Combined Ethanol, Cocaine, Heroin and Methadone Abuse: a Deadly Mix, Review of the Literature

Background: Polysubstance use or abuse is defined as the ingestion or use of more than one drug of abuse within a defined time frame, aiming to enhance or modulate psychoactive effects, alleviate unwanted side effects of one substance and free access to different kinds of substances. Although deaths involving cocaine and other psychostimulants are increasing in many countries, it is not common in Iran due to the high price of cocaine due to a decrease in the supply chain to Iran. Case presentation: We report the case of a death due to polysubstance use. Analytical toxicology results were positive for cocaine, cocaethylene, morphine (heroin metabolite), and methadone in combination with positive blood and vitreous humor alcohol contents. The most significant histopathologic features were vascular hypertrophy, chronic myocardial ischemia, moderate to severe atherosclerosis, acute myocardial infarction, hemorrhagic pulmonary edema, diffuse alveolar collapse, micro-vesicular steatosis, focal hepatocyte necrosis, chronic hepatitis, and steatohepatitis. Discussion: polysubstance users mix drugs to reduce the negative effects of each drug. However, mixing recreational drugs is very dangerous. Pharmacokinetic and pharmacodynamics interactions in polysubstance users can produce health consequences leading to death. Conclusion: Results of this forensic case study increased attention to overdose mortality due to polydrug use.