CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
The following is an editorial contribution from SteelFusion Clinical Toxicology Laboratory LLC. It was authored by Amy J. Reisinger, Autumn C. Miller, Melissa R. Baldwin, Jana L. Champion, and Terra L. Shuma, all of SteelFusion.
January 2022—Death investigators are tasked with the responsibility of providing irrefutable and accurate determinations in the cause and manner of death in a timely fashion for ongoing investigations. Outcomes of any death may be revealed by the specimens submitted for toxicology analysis.1 The conundrum of ample opinions is that there is no “one size fits all” when selecting appropriate specimens. Human nature tends to rely on traditional approaches for the collection, processing, and reporting of results because it’s easier to stay status quo. However, with drug overdose deaths increasing, reports are further delayed, causing an influx of backlogged cases. To assist with these issues, our laboratory developed an economical, time-efficient, safe, and less-invasive collection method that delivers real-time results within 24 to 48 hours, accelerating the autopsy process and the ability to close cases expeditiously.
SteelFusion Clinical Toxicology Laboratory LLC’s patented rapid oral fluid technology has streamlined the toxicology process by collecting one matrix from postmortem decedents for the detection and quantification of medicinal and illicit drugs and alcohol.2-5 William James said, “The aim of science is always to reduce complexity to simplicity”; however, motivating people to adopt new matrices and procedures is easier said than done. It has been stated that the use of oral fluid drug testing for postmortem toxicology has not been extensively researched.6
On the contrary, postmortem oral fluid has been developed and validated to meet the ongoing quality assurance as outlined by accreditation bodies such as the ANSI National Accreditation Board and the American Board of Forensic Toxicology and adopted by medical examiners and coroners since 2016. To date, thousands of cases have been conducted using this patented technology. Prior controlled studies were designed to document the efficacy, accuracy, and rapidity of using oral fluid to detect the presence of drugs and quantify drug concentrations compared with conventional collection modalities used in forensic autopsies. Samples of oral fluid were collected from sublingual and submandibular locations. These studies revealed that drugs collected after death from the sublingual location were preserved in the salivary glands, which served as intact reservoirs2-5 even in cases where blood, purge, or fluids that have seeped from mucosal tissues and capillaries have been observed in the oral cavity. Pharmacokinetics of the drugs in oral fluid are described in literature as being similar to those in blood concentrations, which signifies recent use of the drug. Mathematical models have been developed to predict saliva-plasma drug concentration ratios.7,8 The passive diffusion of drugs from blood to oral fluid is influenced greatly by five factors: the drug’s pKa, protein binding of the drug, lipophilicity, spatial configuration, and molecular size.9-12