Lethal intake of cocaine: accidental or suicide? Presentation of a case after a review of the literature

After attending this presentation, attendees will gain insight into a rare case of fatal cocaine intoxication with suspected suicidal intent, supported by detailed toxicological and pathological findings. The case underscores the importance of integrating scene investigation, personal history, and advanced toxicology to accurately determine the manner of death. This work contributes to the forensic science community by enhancing the understanding of non-recreational drug use patterns and improving the interpretation of complex drug-related fatalities. Cocaine is a powerful stimulant with a significant potential for fatal intoxication. This report presents the case of a 29-year-old male with a known history of substance abuse, who was found dead in a hotel room near his residence. There was no evidence of the presence of others in the room, and his phone was turned off. A small quantity of cocaine was found at the scene. External examination revealed no signs of violence. Nasal swabs tested positive for cocaine, supporting the hypothesis that death occurred after recent cocaine use and providing valuable information about the route of administration. Cocaine was likely insufflated, as further suggested by the presence of a rolled-up one-dollar bill found at the scene. Toxicological screening using gas chromatography-mass spectrometry (GC-MS) and headspace gas chromatography with flame ionization detection (HS-GC-FID) revealed markedly elevated concentrations of cocaine (1602 mg/L), its primary metabolite benzoylecgonine (89173 mg/L), cocaethylene (12417 mg/L), and ethanol (0.61 g/L) in peripheral blood. The presence of cocaine and its metabolites in bile and urine further supported recent and significant intake. Pathological examination, combined with toxicological findings, determined the cause of death to be acute cocaine intoxication, leading to cardiogenic shock. Before ruling the death a suicide, the deceased’s personal history was considered. In the period leading up to his death, he had expressed profound distress to his family, largely due to his inability to find satisfying employment. He was also recently affected by sudden-onset total alopecia, which he struggled to cope with. His decision to book a hotel room alone and turn off his phone suggests a desire for isolation. The elevated levels of cocaine metabolites in peripheral blood suggest that the deceased survived for some time after the initial dose and continued using the drug well beyond the peak intoxication phase. The relatively low ethanol concentration, along with the absence of empty or partially empty bottles in the room, supports the hypothesis that he was in the descending phase of Widmark’s curve at the time of death. Although determining suicidal intent is challenging in the absence of a note, the deceased’s personal history, the circumstances of the scene, autopsy findings, and toxicological results strongly suggest a non-recreational pattern of use, raising the possibility of an intentional overdose. As such, this case represents one of the rare instances in the literature where death resulted from a cocaine overdose potentially taken with suicidal intent. This report will present a case that underscores the necessity, when it comes to an intoxication, to make a diagnosis based on the unequivocal convergence of a series of factors arising from the application of multiple criteria: anamnestic, circumstantial, anatomical-pathological, and chemical-toxicological. Furthermore, the presentation will demonstrate how combining analytical data with scene and behavioral context can inform distinctions between accidental, recreational, and intentional drug-related deaths. The insights gained are intended to support more nuanced, evidence-based conclusions in forensic investigations involving stimulant fatalities.