{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,18]],"date-time":"2026-10-18T11:03:41Z","timestamp":1792321421365,"version":"4.4.0"},"reference-count":12,"publisher":"SAGE Publications","issue":"3","license":[{"start":{"date-parts":[[2018,8,31]],"date-time":"2018-08-31T00:00:00Z","timestamp":1535673600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Academic Forensic Pathology"],"published-print":{"date-parts":[[2018,9]]},"abstract":"<jats:p>Over a three-month period in early 2017, the Hennepin County Medical Examiner\u2019s Office investigated nine apparent opioid toxicity deaths that occurred in three separate urban, suburban, and rural counties in our jurisdiction. All decedents were known substance abusers and had reportedly recently used heroin; most were found with drug paraphernalia. Complete autopsies variably showed classic stigmata of opioid overdose with no significant injury or natural disease to explain death. Initial toxicology screens failed to identify heroin or other narcotic substances. Several cases were presumptively positive for fentanyl by immunoassay, yet failed to confirm positive for fentanyl. Following American Board of Forensic Toxicology reporting standards, these cases were reported as negative for fentanyl by the laboratory. Due to the discrepant scene and toxicology findings suggestive of an opioid toxicity death, further discussion between the medical examiners and toxicologists prompted additional testing at a referral laboratory. This resulted in quantifiable blood carfentanil in all cases (mean 0.26 ng\/mL, range 0.12 \u2013 0.64 ng\/mL). Cointoxicants included ethanol (n=2), methamphetamine (n=3), benzodiazepines (n=3), and cocaine (n=1). No case had definitive evidence of acute heroin intoxication, but two cases had low concentrations of morphine present (0.03 and 0.06 ng\/mL), and two others had 6-monoacetyl morphine in the urine without morphine in the blood, suggesting recent use. All deaths were certified as accidental acute or mixed carfentanil toxicity. These cases present additional information about carfentanil-related deaths and highlight the importance of collaboration between forensic pathologists and toxicologists.<\/jats:p>","DOI":"10.1177\/1925362118797746","type":"journal-article","created":{"date-parts":[[2018,8,31]],"date-time":"2018-08-31T11:24:08Z","timestamp":1535714648000},"page":"729-737","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":9,"title":["The Elephant in the Room"],"prefix":"10.1177","volume":"8","author":[{"given":"Rebecca M.","family":"Wilcoxon","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Owen L.","family":"Middleton","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarah E.","family":"Meyers","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julie","family":"Kloss","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sara A.","family":"Love","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2018,8,31]]},"reference":[{"key":"e_1_3_2_2_2","unstructured":"HHS.gov [Internet]. Washington: US Department of Health and Human Services; c2018. What is the US opioid epidemic; [cited 2017 Aug 28]. Available from: https:\/\/www.hhs.gov\/opioids\/about-the-epidemic\/index.html."},{"key":"e_1_3_2_3_2","unstructured":"CDC.gov [Internet]. Atlanta: Centers for Disease Control and Prevention; c2018. Opioid overdose; 2017 Jul 18 [cited 2018 Jun 13]. Available from: https:\/\/www.cdc.gov\/drugoverdose\/data\/index.html."},{"key":"e_1_3_2_4_2","doi-asserted-by":"crossref","unstructured":"Rudd RA Seth P David F Scholl L. Increases in drug and opioidinvolved overdose deaths - United States 2010-2015. MMWR Morb Mortal Wkly Rep. 2016 12 30;65(5051):1445\u201352. PMID: 28033313. https:\/\/doi.org\/10.15585\/mmwr.mm655051e1.","DOI":"10.15585\/mmwr.mm655051e1"},{"key":"e_1_3_2_5_2","doi-asserted-by":"crossref","unstructured":"Gilson TP Shannon H Freiburger J. The evolution of the opiate\/ opioid crisis in Cuyahoga County. Acad Forensic Pathol. 2017 3; 7(1): 41\u20139. https:\/\/doi.org\/10.23907\/2017.005.","DOI":"10.23907\/2017.005"},{"key":"e_1_3_2_6_2","doi-asserted-by":"crossref","unstructured":"Schueler HE. Emerging synthetic fentanyl analogs. Acad Forensic Pathol. 2017 3; 7(1): 36\u201340. https:\/\/doi.org\/10.23907\/2017.004.","DOI":"10.23907\/2017.004"},{"key":"e_1_3_2_7_2","doi-asserted-by":"crossref","unstructured":"George AV Lu JJ Pisano MV . Carfentanil - an ultra potent opioid. Am J Emerg Med. 2010 5; 28(4):530\u20132. PMID: 20466249. https:\/\/doi.org\/10.1016\/j.ajem.2010.03.003.","DOI":"10.1016\/j.ajem.2010.03.003"},{"key":"e_1_3_2_8_2","doi-asserted-by":"crossref","unstructured":"Riches JR Read RW Black RM . Analysis of clothing and urine from Moscow theatre siege casualties reveals carfentanil and remifentanil use. J Anal Toxicol. 2012 11-12; 36(9):647\u201356. PMID: 23002178. https:\/\/doi.org\/10.1093\/jat\/bks078.","DOI":"10.1093\/jat\/bks078"},{"issue":"4","key":"e_1_3_2_9_2","first-page":"14","article-title":"Carfentanil identified in two driving under the influence of drugs cases","volume":"40","author":"Tiscione NB","year":"2016","unstructured":"Tiscione NB, Shanks KG. Carfentanil identified in two driving under the influence of drugs cases. Tox Talk, 2016 12; 40(4): 14\u20137.","journal-title":"Tox Talk"},{"key":"e_1_3_2_10_2","unstructured":"Forensic toxicology laboratory accreditation checklist [Internet]. Colorado Springs: American Board of Forensic Toxicology; 2013 Nov 1 [cited 2017 Aug 8]. 47 p. Available from: http:\/\/www.abft.org\/files\/ABFT_LAP_Checklist_November_1_2013.docx."},{"key":"e_1_3_2_11_2","unstructured":"Wilcoxon Rebecca (Hennepin County Medical Examiner\u2019s Office). Conversations with: Travis Olives (Medical Toxicologist Minnesota Poison Control System). Toxicology Rounds 2017."},{"key":"e_1_3_2_12_2","doi-asserted-by":"crossref","unstructured":"Dasgupta N Mandl KD Brownstein JS. Breaking the news or fueling the epidemic? Temporal association between news media report volume and opioid-related mortality. PLoS One. 2009 11 18; 4(11): e7758. PMID: 19924221. PMCID: PMC2771898. https:\/\/doi.org\/10.1371\/journal.pone.0007758.","DOI":"10.1371\/journal.pone.0007758"},{"key":"e_1_3_2_13_2","unstructured":"WCCO: CBS Minnesota [Internet]. New York: CBS Local Media; c2018. 5 Minnesota deaths linked to drug 10K times stronger than morphine; 2017 Mar 30 [cited 2018 Jul 24]. Available from: https:\/\/minnesota.cbslocal.com\/2017\/03\/30\/carfentanil-death\/."}],"container-title":["Academic Forensic Pathology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1925362118797746","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/full-xml\/10.1177\/1925362118797746","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/journals.sagepub.com\/doi\/pdf\/10.1177\/1925362118797746","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,4,28]],"date-time":"2026-04-28T08:53:18Z","timestamp":1777366398000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.sagepub.com\/doi\/10.1177\/1925362118797746"}},"subtitle":["Outbreak of Carfentanil Deaths in Minnesota and the Importance of Multiagency Collaboration"],"short-title":[],"issued":{"date-parts":[[2018,8,31]]},"references-count":12,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2018,9]]}},"alternative-id":["10.1177\/1925362118797746"],"URL":"https:\/\/doi.org\/10.1177\/1925362118797746","relation":{},"ISSN":["1925-3621","1925-3621"],"issn-type":[{"value":"1925-3621","type":"print"},{"value":"1925-3621","type":"electronic"}],"subject":[],"published":{"date-parts":[[2018,8,31]]}}}