Journal of Analytical Toxicology 2014;38:592 –598
doi:10.1093/jat/bku086
A Series of Forensic Toxicology and Drug Seizure Cases Involving Illicit Fentanyl
Alone and in Combination with Heroin, Cocaine or Heroin and Cocaine
Laureen J. Marinetti* and Brooke J. Ehlers
Montgomery County Coroner’s Office (MCCO)/Miami Valley Regional Crime Laboratory (MVRCL), Dayton, OH, USA
*Author to whom correspondence should be addressed. Email: LMarinetti@redwoodtoxicology.com
The Montgomery County Coroner’s Office Toxicology Section and the
Miami Valley Regional Crime Lab (MVRCL) Drug Chemistry Section
have been receiving case work in drug seizures, death cases and
human performance cases involving products marketed as heroin
or as illicit fentanyl. Upon analysis by the Drug Chemistry Section,
these products were found to contain various drug(s) including illicit
fentanyl only, illicit fentanyl and heroin, illicit fentanyl and cocaine
and illicit fentanyl, heroin and cocaine. Both the Chemistry and
Toxicology Sections began seeing these combinations starting in
late October 2013. The percentage of the combinations encountered
by the MVRCL as well as the physical appearance of the product, and
the results of presumptive screening tests will be discussed. The de-
mographics of the users and the results of toxicology and autopsy
findings on the decedents will also be discussed. According to re-
gional drug task force undercover agents, there is evidence that
some of the products are being sold as illicit fentanyl and not just
as a heroin product. Also, there is no evidence to support that the fen-
tanyl source is being diverted from pharmaceutical grade fentanyl.
The chemistry section currently has over 109 confirmed cases, and
the toxicology section currently has 81 confirmed drug deaths, 8 driv-
ing under the influence of drugs and 1 suicidal hanging. Both sections
are continuing to see these cases at the present time.
Introduction
This is not the first time that illicit fentanyl has been com-
bined with other drugs in the USA which resulted in numer-
ous fatalities. In Wayne County Michigan in 2005 and 2006,
the Medical Examiner’s Office documented 101 fentanyl- and
heroin-related fatalities with half of those cases having detec-
tible cocaine concentrations (1). During this same time frame,
Massachusetts saw 107 fentanyl deaths combined with opiates,
cocaine or both (2). From 2005 to 2007, Cook County Illinois
experienced a series of 342 illicit fentanyl deaths with the
greatest number of deaths peaking at 47 per month (3, 4).
The fentanyl in the Cook County cases was traced back to
a lab in Mexico and once that lab was shut down in 2007
the deaths ceased. In Philadelphia in 2006, the Medical
Examiner’s Office had a series of seven cases which contained
a combination of fentanyl, heroin and the animal tranquilizer
xylazine (5).
Outside of the USA, Sweden had eight fatalities when fentanyl
was mixed with a low concentration of amphetamine powders
with caffeine, phenazone and sugar as cutting agents (6).
It is not clear what the motivation is to create such combi-
nations with fentanyl but the resulting mixtures are extremely
dangerous with high mortality rates. Fentanyl is an extremely
potent synthetic opioid, significantly more potent than
morphine.
# The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com
Special Issue
Experimental
The Montgomery County Coroner’s Office (MCCO)/Miami
Valley Regional Crime Lab (MVRCL) Toxicology Section
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performs analyses in both human performance and postmortem
forensic toxicology. Cases are received from portions of the
southern half of the state of Ohio, which includes urban, subur-
ban and rural areas. The majority of the presented cases originat-
ed from urban and suburban areas. The toxicology analyses of
each case included: volatile analysis to include methanol, ethanol,
isopropanol and acetone; an enzyme-linked immunosorbent
assay (ELISA) screen comprised of amphetamine, methamphet-
amine, barbiturates, benzodiazepines, cannabinoids, carisopro-
dol, cocaine metabolites and opiates and a basic drug screen by
gas chromatography – mass spectrometry (GC – MS) on blood,
urine or liver. Cases that presented with a history indicative of
illicit drug use were also screened for fentanyl by ELISA. Low
concentrations of fentanyl (1 –2 ng/mL) were not always detect-
ed in the GC –MS drug screen due to the limit of detection of this
method for fentanyl and norfentanyl.
Fentanyl and norfentanyl were confirmed and quantitated by a
solid-phase extraction (SPE) method with the eluent derivatized
with acetic anhydride and pyridine. The analysis was by GC–MS
with a limit of quantitation of 1 ng/mL. Opiates were confirmed
and quantitated using an oxime derivatization, SPE and GC –MS
with a limit of quantitation of 20 ng/mL. Cocaine and metabolites
were confirmed using SPE with BSTFA derivatization and GC–MS
with a limit of quantitation of 50 ng/mL. Benzodiazepines were
confirmed by liquid chromatography–mass spectrometry and ex-
tracted by SPE with a quantitation limit of 10 ng/mL. Gabapentin
and lamotrigine were extracted with methanol and confirmed by
liquid chromatography –mass spectrometry/mass spectrometry
(LC – MS-MS) with a limit of quantitation of 1 mg/mL. Other
basic drugs were extracted with SPE and confirmed by gas chro-
matography – nitrogen – phosphorus detection with a limit of
quantitation of 50 ng/mL. Cyclobenzaprine and antidepressants
were extracted by SPE and confirmed by LC–MS-MS with a limit
of quantitation of 20 ng/mL. Volatiles were analyzed by headspace
gas chromatography with both flame ionization and mass spec-
trometry detection. All SPE columns were supplied by United
Chemical Technologies.
The MCCO cases were chosen based on history or toxicology
findings of illicit drug use with no evidence or history of pre-
scription use of any pharmaceutical grade fentanyl product.
The illicit fentanyl cases comprised: 57 Caucasian males and 24
Caucasian females, 7 African-American males, 1 African-
American female and 1 bi-racial male, for a total number of 90
cases. The number of decedents and age ranges were
Caucasian males 19 – 62 years (63.3%), 24 Caucasian females
25 – 62 years (26.6%), 7 African-American males aged 20 – 66
years (7.7%), 1 African-American female aged 28 (1.1%) and 1
biracial male aged 32 (1.1%). Fourteen different counties in por-
tions of southern Ohio reported cases. Montgomery County had
the greatest number of cases at 51 (56.6%). The postmortem data
will be divided by cases containing fentanyl without the pres-
ence of acute heroin or cocaine, fentanyl and acute heroin, fen-
tanyl and acute cocaine and fentanyl, acute heroin and acute
cocaine and finally antemortem cases containing fentanyl and
postmortem cases where the cause of death was not due to
drugs. Those cases which contained evidence of historic cocaine
or heroin use will be described with the fentanyl cases. Historic
heroin and cocaine cases are defined as those cases which
contained blood morphine of ,20 and no detectable
6-monoacetylmorphine (6-MAM) or cocaine.
Analysis by the MVRCL of seized products consisted of a pre-
sumptive color screen for the presence of heroin called the
Marquis test. GC – MS was used to confirm the presence of the
fentanyl and/or heroin and/or cocaine.
Agilent Technologies was the manufacturer of all of the con-
firmation and quantitation instrumentation used. To date, the
Chemistry Section of the MVRCL received 110 products con-
taining illicit fentanyl in 109 cases with more suspected cases
awaiting analysis. Seizures were from seven different counties
in portions of southern Ohio. Montgomery County had the
greatest number of seizures at 85 or 78%. The products received
were 27 as loose powders, 53 as powder in clear gel caps, 17 in
syringes, 9 on spoons and 4 as residues. The products consisted
of 42 fentanyl only (38%), 57 fentanyl and heroin (52%), 2 fen-
tanyl and cocaine (1.8%) and 9 fentanyl, heroin and cocaine
(8%). One submission had one each of fentanyl and fentanyl
and heroin.
Results
The toxicology and autopsy results from the 90 cases will be di-
vided by those cases containing fentanyl without acute heroin or
cocaine (Table I), antemortem cases and cases containing fenta-
nyl that were not ruled drug deaths (Table II), fentanyl and acute
heroin (Table III), fentanyl and acute cocaine (Table IV) and fen-
tanyl, acute heroin and acute cocaine (Table V). Those cases that
contained evidence of historic cocaine or heroin use are listed in
Table I.
The cases in Table I are comprised of 40 males ranging in age
from 18 to 66 years with an average age of 36 and a median age of
35 and 13 females ranging in age from 25 to 57 years with an av-
erage age of 38 and median age of 38. Three of the females did
not have age information available. Pulmonary edema was the
most common autopsy finding, and there was no relationship be-
tween fentanyl concentration and other autopsy findings such as
heart disease or chronic obstructive pulmonary disease (COPD).
Cases in Table II include four human performance cases and
five postmortem cases. The cases were comprised of five males
ranging in age from 20 to 32 years with a median age of 25 and
an average age of 24 and four females ranging in age from 24 to
37 years with a median and average age of 29 years. Some of these
cases had fentanyl in the presence of acute heroin or cocaine, but
the cause of death for the five postmortem cases was something
other than a drug overdose. The five cases involving human per-
formance had fentanyl concentrations ranging between 4.4 and
13 ng/mL, with a median of 5.7 and an average of 7.6 for all blood
sources. The data from this table clearly demonstrate that toxic
and fatal fentanyl concentrations overlap.
Toxicology and autopsy results from 12 cases are displayed in
Table III in which fentanyl and acute heroin were the most sig-
nificant findings. The ages ranged from 30 to 62 years and includ-
ed three females with an average age of 45 and a median age of 39
years and nine males with an average and median age of 42 years.
Morphine concentrations ranged from 20 to 623 ng/mL in blood
specimens collected from the periphery with an average of 161
and a median of 105. In the single cavity blood specimen, the
morphine concentration was 166 ng/mL. The single blood speci-
men collected from the heart contained 62 ng/mL of morphine.
6-MAM concentrations ranged from ,5 to 23 ng/mL in blood
specimens collected from a peripheral site. In the single cavity
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blood specimen, the 6-MAM concentration was 44 and 12 ng/
mL of 6-MAM was measured in the single blood specimen col-
lected from the heart. Pulmonary edema was the most common
autopsy finding, and there was no relationship between fentanyl
concentration and morphine concentration and other autopsy
findings such as heart disease or COPD. Case numbers 8 and 9
in Table III are typical for individuals that had likely lost opiate
tolerance after being incarcerated.
Toxicology and autopsy results from seven cases are displayed
in Table IV in which fentanyl and acute cocaine were the most
significant findings. The cases were comprised of two females
aged 35 and 42 years and five males aged 30 – 51 years with an
average age of 37 and a median age of 34. Cocaine concentrations
ranged from ,50 to .1,000 ng/mL in blood specimens collect-
ed from a peripheral site.
Toxicology and autopsy results from six cases of male dece-
dents are displayed in Table V in which fentanyl, acute heroin
and acute cocaine were the most significant findings. The ages
ranged from 21 to 59 years with an average age of 42 and a me-
dian age of 46. Morphine concentrations ranged from 25 to
387 ng/mL in four blood specimens collected from a peripheral
site. Morphine concentrations of 25 and 28 ng/mL were present
in two blood specimens collected from the heart. Cocaine con-
centrations were less 50 – 192 ng/mL in four blood specimens
collected from a peripheral site. Cocaine concentrations of 50
and 53 ng/mL were present in blood specimens collected from
the heart. 6-MAM concentrations ranged from ,5 to 27 ng/mL
in blood specimens collected from a peripheral site. Again
there was no relationship between drug concentrations and au-
topsy findings with the most common autopsy finding being pul-
monary edema.
Table VI compares the fentanyl concentrations from peripher-
al blood specimens from Tables I –V. The median fentanyl con-
centrations from Tables I – IV were not significantly different.
Table V did have a significantly different median fentanyl concen-
tration but that could be from the small sample size. Tables I –IV
had the same average fentanyl concentrations, but Table V had a
significantly higher average fentanyl concentration.
Figure 1 shows the expected color of a presumptive color test
called the Marquis test that is positive for heroin, a bright purple
color. Figure 2 shows the color of the Marquis test when fentanyl
is present without heroin, an orange color. At first, some police
agencies that were expecting heroin would see this orange test
result and conclude that no controlled substances were present
and would not submit anything to the lab for testing. This pre-
sumptive color test was able to distinguish fentanyl from heroin
Ohio Cases Containing Drug Combinations Marketed as Heroin 593
Table I
Cases with Fentanyl without Acute Heroin or Acute Cocaine

Race/sex Age Date of death Specimen Fentanyl Tox results in ng/mL or ng/g unless History Autopsy results
otherwise noted
1—c/m 34 28 October 2013 FB 2 None Lighter and foil packet with fentanyl residue confirmed by MVRCL Pulmonary edema and
chemistry section cardiomegaly
2—c/f 25 4 November 2013 FB 7 Morphine , 20 Gel caps, recent drug rehabilitation, needle puncture Pulmonary edema and
congestion
3—c/m 35 5 November 2013 FB 4 None Former heroin addict, 2 years in recovery Pulmonary edema
4—c/f 27 5 November 2013 FB 4 Morphine , 20, DPH , 50, History of heroin and vicodin Pulmonary edema
alprazolam 10
5—c/m 40 7 November 2013 FB 24 Norfentanyl 8, morphine , 20, IV drug abuse, heroin and prescription drug abuse Pulmonary edema, ASCVD and
alprazolam 20 cardiomegaly
6—c/m 21 10 November 2013 FB 27 Morphine , 20, methadone 100, History of gabapentin, fluoxetine and sertraline use, also said he Pulmonary edema
DPH , 50, GABA , 2mcg/mL, took hydrocodone
historic heroin

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7—c/m 38 10 November 2013 HB 29 Morphine 24, EtOH 0.101% IV heroin abuse, syringe and three gel caps at scene Pulmonary edema
8—c/m 32 11 November 2013 FB ,1 EtOH 0.244%, morphine , 20 historic History of drug use, historic heroin Pulmonary congestion
heroin
9—c/f 31 11 November 2013 FB 16 Liver fentanyl 170, morphine , 20, Witnessed ‘heroin’ injection Pulmonary congestion
GABA 6.3 mg/mL, historic cocaine
10—c/m 35 11 November 2013 FB 8 Morphine , 20, historic heroin Found in men’s restroom at McDonalds with syringe at scene Pulmonary congestion,
cardiomegaly and obesity
11—c/f 38 12 November 2013 FB 5 Hydrocodone , 20, alprazolam 51 Witness use of heroin and Xanax Pulmonary edema and obesity
12—c/m 29 16 November 2013 FB 5 Tramadol 170, cyclobenzaprine , 40, Heroin and oxycodone abuse Pulmonary congestion,
historic heroin cardiomegaly and obesity
13—c/m 23 16 November 2013 FB ,1 None Street drug abuse, at a party snoring loudly then unresponsive Pulmonary congestion,
cardiomegaly, acute
bronchopneumonia
14—c/f 54 20 November 2013 FB 1 Hydrocodone , 40, clonazepam 30, IV heroin abuse admitted to hospital Pulmonary edema
7AMC 76
15—c/m 32 21 November 2013 HB 3 EtOH 0.09%, methamphetamine 750 Drug abuse including heroin Pulmonary edema,
cardiomegaly and obesity
16—c/f 50 21 November 2013 FB 13 Alprazolam 62, DPH 60, carbon Unresponsive in car in parking lot Heart disease, kidney disease,
monoxide-not detected seizure disorder
17—c/m 51 29 November 2013 FB 12 Hydrocodone 63, morphine , 20, Heroin abuse with previous overdoses Pulmonary edema and ASCVD
alprazolam , 10, historic cocaine
18—c/m 34 3 December 2013 FB 15 Alprazolam 19, 7AMC 44, Recent release from rehabilitation, syringe cap and spoon at Pulmonary edema and
morphine , 20 historic heroin scene, needle puncture on body cardiomegaly
19—a/m 65 3 December 2013 FB 28 EtOH 0.011, morphine , 20 Heroin abuse with syringe, spoon and band around arm Pulmonary edema,
cardiomegaly and ASCVD
20—c/m 28 10 December 2013 FB 8 None Heroin abuse, syringe at scene, gel cap, injection site on body Pulmonary edema
21—c/f 55 23 December 2013 HB 15 Citalopram 670 Heroin and cocaine abuse, syringe found in pants pocket Pulmonary edema and COPD
22—c/f UNK Unknown VIT Positive No opiates, cocaine not tested Obese, found down with syringe and spoon under her, syringe No autopsy done
analyzed by MVRCL contained fentanyl
23—c/m 47 16 January 2014 FB 10 Morphine , 20, BE , 100, DPH , 50 Heroin and crack cocaine use at scene; two empty gel caps, razor Pulmonary edema and
blade, burned bottom of a soda can containing residue cardiomegaly
24—br/m 32 21 January 2014 FB 5 Norfentanyl , 1, BE 149, historic Reported decedent was having a seizure EMS and police Pulmonary edema
heroin responded, decedent unresponsive
25—c/m 19 21 January 2014 FB 3.1 Morphine , 20, EtOH 0.161% Drinking Tequila all day and had a history of abusing pain meds. No Pulmonary edema
prescription for fentanyl
26—c/m 21 26 January 2014 FB 9.2 Norfentanyl , 1 History of heroin abuse and obesity Pulmonary edema, HTN heart
disease, morbid obesity
27—a/m 66 15 January 2014 CB 11 Liver fentanyl 160, morphine 24, EtOH Decomposed, uncapped syringe at scene, history of heroin and Decomposition
0.047%, sertraline 294, NORSERT 632 cocaine abuse
28—c/f 39 1 February 2014 FB 18 Norfentanyl 2.2, alprazolam 21, 7AMC History of heroin and prescription drug abuse, several gel caps and Pulmonary edema and
27 a syringe at the scene cardiomegaly
29—c/m 41 3 February 2014 FB 5.1 Morphine 22 History of heroin abuse, syringes at scene, rubber type band Pulmonary edema
around arm
30—a/f 28 14 January 2014 FB 6.7 Morphine , 20, alprazolam 18, historic Decedent took four Xanax then was overheard snoring loudly then Generalized visceral
heroin 6-MAM in urine found unresponsive in bed congestion
31—c/m 36 26 January 2014 FB 14 Norfentanyl 1.6 Found unresponsive, decedent had used the belt from his pants as Pulmonary edema,
a tourniquet while using heroin hypertensive heart disease
32—c/f 45 1 February 2014 FB 7.3 Norfentanyl 19, lorazepam 12, vit History heroin abuse, pain medication abuse, diabetes, recent Pulmonary edema
glucose 607 mg/dL, acetone hospitalization for infection arm related to IV drug abuse, several
800 mg/mL clear gel caps found in the decedent’s purse, 100 mg/h. fentanyl
patch on body
33—c/m 29 5 February 2014 AM 2.7 Hospital serum , 1 EtOH 0.093% Unresponsive in his bedroom from a heroin overdose and removed Consistent with remote over
(hospital specimens from admit day) to hospital dose
34—c/m 34 8 February 2014 FB 10 Mirtazapine , 50 Unresponsive on the floor, heroin history, recent release from Pulmonary congestion and an
prison, nine gel caps and belt near body enlarged spleen
35—c/m 27 11 February 2014 FB 3.4 7AMC 112, methamphetamine 97 Syringe, gel cap and spoon were found at the scene. Recent Pulmonary edema
release from prison served time for drug abuse and possession
36—c/f UNK 23 February 2014 HB 6.5 Morphine , 20 History of heroin abuse found with syringe and spoon next to body No autopsy performed
37—c/m 24 21 February 2014 FB 5.1 BE 246 History of heroin abuse, found nude in a fetal position on the Pulmonary congestion and
bathroom floor edema, cardiomegaly
38—c/m 45 21 February 2014 FB 8.8 Therapeutic doxylamine History of heroin abuse found with syringe and spoon next to body Pulmonary congestion and
edema, cardiomegaly
(continued)

594 Marinetti and Ehlers

Table I Continued

Race/sex Age Date of death Specimen Fentanyl Tox results in ng/mL or ng/g unless History Autopsy results
otherwise noted
39—c/m 26 23 February 2014 FB 3.8 EtOH 0.181% Drinking beer and tequila, smoking THC, fell asleep did not wake Pulmonary congestion and
up, abuses pain meds and Xanax edema, right ventricular
dilation
40—c/m 42 20 February 2014 AM 6.7 EtOH 0.166% Found unresponsive at home 6 days before death Anoxic brain injury due to drug
abuse, HTN, cardiomegaly
41—c/m 25 20 February 2014 FB 4.7 Hydrocodone 81 History of heroin overdose, arrived in ER in cardiac arrest, found Cardiomegaly, clinical history
down at home given Narcan by medics failed to respond of asthma
42—c/m 36 4 March 2014 FB 7.3 Urine positive for morphine and Found unresponsive on bathroom floor, syringe and two gel caps Pulmonary edema
6-MAM at scene, recent release from jail
43—c/f 57 6 March 2014 FB 23 Norfentanyl 12, citalopram 700, Found unresponsive, history of narcotic and EtOH abuse Autopsy consistent with
trazodone 153, gabapentin 10 mg/mL overdose
44—c/f UNK 17 March 2014 HB 4.2 Morphine 35, hydromorphone , 5 Collapsed at boyfriend’s house, needle recovered at scene No autopsy performed
45—c/m 36 8 March 2014 FB 21 Norfentanyl , 1, methadone , 50 History of past heroin abuse, found down with drug paraphernalia Pulmonary congestion and

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for smoking and empty gel cap cardiomegaly
46—c/m 41 7 March 2014 FB 8.9 Diphenhydramine 143, Down in bathroom, drug abuse, two empty hydrocodone bottles Pulmonary congestion and
EtOH , 0.010% recently filled the in trash borderline cardiomegaly
47—c/m 44 14 March 2014 FB 23 Norfentanyl 5.2, Urine positive for Found unresponsive with several cut up straws with residue, and Pulmonary congestion and
morphine and 6-MAM an empty gel cap edema, needle puncture
48—c/m 33 14 March 2014 FB 4.2 None Found unresponsive with spoon and several syringes, history of Pulmonary congestion and
heroin abuse and recent release from rehab edema, needle puncture
49—c/m 18 21 March 2014 FB 21 Norfentanyl 1.6 Found unresponsive with an uncapped syringe and a tourniquet on Pulmonary edema
his arm
50—c/m 61 5 March 2014 FB 23 Norfentanyl 1.2, morphine , 20 Found unresponsive history of heroin and pain meds abuse, empty Pulmonary edema,
Rx for oxycodone cardiomegaly, ASCVD
51—c/f 28 10 March 2014 FB 22 Norfentanyl , 1, morphine , 20, Found unresponsive, history of IV heroin abuse, three syringes, Pulmonary edema
6-MAM positive in vitreous four gel caps and a spoon with cotton swab filter at the scene
52—c/m 51 11 March 2014 FB 6.2 EtOH 0.087%, diazepam 192, History of IV heroin abuse used syringe located near decedent Focal ASCVD, lung
nordiazepam 281 hyperinflation with
emphysema
53—c/f 25 11 March 2014 FB 39 Norfentanyl , 1, buprenorphine 1.2 Found unresponsive with white powder on person and in her nose Pulmonary congestion and
and NORB 4.8, alprazolam 199 edema
54—c/m 62 14 March 2014 FB 9.3 Alprazolam 17 Found unresponsive, history of heroin abuse, gel caps and Pulmonary edema
syringes at the scene
55—c/m 39 15 March 2014 FB 6.8 Norfentanyl , 1, BE 729, morphine 71, Found unresponsive, was incarcerated for heroin abuse last year Pulmonary edema, ASCVD
alprazolam 27
56—c/m 46 16 March 2014 FB 48 Morphine , 20 History of heroin and cocaine abuse, syringe with needle on his leg Pulmonary edema

c, Caucasian; m, male; f, female; a, African American; br, bi-racial; FB, femoral blood; HB, heart blood; CB, cavity blood; AM, antemortem blood; VIT, vitreous fluid; DPH, diphenhydramine; GABA, gabapentin;
EtOH, ethanol; 7AMC, 7-aminoclonazepam; BE, benzoylecgonine; NORSERT, norsertraline; EMS, emergency medical services; IV, intravenous; HTN, hypertension; COPD, chronic obstructive pulmonary
disease; ASCVD, atherosclerotic cardiovascular disease obstructive pulmonary disease; 6-MAM, 6-monoacetylmorphine; CO, carbon monoxide; Rx, prescription; UNK, unknown; NORB, norbuprenorphine.

Table II
Cases with Fentanyl without Acute Heroin or Acute Cocaine—Non-Drug Deaths

Race/ Age Date of incident Specimen Fentanyl Tox results in ng/mL or ng/g unless otherwise History Autopsy results
sex noted
1—c/f 24 9 November 2013 AM 5.3 Norfentanyl 1, morphine , 20 Operating under the influence Antemortem, human
performance
2—c/m 25 31 January 2014 AM 13 Norfentanyl 8.6 Operating under the influence, motor vehicle accident Blunt force trauma accident
3—c/m 32 14 March 2014 AM 5.7 Norfentanyl , 1 Passed out behind wheel of vehicle parked in a field, Antemortem, human
incoherent when roused, two empty gel caps found performance
4—a/m 21 13 March 2014 HB 52 Liver fentanyl . 200, morphine 23, promethazine Car burned on the side of the road, spoon and syringes in Inhalation of combustion
57, CO 49% the vehicle products, thermal burns
5—a/m 20 13 March 2014 HB 25 Liver fentanyl . 200, CO 68% Car burned on the side of the road, spoon and syringes in Inhalation of combustion
the vehicle products, thermal burns
6—c/f 29 31 January 2014 FB 7.5 Norfentanyl 8, cocaine 75, COCA , 50, BE 557, History of depression Suicidal hanging
DIAZ 154, NORD 132, EtOH 0.151%
7—c/f 29 14 February 2014 HB 37 Norfentanyl 9.3, morphine 126, 6-MAM 21, 7AMC At fault driver went left of center and was struck head on Multiple blunt force trauma
94, CB methadone . 2000
8—c/m 25 3 April 2014 AM 10 Norfentanyl 3, methadone 228, citalopram 90 Operating under the influence Antemortem, human
performance
9—c/f 37 5 April 2014 AM 4.4 THC 2.4, THC-COOH 7.4, morphine , 20, Witnessed weaving in and out of lane prior to crashing Antemortem, human
alprazolam 10, DPH positive head on into a something, admitted drug abuse history performance

c, Caucasian; m, male; f, female; a, African American; FB, femoral blood; AM, antemortem blood; HB, heart blood; DPH, diphenhydramine; CO, carbon monoxide; BE, benzoylecgonine; COCA, coca ethylene;
EtOH, ethanol; DIAZ, diazepam; NORD, nordiazepam; 6-MAM, 6-monoacetylmorphine; 7AMC, 7-aminoclonazepam; CB, cavity blood.

when one product dominated the mixture. However, mixed orange if the fentanyl was the dominant ingredient. However, if
color results were obtained when the fentanyl and heroin were the cocaine was the dominant ingredient, there would be no
present as a more equal mixture. If the mixture contained fenta- color reaction in the Marquis test. Figure 3 is a typical seizure
nyl and cocaine, the Marquis test would show orange to light of fentanyl powder, Figure 4 is a typical seizure of heroin powder

Ohio Cases Containing Drug Combinations Marketed as Heroin 595

Table III
Cases with Fentanyl and Acute Heroin without Acute Cocaine

Race/sex Age Date of death Specimen Fentanyl 6-MAM Morphine Tox results in ng/mL or ng/g History Autopsy results
unless otherwise noted
1—c/m 42 2 November 2013 FB 3 7 132 None CHF, COPD, obese, diabetic, found dead no heroin Pulmonary edema,
history cardiomegaly and obesity
2—c/f 62 9 November 2013 FB 12 23 623 Clonazepam 14, 7AMC 271, 25 years history of heroin abuse Negative
methadone 110
3—c/m 46 7 November 2013 CB 15 44 166 Liver fentanyl of 52, alprazolam
IV drug abuse with three overdoses this year, syringe Pulmonary edema
positive at scene
4—c/m 50 10 November 2013 HB 46 12 62 Liver fentanyl of 84 IV heroin abuse, methadone and street drugs Pulmonary edema,
cardiomegaly and obesity
5—c/m 35 14 November 2013 FB 19 Pos 75 Vitreous 6-MAM 14 IV heroin abuse, syringe at scene Pulmonary edema
6—c/m 58 3 December 2013 FB 9 7 224 ,10 clonazepam, 26 Missing clonazepam, history of colon cancer, pain, Pulmonary edema and
nordiazepam anxiety and depression cardiomegaly
7—c/m 30 5 December 2013 FB 5 Pos 20 6-MAM in urine, 190 7AMC Gel cap and syringe were located near the body Pulmonary edema

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8—c/m 44 9 December 2013 FB 1 ,5 65 None Released from prison 9 days ago, IV heroin abuse Pulmonary edema, HTN
cardiomegaly, hepatic fibrosis
9—c/m 37 2 January 2014 FB 9 ,5 78 None Found down with syringe and track marks in arm, Pulmonary edema and
heroin history, rehab for 10 months, 2 months ago cardiomegaly
10—c/f 39 16 February 2014 FB 3.5 ,5 179 Norfentanyl , 1, 7AMC 140, History of heroin, cocaine, clonazepam abuse, two Pulmonary edema and
clonazepam , 10 syringes, five gel caps and a bottle of clonazepam congestion
were found
11—c/m 41 24 February 2014 FB 2.4 ND 39 BE 282, methamphetamine 125, Found unresponsive on bathroom floor, history of drug Severe ASCVD, cardiomegaly
vitreous 6-MAM pos abuse, scene cleaned prior to police arrival
12—c/f 36 14 March 2014 FB 12 ,5 177 Alprazolam 40 Found unresponsive in a minivan, history of heroin Pulmonary edema
abuse, evidence of drug abuse at the scene

BE, benzoylecgonine; IV, intravenous; HTN, hypertension; rehab, rehabilitation; pos, positive; c, Caucasian; m, male; f, female; FB, femoral blood; CB, cavity blood; HB, heart blood; 7AMC, 7-aminoclonazepam;
6-MAM, 6-monoacetylmorphine; CHF, chronic heart failure; COPD, chronic obstructive pulmonary disease; ASCVD, atherosclerotic cardiovascular disease.

Table IV
Cases with Fentanyl and Acute Cocaine without Acute Heroin

Race/ Age Date of death Specimen Fentanyl Cocaine Tox results in ng/mL or ng/g unless otherwise History Autopsy results
sex noted
1—c/f 42 18 November FB 14 142 Dextromethorphan 60, trazodone 420, Cocaine abuse, recent release from jail Pulmonary edema
2013 lamotrigine 2.6 mcg/mL
2—c/m 30 12 February FB 3.3 139 7-AMC 58, BE . 1,000 History of drug abuse, an improvised pipe was located ASCVD, hepatic fibrosis,
2014 underneath the right hand and a lighter was being held occluded arteries
in the right hand
3—c/m 39 12 February FB 5.4 ,50 Norfentanyl , 1, BE 950, Recent release from prison, syringe and empty Pulmonary edema, cardiomegaly
2014 dextromethorphan , 50 baggies at scene
4—a/m 51 22 February FB 6.3 ,50 BE 457, mirtazapine , 50 Heroin history but ‘clean’ for 1.5 years, history of doing
Borderline cardiomegaly with
2014 ‘blow’ right ventricular dilatation, heart
390 g
5—a/m 33 2 March 2014 FB 3.9 ,50 Coca ethylene , 50, BE 996, EtOH 0.063% Witnesses high then sleep then unresponsive, history Pulmonary edema, cardiomegaly
of drug abuse
6—c/m 34 7 March 2014 FB 34 85 Norfentanyl 1.6, coca ethylene , 50, BE 524, History of PTSD and heroin abuse found down with Pulmonary congestion and
methadone 654, citalopram 161, EtOH 0.037% used syringe edema and cardiomegaly
7—c/f 35 13 March FB 13 .1,000 Norfentanyl 2, BE . 1,000, cyclobenzaprine 130 Found unresponsive, several gel caps some with white ASCVD, abrasions on arms and
2014 rock-like substance, needle tracks on arms, heroin hand
abuse

c, Caucasian; a, African American; m, male; f, female; FB, femoral blood; BE, benzoylecgonine; EtOH, ethanol; 7-AMC, 7-aminoclonazepam; ASCVD, atherosclerotic coronary vascular disease; PTSD,
posttraumatic stress disorder.

and Figure 5 shows five clear gel caps containing heroin powder.
As can be seen in these pictures, the pure fentanyl or heroin is
not distinguishable by observation of the powder alone. The
same is true for the cocaine and fentanyl mixture. GC –MS was
used to confirm the presence of the fentanyl and/or heroin
and/or cocaine. The results of these tests showed that fentanyl
was present in the mixtures at various concentrations based on
the intensity of the peaks produced in the GC –MS data. The con-
centrations of the fentanyl or other components were not mea-
sured; however, representative aliquots of the specimens were
analyzed. There was no relationship between the form of the sub-
mission and the content of the submission. One submission had
one each of fentanyl and fentanyl and heroin. When the powders
were received in gel caps, the gel caps were always clear no mat-
ter what drugs they contained.
Comparison of the data collected by the MCCO, and the MVRCL
shows that both the products seized and the deaths reported were
predominately from Montgomery County. However, the majority
of the products seized by the MVRCL contained a mixture of fen-
tanyl and heroin but the majority of the death cases reported by
the MCCO were from the acute use of products containing illicit
fentanyl. The second most seized product from the MVRCL data
was the illicit fentanyl, and the second most prevalent product
in the MCCO death cases was those containing illicit fentanyl

596 Marinetti and Ehlers

Table V
Cases with Fentanyl, Acute Heroin and Acute Cocaine

Race/ Age Date of death Specimen Fentanyl 6-MAM Morphine Cocaine Other Tox results in ng/mL or ng/g History Autopsy findings
sex unless otherwise noted
1—c/m 51 15 November HB 33 Pos 28 53 Therapeutic citalopram IV heroin history and was just released from jail Pulmonary edema and
2013 urine hepatitis C
2—a/m 57 19 January FB 60 8.5 210 ,50 Norfentanyl 15, DPH , 50, Found unresponsive, history of heroin use, Pulmonary edema and
2014 syringe, tourniquet, loaded handgun at the scene cardiomegaly
3—c/m 42 6 February FB 3.9 ,5 66 ,50 BE 196, EtOH 0.021% Unresponsive after using heroin, also uses Pulmonary edema,
2014 cocaine and marijuana cardiomegaly, hepatic fibrosis
4—c/m 24 2 March 2014 FB 13 27 387 192 Coca ethylene 161, BE . 1,000, History alcohol and drug abuse, acting Pulmonary edema
EtOH 0.099% intoxicated fell asleep, snoring, then
unresponsive
5—c/m 21 27 March HB 16 Pos vit 25 50 Norfentanyl 4.3, DPH positive Found unresponsive, heroin history and recent Pulmonary edema
2014 release from rehabilitation
6—c/m 59 3 April 2014 FB 8.8 ,5 25 ,50 BE 543, EtOH 0.055%, coca Found unresponsive history or drug abuse, crack Pulmonary congestion

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ethylene , 50 pipe found

c, Caucasian; a, African American; m, male; FB, femoral blood; HB, heart blood; vit, vitreous fluid; DPH, diphenhydramine; BE, benzoylecgonine; EtOH, ethanol; IV, intravenous; pos, positive finding.

Table VI
Comparison of Fentanyl Concentrations in Nanogram per Milliliter for Peripheral Blood Specimens
Collected from Males and Females in Tables I–V

Table I Table II Table III Table IV Table V

Fentanyl Fentanyl Fentanyl Fentanyl with Fentanyl with
drug death non-drug death with heroin cocaine heroin and
cocaine
Range 1 –48 4.4 –13 1 –19 3.3 –34 3.9 –60
Average 11 7.6 7.5 11 21
Median 7.3 6.6 7 6.3 10
N 51 7 10 7 4

Figure 2. Fentanyl with the Marquis reagent.

products as compared with the fentanyl and heroin products are

consistent with the increased potency of the fentanyl over the
morphine produced by heroin use.

Discussion and conclusion

Figure 1. Heroin with the Marquis reagent.
and heroin. Apparently, the mixing of the fentanyl with the heroin
results in a product that contains less fentanyl and is therefore less
potent. The increased death results with use of the fentanyl only
Both postmortem and human performance forensic toxicology
laboratories should be aware of the increased use of illicit fenta-
nyl in place of and in addition to heroin and cocaine products.
Illicit fentanyl and all combinations discussed are still being con-
firmed in products submitted to the MVRCL, and death cases are
still being confirmed from the use of these products by the
MCCO. It is evident that heroin users are the most likely victims.
Many of the decedents had past heroin use history either by in-
jecting or by snorting the drug. Southern Ohio has a serious her-
oin problem. MCCO statistics on drug deaths for 2013 showed
that 58% of all drug deaths were from heroin. In October 2013,

Ohio Cases Containing Drug Combinations Marketed as Heroin 597

Figure 3. Illicit fentanyl with (A) and without (B) ruler.
Figure 4. Heroin.
when the illicit fentanyl and combinations began showing up,
they outnumbered the heroin only deaths.
There is no evidence in these cases that any of the victims
intended to die from their drug use. There is no pattern of
when or where a certain illicit fentanyl product or combination
will show up. When a user consumes their usual amount of drug
and it is contaminated with or consisting of all illicit fentanyl, the
outcome is most likely dire.
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(2013) Fentanyl-associated fatalities among illicit drug users in Wayne
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Toxicology, 9, 106–115.
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Figure 5. Gel caps containing heroin.
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