UNUSUAL SUICIDES IN PHYSICIANS: TWO CASES INVOLVING FENTANYL AND PHENOBARBITAL.

Fentanyl is basic in pain treatment and anesthesiology. Phenobarbital is a GABA-modulator used as hypnotic, sedative, anesthetic and anticonvulsant. Both of them can produce physical dependence, abuse and overdose. Literature unusually reports self-poisoning by Fentanyl, and, rarely, in the last three decades by Phenobarbital, especially in suicide. Two cases of unusual suicides acted by physicians, one by Fentanyl and one by Phenobarbital, are presented. Case 1: A 64-year old retired anesthesiologist was found dead in his countryside house. Two bottles (100 mL each), one empty and the second one half filled with a clear liquid, were found near the body hanging from the chandelier, while a needle was stuck into his left ankle. Case 2: A 65-year old retired cardiologist was found dead at home. A needle was stuck into his left median cubital vein, connected with an empty syringe (20 mL). Eight empty boxes of Gardenale (Phenobarbital) (20 x100 mg tablets) and two empty boxes of 6 vials (1 mL) of Pantopon (a mixture of all natural alkaloids of opium), produced in 1962, were found near the body. In both cases autopsy findings showed no evidence of natural disease or trauma. Biological samples collected at autopsy and paraphernalia seized at death scene were tested by systematic toxicological analysis (STA) using GC-HS (FID), GC-MS and LC-MS/MS for alcohol, most common drugs and pharmaceuticals. Case 1: Fentanyl was revealed in the bottles and in all biological specimens. Its concentration was: blood 30.6 μg/L, urine 87.9 μg/L, bile 70.2 μg/L, liver 0.094 μg/g; brain: 0.064 μg/g. Norfentanyl was present only in the blood and liver suggesting a rapid death. Comparing these data with those reported by the literature, the death was listed as a suicide by Fentanyl. Case 2: Toxicological analyses performed on biological samples were positive for Phenobarbital, Morphine and Codeine. Phenobarbital was present in blood (527.5 μg/mL), urine (106.3 μg/mL) and liver (208.0 μg/g) at concentration above therapeutic levels. In addition Morphine was detected in blood (0.14 μg/mL), urine (2.2 μg/mL), bile (70.7 μg/mL) and liver (53.6 μg/g) associated with Codeine in blood (0.11 μg/mL), urine (1.2 μg/mL), bile (0.75 μg/mL) and liver (0.22 μg/g). The analysis of residues found in the syringe were positive for Phenobarbital, Morphine, Codeine, Papaverine, Noscapine and Hydrocodone. Based on the toxicological results the cause of death was listed as acute intoxication by Phenobarbital. Furthermore, positive results for opiates (Morphine and Codeine), in bile more than in blood, suggested a chronic consumption of opiates. A review of the literature on acute poisoning using Fentanyl and Phenobarbital was applied for the toxicological evaluation of these suicides, performed with an unusual manner.