, not to you.

O.k., here's some more info on the subject. Against my initial intention, I've now performed a quick search in SciFinder (that's a scientific literature database operated by the American Chemical Society).

.

For the search term 'fentanyl metabolism', I've found 491 references (after removing duplicates and including the search term as a concept). Out of these 491 references, only 1 (!) involves Steven Karch - not as an author, but as an editor though.

.

For the search term 'fentanyl toxicity', I've found 383 references (after removing duplicates and including the search term as a concept). Out of these 383 references, 0 (!) involve Steven Karch.

.

For the search term 'fentanyl forensics', I've found 105 references (after removing duplicates and including the search term as a concept). Out of these 105 references, 0 (!) involve Steven Karch.

.

Whatever Dr. Karch's overall scientific contributions might be, he is definitely not the sole source for the topic.

[Edited 6/6/16 6:12am]

A big thing left out off the "Things we do not know"

How bad was the Pain he was in.

When did this pain begin.

Did he have a hip surgery and who performed it since no one is saying they did.

So the thing I don't get about "Walgreens" is he is picking up his own prescriptions, so in that respect he is NOT HIDING anything? Which is conflicting all the other points that are being made. One being that someone else was getting this for him? Why would he be having someone else get them and then go pick them up himself? The plane issue also early on was mentioned that Prince was upset that they landed the plane I guess when he found out, so that would imply he was trying to hide all kinds of suspicion of a plane landing like it had "mechanical issues or threats" which would be a RED FLAG to media, so it is confusing how he was being discreet in one way and then be all out in the open picking things up.

benni said:

Rebeljuice said:

If we put aside all conjecture, the only thing we know is Prince died from fentanyl intoxication, and a few days before he was given a "save shot" because he was not conscious. That is all we know for certain.

What we do not know:

If Prince was suffering chronic pain.

If Prince was found with Percocet on his person

If the plane incident was an OD

If Prince had any underlying illness

How long Prince had been taking fentanyl

If Prince had ever taken percocet

If Prince was long/short term user of fentanyl

If fentanyl was prescribed or not

Why he was at Walgreens

What his doctors visits were about

Whether anyone around him knew anything

We do not kno any of the above. Anything regarding those points has come from the media or our own speculation.

The truth is, I dont think we will ever know unless there is a trial. If someone is charged and it goes to court, then I think all of this will be revealed.

The chronic pain has been reported on by several of those that worked closely with Prince.

True, about the percocets. It was just reported that law enforcement were stating opiods had been found on Prince, and that could have been fentanyl or could have been hogwash.

And true regarding the plane incident.

Also true about underlying medical illnesses.

No, we don't know how long he had been taking fentanyl, but since the official cause of death is listed as accidental fentanyl toxicity, and from what I have read tonight, I don't think he was using that long-term. From an earlier post: Also, the rest of the article is pertinent in establishing whether there was "abuse" involved or not. According to the article, words such as "use" or "abuse" along with "dependence" or "disorder" are more appropriate to use if they are wanting to implicate substance use as the cause of the death. Toxicity is used to indicate "acute toxic events" which is very different from chronic drug use. Acute toxicity is defined as: 1. Acute toxicity refers to those adverse effects occurring following oral or dermal administration of a single dose of a substance, or multiple doses given within 24 hours, or an inhalation exposure of 4 hours. I also found this: The words and terms used on the death certificate can influence the underlying cause assigned to the death. For example, the words “intoxication” or “toxicity” will result in the assignment of drug overdose as the underlying cause, while the words “abuse” or “use” will result in the assignment of an underlying cause related to mental health or behavior (i.e., an ICD-10 “F” coderather than an “X” or “Y” code). ---- So the terminology the ME used as the cause of death at least gives us a clue that she is indicating an "acute toxic event", not substance use, per say.

True, we don't know if he had taken percocets except as reported in news stories which may or may not be true.

Regarding the long term/short term user, see my response to "how long Prince had been taking fentanyl".

Again, no we don't know if it was prescribed. However, I have a hard time imagining Prince buying drugs on the black market. But that doesn't mean he didn't.

Regarding Walgreens, we know from the reports of the pharmacist staff that Prince bought his prescriptions there. But we do not know if he was there at that time to purchase prescriptions.

Regarding the doctor visits, all we know for certain is that he was seen on the 7th and 20th and that the tests had been done, which the doctor stated he was delivering, as well as the doctor having prescribed him medication. What medication? We also know that a pain management doctor / addiction specialist was called in by those closest to Prince. Whether he was called for his pain management expertise or addiction still remains to be seen. The doctor's son is talking addiction, and they are reporting it as a "life saving mission".

Regarding those close to him knowing, for the pain management / addiction specialist to be called in, it states that someone close to Prince knew what was going on.

Also, if none of this were true, the DEA would not have been called in to help investigate.

Yeah if someone knew it had to be someone deep in his circle, I think what people forget is that people like Judith Hill and Third Eye girl etc..were his professional circle. His personal one is VERY small, to me an assistant or possibly Kirk Johnson who was with Prince a really long time.

Glad y'all are still here. I usually just read the posts. But I'm still in mourning and don't understand it. Maybe it's because I was at the 7:00 show on 4/14 and maybe it's just because of just having seen someone, admittedly was smaller looking but sounded great. I heard the 10:00 clock show on SoundCloud and clearly heard several mistakes in his playing. Which was shocking from such perfectionist, but just shows that he wasn't feeling well. I've been mad at him. Then at his doctors. And then at the employees at Paisley Park. I don't care what anyone says, it was NOT his time to go. If the employees were sooo concerned to try and stage an intervention, then why leave him alone right after filling that prescription? If anyone knew what really happened on that plane, they should have known that it potentially could happen again. And all these girls calling themselves his girlfriend or muses or this or that. NO ONE was around when he was sick?

My opinion: I think he panicked when word leaked what happened on the plane. Being such a private person and NOT being in the tabloids, he was desperate to prove that he was fine and wanted to get better faster. I just knew that I'd still be seeing him in concert 20 years from now. I'm hopeful that there will be music released from the vault. And video. Just like I hope they find a will. I can't believe at 57 he didn't have one--with that many assets. But mostly, I find myself moping and missing deadlines. I guess, I say all that because I really didn't comprehend how much Prince meant to me--as an artist. But like he says in Sometimes it Snows in April. "Love isn't love until it's past."

adrianne0791 said:

Glad y'all are still here. I usually just read the posts. But I'm still in mourning and don't understand it. Maybe it's because I was at the 7:00 show on 4/14 and maybe it's just because of just having seen someone, admittedly was smaller looking but sounded great. I heard the 10:00 clock show on SoundCloud and clearly heard several mistakes in his playing. Which was shocking from such perfectionist, but just shows that he wasn't feeling well. I've been mad at him. Then at his doctors. And then at the employees at Paisley Park. I don't care what anyone says, it was NOT his time to go. If the employees were sooo concerned to try and stage an intervention, then why leave him alone right after filling that prescription? If anyone knew what really happened on that plane, they should have known that it potentially could happen again. And all these girls calling themselves his girlfriend or muses or this or that. NO ONE was around when he was sick?

My opinion: I think he panicked when word leaked what happened on the plane. Being such a private person and NOT being in the tabloids, he was desperate to prove that he was fine and wanted to get better faster. I just knew that I'd still be seeing him in concert 20 years from now. I'm hopeful that there will be music released from the vault. And video. Just like I hope they find a will. I can't believe at 57 he didn't have one--with that many assets. But mostly, I find myself moping and missing deadlines. I guess, I say all that because I really didn't comprehend how much Prince meant to me--as an artist. But like he says in Sometimes it Snows in April. "Love isn't love until it's past."

Unless somebody at Wagreens speaks up we don't even know what the Rx was that he picked up. Fentanyl is what they say killed him, was this something new he was given? Was it to strong for him? If it was prescribed, then what was it for, pain or something else, nobody is saying anything so all we have is speculations. Look at how Mr. Ali's family is handling his passing, very forthcoming and a celebration of his life. Our Prince was hustled out of our lives with no real reason given. He deserved better from his family after all he did for them.

EmancipationLover said:

Eileen said:

Okay, that's hilarious. Feel free to seek out the authors of the linked article and study we were quoting/discussing and argue with those people. Or post another resource that has a different take on the subject.

.

I work in an academic Pharmacy department. The pharmacology of opioid drugs, including metabolism, drug-drug interactions etc., has been studied in detail by many researchers worldwide. This is not some voodoo stuff that only a small group of people (let alone a single scientist) has worked on, it is a well-established field of research activity. You can try to argue with me about that, but I'm not going to collect all these research papers via SciFinder, PubMed or any other scientific databank for you.

.

Prince died from fentanyl intoxication, period - the certificate clearly states that. There is no interaction with another drug involved, that would have been listed. I don't see a point in arguing about that, these tests have been performed by qualified professionals with sound scientific training.

You are discussing pharmacology, we are talking pathology.

EmancipationLover said:

Eileen said:

Still don't know why you are (now intently) projecting others opinions or beliefs onto me. There's nothing to discuss on such a basis.

.

My first reply was to benni, not to you.

My reply was in agreement with Eileen.

Eileen said:

benni said:

Yes, you understand correctly. The percocet could have increased the toxicity level of the fentanyl and therefore would not have to be listed, as it in itself, was not considered to be fatal. However, due to the toxicity level then of fentanyl, that would be the cause of the death. I had found another journal article (which I've been searching for again) that stated that a second drug would not have to be listed if it was not at toxic or fatal levels in the system. However, I cannot remember the search items I had used in finding it before, but will post it when I find it.

Also, the rest of the article is pertinent in establishing whether there was "abuse" involved or not...

If you do run across that other piece or other pertinent info yes post, I'll read.

So far as the use/abuse jargon, yes I caught that in my first pass. But the ME had already judged it Toxicity (acute I presumed) so I was stopping there. Goes back to the minimalism of the report... I have no idea how much use (history) they might have evidence of or are concerned with, but I can't imagine the ME would have including any 'editorializing' type diagnosis in this case unless there was no other cause of death to list. They had an acute event responsible, they were good to go. This is still MN and he's still Prince and it wasn't even Hennepin County ME (the city), it's suburban/rural. Plus I think the original CC Sheriff's statement was a warning shot across the bow to other offices as to the degree of discretion expected.

The issues we're discussing are probably why they handled the announcement the way they did, even. Have the world download the document attached to a statement that says, we aren't answering any questions so don't even try. They didn't want to have to address queries like, "Does this mean no other narcotics were present in the body? Is that what you're saying here?"

I'm not agreeing or disagreeing with the minimalism in the report, I accept it as is. However the issues and learnings involved are still very interesting to consider.

I will post anything that I find. There are still too many variables that are unanswered and what is unanswered can lead you on a merry chase with more and more questions that arise. For me, I have a hard time believing addiction to fentanyl, because I cannot see that man putting out the volume of works he did, put out the kind of music he did, battling an addiction like that. Not to mention that there would have been more incidents of missed tour dates, missed obligations, etc. And the volume of his travels and tours in recent times would have been effected much sooner by the addiction, than just the April 7th show cancellation and the plane incident reported on the 14th. I really do believe the fentanyl was a recent development. There are many artists, of course, that were addicted to other illegal/legal substances that continued to work, however, there were extreme indications that they were using substances (missing tour dates, wide-spread reports of their substance abuse, actions that reflected they were "high", etc.). All of that was missing with Prince. I think that is one of the things that makes all of this so surreal, because IF he was addicted, he was not a typical addict.

And it is possible that if their desire to protect Prince they took a minimalist approach, but legally, can they do that?

benni said:

EmancipationLover said:

.

I work in an academic Pharmacy department. The pharmacology of opioid drugs, including metabolism, drug-drug interactions etc., has been studied in detail by many researchers worldwide. This is not some voodoo stuff that only a small group of people (let alone a single scientist) has worked on, it is a well-established field of research activity. You can try to argue with me about that, but I'm not going to collect all these research papers via SciFinder, PubMed or any other scientific databank for you.

.

Prince died from fentanyl intoxication, period - the certificate clearly states that. There is no interaction with another drug involved, that would have been listed. I don't see a point in arguing about that, these tests have been performed by qualified professionals with sound scientific training.

You are discussing pharmacology, we are talking pathology.

.

The two are strongly related in this case. If Prince had died in the area where I live and work, the lab of one of my colleagues might have done the analysis of Prince's samples.

.

Please be so kind and read the facts I have reported (reply #675).

[Edited 6/6/16 9:32am]

Whether we tend to disagree with one another on this site or not, the one I do know is that many of you seem to be asking very valid questions, and if some of you were working on the death of Prince, maybe we would all know what really happened to him, and still would not have so many questions.

EmancipationLover said:

benni said:

You are discussing pharmacology, we are talking pathology.

.

The two are strongly related in this case. If Prince had died in the area where I live and work, the lab of one of my colleagues might have done the analysis of Prince's samples.

.

Please be so kind and read the facts I have reported (reply #675).

[Edited 6/6/16 9:32am]

The two may be related in this case, but again, the article stated that MUCH of what was known about drug related deaths, stemmed from the 25 years of research performed by Dr. Steven Karch, cardiac pathologist. You are looking at the pharmacology of opoid drugs, which would list the contraindications, the side effects, etc., and usually are more involved with the effects of drugs upon a living person. Yes, there has been a lot of research done, by many, on pharmacology, effects upon the body system, interactions with other drugs, etc. However, if you had read the article, it was discussing the difficulty with measuring drugs in the system after death. Looking at Google Scholar, which lists many scientific journals and books, as well as how many times those book or articles were cited, I found over 2550 articles/books/peer reviews just using Dr. Steven Karch in the search engine.

benni said:

EmancipationLover said:

.

The two are strongly related in this case. If Prince had died in the area where I live and work, the lab of one of my colleagues might have done the analysis of Prince's samples.

.

Please be so kind and read the facts I have reported (reply #675).

[Edited 6/6/16 9:32am]

The two may be related in this case, but again, the article stated that MUCH of what was known about drug related deaths, stemmed from the 25 years of research performed by Dr. Steven Karch, cardiac pathologist. You are looking at the pharmacology of opoid drugs, which would list the contraindications, the side effects, etc., and usually are more involved with the effects of drugs upon a living person. Yes, there has been a lot of research done, by many, on pharmacology, effects upon the body system, interactions with other drugs, etc. However, if you had read the article, it was discussing the difficulty with measuring drugs in the system after death. Looking at Google Scholar, which lists many scientific journals and books, as well as how many times those book or articles were cited, I found over 2550 articles/books/peer reviews just using Dr. Steven Karch in the search engine.

.

I have used SciFinder (which is a much more professional search tool than Google Scholar) to look through the publication list of Dr. Karch. I have to conclude that the statement "that MUCH of what was known about drug related deaths, stemmed from the 25 years of research performed by Dr. Steven Karch" seems to be rather adventurous. Dr. Karch has performed quite some work on cocaine and also ecstasy, for instance. He has (co-)authored slightly more than 160 publications (which is good, but certainly not spectacular in this field), with some of them being chapters of a book which he hasn't authored, but just edited (which is not unusual, it just should be taken into account). To sum it up: the article you have cited makes Dr. Karch appear to be a bigger cheese in the field than he actually is. He certainly has some scientific accomplishments, but he has not single-handedly established the forensics of drug abuse.

.

Measuring drugs in the blood sample of a dead person is technically not different than measuring the blood sample of a living individual - the LC-MS does not know who the sample comes from. It's the interpretation of the data which can be different, because the former sample has been taken hours after drug metabolism has stopped, while the latter is taken from an individual with active metabolism and active excretion of the drug or its metabolites. It's a totally different story though to ensure that a certain level of a drug is a safe forensic proof for it to be the cause of death. Naturally, this can vary significantly from drug to drug.

.

Again, please read what I have written: "fentanyl toxicity" and "fentanyl forensics" have zero contribution by Dr. Karch. But just to be on the safe side, I have just run "fentanyl" through SciFinder - ca. 30 000 references, 2 (!) of them associated with Dr. Karch. Guess what: two chapters of the book he has edited (not written, see above). The man has never published a single paper regarding fentanyl, he has worked on totally different drugs.

[Edited 6/6/16 11:37am]

Btw, I have just found one of Dr. Karch's textbooks on the forensics of drug abuse. That seems to be a rather widely used item indeed from what I have found out, but the claim in question was that HE actually did most of the research, so whatever is done in forensic labs when it comes to elucidate drug abuse is traced back solely to HIS work. A look at his publication list simply reveals that this an incorrect claim. That should not dimish the fact that the man is an esteemed expert, it simply means that this field of science is not a one-man show, and it has never been.

.

I hope this helps to clarify my statement.

[Edited 6/6/16 11:38am]

EmancipationLover said:

benni said:

The two may be related in this case, but again, the article stated that MUCH of what was known about drug related deaths, stemmed from the 25 years of research performed by Dr. Steven Karch, cardiac pathologist. You are looking at the pharmacology of opoid drugs, which would list the contraindications, the side effects, etc., and usually are more involved with the effects of drugs upon a living person. Yes, there has been a lot of research done, by many, on pharmacology, effects upon the body system, interactions with other drugs, etc. However, if you had read the article, it was discussing the difficulty with measuring drugs in the system after death. Looking at Google Scholar, which lists many scientific journals and books, as well as how many times those book or articles were cited, I found over 2550 articles/books/peer reviews just using Dr. Steven Karch in the search engine.

.

I have used SciFinder (which is a much more professional search tool than Google Scholar) to look through the publication list of Dr. Karch. I have to conclude that the statement "that MUCH of what was known about drug related deaths, stemmed from the 25 years of research performed by Dr. Steven Karch" seems to be rather adventurous. Dr. Karch has performed quite some work on cocaine and also ecstasy, for instance. He has (co-)authored slightly more than 160 publications (which is good, but certainly not spectacular in this field), with some of them being chapters of a book which he hasn't authored, but just edited (which is not unusual, it just should be taken into account). To sum it up: the article you have cited makes Dr. Karch appear to be a bigger cheese in the field than he actually is. He certainly has some scientific accomplishments, but he has not single-handedly established the forensics of drug abuse.

.

Measuring drugs in the blood sample of a dead person is technically not different than measuring the blood sample of a living individual - the LC-MS does not know who the sample comes from. It's the interpretation of the data which can be different, because the former sample has been taken hours after drug metabolism has stopped, while the latter is taken from an individual with active metabolism and active excretion of the drug or its metabolites. It's a totally different story though to ensure that a certain level of a drug is a safe forensic proof for it to be the cause of death. Naturally, this can vary significantly from drug to drug.

.

Again, please read what I have written: "fentanyl toxicity" and "fentanyl forensics" have zero contribution by Dr. Karch. But just to be on the safe side, I have just run "fentanyl" through SciFinder - ca. 30 000 references, 2 (!) of them associated with Dr. Karch. Guess what: two chapters of the book he has edited (not written, see above). The man has never published a single paper regarding fentanyl, he has worked on totally different drugs.

[Edited 6/6/16 11:37am]

I never made the claim that he worked with fentanyl, and neither did the article. The article was about drug related deaths in general, and the difficulty with determining a drug overdose death. You are nitpicking about my comment (and Eileen's) about our statements regarding the articles claim about "much of what is known about drug related deaths comes from the 25 years of research performed by Dr. Karch". That was a shocking claim

It does not detract from the rest of the articles claims regarding pathology and determing overdose as the cause of death. Included below:

Several scientific factors conspire to complicate the issue: First is the widely acknowledged question of tolerance. Patients who take pain medications over the long-term will necessarily build up some amount of tolerance to the drugs. That means that a dosage of a painkilling opioid such as methadone or fentanyl that would be therapeutically appropriate for a pain patient could be enough to kill a person who has never taken them before; in a methadone patient, an extremely high dose might not even be enough to address withdrawal symptoms.

In other words, Karch says, the "lethal dose" of these drugs is impossible to standardize, even for patients who are taking a single drug rather than a combination of many. A 2000 study by Karch compared methadone patients who had died from clear causes, such as car accidents, with those who had died of a suspected overdose. Karch found that there was no predictable difference in the postmortem blood levels of methadone between the two groups. In fact some of the patients who died of other causes had higher levels of methadone in their bodies than those thought to have overdosed. "You can die from a drug and you can die with a drug," says Karch. "When you have four orders of magnitude separating either end of the curve, many of these deaths may not have to do with drugs at all."

At least one forensic tool helps clarify the question in some cases, according to Karch. In 1999, Karch testified on behalf of the prosecution in a case against a British physician who was convicted of killing 15 patients by injecting them with heroin (a legal painkiller in the U.K.) and is suspected of having killed hundreds of others. By analyzing hair samples, which can record an individual's history of drug use, Karch was able to show that the patients were not prior drug users and were, therefore, almost certainly killed by the drugs the doctor administered. This technology, which can cost thousands of dollars per analysis, was not used in the Schneider case, during which the medical examiner testified that a person's drug history is "not something that I usually consider or go into" when drugs are detected in the body and no other cause of death is apparent.

A second complication in cause-of-death findings is what medical examiners call "postmortem redistribution," the shift in detectable drug levels that occurs after a person dies, according to Fred Apple, medical director of clinical laboratories for the Hennepin County Medical Center in Minnesota. Many drugs that may be contained in fatty tissue in a living body are released into bodily fluids after death, which confuses the analysis of substance samples taken postmortem.

In a study published in March in the American Journal of Clinical Pathology, Apple and colleagues measured fentanyl levels in bodies immediately after death and again several hours later at autopsy. The researchers found that some bodies had no detectable levels of the drug at the first measurement but showed significant levels at the second — and that these levels varied widely depending on which part of the body was sampled. Since it is not always clear when exactly a person died, or how long redistribution takes, the variance could make a therapeutic level of a drug appear toxic, or vice versa.

What is clear, however, is that juries across the country are in some cases hearing evidence based on shaky forensic science or from forensics professionals who lack the necessary expertise. According to a 2009 report by the National Research Council of the National Academy of Sciences: "Rigorous and mandatory certification programs for forensic scientists are currently lacking...as are strong standards and protocols for analyzing and reporting on evidence. And there is a dearth of peer-reviewed, published studies establishing the scientific bases and reliability of many forensic methods. Moreover, many forensic science labs are underfunded, understaffed, and have no effective oversight."

Given the state of the science, then, should it be used in court? Ed Cheng, a professor of law at Brooklyn Law School and expert on scientific testimony, says, yes, noting that more research is still needed. "If we were to require studies and statistical assessment on every assertion, almost nothing would be able to be used in court. My view on this is that the question here is not throwing the baby out with the bathwater," says Cheng. "It's clear that the forensic sciences do not have as much of an empirical basis as we would like them to have. The question becomes how do we motivate them sufficiently to come up with the empirical basis that we want?"

Some experts do agree with Cheng. "The evidence base is improving," says Apple, who is currently conducting a study of blood and tissue samples taken postmortem, in order to build up a usable database of drug information. "So when people have to make death determinations from smaller jurisdictions where they don't have [an expert on staff] like me, they can make them with some assurance."

But Karch is less sanguine about the reliability of such data and thinks that as long as the reliability of forensic evidence is still evolving, it has no place in court. "It's a giant miscarriage of justice," he says. He recalls the malpractice and murder convictions that were won many years ago against doctors who were thought to have killed patients by administering digoxin, a drug for arrhythmia and other heart problems. It turned out that the drug collected in the heart muscle in live patients and was released into the body after death, making safe doses of the drug look deceptively high — a result similar to those seen in current studies of fentanyl and methadone.

In the Schneider case, which entered jury deliberations on Wednesday, the defense team sought and failed to prevent the jury from hearing testimony that it believed did not have sufficient scientific foundations. But according to Cheng, it may be preferable to let the jury hear both sides of the scientific dispute and make up their own minds. "I myself have floated between the poles on this," he says. "I'm currently more on the 'Let the jury hear it' side. I'm not convinced that good science and bad science is always cut and dried."

[Edited 6/6/16 11:50am]

benni said:

EmancipationLover said:

.

I have used SciFinder (which is a much more professional search tool than Google Scholar) to look through the publication list of Dr. Karch. I have to conclude that the statement "that MUCH of what was known about drug related deaths, stemmed from the 25 years of research performed by Dr. Steven Karch" seems to be rather adventurous. Dr. Karch has performed quite some work on cocaine and also ecstasy, for instance. He has (co-)authored slightly more than 160 publications (which is good, but certainly not spectacular in this field), with some of them being chapters of a book which he hasn't authored, but just edited (which is not unusual, it just should be taken into account). To sum it up: the article you have cited makes Dr. Karch appear to be a bigger cheese in the field than he actually is. He certainly has some scientific accomplishments, but he has not single-handedly established the forensics of drug abuse.

.

Measuring drugs in the blood sample of a dead person is technically not different than measuring the blood sample of a living individual - the LC-MS does not know who the sample comes from. It's the interpretation of the data which can be different, because the former sample has been taken hours after drug metabolism has stopped, while the latter is taken from an individual with active metabolism and active excretion of the drug or its metabolites. It's a totally different story though to ensure that a certain level of a drug is a safe forensic proof for it to be the cause of death. Naturally, this can vary significantly from drug to drug.

.

Again, please read what I have written: "fentanyl toxicity" and "fentanyl forensics" have zero contribution by Dr. Karch. But just to be on the safe side, I have just run "fentanyl" through SciFinder - ca. 30 000 references, 2 (!) of them associated with Dr. Karch. Guess what: two chapters of the book he has edited (not written, see above). The man has never published a single paper regarding fentanyl, he has worked on totally different drugs.

[Edited 6/6/16 11:37am]

I never made the claim that he worked with fentanyl, and neither did the article. The article was about drug related deaths in general, and the difficulty with determining a drug overdose death. You are nitpicking about my comment (and Eileen's) about our statements regarding the articles claim about "much of what is known about drug related deaths comes from the 25 years of research performed by Dr. Karch". That was a shocking claim

.

You can copy-paste parts of this article 100 times, it does not take away the facts that

.

1) the claim derived from the article that the forensics of drug abuse is traced back to the scientific work of a single scientist (Karch) is utterly false. I have exemplified this by demonstrating the Karch has, for instance, never published any work regarding fentanyl, which is (for obvious reasons) the focus of this discussion;

.

2) the claim derived from 1) that this is not exact science is therefore utterly false either.

.

I just wanted to clarify this. However, if it helps you in some way to invent wild speculations regarding the validity of the published death certificate, then so be it.