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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.
[Edited 6/5/16 22:53pm] | |
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Here is an interesting article:
"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." | |
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benni said:
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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. 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
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. You are completely wrong. It does not come from one person, and it is a very exact science. | |
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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."
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. 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. | |
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. My first reply was to benni, not to you. | |
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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] | |
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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.
"We went where our music was appreciated, and that was everywhere but the USA, we knew we had fans, but there is only so much of the world you can play at once" Magne F | |
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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. "We went where our music was appreciated, and that was everywhere but the USA, we knew we had fans, but there is only so much of the world you can play at once" Magne F | |
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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." | |
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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. admission is easy, just say U believe, then come 2 this place in your heart. | |
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. 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] | |
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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. | |
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. 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] | |
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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] | |
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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] | |
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. 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. | |
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