Legal medicine (Tokyo, Japan) · 2026
Fatal oral ingestion of a sectioned transdermal fentanyl patch in an opioid-naïve youth with gender incongruence: a forensic case report from Japan.
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Miura Hayato, Miyao Masashi, Furukawa Shota, Kawai Chihiro, Tateno Maiko, Ayatollahi Parisa Sadat, Abiru Hitoshi, Nagai Hideki, Minami Hirozo, Tomohisa Ayu, Sasao Ako, Sano Rie, Namera Akira, Nishitani Yoko
Аннотация
BACKGROUND: Fentanyl is a central driver of the global opioid crisis due to its extreme potency and abuse liability. Japan has historically maintained a low prevalence of opioid use disorders; however, the diversion of prescription pharmaceuticals has emerged as a discrete threat, particularly among adolescents and young adults. Herein, we report a fatal case of acute intoxication caused by the deliberate oral misuse of a transdermal fentanyl patch.
CASE PRESENTATION: An adolescent (late teens) with a history of depression and gender incongruence died at home. The deceased had no history of chronic pain and was not prescribed opioids. A forensic autopsy revealed five sectioned fragments of a transdermal fentanyl patch in the gastric contents. Toxicological analysis using liquid chromatography-tandem mass spectrometry yielded fentanyl concentrations of 23.4 and 23.0 ng/mL in peripheral blood and heart serum, with corresponding norfentanyl concentrations of 9.5 and 12.1 ng/mL, respectively. Pregabalin was concurrently detected at a high therapeutic concentration (3.8 μg/mL in peripheral blood; 7.0 μg/mL in heart serum).
CONCLUSION: The sectioned patch fragments identified in the gastric contents, in conjunction with the overall toxicological findings, supports acute death attributable to oral patch abuse. However, inverted fentanyl-to-norfentanyl ratio (>1.0) was interpreted cautiously, acknowledging that post-mortem redistribution cannot be excluded. The opioid-naïve status of the deceased and concomitant central nervous system depressant effects of pregabalin and co-detected benzodiazepine-related exposure probably contributed to these outcomes. This case highlights the risks associated with high-potency opioid diversion and abusive routes of administration in psychologically vulnerable young people.
CASE PRESENTATION: An adolescent (late teens) with a history of depression and gender incongruence died at home. The deceased had no history of chronic pain and was not prescribed opioids. A forensic autopsy revealed five sectioned fragments of a transdermal fentanyl patch in the gastric contents. Toxicological analysis using liquid chromatography-tandem mass spectrometry yielded fentanyl concentrations of 23.4 and 23.0 ng/mL in peripheral blood and heart serum, with corresponding norfentanyl concentrations of 9.5 and 12.1 ng/mL, respectively. Pregabalin was concurrently detected at a high therapeutic concentration (3.8 μg/mL in peripheral blood; 7.0 μg/mL in heart serum).
CONCLUSION: The sectioned patch fragments identified in the gastric contents, in conjunction with the overall toxicological findings, supports acute death attributable to oral patch abuse. However, inverted fentanyl-to-norfentanyl ratio (>1.0) was interpreted cautiously, acknowledging that post-mortem redistribution cannot be excluded. The opioid-naïve status of the deceased and concomitant central nervous system depressant effects of pregabalin and co-detected benzodiazepine-related exposure probably contributed to these outcomes. This case highlights the risks associated with high-potency opioid diversion and abusive routes of administration in psychologically vulnerable young people.