Tag Archives: Amitriptyline intoxication

Podcasts Cover the Morgan Ingram Tragedy:

Sword and Scale with Mike Boudet recorded a two part podcast covering the tragic death of Morgan Ingram and its aftermath.

Part One

Part Two

Joseph Valo, a self identified victim’s advocate for the Morgan Ingram Foundation, made this podcast.

 

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Clueless

Yesterday, May 20,2013, Toni Ingram tweeted 14 “clues” that she apparently thought were significant in relation to her daughter’s death.  By definition a clue is something that serves as a guide or aid in the solution of a problem or mystery.  Following that definition, these aren’t really clues.  None of these lead anywhere.

Below are Toni’s clues followed by my response.

Quotes are written by Toni Ingram and posted @morgansstalking:

https://twitter.com/morgansstalking

Clue #1 Amitriptyline [sic] in the stomach is not related to PMR but Amitriptyline [sic] in the blood is subject to PER [sic]

Clue #2 How could a person have a blood level of 7900+ng in her blood, when 1,000 ng is lethal?

Clue #3 the amount of Amitriptyline [sic] in Morgan’s stomach fluid was not enough to kill her, but that is what the pathologist based suicide on

Clue #4 if you were a Forensic Toxicologist you would know why the date rape drugs in Morgan’s stomach fluid never made it in to her blood especially because one of those date rape drugs would have gone into the blood at the same time as the Amitriptyline [sic]

Clue #5 The Pathologist that did Morgan’s autopsy blames PMR for her high reading, but PMR kicks in at 24 hrs & goes for the next 24 hrs.

Clue #6 Pathol. est. Morgan took 18 pills, only accts for Ami in gastric not the 7909ng/ml found in her blood. 18-25 mg pills not lethal

I have grouped these first six together since they all concern amitriptyline.

This has all been addressed before, much of it in a previous blog, What Dr. Kurtzman Knew.  Either she does not understand the science or she refuses to accept it.  Toni claims they have consulted with several medical professionals but I find that claim highly suspect.  These first six “clues” show a complete lack of understanding for even basic pharmacology and organic chemistry.

One more time for those who joined us late:

Toxicity and absorption of drugs cannot be discussed without a basic understanding of pharmacogenetics.

Pharmacogenetics is the study of genetic differences that affect an individual’s response to certain drugs. Different drugs undergo different metabolisms as a result of genetic variation, especially in the cytochrome p450 family of enzymes.  My point?  There are no absolutes.  It’s impossible to know Morgan’s cardiotoxic level without knowing if she was or was not deficient in the cytochrome P450 enzyme.

Cardiotoxic levels of amitriptyline generally occur between 450 ng/ml to 1,000 ng/ml.  Okay, so how did Morgan end up with a postmortem level of 7909 ng/ml.

First it is essential to understand that when medical professionals talk about the cardiotoxic level they mean antemortem, prior to death.  Antemortem levels are based on plasma, which is prepared by spinning down a fresh whole blood sample to remove the red blood cells, white blood cells, and platelets. From a pharmacokinetic perspective, red blood cells, white blood cells, and platelets are a tissue compartment.

As I mentioned in What Dr. Kurtzman Knew, amitriptyline is highly lipophilic (lipo=fat + philic=love of) and found in greater concentrations in both fat and protein than in plasma.  The human body begins autolysis, the breakdown of tissue, at the moment of death (the idea that this process waits 24 hours and ends 24 hours later, is laughable).  Amitriptyline, resides mostly in deep tissue compartments and is released into whole blood.

The result is the levels in the whole blood, which is what is used for a postmortem sample, will reflect concentrations from tissue, red blood cells, white blood cells, and plasma and range from 5 to 10 times higher than the antemortem plasma concentration. In addition, there may be redistribution from other tissue compartments into the blood as the body decomposes.

Clue #6 [sic]  Morgan had an overkill dose of drugs in her blood, but no container or syringe was found anywhere in her room or in the house.

The “container” was the pill bottle next to her bed.

Clue #7 Morgan’s nails were torn on her right hand 1-1/2 years later nobody in GarCo can produce a picture from the crime scene of her nails.

According to the medical examiner, her nails were intact when Morgan left his morgue.

Case #11-29169

Det. Sergeant D. Breier

Unattended Death Report

She exhibited a small amount of blood in her mouth [pulminary edema]. There was a very small red mark on the right side of her forehead [lividity]; otherwise there was no apparent evidence of external trauma

Case # 11-29169

Detective J. A. LeMoine

Unattended Death Report

Once the Coroner arrived on scene the towel covering Morgan’s upper portion of her body was removed. Video and photographs of Morgan’s body were taken at this time. I did not observe any signs of trauma on Morgan at this time.

Clue #8 ALL of her jewelry of value went missing on the night she was killed while her #stalker frequents cash for gold establishments.

Toni concluded Morgan’s jewelry was missing only after she heard Keenan was picked up on a theft warrant.  These charges were later dropped.

Case #11-20197

Det. Robert Glassmire:

I explained to Toni that if she wants to report a theft of Morgan’s jewelry I would be happy to assist with that and either generate a new case or add it to the ongoing stalking case. I then told her that she would have to complete a list of stolen items and that she could not look at a list of items and determine what had been stolen from that list.

It should be noted that there is no information to believe that Keenan Vanginkel has stolen any of Morgan Ingram’s jewelry. Furthermore, Toni or Steve Ingram have yet to provide me with a list to base a theft report on.

Clue #9 Morgan’s #panic button was torn from its mount on her nightstand and found hidden in her room.

We only have Toni’s word on this and we all know what that’s worth.

Clue #10 The rain gutter directly over Morgan’s bedroom window was torn in half by repeated bending by her #stalker leaning over the edge!

The gutter was discovered long after the Ingram’s moved from the house.  If someone was leaning on the gutter it would bend, sag, or pull away from the house.  The gutter over Morgan’s windows appears split on a seam

Clue #11 Morgan’s room was completely disheveled with obvious signs of a struggle having taken place there

Case # 11-29169

Detective J. A. LeMoine

Unattended Death Report

During this time I observed that Morgan’s bedroom was disorganized with clothing and other items covering the majority of the floor. I observed that the adjoining bathroom to Morgan’s bedroom was in the same condition.

Did the struggle continue into the bathroom?   If Morgan fought off an attacker to the point that it left her room in disarray (Det. Sergeant Breier called it slovenly), how is it she bore no defensive wounds and her body showed no signs of trauma?  How is it this struggle was not heard by Steve and Toni Ingram?

Clue #12 Figures are caught three times outside the house by video surveillance on the night Morgan was killed.

Case #11-29169

Supplemental report #2

Det. Sergeant D. Breier

The residence has an installed video surveillance systems recorded by a DVR. The video was reviewed which showed the decedent (identified as Morgan Ingram) returning home around 2100 hours. There was no further activity until the decedent’s mother moved the vehicle she had parked in the driveway so emergency responders could access the house

Clue #13 The next door neighbor reported odd things going on in Morgan’s bathroom the night she was killed – but was never questioned

How did the neighbor know what happened in Morgan’s bathroom?  Surely Morgan would have her blinds drawn/shade pulled down etc.

Clue #14 Why would a person that does not know Morgan or her family & wasn’t involved in her stalking/murder be so invested in lying?

First:  I have never lied about Steve, Toni, or Morgan Ingram, Keenan, Brooke, or anyone else connected to this tragedy.  The Truth for Morgan group has NEVER harassed or bullied Steve or Toni Ingram or any of their supporters.  We don’t have to slander Jodin Davunt, Sarah Afshar, or Mark Mann et al.  They have successfully made themselves look far worse than we ever could.

When I discovered distortions and outright lies in the Morgan’s Stalking blog, lies of which Toni was made aware, I delayed exposing her faux pas, to give her every opportunity to correct or retract her mistakes (she didn’t).  Furthermore, I use proper blogging etiquette and strikethrough if I have to make changes, unlike Toni who completely deletes and rewrites posts on a whim.

Essentially Toni is asking why we we would bother to stick up for someone (Keenan Vanginkel) we do not know personally. In my opinion her inability to grasp the why factor is telling.

Toni Ingram has made it her life’s mission to ruin the lives of others based on faulty logic and substandard science.  There is absolutely no evidence that Keenan stalked or murdered Morgan, but that doesn’t matter to Toni.  She slanders and accuses any and all who dare to disagree with her, unfettered by morals or conscience.  The young people Toni bullies have barely crossed into adulthood.  Life is hard; Competition for opportunities to advance is greater than it ever was.  Toni Ingram is robbing these kids of their futures and limiting their opportunities by besmirching their names.

Someone has to stand up to her and say enough is enough

Why?  Because it is the right thing to do……

It’s that simple

What Dr. Kurtzman Knew

March 27, 2013

I apologize for not posting this on the date promised, real life got in the way.

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In her blog Toni Ingram has consistently criticized Dr. Robert Kurtzman for conclusions he reached in the autopsy of Morgan Ingram.  Toni has claimed on more than one occasion that retired medical examiners, two forensic pathologists, doctors, specialists, and a pharmaceutical scientist have all contacted her to let her know that Dr. Kurtzman should have known right away that the level of amitriptyline found in Morgan’s blood was lethal.   Apparently Toni expects readers to believe members of the medical community would criticize one of their own for not jumping to an immediate conclusion and exercising too much caution.  Although I don’t believe Toni I was curious why Dr. Kurtzman did not rule Morgan’s death a suicide from the very beginning.  Did Dr. Kurtzman know something we don’t?  Could death by amitriptyline intoxication be more complex than Toni Ingram would like her readers to believe?  The answers required research.

As I began researching Amitriptyline it became evident to me that information from the Morgan’s Stalking blog contradicted my research.  I will note these contradictions as they occur.

So what exactly is amitriptyline?

Amitriptyline is a disturbingly effective killer; a chemical perfect storm for the suicidal.  It is an extremely complex medication originally approved by the U.S. Food and Drug Administration to treat various forms of depression.  It also has several off-label uses (off-label means not FDA approved) such as treatment of neuropathic pain, and migraine prophylaxis.  Amitriptyline is a tricyclic, antidepressant, so-called because of its three-ring chemical structure.  It is the most frequently abused/misused of the tricyclic antidepressants.  In a review of 165 persons with tricyclic poisonings admitted to one hospital in a two year period, 62% involved amitriptyline.

Amitriptyline is readily absorbed from the gastro-intestinal tract, with peak plasma concentrations occurring within a few hours of oral administration (contradicts MS blog, “She would have to have been given this stuff between noon and nine pm-ish for that high of a levelSeptember 15, 2012  http://morganingram.com/wordpress/?p=1207 )

It is highly lipid soluble meaning it is stored by fat cells and not released until the body exhausts the rest of the dose.Peak drug concentrations occur early and this is the reason why most deaths from poisoning occur outside the hospital.

Amitriptyline undergoes extensive first-pass metabolism and is demethylated in the liver to its primary active metabolite, nortriptyline. Amitriptyline is widely distributed throughout the body and is extensively bound to plasma and tissue protein.

AMI is a mild antiemetic (prevents vomiting) and in fact is used successfully to treat a condition called Cyclic Vomiting Syndrome. (contradicts MS “did not regurgitate any of them back up, as is most common with Amitriptyline” and ”A research scientist and doctor who works at a pharmaceutical company has assured us there is no way Morgan could ingest enough Amitriptyline to produce that level without vomiting it up. It can’t happen” March 12, 2013 http://morganingram.com/wordpress/?p=3198).

Amitriptyline is anticholinergic and therefore will inhibit parasympathetic nerve impulses by blocking acetylcholine. Acetylcholine is a vital neurotransmitter that is released at the ends of nerve fibers in the somatic and parasympathetic nervous systems and transmits nerve impulses across a synapse.  The nerve fibers of the parasympathetic system are responsible for the involuntary movements of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, etc.  This is why Morgan developed pulmonary edema, not because  her heart stopped for only a few seconds, then her lungs would have automatically filled up with fluid and this would have been enough to kill her,”  March 26, 2013  http://morganingram.com/wordpress/?p=3386

The anticholinergic effect is exponential to the amount of the drug consumed. To put it plainly, amitriptyline slows down vital body functions, including significant reduction in gastrointestinal mobility.This results in a prolonged period of absorption.

If all this was not enough, amitriptyline and its active metabolite nortriptyline are subject to enterohepatic recirculation.  This means it is secreted into bile which is held by the gall bladder and dumped back into the small intestine creating an efficient deadly cycle.

Amitriptyline has a narrow therapeutic index, meaning there is a fine line between a therapeutic and toxic dose.  A lethal dose can be as low as 5mg/kg.  Morgan Ingram weighed 115 lbs. or 52.1 kg., so theoretically a fatal dose could have been as low as 260.5 mg or approx. 10 25 mg pills.  The fact that such a small amount could be fatal is another unique characteristic of amitriptyline (contradicts MS “18 – 25mg pills is 450 mg., simple math 18 X 25 = 450.  And it is not a lethal dose, yes you read that right, 450 mg. is not a lethal dose.  Once again I welcome you to find a qualified expert who will testify that 450 mg. of Amitriptyline is a lethal dose” March 15, 2013  http://morganingram.com/wordpress/?p=3272

Any “qualified expert” could tell Toni Ingram the most frightening fact about amitriptyline is scientists do not know how it will behave from one patient to the next due to a high degree of genetic variability in the specific liver enzymes that process the drug.  A lethal amount for one person might have little effect on another.  Depending on the genetic variant, the liver enzyme that processes amitriptyline, known as CYP2D6, will metabolize in one of the following ways:

Poor metabolizer–these subjects have little or no CYP2D6 function

Intermediate metabolizers–these subjects metabolize drugs at a rate somewhere between the poor and extensive metabolizers,

Extensive metabolizer–these subjects have normal CYP2D6 function

Ultra rapid metabolizer–these subjects have multiple copies of the CYP2D6 gene expressed, and therefore greater-than-normal CYP2D6 function

The only way to know which variant a patient will express, other than trial and error, is to run a plasma concentration assay.

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In light of this drug’s many complexities, I hope it’s obvious to readers why Dr. Kurtzman didn’t immediately and carelessly blame amitriptyline for Morgan’s death.  Given Toni Ingram’s previous track record for omitting facts that undermine her version of the “truth,” I don’t think I’m off base suggesting we don’t have the entire story.  I strongly suspect Dr. Kurtzman told the Ingrams he was issuing a tentative death certificate per legality, but cause and manner could change as pending reviews and results became available.

By gaining a greater understanding of amitriptyline I unintentionally gained a greater understanding of Toni Ingram.  I believe the numerous unnamed medical experts and their opinions of Dr Kurtzman are fabrications born out of desperation.   In my opinion this woman is so arrogant, so convinced of her superiority she didn’t even bother to research how amitriptyline is processed.  I don’t think it occurred to her that anyone would question what she says.

Toni knows Keenan Vanginkel and Brooke Harris will never be charged with murder.  The alleged evidence consists of hearsay and lies and the visions of psychics and pet communicators.  There is no chain of custody for the alleged physical evidence.

There is no cover-up being perpetrated by the police or the forensic pathologist. Why would they risk their careers to protect Keenan?  He’s a kid who works at a grocery store.  He doesn’t have any connections or know anyone with political clout.

Toni Ingram knows this but she will never accept it.

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Toni Ingram, full credit for italicized quotes, 2012-2013 Morgan’s Stalking, http://morganingram.com/wordpress/

Gergov, Merja, et al. “CYP2D6 and CYP2C19 genotypes and amitriptyline metabolite ratios in a series of medicolegal autopsies.” Forensic Science International 10 May 2006: 177+. Academic OneFile. Web. 15 Mar. 2013.

Bachofer, Julia, et al. “Amitriptyline or not, that is the question: pharmacogenetic testing of CYP2D6 and CYP2C19 identifies patients with low or high risk for side effects in amitriptyline therapy.” Clinical Chemistry 51.2 (2005): 376+.

Academic OneFile. Web. 15 Mar. 2013

/CASE REPORTS/ In a case of acute overdosage (225 mg) a patient in light coma had temporary complete oculomotor paresis, unresponsive to caloric stimulation or doll’s head maneuvers.

[Grant, W.M. Toxicology of the Eye. 3rd ed. Springfield, IL: Charles C. Thomas Publisher, 1986., p. 85] **PEER REVIEWED**

/CASE REPORTS/ A 34-yr-old man … suffered from severe adverse effects during treatment with amitriptyline, 50 mg/day. It was subsequently shown that the patient was a slow metabolizer of amitriptyline. However, he tolerated a dose of 200 mg of imipramine/day, which was necessary in order to reach a therapeutic level of about 900 nM for imipramine plus desipramine.

[Broson K et al; Ther Drug Monit 13 (2): 177-82 (1991)] **PEER REVIEWED** PubMed Abstract

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Edits:

     March 29, 2013 2:54 P.M.- Grammar

     April  2, 2013  3:16 P.M – Added and corrected attributions.

Please Note…. (updated)

March 22, 2013

I would like to take a moment and point readers to a few small additions made to this site.  On the right hand side of the screen under “Pages,” there are some new links:

Now You See ‘Em; Now You Don’t is where I have posted screenshots of items that have disappeared from Morgan’s Stalking, Sarah Afshar’s blog etc. 

Toni’s Army of Trolls – Documenting the stupidity.

Morgan’s Photobucket  When Toni started her blog, members of Websleuths began researching Morgan’s death.  I learned through Facebook some of Morgan’s user names and located a website where she posted music playlists she edited (in my day they were called mixed tapes).

I was excited about my find and I posted it along with the discovered user names to the Morgan discussion on websleuths.  Someone then did more digging and found Morgan’s Photobucket and Tumblr  Someone from WS, I’ve always thought it was Lera213, emailed Toni and told her WS had dug up Morgan’s personal accounts.  Toni then went through and deleted anything she found inappropriate. I was very angry over this. Morgan was an adult and was well within her rights to upload whatever photos she wanted without her mother expunging them.   I bear a great deal of responsibility for this coming to pass since I was the one who found the user names and posted them.  Luckily I’m not totally inept with a computer and I was able to retrieve many of the pictures from my cache and upload them to a new Photobucket.  All the Tumblr content is there as well. 

Please check back tomorrow Saturday March 23  Sunday March 24 or Monday March 25 for a new blog I have researched and written  It’s about amitriptyline and the things Toni doesn’t want anyone to know.

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