Suicide is a major public health issue and the risk of attempting and committing suicide increases with age. We present the case of an elderly couple who decided to commit suicide together by self-poisoning using levamisole-adulterated cocaine. The choice of committing a double suicide, the method selected (self-poisoning), the drug self-administered (cocaine), and the route of administration (ingestion) are events rarely encountered in the forensic pathology practice, especially not in combination. In this article, we will review the literature regarding the frequency and features of these methods of suicide. An overview of the effects and mechanism of action of levamisole is also provided, highlighting the importance of including this substance and its metabolites in the routine toxicological analyses for cocaine deaths.
RockettIRSmithGSCaineED, et al.Confronting death from drug self-intoxication (DDSI): prevention through a better definition. Am J Public Health. 2014;104(12):e49–e55.
GibbonsRDHurKBhaumikDK, et al.The relationship between antidepressant medication use and rate of suicide. Arch Gen Psychiatry. 2005;62(2):165–172.
6.
ChanJDraperBBanerjeeS. Deliberate self-harm in older adults: a review of the literature from 1995 to 2004. Int J Geriatr Psychiatry. 2007;22(8):720–732.
7.
OECD. Suicide, in Health at a Glance: Europe 2012. OECD Publishing; 2012.
8.
ConejeroIOliéECourtetP, et al.Suicide in older adults: current perspectives. Clin Interv Aging. 2018;13:691–699.
9.
ConwellYThompsonC. Suicidal behavior in elders. Psychiatr Clin North Am. 2008;31(2):333–356.
10.
RostamiMYounesiSJMohammadi ShahboulaghiF, et al.Models of suicide in elderly: a protocol for a systematic review. BMJ Open. 2018;8(10):e022087.
11.
HeiselMJ. Suicide and its prevention among older adults. Can J Psychiatry. 2006;51(3):143–154.
12.
KimYRChoiKHOhY, et al.Elderly suicide attempters by self-poisoning in Korea. Int Psychogeriatr. 2011;23(6):979–985.
13.
BrownMBarracloughB. Epidemiology of suicide pacts in England and Wales, 1988-92. BMJ. 1997;315(7103):286–287.
14.
JensenLLGilbertJDByardRW. Coincident deaths: double suicide or murder-suicide?Med Sci Law. 2009;49(1):27–32.
15.
CohenJ. A study of suicide pacts. Medico-Legal J. 1961;29(3):144–151.
16.
FishbainDAD’AchilleLBaraskyS, et al.A controlled study of suicide pacts. J Clin Psychiatry. 1984;45(4):154–157.
17.
BrownMKingEBarracloughB. Nine suicide pacts a clinical study of a consecutive series 1974-1993. Br J Psychiatry. 1995;167(4):448–451.
18.
HaenelTElsasserPN. Double suicide and homicide-suicide in Switzerland. Crisis. 2000;21(3):122–125.
19.
KugelbergFCJonesAW. Interpreting results of ethanol analysis in postmortem specimens: a review of the literature. Forensic Sci Int. 2007;165(1):10–29.
20.
PisaniARMurrieDCSilvermanMM. Reformulating suicide risk formulation: from prediction to prevention. Acad Psychiatry. 2016;40(4):623–629.
21.
MarcikicMVuksicZDumencicB, et al.Double suicide. Am J Forensic Med Pathol. 2011;32(3):200–201.
22.
ByardRWWinskogCHeathK. Nitrogen inhalation suicide pacts. Med Sci Law. 2019;59(1):57–60.
23.
ByardRWKnightDJamesRA, et al.Murder-suicides involving children: a 29-year study. Am J Forensic Med Pathol. 1999;20(4):323–327.
24.
HuntIMWhileDWindfuhrK, et al.Suicide pacts in the mentally ill: a national clinical survey. Psychiatry Res. 2009;167(1-2):131–138.
25.
RosenbaumM. Crime and punishment—the suicide pact. Arch Gen Psychiatry. 1983;40(9):979–982.
26.
SperryK. Suicide with, and because of, cocaine. JAMA. 1988;259(20):2995–2996.
27.
SperryKSweeneyES. Suicide by intravenous injection of cocaine. A report of three cases. J For Sci. 1989;34(1):244–248.
28.
KondziellaDDanielsenERArlien-SoeborgP. Fatal encephalopathy after an isolated overdose of cocaine. J Neurol Neurosurg Psychiatry. 2007;78(4):437–438.
29.
DoakMWNixonACLuptonDJ. Self-poisoning in older adults: patterns of drug ingestion and clinical outcomes. Age and Ageing. 2009;38(4):407–411.
30.
ChoiNGDiNittoDMMartiCN, et al.Poisoning deaths among late-middle aged and older adults: comparison between suicides and deaths of undetermined intent. Int Psychogeriatr. 2019;31(8):1159–1169.
31.
World Drug Report 2019(United Nations publication, Sales No. E.19.XI.8).
32.
EMCDDA. European Drug Report 2018: Trends and Developments. Publications of the European Union; 2018.
HeardKPalmerRZahniserNR. Mechanisms of acute cocaine toxicity. Open Pharmacol J. 2008;2(9):70–78.
40.
MarellaGLFurnariCPerfettiE, et al.Aortic dissection and cocaine use. J Forensic Leg Med. 2011;18(7):329–331.
41.
PramanikPViduaRK. Sudden cardiac death of a body packer due to cocaine cardiotoxicity. Clin Med Insights Pathol. 2016;9:33-35.
42.
FurnariCOttavianoVSacchettiG, et al.A fatal case of cocaine poisoning in a body packer. J For Sci. 2002;47(1):208–210.
43.
KoehlerSALadhamSRozinL, et al.The risk of body packing: a case of a fatal cocaine overdose. Forensic Sci Int. 2005;151(1):81-84.
44.
de ProstNMégarbaneBQuestelF, et al.Blood cocaine and metabolite pharmacokinetics after cardiac arrest in a body-packer case. Hum Exp Toxicol. 2010;29(1):49-53.
45.
SchulzMIwersen-BergmannSAndresenH, et al.Therapeutic and toxic blood concentrations of nearly 1,000 drugs and other xenobiotics. Crit Care. 2012;16(4):R136.
46.
ReesKAJonesNSMcLaughlinPA, et al.The effect of sodium fluoride preservative and storage temperature on the stability of cocaine in horse blood, sheep vitreous and deer muscle. Forensic Sci Int. 2012;217(1-3):182–188.
47.
MusshoffFMadeaB. Cocaine and benzoylecgonine concentrations in fluorinated plasma samples of drivers under suspicion of driving under influence. Forensic Sci Int. 2010;200(1-3):67–72.
48.
HoffmanRSKirraneBMMarcusSM. A descriptive study of an outbreak of clenbuterol-containing heroin. Ann Emerg Med. 2008;52(5):548–553.
49.
ColeCJonesLMcVeighJ, et al.Adulterants in illicit drugs: a review of empirical evidence. Drug Test Anal. 2011;3(2):89–96.
EngelsD. Cocaine use and levamisole-induced vasculitis: a multiple case study. J Wound Ostomy Continence Nurs. 2020;47(2):182–189.
52.
LeeKCLadizinskiBFedermanDG. Complications associated with use of levamisole-contaminated cocaine: an emerging public health challenge. Mayo Clin Proc. 2012;87(6):581–586.
53.
BaseltRC. Disposition of Toxic Drugs and Chemicals in Man. 10th ed. Biomedical Publications; 2014.
54.
NolanALJenKY. Pathologic manifestations of levamisole-adulterated cocaine exposure. Diagn Pathol. 2015;10:48.
55.
PawlikEMahlerHHartungB, et al.Drug-related death: adulterants from cocaine preparations in lung tissue and blood. Forensic Sci Int. 2015;249:294–303.
56.
KnowlesLBuxtonJASkuridinaN, et al.Levamisole tainted cocaine causing severe neutropenia in Alberta and British Columbia. Harm Reduct J. 2009;6:30.
57.
SolomonNHayesJ. Levamisole: a high performance cutting agent. Acad Forensic Pathol. 2017;7(3):469–476.
58.
LarocqueAHoffmanRS. Levamisole in cocaine: unexpected news from an old acquaintance. Clin Toxicol (Phila). 2012;50(4):231–241.
59.
ValentinoAFuentecillaK. Levamisole: an analytical profile. Microgram Journal. 2005;3:134–137.
60.
ZhuNYLegattDFTurnerAR. Agranulocytosis after consumption of cocaine adulterated with levamisole. Ann Intern Med. 2009;150(4):287–289.
61.
EidenCDiotCMathieuO, et al.Levamisole-adulterated cocaine: what about in European countries?J Psychoactive Drugs. 2014;46(5):389–392.
62.
MartelloSPieriMIalongoC, et al.Levamisole in illicit trafficking cocaine seized: a one-year study. J Psychoactive Drugs. 2017;49(5):408–412.
63.
EidenCPeyrièreHDiotC, et al.Prevalence of levamisole and aminorex in patients tested positive for cocaine in a French University Hospital. Clinical Toxicology. 2015;53(7):604–608.
64.
PopeJDDrummerOHSchneiderHG. The cocaine cutting agent levamisole is frequently detected in cocaine users. Pathology. 2018;50(5):536–539.
65.
RaymonLPIsenschmidDS. Letter to the editor: the possible role of levamisole in illicit cocaine preparations. J Anal Toxicol. 2009;33:620–622.
66.
BruntTMvan den BergJPenningsE, et al.Adverse effects of levamisole in cocaine users: a review and risk assessment. Arch Toxicol. 2017;91(6):2303–2313.
67.
HofmaierTLufASeddikA, et al.Aminorex, a metabolite of the cocaine adulterant levamisole, exerts amphetamine like actions at monoamine transporters. Neurochem Int. 2014;73(100):32–41.
68.
BertolEMariFDi MiliaMG, et al.Determination of aminorex in human urine samples by GC-MS after use of levamisole. J Pharm Biomed Anal. 2011;55(5):1186–1189.
69.
HandleySABelseySLCouchmanL, et al.Plasma and urine levamisole in clinical samples containing benzoylecgonine: absence of aminorex. J Anal Toxicol. 2019;43(4):299–306.
70.
IndoratoFRomanoGBarberaN. Levamisole-adulterated cocaine: two fatal case reports and evaluation of possible cocaine toxicity potentiation. Forensic Sci Int. 2016;265:103–106.
71.
MichaudKGrabherrSShiferawK, et al.Acute coronary syndrome after levamisole-adultered cocaine abuse. J Forensic Leg Med. 2014;21:48–52.
72.
TallaridaCSEganEAlejoGD, et al.Levamisole and cocaine synergism: a prevalent adulterant enhances cocaine’s action in vivo. Neuropharmacology. 2014;79:590–595.
73.
TallaridaCSTallaridaRJRawlsSM. Levamisole enhances the rewarding and locomotor-activating effects of cocaine in rats. Drug Alcohol Depend. 2015;149:145–150.
