Drug Abuse Handbook, Second Edition

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Half Title Page

SECOND EDITION

Drug Abuse Handbook

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Title Page

SECOND EDITION

Drug Abuse Handbook Editor-in-Chief

Steven B. Karch, MD, FFFLM Consultant Pathologist and Toxicologist Berkeley, California

Boca Raton London New York

CRC Press is an imprint of the Taylor & Francis Group, an informa business

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CRC Press Taylor & Francis Group 6000 Broken Sound Parkway NW, Suite 300 Boca Raton, FL 33487-2742 © 2007 by Taylor & Francis Group, LLC CRC Press is an imprint of Taylor & Francis Group, an Informa business No claim to original U.S. Government works Printed in the United States of America on acid-free paper 10 9 8 7 6 5 4 3 2 1 International Standard Book Number-10: 0-8493-1690-1 (Hardcover) International Standard Book Number-13: 978-0-8493-1690-6 (Hardcover) This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted with permission, and sources are indicated. A wide variety of references are listed. Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequences of their use. No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers. For permission to photocopy or use material electronically from this work, please access www.copyright.com (http:// www.copyright.com/) or contact the Copyright Clearance Center, Inc. (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400. CCC is a not-for-profit organization that provides licenses and registration for a variety of users. For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged. Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Drug abuse handbook / [editor-in-chief] Steven B. Karch.-- 2nd ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8493-1690-6 (alk. paper) ISBN-10: 0-8493-1690-1 (alk. paper) 1. Drugs of abuse--Handbooks, manuals, etc. 2. Drug abuse--Handbooks, manuals, etc. 3. Forensic toxicology--Handbooks, manuals, etc. [DNLM: 1. Street Drugs--pharmacology--Handbooks. 2. Forensic Medicine--Handbooks. 3. Substance Abuse Detection--Handbooks. 4. Substance-Related Disorders--Handbooks. QV 39 D794 2006] I. Karch, Steven B. RM316.D76 2006 615’.19--dc22 Visit the Taylor & Francis Web site at http://www.taylorandfrancis.com and the CRC Press Web site at http://www.crcpress.com

2006008334

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Preface By the time this weighty volume is published, more than 10 years will have passed since I first approached Taylor & Francis (formerly CRC Press) about this project. I was surprised and delighted when they agreed to undertake this second edition. In the preface to the first edition I told readers that “a tremendous amount” had been learned about the problem of drug abuse, and I observed that most of the learning had been done not by pathologists, or even toxicologists, but rather by molecular biologists and neurochemists. That observation remains true today, even after all of the opiate receptors have been cloned, at a time when it impossible to look at drug–receptor interactions in ways that were inconceivable only a decade ago. In the preface to the first edition I also complained about the slow progress being made in more traditional, less “exotic” fields. The advent of the phenomenally popular CSI television show helped raise public awareness of crime scene investigation. Industry is certainly aware of the amazing progress and has not been slow to capitalize upon it, even to the extent of funding some badly need research. The same kind of progress in understanding the effects of drug abuse has not occurred in the field of pathology, or any other medical specialties, for that matter. To the best of my knowledge, during the last decade, The National Institute of Drug Abuse (NIDA) has not funded even a single pathologist interested in studying the effects of abused drugs on the heart, or pancreas, or any other organ in the body; no pathologist sits on any of the NIH review boards. Some might say this is the very opposite of progress. There is very little difference between the way doctors treat cases of drug toxicity nowadays and the way they did so 30 years ago. The last really great advance in this field was the introduction of naloxone. “Compassionate,” or not, the medical management of sick drug users is no more a priority of our current administration than of the previous one. Like it or not, the scientific study of drug abuse–related disease constitutes an important part of forensic science. When are drugs the cause of death and when do they cause impairment? It turns out that the metabolism of different drugs varies greatly from individual to individual. Some of these differences remain apparent even after death, but many, if not most, are not visible to the naked eye. Not many medical examiners have the training, let alone the equipment, to test for invisible disease. Does a very high fluoxetene level in a dead child signify a lethal overdose, or attempted murder, or is it a fluke of nature? The questions are more than academic, because the answers may determine whether criminal charges will be filed against the parents. Accordingly, this second edition of the handbook contains new chapters on both toxicogenetics and on the genetics of sudden cardiac death. Anyone who felt that they had mastered the art of DNA had best rethink their conclusions. Far from being a developed discipline, DNA testing is still only in its infancy. Should there be a third edition of this book, it will no doubt focus largely on DNA-related science; a great deal more than matching up single nucleotide polymorphisms is involved. Readers will also note the addition of a section on legal notions of causation. Doctors have known for years that the search for scientific truth is best carried on outside of the courtroom. What most doctors do not know is that in the minds of jury members, their opinions carry no more, and no less, weight than the opinion of any laboratory technician. Worse, both doctor and technician are likely to have only a vague idea of what constitutes proof, and what constitutes junk science. But, in fact, there is an easy way to tell: just use the scientific method. Most of this book is concerned with forensic science, the clinical management of toxic patients, and the management of addicted patients. At some point there must a convergence of these fields, and at some point all of these different disciplines become an evidence-based field. Case reports describing possible episodes of drug toxicity in solitary patients 30 years ago are insufficient to establish causation, not in the courtroom and not in the laboratory. Isolated post-mortem blood drug levels, no matter how “significant,” are insufficient to establish the cause of death. A great deal more work and

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knowledge are required before that can be done. No matter how great the scientific advances of the next decade, there will be no real and lasting impact on everyday practice, at least not until what we do is, in fact, evidence based. As should be apparent from the size of this volume, many individuals expended considerable energy to produce this book. It is probably a good thing that this book took so long to prepare because most of the truly exciting discoveries have occurred only in the last few years. My thanks to all of the contributors, and my best wishes to the next editor. I do hope he or she will have more positive and exciting things to report. Steven B. Karch, M.D., FFFLM

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The Editor Steven B. Karch, M.D., FFFLM, received his undergraduate degree from Brown University. He attended graduate school in anatomy and cell biology at Stanford University. He received his medical degree from Tulane University School of Medicine. Dr. Karch did postgraduate training in neuropathology at the Royal London Hospital and in cardiac pathology at Stanford University. For many years he was a consultant cardiac pathologist to San Francisco’s Chief Medical Examiner. In the U.K., Dr. Karch served as a consultant to the Crown and helped prepare the cases against serial murder Dr. Harold Shipman, who was subsequently convicted of murdering 248 of his patients. He has testified on drug abuse–related matters in courts around the world. He has a special interest in cases of alleged euthanasia, and in episodes where mothers are accused of murdering their children by the transference of drugs, either in utero or by breast feeding. Dr. Karch is the author of nearly 100 papers and book chapters, most of which are concerned with the effects of drug abuse on the heart. He has published seven books. He is currently completing the fourth edition of Pathology of Drug Abuse, a widely used textbook. He is also working on a popular history of Napoleon and his doctors. Dr. Karch is forensic science editor for Humana Press, and he serves on the editorial boards of the Journal of Cardiovascular Toxicology, the Journal of Clinical Forensic Medicine (London), Forensic Science, Medicine and Pathology, and Clarke's Analysis of Drugs and Poisons. Dr. Karch was elected a fellow of the Faculty of Legal and Forensic Medicine, Royal College of Physicians (London) in 2006. He is also a fellow of the American Academy of Forensic Sciences, the Society of Forensic Toxicologists (SOFT), the National Association of Medical Examiners (NAME), the Royal Society of Medicine in London, and the Forensic Science Society of the U.K. He is a member of The International Association of Forensic Toxicologists (TIAFT).

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Contributors Wilmo Andollo, B.S. Quality Assurance Officer Dade County Medical Examiner Toxicology Laboratory Miami, Florida

Neil L. Benowitz, M.D. Division of Clinical Pharmacology and Experimental Therapeutics University of California San Francisco, California

Lidia Avois-Mateus, Ph.D. Swiss Laboratory for Doping Analyses University Institute of Legal Medicine Lausanne, Switzerland

John W. Boja, Ph.D. U.S. Consumer Product Safety Commission Directorate for Health Sciences Bethesda, Maryland

Sanjay J. Ayirookuzhi, M.D. Department of Cardiology and Internal Medicine University of California Davis, California

Marc D. Bollman, M.D. University Institute of Legal Medicine Lausanne, Switzerland

Joanna Banbery, M.B.B.S. The Leeds Addiction Unit Leeds, U.K. Michael H. Baumann, Ph.D. Clinical Psychopharmacology Section Intramural Research Program National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland Norbert Baume, Ph.D. Swiss Laboratory for Doping Analyses University Institute of Legal Medicine Lausanne, Switzerland Michael R. Baylor, Ph.D. Health Sciences Unit Science and Engineering Group RTI International Research Triangle Park, North Carolina Michael D. Bell, M.D. District Medical Examiner Palm Beach Medical Examiner Office West Palm Beach, Florida

Joseph P. Bono, M.A. Supervisory Chemist Drug Enforcement Administration Special Testing and Research Laboratory McLean, Virginia Darlene H. Brunzell, Ph.D. Department of Psychiatry Yale University School of Medicine New Haven, Connecticut Allen P. Burke, M.D. Professor of Pathology and Medical Director Kernan Hospital Pathology Laboratory University of Maryland Medical Center Baltimore, Maryland Donna M. Bush, Ph.D., DABFT Drug Testing Team Leader Division of Workplace Programs Center for Substance Abuse Prevention Substance Abuse and Mental Health Services Administration Rockville, Maryland Jonica Calkins, M.D. Department of Cardiology and Internal Medicine University of California Davis, California

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Yale H. Caplan, Ph.D., DABFT National Scientific Services Baltimore, Maryland Vincent Cirimele, Ph.D. ChemTox Laboratory Illkirch, France Edward J. Cone, Ph.D. ConeChem Research Severna Park, Maryland Kelly P. Cosgrove, Ph.D. Department of Psychiatry Yale University School of Medicine New Haven, Connecticut and VA Connecticut Healthcare System West Haven, Connecticut Dennis J. Crouch, M.B.A. Director Sports Medicine Research and Testing Laboratory and Co-Director Center for Human Toxicology University of Utah Salt Lake City, Utah and Consulting Toxicologist The Walsh Group, P.A. Bethesda, Maryland Susan D. Crumpton, M.S. Health Sciences Unit Science and Engineering Group RTI International Research Triangle Park, North Carolina Henrik Druid M.D., Ph.D. Associate Professor Department of Forensic Medicine Karolinska Institute Stockholm, Sweden

Kenneth C. Edgell, M.S. Past Director (2001–2004) Office of Drug and Alcohol Policy and Compliance U.S. Department of Transportation Washington, D.C. David H. Epstein, Ph.D. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland Francis M. Esposito, Ph.D. Health Science Unit Science and Engineering Group RTI International Research Triangle Park, North Carolina Irina Esterlis, Ph.D. Department of Psychiatry Yale University School of Medicine New Haven, Connecticut and VA Connecticut Healthcare System West Haven, Connecticut Andrew Farb, M.D. U.S. Food and Drug Administration Rockville, Maryland Christian Giroud, Ph.D. Swiss Laboratory for Doping Analyses University Institute of Legal Medicine Lausanne, Switzerland Kathryn A. Glatter, M.D. Department of Cardiology and Internal Medicine University of California Davis, California Bruce A. Goldberger, Ph.D. University of Florida College of Medicine Gainesville, Florida

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Colin N. Haile, Ph.D. Department of Psychiatry Yale University School of Medicine New Haven, Connecticut and VA Connecticut Healthcare System West Haven, Connecticut W. Lee Hearn, Ph.D. Director Dade County Medical Examiner Toxicology Laboratory Miami, Florida

Daniel S. Isenschmid, Ph.D. Toxicology Laboratory Wayne County Medical Examiner’s Office Detroit, Michigan Amanda J. Jenkins, Ph.D. The Office of the Cuyahoga County Coroner Cleveland, Ohio Alan Wayne Jones, D.Sc. Department of Forensic Toxicology University Hospital Linköping, Sweden

Stephen J. Heishman, Ph.D. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland

Graham R. Jones, Ph.D., DABFT Office of the Chief Medical Examiner Edmonton, Alberta, Canada

Anders Helander, Ph.D. Department of Clinical Neuroscience Karolinska Institute and Karolinska University Hospital Stockholm, Sweden

Steven B. Karch, M.D., FFFLM Consultant Pathologist/Toxicologist Berkeley, California

Bradford R. Hepler, Ph.D. Toxicology Laboratory Wayne County Medical Examiner’s Office Detroit, Michigan Joe G. Hollingsworth, J.D. Spriggs & Hollingsworth Washington, D.C. Jonathan Howland, Ph.D. Social and Behavioral Sciences Department Boston University School of Public Health Boston, Massachusetts Marilyn A. Huestis, Ph.D. Chemistry and Drug Metabolism Section Intramural Research Program National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland

Leo Kadehjian, Ph.D. Biomedical Consulting Palo Alto, California

Thomas H. Kelly, Ph.D. Department of Behavioral Science University of Kentucky College of Medicine Lexington, Kentucky Pascal Kintz, Pharm.D., Ph.D. ChemTox Laboratory Illkirch, France Frank D. Kolodgie, Ph.D. Armed Forces Institute of Pathology Washington, D.C. Suchitra Krishnan-Sarin, Ph.D. Department of Psychiatry Yale University School of Medicine New Haven, Connecticut and VA Connecticut Healthcare System West Haven, Connecticut Eric G. Lasker, J.D. Spriggs & Hollingsworth Washington, D.C.

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Nick Lintzeris, M.B.B.S., Ph.D. National Addiction Centre South London and Maudsley NHS Trust London, U.K. Barry K. Logan, Ph.D. Director Washington State Toxicology Laboratory Department of Laboratory Medicine University of Washington Seattle, Washington Patrice Mangin, Ph.D. University Institute of Legal Medicine Lausanne, Switzerland Christopher S. Martin, Ph.D. Western Psychiatric Institute and Clinic Department of Psychiatry University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Deborah C. Mash, Ph.D. Departments of Neurology and Molecular and Cellular Pharmacology University of Miami Miller School of Medicine Miami, Florida William M. Meil, Ph.D. Department of Psychology Indiana University of Pennsylvania Indiana, Pennsylvania John M. Mitchell, Ph.D. Health Science Unit Science and Engineering Group RTI International Research Triangle Park, North Carolina Florabel G. Mullick, M.D. Armed Forces Institute of Pathology Washington, D.C. Rudy Murillo, B.A. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland

Carol S. Myers, Ph.D. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institute of Health Department of Health and Human Services Baltimore, Maryland Jagat Narula, M.D., Ph.D. University of California, Irvine School of Medicine and Medical Center Irvine, California Kent R. Olson, M.D. Division of Clinical Pharmacology and Experimental Therapeutics University of California San Francisco, California Wallace B. Pickworth, Ph.D. Battelle Centers for Public Health Research and Evaluation Baltimore, Maryland Anya Pierce, M.Sc., M.B.A. Toxicology Department Beaumont Hospital Dublin, Ireland, U.K. Derrick J. Pounder, M.D. Department of Forensic Medicine University of Dundee Scotland, U.K. Kenzie L. Preston, Ph.D. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland Duncan Raistrick, M.B.B.S. The Leeds Addiction Unit Leeds, U.K. Neil Robinson, Ph.D. Swiss Laboratory for Doping Analyses University Institute of Legal Medicine Lausanne, Switzerland

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Brett A. Roth, M.D. University of Texas Southwestern Medical Center Dallas, Texas Richard B. Rothman, M.D., Ph.D. Clinical Psychopharmacology Section Intramural Research Program National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland Angela Sampson-Cone, Ph.D. ConeChem Research Severna Park, Maryland Christophe Saudan, Ph.D. Swiss Laboratory for Doping Analyses University Institute of Legal Medicine Lausanne, Switzerland Martial Saugy, Ph.D. Swiss Laboratory for Doping Analyses University Institute of Legal Medicine Lausanne, Switzerland John P. Schmittner, M.D. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland Theodore F. Shults, J.D., M.S. Chairman American Association of Medical Review Officers Research Triangle Park, North Carolina Julie K. Staley, Ph.D. Department of Psychiatry Yale University School of Medicine New Haven, Connecticut and VA Connecticut Healthcare System West Haven, Connecticut

Craig A. Sutheimer, Ph.D. Health Sciences Unit Science and Engineering Group RTI International Research Triangle Park, North Carolina Richard C. Taylor, M.A. Clinical Pharmacology and Therapeutics Branch National Institute on Drug Abuse National Institutes of Health Department of Health and Human Services Baltimore, Maryland Joseph A. Thomasino, M.D., M.S., FACPM JAT MRO, Inc. Jacksonville, Florida Jane S. C. Tsai, Ph.D. Roche Diagnostics Indianapolis, Indiana Alain Verstraete, M.D., Ph.D. Ghent University Hospital Laboratory of Clinical Biology–Toxicology Ghent, Belgium Marion Villain, M.S. ChemTox Laboratory Illkirch, France Renu Virmani, M.D., F.A.C.C. Medical Director CVPath International Registry of Pathology Gaithersburg, Maryland H. Chip Walls, B.S. Department of Pathology Forensic Toxicology Laboratory University of Miami Miami, Florida J. Michael Walsh, Ph.D. The Walsh Group, P.A. Bethesda, Maryland

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Sharon L. Walsh, Ph.D. Department of Behavioral Science Center on Drug and Alcohol Research University of Kentucky College of Medicine Lexington, Kentucky Charles V. Wetli, M.D. Chief Medical Examiner Office of the Suffolk County Medical Examiner Hauppage, New York Robert M. White, Sr., Ph.D. Technical Director DSI Laboratories Fort Myers, Florida Kim Wolff, Ph.D. King’s College London Institute of Psychiatry National Addiction Centre London, U.K.

Steven H.Y. Wong, Ph.D. Professor of Pathology and Director Clinical Chemistry/Toxicology TDM, Pharmacogenomics, Proteomics Medical College of Wisconsin and Scientific Director Toxicology Department Milwaukee County Medical Examiner’s Office Milwaukee, Wisconsin J. Robert Zettl, B.S., M.P.A., DABFE Forensic Consultants, Inc. Centennial, Colorado Shoshanna Zevin, M.D. Department of Internal Medicine Shaare Zedek Medical Center Jerusalem, Israel

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Contents Chapter 1

Criminalistics: Introduction to Controlled Substances..............................................1 Joseph P. Bono, M.A.

Chapter 2

Pathology of Drug Abuse.........................................................................................71 Edited by Charles V. Wetli, M.D.

Chapter 3

Pharmacokinetics: Drug Absorption, Distribution, and Elimination ....................147 Amanda J. Jenkins, Ph.D.

Chapter 4

Pharmacodynamics.................................................................................................207 Edited by Stephen J. Heishman, Ph.D.

Chapter 5

Alcohol ...................................................................................................................313 Edited by Alan Wayne Jones, D.Sc.

Chapter 6

Neurochemistry of Drug Abuse .............................................................................429 Edited by Julie K. Staley, Ph.D. and Kelly P. Cosgrove, Ph.D.

Chapter 7

Addiction Medicine................................................................................................559 Edited by Kim Wolff, Ph.D.

Chapter 8

Medical Complications of Drug Abuse .................................................................597 Edited by Neal L. Benowitz, M.D.

Chapter 9

Sports......................................................................................................................695 Edited by Marc D. Bollmann, M.D. and Martial Saugy, Ph.D.

Chapter 10

Workplace Testing..................................................................................................727 Edited by Yale H. Caplan, Ph.D., DABFT, and Marilyn A. Huestis, Ph.D.

Chapter 11

Point of Collection Drug Testing...........................................................................895 Edited by Dennis J. Crouch, M.B.A.

Chapter 12

Post-Mortem Toxicology .......................................................................................961 Edited by Henrik Druid, M.D., Ph.D.

Chapter 13

Toxicogenetics......................................................................................................1087 Edited by Steven B. Karch, M.D., FFFLM

Chapter 14

Drug Law .............................................................................................................1117

Appendices ..................................................................................................................................1175 Index ............................................................................................................................................1225

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CHAPTER

1

Criminalistics: Introduction to Controlled Substances Joseph P. Bono, M.A. Supervisory Chemist, Drug Enforcement Administration, Special Testing and Research Laboratory, McLean, Virginia

CONTENTS Introduction ........................................................................................................................................3 1.1 Definition and Scheduling of Controlled Substances..............................................................3 1.2 Scheduling of Controlled Substances ......................................................................................3 1.3 Controlled Substance Analogue Enforcement Act of 1986.....................................................4 1.4 Controlled Substances ..............................................................................................................5 1.4.1 Heroin ...........................................................................................................................5 1.4.1.1 Heroin Sources by Region ............................................................................6 1.4.1.2 Isolation of Morphine and Heroin Production .............................................7 References.................................................................................................................................9 1.4.2 Cocaine .........................................................................................................................9 1.4.2.1 Sources of Cocaine .....................................................................................10 1.4.2.2 Historical Considerations ............................................................................11 1.4.2.3 Isolation and Purification ............................................................................11 1.4.2.4 Conversion to “Crack” ................................................................................12 1.4.2.5 Other Coca Alkaloids..................................................................................13 1.4.2.6 Cocaine Adulterants ....................................................................................14 1.4.2.7 Conclusion...................................................................................................14 References...............................................................................................................................14 1.4.3 Marijuana....................................................................................................................15 1.4.3.1 History and Terminology ............................................................................15 1.4.3.2 Laboratory Analysis ....................................................................................16 1.4.4 Peyote .........................................................................................................................17 1.4.5 Psilocybin Mushrooms ...............................................................................................18 References...............................................................................................................................19 1.4.6 Lysergic Acid Diethylamide.......................................................................................20 1.4.7 Phencyclidine..............................................................................................................20 1.4.8 Fentanyl ......................................................................................................................21 1.4.9 Phenethylamines .........................................................................................................22 1


2

1.5

1.6

1.7

1.8

1.9

DRUG ABUSE HANDBOOK, SECOND EDITION

1.4.10 Methcathinone ............................................................................................................28 1.4.11 Catha edulis (Khat) ....................................................................................................29 References...............................................................................................................................29 1.4.12 Anabolic Steroids .......................................................................................................30 1.4.12.1 Regulatory History ......................................................................................30 1.4.12.2 Structure–Activity Relationship..................................................................32 1.4.12.3 Forensic Analysis ........................................................................................33 Acknowledgment ....................................................................................................................34 References...............................................................................................................................34 Legitimate Pharmaceutical Preparations................................................................................35 1.5.1 Benzodiazepines .........................................................................................................35 1.5.2 Other Central Nervous System Depressants..............................................................35 1.5.3 Narcotic Analgesics ....................................................................................................36 1.5.4 Central Nervous System Stimulants ..........................................................................37 1.5.5 Identifying Generic Products .....................................................................................37 Reference ................................................................................................................................37 Unique Identifying Factors.....................................................................................................37 1.6.1 Packaging Logos ........................................................................................................37 1.6.2 Tablet Markings and Capsule Imprints......................................................................38 1.6.3 Blotter Paper LSD ......................................................................................................39 References...............................................................................................................................40 Analyzing Drugs in the Forensic Science Laboratory ..........................................................40 1.7.1 Screening Tests ...........................................................................................................40 1.7.1.1 Physical Characteristics ..............................................................................40 1.7.1.2 Color Tests ..................................................................................................41 1.7.1.3 Thin-Layer Chromatography ......................................................................41 1.7.2 Confirmatory Chemical Tests.....................................................................................42 1.7.2.1 Microcrystal Identifications ........................................................................42 1.7.2.2 Gas Chromatography ..................................................................................42 1.7.2.3 High-Performance Liquid Chromatography ...............................................43 1.7.2.4 Capillary Electrophoresis ............................................................................44 1.7.2.5 Infrared Spectrophotometry ........................................................................44 1.7.2.6 Gas Chromatography/Mass Spectrometry ..................................................45 1.7.2.7 Nuclear Magnetic Resonance Spectroscopy...............................................46 References...............................................................................................................................47 1.7.3 Controlled Substances Examinations .........................................................................47 1.7.3.1 Identifying and Quantitating Controlled Substances..................................48 1.7.3.2 Identifying Adulterants and Diluents..........................................................50 1.7.3.3 Quantitating Controlled Substances............................................................51 1.7.3.4 Reference Standards....................................................................................52 References...............................................................................................................................53 Comparative Analysis.............................................................................................................53 1.8.1 Determining Commonality of Source........................................................................53 1.8.2 Comparing Heroin Exhibits .......................................................................................54 1.8.3 Comparing Cocaine Exhibits .....................................................................................54 References...............................................................................................................................55 Clandestine Laboratories ........................................................................................................55 1.9.1 Safety Concerns..........................................................................................................57 1.9.2 Commonly Encountered Chemicals in the Clandestine Laboratory .........................58 Reference ................................................................................................................................60


CRIMINALISTICS: INTRODUCTION TO CONTROLLED SUBSTANCES

1.9.3

3

Tables of Controlled Substances ................................................................................60 1.9.3.1 Generalized List by Category of Physiological Effects and Medical Uses of Controlled Substances ...................................................................60 1.9.3.2 Listing of Controlled Substances by Schedule Number ............................62 INTRODUCTION

This chapter is concerned with the identification and analysis of physical evidence derived from drugs and drug users. The chapter begins with an introduction to the most popular synthetic routes preferred by clandestine drug makers. Sections are devoted to brief regulatory histories and overviews of the most common drugs (heroin, cocaine, and marijuana) as well as some of the lesser known licit and illicit drug agents. An overview is provided of what information is required to make a defensible forensic identification. This includes an introduction to drug logos, tablet markings and capsule imprints, and blotter acid. The remaining sections provide introductions to the various field and laboratory screening and confirmatory testing procedures. Techniques of comparative analysis are explained, and methods for comparing cocaine and heroin courtroom exhibits are presented. The trade names of commonly encountered chemicals are listed. The chapter concludes with tabular listings of controlled substances by schedule number. 1.1 DEFINITION AND SCHEDULING OF CONTROLLED SUBSTANCES A “controlled substance” is a drug or substance of which the use, sale, or distribution is regulated by the federal government or a state government entity. These controlled substances are listed specifically or by classification on the federal level in the Controlled Substances Act (CSA) or in Part 1308 of the Code of Federal Regulations. The purpose of the CSA is to minimize the quantity of usable substances available to those who are likely to abuse them. At the same time, the CSA provides for the legitimate medical, scientific, and industrial needs of these substances in the U.S. 1.2 SCHEDULING OF CONTROLLED SUBSTANCES Eight factors are considered when determining whether or not to schedule a drug as a controlled substance: 1. 2. 3. 4. 5. 6. 7. 8.

Actual or relative potential for abuse Scientific evidence of pharmacological effect State of current scientific knowledge History of current pattern of abuse Scope, duration, and significance of abuse Risk to the public health Psychic or physiological dependence liability Immediate precursor

The definition of potential for abuse is based on individuals taking a drug of their own volition in sufficient amounts to cause a health hazard to themselves or to others in the community. Data are then collected to evaluate three factors: (1) actual abuse of the drug; (2) the clandestine manufacture of the drug; (3) trafficking and diversion of the drug or its precursors from legitimate channels into clandestine operations. Preclinical abuse liability studies are then conducted on animals to evaluate physiological responses to the drug. At this point, clinical abuse liability studies can be conducted with human subjects, which evaluate preference studies and epidemiology.


4


Accumulating scientific evidence of a drug’s pharmacological effects involves examining the scientific data concerning whether the drug elicits a stimulant, depressant, narcotic, or hallucinogenic response. A determination can then be made regarding how closely the pharmacology of the drug resembles that of other drugs that are already controlled. Evidence is also accumulated about the scientific data on the physical and chemical properties of the drug. This can include determining which salts and isomers are possible and which are available. There is also a concern for the ease of detection and identification using analytical chemistry. Because many controlled substances have the potential for clandestine synthesis, there is a requirement for evaluating precursors, possible synthetic routes, and theoretical yields in these syntheses. At this phase of the evaluation, medical uses are also evaluated. The next three factors — (1) history and patterns of abuse; (2) scope, duration, and significance of abuse; and (3) risks to public health — all involve sociological and medical considerations. The results of these studies focus on data collection and population studies. Psychic and physiological dependence liability studies must be satisfied for a substance to be placed on Schedules II through V. This specific finding is not necessary to place a drug on Schedule I. A practical problem here is that it is not always easy to prove a development of dependence. The last factor is one that can involve the forensic analyst. Under the law, an “immediate precursor” is defined as a substance that is an immediate chemical intermediary used or likely to be used in the manufacture of a specific controlled substance. Defining synthetic pathways in the clandestine production of illicit controlled substances requires knowledge possessed by the experienced analyst. A controlled substance will be classified and named in one of five schedules. Schedule I includes drugs or other substances that have a high potential for abuse, no currently accepted use in the treatment of medical conditions, and little, if any, accepted safety criteria under the supervision of a medical professional. Use of these substances will almost always lead to abuse and dependence. Some of the more commonly encountered Schedule I controlled substances are heroin, marijuana, lysergic acid diethylamide (LSD), 3,4-methylenedioxy-amphetamine (MDA), and psilocybin mushrooms. Progressing from Schedule II to Schedule V, abuse potential decreases. Schedule II controlled substances also include drugs or other substances that have a high potential for abuse, but also have some currently accepted, but severely restricted, medical uses. Abuse of Schedule II substances may lead to dependence, which can be both physical and psychological. Because Schedule II controlled substances do have some recognized medical uses, they are usually available to health professionals in the form of legitimate pharmaceutical preparations. Cocaine hydrochloride is still used as a topical anesthetic in some surgical procedures. Methamphetamine, up until a few years ago, was used in the form of Desoxyn to treat hyperactivity in children. Raw opium is included in Schedule II. Amobarbital and secobarbital, which are used as central nervous system depressants, are included, as is phencyclidine (PCP), which was used as a tranquilizer in veterinary pharmaceutical practices. In humans, PCP acts as a hallucinogen. Although many of the substances seized under Schedule II were not prepared by legitimate pharmaceutical entities, cocaine hydrochloride and methamphetamine are two examples of Schedule II drugs that, when confiscated as white to off-white powder or granules in plastic or glassine packets, have almost always been prepared on the illicit market for distribution. As one progresses from Schedules III through V, most legitimate pharmaceutical preparations are encountered.

1.3 CONTROLLED SUBSTANCE ANALOGUE ENFORCEMENT ACT OF 1986 In recent years, the phenomenon of controlled substance analogues and homologues has presented a most serious challenge to the control of drug trafficking and successful prosecution of clandestine laboratory operators. These homologues and analogues are synthesized drugs that are



5

chemically and pharmacologically similar to substances that are listed in the Controlled Substances Act, but which themselves are not specifically controlled by name. (The term “designer drug” is sometimes used to describe these substances.) The concept of synthesizing controlled substance analogues in an attempt to circumvent existing drug law was first noticed in the late 1960s. At about this time there were seizures of clandestine laboratories engaged in the production of analogues of controlled phenethylamines. In the 1970s variants of methaqualone and phencyclidine were being seized in clandestine laboratories. By the 1980s, Congress decided that the time had come to deal with this problem with a federal law enforcement initiative. The Controlled Substance Analogue Enforcement Act of 1986 amends the Comprehensive Drug Abuse Prevention and Control Act of 1970 by including the following section: Section 203. A controlled substance analogue shall to the extent intended for human consumption, be treated, for the purposes of this title and title III as a controlled substance in schedule I.

The 99th Congress went on to define the meaning of the term “controlled substance analogue” as a substance: (i) the chemical structure of which is substantially similar to the chemical structure of a controlled substance in schedule I or II; (ii) which has a stimulant, depressant, or hallucinogenic effect on the central nervous system that is substantially similar to or greater than the stimulant, depressant, or hallucinogenic effect on the central nervous system of a controlled substance in schedule I or II; or (iii) with respect to a particular person, which person represents or intends to have a stimulant, depressant, or hallucinogenic effect on the central nervous system of a controlled substance in schedule I or II.

The Act goes on to exclude: (i) a controlled substance (ii) any substance for which there is an approved new drug application (iii) with respect to a particular person any substance, if an exemption is in effect for investigational use, for that person, under section 505 … to the extent conduct with respect to such substance is pursuant to such exemption; or (iv) any substance to the extent not intended for human consumption before such an exemption takes effect with respect to that substance.

Treatment of exhibits falling under the purview of the federal court system is described in Public Law 91-513 or Part 1308 of the Code of Federal Regulations. Questions relating to controlled substance analogues and homologues can usually be answered by reference to the Controlled Substances Analogue and Enforcement Act of 1986.

1.4 CONTROLLED SUBSTANCES 1.4.1

Heroin

Whenever one thinks about drugs of abuse and addiction, heroin is one of the most recognized drugs. Heroin is a synthetic drug, produced from the morphine contained in the sap of the opium


6


poppy. The abuse of this particular controlled substance has been known for many years. The correct chemical nomenclature for heroin is O3,O6-diacetylmorphine. Heroin is synthesized from morphine in a relatively simple process. The first synthesis of diacetylmorphine reported in the literature was in 1875 by two English chemists, G.H. Beckett and C.P. Alder Wright.1 In 1898 in Elberfeld, Germany, the Farbenfabriken vorm. Friedrich Bayer & Co. produced the drug commercially. An employee of the company, H. Dresser, named the morphine product “heroin.”2 There is no definitive documentation as to where the name “heroin” originated. However, it probably had its origin in the “heroic remedies” class of drugs of the day. Heroin was used in place of codeine and morphine for patients suffering from lung diseases such as tuberculosis. Additionally, the Bayer Company advertised heroin as a cure for morphine addiction. The analgesic properties of the drug were very effective. However, the addictive properties were quite devastating. In 1924, Congress amended the Narcotic Drug Import and Export Act to prohibit the importation of opium for the manufacture of heroin. However, stockpiles were still available and could be legally prescribed by physicians. The 1925 International Opium Convention imposed drug controls that began to limit the supply of heroin from Europe. Shortly thereafter, the clandestine manufacture of heroin was reported in China. The supplies of opium in the Far East provided a ready source of morphine — the starting material for the synthesis. The medical use of heroin in the U.S. was not banned until July 19, 1956 with the passage of Public Law 728, which required all inventories to be surrendered to the federal government by November 19, 1956. In the past 50 or so years, the source countries for opium used in clandestine heroin production have increased dramatically. Political and economic instability in many areas of the world accounts for much of the increased production of heroin. The opium that is used to produce the heroin that enters the U.S. today has four principal sources. Geographically all of these regions are characterized by a temperate climate with appropriate rainfall and proper soil conditions. However, there are differences in the quality of opium, the morphine content, and the number of harvests from each of these areas. Labor costs are minimal and the profit margins are extremely high for those in the upper echelons of heroin distribution networks. 1.4.1.1 Heroin Sources by Region Southeast Asia — The “Golden Triangle” areas of Burma, China, and Laos are the three major source countries in this part of the world for the production of illicit opium. Of these three countries, 60 to 80% of the total world supply of heroin comes from Burma. Heroin destined for the U.S. transits a number of countries including Thailand, Hong Kong, Japan, Korea, the Philippines, Singapore, and Taiwan. Southeast Asian heroin is usually shipped to the U.S. in significant quantities by bulk cargo carriers. The techniques for hiding the heroin in the cargo are quite ingenious. The shipment of Southeast Asian (SEA) heroin in relatively small quantities is also commonplace. Criminal organizations in Nigeria have been deeply involved in the smallquantity smuggling of SEA heroin into the U.S. The “body carry” technique and ingestion are two of the better known methods of concealment by the Nigerians. SEA heroin is high quality and recognized by its white crystalline appearance. Although the cutting agents are numerous, caffeine and acetaminophen appear quite frequently. Southwest Asia — Turkey, Iraq, Iran, Afghanistan, Pakistan, India, Lebanon, and the newly independent states of the former Soviet Union (NIS) are recognized as source countries in this part of the world. Trafficking of Southwest Asian heroin has been on the decline in the U.S. since the end of 1994. Southwest Asian heroin usage is more predominant in Europe than in the U.S. The Southwest Asian heroin that does arrive in the U.S. is normally transshipped through Europe, Africa, and the NIS. The political and economic conditions of the NIS and topography of the land make these countries ideal as transit countries for heroin smuggling. The rugged mountainous terrain and the absence of significant enforcement efforts enable traffickers to proceed unabated. Most Southwest Asian heroin trafficking groups in the originating countries, the transiting countries, and the U.S. are highly cohesive ethnic groups. These groups rely less on the bulk shipment and more on smaller



7

quantity commercial cargo smuggling techniques. Southwest Asian heroin is characterized by its off-white to tan powdery appearance as compared to the white SEA heroin. The purity of Southwest Asian heroin is only slightly lower than that of SEA heroin. The cutting agents are many: phenobarbital, caffeine, acetaminophen, and calcium carbonate appear quite frequently. Central America — Mexico and Guatemala are the primary source countries for heroin in Central America. Mexico’s long border with the U.S. provides easy access for smuggling and distribution networks. Smuggling is usually small scale and often involves illegal immigrants and migrant workers crossing into the U.S. Heroin distribution in the U.S. is primarily the work of Mexican immigrants from the States of Durango, Michoacan, Nuevo Leon, and Sinaloa. Concealment in motor vehicles, public transportation, external body carries, and commercial package express are common. This heroin usually ranges from a dark brown powder to a black tar. The most commonly encountered adulterants are amorphous (formless and indeterminate) materials and sugars. The dark color of Mexican heroin is attributed to processing by-products. The purity of Mexican heroin varies greatly from seizure to seizure. South America — Heroin production in this part of the world is a relatively new phenomenon. Cultivation of opium has been documented along the Andean mountain range within Colombia in the areas of Cauca, Huila, Tolima, and Santaner. There have been a number of morphine base and heroin processing facilities seized in Colombia in the past few years. Smuggling of South American heroin into the U.S. increased dramatically in 1994 and 1995. The primary method of smuggling has been by Colombian couriers aboard commercial airliners using false-sided briefcases and luggage, hollowed out shoes, or by ingestion. Miami and New York are the primary ports of entry into the U.S. One advantage that the traffickers from South America have is the importation networks that are already in place for the distribution of cocaine into the U.S. Transshipment of this heroin through other South American countries and the Caribbean is also a common practice. South American heroin has many of the same physical characteristics of Southwest Asian heroin. However, the purity of South American heroin is higher, with fewer adulterants than Southwest Asian heroin. Cocaine in small quantities is oftentimes encountered in South American heroin exhibits. In such cases, it is not always clear whether the cocaine is present as a contaminant introduced due to common packaging locations of cocaine and heroin, or whether it has been added as an adulterant.

1.4.1.2 Isolation of Morphine and Heroin Production There are some very specific methods for producing heroin. However, all involve the same four steps: (1) The opium poppy (Papaver somniferum L.) is cultivated; (2) the poppy head is scored and the opium latex is collected; (3) the morphine is the isolated from the latex; and (4) the morphine is treated with an acetylating agent. Isolation of the morphine in Step 3 is accomplished using a rendition of one of the following five methods: 1. Thiboumery and Mohr Process (TMP) — This is the best known of the reported methods for isolating morphine followed by the acetylation to heroin. Dried opium latex is dissolved in three times its weight of hot water. The solution is filtered hot, which removes undissolved botanical substances. These undissolved botanicals are washed with hot water and filtered. This is done to ensure a maximized yield of morphine in the final product. The filtrate is reduced to half its volume by boiling off the water. The laboratory operator then adds to the filtrate a boiling solution of calcium hydroxide, which forms the water-soluble calcium morphinate. The precipitates, which include the insoluble alkaloids from the opium, and the insoluble materials from this step are filtered. These insolubles are then washed three more times with water and filtered. The resulting filtrate, which contains calcium morphinate still in solution, is then evaporated to a weight of approximately twice the weight of the original weight of the opium and then filtered. This results in a concentrated calcium morphinate solution, which is heated to a boil. Ammonium chloride is then added to reduce the pH below 9.85. When this solution cools, morphine base precipitates and is collected by filtration. The morphine base is dissolved in a minimum volume of warm hydrochloric acid. When this solution cools the morphine hydrochloride precipitates. The precipitated morphine hydrochloride is then isolated by filtration.


8


2. Robertson and Gregory Process (RGP) — This method is similar to TMP. The laboratory operator washes the opium with five to ten times its weight of cold water. The solution is then evaporated to a syrup, which is then re-extracted with cold water and filtered. The filtrate is evaporated until the specific gravity of the solution is 1.075. The solution is boiled and calcium chloride is added. Cold water is added to the calcium morphinate solution, which is then filtered. The solution is concentrated and the calcium morphinate then precipitates out of solution as the liquid evaporates. The calcium morphinate is then redissolved in water and filtered. To the filtrate is added ammonia, which allows the morphine base to precipitate. This morphine base can then be further treated to produce the pharmaceutical quality morphine.

The TMP and RGP are used by commercial suppliers for the initial isolation of morphine from opium. In clandestine laboratories, the same methodologies and rudimentary steps are followed. However, since the operators are using “bucket chemistry,” there are modifications to hasten and shortcut the processes. Three other methods can then be utilized to convert the relatively crude morphine base through purification processes to high-quality morphine base or morphine hydrochloride crystals. Modifications of these purifications are used by clandestine laboratory operators. 3. Barbier Purification — The morphine base is dissolved in 80°C water. Tartaric acid is added until the solution becomes acidic to methyl orange. As the solution cools, morphine bitartrate precipitates, is filtered, washed with cold water, and dried. The morphine bitartrate is then dissolved in hot water and ammonia is added to pH 6. This results in a solution of morphine monotartrate. The laboratory operator then adds activated carbon black, sodium bisulfite, sodium acetate, and ammonium oxalate. This process results in a decolorization of the morphine. When this decolorization process is complete, ammonia is added to the solution, which results in white crystals of morphine base. These purified morphine base crystals are then filtered and dried. This high-quality morphine base is converted to morphine hydrochloride by adding 30% ethanolic HCl to a warm solution of morphine in ethanol. The morphine hydrochloride crystallizes from solution as the solution cools. 4. Schwyzer Purification — The acetone-insoluble morphine base (from either the TMB or RGP) is washed in with acetone. The morphine base is then re-crystallized from hot ethyl alcohol. 5. Heumann Purification — The laboratory operator washes the morphine base (from either the TMB or RGP) with trichloroethylene, followed by a cold 40% ethanol wash. This is subsequently followed by an aqueous acetone wash.

The quality of the clandestine product is usually evaluated by the color and texture of the morphine from one of these processes. If the clandestine laboratory is producing morphine as its end product, with the intention of selling the morphine for conversion by a second laboratory, the morphine will usually be very pure. However, if the operator continues with the acetylation of the morphine to heroin, the “intermediate” morphine will frequently be relatively impure. Heroin can be produced synthetically, but requires a ten-step process and extensive expertise in synthetic organic chemistry. The total synthesis of morphine has been reported by Gates and Tschudi in 1952 and by Elad and Ginsburg in 1954.3,4 A more recent synthesis was reported by Rice in 1980.5 All these methods require considerable forensic expertise and result in low yield. There are also methods reported in the literature for converting codeine to morphine using an Odemethylation. The morphine can then be acetylated to heroin. One of these procedures is referred to as “homebake” and was described in the literature by Rapoport et al.6 This particular procedure has been reported only in New Zealand and Australia. Acetylation of Morphine to Diacetylmorphine (Heroin) — This process involves placing dried morphine into a reaction vessel and adding excess acetic anhydride (Figure 1.4.1). Sometimes a co-solvent is also used. The mixture is heated to boiling and stirred for varying periods of time ranging from 30 min up to 3 or 4 h. The vessel and contents are cooled and diluted in cold water. A sodium carbonate solution is then added until precipitation of the heroin base is complete and



9

Acetic Anhydride

CH3

CH3

O O

N

N

CH3COCCH3 +

or O

HO

OH O Morphine

CH3CCl Acetyl Chloride

O CH3CO

O O

OCCH3

Heroin

Figure 1.4.1 Clandestine laboratory synthesis of heroin.

settles to the bottom of the reaction vessel. The heroin base is then either filtered and dried or undergoes further processing to enhance the purity or to convert the base to heroin hydrochloride. Processing By-Products and Degradation Products in Heroin — Pharmaceutical-grade heroin has a purity of greater than 99.5%. Impurities include morphine, the O-3- and O-6-monoacetylmorphines, and other alkaloidal impurities and processing by-products. The impurities found in clandestinely produced heroin include, but are certainly not limited to: the monoacetylmorphines, morphine, codeine, acetylcodeine, papaverine, noscapine, thebaine, meconine, thebaol, acetylthebaol, norlaudanosine, reticuline, and codamine. These impurities (from both quantitative and qualitative perspectives) are retained as the result of anomalies in processing methodologies.

REFERENCES 1. 2. 3. 4. 5.

Anon., Heroin, J. Chem. Soc. London, 28, 315–318, 1875. Anon., Heroin, Arch. Ges. Physiol., 72, 487, 1898. Gates, M. and Tschudi, G., The synthesis of morphine, J. Am. Chem. Soc., 74, 1109–1110, 1952. Elad, E. and Ginsburg, D., The synthesis of morphine, J. Am. Chem. Soc., 76, 312–313, 1954. Rice, K.C., Synthetic opium alkaloids and derivatives. A short total synthesis of (±)-dihydrothebainone, (±)-dihydrocodinone, and (±)-nordihydrocodinone as an approach to the practical synthesis of morphine, codeine, and congeners, J. Org. Chem., 45, 3135–3137, 1980. 6. Rapoport, H. and Bonner, R.M., delta-7-Desoxymorphine, J. Am. Chem. Soc., 73, 5485, 1951.

1.4.2

Cocaine

The social implications of cocaine abuse in the U.S. has been the subject of extensive media coverage from the 1980s to the present day. As a result, the general public has acquired some of the terminology associated with the cocaine usage. “Smoking crack” and “snorting coke” are terms that have become well understood in the American culture from elementary school through adulthood. However, there are facts associated with this drug that are not well understood by the general public. There are documented historical aspects associated with coca and cocaine abuse that go back 500 years. Recognizing some of these historical aspects enables the public to place today’s problem in perspective. Cocaine addiction has been with society for well over 100 years. There are four areas of interest this section will address: (1) Where does cocaine come from? (2) How is cocaine isolated from the coca plant? (3) What does one take into the body from cocaine purchased on the street? (4) How does the chemist analyzing the drug identify and distinguish between the different forms of cocaine? Cocaine is a Schedule II controlled substance. The wording in Title 21, Part 1308.12(b)(4) of the Code of Federal Regulations states: Coca leaves (9040) and any salt, compound, derivative or preparation of coca leaves (including cocaine (9041) and ecgonine (9180) and their salts, isomers, derivatives and salts of isomers and derivatives),


10


and any salt, compound, derivative, or preparation thereof which is chemically equivalent or identical with any of these substances, except that the substances shall not include decocanized coca leaves, or extractions of coca leaves, do not contain cocaine or ecgonine.

It is significant that the term “coca leaves” is the focal point of that part of the regulation controlling cocaine. The significance of this fact will become more apparent as this discussion progresses. 1.4.2.1 Sources of Cocaine Cocaine is just one of the alkaloidal substances present in the coca leaf. Other molecules, some of them psychoactive (norcocaine being the most prominent), are shown in Figure 1.4.2. Cocaine is extracted from the leaves of the coca plant. The primary of source of cocaine imported into the U.S. is South America, but the coca plant also grows in the Far East in Ceylon, Java, and India. The plant is cultivated in South America on the eastern slopes of the Andes in Peru and Bolivia. There are four varieties of coca plants — Erythroxylon coca var. coca (ECVC), E. coca var. ipadu, E. novogranatense var. novogranatense, and E. novogranatense var. truxillense.1–3 ECVC is the variety that has been used for the manufacture of illicit cocaine. While cultivated in many countries of South America, Peru and Bolivia are the world’s leading producers of the coca plant. Cocaine is present in the coca leaves from these countries at dry weight concentrations of from 0.1 to 1%. The average concentration of cocaine in the leaf is 0.7%. The coca shrub has a life expectancy of 50 years and can be harvested three or four times a year. CH3

N

N

COOCH3 H

N

CH3

N

COOH

CH3 COOH H

CH3 COOCH3

OCOC6H5 H

OCOC6H5 H

Cocaine

Ecgonidine

Methylecgonidine

Benzoylecgonine

O CH

N

N

COOCH3 H

H

N

COOCH3 H

OCOC6H5 H

CH3

N

O

Norcocaine

OC H

N

H

COCH3 H O

CH3

Ecgonine

Methylecgonine

C

OC H

H

trans-Cinnamoylcocaine

N

H

COOH

H

O COCH3 H O

C

COOCH3 H OH H

H CH3

CH3

OH H

OCOC6H5 H

N-Formylcocaine

N

COOH H

Ph C C H H

COOH

H

cis-Cinnamoylcocaine

Ph

H

H O COOH

OC H

Tropacocaine Figure 1.4.2 Substances present in coca leaf.

OC H

Benzoic Acid

Ph

H

beta-Truxinic Acid

CH3 H H O

COOH

C C H

trans-Cinnamic Acid

H

H

Ph

COOH

alpha-Truxillic Acid



11

The method of isolating cocaine from the coca leaf does not require a high degree of technical expertise or experience. It requires no formal education or expensive scientific equipment or chemicals. In most instances the methodology is passed from one generation to the next. 1.4.2.2 Historical Considerations Prior to the 1880s, the physiological properties of cocaine and the coca leaf were not readily distinguishable in the literature. During that year, H.H. Rusby and W.G. Mortimer made the distinction between the physiological properties of “isolated” cocaine and the coca leaf. Mortimer wrote: [T]he properties of cocaine, remarkable as they are, lie in an altogether different direction from those of coca.1

In 1884, two significant papers appeared in the literature. Sigmund Freud published the first of his five papers on the medicinal properties of cocaine.2 A few months later, Karl Koller discovered the use of cocaine as local anesthetic.3 In 1886, Sir Arthur Conan Doyle, an eye specialist who had studied at Vienna General Hospital, where Freud and Koller made their discoveries, made reference to Sherlock Holmes’s use of cocaine in The Sign of Four.4 That same year in Atlanta, Georgia, John Pemberton introduced to this country, caught up in the frenzy of alcohol prohibition, a beverage consisting of coca leaf extracts, African kola nuts, and a sweet carbonated syrup. The product was named “Coca-Cola.”5 Pemberton received his inspiration from Angelo Mariani, a Corsican pharmacist working in Paris, who had been selling a coca leaf-Bordeaux wine tincture since the early 1860s. Mariani’s product was the most popular tonic of its time, and was used by celebrities, poets, popes, and presidents.6 Patterns of coca consumption changed dramatically in the 20th century. In the 19th century, cocaine was available only in the form of a botanical product or a botanical product in solution. When chemical houses, such as Merck, began to produce significant quantities of refined cocaine, episodes of toxicity became much more frequent, the views of the medical profession changed, and physicians lost much of their enthusiasm for the drug. Until 1923, the primary source of cocaine was from the coca leaf. In that year, Richard Willstatter was able to synthesize a mixture of D-cocaine, L-cocaine, D-pseudococaine, and L-pseudococaine. This multistep synthesis requires a high degree of technical expertise in organic chemistry and results in low yields.7 These financial and technical factors make the extraction of cocaine from the coca leaf the method by which most, if not all, of the cocaine is isolated for distribution on both the licit and illicit markets. 1.4.2.3 Isolation and Purification The extraction and isolation of cocaine from the coca leaf is not difficult. There is more than one way to do it. South American producers improvise depending on the availability of chemicals. All of the known production techniques involve three primary steps: (1) extraction of crude coca paste from the coca leaf; (2) purification of coca paste to cocaine base; and (3) conversion of cocaine base to cocaine hydrochloride. The paste and base laboratories in South America are deeply entrenched and widespread with thousands of operations, whereas the conversion laboratories are more sophisticated and centralized. They border on semi-industrial pilot-plant type laboratories involving a knowledge of chemistry and engineering. The primary isolation method used until recently is a Solvent Extraction Technique. The essential methodology involves macerating a quantity of coca leaves with lime water, and then adding kerosene with stirring. After a while the kerosene is separated from the aqueous layer. A dilute sulfuric acid solution is added to the kerosene with stirring. This time the kerosene is separated


12


from the aqueous layer and set aside. It is common to save the kerosene for another extraction of the leaves. The aqueous layer is retained and neutralized with limestone or some other alkaline substance. The material that precipitates after the addition of limestone is crude coca paste containing anywhere from 30 to 80% cocaine, with the remainder of the cocaine matrix composed primarily of other alkaloids, hydrolysis products, and basic inorganic salts used in the processing. This solid material is isolated by filtration for purification of the cocaine. The coca paste is then dissolved in dilute sulfuric acid, and dilute potassium permanganate solution is added to oxidize the impurities. This solution is then filtered, and ammonium hydroxide is added to the filtrate to precipitate cocaine base. This “cocaine” is not ready for shipment to the U.S. The cocaine will first be converted to hydrochloride for easier packaging, handling, and shipment. A second method of isolating cocaine from the leaf, which is more predominant today, is the Acid Extraction Technique. In this method, the cocaine leaves are placed directly in the maceration pit with enough sulfuric acid to cover the leaves. The pit is a hole dug into the ground and lined with heavy-duty plastic. The leaves are macerated by workers who stomp in the sulfuric acid/coca leaf pit. This stomping leaches the cocaine base from the leaf and forms an aqueous solution of cocaine sulfate. This stomping can continue for a matter of hours to ensure maximum recovery of the cocaine. After stomping is complete, the coca solution is poured through a coarse filter to remove the insolubles including the plant material. More sulfuric acid is added to the leaves and a second or even third extraction of the remaining cocaine will take place. Maximized recovery of cocaine is important to the laboratory operators. After the extractions and filterings are completed, an excess basic lime or carbonate solution is added to the acidic solution with stirring and neutralizing the excess acid and cocaine sulfate. A very crude coca paste forms. The addition of the base is monitored until the solution is basic to an ethanolic solution of phenolphthalein. The coca paste is then back-extracted with a small volume of kerosene. The solution sets until a separation of the layers occurs. The kerosene is then back-extracted this time with a dilute solution of sulfuric acid. Then, an inorganic base is added to precipitate the coca paste. This coca paste is essentially the same as that generated by the solvent extraction method. The advantage to this Acid Extraction Technique is that a minimal volume of organic solvent is required. And while it is more labor intensive, the cost of labor in Bolivia, the major producing country of coca paste, is very low when compared to the financial return. The resultant cocaine base, produced by either technique, is dissolved in acetone, ether, or a mixture of both. A dilute solution of hydrochloric acid in acetone is then prepared. The two solutions are mixed and a precipitate of cocaine hydrochloride forms almost immediately and is allowed to settle to the bottom of the reaction vessel (usually an inexpensive bucket). The slurry will then be poured through clean bed sheets filtering the cocaine hydrochloride from the solvent. The sheets are then wrung dry to eliminate excess acetone, and the high-quality cocaine hydrochloride is dried in microwave ovens, under heat lamps, or in the sunlight. It is then a simple matter to package the cocaine hydrochloride for shipment. One of the more common packaging forms encountered in laboratories analyzing seizures of illicit cocaine is the “one kilo brick.” This is a brick-shaped package of cocaine wrapped in tape or plastic, sometimes labeled with a logo, with the contents weighing near 1 kg. Once the cocaine hydrochloride arrives in the U.S., drug wholesalers may add mannitol or inositol as diluents, or procaine, benzocaine, lidocaine, or tetracaine as adulterants. This cocaine can then be sold on the underground market in the U.S. either in bulk or by repackaging into smaller containers. 1.4.2.4 Conversion to “Crack” “Crack” is the term used on the street and even in some courtrooms to describe the form of cocaine base that has been converted from the cocaine hydrochloride and can be smoked in a pipe.



13

This procedure of conversion from the acid to the base is usually carried out in the U.S. Cocaine base usually appears in the form of a rock-like material, and is sometimes sold in plastic packets, glass vials, or other suitable packaging. Cocaine hydrochloride is normally ingested by inhalation through a tube or straw, or by injection. Cocaine base is ingested by smoking in an improvised glass pipe. Ingestion in this manner results in the cocaine entering the bloodstream through the lungs and rushes to the brain very quickly. Cocaine hydrochloride is converted to cocaine base in one of two ways. The first method involves dissolving the cocaine hydrochloride in water and adding sodium bicarbonate or household ammonia. The water is then boiled for a short period until all of the precipitated cocaine base melts to an oil, and ice is added to the reaction vessel. This vessel will usually be a metal cooking pan or a deep glass bowl. As the water cools, chunks of cocaine base oil will solidify at the bottom of the cooking vessel. After all the cocaine base has formed, the water can be cooled and then poured off leaving the solid cocaine base, which is easily removed from the collection vessel. The cocaine base can be cut with a knife or broken into “rocks,” which can then be dried either under a heat lamp or in a microwave oven. It is not unusual when analyzing cocaine base produced from this method to identify sodium bicarbonate mixed with the rock-like material. This cocaine base sometimes has a high moisture content due to incomplete drying. A second method of producing cocaine base from cocaine hydrochloride involves dissolving the salt (usually cocaine hydrochloride) in water. Sodium bicarbonate or household ammonia is added to the water and mixed well. Diethyl ether is then added to the solution and stirred. The mixture then separates into two layers with the ether layer on top of the aqueous layer. The ether is decanted leaving the water behind. The ether is then allowed to evaporate and high-quality cocaine base remains. If any of the adulterants mentioned previously (excluding sugars, which are diluents) are mixed with the cocaine hydrochloride prior to conversion, then they will also be converted to the base and will be a part of the rock-like material that results from this process. The term “free base” is used to describe this form of cocaine. Cocaine base in this form is also smoked in a glass pipe. However, residual (and sometimes substantial) amounts of ether remaining in these samples from the extraction process make ignition in a glass pipe very dangerous. 1.4.2.5 Other Coca Alkaloids In the process of examining cocaine samples in the laboratory, it is not uncommon to identify other alkaloids and manufacturing by-products with the cocaine. These other alkaloids are carried over from the coca leaf in the extraction of the cocaine. Many manufacturing by-products result from the hydrolysis of the parent alkaloids (benzoylecgonine from cocaine, or truxillic acid from truxilline). As a forensic chemist, it is important to recognize the sources of these alkaloids as one progresses through an analytical scheme. The major alkaloidal “impurities” present in the coca leaf that are carried over in the cocaine extraction are the cis- and trans-cinnamoylcocaines and the truxillines. There are 11 isomeric truxillic and truxinic acids resulting from the hydrolysis of truxilline. Another naturally occurring minor alkaloid from the coca leaf is tropacocaine. The concentration of tropacocaine will rarely, if ever, exceed 1% of the cocaine concentration and is well below the concentrations of the cisand trans-cinnamoylcocaines and the truxillines. Two other alkaloids from the coca leaf which have been identified are cuscohygrine and hygrine. These two products are not found in cocaine, just in the leaf. The second class of substances found in the analysis of cocaine samples is the result of degradation or hydrolysis. Ecgonine, benzoylecgonine, and methylecgonine found in cocaine samples will be the result of the hydrolysis of cocaine. It is important to recognize that some of these manufacturing by-products, such as ecgonine, can be detected by gas chromatography only if they are derivatized prior to injection. Methyl ecgonidine is a by-product of the hydrolysis of cocaine and is oftentimes identified in the laboratory by gas chromatography/mass spectrometry (GC/MS).


14


This artifact can also result from the thermal degradation of cocaine or the truxillines in the injection port of the GC. Benzoic acid is the other product identified when this decomposition occurs. There are at least two substances that result directly from the permanganate oxidation of cocaine. N-Formyl cocaine results from oxidation of the N-methyl group of cocaine to an N-formyl group. Norcocaine is a hydrolysis product resulting from a Schiff’s base intermediate during the permanganate oxidation. There is also evidence that norcocaine can result from the N-demethylation of cocaine, a consequence of the peroxides in diethyl ether. 1.4.2.6 Cocaine Adulterants The primary adulterants identified in cocaine samples are procaine and benzocaine. Lidocaine is also found with less regularity. These adulterants are found in both the cocaine base and cocaine hydrochloride submissions. The primary diluents are mannitol and inositol. Many other sugars have been found, but not nearly to the same extent. Cocaine hydrochloride concentrations will usually range from 20 to 99%. The moisture content of cocaine hydrochloride is usually minimal. Cocaine base concentrations will usually range from 30 to 99%. There will usually be some moisture in cocaine base (“crack”) submissions from the water/sodium bicarbonate or water/ammonia methods. The concentration of cocaine base (“free base”) from the ether/sodium bicarbonate or ether/ammonia methods will usually be higher and free of water. The methods for identifying cocaine in the laboratory include but are not limited to: infrared spectrophotometry (IR), nuclear magnetic resonance spectroscopy (NMR), mass spectrometry (MS), and gas chromatography (GC). IR and NMR will enable the analyst to distinguish between cocaine hydrochloride and cocaine base. However, it is not possible to identify the form in which the cocaine is present utilizing this instrumentation. 1.4.2.7 Conclusion The user of either cocaine base or cocaine hydrochloride not only ingests the cocaine, but also other alkaloids from the coca plant, processing by-products, organic and inorganic reagents used in processing, diluents, and adulterants. There is no realistic way in which a cocaine user can ensure the quality of the cocaine purchases on the street, and “innocent” recreational drug use may provide more danger than the user would knowingly risk.

REFERENCES 1. Rusby, H.H., Bliss, A.R., and Ballard, C.W., The Properties and Uses of Drugs, Blakiston’s Son & Co., Philadelphia, 1930, 125, 386, 407. 2. Byck, R., Ed., Cocaine Papers by Sigmund Freud, Stonehill, New York, 1975. 3. Pendergrast, M., For God, Country, and Coca-Cola; The Definitive History of the Great American Soft Drink and the Company That Makes It, Basic Books, New York, 2000. 4. Musto, D., A study in cocaine: Sherlock Holmes and Sigmund Freud, J. Am. Med. Assoc., 204: 125, 1968. 5. Brecher, E. and the Editors of Consumer Reports, Licit and Illicit Drugs, Little, Brown, Boston, 1972, 33–36, 270. 6. Mariani, A., Ed., Album Mariani, Les Figures Contemporaines. Contemporary Celebrities from the Album Mariani, etc., various publishers for Mariani & Co., 13 Vols., 1891–1913. 7. Willstatter, R., Wolfes, O., and Mader, H., Synthese des Naturlichen Cocains, Justus Liebigs’s Ann. Chim., 434, 111–139, 1923. 8. Casale, J.F. and Klein, R.F.X., Illicit cocaine production, Forensic Sci. Rev, 5, 96–107, 1993.



1.4.3

15

Marijuana

1.4.3.1 History and Terminology Marijuana is a Schedule I controlled substance. In botanical terms, “marijuana” is defined as Cannabis sativa L. Legally, marijuana is defined as all parts of the plant C. sativa L. (and any of its varieties) whether growing or not, the seeds thereof, the resin extracted from any part of the plant, and every compound, manufacture, salt, derivative, mixture, or preparation of such plant; its seeds and resins. Such terms do not include the mature stalk of the plants, fibers produced from such plants, oils or cakes made from the pressed seeds of such plants, any other compound, manufacture, salt derivative, mixture or preparation of such mature stalks (except the resin extracted therefrom), fiber, oil or cake, pressed seed, or the sterilized seed which is incapable of germination.1 Pharmaceutical preparations that contained the resinous extracts of cannabis were available on the commercial market from the 1900s to 1937. These products were prescribed for their analgesic and sedative effects. In 1937 the U.S. Food and Drug Administration declared these products to be of little medical utility, and they were removed from the market. Cannabis, in the forms of the plant material, hashish, and hashish oil, is the most abused illicit drug in the world. Cannabis is cultivated in many areas of the world. Commercial C. sativa L. is referred to as “hemp.” The plant is cultivated for cloth and rope from its fiber. A valuable drying oil used in art and a substitute for linseed oil is available from the seeds. Bird seed mixtures are also found to contain sterilized marijuana seeds. In the early days of the U.S., hemp was grown in the New England colonies. Its cultivation spread south into Pennsylvania and Virginia. From there it spread south and west most notably into Kentucky and Missouri. Its abundance in the early days of the country is still evident by the fact that it still grows wild in many fields and along many roadways. The plant is now indigenous to many areas, and adapts easily to most soil and moderate climatic conditions. Marijuana is classified as a hallucinogenic substance. The primary active constituents in the plant are cannabinol, cannabidiol, and the tetrahydrocannabinols, illustrated in Figure 1.4.3. The tetrahydrocannabinols (THCs) are the active components responsible for the hallucinogenic properties of marijuana. The THC of most interest is the Δ9 tetrahydrocannabinol. The other THCs of interest in marijuana are the Δ1 cis- and trans-tetrahydrocannabinols, the Δ6 cis- and trans-tetrahydrocannabinols, and the Δ3 and Δ4 tetrahydrocannabinols. The concentrations vary dramatically from geographic area to geographic area, from field to field, and from sample to sample. This concentration range varies from less than 1% to as high as 30%. In recent hash oil exhibits, the highest official reported concentration of Δ9-THC is 43%.2 Five other terms associated with marijuana are as follows: Hashish: Resinous material removed from cannabis. Hashish is usually found in the form of a brown to black cake of resinous material. The material is ingested by smoking in pipes or by consuming in food. Hashish oil: Extract of the marijuana plant which has been heated to remove the extracting solvents. The material exists as a colorless to brown or black oil or tar-like substance. Sinsemilla: The flowering tops of the unfertilized female cannabis plant. (There are no seeds on such a plant.) Sinsemilla is usually considered a “gourmet” marijuana because of its appearance and relatively high concentrations of the THCs. Thai sticks: Marijuana leaves tied around stems or narrow-diameter bamboo splints. Thai sticks are considered a high-quality product by the drug culture. The THC concentrations of the marijuana leaves on Thai sticks are higher than domestic marijuana. Unlike hashish and sinsemilla, seeds and small pieces of stalks and stems are found in Thai sticks. Brick or Kilo: Marijuana compressed into a brick-shaped package with leaves, stems, stalk, and seeds. The pressed marijuana is usually tightly wrapped in paper and tape. This is the form of marijuana encountered in most large-scale seizures. These large-scale seizure packages weigh approximately


16


7CH3 1

6

H

5

4

CH3

3

7 0′

H

10 H3C 9 H 3C

9

OH

2

2′ 1′

8

4′

5′

1 6

6a

C5H11

O

10a

4

H3C H3C

– THC =

– THC =

1(6)

9

OH

10

H

1 2

H 6

4 3

5

O

C5H11

– THC

– THC =

8

– THC

Tetrahydrocannabinol CH3

CH3 OH

C H2C

CH3

OH

OH

C5H11

H3C H3C

Cannabidiol

O

C5H11

Cannabinol

Figure 1.4.3 The primary active constituents in marijuana.

1000 g (1 kg). This is the packaging form of choice for clandestine operators because of the ease of handling, packaging, shipping, and distribution.

1.4.3.2 Laboratory Analysis The specificity of a marijuana analysis is still a widely discussed topic among those in the forensic and legal communities. In the course of the past 25 years, the consensus of opinion concerning the analysis of marijuana has remained fairly consistent. In those situations where plant material is encountered, the marijuana is first examined using a stereomicroscope. The presence of the bear claw cystolithic hairs and other histological features are noted using a compound microscope. The plant material is then examined chemically using Duquenois–Levine reagent in a modified Duquenois–Levine testing sequence. These two tests are considered to be conclusive within the realm of existing scientific certainty in establishing the presence of marijauana.3–5 The modified Duquenois–Levine test is conducted using Duquenois reagent, concentrated hydrochloric acid, and chloroform. The Duquenois reagent is prepared by dissolving 2 g of vanillin and 0.3 ml of acetaldehyde in 100 ml of ethanol. Small amounts (25 to 60 mg is usually sufficient) of suspected marijuana leaf is placed in a test tube and approximately 2 ml of Duquenois reagent is added. After 1 min, approximately 1 ml of concentrated hydrochloric acid is added. Small bubbles rise from the leaves in the liquid. These are carbon dioxide bubbles produced by the reaction of the hydrochloric acid with the calcium carbonate at the base of the cystolithic hair of the marijuana. A blue to blue-purple color forms very quickly in the solution. Approximately 1 ml of chloroform is then added to the Duquenois reagent/hydrochloric acid mixture. Because chloroform is not miscible with water, and because it is heavier than water, two liquid layers are visible in the tube — the Duquenois reagent/hydrochloric acid layer is on top, and the chloroform layer is on the bottom. After mixing with a vortex stirrer and on settling, the two layers are again clearly distin-



17

guishable. However, the chloroform layer has changed from clear to the blue to blue-purple color of the Duquenois reagent/hydrochloric acid mixture. One variation in this testing process involves pouring off the Duquenois reagent sitting in the tube with the leaves before adding the hydrochloric acid. The remainder of the test is conducted using only the liquid. Another variation involves conducting the test in a porcelain spot plate. This works, although some analysts find the color change a bit more difficult to detect. A third variation involves extracting the cannabis resin with ether or some other solvent, separating the solvent from the leaves, allowing the solvent to evaporate, and conducting the modified Duquenois–Levine test on the extract. Marquis reagent is prepared by mixing 1 ml of formaldehyde solution with 9 ml of sulfuric acid. The test is done by placing a small amount of sample (1 to 5 mg) into the depression of a spot plate, adding one or two drops of reagent, and observing the color produced. This color will usually be indicative of the class of compounds, and the first color is usually the most important. A weak response may fade, and samples containing sugar will char on standing because of the sulfuric acid. Marquis reagent produces the following results: 1. Purple with opiates (heroin, codeine). 2. Orange turning to brown with amphetamine and methamphetamine. 3. Black with a dark purple halo with 3,4-methylenedioxyamphetamine (MDA) and 3,4-methylenedioxymethamphetamine (MDMA). 4. Pink with aspirin. 5. Yellow with diphenhydramine.

A thin-layer chromatographic (TLC) analysis, which detects a systematic pattern of colored bands, can then be employed as an additional test.6,7 Though it is not required, some analysts will run a GC/MS analysis to identify the cannabinoids in the sample. The solvent insoluble residue of hashish should be examined with the compound microscope. Cystolythic hairs, resin glands, and surface debris should be present. However, if most of the residue is composed of green leaf fragments, the material is pulverized marijuana or imitation hashish. 1.4.4

Peyote

Peyote is a cactus plant that grows in rocky soil in the wild. Historical records document use of the plant by Indians in northern Mexico from as far back as pre-Christian times, when it was used by the Chichimaec tribe in religious rites. The plant grows as small cylinder-like “buttons.” The buttons were used to relieve fatigue and hunger, and to treat victims of disease. The peyote buttons were used in group settings to achieve a trance state in tribal dances.8 It was used by native Americans in ritualistic ceremonies. In the U.S., peyote was cited in 1891 by James Mooney of the Bureau of American Ethnology.9 Mooney talked about the use of peyote by the Kiowa Indians, the Comanche Indians, and the Mescalero Apache Indians, all in the southern part of the country. In 1918, he came to the aid of the Indians by incorporating the “Native American Church” in Oklahoma to ensure their rights in the use of peyote in religious ceremonies. Although several bills have been introduced over the years, the U.S. Congress has never passed a law prohibiting the Indians’ religious use of peyote. Both mescaline and peyote are listed as Schedule I controlled substances in the Comprehensive Drug Abuse Prevention and Control Act of 1970. The principal alkaloid of peyote responsible for its hallucinogenic response is mescaline, a derivative of β-phenethylamine. Chemically, mescaline is 3,4,5-trimethoxyphenethylamine. As illustrated in Figure 1.4.4, its structure is similar to the amphetamine group in general. Mescaline was first isolated from the peyote plant in 1894 by the German chemist A. Heffter.10 The first complete synthesis of mescaline was in 1919 by E. Späth.11 The extent of abuse of illicit mescaline has not been accurately determined. The use of peyote buttons became popular in the 1950s and


18


Amphetamine

3,4-Methylenedioxyamphetamine (MDA) NH2

Mescaline

NH2

O

NH2

H3CO

H2C CH3

CH3

O

H3CO OCH3

3,4-Methylenedioxymethamphetamine (MDMA)

O

Methamphetamine

H

H

N CH3

N CH3

H2C CH3

CH3

O

Figure 1.4.4 Chemical structure of mescaline.

again in the period from 1967 to 1970. These two periods showed a dramatic increase in experimentation with hallucinogens in general. 1.4.5

Psilocybin Mushrooms

The naturally occurring indoles responsible for the hallucinogen properties in some species of mushrooms are psilocybin (Figure 1.4.5) and psilocin.12 The use of hallucinogenic mushrooms dates to the 16th century, occurring during the coronation of Montezuma in 1502.8 In 1953, R.G. Wassen and V.P. Wasson were credited with the rediscovery of the ritual of the Indian cultures of Mexico and Central America.13 They were able to obtain samples of these mushrooms. The identification of the mushrooms as the species Psilocybe is credited to the French mycologist, Roger Heim.14 Albert Hofmann (the discoverer of lysergic acid diethylamine) and his colleagues at Sandoz Laboratories in Switzerland are credited with the isolation and identification of psilocybin (phosphorylated 4-hydroxydimethyltryptamine) and psilocin (4-hydroxydimethyltryptamine).15 Psilocybin was the major component in the mushrooms, and psilocin was found to be a minor component. However, psilocybin is very unstable and is readily metabolized to psilocin in the body. This phenomenon of phosphate cleavage from the psilocybin to form the psilocin occurs quite easily in the forensic science laboratory. This can be a concern in ensuring the specificity of identification. The availability of the mushroom has existed worldwide wherever proper climactic conditions exist — that means plentiful rainfall. In the U.S., psilocybin mushrooms are reported to be plentiful in Florida, Hawaii,16 the Pacific Northwest, and Northern California.17 Mushrooms analyzed in the forensic science laboratory confirm the fact that the mushrooms spoil easily. The time factor between harvesting the mushrooms and the analysis proves to be the greatest detriment to successfully identifying the psilocybin or psilocin. Storage prior to shipment is best accomplished by drying the mushrooms. Entrepreneurs reportedly resort to storage of mushrooms in honey to preserve the psychedelic properties.18

HN

CH2CH2N

CH3 CH3

HN

CH2CH2N O

OH Psilocin

Figure 1.4.5 Chemical structure of psilocin and psilocybin.

O P Psilocybin

OH OH

CH3 CH3



19

Progressing through the analytical scheme of separating and isolating the psilocybin and psilocin from the mushroom matrix, cleavage of the phosphate occurs quite easily. Prior to beginning the analysis, drying the mushrooms in a desiccator with phosphorus pentoxide ensures a dry starting material. In many instances, the clean-up procedure involves an extraction process carried out through a series of chloroform washes from a basic extract and resolution of the components by TLC. The spots or, more probably, streaks are then scraped from the plate, separated by a backextraction, and then analyzed by IR. Direct analysis by GC is very difficult because both psilocybin and psilocin are highly polar and not suitable for direct GC analysis. Derivatization followed by GC/MS is an option except in those instances where the mushrooms have been preserved in sugar.19 With the development and availability of high-performance liquid chromatography (HPLC), the identification and quantitation of psilocybin and psilocyn in mushrooms are becoming more feasible for many forensic science laboratories.20

REFERENCES 1. Section 102 (15), Public Law 91-513. 2. ElSohly, M.A. and Ross, S.A., Quarterly Report Potency Monitoring Project, Report 53, January 1, 1995 to March 31, 1995. 3. Nakamura, G.R., Forensic aspects of cystolithic hairs of cannabis and other plants, J. Assoc. Off. Anal. Chem., 52, 5–16, 1969. 4. Thornton, J.I. and Nakamura, G.R., The identification of marijuana, J. Forensic Sci. Soc., 24, 461–519, 1979. 5. Hughes, R.B. and Warner, V.J., A study of false positives in the chemical identification of marijuana, J. Forensic Sci., 23, 304–310, 1978. 6. Hauber, D.J., Marijuana analysis with recording of botanical features present with and without the environmental pollutants of the Duquenois-Levine test, J. Forensic Sci., 37, 1656–1661, 1992. 7. Hughes, R.B. and Kessler, R.R., Increased safety and specificity in the thin-layer chromatographic identification of marijuana, J. Forensic Sci., 24, 842–846, 1979. 8. Report Series, National Clearinghouse for Drug Abuse Information, Mescaline, Series 15, No. 1, May 1973. 9. Mooney, J., The mescal plant and ceremony, Ther. Gaz., 12, 7–11, 1896. 10. Heffter, A., Ein Beitrag zur pharmakologishen Kenntniss der Cacteen, Arch. Exp Pathol. Pharmakol., 34, 65–86, 1894. 11. Spath, E., Über die Anhalonium-Alkaloide, Anhalin und Mescalin, Monatsh. Chem. Verw. TL, 40, 1929, 1919. 12. Hofman, A., Heim, R., Brack, A., and Kobel, H., Psilocybin, ein psychotroper Wirkstoff aus dem mexikanishen Rauschpitz Psilocybe mexicana Heim, Experiencia, 14, 107–109, 1958. 13. Wasson, V.P. and Wasson, R.G., Mushrooms, Russia, and History. Pantheon Books, New York, 1957. 14. Heim, R., Genest, K., Hughes, D.W., and Belec, G., Botanical and chemical characterisation of a forensic mushroom specimen of the genus psilocybe, Forensic Sci. Soc. J., 6, 192–201, 1966. 15. Hofmann, A., Chemical aspects of psilocybin, the psychotropic principle from the Mexican fungus, Psilocybe mexicana Heim, in Bradley, P.B., Deniker, P., and Radouco-Thomas, C., Eds. Neuropsychopharmacology, Elsevier, Amsterdam, 1959, 446–448. 16. Pollock, S.H., A novel experience with Panaeolus: a case study from Hawaii, J. Psychedelic Drugs, 6, 85–90, 1974. 17. Weil, H., Mushroom hunting in Oregon, J. Psychedelic Drugs, 7, 89–102, 1975. 18. Pollock, S.H., Psilocybin mycetismus with special reference to Panaeolus, J. Psychedelic Drugs, 8(1), 50. 19. Repke, D.B., Leslie, D.T., Mandell, D.M., and Kish, N.G., GLC-mass spectral analysis of psilocin and psilocybin, J. Psychedelic Drugs, 66, 743–744, 1977. 20. Thomas, B.M., Analysis of psilocybin and psilocin in mushroom extracts by reversed-phase high performance liquid chromatography, J. Forensic Sci., 25, 779–785, 1980.


20


Ergot Alkaloid + H2NNH2

O H C N NH2

HN N CH3

Lysergic Acid Hydrazide O H

O

C N NH2

HN N

+ NaNO2

CH3 Lysergic Acid Azide

Lysergic Acid Hydrazide O

+

O –

C N N N

+ HN

N

CH2 CH3

CN

HN

CH2 CH3

N

CH2CH3 CH2CH3

CH3

CH3 Lysergic Acid Azide

–

N

CH3

HN

+

C N N N

HN

Diethylamine

Lysergic Acid Diethylamide

Figure 1.4.6 Synthetic route utilized for the clandestine manufacture of LSD.

1.4.6

Lysergic Acid Diethylamide

LSD is a hallucinogenic substance produced from lysergic acid, a substance derived from the ergot fungus (Clavica purpurea), which grows on rye. It can also be derived from lysergic acid amide, which is found in morning glory seeds.1 LSD is also referred to as LSD-25 because it was the 25th in a series of compounds produced by Dr. Albert Hofmann in Basel, Switzerland. Hoffman was interested in the chemistry of ergot compounds, especially their effect on circulation. He was trying to produce compounds that might improve circulation without exhibiting the other toxic effects associated with ergot poisoning. One of the products he produced was Methergine™, which is still in use today. When LSD-25 was first tested on animals, in 1938, the results were disappointing. Then, 5 years later, in 1943, Hoffman decided to reevaluate LSD-25. The hallucinogenic experience that ensued when he accidentally ingested some of the compound led to the start of experimentation with “psychedelic” drugs. LSD is the most potent hallucinogenic substance known to humans. Dosages of LSD are measured in micrograms (one microgram equals one one-millionth of a gram). By comparison, dosage units of cocaine and heroin are measured in milligrams (one milligram equals one onethousandth of a gram). LSD is available in the form of very small tablets (“microdots”), thin squares of gelatin (“window panes”), or impregnated on blotter paper (“blotter acid”). The most popular of these forms in the 1990s was blotter paper perforated into 1/4-in. squares. This paper is usually brightly colored with psychedelic designs or line drawings. There have been recent reports of LSD impregnated on sugar cubes.2 Such LSD-laced sugar cubes were commonplace in the 1970s. The precursor to LSD, lysergic acid, is a Schedule III controlled substance. LSD is classified as a Schedule I controlled substance. The synthetic route utilized for the clandestine manufacture of LSD is shown in Figure 1.4.6. 1.4.7

Phencyclidine

The chemical nomenclature of phencyclidine (PCP) is phenylcyclohexylpiperidine. The term “PCP” is used most often used when referring to this drug. The acronym PCP has two origins that



21

are consistent. In the 1960s phencyclidine was trafficked as a peace pill (“PeaCePill”). PhenylCyclohexylPiperidine can also account for the PCP acronym. PCP was first synthesized in 1926.3 It was developed as a human anesthetic in 1957, and found use in veterinary medicine as a powerful tranquilizer. In 1965 human use was discontinued because, as the anesthetic wore off, confusional states and frightening hallucinations were common. Strangely, these side effects were viewed as desirable by those inclined to experiment with drugs. Today even the use of PCP as a primate anesthetic has been all but discontinued. In 1978, the commercial manufacture of PCP ceased and the drug was transferred from Schedule III to Schedule II of the Controlled Substances Act. Small amounts of PCP are manufactured for research purposes and as a drug standard. The manufacture of PCP in clandestine laboratories is simple and inexpensive. Figure 1.4.7 shows three of the synthetic routes utilized for its illegal production. The first clandestinely produced PCP appeared in 1967 shortly after Parke Davis withdrew phencyclidine as a pharmaceutical.4 The clandestine laboratory production of PCP requires neither formal knowledge of chemistry nor a large inventory of laboratory equipment. The precursor chemicals produce phencyclidine when combined correctly using what is termed “bucket chemistry.” The opportunities for a contaminated product from a clandestine PCP are greatly enhanced because of the recognized simplicity of the chemical reactions in the production processes. The final product is often contaminated with starting materials, reaction intermediates, and by-products.5 Clandestine laboratory operators have been known to modify the manufacturing processes to obtain chemically related analogues capable of producing similar physiological responses. The most commonly encountered analogues are N-ethyl-1-phenylcyclohexylamine (PCE), 1-(1-phenylcyclohexyl)-pyrrolidine (PCPy), and 1-[1-(2-thienyl-cyclohexyl)]-piperidine (TCP). In the 1960s, PCP was distributed as a white to off-white powder or crystalline material and ingested orally. In recent years, PCP has been encountered as the base and dissolved in diethyl ether. The liquid is then placed into small bottles that normally would hold commercial vanilla extract. This ether solution is then sprayed on leaves such as parsley and smoked. PCP is commonly encountered on long thin dark cigarettes (“Sherms”) that have been dipped in the PCP/ether solution. 1.4.8

Fentanyl

Fentanyl [the technical nomenclature is N-(1-phenethyl-4-piperidyl)propionanilide] is a synthetic narcotic analgesic approximately 50 to 100 times as potent as morphine.6 The drug had its origin in Belgium as a synthetic product of Janssen Pharmaceutica.7 In the 1960s in Europe and in the 1970s in the U.S., it was introduced for use as an anesthesia and for the relief of post-operative pain. Almost 70% of all surgical procedures in the U.S. use fentanyl for one of these purposes.8 Fentanyl has been called “synthetic heroin.” This is a misnomer. Victims of fentanyl overdoses were often heroin abusers with “tracks” and the typical paraphernalia. The fentanyls as a class of drugs are highly potent synthetic narcotic analgesics with all the properties of opiates and opinoids.4 However, the fentanyl molecule does not resemble heroin. Fentanyl is strictly a synthetic product while the morphine used in heroin production is derived from the opium poppy. Beginning in the late 1970s with -methylfentanyl,9 nine homologues and one analogue (excluding enantiomers) of fentanyl appeared on the illicit marketplace.10 The degrees of potency vary among the fentanyl homologues and analogues. The potencies of the fentanyl derivatives are much higher than those of the parent compound. But the high potencies cited above explain why even dilute exhibits result in the deaths of users who believe they are dealing with heroin. Another name used by addicts when referring to fentanyl and its derivatives is “China White.” This term was first used to described substances seized and later identified as alpha-methylfentanyl in 1981.11 There are many fentanyl homologues and analogues. Because of the size and complexity of fentanyl derivatives, the interpretation of IR, MS, and NMR spectral data proves very valuable in elucidating specific structural information required for the identification of the material.10


22


H

O

KCN + HCl + or NaCN

+

Cyclohexanone

N

NC

N

Piperidine PCC 1-Piperidinocyclohexylcarbonitrile

MgBr N

N

NC

+

Phenylmagnesium Bromide PCP

PCC 1-Piperidinocyclohexylcarbonitrile

1-(1-Phenylcyclohexyl)piperidine

H

O

N

N +

+

Cyclohexanone

KCN or NaCN

1-(1-Cyclohexyl)piperidine

Piperidine MgBr N

N

+


Phenylmagnesium Bromide

PCP 1-(1-Phenylcyclohexyl)piperidine

Figure 1.4.7 Synthetic routes utilized for illegal production of PCP.

Continued.

Several synthetic routes are possible. As shown in Figure 1.4.8a and b, one of the methods requires that fentanyl precursor, N-(1-phenetyl)-4-piperidinlyl) analyine, be produced first. Alternatively, fentanyl can be produced by reacting phenethylamine and methylacrylate to produce the phenethylamine diester (see Figure 1.4.9). 1.4.9

Phenethylamines

The class of compounds with the largest number of individual compounds on the illicit drug market is the phenethylamines. This class of compounds consists of a series of compounds having



H

O

23

p-TolueneSulfonic Acid in Benzene

N

N

+

+

1-(1-Cyclohexyl)piperidine Cyclohexanone

Piperidine MgBr N


N

+ Phenylmagnesium Bromide

PCP 1-(1-Phenylcyclohexyl)piperidine Figure 1.4.7 Continued.

a phenethylamine skeleton. Phenethylamines are easily modified chemically by adding or changing substituents at various positions on the molecule. Phenethylamines fall into one of two categories in terms of physiological effects — these compounds are either stimulants or hallucinogens. Phenethylamines are suitable for clandestine laboratory production. The parent compound in the phenethylamine series is amphetamine, a central nervous system (CNS) stimulant. With this molecule, the modifications begin by adding a methyl group to the nitrogen on the side chain. The resulting structure is the most popular clandestinely produced controlled substance in the U.S. — methamphetamine (Figure 1.4.10). Like amphetamine, methamphetamine is also a CNS stimulant. It is easily produced in clandestine laboratories using two basic synthetic routes. The traditional route used by “meth cooks” began with phenyl-2-propanone; however, when bulk sales were limited by law, most clandestine chemists began using ephedrine as a precursor (Figure 1.4.11), although, as illustrated in Figure 1.4.11, some now synthesize their own supply of phenyl-2-propanone, and still other routes are possible (Figure 1.4.12). New legislation has now limited bulk purchases of ephedrine in the U.S., though not in neighboring countries. And the chemical structure is such that further molecular synthetic modifications are easily accomplished, resulting in a number of homologues and analogues. Few of the synthetic modifications of phenethylamines by clandestine laboratory “chemists” are novel. Most have been documented either in the scientific literature or in underground scientific literature. And the Internet now provides answers to anyone tenacious enough to search for a simple method to synthesize any analogue or homologue of a phenethylamine. The parent compound of a second set of phenethylamine homologues and analogues (Figure 1.4.13) is 3,4-methylenedioxyamphetamine (MDA). This compound was first reported in the literature in 1910.12 In the mid-1980s, the N-methyl analogue of MDA came into vogue and was known then and is still referred to as “Ecstasy.” The synthesis of 3,4-methylenedioxymethamphetamine (MDMA) follows the same synthetic protocols as the less complicated phenethylamines. The clandestine laboratory operator or research chemist selectively adds one N-methyl group, an N,N-dimethyl group, an N-ethyl group, an N-propyl, an N-isopropyl group, and so on. In 1985 the N-hydroxy MDA derivative was reported.13 This was significant because here the modification involved the addition of a hydroxyl group as opposed to an alkyl substitution on the nitrogen. Clandestine laboratory synthesis of MDA and MDMA are shown in Figure 1.4.13 and Figure 1.4.14. The identification of the phenethylamines in the laboratory requires great care because of the chemical and molecular similarities of the exhibits. IR combined with MS and NMR spectrometry


24


A O O

CH2CH2NH2 +

CH2CH2N

CH2 CHCOCH3

CH2CH2COCH3 CH2CH2COCH3 O

Phenethylamine

Methylacrylate

Diester of Phenethylamine

O CH2CH2COCH3

CH2CH2N CH2CH2COCH3

+ NaOCH3

O

CH2CH2 N

O

N-(1-Phenethyl)piperidin-4-one Sodium Methoxide

CH2CH2 N

O +

N-(1-Phenethyl)piperidin-4-one

NH2

CH2CH2 N

NH

N-(1-Phenethyl-4-piperidinyl)aniline

Aniline

B N

NH

CH2CH2Br

+

N CH2CH2

N H 2-Phenyl-1-bromoethane

N-(1-Phenethyl-4-piperidinyl)aniline

N-(4-Piperidinyl)aniline

N CH CH2

N H

N-(1-Phenethyl-4-piperidinyl)aniline + O O

CH2 CH2 N

C

CH3CH2 COCCH2CH3 Propionic Anhydride

N O

CH2CH3

Fentanyl

Figure 1.4.8 (A) Clandestine laboratory synthesis of fentanyl precursor. (B) Clandestine laboratory synthesis of fentanyl.



O CH2CH2COCH3

O CH2CH2NH2 +

CH2CH2N

CH2 CHCOCH3

Phenethylamine

25

CH2CH2COCH3 O Diester of Phenethylamine

Methylacrylate O CH2CH2COCH3 + NaOCH3

CH2CH2N

CH2CH2COCH3 O Sodium Methoxide

=O + F

CH2CH2 N

CH2CH2 N

N-(1-Phenethyl)piperidin-4-one

CH2CH2 N

NH2

p-Fluoroaniline N-(1-Phenethyl)piperidin-4-one

NH

F

N-(1-Phenethyl-4-piperidinyl)4-fluoroaniline

O O CH CH COCCH + 3 2 2CH3 F

NH

=O

CH2CH2 N

CH2CH2 N

O NCCH2CH3

Propionic Anhydride F

N-(1-Phenethyl-4-piperidinyl)4-fluoroaniline

p-Fluorofentanyl

Figure 1.4.9 Clandestine laboratory synthesis of p-fluorofentanyl.

Aluminum Foil

O CH2 CCH3 + CH3NH2

Mercuric Chloride (Catalyst)

Methylamine Phenyl-2-propanone OH CH3

d,l-Methamphetamine CH3

HI

CH CHNHCH3

l- or d-Ephedrine or l- or d-Pseudoephedrine

CH3 CH2CHNHCH3

+

CH2CHNHCH3

P

Hydriodic Acid Red Phosphorus

d- or l-Methamphetamine

Figure 1.4.10 Clandestine laboratory synthesis of methamphetamine.


26


O O O CH2COH + CH3COCCH Phenylacetic Acid

O CH2CCH3

Acetic Anhydride

Phenyl-2-propanone

O CHCCH3

O CH2CN + CH3COC2H5 + C2H5ONa

CN

Ethyl Acetate Sodium Ethoxide

Benzyl Cyanide

O CHCCH3

+

alpha-Phenylacetonitrile

O CH2CCH3

Sulfuric Acid or Phosphoric Acid

CN alpha-Phenylacetonitrile

Phenyl-2-propanone

Figure 1.4.11 Clandestine laboratory synthesis of phenyl-2-propanone (p-2-p).

+

CH2Cl

Mg

CH2MgCl

Magnesium Benzylchloride H

O CH3CH

CH3NH2

CH3C=N CH3

Methylamine

Methyliminoethane

+

Acetaldehyde

CH3 CH2MgCl

+

CH3NH2

CH2CHNHCH3

Methylamine Benzylmagnesiumchloride

d- or l-Methamphetamine

Figure 1.4.12 Clandestine laboratory synthesis of methamphetamine.



27

O

O

O

O Isosafrole

CH2CCH3

CH CHCH3 + Hydrogen Peroxide or Formic Acid

O 3,4-Methylenedioxy-phenyl-2-propanone

O

O CH2CCH3

O

NH2

O

HCNH2 +

CH2CHCH3

or O

O

HCONH4

O MDA

Formamide or Ammonium Formate NHCH3

O

CH2CHCH3 O 3,4-Methylenedioxymethamphetamine

NH2 CH3O Br

CH2CHCH3 O 3,4-Methylenedioxypropylamphetamine

NH2 CH3O CH3CH2

CH2CHCH2CH3

3-Hydroxy-4-methyl-α-ethylphenethylamine

OCH3 Methoxyphenamine Figure 1.4.13 Clandestine laboratory synthesis of MDA.

CH2CHCH3 OCH3

2,5-Dimethoxy-4-methylamphetamine

NHCH3 CH2CHCH3

OCH3

NH2 CH3O CH3

CH3

CH2CHCH3

2,5-Dimethoxy-4-ethylamphetamine

NH2 HO

OCH3

2,5-Dimethoxy-4-bromoamphetamine

NHCH2CH2CH3

O

CH2CHCH3

CH2CH2NH2 Cl 2-(p-Chlorophenyl)ethylamine


28


O

CH CHCH3 + Hydrogen Peroxide or Formic Acid

O Isosafrole

O CH2CCH3

O

O

O CH2CCH3

O

O 3,4-Methylenedioxyphenyl-2-propanone

CH3NH2 + or NaBH3CN

Methylamine and Sodium Cyanoborohydride

HNCH3

O

CH2CHCH3

O MDMA

Figure 1.4.14 Clandestine laboratory synthesis of MDMA.

provide the most specificity in the identifications of phenethylamines in the forensic science laboratory.13,14 From a legal perspective, the laboratory identification of the phenethylamine is part 1 in the forensic process. If prosecution is an option and the phenethylamine in question is not specified as a controlled substance under Public Law 91-51315 or Part 1308 of the Code of Federal Regulations, another legal option is available. In 1986, the U.S. Congress realized that the legal system was at a standstill in attempting to prosecute clandestine laboratory operators involved in molecular modification of phenethylamines and other homologues and analogues of controlled substances. The attempted closing of this loophole was the passage of the Controlled Substances Analogue and Enforcement Act of 1986.16 1.4.10 Methcathinone Methcathinone (CAT) is a structural analogue of methamphetamine and cathinone (Figure 1.4.15 and Figure 1.4.16). It is potent and it, along with the parent compound, is easily manufactured. They are sold in the U.S. under the name CAT. Methcathinone is distributed as a white to off-white chunky powdered material and is sold in the hydrochloride salt form. Outside of the U.S., methcathinone is known as ephedrone and is a significant drug of abuse in Russia and some of the Baltic States.17 Methcathinone was permanently placed in Schedule I of the Controlled Substances Act in October 1993. Prior to its scheduling, two federal cases were effectively prosecuted in Ann Arbor and Marquette, Michigan, utilizing the analogue provision of the Controlled Substances Analogue and Enforcement Act of 1986. O

OH CH

CH3 HC

Sodium Dichromate and + Sulfuric Acid

C N

N H

CH3 HC

CH3

(–) 1R,2S-Ephedrine 1-Ephedrine or (+) 1R,2S-Pseudoephedrine d-Pseudoephedrine Figure 1.4.15 Clandestine laboratory synthesis of methcathinone.

H

CH3

Methcathinone (–) 2S-Methcathinone 1-Ephedrone



29

O

OH CH

CH3 HC

Sodium Dichromate + Sulfuric Acid

C N

N H

CH3 HC

H

H

(–) 1R,2S-Norephedrine 1-Norephedrine

H

Cathinone (–) 2S-Cathinone 1-Cathinone

or (+) 1R,2S-Norpseudoephedrine d-Norpseudoephedrine Figure 1.4.16 Clandestine laboratory synthesis of cathinone.

1.4.11 Catha edulis (Khat) Khat consists of the young leaves and tender shoots of the Catha edulis plant that is chewed for its stimulant properties.18 Catha edulis, a species of the plant family Celastraceae, grows in eastern Africa and southern Arabia. Its effects are similar to the effects of amphetamine. The active ingredients in Khat are cathinone [(–)-a-aminopropiophenone], a Schedule I controlled substance that is quite unstable, and cathine [(+)-norpseudoephedrine], a Schedule IV controlled substance. Identification of cathinone in the laboratory presents problems because of time and storage requirements to minimize degradation.19 Some of the decomposition or transformation products of C. edulis are norpseudoephedrine, norephedrine, 3,6-dimethyl-2,5-diphenylpyrazine, and 1-phenyl-1,2-propanedione.20 REFERENCES 1. Drugs of Abuse, U.S. Department of Justice, Drug Enforcement Administration, 1989, p. 49. 2. Kilmer, S.D., The isolation and identification of lysergic acid diethylamide (LSD) from sugar cubes and a liquid substrate, J. Forensic Sci., 39, 860–862, 1994. 3. Feldman, H.W., Agar, M.H., and Beschner, G.M., Eds., Angel Dust, An Ethnographic Study of PCP Users, Lexington Books, Lexington, MA, 1979, 8. 4. Henderson, G.L., Designer drugs: past history and future prospects, J. Forensic Sci., 33, 569–575, 1988. 5. Angelos, S.A., Raney, J.K., Skoronski, G.T., and Wagenhofer, R.J., The identification of unreacted precursors, impurities, and by-products in clandestinely produced phencyclidine preparations, J. Forensic Sci., 35, 1297–1302, 1990. 6. Smialek, J.E., Levine, B., Chin, L., Wu, S.C., and Jenkins, A.J., A fentanyl epidemic in Maryland 1992, J. Forensic Sci., 3, 159–164, 1994. 7. Janssen, P.A.J., U.S. patent 316400, 1965. 8. Henderson, G.L., The fentanyls, Am. Assoc. Clin. Chem. in-Serv. Train Continuing Ed., 12(2), 5–17, 1990. 9. Riley, R.N. and Bagley, J.R., J. Med. Chem., 22, 1167–1171. 10. Cooper, D., Jacob, M., and Allen, A., Identification of fentanyl derivatives, J. Forensic Sci., 31, 511–528, 1986. 11. Kram, T.C., Cooper, D.A., and Allen, A., Behind the identification of China White, Anal. Chem., 53, 1379–1386, 1981. 12. Mannich, C. and Jacobsohn, W., Hydroxyphenylalkylamines and dihydroxyphenylalkylamines, Berichte, 43, 189–197, 1910. 13. Dal Cason, T.A., The characterization of some 3,4-methylenedioxyphenyl- isopropylamine (MDA) analogues, J. Forensic Sci., 34, 928–961, 1989. 14. Bost, R.O., 3,4-Methylenedioxymethamphetamine (MDMA) and other amphetamine derivatives, J. Forensic Sci., 33, 576–587, 1988. 15. Comprehensive drug abuse prevention and control act of 1970, Public Law 91-513, 91st Congress, 27 Oct. 1970.


30


16. Controlled substance analogue and enforcement act of 1986, Public Law 99-570, Title I, Subtitle E, 99th Congress, 27 Oct. 1986. 17. Zhingel, K.Y., Dovensky, W., Crossman, A., and Allen, A., Ephedrone: 2-methylamino-1-phenylpropan-1-one (jell), J. Forensic Sci., 36, 915–920, 1991. 18. Cath edulis (khat): some introductory remarks, Bull. Narcotics, 32, 1–3, 1980. 19. Lee, M.M., The identification of cathinone in khat (Catha edulis): a time study, J. Forensic Sci., 40, 116–121, 1995. 20. Szendrei, K., The chemistry of khat, Bull. Narcotics, 32, 5–34, 1980.

1.4.12 Anabolic Steroids 1.4.12.1

Regulatory History

In recent years anabolic steroid abuse has become a significant problem in the U.S. There are two physiological responses associated with anabolic steroids: androgenic activity induces the development of male secondary sex characteristics; anabolic activity promotes the growth of various tissues including muscle and blood cells. The male sex hormone testosterone is the prototype anabolic steroid. Individuals abuse these drugs in an attempt to improve athletic performance or body appearance. The more common agents are shown in Figure 1.4.17. Black market availability of anabolic steroids has provided athletes and bodybuilders with a readily available supply of these drugs. Both human and veterinary steroid preparations are found in the steroid black market. Anabolic steroid preparations are formulated as tablets, capsules, and oil- and water-based injectable preparations. There is also a thriving black market for preparations that are either counterfeits of legitimate steroid preparations or are simply bogus. Control of Steroids In 1990, the U.S. Congress passed the Anabolic Steroid Control Act. This act placed anabolic steroids, along with their salts, esters, and isomers, as a class of drugs, into Schedule III of the Federal Controlled Substances Act (CSA). This law provided 27 names of steroids that were specifically defined under the CSA as anabolic steroids. This list, which is provided in the Federal Code of Regulations, is reproduced below. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

Boldenone Chlorotestosterone Clostebol Dehydrochlormethyltestosterone Dihydrotestosterone Drostanolone Ethylestrenol Fluoxymesterone Formebolone Mesterolone Methandienone Methandranone Methandriol Methandrostenolone

15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27.

Methenolone Methyltestosterone Mibolerone Nandrolone Norethandrolone Oxandrolone Oxymesterone Oxymetholone Stanolone Stanozolol Testolactone Testosterone Trenbolone

Unfortunately, the list contains three sets of duplicate names (chlorotestosterone and Clostebol; dihydrotestosterone and stanolone; and methandrostenolone and methandienone) as well as one name (methandranone) for a drug that did not exist. So, the actual number of different steroids specifically defined under the law as anabolic steroids is 23, not 27. Realizing that the list of 23



OH CH3

OH CH3

CH3

OH CH3

CH3

CH3

31

Dromostanolone

CH3

CH3

O

O

OH

O Stanolone

CH3

Oxymetholone

OH

OH CH3

CH3

CH3

CH3

CH3 O HN N

O Oxandrolone

Stanozolol

OH

OH CH3

OH

CH3

CH3

CH3 CH3

CH3

CH3

CH3

CH3 O

O

Cl

O

Methyltestosterone

Methenolone

CH3

HO CH3

Dehydrochloromethyltestosterone

OH HO

CH3

F

CHO

Fluoxymesterone

OH CH3

OH CH3

CH3

CH3

CH3

O

O

CH3

O

Formebulone

Methandienone Methandrostenolone

Figure 1.4.17 Common agents.

substances would not be all inclusive, Congress went on to define within the law the term “anabolic steroid” to mean “any drug or hormonal substance, chemically or pharmacologically related to testosterone (other than estrogens, progestins, and corticosteroids) and that promote muscle growth.” The scheduling of anabolic steroids has necessitated forensic laboratories to analyze exhibits containing steroids. In those cases involving the detection of 1 or more of the 23 steroids specifically defined as anabolic steroids under the law, questions of legality are not likely to arise. However, when a steroid is identified that is not specifically defined under the law, it becomes necessary to further examine the substance to determine if it qualifies as an anabolic steroid under the definition of such a substance under the CSA. The forensic chemist must positively identify the steroid and convey to the pharmacologist the entire structure of the steroid. It then becomes the responsibility of the pharmacologist to determine the pharmacological activity, including effects on muscle growth, of the identified steroid.


32


12

17 13

11 C

D

16

1 10

2

9

14 8

A 3

15

B 5

4

7 6

Figure 1.4.18 Cyclopentanoperhydrophenanthrene.

1.4.12.2

Structure–Activity Relationship

The pharmacology of the identified steroid may be evaluated in at least two ways. The first, and most important way, is to examine the scientific, medical, and patent literature for data on the pharmacological effects of the steroid. Over the years, numerous steroids have been examined in animal and/or human studies for anabolic/androgenic activity. It is possible that the identified steroid will be among that group of steroids. The second method is to evaluate possible pharmacological activity using structure–activity relationships. Such analysis is based on the assumption of a relationship between the structure of the steroid and its pharmacological effects. Small alterations of chemical structure may enhance, diminish, eliminate, or have no effect on the pharmacological activity of the steroid. The structure–activity relationships of androgens and anabolic steroids have been reviewed extensively.1,2 Extensive studies of the structure–activity relationships of anabolic/androgenic steroids have demonstrated that the following structural attributes are necessary for maximal androgenic and anabolic effects: rings A and B must be in the trans configuration;3 hydroxy function at C-17 must be in the β conformational state;5,6 and high electron density must be present in the area of C2 and C33.7 The presence of a keto or hydroxl group at position 3 in the A-ring usually enhances androgenic and anabolic activity, but it is not absolutely necessary for these effects.7 A few examples of structural alterations that enhance anabolic activity include removal of the C-19 methyl group;8 methyl groups at the 2a and 7a positions;9,10 a fluorine at the 9a position; or a chlorine at the 4a position.10,11 To make it easier to visualize where these modifications are made in the ring structure, a numbered steroid skeletal ring structure, namely, the cyclopentanoperhydrophenanthrene ring, is shown in Figure 1.4.18. It is essential to understand that structure–activity analysis can predict only whether or not a steroid is likely to produce androgenic/anabolic effects. It then becomes necessary to examine the steroid in the laboratory to determine whether the prediction is, in fact, true. It is also important to note that numerous studies performed over the years and designed to separate androgenic activity from anabolic activity have failed to obtain such a separation of pharmacological effect. That is, steroids found to possess androgenic activity also have anabolic activity, and vice versa. An examination of the scientific and medical literature reveals that there are, indeed, additional steroids that are not specifically listed in the law but that do, based on available data, probably produce androgenic/anabolic effects. A listing of some of these steroids is provided below. Androisoaxazole Bolandiol Bolasterone Bolenol Flurazebol

Mestanolone Methyltrienolone Norbolethone Norclostebol Oxabolone Cypionate



Mebolazine Mesabolone

1.4.12.3

33

Quinbolone Stenbolone

Forensic Analysis

For the forensic chemist, when a steroid is tentatively identified, an additional problem arises, namely, obtaining an analytical standard. Many products found in the illicit U.S. market are commercially available only outside of the U.S. Locating and making contact with a foreign distributor is one problem. Requesting and then receiving a legitimate standard is another problem. The expense incurred in obtaining these standards can be quite high. Once the standard has been received, authentication then enters the analytical process. If a primary standard is unavailable, an optimized analytical process presents a real problem. Fortunately, most steroids received by forensic science laboratories are labeled directly or have labeled packaging. So a manufacturer can be identified, and there is a starting point for the chemist in confirming the material as a particular steroid. There are no known color tests, crystal tests, or TLC methods that are specific to anabolic steroids. Screening can be accomplished by GLC or HPLC. GLC sometimes presents a problem because of thermal decomposition in the injection port, thereby resulting in several peaks. The steroid will not always be the largest peak. On-column injection will usually solve this problem. However, oil-base steroids rapidly foul or degrade GC columns. Samples in oils can be extracted with methanol/water 9:1 prior to injection onto a GC. Retention times for some anabolic steroids are quite long and nearly triple or quadruple that of heroin. Recognizing that several anabolic steroids are readily oxidized in polar, protic solvents vs. halogenated hydrocarbons, screening and analysis must be accomplished as soon as possible after isolation and dilution. GC/MS does provide definitive spectra; however, different MS systems may provide differences in the spectra for the same steroid. These differences can be traced to the quality of the MS source and the injection liner, thermal decomposition products, and induced hydration reactions related to high source temperatures set by the MS. C13NMR is the most rigorous identification technique. The limitation here is the need for pure samples and high sample concentrations. Identification by infrared alone can result in problems due to polymorphism. This can be minimized by ensuring that the sample and standard are recrystallized from the same solvent. Ideally, all anabolic steroids should be identified using two analytical methodologies that yield the same conclusions. The collection of a library of analytical data on different anabolic steroids is essential for the subsequent identification of steroids sent to the laboratory. An ability to interpret MS data will be important in making an identification insofar as determining a molecular formula. Interpreting NMR data will be important in determining how substitutents are attached to the parent steroid ring structure. It should be noted that selected steroids, such as testosterone, nandrolone, methenolone, boldenone, methandriol, and trenbolone, will often be encountered by the laboratory, not as the parent drug, but instead as an ester. The type of ester will be dependent on the particular steroid. For example, nandrolone is primarily found as a decanoate, laurate, or phenpropionate ester. Testosterone, although it is found as a parent drug, is actually most commonly encountered as the propionate, enanthate, cypionate, decanoate, isocaproate, or undecanoate esters. Less commonly encountered testosterone esters include the acetate, valerate, and undecylenate esters. Methenolone is almost always found in either the acetate or enanthate esterified form. Upon reaching the forensic science laboratory, steroid preparations will be handled differently depending on the way each preparation is formulated. Tablets can be handled by finely grinding and extracting with chloroform or methanol. Aqueous suspensions can be handled by dilution/solution with methanol for HPLC screening or by extraction with chloroform for GC screening. Oils require a more specialized extraction.


34


What steroids have been the most predominant in the U.S. in the past few years? Although the last decade has seen the introduction of many new “designer steroids,” the list of most abused steroids has changed very little in the past 10 years. From January 1990 to October 1994, the following steroids or their esters were identified by DEA laboratories. This list provides an objective evaluation of what this chemist has encountered in the not-too-distant past. The data on these particular steroids should form the basis of a reference collection for comparison with future submissions.

Steroids or Esters of a Steroid

Numbers of Cases Exhibits

Testosterone Nandrolone Methenolone Methandrostenolone Oxymetholone Stanozolol Fluoxymesterone Methyltestosterone Boldenone Mesterolone Oxandrolone Trenbolone Methandriol Drostanolone Mibolerone Stanolone Testolactone

260 140 99 76 67 61 54 48 24 21 16 13 10 6 4 2 1

882 244 189 158 103 115 7 75 28 22 21 20 8 7 7 2 1

Acknowledgment The author wishes to acknowledge the assistance of Dr. James Tolliver, Pharmacologist, of the DEA Office of Diversion Control, for collaborating in the preparation of this work.

REFERENCES 1. Counsell, R.E. and Klimstra, P.D., Androgens and anabolic agents, in Medicinal Chemistry, 3rd ed., Burger, A., Ed., Wiley-Interscience, New York, 1970, 923. 2. Vida, J.A., Androgens and Anabolic Agents: Chemistry and Pharmacology, Academic Press, New York, 1969. 3. Huggins, C., Jensen, E.V., and Cleveland, A.S., Chemical structure of steroids in relation to promotion of growth of the vagina and uterus of the hypophysectomized rat, J. Exp. Med., 100, 225–246, 1954. 4. Gabbard, R.B. and Segaloff, A., Facile preparation of 17 beta-hydroxy-5 beta-androstan-3-one and its 17 alpha-methyl derivative, J. Organic Chem., 27, 655, 1962. 5. Kochakian, C.D., Recent Progress in Hormonal Research, 1, 177, 1948. 6. Kochakian, C.D., Am. J. Physiol., 160, 53, 1950. 7. Bowers, A., Cross, A.D., Edwards, J.A., Carpio, H., Calzada, M.C., and Denot, E., J. Med. Chem., 6, 156, 1963. 8. Hershberger, L.G., Shipley, E.G., and Meyer, R.K., Proc. Soc. Exp. Biol. Med., 83, 175, 1953. 9. Counsell, R.E., Klimstra, P.D., and Colton, F.B., Anabolic agents, derivatives of 5 alpha-androst-1ene, J. Organic Chem., 27, 248, 1962. 10. Sala, G. and Baldratti, G., Proc. Soc. Exp. Biol. Med., 95, 22, 1957. 11. Backle, R.M., Br. Med. J., 1, 1378, 1959.



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1.5 LEGITIMATE PHARMACEUTICAL PREPARATIONS The Controlled Substances Act (CSA) of 1970 created a closed system for the production and distribution of legitimately manufactured controlled substances. The CSA includes contingencies to regulate the domestic commerce, importation, and exportation of these pharmaceutical preparations. Even with all of the controls that are in place, legitimate pharmaceuticals intended to help those in need are diverted onto the illegitimate market. Most of the diversion of these pharmaceuticals occurs at the retail rather than the wholesale level. The analysis of pharmaceutical preparations in the forensic science laboratory is one of the most straightforward types of analysis. These samples are usually recognizable by their labels, which usually include the manufacturer’s logo and name. There are some samples that even have the name of the product inscribed on the tablet or capsule. In those instances where the manufacturer’s logo is not recognized, the Physician’s Desk Reference (PDR) is a readily available source of information, which includes photographs and descriptions of the product along with information of the formulation. Another source of this information is the Logo Index for Tablets and Capsules.1 This particular text lists data including inscriptions on most known products including generics. After the tablet or capsule has been tentatively identified in a reference text, it is the responsibility of the forensic chemist to conduct a series of analyses to verify the presence of a controlled substance. This verification process will usually consist of many of the same analytical processes utilized in the analysis and evaluation of any controlled substance. 1.5.1

Benzodiazepines

The benzodiazepines form one of the largest classes of abused pharmaceuticals. These products are sedative/hypnotics, tranquilizers, and anti-anxiety drugs; they produce a calming effect and are often prescribed as tranquilizers. The drugs in this class are numerous and are included under Schedule IV control because, while they do have a potential for abuse, there are recognized medical benefits that are both physiological and psychological. The most frequently diverted and abused benzodiazepines are alprazolam (Xanax) and diazepam (Valium). Other frequently abused benzodiazepines are lorazepam (Activan), triazolam (Halcion), chlordiazepoxide (Librium), flurazepam (Dalmane), and temazepam (Restoril). Another phenomenon that has been noted for several years is the abuse of legitimate pharmaceuticals in conjunction with illicit controlled substances. Clonazepam (Klonipin) is just such a product. It is an anxiety reducer that is used in combination with methadone and heroin. There has been a recent influx of flunitrazepam (Rohypnol) into the Gulf Coast and other areas of the U.S. This product is a benzodiazepine manufactured principally in Colombia, Mexico, and Switzerland. It is also manufactured in lesser amounts in Argentina, Brazil, Peru, Uruguay, and Venezuela. It is neither manufactured nor marketed legally in the U.S. This is a powerful drug reported to be seven to ten times more potent than diazepam. 1.5.2

Other Central Nervous System Depressants

The oldest of the synthetic sleep-inducing drugs dates back to 1862. Chloral hydrate is marketed as a soft gelatinous capsule under the name Noctec, and controlled under Schedule V. Its popularity declined after the introduction of barbiturates. Barbiturates are the drugs prescribed most frequently to induce sedation. Roughly 15 derivatives of barbituric acid are currently in use to calm nervous conditions. In larger doses they are used to induce sleep. The actions of barbiturates fall into four categories. Some of the ultrashort acting barbiturates are hexobarbital (Sombulex), methohexital (Brevital), thiamylal (Surital), and thiopental (Pentothal). Short-acting and intermediate-acting barbiturates include pentobarbital (Nembutal), seco-


36


O NH2

NHCCH3

O O

COH O

+

COH O

CH3COCCH3 Acetic Anhydride

N-Acetylanthranilic Acid

Anthranilic Acid O NHCCH3 COH O

NH2 +

N-Acetylanthranilic Acid

CH3

o-Toluidine

N

CH3 CH3 N

O Methaqualone

Figure 1.5.1 Clandestine laboratory synthesis of methaqualone.

barbital (Seconal), and amobarbital (Amytal). These three drugs have been among the most abused barbituric acid derivatives. Also included in these categories but not as abused are butabarbital (Butisol), talbutal (Lotusate), and aprobarbital (Alurate). The last category is the long-acting barbiturates. These drugs are used medicinally as sedatives, hypnotics, and anticonvulsants. The group includes phenobarbital (Luminal), mephobarbital or methylphenobarbital (Mebaral), and metharbital (Gemonil). Three other CNS depressants that have been marketed as legitimate pharmaceutical preparations and have a history of abuse include glutethimide (Doriden), methaqualone (Quaalude, Parest, Mequin, Optimil, Somnafac, Sopor, and Mandrax), and meprobamate (Miltown, Equanil, and SK-Bamate). The route for the clandestine synthesis of methaqualone is shown in Figure 1.5.1. 1.5.3

Narcotic Analgesics

When one thinks of opium-like compounds, morphine and heroin immediately come to mind. However, there is another subset of this class of compounds that includes pharmaceutical preparations used to relieve pain, which are purchased legitimately or illegitimately from a pharmacy with a prescription. Frequently used pharmaceutical opiates include oxycodone (Percodan), hydromorphone (Dilaudid), hydrocodone (Tussionex and Vicodin), pentazocine (Talwin), and codeine combinations such as Tylenol with Codeine and Empirin with Codeine. All of these compounds are addictive. Along with Tylenol with Codeine and Empirin with Codeine, which are Schedule III controlled substances, codeine is also available in combination with another controlled substance (butalbital) and sold under the trade name of Fiorinal with Codeine. It is available with acetaminophen in Phenaphen. Codeine is available in liquid preparations under the manufacturers’ names Cosanyl, Robitussin A-C, Cheracol, Cerose, and Pediacof. Because of the amounts of codeine in these preparations, they are controlled under Schedule V. There are also pharmaceutical codeine tablets, which contain no drug other than codeine and are controlled under Schedule II. While the compounds listed above are considered opiates, there is another class of compounds also classified as narcotic, but with synthetic origins. Meperidine (Demerol) is one of the most widely used analgesics for the relief of pain. Methadone (Amidone and Dolophine) is another of these synthetic narcotics. It was synthesized during World War II by German scientists because of a morphine shortage. Although it is chemically unlike morphine or heroin, it produces many of the same effects and is often used to treat narcotic addictions.



37

Dextropropoxyphene is one of those drugs that falls into one of two controlled substance schedules. When marketed in dosage form under the trade names Darvon, Darvocet, Dolene, or Propacet, dextropropoxyphene is a Schedule IV controlled substance. However, when marketed in bulk non-dosage forms, dextropropoxyphene is a Schedule II controlled substance. The significance here is that the penalties for possession of a Schedule II controlled substance are usually much greater than for possession of a Schedule IV controlled substance. 1.5.4

Central Nervous System Stimulants

Amphetamine (Benzedrine and Biphetamine), dextroamphetamine (Dexedrine), and methamphetamine (Desoxyn) are three of the best-known CNS stimulants and were prescribed for many years to treat narcolepsy. At one time, these drugs were sold over the counter without a prescription. For many years these drugs were sold as appetite suppressants. Their availability in the form of prescription drugs has all but been eliminated except under the close scrutiny of a physician. However, the clandestine laboratory production of methamphetamine in the form of a powder or granular material has been one of the major problems facing law enforcement personnel in the past 20 or so years in the U.S. Phenmetrazine (Preludin) and methylphenidate (Ritalin) are two other CNS stimulants that have patterns of abuse similar to the amphetamine and methamphetamine products. In recent years, a number of pharmaceutical products have appeared on the market as appetite suppressants and as replacements for the amphetamines. These anorectic drugs include benzphetamine (Didrex), chlorphentermine (Pre-Sate), clortermine (Voranil), diethylpropion (Tenuate and Tepanil), fenfluramine (Pondimin), mazindol (Sanorex and Mazanor), phendimetrazine (Plegine, Bacarate, Melifat, Statobex, and Tanorex), and phentermine (Ionamin, Fastin, and Adipex-P). 1.5.5

Identifying Generic Products

There are a number of generic products on the market that are legitimate pharmaceutical preparations. These products will usually contain the active ingredient of the brand name product, but at the same time have a different formulation in the way of diluents and binders. These products are cataloged in various publications. When these products are encountered in the forensic science laboratory, the analyst will usually make a preliminary identification using one of the many publications listing the tablet or capsule’s description and the code number that appears in the face of the product. This “preliminary” identification affords a starting point in the analytical process. The analyst will then proceed using the standard chemical techniques and instrumental methods to make an independent identification.

REFERENCE 1. Franzosa, E.S. and Harper W.W., The Logo Index for Tablets and Capsules, 3rd ed., U.S. Government Printing Office, Washington, D.C., 1995, 392–2401.

1.6 UNIQUE IDENTIFYING FACTORS 1.6.1

Packaging Logos

There are unique factors associated with controlled substance examinations that involve packaging. Heroin and cocaine are usually imported into the U.S. clandestinely packaged. Sometimes


38


this packaging takes the form of legitimate household or commercial products that have been hollowed out or have natural crevices into which drugs can be stored for shipment. These kinds of packages will usually be transported via commercial carriers to distributors who will reclaim the drugs and repackage them for street distribution. Sometimes drugs are shipped via human beings who store packages in body cavities, or swallow small packages in order to clear customs checks at points of entry. In these cases, it is not unusual for the packaging to break while in the body of the person transporting the drug. This usually results in severe injury or death. Another common way of transporting controlled substances is to package the controlled substance in brick-size, 1-kg packages for shipment to the U.S. This is often the case with shipments of heroin, cocaine, and marijuana, and the packages are usually wrapped in paper or tape. Sometimes a logo, serving as a type of trademark for the illicit distributor, will be affixed. Logos can take the form of any number of designs. They are applied using a stamping or printing device. Some commonly encountered designs include, but are not limited to, animals, symbols from Greek mythology, replications of brand name product logos, replications of the names of political figures, cartoon characters, and numbers. When a number of these logos are encountered, examinations can be conducted to determined whether two logos have a common source. If the examiner determines that two logos are the same, and were produced using the same printing or stamping device, then the two packages must have originated from the same source. This kind of information is especially useful in tracking distribution networks. Glassine envelopes measuring approximately 1 × 2 in. are commonly used to distribute heroin “on the street” directly to the primary user. More often than not, these glassine envelopes have rubber-stamped images affixed. These rubber stamped images take many forms. Cartoon characters or words with social implications are common. The examiner can determine whether these rubberstamped images have a commonality of source and use this information to track distribution patterns of heroin within a geographical area. 1.6.2

Tablet Markings and Capsule Imprints

Counterfeit tablets and capsules, which closely resemble tablets and capsules of legitimate pharmaceutical companies, are readily available on the clandestine market. They generally contain controlled substances that have been formulated in such a way as to mimic legitimate pharmaceutical preparations.1 They are designed to be sold either on the clandestine or the legitimate market. These counterfeits sometimes are expertly prepared and closely resemble the pharmaceutical products that they are designed to represent. At other times, they are poorly made, inadequate representations of the products they are purported to represent. The examiner in these types of cases will evaluate the suspected tablets or capsules by examining both the class and individual characteristics of the products. Legitimate products are usually prepared with few significant flaws on tablet or capsule surfaces. The lettering or numbering will be symmetrical in every way. The tablet surfaces will have minimal chips or gouges and will usually be symmetrical. The homogeneity of the tablet will be of the highest quality. Counterfeits will usually have tabletting flaws. These flaws can take the forms of imperfect lettering or numbering, rough surfaces, or inconsistencies in the tablet formulation. This can result in different hardening characteristics of the tablet. Legitimate capsules will be highly symmetrical. The lettering or numbering will usually line up on both halves of the capsule.2,3 In recent years, methamphetamine and amphetamine tablets and capsules, crafted to mimic Dexedrine and Benzedrine, have been encountered with some frequency. These two products were distributed and used quite extensively on the legitimate market up until the 1970s. And while they are still available commercially with a prescription, they have been controlled under Schedule II since 1972 and their legal distribution and usage in the medical community has become fairly limited. Counterfeit barbiturate, methaqualone, and benzodiazepine tablets, sometimes from doc-



39

umented clandestine source laboratories from 20 years ago, have been encountered in recent seizures. Counterfeit Quaalude, Mandrax, and Valium tablets are examples of legitimate trademark products that have been the favorites of clandestine laboratory operators. The “look-alike” market was especially lucrative in the 1970s and 1980s and became a $50,000,000 a year industry.4,5 A unique problem, encountered with regularity up until 1975, involved the refilling of capsules. Legitimate capsules were diverted from legitimate manufacturing sources. The capsules were then emptied of their contents and refilled with some innocuous material, such as starch or baking soda, and sold. The original filling, usually containing a controlled substance, was then diverted for sale on the illicit market. These capsules can usually be identified by imperfections in their surface characteristics. There may be small indentations on the gelatinous surface of the capsule and fingerprints indicating excessive handling. The seal holding both halves of the capsule together will not be tight. And there will usually be traces of powder around the seal of the capsule. Refilling capsules by hand or by improvised mechanical devices is not easy and usually results in these visible powder residues. A more common problem today is the refilling of over-the-counter capsules with heroin for distribution at the retail level. A similar problem that is encountered with some frequency in the forensic science laboratory is the pre-packaged syringe from a hospital, which is labeled and supposed to contain an analgesic such as meperidine. Patients complain they are receiving no relief from the injection they have been given. The syringes are then sent to the laboratory for analysis. Not infrequently, they are found to contain water, substituted for the active drug by an addicted doctor or nurse. 1.6.3

Blotter Paper LSD

LSD has been available for years in the forms of small tablets (microdots), small gelatinous squares, clear plastic-like squares (window panes), powders or crystals, liquid, or in capsules. The most commonly encountered form of LSD available today is impregnated blotter paper. This LSD medium is prepared by dissolving the clandestinely produced LSD powder in an alcohol solution, and then spraying or soaking the paper with the solution. The alcohol solution used most frequently is EverClear, a commercial ethyl alcohol product available in liquor stores. This LSD-impregnated paper is referred to as “blotter acid.” It is usually distributed on sheets of paper perforated into 1/4 × 1/4 in. squares. These sheets of paper range in size to hold from 1 square up to 1000 squares. These sheets of blotter paper can be plain white or single colored with no design imprints. More often than not, there will be a brightly colored design on the paper. The design can be simple such as a black and white circle, or it can be extremely intricate. One such design was brightly colored and with a detailed depiction of the crucifixion of Jesus Christ. The design can cover each and every individual square of a 1000-perforated square sheet of paper, or one design can cover the entire sheet of blotter paper where each 1/4 × 1/4 in. perforation square makes up 1/1000 of the total design. By examining the intricate designs on LSD blotter paper from different seizures, it is possible to determine whether there is a common source. Depending on the printing process and the quality of the image, the examiner may be able to characterize an exhibit as having originated from the image transfer process and a specific printing device. This ability to determine source commonality is most valuable in determining the origins of LSD exhibits seized from different parts of the world. The processes described above are most valuable in linking seizures to a particular source. Investigators who are skillful and fortunate enough to seize printing or tabletting devices even without the actual controlled substances can have their efforts rewarded by terminating a controlled substance production operation. A qualified scientific examiner has the opportunity to use these devices as standards and to search reference collections of tablets, capsules, LSD blotter paper designs, or heroin or cocaine packaging logos to determine possible associations to past seizures. When this happens, the opportunity to eliminate another source of illicit drug distribution becomes a possibility.


40


REFERENCES 1. Franzosa, E.S., Solid dosage forms: 1975–1983, J. Forensic Sci., 30, 1194–1205, 1985. 2. Eisenberg, W.V. and Tillson, A.H., Identification of counterfeit drugs, particularly barbiturates and amphetamines by microscopic, chemical, and instrumental techniques, J. Forensic Sci., 11, 529–551, 1966. 3. Tillson, A.H. and Johnson, D.W., Identification of drug and capsule evidence as to source, J. Forensic Sci., 19, 873–883, 1974. 4. Crockett, J. and Franzosa, E., Illicit solid dosage forms: drug trafficking in the United States, paper presented at the 6th Interpol Forensic Sciences Symposium in 1980. 5. Crockett, J. and Sapienza, F., Illicit solid dosage forms: drug trafficking in the United States, paper presented at the 10th Interpol Forensic Sciences Symposium in 1983.

1.7 ANALYZING DRUGS IN THE FORENSIC SCIENCE LABORATORY 1.7.1

Screening Tests

No other topic related to the identification of controlled substances causes as much controversy as testing specificity. Forensic science laboratories conduct two different categories of tests. Tests in the first category are called “screening tests.” They include a series of tests used to make a preliminary determination of whether a particular drug or class of drugs is present. It must be emphasized that screening tests are not used to positively identify any drug. At best, screening tests can only be used to determine the possibility that members of a particular class of drug may be present. Some say that screening tests can result in “false positives,” meaning either that the test indicates the possible presence of a controlled substance when none is present or that the test indicates the possible presence of one controlled substance when a different controlled substance is present. That should not be a problem, so long as it is understood that screening tests have very little if any specificity, and that a false positive test will only lead to more testing, not a false conclusion. The identification of any drug by a chemical analysis is a systematic process involving a progression from less specific methods to more specific methods. The most specific methods involve instrumental analyses. Properly trained scientists should know when a false positive is possible, and how to take steps to narrow the focus of the testing. The more tests used, the fewer the chances for error. False negative screening tests also occur. Very weak or diluted samples containing controlled substances may yield a negative screening test. An example of this situation would be a 1% heroin sample cut with a brown powder. Testing this sample with Marquis reagent, which contains sulfuric acid and formaldehyde, may result in a charring of the brown powder and subsequent masking of the bleeding purple color characteristic of an opium alkaloid. Weak or old reagents may also yield false negatives. Examiner fallibility or inexperience in discerning colors may also result in false negatives. The possibility of a false negative leads many examiners to conduct a series of screening tests or, when warranted, to progress directly to more narrowly focused screening tests. Specificity is the key to the forensic identification of controlled substances. There is no one method that will work as a specific test for any and all exhibits at any and all times. The choice of which specific method one utilizes must be determined by the type of controlled substance, the concentration of the controlled substance in the sample, the nature of the diluents and adulterants, the available instrumentation, and the experience of the examiner. There is an ongoing debate whether one can achieve this scientific certainty by combining a series of nonspecific tests. This is discussed later in this section. 1.7.1.1 Physical Characteristics Occasionally an experienced forensic analyst can just look at an exhibit in a drug case and determine the probable nature of the substance. However, “probable natures” are not enough for



41

an identification, and most examiners will usually conduct more than one test before reporting the presence of a controlled substance. The morphology of botanical substances such as marijuana and the peyote cactus are familiar enough to many laboratory analysts. Marijuana is one of those controlled substances that is examined with such frequency in the laboratory that a preliminary identification is probable based on the morphology of the botanical substance, gross physical appearance, texture, and odor. However, even after a microscopic examination of the cystolithic hairs using a microscope, the modified Duquenois–Levine test is usually run to corroborate the identification. The peyote cactus with its button-like appearance is also unique. In a like manner, the identification of the opium poppy requires a confirmation of the morphine; and the identification of the psilocybin mushroom requires an identification of the psilocybin or the psilocin. The physical characteristics of these four agronomic substances might enable an expert witness with a background in plant taxonomy and botany to make an identification based solely on these characteristics. The forensic analyst relies on the physical characteristics and corroborating chemical examinations to identify these materials as controlled substances. 1.7.1.2 Color Tests The color test is usually the first chemical examination examiners conduct after a package suspected of containing controlled substances is opened and weighed. Small amounts of the unknown material are placed in depressions in a porcelain spot plate or a disposable plastic or glass spot plate. Chemical reagents are then added to the depressions and the results noted: color changes, the way in which the color changes take place (flashing or bleeding), the rate at which the color changes take place, and the intensity of the final colors. The most common color reagents are the Marquis reagent for opium alkaloids, amphetamines, and phenethylamines such as MDA or MDMA; cobalt thyocyanate reagent for cocaine and phencyclidine (PCP); Dille-Koppanyi reagent for barbiturates; Duquenois reagent for marijuana; and Ehrlich’s reagent for LSD. A more complete listing of these tests is available in the literature.1 Many of these tests are multistep and multicomponent. These color tests are designed as a starting place for the examiner in deciding how to proceed as the pyramid of focus narrows in forming a conclusion. Adulterants and diluents can also cause color changes and are sometimes said to be responsible for “false positives.” The resulting color changes are not really false. They simply reflect the presence of a substance that is not the primary focus of the analytical scheme. Problems of “false negatives” and “false positives” are usually recognized very early in the analytical scheme, and they are resolved logically and rationally. 1.7.1.3 Thin-Layer Chromatography Thin-layer chromatography (TLC) is a separation technique. The method utilizes a glass plate that is usually coated evenly with a thin layer of adsorbant. The most commonly used adsorbant is silica gel. A small amount of the sample is put into solution with a chemical solvent. A capillary pipette is then used to place a small amount of the liquid onto the TLC plate approximately 2 cm from the bottom of the plate. A second capillary pipette containing a small amount of a known controlled substance in solution is used to place a second spot on the plate usually next to, but not overlapping, the first spot. The plate is then placed into a tank containing a solvent system, which rises about 1 cm from the bottom of the tank. Through capillary action, the solvent will migrate up the plate, and the components of the unknown will usually separate as the solvent migrates. The separated components can usually be visualized using long-wave or shortwave ultraviolet light, a chemical spray, or some combination of both. The distance each sample migrates is then divided by the distance the solvent in the tank migrates up the plate (know as the Rf value). The result is then compared to published values that have been established for pure samples of the abused drugs. If one of the components of the unknown


42


migrates the same distance up the plate as the known, the examiner has another piece of corroborating information. If the unknown does not contain a component that migrates the same distance as the known, there are many explanations. Perhaps the known and unknown are not the same. Perhaps there is a component in the unknown solution that is binding the chemical of interest to the silica gel. The explanations for matches are numerous. The explanations for non-matches are just as numerous. The literature is replete with values for drug/solvent migration ratios. However, these values can be affected by many factors, including the storage conditions of the TLC plates and solvent temperature. It is not uncommon for the Rf values in the laboratory to differ from those in the literature. The importance of a TLC analysis lies in its ability to separate components in a mixture. A match is another piece of corroborating information. A non-match can usually be explained. Using TLC to identify marijuana, hashish, or hash oil is a much more complicated process than using it to identify other controlled substances.2 The TLC analysis of cannabis exhibits results in a series of bands on the thin-layer plate. Depending on the solvent system, the number of bands can range from at least three to at least six bands.3 Each band will have a specific color and lie at a specified place on the plate corresponding to the known cannabinoids in a standard marijuana, hashish, or THC sample.4 The key point here is that this type of identification involves a specific chromatographic pattern as opposed to one spot where a known is compared directly with an unknown. Even with the increased specificity of a TLC analysis in the examination of cannabis or a cannabis derivative, a modified Duquenois–Levine test is suggested. 1.7.2

Confirmatory Chemical Tests

1.7.2.1 Microcrystal Identifications Microcrystal tests are conducted using a polarized light microscope and chemical reagents. These microscopic examinations are not screening tests. The analyst will usually place a small amount of the sample on a microscope slide, add a chemical reagent, and note the formation of a specific crystal formation. These crystals are formed from specified reagents. There should be very little subjectivity in evaluating a microcrystal test.5 Either the crystal forms or it does not form. If the appropriate crystal forms in the presence of the reagent, the drug is present. If the crystal does not form and the drug is present, the problem is usually one in which the drug concentration is too dilute, or the reagent has outlived its shelf life. One disadvantage of microcrystal tests is the absence of a hard copy of what the analyst sees. Unless a photograph is taken of the crystal formation, the examiner cannot present for review documentation of what he saw under the microscope. Microcrystal tests are an excellent way of evaluating the relative concentration of a drug in a sample to determine the kind of extraction technique for separation and further confirmation. 1.7.2.2 Gas Chromatography Gas chromatography (GC) has been a standard operating procedure in forensic science laboratories for the past three decades. In this technique, a gaseous mobile phase is passed through a column containing a liquid-coated, stationary, solid, support phase. The most common form of GC uses a capillary column of a very fine diameter for separating the component of a mixture. The sample is usually put into solution using an organic solvent such as methanol. The liquid is then introduced into the injection port of the gas chromatograph using a fine needle syringe capable of delivering microliter quantities of the solution. The amount injected depends on the concentration of the sample: 1 μl (one-one hundredth of a milliliter) of 1 mg of solute per l ml of solvent is a typical injection amount. The sample is vaporized in the heated injection port, and with the aid of a carrier gas travels through the long capillary column where the different components are separated. There are many different kinds of capillary columns with different internal coatings, lengths (which



43

can vary from one foot up to tens of meters), and diameters (measured in micrometers). This separation is determined by the polarity and molecular size of each component. Each component exits the column onto a detector. A flame ionization detector (FID) is the most common detector used in most laboratories. Other types of less frequently encountered detectors include the nitrogen phosphorus detector and the electron capture detector. As each component elutes from the column through the FID, a signal is generated, which results in a “peak” on a recording device. The recorder is used to document the resulting data. This recorder is usually a part of a data station that not only generates a representation of the chromatogram on a monitor, but also controls instrument parameters and ensures the consistency of the analysis. The peaks of interest are evaluated by their retention times (RTs) and by the areas under the peaks. The retention time data can be used either as confirmation of the probable identity of the substance generating the peak, or the data can be evaluated as screening information to determine the possible presence of a controlled substance. These RT data are compared to the retention time of a known standard injected onto the same column in the same instrument at the same temperature and rate flow conditions. The RTs of the known and the unknown should be almost the same within a very narrow window. The area under the peak can be used to quantitatively determine the relative concentration of the substance. There are some disadvantages of GC. Retention times are not absolute and usually fall within a narrow window. Other compounds may fall within this same RT window. One way to overcome this problem is to analyze the same sample using a second capillary column with a different internal coating and to note its retention time as compared to the known standard. The values should be the same within a narrow RT window. A second disadvantage of GC is that some samples degrade in the injection liner at high temperatures and must be evaluated by using a derivatizing agent. This derivatizing agent is added to the drug and forms a molecular complex. The molecule complex remains intact as it passes from the injection port, through the column, and onto the detector. GC by itself is a very powerful tool for the forensic analyst. Its most useful application today remains one in which it is interfaced with a mass spectrometer (mass selective detector), which serves as a detector and separate instrumental identification method unto itself. Gas chromatography/mass spectrometry (GS/MS) is discussed later in this section. 1.7.2.3 High-Performance Liquid Chromatography This chromatographic technique is also a separation technique, but with a bit more selectivity than GC. In high-performance liquid chromatography (HPLC), the mobile phase is a liquid and the stationary phase is a solid support or a liquid-coated solid support. In GC, a carrier gas is used to carry the sample through the chromatography column. In HPLC, a high-pressure pump is used to carry the solvent containing the compound of interest through the column. Separation results from selective interactions between the stationary phase and the liquid mobile phase.6 Unlike GC, the mobile phase plays a major role in the separation. HPLC can be used for the direct analysis of a wide spectrum of compounds and is not dependent on solute volatility or polarity. The operator need not worry about chemical changes in the molecule that can occur in GC due to thermal degradation. HPLC chromatograms are evaluated based on retention time and area under the peak of interest. Retention time is not an absolute value, but a time within a narrowly defined window. The five basic parts of the liquid chromatograph include the solvent reservoir, the pump, the sample injection system, the column, and the detector. A recorder is used to document the resulting data. This recorder is usually a part of a data station that controls instrument parameters and ensures the consistency of the analysis. The most common detectors are the ultraviolet/visible detector (UV/VIS), the florescence detector, the electrochemical detector, the refractive index detector, and the mass spectrometer. The UV/VIS detector is the most widely used device, and it is dependent on the ability of the solute to absorb UV or visible light. The variable wavelength detector allows


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the analyst to select any wavelength in the UV or visible range. The diode array or rapid scan detector is also used, which allows a rapid scan of the entire UV spectrum to identify the components eluting from the column. Because the components elute from the UV detector in solution, they do not undergo degradation or destruction. This one very useful characteristic of HPLC affords the analyst the option of collecting fractions of the eluent for further analysis. This is not possible in GC because the eluent is destroyed by the FID. 1.7.2.4 Capillary Electrophoresis Capillary electrophoresis (CE) is a technique that separates components on the basis of chargeto-mass ratios under the influence of an electrical field. It uses high voltage for fast separations and high efficiencies. Osmotic flow is the main driving force in CE, especially at higher pH values, and results primarily from the interaction of positive ions in solution with the silanol groups on the capillary in the presence of an applied field. Narrow bore capillary columns of uncoated fused silica are used for heat dissipation during the separation process. The detector is normally a UV detector. Micellar electrokinetic capillary chromatography (MECC) is a form of CE that allows for the separation of cations, neutral solutes, and anions. CE has several advantages over HPLC and GC. The method can be used with ionic and neutral solutes, which present problems in GC. There is a higher efficiency, resolving power, and speed of analysis compared to HPLC. From a cost perspective, CE requires much less solvent than HPLC, and the CE capillary column is much less expensive than the HPLC or GC capillary columns. Two disadvantages of CE are the limited sensitivity for UV detection (30 to 100 times less than that of HPLC); and fraction collection is troublesome because of mechanical problems and small sample size. This technique uses a micelle as a run buffer additive to give separations that are both electrophoretic and chromatographic. One of the advantages of MECC is the ability to separate racemic mixtures of compounds into the D- and L-isomers. This is an ability that is extremely valuable when identifying compounds where one isomer is controlled (dextropropoxyphene) and the other isomer is not controlled (levopropoxyphene). This is usually accomplished by adding cyclodextrins to the run buffer. 1.7.2.5 Infrared Spectrophotometry Infrared (IR) spectrophotometry is one of the most specific instrumental methods for the identification of a controlled substance. A pure drug as a thin film on a KBr salt plate, or as crystals mounted in a KBr matrix, is placed into the sample compartment of the IR spectrophotometer. A source of electromagnetic radiation in the form of light from a Nernst glower passes light through the sample. The instrument, through a mechanical means, splits the beam into a reference beam and an incident beam. The reference beam passes unobstructed through a monochrometer to a photometer; the incident beam passes through the mounted sample through the same monochrometer to the photometer. The reference beam passes 100% unobstructed to the photometer. The incident beam passing through the sample has some of its energy absorbed by the sample. This energy is absorbed at different wavelengths across the infrared spectrum from 4000 cm–1 down to 250 cm–1. The amount of relative absorption and where on this spectrum the absorption takes place are dependent on the molecular structure and, more specifically, the functional groups of the drug. Different functional groups and molecular interactions brought on by symmetrical and asymmetrical molecular stretching vibrations and in-plane and out-of-plane bending vibrations result in a number of peaks and valleys on the IR chart. The resultant spectrum is usually formed on an x/y coordinate axis. The wavelength (μ) or wave number (cm–1) where the absorption occurs is depicted on the



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x-axis, and a measure of the amount of light absorbed by the sample, but usually referenced by transmittance units from 0 to 100%, is depicted on the y-axis. The IR spectrum of a suspected drug results in a specific pattern that can be used to positively determine the identity of the substance. For most controlled substances, the resulting spectrum consists of 20 to 70 peaks. These peaks form a pattern that is unique to the chemical structure of the drug. This pattern can then be compared with a reference IR spectrum of a primary drug standard. If the analyst determines that the two spectra match within the limits of scientific certainty, an identification is possible. It is rarely, if ever, possible to overlay the reference spectra with the spectra of the unknown and have a “perfect match.” The analyst is looking for a match in the patterns. Any shifts in peak intensity or wave number must be evaluated in conjunction with the pattern. Small shifts of 1 or 2 cm–1 and minor intensity variations of individual peaks are expected. However, major variations must be evaluated on a case by case basis. Some authors refer to IR as a “fingerprint” identification method. This implies an ability to overlay two spectra and obtain a perfect match in every way. This degree of perfection is rarely, if ever, possible. Another factor that must be considered is that when two spectra are being compared peak-bypeak as opposed to pattern-by-pattern, they ideally should be from the same instrument and collected at about the same time. Comparing a literature reference spectrum with an unknown for a pattern match is acceptable. Comparing the same literature reference spectrum wave number by wave number, absolute transmittance value by absolute transmittance value will probably result in minor differences. IR does have limitations. To obtain an acceptable spectrum, the sample must be very clean and dry. For forensic exhibits, this usually means that most samples must go through extraction processes to remove impurities. In the past, sample size was a problem. However, because of advances in Fourier transform IR technology and the interfacing of an IR spectrophotometer with a microscope, evaluating microgram quantities of a sample results in excellent spectra that are conclusive for the identification of a controlled substance. IR has very definite limitations in its ability to quantitate controlled substances, and differentiating some isomers of controlled substances can pose problems. 1.7.2.6 Gas Chromatography/Mass Spectrometry GC/MS is by far the most popular method of identifying controlled substances in the forensic science laboratory. In this method, a gas chromatograph is interfaced with a mass selective detector (MSD). The sample undergoing an examination is placed into solution with a solvent such as methanol. A very small injection volume of 1 or 2 μl is injected into the GC injection port. It then travels through the column where the different components of the sample are separated. The separated components can then be directed into the ionization chamber of MSD where they are bombarded by an electron beam. In electron impact gas chromatography/mass spectrometry (EI MS), high-energy electrons impact the separated component molecules. The resulting spectrum of each component is typically complex with a large number of mass fragments. These fragments are represented as peaks of varying intensity that provide the basis for comparison with a primary reference standard. The components are then ionized and positively charged. This ionization also results in a fission or fragmentation process. The molecular fragments traverse into a magnetic field where they are separated according to their masses. In this magnetic field, larger mass fragments are less affected by the magnetic field, and smaller fragments are more affected and undergo a deflection. Upon exiting the magnetic field, these fragments impact a detector losing the charge generated by the beam of electrons impacting the sample. The result of this fragmentation process is a pattern unique for the substance that is being analyzed. The resulting mass spectrum consists of an x/y coordinate axis. The numerical value on the xaxis represents the mass number determined by the number of neutrons and protons in the nucleus. It is usually the molecular weight of a specific fragment. The largest magnitude peak on the x-axis


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will often be the molecular ion and will represent the molecular weight of the unfragmented compound. There will usually be a very small peak to the right of the molecular ion which represents the molecular weight plus 1. The y-axis represents the relative abundance of each peak comprising the mass spectrum. The tallest peak on the y-axis is the base peak and represents that part of the molecule that is the most stable and undergoes the least amount of fragmentation. The base peak is assigned a relative abundance value of 100. The other peaks in the resulting spectrum are assigned relative values along the y-axis. The numerical values on the x- and y-axis are calculated and assigned by the data station, which is interfaced with the mass spectrometer. The accuracy of these numbers is predicated on the fact that the instrument has been properly tuned. This tuning process can be compared to checking the channel tuning on a television set. This might be accomplished by opening a television guide to determine what programs are scheduled at a particular hour. The television is then turned on and the program for each channel checked. If the programs cited in the television magazine appear on corresponding channels at the proper times, the television has been proved to be properly tuned. The tuning of a mass analyzer presents an analogous situation. The tuning process of a mass analyzer involves a procedure in which a chemical of a known molecular weight and fragmentation pattern is analyzed and the resulting data evaluated. This process includes verifying instrument parameters and the resulting spectrum. If the response of the tuning process falls within specified limits, the mass spectrometer is deemed operationally reliable, and the resulting data can be considered reliable. One such chemical used to tune mass spectrometers is perflurotributylamine (PFTBA). Fragmentation patterns of controlled substances are typically unique. Once a fragmentation pattern has been obtained, the forensic analyst should be able to explain the major peaks of the spectrum and relate them to the molecular structure. If properly evaluated, mass spectral data can usually be used to form a conclusion as to the identity of a controlled substance. GC/MS has many advantages in the analysis of controlled substances. The sample being analyzed need not be pure. Multicomponent samples are separated and each soluble organic component can be individually identified. The analyst must be aware of isomeric compounds that have very similar chemical structures and similar fragmentation patterns. These kinds of situations can usually be handled by noting the GC retention time data to discriminate between similar compounds. Possible coelution of compounds from the capillary GC column and thermal degradation as noted in the gas chromatography section of this chapter should also be recognized. GC/MS does not allow the forensic analyst to directly identify the salt form of the drug. This task can be accomplished by considering the solubility properties of the drug being analyzed. In using this knowledge and performing extractions prior to injection onto the GC column, the salt form can be determined indirectly. When all methods of instrumental analysis of controlled substances are considered, GC/MS is recognized in most instances as one of the efficient analytical techniques. If the analyst is cognizant of maintaining instrument reliability standards and the guidelines of mass spectral interpretation, GC/MS affords one of the highest degrees of specificity in the identification of controlled substances. 1.7.2.7 Nuclear Magnetic Resonance Spectroscopy Nuclear magnetic resonance (NMR) spectroscopy is one of the most powerful instrumental techniques available to the forensic chemist. In those laboratories fortunate enough to have NMR technology, extensive capabilities exist. Data interpretation of NMR spectra requires a high degree of expertise. This instrumental technique allows the analyst to detect paramagnetic atoms. (1H, 2H, 13C, 15N, 17O, 31P, 11B, and 19F are examples.) Most forensic applications of NMR focus on 1H and 13C. The resonant frequency of hydrogen (1H) in the current high-field magnets ranges from 200 to 750 mHz. This instrument generates a high magnetic field more than capable of damaging encrypted data on the back of a credit card. The NMR is a very expensive instrument requiring a high degree of specialized expertise to maintain and interpret the resulting data. The NMR is the one instrument that affords the



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analyst the ability to determine both the molecular structure and the three-dimensional orientation of some individual atoms of the molecule. This means that structural isomers can be determined directly. However, the extent of this kind of information is usually required only by research scientists in those instances where no other information is available from other instrumental methods, or where no primary analytical standard is available to confirm the presence of a controlled substance. The major component of the NMR spectrometer is a high-field super-conducting magnet. The sample is dissolved in a deuterated solvent and then transferred to a long cylindrical glass tube usually measuring 5 mm in diameter. The tube is placed into the NMR probe located near the center of the magnetic field. In proton NMR, the magnetic field causes the hydrogen atoms on the molecule to orient in a particular direction. To obtain high-resolution spectra, the field produced by the magnet must be homogeneous over the entire area of the sample in the probe. The resonance frequencies for all protons in a molecule may be different. These frequencies are dependent on the molecular environment of the nucleus. This correlation between resonance frequencies and molecular environment enables the analyst to make judgments regarding the structure of the drug being analyzed. The NMR spectrum is traced on a two-dimensional x/y coordinate axis. By evaluating an NMR proton spectrum, an analyst can determine an important factor that facilitates the identification of the compound — the area under each peak indicates the number of nuclei that are undergoing a transition and the number of protons that are present. There are other types of examinations that are possible with high-field NMR. A carbon-13 (13C) evaluation enables an analyst to determine the number of carbons and their relative positioning in the molecule. 13C is an isotope of the more abundant 12C. About 1% of naturally occurring carbon is 13C. There are two additional NMR “2D experiments” that are very valuable to the forensic analyst. Correlation spectroscopy (COSY) measures proton to proton (1H to 1H) interactions; and nuclear overhauser effect spectroscopy (NOESY) measures the interaction of protons that are close to one another, but not necessarily on adjoining atoms. Carbon-13, COSY, and NOESY spectra are all much more difficult to interpret and require specialized knowledge. In the forensic analysis of controlled substances, most molecules comprise carbon and hydrogen. Proton NMR provides a unique spectral pattern that can be used to identify a controlled substance. This pattern also enables the analyst to distinguish between the basic and a salt form of the drug. NMR cannot distinguish halogenated salt forms. For instance, it cannot distinguish between heroin hydrochloride and heroin hydrobromide. But it can distinguish between a heroin salt and heroin base.

REFERENCES 1. Johns, S.H., Wist, A.A., and Najam, A.R., Spot tests: a color chart reference for forensic chemists, J. Forensic Sci., 24, 631–649, 1979. 2. Hughes, R.B. and Kessler, R.R., Increased safety and specificity in the thin-layer chromatographic identification of marijuana, J. Forensic Sci., 24, 842–846, 1979. 3. Baggi, T.R., 3-Methylbenzthiazolinone-2-hydrazone (MBTH) as a new visualization reagent in the detection of cannabinoids on thin-layer chromatography, J. Forensic Sci., 25, 691–694, 1980. 4. Parker, K.D., Wright, J.A., Halpern, A.F., and Hine, C.H., Preliminary report on the separation and quantitative determination of cannabis constituents present in plant material and when added to urine by thin-layer and gas chromatography, Bull. Narc., 20, 9–14, 1968. 5. Fulton, C.C., Modern Microcrystal Tests for Drugs, John Wiley & Sons, New York, 1969. 6. Lurie, I.S. and Witmer, J.D., High Performance Liquid Chromatography, Marcel Decker, New York, 1983.

1.7.3

Controlled Substances Examinations

Every examination made by a forensic chemist has a potential legal ramification or consequence. Forensic chemists must be prepared to depart from the familiar natural science setting of the


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laboratory and to enter the confrontational setting of the courtroom and be able to communicate with a prosecuting attorney, a defense attorney, a judge, 12 jurors, and on occasion, the press. The forensic chemist must be able to explain the significance of complicated analytical procedures to individuals with little or no scientific training. If the forensic analyst is to have any credibility on the witness stand, he must be able to describe what he has done in terminology understood by those individuals with whom he is communicating. 1.7.3.1 Identifying and Quantitating Controlled Substances Whenever a controlled substance is identified, the possibility exists that an individual could be imprisoned or suffer some other legal consequence as a result. There is, therefore, an absolute, uncompromised requirement for certainty in the identification of controlled substances. Prior to 1960, the results of microscopic crystal tests, color screening tests, and TLC were considered definitive. From the 1960s through the mid-1970s, UV spectrophotometry and GC gained acceptance. It is interesting to look back 30 years and contemplate the absolute faith placed in a retention time on a gas chromatogram, or upon the UV absorption maxima in acidic or basic solutions. In some instances these numerical values were measured with a ruler! From 1975 through 1985 there were major advances in IR and MS. During those years “specificity,” as we understand the term today, was, for the first time, actually attainable in most cases. As the technology continually evolved, with increased Fourier transform peak resolution in IR and NMR, and multicomponent separations improved with capillary column GS, specificity also increased. In the mid-1980s the advent of “designer drugs” (properly referred to as “controlled substance analogues”) resurrected the problem of specificity. In attempts at circumventing existing controlled substance laws, clandestine laboratory chemists began to alter chemical structures of controlled drugs by increasingly sophisticated syntheses. By replacing a methyl group with an ethyl group, or by using a five-membered ring instead of a six-membered ring in a synthesis, these clandestine laboratory chemists developed what at the time were non-controlled analogues. The Controlled Substance Analogue and Enforcement Act of 1986 was passed by Congress, largely as a response to this problem. This particular piece of legislation also reinforced the responsibility of the chemist to accurately discriminate between controlled substances and endless lists of possible analogues. A direct consequence of the new law’s passage was the development of analytical procedures in Fourier transform infrared spectrophotometry (FTIR), Fourier transform nuclear magnetic resonance spectroscopy (FTNMR), gas chromatography/Fourier transform infrared spectroscopy (GC/FTIR), and CE. These instrumental methods have made their way into the forensic science laboratory and now provide the increased specificity required by the courts. Controlled substances sold on the street are usually mixed with adulterants and diluents in a crude and mostly unspecified manner. In some laboratories, analysts are required to identify and quantitate both the controlled substance and the adulterant drugs and diluent materials. Color tests, TLC, and microcrystal tests of the pre-1960s vintage are still used for screening. These testing procedures were valid then and are still valid today, but today additional instrumental techniques are utilized to make the absolute identification and quantitation. After the analysis has been completed, it must be documented. The final report must be clear, concise, and accurate, with all conclusions substantiated by analytical data. The data may be in the form of notations on paper in the analyst’s writing, or on chromatograms, spectra, or other instrumental printouts. Dates must be checked, and the documented description of the exhibit(s) must be consistent with the actual exhibit. Each time a report is signed, the analyst places his or her reputation and credibility before the scrutiny of the court and his or her peers. Discovering a “mistake” after the report has been submitted to the courts is not good. Cocaine can exist as either the hydrochloride (HCl) salt or as the base. Pursuant to federal law, there are sentencing guidelines based on the identification of cocaine as either the base or as the



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salt form (usually HCl). Cocaine can be adulterated with benzocaine, procaine, lidocaine, or any combination of these non-controlled drugs, and further diluted with mannitol, lactose, or other processing sugars. A variety of instrumental techniques can be used to distinguish cocaine HCl from cocaine base. FTIR spectrophotometry is commonly available and used in many laboratories. The IR spectra of cocaine HCl and cocaine base are quite different and easily distinguished. The IR spectrum of a cocaine HCl sample mixed with an adulterant presents a problem. The same sample analyzed by GC/FTIR presents the chemist with a total response chromatogram showing all peaks in a mixture. The resulting IR spectrum and mass spectrum are identifiable. However, in this technique, cocaine HCl and cocaine base cannot be distinguished. At this point, NMR can provide a solution to distinguishing the two forms of cocaine and identifying the adulterants. The solubility properties of controlled substances can be used to separate different forms of controlled substances. For instance, cocaine base is soluble in diethyl ether; cocaine HCl is insoluble. Therefore, if an analyst is analyzing a material that is believed to be cocaine in a questionable form, the analyst can try placing the material into solution with diethyl ether, separate the ether from the insolubles, evaporate the diethyl ether, and analyze the resulting powder by GC/MS. The resulting cocaine spectrum would indicate the presence of cocaine base because cocaine HCl would not have gone into solution. Methamphetamine is produced in clandestine laboratories from the reaction of ephedrine with hydriodic acid and red phosphorus, or from the reaction of phenyl-2-propanone (P-2-P) with methylamine. Methamphetamine samples submitted to the forensic science laboratory usually contain precursors from the synthesis, by-products for side reactions, and adulterants such as nicotinamide that have been added by the clandestine laboratory operator. As is true of the mass spectrum of some other phenethylamines, the mass spectrum of methamphetamine may not provide enough specificity for positive identification. The most accurate way to identify many phenethylamines is with IR. However, NMR is at least as specific as FTIR, and it also allows for an identification in the presence of diluents. Unfortunately, NMR is not available in many laboratories. Nicotinamide is one of the more commonly encountered adulterants with methamphetamine and can easily be distinguished from isonicotinamide by NMR spectroscopy. The IR spectrum of methamphetamine hydrochloride in a potassium chloride salt matrix is very specific, and GC/FTIR is excellent at separating the components of a methamphetamine sample. However, this method requires great care in selecting the optimized temperature and flow parameters, and column selection. GC/MS is the method most often used for identifying heroin. The mass spectrum of heroin is very specific. Heroin is relatively simple to separate, and identification of the degradation products and the by-products of the heroin synthesis, from morphine and acetic anhydride, is relatively straightforward. Because morphine is derived from opium, many of the by-products from the opium processing are carried over to the final heroin product. Acetylcodeine and acetylmorphine are clearly identified from the corresponding mass spectra. The GC/FTIR also provides excellent spectra for making identifications of heroin, its by-products, degradation products, and precursors. The chloroform insoluble diluents from heroin samples can also be identified in a potassium bromide matrix by FTIR. These materials will usually consist of sugars such as mannitol and inositol. When the heroin has been isolated from diluents and adulterants, FTIR and NMR can be utilized to confirm the salt form of the heroin. Phencyclidine, more properly identified as phenylcyclohexylpiperidine (PCP), is usually submitted to the laboratory as an exhibit of PCP base in diethyl ether, a powder, or sprayed or coated on marijuana. The analysis of PCP is relatively direct by GC/MS. The resulting mass spectrum is specific. The GC/FTIR spectrum of PCP is not as specific when one compares this spectrum with that of PCP analogues and precursors such as phenylcyclohexyl carbonitrile (PCC) and phenylcyohexyl pyrrolidine (PCPy). FTIR spectrophotometry of the solid in a potassium bromide matrix is very specific. A word of caution is in order for anyone handling PCP. PCP is a substance that is believed to be easily absorbed through the skin of the analyst. Minimum handling is recommended.


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1.7.3.2 Identifying Adulterants and Diluents The terms adulterants and diluents are sometimes used in the context of illicitly distributed controlled substances. Adulterants are chemicals added to illicit drugs that, in and of themselves, can affect some sort of a physiological response. This response can range from very mild to quite severe. Diluents are chemicals added to controlled substances that are used more as fillers than to elicit a physiological response. They can be added to affect the color and composition for the sake of satisfying the user. Adulterants and diluents are usually added to the controlled substance mixture by those involved in illicit distribution. There is a third class of materials that is found in controlled substance mixtures. This class includes by-products. These by-products can be processing by-products, or they can exist as naturally occurring by-products found in botanical substances such as the coca leaf or the opium poppy. Most “street” exhibits of heroin and cocaine contain adulterants and diluents. Samples taken from large-scale, brick-size, kilogram seizures will be relatively pure. Except for some by-products from the opium poppy and the coca leaf, there will be little in the way of foreign materials. Adulterants are encountered, in increasing proportions, as the heroin and cocaine progress down the distribution chain from the main supplier to the dealers to the users. Adulterants commonly encountered in heroin include quinine, procaine, acetaminophen, caffeine, diphenhydramine, aspirin, phenobarbital, and lidocaine. Adulterants commonly encountered in cocaine include procaine, benzocaine, and lidocaine. Diluents found in heroin include different kinds of starches. It is not uncommon to find in heroin substances, such as calcium carbonate, that had been added during the morphine extraction processes. Diluents found in both cocaine and heroin include lactose, mannitol, sucrose, and dextrose. The identification of adulterants and diluents may or may not be a requirement as a part of the identification scheme in the forensic science laboratory. In most instances, the requirements of the judicial system will be limited to the identification of the controlled substance. This will usually be accomplished by separating the sample into its component parts, and then identifying all or some of these components. In the case of a heroin exhibit, cut with quinine and mannitol, a capillary GC/MS examination might result in a chromatogram and corresponding spectra with an acetylcodeine peak, an acetylmorphine peak, a morphine peak, a quinine peak, and a heroin peak. The first two peaks are most probably processing by-products; the morphine is from the opium poppy; the heroin is the main peak of interest, and the quinine has probably been added as an adulterant. There is no need to separate the components by extractions to make the identifications. However, if the analyst is desirous of conducting an IR examination or a NMR examination to identify the heroin, an extraction of the heroin from a 3 N hydrochloric acid medium using chloroform is an option. Depending on whether the heroin exists as a salt (heroin hydrochloride) or as heroin base, a set of serial extractions can be conducted to isolate the heroin from the quinine and the other substances. The identification of cocaine in a mixture follows the same procedures. Depending on the type of analysis, the cocaine may or may not need to be chemically separated from the adulterants for an identification. The simplest way to identify diluents in controlled substance mixtures is by microscopic identification. Common diluents along with the sugars/carbohydrates/starches described above include sodium chloride, calcium carbonate, and various types of amorphous materials. Because of their optical properties, these materials lend themselves well to a microscopic identification. Chemical separations are fairly easy because these materials are usually insoluble in solvents such as diethyl ether or hexane, and slightly soluble in solvents such as methanol. Most organic materials are soluble in methanol or some other polar solvent. The sugars/carbohydrates/starches can be further identified using IR following the separation if only one sugar is present. If not, HPLC can be used to identify the sugars.



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Even if the identification of all adulterants, diluents, and by-products is not required in the final report generated by the analyst, such information can prove useful in evaluating trends and possible distribution patterns. 1.7.3.3 Quantitating Controlled Substances A number of different methods can be used to quantitate controlled substances. Capillary column GC or HPLC are probably the two most utilized instrumental methods to accomplish this task. The choice of which instrumental method to use depends on the chemical properties of the substance in question. GC works well with those compounds that are not highly polar, are relatively stable at high temperatures, and are soluble in organic solvents such as methanol or chloroform. Even if these conditions exist, GC can still be used if a derivatizing agent is used. If GC is used, the most common analytical method for quantitation involves the use of an internal standard, providing a consistent concentration of a known chemical in solution. To avoid the obvious problem of choosing an internal standard, which might be present in the sample as an adulterant or diluent, the internal standard can be a straight-chain hydrocarbon (tetracosane, eicosane, or dodecane) that is added in equal amounts to both the sample being analyzed and the calibration samples. The internal standard method is especially advantageous because the expected flame ionization detector response for the internal standard to the drug can be checked for each and every injection. The critical factor for each injection is the ratio of the detector response of the internal standard to the calibration solution of known concentration. This is especially critical if the sample size of the injection is off target by a minuscule amount. The absolute integration values for the known peak and the internal standard peaks may vary. However, the ratio will not be affected. If the detector is responding properly to the internal standard in solution, it is also responding properly for the substance being quantitated. Controlled substances can also be quantitated using what is referred to as the external standard method. In this method, calibration standards of known concentrations are prepared. Injections are then made into the GC injection port, and a calibration table is established. The accuracy of this method is quite good, provided that the injection amounts used in establishing the calibration table are exactly the same from injection to injection. Even small variations of less than 10% volume, when dealing with a 1-μl injection, can lead to less than optimized results. This problem can be overcome by making multiple injections and checking the consistency of the detector response and the injection volume. The ability to be consistent can be developed by an analyst with a good eye. The ability to read the sample size on the microsyringe is, for some, as much an art as a scientific technique. Automatic injectors are now available on many gas chromatographs, which approach consistency from one injection to the next. However, this method will work only when there is a verifiable linear response of the detector within a specified concentration range. In both the internal and external standard methods, there must be a linear response of the detector to the solutions of different concentrations. This is determined by injecting solutions of known concentrations and establishing a calibration table. With most instrument data stations, this is relatively simple. The instrument will then calculate the response ratio of internal standard to drug for the solution of unknown concentration and compare this to the response ratios of internal standard to drug for the solutions of known concentrations in the calibration table. This ratio can then be used to calculate the concentration of the drug that is being analyzed. HPLC can be useful for quantitating controlled substances in solution. This instrumental method also measures the response of different compounds at different ultraviolet/visible absorption bands. These responses are then compared to calibration table values. Internal standards can be used in the same way they are used in GC quantitations. The limitations and comparisons of HPLC and GC are discussed elsewhere.


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Ultraviolet/visible spectrophotometry (UV/VIS) is a technique that has been in use for many years. UV/VIS uses one of the basic tenets of physics — Beer’s law. Absorption of monochromatic light is proportional to the concentration of a sample in solution. The concentration of an exhibit in solution can be determined by comparison with calibration tables. This type of analysis is dependent on the solubility properties of the substance being quantitated in acid, basic, and organic solutions. The UV/VIS method is accurate and reliable only when the compound of interest is pure with no interfering substances. GC and HPLC are used more often because of the added reliability check provided by the internal standard methodology. NMR spectrometry can also be used for the quantitation of controlled substances. The quantitative analytical techniques in NMR are more complicated than those discussed above and require a specialized instrumental expertise. All of the methods discussed are reliable and accurate when properly and conscientiously conducted. There is one very important difference that applies to any quantitative method when compared to an identification method. With proper methods, an analyst can make an identification of a controlled substance with scientific certainty. The quantitation of a controlled substance will usually result in values falling within a narrowly defined “window” of from one-tenth to one or two absolute percent. The reported value will usually be an average value. 1.7.3.4 Reference Standards The first step in ensuring the accuracy of the identification of any controlled substance should be a collection of authenticated reference standards. Reference standards for the forensic science examinations should be 98+% pure. They can be purchased from a reputable manufacturer or distributor, synthesized by an organic chemist within the laboratory, or purified from a bulk secondary standard by using an appropriate methodology. “Reference Standards” that have been authenticated are available from the United States Pharmacopoeia (USP) and National Formulary (NF). Samples obtained from any other source should be authenticated using the appropriate methodology. This authentication process will involve a two-step process of first positively identifying the proposed reference standard and then determining the purity of this standard. At a minimum, the identification of a reference standard should be conducted using IR and MS. The resulting spectra are then compared with reference spectra in the literature. The chemist should be able to evaluate data from both of these instruments and be able to explain the major peaks using, respectively, a functional group analysis or a molecular fragmentation analysis. If no literature spectra are available, a more sophisticated structural analysis such as NMR spectroscopy will be necessary to verify the chemical structure. Additional methods that can be used to supplement, but not replace, IR, MS, and NMR include optical crystallography, X-ray crystallography, and a melting point analysis. The next step in the process is to quantitate the reference standard against a “primary standard.” A primary standard is a sample that has been subjected to the authentication process and meets the criteria of a positive identification and 98+% purity. The quantitation methods of choice are GC or HPLC. With either method, the concentrations of the injections of both the primary standard and the authentication sample must be within the linear range of the detector. The method should utilize an internal standard. The results of all injections should have a relative standard deviation of less than 3%.1 If a primary standard is not available, a purity determination can be accomplished by a peak area percent determination using capillary GC with a flame ionization detector and HPLC using a photo-array ultraviolet detector. A third instrumental method using a differential scanning calorimeter (DSC) should also be considered. In a peak area percent analysis, the area percent of the standard compound is determined vs. any impurities that are present in the batch. A blank injection of the solvent is done prior to the standard injection to detect peaks common to both



53

the solvent and the authentication standard. The GC solution is checked for insolubles. If these insolubles are present, they can be isolated and identified by IR. Of course, if there are insolubles, the sample is no longer considered an authentication standard until it is purified and the foreign material is removed. HPLC can also be used in a peak area percent analysis. For basic drugs, the analyst would use a gradient mobile phase using methanol and an acidic aqueous phosphate buffer. For neutral and acidic drugs, he would use a gradient with methanol and an acidic aqueous phosphate buffer containing sodium dodecyl sulfate. For anabolic steroids, he would use a methanol/water gradient mobile phase. As is the case with GC, with HPLC a blank injection of the solvent always precedes the injection of the authentication standard. Three wavelengths, 210 nm, 228 nm, and 240 nm, are monitored for most drugs. For anabolic steroids, the analyst should monitor 210 nm, 240 nm, and 280 nm. If the resulting UV spectra of all pertinent peaks are similar, the integration of the peaks with the most sensitive wavelengths are used for the calculation of purity. DSC is a method of adding heat to a preweighed sample and monitoring temperature and heat flow as the sample goes through its melting point.2 If decomposition does not occur during the melt, the peak shown on the thermogram can be used to determine melting point and the molar concentration of any melt soluble impurities present. With these data, the analyst can determine the purity of the authentication standard. One drawback of DSC is that structurally dissimilar impurities such as sugars in a supposed heroin “standard” are not always detected by this method. This is because the impurity does not go into solution in the melting main component. With almost all authentication standards, most impurities will be structurally similar to the drug of interest. The dissimilar compounds should have been removed prior to the DSC analysis or detected by GC or HPLC.

REFERENCES 1. CRC Handbook of Tables for Probability and Statistics, 2nd ed., CRC Press, Boca Raton, FL, 1968, 5. 2. McNaughton, J.L. and Mortimer, C.T., Differential scanning calorimetry, IRS; Phys. Chem. Ser. 2, 10, 1975.

1.8 COMPARATIVE ANALYSIS 1.8.1

Determining Commonality of Source

Two different kinds of controlled substance analyses are routinely conducted in the forensic science laboratory. The first is the “identification.” The goal is self-evident — to identify a controlled substance by name. The second, less common, type of analysis is the “comparative analysis.” Its purpose is to determine a commonality of source. A comparative analysis will include a comprehensive examination of the sample’s chemical and physical characteristics, with the goal of demonstrating, with a high degree of certainty, a common origin for two or more samples.1 Sometime it is possible to determine when two items of evidence have a common origin just by physically fitting them together. This applies to exhibits such as a screwdriver and a broken blade, two large paint chips that have broken apart, or a piece of paper torn in two or more pieces. In the forensic examination of illicit drugs, it is possible to state with a high degree of certainty that two exhibits of a white powder share a common source. The wording in stating such a conclusion is critical. Words must be carefully selected to convey the conclusion clearly and concisely, without overstepping the scientific certainty that exists. The following quote, about two samples of cocaine, is from the transcript of drug trial held in 1991. It illustrates the appropriate language to be used on such occasions.


54


After a review of all analytical data, it can be stated with a high level of scientific certainty and beyond a reasonable doubt that a close chemical relationship exists between [the two samples] strongly suggesting that they were derived from the same manufacturing process … and that they were probably derived from the same batch.2

Before undertaking a detailed examination of two samples, a broad overview is desirable. The color and granularity of the exhibits should be examined, and then the components of the sample identified and quantitated. If all of the data from one exhibit compare favorably with all of the data from the second exhibit, the analyst can proceed to a second set of procedures to evaluate the processing by-products and trace materials in the exhibits. It is important to realize that to successfully evaluate two exhibits to determine commonality of source, each exhibit must be analyzed in the same way using the same methodology, instruments, and chemicals and solvents from the same containers. Controlled substances such as cocaine and heroin are the simplest to compare because they are derived from botanical substances (the coca leaf and the opium poppy, respectively).3,4 Many naturally occurring by-products from the plants are carried through the processing stages of the drugs, and these can be used to confirm the existence of a common source. 1.8.2

Comparing Heroin Exhibits

Capillary column gas chromatography (ccGC) and HPLC are the two methods most often utilized in comparing two or more heroin exhibits to determine whether they came from the same source. HPLC can be utilized in the first part of the analytical scheme because the components being evaluated usually are present in substantial amounts. The major components, including heroin, acetylmorphine, acetylcodeine, morphine, codeine, noscapine, papaverine, thebaine, and most diluents can be identified and quantitated. A high degree of resolving power is not required at this point in the analytical scheme. If the HPLC analysis demonstrates that the samples being compared are similar, the analyst proceeds to the second part of the analytical scheme. In the second part of this scheme to evaluate the trace components of the exhibits, ccGC is usually the method of choice, both because of its resolving power and because of its ability to detect minute quantities of the component of interest. The second step of the isolation process involves multiple extractions and derivatizations to isolate the acidic and neutral compounds for analysis and evaluation. This process isolates the precursors, solvents, and respective contaminants, by-products, intermediates, and degradation products. It is desirable to remove the heroin from the sample during the extraction processes in order to keep most of the trace components at the same level of chromatographic attenuation. Once the heroin has been identified and quantitated, only then are the other elements analyzed. If after these two processes the analyst sees no chromatographic differences in the samples being evaluated, a conclusion can be formulated. The number of components from this second part of the process can number from 100 to 300. If all of these components are present in both exhibits at similar relative levels, a conclusion regarding commonality of source is warranted. 1.8.3

Comparing Cocaine Exhibits

The process is different for cocaine comparisons. For one thing, the cocaine need not be removed from the sample. Four different ccGC examinations can be conducted that evaluate and compare the by-products and impurities down to trace levels by: 1. Flame ionization gas chromatography (GC-FID) to evaluate cocaine hydrolysis products, manufacturing impurities, and naturally occurring alkaloids5



55

2. GC-FID to determine trimethoxy-substituted alkaloids as well as other minor naturally occurring tropanes6 3. Electron capture gas chromatography (GC-ECD) to determine the hydroxycocaines and N-nor related compounds4 4. GC-ECD to determine the ten intact truxillines7

These four gas chromatographic methods provide an in-depth evaluation of trace level components and allow the precise comparison of two different cocaine exhibits. The number of components evaluated ranges in the hundreds. These data provide the analyst with an abundance of analytical points to form a conclusion regarding commonality of source. Extraction of the impurities and by-products can be accomplished using a derivatizing reagent.8,9 Heptafluorobutyric anhydride (HFBA) is often used for this purpose. The GC-FID and GC-ECD analyses that follow will result in organic profiles of the many compounds from the cocaine and heroin samples being analyzed. A further MS analysis may serve to identify the chemical composition of many of the components of each exhibit. Many of the resulting peaks represent compounds formed during the manufacturing process; others will be oxidation or hydrolysis products of known compounds; and other peaks will have a degree of uncertainty regarding their exact chemical structure. However, what will be known is that these peaks are present in both exhibits being compared using the ccGC methods and represent cocaine and heroin manufacturing impurities or by-products.

REFERENCES 1. Perillo, B.A., Klein, R.F.X., and Franzosa, E.S., Recent advances by the U.S. drug enforcement administration in drug signature and comparative analysis, Forensic Sci. Int., 69, 1–6, 1994. 2. Moore, J.M., Meyers, R.P., and Jiminez, M.D., The anatomy of a cocaine comparison case: a prosecutorial and chemistry perspective, J. Forensic Sci., 38, 1305–1325, 1993. 3. Moore, J.M. and Cooper, D.A., The application of capillary gas chromatography-electron capture detection in the comparative analyses of illicit cocaine samples, J. Forensic Sci., 38, 1286–1304, 1993. 4. Moore, J.M. and Casale, J.F., In-depth chromatographic analyses of illicit cocaine and its precursor, coca leaves, J. Chromatogr., 674, 165–205, 1994. 5. Casale, J.F. and Waggoner, R.W., A chromatographic impurity signature profile analysis for cocaine using capillary gas chromatography, J. Forensic Sci., 36, 1321–1330, 1991. 6. Casale, J.F. and Moore, J.M., 3´,4´,5´-Trimethoxy-substituted analogues of cocaine, cis-/trans-cinnamoylcocaine and tropacocaine: Characterization and quantitation of new alkaloids in coca leaf, coca paste and refined illicit cocaine, J. Forensic Sci., 39, 462–472, 1994. 7. Moore, J.M., Cooper, D.A., Lurie, I.S., Kram, T.C., Carr, S., Harper, C., and Yeh, J., Capillary gas chromatographic-electron capture detection of coca leaf related impurities of illicit cocaine: 2,4diphenylcyclobutane-1,3-dicarboxylic acids, 1,4-diphenylcyclobutane-2,3-dicarboxylic acids and their alkaloidal precursors, the truxillines, J. Chromatogr., 410, 297–318, 1987. 8. Moore, J.M., Allen, A.C., and Cooper, D.A., Determination of manufacturing impurities in heroin by capillary gas chromatography with electron capture detection after derivatization with heptafluorobutyric acid, Anal. Chem., 56, 642–646, 1984. 9. Moore, J.M., The application of chemical derivatization in forensic drug chemistry for gas and high performance liquid chromatographic methods of analysis, Forensic Sci. Rev., 2, 79–124, 1990.

1.9 CLANDESTINE LABORATORIES There are two kinds of clandestine laboratories. The first is the operational clandestine laboratory. This laboratory, usually operating in secrecy, is engaged in the production of controlled substances, precursors to controlled substances, or controlled substance homologues or analogues. The second


56


is the non-operational clandestine laboratory. This usually is a storage facility that is under investigation because of information obtained from precursor and essential chemical monitoring.1 For the forensic scientist involved in the seizure of a clandestine laboratory, the task of evaluating the possibilities and probabilities begins prior to arrival at the laboratory site. The individual tasked with securing the laboratory for the purpose of collecting evidence must, for his own protection, be trained and certified competent in dealing with the safety and technical considerations of clandestine laboratory seizures. Forensic chemists may be asked to provide assistance in preparing search warrants based on available information, as when investigators know that certain chemicals and pieces of analytical equipment such as gas cylinders, and glassware such as large triple neck round bottom flasks have been purchased. This sort of information is critical in determining what kind of synthesis is taking place. The forensic scientist will also provide technical advice regarding the importance of specific safety considerations and offer suggestions on handling situations such as on-going reactions. After the clandestine laboratory site has been secured by the appropriate law enforcement authorities, the forensic scientist may enter the site to evaluate the environment and decide on the most appropriate actions. The investigator’s most important function is to minimize any health risk to enforcement personnel. This may involve ventilating the environment by opening doors, windows, and using a fan; securing open containers, turning off gases and water; and removing obstacles on the floor, which may prove hazardous to anyone entering the site. The investigator may also decide on whether chemical reactions in progress should be stopped or allowed to proceed. After all of these and other decisions are made and the site is secure, the forensic analyst will begin to sample, package, and mark evidence containers. This process will usually proceed slowly and methodically to ensure accuracy and completeness. Once the clandestine laboratory has been seized and the evidence collected, the forensic analyst will proceed to the laboratory to complete the administrative processes of ensuring accountability and security. When the time approaches for the analytical procedures to commence, the person tasked with this process will attempt to identify as many of the samples as deemed necessary for the required judicial action. This may mean identifying any and all exhibits that were seized, or it may mean that only those exhibits required to form a conclusion regarding an identification of the final product are necessary. The extent of the analysis can be more of a legal question than a scientific question. The forensic scientist should be able to provide the basics of the reaction mechanisms. This information will be based on the chemicals at the site and those identified in the reaction mixtures. He should also be able to provide a theoretical yield of the final product based on the amounts of the chemical precursors. After the work in the laboratory has been completed, the forensic scientist has the responsibility of assisting the legal authorities in understanding what was happening in the clandestine laboratory — what was being synthesized, how was it being synthesized, and what environmental ramifications existed due to the disposing of waste solvents and other chemicals found in the soil or plumbing. The forensic analyst must recognize his responsibilities as an expert witness and provide factual information in as much detail as necessary. However, this task carries with it the responsibility of avoiding unsubstantiated speculation. Evaluating a clandestine laboratory, from the time of notification until the time of testimony in the courtroom, requires an open-minded and analytical approach. As information is gathered and data collection proceeds, the analyst may be involved in an ever-evolving decision-making process. This will probably require him to change his strategies as more information becomes available. Conclusions should be reserved until all the necessary exhibits have been collected and analyzed, the clandestine laboratory operator has been debriefed, the analytical data have been evaluated, and, if necessary, consultations with colleagues have been completed. In the courtroom, the forensic analyst will preserve his status as a credible expert witness by basing his testimony on factual data and possibilities that are within the realm of scientific probability.



1.9.1

57

Safety Concerns

A hazard evaluation is an absolute requirement prior to entering a clandestine laboratory. This should involve an evaluation of the physical and environmental hazards that may be present. This evaluation is usually the result of questioning other law enforcement personnel familiar with the laboratory, or the laboratory operator. Great care should be exercised in evaluating and acting on information from the laboratory operator. The forensic analyst should determine the minimum level of safety equipment required for entry into the laboratory. If there is knowledge regarding the type of drug being synthesized in the clandestine laboratory and the processing methodology, the forensic scientist will have some idea about the types of chemicals that may be encountered. If records are available regarding the purchasing activity of the clandestine laboratory operator, the quantities of the chemicals facing the investigators will be available. All this information should be documented and used to decide the safest and most prudent manner in which to enter the clandestine laboratory. Other concerns that must be considered are the weather conditions, and entry and egress options. Extremes in either heat or cold can affect the way the safety and sampling equipment will function. These conditions will also affect how long the forensic chemist can be expected to work in the appropriate clothing. Egress options from a clandestine laboratory must be determined before entry. In the event of a fire or explosion, those individuals processing the clandestine laboratory must know how to exit the dangerous environment. As a part of the planning scenario for processing the clandestine laboratory, the appropriate authority should make the nearest medical facility aware of the fact that if an investigator is injured, medical attention will be sought. The medical facility may have some requirement for treating a chemical injury. This should be determined beforehand and a protocol to meet these requirements should be established. The most important responsibility of the forensic analyst involved in a clandestine laboratory investigation and seizure is safety. Safety must be considered from a number of perspectives. The forensic scientist must be concerned with the safety and well-being of anyone entering the suspected clandestine laboratory. His training and experience will have prepared him to recognize many of the obvious dangers of the chemical hazards and physical hazards at the site. This awareness is not stagnant. There will usually be a condition that requires an immediate adjustment and reevaluation. He must be constantly aware of the possible hazards when the combination of two minimally unsafe conditions result in fatalities. This results from a failure to recognize that while each condition is dangerous in its own right, combining the dangers is a recipe for disaster if certain precautions are not followed. For instance, if the odor of ether is detected in an enclosed dark room, a possible first step might be to turn on the lights. However, any short circuit in the light switch resulting in a spark could cause the ether vapors in combination with the oxygen in the air to explode. The correct action would be to obtain outside lighting equipment to determine the source of the ether vapors, rectify the conditions resulting in the ether vapors, ventilate the room, check the light switch and wiring, and then turn on the lights. This situation is one in which a chemical hazard and a physical hazard could combine and result in serious injury or death. Before entering the clandestine laboratory, the forensic analyst must take precautions to ensure eye, lung, and skin protection. This will usually mean proper clothing including head gear, boots, outerwear, and gloves; safety glasses and/or a face shield; and the appropriate air purification and breathing apparatus. Consideration should also be given to use of air-monitoring devices, which can detect concentrations of combustible gases or vapors in the atmosphere, oxygen deficiencies, and gas concentrations to lower explosive limits. There are also devices available in the form of glass tubes filled with specific detection granules, which allow for the reasonable determination of airborne chemical hazards in the atmosphere. When these devices are used properly, the forensic scientist entering the clandestine laboratory maximizes his chances for protecting the safety of the seizure team, including himself.


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Even after the atmosphere has been sampled and ventilation has progressed, once inside the clandestine laboratory, the forensic chemist should be aware of the many possibilities posing a threat. The potential chemical dangers include an explosion potential, flammable and combustible chemicals, corrosive chemicals, oxidizers, poisons, compressed gases, irritants, and booby traps. Physical hazards include but are certainly not limited to broken glass, bare electrical wiring, slippery floors, and loud noises. These chemical and physical hazards can be accentuated by a reduction in dexterity because of safety equipment and clothing, a narrow field of vision due to a breathing apparatus, diminished communications, physical and mental stress, heat or cold stress, a confined work space environment, and a prolonged period of time spent processing the clandestine laboratory. After the laboratory processing has been completed, the forensic scientist should be a part of the team that reduces the level of environmental contamination to a controllable level. This will usually involve prior planning for the proper disposal of hazardous chemicals and protective clothing by a waste disposal authority. There should be a standard operating procedure for the decontamination of anyone who entered the clandestine laboratory. This should include provisions for an emergency shower and an eyewash station, first aid kits, and decontamination procedures for injured workers. One of the most important factors anyone processing a clandestine laboratory must remember is the following: no matter how much protective clothing is available, no matter how much pre-planning is done, no matter how careful a person might be in collecting chemicals and assessing danger, if that person fails to recognize his or her limitations in knowledge or physical ability, a disaster is waiting to happen. The greatest danger facing anyone who processes a clandestine laboratory is a false sense of security. 1.9.2

Commonly Encountered Chemicals in the Clandestine Laboratory

The following tabulation of data is intended as an overview of those chemicals most frequently encountered as precursors in clandestine laboratory settings. A precursor is a chemical that becomes a part of the controlled substance either as the basis of the molecular skeleton or as a substituent of the molecular skeleton. This list is not all-inclusive. Modifications to typical synthetic routes on the parts of ingenious organic chemists are typical and cannot always be predicted. Precursor Acetic anhydride

Acetonitrile N-Acetylanthranilic acid Acetylacetone 4-Allyl-1,2-methylenedioxybenzene Ammonium formate Amphetamine Aniline Anthranilic acid Benzaldehyde Benzene Benzyl cyanide Bromobenzene

Controlled Substance Heroin Methaqualone Phenyl-2-Propanone (P2P) Amphetamine Methaqualone Mecloqualone Methaqualone 3,4-Methylenedioxyamphetamine (MDA) Amphetamine MDA alpha-Methyl fentanyl alpha-Methyl fentanyl Methaqualone Amphetamine P-2-P Amphetamine P-2-P Methamphetamine N-Ethyl-1-phenylcyclohexylamine (PCE) Phencyclidine (PCP) 1-Phenylcyclohexylpyrrolidine (PCPy) P-2-P



Precursor 1-Bromo-2,5-dimethoxybenzene Bromohydroquinone 5-Bromoisatin ortho-Bromophenol Bromosafrole 2-Bromothiophene Chloroacetic acid Chloroacetone 1-Chloro2,5-dimethoxybenzene 2-Chloro-N,N-dimethylpropylamine 2-Chloroethylbenzene alpha-Chloroethylmethyl ether Chlorohydroquinone Chlorosafrole ortho-Cresol Diethylamine Ephedrine Ergonovine Ergotamine Ethylamine N-Ethylephedrine N-Ethylpseudoephedrine ortho-Ethylphenol Formamide Hydroxycodeinone Isosafrole

Lysergic acid Methylamine 3,4-Methylenedioxyphenyl2-propanon N-Methyephedrine N-Methylpseudoephedrine Nitroethane

1,2-Methylenedioxy-4-propenylbenzene N-Methylephedrine N-Methylformamide N-Methylformanilide 2-Methyl-4-[3H]-quinazolinone Methyl-3,4,5-trimethoxybenzoate Norpseudoephedrine Phenethylamine

N-(1-Phenethyl)-Piperidin-4-one N-(1-Phenethyl-4-piperidinyl)-aniline Phenylacetic acid

Controlled Substance 4-Bromo-2,5-dimethoxyamphetamine (DOB) DOB Lysergic acid 4-Bromo-2,5-dimethoxyphenethylamine (Nexus) 3,4-Methylenedioxyethylamphetamine (MDEA) 3,4-Methylenedioxymethamphetamine (MDMA) 1-[1-(2-Thienyl)cyclohexyl]piperidine (TCP) P-2-P P-2-P Nexus Methadone Fentanyl P-2-P DOB MDEA MDMA 4-Methyl-2,5-dimethoxyamphetamine (STP) Diethyltryptamine Lysergic acid diethylamide (LSD) Methamphetamine Methcathinone LSD LSD Ethylamphetamine 3,4-Methylenedioxyethylamphetamine (MDEA) N-Ethyl-N-methylamphetamine N-Ethyl-N-methylamphetamine 4-Ethyl-2,5-dimethoxyamphetamine Amphetamine MDA Oxycotin 4-Methylenedioxyamphetamine (MDA) 3,4-Methylenedioxymethamphetamine (MDMA) MDEA LSD Methamphetamine MDMA MDA MDMA MDEA N,N-Dimethylamphetamine N,N-Dimethylamphetamine P-2-P Amphetamine MDA MDEA P-2-P Methamphetamine STP Methaqualone Mescaline 4-Methylaminorex Fentanyl para-Fluoro fentanyl 2-Methyl fentanyl Fentanyl para-Fluoro fentanyl Fentanyl P-2-P

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Precursor

Controlled Substance

Phenylacetonitrile Phenylacetyl chloride D-Phenylalanine

P-2-P P-2-P Amphetamine Methamphetamine Fentanyl alpha-Methyl fentanyl PCP PCPy P-2-P Amphetamine 4-Methylaminorex Amphetamine Methamphetamine Phencyclidine (PCP) Fentanyl alpha-Methyl fentanyl MDA MDMA MDEA N-Hydroxy MDA Fentanyl analogues Methamphetamine PCPy Methamphetamine MDA MDMA 3,4-Methylenedioxy P-2-P Mescaline 3,4,5-Trimethoxyamphetamine

2-Phenyl-1-bromoethane 1-Phenyl-2-bromopropane Phenylmagnesium bromid

Phenylpropanolamine Phenyl-2-propanone (P-2-P) Piperidin N-(4-Piperidinyl)aniline Piperonal

Piperonylacetone Propionic Anhydride1 Propiophenone Pyrrolidine Pseudoephedrine Safrole

3,4,5-Trimethoxybenzaldehyde

REFERENCE 1. Frank, R.S., The clandestine laboratory situation in the United States, J. Forensic Sci., 28, 18–31, 1993.

1.9.3

Tables of Controlled Substances

1.9.3.1 Generalized List by Category of Physiological Effects and Medical Uses of Controlled Substances Controlled Substances — Categorized Listing of the Most Commonly Encountered Controlled Substances Drug

CSA Schedules

Trade or Other Names

Medical Uses

Narcotics Heroin

I

Morphine

II

Codeine

II, III, IV

Hydrocodone

II, III

Diacetylmorphine, Horse, Smack Duramorph, MS-Contin, Roxanol, Oramorph SR Tylenol w/Codeine, Empirin w/Codeine, Robitussin A-C, Fiorinal w/Codeine, APAP w/Codeine Tussionex, Vicodin, Dycodan, Lorcet

None in U.S., analgesic, antitussive Analgesic Analgesic, antitussive

Analgesic, antitussive



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Controlled Substances — Categorized Listing of the Most Commonly Encountered Controlled Substances (Continued) Drug

CSA Schedules

Hydromorphone Oxycodone

II II

Methadone and LAAM

I, II

Fentanyl and analogues

I, II

Other narcotics

II, III, IV, V

Trade or Other Names Dilaudid Percodan, Percocet, Tylox, Roxicet, Roxidone Dolophine, Levo-alphaacetylmethadol, Levomethadyl acetate Innovar, Sublimaze, Alfenta, Sufenta, Duragesic Percocan, Percocet, Tylox, Opium, Darvon, Talwin,a Buprenorphine, Meperidine (Pethidine)

Medical Uses Analgesic Analgesic Analgesic, treatment of dependence Analgesic, adjunct to anesthesia, anesthetic Analgesic, antidiarrheal

Depressants Chloral hydrate Barbiturates

IV II, III, IV

Benzodiazepines

IV

Glutethimide Other depressants

II I, II, III, IV

Noctec, Somnos, Felsules Amytal, Fiorinal, Membutal, Seconal, Tuinal, Penobarbital, Pentobarbital Ativan, Dalmane, Diazepam, Librium, Xanax, Serax, Valium, Tranxene, Verstran, Versed, Halcion, Paxipam, Restoril Doriden Equanil, Miltown, Noludar, Placidyl, Valmid, Methaqualone

Hypnotic Sedative hypnotic, veterinary euthanasia agent Antianxiety, sedative, anticonvulsant, hypnotic

Sedative, hypnotic Antianxiety, sedative, hypnotic

Stimulants b

Cocaine Amphetamine/methamphetamine

II II

Methylphenidate Other stimulants

II I, II, III, IV

Coke, Flake, Snow, Crack Biphetamine, Desoxyn, Dexedrine, Obetrol, Ice Ritalin Adipex, Didrex, Ionamin, Melfiat, Plegine, Captagon, Sanorex, Tenuate, Tepanil, Prelu-2, Preludin

Local anesthetic Attention-deficit disorder, narcolepsy, weight control Attention-deficit disorder Weight control

Cannabis Marijuana

I

Tetrahydro-cannabinol Hashish and hashish oil

I, II I

LSD Mescaline and peyote Phenethylamines

I I I

Phencyclidine and analogues

I, II

Other hallucinogens

I

Pot, Acapulco Gold, Grass, Reefer, Sinsemilla, Thai Sticks THC, Marinol Hash, Hash Oil

None

Antinauseant None

Hallucinogens Acid, Blotter Acid, Microdots Mescal, Buttons, Cactus 2,5-DMA, STP, MDA, MDMA, Ecstasy, DOM, DOB PCP, PCE, PCPy, TCP, Hog, Loveboat, Angel Dust Bufotenine, Ibogaine, DMT, DET, Psilocybin, Psilocin

None None None

None None


62


Controlled Substances — Categorized Listing of the Most Commonly Encountered Controlled Substances (Continued) Drug

CSA Schedules

Trade or Other Names

Medical Uses

Anabolic Steroids Testosterone

III

Nandrolone

III

Oxymetholone

III

a b

Depo-testosterone, Delatestryl (Cypionate, Enanthate) Nandrolone, Durabolin, Deca-Durabolin, Deca Anadrol-50

Hypogonadism

Anemia, breast cancer Anemia

Not designated a narcotic under the CSA. Designated a narcotic under the CSA.

1.9.3.2 Listing of Controlled Substances by Schedule Number Listed below are those substances specifically controlled under the Controlled Substances Act as of June 26, 2006. This list does not include all controlled steroids or controlled substance analogues. These are classes of compounds that are controlled based on chemical and pharmacological criteria that were discussed earlier in this chapter. Schedule I Controlled Substances Controlled Substance 1-(1-Phenylcyclohexyl)pyrrolidine 1-[1-(2-Thienyl)cyclohexyl]piperidine 1-[1-(2-Thienyl)cyclohexyl]pyrrolidine 1-Methyl-4-phenyl-4-propionoxypiperdine 1-(2-Phenylethyl)-4-phenyl-4-acetoxypiperidine 2,5-Dimethoxyamphetamine 2,5-Dimethoxy-4-ethylamphetamine 2,5-Dimethoxy-4-(n)-propylthiophenethylamine 3,4,5-Trimethoxyamphetamine 3,4-Methylenedioxyamphetamine 3,4-Methylenedioxymethamphetamine 3,4-Methylenedioxy-N-ethylamphetamine 3-Methylfentanyl 3-Methylthiofentanyl 4-Bromo-2,5-dimethoxyamphetamine 4-Bromo-2,5-dimethoxyphenethylamine 4-Methoxyamphetamine 4-Methyl-2,5-dimethoxyamphetamine 4-Methylaminorex (cis isomer) 5-Methoxy-3,4-methylenedioxyamphetamine 5-Methoxy-N,N-diisopropyltryptamine Acetorphine Acetyldihydrocodeine Acetylmethadol Acetyl-alpha-methylfentanyl Allylprodine Alphacetylmethadol except levo-alphacetylmethadol alpha-Ethyltryptamine Alphameprodine Alphamethadol alpha-Methylfentanyl alpha-Methylthiofentanyl alpha-Methyltryptamine

Synonym(s) PCPy, PHP, rolicyclidine TCP, tenocyclidine TCPy MPPP, synthetic heroin PEPAP, synthetic heroin DMA, 2,5-DMA DOET 2C-T-7 TMA MDA, Love Drug MDMA, Ecstasy, XTC N-ethyl MDA, MDE, MDEA China White, fentanyl China White, fentanyl DOB, 4-bromo-DMA Nexus, 2-CB, has been sold as Ecstasy, i.e., MDMA PMA DOM, STP U4Euh, McN-422 MMDA 5-MeO-DIPT Acetylcodone Methadyl acetate

ET, Trip

China White, fentanyl China White, fentanyl AMT



63

Schedule I Controlled Substances (Continued) Controlled Substance Aminorex Benzethidine Benzylmorphine Betacetylmethadol Betameprodine Betamethadol Betaprodine beta-Hydroxyfentanyl beta-Hydroxy-3-methylfentanyl Bufotenine Cathinone Clonitazene Codeine methylbromide Codeine-N-oxide Cyprenorphine Desomorphine Dextromoramide Diampromide Diethylthiambutene Diethyltryptamine Difenoxin Dihydromorphine Dimenoxadol Dimepheptanol Dimethylthiambutene Dimethyltryptamine Dioxaphetyl butyrate Dipipanone Drotebanol Ethylmethylthiambutene Etonitazene Etorphine (except HCL) Etoxeridine Fenethylline Furethidine Gamma hydroxybutyric acid Heroin Hydromorphinol Hydroxpethidine Ibogaine Ketobemidone Levomoramide Levophenacylmorphan Lysergic acid diethylamide Marihuana Mecloqualone Mescaline Methaqualone Methcathinone Methyldesorphine Methyldihydromorphine Morpheridine Morphine methylbromide Morphine methylsulfonate Morphine-N-oxide Myrophine N-Benzylpiperazine N-Ethyl-1-phenylcyclohexylamine

Synonym(s) Has been sold as methamphetamine

China White, fentanyl China White, fentanyl Mappine, N,N-dimethylserotonin Constituent of “Khat” plant

Palfium, Jetrium, Narcolo

DET Lyspafen

DMT Dipipan, phenylpiperone HCL, Diconal, Wellconal Metebanyl, oxymethebanol

Captagon, amfetyline, ethyltheophylline amphetamine GHB, gamma hydroxybutyrate, sodium oxybate Diacetylmorphine, diamorphine

Constituent of “Tabernanthe iboga” plant Cliradon

LSD, lysergide Cannabis, marijuana Nubarene Constituent of “Peyote” cacti Quaalude, Parest, Somnafac, Opitimil, Mandrax N-Methylcathinone, “cat”

BZP, 1-benzylpiperazine PCE


64


Schedule I Controlled Substances (Continued) Controlled Substance N-Ethylamphetamine N-Ethyl-3-piperidyl benzilate N-Hydroxy-3,4-methylenedioxyamphetamine N-Methyl-3-piperidyl benzilate N,N-Dimethylamphetamine Nicocodeine Nicomorphine Noracymethadol Norlevorphanol Normethadone Normorphine Norpipanone Parahexyl para-Fluorofentanyl Peyote Phenadoxone Phenampromide Phenomorphan Phenoperidine Pholcodine Piritramide Proheptazine Properidine Propiram Psilocybin Psilocyn Racemoramide Tetrahydrocannabinols Thebacon Thiofentanyl Tilidine Trimeperidine

Synonym(s) NEA JB 323 N-hydroxy MDA JB 336

Vilan

Phenyldimazone

Synhexyl China White, fentanyl Cactus that contains mescaline

Operidine, Lealgin Copholco, Adaphol, Codisol, Lantuss, Pholcolin Piridolan

Algeril Constituent of “Magic Mushrooms” Psilocin, constituent of “Magic Mushrooms” THC, Delta-8 THC, Delta-9 THC, and others Acetylhydrocodone, Acedicon, Thebacetyl China White, fentanyl Tilidate, Valoron, Kitadol, Lak, Tilsa Promedolum

Schedule II Controlled Substances Controlled Substance 1-Phenyleyelohexylamine 1-Piperidinoeyelohexanecarbonitrile Alfentanil Alphaprodine Amobarbital Amphetamine Anilerdine Benzoylecgonine Bezitramide Carfentanil Coca leaves Cocaine Codeine Dextropropoxyphene, bulk (non-dosage forms) Dihydrocodeine Dihydroetorphine Diphenoxylate Diprenorphine Ecgonine Ethylmorphine Etorphine HCL

Synonym(s) Precursor of PCP PCC, precursor of PCP Alfenta Nisentil Amytal, Tuinal Dexedrine, Adderall, Obetrol Leritine Cocaine metabolite Burgodin Wildnil Methyl benzoylecgonine, Crack Morphine methyl ester, methyl morphine Propoxyphene Didrate, Parzone DHE M50-50 Cocaine precursor, in coca leaves Dionin M 99



65

Schedule II Controlled Substances (Continued) Controlled Substance Fentanyl Glutethimide Hydrocodone Hydromorphone Isomethadone Levo-alphacetylmethadol Levomethorphan Levorphanol Meperidine Meperidine intermediate-A Meperidine intermediate-B Meperidine intermediate-C Metazocine Methadone Methadone intermediate Methamphetamine Methylphenidate Metopon Moramide-intermediate Morphine Nabilone Opium, granulated Opium, powdered Opium, raw Opium extracts Opium fluid extract Opium poppy Opium tincture Oxycodone Oxymorphone Pentabarbital Phenazocine Phencyclidine Phenmetrazine Phenylacetone Piminodine Poppy straw Poppy straw concentrate Racemethorphan Racemorphan Remifentanil Secobarbital Sufentanil Thebaine

Synonym(s) Duragesic, Oralet, Actiq, Sublimaze, Innovar Doriden, Dorimide Dihydrocodeinone Dilaudid, dihydromorphinone Isoamidone LAAM, long-acting methadone, levomathadyl acetate Levo-Dromoran Demerol, Mepergan, pethidine Meperidine precursor Meperidine precursor Meperidine precursor Dolophine, Methadose, Amidone Methadone precursor Desoxyn, D-desoxyephedrine, ICE, Crank, Speed Concerta, Ritalin, Methylin

MS Contin, Roxanol, Oramorph, Duramorph, RMS, MSIR Cesamet Granulated opium Powdered opium Raw opium, gum opium

Papaver somniferum Laudanum OxyContin, Percocet, Endocet, Roxicodone, Roxicet Numorphan Nembutal Narphen, Prinadol PCP, Sernylan Preludin P2P, phenyl-2-propanone, benzyl methyl ketone Opium poppy capsules, poppy heads Concentrate of poppy straw, CPS Dromoran Ultiva Seconel, Tuinal Sufenta Precursor of many narcotics

Schedule III Controlled Substances Controlled Substance 1-Androstenediol 1-Androstenedione 3α,17β-Dihydroxy-5α-androstane 3β,17β-Dihydroxy-5α-androstane 4-Androstenediol 4-Androstenedione 4-Dihydrotestosterone 4-Hydrotestosterone

Synonym(s)

4-AD Anabolex, Andractim, Pesomax, Stanolone


66


Schedule III Controlled Substances (Continued) Controlled Substance 4-Hydroxy-19-nortestosterone 5-Androstenediol 5-Androstenedione 13β-Ethyl-7β-hydroxygon-4-en-3-one 17α-Methyl-3β,17β-dihydroxy-5α-androstane 17α-Methyl-3α,17β-dihydroxy-5α-androstane 17α-Methyl-3α,17β-dihydroxyandrost-4-ene 17α-Methyl-4-hydroxynandrolone 17α-Methyl-Δ1-dihydrotestosterone 19-Nor-4-androstenediol 19-Nor-5-androstenediol 19-Nor-4-androstenedione 19-Nor-5-androstenedione Amobarbital suppository dosage form Amobarbital and noncontrolled active ingredients Anabolic steroids Androstanedione Aprobarbital Barbituric acid derivative Benzphetamine Boldenone Bolasterone Buprenorphine Buprenorphine Butabarbital (sec butabarbital) Butalbital Butobarbital (butethal) Calusterone Chlorhexadol Chlorotestosterone (same as clostebol) Chlorphentermine Clortermine Clostebol Codeine combination product 90 mg/du Codeine and isoquinoline alkaloid 90 mg/du Dehydrochlormethyltestotsterone Dihydrocodeine combination product 90 mg/du Delta1-dihydrotestosterone Dronabinol in sesame oil in soft gelatin capsule Dihydrotestosterone (same as stanolone) Drostanolone Ethylestrenol Ethylmorphine combination product 15 mg/du Formebolone Furazabol Gamma Hydroxybutyric Acid preparations Fluoxymesterone Hydrocodone combination product 1.5 cm. On the other hand, if the left ventricular wall measures 60 mg/dL), the microsomal enzymes (P4502E1), which have a higher km for oxidation of ethanol (60 to 80 mg/dL) compared with ADH (km = 2 to 5 mg/dL), become engaged in the metabolism of ethanol.194–196 The P450 enzymes are also involved in the metabolism of many drugs and environmental chemicals, which raises the potential for drug–alcohol interactions, which might explain the toxicity of ethanol in heavy drinkers and alcoholics.197–202 Moreover, the activity of P4502E1 enzymes increases after a period of continuous heavy drinking owing to a faster de novo synthesis of the enzyme and metabolic tolerance develops as reflected in twofold to threefold faster rates of elimination of alcohol from the bloodstream in alcoholics undergoing detoxification.200–204 The detrimental effects of ethanol on performance and behavior are complex and involve interaction with the membrane receptors in the brain associated with the inhibitory neurotransmitters glutamate and gamma aminobutyric acid (GABA).205–208 The behavioral effects of ethanol are dosedependent and after drinking small amounts the individual relaxes, experiences mild euphoria, and becomes more talkative. As drinking continues and the blood-ethanol concentration increases toward 150 to 200 mg/dL, impairment of body functioning becomes pronounced. Many of the pharmacological effects of ethanol can be explained by an altered flux of ions through the chloride channel activated by the neurotransmitter GABA.206 The link between ethanol impairment and neurotransmission at the GABAA receptor also helps to explain observations about cross-tolerance with other classes of depressant drugs like benzodiazepines and barbiturates, which also bind to the GABAA receptor complex to open a chloride ion-channel to alter brain functioning.200 Although there is a reasonably good correlation between degree of ethanol-induced impairment and the person’s BAC, there are large variations in response at the same BAC in different individuals who drink the same amount of alcohol within the same time frame. The reasons for this are twofold; first, larger people tend to have more body water so the same dose of alcohol enters a larger volume resulting in lower BAC compared with lighter people with less body water. This phenomenon is known as consumption tolerance and stems from variations in body weight and the relative amount of adipose tissue, which is influenced by age, gender, and ethnicity.209,210 The second reason for interindividual differences in ethanol-induced performance decrement is called concentration tolerance, which is linked to a gradual habituation of brain cells to the presence of alcohol during repeated exposure to the drug.210,211 Besides the development of acute tolerance (Mellanby effect), which appears during a single exposure (see Chapter 5.1), a chronic tolerance develops after a period of continuous heavy drinking. Among the mechanisms accounting for chronic tolerance are long-term changes in the composition of cell membranes particularly, the cholesterol content, the structure of the fatty acids, and also the arrangement of proteins and phospholipids making up the lipid bilayer.210.211 In occasional drinkers, the impairment effects of ethanol appear gradually, becoming more exaggerated as BAC increases. The various clinical signs and symptoms of intoxication are usually classified as a function of BAC from sober to dead drunk as was first proposed by Bogen.212 This scheme has subsequently been developed further and improved upon by others. For example, at a BAC of 10 to 30 mg/dL alterations in a person’s performance and behavior are insignificant and can only be discerned using highly specialized tests such as divided attention tasks. Between 30 and 60 mg/dL, most people experience euphoria, becoming more talkative and sociable owing to disinhibition. At a BAC between 60 and 100 mg/dL euphoria is more marked, often causing excitement with partial or complete loss of inhibitions and in some individuals judgment and control are seriously impaired. When the BAC is between 100 and 150 mg/dL, which are concentrations


356


seldom reached during moderate social drinking, psychomotor performance deteriorates markedly and poor articulation and speech impediment is obvious. Between 150 and 200 mg/dL ataxia is pronounced and drowsiness and confusion are evident in most people. The relationship between BAC and clinical impairment is well documented in drunk drivers who often reach very high BACs of 350 mg/dL or more, but most of these individuals are obviously chronic alcoholics.213,214 In two recent studies of forensic autopsies, the average BAC when death was attributed to acute alcohol poisoning was 360 mg/dL.215,216 It is important to note that the impairment effects of alcohol depend to a great extent on the dose and the speed of drinking and whether the person starts from zero BAC or not.217,218 The person’s age and experience with alcohol are important owing to the development of central nervous system tolerance.219 People who are capable of functioning with a very high BAC, such as drunk drivers, e.g., 200 to 300 mg/dL, have probably been drinking continuously for several days or even weeks so that a chronic tolerance to alcohol has had time to develop. Drinking a large volume of neat spirits in a short time results in nausea, gross behavioral impairment, and marked drunkenness, and an inexperienced drinker runs the risk of losing consciousness and suffering acute alcohol poisoning. Drinking too much too fast is dangerous, and if gastric emptying is rapid, the BAC rises with such a velocity that a vomit reflex in the brain is triggered. This physiological response to acute alcohol ingestion has probably saved many lives. Conducting controlled studies with people who drink to reach very high BAC are difficult to motivate for ethical reasons. One exceptional study was reported by Zink and Reinhardt,220 who allowed healthy male volunteers to consume very large quantities of alcohol, either as beer or spirits or both, continuously for 8 to 10 h under social conditions. The BAC profiles were established unequivocally by frequent blood sampling from indwelling catheters every 15 to 20 min for up to 10 h. Some of the subjects reached abnormally high BAC of over 3.0 g/kg (300 mg/dL) and all developed a high degree of tolerance to the effects of alcohol. Figure 5.2.11 gives examples of the blood-concentration time profiles for four of the men who participated in this German study. Note that BAC is given in mass/mass (g/kg) as is customary in Germany and not weight/volume. 5.2.7

Clinical Pharmacokinetics of Ethanol

Clinical pharmacokinetics deals with the way that drugs and their metabolites are absorbed, distributed, and metabolized in the body and how these processes can be described in quantitative terms.221–224 5.2.7.1 Widmark Model The clinical pharmacokinetics of ethanol has been investigated extensively since the 1930s thanks to the early availability of a reliable method of analysis in small volumes of blood.209 Figure 5.2.12 shows a typical BAC–time profile after a healthy male subject drank 0.68 g/kg ethanol as neat whisky in the morning on an empty stomach. Before any pharmacokinetic evaluation of this curve is attempted, the data points on the post-absorptive phase should be carefully inspected and shown to fit well on a straight line. One indication of this is a high correlation coefficient (r > 0.98) for the concentration–time data points. The rectilinear declining phase is then extrapolated back to the ordinate (y-axis) or the time of starting to drink to give the C0 parameter. This represents the concentration of ethanol in blood if the entire dose was absorbed and distributed in all body fluids and tissues without any metabolism occurring. The ratio of dose (g/kg) to C0 (g/L) gives the ratio of body alcohol concentration to BAC and is known as the apparent volume of distribution, denoted “r” by Widmark or more recently Vd in units of L/kg. Inspection of this parameter allows a check on the validity of the experiment and the kinetic analysis because Vd can only take certain values. The value expected corresponds to the ratio of water in the whole body (60%) to the water content


ALCOHOL

4.5

S-5

4.0

EOD = 360 min

4.5

tmax = 360 min

4.0

3.5 3.0 2.5 2.0 1.5 5.2 g/kg

1.0

tmax = 420 min

3.0 2.5 2.0 1.5 1.0

0.5

3.7 g/kg

0.5 0

0 0

200

400

600

800

1000

1200

0

200

Time from start of drinking, min 4.5

S-7

4.0

EOD = 440 min

4.5

tmax = 490 min

4.0

3.5 3.0 2.5 2.0 1.5 4.9 g/kg

1.0

400

600

800

1000

1200

Time from start of drinking, min

EOD = 330 min

S-8

tmax = 274 min

3.5

Blood ethanol, mg/g

Blood ethanol, mg/g

EOD = 400 min

S-6

3.5

Blood ethanol, mg/g

Blood ethanol, mg/g

357

3.0 2.5 2.0 1.5 3.3 g/kg

1.0

0.5

0.5

0

0 0

200

400

600

800

1000

1200

200

0


400

600

800

1000

1200


Figure 5.2.11 Concentration–time profiles of ethanol in four subjects (S-5 to S-8) who consumed very large quantities of alcohol (3.3 to 5.2 g/kg body weight) during a drinking time of 8 to 10 hours under controlled social conditions. EOD is time to end of drinking and tmax is time to reach the maximum BAC. Curves are redrawn from information published by Zink and Reinhardt.220 1.5

Vd = Dose (g/kg)/C0

Blood-alcohol, g/L

C0 Cmax

1.0

Ct = C0 – βt β = C0/min0

tmax

0.5 min0

0.0 0

100

200

300

400

500

600

Time after start of drinking, min Figure 5.2.12 Blood-alcohol profile typically obtained after ingestion of a moderate dose of alcohol (0.68 g/kg) as neat whisky in 20 min after an overnight fast. Key pharmacokinetic parameters and how these are calculated are shown on the graph (see text for details).


358


200 Peak BAC

Blood ethanol, mg/dl

150

Diffusion plunge

100 β-slope = Co/mino Co 50 First-order kinetics

AUC Mino 0 0

100

200

300

400

500

600

700

Time after start of infusion, min

Figure 5.2.13 Concentration–time profile of ethanol in venous blood after one subject received 0.8 g ethanol per kg body weight by constant rate intravenous infusion over 40 min. The pharmacokinetic parameters are defined on this graph (see text for details).

of the blood (80%) and thus a ratio of 0.6 to 0.7 L/kg for a healthy male and 0.5 to 0.6 L/kg for a female.209 Alcohol can also be administered intravenously, which is sometimes desirable in research and clinical investigations to avoid problems with variable gastric emptying and to avoid first-pass metabolism occurring in the stomach or the liver or both organs.224 In the example shown in Figure 5.2.13, the test subject received 0.80 g/kg as a 10% w/v solution in saline at a constant rate for 40 min. The peak BAC now coincides with the end of the infusion period and this is followed by a diffusion plunge, during which time ethanol equilibrates between the well-perfused central blood compartment and poorly perfused resting skeletal muscle tissues. At about 90 min post-infusion, the BAC starts to decrease at a constant rate per unit time in accordance with zero-order kinetics and the slope of this rectilinear disappearance phase is commonly referred to as the alcohol burnoff rate or β-slope. However, specialist textbooks in pharmacokinetics refer to the zero-order elimination slope as k0 instead of β.224 When the blood concentration decreases below about 10 mg/dL or after about 450 min post-dosing in Figure 5.2.13, the linear declining phase becomes curvilinear for the remainder of time alcohol is still measurable in the blood.223,224 The elimination of alcohol now follows first-order kinetics and the rate constant is denoted k1 Some studies showed that the half-life of this terminal phase was about 15 min.225 The first person to make a comprehensive mathematical analysis of BAC profiles was Erik M.P. Widmark and details of his life and work have been published.226 Widmark introduced the following equation to represent the elimination kinetics of alcohol from blood in the post-absorptive phase. Ct = C0 – βt

(1)

where Ct = blood alcohol concentration at some time t on the post-absorptive part of the curve, C0 = blood alcohol concentration extrapolated to the time of starting to drink, β = rate of elimination of alcohol from blood, and t = time in minutes. The rate of elimination of alcohol from the blood in moderate drinkers falls within the range 10 to 20 mg/dL/h with a mean value of about 15 mg/dL/h.197,209,225 Higher values are seen in drinking drivers (mean 19 mg/dL/h)227 and in alcoholics undergoing detoxification (mean 22 mg/dL/h).228–231


ALCOHOL

359

The faster burn-off rates seen in heavy drinkers is probably one consequence of enzyme induction, which boosts the activity of the microsomal P4502E1 system during prolonged exposure to high concentrations of ethanol.196,230,232 The P4502EI enzymes have a higher Km (60 to 80 mg/dL) compared with ADH (2 to 5 mg/dL) and the slope of the elimination phase tends to be steeper when starting from a higher initial BAC, such as in alcoholics compared with moderate social drinkers.230 In a controlled study with alcoholics undergoing detoxification, the mean β-slope was 22 mg/dL/h with a range from 13 to 36 mg/dL/h.228 Liver disorders such as alcoholic hepatitis and cirrhosis did not seem to influence the rate of disposal of alcohol in these individuals.228 When recently drinking alcoholics with high rates of alcohol elimination from blood were allowed to sober up for a few days and dosed again with a moderate amount of alcohol, the elimination rate was now in the range expected for moderate drinkers, namely, 15 mg/dL/h.230 The rate of elimination of alcohol from the blood was not much influenced by the time of day when 0.75 g/kg was administered at 9 A.M., 3 P.M., 9 P.M., and 3 A.M., according to an investigation into chrono-pharmacokinetics of ethanol.233 However, gastric emptying seems to occur faster in the morning as reflected in a 32% higher peak BAC and an earlier time of its occurrence when ethanol (1.1 g/kg body weight) was consumed between 7.15 and 7.45 A.M., compared with the same time in the evening.234 Smoking cigarettes slows gastric emptying and as a consequence delays the absorption of a moderate dose (0.50 g/kg) of ethanol resulting in a lower peak BAC in smokers.235 By extrapolating the rectilinear elimination phase back to the time of starting to drink, one obtains the y-intercept (C0), which corresponds to the theoretical BAC expected if the entire dose was absorbed and distributed without any metabolism occurring (Figure 5.2.13). The empirically determined value of C0 will always be greater than the ratio of dose/body weight because whole blood is 80% w/w water compared with the body, which is 60% w/w on average for men and 50% for women. The apparent volume of distribution (Vd) of alcohol is given by the ratio of dose (g/kg) divided by C0 and in clinical pharmacology textbooks this is referred to as Vd with units of L/kg.221–223 However, because BAC in Widmark’s studies was reported in units of mg/g or g/kg, dividing the dose by C0 gives a ratio without any dimensions. This needs to be considered whenever BAC is reported as weight/volume units (e.g., g/L) as is more usual today. The density of whole blood is 1.055 g/mL, which means there is an expected difference of 5.5% compared with values of Vd reported by Widmark.209 Values of the distribution factor “r” differ between individuals depending on age and body composition particularly the proportion of fat to lean body mass.236 Obviously, the value of “r” will also depend on whether whole blood or plasma specimens were analyzed and used to plot the concentration–time profile when back-extrapolation is done to determine C0. As shown in Figure 5.2.2, the plasma–alcohol curves run on a higher level compared with whole blood–alcohol curves because of the differences in water content as discussed earlier. This means that C0 is higher for plasma curves compared with whole-blood curves.47 According to Widmark’s second equation, the relationship between alcohol in the body and alcohol in the blood at equilibrium can be represented by the following equations: A/(p × r) = C0

(2)

A = C0 × (p × r)

(3)

where A = amount of alcohol in grams absorbed and distributed in all body fluids, p = body weight of the person in kg, r = Widmark’s “r” factor, and C0 = y-intercept (Figure 5.2.13). These equations make it is easy to calculate the amount of alcohol in the body from the concentration determined in a sample of blood provided that the value of “r” is known and that absorption and distribution of ethanol were complete at the time of sampling blood. However, in reality 100% absorption of the dose is only achieved when ethanol is given by intravenous infusion. Thus, the above equation will tend to overestimate the person’s true BAC because part of an orally


360


administered dose might be cleared by first-pass metabolism occurring either in the stomach or liver or in both places. Although the above equation has been much used in forensic alcohol calculations, it should not be applied to other drugs and narcotics and especially not in post-mortem toxicology, owing to problems with variation in drug concentrations in different sampling sites (see Section 5.2.3). In the fasting state, the factor “r” will depend on age, gender, and body composition and Widmark reported mean values of 0.68 for 20 men (range 0.51 to 0.85) and 0.55 for 10 women (range 0.49 to 0.76).209 However, in many later studies, which included more volunteer subjects, it was found that average values of “r” were closer to 0.70 L/kg for men and 0.60 L/kg for women with 95% confidence limits of about ±20%.237 The two separate Widmark equations for β and “r” can be easily combined by eliminating C0 to give the following equation: A = pr(Ct + βt)

(4)

The above equation is useful to estimate the total amount of alcohol absorbed from the gastrointestinal tract since the beginning of drinking or by rearrangement, the BAC (Ct) expected after intake of a known amount of alcohol. Ct = (A/pr) – βt

(5)

When calculating BAC from the dose administered, or vice versa, it is necessary to assume that systemic availability is 100% and that absorption and distribution of alcohol into total body water is complete at the time of sampling blood. Furthermore, individual variations in β and “r” introduce uncertainty in the calculated dose (A) or BAC (Ct) when average values are applied to random subjects from the population. Various modifications or improvements have been suggested, such as by using estimates of total body water, lean body mass, or nomograms based on body mass index.236–238 The individual variation has been estimated to ±20% for 95% confidence limits in tests involving more than 100 subjects who drank alcohol on an empty stomach.237 However, in the entire population of drinking drivers, these limits can be expected to be much wider. 5.2.7.2 Michaelis–Menten Model Because the class I ADH enzymes have a low km (2 to 5 mg/dL) for ethanol they become saturated with substrate after one to two drinks.221,222 The rate of disappearance of ethanol from blood therefore follows zero-order kinetics over a large segment of the post-absorptive elimination phase (Figure 5.2.13).236,237 When the BAC decreases below about 10 mg/dL, the ADH enzymes are no longer saturated and the curve changes to a curvilinear disappearance phase (first-order kinetics).221–223,239 However, these low BACs are not very relevant when forensic science aspects of ethanol are concerned. It was first demonstrated by Lundquist and Wolthers240 that the entire post-absorptive elimination phase (zero-order and first-order stages) might be rationalized by an alternative pharmacokinetic model, namely, that of saturation kinetics.223,239 Thanks to the availability of a highly sensitive ADH method of analysis, much lower blood-alcohol concentration (1.0) compared with the value expected of 0.7 in men and 0.6 in women. The notion of a “loss of ethanol” when drinking occurred after a meal was observed by Widmark,109 and he proposed that the mechanism might involve chemical reaction of ethanol with constituents of the food. However, a more modern explanation for this food-induced lowering in the bioavailability of ethanol is presystemic oxidation by gastric and/or hepatic ADH.274,275 Figure 5.2.14 shows individual BAC curves after 12 male subjects drank 0.8 g/kg in the morning after an overnight fast.268 Both Cmax and tmax varied widely between individuals. The time to reach the Cmax ranged from 0 to 150 min after the end of drinking. Those subjects with very slow rates 200 N = 12 male subjects Ethanol dose 0.80 g/kg


150

100

50

0 0

1

2

3

4

5

6

7

8

Time from start of drinking, h Figure 5.2.14 Individual concentration–time profile of ethanol in venous blood for 12 healthy men who drank 0.80 g ethanol per kg body weight in 30 min after an overnight fast.


ALCOHOL

363

150

0.80 g/kg Empty stomach


After food 100

50

0 0

60

120

180

240

300

360

Time, min Figure 5.2.15 Mean blood-alcohol profiles after eight healthy men drank alcohol (0.80 g/kg in 30 min) either on an empty stomach or immediately after eating breakfast.

of absorption might have experienced a pyloric spasm so that the absorption took place through the stomach as opposed to the duodenum and jejunum where rapid absorption occurs. The impact of food and body composition on BAC–time profiles for various drinking scenarios was recently the subject of a comprehensive review by Kalant.277 Ingestion of food immediately before or together with alcohol resulted in a lower Cmax compared with drinking the same dose on an empty stomach. This lowering effect does not seem to be related to the composition of the meal in terms of macronutrients (protein, fat, or carbohydrate), but instead the size of the meal is seemingly more important.274 The delayed gastric emptying meant a slower delivery of alcohol into the small intestine, the site of rapid absorption into the portal blood, and therefore a longer exposure to gastric mucosal ADH thus enhancing the changes of gastric FPM of alcohol. Moreover, the role of FPM, whether gastric or hepatic, is small and highly variable and much depends on the dose of alcohol administered. After very small doses (5 mmol/L in vitreous) are indicative of profound AKA, and these values can be expected in about 10% of all alcoholics subjected to a medicolegal autopsy. Both vitreous and pericardial fluid ketone levels are lower than those in post-mortem blood, possibly because they are less affected by any agonal or post-mortem changes. Alcoholic ketoacidosis can be diagnosed at autopsy by measurement of total ketone bodies (acetone, acetoacetate, and β-hydroxybutyrate) in vitreous humor, pericardial fluid, or peripheral blood. Finding significantly elevated levels is associated with a typical history of an alcoholic binge followed by a day or more of anorexia, and consequently an insignificant BAC. In alcoholics in whom the autopsy is negative (so-called fatty liver deaths), AKA may be an explanation for sudden death as a result of profound acidosis, with a critical fall in blood pH to around 7.0, precipitating vascular collapse. 5.3.11 Post-Mortem Markers for Alcohol Abuse The prevalence of alcoholism in the forensic autopsy population varies between jurisdictions but can be as high as 10% or more. Poor hygiene and multiple bruises of different ages are more common in chronic alcoholics than in the general forensic autopsy population, and raise the index of suspicion in an individual case. The traditional method of diagnosing chronic alcoholism postmortem is to evaluate the BAC and liver histology in the light of the available medical history. However, the presence of alcohol in the blood merely indicates alcohol ingestion prior to death


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and almost half of all alcoholics die with a zero BAC. Also, the pathological features of alcoholic liver disease are relatively nonspecific and the extent of liver disease in many alcoholics is no worse than in the general forensic autopsy population. The spectrum of alcoholic liver disease includes hepatomegaly, steatosis with or without lipogranulomas, alcoholic hepatitis, and cirrhosis.136 This complete spectrum, including alcoholictype hepatitis, can be perfectly mimicked by a few non-alcohol-related conditions such as obesity with or without dieting, jejuno-ileal bypass for obesity, diabetes mellitus, and perhexilline maleate toxicity. Hepatic steatosis is the most common form of alcoholic liver disease seen at necropsy, and significant steatosis may be induced by the amounts of alcohol consumed by many social drinkers. Following the withdrawal of alcohol, the mobilization of this accumulated fat begins in 1 to 2 days and is complete in 4 to 6 weeks even in severe cases. While hepatic steatosis is potentially reversible, alcoholic hepatitis is thought by some to represent the point of no return within the spectrum, for once this stage is reached the disorder tends to progress to cirrhosis. Even so, a person with alcoholic hepatitis may be symptom-free and performing normal social functions. In general, there is not always a good correlation between symptoms and morphological findings in alcoholic hepatitis. Histologically, alcoholic hepatitis is characterized by liver cell necrosis with a predominantly neutrophil polymorph reaction and peri-cellular fibrosis. The hepatitis is mainly centrilobular in distribution and classically associated with the presence of Mallory’s hyaline. More than half of all cases of cirrhosis coming to autopsy are the result of alcohol abuse. The classical alcoholic cirrhosis is micronodular and fatty, but this is not necessarily so since it may not be fatty and may evolve into a macronodular cirrhosis. Persons abusing alcohol frequently abuse other drugs and may develop drug-related hepatotoxicity, in particular late acetaminophen (paracetamol) toxicity from excessive, but not suicidal, doses of this antipyretic drug. The search for a corroborative post-mortem biochemical marker for chronic alcoholism has taken as a starting point those clinical studies on the value of biochemical markers of alcoholism in the living. The serum enzyme γ-glutamyltransferase (GGT) is one of the most frequently used clinical markers and has a reported sensitivity of 39 to 87% but a specificity of only 11 to 50%.137 This poor specificity is mainly the result of interference by various hepatic and other diseases, and drug therapy. At autopsy the difficulties are greater because GGT is subject to significant postmortem changes. GGT levels in right heart blood may be two to eight times greater than in femoral venous blood owing to post-mortem diffusion of GGT from the liver. Furthermore, post-mortem hemolysis interferes with some quantitative enzymatic GGT methods. More recently, carbohydratedeficient transferrin (CDT) has been used as a clinical marker of alcoholism, offering 83 to 90% sensitivity and 99% specificity.137 CDT is thought to become elevated at the threshold of hazardous drinking, which is generally accepted as being 50 to 80 g/day. An assessment of the value of CDT in diagnosing chronic alcoholism at autopsy concluded that it might have a sensitivity of 70% and a specificity of 85% if the cut-off value for the diagnosis of alcohol abuse post-mortem was raised above the accepted clinical cut-off value.138 This suggests that both CDT and GGT are likely to be subject to post-mortem changes. Trace amounts of methanol (less than 1.0 mg/L) are produced in the body in the course of intermediary metabolism and the endogenous levels increase during a period of heavy drinking. Ingestion of methanol as a congener in various alcohol beverages adds to this accumulation.139 When alcoholics consume alcohol over a period of several days or weeks reaching blood ethanol concentrations of 150 to 450 mg/dL, then the methanol levels in blood and urine progressively increase to 20 to 40 mg/L. The elimination of methanol lags behind ethanol by 12 to 24 h and follows approximately the same time course as ethanol withdrawal symptoms leading to speculation on the role of methanol and/or its metabolites in alcohol withdrawal and hangover.139 Below a blood ethanol concentration of about 10 mg/dL, hepatic ADH is no longer saturated with its preferred substrate and the metabolism of methanol can therefore commence. At this low concentration the elimination of ethanol follows first-order kinetics with a half life of 15 min.139 The half-life of methanol, however, is about ten times longer. As a result elevated concentrations of methanol will


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persist in blood for about 10 h after ethanol has reached endogenous levels and can serve as a marker of recent heavy drinking.139 Blood methanol levels in 24 teetotalers ranged from 0.1 to 0.8 mg/L with a mean of 0.44 mg/L so that these levels can be regarded as physiological. By contrast, blood methanol concentrations in samples taken on admission of 20 chronic alcoholics to hospital ranged from 0.22 to 20.1 mg/L.140 The general extent to which methanol may accumulate in the blood of chronic alcoholics can be gauged from a study of ethanol and methanol in blood samples from 519 drunk-driving suspects.139 The concentration of ethanol ranged from 0.01 to 3.52 mg/g and the concentration of methanol in the same sample ranged from 1 to 23 mg/L with a mean of 7.3 (SD 3.6) and a positively skewed distribution. By contrast, in 15 fatalities following hospital admission for methanol poisoning the concentrations of methanol in post-mortem blood from the heart ranged from 23 to 268 mg/dL.141 5.3.12 Methanol Methanol (wood alcohol) is used as antifreeze, photocopier developer, a paint remover, a solvent in varnishes, a denaturant of ethanol, and is readily available as methylated spirit. It may be used also as a substitute for ethanol by alcoholics.142 The distribution of methanol in body fluids (including vitreous humor) and tissues was reported as similar to that of ethanol, but there may be preferential concentration in liver and kidney.143,144 The lethal dose of methanol in humans shows pronounced individual differences ranging from 15 to 500 mL. Clusters of poisonings are seen secondary to consumption of adulterated beverages.141,145,146 Acute methanol poisoning produces a distinct clinical picture with a latent period of several hours to days between consumption and the appearance of first symptoms. A combination of blurred vision with abdominal pain and vomiting is found in the majority of victims within the first 24 h after presentation. Visual disturbances, pancreatitis, metabolic acidosis, and diffuse encephalopathy may be seen in severe cases.145 The characteristic delay between ingestion and onset of symptoms is thought to reflect the delayed appearance of metabolites (formaldehyde and formic acid), which are more toxic than methanol itself. Methanol poisoning is characterized by a metabolic acidosis with an elevated anion gap. The serum anion gap is defined as (sodium + potassium) to (bicarbonate + chloride), and represents the difference in unmeasured cations and unmeasured anions, which includes organic acids. Both formic acid, produced by methanol catabolism, and lactic acid, resulting from disturbed cellular metabolism, are responsible for the metabolic acidosis.147 The severity of the poisoning correlates with the degree of metabolic acidosis more closely than with the blood concentration of methanol.148 Measuring formic acid concentrations may be of some value in assessing methanol poisoning. Reported formic acid levels in two methanol fatalities were 32 and 23 mg/dL in blood and 227 and 47 mg/dL in urine.149 One well-documented outbreak of methanol poisoning150 involved 59 people, 8 of whom died outside hospital while 51 were hospitalized, and of these a further 9 died in hospital, 5 survived with sequelae, and 1 died a year later of cerebral sequelae. In the 51 hospitalized victims, who had a median age of 53 years, the serum concentration of methanol (range 10 to 470 mg/dL, median 80 mg/dL) proved a poor predictor of survival or visual sequelae. Respiratory arrest or coma on hospital admission was associated with 75 and 67% mortality, respectively. Overall, prognosis was closely correlated with the degree of metabolic acidosis, so that a fatal outcome was associated with a pH < 6.9 and base deficit > 28 mmol/L, with an inadequate ability to compensate for the metabolic acidosis by hyperventilation being reflected in an increased blood pCO2. Methanol poisoning has a high mortality mainly because of delay in diagnosis and treatment.150 The standard treatment includes the competitive inhibition of methanol oxidation by the intravenous administration of ethanol, thus preventing the formation of toxic metabolites, formaldehyde and formic acid. Both methanol and ethanol are substrates for hepatic ADH, although the affinity of the enzyme is much higher for ethanol than for methanol by about 10:1.151 Consequently, the biotransformation of methanol into its toxic metabolites can be blocked by the administration of


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ethanol.152 One disadvantage of ethanol is that it exerts its own depressant effect on the central nervous system at the steady-state concentration of 100 to 120 mg/dL in blood, which must be maintained for many hours.152,153 A more modern, and expensive, antidote for methanol poisoning is fomepizole (4-methyl pyrazole or Antizol®), which also acts as a competitive inhibitor of alcohol dehydrogenase.154,155 This drug is preferred to ethanol for treating children and adults with known liver dysfunction.156 During fomepizole treatment, the concentration of formate in blood may be a better prognostic indicator than the methanol concentration.157 5.3.13 Isopropyl Alcohol Isopropyl alcohol (isopropanol) is used as a substitute for ethanol in many industrial processes and in home cleaning products, antifreeze, and skin lotions. A 70% solution is sold as “rubbing alcohol” and may be applied to the skin and then allowed to evaporate, as a means of reducing body temperature in a person with fever. Isopropanol has a characteristic odor and a slightly bitter taste. Although much less dangerous than methanol, deaths have been reported following accidental ingestion of isopropanol, e.g., in alcoholics who use it as an ethanol substitute.158 Fatalities may occur rapidly as a result of central nervous system depression or may be delayed, when the presence or absence of shock with hypotension is the most important single prognostic factor. Isopropyl alcohol has an apparent volume of distribution of 0.6 to 0.7 L/kg, being similar to that of ethanol and with distribution complete within about 2 h.159,160 Elimination most closely approximates first-order kinetics although this is not well defined (t1/2 = 4 to 6 h).161 This secondary alcohol is metabolized to acetone, predominantly by liver alcohol dehydrogenase, and approximately 80% is excreted as acetone in the urine with 20% excreted unchanged.161,162 The acetone causes a sweet ketonic odor on the breath. The elimination of both isopropanol and its major metabolite acetone obeyed apparent first-order kinetics with half-lives of 6.4 and 22.4 h, respectively, in a 46-year-old non-alcoholic female with initial serum isopropanol and acetone concentrations of 200 and 12 mg/dL, respectively.161 In a review of isopropanol deaths, 31 were attributed to isopropanol poisoning alone, and the blood isopropanol concentrations ranged from 10 to 250 mg/dL, mean 140 mg/dL, and acetone ranged from 40 to 300 mg/dL, mean 170 mg/dL.163 Four cases with low blood isopropanol levels (10 to 30 mg/dL) had very high acetone levels (110 to 200 mg/dL). For this reason both acetone and isopropanol should be measured in suspected cases of isopropanol poisoning. High blood levels of acetone may be found in diabetes mellitus and starvation ketosis, which opens the possibility that ADH might reduce acetone to isopropyl alcohol. This is the suggested explanation for the detection of isopropyl alcohol in the blood of persons not thought to have ingested this compound. In 27 such fatalities blood isopropyl alcohol ranged from less than 10 to 44 mg/dL with a mean of 14 mg/dL, and in only 3 cases was the concentration greater than 20 mg/dL. Acetone levels ranged up to 56 mg/dL and in no individual case did the combined isopropanol and acetone levels come close to those seen in fatal isopropyl alcohol poisoning.164 5.3.14 Concluding Remarks Blood ethanol concentration can be expected to be positive in around one half of all unnatural deaths so that routine screening of such deaths for ethanol is highly desirable. For natural deaths as a whole, the return of positives is not sufficiently high to justify screening, unless there is a history of chronic alcoholism or of recent alcohol ingestion. The autopsy blood sample should never be obtained from the heart, aorta, or other large vessels of the chest or abdomen or from blood permitted to pool at autopsy in the pericardial sac, pleural cavities, or abdominal cavity. If by mischance such a specimen is the only one available, then its provenance should be clearly declared and taken into account in the interpretation of the analytical results. Blind needle puncture of the chest to obtain a “cardiac” blood sample or a so-called “subclavian stab” is not recommended


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because at best it produces a chest cavity blood sample of unknown origin and at worst a contaminated sample. The most appropriate routine autopsy blood sample for ethanol analyses, as well as other drug analyses, is one obtained from either the femoral vein or the external iliac vein using a needle and syringe after clamping or tying off the vessel proximally. The sample should be obtained early in the autopsy and prior to evisceration. Samples of vitreous humor and urine, if the latter is available, should also be taken. The interpretation of the significance of the analytical results of these specimens must, of necessity, take into account the autopsy findings, circumstances of death, and recent history of the decedent. To attempt to interpret the significance of an alcohol level in an isolated autopsy blood sample without additional information is to invite a medicolegal disaster.

REFERENCES 1. Senkowski, C.M., Senkowski, B.S., and Thompson, K.A., The accuracy of blood alcohol analysis using headspace gas chromatography when performed on clotted samples, J. Forensic Sci., 35, 176, 1990. 2. Hodgson, B.T. and Shajani, N.K., Distribution of ethanol: plasma to the whole blood ratios, Can. Soc. Forensic Sci. J., 18, 73, 1985. 3. Hak, E.A., Gerlitz, B.J., Demont, P.M., and Bowthorpe, W.D., Determination of serum alcohol: blood alcohol ratios, Can. Soc. Forensic Sci. J., 28, 123, 1995. 4. Felby, S. and Nielsen, E., The postmortem blood alcohol concentration and the water content, Blutalkohol, 31, 24, 1994. 5. Wallgren, H. and Barry, H., Actions of Alcohol, Elsevier, Amsterdam, 1970. 6. Johnson, H.R.M., At what blood levels does alcohol kill, Med. Sci. Law, 25, 127, 1985. 7. Jones, A.W. and Holmgren, P., Comparison of blood-ethanol concentration in deaths attributed to acute alcohol poisoning and chronic alcoholism, J. Forensic Sci., 48, 874, 2003. 8. Niyogi, S.K., Drug levels in cases of poisoning, Forensic Sci., 2, 67, 1973. 9. Taylor, H.L. and Hudson, R.P.J., Acute ethanol poisoning: a two-year study of deaths in North Carolina, J. Forensic Sci., 639, 1977. 10. Wilson, C.I., Ignacio, S.S., and Wilson, G.A., An unusual form of fatal ethanol intoxication, J. Forensic Sci., 50, 676, 2005. 11. Padosch, S.A., Schmidt, P.H., Kroner, L.U., and Madea, B., Death due to positional asphyxia under severe alcoholisation: pathophysiologic and forensic considerations, Forensic Sci. Int., 149, 67, 2005. 12. Bell, M.D., Rao, V.J., Wetli, C.V., and Rodriguez, R.N., Positional asphyxiation in adults, Am. J. Forensic Med. Pathol., 13, 101, 1992. 13. Perper, J.A., Twerski, A., and Wienand, J.W., Tolerance at high blood alcohol concentrations: a study of 110 cases and review of the literature, J. Forensic Sci., 31, 212, 1986. 14. Davis, A.R. and Lipson, A.H., Central nervous system tolerance to high blood alcohol levels, Med. J. Aust., 144, 9, 1986. 15. Lindblad, B. and Olsson, R., Unusually high levels of blood alcohol? J. Am. Med. Assoc., 236, 1600, 1976. 16. Johnson, R.A., Noll, E.C., and MacMillan Rodney, W., Survival after a serum ethanol concentration of 1 1/2%, Lancet, 1394, 1982. 17. Poklis, A. and Pearson, M.A., An unusually high blood ethanol level in a living patient, Clin. Toxicol., 10, 429, 1977. 18. Hammond, K.B., Rumack, B.H., and Rodgerson, D.O., Blood ethanol: a report of unusually high levels in a living patient, J. Am. Med. Assoc., 226, 63, 1973. 19. Berild, D. and Hasselbalch, H., Survival after a blood alcohol of 1127 mg/dL, Lancet, 383, 1981. 20. O’Neill, S., Tipton, K.F., Prichard, J.S., and Quinlan, A., Survival after high blood alcohol levels: association with first-order elimination kinetics, Arch. Intern. Med., 144, 641, 1984. 21. Jones, A.W., The drunkest drinking driver in Sweden: blood-alcohol concentration 545%, J. Stud. Alcohol., 60, 400, 1999. 22. Kortelainen, M., Drugs and alcohol in hypothermia and hyperthermia related deaths: a respective study. J. Forensic Sci., 32, 1704, 1987.


396


23. Teige, B. and Fleischer, E., Blodkonsentrasjoner ved akutte forgiftningsdodsfall, Tidsskr. Nor. Laegeforen., 103, 679, 1983. 24. Teresinki, G., Buszewicz, G., and Madro, R., Biochemical background of ethanol-induced cold susceptibility, Legal Med, 7, 15, 2005. 25. Kortelainen, M., Hyperthermia deaths in Finland in 1970–86. Am. J. Forensic Med. Pathol., 12, 115, 1991. 26. Ramsay, D.A. and Shkrum, M.J., Homicidal blunt head trauma, diffuse axonal injury, alcoholic intoxication, and cardiorespiratory arrest: a case report of a forensic syndrome of acute brainstem dysfunction. Am. J. Forensic Med. Pathol., 16, 107, 1995. 27. Jones, A.W., Alcohol and drug interactions, in Handbook of Drug Interactions, Mozayani, A. and Raymon, L.P., Eds., Humana Press, Totowa, NJ, 2003, 395. 28. King, L.A., Effect of ethanol on drug levels in blood in fatal cases, Med. Sci. Law, 22, 233, 1982. 29. Holmgren, P. and Jones, A.W., Coexistence and concentrations of ethanol and diazepam in postmortem blood specimens: risk for enhanced toxicity? J. Forensic Sci., 48, 1416, 2003. 30. Yamamoto, H., Tangegashima, A., Hosoe, H., and Fukunaga, T., Fatal acute alcohol intoxication in an ALDH2 heterozygote, Forensic Sci. Int., 112, 201, 2000. 31. Heath, M.J., Pachar, J.V., Perez Martinez, A.L., and Toseland, P.A., An exceptional case of lethal disulfiram-alcohol reaction, Forensic Sci. Int., 56, 45, 1992. 32. Cina, S.J., Russell, R.A., and Conradi, S.E., Sudden death due to metronidazole-ethanol interaction, Am. J. Forensic Med. Pathol., 17, 343, 1996. 33. Williams, C.S. and Woodcock, K.R., Do ethanol and metronidazole interact to produce a disufiramlike reaction? Ann. Pharmacother., 34, 255, 2000. 34. Jatlow, P., Cocaethylene. Pharmacologic activity and clinical significance, Ther. Drug Monitor., 15, 533, 1993. 35. Jatlow, P., McChance, E.F., Bradberry, C.W., Elsworth, J.D., Taylor, J.R., and Roth, R.H., Alcohol plus cocaine: the whole is more than the sum of its parts, Ther. Drug Monitor., 18, 460, 1996. 36. Tardiff, K., Marzuk, M.P., Leon, A.C., Hirsch, C.S., Stajic, M., Portera, L., and Hartwell, N., Cocaine, opiates, and ethanol in homicides in New York City: 1990 and 1991, J. Forensic Sci., 40, 387, 1995. 37. Ruttenber, A.J., Kalter, H.D., and Santinga, P., The role of ethanol abuse in the etiology of heroinrelated death. J. Forensic Sci., 35, 891, 1990. 38. Harper, D.R., A comparative study of the microbiological contamination of postmortem blood and vitreous humour samples taken for ethanol determination, Forensic Sci. Int., 43, 37, 1989. 39. Sturner, W.Q., and Coumbis, R.J., The quantitation of ethyl alcohol in vitreous humor and blood by gas chromatography, Am. J. Clin. Pathol., 46, 349, 1966. 40. Leahy, M.S., Farber, E.R., and Meadows, T.R., Quantitation of ethyl alcohol in the postmortem vitreous humor, J. Forensic Sci., 13, 498, 1968. 41. Felby, S. and Olsen, J., Comparative studies of postmortem ethyl alcohol in vitreous humor, blood, and muscle, J. Forensic Sci., 14, 93, 1969. 42. Coe, J.I. and Sherman, R.E., Comparative study of postmortem vitreous humor and blood alcohol, J. Forensic Sci., 15, 185, 1970. 43. Backer, R.C., Pisano, R.V., and Sopher, I.M., The comparison of alcohol concentrations in postmortem fluids and tissues, J. Forensic Sci., 25, 327, 1996. 44. Winek, C.L. and Esposito, F.M., Comparative study of ethanol levels in blood versus bone marrow, vitreous humor, bile and urine, Forensic Sci. Int., 17, 27, 1981. 45. Caughlin, J.D., Correlation of postmortem blood and vitreous humor alcohol concentration, Can. Soc. Forensic Sci. J., 16, 61, 1983. 46. Stone, B.E. and Rooney, P.E., A study using body fluids to determine blood alcohol, J. Anal. Toxicol., 8, 95, 1984. 47. Jollymore, B.D., Fraser, A.D., Moss, M.A., and Perry, R.A., Comparative study of ethyl alcohol in blood and vitreous humor, Can. Soc. Forensic Sci. J., 17, 50, 1984. 48. Yip, D.C. and Shum, B.S., A study on the correlation of blood and vitreous humour alcohol levels in the late absorption and elimination phases, Med. Sci. Law, 30, 29, 1990. 49. Caplan, Y.H. and Levine, B., Vitreous humor in the evaluation of postmortem blood ethanol concentrations, J. Anal. Toxicol., 14, 305, 1990.


ALCOHOL

397

50. Neil, P., Mills, A.J., and Prabhakaran, V.M., Evaluation of vitreous humor and urine alcohol levels as indices of blood alcohol levels in 75 autopsy cases, Can. Soc. Forensic Sci. J., 18, 97, 1985. 51. Pounder, D.J. and Kuroda, N., Vitreous alcohol is of limited value in predicting blood alcohol, Forensic Sci. Int., 65, 73, 1994. 52. Pounder, D.J. and Kuroda, N., Vitreous alcohol: the author’s reply, Forensic Sci. Int., 73, 159, 1995. 53. Kraut, A., Vitreous alcohol, Forensic Sci. Int., 73, 157, 1995. 54. Yip, D.C.P., Vitreous humor alcohol, Forensic Sci. Int., 73, 155, 1995. 55. Jones, A.W. and Holmgren, P., Uncertainty in estimating blood ethanol concentrations by analysis of vitreous humour, J. Clin. Pathol., 54, 699, 2001. 56. Olsen, J.E., Penetration rate of alcohol into the vitreous humor studied with a new in vivo technique, Acta Ophthalmol. Copenh., 49, 585, 1971. 57. Fernandez, P., Lopez-Rivadulla, M., Linares, J.M., Tato, F., and Bermejo, A.M., A comparative pharmacokinetic study of ethanol in the blood, vitreous humour and aqueous humour of rabbits, Forensic Sci. Int., 41, 61, 1989. 58. Scott, W., Root, R., and Sanborn, B., The use of vitreous humor for determination of ethyl alcohol in previously embalmed bodies, J. Forensic Sci., 913, 1974. 59. Singer, P.P. and Jones, G.R., Very unusual ethanol distribution in a fatality, J. Anal. Toxicol., 21, 506, 1997. 60. Basu, P.K., Avaria, M., Jankie, R., Kapur, B.M., and Lucas, D.M., Effect of prolonged immersion on the ethanol concentration of vitreous humor, Can. Soc. Forensic Sci. J., 16, 78, 1983. 61. Kaye, S. and Cardona, E., Errors of converting a urine alcohol value into a blood alcohol level, Am. J. Clin. Pathol., 52, 577, 1969. 62. Kuroda, N., Williams, K., Pounder, D.J., Estimating blood alcohol from urinary alcohol at autopsy, Am. J. Forensic Med. Pathol., 16, 219, 1995. 63. Levine, B. and Smialek, J.E., Status of alcohol absorption in drinking drivers killed in traffic accidents, J. Forensic Sci., 45, 3, 2000. 64. Jones, A.W. and Holmgren, P., Urine/blood ratios of ethanol in deaths attributed to acute alcohol poisoning and chronic alcoholism, Forensic Sci. Int., 135, 206, 2003. 65. Kaye, S. and Hag, H.B., Terminal blood alcohol concentrations in ninety-four fatal cases of acute alcoholism, J. Am. Med. Assoc., 451, 1957. 66. Alha, A.R. and Tamminen, V., Fatal cases with an elevated urine alcohol but without alcohol in the blood, J. Forensic Med., 11, 3, 1964. 67. Jenkins, A.J., Levine, B.S., and Smialek, J.E., Distribution of ethanol in postmortem liver. J. Forensic Sci., 40, 611, 1995. 68. Stone, B.E. and Rooney, P.A., A study using body fluids to determine blood alcohol, J. Anal. Toxicol., 8, 95, 1984. 69. Pounder, D.J., Fuke, C., Cox, D.E., Smith, D., and Kuroda, N., Postmortem diffusion of drugs from gastric residue, Am. J. Forensic Med. Pathol., 17, 1, 1996. 70. Christopoulos, G., Kirch, E.R., and Gearien, J.E., Determination of ethanol in fresh and putrefied postmortem tissues, J. Chromatogr., 87, 455, 1973. 71. Plueckhahn, V.D., Alcohol levels in autopsy heart blood, J. Forensic Med., 15, 12, 1968. 72. Briglia, E.J., Bidanset, J.H., Dal Cortivo, L.A., The distribution of ethanol in postmortem blood specimens, J. Forensic Sci., 37, 991, 1992. 73. Pounder, D.J. and Smith, D.R.W., Postmortem diffusion of alcohol from the stomach, Am. J. Forensic Med. Pathol., 16, 89, 1995. 74. Bowden, K.M. and McCallum, N.E.W., Blood alcohol content: some aspects of its post-mortem uses, Med. J. Aust., 2, 76, 1949. 75. Gifford, H. and Turkel, H.W., Diffusion of alcohol through stomach wall after death: a cause of erroneous postmortem blood alcohol levels, J. Am. Med. Assoc., 161, 866, 1956. 76. Turkel, H.W. and Gifford, H., Erroneous blood alcohol findings at autopsy; avoidance by proper sampling technique, J. Am. Med. Assoc., 164, 1077, 1957. 77. Turkel, H.W. and Gifford, H., Blood alcohol [letter]), J. Am. Med. Assoc., 165, 1993, 1957. 78. Heise, H.A., Erroneous postmortem blood alcohol levels [letter], J. Am. Med. Assoc., 165, 1739, 1957. 79. Muehlberger, C.W., Blood alcohol findings at autopsy [letter], J. Am. Med. Assoc., 165, 726, 1957.


398


80. Harger, R.N., Heart blood vs. femoral vein blood for postmortem alcohol determinations [letter], J. Am. Med. Assoc., 165, 725, 1957. 81. Plueckhahn, V.D., The significance of blood alcohol levels at autopsy, Med. J. Aust., 15, 118, 1967. 82. Plueckhahn, V.D. and Ballard, B., Factors influencing the significance of alcohol concentrations in autopsy blood samples, Med. J. Aust., 1, 939, 1968. 83. Plueckhahn, V.D., The evaluation of autopsy blood alcohol levels, Med. Sci. Law, 8, 168, 1968. 84. Plueckhahn, V.D. and Ballard, B., Diffusion of stomach alcohol and heart blood alcohol concentration at autopsy, J. Forensic Sci., 12, 463, 1967. 85. Plueckhahn, V.D., Postmortem blood chemistry — the evaluation of alcohol (ethanol) in the blood, in Recent Advances in Forensic Pathology, Camps, F.E., Ed., Churchill, London, 1969, 197. 86. Plueckhahn, V.D., The significance of alcohol and sugar determinations in autopsy blood, Med. J. Aust., 10, 46, 1970. 87. Marraccini, J.V., Carroll, T., Grant, S., Halleran, S., and Benz, J.A., Differences between multisite postmortem ethanol concentrations as related to agonal events, J. Forensic Sci., 35, 1360, 1990. 88. Pounder, D.J. and Yonemitsu, K., Postmortem absorption of drugs and ethanol from aspirated vomitus — an experimental model, Forensic Sci. Int., 51, 189, 1991. 89. Corry, J.E., Possible sources of ethanol ante- and post-mortem: its relationship to the biochemistry and microbiology of decomposition, J. Appl. Bacteriol., 44, 1, 1978. 90. Takayasu, T., Ohshima, T., Tanaka, N., Maeda, H., Kondo, T., Nishigami, J., and Nagano, T., Postmortem degradation of administered ethanol-d6 and production of endogenous ethanol: experimental studies using rats and rabbits, Forensic Sci. Int., 76, 129, 1995. 91. Davis, G.L., Leffert, R.L., and Rantanon, N.W., Putrefactive ethanol sources in postmortem tissues of conventional and germ-free mice, Arch. Pathol., 94, 71, 1972. 92. Nanikawa, R., Moriya, F., and Hashimoto, Y., Experimental studies on the mechanism of ethanol formation in corpses, Z. Rechtsmed., 101, 21, 1988. 93. Bogusz, M., Guminska, M., and Markiewicz, J., Studies on the formation of endogenous ethanol in blood putrefying in vitro, J. Forensic Med., 17, 156, 1970. 94. de Lima, I.V. and Midio, A.F., Origin of blood ethanol in decomposed bodies, Forensic Sci. Int., 106, 157, 1999. 95. Moriya, F. and Ishizu, H., Can micro-organisms produce alcohol in body cavities of a living person? J. Forensic Sci., 39, 883, 1994. 96. Blackmore, D.J., The bacterial production of ethyl alcohol, J. Forensic Sci. Soc., 8, 73, 1968. 97. Gormsen, H., Yeasts and the production of alcohol postmortem, J. Forensic Med., 1, 170, 1954. 98. Kaji, H., Asanuma, Y., Yahara, O., Shibue, H., et al., Intragastrointestinal alcohol fermentation syndrome: report of two cases and review of the literature, J. Forensic Sci. Soc., 24, 461, 1984. 99. Zumwalt, R.E., Bost, R.O., and Sunshine, I., Evaluation of ethanol concentrations in decomposed bodies, J. Forensic Sci., 27, 549, 1982. 100. Clark, M.A. and Jones, J.W., Studies on putrefactive ethanol production: I: Lack of spontaneous ethanol production in intact human bodies, J. Forensic Sci., 27, 366, 1982. 101. Canfield, D.V., Kupiec, T., and Huffine, E., Postmortem alcohol production in fatal aircraft accidents. J. Forensic Sci., 38, 914, 1993. 102. Mayes, R., Levine, B., Smith, M.L., Wagner, G.N., and Froede, R., Toxicological findings in the USS Iowa disaster, J. Forensic Sci., 37, 1352, 1992. 103. Ball, W. and Lichtenwalner, M., Ethanol production in infected urine, N. Engl. J. Med., 301, 614, 1979. 104. Gilliland, M.G.F. and Bost, R.O., Alcohol in decomposed bodies: postmortem synthesis and distribution. J. Forensic Sci., 38, 1266, 1993. 105. Levine, B., Smith, M.L., Smialek, J.E., and Caplan, Y.H., Interpretation of low postmortem concentrations of ethanol. J. Forensic Sci., 38, 663, 1993. 106. Nanikawa, R., Ameno, K., Hashimoto, Y., and Hamada, K., Medicolegal studies on alcohol detected in dead bodies — alcohol levels in skeletal muscle, Forensic Sci Int., 20, 133, 1982. 107. Wurst, F.M., Kempter, C., Metzger, J., Seidl, S., and Alt, A., Ethyl glucuronide: a marker of recent alcohol consumption with clinical and forensic implications, Alcohol, 20, 111, 2000. 108. Droenner, P., Schmitt, G., Aderjan, R., and Zimmer, H., A kinetic model describing the pharmacokinetics of ethyl glucuronide in humans, Forensic Sci. Int., 126, 24, 2002.


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399

109. Helander, A. and Beck, O., Mass spectrometric identification of ethyl sulphate as an ethanol metabolite in humans, Clin. Chem., 50, 936, 2004. 110. Hansson, P., Varga, A., Krantz, P., and Alling, C., Phosphatidylethanol in post-mortem blood as a marker of previous heavy drinking, Int. J. Legal Med., 115, 158, 2001. 111. Refaai, M.A., Nguyen, P.N., Steffensen, T.S., Evans, R.J. et al., Liver and adipose tissue fatty acid ethyl esters obtained at autopsy are post-mortem markers for pre-mortem ethanol intake, Clin. Chem., 48, 77, 2002. 112. Helander, A., Biological markers in alcoholism, J. Neural Transm., 66(Suppl.), 15, 2003. 113. Helander, A., Beck, O., and Jones, A.W., Distinguishing ingested ethanol from microbial formation by analysis of urinary 5-hydroxytryptophol and 5-hydroxyindoleacetic acid, J. Forensic Sci., 40, 95, 1995. 114. Helander, A., Beck, O., and Jones, A.W., Urinary 5HTOL/5HIAA as biochemical marker of postmortem ethanol synthesis, Lancet, 340, 1159, 1992. 115. Johnson, R.D., Lewis, R.J., Canfield, D.V., and Blank, C.L., Accurate assignment of ethanol origin in post-mortem urine: liquid chromatographic-mass spectrometric determination of serotonin metabolites, J. Chromatogr. B, 805, 223, 2004. 116. Lewis, R.J., Johnson, R.D., Angier, M.K., and Vu, N.T., Ethanol formation in unadulterated postmortem tissues, Forensic Sci. Int., 146, 17, 2004. 117. Johnson, R.D., Lewis, R.J., Canfield, D.V., Dubowski, K.M., and Blank, C.L., Utilizing the urinary 5-HTOL/5-HIAA ratio to determine ethanol origin in civil aviation accident victims, J. Forensic Sci., 50, 670, 2005. 118. Hirsch, C.S. and Adelson, L., Ethanol in sequestered hematomas, Am. J. Clin. Pathol., 59, 429, 1973. 119. Buchsbaum, R.M., Adelson, L., and Sunshine, I., A comparison of post-mortem ethanol levels obtained from blood and subdura specimens, Forensic Sci. Int., 41, 237, 1989. 120. Eisele, J.W., Reay, D.T., and Bonnell, H.J., Ethanol in sequestered hematomas: quantitative evaluation, Am. J. Clin. Pathol., 81, 352, 1984. 121. Nanikawa, R., Ameno, K., and Hashimoto, Y., Medicolegal aspects on alcohol detected in autopsy cases — alcohol levels in hematomas [in Japanese], Jpn. J. Leg. Med., 31, 241, 1977. 122. Freireich, A.W., Bidanset, J.H., and Lukash. L., Alcohol levels in intracranial blood clots, J. Forensic Sci., 20, 83, 1975. 123. Smialek, J.E., Spitz, W.U., and Wolfe, J.A., Ethanol in intracerebral clot: report of two homicidal cases with prolonged survival after injury, Am. J. Forensic Med. Pathol., 1, 149, 1980. 124. Cassin, B.J. and Spitz, W.U., Concentration of alcohol in delayed subdural hematoma, J. Forensic Sci., 28, 1013, 1983. 125. Randall, B., Fatty liver and sudden death, Hum. Pathol., 11, 147, 1980. 126. Pounder, D.J., Stevenson, R.J., and Taylor, K.K., Alcoholic ketoacidosis at autopsy, J. Forensic Sci., 43, 812, 1998. 127. Kanetake, J., Kanawaku, Y., Mimasaka, S. et al., The relationship of a high level of serum betahydroxybutyrate to cause of death, Legal Med., 7, 169, 2005. 128. Jenkins, D.W., Eckel, R.E., and Craig, J.W., Alcoholic ketoacidosis, J. Am. Med. Assoc., 217, 177, 1971. 129. Levy, L.J., Duga, J., Girgis, M., and Gordon E.E., Ketoacidosis associated with alcoholism in nondiabetic subjects, Ann. Intern. Med., 78, 213, 1973. 130. Bremer, J., Pathogenesis of ketonemia, Scand. J. Clin. Lab. Invest., 23, 105, 1969. 131. Wrenn, K.D., Slovis, C.M., Minion, G.E., and Rutkowski, R., The syndrome of alcoholic ketoacidosis, Am. J. Med., 91, 119, 1991. 132. Palmer, J.P., Alcoholic ketoacidosis: clinical and laboratory presentation, pathophysiology and treatment, Clin. Endocrinol. Metab., 12, 381, 1983. 133. Halperin, M.L., Hammeke, M., Josse, R.G., and Jungas, R.L., Metabolic acidosis in the alcoholic: a pathophysiologic approach, Metabolism, 32, 308, 1983. 134. Cahill, G.F., Ketosis, Kidney Int., 20, 416, 1981. 135. Isselbacher, K.H., Metabolic and hepatic effects of alcohol, N. Engl. J. Med., 296, 612, 1977. 136. Pounder, D.J., Problems in the necropsy diagnosis of alcoholic liver disease, Am. J. Forensic Med. Pathol., 5, 103, 1984.


400


137. Mihas, A.A. and Tavaossli, M., Laboratory markers of ethanol intake and abuse: a critical appraisal, Am. J. Med. Sci., 303, 415, 1992. 138. Sadler, D.W., Girela, E., and Pounder, D.J., Post mortem markers of chronic alcoholism, Forensic Sci. Int., 82, 153, 1996. 139. Jones, A.W. and Lowinger, H., Relationship between the concentration of ethanol and methanol in blood samples from Swedish drinking drivers, Forensic Sci. Int., 37, 277, 1987. 140. Markiewicz, J., Chlobowska, Z., Sondaj, K., and Swiegoda, C., Trace quantities of methanol in blood and their diagnostic value, Z. Zagadnien. Nauk. Sadowych., 33, 9, 1996. 141. Hashemy Tonkabony, S.E., Post-mortem blood concentration of methanol in 17 cases of fatal poisoning from contraband vodka, Forensic Sci., 6, 1, 1975. 142. MacDougall, A.A., Clasg, M.A., and MacAulay, K., Addiction to methylated spirit, Lancet, Special Articles, 498, 1956. 143. Wu Chen, N.B., Donoghue, E.R., and Schaffer, M.I., Methanol intoxication: Distribution in postmortem tissues and fluids including vitreous humor, J. Forensic Sci., 30, 213, 1985. 144. Pla, A., Hernandez, A.F., Gil, F., Garcia-Alonso, M., and Villanueva, E., A fatal case of oral ingestion of methanol. Distribution in postmortem tissues and fluids including pericardial fluid and vitreous humor, Forensic Sci. Int., 49, 193, 1991. 145. Naraqi, S., Dethlefs, R.F., Slobodniuk, R.U., and Sairere, J.S., An outbreak of acute methyl alcohol intoxication, Aust. N.Z. Med., 9, 65, 1979. 146. Swartz, R.D.M., McDonald, J.R., Millman, R.P., Billi, J.E., Bondar, N.P., Migdal, S.D., Simonian, S.K., Monforte, J.R., McDonald, F.D., Harness, J.K., and Cole, K.L., Epidemic methanol poisoning: clinical and biochemical analysis of a recent episode, Medicine, 60, 373, 1996. 147. Shahangian, S. and Owen Ash, K., Formic and lactic acidosis in a fatal case of methanol intoxication, Clin. Chem., 32, 395, 1996. 148. Jacobsen, D., Jansen, H., Wiik-Larsen, E., Bredesen, J.E., and Halvorsen, S., Studies on methanol poisoning, Acta Med. Scand., 212, 5, 1982. 149. Tanaka, E., Honda, K., Horiguchi, H., and Misawa, S., Postmortem determination of the biological distribution of formic acid in methanol intoxication, J. Forensic Sci., 36, 936, 1991. 150. Houvda, K.E., Hunderi, O.H., Tafjord, A.B., Dunlop, O., Rudberg, N., and Jacobsen, D., Methanol outbreak in Norway 2002–2004: epidemiology, clinical features and prognostic signs, J. Intern. Med., 258, 181, 2005. 151. Mani, J. C., Pietruszko, R., and Theorell, H., Methanol activity of alcohol dehydrogenase from human liver, horse liver, and yeast, Arch. Biochem. Biophys., 140, 52, 1970. 152. Jacobsen, D. and McMartin, K.E., Antidotes for methanol and ethylene glycol poisoning, Clin. Toxicol., 35, 127, 1997. 153. Barceloux, D.G., Bond, G.R., Krenzelok, E.P., Cooper, H., and Vale, J.A., American Academy of Clinical Toxicology practice guidelines on the treatment of methanol poisoning, J. Toxicol. Clin. Toxicol., 40, 415, 2002. 154. Mycyk, M.B. and Leikin, J.B., Antidote review: fomepizole for methanol poisoning, Am. J. Ther., 10, 68, 2003. 155. Brent, J., McMartin, K., Phillips, S., Aaron, C., and Kulig, K., Fomepizole for the treatment of methanol poisoning, N. Engl. J. Med., 344, 424, 2001. 156. De Brabander, N., Wojciechowski, M., De Decker, K., De Weerdt, A., and Jorens, P.G., Fomepizole as a therapeutic strategy in paediatric methanol poisoning. A case report and review of the literature, Eur. J. Pediatr., 164, 158, 2005. 157. Hovda, K.E., Andersson, K.S., Utdal, P., and Jacobsen, D., Methanol and formate kinetics during treatment with fomepizole, Clin. Toxicol., 43, 221, 2005. 158. Adelson, L., Fatal intoxication with isopropyl alcohol (rubbing alcohol), Am. J. Clin. Pathol., 38, 144, 1962. 159. Lacouture, P.G., Wason, S., Abrams, A., and Lovejoy, F.H., Acute isopropyl alcohol intoxication, Am. J. Med., 75, 680, 1996. 160. Baselt, R.C. and Cravey, R.H., Disposition of Toxic Drugs and Chemicals in Man. 4th ed., Chemical Toxicology Institute, Foster City, CA, 1995. 161. Natowicz, M., Donahue, J., Gorman, L., Kane, M., and McKissick, J., Pharmacokinetic analysis of a case of isopropanol intoxication, Clin. Chem., 31, 326, 1985.


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162. Jones, A.W., Elimination half-life of acetone in humans: case-report and review of the literature, J. Anal. Toxicol., 24, 8, 2000. 163. Alexander, C.B., McBay, A.J., and Hudson, R.P., Isopropanol and isopropanol deaths — ten years’ experience, J. Forensic Sci., 27, 541, 1982. 164. Lewis, G.D., Laufman, A.K., McAnalley, B.H., and Garriot, J.C., Metabolism of acetone to isopropyl alcohol in rats and humans, J. Forensic Sci., 29, 541, 1996.

5.4 RECENT ADVANCES IN BIOCHEMICAL TESTS FOR ACUTE AND CHRONIC ALCOHOL CONSUMPTION

Anders Helander, Ph.D.1 and Alan Wayne Jones, D.Sc.2 1

Department of Clinical Neuroscience, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden 2 Department of Forensic Toxicology, University Hospital, Linköping, Sweden

5.4.1

Introduction

Most people enjoy a drink and, for the vast majority of individuals, alcohol is a harmless, socially accepted recreational drug.1 However, for about 10% of the population, especially among men, moderate drinking eventually leads to alcohol abuse and dependence with serious consequences for the individual and society.2,3 Overconsumption of alcohol is a major public health hazard and a cause of premature death and morbidity.4,5 Binge drinking, which is usually defined as consumption of five or more drinks on one occasion, is often associated with acute intoxication, hooliganism, drunk driving, and other deviant behavior with negative consequences for the person’s family and friends.6,7 Statistics show that alcohol consumption is increasing worldwide in both sexes and this legal drug creates enormous costs for society in terms of treatment and rehabilitation of those who abuse alcohol.8–10 Early recognition of problem drinkers in the society is therefore important to ensure adequate treatment strategies.11 According to the American Medical Association, the difference between moderate use, abuse, and alcohol dependence (“alcoholism”) are summarized as follows: 1. The consumption of alcohol in amounts considered harmless to health entails drinking at most one to two drinks per day (∼10 to 20 g ethanol), and never first thing in the morning or on an empty stomach and the resulting blood alcohol concentration (BAC) should not exceed 0.2 g/L (0.02 g%) on any drinking occasion. 2. Abuse of alcohol is a pattern of drinking that is accompanied by one or more of the following problems: (a) failure to fulfill major work, school, or home responsibilities because of drinking, (b) drinking in situations that are physically dangerous, such as driving a car or operating machinery, (c) recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk, and (d) having social or relationship problems that are caused by or worsened by the effects of alcohol. 3. Alcohol dependence is a more severe pattern of drinking that includes the problems of alcohol abuse and persistent drinking in spite of obvious physical, mental, and social problems caused by alcohol. Also typical are (a) loss of control and inability to stop drinking once begun, (b) withdrawal symptoms associated with stopping drinking such as nausea, sweating, shakiness, and anxiety, and (c) tolerance to alcohol, needing increased amounts of alcohol in order to feel drunk.

Denial of drinking practices has always been a major stumbling block in the effective treatment of alcohol abuse and dependence.12 Drinking histories are notoriously unreliable and this tends to complicate early detection and treatment of the underlying alcohol problem.13,14 Much research effort has therefore focused on developing more objective ways to disclose excessive drinking, so that help


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Table 5.4.1 Examples of Biochemical Markers of Alcohol Use and Abuse, and Possible Predisposition to Alcohol Dependence Classification

Examples of Biochemical Markers

Acute Markers

Ethanol 5-Hydroxytryptophol (5HTOL) Ethyl glucuronide (EtG) Ethyl sulfate (EtS) Fatty-acid ethyl esters (FAEE) γ-Glutamyl transferase (GGT) Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Mean corpuscular volume (MCV) Carbohydrate-deficient transferrin (CDT) Phosphatidylethanol (PEth) Monoamine oxidase (MAO) Adenylyl cyclase (AC) Neuropeptide Y (NPY)

State Markers

Trait Markers

can be given to those at risk of becoming dependent on alcohol.15 In this connection, the use of various clinical laboratory tests is a useful complement to self-report questionnaires, such as the MAST and CAGE,16,17 which are intended to divulge the quantity and frequency of alcohol consumption as well as various social-medical problems associated with alcohol abuse and dependence. Accordingly, a multitude of biochemical markers have been developed to provide more objective ways of diagnosing overconsumption of alcohol and risk for alcohol-induced organ and tissue damage.18–21 The liver is particularly vulnerable to heavy drinking and damage to liver cells is often reflected in an increased activity of various enzymes in the bloodstream, such as γ-glutamyl transferase (GGT) and alanine and aspartate aminotransferase (ALT and AST).22,23 However, it seems that some individuals can drink excessively for months or years without displaying abnormal results with this kind of biochemical test, which implies a low sensitivity for detecting hazardous drinking. By contrast, some biological markers yield positive results in people suffering from nonalcohol-related liver problems, or after taking certain kinds of medication, which implies a low specificity for detecting alcohol abuse. Nevertheless, interest in the use of biochemical tests or biomarkers for screening those individuals at most risk of developing problems with alcohol consumption has expanded greatly.21,24,25 Besides many applications in clinical practice, such as in the rehabilitation of alcoholics and in drug-abuse treatment programs,26 biochemical markers have found uses in occupational medicine,27,28 forensic science,29–32 and experimental alcohol research.33,34 In general, three major classes of biochemical markers have been distinguished (examples are given in Table 5.4.1): 1. Tests sufficiently sensitive to detect even a single intake of alcohol, known as acute markers or relapse markers. 2. Tests that indicate disturbed metabolic processes or malfunctioning of body organs and/or tissue damage caused by long-term exposure to alcohol. This is reflected in altered hematological and/or biochemical parameters in blood or other body fluids. Such tests are referred to as state markers of hazardous alcohol consumption. 3. Tests that indicate whether a person carries a genetic predisposition for heavy drinking, abuse of alcohol, and development of alcohol dependence. Such tests are known as trait markers and often rely on identifying an abnormal enzyme or receptor pattern at the molecular level. Those prone to develop into heavy drinkers exhibit at an early age marked personality disorders, including sensation-seeking behavior, binge drinking, and abuse of other drugs.

In this chapter, we present an update of research dealing with laboratory markers for both acute and chronic drinking. The advantages and limitations of various laboratory tests are discussed and suggestions are made for their rational use in clinical and forensic medicine.


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5.4.2

403

Diagnostic Sensitivity and Specificity

Biochemical markers are usually evaluated in terms of diagnostic sensitivity and specificity. Sensitivity refers to the ability of a test to detect the presence of the trait in question, whereas specificity refers to its ability to exclude individuals without the trait. Consequently, a marker with high sensitivity yields relatively few false negative results and one with high specificity gives few false positives. The ideal marker should, of course, be both 100% sensitive and specific, but this is never achieved because reference ranges for normal and abnormal values always tend to overlap. Instead, a cutoff, or threshold limit, is established for what is considered normal. These limits are usually determined empirically as the mean plus or minus two standard deviations (SD) of the test results for a healthy control population. Accordingly, 2.5% of individuals will be above the upper limit and 2.5% below the lower limit and the test specificity will always be less than 100%. To obtain a sufficiently high specificity for routine purposes, the sensitivity of some markers has to be gradually reduced. On the other hand, most tests aimed at indicating liver damage caused by prolonged alcohol abuse often suffer from low specificity, because many liver diseases have non-alcoholic origin. So-called receiver-operating characteristic (ROC) curves are widely used for evaluating utility of biochemical markers and for comparing different analytical methods.35 ROC curves are graphic illustrations created by plotting the relation between sensitivity (i.e., the percentage of true positives) against 1-specificity (i.e., the percentage of false positives) at different cutoff limits between normal and abnormal values.36 Most studies aimed at evaluating the sensitivity and specificity of alcohol biomarkers rely heavily on patient self-reports about drinking as the gold standard. However, considering that many patients fail to provide an accurate history of their true alcohol consumption, this creates a validity problem. Hence, besides the use of sensitive and specific markers of excessive alcohol consumption, there is also a need to develop and evaluate laboratory tests to monitor recent alcohol consumption in a more objective way. 5.4.3

Tests for Acute Alcohol Ingestion

5.4.3.1 Measuring Ethanol in Body Fluids and Breath Ethanol and water mix together in all proportions and, after drinking alcoholic beverages, the ethanol distributes into all body fluids and tissues in proportion to the amount of water in these fluids and tissues. The body water in men makes up about 60% of their body weight and the corresponding figure for women is ~50%, although there are large inter-individual differences in these average figures, depending on age and, especially, the amount of adipose tissue. Accordingly, the most specific and direct way to demonstrate that a person has been drinking alcohol is to analyze a sample of blood, breath, urine, or saliva. However, because concentrations of ethanol in these body fluids decrease over time, owing to metabolism and excretion processes, the time frame for positive identification is rather limited.37,38 The smell of alcohol on the breath is perhaps the oldest and most obvious indication that a person has been drinking. But many alcoholics use breath fresheners or can regulate their intake so that the BAC is low or zero when they are examined by a physician.39 A more objective way to disclose recent alcohol consumption is to measure the concentration of ethanol in the exhaled air. Several kinds of handheld breath alcohol analyzers are available for this purpose, such as Alcolmeter SD-400, AlcoSensor IV, or Alcotest 4010. The ethanol in a sample of breath is oxidized with an electrochemical sensor and the magnitude of the response is directly proportional to the concentration of ethanol present.40 Studies have shown that these breath analyzers are accurate, precise, and selective for their intended purpose. Endogenous breath volatiles, such as acetone, are not oxidized under the same conditions and therefore does not interfere with the selectivity of the test for ethanol.


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Breath alcohol concentration (BrAC) tests should become a standard procedure, if a patient is required to refrain from drinking as part of rehabilitation or treatment or because of workplace regulations concerning the use of alcohol.41 However, a positive breath test needs to be confirmed by making a repeat test not less than 15 min later, to rule out the presence of ethanol in the mouth from recent drinking. Most of the currently available handheld breath alcohol analyzers have an analytical sensitivity of about 0.05 mg ethanol per liter breath, which corresponds to a blood ethanol equivalent of 10 mg/dL (~2.2 mmol/L). The result of a breath alcohol test appears immediately after capturing the sample and results are reported in units of g/210 L (U.S.) or mg/L (Sweden) or μg/100 mL (U.K.). Alternatively, the result of the test is translated into the presumed coexisting BAC and for this application the breath alcohol instrument is precalibrated with a blood/breath conversion factor, usually assumed to be 2100:1 or 2300:1. Careful control of calibration and maintenance of these breath test instruments is important to ensure obtaining valid and reliable results. Measuring the concentration of ethanol in whole blood or plasma/serum will also provide reliable information about recent drinking. However, obtaining a sample of blood is an invasive procedure and the concentration of ethanol, if any, is not obtained immediately after sampling. The analysis of ethanol in blood or plasma is therefore less practical than breath testing, for clinical purposes, as a rapid screening test for recent drinking. The sensitivity of methods for blood alcohol analysis (e.g., gas chromatography; GC) is higher than breath test instruments and a BAC as low as 1 mg/dL can be measured. However, for clinical applications, it is wise to use a higher cutoff (i.e., decision limit) such as 5 or 10 mg/dL, to avoid discussions and debate that the ethanol came from some dietary constituent, such as fresh fruits or soft drinks. After absorption and distribution of ethanol in body fluids and tissues is complete, there is a close correlation between the concentrations in saliva, blood, and urine. The equilibration of ethanol between blood and saliva is fairly rapid, which makes saliva sampling more suitable than urine for clinical purposes.42,43 A number of devices have been developed for measuring ethanol in saliva and these have proved useful for alcohol screening purposes in clinical settings. A saliva-test device called QED has been evaluated extensively and gives on-the-spot results as to whether a person has consumed alcohol. The QED test incorporates alcohol dehydrogenase (ADH) to oxidize ethanol with the coenzyme NAD+ at pH 8.6. Ethanol is converted into acetaldehyde and the NADH is formed in direct proportion to the concentration of ethanol present. The acetaldehyde is trapped with semicarbazide to drive the reaction to completion. The NADH is then re-oxidized to produce a colored end product, by reaction with the enzyme diaphorase and a tetrazolium salt incorporated on a solid phase support. The length of the resulting blue-colored bar is directly proportional to the concentration of ethanol in the saliva sample and permits a direct readout of the test result about 1 min later. Saliva alcohol concentrations determined with QED agreed well with BAC and BrAC in controlled drinking experiments.44,45 Numerous studies have compared concentrations of ethanol in blood and urine sampled at various times after end of drinking.46,47 In the post-absorptive phase, the urine-alcohol concentration (UAC) and the BAC are highly correlated (r > 0.95). Some have tried to estimate BAC indirectly from UAC, assuming a population average UAC/BAC, such as 1.3:1. However, there are large interand intra-individual variations in this relationship, which means that the estimated BAC will have a considerable uncertainty in any individual case. One expects to find a higher concentration of ethanol in urine compared with blood, because of the difference in water content of these body fluids, namely, 100% vs. 80%. This suggests a UAC/BAC ratio of 1.25:1 for freshly produced urine. In reality, however, the UAC/BAC ratio also depends on the time after drinking, when the bladder was last voided, and how frequently the person urinates. Urine is stored but not metabolized in the bladder, whereas the BAC changes continuously, depending on the stage of metabolism and the rate of hepatic oxidation. Shortly after drinking during the absorption phase, the UAC and BAC are not well correlated, whereas in the post-peak phase, when BAC is decreasing at a constant rate of about 15 mg/dL/h, a good correlation exists between BAC and UAC.


ALCOHOL

405

2.0 Ethanol concentration (g/L)

Blood Urine 1.5

1.0

0.5

0.0 0

100

200

300

400

500

600

Time after start of drinking (min) Figure 5.4.1 Mean concentration-time profiles of ethanol in blood and urine in 30 healthy men who drank 0.85 g/kg body weight after an overnight fast. The bladder was emptied before the start of drinking and alcohol was taken in the form of neat whisky.

The average curves for venous blood and urine concentration–time profiles of ethanol are compared in Figure 5.4.1. One notes that UAC and BAC curves are shifted in time, as a consequence of the time-lag between ethanol being absorbed into the bloodstream, reaching the kidney, and passing into the glomerular filtrate, and its storage in the bladder until voided. Shortly after the end of drinking, the UAC is less than the BAC (UAC/BAC < 1.0). After the peak BAC is reached, the two curves cross and the UAC has a higher Cmax compared with the BAC. In the post-absorptive phase, the UAC is always higher than the corresponding BAC by a factor of 1.3 to 1.4. Note that the UAC reflects the average BAC prevailing during the time that urine was produced and stored in the bladder since the previous void. The UAC in a random void does not reflect the BAC at the time of emptying the bladder and, in this respect, is less useful than blood, saliva, or breath as a test of alcohol influence. Instead, the UAC reflects the BAC during production and storage of urine in the bladder. The UAC remains elevated for about 1 h after the BAC has already reached zero. Accordingly, the first morning void after an evening’s drinking might be positive for ethanol, although the concentrations in blood or breath have already reached zero.48 This relationship suggests that the BAC has reached zero sometime during the night and any ethanol already in the urine gets diluted with ethanol-free urine produced after complete metabolism of the alcohol consumed. Metabolism of ethanol does not occur in the urinary bladder, and back-diffusion of ethanol into the bloodstream is negligible, owing to the limited blood circulation. Small quantities of ethanol are excreted through the skin by passive diffusion and also secreted through the sweat glands. The transdermal elimination of ethanol corresponds to about 0.5 to 1% of the dose ingested.49 However, this route of excretion has found applications in clinical medicine, as a way to monitor alcohol consumption over periods of several weeks or months. This approach might be useful to control if alcoholics and others manage to remain abstinent, and has led to the introduction of a procedure known as transdermal dosimeter or, more simply, the sweat-patch test.50,51 Although the first attempts to monitor alcohol consumption in this way were not very successful, owing to technical difficulties with the equipment used for collecting sweat, the procedures are now much improved and can be used to analyze other drugs of abuse as well.52,53 The test person wears a tamper-proof and water-proof pad, positioned on an arm or leg, and the lowmolecular substances that pass through the skin are collected during the time the patch remains intact. Ethanol and other volatiles are extracted with water and the concentration determined provides a cumulative index of alcohol exposure. The ethanol collected in the cotton pad can be determined in a number of ways, such as by extraction with water and GC analysis or by headspace


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Oxidative metabolism and excretion (~99%)

Non-oxidative metabolism(~1%)

Urine

Ethyl glucuronide

Sweat

Breath

Ethanol ADH

Ethyl sulfate

Ethanol

Fatty acid ethyl esters

Phosphatidylethanol

Acetaldehyde ALDH Acetate

CO2

H 2O

Figure 5.4.2 Fate of alcohol in the body illustrating both the oxidative and non-oxidative pathways of ethanol metabolism.

vapor analysis with a handheld electrochemical sensor, which was originally designed for breath alcohol testing.54 A miniaturized electronic device for continuous sampling and monitoring of transcutaneous ethanol has recently been introduced.55,56 5.4.3.2 Metabolism of Ethanol The disposition and fate of ethanol in the body has been studied extensively since the 1930s and our knowledge about this legal drug exceeds that of other abused substances. Ethanol is cleared from the bloodstream by both oxidative and non-oxidative metabolic pathways (Figure 5.4.2). The minor non-oxidative pathway of alcohol metabolism has received considerable research interest since the first edition of this book appeared and this topic is covered later in this chapter. The main alcohol-metabolizing enzymes are located in the liver, the kidney, and the gastric mucosa. The bulk of the alcohol a person consumes undergoes hepatic metabolism by the action of Class I ADH, which exists in various molecular forms, so-called isozymes. Ethanol is metabolized in a two-stage process, first to acetaldehyde and this primary metabolite is rapidly converted to acetate (acetic acid) by the action of low Km aldehyde dehydrogenase (ALDH2) located in the mitochondria. The end products of the oxidation of ethanol are carbon dioxide and water (see Figure 5.4.2). Hepatic ADH is not specific for oxidation of ethanol, and other aliphatic alcohols, if present in the blood, as well as a number of endogenous substances (e.g., prostaglandins and hydroxysteroids), also serve as substrates. The substrate specificity of ADH toward aliphatic alcohols differs widely, and the rate of oxidation of methanol is considerably slower than that of ethanol by a factor of about 10:1.57 The biotransformation of ethanol and methanol and the various metabolic products formed are compared in Figure 5.4.3. Raised concentrations of the intermediary products of ethanol oxidation have been proposed as a way to test for recent drinking.56 However, measuring acetaldehyde is not very practical, because of the extremely low concentrations present (2 weeks) on in vivo indicators of 5-HT function in rats, as measured by microdialysis sampling, neuroendocrine secretion, and specific aspects of behavior. A number of key findings are summarized in Table 6.7.5. In general, few published studies have been able to relate the magnitude of MDMA-induced 5-HT depletion to the degree of specific functional impairment. MDMA administration rarely causes persistent changes in baseline measures of neural function, and deficits are most readily demon-


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Table 6.7.5 Long-Term Effects of MDMA on Functional Indices of 5-HT Transmission in Rats CNS Effect

Dosing Regimen

Reductions in evoked 5-HT release in vivo

20 mg/kg, s.c., twice daily, 4 days 10 mg/kg, i.p., twice daily, 4 days 20 mg/kg, s.c. 20 mg/kg, s.c., twice daily, 4 days 10–20 mg/kg, s.c., twice daily, 3 days 5 mg/kg, s.c., 1 or 4 doses, 2 days 7.5 mg/kg, s.c., twice daily, 3 days

Changes in corticosterone and prolactin secretion Impairments in short-term memory Increased anxiety-like behaviors

Survival Interval

Ref.

2 weeks 1 week

Series et al.114 Shankaran and Gudelsky

2 weeks 4, 8, and 12 months 2 weeks

Poland et al.124,125 Poland et al.125

3 months 2 weeks

115

*Marston et al.134 **Morley et al.135; McGregor et al.138 **Fone et al.137

* Most studies show no effect of MDMA on learning and memory in rats (see text). ** These investigators noted marked increases in anxiogenic behaviors in the absence of significant MDMAinduced 5-HT depletion in brain.

strated by provocation of the 5-HT system by pharmacological (e.g., drug challenge) or physiological means (e.g., environmental stress). 6.7.5.1 In Vivo Microdialysis Studies In vivo microdialysis has been used to evaluate the persistent neurochemical consequences of MDMA exposure in rats.88,114–116 Series et al.114 carried out microdialysis in rat frontal cortex 2 weeks after a 4-day regimen of 20 mg/kg s.c. MDMA. Prior MDMA exposure did not affect baseline extracellular levels of 5-HT, but decreased levels of the 5-HT metabolite, 5-hydroxyindoleacetic acid (5-HIAA), to ~30% of control. Moreover, the ability of (+)-fenfluramine to evoke 5-HT release was markedly blunted in MDMA-pretreated rats. In an analogous investigation, Shankaran and Gudelsky115 assessed neurochemical effects of acute MDMA challenge in rats that had previously received 4 doses of 10 mg/kg i.p. MDMA. A week after MDMA pretreatment, baseline levels of dialysate 5-HT and DA in striatum were not altered even though tissue levels of 5-HT were depleted by 50%. The ability of MDMA to evoke 5-HT release was severely impaired in MDMA-pretreated rats while the concurrent DA response was normal. In this same study, effects of MDMA on body temperature and 5-HT syndrome were attenuated in MDMA-pretreated rats, suggesting drug tolerance. Taken together, the microdialysis data reveal several important consequences of MDMA administration: (1) baseline levels of dialysate 5-HT are unaltered, despite depletion of tissue indoles, (2) baseline levels of dialysate 5-HIAA are consistently decreased, and (3) stimulated release of 5-HT is blunted in response to pharmacological or physiological provocation. The microdialysis findings in MDMA-pretreated rats resemble those obtained with 5,7-DHT, in which drug-pretreated rats display normal baseline extracellular 5-HT but decreased 5-HIAA.117–119 In a representative study, Kirby et al.117 performed microdialysis in rat striatum 4 weeks after intracerebroventricular 5,7-DHT. These investigators found that reductions in baseline dialysate 5-HIAA and impairments in stimulated 5-HT release are highly correlated with the degree of tissue 5-HT depletion, whereas baseline dialysate 5-HT is not. In fact, depletions of brain tissue 5-HT up to 90% did not affect baseline levels of dialysate 5-HT. Clearly, adaptive mechanisms serve to maintain normal concentrations of synaptic 5-HT, even under conditions of severe transmitter depletion. A comparable situation exists after lesions of the nigrostriatal DA system in rats where baseline levels of extracellular DA are maintained in the physiological range despite substantial loss of tissue DA.120 In the case of high-dose MDMA treatment, it seems feasible that reductions in 5-HT uptake (e.g.,


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less functional SERT protein) and metabolism (e.g., decreased monoamine oxidase activity) can compensate for 5-HT depletions in order to keep optimal concentrations of 5-HT bathing nerve cells. On the other hand, deficits in the ability to release 5-HT are readily demonstrated in MDMApretreated rats when 5-HT systems are taxed by drug challenge or stressors. 6.7.5.2 Neuroendocrine Challenge Studies 5-HT neurons projecting to the hypothalamus provide stimulatory input for the secretion of adrenocorticotropin (ACTH) and prolactin from the anterior pituitary.121 Accordingly, 5-HT releasers (e.g., fenfluramine) and 5-HT receptor agonists increase plasma levels of these hormones in rats and humans.122 Neuroendocrine challenge experiments have identified changes in serotonergic responsiveness in rats treated with MDMA.123–125 In the most comprehensive study, Poland et al.125 examined effects of high-dose MDMA on hormone responses elicited by acute fenfluramine challenge. Rats received injections of 20 mg/kg s.c. MDMA and were tested 2 weeks later. Prior MDMA exposure did not alter baseline levels of circulating ACTH or prolactin. However, in MDMA-pretreated rats, fenfluramine-induced ACTH secretion was reduced while prolactin secretion was enhanced. The MDMA dosing regimen caused significant depletions of tissue 5-HT in various brain regions, including hypothalamus. In a follow-up time-course study, rats exposed to multiple doses of 20 mg/kg MDMA displayed blunted ACTH responses that persisted for 12 months, even though tissue levels of 5-HT were not depleted at this time point. The data show that highdose MDMA can cause functional abnormalities for up to 1 year, and such changes are not necessarily coupled to 5-HT depletions. In our laboratory, we wished to further explore the long-term neuroendocrine consequences of MDMA administration. Utilizing the “effect scaling” regimen described previously, male SpragueDawley rats received 3 i.p. injections of 1.5 or 7.5 mg/kg MDMA, one dose every 2 h. Control rats received saline vehicle according to the same schedule. A week after MDMA treatment, rats were fitted with indwelling jugular catheters under pentobarbital anesthesia. After 1 week of recovery from surgery (i.e., 2 weeks after MDMA or saline), rats were brought into the testing room, i.v. doses of 1 and 3 mg/kg MDMA were administered, and blood samples were withdrawn. Plasma levels of corticosterone and prolactin were measured by radioimmunoassay methods.126 The data depicted in Figure 6.7.9 show that MDMA pretreatment did not alter baseline levels of either hormone. Acute 40

Saline 1.5 mg/kg

Saline 1.5 mg/kg

7.5 mg/kg 400 ∗ ∗

200

Prolactin (ng/ml)

Corticosterone (ng/ml)

600

30

7.5 mg/kg

20 ∗ 10 ∗

0

Basal

1 MDMA (mg/kg, i.v.)

3

0

Basal

1

3

MDMA (mg/kg, i.v.)

Figure 6.7.9 Effects of MDMA pretreatment on secretion of corticosterone (left panel) and prolactin (right panel) evoked by acute MDMA challenge. Male rats received three i.p. injections of 1.5 or 7.5 mg/kg MDMA, one dose every 2 h. Saline was administered on the same schedule. Then 2 weeks later rats received i.v. injections of 1 and 3 mg/kg MDMA. Blood samples were drawn via indwelling catheters; plasma corticosterone and prolactin were measured by RIA.126 Data are mean ± SEM, expressed as ng/ml of plasma for N = 8 rats/group. Baseline corticosterone and prolactin levels were 73 ± 18 and 2.4 ± 0.6 ng/ml of plasma, respectively. *Significant compared to salinepretreated control group (P < 0.05 Duncan’s).


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administration of MDMA elicited dose-dependent elevations in circulating corticosterone and prolactin as shown by others.43 Rats exposed to high-dose MDMA pretreatment displayed significant reductions in corticosterone and prolactin secretion in response to acute MDMA challenge, whereas hormone responses in the low-dose MDMA rats were indistinguishable from controls. Our neuroendocrine results are consistent with the development of tolerance to hormonal effects of MDMA. These findings do not agree completely with the data of Poland et al.125 discussed above. However, our findings are consistent with previous data showing blunted hormonal responses to fenfluramine in rats with fenfluramine-induced 5-HT depletions.126 Perhaps more importantly, the data shown in Figure 6.7.9 are strikingly similar to clinical findings in which cortisol and prolactin responses to acute (+)-fenfluramine administration are reduced in human MDMA users.85,127,128 Indeed, Gerra et al.128 reported that (+)-fenfluramine-induced prolactin secretion is blunted in abstinent MDMA users for up to 1 year after cessation of drug use. The mechanism(s) underlying altered sensitivity to (+)-fenfluramine and MDMA are not known, but it is tempting to speculate that MDMA-induced impairments in evoked 5-HT release are involved, as shown by in vivo microdialysis studies. While some investigators have cited neuroendocrine changes in human MDMA users as evidence for 5-HT neurotoxicity, Gouzoulis-Mayfrank et al.85 provide a compelling argument that endocrine abnormalities in MDMA users could be related to cannabis use rather than MDMA. Further experiments will be required to resolve the precise nature of neuroendocrine changes in MDMA users. 6.7.5.3 Behavioral Assessments One of the more serious and disturbing clinical findings is that MDMA causes persistent cognitive deficits in human users.7,8,87 Numerous studies have examined the effects of MDMA treatment on learning and memory in rats, and most studies failed to identify persistent impairments — even when extensive 5-HT depletions were present.45,129–133 While an exhaustive review of this literature is not possible here, representative findings will be mentioned. In an extensive series of experiments, Seiden et al.129 evaluated the effects of high-dose MDMA on a battery of tests including open-field behavior, schedule-controlled behavior, one-way avoidance, discriminated two-way avoidance, forced swim, and radial maze performance. Male rats received twice daily s.c. injections of 10 to 40 mg/kg MDMA for 4 days, and were tested beginning 2 weeks after treatment. Despite large depletions of brain tissue 5-HT, MDMA-pretreated rats exhibited normal behaviors in all paradigms. Likewise, Robinson et al.130 found that MDMA-induced depletion of cortical 5-HT up to 70% did not alter spatial navigation, skilled forelimb use, or foraging behavior in rats. In contrast, Marston et al.134 reported that MDMA administration produces persistent deficits in a delayed nonmatch to performance (DNMTP) procedure when long delay intervals are employed (i.e., 30 s). The authors theorized that delay-dependent impairments in the DNMTP procedure reflect MDMAinduced deficits in short-term memory consolidation, possibly attributable to 5-HT depletion. With the exception of the findings of Marston et al., the collective behavioral data in rats indicate that MDMA-induced depletions of brain 5-HT have little or no effect on cognitive processes. There are several potential explanations for this apparent paradox. First, high-dose MDMA administration produces only partial depletion of 5-HT in the range of 40 to 60% in most brain areas. This level of 5-HT loss may not be sufficient to elicit behavioral alterations, as compensatory adaptations in 5-HT neurons could maintain normal physiological function. Second, MDMA appears to selectively affect fine diameter fibers arising from the dorsal raphe, and it seems possible that these 5-HT circuits may not subserve the behaviors being monitored. Third, the behavioral tests utilized in rat studies might not be sensitive enough to detect subtle changes in learning and memory processes. Finally, the functional reserve capacity in the CNS might be sufficient to compensate for even large depletions of a single transmitter. While MDMA appears to have few long-term effects on cognition in rats, a growing body of evidence demonstrates that MDMA administration can cause persistent anxiety-like behaviors in



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this species.135–137 Morley et al.135 first reported that MDMA induces long-term anxiety in male rats. These investigators administered one or 4 i.p. injections of 5 mg/kg MDMA on 2 consecutive days, then tested rats 3 months later in a battery of anxiety-related paradigms including elevated plus maze, emergence, and social interaction tests. Rats receiving single or multiple MDMA injections displayed marked increases in anxiogenic behaviors in all three tests. In a follow-up study, Gurtman et al.136 replicated the original findings of Morley et al. using rats pretreated with 4 i.p. injections of 5 mg/kg MDMA for 2 days — persistent anxiogenic effects of MDMA were associated with depletions of 5-HT in the amygdala, hippocampus, and striatum. Interestingly, Fone et al.137 showed that administration of MDMA to adolescent rats caused anxiety-like impairments in social interaction, even in the absence of 5-HT depletions or reductions in [3H]-paroxetinelabeled SERT binding sites. These data suggest that MDMA-induced anxiety does not require 5HT deficits. In an attempt to determine potential mechanisms underlying MDMA-induced anxiety, McGregor et al.138 evaluated effects of the drug on anxiety-related behaviors and a number of post-mortem parameters including autoradiography for SERT and 5-HT receptor subtypes. Rats received moderate (5 mg/kg, i.p., 2 days) or high (5 mg/kg, i.p., 4 injections, 2 days) doses of MDMA, and tests were conducted 10 weeks later. This study confirmed that moderate doses of MDMA can cause protracted increases in anxiety-like behaviors without significant 5-HT depletions. Furthermore, the autoradiographic analysis revealed that anxiogenic effects of MDMA may involve long-term reductions in 5-HT2A/2C receptors rather than reductions in SERT binding. Additional work by Bull et al.139,140 suggests that decreases in the sensitivity of 5-HT2A receptors, but not 5-HT2C receptors, could underlie MDMA-associated anxiety. Clearly, more investigation into this important area of research is warranted. 6.7.6

Conclusions

The findings reviewed here allow a number of tentative conclusions to be made with regard to MDMA neurobiology. (1) MDMA is a substrate for monoamine transporters, and non-exocytotic release of 5-HT, NE, and DA underlies pharmacological effects of the drug. While MDMA is often considered a selective serotonergic agent, many actions including cardiovascular stimulation and hyperthermia likely involve NE and DA mechanisms. (2) MDMA produces long-term changes in 5-HT neurons, as exemplified by sustained depletions of forebrain 5-HT in rats. Emerging evidence indicates that 5-HT deficits are not synonymous with neuronal damage, however, since doses of MDMA that cause marked 5-HT depletions (e.g., 10 to 20 mg/kg) are not associated with cell death, silver-positive staining, or reactive gliosis. Like many other psychotropic agents, MDMA is capable of producing bona fide neurotoxicity at sufficient doses (e.g., >30 mg/kg) and damage is not confined to 5-HT neurons. (3) There appears to be no scientific rationale for using interspecies scaling to adjust doses of MDMA between rats and humans because behaviorally active doses are similar in both species (e.g., 1 to 2 mg/kg). Nonetheless, the complex metabolism of MDMA needs to be examined in various animal species to permit comparison with clinical literature and to validate appropriate preclinical models. (4) MDMA-induced 5-HT depletions in rats are accompanied by abnormalities in evoked 5-HT release, neuroendocrine secretion, and specific behaviors. The clinical relevance of preclinical findings is uncertain, but the fact that MDMA can produce persistent increases in anxiety-like behaviors in rats without measurable 5-HT deficits suggests even moderate doses may pose risks. Acknowledgments This research was generously supported by the NIDA Intramural Research Program. The authors are indebted to John Partilla, Chris Dersch, Mario Ayestas, Robert Clark, Fred Franken, and John Rutter for their expert technical assistance during these studies.


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REFERENCES 1. Liechti, M.E. and Vollenweider, F.X., Which neuroreceptors mediate the subjective effects of MDMA in humans? A summary of mechanistic studies, Hum. Psychopharmacol. 16(8), 589–598, 2001. 2. Vollenweider, F.X., Gamma, A., Liechti, M., and Huber, T., Psychological and cardiovascular effects and short-term sequelae of MDMA (“ecstasy”) in MDMA-naive healthy volunteers, Neuropsychopharmacology 19(4), 241–251, 1998. 3. Landry, M.J., MDMA: a review of epidemiologic data, J. Psychoactive Drugs 34(2), 163–9, 2002. 4. Yacoubian, G.S., Jr., Tracking ecstasy trends in the United States with data from three national drug surveillance systems, J. Drug Educ. 33(3), 245–258, 2003. 5. Banken, J.A., Drug abuse trends among youth in the United States, Ann. N.Y. Acad. Sci. 1025, 465–471, 2004. 6. Schifano, F., A bitter pill. Overview of ecstasy (MDMA, MDA) related fatalities, Psychopharmacology (Berlin) 173(3–4), 242–248, 2004. 7. Morgan, M.J., Ecstasy (MDMA): a review of its possible persistent psychological effects, Psychopharmacology (Berlin) 152(3), 230–248, 2000. 8. Parrott, A.C., Recreational Ecstasy/MDMA, the serotonin syndrome, and serotonergic neurotoxicity, Pharmacol. Biochem. Behav. 71(4), 837–844, 2002. 9. Doblin, R., A clinical plan for MDMA (Ecstasy) in the treatment of posttraumatic stress disorder (PTSD): partnering with the FDA, J. Psychoactive Drugs 34(2), 185–94, 2002. 10. Check, E., Psychedelic drugs: the ups and downs of ecstasy, Nature 429(6988), 126–128, 2004. 11. Mas, M., Farre, M., de la Torre, R., Roset, P.N., Ortuno, J., Segura, J., and Cami, J., Cardiovascular and neuroendocrine effects and pharmacokinetics of 3,4-methylenedioxymethamphetamine in humans, J. Pharmacol. Exp. Ther. 290(1), 136–145, 1999. 12. Harris, D.S., Baggott, M., Mendelson, J.H., Mendelson, J.E., and Jones, R.T., Subjective and hormonal effects of 3,4-methylenedioxymethamphetamine (MDMA) in humans, Psychopharmacology (Berlin) 162(4), 396–405, 2002. 13. Bell, S.E., Burns, D.T., Dennis, A.C., and Speers, J.S., Rapid analysis of ecstasy and related phenethylamines in seized tablets by Raman spectroscopy, Analyst 125(3), 541–544, 2000. 14. Huang, Y.S., Liu, J.T., Lin, L.C., and Lin, C.H., Chiral separation of 3,4-methylenedioxymethamphetamine and related compounds in clandestine tablets and urine samples by capillary electrophoresis/fluorescence spectroscopy, Electrophoresis 24(6), 1097–1104, 2003. 15. Cho, A.K., Hiramatsu, M., Distefano, E.W., Chang, A.S., and Jenden, D.J., Stereochemical differences in the metabolism of 3,4-methylenedioxymethamphetamine in vivo and in vitro: a pharmacokinetic analysis, Drug Metab. Dispos. 18(5), 686–691, 1990. 16. Lim, H.K. and Foltz, R.L., In vivo and in vitro metabolism of 3,4-(methylenedioxy)methamphetamine in the rat: identification of metabolites using an ion trap detector, Chem. Res. Toxicol. 1(6), 370–378, 1988. 17. Nichols, D.E., Lloyd, D.H., Hoffman, A.J., Nichols, M.B., and Yim, G.K., Effects of certain hallucinogenic amphetamine analogues on the release of [3H]serotonin from rat brain synaptosomes, J. Med. Chem. 25(5), 530–535, 1982. 18. Johnson, M.P., Hoffman, A.J., and Nichols, D.E., Effects of the enantiomers of MDA, MDMA and related analogues on [3H]serotonin and [3H]dopamine release from superfused rat brain slices, Eur. J. Pharmacol. 132(2–3), 269–276, 1986. 19. Schmidt, C.J., Levin, J.A., and Lovenberg, W., In vitro and in vivo neurochemical effects of methylenedioxymethamphetamine on striatal monoaminergic systems in the rat brain, Biochem. Pharmacol. 36(5), 747–755, 1987. 20. Fitzgerald, J.L. and Reid, J.J., Interactions of methylenedioxymethamphetamine with monoamine transmitter release mechanisms in rat brain slices, Naunyn Schmiedeberg’s Arch. Pharmacol. 347(3), 313–323, 1993. 21. Berger, U.V., Gu, X.F., and Azmitia, E.C., The substituted amphetamines 3,4-methylenedioxymethamphetamine, methamphetamine, p-chloroamphetamine and fenfluramine induce 5-hydroxytryptamine release via a common mechanism blocked by fluoxetine and cocaine, Eur. J. Pharmacol. 215(2–3), 153–160, 1992.



553

22. Crespi, D., Mennini, T., and Gobbi, M., Carrier-dependent and Ca(2+)-dependent 5-HT and dopamine release induced by (+)-amphetamine, 3,4-methylendioxymethamphetamine, p-chloroamphetamine and (+)-fenfluramine, Br. J. Pharmacol. 121(8), 1735–1743, 1997. 23. Rothman, R.B. and Baumann, M.H., Therapeutic and adverse actions of serotonin transporter substrates, Pharmacol. Ther. 95(1), 73–88, 2002. 24. Rudnick, G. and Wall, S.C., The molecular mechanism of “ecstasy” [3,4-methylenedioxy-methamphetamine (MDMA)]: serotonin transporters are targets for MDMA-induced serotonin release, Proc. Natl. Acad. Sci. U.S.A. 89(5), 1817–1821, 1992. 25. Schuldiner, S., Steiner-Mordoch, S., Yelin, R., Wall, S.C., and Rudnick, G., Amphetamine derivatives interact with both plasma membrane and secretory vesicle biogenic amine transporters, Mol. Pharmacol. 44(6), 1227–1231, 1993. 26. Rothman, R.B., Baumann, M.H., Dersch, C.M., Romero, D.V., Rice, K.C., Carroll, F.I., and Partilla, J.S., Amphetamine-type central nervous system stimulants release norepinephrine more potently than they release dopamine and serotonin, Synapse 39(1), 32–41, 2001. 27. Rothman, R.B., Partilla, J.S., Baumann, M.H., Dersch, C.M., Carroll, F.I., and Rice, K.C., Neurochemical neutralization of methamphetamine with high-affinity nonselective inhibitors of biogenic amine transporters: a pharmacological strategy for treating stimulant abuse, Synapse 35(3), 222–227, 2000. 28. Partilla, J.S., Dersch, C.M., Yu, H., Rice, K.C., and Rothman, R.B., Neurochemical neutralization of amphetamine-type stimulants in rat brain by the indatraline analog (–)-HY038, Brain Res. Bull. 53(6), 821–826, 2000. 29. Setola, V., Hufeisen, S.J., Grande-Allen, K.J., Vesely, I., Glennon, R.A., Blough, B., Rothman, R.B., and Roth, B.L., 3,4-Methylenedioxymethamphetamine (MDMA, “Ecstasy”) induces fenfluraminelike proliferative actions on human cardiac valvular interstitial cells in vitro, Mol. Pharmacol. 63(6), 1223–1229, 2003. 30. Baumann, M.H. and Rutter, J.J., Application of in vivo microdialysis methods to the study of psychomotor stimulant drugs, in Methods in Drug Abuse Research, Cellular and Circuit Level Analysis, Warerhouse, B.D. CRC Press, Boca Raton, FL, 2003, 51–86. 31. Nash, J.F. and Nichols, D.E., Microdialysis studies on 3,4-methylenedioxyamphetamine and structurally related analogues, Eur. J. Pharmacol. 200(1), 53–58, 1991. 32. Yamamoto, B.K., Nash, J.F., and Gudelsky, G.A., Modulation of methylenedioxymethamphetamineinduced striatal dopamine release by the interaction between serotonin and gamma-aminobutyric acid in the substantia nigra, J. Pharmacol. Exp. Ther. 273(3), 1063–1070, 1995. 33. Gudelsky, G.A. and Nash, J.F., Carrier-mediated release of serotonin by 3,4-methylenedioxymethamphetamine: implications for serotonin-dopamine interactions, J. Neurochem. 66(1), 243–249, 1996. 34. Kankaanpaa, A., Meririnne, E., Lillsunde, P., and Seppala, T., The acute effects of amphetamine derivatives on extracellular serotonin and dopamine levels in rat nucleus accumbens, Pharmacol. Biochem. Behav. 59(4), 1003–1009, 1998. 35. Mechan, A.O., Esteban, B., O’Shea, E., Elliott, J.M., Colado, M.I., and Green, A.R., The pharmacology of the acute hyperthermic response that follows administration of 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”) to rats, Br. J. Pharmacol. 135(1), 170–180, 2002. 36. Nash, J.F. and Brodkin, J., Microdialysis studies on 3,4-methylenedioxymethamphetamine-induced dopamine release: effect of dopamine uptake inhibitors, J. Pharmacol. Exp. Ther. 259(2), 820–825, 1991. 37. Shankaran, M., Yamamoto, B.K., and Gudelsky, G.A., Mazindol attenuates the 3,4-methylenedioxymethamphetamine-induced formation of hydroxyl radicals and long-term depletion of serotonin in the striatum, J. Neurochem. 72(6), 2516–2522, 1999. 38. Schmidt, C.J., Sullivan, C.K., and Fadayel, G.M., Blockade of striatal 5-hydroxytryptamine2 receptors reduces the increase in extracellular concentrations of dopamine produced by the amphetamine analogue 3,4-methylenedioxymethamphetamine, J. Neurochem. 62(4), 1382–1389, 1994. 39. Baumann, M.H., Clark, R.D., Budzynski, A.G., Partilla, J.S., Blough, B.E., and Rothman, R.B., Nsubstituted piperazines abused by humans mimic the molecular mechanism of 3,4-methylenedioxymethamphetamine (MDMA, or “Ecstasy”), Neuropsychopharmacology 30(3), 550–560, 2005. 40. Cole, J.C. and Sumnall, H.R., The pre-clinical behavioural pharmacology of 3,4-methylenedioxymethamphetamine (MDMA), Neurosci. Biobehav. Rev. 27(3), 199–217, 2003.


554


41. Sprouse, J.S., Bradberry, C.W., Roth, R.H., and Aghajanian, G.K., MDMA (3,4-methylenedioxymethamphetamine) inhibits the firing of dorsal raphe neurons in brain slices via release of serotonin, Eur. J. Pharmacol. 167(3), 375–383, 1989. 42. Gartside, S.E., McQuade, R., and Sharp, T., Acute effects of 3,4-methylenedioxymethamphetamine (MDMA) on 5-HT cell firing and release: comparison between dorsal and median raphe 5-HT systems, Neuropharmacology 36(11–12), 1697–703, 1997. 43. Nash, J.F., Jr., Meltzer, H.Y., and Gudelsky, G.A., Elevation of serum prolactin and corticosterone concentrations in the rat after the administration of 3,4-methylenedioxymethamphetamine, J. Pharmacol. Exp. Ther. 245(3), 873–879, 1988. 44. Gold, L.H., Koob, G.F., and Geyer, M.A., Stimulant and hallucinogenic behavioral profiles of 3,4methylenedioxymethamphetamine and N-ethyl-3,4-methylenedioxyamphetamine in rats, J. Pharmacol. Exp. Ther. 247(2), 547–555, 1988. 45. Slikker, W., Jr., Holson, R.R., Ali, S.F., Kolta, M.G., Paule, M.G., Scallet, A.C., McMillan, D.E., Bailey, J.R., Hong, J.S., and Scalzo, F.M., Behavioral and neurochemical effects of orally administered MDMA in the rodent and nonhuman primate, Neurotoxicology 10(3), 529–542, 1989. 46. Spanos, L.J. and Yamamoto, B.K., Acute and subchronic effects of methylenedioxymethamphetamine [(+/–)MDMA] on locomotion and serotonin syndrome behavior in the rat, Pharmacol. Biochem. Behav. 32(4), 835–840, 1989. 47. Bankson, M.G. and Cunningham, K.A., 3,4-Methylenedioxymethamphetamine (MDMA) as a unique model of serotonin receptor function and serotonin-dopamine interactions, J. Pharmacol. Exp. Ther. 297(3), 846–852, 2001. 48. Green, A.R., Mechan, A.O., Elliott, J.M., O’Shea, E., and Colado, M.I., The pharmacology and clinical pharmacology of 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”), Pharmacol. Rev. 55(3), 463–508, 2003. 49. O’Cain, P.A., Hletko, S.B., Ogden, B.A., and Varner, K.J., Cardiovascular and sympathetic responses and reflex changes elicited by MDMA, Physiol. Behav. 70(1–2), 141–148, 2000. 50. Badon, L.A., Hicks, A., Lord, K., Ogden, B.A., Meleg-Smith, S., and Varner, K.J., Changes in cardiovascular responsiveness and cardiotoxicity elicited during binge administration of Ecstasy, J. Pharmacol. Exp. Ther. 302(3), 898–907, 2002. 51. Fitzgerald, J.L. and Reid, J.J., Sympathomimetic actions of methylenedioxymethamphetamine in rat and rabbit isolated cardiovascular tissues, J. Pharm. Pharmacol. 46(10), 826–832, 1994. 52. Lyon, R.A., Glennon, R.A., and Titeler, M., 3,4-Methylenedioxymethamphetamine (MDMA): stereoselective interactions at brain 5-HT1 and 5-HT2 receptors, Psychopharmacology (Berlin) 88(4), 525–526, 1986. 53. Battaglia, G. and De Souza, E.B., Pharmacologic profile of amphetamine derivatives at various brain recognition sites: selective effects on serotonergic systems, NIDA Res. Monogr. 94, 240–258, 1989. 54. Lavelle, A., Honner, V., and Docherty, J.R., Investigation of the prejunctional alpha2-adrenoceptor mediated actions of MDMA in rat atrium and vas deferens, Br. J. Pharmacol. 128(5), 975–980, 1999. 55. Dafters, R.I., Hyperthermia following MDMA administration in rats: effects of ambient temperature, water consumption, and chronic dosing, Physiol. Behav. 58(5), 877–882, 1995. 56. de la Torre, R., Farre, M., Roset, P.N., Pizarro, N., Abanades, S., Segura, M., Segura, J., and Cami, J., Human pharmacology of MDMA: pharmacokinetics, metabolism, and disposition, Ther. Drug Monit. 26(2), 137–144, 2004. 57. Charlier, C., Broly, F., Lhermitte, M., Pinto, E., Ansseau, M., and Plomteux, G., Polymorphisms in the CYP 2D6 gene: association with plasma concentrations of fluoxetine and paroxetine, Ther. Drug Monit. 25(6), 738–742, 2003. 58. Malpass, A., White, J.M., Irvine, R.J., Somogyi, A.A., and Bochner, F., Acute toxicity of 3,4methylenedioxymethamphetamine (MDMA) in Sprague-Dawley and Dark Agouti rats, Pharmacol. Biochem. Behav. 64(1), 29–34, 1999. 59. Maurer, H.H., Bickeboeller-Friedrich, J., Kraemer, T., and Peters, F.T., Toxicokinetics and analytical toxicology of amphetamine-derived designer drugs (“Ecstasy”), Toxicol. Lett. 112–113, 133–142, 2000. 60. de la Torre, R. and Farre, M., Neurotoxicity of MDMA (ecstasy): the limitations of scaling from animals to humans, Trends Pharmacol. Sci. 25(10), 505–508, 2004.



555

61. Forsling, M.L., Fallon, J.K., Shah, D., Tilbrook, G.S., Cowan, D.A., Kicman, A.T., and Hutt, A.J., The effect of 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”) and its metabolites on neurohypophysial hormone release from the isolated rat hypothalamus, Br. J. Pharmacol. 135(3), 649–656, 2002. 62. Monks, T.J., Jones, D.C., Bai, F., and Lau, S.S., The role of metabolism in 3,4-(+)-methylenedioxyamphetamine and 3,4-(+)-methylenedioxymethamphetamine (ecstasy) toxicity, Ther. Drug Monit. 26(2), 132–136, 2004. 63. de la Torre, R., Farre, M., Ortuno, J., Mas, M., Brenneisen, R., Roset, P.N., Segura, J., and Cami, J., Non-linear pharmacokinetics of MDMA (“ecstasy”) in humans, Br. J. Clin. Pharmacol. 49(2), 104–109, 2000. 64. Wu, D., Otton, S.V., Inaba, T., Kalow, W., and Sellers, E.M., Interactions of amphetamine analogs with human liver CYP2D6, Biochem. Pharmacol. 53(11), 1605–1612, 1997. 65. Chu, T., Kumagai, Y., DiStefano, E.W., and Cho, A.K., Disposition of methylenedioxymethamphetamine and three metabolites in the brains of different rat strains and their possible roles in acute serotonin depletion, Biochem. Pharmacol. 51(6), 789–796, 1996. 66. Lyles, J. and Cadet, J.L., Methylenedioxymethamphetamine (MDMA, Ecstasy) neurotoxicity: cellular and molecular mechanisms, Brain Res. Brain Res. Rev. 42(2), 155–168, 2003. 67. Battaglia, G., Yeh, S.Y., O’Hearn, E., Molliver, M.E., Kuhar, M.J., and De Souza, E.B., 3,4-Methylenedioxymethamphetamine and 3,4-methylenedioxyamphetamine destroy serotonin terminals in rat brain: quantification of neurodegeneration by measurement of [3H]paroxetine-labeled serotonin uptake sites, J. Pharmacol. Exp. Ther. 242(3), 911–916, 1987. 68. Commins, D.L., Vosmer, G., Virus, R.M., Woolverton, W.L., Schuster, C.R., and Seiden, L.S., Biochemical and histological evidence that methylenedioxymethylamphetamine (MDMA) is toxic to neurons in the rat brain, J. Pharmacol. Exp. Ther. 241(1), 338–345, 1987. 69. Schmidt, C.J., Neurotoxicity of the psychedelic amphetamine, methylenedioxymethamphetamine, J. Pharmacol. Exp. Ther. 240(1), 1–7, 1987. 70. Stone, D.M., Merchant, K.M., Hanson, G.R., and Gibb, J.W., Immediate and long-term effects of 3,4methylenedioxymethamphetamine on serotonin pathways in brain of rat, Neuropharmacology 26(12), 1677–1683, 1987. 71. Molliver, M.E., Berger, U.V., Mamounas, L.A., Molliver, D.C., O’Hearn, E., and Wilson, M.A., Neurotoxicity of MDMA and related compounds: anatomic studies, Ann. N.Y. Acad. Sci. 600, 649–661; discussion 661–664, 1990. 72. O’Hearn, E., Battaglia, G., De Souza, E.B., Kuhar, M.J., and Molliver, M.E., Methylenedioxyamphetamine (MDA) and methylenedioxymethamphetamine (MDMA) cause selective ablation of serotonergic axon terminals in forebrain: immunocytochemical evidence for neurotoxicity, J. Neurosci. 8(8), 2788–2803, 1988. 73. Battaglia, G., Yeh, S.Y., and De Souza, E.B., MDMA-induced neurotoxicity: parameters of degeneration and recovery of brain serotonin neurons, Pharmacol. Biochem. Behav. 29(2), 269–274, 1988. 74. Scanzello, C.R., Hatzidimitriou, G., Martello, A.L., Katz, J.L., and Ricaurte, G.A., Serotonergic recovery after (+/–)3,4-(methylenedioxy) methamphetamine injury: observations in rats, J. Pharmacol. Exp. Ther. 264(3), 1484–1491, 1993. 75. Sprague, J.E., Everman, S.L., and Nichols, D.E., An integrated hypothesis for the serotonergic axonal loss induced by 3,4-methylenedioxymethamphetamine, Neurotoxicology 19(3), 427–441, 1998. 76. Kuhn, D.M. and Geddes, T.J., Molecular footprints of neurotoxic amphetamine action, Ann. N.Y. Acad. Sci. 914, 92–103, 2000. 77. Gudelsky, G.A. and Yamamoto, B.K., Neuropharmacology and neurotoxicity of 3,4-methylenedioxymethamphetamine, Methods Mol. Med. 79, 55–73, 2003. 78. Malberg, J.E. and Seiden, L.S., Small changes in ambient temperature cause large changes in 3,4methylenedioxymethamphetamine (MDMA)-induced serotonin neurotoxicity and core body temperature in the rat, J. Neurosci. 18(13), 5086–5094, 1998. 79. Green, A.R., O’Shea, E., and Colado, M.I., A review of the mechanisms involved in the acute MDMA (ecstasy)-induced hyperthermic response, Eur. J. Pharmacol. 500(1–3), 3–13, 2004. 80. Carlsson, A., The contribution of drug research to investigating the nature of endogenous depression, Pharmakopsychiatr. Neuropsychopharmakol. 9(1), 2–10, 1976.


556


81. Benmansour, S., Cecchi, M., Morilak, D.A., Gerhardt, G.A., Javors, M.A., Gould, G.G., and Frazer, A., Effects of chronic antidepressant treatments on serotonin transporter function, density, and mRNA level, J. Neurosci. 19(23), 10494–10501, 1999. 82. Benmansour, S., Owens, W.A., Cecchi, M., Morilak, D.A., and Frazer, A., Serotonin clearance in vivo is altered to a greater extent by antidepressant-induced downregulation of the serotonin transporter than by acute blockade of this transporter, J. Neurosci. 22(15), 6766–6772, 2002. 83. Frazer, A. and Benmansour, S., Delayed pharmacological effects of antidepressants, Mol. Psychiatry 7(Suppl. 1), S23–S28, 2002. 84. Kalia, M., O’Callaghan, J.P., Miller, D.B., and Kramer, M., Comparative study of fluoxetine, sibutramine, sertraline and dexfenfluramine on the morphology of serotonergic nerve terminals using serotonin immunohistochemistry, Brain Res. 858(1), 92–105, 2000. 85. Gouzoulis-Mayfrank, E., Becker, S., Pelz, S., Tuchtenhagen, F., and Daumann, J., Neuroendocrine abnormalities in recreational ecstasy (MDMA) users: is it ecstasy or cannabis? Biol. Psychiatry 51(9), 766–769, 2002. 86. Kish, S.J., How strong is the evidence that brain serotonin neurons are damaged in human users of ecstasy? Pharmacol. Biochem. Behav. 71(4), 845–855, 2002. 87. Reneman, L., Designer drugs: how dangerous are they? J. Neural Transm. Suppl. 66, 61–83, 2003. 88. Gartside, S.E., McQuade, R., and Sharp, T., Effects of repeated administration of 3,4-methylenedioxymethamphetamine on 5-hydroxytryptamine neuronal activity and release in the rat brain in vivo, J. Pharmacol. Exp. Ther. 279(1), 277–283, 1996. 89. Aghajanian, G.K., Wang, R.Y., and Baraban, J., Serotonergic and non-serotonergic neurons of the dorsal raphe: reciprocal changes in firing induced by peripheral nerve stimulation, Brain Res. 153(1), 169–175, 1978. 90. Hajos, M. and Sharp, T., A 5-hydroxytryptamine lesion markedly reduces the incidence of burst-firing dorsal raphe neurones in the rat, Neurosci. Lett. 204(3), 161–164, 1996. 91. Switzer, R.C., III, Application of silver degeneration stains for neurotoxicity testing, Toxicol. Pathol. 28(1), 70–83, 2000. 92. Jensen, K.F., Olin, J., Haykal-Coates, N., O’Callaghan, J., Miller, D.B., and de Olmos, J.S., Mapping toxicant-induced nervous system damage with a cupric silver stain: a quantitative analysis of neural degeneration induced by 3,4-methylenedioxymethamphetamine, NIDA Res. Monogr. 136, 133–149; discussion 150–154, 1993. 93. Steinbusch, H.W., Distribution of serotonin-immunoreactivity in the central nervous system of the rat-cell bodies and terminals, Neuroscience 6(4), 557–618, 1981. 94. O’Callaghan, J.P. and Sriram, K., Glial fibrillary acidic protein and related glial proteins as biomarkers of neurotoxicity, Expert Opin. Drug Saf. 4(3), 433–442, 2005. 95. O’Callaghan, J.P., Jensen, K.F., and Miller, D.B., Quantitative aspects of drug and toxicant-induced astrogliosis, Neurochem. Int. 26(2), 115–124, 1995. 96. O’Callaghan, J.P. and Miller, D.B., Quantification of reactive gliosis as an approach to neurotoxicity assessment, NIDA Res. Monogr. 136, 188–212, 1993. 97. Wang, X., Baumann, M.H., Xu, H., and Rothman, R.B., 3,4-Methylenedioxymethamphetamine (MDMA) administration to rats decreases brain tissue serotonin but not serotonin transporter protein and glial fibrillary acidic protein, Synapse 53(4), 240–248, 2004. 98. Pubill, D., Canudas, A.M., Pallas, M., Camins, A., Camarasa, J., and Escubedo, E., Different glial response to methamphetamine- and methylenedioxymethamphetamine-induced neurotoxicity, Naunyn Schmiedeberg’s Arch. Pharmacol. 367(5), 490–499, 2003. 99. Wang, X., Baumann, M.H., Xu, H., Morales, M., and Rothman, R.B., ({+/–})-3,4-Methylenedioxymethamphetamine administration to rats does not decrease levels of the serotonin transporter protein or alter its distribution between endosomes and the plasma membrane, J. Pharmacol. Exp. Ther. 314(3), 1002–1012, 2005. 100. Ricaurte, G.A., Yuan, J., and McCann, U.D., (+/–)3,4-Methylenedioxymethamphetamine (“Ecstasy”)induced serotonin neurotoxicity: studies in animals, Neuropsychobiology 42(1), 5–10, 2000. 101. White, C.R. and Seymour, R.S., Allometric scaling of mammalian metabolism, J. Exp. Biol. 208(9), 1611–1619, 2005.



557

102. West, G.B. and Brown, J.H., The origin of allometric scaling laws in biology from genomes to ecosystems: towards a quantitative unifying theory of biological structure and organization, J. Exp. Biol. 208(9), 1575–1592, 2005. 103. Lin, J.H., Applications and limitations of interspecies scaling and in vitro extrapolation in pharmacokinetics, Drug Metab. Dispos. 26(12), 1202–1212, 1998. 104. Mahmood, I., Allometric issues in drug development, J. Pharm. Sci. 88(11), 1101–1106, 1999. 105. Campbell, D.B., The use of toxicokinetics for the safety assessment of drugs acting in the brain, Mol. Neurobiol. 11(1–3), 193–216, 1995. 106. Liechti, M.E. and Vollenweider, F.X., The serotonin uptake inhibitor citalopram reduces acute cardiovascular and vegetative effects of 3,4-methylenedioxymethamphetamine (“Ecstasy”) in healthy volunteers, J. Psychopharmacol. 14(3), 269–274, 2000. 107. Glennon, R.A. and Higgs, R., Investigation of MDMA-related agents in rats trained to discriminate MDMA from saline, Pharmacol. Biochem. Behav. 43(3), 759–763, 1992. 108. Schechter, M.D., Serotonergic-dopaminergic mediation of 3,4-methylenedioxymethamphetamine (MDMA, “ecstasy”), Pharmacol. Biochem. Behav. 31(4), 817–824, 1988. 109. Johanson, C.E., Kilbey, M., Gatchalian, K., and Tancer, M., Discriminative stimulus effects of 3,4methylenedioxymethamphetamine (MDMA) in humans trained to discriminate among d-amphetamine, meta-chlorophenylpiperazine and placebo, Drug Alcohol Depend. 81, 27–36, 2006. 110. Schenk, S., Gittings, D., Johnstone, M., and Daniela, E., Development, maintenance and temporal pattern of self-administration maintained by ecstasy (MDMA) in rats, Psychopharmacology (Berlin) 169(1), 21–27, 2003. 111. Tancer, M. and Johanson, C.E., Reinforcing, subjective, and physiological effects of MDMA in humans: a comparison with d-amphetamine and mCPP, Drug Alcohol Depend. 72(1), 33–44, 2003. 112. Baumann, M.H., Ayestas, M.A., Dersch, C.M., and Rothman, R.B., 1-(m-chlorophenyl)piperazine (mCPP) dissociates in vivo serotonin release from long-term serotonin depletion in rat brain, Neuropsychopharmacology 24(5), 492–501, 2001. 113. O’Shea, E., Granados, R., Esteban, B., Colado, M.I., and Green, A.R., The relationship between the degree of neurodegeneration of rat brain 5-HT nerve terminals and the dose and frequency of administration of MDMA (“ecstasy”), Neuropharmacology 37(7), 919–926, 1998. 114. Series, H.G., Cowen, P.J., and Sharp, T., p-Chloroamphetamine (PCA), 3,4-methylenedioxy-methamphetamine (MDMA) and d-fenfluramine pretreatment attenuates d-fenfluramine-evoked release of 5HT in vivo, Psychopharmacology (Berlin) 116(4), 508–514, 1994. 115. Shankaran, M. and Gudelsky, G.A., A neurotoxic regimen of MDMA suppresses behavioral, thermal and neurochemical responses to subsequent MDMA administration, Psychopharmacology (Berlin) 147(1), 66–72, 1999. 116. Matuszewich, L., Filon, M.E., Finn, D.A., and Yamamoto, B.K., Altered forebrain neurotransmitter responses to immobilization stress following 3,4-methylenedioxymethamphetamine, Neuroscience 110(1), 41–48, 2002. 117. Kirby, L.G., Kreiss, D.S., Singh, A., and Lucki, I., Effect of destruction of serotonin neurons on basal and fenfluramine-induced serotonin release in striatum, Synapse 20(2), 99–105, 1995. 118. Romero, L., Jernej, B., Bel, N., Cicin-Sain, L., Cortes, R., and Artigas, F., Basal and stimulated extracellular serotonin concentration in the brain of rats with altered serotonin uptake, Synapse 28(4), 313–321, 1998. 119. Hall, F.S., Devries, A.C., Fong, G.W., Huang, S., and Pert, A., Effects of 5,7-dihydroxytryptamine depletion of tissue serotonin levels on extracellular serotonin in the striatum assessed with in vivo microdialysis: relationship to behavior, Synapse 33(1), 16–25, 1999. 120. Zigmond, M.J., Abercrombie, E.D., Berger, T.W., Grace, A.A., and Stricker, E.M., Compensations after lesions of central dopaminergic neurons: some clinical and basic implications, Trends Neurosci. 13(7), 290–296, 1990. 121. Van de Kar, L.D., Neuroendocrine pharmacology of serotonergic (5-HT) neurons, Annu. Rev. Pharmacol. Toxicol. 31, 289–320, 1991. 122. Levy, A.D., Baumann, M.H., and Van de Kar, L.D., Monoaminergic regulation of neuroendocrine function and its modification by cocaine, Front. Neuroendocrinol. 15(2), 85–156, 1994.


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123. Series, H.G., le Masurier, M., Gartside, S.E., Franklin, M., and Sharp, T., Behavioural and neuroendocrine responses to d-fenfluramine in rats treated with neurotoxic amphetamines, J. Psychopharmacol. 9, 214–222, 1995. 124. Poland, R.E., Diminished corticotropin and enhanced prolactin responses to 8-hydroxy-2(di-n-propylamino)tetralin in methylenedioxymethamphetamine pretreated rats, Neuropharmacology 29(11), 1099–1101, 1990. 125. Poland, R.E., Lutchmansingh, P., McCracken, J.T., Zhao, J.P., Brammer, G.L., Grob, C.S., Boone, K.B., and Pechnick, R.N., Abnormal ACTH and prolactin responses to fenfluramine in rats exposed to single and multiple doses of MDMA, Psychopharmacology (Berlin) 131(4), 411–419, 1997. 126. Baumann, M.H., Ayestas, M.A., and Rothman, R.B., Functional consequences of central serotonin depletion produced by repeated fenfluramine administration in rats, J. Neurosci. 18(21), 9069–9077, 1998. 127. Gerra, G., Zaimovic, A., Giucastro, G., Maestri, D., Monica, C., Sartori, R., Caccavari, R., and Delsignore, R., Serotonergic function after (+/–)3,4-methylene-dioxymethamphetamine (“Ecstasy”) in humans, Int. Clin. Psychopharmacol. 13(1), 1–9, 1998. 128. Gerra, G., Zaimovic, A., Ferri, M., Zambelli, U., Timpano, M., Neri, E., Marzocchi, G.F., Delsignore, R., and Brambilla, F., Long-lasting effects of (+/–)3,4-methylenedioxymethamphetamine (ecstasy) on serotonin system function in humans, Biol. Psychiatry 47(2), 127–136, 2000. 129. Seiden, L.S., Woolverton, W.L., Lorens, S.A., Williams, J.E., Corwin, R.L., Hata, N., and Olimski, M., Behavioral consequences of partial monoamine depletion in the CNS after methamphetaminelike drugs: the conflict between pharmacology and toxicology, NIDA Res. Monogr. 136, 34–46; discussion 46–52, 1993. 130. Robinson, T.E., Castaneda, E., and Whishaw, I.Q., Effects of cortical serotonin depletion induced by 3,4-methylenedioxymethamphetamine (MDMA) on behavior, before and after additional cholinergic blockade, Neuropsychopharmacology 8(1), 77–85, 1993. 131. Ricaurte, G.A., Markowska, A.L., Wenk, G.L., Hatzidimitriou, G., Wlos, J., and Olton, D.S., 3,4Methylenedioxymethamphetamine, serotonin and memory, J. Pharmacol. Exp. Ther. 266(2), 1097–1105, 1993. 132. McNamara, M.G., Kelly, J.P., and Leonard, B.E., Some behavioural and neurochemical aspects of subacute (+/–)3,4-methylenedioxymethamphetamine administration in rats, Pharmacol. Biochem. Behav. 52(3), 479–484, 1995. 133. Byrne, T., Baker, L.E., and Poling, A., MDMA and learning: effects of acute and neurotoxic exposure in the rat, Pharmacol. Biochem. Behav. 66(3), 501–508, 2000. 134. Marston, H.M., Reid, M.E., Lawrence, J.A., Olverman, H.J., and Butcher, S.P., Behavioural analysis of the acute and chronic effects of MDMA treatment in the rat, Psychopharmacology (Berlin) 144(1), 67–76, 1999. 135. Morley, K.C., Gallate, J.E., Hunt, G.E., Mallet, P.E., and McGregor, I.S., Increased anxiety and impaired memory in rats 3 months after administration of 3,4-methylenedioxymethamphetamine (“ecstasy”), Eur. J. Pharmacol. 433(1), 91–99, 2001. 136. Gurtman, C.G., Morley, K.C., Li, K.M., Hunt, G.E., and McGregor, I.S., Increased anxiety in rats after 3,4-methylenedioxymethamphetamine: association with serotonin depletion, Eur. J. Pharmacol. 446(1–3), 89–96, 2002. 137. Fone, K.C., Beckett, S.R., Topham, I.A., Swettenham, J., Ball, M., and Maddocks, L., Long-term changes in social interaction and reward following repeated MDMA administration to adolescent rats without accompanying serotonergic neurotoxicity, Psychopharmacology (Berlin) 159(4), 437–444, 2002. 138. McGregor, I.S., Clemens, K.J., Van der Plasse, G., Li, K.M., Hunt, G.E., Chen, F., and Lawrence, A.J., Increased anxiety 3 months after brief exposure to MDMA (“Ecstasy”) in rats: association with altered 5-HT transporter and receptor density, Neuropsychopharmacology 28(8), 1472–1484, 2003. 139. Bull, E.J., Hutson, P.H., and Fone, K.C., Reduced social interaction following 3,4-methylenedioxymethamphetamine is not associated with enhanced 5-HT 2C receptor responsivity, Neuropharmacology 44(4), 439–448, 2003. 140. Bull, E.J., Hutson, P.H., and Fone, K.C., Decreased social behaviour following 3,4-methylenedioxymethamphetamine (MDMA) is accompanied by changes in 5-HT2A receptor responsivity, Neuropharmacology 46(2), 202–210, 2004.

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CHAPTER

7

Addiction Medicine Edited by Kim Wolff, Ph.D. King’s College London, Institute of Psychiatry, National Addiction Centre, London, U.K.

CONTENTS Introduction ....................................................................................................................................560 7.1 The Principles of Addiction Medicine.................................................................................560 7.1.1 Understanding the Nature of Dependence...............................................................561 7.1.2 Understanding the Dependence-Forming Potential of Drugs .................................562 7.1.2.1 Potency of Psychoactive Effect ................................................................562 7.1.2.2 Pharmacokinetics.......................................................................................563 7.1.2.3 Plasticity ....................................................................................................564 7.1.3 Understanding the Importance of Motivation..........................................................564 7.1.4 Prescribing in Context..............................................................................................565 7.1.5 General Precautions..................................................................................................565 7.2 Substitute Prescribing...........................................................................................................566 7.2.1 Opioid-Specific Prescribing......................................................................................567 7.2.1.1 Methadone Maintenance Prescribing........................................................567 7.2.1.2 Treatment Compliance ..............................................................................567 7.2.1.3 Therapeutic Drug Monitoring for Methadone..........................................568 7.2.1.4 Indications for Plasma Methadone Monitoring........................................568 7.2.2 Buprenorphine Maintenance Prescribing .................................................................569 7.2.2.1 Pharmacokinetics.......................................................................................570 7.2.3 Stimulant Specific.....................................................................................................571 7.2.4 Benzodiazepine Specific...........................................................................................572 7.2.5 Outcomes for Substitute Prescribing .......................................................................572 7.3 Treatment of Withdrawal Syndromes ..................................................................................572 7.3.1 Understanding Withdrawal Syndromes....................................................................572 7.3.1.1 Detoxification ............................................................................................573 7.3.2 Opiate-Specific Withdrawal Syndrome ....................................................................574 7.3.2.1 Detoxification Using Methadone ..............................................................575 7.3.2.2 Detoxification Using Buprenorphine ........................................................575 7.3.2.3 Detoxification Using Adrenergic Agonists ...............................................577 7.3.2.4 Naltrexone-Assisted Detoxification ..........................................................577 7.3.3 Stimulant-Specific Withdrawal Syndrome ...............................................................578 7.3.4 Hypnotic and Sedative Withdrawal Syndrome ........................................................579 559


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7.5

7.6


7.3.4.1 Management of Withdrawal......................................................................580 Replacement Prescribing ......................................................................................................580 7.4.1 Opioid-Specific Prescribing......................................................................................580 7.4.2 Stimulant-Specific Prescribing .................................................................................582 7.4.2.1 Neurochemical Approach: Dopaminergic Agents and Selective Serotonin-Reuptake Inhibitors ..................................................................582 7.4.2.2 Clinical Approach, Tricyclic Antidepressants, and Antisensitizing Agents........................................................................................................583 7.4.3 New Approaches.......................................................................................................584 Management of Comorbidity ...............................................................................................584 7.5.1 Understanding Comorbidity .....................................................................................584 7.5.2 Making Prescribing Decisions .................................................................................585 Toxicologic Issues ................................................................................................................587 7.6.1 Heat and Drug Stability ...........................................................................................587 7.6.2 Analysis Using Other Body Fluids ..........................................................................588 References.............................................................................................................................589 INTRODUCTION

Substance misuse is often considered to be an unpopular subject with many doctors, partly because of the frequent relapse experienced by addicts and partly because of the behavioral problems that can occur when drug users interact with substance misuse treatment services. Many clinical drug treatment services are dominated by the prescribing of methadone to those dependent on heroin (diacetylmorphine). Methadone maintenance treatment (MMT) has been the most rapidly expanded treatment for heroin dependence over the last 30 years with increasingly large numbers of countries providing such treatment for extensive treatment populations. Even more recently buprenorphine, a partial agonist, has been introduced into drug treatment services and has provided an alternative to methadone. Many doctors involved with addiction problems will see themselves as having only a prescribing role whereas specialists in the field will, in addition, require a repertoire of psychotherapy skills. Prescribing for patients who may have a dependence on a number of drugs, who may wish to conceal the extent of their substance use, and who may have a marked tolerance to some classes of drug is discussed in order to help inform the practitioner. This chapter is divided into six sections, mainly intended to provide an overview for the nonspecialist. The first section explains the psychology of addiction, as opposed to the neurochemistry of addiction discussed in Chapter 6. Overviews are provided of substitute prescribing, an increasingly accepted practice. Considerable discussion is devoted to the identification and management of withdrawal syndromes, whether sedative or stimulant. The final section briefly discusses toxicological testing, primarily for the purpose of assessing compliance. Additional information on this subject can be found in Chapters 1, 3, and 11. 7.1 THE PRINCIPLES OF ADDICTION MEDICINE Duncan Raistrick, M.B.B.S. The Leeds Addiction Unit, Leeds, U.K.

Many doctors involved with addiction problems will see themselves as having only a prescribing role whereas specialists in the field will, in addition, require a repertoire of psychotherapy skills.


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Prescribing for patients who may have a dependence on a number of drugs, who may wish to conceal the extent of their substance use, and who may have a marked tolerance to some classes of drug presents difficulties for the unwary or ill-informed doctor. In order to prescribe safely and effectively doctors must: 1. Understand the nature of dependence 2. Understand the dependence-forming potential of drugs 3. Understand the importance of motivation

7.1.1

Understanding the Nature of Dependence

In the U.K. and North America, the understanding of addiction has been dominated by the disease theory and the social learning theory. Heather1 succinctly describes the history and development of thinking underpinning these theories. Other theories or, perhaps more correctly, models of addiction have been popular in particular cultures or where partial explanations have utility; for example, psychoanalytical interpretations of addictive behavior are common in some European countries, and equally, religious or moral failures are attractive reasons to account for addictive behavior where spiritual values are important as in many Asian and Indian communities. The important implications of the disease theory depend on the notion that addiction is caused by some irreversible deficiency or pathology and that treatment is, therefore, primarily a medical concern. Certain conclusions inevitably follow from such a premise: (1) abstinence is the only treatment goal, (2) loss of control is the hallmark feature, (3) patients are not responsible for their illness, (4) therapists tend to be medical practitioners, and, finally, (5) community-based prevention will be ineffective. In formulating a description of alcohol and later other drug dependence, Edwards and Gross2 argued against the disease model in favor of a biopsychosocial construction of dependence, which was identified as belonging to a separate dimension from substance-related harms. This formulation has been adopted in the International Classification of Diseases, ICD-10.3 The important implications of social learning theory are: a range of treatment goals is possible, the ability to control substance use is emphasized, users are active participants in treatment, therapists tend to be nonmedical, and fiscal and other control measures will be effective. The biopsychosocial description of dependence has been criticized for placing unwarranted emphasis on withdrawal symptoms. While the anticipation or experience of withdrawal may indeed be a potent source of negative reinforcement for drinking, it is not the only source of reinforcement, and it may be that the positive reinforcement of a pharmacological (drug) effect is more important whether or not an individual also experiences withdrawal. To take account of this, Raistrick et al.4 have proposed a modified description of the dependence syndrome and developed the idea of substance dependence as a purely psychological phenomenon where tolerance and withdrawal are understood as consequences of regular drinking, rather than being a part of dependence. The withdrawal symptoms themselves are one step removed from the cognitive response to the symptoms, which may or may not include thoughts about drinking. If withdrawal symptoms were themselves a defining element of dependence, then different drugs would be associated with different kinds of dependence, but this is not a widely held view. Rather, it is believed that dependence can readily shift from one substance to another.5 The markers of substance dependence translate the neuroadaptive elements of the biopsychosocial description of dependence into cues that condition cognitions and behaviors and are therefore of more universal application. There are ten markers of substance dependence: 1. 2. 3. 4.

Preoccupation with drinking or taking drugs Salience of substance use behavior Compulsion to start using alcohol or drugs Planning alcohol- or drug-related behaviors


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5. 6. 7. 8. 9. 10.


Maximizing the substance effect Narrowing of substance use repertoire Compulsion to continue using alcohol and drugs Primacy of psychoactive effect Maintaining a constant state (of intoxication) Expectations of need for substance use

In summary, the most complete account of addictive behaviors comes from a synthesis of physiology, pharmacology, psychology, sociology, and social learning. Dependence exists along a continuum of severity implying the need for different treatments and outcome goals. Substance-related harms in physical, psychological, and social spheres belong to a separate domain. Addiction has become a term without precise meaning, but is generally taken to include dependence, problem use, and any related harms. While social learning allows that anyone may become dependent on psychoactive substances and may also unlearn their dependence, it does not preclude the possibility that substance use may cause deficiencies of endogenous neurotransmitters, which are usually reversible, or permanent damage to receptor structure and connectivity. Indeed, it is likely that such changes occur. 7.1.2

Understanding the Dependence-Forming Potential of Drugs

7.1.2.1 Potency of Psychoactive Effect In humans, the reinforcing properties of psychoactive substances, which combine to generate the umbrella construct dependence, are complex: a prominent view attaches importance to the positive reinforcing effects of inducing pleasurable mood states and the negative reinforcement of avoiding painful affects. Pervin5 explores this very issue in a study of four polydrug users: subjects were asked to describe situations (1) where they wanted to use drugs, (2) after they had used drugs, (3) where they wanted to use drugs but could not, and (4) unrelated to drug use, and then to associate affects from a prepared list with the four situations they described. A factor analysis produced three factors accounting for 44% of the variance: the first factor, Wish, was characterized as being tense, helpless, jittery, lonely; the second factor, After Drugs, was characterized as lonely, empty, inhibited, angry; and the third factor, Taking Drugs, included confidence, relaxed, high, secure, strong, satisfied. The results also indicated that subjects discriminated between drugs suited to dealing with different effects. In two complementary reports, Johanson and Uhlenbuth6,7 compared changes in mood among normal volunteers in a choice experiment between placebo, diazepam, and amphetamine. Amphetamine 5 mg was chosen significantly more often than placebo, 81% of possible choices, with increased scores for vigor, friendliness, elation, arousal, positive mood, and decreased scores for confusion. In contrast, diazepam 5 and 10 mg were chosen significantly less often than placebo, 28 and 27% of choices, respectively, with decreased scores on vigor and arousal and increased scores on confusion and fatigue. The point to underline here is that normal subjects are likely to have different effects to patient groups and the reinforcing potential of different substances will therefore vary between such groups: within matched subjects the reinforcing properties of different substances will also vary in strength. At a clinical level, most doctors are wary of addictive drugs: for example, long-term methadone prescribing is intended to achieve pharmacological stability, at least partially block the effect of other opioids, and prevent withdrawal symptoms. However, Bickel et al.8 suggest that, although methadone is seen as a low tariff drug, treatment retention is, in part, associated with its reinforcing properties. Using a choice paradigm, subjects maintained on methadone 50 mg daily, identified to subjects as capsule A, had the option of taking capsule B, which, in different trials, contained either methadone 50, 60, 70, or 100 mg, in place of Capsule A. Capsule B was chosen on 50, 73, 87, and 97%, respectively, of occasions: at the highest dose, subjects identified an opioid effect and a


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liking for the drug but no high or withdrawal was reported. The clinical implications are quantified by McGlothlin and Anglin9 in a 7-year follow-up of patients attending high- vs. low-dose methadone maintenance programs: the high-dose program performed better in terms of retention, significantly fewer arrests and periods of incarceration, less criminal activity, and less supplementary drug use. In a similar type of study, Hartnoll et al.10 followed up addicts randomly allocated to an injectable heroin or oral methadone program: at 1-year follow-up, 74% of the heroin group against 29% of the methadone group were still in treatment but only 10% against 30% had achieved abstinence from illicit drugs. So, the dilemma is that prescriptions most liked by addicts, namely, those that are more reinforcing, achieve good program retention and a degree of stability, but at the cost of slowing movement away from substance use and the associated subculture. The potency of psychoactive effect is not simply a function of dose or plasma level, but also depends on receptor uptake characteristics. For example, Chiang and Barnett11 have shown that immediately after intravenous tetrahydrocannabinal a rising plasma concentration of approximately 45 ng/ml relates to a subjective high of 10% whereas the same falling plasma concentration 15 min later relates to a high of nearly 80% on a self-rating 0 to 100% scale. This phenomenon is accounted for by a slow uptake of THC at the receptors. Active metabolites may spuriously suggest the same phenomenon. Similarly, the partial agonist buprenorphine has a high, but slow, binding affinity at the opiate mu receptor: it has the potential to act as antagonist against pure opioid agonists and itself appears to have a ceiling effect at about 1 mg subcutaneously for subjective response. Although addicts identify buprenorphine as having an opioid effect and therefore potential for misuse, its binding affinity at the mu receptor and antagonist activity confer a quite different reinforcement profile to pure agonists such as diamorphine (heroin). The clinical significance is demonstrated by Johnson et al.12 who substituted heroin for buprenorphine in ascending daily doses of 2, 4, and 8 mg: using this regimen, diamorphine withdrawal symptoms were avoided and, overall, subjects reported a feeling of well-being. Withdrawal from buprenorphine 8 mg daily does not precipitate an opiate withdrawal syndrome. 7.1.2.2 Pharmacokinetics The previous section argued that the mood-altering effects of psychoactive drugs may, depending on the pre-drug mental state, have both positive and negative reinforcing properties. Psychoactive effect alone is insufficient explanation of within-drug-group differences of dependence forming potential: different pharmacokinetics is important. The benzodiazepines and opioids are the most fruitful source of investigation here because both drug groups contain many different compounds that are widely used and misused. However, it is difficult to conduct studies that control for confounding factors such as absorption rate, potency, purity, half-life, or street availability (and likelihood of supplementing). It is perhaps not surprising that researchers are parsimonious with conclusions. There are ethical problems in conducting laboratory experiments with potent drugs such as heroin and to avoid this problem Mello et al.13 investigated the reinforcing efficacy in primates for three opioids: they found buprenorphine and methadone to have similar strength but heroin to be more powerful. Equally in humans heroin is preferred to other opiates including morphine.14 Since heroin is converted to morphine within the central nervous system (CNS), it can be concluded that its faster rate of CNS availability accounts for the difference. Absorption rate and, therefore, immediacy of effect have similarly been shown to be important for benzodiazepines. Funderburk et al.15 compared the effects of equipotent oral doses of lorazepam (0, 1.5, 3, and 6 mg) and diazepam (0, 10, 20, and 40 mg) in recreational benzodiazepine users: the drug liking ratings were similar for both drugs, suggesting that the absorption rate, which is similar for the two drugs, is more important than the elimination half-life, which is much shorter for lorazepam even though subjective ratings of effect persist much longer for this compound. Learning theory predicts the


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importance of absorption rate in that the most immediate positive consequence of a behavior (drug taking) is the most reinforcing. While potency and the speed of onset of effect are particularly important for initiating dependence, elimination rate assumes greater importance in building and maintaining dependence. As a rule, the more quickly a drug is metabolized, the sooner the user experiences a loss of effect and possibly also withdrawal symptoms. Both of these consequences become cues for further drug use. 7.1.2.3 Plasticity Plasticity is defined as the degree to which the effect of a drug is independent of internal environment (e.g., mood, thirst) and external environment (e.g., with friends, comfort). Edwards16 has described substances as existing along a continuum: highly plastic substances, that is, those where the content of the effect is markedly influenced by environment, exist at one end (e.g., solvents, LSD), and substances with very predictable content (e.g., heroin, cocaine) exist at the opposite end. Plasticity has a bearing on the dependence-forming potential of substances; where the content of a drug effect is uncertain, repeated use is unlikely. In contrast, a very predictable effect may not suit the variety of uses demanded of a recreational substance, but yet be powerfully reinforcing, that is, addictive. It is interesting that the most popular recreational drugs, alcohol and cannabis, fall around the middle of the plasticity continuum, perhaps signaling a point that allows an agreeable interaction between drug and expectation effects. In summary, the dependence-forming potential of a drug is a function of: 1. 2. 3. 4. 5.

7.1.3

Potency of effect Speed of entering the CNS Speed of joining with receptors Elimination rate Predictability of effect

Understanding the Importance of Motivation

The measurement of dependence and the identification of substance-related problems tell the clinician what outcome goals are likely to be successful and how much treatment is needed; alongside this an understanding of motivation informs what kind of treatment is needed. The Model of Change described by Prochaska and DiClemente17 is a motivational model widely used in the addiction field. The purpose of using the model is twofold: first, to understand what is going on for a patient at a given time; second, to inform the patient of the choice of interventions. People who are not motivated to change their substance use are said to be at the pre-contemplation stage, which is characterized by denial and rationalization of substance use and its consequences. There are two strands to treatment strategy at this stage: one is to minimize harm without expecting to change the substance use behavior (for example, by giving nutritional supplements or substitute prescribing). The second is to introduce conflict about the substance use (for example, by making links with untoward life events and thereby creating motivation for change). The temptation is to offer treatments aimed at changing substance use behavior before the patient is ready to change. In such circumstances the treatment will always fail. The experience of significant conflict about substance use (for example, when an arrest is felt to be incompatible with a self-image of being a sensible and responsible person) or when the cost of substance use is causing family hardship indicates movement into the contemplation stage. At this stage, motivational interventions, which may involve the use of simple clinical tools (for example, the decision matrix), or may draw on more sophisticated skills (for example, motivational interviewing),18 are indicated. At this stage substitute prescribing or agonist prescribing may be helpful.


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The action stage is reached when conflict is resolved and there is a commitment to change. A number of things will have happened at a psychological level: the person will believe that life will be better on stopping or controlling their substance use (positive outcome expectancy), they are able to change (self-efficacy), and they will know how to change (skills learning). Elective detoxification is the most common medical intervention at the action stage. The maintenance stage follows behavioral change. This is the achievement of abstinence or controlled substance use. Maintenance of behavior change for alcohol misuse may be assisted by prescribing a sensitizing agent such as disulfiram or, for opiate misuse, prescribing an antagonist such as naltrexone. Pharmacological interventions are no more than an adjunct to the main task of achieving lifestyle change. Successful exit from the maintenance stage, recovery, requires that the patient has confidence and skills to deal with substance use cues. Achieving the right mix of pharmacology and psychology is more art than science, but an understanding of the underlying brain mechanisms, reviewed for clinicians by Nutt,19 and a parallel understanding of motivation will help achieve safe and effective prescribing. 7.1.4

Prescribing in Context

Addiction problems are everyone’s business: the sociologist, the politician, the biochemist, the doctor, the police officer, the parent, the pharmacist, the taxpayer, the drug dealer, and the public. The list is long; such is the diversity of interests vested in substance use and misuse. Everyone will have opinions about addiction including opinions about what doctors should prescribe. Doctors should seek the widest possible clinical freedom to manage addiction patients and to secure this freedom. It follows that prescribers must be sensitive to the prevailing medicopolitical views on what constitutes good practice. People who misuse substances, particularly illicit substances, may have particularly forceful views about what doctors should prescribe, but these views are likely to change depending on where a person is within his or her addiction career. It follows that prescribers must have an understanding of addictive behaviors and characteristics of addictive substances. The Model of Change (described above) is a simple, commonly used tool that offers a framework for prescribing and other interventions. For most people who have developed a moderate or severe dependence, pharmacotherapy will, at some time, be an important part of treatment. However, prescribing alone will never be sufficient. It follows that prescribers must have a repertoire of skills, including behavior therapy and psychotherapy or, alternatively, must work with a co-therapist. When working with a co-therapist, the doctor must be satisfied with the reasons for prescribing and take responsibility for the prescription given. 7.1.5

General Precautions

Doctors who are inexperienced in the field of addiction often feel pressured to prescribe beyond their knowledge and skills, and as a result may issue inappropriate prescriptions. In contrast, specialists are likely to be circumspect about the place of pharmacotherapy and especially so when this means prescribing addictive drugs.20 The precautions listed below are applicable to any prescribing; however, patients who misuse both prescribed and illicit drugs are especially at risk, not least because prescriptions are often for potent preparations in doses higher than normally recommended. Doctors may be required to justify their prescribing to a variety of authorities and are more likely to fall afoul of legal action or audit because of precipitate rather than delayed prescribing. Having established the appropriateness of prescribing, the following checklist will ensure the safety of a prescription: Prescribe drugs with low dependence-forming potential. Prescribe drugs with low injection potential.


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Prescribe drugs with low “street value.” Prescribe inherently stabilizing drugs. Assess: Risk of overdose by patient Risk of overdose by others living with patient Risk of diversion for profit or misuse Risk of failing to control use as prescribed Assess tolerance before prescribing potentially lethal doses. Check other prescribed medication. Check on co-existing medical conditions. Monitor compliance.

Safety of prescribing needs to be balanced against a regimen that is convenient for the patient and which will therefore achieve the best results in terms of retention and compliance.21,22 Before finally giving a prescription, it is crucial to ensure that both the doctor and the patient understand the purpose of the prescription.23 There should be agreement on how to monitor whether or not the intended purpose is being achieved; if the purpose is not achieved then the prescription should be reviewed and possibly discontinued. This does not imply an end to therapy but rather consideration of a shift to an alternative, possibly nonpharmacological treatment.

7.2 SUBSTITUTE PRESCRIBING

Kim Wolff, Ph.D. King’s College London, Institute of Psychiatry, National Addiction Centre, London, U.K.

Substitute prescribing is the prescription of the main drug of misuse or a drug from the same pharmacological group but of lower dependence potential to a dependent individual. The main purpose of substitute prescribing is to stabilize a person’s substance use and offer a period of time to work on non-drug-focused interventions. Slow reduction or detoxification can occur at any time during substitute prescribing. Recipients of substitute prescribing may fall into one or more of the following categories: 1. 2. 3. 4. 5.

Diagnosis of opioid, cocaine, amphetamine, or benzodiazepine dependence Minimum 6-month history of regular use Regular injecting, especially if high risk, of whatever duration Failed attempts to achieve abstinence At time of initial assessment, likely to be at the pre-contemplation or contemplation stage of change

Evidenced-based guidelines for providing substitute treatment for drug misusers have been reported23–25 and, in brief, aim to bring about: Short term: Attract patients into treatment Relieve withdrawal symptoms Long term: Retain in treatment Reduce injecting behavior Stabilize drug use Stabilize lifestyle


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Reduce criminal behavior Reduce human immunodeficiency virus (HIV), HBV, and HBC transmission Reduce death rate

7.2.1

Opioid-Specific Prescribing

Maintenance prescribing differs from substitute prescribing only in that there is no active effort to bring about change in a person’s drug use or psychological state. The majority of clinical drug misuse services are concerned principally with the prescription of methadone to heroin users. American reviews tend to cite methadone as a direct pharmacological treatment in the way that insulin is used for diabetes. Many Europeans, however, would view methadone more as a substitute treatment whereby the improvements that are seen result from removing individuals from the process of using street drugs.24 7.2.1.1 Methadone Maintenance Prescribing Methadone, a synthetic opioid first reported as a maintenance (long-term, fixed-dose) treatment for opiate dependence by Dole and Nyswander,26 is the most widely used pharmacological treatment for this type of addiction in Britain and North America. Methadone first appeared in Europe in the late 1960s in response to an emerging use of heroin and was officially introduced into Britain in 1968.27 Today methadone remains the preferred drug of choice for the treatment of heroin dependence,28 dominating the substitute prescribing market.29 Substantial evidence exists in the international literature to support the effectiveness of methadone maintenance treatment (MMT), particularly with regard to reduction in intravenous drug misuse,30,31 less crime,32,33 reemployment,34 social rehabilitation,35 overall health status,34 improved quality of lifestyle,36 and safety and cost effectiveness compared to other (drug-free) alternatives.37 The National Treatment Outcome Research Study (NTORS) reported similar findings in Britain.38 Retention in treatment is the key, however, and discernible treatment effects are only seen when patients remain in treatment for longer than 1 year.39 The available evidence indicates that it is methadone per se that retains patients in treatment.40 Following a move toward a harm minimization (rather than abstinence) in response to the perceived threat from the HIV, there was a rapid expansion of methadone treatment in Britain, the U.S., and Australia.41 Methadone treatment continues to play an important role in the prevention of the transmission of HIV infection among injectors of heroin.42,43 7.2.1.2 Treatment Compliance Studies of treatment response have shown that patients who comply with the recommended course of treatment have favorable outcomes during treatment and longer-lasting post-treatment benefits. Thus, it is discouraging for many practitioners that opiate users are frequently poorly compliant or noncompliant and subsequently resume substance use.44 Insufficient methadone dose has been identified as a major cause of therapeutic failure and relapse to re-abuse drugs,40 affecting behavior above and beyond individual differences in motivation and severity of drug dependence. Despite more than 35 years of clinical use of methadone for the treatment of heroin dependence, appropriate dosing remains controversial. However, a consistent relationship between higher doses of the drug, less illicit opioid use, and retention in treatment has been frequently observed.50,51 Previous research indicates that an insufficient dose (inadequate for the prevention of withdrawal symptoms for the total duration of the dosing interval, 24 h) is a major problem for opioid users during treatment.52 Unfortunately, the likelihood of success is offset by the fact that many patients do not remain in treatment until they are rehabilitated, and those who drop out usually return (relapse) to drug misuse.53


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7.2.1.3 Therapeutic Drug Monitoring for Methadone Many different parameters have been investigated to help assess the efficacy of methadone maintenance treatment. Randomized controlled trials to investigate methadone treatment have been advocated recently.32 A randomized-controlled trial of methadone maintenance treatment in 593 Australian prisoners indicated that heroin use was significantly lower among treated prisoners than control subjects at follow up.54,55 The usual procedure for assessing opioid users at clinics involves urinalysis screening for drugs of abuse (see Chapter 7.6). Urinalysis drug screening is an important way of assessing drug misuse by patients undergoing methadone treatment, but sheds no light on patient compliance, i.e., whether the patient is taking medication as prescribed. It is essential to know if a patient is taking all of their medication (at the correct time and in the correct amount) and to find out whether the patient is using extra methadone (obtained illicitly) or selling some of the prescription, perhaps to other users. Urinalysis will only indicate whether or not a patient has taken some of the medication. Dosage alterations based on interpretation of plasma measurements may help more patients do well on methadone.56–58 Scientific measurements, in addition to urinalysis and report systems, are clearly needed to evaluate patients. It was found that plasma measurements of methadone filled the gap and provided much needed evidence on compliance. Compliance in methadone maintenance patients has been measured using a pharmacological indicator to “estimate” plasma methadone concentrations. The study showed that many patients took their medication haphazardly (incorrect self-administration), whereas others supplemented their dose with illicit methadone.59 The success or failure of patients in methadone treatment may be related to the determination of an appropriate daily oral dose,60 identifying patients who respond poorly to treatment,61 and ensuring compliance to the dosage regimen. Such tasks are difficult as clinicians are currently without an accurate, convenient, and objective therapeutic tool for therapeutic drug monitoring. Blood is the primary biological sample for pharmacokinetic analyses, as both parent and metabolite concentrations can be quantified and samples cannot be adulterated by the donor.62 Methadone plasma concentration has been correlated to oral dose when compliance is good61,63,64 and plasma methadone concentration can be used to determine an appropriate oral dose. Studies have reported that there is a robust linear relationship between plasma methadone concentration and oral dose, when patients are on a constant dose, and compliance is good.64,65 This relationship can be demonstrated over a wide range of dosages (3 to 100 mg), and the correlation has been reported at r = 0.89.64 7.2.1.4 Indications for Plasma Methadone Monitoring Take-home methadone: Initially attendance at a methadone dispensing clinic is required on a daily basis to consume medication under staff supervision. This requirement becomes impractical when the patient is assuming responsibility and trying to engage in work, rehabilitation, education programs, or responsible homemaking. Shared-care may be a sensible solution. A collaborative relationship between the prescribing doctor, community pharmacist, and specialist drug treatment center has been advocated as good practice as a means to allow flexibility with prescribing. Unfortunately, the practice of permitting take-home supplies for unsupervised self-administration have contributed problems, including:66 1. 2. 3. 4.

Accidental ingestion of methadone by nontolerant persons, especially children Methadone toxic reactions Overdose fatalities Diversion for illicit sale


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5. Redistribution to other heroin users suffering from withdrawal symptoms 6. Redistribution to drug users seeking a new euphoriant

Monitoring the concentration of methadone in patients who take the drug away from the clinic is advisable to confirm that the prescribed dose is being consumed in the correct amount and at the correct time. Methadone is metabolized by a specific cytochrome P450 pathway, but as a predominantly oral drug absorption is a prerequisite for its activity. The absorption process is affected by many factors, not least the degree of intestinal first-pass metabolism, which occurs by cytochrome P4503A (CYP3A) and the active extrusion of absorbed drug by the multidrug efflux pump, Pglycoprotein (P-gr). Measuring N-demethylation activity or depletion in human liver microsomes and recombinant P450 isoform showed the highest contribution for CYP3A4.67,68 However, the metabolism of methadone is complex and has been shown to be subject to N-demethylation by CYP2B6, 2CI9, 2D6, and 2C9.69 Accordingly, CYP3A4 selective inhibitors or monoclonal human anti-CYP3A4 antibodies are able to inhibit the foundation of the main metabolic product EDDP by up to 80%,70 and CYP3A4 inducers produce a similar reaction in the opposite direction. Hence many compounds may affect methadone kinetics. Concomitant administration of enzyme-inducing (or inhibiting) drugs is said to be a factor influencing methadone kinetics. Reports suggest that rifampicin,71,72 phenytoin,73 barbiturates,74 and disulfiram75 are associated with unexpectedly low plasma methadone concentrations. Similar affects have been reported with zidovudine (azidothymidine; AZT), fucidic acid,76 and amitriptyline,77 which are not known enzyme inducers. Reports of the effect of drug inhibitors on the kinetics of methadone are less apparent clinically, but the effect has been demonstrated for fluconzole.78 Diazepam appears to inhibit the metabolism of methadone,79 but not with therapeutic (6–12

Source: Adapted from Olson.333

very short acting (midazolam), short acting (triazolam), intermediate acting (alprazolam), long acting (diazepam), and very long acting (flurazepam). Most of the benzodiazepines, except oxazepam and lorazepam, which are glucuronidated, are metabolized by liver cytochrome P450 and have active metabolites. Tolerance usually develops to benzodiazepines’ effects after continuous use, slowly for long-acting drugs (after about 1 month or more) and more rapidly for short-acting ones. Most users of benzodiazepines obtain the drugs by prescription. Benzodiazepines are abused usually by people who abuse other drugs as well.230,231 However, inappropriate chronic use by patients is also common.231,232 Because benzodiazepines cause physical and psychological dependence, they are generally recommended for limited periods of time (several weeks) and the doses carefully titrated.230,233,234 Side effects of use include daytime drowsiness, aggravation of depression, and memory impairment, especially anterograde amnesia.233,235–238 Benzodiazepine use in elderly individuals has been associated with falls and hip fractures, due to drowsiness and ataxia.239 Chronic benzodiazepine exposure in elderly individuals was associated with functional impairment similar to that caused by medical conditions.234 However, discontinuation of benzodiazepines results in normalization of memory and psychomotor performance.240,241 Short-acting benzodiazepines, in particular triazolam, have been associated with withdrawal symptoms during treatment. The symptoms include rebound insomnia and anxiety when the drug is stopped. The use of triazolam as a hypnotic has also been associated with global amnesia242 and affective and psychiatric disturbances.236 Intoxication with benzodiazepines results in CNS depression. In general, they have a very high toxic-therapeutic ratio, and doses 15 to 20 times the therapeutic dose may not cause serious side

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Table 8.1.11 Intoxication Mild

Moderate

Severe

Withdrawal

Manifestations of Sedative–Hypnotic Drug Intoxication and Withdrawal Sedation Disorientation Slurred speech Ataxia Nystagmus Coma, arousable by painful stimuli Hypoventilation Depressed deep tendon reflexes Coma, unarousable Absent corneal, gag, and deep tendon reflexes Hypoventilation, apnea Hypotension, shock Hypothermia Anxiety Insomnia Irritability Agitation Anorexia Tremor Seizures (short-acting benzodiazepines and barbiturates)

Source: Modified from Benowitz.186

effects. With high doses the patients present with lethargy, ataxia, or slurred speech (Table 8.1.11). With very high doses, and especially when there is co-ingestion of alcohol or barbiturates, coma and respiratory depression may occur. Rapid intravenous injection of diazepam and midazolam may cause respiratory arrest. Respiratory depression has also been reported with short-acting benzodiazepines, particularly triazolam. Withdrawal: Withdrawal usually occurs after sudden cessation of benzodiazepines; it is usually associated with a prolonged use of high doses, but also after therapeutic doses when the drug was used for several months. The symptoms include anxiety, panic attacks, insomnia, irritability, agitation, tremor, and anorexia (Table 8.1.11). Withdrawal from high doses of benzodiazepines and from short-acting benzodiazepines is usually more severe, and may result in seizures and psychotic reactions.243 The time course of the withdrawal syndrome depends on the half-life of the specific compound. 8.1.5.2 Barbiturates Barbiturates are clinically used as sedative–hypnotic drugs, and also for the treatment of epilepsy and induction of anesthesia. They modulate GABA receptor binding sites and potentiate the effects of the inhibitory neurotransmitter GABA. In high concentrations the barbiturates may enhance chloride ion flux independently.244 There are several classes of barbiturates based on their elimination half-life (Table 8.1.10B). The commonly used antiepileptic agent phenobarbital has a half-life of 80 to 120 h. Serious toxicity may occur when the ingested dose is five to ten times the therapeutic. Intoxication with barbiturates results in progressive encephalopathy and coma. Mild intoxication may present as oversedation, slurred speech, ataxia, and nystagmus. Severe intoxication may present with coma, absent reflexes, hypothermia, hypotension, and respiratory depression. Apnea and shock may occur. The time course of intoxication depends on the pharmacokinetics of the specific drug; for phenobarbital coma may last for 5 to 7 days. Barbiturates are usually abused as a “treatment” for unpleasant symptoms of stimulant intoxication; in this context, short-acting drugs, such as pentobarbital and secobarbital, are often used.245 Withdrawal: Withdrawal symptoms upon cessation of barbiturates occur after prolonged use even of therapeutic doses, although severe withdrawal is seen most commonly in polydrug abusers.


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The presentation is similar to that of benzodiazepines withdrawal, but there may be a greater risk of seizures with barbiturates withdrawal (Table 8.1.11). 8.1.5.3 Solvents Solvent abuse has been a problem for many years, particularly among adolescents. The most frequently abused agents are glues, paint thinners, nail lacquer removers, lighter fluids, cleaning solutions, aerosols, and gasoline.246,247 The most frequently encountered chemical is toluene, which is an ingredient in glues, paint thinners, and some petroleum products. Other chemicals are acetone in nail lacquer remover, naphtha, fluorinated hydrocarbons, trichloroethylene, and others. The methods of inhalation are breathing the substance from a plastic bag placed directly over the nose or the mouth, inhaling directly from the container or from impregnated rags, and spraying aerosols directly into the mouth. All the solvents are lipid-soluble, and thus easily cross the blood–brain barrier and cell membranes. They typically produce similar effects. The acute effects of solvent inhalation begin within minutes, and last 15 to 45 min after inhalation. Habitual abusers of solvents may have a rash around the nose and mouth from inhaling, and may have the odor of solvent on their breath.248 The typical effects are feelings of euphoria, disinhibition, and dizziness (Table 8.1.12). There may be also slurred speech, lack of coordination, and impaired judgment.248,249 More severe intoxication may result in nausea and vomiting, diarrhea, tremor, ataxia, paresthesia, diffuse pains, and hallucinations. Seizures and coma may ensue.247–250 The acute intoxication usually resolves quickly. Toluene abuse has been associated with renal tubular acidosis and severe hypokalemia, as well as interstitial nephritis, and acute tubular necrosis.251 There are deaths associated with acute solvent abuse, about half of them the result of accidents such as asphyxiation from the plastic bag. Almost all the rest are thought to be from cardiac causes, including ventricular fibrillation and pulmonary edema.249 Persistent toxic effects have been reported in chronic frequent abusers of volatile substances (Table 8.1.12). These include cerebellar syndrome, parkinsonism, and peripheral neuropathy and cognitive impairments. On magnetic resonance imaging (MRI), cerebral atrophy is seen, particularly in the areas of corpus callosum and cerebellar vermis; SPECT studies have demonstrated areas of hypoperfusion in the brain.252–254 Cerebellar syndrome is associated mainly with toluene abuse and presents with nystagmus, ataxia, and tremor. It may be reversible with continued abstinence.248 However, MRI changes demonstrating cerebral and cerebellar atrophy were found.254 There was a report of parkinsonism in a young patient who Table 8.1.12 Mild

Moderate

Severe Chronic

Manifestations of Solvent Intoxication and Abuse Euphoria Disinhibition Dizziness Slurred speech Lack of coordination Sneezing and coughing Lethargy, stupor Hallucinations Nausea, vomiting Diarrhea Ataxia Tremors Myalgias Paresthesias Coma Seizures Cerebellar syndrome: ataxia, nystagmus, tremor (toluene) Parkinsonism (toluene) Peripheral neuropathy: symmetrical, motor, mainly involving hands and feet (n-hexene, naphtha)


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chronically abused lacquer thinner; the symptoms persisted for more than 3 months after cessation of use.255 Peripheral neuropathy, predominantly motor and symmetrical, is associated with n-hexene and naphtha. Symptoms usually start weeks after the first exposure, and the deterioration may continue for several months after the cessation of solvents. There are reports of hepatitis and liver failure, renal failure, and aplastic anemia associated with chronic solvent abuse.256 Acknowledgments The authors acknowledge the support of NIH Grant DD01696.

REFERENCES 1. Gawin FH, Ellinwood EH, Jr. Cocaine and other stimulants. Actions, abuse, and treatment. N Engl J Med 1988;318(18):1173–82. 2. Boghdadi MS, Henning RJ. Cocaine: pathophysiology and clinical toxicology. Heart Lung 1997;26(6):466–83. 3. Williamson S, Gossop M, Powis B, Griffiths P, Fountain J, Strang J. Adverse effects of stimulant drugs in a community sample of drug users. Drug Alcohol Depend 1997;44(2–3):87–94. 4. Fleckenstein AE, Gibb JW, Hanson GR. Differential effects of stimulants on monoaminergic transporters: pharmacological consequences and implications for neurotoxicity. Eur J Pharmacol 2000;406(1):1–13. 5. Ramamoorthy S, Blakely RD. Phosphorylation and sequestration of serotonin transporters differentially modulated by psychostimulants. Science 1999;285(5428):763–6. 6. Lowenstein DH, Massa SM, Rowbotham MC, Collins SD, McKinney HE, Simon RP. Acute neurologic and psychiatric complications associated with cocaine abuse. Am J Med 1987;83(5):841–6. 7. Majewska MD. Cocaine addiction as a neurological disorder: Implications for treatment. NIDA Res Monogr 1996;163:1–26. 8. Daras M. Neurologic complications of cocaine. NIDA Res Monogr 1996;163:43–65. 9. Christensen JD, Kaufman MJ, Levin JM, Mendelson JH, Holman BL, Cohen BM, et al. Abnormal cerebral metabolism in polydrug abusers during early withdrawal: a 31P MR spectroscopy study. Magn Reson Med 1996;35(5):658–63. 10. Mueller PD, Benowitz NL, Olson KR. Cocaine. Emerg Med Clin North Am 1990;8(3):481–93. 11. Rowbotham MC. Neurologic aspects of cocaine abuse [clinical conference]. West J Med 1988;149(4):442–8. 12. Effiong C, Ahuja TS, Wagner JD, Singhal PC, Mattana J. Reversible hemiplegia as a consequence of severe hyperkalemia and cocaine abuse in a hemodialysis patient. Am J Med Sci 1997;314(6):408–10. 13. Petitti DB, Sidney S, Quesenberry C, Bernstein A. Stroke and cocaine or amphetamine use. Epidemiology 1998;9(6):596–600. 14. Tardiff K, Gross E, Wu J, Stajic M, Millman R. Analysis of cocaine-positive fatalities. J Forensic Sci 1989;34(1):53–63. 15. Keller TM, Chappell ET. Spontaneous acute subdural hematoma precipitated by cocaine abuse: case report. Surg Neurol 1997;47(1):12–4. 16. Kaufman MJ, Levin JM, Ross MH, Lange N, Rose SL, Kukes TJ, et al. Cocaine-induced cerebral vasoconstriction detected in humans with magnetic resonance angiography. JAMA 1998;279(5):376–80. 17. Fritsma GA, Leikin JB, Maturen AJ, Froelich CJ, Hryhorczuk DO. Detection of anticardiolipin antibody in patients with cocaine abuse. J Emerg Med 1991;9 Suppl 1:37–43. 18. Sanchez-Ramos JR. Psychostimulants. Neurol Clin 1993;11(3):535–53. 19. Catalano G, Catalano MC, Rodriguez R. Dystonia associated with crack cocaine use. South Med J 1997;90(10):1050–2. 20. Daras M, Koppel BS, Atos Radzion E. Cocaine-induced choreoathetoid movements (“crack dancing”). Neurology 1994;44(4):751–2.



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21. Winbery S, Blaho K, Logan B, Geraci S. Multiple cocaine-induced seizures and corresponding cocaine and metabolite concentrations. Am J Emerg Med 1998;16(5):529–33. 22. Zagnoni PG, Albano C. Psychostimulants and epilepsy. Epilepsia 2002;43 Suppl 2:28–31. 23. Naveen RA. Brain abscess: A complication of cocaine inhalation. NY State J Med 1988;88:548–50. 24. Benowitz NL. Clinical pharmacology and toxicology of cocaine [published erratum appears in Pharmacol Toxicol 1993 Jun;72(6):343]. Pharmacol Toxicol 1993;72(1):3–12. 25. Ghuran A, Nolan J. Recreational drug misuse: Issues for the cardiologist. Heart 2000;83(6):627–33. 26. Lange RA, Hillis LD. Cardiovascular complications of cocaine use. N Engl J Med 2001;345(5):351–8. 27. Benzaquen BS, Cohen V, Eisenberg MJ. Effects of cocaine on the coronary arteries. Am Heart J 2001;142(3):402–10. 28. Mittleman MA, Mintzer D, Maclure M, Tofler GH, Sherwood JB, Muller JE. Triggering of myocardial infarction by cocaine. Circulation 1999;99(21):2737–41. 29. Feldman JA, Fish SS, Beshansky JR, Griffith JL, Woolard RH, Selker HP. Acute cardiac ischemia in patients with cocaine-associated complaints: results of a multicenter trial. Ann Emerg Med 2000;36(5):469–76. 30. Nademanee K. Cardiovascular effects and toxicities of cocaine. J Addict Dis 1992;11(4):71–82. 31. Boutros HH, Pautler S, Chakrabarti S. Cocaine-induced ischemic colitis with small-vessel thrombosis of colon and gallbladder. J Clin Gastroenterol 1997;24(1):49–53. 32. Linder JD, Monkemuller KE, Raijman I, Johnson L, Lazenby AJ, Wilcox CM. Cocaine-associated ischemic colitis. South Med J 2000;93(9):909–13. 33. Niazi M, Kondru A, Levy J, Bloom AA. Spectrum of ischemic colitis in cocaine users. Dig Dis Sci 1997;42(7):1537–41. 34. Gamouras GA, Monir G, Plunkitt K, Gursoy S, Dreifus LS. Cocaine abuse: Repolarization abnormalities and ventricular arrhythmias. Am J Med Sci 2000;320(1):9–12. 35. Mirchandani HG, Rorke LB, Sekula-Perlman A, Hood IC. Cocaine-induced agitated delirium, forceful struggle, and minor head injury. A further definition of sudden death during restraint. Am J Forensic Med Pathol 1994;15(2):95–9. 36. Wetli CV, Mash D, Karch SB. Cocaine-associated agitated delirium and the neuroleptic malignant syndrome. Am J Emerg Med 1996;14(4):425–8. 37. Ruttenber AJ, McAnally HB, Wetli CV. Cocaine-associated rhabdomyolysis and excited delirium: Different stages of the same syndrome. Am J Forensic Med Pathol 1999;20(2):120–7. 38. Ruttenber AJ, Lawler Heavner J, Yin M, Wetli CV, Hearn WL, Mash DC. Fatal excited delirium following cocaine use: epidemiologic findings provide new evidence for mechanisms of cocaine toxicity. J Forensic Sci 1997;42(1):25–31. 39. Marzuk PM, Tardiff K, Leon AC, Hirsch CS, Stajic M, Portera L, et al. Fatal injuries after cocaine use as a leading cause of death among young adults in New York City. N Engl J Med 1995;332(26):1753–7. 40. Kissner DG, Lawrence WD, Selis JE, Flint A. Crack lung: pulmonary disease caused by cocaine abuse. Am Rev Respir Dis 1987;136(5):1250–2. 41. Tashkin DP. Airway effects of marijuana, cocaine, and other inhaled illicit agents. Curr Opin Pulm Med 2001;7(2):43–61. 42. Albertson TE, Walby WF. Respiratory toxicities from stimulant use. Clin Rev Allergy Immunol 1997;15(3):221–41. 43. Baldwin GC, Tashkin DP, Buckley DM, Park AN, Dubinett SM, Roth MD. Marijuana and cocaine impair alveolar macrophage function and cytokine production. Am J Respir Crit Care Med 1997;156(5):1606–13. 44. Crandall CG, Vongpatanasin W, Victor RG. Mechanism of cocaine-induced hyperthermia in humans. Ann Intern Med 2002;136(11):785–91. 45. Marzuk PM, Tardiff K, Leon AC, Hirsch CS, Portera L, Iqbal MI, et al. Ambient temperature and mortality from unintentional cocaine overdose. JAMA 1998;279(22):1795–800. 46. Bateman DA, Chiriboga CA. Dose–response effect of cocaine on newborn head circumference. Pediatrics 2000;106(3):E33. 47. Chiriboga CA, Brust JC, Bateman D, Hauser WA. Dose–response effect of fetal cocaine exposure on newborn neurologic function. Pediatrics 1999;103(1):79–85.


622


48. Lago JA, Kosten TR. Stimulant withdrawal. Addiction 1994;89(11):1477–81. 49. Yousef G, Huq Z, Lambert T. Khat chewing as a cause of psychosis. Br J Hosp Med 1995;54(7):322–6. 50. Battig K. Acute and chronic cardiovascular and behavioural effects of caffeine, aspirin and ephedrine. Int J Obes Relat Metab Disord 1993;17 Suppl 1:S61–4. 51. Bruno A, Nolte KB, Chapin J. Stroke associated with ephedrine use. Neurology 1993;43(7):1313–6. 52. Wooten MR, Khangure MS, Murphy MJ. Intracerebral hemorrhage and vasculitis related to ephedrine abuse. Ann Neurol 1983;13(3):337–40. 53. MMWR. Adverse events associated with ephedrine-containing products — Texas, December 1993–September 1995. MMWR Morb Mortal Wkly Rep 1996;45(32):689–93. 54. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000;343(25):1833–8. 55. Samenuk D, Link MS, Homoud MK, Contreras R, Theohardes TC, Wang PJ, et al. Adverse cardiovascular events temporally associated with ma huang, an herbal source of ephedrine. Mayo Clin Proc 2002;77(1):12–6. 56. Powell T, Hsu FF, Turk J, Hruska K. Ma-huang strikes again: Ephedrine nephrolithiasis. Am J Kidney Dis 1998;32(1):153–9. 57. Luqman W, Danowski TS. The use of khat (Catha edulis) in Yemen. Social and medical observations. Ann Intern Med 1976;85(2):246–249. 58. Pantelis C, Hindler CG, Taylor JC. Use and abuse of khat (Catha edulis): A review of the distribution, pharmacology, side effects and a description of psychosis attributed to khat chewing. Psychol Med 1989;19(3):657–68. 59. Morrish PK, Nicolaou N, Brakkenberg P, Smith PE. Leukoencephalopathy associated with khat misuse. J Neurol Neurosurg Psychiatry 1999;67(4):556. 60. Hassan NA, Gunaid AA, Abdo Rabbo AA, Abdel Kader ZY, al Mansoob MA, Awad AY, et al. The effect of Qat chewing on blood pressure and heart rate in healthy volunteers. Trop Doct 2000;30(2):107–8. 61. Al Motarreb A, Al Kebsi M, Al Adhi B, Broadley KJ. Khat chewing and acute myocardial infarction. Heart 2002;87(3):279–80. 62. Derlet RW, Rice P, Horowitz BZ, Lord RV. Amphetamine toxicity: Experience with 127 cases. J Emerg Med 1989;7(2):157–61. 63. Agaba EA, Lynch RM, Baskaran A, Jackson T. Massive intracerebral hematoma and extradural hematoma in amphetamine abuse. Am J Emerg Med 2002;20(1):55–7. 64. El Omar MM, Ray K, Geary R. Intracerebral haemorrhage in a young adult: consider amphetamine abuse. Br J Clin Pract 1996;50(2):115–6. 65. Matick H, Anderson D, Brumlik J. Cerebral vasculitis associated with oral amphetamine overdose. Arch Neurol 1983;40(4):253–4. 66. Shaw HE, Jr., Lawson JG, Stulting RD. Amaurosis fugax and retinal vasculitis associated with methamphetamine inhalation. J Clin Neuroophthalmol 1985;5(3):169–76. 67. Buxton N, McConachie NS. Amphetamine abuse and intracranial haemorrhage. J R Soc Med 2000;93(9):472–7. 68. Harris D, Batki SL. Stimulant psychosis: symptom profile and acute clinical course. Am J Addict 2000;9(1):28–37. 69. Flaum M, Schultz SK. When does amphetamine-induced psychosis become schizophrenia? Am J Psychiatry 1996;153(6):812–5. 70. Costa GM, Pizzi C, Bresciani B, Tumscitz C, Gentile M, Bugiardini R. Acute myocardial infarction caused by amphetamines: A case report and review of the literature. Ital Heart J 2001;2(6):478–80. 71. Waksman J, Taylor RN, Jr., Bodor GS, Daly FF, Jolliff HA, Dart RC. Acute myocardial infarction associated with amphetamine use. Mayo Clin Proc 2001;76(3):323–6. 72. Smith HJ, Roche AH, Jausch MF, Herdson PB. Cardiomyopathy associated with amphetamine administration. Am Heart J 1976;91(6):792–7. 73. Welling TH, Williams DM, Stanley JC. Excessive oral amphetamine use as a possible cause of renal and splanchnic arterial aneurysms: a report of two cases. J Vasc Surg 1998;28(4):727–31. 74. Callaway CW, Clark RF. Hyperthermia in psychostimulant overdose. Ann Emerg Med 1994; 24(1):68–76.



623

75. Albertson TE, Derlet RW, Van Hoozen BE. Methamphetamine and the expanding complications of amphetamines. West J Med 1999;170(4):214–9. 76. Buchanan JF, Brown CR. ‘Designer drugs.’ A problem in clinical toxicology. Med Toxicol Adverse Drug Exp 1988;3(1):1–17. 77. Rothrock JF, Rubenstein R, Lyden PD. Ischemic stroke associated with methamphetamine inhalation. Neurology 1988;38(4):589–92. 78. Perez JA, Jr., Arsura EL, Strategos S. Methamphetamine-related stroke: four cases. J Emerg Med 1999;17(3):469–71. 79. Richards JR, Johnson EB, Stark RW, Derlet RW. Methamphetamine abuse and rhabdomyolysis in the ED: A 5-year study. Am J Emerg Med 1999;17(7):681–5. 80. Schteinschnaider A, Plaghos LL, Garbugino S, Riveros D, Lazarowski A, Intruvini S, et al. Cerebral arteritis following methylphenidate use. J Child Neurol 2000;15(4):265–7. 81. Pentel P. Toxicity of over-the-counter stimulants. JAMA 1984;252(14):1898–903. 82. Kikta DG, Devereaux MW, Chandar K. Intracranial hemorrhages due to phenylpropanolamine. Stroke 1985;16(3):510–2. 83. Edwards M, Russo L, Harwood-Nuss A. Cerebral infarction with a single oral dose of phenylpropanolamine. Am J Emerg Med 1987;5(2):163–4. 84. Kernan WN, Viscoli CM, Brass LM, Broderick JP, Brott T, Feldmann E, et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med 2000;343(25):1826–32. 85. Mersfelder TL. Phenylpropanolamine and stroke: the study, the FDA ruling, the implications. Cleve Clin J Med 2001;68(3):208–9, 213–9, 223. 86. SoRelle R. FDA warns of stroke risk associated with phenylpropanolamine; cold remedies and drugs removed from store shelves. Circulation 2000;102(21):E9041–3. 87. Mueller SM. Neurologic complications of phenylpropanolamine use. Neurology 1983;33(5):650–2. 88. Goodhue A, Bartel RL, Smith NB. Exacerbation of psychosis by phenylpropanolamine. Am J Psychiatry 2000;157(6):1021–2. 89. Lake CR, Masson EB, Quirk RS. Psychiatric side effects attributed to phenylpropanolamine. Pharmacopsychiatry 1988;21(4):171–81. 90. Glick R, Hoying J, Cerullo L, Perlman S. Phenylpropanolamine: An over-the-counter drug causing central nervous system vasculitis and intracerebral hemorrhage. Case report and review. Neurosurgery 1987;20(6):969–74. 91. Aghajanian GK, Marek GJ. Serotonin model of schizophrenia: emerging role of glutamate mechanisms. Brain Res Brain Res Rev 2000;31(2–3):302–12. 92. Aghajanian GK, Marek GJ. Serotonin and hallucinogens. Neuropsychopharmacology 1999;21(2 Suppl):16s–23s. 93. Bruhn JG, De Smet PAGM, El Seedi HR, Beck O. Mescaline use for 5700 years. Lancet 2002;359(9320):1866. 94. Hollister LE, Hartman AM. Mescaline, lysergic acid diethylamide and psilocybin: comparison of clinical syndromes, effects on color perception and biochemical measures. Comprehensive Psychiatry 1962;3:235–241. 95. Leikin JB, Krantz AJ, Zell-Kanter M, Barkin RL, Hryhorczuk DO. Clinical features and management of intoxication due to hallucinogenic drugs. Med Toxicol Adverse Drug Exp 1989;4(5):324–50. 96. Kapadia GJ, Fayez MB. Peyote constituents: chemistry, biogenesis, and biological effects. J Pharm Sci 1970;59(12):1699–727. 97. Nolte KB, Zumwalt RE. Fatal peyote ingestion associated with Mallory-Weiss lacerations. West J Med 1999;170(6):328. 98. Hashimoto H, Clyde VJ, Parko KL. Botulism from peyote. N Engl J Med 1998;339(3):203–4. 99. Mack RB. Marching to a different cactus: peyote (mescaline) intoxication. N C Med J 1986;47(3):137–8. 100. Shulgin AT. Profiles of psychedelic drugs: TMA-2. J Psychedelic Drugs 1976;8:169. 101. Shulgin AT. Profiles of psychedelic drugs: STP. J Psychedelic Drugs 1977;9:171–172. 102. James RA, Dinan A. Hyperpyrexia associated with fatal paramethoxyamphetamine (PMA) abuse. Med Sci Law 1998;38(1):83–5. 103. Kraner JC, McCoy DJ, Evans MA, Evans LE, Sweeney BJ. Fatalities caused by the MDMA-related drug paramethoxyamphetamine (PMA). J Anal Toxicol 2001;25(7):645–8.


624


104. Byard RW, Gilbert J, James R, Lokan RJ. Amphetamine derivative fatalities in South Australia — is “Ecstasy” the culprit? Am J Forensic Med Pathol 1998;19(3):261–5. 105. Shulgin A. Profiles of psychedelic drugs: DOB. J Psychoactive Drugs 1981;13(1):99. 106. Buhrich N, Morris G, Cook G. Bromo-DMA: the Australasian hallucinogen? Aust NZ J Psychiatry 1983;17(3):275–9. 107. Simpson DL, Rumack BH. Methylenedioxyamphetamine. Clinical description of overdose, death, and review of pharmacology. Arch Intern Med 1981;141(11):1507–9. 108. Strote J, Lee JE, Wechsler H. Increasing MDMA use among college students: results of a national survey. J Adolesc Health 2002;30(1):64–72. 109. Steele TD, McCann UD, Ricaurte GA. 3,4-Methylenedioxymethamphetamine (MDMA, “Ecstasy”): pharmacology and toxicology in animals and humans. Addiction 1994;89(5):539–51. 110. Liechti ME, Gamma A, Vollenweider FX. Gender differences in the subjective effects of MDMA. Psychopharmacology (Berlin) 2001;154(2):161–8. 111. McCann UD, Ricaurte GA. MDMA (“ecstasy”) and panic disorder: induction by a single dose. Biol Psychiatry 1992;32(10):950–3. 112. Alciati A, Scaramelli B, Fusi A, Butteri E, Cattaneo ML, Mellado C. Three cases of delirium after “ecstasy” ingestion. J Psychoactive Drugs 1999;31(2):167–70. 113. Vaiva G, Boss V, Bailly D, Thomas P, Lestavel P, Goudemand M. An “accidental” acute psychosis with ecstasy use. J Psychoactive Drugs 2001;33(1):95–8. 114. Vollenweider FX, Gamma A, Liechti M, Huber T. Psychological and cardiovascular effects and shortterm sequelae of MDMA (“ecstasy”) in MDMA-naive healthy volunteers. Neuropsychopharmacology 1998;19(4):241–51. 115. Morgan MJ, McFie L, Fleetwood H, Robinson JA. Ecstasy (MDMA): Are the psychological problems associated with its use reversed by prolonged abstinence? Psychopharmacology (Berlin) 2002;159(3):294–303. 116. MacInnes N, Handley SL, Harding GF. Former chronic methylenedioxymethamphetamine (MDMA or ecstasy) users report mild depressive symptoms. J Psychopharmacol 2001;15(3):181–6. 117. Gerra G, Zaimovic A, Ampollini R, Giusti F, Delsignore R, Raggi MA, et al. Experimentally induced aggressive behavior in subjects with 3,4-methylenedioxy-methamphetamine (“Ecstasy”) use history: psychobiological correlates. J Subst Abuse 2001;13(4):471–91. 118. McCann UD, Slate SO, Ricaurte GA. Adverse reactions with 3,4-methylenedioxymethamphetamine (MDMA; “Ecstasy”). Drug Saf 1996;15(2):107–115. 119. Ricaurte GA, McCann UD. Assessing long-term effects of MDMA (Ecstasy). Lancet 2001;358(9296):1831–2. 120. Reneman L, Lavalaye J, Schmand B, de Wolff FA, van den Brink W, den Heeten GJ, et al. Cortical serotonin transporter density and verbal memory in individuals who stopped using 3,4-methylenedioxymethamphetamine (MDMA or “ecstasy”): preliminary findings. Arch Gen Psychiatry 2001;58(10):901–6. 121. Gouzoulis Mayfrank E, Daumann J, Tuchtenhagen F, Pelz S, Becker S, Kunert HJ, et al. Impaired cognitive performance in drug free users of recreational ecstasy (MDMA). J Neurol Neurosurg Psychiatry 2000;68(6):719–25. 122. Parrott AC, Sisk E, Turner JJ. Psychobiological problems in heavy “ecstasy” (MDMA) polydrug users. Drug Alcohol Depend 2000;60(1):105–10. 123. Verkes RJ, Gijsman HJ, Pieters MS, Schoemaker RC, de Visser S, Kuijpers M, et al. Cognitive performance and serotonergic function in users of ecstasy. Psychopharmacology (Berlin) 2001;153(2):196–202. 124. McCann UD, Ridenour A, Shaham Y, Ricaurte GA. Serotonin neurotoxicity after (+/–)3,4-methylenedioxymethamphetamine (MDMA; “Ecstasy”): a controlled study in humans. Neuropsychopharmacology 1994;10(2):129–38. 125. Kish SJ, Furukawa Y, Ang L, Vorce SP, Kalasinsky KS. Striatal serotonin is depleted in brain of a human MDMA (Ecstasy) user. Neurology 2000;55(2):294–6. 126. McCann UD, Szabo Z, Scheffel U, Dannals RF, Ricaurte GA. Positron emission tomographic evidence of toxic effect of MDMA (“Ecstasy”) on brain serotonin neurons in human beings. Lancet 1998;352(9138):1433–7.



625

127. Reneman L, Booij J, de Bruin K, Reitsma JB, de Wolff FA, Gunning WB, et al. Effects of dose, sex, and long-term abstention from use on toxic effects of MDMA (ecstasy) on brain serotonin neurons. Lancet 2001;358(9296):1864–9. 128. Lester SJ, Baggott M, Welm S, Schiller NB, Jones RT, Foster E, et al. Cardiovascular effects of 3,4methylenedioxymethamphetamine. A double-blind, placebo-controlled trial. Ann Intern Med 2000;133(12):969–73. 129. Mas M, Farre M, de la Torre R, Roset PN, Ortuno J, Segura J, et al. Cardiovascular and neuroendocrine effects and pharmacokinetics of 3, 4-methylenedioxymethamphetamine in humans. J Pharmacol Exp Ther 1999;290(1):136–45. 130. Henry JA. Ecstasy and the dance of death. Br Med J 1992;305(6844):5–6. 131. Milroy CM, Clark JC, Forrest AR. Pathology of deaths associated with “ecstasy” and “eve” misuse. J Clin Pathol 1996;49(2):149–53. 132. Jones AL, Simpson KJ. Review article: mechanisms and management of hepatotoxicity in ecstasy (MDMA) and amphetamine intoxications. Aliment Pharmacol Ther 1999;13(2):129–33. 133. Brauer RB, Heidecke CD, Nathrath W, Beckurts KT, Vorwald P, Zilker TR, et al. Liver transplantation for the treatment of fulminant hepatic failure induced by the ingestion of ecstasy. Transpl Int 1997;10(3):229–33. 134. Garbino J, Henry JA, Mentha G, Romand JA. Ecstasy ingestion and fulminant hepatic failure: liver transplantation to be considered as a last therapeutic option. Vet Hum Toxicol 2001;43(2):99–102. 135. Maxwell DL, Polkey MI, Henry JA. Hyponatraemia and catatonic stupor after taking “ecstasy” [see comments]. Br Med J 1993;307(6916):1399. 136. Satchell SC, Connaughton M. Inappropriate antidiuretic hormone secretion and extreme rises in serum creatinine kinase following MDMA ingestion. Br J Hosp Med 1994;51(9):495. 137. Forsling M, Fallon JK, Kicman AT, Hutt AJ, Cowan DA, Henry JA. Arginine vasopressin release in response to the administration of 3,4-methylenedioxymethamphetamine (“ecstasy”): Is metabolism a contributory factor? J Pharm Pharmacol 2001;53(10):1357–63. 138. Henry JA, Fallon JK, Kicman AT, Hutt AJ, Cowan DA, Forsling M. Low-dose MDMA (“ecstasy”) induces vasopressin secretion. Lancet 1998;351(9118):1784. 139. Wilkins B. Cerebral oedema after MDMA (“ecstasy”) and unrestricted water intake. Hyponatraemia must be treated with low water input. Br Med J 1996;313(7058):689–90. 140. Williams H, Dratcu L, Taylor R, Roberts M, Oyefeso A. “Saturday night fever”: Ecstasy related problems in a London accident and emergency department. J Accid Emerg Med 1998;15(5):322–6. 141. Mueller PD, Korey WS. Death by “ecstasy”: The serotonin syndrome? Ann Emerg Med 1998;32(3 Pt 1):377–80. 142. Henry JA, Hill IR. Fatal interaction between ritonavir and MDMA. Lancet 1998;352(9142):1751–2. 143. Harrington RD, Woodward JA, Hooton TM, Horn JR. Life-threatening interactions between HIV-1 protease inhibitors and the illicit drugs MDMA and gamma-hydroxybutyrate. Arch Intern Med 1999;159(18):2221–4. 144. McElhatton PR, Bateman DN, Evans C, Pughe KR, Thomas SH. Congenital anomalies after prenatal ecstasy exposure. Lancet 1999;354(9188):1441–2. 145. Webb E, Ashton CH, Kelly P, Kamali F. Alcohol and drug use in UK university students. Lancet 1996;348(9032):922–5. 146. Golub A, Johnson BD, Sifaneck SJ, Chesluk B, Parker H. Is the U.S. experiencing an incipient epidemic of hallucinogen use? Subst Use Misuse 2001;36(12):1699–729. 147. Jacobs BL. How hallucinogenic drugs work. Am Sci 1987;75:386–392. 148. Schwartz RH. LSD. Its rise, fall, and renewed popularity among high school students. Pediatr Clin North Am 1995;42(2):403–13. 149. Abraham HD, Aldridge AM. Adverse consequences of lysergic acid diethylamide. Addiction 1993;88(10):1327–34. 150. Kawasaki A, Purvin V. Persistent palinopsia following ingestion of lysergic acid diethylamide (LSD). Arch Ophthalmol 1996;114(1):47–50. 151. Contreras PC, Monahan JB, Lanthorn TH, Pullan LM, DiMaggio DA, Handelmann GE, et al. Phencyclidine. Physiological actions, interactions with excitatory amino acids and endogenous ligands. Mol Neurobiol 1987;1(3):191–211.


626


152. Sonders MS, Keana JF, Weber E. Phencyclidine and psychotomimetic sigma opiates: recent insights into their biochemical and physiological sites of action. Trends Neurosci 1988;11(1):37–40. 153. Brust JC. Other agents. Phencyclidine, marijuana, hallucinogens, inhalants, and anticholinergics. Neurol Clin 1993;11(3):555–61. 154. McCarron MM, Schulze BW, Thompson GA, Conder MC, Goetz WA. Acute phencyclidine intoxication: Clinical patterns, complications, and treatment. Ann Emerg Med 1981;10(6):290–7. 155. Aniline O, Pitts FN, Jr. Phencyclidine (PCP): a review and perspectives. Crit Rev Toxicol 1982;10(2):145–77. 156. Martin BR, Mechoulam R, Razdan RK. Discovery and characterization of endogenous cannabinoids. Life Sci 1999;65(6–7):573–95. 157. Ameri A. The effects of cannabinoids on the brain. Prog Neurobiol 1999;58(4):315–48. 158. Ashton CH. Pharmacology and effects of cannabis: a brief review. Br J Psychiatry 2001;178:101–6. 159. Gruber AJ, Pope HG, Jr. Marijuana use among adolescents. Pediatr Clin North Am 2002;49(2):389–413. 160. Gledhill Hoyt J, Lee H, Strote J, Wechsler H. Increased use of marijuana and other illicit drugs at US colleges in the 1990s: results of three national surveys. Addiction 2000;95(11):1655–67. 161. Harris D, Jones RT, Shank R, Nath R, Fernandez E, Goldstein K, et al. Self-reported marijuana effects and characteristics of 100 San Francisco medical marijuana club members. J Addict Dis 2000;19(3):89–103. 162. Hall W, Solowij N. Adverse effects of cannabis. Lancet 1998;352(9140):1611–6. 163. Johns A. Psychiatric effects of cannabis. Br J Psychiatry 2001;178:116–22. 164. Nunez LA, Gurpegui M. Cannabis-induced psychosis: a cross-sectional comparison with acute schizophrenia. Acta Psychiatr Scand 2002;105(3):173–8. 165. Farber SJ, Huertas VE. Intravenously injected marijuana syndrome. Arch Int Med 1976;136:337–339. 166. Solowij N, Stephens RS, Roffman RA, Babor T, Kadden R, Miller M, et al. Cognitive functioning of long-term heavy cannabis users seeking treatment. JAMA 2002;287(9):1123–31. 167. Pope HG, Jr., Yurgelun Todd D. The residual cognitive effects of heavy marijuana use in college students. JAMA 1996;275(7):521–7. 168. Pope HG, Jr., Gruber AJ, Hudson JI, Huestis MA, Yurgelun Todd D. Neuropsychological performance in long-term cannabis users. Arch Gen Psychiatry 2001;58(10):909–15. 169. Pope HG, Jr. Cannabis, cognition, and residual confounding. JAMA 2002;287(9):1172–4. 170. Hollister LE. Health aspects of cannabis. Pharmacol Rev 1986;38(1):1–20. 171. Fergusson DM, Horwood LJ, Northstone K. Maternal use of cannabis and pregnancy outcome. BJOG 2002;109(1):21–7. 172. Fried PA, Smith AM. A literature review of the consequences of prenatal marihuana exposure. An emerging theme of a deficiency in aspects of executive function. Neurotoxicol Teratol 2001;23(1):1–11. 173. Taylor FMd. Marijuana as a potential respiratory tract carcinogen: a retrospective analysis of a community hospital population. South Med J 1988;81(10):1213–6. 174. Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. N Engl J Med 1988;318(6):347–51. 175. Taylor DR, Poulton R, Moffitt TE, Ramankutty P, Sears MR. The respiratory effects of cannabis dependence in young adults. Addiction 2000;95(11):1669–77. 176. Van Hoozen BE, Cross CE. Marijuana. Respiratory tract effects. Clin Rev Allergy Immunol 1997;15(3):243–69. 177. Zhang ZF, Morgenstern H, Spitz MR, Tashkin DP, Yu GP, Marshall JR, et al. Marijuana use and increased risk of squamous cell carcinoma of the head and neck. Cancer Epidemiol Biomarkers Prev 1999;8(12):1071–8. 178. Feldman AL, Sullivan JT, Passero MA, Lewis DC. Pneumothorax in polysubstance-abusing marijuana and tobacco smokers: three cases. J Subst Abuse 1993;5(2):183–6. 179. von Sydow K, Lieb R, Pfister H, Hofler M, Sonntag H, Wittchen HU. The natural course of cannabis use, abuse and dependence over four years: a longitudinal community study of adolescents and young adults. Drug Alcohol Depend 2001;64(3):347–61. 180. Swift W, Hall W, Teesson M. Characteristics of DSM-IV and ICD-10 cannabis dependence among Australian adults: results from the National Survey of Mental Health and Wellbeing. Drug Alcohol Depend 2001;63(2):147–53.



627

181. Rosenberg MF, Anthony JC. Early clinical manifestations of cannabis dependence in a community sample. Drug Alcohol Depend 2001;64(2):123–31. 182. Coffey C, Carlin JB, Degenhardt L, Lynskey M, Sanci L, Patton GC. Cannabis dependence in young adults: an Australian population study. Addiction 2002;97(2):187–94. 183. Budney AJ, Hughes JR, Moore BA, Novy PL. Marijuana abstinence effects in marijuana smokers maintained in their home environment. Arch Gen Psychiatry 2001;58(10):917–24. 184. Kouri EM, Pope HG, Jr. Abstinence symptoms during withdrawal from chronic marijuana use. Exp Clin Psychopharmacol 2000;8(4):483–92. 185. Foley KM. Opioids. Neurol Clin 1993;11(3):503–22. 186. Benowitz NL. Substance abuse: dependence and treatment. In: Melmon KL, Morrelli HF, Hoffman BB, Nierenberg DW, Eds. Clinical Pharmacology. 3 ed: New York: McGraw-Hill; 1992. p. 763–786. 187. Zebraski SE, Kochenash SM, Raffa RB. Lung opioid receptors: pharmacology and possible target for nebulized morphine in dyspnea. Life Sci 2000;66(23):2221–31. 188. Karch SB. The Pathology of Drug Abuse. Boca Raton, FL: CRC Press; 1993. 189. Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics. JAMA 2000;283(13):1710–4. 190. Pasternak GW. Insights into mu opioid pharmacology: the role of mu opioid receptor subtypes. Life Sci 2001;68(19–20):2213–9. 191. Pasternak GW. The pharmacology of mu analgesics: from patients to genes. Neuroscientist 2001;7(3):220–31. 192. Zaki PA, Bilsky EJ, Vanderah TW, Lai J, Evans CJ, Porreca F. Opioid receptor types and subtypes: the delta receptor as a model. Annu Rev Pharmacol Toxicol 1996;36:379–401. 193. Pappagallo M. Incidence, prevalence, and management of opioid bowel dysfunction. Am J Surg 2001;182(5A Suppl):11s–18s. 194. Ling GS, Spiegel K, Lockhart SH, Pasternak GW. Separation of opioid analgesia from respiratory depression: evidence for different receptor mechanisms. J Pharmacol Exp Ther 1985;232(1):149–55. 195. Ballantyne JC, Loach AB, Carr DB. Itching after epidural and spinal opiates. Pain 1988;33(2):149–60. 196. Dray A. Epidural opiates and urinary retention: new models provide new insights [editorial]. Anesthesiology 1988;68(3):323–4. 197. Smith MT. Neuroexcitatory effects of morphine and hydromorphone: evidence implicating the 3glucuronide metabolites. Clin Exp Pharmacol Physiol 2000;27(7):524–8. 198. Mercadante S. Opioid rotation for cancer pain: rationale and clinical aspects. Cancer 1999;86(9):1856–66. 199. Chan P, Lin TH, Luo JP, Deng JF. Acute heroin intoxication with complications of acute pulmonary edema, acute renal failure, rhabdomyolysis and lumbosacral plexitis: a case report. Chung Hua I Hsueh Tsa Chih (Taipei) 1995;55(5):397–400. 200. Richter RW. Muscle damage in heroin addicts. N Engl J Med 1971;284(15):920. 201. Klockgether T, Weller M, Haarmeier T, Kaskas B, Maier G, Dichgans J. Gluteal compartment syndrome due to rhabdomyolysis after heroin abuse. Neurology 1997;48(1):275–6. 202. Rice EK, Isbel NM, Becker GJ, Atkins RC, McMahon LP. Heroin overdose and myoglobinuric acute renal failure. Clin Nephrol 2000;54(6):449–54. 203. Dubrow A, Mittman N, Ghali V, Flamenbaum W. The changing spectrum of heroin-associated nephropathy. Am J Kidney Dis 1985;5(1):36–41. 204. Niehaus L, Meyer BU. Bilateral borderzone brain infarctions in association with heroin abuse. J Neurol Sci 1998;160(2):180–2. 205. Buttner A, Mall G, Penning R, Weis S. The neuropathology of heroin abuse. Forensic Sci Int 2000;113(1–3):435–42. 206. Schoser BG, Groden C. Subacute onset of oculogyric crises and generalized dystonia following intranasal administration of heroin. Addiction 1999;94(3):431–4. 207. Kathiramalainathan K, Kaplan HL, Romach MK, Busto UE, Li NY, Sawe J, et al. Inhibition of cytochrome P450 2D6 modifies codeine abuse liability. J Clin Psychopharmacol 2000;20(4): 435–44. 208. Romach MK, Otton SV, Somer G, Tyndale RF, Sellers EM. Cytochrome P450 2D6 and treatment of codeine dependence. J Clin Psychopharmacol 2000;20(1):43–5. 209. Drummer OH, Opeskin K, Syrjanen M, Cordner SM. Methadone toxicity causing death in ten subjects starting on a methadone maintenance program. Am J Forensic Med Pathol 1992;13(4):346–50.


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210. Ng B, Alvear M. Dextropropoxyphene addiction — a drug of primary abuse. Am J Drug Alcohol Abuse 1993;19(2):153–8. 211. Lawson AA, Northridge DB. Dextropropoxyphene overdose. Epidemiology, clinical presentation and management. Med Toxicol Adverse Drug Exp 1987;2(6):430–44. 212. Stork CM, Redd JT, Fine K, Hoffman RS. Propoxyphene-induced wide QRS complex dysrhythmia responsive to sodium bicarbonate — A case report. J Toxicol Clin Toxicol 1995;33(2):179–83. 213. Yee LY, Lopez JR. Transdermal fentanyl. Ann Pharmacother 1992;26(11):1393–9. 214. Sprung J, Schedewie HK. Apparent focal motor seizure with a jacksonian march induced by fentanyl: a case report and review of the literature. J Clin Anesth 1992;4(2):139–43. 215. Caspi J, Klausner JM, Safadi T, Amar R, Rozin RR, Merin G. Delayed respiratory depression following fentanyl anesthesia for cardiac surgery. Crit Care Med 1988;16(3):238–40. 216. Drummer OH, Syrjanen ML, Phelan M, Cordner SM. A study of deaths involving oxycodone. J Forensic Sci 1994;39(4):1069–75. 217. Stock SL, Catalano G, Catalano MC. Meperidine associated mental status changes in a patient with chronic renal failure. J Fla Med Assoc 1996;83(5):315–9. 218. Hassan H, Bastani B, Gellens M. Successful treatment of normeperidine neurotoxicity by hemodialysis. Am J Kidney Dis 2000;35(1):146–9. 219. Kussman BD, Sethna NF. Pethidine-associated seizure in a healthy adolescent receiving pethidine for postoperative pain control. Paediatr Anaesth 1998;8(4):349–52. 220. Latta KS, Ginsberg B, Barkin RL. Meperidine: a critical review. Am J Ther 2002;9(1):53–68. 221. Zabetian CP, Staley JK, Flynn DD, Mash DC. [3H]-(+)-Pentazocine binding to sigma recognition sites in human cerebellum. Life Sci 1994;55(20):L389–95. 222. Pfeiffer A, Brantl V, Herz A, Emrich HM. Psychotomimesis mediated by kappa opiate receptors. Science 1986;233(4765):774–6. 223. Das CP, Thussu A, Prabhakar S, Banerjee AK. Pentazocine-induced fibromyositis and contracture. Postgrad Med J 1999;75(884):361–2. 224. Sinsawaiwong S, Phanthumchinda K. Pentazocine-induced fibrous myopathy and localized neuropathy. J Med Assoc Thai 1998;81(9):717–21. 225. Farrell M. Opiate withdrawal. Addiction 1994;89(11):1471–5. 226. Tallman JF, Gallager DW, Mallorga P, Thomas JW, Strittmatter W, Hirata F, et al. Studies on benzodiazepine receptors. Adv Biochem Psychopharmacol 1980;21:277–83. 227. Miller LG, Greenblatt DJ, Roy RB, Summer WR, Shader RI. Chronic benzodiazepine administration. II. Discontinuation syndrome is associated with upregulation of gamma-aminobutyric acidA receptor complex binding and function. J Pharmacol Exp Ther 1988;246(1):177–82. 228. Lader M. Biological processes in benzodiazepine dependence. Addiction 1994;89(11):1413–8. 229. Bateson AN. Basic pharmacologic mechanisms involved in benzodiazepine tolerance and withdrawal. Curr Pharm Des 2002;8(1):5–21. 230. Woods JH, Winger G. Current benzodiazepine issues. Psychopharmacology (Berlin) 1995;118(2):107–15; discussion 118, 120–1. 231. Griffiths RR, Weerts EM. Benzodiazepine self-administration in humans and laboratory animals — implications for problems of long-term use and abuse. Psychopharmacology (Berlin) 1997;134(1):1–37. 232. Michelini S, Cassano GB, Frare F, Perugi G. Long-term use of benzodiazepines: tolerance, dependence and clinical problems in anxiety and mood disorders. Pharmacopsychiatry 1996;29(4):127–34. 233. Ashton H. Guidelines for the rational use of benzodiazepines. When and what to use. Drugs 1994;48(1):25–40. 234. Nelson J, Chouinard G. Guidelines for the clinical use of benzodiazepines: pharmacokinetics, dependency, rebound and withdrawal. Canadian Society for Clinical Pharmacology. Can J Clin Pharmacol 1999;6(2):69–83. 235. Vgontzas AN, Kales A, Bixler EO. Benzodiazepine side effects: role of pharmacokinetics and pharmacodynamics. Pharmacology 1995;51(4):205–23. 236. Fraser AD. Use and abuse of the benzodiazepines. Ther Drug Monit 1998;20(5):481–9. 237. Buffett Jerrott SE, Stewart SH. Cognitive and sedative effects of benzodiazepine use. Curr Pharm Des 2002;8(1):45–58.



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238. Buffett Jerrott SE, Stewart SH, Teehan MD. A further examination of the time-dependent effects of oxazepam and lorazepam on implicit and explicit memory. Psychopharmacology (Berlin) 1998;138(3–4):344–53. 239. Wysowski DK, Baum C, Ferguson WJ, Lundin F, Ng MJ, Hammerstrom T. Sedative–hypnotic drugs and the risk of hip fracture. J Clin Epidemiol 1996;49(1):111-3. 240. Rickels K, Lucki I, Schweizer E, Garcia Espana F, Case WG. Psychomotor performance of long-term benzodiazepine users before, during, and after benzodiazepine discontinuation. J Clin Psychopharmacol 1999;19(2):107–13. 241. Kilic C, Curran HV, Noshirvani H, Marks IM, Basoglu M. Long-term effects of alprazolam on memory: a 3.5 year follow-up of agoraphobia/panic patients. Psychol Med 1999;29(1):225–31. 242. Morris HHd, Estes ML. Traveler’s amnesia. Transient global amnesia secondary to triazolam. JAMA 1987;258(7):945–6. 243. Petursson H. The benzodiazepine withdrawal syndrome. Addiction 1994;89(11):1455–9. 244. Ito T, Suzuki T, Wellman SE, Ho IK. Pharmacology of barbiturate tolerance/dependence: GABAA receptors and molecular aspects. Life Sci 1996;59(3):169–95. 245. Coupey SM. Barbiturates. Pediatr Rev 1997;18(8):260–4. 246. Kurtzman TL, Otsuka KN, Wahl RA. Inhalant abuse by adolescents. J Adolesc Health 2001;28(3):170–80. 247. Brouette T, Anton R. Clinical review of inhalants. Am J Addict 2001;10(1):79–94. 248. Ron MA. Volatile substance abuse: a review of possible long-term neurological, intellectual and psychiatric sequelae. Br J Psychiatry 1986;148:235–46. 249. al-Alousi LM. Pathology of volatile substance abuse: a case report and a literature review. Med Sci Law 1989;29(3):189–208. 250. Meadows R, Verghese A. Medical complications of glue sniffing. South Med J 1996;89(5):455–62. 251. Crowe AV, Howse M, Bell GM, Henry JA. Substance abuse and the kidney. QJM 2000;93(3):147–52. 252. Rosenberg NL, Grigsby J, Dreisbach J, Busenbark D, Grigsby P. Neuropsychologic impairment and MRI abnormalities associated with chronic solvent abuse. J Toxicol Clin Toxicol 2002;40(1):21–34. 253. Kucuk NO, Kilic EO, Ibis E, Aysev A, Gencoglu EA, Aras G, et al. Brain SPECT findings in longterm inhalant abuse. Nucl Med Commun 2000;21(8):769–73. 254. Kamran S, Bakshi R. MRI in chronic toluene abuse: low signal in the cerebral cortex on T2-weighted images. Neuroradiology 1998;40(8):519–21. 255. Uitti RJ, Snow BJ, Shinotoh H, Vingerhoets FJ, Hayward M, Hashimoto S, et al. Parkinsonism induced by solvent abuse. Ann Neurol 1994;35(5):616–9. 256. Schuckit MA. Drug and Alcohol Abuse. 3 ed. New York: Plenum Press; 1989. 257. Olson KR, Pentel PR, Kelly MT. Physical agreement and differential diagnosis of the poisoned patient. Med Toxicol 1987;2:52–81. 258. Albertson TE. Barbiturates. In: Olson KR, Ed. Poisoning and Drug Overdose. 3 ed. Stamford, CT: Appleton & Lange; 1999.

8.2 EMERGENCY MANAGEMENT OF DRUG ABUSE

Brett A. Roth, M.D.,1 Neal L. Benowitz, M.D.,2 and Kent R. Olson, M.D.2 1

University of Texas Southwestern Medical Center, Dallas, Texas Division of Clinical Pharmacology and Experimental Therapeutics, University of California, San Francisco, California 2

The management of complications from drug abuse demands a variety of skills from airway management to control of seizures and shock. Several reviews have addressed the issues of general resuscitation1–3 and toxidromes.4–8 The purpose of this chapter is to present a series of management strategies for the emergency physician or other clinical personnel caring for patients with acute


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complications from drug abuse. Immediate interventions (e.g., resuscitation and stabilization), secondary interventions (e.g., emergency care after the patient is stable), as well as diagnostic workup (e.g., laboratory data, imaging), and disposition of the patient are discussed. This chapter proposes a variety of treatment approaches based on a review of the pertinent literature and clinical experience. A general treatment approach based on symptom complex (i.e., seizures, coma, hyperthermia) is presented since initial management decisions frequently have to be made without the benefit of a reliable history. This is followed by a brief review of the each particular drug of abuse (i.e., psychostimulants, opiates, hallucinogens). The reader is referred to the previous chapter, Medical Aspects of Drug Abuse, for a detailed description of the clinical toxicology associated with each drug of abuse. It should be emphasized that the adverse reaction to a drug may depend on the unique characteristics of an individual (i.e., presence of cardiovascular disease) as well as the type of drug abused. These protocols serve as guidelines only and an individualized approach to management should be made whenever possible. 8.2.1

Decreased Mental Status: Coma, Stupor, and Lethargy

8.2.1.1 General Comments In the setting of drug overdose, coma usually reflects global depression of the brain’s cerebral cortex. This can be a direct effect of the drug on specific neurotransmitters or receptors or an indirect process such as trauma or asphyxia. Treatment deals largely with maintaining a functional airway, the administration of potential antidotes, and evaluation for underlying medical conditions. The following section describes the appropriate use of antidotes and the approach to the patient with a decreased level of consciousness from drug abuse. Level vs. content of consciousness: It is often useful to distinguish between the level and the content of consciousness. Alertness and wakefulness refer to the level of consciousness; awareness is a reflection of the content of consciousness.9 In referring to coma, stupor, and lethargy here we address the level of consciousness as it applies to the drug-abusing patient along a clinical spectrum with deep coma on one end, stupor in the middle, and lethargy representing a mildly decreased level of consciousness. Agitation, delirium, and psychosis is addressed in a subsequent section with a greater focus on content of consciousness, i.e., presence or absence of hallucinations, paranoia, severe depression, etc. Attributes of a good antidote: The ideal antidote should be safe, effective, rapidly acting, and easy to administer. It should also have low abuse potential, and act as long as the intoxicating drug. The following standard antidotes are of potentially great benefit and little harm in all patients. Thiamine: Thiamine is an important cofactor for several metabolic enzymes that are vital for the metabolism of carbohydrates and for the proper function of the pentose–phosphate pathway.10 When thiamine is absent or deficient, Wernicke’s encephalopathy, classically described as a triad of oculomotor abnormalities, ataxia, and global confusion, may result. Although Wernicke’s is rare, empiric treatment for this disease is safe,11 inexpensive (wholesale price of 100 mg of thiamine is approximately $1), and cost-effective.12 Dextrose: Hypoglycemia is a common cause of coma or stupor and should be assessed or treated empirically in all patients with deceased level of consciousness. Concerns about 50% dextrose causing an increase in infarct size and mortality in stroke,13–15 as well as increasing serum hypertonicity in hyperosmolar patients, have been raised when arguing the benefits of routine administration of 50% dextrose. Animal models of stroke16 that showed worse outcomes associated with hyperglycemic subjects used large doses of dextrose (approximately 2 mg/kg) as opposed to the 0.3 g/kg (25 g in a 70-kg adult) routinely given as part of the coma cocktail. Also, one ampoule of 50% dextrose in water should only raise the serum glucose level of a 70-kg patient by about 60 mg/dl (0.3 mOsm) if it distributes into total body water prior to any elimination or metabolism.17



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Naloxone: A 19th-century method for treating opiate overdose: The surface of the body may be stimulated by whipping,… the patient should be made to walk around for 6–8 hours18 Shoemaker, 1896

Fortunately, the use of modern antidotes such as naloxone can provide a more effective and less abusive reversal of opiate-induced narcosis. In addition to reversing respiratory depression and eliminating the need for airway interventions, naloxone may assist in the diagnosis of opiate overdose and eliminate the need for diagnostic studies such as lumbar puncture and computed tomography (CT) scanning. Despite its advances over 19th-century treatments for narcotic overdose, naloxone may not always be the best approach to management. The risk of “unmasking,” or exposing the effects of dangerous co-ingestions such as cocaine or PCP19 and of precipitating opiate withdrawal must be considered. The main effects of naloxone include the reversal of coma and respiratory depression induced by exogenous opiates, but it also reverses miosis, analgesia, bradycardia, and gastrointestinal stasis.20 Presumably related to the reversal of the effects of endogenous opioid peptides, such as endorphins and enkephalins, naloxone has also been reported to have nonspecific benefit (e.g., reversing properties) for the treatment of ethanol, clonidine, captopril, and valproic acid.21–24 These “nonspecific” responses are usually not as complete as a true reversal of opiateinduced coma by naloxone. The current literature raises many serious concerns about the safety of naloxone. Pulmonary edema,25–30 hypertension,31–33 seizures,34 arrhythmias,33,35 and cardiac arrest36 have been reported following naloxone administration. In addition, reversing the sedating effects of a drug like heroin may produce acute withdrawal symptoms,37 which, although they are not lifethreatening, can cause the patient to become agitated, demanding, or even violent.38 Considering the great number of patients who have received large doses of naloxone as part of controlled trials for shock,39–42 stroke,43–46 and spinal cord injuries,47–49 as part of healthy volunteer studies,50,51 and for overdose management,52,53 all without significant complications, the use of naloxone appears relatively safe.17 Opioid withdrawal symptoms commonly occur in addicted patients given naloxone.37 While withdrawal symptoms are treatable, the best approach is avoidance. Withdrawal symptoms may be avoided either by (1) withholding opioid antagonists from known drug addicts and supporting the airway with traditional methods (e.g., endotracheal intubation) or (2) by titrating the dose of naloxone slowly such that enough antidote is given to arouse the patient but not to precipitate withdrawal. The latter can be done by administering small doses (0.2 to 0.4 mg) intravenously in a repetitive manner. While conjunctival54 and nasal55,56 testing for opioid addiction have been described, these tests are impractical in the patient with altered mental status in whom immediate action is necessary. Nalmefene: Nalmefene (t1/2 = 8 to 9 hours) is a methylene analogue of naltrexone that, like naloxone, is a pure opioid antagonist. It was developed to address concerns about the short duration of action of naloxone (~60 min). Studies have proved it to be as safe and effective with a duration of action at least twice as long as naloxone.57 Other reports suggest a duration of action of up to 4 h.57–59 However, 4 h is still not long enough to safely manage patients who have overdosed on long-lasting opiates such as methadone (t1/2 up to 48 h) or propoxyphene (t1/2 of active metabolite up to 36 h), or in those patients with delayed absorption. The use of nalmefene may potentially be advantageous due to (1) less risk of recurrent respiratory depression in the patient who leaves the emergency department against medical advise, (2) fewer doses of antagonist needed, cutting down on nursing time, and (3) fewer complications resulting from fluctuations in levels of consciousness (e.g., sedation, aspiration, occult respiratory insufficiency).60 The dose is 0.25 to 1.0 mg IVP, with the lower dose recommended to avoid opiate withdrawal. The disadvantage of nalmefene is its cost (average wholesale price of nalmefene is $31.21/1 mg versus $5.52/0.4 mg of naloxone). Current use of nalmefene has been limited to the reversal of procedural sedation,61 alcohol dependence,62 and avoidance of opiate side effects in patients receiving epidural analgesia.63


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Flumazenil: Flumazenil is a highly selective competitive inhibitor of benzodiazepines at the GABA/benzodiazepine-receptor complex.64 Like naloxone it is a pure antagonist lacking agonist properties or abuse potential. It has been shown to be safe and effective for the reversal of benzodiazepine-induced sedation in volunteer studies65 and in patients undergoing short procedures such as endoscopy.66–70 There has been some debate about the role of flumazenil in the treatment of patients presenting with an acute drug overdose. Although initially recommended with caution for this population,71,72 recent advice would be to administer it only when there is a reliable history of benzodiazepine ingestion and the likelihood of a significant proconvulsant or proarrhythmic coingestion or benzodiazepine dependency is limited. Adverse effects including precipitation of benzodiazepine withdrawal,73,74 seizures,75–78 ballism,79 arrhythmias,80,81 and even death82,83 have occurred. In a review of 43 cases of seizure activity associated with flumazenil administration, 42% of the patients had ingested overdoses of cyclic antidepressants.75 In addition to patients with concurrent cyclic antidepressant poisoning, high-risk populations include patients who have been receiving benzodiazepines for a seizure disorder or an acute convulsive episode, patients with concurrent major sedative–hypnotic drug withdrawal, patients who have recently been treated with repeated doses of parenteral benzodiazepines, and overdose patients with myoclonic jerking or seizure activity before flumazenil administration.75 To minimize the likelihood of a seizure, it is recommended that flumazenil not be administered to patients who have used benzodiazepines for the treatment of seizure disorders or to patients who have ingested drugs that place them at risk for the development of seizures75 (e.g., cyclic antidepressants, cocaine, amphetamines, diphenhydramine, lithium, methylxanthines, isoniazid, propoxyphene, buproprion HCl, etc.). As with naloxone, flumazenil may also uncover the effects of a more serious intoxication such as cocaine making the patient unmanageable. Because benzodiazepine overdoses are associated with only rare mortality84 and only mild morbidity (the major complication being aspiration pneumonia),85 a conservative approach with supportive airway maneuvers (e.g., endotracheal intubation) seems safest. Despite concerns over side effects, the use of flumazenil in patients with acute overdose is justified under certain circumstances. When there is a reliable history of a single drug ingestion supported by clinical manifestations consistent with benzodiazepine intoxication, and the likelihood of a significant proconvulsant or proarrhythmic co-ingestion or benzodiazepine dependency is limited, reversal of sedation may be warranted.17 One case report described continuous flumazenil infusion for 16 days without adverse effects for clonazepam-induced sedation.86 Errors can be avoided by obtaining a thorough history and by performing a thorough physical examination as well as a screening electrocardiogram to exclude the possibility of significant cyclic antidepressant intoxication; correction of hypoxia, hypotension, acidosis, and arrhythmias; and then by administering the agent slowly. Greenblatt85 showed that of 99 cases in which patients overdosed on benzodiazepines only 12 were known to ingest benzodiazepines alone. Given the high incidence of co-ingestions in the drug-abusing population the risk for unmasking proconvulsants such as cocaine or amphetamine must be considered high. It is interesting that flumazenil has been credited with the reversal of paradoxical benzodiazepine-induced agitation87 and hepatic encephalopathy88 and that it is being investigated as a treatment aid for benzodiazepine withdrawal.89 8.2.1.2 Stepwise Approach to Management Immediate Interventions 1. Airway, Breathing, Circulation: Maintain the airway and assist ventilation if necessary. Administer supplemental oxygen. Treat hypotension, and resuscitate as per previous reviews.2,90 2. Thiamine: Administer thiamine,100 mg IVP over 2 min to all the following patients: a. Patients with altered mental status if the patient has signs or symptoms of Wernicke’s encephalopathy



b. c. d. e.

Patients Patients Patients Patients

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who are malnourished91 with a history of alcoholism10 with prolonged history of vomiting92 who are chronically ill93

Comment: There is no need to withhold hypertonic dextrose (D50, D25) until thiamine administration since thiamine uptake into cells is slower than the entry of dextrose into cells.94 Previous reports describing adverse reactions to IV thiamine95 have recently been disputed. In a review by Wrenn et al.11 the incidence of adverse reactions to IV thiamine (n = 989) was 1.1% and consisted of transient local irritation in all patients except one who developed generalized pruritis. Thiamine may also be administered intramuscularly (IM) or by mouth (po). 3. Dextrose Bedside fingerstick glucose level: Perform rapid bedside testing in all patients. If hypoglycemia is detected then the patient should receive hypertonic dextrose (25 g of 50% hypertonic dextrose solution IVP). Comment: This approach avoids giving dextrose solution to patients who do not need it (eliminating concerns that hyperglycemia impairs cerebral resuscitation) and detects the vast majority of hypoglycemic patients. Relying on physical signs and symptoms such as tachycardia and diaphoresis in combination with a history of diabetes mellitus is an unreliable way to predict hypoglycemia, missing up to 25% of hypoglycemic patients.17 Borderline rapid assay results: In any patient with borderline rapid assay results (60 to 100 mg/dl) a decision on whether or not to treat should be based on the clinical suspicion of hypoglycemia and a repeat rapid assay. Alternatively, simply treat all patients with borderline blood sugar results. Comment: Rapid reagent assays for blood glucose may, at times, be inaccurate. Failure to detect hypoglycemia has been described in 6 to 8% of patients tested in the prehospital setting,96,97 but results are generally more accurate inside of the hospital. False-negative results have also been reported in neonatal populations98 and in patients with severe anemia.99 False-positive tests (false hypoglycemia) has occurred in patients with severe peripheral vascular disease,100 shock,101 and hyperthermia.102 Because most errors occur in patients with borderline glucose readings (60 to 100 mg/dl),17 the recommendation to treat borderline glucose values is made. This also makes sense in light of recent reports that describe individual variability in response to borderline hypoglycemia;103 e.g., patients with poorly controlled diabetes mellitus may experience clinical symptoms of hypoglycemia at greater glucose concentrations than nondiabetics. Empiric treatment: In patients where rapid bedside testing for serum glucose is not available, administer 25 g of 50% hypertonic dextrose solution IVP after collecting a specimen of blood for glucose analysis at a later time.

4. Naloxone/Nalmefene: a. Restraint: Consider restraining and disrobing the patient prior to administration. b. Antidote: All patients with classic signs (RR < 12, pupils miotic, needle marks) and symptoms of opioid intoxication should receive naloxone. Comment: Because of nalmefene’s expense, naloxone is generally recommended. Nalmefene may be advantageous in the patient who leaves the emergency department against medical advice or if close monitoring of the patient is not possible. The usual initial dose is 0.25 mg IV followed by repeated doses until adequate response is achieved. Comment: Hoffman et al.,104 using a clinical criteria of respiratory rate less than 12 breaths/min, circumstantial evidence of opioid abuse, or miosis, decreased the use of naloxone by 75 to 90% while still administering it to virtually all naloxone responders who had a final diagnosis of opiate overdose. c. Initial Doses: Small doses (0.2 to 0.4 mg IV of naloxone) should be given to patients who are breathing, and at possible risk for withdrawal. If no response, repeat or titrate the same dose IV every minute until 2.0 mg of naloxone or 1.0 mg of nalmefene have been given or the patient wakes up.


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Table 8.2.1 Half-Lives and Observation Times Required after Acute Narcotic Overdose Opioid

Duration of Action via IV Route

t1/2

Observation Time (h)

Propoxyphene (Darvon, Doloxene) Methadone (Dolophine, Amidone) Morphine Heroin Fentanyl (Sublimaze) Codeine Meperidine (Demerol) Pentazocine (Talwin) Dextromethorphan

May be >24 h May be days Usually 2–4 h Usually 2–4 h Minutes 2–4 h (oral) 2–4 h 2–4 h 2–4 h (oral)

6-12a 15b–72c 3 Very shortd 4 3d 2.5 2 6–29

24 24–36 or longer 6 6 6 6 6 6 4

Note: Generally, if patients remain asymptomatic 6 h after the administration of naloxone, they may be discharged. a About 1/2 of dose is metabolized to norproxyphene, an active metabolite with a t 1/2 of 30–36 h. b Single dose. c Repeated dosing. d Rapidly deacetylated to morphine.

Comment: If the patient is not suspected to be at risk for opiate withdrawal (i.e., most children) and there is no risk of unmasking a dangerous co-intoxicant such as cocaine or phencyclidine (PCP), 2.0 mg of naloxone may be given initially. d. High-dose antidote: If there is still no response to a total of 2.0 mg of naloxone and opiate overdose is highly suspected by history or clinical presentation, one can give 10 to 20 mg of naloxone in one bolus dose. Certain opiates (i.e., propoxyphene, pentazocine, diphenoxylate, butorphanol, nalbuphine, codeine) may require larger doses of naloxone due to higher affinity for the kappa receptors.105 Comment: Reversal of opioid toxicity, once achieved, will be sustained for approximately 20 to 60 min (t1/2 = 1 h). Because the duration of action of most opioids exceeds the duration of action of naloxone, the patient may require repeated bolus doses or to be started on a continuous infusion at a dose sufficient to prevent the reappearance of respiratory depression (see Section 8.2.10.2 on opiates). Comment: A true response to naloxone or nalmefene is a dramatic improvement. Anything less should be considered a sign of a coexisting intoxication or illness, a nonspecific improvement from the reversal of endogenous opiates, or the presence of anoxic encephalopathy from prolonged respiratory depression. If dramatic improvement is noted, further management depends on the type on narcotic involved and the amount taken (Table 8.2.1). e. Dose in respiratory arrest: Patients with respiratory arrest should either be given larger does (0.4 to 2.0 mg of naloxone) or endotracheally intubated and artificially ventilated. Comment: Naloxone is easily administered via the IV, IM, intratracheal,105 intralingual,106 or even the intranasal56 routes. The intravenous route is preferred since it allows more exact titration and because it provides for a rapid onset of action (about 1 min) and predictable delivery of drug. The intramuscular route (1.0 to 2.0 mg) usually works within minutes, but makes titration more difficult and takes longer to work (5 to 10 min). It may be advantageous in the prehospital setting. The intralingual route, with antidote given near the venous plexus on the ventral lateral tongue, may work as rapidly as the intravenous route, but does not allow for titration of dosage. f. Aspiration: Guard against aspiration.

5. Flumazenil a. Caution: Because of a higher incidence of severe adverse effects flumazenil should be used only under the limited circumstances described previously. b. Restraint: Consider restraining and disrobing the patient prior to administering antidote. c. Antidote: If a pure benzodiazepine overdose is suspected, treat hypoxia, hypotension, acidosis, and arrhythmias and check a 12-lead electrocardiogram (ECG) for QRS widening. If the ECG is



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normal, and the patient has no known seizure disorders, and is not taking proconvulsant medications, flumazenil may be administered. Comment: Generally flumazenil should be used only to reverse serious respiratory depression. Its use is not advised to waken a stable, mildly somnolent patient. If serious respiratory depression does exist, consider endotracheal intubation and mechanical ventilation as an alternative to flumazenil. Comment: In a study of 50 patients treated with flunitrazepam (t1/2 = 20 to 29 h) Claeys et al.107 showed that 90 min after administration of flumazenil significant recurrent sedation was observed in healthy patients undergoing orthopedic surgery. Because the binding of flumazenil to the benzodiazepine-receptor complex is competitive, and because flumazenil has a much shorter duration of action (t1/2 = 40 to 80 min) than most benzodiazepines, patients should be closely monitored for resedation. d. Dose: Give flumazenil 0.2 mg over 30 s, to be followed 30 s later by 0.3 mg if the patient does not respond. Subsequent doses of 0.5 mg may also be given although most patients respond to less than 1.0 mg.108 Although the manufacturers recommend the administration of up to 3 mg we recommend a maximal dosage of 1.0 mg in the drug-abusing patient at high risk for withdrawal. Comment: As long as flumazenil is administered slowly with a total dose of less than 1 mg, only 50% of benzodiazepine receptors will be occupied by the drug.109 In theory, this should prevent the severe manifestations of withdrawal associated with higher doses.17

Secondary Interventions 1. Reassess: If the patient remains comatose, stuporous, or lethargic despite antidotes, reassess for underlying medical causes (meningitis, trauma, epilepsy, etc.) and admit to hospital. 2. Monitor: Maintain continuous monitoring (cardiac status, oxygen saturation, blood pressure) at all times. Comment: This is particularly important since the duration of action of most narcotics and benzodiazepines of abuse is much longer than the duration of action of their respective antidote. 3. CT/lumbar puncture: Consider CT and lumbar puncture if the patient is febrile or has persistently decreased level of consciousness or focal neurological findings. 4. ECG: Perform an ECG on all elderly patients. 5. Laboratory Data: For patients who respond to antidotes and return to their baseline mental status within an observation period of several hours, no laboratory testing may be necessary given a normal physical examination on reassessment. If the patient remains persistently altered or has significantly abnormal vital signs check electrolytes, CBC, CPK, CPK-MB, renal function, and possibly hepatic function. While the use of toxicology screens of blood and urine are generally overutilized,5 they are recommended if the diagnosis remains questionable. 6. Disposition Admission: All patients who have required more than one dose of antidote to maintain their mental status should be admitted for further evaluation and therapy including possible infusion of naloxone or flumazenil. Comment: Infusions should be maintained in an intensive care setting and patients should be closely monitored any time the infusion is stopped. Duration of observation depends on the route of drug administration, the drug ingested, the presence or absence of liver dysfunction, and the possibility of ongoing drug absorption from the gastrointestinal tract. Usually 6 h is adequate. Flumazenil infusion: Infuse 0.2 to 0.5 h in maintenance fluids (D5W, D51/2NS, 1/2NS, NS), adjusting rate to provide the desired level of arousal. Hojer et al.110 demonstrated that infusions of 0.5 mg/h were well tolerated and that this dose prevented patients with severe benzodiazepine poisoning from relapsing into coma after arousal with a single bolus injection. Naloxone infusion: Goldfrank et al.111 suggest taking two thirds the amount of naloxone required for the patient to initially wake up and administering that amount at an hourly rate in the patient’s maintenance IV (D5W, D51/2NS, 1/2NS, NS). Based on the half-life of naloxone this regimen will


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maintain the plasma naloxone levels at or greater than those that would have existed 30 min after the bolus dose.111,112 Example: The patient responds to 3 mg of naloxone initially. Add 20 mg naloxone to 1 L maintenance fluids and run at 100 cc/h thus delivering 2 mg naloxone/h (e.g., 2/3 the initial dose per hour).

7. Discharge: Stable patients who have regained normal mental status and have normal (or near normal) laboratory data may be observed for a period of time, which depends on the drug ingested (see Table 8.2.1 for recommended observation period after opioid overdose) and underlying conditions. Usually if the patient is awake and alert 6 h after administration of antidote, the patient may be safely discharged if there is no further drug absorption from the gastrointestinal tract. 8.2.2

Agitation, Delirium, and Psychosis

8.2.2.1 General Comments Confounders: Rapid control of drug-induced agitation, delirium, or psychosis is one of the most difficult skills to master when dealing with complications of drug abuse. The use of sedation and restraints is fraught with a host of ethical and legal issues.113–116 Safety issues for the patient as well as the medical staff must be considered. Numerous reports of injuries to emergency department personnel117,118 exist. Diagnostic confusion may occur since agitation or delirium may be the result of a drug overdose alone, or may be from a medical problem combined with drug intoxication (i.e., myocardial infarction from cocaine abuse), or simply a medical problem masquerading as drug abuse (i.e., meningitis). Finally, failing to understand the differences between agitation, psychosis, and delirium (see following discussion) often leads to incorrect management schemes. Regardless of the cause, effective, compassionate, and rapid control of agitation is necessary to decrease the incidence of serious complications and to provide a thorough evaluation of the patient. One can never safely say that the patient was “too agitated” or “too uncooperative” to assess. Delirium vs. psychosis with and without agitation: Altered sensorium (disorientation and confusion) and visual hallucinations are characteristic of delirium. In contrast, psychosis is associated with paranoia, auditory hallucinations, and usually an intact sensorium.5 Agitation (physical or psychic perturbation) may complicate either delirium or psychosis and is commonly seen in patients with stimulant overdose. Differentiating between delirium and psychosis with or without agitation and agitation alone is useful because it may suggest specific groups of drugs and potentially, specific treatment.5 For example, a patient with anticholinergic poisoning from Jimson weed typically has delirium with confusion and disorientation, while an amphetamine- or cocaineintoxicated person usually has paranoid psychosis with agitation, but is oriented. Physostigmine is useful in the diagnosis of anticholinergic syndrome,119 but would not be helpful for amphetamineor cocaine-induced agitation. Agitation from stimulants should be treated with benzodiazepines, while psychosis alone can be treated with haloperidol with or without benzodiazepines. Benzodiazepines vs. neuroleptics: There is significant controversy regarding the optimal choice of sedating agents. Much research has dealt directly with agitated patients in the psychiatric setting,120–122 but no controlled clinical studies of benzodiazepines or neuroleptic medications in treating strictly drug-induced agitation have been described. Animal research123–125 and human experience126 support the use of benzodiazepines for cocaine-induced agitation as well as generalized anxiety.127,128 Neuroleptics (e.g., haloperidol) have been shown to decrease the lethal effects of amphetamines in rats129–131 and chlorpromazine was found to be effective in treating a series of 22 children with severe amphetamine poisoning.132 Many of the children exhibited seizures before receiving chlorpromazine, but ongoing motor activity was reduced in all cases. These data are consistent with the observation that chlorpromazine antagonizes cocaine-induced seizures in dogs.123 Callaway et al.133 argue that neuroleptics have been used safely in other patient populations at risk



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for seizures, such as the treatment of alcoholic hallucinosis during alcohol withdrawal.134 Concerns about neuroleptics potentiating drug-induced seizures may therefore be exaggerated. Butyrophenone neuroleptics such as haloperidol have less effect on seizure thresholds than do phenothiazines such as chlorpromazine135 and also produce less interference with sweat-mediated evaporative cooling (e.g., anticholinergic effect) in cases of drug-induced hyperthermia.133 Hoffman136 has argued against the use of haloperidol for cocaine intoxication on the basis of controlled animal studies showing haloperidol failed to improve survival, and possibly increased lethality.137 He also argues that haloperidol causes a variety of physiologic responses that limit heat loss. These include (1) presynaptic dopamine-2 (D2) receptor blockage, causing a loss of inhibition of norepinephrine release and increased central and peripheral adrenergic activity; (2) hypothalamic D2 blockade causing direct inhibition of central heat dissipating mechanisms; and (3) anticholinergic effects causing loss of evaporative cooling via loss of sweat. The risk of a dystonic reaction, which has been associated with fatal laryngospasm138,139 and rhabdomyolysis,140 is also of concern. Acute dystonia, which is more common in young males,141 could severely impair a resuscitation attempt and may aggravate hyperthermia. Interestingly, the incidence of dystonic reactions from neuroleptic agents has been shown to be dramatically reduced when benzodiazepines are coadministered.142 Recently the use of the atypical antipsychotic agent ziprazidone has been recommended for controlling acute psychotic agitation. Although study populations are mixed, they are primarily composed of psychiatric patients with functional, as opposed to drug-induced psychosis. Nevertheless, ziprazidone has not been associated with hyperthermia, dystonia, nor the anticholinergic effects of haloperidol. Studies suggest beneficial effects similar to lorazepam or haloperidol with less sedation.143–145 Recommendations: Because of the complex neuropharmacology associated with agitation, delirium, and psychosis in the drug abusing patient our preference is a selective approach based on symptom complex: Severe agitation: In cases of severe agitation, regardless of underlying delirium or psychosis, we recommend starting with benzodiazepines due to their proven safety and known ability to increase the seizure threshold. They should be given in incremental doses until the patient is appropriately sedated and large doses should not be withheld as long as the blood pressure remains stable and the airway is secure. If respiratory depression occurs, the patient should be endotracheally intubated and mechanically ventilated.136 Psychosis: If severe agitation includes marked psychotic features or there is known amphetamine or amphetamine-derivative overdose (i.e., 3,4-methylenedioxymethamphetamine or MDMA), or if the major symptom complex has psychotic features, then haloperidol may be used. Due to synergistic effects122 and to decrease the incidence of dystonic reactions,142 haloperidol should be administered in combination with a benzodiazepine. Anticholinergic agents (i.e., benztropine) reduce the incidence of dystonic reactions;146 however, because of the potential to confuse an anticholinergic syndrome with psychosis147 and because anticholinergic agents limit heat dissipation, they are not routinely recommended. Delirium: As long as agitation is not prominent the administration of low dose benzodiazepines, or observation alone, is usually adequate to control symptoms of mild delirium until drug effects wear off. Intramuscular ziprazidone may also be considered in this setting. In selected anticholinergic poisonings involving uncontrollable agitation or severe hyperthermia, physostigmine (0.5 to 1.0 mg slow IV push) should be considered.148 Physostigmine may potentiate the effects of depolarizing neuromuscular-blocking agents (e.g., succinylcholine decamethonium)149,150 and may have additive depressant effects on cardiac conduction in patients with cyclic antidepressant overdose.151,152 Its use is therefore contraindicated in patients with tricyclic antidepressant poisoning and poisoning that impairs cardiac conduction. Physostigmine may induce arousal in patients with benzodiazepine or sedative-hypnotic intoxication153 due to its nonspecific analeptic effects. A word of caution: Control of agitation, delirium, and psychosis is important, but even more important is the treatment of the underlying cause. Algorithms for detecting hypoxia, hypotension, and hypoglycemia still apply. In the mentally unstable patient, who will not allow evaluation or examination, physical restraint and the liberal use of benzodiazepines (see below) may be necessary.


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8.2.2.2 Stepwise Approach to Management Immediate Interventions 1. Airway, Breathing, Circulation: Maintain the airway and assist ventilation if necessary. Administer supplemental oxygen. Treat hypotension, and resuscitate as per previous reviews.90 2. Antidotes: Administer appropriate antidotes, including 25 g dextrose IV if the patient is hypoglycemic, as per the section on coma. If the patient does not allow assessment and stabilization, proceed as follows (once the patient is under control, reassess the need for antidotes). 3. Reduction of environmental stimuli: If possible attempt calming the patient by eliminating excessive noise, light, and physical stimulation. Generally, this is all that is necessary for the treatment of panic attacks from mild cocaine overdose, or from certain hallucinogens such as LSD or marijuana.148,154 Talk to the patient and attempt to address the patient’s immediate needs (minor pain, anxiety, need to use the bathroom). An offer of food or water may calm the patient and avoid further confrontation. Gay et al.154 from the Haight-Ashbury Free Medical Clinics, in San Francisco, have described the “ART” technique as a way of establishing credibility with the intoxicated patient: A = Acceptance. Acceptance disarms patients who may already be experiencing fear of their surroundings or paranoid ideation. R = Reduction of stimuli, rest, and reassurance. If patients are stable and symptoms are mild, place them in a quiet surrounding, and reassure them that they are going to be all right as you proceed to assess them. If patients are dangerous or seriously ill, control them with physical and/or medical restraints (see following section). When stable, proceed to eliminate any source of obvious distraction or distress (too many people in the resuscitation room, bright lights, loud noises, etc.). T = Talkdown technique. Use verbal sincerity, concern, and a gentle approach since drug abusers can misinterpret insincere and/or abrupt actions as being hostile. If patients are obviously beyond reason or dangerous do not attempt to “talk them down.” Generally, this step should be restricted to patients who are oriented and simply frightened. It is also not recommended for patients who have taken phencyclidine (PCP) due to the unpredictable effects of this drug.155 Staff members should be careful to never position themselves with a potentially violent or distraught patient between them and the door.

4. Sedation: Medical management may be necessary if the patient remains uncooperative. Explain to the patient your intention to use medications. 5. Paralysis: If significant hyperthermia occurs as a result of excessive muscular hyperactivity, or if significant risk for spinal injury is present, consider early skeletal muscle paralysis (see discussion under hyperthermia). Procedures for the rapid sequence induction for airway management and paralysis are reviewed elsewhere.2 6. Physical restraints: Restraint has proven efficacy in reducing injury and agitation.156 If the patient continues to be uncooperative, rapidly gain control of the individual using several trained staff and physical restraints (Table 8.2.2 on restraining technique and Table 8.2.3 on universal precautions). Empty the room of all extraneous and/or potentially dangerous objects and apply the restraints in a humane and professional manner.157 The method of restraint should be the least restrictive necessary for the protection of the patient and others.113 Secondary Interventions 1. Insert IV, monitor: Once the patient is restrained insert an intravenous line, and assess vital signs. 2. Assess underlying medical conditions: Draw blood and assess for serious medical conditions. Rule out metabolic disturbances (e.g., hypoxia, hypoglycemia, hyponatremia, thyrotoxicosis,



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Table 8.2.2 Patient Management with Use of Restraints A. B. C. D.

Rehearse strategies before employing these techniques. Use restraints sooner rather than later and thoroughly document all actions. Remember universal precautions (see Table 8.2.3). Use restraints appropriately. The use of overwhelming force will often be all that is necessary to preclude a fight. 1. When it is time to subdue the patient, approach him or her with at least five persons, each with a prearranged task. 2. Grasp the clothing and the large joints to attempt to “sandwich” the patient between two mattresses. 3. Place the patient on the stretcher face down to reduce leverage and to make it difficult for the patient to lash out. 4. Remove the patient’s shoes or boots. 5. In exceptional circumstances, as when the patient is biting, grasp the hair firmly. 6. Avoid pressure to the chest, throat, or neck. E. The specific type of restraint used (hands, cloth, leather, etc.) is determined by the amount of force needed to subdue (i.e., use hard restraints for PCP-induced psychoses). F. Keep in mind, when using physical restraints, that the minimum amount of force necessary is the maximum that ethical practice allows. The goal is to restrain, not to injure. Restraining ties should be adequate but not painfully constricting when applied (being able to slip your finger underneath is a good standard). The restrained patient should be observed in a safe, quiet room away from the other patients; however, the patient must be reevaluated frequently, as the physical condition of restrained patients could deteriorate. Source: From Wasserberger, J. et al., Top. Emerg. Med., 14, 71, 1992. With permission.

Table 8.2.3 Universal Precautions 1. Appropriate barrier precautions should be routinely used when contact with blood or other body fluids is anticipated. Wear gloves. Masks and eye protection are indicated if mucous membranes of the mouth, eyes, and nose may be exposed to drops of blood or other body fluids. Gowns should be worn if splashes of blood are likely. 2. Hands and skin should be washed immediately if contaminated. Wash hands as soon as gloves are removed. 3. Exercise care in handling all sharps during procedures, when cleaning them, and during disposal. Never recap or bend needles. Carefully dispose of sharps in specially designed containers. 4. Use a bag-valve-mask to prevent the need for mouth-to-mouth resuscitation. Such devices should be readily available. 5. Health care workers with weeping dermatitis should avoid direct patient care until the condition resolves. 6. Because of the risk of perinatal HIV transmission, pregnant health care workers should strictly adhere to all universal precautions. Note: In its 1987 recommendations, the Centers for Disease Control (CDC) stated that universal precautions “should be used in the care of all patients, especially including those in emergency-care settings in which the risk of blood exposure is increased and the infection status of the patient is usually unknown.” The CDC stipulated the six basic universal precautions above.

uremia), alcohol or sedative-hypnotic withdrawal, CNS infection (e.g., meningitis, encephalitis) or tumor, hyperthermia, postictal state, trauma, etc. 3. Frequent reassessment: Any patient left in physical restraints must have frequent reassessments of vital signs, neurological status, and physical examination.113 Sudden death, and asphyxiation, have occurred in individuals while in restraints.115,158–160 4. Documentation: The patient’s danger to him- or herself, degree of agitation, specific threats, and verbal hostilities should all be documented in case of future charges by the patient that the patient was improperly restrained against his or her will (i.e., battery). Documentation should include the reasons for, and means of, restraint and the periodic assessment (minimum of every 20 min) of the restrained patient. Legal doctrines pertinent to involuntary treatment have been reviewed elsewhere.116 5. Medications: Sedation is necessary for patients struggling vigorously against restraints, or for patients who are persistently agitated, hyperthermic, panicking, or hyperadrenergic. Consider one of the following sedatives or combinations: See previous discussion under general comments.


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Lorazepam Diazepam

0.05–0.10 mg (2–7 mg) IM or IV initially over 1–2 min to 0.20 mg/kg (5–10 mg) IV initially over 1–2 min

Haloperidol

0.1–0.2 mg/kg (5–10 mg) IM or IV initially over 1–2 min

Ziprasidone

10–20 mg IM

May repeat doses every 5 min until sedation is achieved May repeat doses every 5 min until sedation is achieved Diazepam is not recommended in patients >60 years old due to prolonged duration of action in this group May repeat dosing 5 mg every 15 min until sedation is achieved Probably safe in most overdoses although more studies are necessary to confirm Studies still pending for use in patients with drug-induced agitation

6. Reassess medical condition: For persistently altered mental status perform CT of the head and consider lumbar puncture. Cases involving body packers161–163 or stuffers164 with ongoing absorption of drug, or certain drugs that delayed absorption (i.e., belladonna alkaloids in Jimson weed165) may have prolonged duration of symptoms. 7. Laboratory Data: Electrolytes, CBC, BUN, Cr, CPK, CPK with MB fraction if myocardial infarction or ischemia is suspected. Consider liver function studies including PT/ PTT in severely ill patients. Rule out coagulopathy with a disseminated intravascular coagulation (DIC) panel. Obtain blood and urine cultures if hyperthermic. While the use of toxicology screens of blood and urine are generally overutilized,5 they are recommended if the diagnosis remains questionable. 8. Disposition: Consider discharging patients who meet all the following criteria after an appropriate period of observation: a. Normal vital signs and mental status b. Normal or near normal laboratory data

Patients who have a chronically altered mental status, e.g., schizophrenia, or organic psychosis, and who are not at risk to themselves or others may be considered for discharge with appropriate psychological counseling and follow up. Patients with true delirium, or escalating agitation, or abnormal vital signs must be either admitted to the hospital or observed for further improvement. 8.2.3

Seizures

8.2.3.1 General Comments Seizures from drug abuse have been known to be lethal166–168 or cause permanent neurological injury.169–171 Primate studies using baboons172 have shown that 82 min of induced status epilepticus produced visible neuropathological injury in nonparalyzed ventilated animals. Results were similar if the baboons were paralyzed and ventilated first. In addition to the potential for direct brain injury, prolonged seizure activity may cause or aggravate hyperthermia, which can further injury to the brain and produce rhabdomyolysis. Mechanisms: Drugs may precipitate seizures through several distinct mechanisms (Table 8.2.4). A direct CNS stimulant effect is probably the mechanism in most cocaine-, phencyclidine-, and amphetamine-induced seizures.173,174 Seizures from these drugs generally occur at the time of use while seizures associated with other drugs such as alcohol, benzodiazepines, and barbiturates, generally occur during a time of withdrawal from chronic, high doses of the drug.173 Other indirect causes of seizures exist. Cerebral infarction or hemorrhage may precipitate seizures in patients abusing cocaine or amphetamines.175,176 Vasculitis has been associated with amphetamine and cocaine abuse and may result in seizures.177 Intravenous drug-abusing (IVDA) patients with acquired immune deficiency syndrome (AIDS) are susceptible to CNS infections such as toxoplasmosis, cryptococcus, viral encephalitis, and syphilis or lymphoma, which can precipitate seizures. IVDA also is frequently complicated by bacterial endocarditis, septic cerebral emboli, and seizures.



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Table 8.2.4 Mechanisms of Drug-Related Seizures 1. Direct CNS toxicity: Cocaine, phencyclidine, amphetamines 2. CNS hyperactivity after cessation of drug: Alcohol, barbiturates, benzodiazepines 3. Indirect CNS toxicity a. Trauma: subdural, epidural hematoma due to blunt force b. Stroke: cerebral infarct, hemorrhage, or vasculitis c. Infection of CNS d. Foreign materials (e.g., talc), other drug adulterants (see Tables 8.2.5 to 8.2.7) e. Systemic metabolic problems (e.g., hypoglycemia, liver, or renal failure) f. Post-traumatic epilepsy, or epilepsy exacerbated by drug abuse g. Epilepsy additional to drug use

Foreign material (e.g., talc or cotton) emboli and toxic drug by-products or expanders have been implicated178 (Table 8.2.5 through Table 8.2.7) as well as brain trauma or closed head injury. Finally, chronic alcohol abuse often leads to systemic medical problems such as hypoglycemia, liver failure, sepsis, or meningitis, all of which may precipitate seizure activity. Benzodiazepines: Benzodiazepines are the preferred choice for the initial control of the actively seizing patient.179 Accordingly, pharmacological studies demonstrated that cocaine-induced seizures Table 8.2.5 Cocaine Additives Pharmacologically Active Lidocaine Cyproheptidine Methephedrine Diphenhydramine Benzocaine Mepivacaine Aminopyrine Methapyrilene Tetracaine Nicotinamide Ephedrine Phenylpropanolamine Acetaminophen Procaine base Caffeine Acetophenetidin 1-(1-Phenylcyclohexyl)pyrrolidine Methaqualone Dyclonine Pyridoxine Codeine Stearic acid Piracetum Rosin (colophonum) Fencanfamine Benzoic acid Phenothiazines L -Threonine Heroin Boric acid Aspirin Dibucaine Propoxyphene Heroina Amphetaminea Methamphetaminea a

Inert Inositol Mannitol Lactose Dextrose Starch Sucrose Sodium bicarbonate Barium carbonate Mannose Volatile Compounds Benzene Methyl ethyl ketone Ether Acetone

Considered frequent additives/coinjectants; absolute frequency unknown. Source: Shesser, R. et al., Am. J. Emerg. Med. 9, 336, 1991. With permission.


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Table 8.2.6 Phencyclidine Additives Active Phenylpropanolamine Benzocaine Procaine Ephedrine Caffeine Piperidine PCC (1-piperidinocyclohexanecarbonitrile) TCP (1-[1-(2-thienyl)cyclohexyl]-piperdine) PCE (cyclohexamine) PHP (phenylcyclohexylpyrrolidine) Ketamine

Inert Magnesium sulfate Ammonium chloride Ammonium hydroxide Phenyllithium halide Phenylmagnesium halide Volatile Ethyl ether Toluene Cyclohexanol Isopropanol

Source: Shesser, R. et al., Am. J. Emerg. Med. 9, 336, 1991. With permission.

Table 8.2.7 Heroin Additives Alkaloids

Inert

Thebaine Acetylcodeine Papaverine Noscapine Narceine Active Nonalkaloids Tolmectin Quinine Phenobarbital Methaqualone Lidocaine Phenolphthalein Caffeine Dextromoramide Chloroquine Diazepam Nicotinamide N-Phenyl-2-naphthylamine Phenacetin Acetaminophen Fentanyl Doxepin Naproxen Promazine Piracetem Procaine Diphenhydramine Aminopyrine Allobarbital Indomethacin Glutethimide Scopolamine Sulfonamide Arsenic Strychnine Cocainea Amphetaminea Methamphetaminea

Starch Sugar Calcium tartrate Calcium carbonate Sodium carbonate Sucrose Dextrin Magnesium sulfate Dextrose Lactose Barium sulfate Silicon dioxide Vitamin C

a

Volatile Rosin Toluene Methanol Acetaldehyde Ethanol Acetone Diethyl ether Chloroform Acetic Acid

Considered frequent additives/coinjectants; absolute frequency unknown. Source: Shesser, R. et al., Am. J. Emerg. Med. 9, 336, 1991. With permission.



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were efficiently inhibited by GABAA receptor agonists and NMDA receptor antagonists, whereas sodium and calcium channel blockers were ineffective.174 Benzodiazepines, unlike MNDA receptor antagonists, are readily available, require no prolonged loading, and are quite safe from a cardiovascular standpoint.180–182 The main disadvantages are excessive sedation and respiratory depression, especially when given with barbiturates such as phenobarbital. Lorazepam is also quite viscous and must be refrigerated and diluted before infusion.179 Diazepam is irritating to veins and after intramuscular dosing absorption is unpredictable. Which Benzodiazepine?: Of the benzodiazepines lorazepam has the longest anticonvulsant activity183 (4 to 6 h) and is considered the agent of first choice. Lorazepam has a tendency to persist in the brain while agents like diazepam and midazolam both redistribute out of the brain more rapidly and thus have a shorter protective effect.184 Leppik et al.185 found no significant statistical difference between diazepam and lorazepam in clinical efficacy for initial control of convulsive status. It was found, however, that lorazepam provided seizure control in 78% of patients with the first intravenous dose while diazepam provided seizure control after the first injection only 58% of the time. Levy and Kroll186 found that the average dose of lorazepam to control status epilepticus in a study of 21 patients was 4 mg and all patients responded within 15 min. Chiulli et al. reported on a retrospective study of 142 equally matched children given benzodiazepines and phenytoin for control of seizures.530 The intubation rate for those given lorazepam (mean dose 2.7 mg) was 27% while 73% of those given diazepam (mean dose 5.2 mg) had to be intubated. This study had an overall intubation rate that was quite high (45%), raising the question why so many children needed to be intubated.179 Interestingly, lorazepam is not FDA-approved for seizure control. Midazolam may be used alternatively and has the advantage of rapid IM absorption in patients without venous access. In one study it was found to have a stronger influence on electroencephalographic measures,187 and may be more effective in status epilepticus than diazepam or lorazepam.188 Barbiturates: Barbiturates are associated with a higher incidence of hypotension than benzodiazepines,189–191 and as a result should not be administered in the hypotensive patient. Furthermore, they require time-consuming loading (greater than 30 min). Although phenobarbital may be administered at an IV rate of 100 mg/min (requiring only 10 min to fully load a 70-kg patient with 15 mg/kg) most nursing protocols require the physician to institute phenobarbital loading or to give no more than 60 mg/min IV.179 Finally, barbiturates frequently cause prolonged sedation (especially after the co-administration of benzodiazepines) thus hindering the ability of the physician to perform serial examinations. Barbiturates do have an advantage of lowering intracranial pressure190 in the head-injured patient and are helpful for treating withdrawal symptoms in patients with sedative–hypnotic addiction.192,193 Barbiturates (i.e., phenobarbital) are considered second-line agents after the use of benzodiazepines (i.e., lorazepam) for seizures caused by drugs of abuse. Fosphenytoin: Phenytoin is a poorly soluble anticonvulsant that is mixed with propylene glycol to enhance its solubility. The propylene glycol, not the phenytoin, is a cardiac depressant and may cause hypotension and cardiovascular collapse if administered too rapidly. Fosphenytoin was recently introduced to eliminate the poor aqueous solubility and irritant properties of intravenous phenytoin and to eliminate the need for the propylene glycol solvent. Fosphenytoin is rapidly converted to phenytoin after intravenous or intramuscular administration and unlike phenytoin does not require prolonged administration of a loading dose on a cardiac monitor. In clinical studies, this prodrug showed minimal evidence of adverse events and no serious cardiovascular or respiratory adverse reactions.194 Unlike phenobarbital and benzodiazepines, which elevate the seizure threshold, phenytoin exerts its anticonvulsant effects mainly by limiting the spread of seizure activity and reducing seizure propagation. Because phenytoin does not elevate the seizure threshold, it is less effective against drug-induced seizures.195 Animal models196 of cocaine-induced seizures and human studies197 of alcohol withdrawal seizures have supported this claim. Cardiac toxicity of phenytoin was suggested by Callaham et al.198 who showed an increased incidence of ventricular tachycardia in dogs intoxicated with amitriptyline treated with phenytoin. Fosphenytoin and phenytoin are thus


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considered third-line agents for drug-induced seizures. They may be considered more useful for the drug-abusing patient with epilepsy whose seizures have responded to phenytoin in the past. General anesthesia: Pentobarbital or thiopental anesthesia may be used as a last resort, usually with the aid of an anesthesiologist, to induce general anesthesia.199,200 If paralysis is used, the patient must be intubated and mechanically ventilated. It is important to remember that when patients having seizures are paralyzed with neuromuscular blockers such that seizure activity is not readily apparent, they may continue to have electrical seizure activity, which results in persistent cerebral hypermetabolism and the continued risk of brain injury.172 Munn and Farrell201 reported on a 14year-old girl who was pharmacologically paralyzed during 14 h of unrecognized status epilepticus. The originally healthy girl suffered persistent, serious cognitive impairment and subsequent epilepsy. An EEG should be used to monitor in all patients paralyzed for a seizure disorder to determine the need for further anticonvulsant therapy. 8.2.3.2 Stepwise Approach to Management Immediate Interventions 1. Airway, Breathing, Circulation: Maintain the airway and assist ventilation if necessary. Administer supplemental oxygen. Treat hypotension, and resuscitate as per previous reviews.90 2. Antidotes: Administer appropriate antidotes, including 25 g dextrose IV if the patient is hypoglycemic. Administer naloxone only if seizures are thought to be caused by hypoxia resulting from narcotic-associated respiratory depression. 3. Anticonvulsants: Administer one of the drugs listed in the tabulation below. Comment: As noted above the authors have a strong preference for benzodiazepines (i.e., lorazepam). If lorazepam is chosen, most seizures stop after 2 to 4 mg, but there are no clear dose–response data available.179 Some authorities stop if 4 mg is unsuccessful, but it seems reasonable to give up to 10 to 12 mg of lorazepam before switching to an alternative therapy. Neurologists generally recommend the aggressive use of a single drug before switching to another drug. Switching too quickly frequently results in the underdosing of both drugs. Respiratory depression should not keep one from using large doses of benzodiazepines179 (as has been done safely with delirium tremens202), especially in the drug-abusing patient with status epilepticus. If large doses of benzodiazepines are used, patients frequently require intubation and mechanical ventilation. Drugs Used for Seizure Control Lorazepam

0.05–0.10 mg/kg IV over 2 min

Midazolam Diazepam Phenobarbital Fosphenytoin

0.05 mg/kg IV over 2 min 0.10 mg/kg IV over 2 min 15–20 mg/kg IV over 20 min 15–20 mg/kg IV given at 100–150 mg/min (7–14 min) 5–6 mg/kg IV, slow infusion over 8–10 min, then continuous infusion at 0.5–3.0 mg/kg/h titrated to effect

Pentobarbital

May repeat as necessary, may give intramuscularly (IM) although IV route preferred May repeat as necessary May repeat as necessary Watch for hypotension, prolonged sedation Generally not as effective as benzodiazepines or barbiturates, may give IM although IV route preferred Use as inducing agent for general anesthesia, watch for hypotension, continuous EEG monitoring necessary after general anesthesia

4. Reassess temperature: Immediately check the rectal temperature and cool the patient rapidly if the temperature is above 40°C (104°F) (see Section 8.2.4 on hyperthermia). 5. Lumbar puncture: Perform lumbar puncture if the patient is febrile to rule out meningitis. Do not wait for CT results or laboratory analysis of cerebral spinal fluid (CSF) to initiate therapy with appropriate antibiotics (i.e., a third-generation cephalosporin) if meningitis is suspected. Perform CT prior to lumbar puncture if the patient is at risk for having a CNS mass lesion.



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Table 8.2.8 High-Risk Seizures Neurological deficit Evidence of head trauma Prolonged postictal state Focal seizures or focal onset with secondary generalizationa Seizures occurring after a period of prolonged abstinencea Onset of seizures before age 30 if alcohol only involved Mental illness or inability to fully evaluate the patient’s baseline mental function a

High risk for having a positive CT result requiring intervention.

6. Gastric decontamination: Consider gastrointestinal decontamination if the patient is a body packer or stuffer or if the patient has ingested large quantities of drug (see Section 8.2.9, gastric decontamination). 7. Laboratory Data: Electrolytes, glucose, calcium, magnesium, and biochemical screens for liver and renal disease are generally recommended.173 Check creatine kinase levels to detect evidence of rhabdomyolysis. Although the use of urine and blood toxicologic screens are generally overutilized,5 they are recommended in the case of new onset seizures to avoid an inappropriate diagnosis of idiopathic epilepsy. Secondary Interventions 1. Computerized Tomography (CT): Earnest et al.178 documented a 16% incidence of “important intracranial lesions on CT scan” in a series of 259 patients with first alcohol-related seizures, and Pascual-Leone et al.203 found CT scan lesions in 16% (n = 44) of cocaine-induced seizures. Cocaine-induced thrombosis and hypertension have been implicated as the cause of stroke in patients with seizures.204–206 Considering these studies and also the high incidence of traumatic, hemorrhagic, and infectious injuries associated with drug abuse, a CT of the brain (with contrast) is recommended for new-onset seizures or for any high-risk seizures (Table 8.2.8). In a smaller study Holland et al.207 performed a retrospective review of 37 cocaine-associated seizures and concluded that CT scanning was not necessary regardless of the patient’s previous seizure history if the patient suffered a brief, generalized, tonic–clonic seizure and had normal vital signs, physical examination, and a postictal state lasting 30 min or less. We await larger studies to confirm the Holland et al. findings prior to making similar recommendations. 2. Monitor: Monitor neurological and cardiovascular status as well as hydration and electrolyte balance. 3. Anticonvulsant therapy: Chronic anticonvulsant or other specific treatment of alcohol- or drug-related seizures rarely is indicated. For patients who present with multiple seizures, status epilepticus, or high-risk seizures (Table 8.2.8) continued outpatient therapy may be indicated. 4. Disposition: Only patients with normal vital signs, and physical examination; after a brief isolated seizure; with a normal evaluation (i.e., CT scan, laboratory data, etc.) should be considered for discharge from the emergency department. 8.2.4

Hyperthermia/Heat Stroke

8.2.4.1 General Comments While mild hyperthermia is usually benign, in the setting of drug overdose it may be a sign of impending disaster. Severe hyperthermia (>40.5°C) is a well-recognized cause of major morbidity and mortality, regardless of the cause. Classic heat stroke, for example, characterized by a core temperature of 40.5°C or higher, and severe CNS dysfunction has been associated with mortality rates of up to 80% as well as with a high likelihood of disabling neurologic sequelae.208 Although


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no study has documented the incidence of death as it relates to drug abuse per se, a case series by Rosenberg et al.209 described 12 patients who presented with temperatures 40.5°C or greater for at least 1 h. Five of 12 patients died and four had severe permanent neurologic sequelae. Clinical signs common to patients who went on to develop severe hyperthermia were increased muscular activity and absence of sweating. Classic vs. drug-induced heat stroke: If a patient with apparent environmental heat illness has a continuing rise in temperature even after removal from ambient heat and ongoing exertion, drug-induced hyperthermia must be strongly considered. Rosenberg et al. reported a 3 to 12 h delay to the onset of severe hyperthermia in 7 of 12 patients with drug-induced hyperthermia.209 A variety of drugs133,210–213 and toxins171 can cause hyperthermia, and this may initially be overlooked while the more familiar manifestations (i.e., seizures) of the intoxication are being managed. Patients with hyperthermia and altered mental status may be diagnosed as having environmental or exertional heat stroke while the potential contribution of drugs is neglected.209 Clues to drug-induced hyperthermia from the history and physical examination must be aggressively pursued. Mechanisms: Mechanisms of drug-induced hyperthermia are varied. Most commonly, excessive heat production results from muscular hyperactivity (sympathomimetic and epileptogenic agents) or metabolic hyperactivity (salicylates). Heat dissipation is often impaired by inhibition of sweating (anticholinergic agents), cutaneous vasoconstriction (sympathomimetic agents), and/or by interference with central thermoregulation (phenothiazines, cocaine, amphetamines).209,214–216 When healthy, cocaine-naive persons are subjected to passive heating, pretreatment with even a small dose of intranasal cocaine impairs sweating and cutaneous vasodilation (the major autonomic adjustments to thermal stress) and heat perception (the key trigger for behavioral adjustments).217 The combined serotonin-releasing and dopamine-releasing drug MDMA produces lethal hyperthermia more potently than amphetamine,218 supporting a synergistic role for serotonergic with dopamine in druginduced hyperthermia.133 Phencyclidine is a sympathetic nervous system stimulant, and may also have anticholinergic properties,219 which inhibit sweating. This property plus the tendency to generate unrestrained outbursts of violent activity and seizures have resulted in hyperthermia and rhabdomyolysis and death.220 Of 1000 cases of PCP intoxication reviewed by McCarron et al.221 26 had temperatures over 38.9°C and four had temperatures over 41°C. Large overdoses of LSD have been associated with severe hyperthermia.222,223 This has been suggested to be due to its serotonergic effects210 and a tendency to provoke panic. A patient retrained in a straitjacket after becoming violent after LSD ingestion developed hyperthermia to 41.6°C, hypotension, rhabdomyolysis, renal failure, and died.224 Specific mechanisms may dictate the specific form of hyperthermic syndrome although classically five syndromes are described: malignant hyperthermia, neuroleptic malignant syndrome, anticholinergic poisoning, sympathomimetic poisoning, and serotonin syndrome. Malignant hyperthermia: Less commonly, drug-induced hyperthermia may develop as a form of malignant hyperthermia. Although hyperthermia associated with cocaine and PCP have been ascribed this diagnosis,225,226 malignant hyperthermia is a rare complication that is usually associated with exposure to volatile anesthetic agents or depolarizing muscle relaxants.171 The primary defect is felt to be an alteration in cellular permeability, which results in an inability to regulate calcium concentrations within the skeletal muscle fibers.227 As a result neuromuscular paralysis (acting at the neuromuscular junction) is not effective in controlling the severe muscular rigidity and heat generation seen with malignant hyperthermia. Dantrolene (1 to 2 mg/kg rapidly IV) is the most effective treatment for malignant hyperthermia. While dantrolene has been suggested to diminish hyperthermia associated with amphetamine228,229and LSD230 overdose, it has not been shown in any controlled study to be effective and confirmation of its usefulness for these indications requires further evaluation. Neuroleptic malignant syndrome: Neuroleptic malignant syndrome (NMS) is another uncommon cause of drug-induced hyperthermia associated with the use of haloperidol and certain other neuroleptic agents. It has been reviewed in depth elsewhere.212,231,232 Muscular rigidity, autonomic instability, and metabolic disturbances are presumed to occur due to neurotransmitter imbalances.



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Neuromuscular paralysis and routine external cooling measures are generally effective for treatment of the severe rigidity and hyperthermia in this condition. In case reports NMS has been attributed to cocaine233,234 and LSD,230 although exertional hyperthermia seems a more probable diagnosis in these instances. Treatment includes the use of bromocriptine (5.0 mg per nasogastric tube every 6 h),235 and supportive care. Serotonin syndrome: A clinical syndrome associated with increased free serotonin levels; usually the result of a prescription drug interaction such as selective serotonin-reuptake inhibitor with cocaine or amphetamines. Muscle rigidity is not as prominent as with NMS and sweating and gastrointestinal complaints are much more common. Symptoms of hyperthermia hyperreflexia, agitation, and an exaggerated tremor predominate.214–216 Importance of paralysis and cooling: Zalis et al.236,237 showed that hyperthermia was directly related to mortality in mongrel dogs with amphetamine overdose. Paralysis was shown to stop muscle hyperactivity, reduce hyperthermia, and decrease mortality.238 Davis et al.239 showed that dogs treated with toxic doses of PCP exhibited toxicity, which was diminished by paralysis and cooling measures.239 Animal studies also indicate a key role for hyperthermia in complications associated with cocaine overdosage. Catravas and Waters123 demonstrated that dogs given otherwise lethal cocaine infusions survived if severe hyperthermia was prevented. In this study temperature correlated better with survival than did pulse or blood pressure. Measures to prevent hyperthermia have included paralysis with pancuronium, sedation with chlorpromazine or diazepam, and external cooling. Prognosis: Prognosis for severe hyperthermia depends on the duration of temperature elevation, the maximum temperature reached, and the affected individual’s underlying health.240 Coagulopathy was reported to be associated with death in four of five cases in one report209 and has been shown to correlate with mortality in other studies.241 Seizures are also associated with a poor prognosis.209 This may in part be because they are often resistant to treatment in the hyperthermic individual. Any delay in cooling has been associated with a significantly increased incidence of mortality as well.242 8.2.4.2 Stepwise Approach to Management It does not take long either to boil an egg or to cook neurons.243 Immediate Interventions 1. Airway, Breathing, Circulation: Maintain the airway and assist ventilation if necessary. Administer supplemental oxygen. Treat hypotension, and resuscitate as per previous reviews.1–3 2. Antidotes: Administer appropriate antidotes, including 25 g dextrose IV if the patient is hypoglycemic, as per the section on coma. 3. Control seizures and muscular hyperactivity: See Section 8.2.3, seizures, and Section 8.2.2, agitation. 4. Cooling: The fastest cooling techniques reported in the literature have usually been implemented in a research laboratory environment, utilizing animal models and equipment and techniques that are not universally available. In clinical practice, a technique that allows easy patient access and is readily available is preferable to a technique that may be more effective, but is difficult to perform. A comparison of the cooling rates achieved in several animal and human models with various cooling techniques is shown in Table 8.2.9. The advantages and disadvantages are summarized in Table 8.2.10. We favor evaporative cooling as the technique of choice. Evaporative cooling combines the advantages of simplicity and noninvasiveness with the most rapid cooling rates that can be achieved with any external techniques.244 Some authors advocate the use of strategically placed ice packs although there are no controlled studies demonstrating their effectiveness and ice packs may contribute to shivering, which may further increase heat generation. In the authors’ experience with exercise-induced heat stroke, ice packs placed at the groin and axillae do not causing shivering if they were used when the temperature is high (>40°C) and removed as the


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Table 8.2.9 Cooling Rates Achieved with Various Cooling Techniques Technique

Author/Year 520

Evaporative

Immersion (ice water)

Icepacking (whole body) Strategic ice packs Evaporative and strategic ice packs Cold gastric lavage Cold peritoneal lavage

Species

Weiner/1980 Barner/1984521 Al-Aska/1987522 Kielblock/1986523 Wyndam/1959524 White/1987525 Daily/1948526 Weiner/1980520 Wyndam/1959524 Magazanik/1980527 Daily/1948526 Kielblock/1986523 Bynum/1978528 Kielblock/1986523 Kielblock/1986523 Syverud/1985529 White/1987525 Bynum/1978528

Human Human Human Human Human Dog Rat Human Human Dog Rat Human Dog Human Human Dog Dog Dog

Rate °C/min 0.31 0.04 0.09 0.034 0.23 0.14 0.93 0.14 0.14 0.27 1.86 0.034 0.11 0.028 0.036 0.15 0.06 0.56

Source: Helmrich, D.E. and Syverud, S.A., Roberts, J.R. and Hedges, J.R., Eds., Clinical Procedures in Emergency Medicine, 2nd ed. Philadelphia: Saunders, 1991. With permission. Table 8.2.10

Various Cooling Techniques

Technique

Advantages

Evaporative

Simple, readily available Noninvasive Easy monitoring and patient access Relatively more rapid

Immersion

Noninvasive Relatively more rapid

Ice packing

Cold gastric lavage

Noninvasive Readily available Noninvasive Readily available Can be combined with other techniques Can be combined with other techniques

Cold peritoneal lavage

Very rapid

Strategic ice packs

Disadvantages Constant moistening of skin surface required to maximize heat loss

Cumbersome Patient monitoring and access difficult — inability to defibrillate Shivering Poorly tolerated by conscious patients Shivering Poorly tolerated by conscious patients Relatively slower Shivering Poorly tolerated by conscious patients Relatively slower Invasive May require airway protection Human experience limited Invasive Invasive Human experience limited

Source: Helmrich, D.E., Syverud, S.A., Roberts, J.R. and Hedges, J.R., Eds., Clinical Procedures in Emergency Medicine, 2nd ed. Philadelphia: Saunders, 1991. With permission.

patient cools. Gastric lavage with cold water or saline is an effective and rapid central cooling technique that can be used in combination with evaporation in severe cases. Neuromuscular paralysis is recommended in all severe cases in which temperature is persistently greater than 40°C. Cooling technique is as follows: a. Completely remove all clothing. b. Place cardiac monitor leads on the patient’s back so that they adhere to the skin during the cooling process. c. Wet the skin with lukewarm tap water with a sponge or spray bottle (plastic spray bottles work the best).



d. e. f. g.

h. i. j. k.

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Position large high-speed fan(s) close to the patient and turn them on. Place ice pack to the groin and axillae (optional). If shivering occurs, treat with diazepam, 0.1 to 0.2 mg/kg IV, or midazolam, 0.05 mg/kg IV. Treat continued muscular hyperactivity, i.e., either severe shivering, rigidity, or agitation, with neuromuscular paralysis (vecuronium, 0.1 mg/kg IVP) with endotracheal intubation and mechanical ventilation. Employ vigorous fluid replacement to correct volume depletion and to facilitate thermoregulation by sweating. If the patient continues to exhibit muscle rigidity despite administration of neuromuscular blockers, give dantrolene, 1 mg/kg rapid IV push. Repeat as necessary up to 10 mg/kg. Place a Foley catheter and monitor urine output closely. Monitor the rectal or esophageal temperature and discontinue cooling when the temperature reaches 38.5°C to avoid hypothermia.

Comments: Immersion: Immersion in an ice water bath is also a highly effective measure to reduce core temperatures, but limits the health care provider’s access to the patient, and requires more equipment and preparation. Thermometry: Unfortunately, most standard measurements of body temperature differ substantially from actual core temperature. Oral thermometry is affected by mouth breathing and is a poor approximation of core temperature. Rectal thermometry is less variable, but responds to changes in core temperature slowly. Thermistors that are inserted 15 cm into the rectum offer continuous monitoring of temperature with less variability and, although slower to respond to changes in core temperature than tympanic temperature readings, are not biased by head skin temperature. Temperatures taken using infrared thermometers that scan the tympanic membrane are of variable reliability and reproducibility.245–248 Studies have shown that infrared tympanic membrane thermometers may be influenced by patient age,249measuring technique,250 the presence or absence of cerumen,245,251 and head skin temperature as noted above.252 If a patient has a Swan-Ganz catheter, pulmonary arterial temperature may be measured precisely with a thermistor catheter. An esophageal thermistor positioned adjacent to the heart closely correlates with core temperature as well. It is the least invasive, most accurate method available in the emergency department and is recommended (although rectal thermistors will suffice for most cases). Thermistors attached to urinary catheters may work equally well. Circulatory support: Usually, fluid requirements are modest, averaging 1200 ml of Ringer’s lactate or saline solution in the first 4 h.253,254 This is because a major factor in the hypotensive state is peripheral vasodilation.171 With cooling there may be a sudden rise in systemic vascular resistance, and pulmonary edema may be caused, or exacerbated, by overzealous fluid administration.255,256 Insertion of a Swan-Ganz catheter or central venous pressure monitor is indicated whenever necessary to guide fluid therapy. Patients with low cardiac output and hypotension should not be treated with α-adrenergic agents since these drugs promote vasoconstriction without improving cardiac output or perfusion, decrease cutaneous heat exchange, and perhaps enhance ischemic renal and hepatic damage.257 One case report described excellent results using low-dose continuous isoproterenol infusion (1 μg/min).253 Shivering: Since shivering may occur with rapid cooling, and thus generate more heat, some authors257,258 recommend chlorpromazine as an adjunct measure. Chlorpromazine is felt to act as a muscle relaxant and vasodilator promoting heat exchange at the skin surface. Phenothiazines, however, may aggravate hypotension, and have anticholinergic properties. They are also associated with serious dystonic reactions that may exacerbate hyperthermia. Distinct subtypes of dopamine receptors have been identified, including D1 and D2 receptors. Chlorpromazine and haloperidol are D2 receptor antagonists and rat studies have shown that specific D1 receptor antagonist, but not D2 receptor antagonists reduced the hyperthermic response to cocaine infusion.259 Dopamine is also known to participate in core temperature regulation, but it is unclear whether a predominance of D1 or D2 receptor activation results in hyperthermia or hypothermia.260 Until more is understood about the exact role of the dopaminergic system in hyperthermia, the use of chlorpromazine and other dopamine blockers in the management of hyperthermia victims is not recommended.


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Other pharmacologic interventions: Pharmacologic interventions aimed specifically at hyperthermia (i.e., dantrolene) have been suggested for such drugs as MDMA (i.e., ecstasy)228 but have not been proven to be of any benefit.229,261 Antipyretics are of no specific benefit262and salicylates may aggravate bleeding tendencies.263 Alcohol sponge baths are not recommended, particularly in small children, since alcohol may be absorbed through dilated cutaneous blood vessels and inhaled, producing isopropanol poisoning and coma.264

Secondary Interventions 1. Laboratory Data: Send blood for complete blood count, platelet count, PT, PTT, electrolytes, calcium, CPK, cardiac enzymes, BUN, creatinine, and liver function tests. Type and cross-match blood and send blood cultures. For severely ill patients send lactic acid level, and ABG. Check serum CPK and urine for myoglobin. If rhabdomyolysis is suspected, see Section 8.2.5 on rhabdomyolysis. Although urine and blood toxicologic screens are generally overutilized,5 they should be sent if the diagnosis is in question. Send salicylate levels on all cases with an unknown cause of hyperthermia. 2. CT: Consider CT of brain for persistently altered mental status, focal neurological deficit. 3. Lumbar puncture: Perform lumbar puncture and send cerebral spinal fluid for analysis if patient has signs or symptoms of meningitis. Do not wait for results before administering empiric antibiotics. 4. Cardiac evaluation: ECG, CXR. 5. Disposition: All patients with serious hyperthermia or heat stroke should be admitted to the hospital. Patients with normal or mildly abnormal laboratory values who become normothermic in the emergency department may be admitted to the medical floor. All others require intensive monitoring. 8.2.5

Rhabdomyolysis

8.2.5.1 General Comments Rhabdomyolysis is defined as a syndrome of skeletal muscle injury or necrosis with release of muscle cell contents into the blood.265 It has been associated with all drugs of abuse.133,224,266–277 Since the classic signs and symptoms of nausea, vomiting, myalgias, muscle swelling, tenderness, and weakness are present in only a minority of cases (13% in one study278), the diagnosis depends on laboratory evaluation and a high clinical suspicion. Elevated levels of serum CK, in the absence of CK from other sources (brain or heart), is the most sensitive indicator of muscle injury265 with most authors recognizing a CK level of more than fivefold that of the upper limit of normal as diagnostic. The diagnosis may also be suspected with a positive urine dipstick for heme: if no red blood cells are present on the urine microscopic examination, the positive orthotolidine reaction may be attributed to myoglobin (or hemoglobin). Because myoglobin is cleared from the plasma in 1 to 6 h by renal excretion and by metabolism to bilirubin,265 the urine dipstick test for myoglobin may occasionally be negative due to rapid clearance.279,280 Gabow et al.265 reported that in the absence of hematuria, only 50% of patients with rhabdomyolysis had urine that was orthotolidine-positive. The diagnosis of rhabdomyolysis is important because it may produce life-threatening hyperkalemia and myoglobinuric renal failure; it is often associated with disseminated intravascular coagulation (DIC), and acute cardiomyopathy from serious underlying conditions such as heat stroke or severe acidosis.265,277,280–282 Myoglobinuric renal failure may frequently be prevented by vigorous treatment. Case in point: In 1984, Ron and colleagues283 described seven patients at very high risk for developing renal failure as a result of extensive crush injuries, severe rhabdomyolysis, and gross



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myoglobinurea following the collapse of a building. Their treatment goal was to rapidly obtain a urine pH of 6.5 and to maintain diuresis of 300 ml/h or more. Crystalloid infusions were begun at the scene and continued during transport to the hospital. If urine output did not rise to 300 ml/h and the central venous pressure rose by more than 4 cm H2O, the infusion was halted and 1 g mannitol/kg body weight as a 20% solution was administered IV. Sodium bicarbonate (44 mEq) was added to every other bottle of 500-ml crystalloid solution. The electrolyte composition of IV solutions was adjusted to maintain a serum sodium concentration of 135 to 145 mmol/L and a serum potassium concentration between 3.5 and 4.5 mmol/L. Repeated doses of mannitol (1 g/kg body wt) were given if the urine output fell below 300 ml/h for 2 consecutive hours and if the central venous pressure rose by more than 4 cm H2O. Further does of bicarbonate were given if the urine pH fell below 6.5. Acetazolamide was given intravenously if plasma pH approached 7.45. Despite peak creatinine kinase (CK) levels exceeding 30,000 IU/dl none of the seven patients developed renal failure. Assessing risk for developing acute renal failure: Several heterogeneous studies have attempted to identify which patients will progress to myoglobinuric renal failure based on their laboratory values. Unfortunately, there are no prospective studies with standardized treatment regimens to determine which patients are at risk. A study of 200 victims of severe beatings in South Africa found that base deficit, delay in treatment, and CK levels were significant risk factors for the development of ARD and death.284 Ward et al.,284a in another retrospective study (n = 157) found that the factors predictive of renal failure included (1) a peak CK level greater than 16,000 IU/dl (58% of patients with CK above 16,000 IU/dl vs. 11% of patients with CK below 16,000 IU/dl developed renal failure), (2) a history of hypotension, (3) dehydration, (4) older age, (5) sepsis, and (6) hyperkalemia. A retrospective review of 93 patients with “severe” rhabdomyolysis (serum CK greater than 5000 U/L) found that patients with a peak CK level of greater than 15,000 U/L had significantly higher rates of acute renal dysfunction (72% vs. 38%).285 A recent analysis of 372 patients with crush syndrome after the 1995 earthquake in Kobe, Japan, demonstrated that patients with a peak CK level greater than 75,000 U/L had a higher rate of acute renal failure and mortality than those with a peak CK less than 75,000 U/L (84% vs. 39% and 4% vs. 17%, respectively).286 Eneas et al.287 found that only patients with a peak CK greater than 20,000 U/L failed to respond to a mannitol–bicarbonate diuresis and went on to require dialysis. The nonresponders also had significantly higher serum phosphate levels and hematocrit readings upon admission, indicative of more severe muscle injury and hemoconcentration. Several studies have attempted to predict the development of renal failure using serum or urine myoglobin levels. A prospective study of eight patients by Feinfeld288 found that four of five patients with urine myoglobin levels greater than 1000 ng/ml (normal = 200 mL/hr

Yes

Maintain Mannitol/ NaHCO3 infusion

Reduce Mannitol and Saline by 50% if urine output maintained > 250 mL/hr x 2 hours

Oliguria in patients with Rhabdomyolysis requires conversion to a diuresis within one to two hours to avoid acute renal failure.

MONITOR URINE pH EVERY 4 HOURS

7

Bolus with 50 mEq NaHCO3 Recheck urine pH after 2 hours

6–7

If pH < 6.0 DO NOT BOLUS with NaHCO3 VBG or ABG daily while on NaHCO3

Monitor ABG pH

50 mEq NaHCO3 Bolus

No

Serum pH > 7.5

CONTINUE TREATMENT

STOP NaHCO3 Use D5 0.45% NaCL only

1) STOP NaHCO3 Consider acetazolamide 5mg/kg IV (DO NOT use acetazolamide if allergic to sulfa) 2) Continue Mannitol Diuresis

Yes

No

CPK 120 mm Hg diastolic) despite sedation, one should consider the use of a vasodilator such as nitroglycerin or phentolamine, or possibly a calcium channel blocker.327 In contrast to patients with chronic hypertension, most young patients with drug-induced hypertension do not have chronic compensatory changes in their cerebral


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and cardiovascular system. For this reason blood pressure in previously normotensive individuals may be reduced rapidly to normal levels.328 Hypertensive emergencies: Hypertensive emergencies, defined as an increase in blood pressure that causes functional disturbances of the CNS, the heart, or the kidneys,329 require a more aggressive approach.330–332 Evidence of hypertensive encephalopathy, acute heart failure, aortic dissection, or coronary insufficiency requires rapid reduction of blood pressure (usually within 60 min) in a controlled fashion. Direct arteriolar dilating agents such as nitroglycerin, or nitroprusside, a pure alpha-adrenergic blocking agent such as phentolamine, or a calcium antagonist333 may be used. Stroke: Hypertension in the presence of a stroke is a more complicated issue, since hypertension may be a homeostatic response to maintain intracerebral blood flow in the presence of intracranial hypertension.334 In this case blood pressure should not be lowered, or, if there is ongoing evidence of sympathomimetic drug intoxication, lowered gradually to a diastolic blood pressure no less than the 100 to 110 mm Hg range. Beta-blockers: In animal models of cocaine intoxication associated with hemodynamic dysfunction and mortality, propanolol has been shown to be protective,335 to have no effect,336 or to increase mortality.337,338 The reasons for the differences in these experimental results are unclear but may be related to the different doses of cocaine or the type of beta-adrenergic antagonist utilized.339 Human studies, however, have been more consistent. In a randomized, double-blinded, placebo-controlled trial, Lange et al.340 administered intranasal cocaine to 30 stable volunteers referred for cardiac catheterization. In this study it was found that intracoronary propranolol administration caused no change in arterial blood pressure but decreased coronary sinus blood flow and increased coronary vascular resistance. Several case reports have also documented an aggravation of hypertension when nonselective beta-adrenergic antagonists have been used in the treatment of acute cocaine intoxication.341–343 Labetalol: The exacerbation of hypertension and coronary vasospasm when nonselective betaadrenergic antagonists are administered to cocaine-intoxicated patients may result from blockade of beta-2 receptor-induced vasodilation causing an “unopposed” peripheral alpha-adrenergic vasoconstriction.339 It has therefore been suggested that labetalol, which has both alpha-adrenergic and beta-adrenergic antagonist activity, may be safer.154,342 Controversy exists since the beta-adrenergic antagonist potency of labetalol is seven times greater than its relatively weak alpha antagonist potency,344 and studies of hypertension in cocaine-intoxicated animals are conflicting: some have shown hemodynamic improvement345 while others show no hemodynamic effect.346 Mortality data are difficult to decipher as studies have shown decreased mortality,335 increased mortality,337,338 or no change in mortality.336 The human experience (case reports) with labetalol has been better than with propanolol,342,347,348 but in two unusual cases involving catecholamine excess that physiologically resemble cocaine intoxication (one involving pheochromocytoma,349 and the other an accidental epinephrine overdosage350), hypertension was exacerbated by the administration of labetalol. In a study similar to that of Lange et al.,351 Boehrer et al.352 evaluated 15 patients referred for cardiac catheterization and found that while labetalol reversed the cocaine-induced rise in mean arterial pressure it did not alleviate cocaine-induced coronary vasoconstriction. An interesting case report described the induction of life-threatening hyperkalemia in a dialysis patient with hypertensive emergency treated with labetalol.353 Esmolol: Esmolol, an ultra-short acting (t1/2 = 9 min), easily titrated, beta-1 selective, adrenoreceptor blocking agent, has been used successfully in the treatment of cocaine-induced adrenergic crises.126,343,354 However, the effects of esmolol on coronary vasoconstriction have not been evaluated. Its use may be most appropriate to control heart rate in the setting of acute aortic dissection355 induced by hypertension from stimulant abuse. If esmolol is used, it is recommended that vasodilators such as nitroglycerin be given simultaneously since nitroglycerin is known to alleviate stimulant-induced vasoconstriction.356 Pollan et al.354 reported a case of a 64-year-old man who became hypertensive and tachycardic after the administration of cocaine for nasal polyp removal. This patient had resolution of ST segment depression after the administration of 20 mg IV of



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esmolol with good control of hemodynamic parameters. Esmolol has also been used in the management of pheochromocytoma with a rapid decrease in systolic blood pressure without effect on diastolic pressure.357,358 8.2.6.2 Stepwise Approach to Management Immediate Interventions 1. Airway, Breathing, Circulation: Maintain the airway and assist ventilation if necessary. Administer supplemental oxygen. Resuscitate as per previous reviews.3 2. Antidotes: Administer appropriate antidotes, including 25 g dextrose IV if the patient is hypoglycemic, as per Section 8.2.1. 3. Agitation or Seizures: Administer a benzodiazepine such as lorazepam (0.05 to 0.10 mg/kg) and control agitation as described under Section 8.2.2. 4. Medications: If the patient is persistently hypertensive and a hypertensive emergency exists, then administer one of the following drugs: Treatment for Drug-Induced, Hypertensive Emergency Drug

Dose

Onset

Mechanism of Action

Sodium nitroprusside Nitroglycerin Esmolol

0.25–10 μg/kg/min as IV infusion 5–100 μg as IV infusion Load with 500 μg/kg/min over 1 min Maintenance infusion: 50–200 μg/kg/min 5–10 mg IVP

2–5 min 2–5 min 2–5 min

Direct arterial and venous vasodilator Direct arterial and venous vasodilator B1 adrenoreceptor blocker

2–5 min

Alpha-adrenergic blocker

Phentolamine

The treatment goal is to lower the blood pressure to a level that is “normal” for that patient within 30 to 60 min in a controlled, graded manner.329 Although there is a broad range of normal blood pressures for an individual, if the patient’s normal blood pressure is unknown, the diastolic blood pressure should be lowered to a minimum of 120 mm Hg or until there is no evidence of ongoing organ injury. The use of nitroprusside generally requires continuous intra-arterial blood pressure monitoring. Comment: Phenylpropanolamine, an indirect sympathomimetic and direct alpha agonist, is frequently substituted for stimulants such as amphetamine and cocaine. The combination of severe hypertension with reflex bradycardia is a clue to vasoconstriction from the direct alpha-stimulation from phenylpropanolamine. Hypertension from phenylpropanolamine is usually best treated with phentolamine. 5. Laboratory data/imaging: For patients with hypertensive emergencies: Draw electrolytes, CK, CK-MB, BUN, creatinine, and PT/PTT. Perform EKG, and CXR. For apparently uncomplicated hypertension: Laboratory data may be done at the discretion of the physician. An ECG is recommended to rule out silent ischemia. Secondary Interventions 1. Monitoring: Continue close monitoring of patient’s blood pressure and cardiac status with frequent manual blood pressure readings. Consider placing an arterial line for better monitoring in patients with persistently labile hypertension or for those who have hypertension that is difficult to control. 2. CT of brain: Patients with severe headaches that do not resolve after the control of hypertension should undergo CT of the head to rule out intracranial bleeding.


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3. Lumbar puncture: If CT of head is negative and the patient continues to have symptoms of severe headache and/or nuchal rigidity, perform lumbar puncture to rule out small subarachnoid hemorrhage. 4. Disposition: All patients that meet the following conditions may be considered for discharge from the emergency department: a. Moderate uncomplicated hypertension controlled with sedation or a single dose of antihypertensive agents b. Normal vital signs after a period of observation of 4 to 6 h c. Normal ECG d. Normal physical examination

All patients with hypertensive emergencies should be admitted to the hospital regardless of response to initial therapy. 8.2.7

Cardiac Care

8.2.7.1 General Comments Almost all drugs of abuse can be associated with acute cardiac complications ranging from benign supraventricular tachycardia to ventricular fibrillation, sudden death, and myocardial infarction. Cocaine is a prototype cardiac toxin among drugs of abuse. As such, most of this section pertains directly to cocaine. Other stimulants (i.e., amphetamines,359,360 phenylpropanolamine,361,362 and methylphenidate363,364) may be associated with cardiac complications as well, and management should proceed in a fashion similar to that of the cocaine-intoxicated patient. One should also consider the likely possibility that cocaine has been mixed with or substituted for other stimulants (see Table 8.2.5 to Table 8.2.7).365 If cardiac complications occur from drugs of abuse other than stimulants (i.e., heroin, barbiturates) cardiac care parallels current advanced cardiac life support guidelines,366 with a few exceptions. Mechanisms: The ability of cocaine to increase myocardial oxygen demand secondary to induction of hypertension and tachycardia, while decreasing coronary blood flow through vasoconstriction, and induction of coronary thromboses (the latter due to enhancement of platelet aggregation) makes it an ideal precipitant of myocardial ischemia and infarction.367,368 Benzodiazepines: In experiments in animals, benzodiazepines attenuate the cardiac and CNS toxicity of cocaine.123,124,369 Perhaps through their anxiolytic effects, benzodiazepines reduce blood pressure and heart rate, thereby decreasing myocardial oxygen demand.367 They are recommended as first-line agents for treatment of cocaine-intoxicated patients with myocardial ischemia who are anxious, have tachycardia, and/or are hypertensive. Aspirin: Aspirin should be administered to help prevent the formation of thrombi in patients with suspected ischemia. This recommendation is based on theoretical considerations (e.g., decreasing platelet aggregation),370–372 the drug’s good safety profile, and the extensive investigation of aspirin in patients with ischemic heart disease unrelated to cocaine. There are, however, no clinical data on the use of aspirin in patients with cocaine-associated myocardial ischemia.367 Nitroglycerin: Nitroglycerin is recommended as first-line therapy for cocaine-induced cardiac ischemia based on studies that show a reversal of cocaine-induced coronary artery vasoconstriction356 and reports of its ability to relieve cocaine-associated chest pain.373 Calcium-channel blockers: In studies of cocaine intoxication in animals, calcium-channel blockers prevent malignant arrhythmias,374 blunt negative ionotropic effects,375 limit the increase in systemic vascular resistance,375 and protect against myocardial infarction.336 However, one study by Derlet et al.376 showed that calcium-channel blockers may increase CNS toxicity and mortality.376 This study, which was performed on rats, has been criticized on the basis that the cocaine was



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administered intraperitoneally and that pretreatment with a calcium antagonist might have accelerated peritoneal absorption.377 Another study by Nahas et al.378 showed that nitrendipine (a calcium antagonist with good CNS penetration) protected rats against cocaine-induced seizures and lethality. Verapamil reverses cocaine-induced coronary artery vasoconstriction379 and may play a role in the treatment of refractory myocardial ischemia secondary to cocaine use. Phentolamine: Phentolamine, an alpha-adrenergic antagonist, reverses cocaine-induced coronary artery vasoconstriction,351 and electrocardiographic resolution of ischemia has been documented in some patients.367 The use of a low dose (1 mg) may avoid the hypotensive effects of the drug while maintaining the anti-ischemic effects.380 Beta-blockers: Because of their association with coronary vasoconstriction and conflicting animal studies (see previous section on hypertension), beta-adrenergic blockers are not routinely recommended for the treatment of cocaine-associated ischemic chest pain. However, esmolol is indicated for severe adrenergic crisis associated with tachycardia and hypertension. Esmolol or metoprolol may play a role in the treatment of cocaine-induced malignant ventricular ectopy if lidocaine and defibrillation fail380 (see section below on arrhythmias). Thrombolytic therapy: Biogenic amines such as serotonin and epinephrine, which are released in large quantities by drugs such as cocaine, stimulate platelet aggregation. Stimulated platelets release thromboxane A2, which exacerbates ischemia by increasing vasoconstriction. The activation of the coagulation cascade and the formation of thrombin clot may follow. Thus, thrombolytic therapy seems rational in the setting of cocaine-induced myocardial infarction. However, the safety of thrombolysis has been questioned by Bush381 after one patient died of an intracerebral hemorrhage. A larger study by Hollander et al.382 noted no such complications among 36 patients who received thrombolytic therapy. Although thrombolytic agents may be safe, several concerns persist among clinicians: First, the mortality from cocaine-associated myocardial infarction is extremely low in patients who reach the hospital alive (0/136 patients in one study).383 Second, the clinical benefit of thrombolytic therapy in cocaine-induced coronary thrombosis has not been demonstrated.382 Finally, young patients with cocaine-associated chest pain have a high incidence of early repolarization (a variant of the normal ECG384,385); as a result they may inadvertently receive thrombolysis when it is not necessary.381,384,385 Because of these concerns as well as the belief by some386 that the major mechanism of cocaine-mediated infarction is vasospasm, thrombolytic therapy is only recommended under the following circumstances: (1) when percutaneous coronary intervention and angioplasty is not available; (2) in acute myocardial infarction with an electrocardiogram with >2 mm ST-segment elevation in two or more contiguous precordial leads, or >1 mm ST-segment elevation in two or more contiguous limb leads; and (3) when no contraindications to thrombolytic therapy exist (Table 8.2.11). It is interesting to note that studies have shown significant coronary artery disease (i.e., stenosis > 50%) is present in up to 77% of patients with cocaine induced myocardial infarction.387 Lidocaine: Lidocaine, a sodium channel blocker, was initially thought to increase the risk of arrhythmias and seizures in patients with cocaine intoxication, based on studies in Sprague-Dawley rats.388 Recent evidence from dog389 and guinea pig hearts390 suggests that lidocaine competes with cocaine for binding sites at the sodium channels and is then rapidly released from the sodium channel without harmful effects. A retrospective review of 29 patients who received lidocaine in the context of cocaine-associated dysrhythmias showed no adverse outcomes.391 Cautious use of lidocaine to treat ventricular arrhythmias occurring after cocaine use therefore seems reasonable. Ventricular arrhythmias that occur within a few hours after the use of cocaine may be the result of sodium channel blockade (e.g., quinidine-like effects) or from excessive levels of circulating catecholamines. For this reason cardioselective beta-blockers and/or sodium bicarbonate may be effective as well.392 Arrhythmias: Arrhythmias that occur after cocaine abuse may be associated with myocardial infarction, excessive catecholinergic surge, and/or sodium channel blockade (e.g., “quinidinelike” effects).393


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Table 8.2.11

Contraindications to Thrombolytic Therapy Absolute Contraindications

Active internal bleeding Altered consciousness Cerebrovascular accident (CVA) in the past 6 months or any history of hemorrhagic CVA Intracranial or intraspinal surgery within the previous 2 months Intracranial or intraspinal neoplasm, aneurysm, or arteriovenous malformation Known bleeding disorder Persistent, severe hypertension (systolic BP > 200 mm Hg and/or diastolic BP > 120 mm Hg) Pregnancy Previous allergy to a streptokinase product (this does not contraindicate tPA administration) Recent (within 1 month) head trauma Suspected aortic dissection Suspected pericarditis Trauma or surgery within 2 weeks that could result in bleeding into a closed space Relative Contraindications Active peptic ulcer disease Cardiopulmonary resuscitation for > 10 min Current use of oral anticoagulants Hemorrhagic ophthalmic conditions History of chronic, uncontrolled hypertension (diastolic BP > 100 mm Hg), treated or untreated History of ischemic or embolic CVA > 6 months ago Significant trauma or major surgery > 2 weeks ago but < 2 months ago Subclavian or internal jugular venous cannulation Source: Adapted from National Heart Attack Alert Program Coordinating Committee 60 Minutes to Treatment Working Group, NIH Publication No. 93-3278. September 1993, p. 19.

Supraventricular arrhythmias: Supraventricular arrhythmias due to cocaine include paroxysmal supraventricular tachycardia, rapid atrial fibrillation, and atrial flutter.394 These arrhythmias are usually short-lived and if the patient is hemodynamically stable do not require immediate therapy.395–397 Benzodiazepines modulate the stimulatory effects of cocaine on the CNS154,170,398 and may blunt the hypersympathetic state driving the arrhythmia. Patients with persistent supraventricular arrhythmias should be treated initially with a benzodiazepine (i.e., lorazepam or diazepam), and then if necessary with a cardioselective beta-blocker such as esmolol (see discussion under stepwise approach to management). Unstable supraventricular rhythms should be managed in accordance with the American Heart Association’s American Cardiac Life Support (ACLS) protocols. Ventricular arrhythmias (stable): As with supraventricular arrhythmias from cocaine, ventricular ectopy and short runs of ventricular tachycardia (VT) are usually transient, and most often resolve with careful observation supplemented by titrated doses of a benzodiazepine.366 In cases with persistent ventricular ectopy, cardioselective beta-blockers (i.e., metoprolol or esmolol) may reverse excessive catecholaminergic stimulation and suppress the ectopy. Lidocaine may also be of benefit.123,399,400 Ventricular arrhythmias (unstable): Ventricular fibrillation (VF) and malignant VT (VT) with hypotension, or evidence of congestive heart failure, or ischemia, should initially be treated as recommended by the ACLS algorithm. Lidocaine (1.0 to 1.5 mg/kg) may be given with caution as previously discussed. Defibrillation should proceed as usual.366

Epinephrine: Concerns about epinephrine have been raised since it has similar cardiovascular effects as cocaine and may even mediate many of its effects. There is, however, no good evidence to suggest eliminating the initial epinephrine dose in treating cocaine-induced VF. Clinicians should, however, increase the interval between subsequent doses of epinephrine to every 5 to 10 min and avoid high-dose epinephrine (greater than 1 mg per dose) in refractory patients.366 Propranolol or other beta-blocker: Propranolol continues to be recommended by the Committee on Emergency Cardiac Care for the treatment of malignant cocaine-induced VF and VT. This recommendation is based on animal data and empiric reports but is not supported by any



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human studies.154,369,401,402 The risk of beta-blockade in cocaine toxicity is that of unopposed alphastimulation resulting in severe hypertension, as well as coronary vasoconstriction.341 This is of less concern with the use of a cardioselective beta-blocker such as esmolol or metoprolol. 8.2.7.2 Stepwise Approach to Management Immediate Interventions 1. Airway, Breathing, Circulation: Maintain the airway and assist ventilation if necessary. Administer supplemental oxygen. Treat hypotension, and resuscitate as per previous reviews.3,366 2. Antidotes: Administer appropriate antidotes, including 25 g dextrose IV if the patient is hypoglycemic, as per the Section 8.2.1 on coma. 3. IV, Monitor, O2: Administer oxygen by nasal cannula at 4 L/min, monitor cardiac status (obtain ECG) and start a peripheral intravenous line. Hang normal saline to keep vein open. 4. Benzodiazepines: Administer a benzodiazepine (i.e., 0.25 to 0.5 mg, or 2 to 4 mg IVP lorazepam) if the patient is anxious, hypertensive, or is experiencing cardiac chest pain or transient arrhythmias. 5. Sublingual and transdermal nitroglycerin/aspirin: If hemodynamically stable but chest pain persists, administer nitroglycerin sublingually (up to three tablets or three sprays of 0.4 mg each). Apply a nitroglycerin paste, 1 in., to the chest. Give one aspirin (325 mg) by mouth. 6. IV nitroglycerin: If chest pain is present and the patient is hemodynamically stable, begin a nitroglycerin drip starting at 8 to 10 μg/min. Titrate upward to control of pain if blood pressure remains stable. 7. Calcium-channel blocker: Consider the use of calcium-channel blocker such as verapamil (5.0 mg IV over 2 min, with a repeat 5 mg dose IV if symptoms persist) or diltiazem (0.25 mg/ kg IV over 2 min, with repeat dose of 0.35 mg/kg IV over 2 min if symptoms persist) for resistant myocardial ischemia. Consider administration of morphine sulfate for chest pain if hemodynamically stable (2.0 mg IVP with additional doses titrated to control pain and anxiety). 8. Phentolamine: Use phentolamine, 1.0 to 5.0 mg IVP for resistant chest pain. 9. Thrombolytics: If ECG shows new ST segment elevation (greater than 2 mm in two consecutive leads) that persist despite nitrates or calcium-channel blockers, no contraindications exist (Table 8.2.11), and percutaneous coronary intervention is not readily available, administer a thrombolytic agent (Table 8.2.12, dosing). See previous reviews for comprehensive guide to thrombolytics.403–406 Comment: Establish two peripheral IVs, and perform a 12-lead ECG q 30 min until infusion completed. Avoid all unnecessary venous and arterial sticks and beware that automated blood pressure cuffs, nasogastric tubes, Foley catheters, and central lines are associated with increased bleeding.407 10. Arrhythmias: Supraventricular arrhythmias: See discussion above. Generally, treatment parallels ACLS guidelines with the use of benzodiazepines and beta-blockers in the doses recommended below. Ventricular arrhythmias: If stable ventricular tachycardia does not respond to benzodiazepines (i.e., lorazepam 0.25 to 0.50 mg/kg or 2 to 4 mg IVP) it should be treated with lidocaine (1.5 mg/kg IVP) and/or beta-blockers (metoprolol 5.0 mg IV every 5 min, to a total of 15 mg; or esmolol, load with 500 μg/kg/min over 1 min and run a maintenance infusion at 50 to 200 μg/kg/min; or propranolol, 1.0 mg IV every 5 min to a total of 3 mg). Esmolol has the advantage of being a beta1, cardioselective agent with a short half life (t1/2 = 9 min) allowing it to be rapidly discontinued in the event of an adverse reaction. Unstable ventricular tachycardia should be treated with immediate cardioversion or defibrillation (see ACLS recommendations on VT, VF) along with the administration of lidocaine, beta-blockers, and benzodiazepines. Patients should be reshocked after each administration of lidocaine or beta-blocker.366 The quinidine-like effects of cocaine are man-


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Table 8.2.12

Current Thrombolytic Agents and Their Dosing in the Acute MI Patient

Drug

Dose

Streptokinase (SK) (Cost $300)a

1.5 million units IV over 60 min

APSAC (Anistreplase) (Cost $1675)a

30 units IV over 2–5 min

Reteplase (Retavase) (Cost $3200)a

10 units IV over 2 min, followed by a second dose of 10 units IV over 2 min, 30 min after the first dose

tPA (Alteplase) (Cost $3200)a

“Front-loaded” dosing: 15 mg IV over 2 min, followed by 0.75 mg/kg (50 mg maximum) IV over 30 min, followed by 0.5 mg/kg (35 mg maximum) IV over 60 min

Tenecteplase (TNKase) (Cost $2850)

A single bolus dose should be administered over 5 s based on patient weight (30–50 mg)

a

Comments SK is antigenic; allergic reaction and rarely anaphylaxis (2.0 mg) naloxone in any patient at risk for opiate withdrawal. Naloxone infusion: Take two-thirds the amount of naloxone required for the patient to initially wake up and give that amount at an hourly rate. Mix the naloxone in the patient’s maintenance IV (D5W, D51/2NS, 1/2NS, NS, etc.). Infusions should be maintained in an intensive care setting. Patients should be closely watched any time the infusion is stopped. Duration of observation depends on the route of drug administration, the drug ingested, the presence or absence of liver dysfunction, and the possibility of ongoing drug absorption from the gastrointestinal tract. Usually 6 h is adequate. 8.2.10.3

Sedative–Hypnotic Agents Drug

Unique Characteristics

Key Management Issues

Benzodiazepines

High therapeutic index makes death unlikely unless coingestions involved; memory impairment common

GHB

Common at “raves,” associated with profound coma that rapidly resolves within 2 h, increased muscle tone with jerking Phenobarbital (t1/2 = 24–140 h) may induce prolonged deep coma (5–7 days) mimicking death; pneumonia is a common complication due to prolonged coma; hypothermia Commonly abused barbiturates; chronic drowsiness, psychomotor retardation; hypothermia

Respiratory depression, coma, compartment syndromes; severe withdrawal; use flumazenil in selected cases only; supportive care usually all that is required Supportive care, rarely requires endotracheal intubation, guard against aspiration

Long-lasting barbiturates (i.e., phenobarbital); duration of action = 10–12 h

Other barbiturates: Intermediate acting (i.e., amobarbital) Short acting (i.e., secobarbital) Ultrashort acting (i.e., thiopental)

As with benzodiazepines, although cardiac depression and hypotension are more common and may necessitate cardiac support; alkalinization of urine may increase elimination; MDAC in selected cases (see discussion); hemoperfusion in selected cases As above, although alkalinization, MDAC not helpful; hemoperfusion in selected cases; major withdrawal may necessitate hospitalization Continued.


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Drug Ethchlorvynol (Placidyl)

Glutethimide (Doriden)

Meprobamate (Miltown)

Methqualone (Quaalude)

Chloral hydrate

Unique Characteristics Pungent odor sometimes described as pearlike, gastric fluid often has a pink or green color, noncardiac pulmonary edema Prominent anticholinergic side effects including mydriasis Prolonged cyclic or fluctuating coma (average 36–38 h); often mixed with codeine as a heroin substitute Forms concretions, hypotension is more common than with other sedativehypnotics, prolonged coma (average 38–40 h) Muscular hypertonicity, clonus, and hyperpyrexia, popular as an “aphrodisiac” or “cocaine downer”; no longer manufactured in the U.S. Metabolized to trichloroethanol which may sensitize the myocardium to the effects of catecholamines, resulting in cardiac arrhythmias

Key Management Issues See barbiturates

See barbiturates

If concretions suspected, WBI or gastroscopic or surgical removal of drug may be necessary; hemoperfusion useful in severe cases Charcoal hemoperfusion increases clearance and may be useful in severe cases; diazepam may be necessary to treat severe muscular hypertonicity or “seizures” Tachyarrhythmias may respond to propranolol, 1–2 mg IV or esmolol; flumazenil has been reported to produce dramatic reversal of coma in one case; amenable to hemodialysis

Note: Catecholamines (especially dopamine and epinephrine) are relatively contraindicated in cases of chloral hydrate-induced tachyarrhythmias. Abbreviations: GHB, gammahydroxybuterate; MDAC, multiple-dose activated charcoal; WBI, whole bowel irrigation.

8.2.10.4

Hallucinogens Drug



LSD

Potent agent associated with panic attacks, acute psychotic reaction, and flashbacks in chronic users; vital signs are usually relatively normal; hallucinations for 1–8 h

Marijuana

Commonly used, associated with conjunctival injection, stimulation of appetite, orthostatic hypotension, and mild tachycardia; duration of effect: 3 h Dissociative anesthetic with hallucinations characterized by profound analgesia, amnesia, and catalepsy Increasingly common as drug of abuse; duration of effect: 1–3 hours Anticholinergic syndrome with true delirium, symptoms may continue for 24–48 h because of delayed GI motility

Patients usually respond to benzodiazepines and seclusion in a quiet environment; toxicology screen negative; in extremely agitated patients watch for hyperthermia, rhabdomyolysis Usually respond to simple reassurance and possible adjunctive benzodiazepine

Ketamine

Atropine, hycosyamine, scopolamine (Datura stramonium or Jimson weed)

Provide supportive care until drug effects wear off; cardiovascular parameters are usually well preserved

Usually supportive care only, consider activated charcoal; physostigmine for uncontrolled agitation, hyperthermia Continued.



Drug Solvents

Psilocybin

675



Products of petroleum distillation abused by spraying them into a plastic bag or soaking a cloth and then deeply inhaling; cardiac sensitization may result in malignant arrhythmias, low viscosity agents (i.e., gasoline) are associated with aspiration); chronic exposure associated with hepatitis and renal failure From the Stropharia and Conocybe mushrooms; suppresses serotonergic neurons, less potent than LSD with hallucinations that last from 2–8 h, patients may exhibit destructive behavior; hallucinations for 1–6 h

Usually hallucinogenic effects are short lived; removing the patient from the offending agent and providing fresh air are all that is necessary; treat aspiration by supporting airway; arrhythmias may respond to beta-blockers, epinephrine may worsen arrhythmias As with LSD

Note: Epinephrine is contraindicated in cases of solvent-induced tachyarrhythmias. Abbreviations: LSD, lysergic acid diethylamide, GI, gastrointestinal.

REFERENCES 1. Barnes, T.A., et al., Cardiopulmonary resuscitation and emergency cardiovascular care. Airway devices. Ann Emerg Med, 2001. 37(4 Suppl): p. S145–51. 2. Blanda, M. and U.E. Gallo, Emergency airway management. Emerg Med Clin North Am, 2003. 21(1): p. 1–26. 3. Kern, K.B., H.R. Halperin, and J. Field, New guidelines for cardiopulmonary resuscitation and emergency cardiac care: changes in the management of cardiac arrest. JAMA, 2001. 285(10): p. 1267–9. 4. Krenzelok, E.P. and J.B. Leikin, Approach to the poisoned patient. Dis Mon, 1996. 42(9): p. 509–607. 5. Olson, K.R., P.R. Pentel, and M.T. Kelley, Physical assessment and differential diagnosis of the poisoned patient. Med Toxicol, 1987. 2(1): p. 52–81. 6. Proudfoot, A., Practical management of the poisoned patient. Ther Drug Monit, 1998. 20(5): p. 498–501. 7. Riordan, M., G. Rylance, and K. Berry, Poisoning in children 1: general management. Arch Dis Child, 2002. 87(5): p. 392–6. 8. Mokhlesi, B., et al., Adult toxicology in critical care: part I: general approach to the intoxicated patient. Chest, 2003. 123(2): p. 577–92. 9. Peterson, J., Coma, in Emergency Medicine, Concepts and Clinical Practice, P. Rosen and R.M. Barkin, Eds. 1992, Mosby Year Book: St Louis. p. 1728–1751. 10. Guido, M.E., W. Brady, and D. DeBehnke, Reversible neurological deficits in a chronic alcohol abuser: a case report of Wernicke’s encephalopathy. Am J Emerg Med, 1994. 12(2): p. 238–40. 11. Wrenn, K.D., F. Murphy, and C.M. Slovis, A toxicity study of parenteral thiamine hydrochloride. Ann Emerg Med, 1989. 18(8): p. 867–70. 12. Centerwall, B.S. and M.H. Criqui, Prevention of the Wernicke–Korsakoff syndrome: a cost-benefit analysis. N Engl J Med, 1978. 299(6): p. 285–9. 13. Kagansky, N., S. Levy, and H. Knobler, The role of hyperglycemia in acute stroke. Arch Neurol, 2001. 58(8): p. 1209–12. 14. Parsons, M.W., et al., Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol, 2002. 52(1): p. 20–8. 15. Lindsberg, P.J. and R.O. Roine, Hyperglycemia in acute stroke. Stroke, 2004. 35(2): p. 363–4. 16. Dietrich, W.D., O. Alonso, and R. Busto, Moderate hyperglycemia worsens acute blood–brain barrier injury after forebrain ischemia in rats. Stroke, 1993. 24(1): p. 111–6.


676


17. Hoffman, R.S. and L.R. Goldfrank, The poisoned patient with altered consciousness. Controversies in the use of a “coma cocktail.” JAMA, 1995. 274(7): p. 562–9. 18. Fowkes, J. Opiates in the Emergency Department, in Toxicology and Infectious Disease in Emergency Medicine. 1992. San Diego, CA. 19. Osterwalder, J.J., Naloxone — for intoxications with intravenous heroin and heroin mixtures — harmless or hazardous? A prospective clinical study. J Toxicol Clin Toxicol, 1996. 34(4): p. 409–16. 20. Meissner, W. and K. Ullrich, Re: naloxone, constipation and analgesia. J Pain Symptom Manage, 2002. 24(3): p. 276–7; author reply 277–9. 21. Dole, V.P., et al., Arousal of ethanol-intoxicated comatose patients with naloxone. Alcohol Clin Exp Res, 1982. 6(2): p. 275–9. 22. Wedin, G.P. and L.J. Edwards, Clonidine poisoning treated with naloxone [letter]. Am J Emerg Med, 1989. 7(3): p. 343–4. 23. Alberto, G., et al., Central nervous system manifestations of a valproic acid overdose responsive to naloxone. Ann Emerg Med, 1989. 18(8): p. 889–91. 24. Varon, J. and S.R. Duncan, Naloxone reversal of hypotension due to captopril overdose. Ann Emerg Med, 1991. 20(10): p. 1125–7. 25. Harrington, L.W., Acute pulmonary edema following use of naloxone: a case study. Crit Care Nurse, 1988. 8(8): p. 69–73. 26. Schwartz, J.A. and M.D. Koenigsberg, Naloxone-induced pulmonary edema. Ann Emerg Med, 1987. 16(11): p. 1294–6. 27. Partridge, B.L. and C.F. Ward, Pulmonary edema following low-dose naloxone administration [letter]. Anesthesiology, 1986. 65(6): p. 709–10. 28. Prough, D.S., et al., Acute pulmonary edema in healthy teenagers following conservative doses of intravenous naloxone. Anesthesiology, 1984. 60(5): p. 485–6. 29. Taff, R.H., Pulmonary edema following naloxone administration in a patient without heart disease. Anesthesiology, 1983. 59(6): p. 576–7. 30. Flacke, J.W., W.E. Flacke, and G.D. Williams, Acute pulmonary edema following naloxone reversal of high-dose morphine anesthesia. Anesthesiology, 1977. 47(4): p. 376–8. 31. Wasserberger, J. and G.J. Ordog, Naloxone-induced hypertension in patients on clonidine [letter]. Ann Emerg Med, 1988. 17(5): p. 557. 32. Levin, E.R., et al., Severe hypertension induced by naloxone. Am J Med Sci, 1985. 290(2): p. 70–2. 33. Azar, I. and H. Turndorf, Severe hypertension and multiple atrial premature contractions following naloxone administration. Anesth Analg, 1979. 58(6): p. 524–5. 34. Mariani, P.J., Seizure associated with low-dose naloxone. Am J Emerg Med, 1989. 7(1): p. 127–9. 35. Michaelis, L.L., et al., Ventricular irritability associated with the use of naloxone hydrochloride. Two case reports and laboratory assessment of the effect of the drug on cardiac excitability. Ann Thorac Surg, 1974. 18(6): p. 608–14. 36. Cuss, F.M., C.B. Colaco, and J.H. Baron, Cardiac arrest after reversal of effects of opiates with naloxone. Br Med J (Clin Res Ed), 1984. 288(6414): p. 363–4. 37. Lubman, D., Z. Koutsogiannis, and I. Kronborg, Emergency management of inadvertent accelerated opiate withdrawal in dependent opiate users. Drug Alcohol Rev, 2003. 22(4): p. 433–6. 38. Gaddis, G.M. and W.A. Watson, Naloxone-associated patient violence: an overlooked toxicity? Ann Pharmacother, 1992. 26(2): p. 196–8. 39. Rock, P., et al., Efficacy and safety of naloxone in septic shock. Crit Care Med, 1985. 13(1): p. 28–33. 40. Groeger, J.S., G.C. Carlon, and W.S. Howland, Naloxone in septic shock. Crit Care Med, 1983. 11(8): p. 650–4. 41. Gurll, N.J., et al., Naloxone without transfusion prolongs survival and enhances cardiovascular function in hypovolemic shock. J Pharmacol Exp Ther, 1982. 220(3): p. 621–4. 42. Groeger, J.S. and C.E. Inturrisi, High-dose naloxone: pharmacokinetics in patients in septic shock. Crit Care Med, 1987. 15(8): p. 751–6. 43. Olinger, C.P., et al., High-dose intravenous naloxone for the treatment of acute ischemic stroke. Stroke, 1990. 21(5): p. 721–5. 44. Baskin, D.S., C.F. Kieck, and Y. Hosobuchi, Naloxone reversal and morphine exacerbation of neurologic deficits secondary to focal cerebral ischemia in baboons. Brain Res, 1984. 290(2): p. 289–96.



677

45. Baskin, D.S. and Y. Hosobuchi, Naloxone and focal cerebral ischemia [letter]. J Neurosurg, 1984. 60(6): p. 1328–31. 46. Baskin, D.S. and Y. Hosobuchi, Naloxone reversal of ischaemic neurological deficits in man. Lancet, 1981. 2(8241): p. 272–5. 47. Flamm, E.S., et al., A phase I trial of naloxone treatment in acute spinal cord injury. J Neurosurg, 1985. 63(3): p. 390–7. 48. Young, W., et al., Pharmacological therapy of acute spinal cord injury: studies of high dose methylprednisolone and naloxone. Clin Neurosurg, 1988. 34: p. 675–97. 49. Bracken, M.B., et al., A randomized, controlled trial of methylprednisolone or naloxone in the treatment of acute spinal-cord injury. Results of the Second National Acute Spinal Cord Injury Study [see comments]. N Engl J Med, 1990. 322(20): p. 1405–11. 50. Cohen, M.R., et al., High-dose naloxone infusions in normals. Dose-dependent behavioral, hormonal, and physiological responses. Arch Gen Psychiatry, 1983. 40(6): p. 613–9. 51. Cohen, R.M., et al., High-dose naloxone affects task performance in normal subjects. Psychiatry Res, 1983. 8(2): p. 127–36. 52. Gerra, G., et al., Clonidine and opiate receptor antagonists in the treatment of heroin addiction. J Subst Abuse Treat, 1995. 12(1): p. 35–41. 53. Stine, S.M. and T.R. Kosten, Use of drug combinations in treatment of opioid withdrawal. J Clin Psychopharmacol, 1992. 12(3): p. 203–9. 54. Creighton, F.J. and A.H. Ghodse, Naloxone applied to conjunctiva as a test for physical opiate dependence. Lancet, 1989. 1(8641): p. 748–50. 55. Loimer, N., P. Hofmann, and H.R. Chaudhry, Nasal administration of naloxone for detection of opiate dependence. J Psychiatr Res, 1992. 26(1): p. 39–43. 56. Kelly, A.M. and Z. Koutsogiannis, Intranasal naloxone for life threatening opioid toxicity. Emerg Med J, 2002. 19(4): p. 375. 57. Wilhelm, J.A., et al., Duration of opioid antagonism by nalmefene and naloxone in the dog. A nonparametric pharmacodynamic comparison based on generalized cross-validated spline estimation. Int J Clin Pharmacol Ther, 1995. 33(10): p. 540–5. 58. Barsan, W.G., et al., Duration of antagonistic effects of nalmefene and naloxone in opiate-induced sedation for emergency department procedures. Am J Emerg Med, 1989. 7(2): p. 155–61. 59. Kaplan, J.L. and J.A. Marx, Effectiveness and safety of intravenous nalmefene for emergency department patients with suspected narcotic overdose: a pilot study. Ann Emerg Med, 1993. 22(2): p. 187–90. 60. Ellenhorn, M., Ellenhorn’s Medical Toxicology. 2nd ed., M. Ellenhorn, Ed. 1997, New York: Elsevier Science Publishing Company. p. 437–8. 61. Chumpa, A., et al., Nalmefene for elective reversal of procedural sedation in children. Am J Emerg Med, 2001. 19(7): p. 545–8. 62. Nalmefene for alcohol dependence. Harv Ment Health Lett, 2000. 16(9): p. 7. 63. Rosen, D.A., et al., Nalmefene to prevent epidural narcotic side effects in pediatric patients: a pharmacokinetic and safety study. Pharmacotherapy, 2000. 20(7): p. 745–9. 64. Kearney, T., Flumazenil, in Poisoning and Drug Overdose, Olson, K.R., Ed. 1994, Appleton & Lange: Englewood Cliffs, NJ. p. 340–1. 65. Dunton, A.W., et al., Flumazenil: U.S. clinical pharmacology studies. Eur J Anaesthesiol Suppl, 1988. 2: p. 81–95. 66. Jensen, S., L. Knudsen, and L. Kirkegaard, Flumazenil used in the antagonizing of diazepam and midazolam sedation in out-patients undergoing gastroscopy. Eur J Anaesthesiol Suppl, 1988. 2: p. 161–6. 67. Kirkegaard, L., et al., Benzodiazepine antagonist Ro 15-1788. Antagonism of diazepam sedation in outpatients undergoing gastroscopy. Anaesthesia, 1986. 41(12): p. 1184–8. 68. Sewing, K.F., The value of flumazenil in the reversal of midazolam-induced sedation for upper gastrointestinal endoscopy [letter; comment]. Aliment Pharmacol Ther, 1990. 4(3): p. 315. 69. Bartelsman, J.F., P.R. Sars, and G.N. Tytgat, Flumazenil used for reversal of midazolam-induced sedation in endoscopy outpatients. Gastrointest Endosc, 1990. 36(3 Suppl): p. S9–12. 70. Davies, C.A., et al., Reversal of midazolam sedation with flumazenil following conservative dentistry. J Dent, 1990. 18(2): p. 113–8.


678


71. Chern, T.L., et al., Diagnostic and therapeutic utility of flumazenil in comatose patients with drug overdose. Am J Emerg Med, 1993. 11(2): p. 122–4. 72. Weinbroum, A., P. Halpern, and E. Geller, The use of flumazenil in the management of acute drug poisoning — a review. Intensive Care Med, 1991. 17 Suppl 1: p. S32–8. 73. Weinbroum, A., et al., Use of flumazenil in the treatment of drug overdose: a double-blind and open clinical study in 110 patients. Crit Care Med, 1996. 24(2): p. 199–206. 74. Thomas, P., C. Lebrun, and M. Chatel, De novo absence status epilepticus as a benzodiazepine withdrawal syndrome. Epilepsia, 1993. 34(2): p. 355–8. 75. Spivey, W.H., Flumazenil and seizures: analysis of 43 cases. Clin Ther, 1992. 14(2): p. 292–305. 76. Chern, T.L. and A. Kwan, Flumazenil-induced seizure accompanying benzodiazepine and baclofen intoxication [letter]. Am J Emerg Med, 1996. 14(2): p. 231–2. 77. McDuffee, A.T. and J.D. Tobias, Seizure after flumazenil administration in a pediatric patient. Pediatr Emerg Care, 1995. 11(3): p. 186–7. 78. Mordel, A., et al., Seizures after flumazenil administration in a case of combined benzodiazepine and tricyclic antidepressant overdose. Crit Care Med, 1992. 20(12): p. 1733–4. 79. Kim, J.S., et al., Flumazenil-induced ballism. J Korean Med Sci, 2003. 18(2): p. 299–300. 80. Lheureux, P., et al., Risks of flumazenil in mixed benzodiazepine-tricyclic antidepressant overdose: report of a preliminary study in the dog. J Toxicol Clin Exp, 1992. 12(1): p. 43–53. 81. Treatment of benzodiazepine overdose with flumazenil. The Flumazenil in Benzodiazepine Intoxication Multicenter Study Group. Clin Ther, 1992. 14(6): p. 978–95. 82. Haverkos, G.P., R.P. DiSalvo, and T.E. Imhoff, Fatal seizures after flumazenil administration in a patient with mixed overdose. Ann Pharmacother, 1994. 28(12): p. 1347–9. 83. Lim, A.G., Death after flumazenil [letter] [published erratum appears in BMJ 1989 Dec 16;299(6714):1531] [see comments]. BMJ, 1989. 299(6703): p. 858–9. 84. Serfaty, M. and G. Masterton, Fatal poisonings attributed to benzodiazepines in Britain during the 1980s [see comments]. Br J Psychiatry, 1993. 163: p. 386–93. 85. Greenblatt, D.J., et al., Acute overdosage with benzodiazepine derivatives. Clin Pharmacol Ther, 1977. 21(4): p. 497–514. 86. Guglielminotti, J., et al., Prolonged sedation requiring mechanical ventilation and continuous flumazenil infusion after routine doses of clorazepam for alcohol withdrawal syndrome. Intensive Care Med, 1999. 25(12): p. 1435–6. 87. Saltik, I.N. and H. Ozen, Role of flumazenil for paradoxical reaction to midazolam during endoscopic procedures in children. Am J Gastroenterol, 2000. 95(10): p. 3011–2. 88. Reichen, J., Review: flumazenil leads to clinical and electroencephalographic improvement in hepatic encephalopathy in patients with cirrhosis. ACP J Club, 2003. 138(1): p. 15. 89. Gerra, G., et al., Intravenous flumazenil versus oxazepam tapering in the treatment of benzodiazepine withdrawal: a randomized, placebo-controlled study. Addict Biol, 2002. 7(4): p. 385–95. 90. Proceedings of the Guidelines 2000 Conference for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: An International Consensus on Science. Ann Emerg Med, 2001. 37(4 Suppl): p. S1–200. 91. Harper, C., et al., An international perspective on the prevalence of the Wernicke–Korsakoff syndrome. Metab Brain Dis, 1995. 10(1): p. 17–24. 92. Peeters, A., et al., Wernicke’s encephalopathy and central pontine myelinolysis induced by hyperemesis gravidarum. Acta Neurol Belg, 1993. 93(5): p. 276–82. 93. Boldorini, R., et al., Wernicke’s encephalopathy: occurrence and pathological aspects in a series of 400 AIDS patients. Acta Biomed Ateneo Parmense, 1992. 63(1–2): p. 43–9. 94. Tate, J.R. and P.F. Nixon, Measurement of Michaelis constant for human erythrocyte transketolase and thiamin diphosphate. Anal Biochem, 1987. 160(1): p. 78–87. 95. Reuler, J.B., D.E. Girard, and T.G. Cooney, Current concepts. Wernicke’s encephalopathy. N Engl J Med, 1985. 312(16): p. 1035–9. 96. Cheeley, R.D. and S.M. Joyce, A clinical comparison of the performance of four blood glucose reagent strips. Am J Emerg Med, 1990. 8(1): p. 11–5. 97. Jones, J.L., et al., Determination of prehospital blood glucose: a prospective, controlled study. J Emerg Med, 1992. 10(6): p. 679–82.



679

98. Wilkins, B.H. and D. Kalra, Comparison of blood glucose test strips in the detection of neonatal hypoglycaemia. Arch Dis Child, 1982. 57(12): p. 948–50. 99. Barreau, P.B. and J.E. Buttery, The effect of the haematocrit value on the determination of glucose levels by reagent-strip methods. Med J Aust, 1987. 147(6): p. 286–8. 100. Tanvetyanon, T., M.D. Walkenstein, and A. Marra, Inaccurate glucose determination by fingerstick in a patient with peripheral arterial disease. Ann Intern Med, 2002. 137(9): p. W1. 101. Atkin, S.H., et al., Fingerstick glucose determination in shock. Ann Intern Med, 1991. 114(12): p. 1020–4. 102. Fazel, A., et al., Influence of sample temperature on reflectance photometry and electrochemical glucometer measurements. Diabetes Care, 1996. 19(7): p. 771–4. 103. Boyle, P.J., et al., Plasma glucose concentrations at the onset of hypoglycemic symptoms in patients with poorly controlled diabetes and in nondiabetics. N Engl J Med, 1988. 318(23): p. 1487–92. 104. Hoffman, J.R., D.L. Schriger, and J.S. Luo, The empiric use of naloxone in patients with altered mental status: a reappraisal. Ann Emerg Med, 1991. 20(3): p. 246–52. 105. Weisman, R., Naloxone, in Goldfrank’s Toxicologic Emergencies, Goldfrank, L.R., Lewin, N.A., et al., Eds. 1994, Appleton & Lange: Englewood Cliffs, NJ. p. 784. 106. Maio, R.F., B. Gaukel, and B. Freeman, Intralingual naloxone injection for narcotic-induced respiratory depression. Ann Emerg Med, 1987. 16(5): p. 572–3. 107. Claeys, M.A., et al., Reversal of flunitrazepam with flumazenil: duration of antagonist activity. Eur J Anaesthesiol Suppl, 1988. 2: p. 209–17. 108. Martens, F., et al., Clinical experience with the benzodiazepine antagonist flumazenil in suspected benzodiazepine or ethanol poisoning. J Toxicol Clin Toxicol, 1990. 28(3): p. 341–56. 109. Persson, A., et al., Imaging of [11C]-labelled Ro 15-1788 binding to benzodiazepine receptors in the human brain by positron emission tomography. J Psychiatr Res, 1985. 19(4): p. 609–22. 110. Hojer, J., et al., A placebo-controlled trial of flumazenil given by continuous infusion in severe benzodiazepine overdosage. Acta Anaesthesiol Scand, 1991. 35(7): p. 584–90. 111. Goldfrank, L., et al., A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med, 1986. 15(5): p. 566–70. 112. Mofenson, H.C. and T.R. Caraccio, Continuous infusion of intravenous naloxone [letter]. Ann Emerg Med, 1987. 16(5): p. 600. 113. Use of patient restraint. American College of Emergency Physicians. Ann Emerg Med, 1996. 28(3): p. 384. 114. Shanaberger, C.J., What price patient restraint? Orwick v. Fox. J Emerg Med Serv JEMS, 1993. 18(6): p. 69–71. 115. Stratton, S.J., C. Rogers, and K. Green, Sudden death in individuals in hobble restraints during paramedic transport. Ann Emerg Med, 1995. 25(5): p. 710–2. 116. Lavoie, F.W., Consent, involuntary treatment, and the use of force in an urban emergency department. Ann Emerg Med, 1992. 21(1): p. 25–32. 117. Gunnels, M., Violence in the emergency department: a daily challenge. J Emerg Nurs, 1993. 19(4): p. 277. 118. Cembrowicz, S.P. and J.P. Shepherd, Violence in the accident and emergency department. Med Sci Law, 1992. 32(2): p. 118–22. 119. Rumack, B.H., Editorial: Physostigmine: rational use. JACEP, 1976. 5(7): p. 541–2. 120. Lenox, R.H., et al., Adjunctive treatment of manic agitation with lorazepam versus haloperidol: a double-blind study. J Clin Psychiatry, 1992. 53(2): p. 47–52. 121. Cavanaugh, S.V., Psychiatric emergencies. Med Clin North Am, 1986. 70(5): p. 1185–202. 122. Stevens, A., et al., Haloperidol and lorazepam combined: clinical effects and drug plasma levels in the treatment of acute schizophrenic psychosis. Pharmacopsychiatry, 1992. 25(6): p. 273–7. 123. Catravas, J.D. and I.W. Waters, Acute cocaine intoxication in the conscious dog: studies on the mechanism of lethality. J Pharmacol Exp Ther, 1981. 217(2): p. 350–6. 124. Guinn, M.M., J.A. Bedford, and M.C. Wilson, Antagonism of intravenous cocaine lethality in nonhuman primates. Clin Toxicol, 1980. 16(4): p. 499–508. 125. Derlet, R.W. and T.E. Albertson, Diazepam in the prevention of seizures and death in cocaineintoxicated rats. Ann Emerg Med, 1989. 18(5): p. 542–6.


680


126. Merigian, K.S., et al., Adrenergic crisis from crack cocaine ingestion: report of five cases. J Emerg Med, 1994. 12(4): p. 485–90. 127. Shephard, R.A., Behavioral effects of GABA agonists in relation to anxiety and benzodiazepine action. Life Sci, 1987. 40(25): p. 2429–36. 128. Norman, T.R. and G.D. Burrows, Anxiety and the benzodiazepine receptor. Prog Brain Res, 1986. 65: p. 73–90. 129. Derlet, R.W., T.E. Albertson, and P. Rice, The effect of haloperidol in cocaine and amphetamine intoxication. J Emerg Med, 1989. 7(6): p. 633–7. 130. Derlet, R.W., T.E. Albertson, and P. Rice, Antagonism of cocaine, amphetamine, and methamphetamine toxicity. Pharmacol Biochem Behav, 1990. 36(4): p. 745–9. 131. Derlet, R.W., T.E. Albertson, and P. Rice, Protection against d-amphetamine toxicity. Am J Emerg Med, 1990. 8(2): p. 105–8. 132. Espelin, D., Amphetamine poisoning: Effectiveness of clorpromazine. N Engl J Med, 1968. 278: p. 1361–5. 133. Callaway, C.W. and R.F. Clark, Hyperthermia in psychostimulant overdose. Ann Emerg Med, 1994. 24(1): p. 68–76. 134. Soyka, M., C. Botschev, and A. Volcker, Neuroleptic treatment in alcohol hallucinosis: no evidence for increased seizure risk. J Clin Psychopharmacol, 1992. 12: p. 66–7. 135. Lipka, L.J. and C.M. Lathers, Psychoactive agents, seizure production, and sudden death in epilepsy. J Clin Pharmacol, 1987. 27(3): p. 169–83. 136. Hoffman, R.S., Cocaine intoxication considerations, complications and strategies: point and counterpoint. Emerg Med, 1992. 1: p. 1–6. 137. Witkin, J., S.R. Godberg, and J.L. Katz, Lethal effects of cocaine are reduced by the dopamine-1 receptor antagonist SCH 23390 but not by haloperidol. Life Sci, 1989. 44: p. 1285–91. 138. Pollera, C.F., et al., Sudden death after acute dystonic reaction to high-dose metoclopramide [letter]. Lancet, 1984. 2(8400): p. 460–1. 139. Barach, E., et al., Dystonia presenting as upper airway obstruction. J Emerg Med, 1989. 7(3): p. 237–40. 140. Cavanaugh, J.J. and R.E. Finlayson, Rhabdomyolysis due to acute dystonic reaction to antipsychotic drugs. J Clin Psychiatry, 1984. 45(8): p. 356–7. 141. Addonizio, G. and G.S. Alexopoulos, Drug-induced dystonia in young and elderly patients. Am J Psychiatry, 1988. 145(7): p. 869–71. 142. Menza, M.A., et al., Controlled study of extrapyramidal reactions in the management of delirious, medically ill patients: intravenous haloperidol versus intravenous haloperidol plus benzodiazepines. Heart Lung, 1988. 17(3): p. 238–41. 143. Yildiz, A., G.S. Sachs, and A. Turgay, Pharmacological management of agitation in emergency settings. Emerg Med J, 2003. 20(4): p. 339–46. 144. Brook, S., J.V. Lucey, and K.P. Gunn, Intramuscular ziprasidone compared with intramuscular haloperidol in the treatment of acute psychosis. Ziprasidone I.M. Study Group. J Clin Psychiatry, 2000. 61(12): p. 933–41. 145. Brook, S., Intramuscular ziprasidone: moving beyond the conventional in the treatment of acute agitation in schizophrenia. J Clin Psychiatry, 2003. 64 Suppl 19: p. 13–8. 146. Spina, E., et al., Prevalence of acute dystonic reactions associated with neuroleptic treatment with and without anticholinergic prophylaxis. Int Clin Psychopharmacol, 1993. 8(1): p. 21–4. 147. Shenoy, R.S., Pitfalls in the treatment of jimsonweed intoxication [letter]. Am J Psychiatry, 1994. 151(9): p. 1396–7. 148. Hurlbut, K.M., Drug-induced psychoses. Emerg Med Clin North Am, 1991. 9(1): p. 31–52. 149. Kopman, A.F., G. Strachovsky, and L. Lichtenstein, Prolonged response to succinylcholine following physostigmine. Anesthesiology, 1978. 49(2): p. 142–3. 150. Manoguerra, A.S. and R.W. Steiner, Prolonged neuromuscular blockade after administration of physostigmine and succinylcholine. Clin Toxicol, 1981. 18(7): p. 803–5. 151. Pentel, P. and C.D. Peterson, Asystole complicating physostigmine treatment of tricyclic antidepressant overdose. Ann Emerg Med, 1980. 9(11): p. 588–90. 152. Newton, R.W., Physostigmine salicylate in the treatment of tricyclic antidepressant overdosage. JAMA, 1975. 231(9): p. 941–3.



681

153. Nattel, S., L. Bayne, and J. Ruedy, Physostigmine in coma due to drug overdose. Clin Pharmacol Ther, 1979. 25(1): p. 96–102. 154. Gay, G.R., Clinical management of acute and chronic cocaine poisoning. Ann Emerg Med, 1982. 11(10): p. 562–72. 155. Khantzian, E.J. and G.J. McKenna, Acute toxic and withdrawal reactions associated with drug use and abuse. Ann Intern Med, 1979. 90(3): p. 361–72. 156. Fisher, W.A., Restraint and seclusion: a review of the literature. Am J Psychiatry, 1994. 151(11): p. 1584–91. 157. Splawn, G., Restraining potentially violent patients. J Emerg Nurs, 1991. 17(5): p. 316–7. 158. Wetli, C.V. and D.A. Fishbain, Cocaine-induced psychosis and sudden death in recreational cocaine users. J Forensic Sci, 1985. 30(3): p. 873–80. 159. O’Halloran, R.V. and L.V. Lewman, Restraint asphyxiation in excited delirium [see comments]. Am J Forensic Med Pathol, 1993. 14(4): p. 289–95. 160. Miles, S.H., Restraints and sudden death [letter; comment]. J Am Geriatr Soc, 1993. 41(9): p. 1013. 161. Introna, F., Jr. and J.E. Smialek, The “mini-packer” syndrome. Fatal ingestion of drug containers in Baltimore, Maryland. Am J Forensic Med Pathol, 1989. 10(1): p. 21–4. 162. Simon, L.C., The cocaine body packer syndrome. West Indian Med J, 1990. 39(4): p. 250–5. 163. Geyskens, P., L. Coenen, and J. Brouwers, The “cocaine body packer” syndrome. Case report and review of the literature. Acta Chir Belg, 1989. 89(4): p. 201–3. 164. Pollack, C.V., Jr., et al., Two crack cocaine body stuffers [clinical conference]. Ann Emerg Med, 1992. 21(11): p. 1370–80. 165. Jimson weed poisoning — Texas, New York, and California, 1994. MMWR Morb Mortal Wkly Rep, 1995. 44(3): p. 41–4. 166. Wetli, C.V. and R.K. Wright, Death caused by recreational cocaine use. JAMA, 1979. 241(23): p. 2519–22. 167. Simpson, D.L. and B.H. Rumack, Methylenedioxyamphetamine. Clinical description of overdose, death, and review of pharmacology. Arch Intern Med, 1981. 141(11): p. 1507–9. 168. Campbell, B.G., Cocaine abuse with hyperthermia, seizures and fatal complications. Med J Aust, 1988. 149(7): p. 387–9. 169. Olson, K.R., et al., Seizures associated with poisoning and drug overdose [corrected and republished article originally printed in Am J Emerg Med 1993 Nov;11(6):565–8]. Am J Emerg Med, 1994. 12(3): p. 392–5. 170. Jonsson, S., M. O’Meara, and J.B. Young, Acute cocaine poisoning. Importance of treating seizures and acidosis. Am J Med, 1983. 75(6): p. 1061–4. 171. Olson, K.R. and N.L. Benowitz, Environmental and drug-induced hyperthermia. Pathophysiology, recognition, and management. Emerg Med Clin North Am, 1984. 2(3): p. 459–74. 172. Meldrum, B.S., R.A. Vigouroux, and J.B. Brierley, Systemic factors and epileptic brain damage. Prolonged seizures in paralyzed, artificially ventilated baboons. Arch Neurol, 1973. 29(2): p. 82–7. 173. Earnest, M.P., Seizures. Neurol Clin, 1993. 11(3): p. 563–75. 174. Lason, W., Neurochemical and pharmacological aspects of cocaine-induced seizures. Pol J Pharmacol, 2001. 53(1): p. 57–60. 175. Jacobs, I.G., et al., Cocaine abuse: neurovascular complications. Radiology, 1989. 170(1 Pt 1): p. 223–7. 176. Auer, J., R. Berent, and B. Eber, Cardiovascular complications of cocaine use. N Engl J Med, 2001. 345(21): p. 1575; author reply 1576. 177. Rumbaugh, C.L., et al., Cerebral angiographic changes in the drug abuse patient. Radiology, 1971. 101(2): p. 335–44. 178. Earnest, M.P., et al., Neurocysticercosis in the United States: 35 cases and a review. Rev Infect Dis, 1987. 9(5): p. 961–79. 179. Roberts, J.R., Initial therapeutic strategies for the treatment of status epilepticus. Emerg Med News, 1996. 10: p. 2, 14–5. 180. Finder, R.L. and P.A. Moore, Benzodiazepines for intravenous conscious sedation: agonists and antagonists. Compendium, 1993. 14(8): p. 972, 974, 976–80 passim; quiz 984–6. 181. Roth, T. and T.A. Roehrs, A review of the safety profiles of benzodiazepine hypnotics. J Clin Psychiatry, 1991. 52 Suppl: p. 38–41.


682


182. Dement, W.C., Overview of the efficacy and safety of benzodiazepine hypnotics using objective methods. J Clin Psychiatry, 1991. 52 Suppl: p. 27–30. 183. Treiman, D.M., The role of benzodiazepines in the management of status epilepticus. Neurology, 1990. 40(5 Suppl 2): p. 32–42. 184. Kyriakopoulos, A.A., D.J. Greenblatt, and R.I. Shader, Clinical pharmacokinetics of lorazepam: a review. J Clin Psychiatry, 1978. 39(10 Pt 2): p. 16–23. 185. Leppik, I.E., et al., Double-blind study of lorazepam and diazepam in status epilepticus. JAMA, 1983. 249(11): p. 1452–4. 186. Levy, R.J. and R.L. Krall, Treatment of status epilepticus with lorazepam. Arch Neurol, 1984. 41(6): p. 605–11. 187. Bebin, M. and T.P. Bleck, New anticonvulsant drugs. Focus on flunarizine, fosphenytoin, midazolam and stiripentol. Drugs, 1994. 48(2): p. 153–71. 188. Kumar, A. and T.P. Bleck, Intravenous midazolam for the treatment of refractory status epilepticus. Crit Care Med, 1992. 20(4): p. 483–8. 189. Schalen, W., K. Messeter, and C.H. Nordstrom, Complications and side effects during thiopentone therapy in patients with severe head injuries. Acta Anaesthesiol Scand, 1992. 36(4): p. 369–77. 190. Singbartl, G. and G. Cunitz, [Pathophysiologic principles, emergency medical aspects and anesthesiologic measures in severe brain trauma]. Anaesthesist, 1987. 36(7): p. 321–32. 191. Lee, T.L., Pharmacology of propofol. Ann Acad Med Singapore, 1991. 20(1): p. 61–5. 192. Sellers, E.M., Alcohol, barbiturate and benzodiazepine withdrawal syndromes: clinical management. Can Med Assoc J, 1988. 139(2): p. 113–20. 193. Sullivan, J.T. and E.M. Seller, Treating alcohol, barbiturate, and benzodiazepine withdrawal. Ration Drug Ther, 1986. 20(2): p. 1–9. 194. Ramsay, R.E. and J. DeToledo, Intravenous administration of fosphenytoin: options for the management of seizures. Neurology, 1996. 46(6 Suppl 1): p. S17–9. 195. Staff, Clinical Pharmacology: An Electronic Drug Reference and Teaching Guide. 1.5 ed, S. Reents, Ed. 1995, Gainesville, FL: Gold Standard Multimedia. 196. Derlet, R.W. and T.E. Albertson, Anticonvulsant modification of cocaine-induced toxicity in the rat. Neuropharmacology, 1990. 29(3): p. 255–9. 197. Alldredge, B.K., D.H. Lowenstein, and R.P. Simon, Placebo-controlled trial of intravenous diphenylhydantoin for short-term treatment of alcohol withdrawal seizures. Am J Med, 1989. 87(6): p. 645–8. 198. Callaham, M., H. Schumaker, and P. Pentel, Phenytoin prophylaxis of cardiotoxicity in experimental amitriptyline poisoning. J Pharmacol Exp Ther, 1988. 245(1): p. 216–20. 199. Appleton, R., T. Martland, and B. Phillips, Drug management for acute tonic-clonic convulsions including convulsive status epilepticus in children. Cochrane Database Syst Rev, 2002(4): p. CD001905. 200. Lowenstein, D.H., Treatment options for status epilepticus. Curr Opin Pharmacol, 2003. 3(1): p. 6–11. 201. Munn, R.I. and K. Farrell, Failure to recognize status epilepticus in a paralyzed patient. Can J Neurol Sci, 1993. 20(3): p. 234–6. 202. Wolf, K.M., A.F. Shaughnessy, and D.B. Middleton, Prolonged delirium tremens requiring massive doses of medication [see comments]. J Am Board Fam Pract, 1993. 6(5): p. 502–4. 203. Pascual-Leone, A., et al., Cocaine-induced seizures. Neurology, 1990. 40(3 Pt 1): p. 404–7. 204. Brown, E., et al., CNS complications of cocaine abuse: prevalence, pathophysiology, and neuroradiology. AJR Am J Roentgenol, 1992. 159(1): p. 137–47. 205. Daras, M., A.J. Tuchman, and S. Marks, Central nervous system infarction related to cocaine abuse. Stroke, 1991. 22(10): p. 1320–5. 206. Tuchman, A.J. and M. Daras, Strokes associated with cocaine use [letter]. Arch Neurol, 1990. 47(11): p. 1170. 207. Holland, R.W.D., et al., Grand mal seizures temporally related to cocaine use: clinical and diagnostic features [see comments]. Ann Emerg Med, 1992. 21(7): p. 772–6. 208. Sarnquist, F. and C.P. Larson, Jr., Drug-induced heat stroke. Anesthesiology, 1973. 39(3): p. 348–50. 209. Rosenberg, J., et al., Hyperthermia associated with drug intoxication. Crit Care Med, 1986. 14(11): p. 964–9. 210. Sporer, K.A., The serotonin syndrome. Implicated drugs, pathophysiology and management. Drug Saf, 1995. 13(2): p. 94–104.



683

211. Walter, F.G., et al., Marijuana and hyperthermia. J Toxicol Clin Toxicol, 1996. 34(2): p. 217–21. 212. Ebadi, M., R.F. Pfeiffer, and L.C. Murrin, Pathogenesis and treatment of neuroleptic malignant syndrome. Gen Pharmacol, 1990. 21(4): p. 367–86. 213. Lecci, A., et al., Effect of psychotomimetics and some putative anxiolytics on stress-induced hyperthermia. J Neural Transm Gen Sect, 1991. 83(1–2): p. 67–76. 214. Halloran, L.L. and D.W. Bernard, Management of drug-induced hyperthermia. Curr Opin Pediatr, 2004. 16(2): p. 211–5. 215. Hadad, E., A.A. Weinbroum, and R. Ben-Abraham, Drug-induced hyperthermia and muscle rigidity: a practical approach. Eur J Emerg Med, 2003. 10(2): p. 149–54. 216. McGregor, I.S., et al., Increased anxiety and “depressive” symptoms months after MDMA (“ecstasy”) in rats: drug-induced hyperthermia does not predict long-term outcomes. Psychopharmacology (Berlin), 2003. 168(4): p. 465–74. 217. Crandall, C.G., W. Vongpatanasin, and R.G. Victor, Mechanism of cocaine-induced hyperthermia in humans. Ann Intern Med, 2002. 136(11): p. 785–91. 218. Gordon, C.J., et al., Effects of 3,4-methylenedioxymethamphetamine on autonomic thermoregulatory responses of the rat. Pharmacol Biochem Behav, 1991. 38(2): p. 339–44. 219. Aniline, O. and F.N. Pitts, Jr., Phencyclidine (PCP): a review and perspectives. Crit Rev Toxicol, 1982. 10(2): p. 145–77. 220. Eastman, J.W. and S.N. Cohen, Hypertensive crisis and death associated with phencyclidine poisoning. JAMA, 1975. 231(12): p. 1270–1. 221. McCarron, M.M., et al., Acute phencyclidine intoxication: incidence of clinical findings in 1,000 cases. Ann Emerg Med, 1981. 10(5): p. 237–42. 222. Friedman, S.A. and S.E. Hirsch, Extreme hyperthermia after LSD ingestion. JAMA, 1971. 217(11): p. 1549–50. 223. Klock, J.C., U. Boerner, and C.E. Becker, Coma, hyperthermia and bleeding associated with massive LSD overdose. A report of eight cases. West J Med, 1974. 120(3): p. 183–8. 224. Mercieca, J. and E.A. Brown, Acute renal failure due to rhabdomyolysis associated with use of a straitjacket in lysergide intoxication. Br Med J (Clin Res Ed), 1984. 288(6435): p. 1949–50. 225. Armen, R., G. Kanel, and T. Reynolds, Phencyclidine-induced malignant hyperthermia causing submassive liver necrosis. Am J Med, 1984. 77(1): p. 167–72. 226. Loghmanee, F. and M. Tobak, Fatal malignant hyperthermia associated with recreational cocaine and ethanol abuse. Am J Forensic Med Pathol, 1986. 7(3): p. 246–8. 227. Zorzato, F., et al., Role of malignant hyperthermia domain in the regulation of Ca2+ release channel (ryanodine receptor) of skeletal muscle sarcoplasmic reticulum. J Biol Chem, 1996. 271(37): p. 22759–63. 228. Singarajah, C. and N.G. Lavies, An overdose of ecstasy. A role for dantrolene [see comments]. Anaesthesia, 1992. 47(8): p. 686–7. 229. Watson, J.D., et al., Exertional heat stroke induced by amphetamine analogues. Does dantrolene have a place? Anaesthesia, 1993. 48(12): p. 1057–60. 230. Behan, W., A.M.O. Bakheit, P.W. Hegan, and I.A.R. More, The muscle findings in the neuroleptic malignant syndrome associated with lysergic acid deithylamide. J Neurol Neurosurg Psychiatry, 1991. 54: p. 741–743. 231. Woodbury, M.M. and M.A. Woodbury, Neuroleptic-induced catatonia as a stage in the progression toward neuroleptic malignant syndrome. J Am Acad Child Adolesc Psychiatry, 1992. 31(6): p. 1161–4. 232. Totten, V.Y., E. Hirschenstein, and P. Hew, Neuroleptic malignant syndrome presenting without initial fever: a case report. J Emerg Med, 1994. 12(1): p. 43–7. 233. Daras, M., et al., Rhabdomyolysis and hyperthermia after cocaine abuse: a variant of the neuroleptic malignant syndrome? Acta Neurol Scand, 1995. 92(2): p. 161–5. 234. Wetli, C.V., D. Mash, and S.B. Karch, Cocaine-associated agitated delirium and the neuroleptic malignant syndrome. Am J Emerg Med, 1996. 14(4): p. 425–8. 235. SFPCC, Poisoning & Drug Overdose. A Lange Clinical Manual, K. Olson, Ed. 1994, Norwalk, CT: Appleton & Lange. 236. Zalis, E.G. and G. Kaplan, The effect of aggregation on amphetamine toxicity in the dog. Arch Int Pharmacodyn Ther, 1966. 159(1): p. 196–9. 237. Zalis, E.G., G.D. Lundberg, and R.A. Knutson, The pathophysiology of acute amphetamine poisoning with pathologic correlation. J Pharmacol Exp Ther, 1967. 158(1): p. 115–27.


684


238. Zalis, E.G., G.D. Lundberg, and R.A. Knutson, Acute lethality of the amphetamines in dogs and its antagonism by curare. Proc Soc Exp Biol Med, 1965: p. 557. 239. Davis, W.M., et al., Factors in the lethality of i.v. phencyclidine in conscious dogs. Gen Pharmacol, 1991. 22(4): p. 723–8. 240. Tek, D. and J.S. Olshaker, Heat illness. Emerg Med Clin North Am, 1992. 10(2): p. 299–310. 241. Callaham, M., Tricyclic antidepressant overdose. JACEP, 1979. 8(10): p. 413–25. 242. Sprung, C.L., Heat stroke; modern approach to an ancient disease. Chest, 1980. 77(4): p. 461–2. 243. Hamilton, D., Heat stroke. Anaesthesia, 1976. 32: p. 271. 244. Walker, J. and M.V. Vance, Heat emergencies, in Emergency Medicine: A Comprehensive Study Guide, J. Tintinalli, Ruiz, E, Krome, R.L., Eds. 1996, McGraw-Hill: New York. p. 850–856. 245. Rabinowitz, R.P., et al., Effects of anatomic site, oral stimulation, and body position on estimates of body temperature. Arch Intern Med, 1996. 156(7): p. 777–80. 246. Hooker, E.A., et al., Subjective assessment of fever by parents: comparison with measurement by noncontact tympanic thermometer and calibrated rectal glass mercury thermometer. Ann Emerg Med, 1996. 28(3): p. 313–7. 247. Yaron, M., S.R. Lowenstein, and J. Koziol-McLain, Measuring the accuracy of the infrared tympanic thermometer: correlation does not signify agreement. J Emerg Med, 1995. 13(5): p. 617–21. 248. Craig, J.V., et al., Infrared ear thermometry compared with rectal thermometry in children: a systematic review. Lancet, 2002. 360(9333): p. 603–9. 249. Selfridge, J. and S.S. Shea, The accuracy of the tympanic membrane thermometer in detecting fever in infants aged 3 months and younger in the emergency department setting. J Emerg Nurs, 1993. 19(2): p. 127–30. 250. White, N., S. Baird, and D.L. Anderson, A comparison of tympanic thermometer readings to pulmonary artery catheter core temperature recordings. Appl Nurs Res, 1994. 7(4): p. 165–9. 251. Doezema, D., M. Lunt, and D. Tandberg, Cerumen occlusion lowers infrared tympanic membrane temperature measurement. Acad Emerg Med, 1995. 2(1): p. 17–9. 252. Cabanac, M. and H. Brinnel, The pathology of human temperature regulation: thermiatrics. Experientia, 1987. 43(1): p. 19–27. 253. O’Donnell, T.F., Jr. and G.H. Clowes, Jr., The circulatory abnormalities of heat stroke. N Engl J Med, 1972. 287(15): p. 734–7. 254. O’Donnell, T.F., Jr. and G.H. Clowes, Jr., The circulatory requirements of heat stroke. Surg Forum, 1971. 22: p. 12–4. 255. Seraj, M.A., et al., Are heat stroke patients fluid depleted? Importance of monitoring central venous pressure as a simple guideline for fluid therapy. Resuscitation, 1991. 21(1): p. 33–9. 256. Zahger, D., A. Moses, and A.T. Weiss, Evidence of prolonged myocardial dysfunction in heat stroke. Chest, 1989. 95(5): p. 1089–91. 257. Clowes, G.H., Jr. and T.F. O’Donnell, Jr., Heat stroke. N Engl J Med, 1974. 291(11): p. 564–7. 258. Gottschalk, P.G. and J.E. Thomas, Heat stroke. Mayo Clin Proc, 1966. 41(7): p. 470–82. 259. Rockhold, R.W., et al., Dopamine receptors mediate cocaine-induced temperature responses in spontaneously hypertensive and Wistar-Kyoto rats. Pharmacol Biochem Behav, 1991. 40(1): p. 157–62. 260. Kosten, T.R. and H.D. Kleber, Rapid death during cocaine abuse: a variant of the neuroleptic malignant syndrome? Am J Drug Alcohol Abuse, 1988. 14(3): p. 335–46. 261. Fox, A.W., More on rhabdomyolysis associated with cocaine intoxication [letter]. N Engl J Med, 1989. 321(18): p. 1271. 262. Travis, S.P., Management of heat stroke. J R Nav Med Serv, 1988. 74(1): p. 39–43. 263. Rumack, B.H., Aspirin versus acetaminophen: a comparative view. Pediatrics, 1978. 62(5 Pt 2 Suppl): p. 943–6. 264. McFadden, S. and J.E. Haddow, Coma produced by topical application of isopropanol. Pediatrics, 1969. 43: p. 622. 265. Gabow, P.A., W.D. Kaehny, and S.P. Kelleher, The spectrum of rhabdomyolysis. Medicine, 1982. 61: p. 141–52. 266. Bogaerts, Y., N. Lameire, and S. Ringoir, The compartmental syndrome: a serious complication of acute rhabdomyolysis. Clin Nephrol, 1982. 17: p. 206–11. 267. Akisu, M., et al., Severe acute thinner intoxication. Turk J Pediatr, 1996. 38(2): p. 223–5.



685

268. Akmal, M., et al., Rhabdomyolysis with and without acute renal failure in patients with phencyclidine intoxication. Am J Nephrol, 1981. 1(2): p. 91–6. 269. Anand, V., G. Siami, and W.J. Stone, Cocaine-associated rhabdomyolysis and acute renal failure [see comments]. South Med J, 1989. 82(1): p. 67–9. 270. Bakir, A.A. and G. Dunea, Drugs of abuse and renal disease. Curr Opin Nephrol Hypertens, 1996. 5(2): p. 122–6. 271. Chan, P., et al., Acute heroin intoxication with complications of acute pulmonary edema, acute renal failure, rhabdomyolysis and lumbosacral plexitis: a case report. Chung Hua I Hsueh Tsa Chih (Taipei), 1995. 55(5): p. 397–400. 272. Chan, P., et al., Fatal and nonfatal methamphetamine intoxication in the intensive care unit. J Toxicol Clin Toxicol, 1994. 32(2): p. 147–55. 273. Cogen, F.C., et al., Phencyclidine-associated acute rhabdomyolysis. Ann Intern Med, 1978. 88(2): p. 210–2. 274. Henry, J.A., K.J. Jeffreys, and S. Dawling, Toxicity and deaths from 3,4-methylenedioxymethamphetamine (“ecstasy”) [see comments]. Lancet, 1992. 340(8816): p. 384–7. 275. Melandri, R., et al., Myocardial damage and rhabdomyolysis associated with prolonged hypoxic coma following opiate overdose. J Toxicol Clin Toxicol, 1996. 34(2): p. 199–203. 276. Tehan, B., R. Hardern, and A. Bodenham, Hyperthermia associated with 3,4-methylenedioxyethamphetamine (“Eve”). Anaesthesia, 1993. 48(6): p. 507–10. 277. Curry, S.C., D. Chang, and D. Connor, Drug- and toxin-induced rhabdomyolysis. Ann Emerg Med, 1989. 18(10): p. 1068–84. 278. Welch, R.D., K. Todd, and G.S. Krause, Incidence of cocaine-associated rhabdomyolysis. Ann Emerg Med, 1991. 20(2): p. 154–7. 279. Knochel, J.P., Rhabdomyolysis and myoglobinuria. Annu Rev Med, 1982. 33: p. 435–443. 280. Koffler, A., R.M. Friedler, and S.G. Massry, Acute renal failure due to nontraumatic rhabdomyolysis. Ann Intern Med, 1976. 85: p. 23–28. 281. Grossman, R.A., et al., Nontraumatic rhabdomyolysis and acute renal failure. N Engl J Med, 1974. 291(16): p. 807–11. 282. Knochel, J.P., Rhabdomyolysis and myoglobinuria. Semin Nephrol, 1981. 1: p. 75–86. 283. Ron, D., et al., Prevention of acute renal failure in traumatic rhabdomyolysis. Arch Intern Med, 1984. 144(2): p. 277–80. 284. Knottenbelt, J.D., Traumatic rhabdomyolysis from severe beating — experience of volume diuresis in 200 patients. J Trauma, 1994. 37(2): p. 214–9. 285. Veenstra, J., et al., Relationship between elevated creatine phosphokinase and the clinical spectrum of rhabdomyolysis. Nephrol Dial Transplant, 1994. 9(6): p. 637–41. 286. Oda, J., et al., Analysis of 372 patients with crush syndrome caused by the Hanshin-Awaji earthquake. J Trauma, 1997. 42(3): p. 470–5; discussion 475–6. 287. Eneas, J.F., P.Y. Schoenfeld, and M.H. Humphreys, The effect of infusion of mannitol-sodium bicarbonate on the clinical course of myoglobinuria. Arch Intern Med, 1979. 139(7): p. 801–5. 288. Feinfeld, D.A., et al., A prospective study of urine and serum myoglobin levels in patients with acute rhabdomyolysis. Clin Nephrol, 1992. 38(4): p. 193–5. 289. Loun, B., et al., Adaptation of a quantitative immunoassay for urine myoglobin. Predictor in detecting renal dysfunction. Am J Clin Pathol, 1996. 105(4): p. 479–86. 290. Thomas, M.A. and L.S. Ibels, Rhabdomyolysis and acute renal failure. Aust NZ J Med, 1985. 15(5): p. 623–8. 291. Cadnapaphornchai, P., S. Taher, and F.D. McDonald, Acute drug-associated rhabdomyolysis: an examination of its diverse renal manifestations and complications. Am J Med Sci, 1980. 280(2): p. 66–72. 292. Knochel, J.P., Catastrophic medical events with exhaustive exercise: “white collar rhabdomyolysis.” Kidney Int, 1990. 38(4): p. 709–19. 293. Kageyama, Y., Rhabdomyolysis: clinical analysis of 20 patients. Nippon Jinzo Gakkai Shi, 1989. 31(10): p. 1099–103. 294. Ellinas, P.A. and F. Rosner, Rhabdomyolysis: report of eleven cases. J Natl Med Assoc, 1992. 84(7): p. 617–24.


686


295. Ward, M.M., Factors predictive of acute renal failure in rhabdomyolysis. Arch Intern Med, 1988. 148(7): p. 1553–7. 296. Gardner, J.W. and J.A. Kark, Fatal rhabdomyolysis presenting as mild heat illness in military training. Mil Med, 1994. 159(2): p. 160–3. 297. Morocco, P.A., Atraumatic rhabdomyolysis in a 20-year-old bodybuilder. J Emerg Nurs, 1991. 17(6): p. 370–2. 298. Uberoi, H.S., et al., Acute renal failure in severe exertional rhabdomyolysis [see comments]. J Assoc Physicians India, 1991. 39(9): p. 677–9. 299. Zurovsky, Y., Effects of changes in plasma volume on fatal rhabdomyolysis in the rat induced by glycerol injections. J Basic Clin Physiol Pharmacol, 1992. 3(3): p. 223–37. 300. Sinert, R., et al., Exercise-induced rhabdomyolysis. Ann Emerg Med, 1994. 23(6): p. 1301–6. 301. Bunn, H.F. and J.H. Jandi, Exchange of heme analogue hemoglobin molecules. Proc Natl Acad Sci USA, 1977. 56: p. 974–8. 302. Paller, M.S., Hemoglobin- and myoglobin-induced acute renal failure in rats: role of iron in nephrotoxicity. Am J Physiol, 1988. 255(3 Pt 2): p. F539–44. 303. Anderson, W.A.D., D.B. Morrison, and E.F. Williams, Pathologic changes following injection of ferrihemate (hematin) in dogs. Arch Pathol, 1942. 33: p. 589–602. 304. Garcia, G., et al., Nephrotoxicity of myoglobin in the rat: Relative importance of urine pH and prior dehydration (abstract). Kidney Int, 1981. 19: p. 200. 305. Perri, G.C. and P. Gerini, Uraemia in the rabbit after injection of crystalline myoglobin. Br J Exp Pathol, 1952. 33: p. 440–4. 306. POISONDEX(R) Editorial Staff and K. Kulig, Rhabdomyolysis. 1992, POISONDEX(R): Treatment protocols. 307. Eneas, J.F., P.Y. Schoenfeld, and M.H. Humphreys, The effect of infusion of mannitol-sodium bicarbonate on the clinical course of myoglobinuria. Arch Intern Med, 1979. 139: p. 801–5. 308. Lameire, N., et al., Pathophysiology, causes, and prognosis of acute renal failure in the elderly. Renal Fail, 1996. 18(3): p. 333–46. 309. Druml, W., Prognosis of acute renal failure 1975–1995. Nephron, 1996. 73(1): p. 8–15. 310. Wilson, D.R., et al., Glycerol induced hemoglobinuric acute renal failure in the rat. 3. Micropuncture study of the effects of mannitol and isotonic saline on individual nephron function. Nephron, 1967. 4(6): p. 337–55. 311. Kjellmer, I., Potassium ion as a vasodilator during muscular exercise. Acta Physiol Scand, 1965: p. 466–8. 312. Knochel, J.P. and E.M. Schlein, On the mechanism of rhabdomyolysis in potassium depletion. J Clin Invest, 1972. 51(7): p. 1750–8. 313. Temple, A.R., Acute and chronic effects of aspirin toxicity and their treatment. Arch Intern Med, 1981. 141(3 Spec No): p. 364–9. 314. Javaheri, S., Effects of acetazolamide on cerebrospinal fluid ions in metabolic alkalosis in dogs. J Appl Physiol, 1987. 62(4): p. 1582–8. 315. Kaplan, S.A. and F.T. Del Carmen, Experimental salicylate poisoning. Observation on the effects of carbonic anhydrase inhibitor and bicarbonate. Pediatrics, 1958. 21: p. 762–70. 316. Lijnen, P., et al., Biochemical variables in plasma and urine before and after prolonged physical exercise. Enzyme, 1985. 33(3): p. 134–42. 317. Davis, A.M., Hypocalcemia in rhabdomyolysis [letter] [published erratum appears in JAMA 1987 Oct 9;258(14):1894]. JAMA, 1987. 257(5): p. 626. 318. Malinoski, D.J., M.S. Slater, and R.J. Mullins, Crush injury and rhabdomyolysis. Crit Care Clin, 2004. 20(1): p. 171–92. 319. Qureshi, A.I., et al., Cocaine use and hypertension are major risk factors for intracerebral hemorrhage in young African Americans. Ethn Dis, 2001. 11(2): p. 311–9. 320. Brecklin, C.S. and J.L. Bauman, Cardiovascular effects of cocaine: focus on hypertension. J Clin Hypertens (Greenwich), 1999. 1(3): p. 212–7. 321. Eagle, K.A., E.M. Isselbacher, and R.W. DeSanctis, Cocaine-related aortic dissection in perspective. Circulation, 2002. 105(13): p. 1529–30. 322. Brown, C., Phenylpropanolamine — an ongoing problem. Clin Toxicol Update, 1987. 9(2): p. 5–8.



687

323. Glick, R., et al., Phenylpropanolamine: an over-the-counter drug causing central nervous system vasculitis and intracerebral hemorrhage. Case report and review. Neurosurgery, 1987. 20(6): p. 969–74. 324. Jackson, C., A. Hart, and M.D. Robinson, Fatal intracranial hemorrhage associated with phenylpropanolamine, pentazocine, and tripelennamine overdose. J Emerg Med, 1985. 3(2): p. 127–32. 325. Nahas, G.G., R. Trouve, and W.M. Manger, Cocaine, catecholamines and cardiac toxicity. Acta Anaesthesiol Scand Suppl, 1990. 94: p. 77–81. 326. Rothman, R.B., et al., Amphetamine-type central nervous system stimulants release norepinephrine more potently than they release dopamine and serotonin. Synapse, 2001. 39(1): p. 32–41. 327. McDonald, A.J., D.M. Yealy, and S. Jacobson, Oral labetalol versus oral nifedipine in hypertensive urgencies in the ED. Am J Emerg Med, 1993. 11(5): p. 460–3. 328. Benowitz, N.L., Discussion over hypertension in drug abuse, 1996. Personal communication. 329. Rahn, K.H., How should we treat a hypertensive emergency? Am J Cardiol, 1989. 63(6): p. 48C–50C. 330. Somberg, J.C., The therapeutics of hypertensive emergency. Am J Ther, 1996. 3(11): p. 741. 331. Vidt, D.G., Emergency room management of hypertensive urgencies and emergencies. J Clin Hypertens (Greenwich), 2001. 3(3): p. 158–64. 332. Kumar, A.M., E.S. Nadel, and D.F. Brown, Case presentations of the Harvard Emergency Medicine Residency. Hypertensive crisis. J Emerg Med, 2000. 19(4): p. 369–73. 333. Haft, J.I., Use of the calcium-channel blocker nifedipine in the management of hypertensive emergency. Am J Emerg Med, 1985. 3(6 Suppl): p. 25–30. 334. Benowitz, N.L., Central nervous system manifestations of toxic disorders, in Metabolic Brain Dysfunction in Systemic Disorders, A.L. Arieff and R.C. Griggs, Ed. 1992, Boston: Little, Brown. p. 409–36. 335. Derlet, R.W. and T.E. Albertson, Acute cocaine toxicity: antagonism by agents interacting with adrenoceptors. Pharmacol Biochem Behav, 1990. 36(2): p. 225–31. 336. Trouve, R. and G.G. Nahas, Antidotes to lethal cocaine toxicity in the rat. Arch Int Pharmacodyn Ther, 1990. 305: p. 197–207. 337. Murphy, D.J., et al., Effects of adrenergic antagonists on cocaine-induced changes in respiratory function. Pulm Pharmacol, 1991. 4(3): p. 127–34. 338. Smith, M., D. Garner, and J.T. Niemann, Pharmacologic interventions after an LD50 cocaine insult in a chronically instrumented rat model: are beta-blockers contraindicated? Ann Emerg Med, 1991. 20(7): p. 768–71. 339. Hessler, R., Cardiovascular principles, in Goldfrank’s Toxicologic Emergencies, L.R. Goldrank, N.E. Flomenbaum, and N.A. Lewin, Eds. 1992, Norwalk, CT: Appleton & Lange. p. 181–204. 340. Lange, R.A., et al., Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade [see comments]. Ann Intern Med, 1990. 112(12): p. 897–903. 341. Ramoska, E. and A.D. Sacchetti, Propranolol-induced hypertension in treatment of cocaine intoxication. Ann Emerg Med, 1985. 14(11): p. 1112–3. 342. Dusenberry, S.J., M.J. Hicks, and P.J. Mariani, Labetalol treatment of cocaine toxicity [letter]. Ann Emerg Med, 1987. 16(2): p. 235. 343. Sand, I.C., et al., Experience with esmolol for the treatment of cocaine-associated cardiovascular complications. Am J Emerg Med, 1991. 9(2): p. 161–3. 344. Darmansjah, I., et al., A dose-ranging study of labetalol in moderate to moderately severe hypertension. Int J Clin Pharmacol Ther, 1995. 33(4): p. 226–31. 345. Kenny, D., P.S. Pagel, and D.C. Warltier, Attenuation of the systemic and coronary hemodynamic effects of cocaine in conscious dogs: propranolol versus labetalol. Basic Res Cardiol, 1992. 87(5): p. 465–77. 346. Schindler, C.W., S.R. Tella, and S.R. Goldberg, Adrenoceptor mechanisms in the cardiovascular effects of cocaine in conscious squirrel monkeys. Life Sci, 1992. 51(9): p. 653–60. 347. Karch, S.B., Managing cocaine crisis [comment]. Ann Emerg Med, 1989. 18(2): p. 228–30. 348. Gay, G.R. and K.A. Loper, The use of labetalol in the management of cocaine crisis [see comments]. Ann Emerg Med, 1988. 17(3): p. 282–3. 349. Briggs, R.S., A.J. Birtwell, and J.E. Pohl, Hypertensive response to labetalol in phaeochromocytoma [letter]. Lancet, 1978. 1(8072): p. 1045–6. 350. Larsen, L.S. and A. Larsen, Labetalol in the treatment of epinephrine overdose. Ann Emerg Med, 1990. 19(6): p. 680–2.


688


351. Lange, R.A., et al., Cocaine-induced coronary-artery vasoconstriction [see comments]. N Engl J Med, 1989. 321(23): p. 1557–62. 352. Boehrer, J.D., et al., Influence of labetalol on cocaine-induced coronary vasoconstriction in humans. Am J Med, 1993. 94(6): p. 608–10. 353. Hamad, A., et al., Life-threatening hyperkalemia after intravenous labetolol injection for hypertensive emergency in a hemodialysis patient. Am J Nephrol, 2001. 21(3): p. 241–4. 354. Pollan, S. and M. Tadjziechy, Esmolol in the management of epinephrine- and cocaine-induced cardiovascular toxicity. Anesth Analg, 1989. 69(5): p. 663–4. 355. O’Connor, B. and J.B. Luntley, Acute dissection of the thoracic aorta. Esmolol is safer than and as effective as labetalol [letter; comment]. BMJ, 1995. 310(6983): p. 875. 356. Brogan, W.C.D., et al., Alleviation of cocaine-induced coronary vasoconstriction by nitroglycerin. J Am Coll Cardiol, 1991. 18(2): p. 581–6. 357. Gray, R.J., et al., Comparison of esmolol and nitroprusside for acute post-cardiac surgical hypertension. Am J Cardiol, 1987. 59(8): p. 887–91. 358. de Bruijn, N.P., et al., Pharmacokinetics of esmolol in anesthetized patients receiving chronic beta blocker therapy. Anesthesiology, 1987. 66(3): p. 323–6. 359. Bashour, T.T., Acute myocardial infarction resulting from amphetamine abuse: a spasm-thrombus interplay? Am Heart J, 1994. 128(6 Pt 1): p. 1237–9. 360. Ragland, A.S., Y. Ismail, and E.L. Arsura, Myocardial infarction after amphetamine use. Am Heart J, 1993. 125(1): p. 247–9. 361. Burton, B.T., M. Rice, and L.E. Schmertzler, Atrioventricular block following overdose of decongestant cold medication. J Emerg Med, 1985. 2(6): p. 415–9. 362. Pentel, P.R., J. Jentzen, and J. Sievert, Myocardial necrosis due to intraperitoneal administration of phenylpropanolamine in rats. Fundam Appl Toxicol, 1987. 9(1): p. 167–72. 363. Lucas, P.B., et al., Methylphenidate-induced cardiac arrhythmias [letter]. N Engl J Med, 1986. 315(23): p. 1485. 364. Jaffe, R.B., Cardiac and vascular involvement in drug abuse. Semin Roentgenol, 1983. 18(3): p. 207–12. 365. Lewin, N.G., L.R., and R.S. Hoffman, Cocaine, in Goldfrank’s Toxicologic Emergencies, L. Goldfrank, Ed. 1994, Norwalk, CT: Appleton & Lange. p. 847–62. 366. Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 6: advanced cardiovascular life support: section 6: pharmacology II: agents to optimize cardiac output and blood pressure. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation, 2000. 102(8 Suppl): p. I129–35. 367. Hollander, J.E., The management of cocaine-associated myocardial ischemia. N Engl J Med, 1995. 333(19): p. 1267–72. 368. Benowitz, N.L., Clinical pharmacology and toxicology of cocaine [published erratum appears in Pharmacol Toxicol 1993 Jun;72(6):343]. Pharmacol Toxicol, 1993. 72(1): p. 3–12. 369. Catravas, J.D., et al., Acute cocaine intoxication in the conscious dog: pathophysiologic profile of acute lethality. Arch Int Pharmacodyn Ther, 1978. 235(2): p. 328–40. 370. Togna, G., et al., Platelet responsiveness and biosynthesis of thromboxane and prostacyclin in response to in vitro cocaine treatment. Haemostasis, 1985. 15(2): p. 100–7. 371. Schnetzer, G.W.D., Platelets and thrombogenesis — current concepts. Am Heart J, 1972. 83(4): p. 552–64. 372. Rezkalla, S.H., et al., Effects of cocaine on human platelets in healthy subjects. Am J Cardiol, 1993. 72(2): p. 243–6. 373. Hollander, J.E., et al., Nitroglycerin in the treatment of cocaine associated chest pain — clinical safety and efficacy. J Toxicol Clin Toxicol, 1994. 32(3): p. 243–56. 374. Billman, G.E., Effect of calcium channel antagonists on cocaine-induced malignant arrhythmias: protection against ventricular fibrillation. J Pharmacol Exp Ther, 1993. 266(1): p. 407–16. 375. Knuepfer, M.M. and C.A. Branch, Calcium channel antagonists reduce the cocaine-induced decrease in cardiac output in a subset of rats. J Cardiovasc Pharmacol, 1993. 21(3): p. 390–6. 376. Derlet, R.W. and T.E. Albertson, Potentiation of cocaine toxicity with calcium channel blockers. Am J Emerg Med, 1989. 7(5): p. 464–8. 377. Hoffman, R., Comment to calcium channel blockers may potentiate cocaine toxicity. AACT clinical toxicology update, 1990 (March).



689

378. Nahas, G., et al., A calcium-channel blocker as antidote to the cardiac effects of cocaine intoxication [letter]. N Engl J Med, 1985. 313(8): p. 519–20. 379. Negus, B.H., et al., Alleviation of cocaine-induced coronary vasoconstriction with intravenous verapamil. Am J Cardiol, 1994. 73(7): p. 510–3. 380. Hollander, J.E., W.A. Carter, and R.S. Hoffman, Use of phentolamine for cocaine-induced myocardial ischemia [letter]. N Engl J Med, 1992. 327(5): p. 361. 381. Bush, H.S., Cocaine-associated myocardial infarction. A word of caution about thrombolytic therapy [see comments]. Chest, 1988. 94(4): p. 878. 382. Hollander, J.E., et al., Cocaine-associated myocardial infarction. Clinical safety of thrombolytic therapy. Cocaine Associated Myocardial Infarction (CAMI) Study Group. Chest, 1995. 107(5): p. 1237–41. 383. Hollander, J.E., et al., Cocaine-associated myocardial infarction. Mortality and complications. Cocaine-Associated Myocardial Infarction Study Group. Arch Intern Med, 1995. 155(10): p. 1081–6. 384. Gitter, M.J., et al., Cocaine and chest pain: clinical features and outcome of patients hospitalized to rule out myocardial infarction [see comments]. Ann Intern Med, 1991. 115(4): p. 277–82. 385. Hollander, J.E., et al., “Abnormal” electrocardiograms in patients with cocaine-associated chest pain are due to “normal” variants. J Emerg Med, 1994. 12(2): p. 199–205. 386. Keller, K.B. and L. Lemberg, The cocaine-abused heart. Am J Crit Care, 2003. 12(6): p. 562–6. 387. Kontos, M.C., et al., Coronary angiographic findings in patients with cocaine-associated chest pain. J Emerg Med, 2003. 24(1): p. 9–13. 388. Derlet, R.W., T.E. Albertson, and R.S. Tharratt, Lidocaine potentiation of cocaine toxicity. Ann Emerg Med, 1991. 20(2): p. 135–8. 389. Liu, D., R.J. Hariman, and J.L. Bauman, Cocaine concentration-effect relationship in the presence and absence of lidocaine: evidence of competitive binding between cocaine and lidocaine. J Pharmacol Exp Ther, 1996. 276(2): p. 568–77. 390. Winecoff, A.P., et al., Reversal of the electrocardiographic effects of cocaine by lidocaine. Part 1. Comparison with sodium bicarbonate and quinidine. Pharmacotherapy, 1994. 14(6): p. 698–703. 391. Shih, R.D., et al., Clinical safety of lidocaine in patients with cocaine-associated myocardial infarction. Ann Emerg Med, 1995. 26(6): p. 702–6. 392. Beckman, K.J., et al., Hemodynamic and electrophysiological actions of cocaine. Effects of sodium bicarbonate as an antidote in dogs. Circulation, 1991. 83(5): p. 1799–807. 393. Goel, P. and G.C. Flaker, Cardiovascular complications of cocaine use. N Engl J Med, 2001. 345(21): p. 1575–6. 394. Barth, C.W.d., M. Bray, and W.C. Roberts, Rupture of the ascending aorta during cocaine intoxication. Am J Cardiol, 1986. 57(6): p. 496. 395. Brody, S.L., C.M. Slovis, and K.D. Wrenn, Cocaine-related medical problems: consecutive series of 233 patients [see comments]. Am J Med, 1990. 88(4): p. 325–31. 396. Derlet, R.W. and T.E. Albertson, Emergency department presentation of cocaine intoxication. Ann Emerg Med, 1989. 18(2): p. 182–6. 397. Rich, J.A. and D.E. Singer, Cocaine-related symptoms in patients presenting to an urban emergency department. Ann Emerg Med, 1991. 20(6): p. 616–21. 398. Silverstein, W., N.A. Lewin, and L. Goldfrank, Management of the cocaine-intoxicated patient [letter]. Ann Emerg Med, 1987. 16(2): p. 234–5. 399. Kloner, R.A., et al., The effects of acute and chronic cocaine use on the heart. Circulation, 1992. 85(2): p. 407–19. 400. Isner, J.M., et al., Acute cardiac events temporally related to cocaine abuse. N Engl J Med, 1986. 315(23): p. 1438–43. 401. Cregler, L.L. and H. Mark, Medical complications of cocaine abuse. N Engl J Med, 1986. 315(23): p. 1495–500. 402. Robin, E.D., R.J. Wong, and K.A. Ptashne, Increased lung water and ascites after massive cocaine overdosage in mice and improved survival related to beta-adrenergic blockage. Ann Intern Med, 1989. 110(3): p. 202–7. 403. Ouriel, K., Comparison of safety and efficacy of the various thrombolytic agents. Rev Cardiovasc Med, 2002. 3 Suppl 2: p. S17–24. 404. Baker, W.F., Jr., Thrombolytic therapy. Clin Appl Thromb Hemost, 2002. 8(4): p. 291–314.


690


405. Baker, W.F., Jr., Thrombolytic therapy: clinical applications. Hematol Oncol Clin North Am, 2003. 17(1): p. 283–311. 406. Nordt, T.K. and C. Bode, Thrombolysis: newer thrombolytic agents and their role in clinical medicine. Heart, 2003. 89(11): p. 1358–62. 407. Williams, M.L. and D.A. Tate, Emergency Medicine: A Comprehensive Study Guide. 4th ed, J. Tintinalli, E. Ruiz, and R.L. Krome, Eds. 1996, New York: McGraw-Hill. p. 344–54. 408. Grawe, J.J., et al., Reversal of the electrocardiographic effects of cocaine by lidocaine. Part 2. Concentration-effect relationships. Pharmacotherapy, 1994. 14(6): p. 704–11. 409. Tokarski, G.F., et al., An evaluation of cocaine-induced chest pain [see comments]. Ann Emerg Med, 1990. 19(10): p. 1088–92. 410. Hollander, J.E., et al., Prospective multicenter evaluation of cocaine-associated chest pain. Cocaine Associated Chest Pain (COCHPA) Study Group. Acad Emerg Med, 1994. 1(4): p. 330–9. 411. Adams, J.E., 3rd, et al., Cardiac troponin I. A marker with high specificity for cardiac injury. Circulation, 1993. 88(1): p. 101–6. 412. Kontos, M.C., et al., Utility of troponin I in patients with cocaine-associated chest pain. Acad Emerg Med, 2002. 9(10): p. 1007–13. 413. Wu, A.H., et al., Comparison of myoglobin, creatine kinase-MB, and cardiac troponin I for diagnosis of acute myocardial infarction. Ann Clin Lab Sci, 1996. 26(4): p. 291–300. 414. Graff, L., et al., American College of Emergency Physicians information paper: chest pain units in emergency departments — a report from the Short-Term Observation Services Section. Am J Cardiol, 1995. 76(14): p. 1036–9. 415. Lee, T.H., et al., Ruling out acute myocardial infarction. A prospective multicenter validation of a 12hour strategy for patients at low risk. N Engl J Med, 1991. 324(18): p. 1239–46. 416. Weber, J.E., et al., Validation of a brief observation period for patients with cocaine-associated chest pain. N Engl J Med, 2003. 348(6): p. 510–7. 417. Hollander, J.E. and R.S. Hoffman, Cocaine-induced myocardial infarction: an analysis and review of the literature. J Emerg Med, 1992. 10(2): p. 169–77. 418. Zimmerman, J.L., R.P. Dellinger, and P.A. Majid, Cocaine-associated chest pain. Ann Emerg Med, 1991. 20(6): p. 611–5. 419. Kokkinos, J. and S. Levine, Stroke. Neurol Clin, 1993. 11(3): p. 577–90. 420. Petitti, D.B., et al., Stroke and cocaine or amphetamine use. Epidemiology, 1998. 9(6): p. 596–600. 421. Qureshi, A.I., et al., Cocaine use and the likelihood of nonfatal myocardial infarction and stroke: data from the Third National Health and Nutrition Examination Survey. Circulation, 2001. 103(4): p. 502–6. 422. Friedman, E.H., Cocaine-induced stroke. Neurology, 1993. 43(9): p. 1864–5. 423. Tolat, R.D., et al., Cocaine-associated stroke: three cases and rehabilitation considerations. Brain Inj, 2000. 14(4): p. 383–91. 424. Riggs, J.E. and L. Gutmann, Crack cocaine use and stroke in young patients. Neurology, 1997. 49(5): p. 1473–4. 425. Kaku, D. and D.H. Lowenstein, Emergence of recreational drug abuse as a major risk factor for stroke in young adults. Ann Intern Med, 1990. 113: p. 821. 426. Konzen, J.P., S.R. Levine, and J.H. Garcia, Vasospasm and thrombus formation as possible mechanisms of stroke related to alkaloidal cocaine. Stroke, 1995. 26(6): p. 1114–8. 427. Tardiff, K., et al., Analysis of cocaine-positive fatalities. J Forensic Sci, 1989. 34(1): p. 53–63. 428. Mueller, P.D., N.L. Benowitz, and K.R. Olson, Cocaine. Emerg Med Clin North Am, 1990. 8(3): p. 481–93. 429. Barsan, W.G. and M. Bain, Stroke, in Emergency Medicine: Concepts and Clinical Practice, P. Rosen and R.M. Barkin, Eds. 1992, St. Louis: Mosby Year Book. p. 1825–41. 430. Hacke, W., et al., Intravenous thrombolysis with recombinant tissue plasminogen activator for acute hemispheric stroke. The European Cooperative Acute Stroke Study (ECASS). JAMA, 1995. 274(13): p. 1017–25. 431. Randomised controlled trial of streptokinase, aspirin, and combination of both in treatment of acute ischaemic stroke. Multicentre Acute Stroke Trial — Italy (MAST-I) Group. Lancet, 1995. 346(8989): p. 1509–14. 432. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med, 1995. 333(24): p. 1581–7.



691

433. Thrombolytic therapy with streptokinase in acute ischemic stroke. The Multicenter Acute Stroke Trial — Europe Study Group. N Engl J Med, 1996. 335(3): p. 145–50. 434. Donnan, G.A., et al., Streptokinase for acute ischemic stroke with relationship to time of administration: Australian Streptokinase (ASK) Trial Study Group. JAMA, 1996. 276(12): p. 961–6. 434a. Hoffman, J.R., Should physicians give tPA to patients with acute ischemic stroke? West J Med, 2000. 173: p. 149–50. 435. Libman, R.B., et al., Conditions that mimic stroke in the emergency department. Implications for acute stroke trials. Arch Neurol, 1995. 52(11): p. 1119–22. 436. Turpie, A.G., R. Bloch, and R. Duke, Heparin in the treatment of thromboembolic stroke. Ann N Y Acad Sci, 1989. 556: p. 406–15. 437. Sage, J.I., Stroke. The use and overuse of heparin in therapeutic trials. Arch Neurol, 1985. 42(4): p. 315–7. 438. Korczyn, A.D., Heparin in the treatment of acute stroke. Neurol Clin, 1992. 10(1): p. 209–17. 439. Salgado, A.V., et al., Neurologic complications of endocarditis: a 12-year experience. Neurology, 1989. 39(2 Pt 1): p. 173–8. 440. Hart, R.G., et al., Stroke in infective endocarditis. Stroke, 1990. 21(5): p. 695–700. 441. Showalter, C.V., T’s and blues. Abuse of pentazocine and tripelennamine. JAMA, 1980. 244(11): p. 1224–5. 442. Caplan, L.R., C. Thomas, and G. Banks, Central nervous system complications of addiction to “T’s and Blues.” Neurology, 1982. 32(6): p. 623–8. 443. Lipton, R.B., M. Choy-Kwong, and S. Solomon, Headaches in hospitalized cocaine users. Headache, 1989. 29(4): p. 225–8. 444. Benowitz, N.L., How toxic is cocaine? Ciba Found Symp, 1992. 166: p. 125–43; discussion 143–8. 445. Satel, S.L. and F.H. Gawin, Migrainelike headache and cocaine use. JAMA, 1989. 261(20): p. 2995–6. 446. Rothrock, J.F., R. Rubenstein, and P.D. Lyden, Ischemic stroke associated with methamphetamine inhalation. Neurology, 1988. 38(4): p. 589–92. 447. Rumbaugh, C.L., et al., Cerebral vascular changes secondary to amphetamine abuse in the experimental animal. Radiology, 1971. 101(2): p. 345–51. 448. Wadworth, A.N. and D. McTavish, Nimodipine. A review of its pharmacological properties, and therapeutic efficacy in cerebral disorders. Drugs Aging, 1992. 2(4): p. 262–86. 449. Rickels, E. and M. Zumkeller, Vasospasm after experimentally induced subarachnoid haemorrhage and treatment with nimodipine. Neurochirurgia (Stuttgart), 1992. 35(4): p. 99–102. 450. Ansah, T.A., L.H. Wade, and D.C. Shockley, Effects of calcium channel entry blockers on cocaine and amphetamine-induced motor activities and toxicities. Life Sci, 1993. 53(26): p. 1947–56. 451. Derlet, R.W., C.C. Tseng, and T.E. Albertson, Cocaine toxicity and the calcium channel blockers nifedipine and nimodipine in rats. J Emerg Med, 1994. 12(1): p. 1–4. 452. Kaste, M., et al., A randomized, double-blind, placebo-controlled trial of nimodipine in acute ischemic hemispheric stroke. Stroke, 1994. 25(7): p. 1348–53. 453. Wooten, M.R., M.S. Khangure, and M.J. Murphy, Intracerebral hemorrhage and vasculitis related to ephedrine abuse. Ann Neurol, 1983. 13(3): p. 337–40. 454. Rumbaugh, C.L., et al., Cerebral microvascular injury in experimental drug abuse. Invest Radiol, 1976. 11(4): p. 282–94. 455. Citron, B.P., et al., Necrotizing angiitis associated with drug abuse. N Engl J Med, 1970. 283(19): p. 1003–11. 456. Loizou, L.A., J.G. Hamilton, and S.A. Tsementzis, Intracranial haemorrhage in association with pseudoephedrine overdose. J Neurol Neurosurg Psychiatry, 1982. 45(5): p. 471–2. 457. Brust, J.C. and R.W. Richter, Stroke associated with addiction to heroin. J Neurol Neurosurg Psychiatry, 1976. 39(2): p. 194–9. 458. Woods, B.T. and G.J. Strewler, Hemiparesis occurring six hours after intravenous heroin injection. Neurology, 1972. 22(8): p. 863–6. 459. Trugman, J.M., Cerebral arteritis and oral methylphenidate [letter]. Lancet, 1988. 1(8585): p. 584–5. 460. Fredericks, R.K., et al., Cerebral vasculitis associated with cocaine abuse. Stroke, 1991. 22(11): p. 1437–9. 461. Krendel, D.A., et al., Biopsy-proven cerebral vasculitis associated with cocaine abuse. Neurology, 1990. 40(7): p. 1092–4.


692


462. Kaye, B.R. and M. Fainstat, Cerebral vasculitis associated with cocaine abuse. JAMA, 1987. 258(15): p. 2104–6. 463. Nalls, G., et al., Subcortical cerebral hemorrhages associated with cocaine abuse: CT and MR findings. J Comput Assist Tomogr, 1989. 13(1): p. 1–5. 464. Salanova, V. and R. Taubner, Intracerebral haemorrhage and vasculitis secondary to amphetamine use. Postgrad Med J, 1984. 60(704): p. 429–30. 465. Cerebral vasculitis associated with cocaine abuse or subarachnoid hemorrhage? [letter]. JAMA, 1988. 259(11): p. 1648–9. 466. Powers, W.J., Acute hypertension after stroke: the scientific basis for treatment decisions. Neurology, 1993. 43(3 Pt 1): p. 461–7. 467. Kenton, E.J., III, Diagnosis and treatment of concomitant hypertension and stroke. J Natl Med Assoc, 1996. 88(6): p. 364–8. 468. Shephard, T.J. and S.W. Fox, Assessment and management of hypertension in the acute ischemic stroke patient. J Neurosci Nurs, 1996. 28(1): p. 5–12. 469. Brucia, J.J., D.C. Owen, and E.B. Rudy, The effects of lidocaine on intracranial hypertension. J Neurosci Nurs, 1992. 24(4): p. 205–14. 470. Lev, R. and P. Rosen, Prophylactic lidocaine use preintubation: a review. J Emerg Med, 1994. 12(4): p. 499–506. 471. Malouf, R. and J.C. Brust, Hypoglycemia: causes, neurological manifestations, and outcome. Ann Neurol, 1985. 17(5): p. 421–30. 472. Swartz, M.H., L.E. Teichholz, and E. Donoso, Mitral valve prolapse: a review of associated arrhythmias. Am J Med, 1977. 62(3): p. 377–89. 473. Savage, D.D., et al., Mitral valve prolapse in the general population. 3. Dysrhythmias: the Framingham Study. Am Heart J, 1983. 106(3): p. 582–6. 474. Washington, J.A.D., The role of the microbiology laboratory in the diagnosis and antimicrobial treatment of infective endocarditis. Mayo Clin Proc, 1982. 57(1): p. 22–32. 475. Hoffman, R.S., M.J. Smilkstein, and L.R. Goldfrank, Whole bowel irrigation and the cocaine bodypacker: a new approach to a common problem. Am J Emerg Med, 1990. 8(6): p. 523–7. 476. Duenas-Laita, A., S. Nogue, and G. Burillo-Putze, Body packing. N Engl J Med, 2004. 350(12): p. 1260–1; author reply 1260–1. 477. Bulstrode, N., F. Banks, and S. Shrotria, The outcome of drug smuggling by ‘body packers’ — the British experience. Ann R Coll Surg Engl, 2002. 84(1): p. 35–8. 478. Traub, S.J., et al., Pediatric “body packing.” Arch Pediatr Adolesc Med, 2003. 157(2): p. 174–7. 479. Roberts, J.R., et al., The bodystuffer syndrome: a clandestine form of drug overdose. Am J Emerg Med, 1986. 4(1): p. 24–7. 480. Olson, K.R., Is gut emptying all washed up? [editorial]. Am J Emerg Med, 1990. 8(6): p. 560–1. 481. Kulig, K., et al., Management of acutely poisoned patients without gastric emptying. Ann Emerg Med, 1985. 14(6): p. 562–7. 482. Albertson, T.E., et al., Superiority of activated charcoal alone compared with ipecac and activated charcoal in the treatment of acute toxic ingestions [see comments]. Ann Emerg Med, 1989. 18(1): p. 56–9. 483. Merigian, K.S., et al., Prospective evaluation of gastric emptying in the self-poisoned patient. Am J Emerg Med, 1990. 8(6): p. 479–83. 484. Pond, S.M., et al., Gastric emptying in acute overdose: a prospective randomised controlled trial [see comments]. Med J Aust, 1995. 163(7): p. 345–9. 485. Curtis, R.A., J. Barone, and N. Giacona, Efficacy of ipecac and activated charcoal/cathartic. Prevention of salicylate absorption in a simulated overdose. Arch Intern Med, 1984. 144(1): p. 48–52. 486. Tenenbein, M., S. Cohen, and D.S. Sitar, Efficacy of ipecac-induced emesis, orogastric lavage, and activated charcoal for acute drug overdose. Ann Emerg Med, 1987. 16(8): p. 838–41. 487. Olkkola, K.T., Effect of charcoal-drug ratio on antidotal efficacy of oral activated charcoal in man. Br J Clin Pharmacol, 1985. 19(6): p. 767–73. 488. Pollack, M.M., et al., Aspiration of activated charcoal and gastric contents. Ann Emerg Med, 1981. 10(10): p. 528–9. 489. Menzies, D.G., A. Busuttil, and L.F. Prescott, Fatal pulmonary aspiration of oral activated charcoal. BMJ, 1988. 297(6646): p. 459–60.



693

490. Givens, T., M. Holloway, and S. Wason, Pulmonary aspiration of activated charcoal: a complication of its misuse in overdose management. Pediatr Emerg Care, 1992. 8(3): p. 137–40. 491. Mariani, P.J. and N. Pook, Gastrointestinal tract perforation with charcoal peritoneum complicating orogastric intubation and lavage. Ann Emerg Med, 1993. 22(3): p. 606–9. 492. Ray, M.J., et al., Charcoal bezoar. Small-bowel obstruction secondary to amitriptyline overdose therapy [published erratum appears in Dig Dis Sci 1988 Oct;33(10):1344]. Dig Dis Sci, 1988. 33(1): p. 106–7. 493. Watson, W.A., K.F. Cremer, and J.A. Chapman, Gastrointestinal obstruction associated with multipledose activated charcoal. J Emerg Med, 1986. 4(5): p. 401–7. 494. Longdon, P. and A. Henderson, Intestinal pseudo-obstruction following the use of enteral charcoal and sorbitol and mechanical ventilation with papaveretum sedation for theophylline poisoning. Drug Saf, 1992. 7(1): p. 74–7. 495. Bradberry, S.M. and J.A. Vale, Multiple-dose activated charcoal: a review of relevant clinical studies. J Toxicol Clin Toxicol, 1995. 33(5): p. 407–16. 496. Pond, S.M., et al., Randomized study of the treatment of phenobarbital overdose with repeated doses of activated charcoal. JAMA, 1984. 251(23): p. 3104–8. 497. Boldy, D.A., J.A. Vale, and L.F. Prescott, Treatment of phenobarbitone poisoning with repeated oral administration of activated charcoal. Q J Med, 1986. 61(235): p. 997–1002. 498. Eroglu, A., et al., Multiple dose-activated charcoal as a cause of acute appendicitis. J Toxicol Clin Toxicol, 2003. 41(1): p. 71–3. 499. Everson, G.W., E.J. Bertaccini, and J. O’Leary, Use of whole bowel irrigation in an infant following iron overdose. Am J Emerg Med, 1991. 9(4): p. 366–9. 500. Turk, J., et al., Successful therapy of iron intoxication in pregnancy with intravenous deferoxamine and whole bowel irrigation. Vet Hum Toxicol, 1993. 35(5): p. 441–4. 501. Bock, G.W. and M. Tenenbein, Whole bowel irrigation for iron overdose [letter]. Ann Emerg Med, 1987. 16(1): p. 137–8. 502. Janss, G.J., Acute theophylline overdose treated with whole bowel irrigation. S D J Med, 1990. 43(6): p. 7–8. 503. Buckley, N., et al., Slow-release verapamil poisoning. Use of polyethylene glycol whole-bowel lavage and high-dose calcium. Med J Aust, 1993. 158(3): p. 202–4. 504. Burkhart, K.K., K.W. Kulig, and B. Rumack, Whole-bowel irrigation as treatment for zinc sulfate overdose. Ann Emerg Med, 1990. 19(10): p. 1167–70. 505. Melandri, R., et al., Whole bowel irrigation after delayed release fenfluramine overdose. J Toxicol Clin Toxicol, 1995. 33(2): p. 161–3. 506. Roberge, R.J. and T.G. Martin, Whole bowel irrigation in an acute oral lead intoxication. Am J Emerg Med, 1992. 10(6): p. 577–83. 507. Utecht, M.J., A.F. Stone, and M.M. McCarron, Heroin body packers. J Emerg Med, 1993. 11(1): p. 33–40. 508. Niazi, S., Effect of polyethylene glycol 4000 on dissolution properties of sulfathiazole polymorphs. J Pharm Sci, 1976. 65(2): p. 302–4. 509. Diacetylmorphine, in Merck Index. 1984, Rahway, NJ: Merck & Co, Inc. p. 429. 510. Rosenberg, P.J., D.J. Livingstone, and B.A. McLellan, Effect of whole-bowel irrigation on the antidotal efficacy of oral activated charcoal. Ann Emerg Med, 1988. 17(7): p. 681–3. 511. Tenenbein, M., Whole bowel irrigation and activated charcoal [letter]. Ann Emerg Med, 1989. 18(6): p. 707–8. 512. Ilkhanipour, K., D.M. Yealy, and E.P. Krenzelok, The comparative efficacy of various multiple-dose activated charcoal regimens. Am J Emerg Med, 1992. 10(4): p. 298–300. 513. Park, G.D., et al., Effects of size and frequency of oral doses of charcoal on theophylline clearance. Clin Pharmacol Ther, 1983. 34(5): p. 663–6. 514. Marc, B., et al., Managing drug dealers who swallow the evidence. BMJ, 1989. 299(6707): p. 1082. 515. Sporer, K., Cocaine body stuffers. 1997, unpublished data. 516. McCarron, M.M. and J.D. Wood, The cocaine ‘body packer’ syndrome. Diagnosis and treatment. JAMA, 1983. 250(11): p. 1417–20. 517. Caruana, D.S., et al., Cocaine-packet ingestion. Diagnosis, management, and natural history. Ann Intern Med, 1984. 100(1): p. 73–4.


694


518. Farmer, J.W. and S.B. Chan, Whole body irrigation for contraband bodypackers. J Clin Gastroenterol, 2003. 37(2): p. 147–50. 519. Jeanmarie, P., Cocaine, in Emergency Medicine, A Comprehensive Study Guide, J. Tintinalli, Ed. 1996, New York: McGraw-Hill. p. 777–778. 520. Weiner, J.S. and M. Khogali, A physiological body-cooling unit for treatment of heat stroke. Lancet, 1980. 1(8167): p. 507–9. 521. Barner, H.B., et al., Field evaluation of a new simplified method for cooling of heat casualties in the desert. Mil Med, 1984. 149(2): p. 95–7. 522. Al-Aska, A.K., et al., Simplified cooling bed for heatstroke. Lancet, 1987. 1(8529): p. 381. 523. Kielblock, A.J., J.P. Van Rensburg, and R.M. Franz, Body cooling as a method for reducing hyperthermia. An evaluation of techniques. S Afr Med J, 1986. 69(6): p. 378–80. 524. Wyndham, C.H., N.B. Strydom, and H.M. Cooke, Methods of cooling subjects with hyperpyrexia. J Appl Physiol, 1959. (14): p. 771. 525. White, J.D., et al., Evaporation versus iced gastric lavage treatment of heatstroke: comparative efficacy in a canine model. Crit Care Med, 1987. 15(8): p. 748–50. 526. Daily, W.M. and T.R. Harrison, A study of the mechanism and treatment of experimental heat pyrexia. Am J Med Sci, 1948. 215: p. 42. 527. Magazanik, A., et al., Tap water, an efficient method for cooling heatstroke victims — a model in dogs. Aviat Space Environ Med, 1980. 51(9 Pt 1): p. 864–6. 528. Bynum, G., et al., Peritoneal lavage cooling in an anesthetized dog heatstroke model. Aviat Space Environ Med, 1978. 49(6): p. 779–84. 529. Syverud, S.A., et al., Iced gastric lavage for treatment of heatstroke: efficacy in a canine model. Ann Emerg Med, 1985. 14(5): p. 424–32. 530. Chiulli, D.A., T.E. Terndrup, and R.K. Kaufer, The influence of diazepam or lorazepam on the frequency of endotracheal intubation in childhood status epilepticus. J Emerg Med, 1991. 9: p. 13–17.

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CHAPTER

9

Sports Edited by Marc D. Bollmann, M.D.1 and Martial Saugy, Ph.D.2 1 2

University Institute of Legal Medicine, Lausanne, Switzerland Swiss Laboratory for Doping Analyses, University Institute of Legal Medicine, Lausanne, Switzerland

CONTENTS Prohibited List of Substances and Methods..................................................................................697 International Standards for Testing................................................................................................698 International Standard for Laboratories.........................................................................................698 International Standard for Therapeutic Use Exemptions ..............................................................699 9.1 Testosterone and Synthetic Anabolic Steroids.....................................................................700 9.1.1 Introduction...............................................................................................................700 9.1.2 Pharmaceutical Action of Anabolic Steroids ...........................................................700 9.1.3 Therapeutic Uses ......................................................................................................701 9.1.4 Athletic Use ..............................................................................................................701 9.1.5 Anabolic Testing.......................................................................................................701 9.2 Stimulants .............................................................................................................................703 9.2.1 Introduction...............................................................................................................703 9.2.2 Caffeine.....................................................................................................................703 9.2.3 Amphetamine............................................................................................................704 9.2.3.1 Metabolism of Amphetamines ..................................................................704 9.2.3.2 Amphetamine Action ................................................................................704 9.2.3.3 Amphetamine in Sport ..............................................................................704 9.2.4 Cocaine .....................................................................................................................705 9.2.4.1 Cocaine’s Actions......................................................................................705 9.2.4.2 Cocaine in Sport........................................................................................705 9.2.5 Ephedrine..................................................................................................................706 9.2.5.1 Ephedrine Action.......................................................................................706 9.2.5.2 Ephedrine in Sport ....................................................................................706 9.3 Erythropoietin — Blood Doping .........................................................................................707 9.3.1 Introduction to Erythropoiesis..................................................................................707 9.3.2 Production of Erythropoietin....................................................................................707 9.3.3 Mechanism of Erythropoietin Action.......................................................................708

695


696


9.3.4

9.4

9.5 9.6 9.7

9.8 9.9

Detecting Recombinant EPO (rHuEPO) Abuse in Sports.......................................708 9.3.4.1 Indirect Methods .......................................................................................708 9.3.4.2 Direct Methods..........................................................................................709 9.3.4.3 Abnormal Blood Profiles ..........................................................................710 9.3.5 Conclusion ................................................................................................................711 Human Growth Hormone.....................................................................................................711 9.4.1 Introduction...............................................................................................................711 9.4.2 Growth Hormone and Exercise................................................................................711 9.4.3 Physiological Action of GH .....................................................................................712 9.4.4 Therapeutic Use of GH ............................................................................................712 9.4.5 GH as a Doping Agent.............................................................................................712 9.4.6 Detection of GH Doping..........................................................................................713 9.4.6.1 The Urine Strategy....................................................................................713 9.4.6.2 The Indirect and Direct Approaches in Blood .........................................713 Cannabinoids ........................................................................................................................714 Ethanol Use in Sport and Interaction with Other Doping Agents ......................................716 Morbidity of Doping ............................................................................................................716 9.7.1 Anabolic-Androgenic Steroids (AAS) .....................................................................716 9.7.1.1 Cardiovascular...........................................................................................716 9.7.1.2 Hepatic.......................................................................................................717 9.7.1.3 Endocrine/Reproductive ............................................................................717 9.7.1.4 Psychological.............................................................................................718 9.7.1.5 Tendon Injuries..........................................................................................718 9.7.2 Stimulants .................................................................................................................718 9.7.2.1 Amphetamine ............................................................................................718 9.7.2.2 Cocaine......................................................................................................718 9.7.2.3 Ephedrine...................................................................................................719 9.7.3 Erythropoietin ...........................................................................................................719 9.7.4 Human Growth Hormone (GH) ...............................................................................719 Mortality of Doping — Sudden Death in Athletes .............................................................720 The Future of Doping: New Drugs and Genetic Doping....................................................721 References.............................................................................................................................722 Doping contravenes the ethics of both sport and medical science. It consists of the administration of substances belonging to prohibited classes of pharmacological agents, and/or the use of various prohibited methods. WADA — IOC Definition, 2004

Doping is not a new phenomenon. Ancient Greek athletes tried to enhance performance by ingestion of alcoholic drinks and sheep testicles. The term “doping” is said to have its roots in the Dutch word Dop, which, in South Africa, referred to an alcoholic drink used as a stimulant by the Zulus in ceremonial dancing. At the end of 19th century, athletes experimented with cocaine, heroin, and strychnine. In the 1904, Thomas Hicks nearly died using strychnine in combination with brandy during a bicycle race. Today modern drugs have replaced alcohol as doping agent, although strychnine is still rarely reported. These examples illustrate that misuse of drugs by athletes has been a problem since the beginning of sports history. About 35 years ago, after the first widely reported doping scandals, health and sports ethics became a major concern of the medical commission of the International Olympic Commission (IOC) and also of the individual sport federations. Doping has also become a problem even in recreational sports. Thus, the fight against doping began.


SPORTS

697

The medical commission of the IOC has created a list of forbidden substances and prohibited methods, which is included in the IOC’s medical code. Doping control is performed by a network of IOC accredited laboratories, which analyze urine samples collected after or out of competition. Following the World Anti-Doping Conference in Lausanne in 1999, sports authorities and governments decided to produce a World anti-doping code (Code) and to fund a World Anti-Doping Agency (WADA). The main aim of WADA is to harmonize the fight against doping around the world. The anti-doping Code works in conjunction with four International Standards aimed at harmonization among anti-doping organizations: 1. 2. 3. 4.

Prohibited List of substances and methods International standards for testing International standards for laboratories Therapeutic use exemptions (TUES)

These standards have been the subject of lengthy consultation among the WADA stakeholders and are mandatory for all signatories of the World Anti-Doping Code. Prohibited List of Substances and Methods The Prohibited List (List) was first published in 1963 under the leadership of the International Olympic Committee. Since 2004, it had been updated and published by the WADA. The List is the cornerstone of the Code and a key component of harmonization. It lists substances and methods prohibited in and out of competition, as well as substances prohibited for particular disciplines. The use of prohibited substances can be authorized for medical reasons by virtue of a TUES. Prohibited Substance Classes: 1. S1. Anabolic Agents Anabolic Androgenic Steroids (AAS), e.g., testosterone, nandrolone, methandienone, stanozolol, etc. Other anabolic agents, e.g., Clenbuterol 2. S2. Hormones and related substances Erythropoietin (EPO) Growth hormone (GH), insulin-like growth factor (IGF-1), mechano growth factors (MGFs) Gonadotrophins (LH, HCG) Insulin Corticotrophins 3. S3. Beta-2-agonists 4. S4. Agents with anti-estrogenic activity Aromatase inhibitors, including anastrazole, letrozole, etc. Selective estrogen receptor modulators (SERMs), including tamoxifène, toremifene, etc. Other anti-estrogenic substances, including clomiphene, cyclofenyl, etc. 5. S5. Diuretics and other masking agents Masking agents, including epitestosterone, probenecid, plasma expanders Diuretics, including acetazolamide, furosemide, etc. 6. S6. Stimulants Examples: Amphetamine, ethylefrine, modafinil, ephedrine, cathine, methylephedrine, etc. Note: For ephedrine, methylephedrine, and cathine a cutoff urine concentration has been defined 7. S7. Narcotics Examples: Buprenorphine, fentanyl, methadone, etc. 8. S8. Cannabinoids 9. S9. Glucocorticoids 10. P1. Alcohol and P2. Beta-blockers are prohibited in some specific sports


698


Table 9.1 General Statistics for 2004 Sports

Samples Analyzed

Adverse Analytical Findings

% Adverse of Total

Olympic Non-Olympic Total

128,591 40,596 169,187

2,145 764 2,909

1.67 1.88 1.72

Table 9.2 Number of Substances Identified for 2004 Substance Group Anabolic agents Glucocorticoids Cannabinoids Stimulants beta-2-Agonists Masking agents Peptide hormones beta-Blockers Narcotics Anti-Estrogens Blood transfusion Total

No. 1191 548 518 382 381 157 78 25 15 8 2 3305

% of All Adverse Analytical Findings 36.0 16.6 15.7 11.6 11.5 4.8 2.4 0.8 0.5 0.2 0.1

Prohibited Methods: 1. M1. Enhancement of oxygen transfer Blood doping, for example, homologous or autologous blood transfusion Artificial transport of oxygen, for example, PFCs, modified hemoglobins, etc. 2. M2. Chemical and physical manipulation Tampering with the sample Intravenous infusions 3. M3. Gene doping

International Standards for Testing The purpose of the International Standards for Testing is to plan for effective testing and to maintain the integrity and identity of samples throughout the testing process, from notifying the athlete to transport of the samples for analysis. International Standard for Laboratories The purpose of the International Standard for Laboratories (ISL) is to ensure production of valid test results and evidentiary data, and to achieve uniform and harmonized results and reporting from all accredited laboratories. The ISL includes requirements for WADA accreditation of doping laboratories, operating standards for laboratory performance, and description of the accreditation process. WADA publishes annually an overview of the results reported by its accredited laboratories.1 The 2004 statistics include analyses conducted by WADA-accredited laboratories for in- and outof-competition testing (Table 9.1 through Table. 9.3). When looking at the statistics of 2004, anabolic steroids are still the most often reported doping agents, as it has been the case every year since the beginning of the 1990s. Surprisingly, the glucocorticoids and cannabinoids are nowadays at second and third place. The large number of testosterone cases should be taken with caution


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Table 9.3 The 12 Most Identified Substances for 2004 Substance 1 2 3 4 5 6 7 8 9 10 11 12 a

b

Cannabis Testosteronea Nandrolone Salbutamolb Triamcinolone Ac.b Stanozolol Betamethasoneb Amphetamine Ephedrine Terbutalineb Cocaine Methandienone

Group Cannabinoids Anabolic steroids Anabolic steroids beta-2-Agonists Glucocorticoids Anabolic steroids Glucocorticoids Stimulants Stimulants beta-2-Agonists Stimulants Anabolic steroids

No. 518 392 339 251 246 226 121 112 102 78 75 62

These are adverse analytical findings reported from laboratories. Some of these results can be due to naturally elevated testosterone levels. beta-2-Agonist and glucocorticoid adverse analytical findings could have been justified by therapeutic use exemption (TUE).

because the differentiation between a naturally elevated concentration of the endogenous hormone and abuse of testosterone esters cannot always be done. International Standard for Therapeutic Use Exemptions The purpose of the International Standard for TUE is to ensure that the process of granting TUEs is harmonized across sports and countries. But what is a TUE? Athletes, like all others, may have illnesses or conditions that require them to take particular medications. If the medication happens to fall under the Prohibited List, a TUE authorizes the athlete to take the needed drug. The criteria to grant a TUE are: The athlete would experience significant health problems without taking the prohibited substance or method The therapeutic use of the substance would not produce significant enhancement of performance There is no reasonable therapeutic alternative to the use of the prohibited substance or method.

Under the World Anti-Doping Code, WADA has issued an International Standard for the granting of TUEs. The standard states that all International Federations and National Anti-Doping Organizations must have a process in place whereby athletes with documented medical conditions can request a TUE. A panel of independent physicians called the Therapeutic Use Exemption Committee (TUEC) examines the request. International Federations and National Anti-Doping Organizations are responsible for granting or declining such applications. There are two types of TUEs: abbreviated and standard. Abbreviated TUE: Only for glucocorticosteroids by nonsystemic routes (topical application) and beta2 agonists (formoterol, salbutamol, salmeterol, and terbutaline) by inhalation. Dermatological applications are not prohibited and do not require any TUE. A notification is sent to the athlete by the relevant organization upon receipt of a duly completed request. The athlete can begin treatment as soon as the form has been received by the relevant organization. Standard TUE: For any treatment involving a substance or a method on the Prohibited List that does not qualify for an abbreviated TUE, the prescription must be reviewed by a TUEC. If approved, the athlete may begin treatment only after receiving the authorization notice from the relevant organization (except in rare cases of an acute life-threatening condition for which a retroactive approval may be considered).


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9.1 TESTOSTERONE AND SYNTHETIC ANABOLIC STEROIDS

Christophe Saudan, Ph.D. and Norbert Baume, Ph.D. Swiss Laboratory for Doping Analyses, University Institute of Legal Medicine, Lausanne, Switzerland

9.1.1

Introduction

Anabolic steroids are synthetic derivatives of testosterone modified to enhance the anabolic rather than the androgenic actions of the hormone. Testosterone is hormone-synthesized in the human body from cholesterol. It serves distinct functions at different stages of life. During embryonic life, androgen action is central to the development of the male phenotype. At puberty, the hormone is responsible for the secondary sexual characteristics that transform boys into men. Testosterone intervenes in many physiological processes in the adult male including muscle protein metabolism, sexual and cognitive functions, erythropoiesis, plasma lipids, and bone metabolism (Figure 9.1.1). 9.1.2

Pharmaceutical Action of Anabolic Steroids

Testosterone is virtually inactive when taken orally. After oral ingestion, testosterone is absorbed from the small intestine and passes via the portal vein to the liver where it is rapidly metabolized, mostly to inactive compounds. Accordingly, chemical modifications of testosterone have been made to alter the relative anabolic–androgenic potency, slow the rate of inactivation, and change the pattern of metabolism. Most orally anabolic-androgenic steroids (AAS) preparations are 17-β alkylated derivatives of testosterone that are relatively resistant to hepatic inactivation. Esterification of the 17-β hydroxyl group makes the molecule more soluble in lipid vesicles for injection. This slows the release of the injected steroid into the circulation. Commonly used 17-β alkyl and 17-β ester derivatives are: 17-β alkyl derivatives: Stanozolol, danazol, fluoxymesterone, methyltestosterone, methandrostenolone, oxandrolone, and oxymetholone 17-β ester derivatives: Nandrolone decanoate, boldenone, trenbolone, methenolone, and testosterone enanthate

Evidence suggests that with normal male physiological plasma levels of testosterone, the androgen receptors, to which testosterone and dihydrotestosterone (DHT, an active metabolite of testosterone) bind, are fully saturated. In vitro studies have demonstrated that the dose–response relationship of testosterone and skeletal muscle growth reaches a plateau once the physiological concentration is exceeded. It has been suggested that when anabolic steroids are abused by athletes, the drugs exert their effects by another receptor mechanism that is unsaturated or unaffected by normal plasma OH 17

O Figure 9.1.1 Molecular structure of testosterone.


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testosterone and DHT levels. Indeed, it is believed that the effects of supraphysiological doses of testosterone on muscle are mediated through an antiglucocorticoid action, independent of the androgen receptor. Glucocorticoids such as cortisol and corticosterone are hormones that influence glucose synthesis and protein catabolism. Stimulation of glucocorticoid receptor will lead to an enhancement of protein breakdown in muscle. According to one theory the high doses of anabolic steroids used by many athletes displace glucocorticoids from glucocorticoid receptor and inhibit muscle protein catabolism, leading overall to an anabolic or muscle-building effect.2 9.1.3

Therapeutic Uses

A number of clinical studies using a variety of experimental designs have shown that the potent anabolic effects of AAS have a positive effect on various pathological conditions.3 Physiologic replacement doses of testosterone have been used to stimulate sexual development in cases of delayed puberty, and to substitute for the hormone after surgical removal of a testis. The first major clinical use of anabolic steroids was to inhibit the loss of protein and aid muscle regeneration after major surgery. Anabolic steroids may also be used to increase growth in prepubertal boys who have failed to reach their expected minimal height for their age. 9.1.4

Athletic Use

For many years, the medical community fought AAS use by denying that they had any effects on the lean body mass. Early studies were flawed and did not reflect the way AAS are actually used. Athletes “cycle” on and off compounds, switching from one to another to avoid developing tolerance. They “stack” AAS, taking several different steroids at the same time to lower the dose of each, and to activate different steroid receptors. The scientific basis for stacking is, however, highly questionable and has not been proved. AAS are generally accepted as having the desired anabolic effects, provided athletes also have an adequate protein supply and exercise intensely. In a randomized controlled trial, those taking 600 mg testosterone intramuscular injections weekly for 10 weeks had significantly increased muscle mass, muscle strength, and fat-free mass compared to those taking a placebo. However, not all studies have found such strength gains. 9.1.5

Anabolic Testing

The latest list of prohibited substances, established by the WADA for 2005, includes two types of steroids: (1) typically exogenous steroids, main examples of which have been given previously, and (2) typically endogenous steroids, e.g., androstenediol, androstendione, dehydroepiandrosterone (DHEA), dihydrotestosterone (DHT), testosterone, and related substances. Testing for anabolic agents in the urine of athletes was first implemented on a large scale during the 1976 Montreal Olympic Games. Testing was mainly based on radioimmunoassay (RIA) techniques. The techniques for the identification and characterization of steroids and their metabolites in urine have improved considerably during the last three decades. This improvement is largely due to the use of gas chromatography-mass spectrometry (GC-MS) techniques. Today, most antidoping laboratories use techniques that are based on the solid-phase extraction of the urine sample, followed by chemical modifications prior to GC-MS analysis.4 The confirmation procedure for the unequivocal identification of an anabolic doping agent consists in matching GC and MS data of the supposed substance and/or its metabolites with pure standards, or matching the metabolite profile of the sample with reference urine originating from an excretion study. The detection of exogenous substances requires the identification of a parent compound and/or at least one metabolite. However, with endogenously produced substances, such as


702


testosterone, the presence of the substance alone cannot be considered as an offense. Moreover, a cutoff value for testosterone concentration cannot be used because of large inter-individual and intra-individual urinary concentrations of the hormone.5 However, the intake of testosterone causes characteristic changes in the pattern of steroids excreted in the urine. In 1983, based on studies performed on athletes, the IOC adopted a ratio of testosterone to epitestosterone (T/E) of up to 6.0, as a criterion for the administration of testosterone. Epitestosterone formation seems to parallel testosterone formation,6 but it does not increase to the same extent as testosterone after exogenous testosterone administration, resulting in an increase of the T/E ratio. In populations of athletes, a mean T/E ratio of less than 2.0 is observed. For that reason the IOC rules clearly state that a T/E ratio greater than 6.0 constitutes an offense, unless there is evidence that the result is due to an extraordinary physiological or pathological condition (e.g., low epitestosterone excretion, androgen producing tumor, and enzyme deficiencies). Before a sample is declared positive, further investigations are conducted as a confirmational study.7 As a first step, a comparison with previous values is made. After that, or if no previous values are available, several additional urine samples are analyzed over a short period. This longitudinal study may represent a useful tool to detect false-positive results (naturally elevated T/E ratios). WADA suggested in 2004 that urine samples should now be submitted to isotopic ratio mass spectrometry (IRMS) if the T/E is greater than or equal to 4.0, and testosterone, testosterone metabolites, epitestosterone, and DHEA concentrations are greater than fixed cutoff concentrations.8 Even if additional studies of the particular athlete suggest the potential steroid profile manipulation, there is a lack of definitive proof for the exogenous application of natural steroids. This problem can be solved by the determination of the ratio of the two stable carbon isotopes 13C/12C, which allow the differentiation of natural and synthetic steroids. As exogenous testosterone or precursors contain less 13C than their endogenous homologues, a lower urinary 13C/12C ratio can be expected if steroids have been administered. The method for determining the isotopic composition of the relevant analyte includes GS, a subsequent combustion to CO2, and, finally, MS analysis of the gas in a special multicollector mass spectrometer (isotope-ratio-mass-spectrometry, IRMS). The 13C/12C ratio of testosterone or its metabolites is measured and compared to urinary reference steroids within the sample.9 It should be emphasized that the 13C/12C ratio of these endogenous reference compounds should not be affected by steroid administration.10 The result will be reported as consistent with the administration of a steroid, if a significant difference is observed between the 13C/12C values of testosterone metabolites and the endogenous reference compound. According to population studies, the WADA Laboratory Committee has stated a difference cutoff for positivity in 2004. If the IRMS study does not clearly indicate exogenous administration, an inconclusive result may be reported and further longitudinal studies can be performed.8 Nandrolone, or 19-nortestosterone, is a synthetic AAS, a member of the norsteroids family derived from the testosterone molecule. A small chemical modification (on the carbon atom 19) gives nandrolone more anabolic rather than androgenic properties. Some nandrolone-positive cases with low levels of metabolites (19-norandrosterone and 19-noretiocholanolone) are encountered in several sports such as football, judo, and tennis. A debate about the capability of the human body to endogenously produce traces of nandrolone metabolites, without any intake of forbidden substances, was initiated a decade ago. Research projects on the effects of nandrolone and on its metabolism were performed and provided the following results: Endogenous production of nandrolone has been observed. It is due to enzymatic transformation of endogenous testosterone to endogenous 19-nortestosterone (nandrolone).11 A possible exogenous source is the intake of nutritional supplements and/or over-the-counter drugs, which have previously been intentionally or accidentally contaminated by nandrolone precursors.12–14 Physical exercise may also influence the excretion of nandrolone, but studies on this subject have produced mixed results.15–18


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9.2 STIMULANTS

Lidia Avois-Mateus, Ph.D. Swiss Laboratory for Doping Analyses, University Institute of Legal Medicine, Lausanne, Switzerland

9.2.1

Introduction

These drugs stimulate the central nervous system (CNS) and may be used to reduce fatigue, as well as increase alertness, competitiveness, and aggression. They are considered to have a performance-enhancing effect in explosive power activities and endurance events, since the capacity to exercise strenuously is increased and sensitivity to pain is reduced. Because of their short half-life, stimulants are mostly used on the day of a competition. They may also be used in training, to allow an increase in intensity of the training session. Testing for stimulants is done in-competition only. Because stimulants can increase an athlete’s aggression toward other competitors or officials, their misuse in contact sports may be dangerous. Relatively high doses are needed to reduce fatigue, and performance may be reduced by side effects such as tremor. The stimulant class includes psychomotor stimulants, sympathomimetics, and miscellaneous CNS stimulants.19,20 Specific examples of this class include caffeine, amphetamines, ephedrines, and cocaine (Figure 9.2.1). 9.2.2

Caffeine

Caffeine is the pharmacologically active substance found in tea, coffee, and cola. The amount of caffeine present varies according to the type of drink and the way it has been prepared. In addition, caffeine may be an ingredient of some common medications (e.g., against the common cold, pain relievers), but usually in quantities of less than 100 mg per dose. Caffeine produces mild CNS stimulation, similar to that of amphetamines, reducing fatigue and increasing concentration and alertness. Physiological effects include increased cardiac output, and increased metabolic rate and urine production. High doses can cause anxiety, insomnia, and nervousness.20 Since 2004, caffeine has been removed from the list of prohibited substances and included, instead, in the Monitoring Program. The Monitoring Program is concerned with substances that are not on the Prohibited List, but which WADA wishes to monitor in order to detect patterns of misuse in sport (WADA Code 4.5). CH3

O C CH3

H NH2 H

C

N CH3

CH2

Amphetamine Figure 9.2.1 Common stimulants.

H3C

C

H

O

H

C

OH

C

Ephedrine

Cocaine

O

N

CH3


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9.2.3


Amphetamine

Amphetamine was synthesized in 1920 and used to reduce fatigue and increase alertness in soldiers during World War II. Many derivatives have since been elaborated, such as methamphetamine, dimethamphetamine, methylendioxyamphetamine (MDA), methylendioxymethamphetamine (MDMA, “ecstasy”), selegiline, etc. They are all forbidden in the practice of sport. Amphetamine was used as a nasal decongestant, antidepressant, and appetite suppressant, but its powerful CNS stimulant properties were soon discovered. It acts primarily by enhancing the brain activity of norepinephrine and dopamine, resulting in intensification of alertness, concentration, and selfconfidence. Amphetamines may induce dependence, and generally fall under the drug legislation of the athlete’s own country. 9.2.3.1 Metabolism of Amphetamines Amphetamine is readily absorbed, mainly from the small intestine, and the peak concentration occurs 1 to 2 h following administration. Absorption is usually complete in 2.5 to 4 h and is accelerated by food intake. The metabolism of amphetamine has been difficult to investigate because of the wide variation between species in its metabolic effects. The principal amphetamine metabolites are p-hydroxyephedrine and p-hydroxyamphetamine. Amphetamine is eliminated by renal filtration. For the detection of amphetamine use in sport, the urine is analyzed for the parent compound amphetamine. After a single dose of amphetamine, it can be found in the first void urine and continues to be detectable for at least 48 h after the intake of the drug. The peak urine concentration is quite variable and occurs between 3 and 12 h after the intake of the drug. Amphetamine excretion may be accelerated by acidification of the urine — this property has been used in the treatment of amphetamine overdose. 9.2.3.2 Amphetamine Action Amphetamine’s positive effects include an increase in physical energy and an improvement in some mental skills, but there are also increased talkativeness, restlessness, and excitement. Subjects taking amphetamine also report that they feel confident, efficient, ambitious, and that their food intake is reduced. Other negative effects of amphetamine — which can be dose-dependent — are anxiety, indifference, slowness in reasoning, irresponsible behavior, irritability, dry mouth, tremors, insomnia, and, following withdrawal, depression. Tolerance develops rapidly to many of the effects of the amphetamines. Amphetamines induce dependence and the amphetamine-dependent person may become psychotic, aggressive, and antisocial. Withdrawal of amphetamines is associated with mental and physical depression. Other major side effects of amphetamine administration include confusion, delirium, sweating, palpitations, mydriasis, tachypnea, hypertension, tachycardia, tremors, as well as muscle and joint pain. Chronic amphetamine administration is also associated with myocardial pathology and possibly with growth retardation in adolescents. High chronic doses may lead to a variety of persistent personality changes, paranoid delusions, and tactile hallucinations called amphetamine psychosis. Transient changes indistinguishable from schizophrenia were commonly reported during the 1950s, when amphetamine abuse was very widespread. 9.2.3.3 Amphetamine in Sport The action of amphetamine on sporting performance was first investigated in 1959 and it has been concluded that it enhances anaerobic performances while having little or no effect on aerobic activity. Since then, amphetamine has been studied in attempts to enhance performance in various disciplines. It might improve reaction time when fatigued, increase muscular strength and endur-


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ance, increase acceleration, increase lactic acid level at maximal exercise, increase anaerobic endurance capacity, and stimulate metabolism with loss of body fat. Dosage seems to be important depending on the desired effect. Aggressiveness increases with high dosage, whereas alertness is enhanced with lower quantities. All amphetamines are banned by the WADA and IOC codes. No quantification is necessary, as the qualitative demonstration of the substance is sufficient to declare the case an analytical adverse finding. The presence of amphetamine in urine is considered a severe doping offense, because amphetamine has no medical indication any more and its use is prohibited in many countries. 9.2.4

Cocaine

Cocaine is the most potent stimulant of natural origin. Unlike amphetamines, which are synthetic compounds, cocaine is obtained from naturally occurring Coca species, although it can be produced synthetically. Its current notoriety belies the fact that people have used the drug as a stimulant for thousands of years. In the past cocaine was used in a number of patent medicines and even in soft drinks. Except for head and neck surgery, where it is still used as a local anesthetic (because it is a vasoconstrictor in addition to being an anesthetic), its therapeutic indications are now mostly obsolete, as much safer drugs have been produced. Cocaine can be snorted, smoked, or injected. 9.2.4.1 Cocaine’s Actions Physical effects of cocaine use include vasoconstriction, thermogenesis, increased heart rate, and increased blood pressure. Cocaine also increases motor activity, talkativeness, and is a potent euphoriant. Users feel an initial “rush” or sense of well-being, of having more energy, and of being more alert. The duration of cocaine’s immediate euphoric effects, which include hyperstimulation, reduced fatigue, and increased mental clarity, depends on the route of administration, but generally is very short. 9.2.4.2 Cocaine in Sport Despite popular myth, cocaine does not really enhance performance whether at work, in sports, at school, or with sex. On the contrary, long-term use can lead to loss of concentration, irritability, loss of memory, paranoia, loss of energy, anxiety, and a loss of interest in sex. Several studies have demonstrated that cocaine has no beneficial effect on running times and reduces endurance performance. Furthermore, at all doses, cocaine significantly increases glycogen utilization and plasma lactate concentration, without producing consistent changes in plasma catecholamine levels. The controlling effect cocaine has on an addict’s life can lead to exclusion of all other facets of life. Nevertheless, despite these apparently detrimental effects, cocaine continues to be abused in sport. The reason may be that cocaine has positive ergogenic effect on activities of short duration requiring a burst of high-intensity energy output. The activities associated with the drug’s CNS stimulatory effect may be more important than its action on peripheral metabolism. It has been suggested that it is precisely because of central heightened arousal and increased alertness, achieved principally at low doses, that cocaine is used in sport. Cocaine can currently be administered by a doctor for legitimate medical uses, such as local anesthetic for some eye, ear, and throat surgeries. Both WADA and IOC ban cocaine, including its use as a local anesthetic. A recent report showed positive urine test results for benzoylecgonine (metabolite of cocaine) within 24 h in subjects after ingestion of a 250 ml infusion of Mate de Coca tea.21 Cocaine, like amphetamine, is part of the category S6 of the prohibited substances in competition and its — and/or its metabolites — presence in urine can be considered a severe doping offense.


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9.2.5


Ephedrine

Ephedra alkaloids, which are popular components of many nutritional supplements, are naturally occurring CNS stimulants, which may be obtained from several Ephedra plant species. Naturally occurring Ephedra plants contain ephedrine, pseudoephedrine, norephedrine, methylephedrine, norpseudoephedrine, and methylpseudoephedrine. Phenylpropanolamine is a synthetic compound with effects similar to ephedra-alkaloids. Methylephedrine is a very widely used cough suppressant, popular in Asia. Historically, ephedra-alkaloids have been used for both asthma and allergies in China for more than 5000 years. The structure of ephedrine is closely related to methamphetamine, although its effects on the CNS are much less potent and longer acting than those of the amphetamines. Its peripheral stimulant actions are similar to but less powerful than those of epinephrine (also called adrenaline), a hormone produced in the body by the adrenal glands. 9.2.5.1 Ephedrine Action Ephedrine is a mixed sympathomimetic agent that acts as a stimulant in the CNS by enhancing the release of norepinephrine from sympathetic neurons and stimulating alpha- and beta-receptors. Ephedrine is the most potent thermogenic agent of the ephedra alkaloids. It increases heart rate, but only by an average of 8 to 10 beats per minute, and thereby cardiac output. In multiple controlled studies it has been found to cause minimal effect on systolic pressure and no effect or even a decrease in diastolic pressure (the phenomenon known as diastolic runoff). When given as an intravenous bolus it causes peripheral vasoconstriction resulting in an increase of peripheral resistance that may lead to a sustained rise in blood pressure, which is why it is still very widely used to counter the hypotensive effects of spinal anesthesia. Ephedrine relaxes bronchial smooth muscle and is used as a decongestant and for temporary relief of shortness of breath caused by asthma, although it quickly loses its effect because of beta-receptor downregulation. It is present in numerous nutritional and dietary supplements, such as energy stimulants and anorexic agents, although its use in the U.S. has now been banned. Pseudoephedrine can be found in many over-the-counter preparations for respiratory infections or allergies. Phenylpropanolamine, similarly to pseudoephedrine, has still been used recently in over-the-counter diet pills. Ephedrine is excreted largely unchanged in the urine and the usual elimination half-life is 3 to 6 h, which can be prolonged with increased urine pH. 9.2.5.2 Ephedrine in Sport With their stimulant properties and sympathomimetic actions, ephedra-alkaloids have been perceived as potential performance-enhancing substances, offering unfair advantages to athletes, even if used in supplement forms.22 It appears, through various studies, that the isolated use of ephedrine, pseudoephedrine, and phenylpropanolamine at the usual dosages has an inconsistent, and probably insignificant, ergogenic benefit for power, endurance, strength, or speed. Other studies looking at the use of ephedrine combined with vitamins, minerals, or caffeine have, nevertheless, supported potential ergogenic effects. Many athletes indeed use food supplements containing ephedra alkaloids because of supposed energy increase and potential increase of metabolism with fat loss and increased muscular strength. A number of placebo-controlled studies have evaluated the effects of ephedrine in combination with caffeine. They demonstrated a prolonged time until exhaustion and a decreased perception of exhaustion on cycle ergometry. WADA and IOC tolerate the medical use of ephedrine at therapeutic levels. Nevertheless, an ephedrine urine concentration of higher than 10 μg/ml is considered as positive result. Unlike amphetamine and cocaine, even if ephedrine is part of the category S6 of the prohibited substances in competition, its presence in urine is not considered as a severe doping offense and the sanctions are often milder or submitted to discussion.


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9.3 ERYTHROPOIETIN — BLOOD DOPING

Neil Robinson, Ph.D. Swiss Laboratory for Doping Analyses, University Institute of Legal Medicine, Lausanne, Switzerland

9.3.1

Introduction to Erythropoiesis

Erythropoiesis is part of the larger process of hematopoiesis, which involves the production of mature cells found in the blood and lymphoid organs. Hematopoiesis is continuously required because of normal turnover in the cell populations in the blood and lymphoid organs. In the normal adult human, the daily turnover of erythrocytes exceeds 1011 cells. In case of acute erythrocyte loss due to hemolysis or hemorrhage, the production of erythrocytes increases rapidly and markedly. In hematopoiesis, rare hematopoietic stem cells in the bone marrow proliferate and differentiate so as to give rise to all the cellular components of the blood and the lymphoid system. During this process, an individual hematopoietic cell undergoes an apparent random process called commitment. When a cell undergoes commitment, its proliferation becomes limited and its potential to develop into multiple types of mature cells is restricted. Thus, these hematopoietic cells are termed committed, lineage-specific progenitor cells. The major stages of differentiation in mammalian erythropoiesis are the following: The most immature stage of committed erythroid progenitors is the burst-forming unit-erythroid (BFU-E). The next major stage of erythroid progenitor cell development is the colony-forming unit-erythroid (CFU-E). A continuum of erythroid progenitor stages exists between the BFU-E and CFU-E, with decreasing proliferative potential as the progenitors approach the CFU-E stage. The descendant cells of the CFU-E are termed erythroid precursor cells. The erythroid precursors are proerythroblasts, basophilic erythroblasts, polychromatophilic erythroblasts, and orthochromatic erythroblasts. The orthochromatic erythroblasts do not divide but they enucleate, forming the nascent erythrocyte called the reticulocyte. 9.3.2

Production of Erythropoietin

EPO is a 30,400 D glycoprotein hormone produced mainly in the kidney, in the liver (50 covered employees) and January 1, 1996 for small employers. Currently the DOT regulations cover more than 12 million transportation workers nationwide. Drug testing in the workplace has changed considerably over the last 20 years and the changes have improved the program. The development and scope of regulations related to testing have had an important effect not only to improve the accuracy and reliability of employee drug testing but also to establish the credibility of the testing process and the laboratories’ capabilities to routinely perform these tests. The stringent laboratory certification standards imposed on forensic drug-testing laboratories have influenced clinical laboratory medicine, with dramatic improvement over the last decade. A real concern is that the federal regulations may have become too rigid, precluding technological advances. The Substance Abuse and Mental Health Services Administration (SAMHSA), which was mandated oversight of workplace drug testing in 1992, has regularly modified regulations and, most recently, proposed new adaptations in technology in a broad sweeping proposal to include the testing of hair, sweat, and oral fluid in addition to urine specimens. It also proposes the use of on-site tests of urine and oral fluid at the collection site, the establishment of instrumented initial test facilities, and changes in operational standards.2 10.1.2 Incidence of Drugs in the Workplace Good comprehensive statistics regarding drug use and testing incidence have not been developed. The National Household Survey (2003) shows that 19.5 million people over 12 years of age used drugs during the past month. Of these 54.6% used marijuana, 20.6% marijuana and other drugs, and 24.8% used other drugs. Use was predominately in the 14- to 29-year-old age group as follows: 10.9% (14–15), 19.2% (16–17), 23.3% (18–20), 18.3% (21–25), 13.4% (26–29), and 14.9% (all others). The only comprehensive compilation of drug test data is published by Quest Diagnostics. Its Drug Testing Index is compiled semiannually. Quest Diagnostics is one of the largest providers of workplace drug tests performing more than 12 million tests annually. Its results are the best available statistical indication of trends in the field. Over the years the drug positivity rates have gone from a high in 1988 (13.6%) when drug-testing programs started to 4.5% in 2004. The number of positives has been relatively consistent since 1997 (5.0 to 4.5%); see Table 10.1.1. The positivity rates by drug category for the combined workforce for the last 5 years (2000 to 2004) is shown in Table 10.1.2. Updated revisions and more specific breakdowns of these statistics may be found on the Quest Diagnostics Web site www.questdiagnostics.com.


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Table 10.1.1

Annual Positivity Rates for Combined U.S. Workforce (more than 7.2 million tests from January to December 2004)

Year

Drug Positive Rate

1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

13.6% 12.7% 11.0% 8.8% 8.8% 8.4% 7.5% 6.7% 5.8% 5.0% 4.8% 4.6% 4.7% 4.6% 4.4% 4.5% 4.5%

Source: Courtesy of Quest Diagnostics. Table 10.1.2

Positivity Rates by Drug Category for Combined U.S. Workforce as a Percentage of All Positives (more than 7.2 million tests from January to December 2004)

Drug Category

2004

2003

2002

2001

2000

Acid/base Amphetamines Barbiturates Benzodiazepines Cocaine Marijuana Methadone Methaqualone Opiates Oxidizing adulterants (incl. nitrites) PCP Propoxyphene Substituted

0.13% 10.2% 2.5% 4.5% 14.7% 54.8% 1.5% 0.00% 6.2% 0.09% 0.38% 4.4% 0.66%

0.18% 9.3% 2.5% 4.7% 14.6% 54.9% 1.4% 0.00% 6.4% 0.19% 0.61% 4.5% 0.73%

0.27% 7.1% 2.6% 4.5% 14.6% 57.6% 1.1% 0.00% 5.5% 0.52% 0.58% 5.1% 0.68%

0.24% 5.9% 2.9% 4.5% 13.9% 60.6% 0.88% 0.00% 5.8% 0.54% 0.59% 3.5% 0.51%

0.08% 5.1% 3.2% 3.9% 14.4% 62.8% 0.82% 0.00% 5.4% 0.92% 0.56% 2.3% 0.58%

Source: Courtesy of Quest Diagnostics.

REFERENCES 1. Walsh, J.M., Development and scope of regulated testing. In Workplace Testing, Y.H. Caplan, Ed., Drug Abuse Handbook, S.B. Karch, Ed. in Chief. CRC Press, Boca Raton, FL, 1998, 729–736. 2. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Proposed Revisions to Mandatory Guidelines for Workplace Drug Testing Programs (69 FR 19673), April 13, 2004.


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10.2 FEDERAL REGULATION OF WORKPLACE DRUG AND ALCOHOL TESTING 10.2.1 An Overview of the Mandatory Guidelines for Federal Workplace Drug Testing Programs

Donna M. Bush, Ph.D., DABFT Drug Testing Team Leader, Division of Workplace Programs, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, Rockville, Maryland

10.2.1.1

History

“The Federal Government, as the largest employer in the world, can and should show the way towards achieving drug-free workplaces through a program designed to offer drug users a helping hand.” These words are part of President Reagan’s Executive Order (EO) Number 12564,1 issued September 15, 1986, which served to launch the Federal Drug-Free Workplace Program. This EO authorized the Secretary of Health and Human Services (HHS) to promulgate scientific and technical guidelines for drug testing programs, and required agencies to conduct their drug testing programs in accordance with these guidelines once promulgated. This Federal Drug-Free Workplace Program covers approximately 1.8 million federal employees. Of this total number, approximately 400,000 federal employees and job applicants work in health- and safety-sensitive positions identified as Testing Designated Positions, and are subject to urine drug testing. The Supplemental Appropriations Act of 1987 (Public Law 100-71, Section 503) outlined the general provisions for drug testing programs within the federal sector, and directed the Secretary of the Department of Health and Human Services (DHHS) to set comprehensive standards for all aspects of laboratory drug testing. The authority to develop and promulgate these standards was delegated to the National Institute on Drug Abuse (NIDA), an institute within the Alcohol, Drug Abuse and Mental Health Administration (ADAMHA). Following the ADAMHA Reorganization Act (Public Law No. 102–321) in 1992, the authority for this oversight now resides within the Center for Substance Abuse Prevention (CSAP), Substance Abuse and Mental Health Services Administration (SAMHSA). The Division of Workplace Programs (DWP) in CSAP, SAMHSA, administers and directs the National Laboratory Certification Program (NLCP), which certifies laboratories to perform drug testing in accordance with the “Mandatory Guidelines for Federal Workplace Drug Testing Programs” (Guidelines). These Guidelines were first published by the Secretary of HHS in the Federal Register on April 11, 1988,2 and were revised and published in the Federal Register on June 9, 19943 and again on November 13, 1998.4 Another revision was recently published in the Federal Register on April 13, 2004, and now includes specific urine specimen validity testing (SVT) requirements.5 The intent of these Guidelines is to ensure the accuracy, reliability, and forensic supportability of drug and SVT results as well as protect the privacy of individuals (federal employees) who are tested. Subpart B of these Guidelines sets scientific and technical requirements for drug testing and forms the framework for the NLCP. Subpart C focuses on specific laboratory requirements and certification of laboratories engaged in drug testing for federal agencies. The Guidelines cover requirements in many aspects of analytical testing, standard operating procedures, quality assurance, and personnel qualifications. Requirements for a comprehensive drug-free workplace model outlined in the Guidelines1–5 include: 1. A policy that clearly defines the prohibition against illegal drug use and its consequences 2. Employee education about the dangers of drug use


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3. Supervisor training concerning their responsibilities in a Drug-Free Workplace Program 4. A helping hand in the form of an Employee Assistance Program for employees who have a drug problem 5. Provisions for identifying employees who are illegal drug users, including drug testing on a controlled and carefully monitored basis

Several different types of drug testing are performed under federal authority. These include job applicant, accident/unsafe practice, reasonable suspicion, follow-up to treatment, random, and voluntary testing. Under separate authority and public law, the U.S. Departments of Transportation (DOT) also conducts a similar Drug-Free Workplace Program that applies to more than 250,000 regulated industry employers who employ more than 12 million workers. The Nuclear Regulatory Commission conducts a similar Drug-Free Workplace Program that applies to about 104,000 employees working for its licensees. Both of these programs require that any drug testing performed as part of these Drug-Free Workplace Programs be conducted in a laboratory certified by the U.S. DHHS to perform testing in accordance with the scientific and technical requirements in the Guidelines. In December 1988, the first ten laboratories were certified by DHHS through the NLCP to perform urine drug testing in accordance with the requirements specified in the Guidelines. As of July 2005, there are 49 certified laboratories in the NLCP. The largest number of laboratories certified at any one time was 91 in 1993. Even though there are fewer NLCP-certified laboratories today, the testing capability of the laboratories overall has greatly increased. This reflects the evolution of the business of drug testing, which includes laboratory chains and individual largescale laboratories that can consistently and accurately test more than 10,000 specimens/day in accordance with the requirements of the mandatory Guidelines. In 2004, more than 6.5 million specimens were tested under federal requirements. 10.2.1.2

Specimen Collection

It is important to ensure the integrity, security, and proper identification of a donor’s urine specimen. The donor’s specimen is normally collected in the privacy of a bathroom stall or other partitioned area. Occasionally, a donor may try to avoid detection of drug use by tampering with, adulterating, or substituting their urine specimen. Precautions taken during the collection process include, but are not limited to the following: 1. Placing a bluing (dye) agent in the toilet bowl to deter specimen dilution with toilet bowl water 2. Requiring photo identification of the donor to prevent another individual from providing the specimen 3. Requiring the donor to empty his or her pockets and display the items to the collector 4. Requiring the donor to wash his or her hands prior to the collection 5. Collector remaining close to the donor to deter tampering, adulterating, or substituting by the donor 6. Taking the temperature of the specimen within 4 min of collection

A label that is made of tamper-evident material is used to seal the specimen bottle, and a standardized Federal Custody and Control Form (CCF) is used to identify the individuals who handled the specimen, for what purpose, and when they had possession of the specimen. The entire collection process must be able to withstand the closest scrutiny and challenges to its integrity, especially if a specimen is reported positive for a drug or metabolite, substituted, adulterated, or invalid. To ensure uniformity among all federal agency and federally regulated workplace drug testing programs, the use of an OMB-approved federal CCF is required. Based on the experiences of using the current federal CCF for the past several years, SAMHSA and DOT initiated a joint effort to develop a new federal CCF that was easier to use and that more accurately reflected both the


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collection process and how results were reported by the drug testing laboratories. The federal CCF is a five-page carbonless document, with copies distributed to all parties involved in specimen collection, testing, and reporting. Copy 1 is the Laboratory Copy and accompanies the specimen(s) to the testing laboratory; Copy 2 is the Medical Review Officer (MRO) Copy and is sent directly to the MRO; Copy 3 is the Collector Copy and is retained by the specimen collector for a period of time; Copy 4 is the Employer Copy and is sent to the Agency representative; Copy 5 is given to the donor when the collection is completed. An image of Copy 1 is shown in Figure 10.2.1. The entire form, including instructions, may be viewed at http://workplace.samhsa.gov. Briefly, the Instruction for Completing the Federal Drug Testing Custody and Control Form is as follows: A. The collector ensures that the name and address of the drug testing laboratory appear on the top of the CCF and the Specimen I.D. number on the top of the CCF matches the Specimen I.D. number on the labels/seals. B. The collector provides the required information in STEP 1 on the CCF. The collector provides a remark in STEP 2 if the donor refuses to provide his/her SSN or Employee I.D. number. C. The collector gives a collection container to the donor for providing a specimen. D. After the donor gives the specimen to the collector, the collector checks the temperature of specimen within 4 minutes and marks the appropriate temperature box in STEP 2 on the CCF. The collector provides a remark if the temperature is outside the acceptable range. E. The collector checks the split or single specimen collection box. If no specimen is collected, that box is checked and a remark is provided. If it is an observed collection, that box is checked and a remark is provided. If no specimen is collected, Copy 1 is discarded and the remaining copies are distributed as required. F. The donor watches the collector pouring the specimen from the collection container into the specimen bottle(s), placing the cap(s) on the specimen bottle(s), and affixing the label(s)/seal(s) on the specimen bottle(s). G. The collector dates the specimen bottle label(s) after they are placed on the specimen bottle(s). H. Donor initials the specimen bottle label(s) after the label(s) have been placed on the specimen bottle(s). I. The collector turns to Copy 2 (MRO Copy) and instructs the donor to read the certification statement in STEP 5 and to sign, print name, date, provide phone numbers, and date of birth after reading the certification statement. If the donor refuses to sign the certification statement, the collector provides a remark in STEP 2 on Copy 1. J. The collector completes STEP 4 (i.e., provides signature, printed name, date, time of collection, and name of delivery service), immediately places the sealed specimen bottle(s) and Copy 1 of the CCF in a leak-proof plastic bag, releases specimen package to the delivery service, and distributes the other copies as required.

DWP publishes a Urine Specimen Collection Handbook for Federal Agency Workplace Drug Testing Programs, available at http://workplace.samhsa.gov, which provides additional guidance to those who will be collecting federal employee urine specimens in accordance with the Guidelines.6 10.2.1.3

Specimen Testing

The procedures described in the Guidelines include, but are not limited to, collecting a urine specimen, transporting specimens to the laboratories, drug and validity testing of the specimen, evaluating test results by qualified personnel, specifying quality control measures within the labo-


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Figure 10.2.1 Copy 1 of federal CCF.

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ratory, specifying record keeping and reporting of laboratory results to an MRO, and standards for certification of drug testing laboratories by SAMHSA. The cornerstone of the analytical testing requirements specified in the Guidelines is the “twotest” concept: (1) an initial test is performed for each class of drugs tested and a drug(s) for creatinine, pH, and oxidizing adulterants; if an initial test is positive for drugs or outside defined limits for SVT, (2) a confirmatory test using a different chemical principle is performed on a different aliquot of the original specimen. Specifically, the initial test technology requires an immunoassay for drugs and colorimetric test for creatinine, pH, and oxidizing adulterants. The confirmatory testing technology requires gas chromatography/mass spectrometry (GC/MS) for drugs, and potentiometry using a pH meter, multiwavelength spectrophotometry, ion chromatography, atomic absorption spectrophotometry, inductively coupled plasma mass spectrometry, capillary electrophoresis, or GC/MS for SVT. The initial test cutoffs as published in the Guidelines5 are as follows:

Drug Class

Cutoff (ng/ml)

Marijuana metabolites Cocaine metabolites Opiate metabolites Phencyclidine Amphetamines

50 300 2000 25 1000

The confirmatory test cutoffs as published in the Guidelines5 are as follows: Drug

Cutoff (ng/ml)

Marijuana metabolitea Cocaine metaboliteb

15 150

Opiates Morphine Codeine 6-Acetylmorphinec Phencyclidine

2000 2000 10 25

Amphetamines Amphetamine Methamphetamined a

b c

d

500 500

delta-9-Tetrahydrocannabinol-9-carboxylic acid. Benzoylecgonine. 6-Acetylmorphine tested when the morphine concentration is greater than or equal to 2000 ng/ml. Specimen must also contain 200 ng/ml amphetamine.

SVT for federal employee specimens collected under the Guidelines is required as of November 1, 2004. This includes, but is not limited to, determining creatinine concentration, the specific gravity of every specimen for which the creatinine concentration is less than 20 mg/dl, pH, and performing one or more validity tests for oxidizing adulterants. A much more complete discussion of specimen testing and reporting results can be found in the Guidelines.6 As part of an overall quality assurance program, there are three levels of quality control (QC) required of each certified laboratory:


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1. Internal open and blind samples constituting 10% of the daily, routine sample workload (these are constructed by the laboratory as part of their daily testing protocols). 2. External open performance testing samples, which are distributed quarterly (these are prepared by the government under contract). 3. Double-blind QC samples, which constitute 1% of the total number of specimens submitted to the laboratory for analysis, not to exceed 100 per quarter; 80% of these samples are negative for drugs. 4. Federal agencies are required to procure and submit these samples from reputable suppliers.

10.2.1.4

Laboratory Result Reporting to and Review of Laboratory Results by an MRO

After accurate and reliable urine drug test results are completed by a SAMHSA-certified laboratory, the Guidelines require these results to be reported to an agency’s MRO. As defined in the Guidelines, the MRO is a licensed physician responsible for receiving laboratory results generated by an agency’s drug testing program who has knowledge of substance abuse disorders and who has appropriate medical training to interpret and evaluate an individual’s positive test result together with the medical records provided to the MRO by the donor, his or her medical history, and any other relevant biomedical information. The MRO must contact the donor when the donor’s specimen is reported by the laboratory as drug positive, adulterated, substituted, or invalid, and give the donor the opportunity to discuss the results prior to making a final decision to verify the test result. The donor is given the opportunity to request a retest when his or her specimen is reported as positive, substituted, or adulterated. The retest (i.e., an aliquot of the single specimen collection or Bottle B of a split specimen collection) is performed at a second certified laboratory, with specific procedures applied, depending on the results reported by the first testing laboratory. A positive test result does not automatically identify an individual as an illegal drug user. The MRO evaluates all relevant medical information provided to him or her by the donor who tested positive. If there was a legitimate, alternative medical explanation for the presence of the drug(s) in the donor’s urine, the test result is reported as negative to the employer; if there is no alternative medical explanation for the presence of drug(s) in the donor’s urine, the MRO reports the result as positive to the agency/employer. Additional instruction and guidance for evaluating adulterated, substituted, and invalid test results for federal employee specimens is provided in the MRO Manual for Federal Agency Drug Testing Programs.7 It is also necessary that negative laboratory results be reviewed by an MRO. Laboratory results for double blind performance test samples (many of which are negative) are reported to the MRO in the same manner as results for donor specimens. In this manner, negative laboratory results are evaluated as part of ongoing quality control programs initiated prior to specimen submission to the laboratory. 10.2.1.5

Laboratory Participation in the National Laboratory Certification Program

Application A laboratory applying to become part of the NLCP must complete a comprehensive application form, which reflects in detail each section of the Laboratory Information Checklist and General Laboratory Inspection Reports. Evaluation of this completed application must show that the laboratory is equipped and staffed in a manner to test specimens in compliance with the Guidelines’ requirements in order for the laboratory to proceed with the initial certification process. In essence, the Guidelines promulgate forensic drug testing standards for the evaluation of a specimen provided by a federal employee, on which critical employment decisions will be made. The processes that govern this testing are regulatory in nature, designed to ensure that this testing is accurate, reliable, and forensically supportable.


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Performance Testing As part of the initial certification process, the applicant laboratory must successfully analyze three sets of 25 samples (minimum), in a sequential order. The progress of this phase of the certification process is determined by the successful identification and quantification of analytes by the laboratory. If the first two sets of 25 samples are successfully completed, the third set of 25 samples is scheduled for receipt, accessioning, and analysis during the initial laboratory inspection site visit. As part of the maintenance certification process, each certified laboratory must successfully analyze a set of 25 samples (20 drug related and 5 SVT related) sent on a quarterly basis by the NLCP. There are five different types of samples developed by the NLCP to ensure accurate and reliable analyte identification and quantification for drugs and validity testing: 1. Routine samples, which may contain an analyte specified in the Guidelines, and are screened and confirmed in accordance with established cutoffs 2. Routine negative samples, which may contain a drug analyte specified in the Guidelines, but at a concentration less than or equal to 10% of cutoff 3. Routine plus samples, which may contain an analyte specified in the Guidelines and interfering and/or cross-reacting substances 4. Routine retest samples 5. Retest samples with interfering substances

For details on the evaluation of the performance test results, please refer directly to Section 3.18 of the April 13, 2004 Guidelines.5 Laboratory Inspection The laboratory facility must be inspected and found acceptable in accordance with the conditions stated in the Guidelines and further detailed in the Laboratory Information Checklist, General Laboratory Inspection Report, Computer Systems Report, and Records Audit Report. Inspectors are trained by the NLCP staff (SAMHSA/DWP technical staff and their contractors) in the use of the detailed NLCP Laboratory Information Checklist and Reports, and the NLCP Manual for Laboratories and Inspectors. Prior to the inspection, the laboratory is required to submit detailed information concerning its operations. This information is provided to the inspectors prior to the actual inspection. In this way, the inspectors become familiar with the laboratory operation prior to arrival. A brief description of each section completed by the laboratory follows: A. Instructions to Laboratory B. Laboratory Information — Physical aspects of the laboratory such as location, hours of operation, staffing, specimen testing throughput, and licenses C. Laboratory Procedures — Type of analytical equipment, calibration procedures, reagent kits, derivatives and ions monitored for each drug analyte, as well as similar information relating to validity testing

In addition, there are questions relating to certification and reporting of results, electronic reporting of results, as well as a description of the Laboratory Information Management System (LIMS). In the past few years, a number of significant updates have been implemented in the NLCP inspection program. These improvements were the result of a careful review of the program experience over several years and also reflected the reality of market consolidation and growth that significantly increased the number of specimens tested under the Guidelines. This workload increase made it difficult for inspectors to review sufficient non-negative test results (i.e., positive, adulterated, invalid, and substituted) during the scheduled laboratory inspection. To address this issue, the NLCP


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increased the number of inspectors and hours of inspections for some of the laboratory inspection categories. By increasing the number of inspectors, the percentage of non-negative test results reviewed by each inspection team was enhanced in the larger laboratories. The number of inspectors for Categories I and II remained unchanged. That is, a Category I inspection consisted of two inspectors (one checklist inspector and one data auditor) performing a 2-day inspection, and a Category II inspection consisted of three inspectors (one checklist inspector and two data auditors) performing a 2-day inspection. For the larger laboratories (i.e., Categories III to V) the NLCP increased the number of inspectors, and greatly enhanced the percentage of non-negative test results reviewed by the inspection teams. A Category III inspection now requires a team of four inspectors (two checklist inspectors and two data auditors, rather than the three inspectors previously inspecting this category of laboratory) conducting a 3-day inspection. A Category IV inspection has a team of five inspectors (two checklist inspectors and three data auditors) conducting a 3-day inspection. A new Category V inspection was established for laboratories with large workloads, usually testing more than 2000 regulated specimens per day. A Category V inspection has a team of nine inspectors (three checklist inspectors and six data auditors) conducting a 3-day inspection. For those laboratories that use corporate LIMS not under the direct day-to-day observation and control of the responsible persons (RPs) of the laboratories that it serves, there will be a special inspection of the LIMS at the facility where the LIMS is located. This special inspection will be a 1-day inspection using two inspectors, with one a LIMS professional. Each corporate LIMS facility will undergo this inspection regardless of the number of laboratories that it serves. This new approach began in January 2005. Historically, the NLCP has primarily focused the inspection on the procedures of the laboratory. The NLCP has now balanced that focus with an increased examination of the laboratory’s forensic product. To accomplish this, a major audit component has been incorporated into NLCP inspections. To facilitate these audits, HHS requires each laboratory to submit a list to the NLCP staff of the non-negative (i.e., drug positive, adulterated, invalid, substituted, and rejected for testing) primary specimens and split specimens reported for a 6-month period prior to an inspection. Specific guidance on the format and information to be included on the list is provided to the laboratories. For each of the following specimen categories, the laboratory must submit a separate spreadsheet in a workbook to the NLCP: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Positive for delta-9-tetrahydrocannabinol-9-carboxylic acid Positive for benzoylecgonine Positive for opiates (morphine, codeine, and/or 6-acetylmorphine) Positive for amphetamines (amphetamine and/or methamphetamine and d-methamphetamine if performed) Positive for phencyclidine Adulterated Invalid test Substituted Rejected for testing

NLCP technical staff direct the laboratory to make available all the batch data and documentation for a selected number of those non-negative and split specimen test results to facilitate review by the inspectors. A specific number of non-negative specimens (NNS) are identified for in-depth review consisting of all analytical test records and chain of custody documentation. The number of NNSs selected for this in-depth information review is determined by the category of the laboratory and is as follows: 40 for Category I, 120 for Category II, 200 for Category III, 310 for Category IV, and 650 for Category V laboratories. Additionally, the same in-depth information review for 40 PT samples is conducted at each laboratory regardless of category. As a key part of updating the NLCP laboratory inspection system, the inspector cadre was reviewed with the goal of using a smaller core group of inspectors, each of whom has committed


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to participating in multiple inspections per year. This has significantly enhanced the consistency and uniformity in the NLCP inspection process. NLCP inspectors now are required to perform at least two to three inspections per year, to document active participation in forensic toxicology/workplace drug testing/regulated drug testing, and to attend mandatory NLCP inspector training on an annual basis. The document previously known as the Laboratory Inspection Checklist was reorganized into two documents, from which two reports are generated by the inspection team. These two reports are the General Laboratory Inspection Report and the Records Audit Report. There were also some significant changes in the roles and configurations of NLCP inspection teams that represent the combined observations of the individual team members. Although each inspector does not complete a separate checklist, all team members tour the laboratory and participate in documenting/verifying any checklist deficiencies. Inspectors assigned to the roles of “Lead Inspector” and “Inspector” use the General Laboratory Inspection Report to inspect the laboratory’s current standard operating procedures (SOP) and forensic operations and may aid in the review of the NLCP PT records, and method validation. The Lead Inspector has the responsibility to finalize and submit the team’s summary General Laboratory Inspection Report to RTI, Research Triangle Park, NC, the contractor currently handling the technical and logistical aspects of the National Laboratory Certification Program for SAMHSA/HHS. Inspectors assigned to the roles of “Lead Auditor” and “Auditor” use the Data Audit Inspection Report and review a number of non-negative test results (i.e., positive, adulterated, invalid, and substituted), NLCP PT records, and method validation records. The Lead Auditor has the responsibility to finalize and submit the team’s summary Data Audit Inspection Report and NNS Review List to the NLCP. The checklist inspector(s) review and document all aspects of forensic urine drug testing processes and procedures at that laboratory for program review and evaluation for compliance with the minimum standards of the Guidelines. The lead checklist inspector prepares a summary report reflecting the 12 sections of the inspection checklist and one section of the Computer System checklist reviewed during their site visit along with an Inspection Evaluation Summary. A brief description of each section follows: D. Chain of Custody — Assesses laboratory practices to verify specimen identity, maintain specimen integrity, secure specimens, and maintain chain of custody during specimen receiving/accessioning, aliquoting, initial drug testing, SVT, confirmation testing, and specimen and aliquot disposal E. Accessioning — Assesses laboratory practices to accept or reject specimens, evaluate specimen integrity, handle split specimens, maintain specimen integrity F. Security — Assesses laboratory practices to control and document specimen and record access G. Quality Control Materials and Reagents — Assess laboratory practices to prepare or procure and verify drug or SVT QC samples, properly identify them, and establish acceptable performance limits H. Quality Assurance: Review of QC Results — Assess laboratory practices to review control results so as to detect assay problems I. Equipment and Maintenance — Assess laboratory practices for checking and maintaining all laboratory equipment J. Specimen Validity Tests — Assess laboratory practices for handling of aliquots of specimens during validity testing, performing initial and confirmatory testing as required (at a minimum a test for creatinine, pH, and oxidizing adulterant on all specimens), applying appropriate cutoffs, analyzing appropriate QC samples for both initial and confirmatory testing as required K. Initial Drug Tests — Assess laboratory practices to analyze specimens with specific immunoassay methods and analyze appropriate QC samples L. Confirmatory Drug Tests — Assess laboratory practices to analyze specimens with appropriate GC/MS procedures and analyze appropriate QC samples M. Certification and Reporting — Assess laboratory practices to report negative and non-negative results to the MRO with both the federal CCF, and electronically if so desired


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N. Standard Operating Procedures, Procedures Manual — Assess laboratory procedure manual for content, comprehensiveness, agreement with day-to-day observed operations of the laboratory, determine availability to staff as a routine reference, and any modifications made to reflect changes in current practice in the laboratory O. Personnel — Assess qualifications of the RP, scientists who certify the accuracy and reliability of results, and supervisory staff; assesses staffing adequacy of these personnel in relationship to the number of specimens analyzed P. Laboratory Computer Systems — Assess laboratory policies and procedures for the validation and security of the LIM system, the handling of electronic records and reports, the ability to provide audit trails, monitoring the LIM system, and responding to incidents and providing disaster recovery, as well as documenting the qualifications of the LIMS personnel

The auditor(s) extensively review the laboratory’s chain of custody documentation, analytical data, and reported results for non-negative specimens (i.e., positive, adulterated, substituted, invalid, rejected for testing) reported in the defined 6-month period (1 month prior to the last inspection to 1 month prior to the current inspection). The lead auditor prepares a summary report reflecting the four sections of the records audit report along with an Inspection Evaluation Summary and Summary of Issues. A brief description of each section follows: R. Specimen Records — Review and evaluate specimen records for completion of chain of custody documents, for identity of specimens, calibrators and controls, for the individuals performing and reviewing the testing, evidence that the certifying scientists who reported the results to the MROs reviewed all appropriate information S. Method Validation, Periodic Re-Verification — Review and evaluate revised test methods, and both SVT and confirmatory drug assays for periodic re-verification for levels of detection, linearity, and specificity T. NLCP Performance Test Records — Review and evaluate the NLCP PT records to determine if they support the reported results and if all remediation to PT errors was taken and acceptable U. Reports — Review and evaluate non-negative specimen reports, both hard copy and electronic, to determine if they are in accordance with NLCP guidance

The laboratory’s first (initial) inspection is performed by two NLCP-trained inspectors. Prior to their arrival at the laboratory site, the inspectors are provided copies of the information supplied by the laboratory concerning its operations, its standard operating procedures, and its testing procedures. The inspectors complete sections of the checklist similar to those completed by the inspection team for a maintenance inspection and submit the completed document to the NLCP. A summary, or critique, is prepared from the report by an individual independent of that laboratory’s inspection. The items in the critique are then evaluated for compliance with the minimum requirements of the Guidelines. It is necessary that a laboratory’s operation be consistent with good forensic laboratory practice. Once all requirements are met, the laboratory is certified by the Secretary, DHHS, as being able to perform drug testing of federal employees’ specimens in compliance with the Guidelines. A letter is sent to the laboratory conveying its certification in the NLCP. Then, 3 months after its initial certification, the laboratory is again inspected, with a broadened focus, now evaluating both practice and the results reported by the laboratory. A critique developed from the individual checklist and audit reports is developed by an individual independent of that laboratory’s inspection. The issues in the critique are then evaluated for compliance with the minimum requirements of the Guidelines. It is necessary that a laboratory’s operation be consistent with good forensic laboratory practice. If all requirements are met or there are minor easily correctable deficiencies, the inspection critique is sent to the laboratory. A cover letter may also be included, which outlines issues that must be addressed within a defined timeframe. After successful completion of this inspection, a 6-month cycle of site inspections begins. The number of inspectors sent to the laboratory for an inspection depends on the resources necessary to adequately evaluate the laboratory’s operation. These resources are allocated based on the


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laboratory’s personnel involved in accessioning and certification, the number of specimens performed under the laboratory’s certification, and the number of non-negative specimens reported by the laboratory. During the maintenance phase of a laboratory’s certification, if all requirements are met or there are minor easily correctable deficiencies, the inspection critique is sent to the laboratory. A cover letter may also be included, which outlines issues that must be addressed within a defined time frame. A laboratory continues its certified status as long as its operation is in compliance with the Guidelines and consistent with good forensic laboratory practice. Since participation in the NLCP is a business decision on the part of a laboratory and is voluntary, a laboratory may choose to withdraw from the NLCP. Upon such voluntary withdrawal from the NLCP, a laboratory must inform its clients that it is no longer certified in the NLCP and cease to advertise itself as an NLCPcertified laboratory. Suspension of Certification If significant deficiencies in the laboratory’s procedures are found, an evaluation of these deficiencies is performed by the NLCP, the program staff in the DWP, and the Office of the General Counsel. A report is prepared for the Director, DWP. If it is determined that there is imminent harm to the government and its employees, action may be taken by the Secretary to immediately suspend the laboratory’s certification to perform drug testing of federal, federally regulated, and private sector specimens tested in accordance with the Guidelines. The period and terms of suspension depend on the facts and circumstances of the suspension and the need to ensure accurate and reliable drug testing of federal employees. Revocation of Certification Several factors may be considered by the Secretary in determining whether revocation is necessary. Among these are (1) unsatisfactory performance of employee drug testing, (2) unsatisfactory results of performance testing and/or laboratory inspections, (3) federal drug testing contract violations, (4) conviction for any criminal offense committed incident to operation of the laboratory, and (5) other causes that affect the accuracy and reliability of drug test results from that laboratory. 10.2.1.6

Conclusion

Illicit drug use and abuse continues to affect safety and security in the American workplace. Data from the 1995 National Household Survey on Drug Abuse8 reveal that there were 12.8 million current (or past month) users of illicit drugs. Since that time, there has been an increase in drug use and abuse. In 2003, the last year for which this report is available,9 the number of individuals, 12 or older, indicating current drug use was 19.4 million individuals. Tragic events serve as examples of how drug abuse in the workplace can affect society and cause long-term environmental and economic consequences. Examples of such tragedies where substance abuse in the workplace was responsible for death and destruction include the 1986 railroad accident in Chase, MD, the 1991 subway accident in New York City, and the 1989 environmental disaster in Prince William Sound, AK, caused by the grounding of the Exxon Valdez oil tanker.

REFERENCES 1. Executive Order 12564, Drug-Free Federal Workplace, Federal Register, 51(180), 32889–32893, September 15, 1986, available at http://workplace.samhsa.gov.


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2. Mandatory Guidelines for Federal Workplace Drug-Testing Programs, Federal Register, 53(69), 11970–11989, April 11, 1988, available at http://workplace.samhsa.gov. 3. Mandatory Guidelines for Federal Workplace Drug-Testing Programs, Federal Register, 59(110), 29908–29931, June 9, 1994, available at http://workplace.samhsa.gov. 4. Mandatory Guidelines for Federal Workplace Drug-Testing Programs, Federal Register, 63(219), 63483–63484, November 14, 1998, available at http://workplace.samhsa.gov. 5. Mandatory Guidelines and Proposed Revisions to Mandatory Guidelines for Federal Workplace DrugTesting Programs, Federal Register, 69(71), 19644–19673, April 13, 2004, available at http://workplace.samhsa.gov. 6. Urine Specimen Collection Handbook for Federal Workplace Drug Testing Programs, Division of Workplace Programs, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, available at http://workplace.samhsa.gov. 7. Medical Review Officer Manual for Federal Employee Drug Testing Programs, Division of Workplace Programs, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services, available at http://workplace.samhsa.gov. 8. National Household Survey on Drug Abuse: Main Findings 1995, Office of Applied Studies, Substance Abuse and Mental Health Services Administration, DHHS Publication Number (SMA) 97-3127, 1997, available at http://www.oas.samhsa.gov. 9. National Survey on Drug Use and Health: Main Findings 2003, Office of Applied Studies, Substance Abuse and Mental Health Services Administration, DHHS Publication Number (SMA) 04-3964, 2004, available at http://www.oas.samhsa.gov.

10.2.2 The Department of Transportation’s Workplace Testing Program

Kenneth C. Edgell, M.S. Past Director (2001–2004), Office of Drug and Alcohol Policy and Compliance, U.S. Department of Transportation, Washington, D.C.

The Department of Transportation (DOT) oversees the largest drug- and alcohol-testing program in the country. The DOT rules affect more than 12 million transportation employees across the U.S. The program also has international impact in that all motor carriers and some railroad workers whose work brings them into the U.S., either from Canada or Mexico, are subject to the same testing requirements as their American counterparts. The overall responsibility for management and coordination of the DOT program resides with the Office of the Secretary of Transportation (OST), an Executive Cabinet position appointed by the president. Compliance and enforcement within the different transportation industries are the responsibility of the DOT agency that has regulatory authority over the particular industry. Those DOT agencies are the Federal Aviation Administration (FAA), Federal Motor Carrier Safety Administration (FMCSA), Federal Railroad Administration (FRA), Federal Transit Administration (FTA), and Pipeline and Hazardous Materials Safety Administration (PHMSA). Safety has been the highest priority for the Secretary of Transportation since Congress established the department in 1966. One of the means used by the Secretary to ensure DOT maintains the highest degree of safety possible is to subject transportation workers to drug and alcohol testing. The workers who are tested have direct impact on the safety of the traveling public or the safety of those potentially affected by the transportation of hazardous products, such as gas and oil pipeline operations. Any worker, who has a positive test, or other drug and alcohol violation, becomes ineligible to continue performing the duties of his or her safety job. In order for the individual to return to a safety job in transportation, that person must satisfactorily complete certain DOT returnto-duty requirements.


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Since the outset of the DOT program, there have been a number of legal challenges from those who oppose drug testing. However, because safety is its sole reason for existing, court decisions have allowed the testing to continue without any major setbacks. The Supreme Court, in fact, found a compelling government need “in an industry that is regulated pervasively to ensure safety.”1 So, the program continues. As might be expected, most states that have developed statutes regarding nonregulated testing have referred to the DOT program as the standard of practice they would also follow. 10.2.2.1

Background

The Department of Transportation drug and alcohol testing rules were an outgrowth of a highly visible and tragic transportation accident that occurred in 1987. The investigation of the accident revealed that employees in safety jobs, regulated by DOT (in this case train crew members), admitted using marijuana and alcohol prior to the accident. In response to the findings of the accident investigation, Senators Earnest Hollings (D-SC) and John Danforth (R-MO) sponsored legislation requiring drug and alcohol testing in the rail, aviation, and trucking industries. DOT, feeling the obvious impact of the accident and the duty to respond to the public, did not wait for the passage of the bill, but instead implemented drug testing under its own authority in 1989. The action of DOT appeared to have been insightful in the years to follow. In August 1991, another deadly transportation accident occurred. Barely 2 months later, the Hollings-Danforth bill, which had been stymied in Congress for more than 4 years, was passed and signed into law by then-President George H.W. Bush. That legislation, cited as the “Omnibus Transportation Employee Testing Act of 1991” (OTETA),2 required drug and alcohol testing of employees occupying safety-sensitive jobs in the transportation industries of aviation, trucking, railroads, and mass transit “in the interests of safety.” While the gas and oil pipeline industry and the U.S. Coast Guard’s (USCG) maritime industry were not mentioned in OTETA, testing within those industries also began, and continues, under the authority granted to DOT as a government agency with regulatory responsibility. Like most laws, OTETA provided a general overview of what Congress expected to occur. It provided high-level instructions on who would be tested and for what reasons, how the tests would be conducted, and what would happen if and when someone tested positive. With that basic guidance, the statute put the burden of prescribing the remainder of the detail (i.e., the regulations) on the Secretary of Transportation. To fully meet the requirements of OTETA — and develop regulations that were as consistent as possible across all of DOT — the Secretary established the Office of Drug and Alcohol Policy and Compliance (ODAPC) to manage the development effort for workplace drug and alcohol testing. ODAPC is a “small” office (staffing has never exceeded more than ten people) whose mission is to ensure that the drug and alcohol testing policies and goals of the Secretary are developed and carried out in a consistent, efficient, and effective manner within the transportation industries for the ultimate safety and protection of the traveling public. This is accomplished through program review, compliance evaluation, and the issuance of consistent guidance material for DOT Operating Administrations (OAs) and for their regulated industries. The director of ODAPC is a “political appointee,” in that as the administration changes, the director changes; the staff are career employees. Information about this office, along with the most current updates of program documents, can be found at the ODAPC Web site: www.dot.gov/ost/dapc/. 49 CFR Part 40, the “Procedures for Transportation Workplace Drug and Alcohol Testing Programs,”3 was developed by ODAPC. With this document, DOT set the standard by which all of its required drug and alcohol testing would be conducted. Such a standard assures that whether the employee is an airline pilot, truck driver, or railroad engineer, their drug and alcohol tests are conducted and reviewed using the same procedures. This regulation also sets the criteria that must be met before a person can return to safety-sensitive work after a drug or alcohol violation. Better


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Table 10.2.1

Number of Federally Regulated Employers and Employees Subject to Testing

Industry

Government Agency

Aviation Highway Railroad Transit Pipeline Maritime Totals

FAA FMCSA FRA FTA PHMSA USCG5

No. Employers

No. Employees

7,200 650,000 650 2,600 2,450 12,000 674,900

525,000 10,941,000 97,000 250,000 190,000 132,000 12,135,000

known simply as “Part 40,” this regulation, or rule (the terms are used interchangeably) has become the standard for drug and alcohol testing in the workplaces across the U.S. ODAPC is responsible for providing any authoritative interpretations, if and when they are necessary, on Part 40. In 1994, also in response to OTETA, six agencies (or “modes,” as they are known) within DOT also published testing regulations.4 These regulations covered who would be subject to drug and alcohol tests, when and why those tests would occur, and what responsibilities the transportation employers would bear in ensuring that the program was implemented properly. By the end of calendar year 2005, the scope of DOT testing covered approximately 12.1 million transportation workers (Table 10.2.1). It is estimated that out of this total population about 7,000,000 drug tests are conducted each year under DOT authority. This figure represents approximately 20% of the drug tests conducted in this country on an annual basis. The remaining 80% of the testing falls under “non-regulated” status, where companies of their own volition, not due to any government mandate, conduct tests. The number of alcohol tests conducted each year under DOT authority is far less than the number of drug tests; this number could be as little as 1,000,000 tests per year. 10.2.2.2

DOT Relationship with Health and Human Services

DOT drug testing follows the guidelines established by the Department of Health and Human Services (HHS). HHS was tasked6 during, the Reagan Administration’s “War on Drugs,” to develop standards for conducting drug tests on federal employees who occupied positions of a safety- or security-related nature. Ultimately, HHS determined which drugs to test for and how laboratories should conduct the tests, including what cutoffs to use. HHS also established specific standards for certifying the laboratories to conduct drug tests for federal agencies. This material is published in an oddly titled regulation called the “Mandatory Guidelines.”7 More detail on the content of the HHS Guidelines can be found in elsewhere in this volume (see Section 10.2.1). OTETA required DOT to “develop requirements that, for laboratories and testing procedures for controlled substances, incorporate the Department Health and Human Services scientific and technical guidelines dated April 11, 1988, and any amendments to those guidelines, including mandatory guidelines.” With that direction, DOT has taken most of the testing requirements contained in the HHS Guidelines, either by reference or by actually repeating the language, and incorporated them into Part 40 for those entities subject to DOT rules. This approach may seem a little repetitious, but it does allow those having to implement the programs not to have to maintain proficiency with two sets of drug testing rules issued by two government agencies. The DOT drug-testing program is a laboratory-based urine-testing program, exclusively. While much ado was made of an “alternative specimen” proposal issued by HHS in 2004, which proposed allowing federal agencies to collect and test specimens other than urine (i.e., hair, oral fluid, and sweat), those specimens are not allowed for use under the DOT rules. Neither is any sort of “onsite” test. In fact, the HHS proposal does not apply to DOT.


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For the record: Regardless of what conclusion HHS comes to with respect to “alternative specimens,” the DOT drug test program will not change until DOT issues a change to its rule — 49 CFR Part 40. Changing any government rule takes time and includes a public notice that seeks public comment. Prior to issuing a final rule, DOT will publish a Notice of Proposed Rulemaking (NPRM). (The NPRM is the document that will solicit public comment.) Complicated rulemaking, which would be the case if additional specimens were required for use by the DOT program, could take several years to finalize. Bottom line: Any utilization of alternative specimens in DOT drug testing is uncertain at this time. It may be an appropriate subject for a future edition of this text. The remainder of this section provides a general summary of Part 40. For further understanding or more detailed information on a particular subject, especially for the purposes of trying to implement a DOT program, the reader should obtain a copy of the rule. It is written in what the government refers to as “plain language,” rather than gobbledygook, a style of writing more reminiscent of past federal offerings. The regulation is divided into functional sections and, while somewhat lengthy, is fairly easy to follow and understand. 10.2.2.3

Program Responsibility

The responsibility to assure that drug and alcohol testing is carried out according to the requirements of DOT lies with the transportation employers. Sometimes referred to as an “unfunded mandate,” the U.S. Congress, through the OTETA statute, mandated drug and alcohol testing for certain transportation industries, and instructed the Secretary of Transportation to develop the rules under which each industry must abide. However, neither DOT nor any of its agencies provides funding to transportation employers to offset any of the program costs. The DOT rules instruct transportation employers to implement this very comprehensive program and then hold the employers responsible for compliance. Employers are expected to absorb the costs; the benefit is a safer workplace. Transportation employers are free to contract out any portion of the drug and alcohol testing program functions; however, employers cannot outsource their compliance responsibilities. Service agents is the term given to those who contract directly or indirectly with employers to accomplish the tasks set forth in DOT rules. Service agents include collectors, laboratories, medical review officers (MROs), breath alcohol technicians, consortia/third party administrators, and substance abuse professionals. 10.2.2.4

Safety-Sensitive Employees

OTETA required each DOT administration to specify those under its regulatory purview who are subject to testing. These individuals occupy positions known as “covered functions,” or, more universally, as “safety-sensitive” positions (Table 10.2.2). A person who occupies a safety-sensitive job and performs its functions, whether on a full-time, part-time, or intermittent basis, is subject to testing. Table 10.2.2

Government Agencies and Safety-Sensitive Job Positions

Industry (Mode) Aviation (FAA)

Highways (FMCSA) Railroads (FRA) Mass Transit (FTA) Oil and Gas Pipeline (PHMSA) Maritime (USCG)

Safety-Sensitive Job Positions Flight crew members, flight attendants, flight instructors, air traffic controllers, aircraft dispatchers, maintenance personnel, and screening and ground security coordinator personnel Commercial motor vehicle operators Hours-of-service employees (engine, train and signal services, dispatchers, and operators) Vehicle operators, dispatchers, mechanics, and safety personnel (carrying firearms) Pipeline operations and maintenance personnel, and emergency response personnel Maritime crew members (operating a commercial vessel)


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Reasons for Testing

The DOT drug-testing program is a deterrence-based program, testing for prohibited use of illegal drugs regardless of when the employee might use the drugs. The DOT alcohol-testing program is more a fitness-for-duty program; testing for prohibited use of a legal substance in and around the time a person is working. Drug tests may be conducted at any time the employee is at work, while alcohol tests are only conducted prior to, during, or just after the performance of safetysensitive functions. OTETA requires DOT to have specific categories of testing, or “reasons for test.” There are six testing categories: pre-employment, post-accident, random, reasonable suspicion, return-to-duty, and follow-up. Pre-employment tests may be conducted before an applicant is hired or after an offer to hire. These tests must be conducted prior to the actual first-time performance of the individual’s safetysensitive functions. Pre-employment tests are also required when employees transfer to a safetysensitive position from a non-safety-sensitive position within the same company. All DOT modes require new employees to take (and pass) a pre-employment drug test before they begin work. Preemployment alcohol tests are authorized, but not mandated by all modes. DOT leaves the decision to conduct pre-employment alcohol tests to each individual transportation employer. Post-accident testing is conducted after qualifying accidents or where the performance of the employee could have contributed to the accident. Each administration determines what “qualifying” means, with respect to an accident within its particular industry. Obviously, aviation accidents are drastically different from highway accidents. Referencing the rule that corresponds to one of the six administrations would be necessary to determine the criteria for a qualifying accident and subsequent requirements for testing. Contributing to an accident could be seen, for example, in a citation given to a driver by law enforcement after a moving traffic violation. All modes do require that post-accident alcohol tests be conducted within 8 h, and post-accident drug tests be conducted within 32 h of the occurrence of the accident. Random tests are conducted on a random, unannounced basis. Random testing rates are established in a consistent manner at the beginning of each year, but can be different from mode to mode. Each administration sets the annual random testing rate, one for drugs and one for alcohol, based on the industry’s respective random positive rate for the previous year. There are two possible annual rates for random drug testing — 25 or 50%; random alcohol testing has three possible rates of testing — 10, 25, and 50%. If an industry has a random drug-positive rate of 1% or less for 2 consecutive years, the administrator may reduce the random testing rate to 25% per year for that industry. If the random positive rate is greater than 1% for any year, the random testing rate must move back to 50% per year. Like random drug testing, a random alcohol testing rate is calculated for each industry based on that industry’s positive rate for the past 1 to 2 years. If the industry’s positive rate is less than 0.5% for 2 consecutive years, the modal administrator can set the resulting alcohol testing rate at 10%. Between 0.5 and 1% for 2 consecutive years, the administrator can set the rate at 25%. When the industry positive rate goes above 1%, the random testing rate is set at 50%. A mode must hold a random positive rate within the above ranges for 2 consecutive years in order for the testing rate to be reduced; a 1-year increase returns the industry to the next higher testing rate. Employees in the pipeline industry, under PHMSA, and employees in the maritime industry, under USCG, are not subject to random alcohol testing. The best explanation for this difference is that neither industry was mentioned in OTETA. Reasonable suspicion testing is conducted when a supervisor, previously trained in the signs and symptoms of drug abuse and alcohol misuse, observes behavior or appearance that is characteristic of drug or alcohol abuse of the employee. The test must be based on observations that are specific, contemporaneous, and articulable. A rumor of “a big party” over the weekend is not reason enough to conduct a reasonable suspicion test.


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Return-to-duty and follow-up testing is conducted when an individual, who has a drug or alcohol violation (e.g., positive test), returns to the workplace to resume his or her safety-sensitive work. Initially, a return-to-duty test is given. After passing the return-to-duty test, the employee is eligible to return to safety work. Upon returning to work, the person will be placed back in the company’s random testing pool. At the same time, the person must also be subject to unannounced follow-up testing to be conducted at least six times within the first 12 months of returning to work. 10.2.2.6

Consequences of a Drug or Alcohol Violation

All workers committing a violation of the DOT drug or alcohol rules must be removed immediately from their safety-sensitive job and are ineligible to return until they satisfactorily complete the DOT return-to-duty requirements. A DOT drug or alcohol violation includes: • • • •

Alcohol tests with a result of 0.04 or higher alcohol concentration Verified positive drug tests Refusals to be tested (including verified adulterated or substituted drug test results) Other violations of DOT agency drug and alcohol testing regulations (such as, using or possessing alcohol or illicit drugs while on duty, or using alcohol within 4 h–8 h for flight crews and flight attendants — of reporting for duty, or using alcohol within 8 h after an accident or prior to a postaccident test being conducted, whichever comes first)

10.2.2.7

Specimen Collections

DOT has established a specific set of procedures for collecting a urine specimen. Precautions are built into the process to help ensure the control and integrity of the collection. The detail that DOT has devoted to collecting the specimen will serve to minimize the collection errors and maximize the probability that the employer will be able to rely on the test result, regardless of its outcome. DOT has built the model system, but it is the individual diligence of each collector upon which that system relies. Obviously, a problem occurring during the collection has the potential to “ripple” and affect the test outcome. A DOT urine specimen must be collected using a standard collection kit, documented with a standard form, and conducted by a trained collector. All DOT specimens are collected as “split specimens.” The standard kit consists of a single-use collection container that has an attached temperature strip for reading the urine temperature, two sealable plastic bottles for the “split specimens,” a leak-resistant plastic bag with two separate pouches (one for the bottles and the other for the collection paperwork), absorbent material, and a shipping container to protect the specimen during transit to the laboratory (Figure 10.2.2). The standard form for all DOT collections is the Federal Drug Testing Custody and Control Form, or CCF. The CCF is a five-part form. DOT requires the same form for collections as is used within the federal program, under the purview of HHS. Figure 10.2.1 in the previous section presents an illustration of the CCF. The collector is the person who is in charge of and assists with the collection and has been trained under the provisions of DOT’s Part 40 and the DOT Urine Specimen Collection Guidelines,8 written by ODAPC. Collectors need to be trained prior to collecting their first specimen. All DOT collections allow the donor to provide the specimen in the privacy of a bathroom stall unless there is a suspicion of tampering, on the part of the donor, or preexisting conditions allow an exception (i.e., return-to-duty and follow-up). The exception would be to conduct the collection under direct-observation procedures, whereby a same-sex collector watches the specimen flow directly from the donor’s body and into the collection cup. DOT has broken down the specimen collection procedure into some 23 different steps in the Collection Guidelines. In general, the donor will present for a urine collection and provide the


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Figure 10.2.2 Example of DOT Standard Urine Collection Kit.

collector with a form of identification that includes a picture ID. The collector will briefly explain the collection process to the donor emphasizing that, once the collection begins, the donor cannot leave the collection site until excused by the collector. DOT directs collectors to obtain a minimum of 45 ml of urine in one single void; 30 ml is for the primary specimen and 15 ml is for the “split” specimen. Generally collections take less than 15 min to complete. Donors will be informed that their collection period will be extended up to 3 h in order to obtain the requisite volume of urine should the donor be unable to provide the full 45 ml in a single void. During the additional time period, the donor will be encouraged to drink up to 40 oz. of fluid. After 3 h, if the donor fails to provide the required amount, the collector will inform the donor’s employer. The employer must then send the employee for a physical examination. The finding of the examination must be that the individual has a current physical, or a pre-documented psychiatric, condition, or the final result will be deemed a “refusal to test.” This expanded collection, with the follow-on physical examination, is referred to as the “shy bladder” process. During the instruction phase of the collection, the collector will also instruct the donor that the failure to follow any of the collector’s instructions could result in the collector stopping the testing process and informing the donor’s employer that the donor has “refused to test.” The collection procedures include precautions to guard against possible tampering, such as toilet-water bluing and having donors empty their pockets to reveal any adulterating-type products. Donor are also required to wash their hands before entering the bathroom stall. When the donor presents the collector with the specimen, the collector will examine the specimen for signs of tampering and check the temperature to make sure it is within the acceptable range (90 to 100°F). Any attempt by the donor to adulterate the specimen, which is detected by the collector (e.g., a blue specimen), will result in a second collection to follow immediately. That collection will be conducted using the direct-observation procedures. Should the donor refuse to permit the same-sex, direct-observation collection to occur, the collector will stop the collection and inform the donor that the donor has refused to test. “Refusals to test” are final results of record, and are DOT violations. Assuming that the collection has gone without incident, the collector will divide, or “split,” the specimen into two separate specimen bottles and seal and label both bottles with uniquely numbered tampering-evident labels that are an integral part of the CCF. This is an important step and must be witnessed by the donor. The CCF paperwork is completed with both the donor and collector filling out their specific sections, and then the split specimens and one copy of the CCF are placed in the leak-proof plastic bag, which is sealed and ready to be sent to the laboratory.


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It is the responsibility of the collector to secure the specimens until they are sent to the laboratory. The final duty of the collector is to distribute the remaining copies of the CCF to the appropriate parties (i.e., MRO, collector, employer, and employee). Even though DOT has developed specific training requirements for all collectors, with more than 7,000,000 collections each year, collection errors still occur. This is perhaps inevitable since the position of collector is still an entry-level position in most companies and, thus, subject to high turnover. Lack of proper training or training that is administered in a hurried manner is another cause of collection errors. However, any collector who makes an error that results in a test being canceled must be retrained. 10.2.2.8

Laboratory Testing

DOT makes exclusive use of laboratories certified under the HHS National Laboratory Certification Program. HHS publishes a listing of certified laboratories (each month in the Federal Register) of those meeting the criteria set forth in the HHS Guidelines. Currently, the vast majority of these laboratories are located in the U.S.; there are a couple in Canada, but none in Mexico. DOT follows HHS criteria for both drug testing and specimen validity testing. The criteria are specified in detail in Section 10.2.1 of this text. Therefore, only general references are made to DOT test criteria in this text section. All laboratories receive, unpackage, and enter a DOT specimen into the testing process. This is called accessioning. All DOT specimens are tested for the five drugs of abuse: marijuana, cocaine, opiates, amphetamines, and phencyclidine. The drug panel has not changed since the outset of the program. DOT follows the protocols set up by HHS. Some of the test criteria, such as the cutoffs for initial or confirmation tests, have changed over the years. As testing technology advances and drug-use tendencies change, it is quite possible that similar changes may occur again in the future. It is also possible that additional drugs could be added to the test panel. However, such changes are not made without first being proposed to the public, in order that the public may comment on the recommendations, and then issuing a change to the HHS and DOT rules. All DOT specimens also undergo “specimen validity” testing. This is a relatively new category of tests brought on in the late 1990s by attempts of individuals to beat the test by tampering with the specimen (e.g., adding a substance to the urine specimen in hopes of altering the test result). Specimen validity testing (SVT) consists of measuring creatinine and specific gravity to detect a diluted or substituted specimen. pH is measured as one criterion established to detect an adulterated specimen. HHS has developed criteria to be used in testing for specific adulterants such as nitrites, chromates, surfactants, and other active chemical compounds. Substituted or adulterated specimen results are DOT rule violations and have the same weight as a positive test. Sometimes neither drug testing nor SVT can produce a result that is conclusive. The laboratory may be able to determine only that the specimen has some abnormal reaction. Testing the specimen reveals that it has definitely not met criteria to be reported as negative, however, criteria are not met to call it positive, substituted, or adulterated. This result is classified as invalid. Most invalid test results are recollected using directly observed collection procedures. All results fall into one of two categories: negative and non-negative. Negative specimens are those that prove to be negative for drugs and do not have any specimen-validity issues. Negative results may also show that the specimen was dilute. (Dilute specimen results are not violations; however, DOT allows employers to have a policy of recollecting specimens from employees who have dilute results.) Approximately 95% of all DOT specimens are negative. Negative results are reached in less (laboratory) time than non-negative results. DOT gives laboratories the authority to report negative results using only computer-generated reports. Non-negative specimens are all other results — positive, substituted, adulterated, and invalid. Since some of these results will require that the employee be removed from his safety-sensitive job, and possibly terminated, DOT requires more documentation be included with these test reports.


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The laboratory must also provide a copy of the corresponding CCF, generated at the time of the collection and completed by the certifying laboratory scientist who verifies the laboratory results, when the report is released. DOT test results may only be reported to a physician who will review the drug test. This physician is called the Medical Review Officer. DOT prohibits laboratories from reporting results to anyone other than the MRO (e.g., consortia/third-party administrators, employers). 10.2.2.9

Medical Review Officer

The MRO has been designated by DOT as the “gatekeeper” of the drug-testing program. “MROs” are physicians (a doctor of medicine or osteopathy) who receive all drug test results and make determinations whether the employee has committed a drug violation (e.g., verified positive test result), while maintaining the confidentiality for the employee during an interview process. MROs are required to have knowledge and clinical experience in substance abuse disorders, to be trained on Part 40, and to pass a written examination. Chasing paperwork, listening to far-fetched stories as to why a person was positive or how the specimen became adulterated, and dealing with employers anxious to put people to work are all part of the MRO’s duties. Laboratories certify drug test results, while MROs verify drug test results. The MRO receives all DOT drug test results directly from the laboratory. Employers or third-party administrators are not authorized to receive the drug test results or act as an intermediary to the MRO. Staff, under the supervision of the MRO, may assist with paperwork duties, establishing donor contact, and reporting results to employers. However, only the MRO can conduct the interview with the donor to determine if there is a legitimate medical explanation for the positive, substituted, or adulterated test result. “Legitimate medical explanations,” while rare for these test results, are possible. Recognizing what is acceptable and what is not is subject-matter training for MROs in the DOT-required MRO training courses. Generally, such explanations are limited to prescriptions or medical procedures where drugs are introduced to the donor and can subsequently be verified by the MRO. Additionally, special studies may be set up to prove that the donor can naturally produce a substituted or adulterated urine specimen. To date, there has been one such case for the former (substituted specimen), but none for the latter (adulterated specimen). In fact, as of this writing, there is no known adulterant, introduced in vivo, that can interfere with a laboratory’s analytical procedure. All adulterants that have an effect on the analytical process or can be detected by laboratory analysis are introduced into the specimen cup — by the donor — in vitro. When the MRO gets a result that is positive, substituted, adulterated, or invalid, the donor will be contacted and interviewed by telephone. Through the interview, if the MRO determines that there is a legitimate medical reason for the donor’s test result, the MRO has the discretion to “downgrade” the result (from positive) to negative and forward that result to the employer. The process devised by DOT gives the MRO latitude to downgrade the final result to negative and still provide a safety warning to the employer if the donor is using a medication that would medically disqualify the donor under agency rules or where continued use would pose a safety risk, even though the medication was obtained with a valid prescription. For those individuals for whom the MRO determines that the reported result will be positive, substituted, or adulterated, the MRO will also provide the donor with the opportunity of having the split specimen tested at another HHS-certified laboratory. However, the employer will immediately remove the donor from the safety job being performed on the initial report by the MRO. If the split specimen result does not confirm the initial specimen result, the result reported to the employer will be canceled by the MRO — as if the test never occurred — and the donor will undergo a second collection where the process starts over from scratch. If the split confirms the initial result, which is what normally occurs, the employer and the donor are so notified. MROs may also be called upon for consultation during the post-violation assessment process that the donor must undergo in order to return to the transportation workplace. MROs are encouraged


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to cooperate with this part of the process, which usually involves providing only drug quantitations that may be helpful during the assessment. MROs may also be asked to assist the donor in obtaining test records from the laboratory that conducted the testing. DOT requires laboratories to interface with MROs, not donors. Donors are entitled to any records produced as a result of their drug test, and having the MRO act as the intermediary keeps it simple. Likewise, donors have access to MRO records, pertaining to their test, as well as laboratory records. 10.2.2.10

Alcohol Testing

OTETA mandated that alcohol tests be part of the dual-testing program. For the first time in the workplace setting, alcohol tests would be conducted alongside drug tests. This new territory presented especially difficult challenges for the DOT. Alcohol, unlike the drugs that DOT tests for, is a legal substance. While it could not be tolerated in the safety-sensitive workplace, parameters had to be established for off-duty use occurring near the time when the employee would report for duty. Additionally, consideration needed to be given to the period after accidents, but prior to a test being conducted. Originally the DOT interpreted OTETA language as requiring alcohol testing for all reasonsfor-test: pre-employment, random, reasonable suspicion, post-accident, return-to-duty, and followup. The 1994 testing rules issued by DOT included requirements for all six test categories. Eventually, the 4th Circuit Court of Appeals ruled that pre-employment testing was problematic as a routine, mandated test. It was subsequently reverted back to DOT for resolution. DOT decided to “authorize” employers to conduct pre-employment alcohol tests as a condition of employment, and definitively modified the rules in 2001. Today, alcohol testing is authorized for pre-employment and mandated for other test reasons (except random testing) in the same manner as drug tests. Random alcohol tests are not required under PHMSA and USCG rules. Personnel who conduct alcohol tests are called screening test technicians (STT) and breath alcohol technicians (BAT). Most of the tests are conducted by “BATs,” as they are called. Both

Figure 10.2.3 DOT Breath Alcohol Testing in process.


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Figure 10.2.4 Example of Evidential Breath Testing device.

technicians need to be trained and only use instruments for the test that have been approved by DOT. All alcohol test devices approved for DOT use are certified by DOT’s National Highway Traffic Safety Administration (NHTSA) and placed on a use approved listing,9 which is published in the Federal Register. Alcohol tests (Figure 10.2.3), like drug tests, use a standard form and a specific set of procedures,10 both designed and developed by DOT. Unlike drug testing, when alcohol was mandated by OTETA, DOT did not have the luxury of following HHS guidelines — no other branch of the government tests for alcohol. Procedures for workplace alcohol testing had to be developed by DOT. Alcohol tests, like drug tests, use a two-test procedure. The first test, or initial test, can use either breath or saliva testing devices, and may be non-evidential in nature. The second test can only use an Evidential Breath Testing (EBT) device (Figure 10.2.4). This device produces a printed record documenting all aspects of the test (e.g., time of test, specific device, breath alcohol concentration). Any individual who shows the presence of alcohol at a concentration of 0.02 or higher on the initial test must be subjected to a second test, or confirmation test. Prior to conducting the second test, the BAT will wait at least 15 min, but not more than 30 min, before proceeding. This 15-min waiting period allows any alcohol that may be in the person’s mouth to dissipate. “Mouth alcohol” can be attributed to mouthwash or breath lozenges. The waiting period is precautionary to protect the person being tested. During this wait period, the BAT will also conduct an “air blank” on the EBT to show that the device does not contain any residual alcohol. The result of the second test becomes the result of record. An alcohol concentration of 0.04 or higher is a DOT violation (e.g., similar to a positive drug test); an alcohol concentration between 0.02 and 0.039 is prohibited conduct, and the person cannot perform safety-sensitive work while testing within this range. The services of an MRO, to review an alcohol test, are not required. The reason is that there is no legitimate medical explanation for alcohol in one’s system. Alcohol is alcohol. Whether its source was from beer, whiskey, or mouthwash, the effect is still the same. The BAT will report the result immediately to the employer and the employer will respond by removing the person from duty. 10.2.2.11

Substance Abuse Professional

OTETA requires that an opportunity for treatment be made available to covered employees. In order to implement this mandate, an employer must refer any transportation worker, who has engaged in conduct prohibited by DOT drug or alcohol rules, for evaluation and treatment. Modeled


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with the substance abuse profession in mind, the DOT rules require substance abuse professionals, or SAPs, to have certain credentials, possess specific knowledge, receive training, and achieve a passing score on an examination. There is also a continuing education requirement. The SAP Guidelines,11 written by ODAPC, supplement Part 40. The primary safety objective of the DOT rules is to prevent, through deterrence and detection, alcohol and controlled substance users from performing transportation industry safety-sensitive functions. The SAP is responsible for several duties important to the evaluation, referral, and treatment of employees identified through breath and urinalysis testing as positive for alcohol and controlled substance use, or who refuse to be tested, or who have violated other provisions of the DOT rules. A SAP’s fundamental responsibility is to provide a comprehensive face-to-face assessment and clinical evaluation to determine what level of assistance the employee needs in resolving problems associated with alcohol use or prohibited drug use. Following the evaluation, education and/or treatment is recommended, whereby the employee must demonstrate successful compliance in order to return to DOT safety-sensitive duty. Prior to the employee’s return to safety-sensitive duties, the SAP conducts a face-to-face followup evaluation with the employee to determine if the individual has demonstrated successful compliance with recommendations of the initial evaluation. This evaluation must be accomplished before an employer can consider the employee for return to safety-sensitive functions. Therefore, the evaluation serves to provide the employer with assurance that the employee has made appropriate clinical progress sufficient to return to work. The SAP also develops and directs a follow-up testing plan for the employee returning to work following successful compliance, specifying the number and frequency of unannounced follow-up tests. If polysubstance use has been indicated, the follow-up testing plan should include testing for drugs as well as alcohol, even though a violation of both was not the original offense. If the MRO is considered the “gatekeeper” in the drug-testing process, then the metaphor is equally appropriate for the SAP in the return-to-duty process. 10.2.2.12

Confidentiality and Release of Information

Part 40 is very clear about what information is to be generated, where it goes, and who is authorized to receive it. Beyond the Part 40 instruction, service agents and employers participating in the DOT drug or alcohol testing process are prohibited from releasing individual test results or medical information about an employee to third parties without the employee’s specific written consent. A “third party” is any person or organization that the rule (Part 40) does not explicitly authorize or require the transmission of information from in the course of the drug or alcohol testing process. “Specific written consent” means a statement signed by the employee agreeing to the release of a particular piece of information to a particular, explicitly identified, person or organization at a particular time. “Blanket releases,” in which an employee agrees to a release of a category of information (e.g., all test results) or to release information to a category of parties (e.g., other employers who are members of a C/TPA, companies to which the employee may apply for employment), are prohibited by DOT. Information pertaining to an employee’s drug or alcohol test may be released in certain legal proceedings without the employee’s consent. These include a lawsuit (e.g., a wrongful discharge action), grievance (e.g., an arbitration concerning disciplinary action taken by the employer), or administrative proceeding (e.g., an unemployment compensation hearing) brought by, or on behalf of, an employee and resulting from a positive DOT drug or alcohol test or a refusal to test. Also included are criminal or civil actions resulting from an employee’s performance of safety-sensitive duties, in which a court of competent jurisdiction determines that the drug or alcohol test information sought is relevant to the case and issues an order directing the employer to produce the information. For example, in personal injury litigation following a truck or bus collision, the court could


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determine that a post-accident drug test result of an employee is relevant to determining whether the driver or the driver’s employer was negligent. The employer is authorized to respond to the court’s order to produce the records. DOT instructs employers and service agents to notify the employee in writing of any information released without the employee’s written consent. Lastly, release of DOT program information is not in conflict with the HHS Health Insurance Portability and Accountability (HIPAA) rules.12 HIPAA rules do not conflict with the DOT drug and alcohol-testing program for employer and service agent responsibilities under Part 40 and operating administration drug and alcohol testing rules. Information may be generated and flow to its intended parties, as required by Part 40, without the employee signing a HIPAA-type consent. 10.2.2.13

Consortium/Third-Party Administrators

In the early days of the DOT testing program, the department believed that employers might pool their resources or band together to help each other accomplish the things the testing rules required. This did not happen. What did happen was that the DOT program created an entire “cottage industry” of service agents, including consortia/third-party administrators (C/TPA), and substance abuse providers, who contract directly or indirectly with employers to accomplish the tasks set forth in DOT rules. In short, a C/TPA will handle all of the administrative processes for an employer’s testing program. The types of services typically offered by C/TPAs are: • • • • • • • • •

Urine collections, including permanent and mobile facilities Laboratory testing Random selections Background checks on new hires Policy and procedures Supervisory training Providing MRO test review and SAP referrals Maintaining records and preparing statistical data Assisting employers preparing for DOT audits

Employers are allowed to contract with C/TPAs (service agents) to get the job done. Service agents are obligated to do the work they have signed on to do as if they were the employer. However, even though the department has a method to rid the testing community of a “bad” service agent, the employer is still held responsible for the actions of the service agent. 10.2.2.14

Public Interest Exclusion

Service agents perform the bulk of drug and alcohol testing services for transportation employers. Employers, particularly small employers, necessarily rely on service agents to comply with their testing obligations. Employers are ultimately responsible for all aspects of the program. However, in good faith, they may hire a service agent who purposely does not comply with the rules. These employers often do not have the expertise in testing matters that would enable them to evaluate independently the quality, or even the regulatory compliance, of the work that service agents perform for them. Subpart R of Part 40 provides a mechanism to help ensure that service agents will be held accountable for serious noncompliance with DOT rules. The public interest exclusion (PIE) is based in concept on the existing DOT non-procurement suspension and debarment rule13 and permits DOT to suspend a service agent for willful noncompliance with the drug and alcohol testing rules. The mechanism, both for policy and resource reasons, is only used in cases of serious misconduct. An employer’s compliance with DOT regulations is largely dependent on its service agents’ performance. If a service agent makes a serious mistake that results in the employer being out of compliance with a DOT rule, accountability must be addressed. The employer may be subject to


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civil penalties from a DOT agency. The employer can be subject to litigation resulting from personnel action it took on the basis of the service agent’s noncomplying services. Most importantly, the employer’s efforts to ensure the safety of its operations may be damaged, e.g., as when an employee who apparently uses drugs is returned to duty because of a service agent’s noncompliance. The standard of proof in a PIE proceeding is “the preponderance of the evidence.” There is no policy or legal basis apparent for raising this burden to the higher “clear and convincing evidence” level. A PIE could apply to all the divisions, organizational elements, and types of services provided by the service agent involved, unless the director limited the scope of the proceeding. Under some circumstances, affiliates and individuals could also be subject to a PIE. The intent of the PIE is to protect the public from the misconduct of an organization. As of mid-2006, the DOT had not suspended any service agents. 10.2.2.15

Conclusion

The history of the DOT drug- and alcohol-testing program is a relatively short one. The benefits of the last 10-plus years of program implementation are not fully known. However, data on illegal drug use by transportation employees, accidents related to use, and changes in attitudes about workplace safety and substance abuse are encouraging. The ultimate success of OTETA and the employer-based programs that it mandates will be measured over time in terms of lives saved, injuries prevented, and property losses reduced. OTETA is not a cure-all for safety problems or problem workers. Only everyday due diligence on the part of all safety workers will help in that area.

NOTES 1. Skinner v. Railway Executives’ Association, 489 U.S. 616-617 (1989); and National Treasury Employees Union v. Von Robb, 489 U.S. 656, 674-675 (1989). 2. Public Law 102-143, October 28, 1991, Title V — Omnibus Transportation Employee Testing, 105 Stat. 952-965; 49 U.S.C. 45104(2). 3. Title 49, Code of Federal Regulations (CFR), Part 40, Procedures for Transportation Workplace Drug and Alcohol Testing Programs, Office of the Secretary of Transportation, Department of Transportation. 4. Federal Aviation Administration (FAA): 14 CFR Part 121, Appendix I & J; Federal Motor Carrier Safety Administration (FMCSA): 49 CFR Part 382; Federal Railroad Administration (FRA): 49 CFR Part 219; Federal Transit Administration (FTA): 49 CFR Part 655; Pipeline and Hazardous Materials Safety Administration (PHMSA): 49 CFR Part 199; and U.S. Coast Guard (USCG); 46 CFR Part 16 and 46 CFR Part 4. 5. The USCG transferred to the Department of Homeland Security in March 2003, but still conducts drug testing under DOT rules. 6. Executive Order 12564, Drug-Free Federal Workplace, September 15, 1986. 7. Mandatory Guidelines for Federal Workplace Drug Testing Programs, Division of Workplace Programs (DWP), Substance Abuse and Mental Health Services Administration (SAMHSA), Department of Health and Human Services (HHS). 8. Urine Specimen Collection Guidelines, Office of Drug and Alcohol Policy and Compliance, DOT, Version 1.01, August 2001. 9. Conforming Products Listing, National Highway Traffic Safety Administration, 69 FR 42237. 10. DOT Model Course for Breath Alcohol Technicians and Screening Test Technicians, Office of Drug and Alcohol Policy and Compliance, DOT, August 2001. 11. Substance Abuse Professional Guidelines, Office of Drug and Alcohol Policy and Compliance, DOT, August 2001. 12. Health Insurance Portability and Accountability Act of 1996 (HIPAA), Department of Health and Human Services, 45 CFR Part 164. 13. 49 CFR Part 29, Governmentwide Debarment and Suspension (Nonprocurement), Office of the Secretary, DOT.


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10.2.3 Drug Testing in the Nuclear Power Industry: The NRC Fitness-for-Duty Rules

Theodore F. Shults, J.D., M.S. Chairman, American Association of Medical Review Officers, Research Triangle Park, North Carolina

10.2.3.1

Background

The private nuclear power generating industry in the U.S. is highly regulated. The primary federal regulator is the Nuclear Regulatory Commission (NRC). The NRC has a great deal of oversight, inspection responsibilities, safety analysis, and involvement in every aspect of the operation of a nuclear generating facility. The nuclear industry has been highly sensitive to the public safety aspect of its operations and recognizes that in addition to the fundamental engineering issues involved in maintaining the safe operation and security of a reactor and its fuel, a great deal of attention must be paid to the basic human performance issues as well. In this industry careful consideration is given to who has access to the facility, their background, their health and their behavior — particularly in respect to illegal drug use and alcohol abuse. The rules that govern drug and alcohol testing in the nuclear industry are called the Fitnessfor-Duty Rules (FFD) and are found in Title 10 Code of Federal Regulations, Section 26, or ubiquitously known in the industry as 10 CFR 26. The initial Fitness-for-Duty rule was published in 1989. This rule requires that each nuclear power plant licensee establish a Fitness-for-Duty program. The NRC crafted these rules at the same time that the HHS Mandatory Guidelines were put together. The NRC adopted the fundamental requirement of using MROs, certified laboratories, and many of the procedural safeguards. There were, however, a few fundamental differences in philosophy and goals between the HHS Mandatory Guidelines and the NRC fitness-for-duty programs. The NRC had an interest in deterrence of illegal drugs, but the NRC and the industry as a whole also was deeply interested in the concept of overall “fitness” of the employee, the safety of operations, the overall security of the facility and “trustworthiness” of individuals who had access to nuclear plants and facilities. As a result of these considerations, the NRC program that was adopted back in 1988 looked similar to the HHS procedures but contained a number of radically different elements. First, the NRC gave the individual nuclear electric generating plant (called a licensee) a great deal of flexibility. For example, whereas HHS Mandatory Guidelines restrict drug testing to five categories of drugs, the NRC allows the licensee to test for additional drugs and to test for drugs at lower cutoff levels than specified and required in the HHS Mandatory Guidelines. The NRC also allowed for the on-site testing for specimen validity at the collection site, and allowed the licensee to have an on-site immunoassay screening laboratory for initial screening of urine specimens. The NRC also adopted a modified stand-down provision that a licensee can use. All these deviations from HHS provisions were controversial at the time, but they have worked for the nuclear power industry. Another fundamental difference is that unlike the DOT/HHS testing model, the NRC does not require the MRO to receive all of the laboratory results from the certified laboratory, or even to review the negative results. (Everything in the nuclear industry is reviewed about ten times — but not by the MRO.) The results typically go to a fitness-for-duty coordinator, who again typically has access to all the testing information, including the MRO records. This is a very different process than seen in DOT testing. On the other hand, the MRO in the nuclear industry often has to play an expanded role in respect to management of the health, qualifications, and prescription drug use of the employees in the program. In 1995, the NRC published a proposed update to its Fitness-for-Duty Regulations. These proposed rules were open for comment in 1996, were debated, and then went into a state of


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regulatory limbo. Meanwhile, utilities continued to follow the existing rules and modify and update their programs within the regulatory framework of 10 CFR 26. While the proposed rules were in limbo, a lot happened in other areas of testing. HHS implemented program documents giving laboratories guidelines on how to test for adulterants, and subsequently adopted a mandatory specimen validity rule. DOT has rewritten its drug and alcohol testing rules, adopted procedures for managing insufficient urine volume (shy bladder), and established procedures for testing of adulterated and substituted urine. During this time the nuclear industry was going through a challenging period of reorganization in order to adapt to a new “deregulated” industry of gyrating market conditions. In 2000, prior to establishing an implementation date for the 1995 “new” rule to go into effect, the NRC held a meeting for the industry to provide any additional clarifications. It was a difficult meeting for all parties. What became clear was that many aspects of what were viewed as enhancements in 1995 looked stale in 2000. In 1995, the regulatory language was still of the old school, as opposed to the new question-and-answer format used by DOT and HHS. The world changed in September 2001, and the NRC refocused its efforts on counterterrorism and security. In the fitness-for-duty area there was more emphasis and interest in managing fatigue and enhancing background checks. The NRC staff was continuing to work on updating the fitnessfor-duty rules, and the industry recognized the benefit of incorporating the DOT and HHS experience with respect to managing specimen validity. The NRC and the nuclear industry also took the opportunity to develop a comprehensive rule (framed as amendments to the existing rules) that better addresses the issues of adulteration, emerging technologies, drug and alcohol abuse, and safety in a less cumbersome way and to integrate a decade and a half of experience from well-run programs. Thus, after a 10-year period of struggle and at times a mind-numbing regulatory process, the NRC pre-released a proposed new rule in April 2005. This new proposal represents countless hours of work on the part of all of the stakeholders, and a significant catch-up and enhancement of the existing program. True to its original intent, the “fitness-for-duty” rules include the procedures and requirements for the management of “fatigue,” which are outlined below. 10.2.3.2

The 2005 Proposed Amendments to the NRC Fitness-for-Duty Rules

On May 16, 2005, the NRC published in the Federal Register a notice that stated that it intended to propose: A rule (that) would amend the Commission’s regulations to ensure compatibility with the Department of Health and Human Services guidelines, eliminate or modify unnecessary requirements in some areas, clarify the Commission’s original intent of the rule, and improve overall program effectiveness and efficiency and establish threshold for the control of working hours at nuclear power plants to ensure that working hours in excess of the thresholds are controlled through a risk-informed deviation process. Because of the issues raised in response to the earlier affirmed (fitness for duty) rule, a new proposed rule will be published, including provisions to provide significantly greater assurance that worker fatigue does not adversely affect the operational safety of nuclear power plants. This new proposed rule is scheduled to be provided to the Commission by June 1, 2005.*

This new fitness-for-duty rule is available on the NRC Web site.† It is awaiting approval from the Office of Management and Budget, which should take some additional time. The rule when published will provide at least 120 days before going into effect. As could be anticipated in updating a 10-year-old drug and alcohol testing rule, the proposed fitness-for-duty rule contains a significant number of changes to the existing program. The following * The NRC is reviewing the public comments and projects that the rule will become final in January 2007. † Go to nrc.gov and use the search feature to find “fitness for duty.” The searcher should find the old rule, the history of the rule, a wealth of background material, and the new rule in its pre-published form.


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are some of the most significant changes that deal directly with drug and alcohol testing. The proposed new fitness-for-duty rule would: • Add requirements for validity tests on urine specimens to determine if a specimen has been adulterated, diluted, or substituted. At the request of stakeholders, the rule would permit licensee testing facilities to perform validity screening tests using non-instrumented testing devices, as proposed by HHS on April 13, 2004 (69 FR 19672), but not yet incorporated into final HHS guidelines. • Add a requirement that assays used for testing for drugs in addition to those specified in this part, or testing at more stringent cutoff levels than those specified in this part, would be evaluated and certified by an independent forensic toxicologist. (§26.31(d)) • Add a requirement that cutoff levels would be applied equally to all individuals subject to testing. (§26.31(d)) • Establish a process for determining whether there is a medical reason that a donor is unable to provide a urine specimen of at least 30 ml. (§25.119)

Alcohol Testing With respect to alcohol testing the new provisions would: • Add requirements for the use of oral fluids (i.e., saliva) as acceptable specimens for initial alcohol tests. • Lower the blood alcohol concentration (BAC) at which a confirmatory test is required from 0.04 to 0.02%. (§26.31(d)) This is a significant change. One of the reasons for the change has been the observation of the occasional donors who had been on the job for a few hours and still had a breath alcohol test above 0.03%. • Eliminate blood testing for alcohol. (§26.31(d)) Blood testing is allowed under the existing program as a “voluntary procedure” for individuals who had tested positive on two sequential evidentiary breath testing devices. This extraordinary provision allowing a positive donor to obtain a blood alcohol result was incorporated in an abundance of caution and concern over defending the results in respect to an individual’s challenge of the EBT alcohol testing results. The elimination of this provision is recognition that having not just one but two evidential breath testing devices is overkill.

Sanctions As distinguishable from the general DOT rules (with a few notable exceptions in the FAA rules), the NRC does specify employment sanctions for violations of the fitness-for-duty rule. The sanctions are made more severe under the new provisions. Significantly, they include: • Require unfavorable termination of authorization for 14 days for a first confirmed positive drug or alcohol test result. (§26.75(e)) • Increase the authorization denial period for a second confirmed positive drug or alcohol test result from 3 to 5 years. (§26.75(e)) • Add permanent denial of authorization for additional FFD violations following any previous denial for 5 years. (§26.75(g)) • Require permanent denial of authorization for refusing to be tested or attempting to subvert the testing process. (§26.75(b)) • Add a 5-year denial of authorization for resignation to avoid removal for an FFD violation. (§26.75(d))

Catch-Up Provisions The new rule also proposes a number of “catch-up” provisions that incorporate standards already established in DOT and HHS rules. These provisions include such items as:


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• Add cutoff levels for initial validity tests of urine specimens at licensee testing facilities and certified laboratories, and require tests for creatinine, pH, and one or more oxidizing adulterants. The rule would not allow licensees and other entities to establish more stringent cutoff levels for validity testing, and would also specify the criteria for determining that a specimen must be forwarded to an HHS-certified laboratory for further testing. (§26.131) • Replace and amend cutoff levels for initial tests for drugs and drug metabolites to be consistent with HHS cutoff levels. (Decrease the cutoff level for marijuana metabolites from 100 to 50 ng/ml. Increase the cutoff level for opiate metabolites from 300 to 2,000 ng/ml.) (§26.133)

Provisions for MROs With respect to MROs, the following provisions are being proposed: • Clarify requirements concerning donor requests to test the specimen in Bottle B of a split sample. (§26.135) • Clarify and expand the requirements relating to qualifications, relationships, and responsibilities of the MRO. • Add a requirement that the MRO pass a certification examination within 2 years of rule implementation. (§26.183) • Add specific prohibitions concerning conflicts of interest. (§26.183) • Specify MRO programmatic responsibilities. (§26.183) • Establish the requirements and responsibilities of the MRO staff. • Add a requirement for the MRO to be directly responsible for the activities of individuals who perform MRO staff duties. (§26.183) • Add a requirement that MRO staff duties must be independent from any other activity or interest of the licensee or other entity. (§26.183) • Prohibit the MRO from delegating his or her responsibilities for directing MRO staff activities to any individual or entity other than another MRO. (§26.183) • Specify the job duties that MRO staff may and may not perform. (§26.183) • Clarify and expand MRO responsibilities for verifying an FFD violation. • Make the MRO responsible for assisting the licensee or other entity in determining whether the donor has attempted to subvert the testing process. (§26.185) • Provide detailed guidance on circumstances in which the MRO may verify a non-negative test result as an FFD policy violation without prior discussion with the donor. (§26.185) • Clarify MRO responsibilities when the HHS-certified laboratory reports that a specimen is invalid. (§26.185) • Specify actions the MRO may take if he or she has reason to believe that the donor may have diluted a specimen in a subversion attempt, including confirmatory testing of the specimen at the assay’s lowest level of detection for any drugs or drug metabolites. (§26.185) • Add requirements for the MRO to determine whether a donor has provided an acceptable medical explanation for a specimen that the HHS-certified laboratory reported as adulterated or substituted. (§26.185) • Incorporate HHS recommendations on verifying a positive drug test for opiates. (§26.185) • Incorporate federal policy prohibiting acceptance of an assertion of consumption of a hemp food product or coca leaf tea as a legitimate medical explanation for a prohibited substance or metabolite in a specimen. (§26.185) • Provide detailed requirements for evaluation of whether return-to-duty drug test results indicate subsequent drug use. (§26.185)

Return to Duty In respect to return-to-duty provisions the new proposed rule would: • Add a new position, substance abuse expert (SAE), to the minimum requirements for FFD programs and specify the qualifications and responsibilities of the SAE. (§26.187) This SAE may or may


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not be defined as the SAP is defined in DOT regulations. Nevertheless, the change in the acronym is a significant improvement. • Specify the role of the SAE in making determinations of fitness and the return-to-duty process, including the initial evaluation, referrals for education and/or treatment, the follow-up evaluation, continuing treatment recommendations, and the follow-up testing plan. The rule would specify the role of the SAE in determinations of fitness based on the types of professional qualifications possessed by the SAE. (§26.189)

Managing Fatigue The new rule integrates fatigue management and fitness for duty. It is a logical association, but the development of sound fatigue rules that are not burdensome on the industry is a daunting challenge. In summary, the proposed rules: • Establish program requirements for fatigue management at nuclear power plants. • Codify a process for workers to self-declare that they are not fit for duty because of fatigue. (§26.197) • Require training for workers and supervisors on symptoms of and contributors to fatigue and on fatigue countermeasures. (§26.197) • Require licensees to include fatigue management information in the annual FFD program performance report that would be required under §26.217, including the number of waivers of the individual limits and break requirements that were granted, the collective work hours of any job duty group that exceeded the group average limit in any averaging period, and certain details of fatigue assessments conducted. (§26.197)

10.2.3.3

Conclusion

This is just an outline of the significant differences. Overall, the NRC has had an exceptional record of performance, even while working with a rule that was clearly long in the tooth. A key to the success of the NRC fitness-for-duty program has been a combination of the rigorous analysis that nuclear managers bring to the table in respect to safety concerns as well as some degree of regulatory flexibility. One can also anticipate that there may be some changes between the pre-published amendments and what becomes final law, and no doubt the NRC will be evaluating the final rule that HHS is expected to publish with respect to the effectiveness of alternative drug testing technologies. It is also safe to assume that it will be unlikely that the NRC will fall behind again in the race for effective management of substance abuse and employee fitness.

10.3 WORKPLACE DRUG TESTING OUTSIDE THE U.S.

Anya Pierce, M.Sc., M.B.A. Toxicology Department, Beaumont Hospital, Dublin, Ireland, U.K.

10.3.1 Introduction Although workplace drug testing (WDT) began in the U.S., it is increasingly prevalent in all parts of the globe.1 A major contributor to its spread was U.S. multinational corporations introducing the practice internationally. The amount of WDT performed is still minimal compared to the U.S. but it is steadily increasing.


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WDT began in the U.S. military and this trend has continued worldwide, with armed forces everywhere adopting the practice. It is impossible to obtain accurate statistics for most countries, and even when statistics are available, there often is no agreement about what constitutes WDT. For example, many countries include prison testing programs in their statistics. There is an aura of secrecy about WDT in Europe, as if it were somehow shameful for companies to admit involvement. This is hard to understand because WDT in Europe and Australia is led by health and safety concerns. The greater prevalence of trade unions in Europe appears to inhibit the acceptance of WDT. There is also much greater use of point-of-care testing (POCT) outside the U.S., with its consequent problems of little or no elements of quality assurance. 10.3.2 Scope This section covers the state of workplace drug testing and the development of regulations, both in place or proposed, accepted methods, and cutoffs in Europe, Australia, and other international arenas. 10.3.3 Workplace Drug Testing in Europe 10.3.3.1

History

In 1989, Spain held the presidency of the European Economic Community (EEC) and made the following proposals concerning drug testing: • Examine the criteria currently used for reporting positive results, including the need to distinguish between screening and confirmation results. • Examine the existing quality assurance programs. • Examine the validity of certified reference materials for illicit drugs and their metabolites.

This work was followed by a questionnaire to collect information on: • • • • • •

Substances tested Cutoff values Test methods Need for duplicate samples Interpretation and transmission of results External quality assurance practices

Last, a survey on quality and reliability was distributed. This led to the formation of an expert group under the aegis of Marie Therese Van der Venne of DG VI of the European Commission. Several meetings were held in Luxembourg with one or two representatives from each EEC country. This culminated in a 2-day meeting in Barcelona with original representatives and additional experts. Recommendations2 were finalized and published in journals nominated by the experts from each country under the following categories: • • • • •

Sample handling and chain of custody Cutoff values Analytical methodology Educational requirements External quality assurance and accreditation

These recommendations met with a great deal of opposition. Some thought they were too limited, while others thought they were too restrictive. Some disliked the specific cutoffs selected. Different countries had widely varying attitudes, socially and legally, to drug use.


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European Workplace Drug Testing Society

The sponsor in the European Commission died suddenly and workplace testing guidelines failed to progress until a meeting entitled “Drug Testing at the Workplace” was held in Huddinge Hospital in Stockholm, Sweden. This meeting led to the formation of the European Workplace Drug Testing Group (EWDTG) on March 1, 1998. The group consisted of one or two members from each EU country and representatives from Norway and Switzerland. From this core group the European Workplace Drug Testing Society (EWDTS) developed. The mission of the EWDTS is to ensure that workplace drug testing in Europe is performed to a defined quality standard, in a legally secure manner, and to provide an independent forum for discussion of all aspects of workplace drug testing. Guidelines for urine testing are published and are discussed below. Guidelines for other matrices are under development. The EWDTS objectives are to: • • • • •

Provide the source of expertise on WDT in Europe Function as the primary advisor to the European Commission Develop relevant literature and dispense information via the EDWTS Web site Train medical review officers (MROs) Train sample collectors

There is no specific legislation regarding WDT in any country in Europe. Finland had planned to introduce it, but at the last minute deleted the section from the relevant act. Industries that perform WDT are mainly in: • • • • • •

Transport Information technology Petrochemicals Shipping Pharmaceuticals Customer support (call) centers

Testing occurs predominantly at the pre-employment level, although in transport it is also routinely performed after an accident. Government employees outside the U.S. are not tested. 10.3.3.3

Sweden

In 1995, the Swedish government evaluated WDT and found no need for legislation. Instead, it was found preferable for the labor market to regulate this issue itself. In 1998, 23,997 people were tested, of whom 2.3% were positive. A person working as a cleaner in a non-safety critical area of a nuclear power plant objected to drug testing. The case was referred to the European Court of Human Rights. The court handed down a judgment on March 9, 2004 rejecting the application, saying it was impractical to differentiate employees and that drug testing of all its employees was a proportionate measure that did not violate Article 8.2 of the European Convention on Human Rights. This is the only case law in Europe at present. 10.3.3.4

The Netherlands

Interestingly, the only laws referring to WDT in the EU are in the Netherlands, where preemployment testing is prohibited. There is also opposition from trade unions and occupational health specialists, who believe that it is an infringement of individual privacy. In companies that do drug testing, it cannot be obligatory and employees have the right to refuse.


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Only one laboratory performs WDT. It is located in Rotterdam with a client-base of petrochemical and shipping industries, many of whose employees work offshore. About 20,000 tests are performed annually. Amsterdam, renowned for its coffee shops where small amounts of cannabis can be purchased, has almost no WDT. 10.3.3.5

Spain and Portugal

In a 1994 survey of companies in the Lisbon district with more than 50 workers, Vitòria3 estimated that 20% were doing drug testing. Pinheiro et al.4 found that 14% of the largest Portuguese companies (with a workforce greater than 1000) were performing tests in 1997, the majority without correct chain of custody or confirmation. No statistics are available from Spain. The majority of WDT on the Iberian Peninsula is done by the military. The most representative (and probably sole) indicators of WDT activity are those of the Portuguese army, where positive results have decreased from 17% in 1986 to 5.8% in 1995. Positive cannabis and opiate tests accounted for 4.1 and 1.4% of total positive tests. 10.3.3.6

Luxembourg

Some private companies are performing on-site testing for drugs of abuse, and some companies are sending urine specimens to special laboratories. Again, there are no firm statistics. 10.3.3.7

France

Air France and the automobile industry do the majority of drug testing. Private laboratories provide these services. In August 2004 the Department of Transport allowed occupational physicians in the railroad industry to drug test workers in safety-critical positions. 10.3.3.8

Germany

There is very little WDT in Germany. Most of the major companies in transport and manufacture do not test. Generally, WDT is perceived as an invasion of privacy, although some companies, mainly around Frankfurt, have begun testing. 10.3.3.9

Greece

WDT is done only in Thessaloniki, at the Aristotelian University.5 Specimens for analysis come from: • District attorney offices for testing of prisoners’ specimens • Directorate of Transportation for drivers seeking the reinstatement of driving licenses revoked for previous drug abuse • Private individuals during pre-employment testing • Security services under a law passed in 1997 • Prostitutes and housekeepers at houses of prostitution under a law passed in November 1999

10.3.3.10

Ireland

Ireland has a large number of nonindigenous pharmaceutical and information technology companies. The majority of them test at the pre-employment level and use the policies of their parent companies. The armed forces began random testing in September 2002, although they have performed pre-employment testing for many years. Some companies use laboratories in other countries. The use of POCT is widespread; it is estimated that 50,000 tests are performed annually.


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In 2006 the Health and Safety Authority enacted into law the Safety, Health and Welfare at Work Act 2005. One of the more controversial sections states as follows: An employee shall, while at work — (a) comply with the relevant statutory provisions, etc. (b) ensure that he or she is not under the influence of an intoxicant to the extent that he or she is in such a state as to endanger his or her own safety, health or welfare at work or that of any other person. (c) if reasonably required by his or her employer, submit to any appropriate reasonable and proportionate tests, by or under the supervision of a registered medical practitioner who is a competent person, as may be prescribed. This is the first such law in Europe. It still has to be fine tuned to decide which occupations are considered safety critical and what drugs are to be looked for.

10.3.3.11

U.K.

Testing became more prevalent in the 1980s and is growing. The discovery of oil and the opening of oil rigs in the North Sea and chemical and transport industries have increased testing demand. At present, it is estimated that more than 500,000 tests are performed annually. It is not known how many of the analyses are generated from outside the U.K. The Railway & Transport Safety Act covers air/road/rail and sea, which includes any person in charge of a vehicle and means they can be tested. The rail sector is the most rigorous with preemployment “with cause” testing for all and random testing for those in safety-critical positions, and education and help for anyone who discloses a problem. Overall, there is a trend of taking a risk assessment approach to drugs and alcohol, and looking at business-critical as well as safetycritical issues. 10.3.3.12

Belgium

The main users of WDT are in transport and the automobile industry. There are again no reliable statistics. The General Medical Council established strict guidelines in 1993: analysis may only be performed in a laboratory, drug testing is only allowed if clinical examination of impairment is not possible, and positive results must be confirmed by another laboratory. A recent (2002) initiative to amend these rules was not successful. 10.3.3.13

Finland

An Act on the Protection of Privacy in Working Life, which was recently enacted into law, covers several aspects of workplace drug testing. The Finnish guidelines on drug testing are the European Workplace Drug Testing (EWDTS) guidelines. WDT in Finland is mostly pre-employment testing, but random testing is increasing. WDT is usually part of health screening and the employer may often be told only that the applicant has failed the medical examination, with no further details provided. 10.3.3.14

Denmark

There is no legislation regarding WDT in Denmark. It is organized at the local level and mainly for the transport sector, offshore workers, and the police force. Persistent findings indicate that up to 12% of the workforce is influenced by one or more drugs. Approximately 10,000 tests per year are performed, mainly random testing or cluster testing, with very few pre-employment tests. Approximately 90% of all drug tests are performed as on-site testing (immunoassay screening) by health professionals, who also play a role in developing drugfree workplace programs.


770


10.3.4 Attitude Surveys 10.3.4.1

U.K. CIPD Survey

A 2001 survey of 281 organizations by the Chartered Institute of Personnel and Development reported6 that: 20% of the organizations were considered safety-critical, 38% partly so 56% have an alcohol and drug policy 18% carry out drug testing 12% perform drug testing when drug use is suspected 9% test for pre-employment 7% test for post-accident evaluation 6% perform random testing 6% do post-rehabilitation testing 2% test prior to promotion

10.3.4.2

Drug Testing in Prisons

Drug testing in prisons varies within and between countries. Positive tests tend to result in loss of privileges only. A split sample is taken, and re-screening and confirmation are available in some countries upon receipt of payment from the prisoner. The U.K. has a mix of mandatory and voluntary testing. Sweden also tests for anabolic steroids. 10.3.4.3

Employee Attitudes Survey

A survey was conducted in Sweden, Portugal, and Ireland in 2000 to acquire knowledge about attitudes toward drug testing in the workplace.7 Questionnaires were given to people who were tested for drugs at pre-employment. The answers were voluntary and anonymous. The questions asked were: Do you think that drug testing can be a good method to achieve a more drug free workplace? Do you consider donating a urine sample for this purpose in any way offensive? If you had a choice, what matrix would you prefer? Do you think that narcotics are a problem in our society? What are your views on the use of recreational drugs such as cannabis or ecstasy?

The results showed little difference between countries with the Swedish most certain of the benefits of WDT and the Portuguese the least. The Irish preferred urine as a matrix with very few countries in favor of sweat testing. Individuals under 20 and those over 40 saw the least danger in the use of recreational drugs. The main problem with the survey was that the number of participants was small, self-selecting, and the survey should have involved more countries. Interestingly, a number of people who responded had reservations about the failure to differentiate between cannabis and ecstasy use. They felt that ecstasy was much more dangerous and should have been treated separately. 10.3.5 European Laboratory Guidelines for Legally Defensible Workplace Drug Testing 10.3.5.1

Introduction

The EWDTS guidelines8 are based on the U.K. WDT guidelines. Urine is the only matrix included at present, although it is planned to introduce breath, oral fluid, hair, etc. The guidelines


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771

Table 10.3.1

European Screening Cutoffs Drug

Amphetamine Benzodiazepines Cannabis metabolites Cocaine metabolites Opiates (total) Methadone/metabolites Barbiturates Phencyclidine Buprenorphine/metabolites LSD/metabolites Propoxyphene/metabolites Methaqualone

ng/ml 300 200 50 300 300 300 200 25 5 1 300 300

represent best practice, which can withstand legal scrutiny, and are intended to provide a common standard throughout Europe. The guidelines have now been accepted by the European Accreditation (EA) body as the benchmark for WDT. The guidelines include: • • • • •

Specimen collection Laboratory organization Laboratory analysis Quality control and quality assurance Medical review officer

10.3.5.2

Screening Cutoffs

Table 10.3.1 presents European screening cutoffs. 10.3.5.3

Confirmation Cutoffs

Table 10.3.2 presents European confirmation cutoffs. 10.3.6 U.S.–EU Comparison Neither the individual European governments nor the EU parliament has shown real interest in WDT compared to the U.S. government. The U.S. has legally enforceable guidelines, while the European guidelines have no legal standing. In Europe, there is greater use of POCT and small non-accredited laboratories. In the U.S., testing is performed in a small number of large laboratories that are accredited and operated under very strict controls. Testing in the U.S. is mandatory for federal employees, which is not the case in Europe. 10.3.7 WDT in Australia and New Zealand 10.3.7.1

Standards

WDT is increasing in Australia. Although mining is the main industry to embrace WDT, other industries are also testing, including: • Metalliferous • Quarrying


772


• Transport • Construction

Neither transport nor construction industries have introduced a systematic procedure to measure the extent of drug use within their workforce. Some transport industries across Australia do have ad hoc testing. Similar to Europe, drug testing in Australia is conducted as part of an overall Occupational Health and Safety policy. Thus, there are many safeguards for employees who test positive. They are not dismissed, but instead are referred to a rehabilitation program. Only after repeatedly testing positive are individuals liable for dismissal. Many unions and even Employee Assistance Providers do not support drug testing. In general, within the workforce, the most common drugs of abuse identified are cannabis and methamphetamine. The most common drugs detected are therapeutic codeine and pseudoephedrine. Tables 10.3.3 and 10.3.4 present Australia/New Zealand screening and confirmatory cutoffs. 10.3.7.2

The Australian Mining Industry

This industry is the leader in the introduction of drug and alcohol testing of its workforce. Drug testing is carried out as part of occupational health and safety requirements. The mining industries in Western Australia, Queensland, and New South Wales are in the forefront. Policies, including compulsory drug and alcohol testing, usually require that an employee Table 10.3.2

European Confirmation Cutoffs

Amphetamine Methylamphetamine MDA MDMA MDEA Other amphetamines Temazepam Oxazepam Desmethyldiazepam Other benzodiazepines 11-Nor-9-tetra hydrocannabinol-9-carboxylic acid Benzoylecgonine Morphine Codeine Dihydrocodeine 6-Monoacetylmorphine Methadone/metabolites Barbiturates Phencyclidine Buprenorphine/metabolite LSD/metabolites Propoxyphene/metabolite Methaqualone Table 10.3.3

Australian/New Zealand (AS/NZS 4308) Screening Cutoffs Drug

ng/ml

Opiates Sympathomimetic amines Cannabis Cocaine Benzodiazepines

300 300 50 300 200

200 200 200 200 200 200 100 100 100 TBA 15 150 300 300 300 10 250 150 25 5 1 300 300


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Table 10.3.4

773

Australian/New Zealand (AS/NZS 4308) Confirmation Cutoffs Drug

ng/ml

Morphine, codeine Amphetamine, methamphetamine, MDMA Phentermine, ephedrine, pseudoephedrine Carboxytetrahydrocannabinol Benzoylecgonine, ecognine methyl ester Oxazepam, temazepam, diazepam, nordiazepam, 7-aminoclonazepam, 7-aminonitrazepam, 7-aminoflunitrazepam

300 300 500 15 150 150

is not impaired due to the ingestion of illicit drugs. This wording has created problems, as it is impossible to prove impairment, particularly in the case of a positive cannabis test. There is a lobby to increase the cannabis cutoff to reduce this perceived problem. Unfortunately, policy makers have used terminology from established alcohol testing for drug testing. Even though drug testing has been introduced under health and safety regulations, the unions have concerns. They defend an individual’s right to privacy, are concerned about the accuracy of drug testing, and state that individuals should not be penalized for using cannabis on their own time. Each Australian state has its own mining legislation. In effect, it is the duty of mine managers to ensure that no person is impaired by alcohol or drugs while on site. On-site drug testing is well established. Accredited laboratories perform confirmation analyses. Although there are no legal requirements, most companies select laboratories that are accredited by the National Association of Testing Authorities (NATA) to conduct analyses according to Australian/New Zealand Standards AS/NZS 4308. More recently, drug and alcohol testing has been extended to include contractors to the mining industry. To date, contractors present a greater risk for impairment than do employees of a company. In due course, it is expected that testing will significantly reduce the incidence of recreational drugs by workers, either employed full time or contracted to the mining industry. 10.3.7.3

New Zealand

Laboratories perform WDT work to the standards of the AS/NZS 4308.9 The 2001 standard is currently being updated to include a section for use of “on-site” screening devices. Standards Australia is also developing an Oral Fluid Standard. The number of tests is rising each year. In 1998/1999, about 3000 urine specimens were tested. This rose to an estimated 50,000 in 2005/2006. The industries that test are divided as follows (2005/2006): Road/Horizontal Construction Forestry Transport Meat/Poultry Dairy Fishing/Shipping Aluminum Smelting Power/Oil Manufacturing Vertical Construction Mining Personnel Consulting

21% 15% 13% 11% 10% 6% 4% 3% 2% 2% 6-AM > HER Collection time, multiple dosing and long t1/2 of MOR alters MOR-G/MOR/6-AM ratios; HER and 6-AM frequently not detected17,96,97,141–148

BZE > COC > EME > NCOC; CE (with ethanol) Collection time, multiple dosing and long t1/2 of BZE alters BZE/COC ratio; COC in combination with ethanol forms CE3,19,87–104

THCCOOH > THC Collection time, multiple dosing and long t1/2 of THCCOOH alters THCCOOH/THC ratio44–50

Blood/Plasma/Serum

COD-G > COD > MOR > NCOD Collection time, multiple dosing may alter CODG/COD/MOR/NCOD ratios; MOR may exceed COD late in excretion phase17,149,160,179–184

MOR-G > MOR > 6-AM > HER Collection time, multiple dosing and long t1/2 of MOR alters MOR-G/MOR/6-AM ratios; HER and 6-AM frequently not detected17,87,143,144,149–163

Collection time, multiple dosing and long t1/2 of BZE alters COC/BZE ratio; COC in combination with ethanol forms CE25,60,87,89–91,93–95,105–117

BZE > COC

THCCOOH-G > THCCOOH Multiple dosing and long t1/2 of THCCOOH produces accumulation and prolongs detection23,51–68

Urine

Collection time, multiple dosing may alter COD/MOR ratio32,123,189,190

Collection time, multiple dosing may alter COD/MOR ratio; MOR may not be detected17,123,142,166,175,177,178, 185–188

COD > MOR

6-AM and MOR most frequently detected; HER also may be detected74–76,125,126,163,167–169

6-AM MOR > HER

Collection time, multiple dosing and long t1/2 of BZE alters COC/BZE ratio; COC in combination with ethanol forms CE25,32,76,125,126

COC > BZE

THC Multiple dosing may produce accumulation and prolonged detection71,74–78

Sweat

COD > MOR

159,164–166

6-AM and MOR most frequently detected; HER may also be detected17,75,87,96,141,142,150,

6-AM MOR > HER

Collection time, multiple dosing and long t1/2 of BZE alters COC/BZE ratio; COC in combination with ethanol forms CE92,94–96,105,118–124

BZE > COC

THC Multiple dosing may produce accumulation and prolonged detection35,69–73

Oral Fluid

Continued

Multiple dosing may be necessary for detection17,18,127,142,191–197

COD > MOR> NCOD

135,139,142,143,165,170–174

Multiple dosing may be necessary for detection; 6AM and MOR most frequently detected, but HER also may be detected17,83,87,97,127,128,130–

6-AM > MOR

COC > BZE > NCOC; CE (with ethanol) Metabolite identification, e.g., NCOC, important to eliminate environmental contamination; presence of CE indicates systemic COC and ethanol exposure18,83,87,97,118,127–140

THC > THCCOOH Multiple dosing may be necessary for detection; metabolite identification important to eliminate environmental contamination79–86

Hair

Relative Abundances of Target Analytes in Alternative Matrices, Pharmacokinetic Considerations, and Selected References to Aid Interpretation of Results

Cannabis Target analytes PK effects

Drug

Table 10.6.2


WORKPLACE TESTING 825

Rapidly excreted primarily as parent drug, Ndesmethyl-metabolites, and hydroxylmetabolites233,279–285

243,258,261–268

METH > AMP Collection time, multiple dosing may alter METH/AMP ratio221,226,229,231–233,235,237,241-

AMP Multiple dosing may increase detection time221,225–242

Acidic pH of oral fluid enhances concentration compared to blood277,281

METH > AMP Collection time, multiple dosing may alter METH/AMP ratio241,243,244,269

AMP Multiple dosing may increase detection time35,36,75,223,224,241,243,244

PCP Multiple dosing may substantially increase detection time212,213

Oral Fluid

Detectable in sweat for 2–12 h after administration286,287

METH > AMP Collection time, multiple dosing may alter METH/AMP ratio243,269,270

AMP Multiple dosing may increase detection time35,75,243,245

PCP Multiple dosing may substantially increase detection time76

Sweat

251–253,288-292

MDA/MDMA/ MDEAMDMA concentrations usually exceed MDA (metabolite)135,219,247–249,

271–275

METH > AMP Multiple dosing may be necessary for detection; AMP present in lower amounts243,248,249,251–255,269,

243,246–255

AMP Multiple dosing may be necessary for detection36,38,82,97,128,131,222,

PCP Multiple dosing may be necessary for detection136,214–219

Hair

Abbreviations: THC = tetrahydrocannabinol; THCCOOH = 11-nor-9-carboxy-Δ9-tetrahydrocannibinol; THCCOOH-G = 11-nor-9-carboxy-Δ9-tetrahydrocannibinol-glucuronine; COC = cocaine; BZE = benzoylecgonine; EME = ecgonine methyl ester; NCOC = norcocaine; CE = cocaethylene; MOR-G = morphine glucuronide; MOR = morphine; HER = heroin; 6-AM = 6-acetylmorphine; COD-G = codeine glucuronide; COD = codeine; PCP = phencyclidine; HO-PCP = hydroxyphencyclidine; METH = methamphetamine; AMP = amphetamine; MDA = methylenedioxyamphetamine; MDMA = methylenedioxymethamphetamine; MDEA = methylenedioxyethylamphetamine.

MDMA demonstrates nonlinear rise in plasma levels with increasing dose; poor CYP2D6 metabolizers may be at risk of toxicity276–281

METH > AMP Multiple dosing may increase detection time204,220,221,243,256–260

AMP Multiple dosing may increase detection time204,220–224

PCP > HO-PCP Multiple dosing may substantially increase detection time202,208–211

Urine

826

MDA/MDMA/MDEA Target analytes PK effects

Methamphetamine Target analytes PK effects

Amphetamine Target analytes PK effects

PCP Multiple dosing may substantially increase detection time198–207

Blood/Plasma/Serum

Relative Abundances of Target Analytes in Alternative Matrices, Pharmacokinetic Considerations, and Selected References to Aid Interpretation of Results (Continued)

PCP Target analytes PK effects

Drug

Table 10.6.2




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827

Specimen Detection Windows C O L L E C T I O N

Blood Oral Fluid Sweat (7days) Urine (Acute) Urine (Chronic MJ, PCP) Hair

-100

-80

-40

-60

-20

0

Days Figure 10.6.8 General detection times for drugs in blood, oral fluid, urine, sweat, and hair. Lighter shaded area of sweat indicates possible detection of drug use that occurred 24–48 h prior to application of sweat patch.

48 h prior to application of the patch may also produce positive results.25 However, drug use just prior to patch removal is not likely to be detected because of the delay in appearance of drug in sweat. Multiple mechanisms for drug entry into hair may account for the confusion regarding the beginning of the drug detection window.18,26,27 Drug excreted in sweat may appear on hair within hours after use, but also may be more difficult to detect if washing procedures efficiently remove the bulk of drug residue. A period of hair growth estimated to be 3 to 5 days14 must occur for drug in hair to appear at the skin surface, thereby accounting for the “lag” period (days) in its detection window. Changes in analytical sensitivity and specificity, e.g., antibody changes in the screening assay, may result in enhanced or diminished detection times for all types of specimens. Also, administrative changes in recommended cutoff concentrations could have a similar effect. 10.6.5.2

Multiple Specimen Testing

Continued development, approval, and use of alternative matrices in drug testing programs may present interesting problems in interpretation of results. In the past, it was rare to have test results from more than one type of specimen, particularly in workplace testing. The financial costs of testing more than one type of biological specimen almost certainly will force most drug testing programs to choose a single type of specimen best suited to their needs; however, there are likely to be instances when individuals and even entire drug testing programs decide to test more than one biological specimen. Already, individuals informed of positive test results may request additional testing; e.g., an individual who tested positive in a urine testing program may choose to undergo hair testing. Medical Review Officers may also request additional testing if there is reasonable doubt concerning the validity of a test result. Post-accident testing calls for the highest scrutiny regarding the potential role of drugs as causative factors; hence, multiple specimens may become the norm in this type of testing arena. In addition, drug testing authorities may want information on test comparability, e.g., urine vs. oral fluid testing, prior to switching to a new matrix. Consequently, it is quite likely that there will be many instances where multiple test results from different biological matrices will be collected and require interpretation. 10.6.5.3

Guidance in Interpretation of Alternative Matrices Results

Considerable guidance information is available for interpretation of positive urine test results.22,28 Although there is less information available for alternative matrices, a number of reviews


828


are helpful in this regard.1,2,4,29–43 When multiple test results from different matrices are available, interpretation may be considerably more complex, particularly for disparate results. There are a number of legitimate reasons why one might obtain disparate results. Each type of biological specimen has unique physiological and chemical properties that may alter the pattern of drug disposition. For example, renal excretion processes favor elimination of water soluble metabolites, whereas excretion of drug into oral fluid favors parent drugs capable of rapid passive diffusion across membranes. Sweat excretion processes also appear to favor parent drug. The acidic nature of oral fluid and sweat favors excretion and trapping of drugs containing basic nitrogen moieties. Although the complex mechanisms for drug binding to hair pigment and proteins have not been fully elucidated, it is clear that these binding processes exhibit greater affinity for drugs containing basic nitrogen moieties. Residence times in each matrix also differ substantially, yielding wide variability in windows of detection. The many differences in physiological and chemical properties of alternative matrices undoubtedly result in production of occasional disparate test results when more than one type of biological specimen is utilized for testing. There are many possible explanations for disparate results. For example, testing two different matrices, e.g., urine and oral fluid, may result in two equivalent or two disparate results. When one considers the possible combinations of results that could arise from testing of blood, urine, oral fluid, sweat, and hair, there are 20 possible disparate results if only two matrices are tested. The different scenarios of disparate results for two specimens and some of the possible explanations are depicted in Table 10.6.3. It will become the responsibility of the Medical Review Officer and forensic toxicologists to provide interpretation of such results. Clearly, much information must be available to provide a scientific basis for the interpretation of alternative matrices’ results.


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Table 10.6.3

829

Disparate Results from Testing Two Different Biological Matrices and Possible Explanations

Scenario

Blood

Urine

1

Positive

Negative

2

Positive

3

Positive

4

Positive

5

Negative

Negative

Positive

7

Positive

8

Positive

Negative

Negative

Negative Negative

Positive Negative

Positive

11

Positive

12

Positive

13 14 15 16

Negative

17 18 19 20

Negative

Hair

Negative

Positive

10

Sweat

Negative

6

9

Matrix Oral Fluid

Negative Negative

Negative

Negative

Positive Positive Positive Positive

Negative

Negative

Positive Positive Positive Positive

Negative Negative

Possible Explanations for Disparate Results Time of urine collection too close to time of drug use Highly protein-bound drugs may be poorly distributed to oral fluid, e.g., benzodiazepines Low drug dose; sampling time outside detection “window” Low drug dose; low binding affinity to hair matrix; hair treatments, e.g., bleaching, straighteners; sampling time outside detection “window” Long interval after dosing; concentration effect by kidney Long interval after dosing; concentration effect by kidney; highly protein-bound drug; sampling time outside detection “window” Concentration effect by kidney; sampling time outside detection “window” Concentration effect by kidney; low dose; low binding affinity to hair matrix; sampling time outside detection “window” Insufficient time for drug absorption; “depot” effect Insufficient time for drug absorption, metabolism and excretion; “depot” effect Insufficient time for drug absorption, metabolism and excretion; “depot” effect; sampling time outside detection “window” Low drug dose; low binding affinity to hair matrix; insufficient time for drug absorption, metabolism and excretion; sampling time outside detection “window” Sampling time outside detection “window” Sampling time outside detection “window” Sampling time outside detection “window” Low drug dose; low binding affinity to hair matrix; insufficient time for drug absorption, metabolism and excretion; sampling time outside detection “window” Sampling time outside detection “window” Sampling time outside detection “window” Sampling time outside detection “window” Sampling time outside detection “window”

REFERENCES 1. R. Haeckel. Factors influencing the saliva/plasma ratio of drugs. Ann. N. Y. Acad. Sci. 694: 128–142 (1993). 2. N. Samyn, A. Verstraete, C. van Haeren, and P. Kintz. Analysis of drugs of abuse in saliva. Forensic Sci. Rev. 11: 1–19 (1999). 3. E.J. Cone. Pharmacokinetics and pharmacodynamics of cocaine. J. Anal. Toxicol. 19: 459–478 (1995). 4. E.J. Cone. Saliva testing for drugs of abuse. Ann. N. Y. Acad. Sci. 694: 91–127 (1993). 5. E.J. Cone, L. Presley, M. Lehrer, W. Seiter, M. Smith, K. Kardos, D. Fritch, S. Salamone, and R.S. Niedbala. Oral fluid testing for drugs of abuse: Positive prevalence rates by InterceptTM immunoassay screening and GC–MS–MS confirmation and suggested cutoff concentrations. J. Anal. Toxicol. 26: 541–546 (2002).


830


6. S. Robinson and A.H. Robinson. Chemical composition of sweat. Psychol. Rev. 34: 202–220 (1954). 7. W.C. Randall. The physiology of sweating. Am. J. Phys. Med. 32: 292–318 (1953). 8. D. Doran, J. Terney, M. Varano, and S. Ware. A study of the pH of perspiration from male and female subjects exercising in the gymnasium. J. Chem. Educ. 70: 412–414 (1993). 9. H.L. Johnson and H.I. Maibach. Drug excretion in human eccrine sweat. J. Invest. Dermatol. 56: 182–188 (1971). 10. L. Potsch. On physiology and ultrastructure of human hair. In Hair Analysis in Forensic Toxicology: Proceedings of the 1995 International Conference and Workshop, R.A. de Zeeuw, I. Al Hosani, S. Al Munthiri, and A. Maqbool, Eds. Organizing Committee of the Conference, Abu Dhabi, 1995, 1–27. 11. M.R. Harkey. Anatomy and physiology of hair. Forensic Sci. Int. 63: 9–18 (1993). 12. Human Hair Volume I: Fundamentals and Methods for Measurement of Elemental Composition, CRC Press, Boca Raton, FL, 1988, 1–88. 13. L. Potsch, R. Aderjan, G. Skopp, and M. Herbold. Stability of opiates in the hair fibers after exposures to cosmetic treatment and UV radiation. In Proceedings of the 1994 JOINT TIAFT/SOFT International Meeting, V. Spiehler, Ed. TIAFT/SOFT Joint Congress, 1994, 65–72. 14. M. Saitoh, M. Uzuka, and M. Sakamoto. Rate of hair growth. In Advances in Biology of Skin, Vol. IX. Hair Growth, W. Montagna and R.L. Dobson, Eds. Pergamon, Oxford, 1969, 183–201. 15. P. Mangin and P. Kintz. Variability of opiates concentrations in human hair according to their anatomical origin: head, axillary and pubic regions. Forensic Sci. Int. 63: 77–83 (1993). 16. G.L. Henderson. Mechanisms of drug incorporation into hair. Forensic Sci. Int. 63: 19–29 (1993). 17. E.J. Cone. Testing human hair for drugs of abuse. I. Individual dose and time profiles of morphine and codeine in plasma, saliva, urine, and beard compared to drug-induced effects on pupils and behavior. J. Anal. Toxicol. 14: 1–7 (1990). 18. R.E. Joseph, Jr., K.M. Hold, D.G. Wilkins, D.E. Rollins, and E.J. Cone. Drug testing with alternative matrices II. Mechanisms of cocaine and codeine disposition in hair. J. Anal. Toxicol. 23: 396–408 (1999). 19. R.E. Joseph, J.M. Oyler, A.T. Wstadik, C. Ohuoha, and E.J. Cone. Drug testing with alternative matrices I. Pharmacological effects and disposition of cocaine and codeine in plasma, sebum, and stratum corneum. J. Anal. Toxicol. 22: 6–17 (1998). 20. W.L. Wang and E.J. Cone. Testing human hair for drugs of abuse. IV. Environmental cocaine contamination and washing effects. Forensic. Sci. Int. 70: 39–51 (1995). 21. G. Romano, N. Barbera, and I. Lombardo. Hair testing for drugs of abuse: evaluation of external cocaine contamination and risk of false positives. Forensic Sci. Int. 123: 119–129 (2001). 22. M. Vandevenne, H. Vandenbussche, and A. Verstraete. Detection time of drugs of abuse in urine. Acta Clin. Belg. 55: 323–333 (2000). 23. A. Smith-Kielland, B. Skuterud, and J. Morland. Urinary excretion of 11-nor-9-carboxy-delta9tetrahydrocannabinol and cannabinoids in frequent and infrequent drug users. J. Anal. Toxicol. 23: 323–332 (1999). 24. R.S. Niedbala, K.W. Kardos, D.F. Fritch, S. Kardos, T. Fries, J. Waga, J. Robb, and E.J. Cone. Detection of marijuana use by oral fluid and urine analysis following single-dose administration of smoked and oral marijuana. J. Anal. Toxicol. 25: 289–303 (2001). 25. K.L. Preston, M.A. Huestis, C.J. Wong, A. Umbricht, B.A. Goldberger, and E.J. Cone. Monitoring cocaine use in substance-abuse-treatment patients by sweat and urine testing. J. Anal. Toxicol. 23: 313–322 (1999). 26. D.A. Kidwell and D.L. Blank. Mechanisms of incorporation of drugs into hair and the interpretation of hair analysis data. In Hair Testing for Drugs of Abuse: International Research on Standards and Technology, E.J. Cone, M.J. Welch, and M.B. Grigson Babecki, Eds. NIH Pub. 95-3727, National Institute on Drug Abuse, Rockville, MD, 1995, 19–90. 27. M.R. Harkey and G.L. Henderson. Hair analysis for drugs of abuse. In Advances in Biomedical Analytical Toxicology, Vol. II, R.C. Baselt, Ed. Biomedical Publishers, Chicago, 1989, 298–329. 28. Medical Review Officer Manual for Federal Workplace Drug Testing Programs, W.F. Vogl and D.M. Bush, Eds. Department of Health and Human Services, Washington, D.C., 1997, 1–72. 29. B. Caddy. Saliva as a specimen for drug analysis. In Advances in Analytical Toxicology, R.C. Baselt, Ed. Biomedical Publications, Foster City, 1984, 198–254. 30. Y.H. Caplan and B.A. Goldberger. Alternative specimens for workplace drug testing. J. Anal. Toxicol. 25: 396–399 (2001).


WORKPLACE TESTING

831

31. Y. Gaillard and G. Pepin. Testing hair for pharmaceuticals. J. Chromatogr. B. 733: 231–246 (1999). 32. M.A. Huestis, J.M. Oyler, E.J. Cone, A.T. Wstadik, D. Schoendorfer, and R.E. Joseph, Jr. Sweat testing for cocaine, codeine and metabolites by gas chromatography-mass spectrometry. J. Chromatogr. B Biomed. Sci. Appl. 733: 247–264 (1999). 33. O.R. Idowu and B. Caddy. A review of the use of saliva in the forensic detection of drugs and other chemicals. J. Forensic Sci. Soc. 22: 123–135 (1982). 34. D.A. Kidwell, E.H. Lee, and S.F. DeLauder. Evidence for bias in hair testing and procedures to correct bias. Forensic Sci. Int. 107: 39–61 (2000). 35. D.A. Kidwell, J.C. Holland, and S. Athanaselis. Testing for drugs of abuse in saliva and sweat. J Chromatogr. B 713: 111–135 (1998). 36. P. Kintz and N. Samyn. Use of alternative specimens: drugs of abuse in saliva and doping agents in hair. Ther. Drug Monit. 24: 239–246 (2002). 37. P. Mangin. Drug analyses in nonhead hair. In Drug Testing in Hair, P. Kintz, Ed. CRC Press, Boca Raton, FL, 1996, 279–287. 38. M.R. Moeller. Hair analysis as evidence in forensic cases. Ther. Drug Monit. 18: 444–449 (1996). 39. J.C. Mucklow, M.R. Bending, G.C. Kahn, and C.T. Dollery. Drug concentration in saliva. Clin. Pharmacol. Ther. 24: 563–570 (1978). 40. H. Sachs. Forensic applications of hair analysis. In Drug Testing in Hair, P. Kintz, Ed. CRC Press, Boca Raton, FL, 1996, 211–222. 41. W. Schramm, R.H. Smith, P.A. Craig, and D.A. Kidwell. Drugs of abuse in saliva: a review. J. Anal. Toxicol. 16: 1–9 (1992). 42. G. Skoand and L. Potsch. Perspiration versus saliva — basic aspects concerning their use in roadside drug testing. Int. J. Leg. Med. 112: 213–221 (1999). 43. V. Spiehler. Hair analysis by immunological methods from the beginning to 2000. Forensic Sci. Int. 107: 249–259 (2000). 44. S.J. Heishman, M.A. Huestis, J.E. Henningfield, and E.J. Cone. Acute and residual effects of marijuana: profiles of plasma THC levels, physiological, subjective, and performance measures. Pharmacol. Biochem. Behav. 37: 561–565 (1990). 45. E.J. Cone and M.A. Huestis. Relating blood concentrations of tetrahydrocannabinol and metabolites to pharmacologic effects and time of marijuana usage. Ther. Drug Monit. 15: 527–532 (1993). 46. M.A. Huestis, J.E. Henningfield, and E.J. Cone. Blood cannabinoids. I. Absorption of THC and formation of 11-OH-THC and THCCOOH during and after smoking marijuana. J. Anal. Toxicol. 16: 276–282 (1992). 47. M.A. Huestis, J.E. Henningfield, and E.J. Cone. Blood cannabinoids. II. Models for the prediction of time of marijuana exposure from plasma concentrations of delta-9-tetrahydrocannabinol (THC) and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THCCOOH). J. Anal. Toxicol. 16: 283–290 (1992). 48. M.A. Huestis, A.H. Sampson, B.J. Holicky, J.E. Henningfield, and E.J. Cone. Characterization of the absorption phase of marijuana smoking. Clin. Pharmacol. Ther. 52: 31–41 (1992). 49. D.E. Moody, L.F. Rittenhouse, and K.M. Monti. Analysis of forensic specimens for cannabinoids I. comparison of RIA and GC/MS analysis of blood. J. Anal. Toxicol. 16: 297–301 (1992). 50. D.E. Moody, K.M. Monti, and D.J. Crouch. Analysis of forensic specimens for cannabinoids. II. Relationship between blood delta-9-tetrahydrocannabinol and blood and urine 11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid concentrations. J. Anal. Toxicol. 16: 302–306 (1992). 51. M.A. Huestis and E.J. Cone. Urinary excretion half-life of 11-nor-9-carboxy-delta9-tetrahydrocannabinol in humans. Ther. Drug Monit. 20: 570–576 (1998). 52. P.M. Kemp, I.K. Abukhalaf, J.E. Manno, B.R. Manno, D.D. Alford, M.E. McWilliams, F.E. Nixon, M.J. Fitzgerald, R.R. Reeves, and M.J. Wood. Cannabinoids in humans. II. The influence of three methods of hydrolysis on the concentration of THC and two metabolites in urine. J. Anal. Toxicol. 19: 292–298 (1995). 53. P.C. Painter, J.H. Evans, J.D. Greenwood, and W.W. Fain. Urine cannabinoids monitoring. Diagn. Clin. Testing 27: 29–33 (1989). 54. G.M. Ellis, M.A. Mann, B.A. Judson, N.T. Schramm, and A. Tashchian. Excretion patterns of cannabinoid metabolites after last use in a group of chronic users. Clin. Pharmacol. Ther. 38: 572–578 (1985).


832


55. P.M. Kemp, I.K. Abukhalaf, J.E. Manno, B.R. Manno, D.D. Alford, and G.A. Abusada. Cannabinoids in humans. I. Analysis of delta-9-tetrahydrocannabinol and six metabolites in plasma and urine using GC-MS. J. Anal. Toxicol. 19: 285–291 (1995). 56. M.A. Huestis, J.M. Mitchell, and E.J. Cone. Lowering the federally mandated cannabinoid immunoassay cutoff increases true-positive results. Clin. Chem. 40: 729–733 (1994). 57. E.J. Cone and R.E. Johnson. Contact highs and urinary cannabinoid excretion after passive exposure to marijuana smoke. Clin. Pharmacol. Ther. 40: 247–254 (1986). 58. R.J. Bastiani. Urinary cannabinoid excretion patterns. In The Cannabinoids: Chemical, Pharmacologic, and Therapeutic Aspects, S. Agurell, W.L. Dewey, and R.E. Willette, Eds. Academic Press, Orlando, FL, 1984, 263–280. 59. E.J. Cone, R.E. Johnson, B.D. Paul, L.D. Mell, and J. Mitchell. Marijuana-laced brownies: behavioral effects, physiologic effects, and urinalysis in humans following ingestion. J. Anal. Toxicol. 12: 169–175 (1988). 60. E.J. Cone, R. Lange, and W.D. Darwin. In vivo adulteration: Excess fluid ingestion causes falsenegative marijuana and cocaine urine test results. J. Anal. Toxicol. 22: 460–473 (1998). 61. A. Costantino, R.H. Schwartz, and P. Kaplan. Hemp oil ingestion causes positive urine tests for delta9tetrahydrocanabinol carboxylic acid. J. Anal. Toxicol. 21: 482–485 (1997). 62. M.A. Huestis, J.M. Mitchell, and E.J. Cone. Urinary excretion profiles of 11-nor-9-carboxy-Δ9tetrahydrocannabinol in humans after single smoked doses of marijuana. J. Anal. Toxicol. 20: 441–452 (1996). 63. M.A. Huestis, J.M. Mitchell, and E.J. Cone. Detection times of marijuana metabolites in urine by immunoassay and GC-MS. J. Anal. Toxicol. 19: 443–449 (1995). 64. M.A. Huestis and E.J. Cone. Differentiating new marijuana use from residual drug excretion in occasional marijuana users. J. Anal. Toxicol. 22: 445–454 (1998). 65. D.S. Isenschmid and Y.H. Caplan. Incidence of cannabinoids in medical examiner urine specimens. J. Forensic Sci. 33(6): 1421–1431 (1988). 66. R.C. Meatherall and R.J. Warren. High urinary cannabinoids from a hashish body packer. J. Anal. Toxicol. 17: 439–440 (1993). 67. C. Tomaszewski, M. Kirk, E. Bingham, B. Saltzman, R. Cook, and K. Kulig. Urine toxicology screens in drivers suspected of driving while impaired from drugs. Clin. Toxicol. 34(1): 37–44 (1996). 68. R.A. Gustafson, B. Levine, P.R. Stout, K.L. Klette, M.P. George, E.T. Moolchan, and M.A. Huestis. Urinary cannabinoid detection times after controlled oral administration of delta9-tetrahydrocannabinol to humans. Clin. Chem. 49: 1114–1124 (2003). 69. M.A. Huestis, S. Dickerson, and E. J. Cone. Can saliva THC levels be correlated to behavior? In American Academy of Forensic Science, Fittje Brothers, Colorado Springs, 1992, 190. 70. N. Fucci, N. De Giovanni, M. Chiarotti, and S. Scarlata. SPME-GC analysis of THC in saliva samples collected with “EPITOPE” device. Forensic Sci. Int. 119: 318–321 (2001). 71. P. Kintz, V. Cirimele, and B. Ludes. Detection of cannabis in oral fluid (saliva) and forehead wipes (sweat) from impaired drivers. J. Anal. Toxicol. 24: 557–561 (2000). 72. D.B. Menkes, R.C. Howard, G.F.S. Spears, and E.R. Cairns. Salivary THC following cannabis smoking correlates with subjective intoxication and heart rate. Psychopharmacology 103: 277–279 (1991). 73. A. Jehanli, S. Brannan, L. Moore, and V.R. Spiehler. Blind trials of an onsite saliva drug test for marijuana and opiates. J. Forensic Sci. 46: 1214–1220 (2001). 74. P. Kintz, A. Tracqui, P. Mangin, and Y. Edel. Sweat testing in opioid users with a sweat patch. J. Anal. Toxicol. 20: 393–397 (1996). 75. N. Samyn and C. van Haeren. On-site testing of saliva and sweat with Drugwipe and determination of concentrations of drugs of abuse in saliva, plasma and urine of suspected users. Int. J. Legal Med. 113: 150–154 (2000). 76. D.J. Crouch, R.F. Cook, J.V. Trudeau, D.C. Dove, J.J. Robinson, H.L. Webster, and A.A. Fatah. The detection of drugs of abuse in liquid perspiration. J. Anal. Toxicol. 25: 625–627 (2001). 77. L.K. Thompson and E.J. Cone. Determination of delta-9-tetrahydrocannabinol in human blood and saliva by high-performance liquid chromatography with amperometric detection. J. Chromatogr. 421: 91–97 (1987). 78. P. Kintz. Drug testing in addicts: a comparison between urine, sweat, and hair. Ther. Drug Monit. 18: 450–455 (1996).


WORKPLACE TESTING

833

79. V. Cirimele, H. Sachs, P. Kintz, and P. Mangin. Testing human hair for cannabis. III. Rapid screening procedure for the simultaneous identification of delta9-tetrahydrocannabinol, cannabinol, and cannabidiol. J. Anal. Toxicol. 20: 13–16 (1996). 80. D. Wilkins, H. Haughey, E. Cone, M.A. Huestis, R. Foltz, and D. Rollins. Quantitative analysis of THC, 11-OH-THC, and THCCOOH in human hair by negative ion chemical ionization mass spectrometry. J. Anal. Toxicol. 19: 483–491 (1995). 81. T. Cairns, D. J. Kippenberger, H. Scholtz, and W. A. Baumgartner. Determination of carboxy-THC in hair by mass spectrometry. In Hair Analysis in Forensic Toxicology: Proceedings of the 1995 International Conference and Workshop, R.A. de Zeeuw, I. Al Hosani, S. Al Munthiri, and A. Maqbool, Eds. Organizing Committee of the Conference, Abu Dhabi, 1995, 185–193. 82. V. Cirimele. Cannabis and amphetamine determination in Human Hair. In Drug Testing in Hair, P. Kintz, Ed. CRC Press, Boca Raton, FL, 1996, 181–189. 83. C. Jurado, M.P. Gimenez, M. Menendez, and M. Repetto. Simultaneous quantification of opiates, cocaine and cannabinoids in hair. Forensic Sci. Int. 70: 165–174 (1995). 84. P. Kintz, V. Cirimele, and P. Mangin. Testing human hair for cannabis II. Identification of THC-COOH by GC-MS-NCI as a unique proof. J. Forensic Sci. 40: 619–622 (1995). 85. P. Kintz, V. Cirimele, and P. Mangin. Testing human hair for cannabis. Identification of natural ingredients of cannabis sativa metabolites of THC. In Hair Analysis in Forensic Toxicology: Proceedings of the 1995 International Conference and Workshop, R.A. de Zeeuw, I. Al Hosani, S. Al Munthiri, and A. Maqbool, Eds. Organizing Committee of the Conference, Abu Dhabi, 1995, 194–202. 86. S. Strano-Rossi and M. Chiarotti. Solid-phase microextraction for cannabinoids analysis in hair and its possible application to other drugs. J. Anal. Toxicol. 23: 7–10 (1999). 87. W.L. Wang, W.D. Darwin, and E.J. Cone. Simultaneous assay of cocaine, heroin and metabolites in hair, plasma, saliva and urine by gas chromatography-mass spectrometry. J. Chromatogr. 660: 279–290 (1994). 88. A.J. Jenkins, R.M. Keeenan, J.E. Henningfield, and E.J. Cone. Correlation between pharmacological effects and plasma cocaine concentrations after smoked administration. J. Anal. Toxicol. 26: 382–392 (2002). 89. R.H. Williams, J.A. Maggiore, S.M. Shah, T.B. Erickson, and A. Negrusz. Cocaine and its major metabolites in plasma and urine samples from patients in an urban emergency medicine setting. J. Anal. Toxicol. 24: 478–481 (2000). 90. E.T. Shimomura, G.D. Hodge, and B.D. Paul. Examination of postmortem fluids and tissues for the presence of methylecgonidine, ecgonidine, cocaine, and benzoylecgonine using solid-phase extraction and gas chromatography-mass spectrometry. Clin. Chem. 47: 1040–1047 (2001). 91. M.W. Linder, G.M. Bosse, M.T. Henderson, G. Midkiff, and R. Valdes. Detection of cocaine metabolite in serum and urine: frequency and correlation with medical diagnosis. Clin. Chim. Acta 295: 179–185 (2000). 92. E.T. Moolchan, E.J. Cone, A. Wstadik, M.A. Huestis, and K.L. Preston. Cocaine and metabolite elimination patterns in chronic cocaine users during cessation: plasma and saliva analysis. J. Anal. Toxicol. 24: 458–466 (2000). 93. J.C. Garriott, R.G. Rodriguez, and J.L. Castorena. Cocaine metabolites in urine and blood after ingestion of Health Inca Tea. SWAFS (1988). 94. R.A. Jufer, A. Wstadik, S.L. Walsh, B.S. Levine, and E.J. Cone. Elimination of cocaine and metabolites in plasma, saliva, and urine following repeated oral administration to human volunteers. J. Anal. Toxicol. 24: 467–477 (2000). 95. W. Schramm, P.A. Craig, R.H. Smith, and G.E. Berger. Cocaine and benzoylecgonine in saliva, serum, and urine. Clin. Chem. 39: 481–487 (1993). 96. A.J. Jenkins, J.M. Oyler, and E.J. Cone. Comparison of heroin and cocaine concentrations in saliva with concentrations in blood and plasma. J. Anal. Toxicol. 19: 359–374 (1995). 97. R. Kronstrand, R. Grundin, and J. Jonsson. Incidence of opiates, amphetamines, and cocaine in hair and blood in fatal cases of heroin overdose. Forensic Sci. Int. 92: 29–38 (1998). 98. D.N. Bailey. Serial plasma concentrations of cocaethylene, cocaine, and ethanol in trauma victims. J. Anal. Toxicol. 17: 79–83 (1993). 99. G.W. Hime, W.L. Hearn, S. Rose, and J. Cofino. Analysis of cocaine and cocaethylene in blood and tissues by GC-NPD and GC-ion trap mass spectrometry. J. Anal. Toxicol. 15: 241–245 (1991).


834


100. M. Perez-Reyes and A.R. Jeffcoat. Ethanol/cocaine interaction: cocaine and cocaethylene plasma concentrations and their relationship to subjective and cardiovascular effects. Life Sci. 51: 553–563 (1992). 101. P.R. Puopolo, P. Chamberlin, and J.G. Flood. Detection and confirmation of cocaine and cocaethylene in serum emergency toxicology specimens. Clin. Chem. 38: 1838–1842 (1992). 102. R.M. Smith. Ethyl esters of arylhydroxy-and arylhydroxymethoxycocaines in the urines of simultaneous cocaine and ethanol users. J. Anal. Toxicol. 8: 38–42 (1984). 103. J. Sukbuntherng, A. Walters, H.-H. Chow, and M. Mayersohn. Quantitative determination of cocaine, cocaethylene (ethylcocaine), and metabolites in plasma and urine by high-performance liquid chromatography. J. Pharm. Sci. 84(7): 799–804 (1995). 104. A.H.B. Wu, T.A. Onigbinde, K.G. Johnson, and G.H. Wimbish. Alcohol-specific cocaine metabolites in serum and urine of hospitalized patients. J. Anal. Toxicol. 16: 132–136 (1992). 105. J. Leonard, M. Doot, C. Martin, and W. Airth-Kindree. Correlation of buccal mucosal transudate collected with a buccal swab and urine levels of cocaine. J. Addict. Dis. 13: 27–33 (1994). 106. M.A. ElSohly, D.F. Stanford, and H.N. ElSohly. Coca tea and urinalysis for cocaine metabolites. J. Anal. Toxicol. 10: 256–256 (1986). 107. A.J. Jenkins, T. Llosa, I. Montoya, and E.J. Cone. Identification and quantitation of alkaloids in coca tea. Forensic Sci. Int. 77: 179–189 (1996). 108. K.L. Preston, D.H. Epstein, E.J. Cone, A.T. Wtsadik, M.A. Huestis, and E.T. Moolchan. Urinary elimination of cocaine metabolites in chronic cocaine users during cessation. J. Anal. Toxicol. 26: 393–400 (2002). 109. K.L. Preston, K. Silverman, C.R. Schuster, and E.J. Cone. Assessment of cocaine use with quantitative urinalysis and estimation of new uses. Addiction 92: 717–727 (1997). 110. K.M. Kampman, A.I. Alterman, J.R. Volpicelli, I. Maany, E.S. Muller, D.D. Luce, E.M. Mulholland, A.F. Jawad, G.A. Parikh, F.D. Mulvaney, R.M. Weinrieb, and C.P. O’Brien. Cocaine withdrawal symptoms and initial urine toxicology results predict treatment attrition in outpatient cocaine dependence treatment. Psychol. Addict. Behav. 15: 52–59 (2001). 111. D.M. Jacobson, R. Berg, G.F. Grinstead, and J.R. Kruse. Duration of positive urine for cocaine metabolite after ophthalmic administration: implications for testing patients with suspected Horner syndrome using ophthalmic cocaine. Am. J. Ophthalmol. 131: 742–747 (2001). 112. E.J. Cone, A. Tsadik, J. Oyler, and W.D. Darwin. Cocaine metabolism and urinary excretion after different routes of administration. Ther. Drug Monit. 20: 556–560 (1998). 113. E.J. Cone, S.L. Menchen, B.D. Paul, L.D. Mell, and J. Mitchell. Validity testing of commercial urine cocaine metabolites assays: I. Assay detection times, individual excretion patterns, and kinetics after cocaine administration to humans. J. Forensic Sci. 34: 15–31 (1989). 114. J. Ambre, T.I. Ruo, J. Nelson, and S. Belknap. Urinary excretion of cocaine, benzoylecgonine, and ecgonine methyl ester in humans. J. Anal. Toxicol. 12: 301–306 (1988). 115. F.K. Rafla and R.L. Epstein. Identification of cocaine and its metabolites in human urine in the presence of ethyl alcohol. J. Anal. Toxicol. 3: 59–63 (1979). 116. R. de La Torre, M. Farre, J. Ortuno, J. Cami, and J. Segura. The relevance of urinary cocaethylene following the simultaneous administration of alcohol and cocaine. J. Anal. Toxicol. 15: 223 (1991). 117. D.L. Phillips, I.R. Tebbett, and R.L. Bertholf. Comparison of HPLC and GC-MS for measurement of cocaine and metabolites in human urine. J. Anal. Toxicol. 20: 305–308 (1996). 118. F.P. Smith and D.A. Kidwell. Cocaine in hair, saliva, skin swabs, and urine of cocaine users’ children. Forensic Sci. Int. 83: 179–189 (1996). 119. E.J. Cone, J. Oyler, and W.D. Darwin. Cocaine disposition in saliva following intravenous, intranasal, and smoked administration. J. Anal. Toxicol. 21: 465–475 (1997). 120. K. Kato, M. Hillsgrove, L. Weinhold, D.A. Gorelick, W.D. Darwin, and E.J. Cone. Cocaine and metabolite excretion in saliva under stimulated and nonstimulated conditions. J. Anal. Toxicol. 17: 338–341 (1993). 121. R.S. Niedbala, K. Kardos, T. Fries, A. Cannon, and A. Davis. Immunoassay for detection of cocaine/metabolites in oral fluids. J. Anal. Toxicol. 25: 62–68 (2001). 122. E.J. Barbieri, G.J. DiGregorio, A.P. Ferko, and E.K. Ruch. Rat cocaethylene and benzoylecgonine concentrations in plasma and parotid saliva after the administration of cocaethylene. J. Anal. Toxicol. 18: 60–61 (1994).


WORKPLACE TESTING

835

123. P. Kintz, V. Cirimele, and B. Ludes. Codeine testing in sweat and saliva with the Drugwipe. Int. J. Leg. Med. 111: 82–84 (1998). 124. P. Campora, A.M. Bermejo, M.J. Tabernero, and P. Fernandez. Quantitation of cocaine and its major metabolites in human saliva using gas chromatography-positive chemical ionization-mass spectrometry (GC-PCI-MS). J. Anal. Toxicol. 27: 270–274 (2003). 125. M.A. Huestis, E.J. Cone, C.J. Wong, K. Silverman, and K.L. Preston. Efficacy of sweat patches to monitor cocaine and opiate use during treatment. Problems of Drug Dependence 1997: Proceedings of the 59th Annual Scientific Meeting, NIDA Monograph 187, p. 223, NIH Pub. No. 98-43051, National Institute of Drug Abuse, Rockville, MD (1997). 126. E.J. Cone, M.J. Hillsgrove, A.J. Jenkins, R.M. Keenan, and W.D. Darwin. Sweat testing for heroin, cocaine, and metabolites. J. Anal. Toxicol. 18: 298–305 (1994). 127. K.M. Hold, D.G. Wilkins, D.E. Rollins, R.E. Joseph, and E.J. Cone. Simultaneous quantitation of cocaine, opiates, and their metabolites in human hair by positive ion chemical ionization gas chromatographymass spectrometry. J. Chromatogr. Sci. 36: 125–130 (1998). 128. M.R. Moeller, P. Fey, and R. Wennig. Simultaneous determination of drugs of abuse (opiates, cocaine and amphetamine) in human hair by GC/MS and its application to a methadone treatment program. Forensic Sci. Int. 63: 185–206 (1993). 129. E.J. Cone, D. Yousefnejad, W.D. Darwin, and T. Maquire. Testing human hair for drugs of abuse. II. Identification of unique cocaine metabolites in hair of drug abusers and evaluation of decontamination procedures. J. Anal. Toxicol. 15: 250–255 (1991). 130. D. Garside and B. A. Goldberger. Determination of cocaine and opioids in hair. In Drug Testing in Hair, P. Kintz, Ed. CRC Press, Boca Raton, FL, 1996, 151–177. 131. P. Kintz and P. Mangin. Determination of gestational opiate, nicotine, benzodiazepine, cocaine and amphetamine exposure by hair analysis. J. Forensic Sci. Soc. 33: 139–142 (1993). 132. S. Magura, R.C. Freeman, Q. Siddiqi, and D.S. Lipton. The validity of hair analysis for detecting cocaine and heroin use among addicts. Int. J. Addict. 27: 51–69 (1992). 133. G. Pepin and Y. Gaillard. Concordance between self-reported drug use and findings in hair about cocaine and heroin. Forensic Sci. Int. 84: 37–41 (1997). 134. S. Strano-Rossi, A.B. Barrera, and M. Chiarotti. Segmental hair analysis for cocaine and heroin abuse determination. Forensic Sci. Int. 70: 211–216 (1995). 135. F. Tagliaro, R. Valentini, G. Manetto, F. Crivellente, G. Carli, and M. Marigo. Hair analysis by using radioimmunoassay, high-performance liquid chromatography and capillary electrophoresis to investigate chronic exposure to heroin, cocaine and/or ecstasy in applicants for driving licenses. Forensic Sci. Int 107: 121–128 (2000). 136. T. Cairns, D.J. Kippenberger, and A.M. Gordon. Hair analysis for detection of drugs of abuse. Handbook of Analytical Therapeutic Drug Monitoring and Toxicology, S.H.Y. Wong and I. Sunshine, Eds. CRC Press, Boca Raton, FL, 1997, 237–251. 137. A.C. Gruszecki, C.A. Robinson, Jr., J.H. Embry, and G.G. Davis. Correlation of the incidence of cocaine and cocaethylene in hair and postmortem biologic samples. Am. J. Forensic Med. Pathol. 21: 166–171 (2000). 138. K. Janzen. Concerning norcocaine, ethylbenzoylecgonine, and the identification of cocaine use in human hair. J. Anal. Toxicol. 16: 402 (1992). 139. J. Segura, C. Stramesi, A. Redon, M. Ventura, C.J. Sanchez, G. Gonzalez, L. San, and M. Montagna. Immunological screening of drugs of abuse and gas chromatographic-mass spectrometric confirmation of opiates and cocaine in hair. J. Chromatogr. B Biomed. Sci. Appl. 724: 9–21 (1999). 140. G.L. Henderson, M.R. Harkey, C. Zhou, R.T. Jones, and P. Jacob III. Incorporation of isotopically labeled cocaine and metabolites into human hair: 1. Dose–response relationships. J. Anal. Toxicol. 20: 1-12 (1996). 141. E.A. Kopecky, S. Jacobson, J. Klein, B. Kapur, and G. Koren. Correlation of morphine sulfate in blood plasma and saliva in pediatric patients. Ther. Drug Monit. 19: 530–534 (1997). 142. W. Piekoszewski, E. Janowska, R. Stanaszek, J. Pach, L. Winnik, B. Karakiewicz, and T. Kozielec. Determination of opiates in serum, saliva and hair addicted persons. Przegl. Lek. 58: 287–289 (2001). 143. M.R. Moeller and C. Mueller. The detection of 6-monoacetylmorphine in urine, serum and hair by GC/MS and RIA. Forensic Sci. Int. 70: 125–133 (1995).


836


144. L.W. Hayes, W.G. Krasselt, and P.A. Mueggler. Concentrations of morphine and codeine in serum and urine after ingestion of poppy seed. Clin. Chem. 33: 806–808 (1987). 145. A.J. Jenkins, R.M. Keenan, J.E. Henningfield, and E.J. Cone. Pharmacokinetics and pharmacodynamics of smoked heroin. J. Anal. Toxicol. 18: 317–330 (1994). 146. B.A. Goldberger, W.D. Darwin, T.M. Grant, A.C. Allen, Y.H. Caplan, and E.J. Cone. Measurement of heroin and its metabolites by isotope-dilution electron-impact mass spectrometry. Clin. Chem. 39: 670–675 (1993). 147. M.J. Burt, J. Kloss, and F.S. Apple. Postmortem blood free and total morphine concentrations in medical examiner cases. J. Forensic Sci. 46: 1138–1142 (2001). 148. G. Ceder and A.W. Jones. Concentration ratios of morphine to codeine in blood of impaired drivers as evidence of heroin use and not medication with codeine. Clin. Chem. 47: 1980–1984 (2001). 149. L.H. Yong and N.T. Lik. The human urinary excretion pattern of morphine and codeine following the consumption of morphine, opium, codeine and heroin. Bull. Narcotics 29: 45–74 (1977). 150. G.S. Yacoubian, Jr., E.D. Wish, and D.M. Perez. A comparison of saliva testing to urinalysis in an arrestee population. J. Psychoactive Drugs 33: 289–294 (2001). 151. S.J. Mule and G.A. Casella. Rendering the “poppy-seed defense” defenseless: Identification of 6monoacetylmorphine in urine by gas chromatography/mass spectroscopy. Clin. Chem. 34: 1427–1430 (1988). 152. M.L. Smith, E.T. Shimomura, J. Summers, B.D. Paul, D. Nichols, R. Shippee, A.J. Jenkins, W.D. Darwin, and E.J. Cone. Detection times and analytical performance of commercial urine opiate immunoassays following heroin administration. J. Anal. Toxicol. 24: 522–529 (2000). 153. A.C. Spanbauer, S. Casseday, D. Davoudzadeh, K.L. Preston, and M.A. Huestis. Detection of opiate use in a methadone maintenance treatment population with the CEDIA 6-acetylmorphine and CEDIA DAU opiate assays. J. Anal. Toxicol. 25: 515–519 (2001). 154. E.J. Cone, R. Jufer, and W.D. Darwin. Forensic drug testing for opiates. VII. Urinary excretion profile of intranasal (snorted) heroin. J. Anal. Toxicol. 20: 379–391 (1996). 155. E.J. Cone, P. Welch, J.M. Mitchell, and B.D. Paul. Forensic drug testing for opiates: I. Detection of 6-acetylmorphine in urine as an indicator of recent heroin exposure; Drug and assay considerations and detection times. J. Anal. Toxicol. 15: 1–7 (1991). 156. H.J.G.M. Derks, K.V. Twillert, and G. Zomer. Determination of 6-acetylmorphine in urine as a specific marker for heroin abuse by high-performance liquid chromatography with fluorescence detection. Anal. Chim. Acta 170: 13–20 (1985). 157. C.L. O’Neal and A. Poklis. The detection of acetylcodeine and 6-acetylmorphine in opiate positive urines. Forensic Sci. Int. 95: 1–10 (1998). 158. J.M. Mitchell, B.D. Paul, P. Welch, and E.J. Cone. Forensic drug testing for opiates. II. Metabolism and excretion rate of morphine in humans after morphine administration. J. Anal. Toxicol. 15: 49–53 (1991). 159. I.M. Speckl, J. Hallbach, W.G. Guder, L.V. Meyer, and T. Zilker. Opiate detection in saliva and urine — a prospective comparison by gas chromatography-mass spectrometry. J. Toxicol. Clin. Toxicol. 37: 441–445 (1999). 160. E.J. Cone, S. Dickerson, B.D. Paul, and J.M. Mitchell. Forensic drug testing for opiates. V. Urine testing for heroin, morphine, and codeine with commercial opiate immunoassays. J. Anal. Toxicol. 17: 156–164 (1993). 161. J. Fehn and G. Megges. Detection of O6-monoacetylmorphine in urine samples by GC/MS as evidence for heroin use. J. Anal. Toxicol. 9: 134–138 (1985). 162. G. Fritschi and W.R. Prescott, Jr. Morphine levels in urine subsequent to poppy seed consumption. Forensic Sci. Int. 27: 111–117 (1985). 163. M.A. Huestis, E.J. Cone, C.J. Wong, A. Umbricht, and K.L. Preston. Monitoring opiate use in substance abuse treatment patients with sweat and urine drug testing. J. Anal. Toxicol. 24: 509–521 (2000). 164. L. Presley, M. Lehrer, W. Seiter, D. Hahn, B. Rowland, M. Smith, K.W. Kardos, D. Fritch, S. Salamone, R.S. Niedbala, and E.J. Cone. High prevalence of 6-acetylmorphine in morphine-positive oral fluid specimens. Forensic Sci. Int. 133: 22–25 (2003). 165. J. Jones, K. Tomlinson, and C. Moore. The simultaneous determination of codeine, morphine, hydrocodone, hydromorphone, 6-acetylmorphine, and oxycodone in hair and oral fluid. J. Anal. Toxicol. 26: 171–175 (2002).


WORKPLACE TESTING

837

166. R.S. Niedbala, K. Kardos, J. Waga, D. Fritch, L. Yeager, S. Doddamane, and E. Schoener. Laboratory analysis of remotely collected oral fluid specimens for opiates by immunoassay. J. Anal. Toxicol. 25: 310–315 (2001). 167. P. Kintz, R. Brenneisen, P. Bundeli, and P. Mangin. Sweat testing for heroin and metabolites in a heroin maintenance program. Clin. Chem. 43: 736–739 (1997). 168. J.A. Levisky, D.L. Bowerman, W.W. Jenkins, and S.B. Karch. Drug deposition in adipose tissue and skin: evidence for an alternative source of positive sweat patch tests. Forensic Sci. Int. 110: 35–46 (2000). 169. D.A. Kidwell and F.P. Smith. Susceptibility of PharmChek drugs of abuse patch to environmental contamination. Forensic Sci. Int. 116: 89–106 (2001). 170. S. Darke, W. Hall, S. Kaye, J. Ross, and J. Duflou. Hair morphine concentrations of fatal heroin overdose cases and living heroin users. Addiction 97: 977–984 (2002). 171. B. Ahrens, F. Erdmann, G. Rochholz, and H. Schutz. Detection of morphine and monoacetylmorphine (MAM) in human hair. J. Anal. Chem. 344: 559–560 (1992). 172. E.J. Cone, W.D. Darwin, and W.L. Wang. The occurrence of cocaine, heroin and metabolites in hair of drug abusers. Forensic. Sci. Int. 63: 55–68 (1993). 173. P. Kintz, C. Jamey, V. Cirimele, R. Brenneisen, and B. Ludes. Evaluation of acetylcodeine as a specific marker of illicit heroin in human hair. J. Anal. Toxicol. 22: 425–429 (1998). 174. B.A. Goldberger, Y.H. Caplan, T. Maguire, and E.J. Cone. Testing human hair for drugs of abuse. III. Identification of heroin and 6-acetylmorphine as indicators of heroin use. J. Anal. Toxicol. 15: 226–231 (1991). 175. C.L. O’Neal, D.J. Crouch, D.E. Rollins, A. Fatah, and M.L. Cheever. Correlation of saliva codeine concentrations with plasma concentrations after oral codeine administration. J. Anal. Toxicol. 23: 452–459 (1999). 176. M.K. Brunson and J.F. Nash. Gas-chromatographic measurement of codeine and norcodeine in human plasma. Clin. Chem. 21: 1956–1960 (1975). 177. I. Kim, A.J. Barnes, J.M. Oyler, R. Schepers, R.E. Joseph, Jr., E.J. Cone, D. Lafko, E.T. Moolchan, and M.A. Huestis. Plasma and oral fluid pharmacokinetics and pharmacodynamics after oral codeine administration. Clin. Chem. 48: 1486–1496 (2002). 178. R.J. Schepers, J.M. Oyler, R.E. Joseph, Jr., E.J. Cone, E.T. Moolchan, and M.A. Huestis. Methamphetamine and amphetamine pharmacokinetics in oral fluid and plasma after controlled oral methamphetamine administration to human volunteers. Clin. Chem. 49: 121–132 (2003). 179. E.J. Cone, P. Welch, B.D. Paul, and J.M. Mitchell. Forensic drug testing for opiates. III. Urinary excretion rates of morphine and codeine following codeine administration. J. Anal. Toxicol. 15: 161–166 (1991). 180. H.N. ElSohly, D.F. Stanford, A.B. Jones, M.A. ElSohly, H. Snyder, and C. Pedersen. Gas chromatographic/mass spectrometric analysis of morphine and codeine in human urine of poppy seed eaters. J. Forensic Sci. 33: 347–356 (1988). 181. P. Lafolie, O. Beck, Z. Lin, F. Albertioni, and L. Boreus. Urine and plasma pharmacokinetics of codeine in healthy volunteers: implications for drugs-of-abuse testing. J. Anal. Toxicol. 20: 541–546 (1996). 182. F. Mari and E. Bertol. Observations on urinary excretion of codeine in illicit heroin addicts. J. Pharm. Pharmacol. 33: 814–815 (1981). 183. J.M. Oyler, E.J. Cone, R.E. Joseph, Jr., and M.A. Huestis. Identification of hydrocodone in human urine following controlled codeine administration. J. Anal. Toxicol. 24: 530–535 (2000). 184. G. Ceder and A.W. Jones. Concentrations of unconjugated morphine, codeine and 6-acetylmorphine in urine specimens from suspected drugged drivers. J. Forensic Sci: 366–368 (2002). 185. M.E. Sharp, S.M. Wallace, K.W. Hindmarsh, and H.W. Peel. Monitoring saliva concentrations of methaqualone, codeine, secobarbital, diphenhydramine and diazepam after single oral doses. J. Anal. Toxicol. 7: 11–14 (1983). 186. G.J. Di-Gregorio, A.J. Piraino, B.T. Nagle, and E.K. Knaiz. Secretion of drugs by the parotid glands of rats and human beings. J. Dental Res. 56: 502–509 (1977). 187. C.L. O’Neal, D.J. Crouch, D.E. Rollins, and A.A. Fatah. The effects of collection methods on oral fluid codeine concentrations. J. Anal. Toxicol. 24: 536–542 (2000). 188. G. Skopp, L. Potsch, K. Klinder, B. Richter, R. Aderjan, and R. Mattern. Saliva testing after single and chronic administration of dihydrocodeine. Int. J. Legal Med. 114: 133–140 (2001).


838


189. P. Kintz, A. Tracqui, C. Jamey, and P. Mangin. Detection of codeine and phenobarbital in sweat collected with a sweat patch. J. Anal. Toxicol. 20: 197–201 (1996). 190. A. Tracqui, P. Kintz, B. Ludes, C. Jamey, and P. Mangin. The detection of opiate drugs in nontraditional specimens (clothing): a report of ten cases. J. Forensic Sci. 40: 263–265 (1995). 191. D.E. Rollins, D.G. Wilkins, G.G. Krueger, M.P. Augsberger, A. Mizuno, C. O’Neal, C.R. Borges, and M.H. Slawson. The effect of hair color on the incorporation of codeine into human hair. J. Anal. Toxicol. 27: 545–551 (1999). 192. V. Cirimele, P. Kintz, and P. Mangin. Drug concentrations in human hair after bleaching. J. Anal. Toxicol. 19: 331 (1995). 193. S.P. Gygi, R.E. Joseph, Jr., E.J. Cone, D.G. Wilkins, and D.E. Rollins. Incorporation of codeine and metabolites into hair. Role of pigmentation. Drug Metab. Dispos. 24: 495–501 (1996). 194. R. Kronstrand, S. Forstberg-Peterson, B. Kagedal, J. Ahlner, and G. Larson. Codeine concentration in hair after oral administration is dependent on melanin content. Clin. Chem. 45: 1485–1494 (1999). 195. H. Sachs, R. Denk, and I. Raff. Determination of dihydrocodeine in hair of opiate addicts by GC/MS. Intl. J. Legal. Med. 105: 247–250 (1993). 196. M. Scheller and H. Sachs. The detection of codeine abuse by hair analysis. Dtsch. Med. Wochenschr. 115: 1313–1315 (1990). 197. D.G. Wilkins, H.M. Haughey, G.G. Krueger, and D.E. Rollins. Disposition of codeine in female human hair after multiple-dose administration. J. Anal. Toxicol. 19: 492–498 (1995). 198. D.N. Bailey and J.J. Guba. Gas-chromatographic analysis for phencyclidine in plasma, with use of a nitrogen detector. Clin. Chem. 26: 437–440 (1980). 199. D.N. Bailey. Phencyclidine abuse. Clinical findings and concentrations in biological fluids after nonfatal intoxication. Am. J. Clin. Pathol. 72: 795–799 (1979). 200. D.N. Bailey, R.F. Shaw, and J.J. Guba. Phencyclidine abuse: Plasma levels and clinical findings in casual users and in phencyclidine-related deaths. J. Anal. Toxicol. 2: 233–237 (1978). 201. C.E. Cook, D.R. Brine, A.R. Jeffcoat, J.M. Hill, M.E. Wall, M. Perez-Reyes, and S.R. DiGuiseppi. Phencyclidine disposition after intravenous and oral doses. Clin. Pharmacol. Ther. 31: 625–634 (1982). 202. E.F. Domino and A.E. Wilson. Effects of urine acidification on plasma and urine phencyclidine levels in overdosage. Clin. Pharmacol. Ther. 22: 421–424 (1977). 203. J.O. Donaldson and R.C. Baselt. CSF phencyclidine. Am. J. Psychiatry 136: 1341–1342 (1979). 204. S. Kerrigan and J.W. Phillips, Jr. Comparison of ELISAs for opiates, methamphetamine, cocaine metabolite, benzodiazepines, phencyclidine, and cannabinoids in whole blood and urine. Clin. Chem. 47: 540–547 (2001). 205. G.W. Kunsman, B. Levine, A. Costantino, and M.L. Smith. Phencyclidine blood concentrations in DRE cases. J. Anal. Toxicol. 21: 498–502 (1997). 206. A.L. Misra, R.B. Pontani, and J. Bartolomeo. Persistence of phencyclidine (PCP) and metabolites in brain and adipose tissue and implications for long-lasting behavioural effects. Res. Commun. Chem. Path. Pharmacol. 24: 431–445 (1979). 207. A.E. Wilson and E.F. Domino. Plasma phencyclidine pharmacokinetics in dog and monkey using a gas chromatography selected ion monitoring assay. Biomed. Mass Spectrom. 5: 112–116 (1978). 208. D.N. Bailey. Percutaneous absorption of phencyclidine hydrochloride in vivo. Res. Commun. Subst. Abuse 1: 443–450 (1980). 209. W. Bronner, P. Nyman, and D. von Minden. Detectability of phencyclidine and 11-nor-delta-9tetrahydrocannabinol-9-carboxylic acid in adulterated urine by radioimmunoassay and fluorescence polarization immunoassay. J. Anal. Toxicol. 14: 368–371 (1990). 210. E.J. Cone, D.B. Vaupel, and D. Yousefnejad. Monohydroxymetabolites of phencyclidine (PCP): activities and urinary excretion by rat, dog, and mouse. J. Pharm. Pharmacol. 34: 197–199 (1982). 211. C.C. Stevenson, D.L. Cibull, G.E. Platoff, D.M. Bush, and J.A. Gere. Solid phase extraction of phencyclidine from urine followed by capillary gas chromatography/mass spectrometry. J. Anal. Toxicol. 16: 337–339 (1992). 212. D.N. Bailey and J.J. Guba. Measurement of phencyclidine in saliva. J. Anal. Toxicol. 4: 311–313 (1980). 213. M.M. McCarron, C.B. Walberg, J.R. Soares, S.J. Gross, and R.C. Baselt. Detection of phencyclidine usage by radioimmunoassay of saliva. J. Anal. Toxicol. 8: 197–201 (1984).


WORKPLACE TESTING

839

214. W.A. Baumgartner, V.A. Hill, and W.H. Blahd. Hair analysis for drugs of abuse. J. Forensic Sci. 34: 1433–1453 (1989). 215. T. Sakamoto and A. Tanaka. Determination of PCP and its major metabolites, PCHP and PPC, in rat hair after administration of PCP. In Proceedings of the 1994 JOINT TIAFT/SOFT International Meeting, V. Spiehler, Ed. TIAFT/SOFT Joint Congress, 1994, 215–224. 216. D.A. Kidwell. Analysis of phencyclidine and cocaine in human hair by tandem mass spectrometry. J. Forensic Sci. 38: 272–284 (1993). 217. Y. Nakahara, K. Takahashi, T. Sakamoto, A. Tanaka, V.A. Hill, and W.A. Baumgartner. Hair analysis for drugs of abuse XVII. Simultaneous detection of PCP, PCHP, and PCPdiol in human hair for confirmation of PCP use. J. Anal. Toxicol. 21: 356–362 (1997). 218. T. Sakamoto, A. Tanaka, and Y. Nakahara. Hair analysis for drugs of abuse XII. Determination of PCP and its major metabolites, PCHP and PPC, in rat hair after administration of PCP. J. Anal. Toxicol. 20: 124–130 (1996). 219. Y. Nakahara, R. Kikura, T. Sakamoto, T. Mieczkowski, F. Tagliaro, and R. L. Foltz. Findings in hair analysis for some hallucinogens (LSD, MDA/MDMA and PCP). In Hair Analysis in Forensic Toxicology: Proceedings of the 1995 International Conference and Workshop, R.A. de Zeeuw, I. Al Hosani, and S. Al Munthiri, Eds. Organizing Committee of the Conference, Abu Dhabi, 1995, 161–184. 220. H. Gjerde, I. Hasvold, G. Pettersen, and A.S. Christophersen. Determination of amphetamine and methamphetamine in blood by derivatization with perfluorooctanoyl chloride and gas chromatography/mass spectrometry. J. Anal. Toxicol. 17: 65–68 (1993). 221. S. Cheung, H. Nolte, S.V. Otton, R.F. Tyndale, P.H. Wu, and E.M. Sellers. Simultaneous gas chromatographic determination of methamphetamine, amphetamine and their p-hydroxylated metabolites in plasma and urine. J. Chromatogr. 690: 77–87 (1997). 222. Y. Gaillard, F. Vayssette, and G. Pepin. Compared interest between hair analysis and urinalysis in doping controls. Results for amphetamines, corticosteroids and anabolic steroids in racing cyclists. Forensic Sci. Int 107: 361–379 (2000). 223. S.B. Matin, S.H. Wan, and J.B. Knight. Quantitative determination of enantiomeric compounds. I:Simultaneous measurement of the optical isomers of amphetamine in human plasma and saliva using chemical ionization mass spectrometry. Biomed. Mass Spectrom. 4: 118–121 (1977). 224. F.P. Smith. Detection of amphetamine in bloodstains, semen, seminal stains, saliva, and saliva stains. Forensic Sci. Int. 17: 225–228 (1981). 225. J.M. Davis, I.J. Kopin, L. Lemberger, and J. Axelrod. Effects of urinary pH on amphetamine metabolism. Ann. N. Y. Acad. Sci. 179: 493–501 (1971). 226. B.D. Paul, M.R. Past, R.M. McKinley, J.D. Foreman, L.K. McWhorter, and J.J. Snyder. Amphetamine as an artifact of methamphetamine during periodate degradation of interfering ephedrine, pseudoephedrine, and phenylpropanolamine: an improved procedure for accurate quantitation of amphetamines in urine. J. Anal. Toxicol. 18: 331–336 (1994). 227. G.A. Alles and B.B. Wisegarver. Amphetamine excretion studies in man. Toxicol. App. Pharmacol. 3: 678–688 (1961). 228. A.H. Beckett and M. Rowland. Determination and identification of amphetamine in urine. J. Pharm. Pharmacol. 17: 59–60 (1965). 229. J. D’Nicuola, R. Jones, B. Levine, and M.L. Smith. Evaluation of six commercial amphetamine and methamphetamine immunoassays for cross-reactivity to phenylpropanolamine and ephedrine in urine. J. Anal. Toxicol. 16: 211–213 (1992). 230. A.H. Beckett and M. Rowland. Urinary excretion kinetics of amphetamine in man. J. Pharm. Pharmacol. 17: 628–638 (1965). 231. D.E. Blandford and P.R.E. Desjardins. Detection and identification of amphetamine and methamphetamine in urine by GC/MS. Clin. Chem. 40: 145–147 (1994). 232. J.T. Cody and S. Valtier. Detection of amphetamine and methamphetamine following administration of benzphetamine. J. Anal. Toxicol. 22: 299–309 (1998). 233. B.K. Gan, D. Baugh, R.H. Liu, and A.S. Walia. Simultaneous analysis of amphetamine, methamphetamine, and 3,4-methylenedioxymethamphetamine MDMA in urine samples by solid-phase extraction, derivatization, and gas chromatography/mass spectrometry. J. Forensic Sci. 36: 1331–1341 (1991). 234. L.M. Gunne. The urinary output of d-and l-amphetamine in man. Biochem. Pharmacol. 16: 863–869 (1967).


840


235. S.J. Mule and G.A. Casella. Confirmation of marijuana, cocaine, morphine, codeine, amphetamine, methamphetamine, phencyclidine by GC/MS in urine following immunoassay screening. J. Anal. Toxicol. 12: 102–107 (1988). 236. A. Nice and A. Maturen. False-positive urine amphetamine screen with Ritodrine. Clin. Chem. 35: 1542– (1989). 237. J.L. Valentine, G.L. Kearns, C. Sparks, L.G. Letzig, C.R. Valentine, S.A. Shappell, D.F. Neri, and C.A. DeJohn. GC/MS determination of amphetamine and methamphetamine in human urine for 12 hours following oral administration of dextro-methamphetamine: Lack of evidence supporting the established forensic guidelines for methamphetamine confirmation. J. Anal. Toxicol. 19: 581–590 (1995). 238. M.R. Peace, L.D. Tarnai, and A. Poklis. Performance evaluation of four on-site drug-testing devices for detection of drugs of abuse in urine. J. Anal. Toxicol. 24: 589–594 (2000). 239. A. Poklis and K.A. Moore. Response of EMIT amphetamine immunoassays to urinary desoxyephedrine following Vicks inhaler use. Ther. Drug Monit. 17: 89–94 (1995). 240. A. Smith-Kielland, B. Skuterud, and J. Morland. Urinary excretion of amphetamine after termination of drug abuse. J. Anal. Toxicol. 21: 325–329 (1997). 241. H. Vapaatalo, S. Karkkainen, and K.E.O. Senius. Comparison of saliva and urine samples in thinlayer chromatographic detection of central nervous stimulants. Int. J. Clin. Pharmacol. 1: 5–8 (1984). 242. E.M. Thurman, M.J. Pedersen, R.L. Stout, and T. Martin. Distinguishing sympathomimetic amines from amphetamine and methamphetamine in urine by gas chromatography/mass spectrometry. J. Anal. Toxicol. 16: 19–27 (1992). 243. K. Takahashi. Determination of methamphetamine and amphetamine in biological fluids and hair by gas chromatography. Dep. Legal Med. 38: 319–336 (1984). 244. S.H. Wan, S.B. Matin, and D.L. Azarnoff. Kinetics, salivary excretion of amphetamine isomers, and effect of urinary pH. Clin. Pharmacol. Ther. 23: 585–590 (1978). 245. T.B. Vree, A.T. Muskens, and J.M. Van Rossum. Excretion of amphetamines in human sweat. Arch. Int. Pharmacodyn. Ther. 199: 311–317 (1972). 246. Y. Nakahara and R. Kikura. Hair analysis for drugs of abuse. XIII. Effect of structural factors on incorporation of drugs into hair: the incorporation rates of amphetamine analogs. Arch. Toxicol. 70: 841–849 (1996). 247. M. Rothe, F. Pragst, K. Spiegel, T. Harrach, K. Fischer, and J. Kunkel. Hair concentrations and selfreported abuse history of 20 amphetamine and ecstasy users. Forensic Sci. Int. 89: 111–128 (1997). 248. F. Musshoff, H.P. Junker, D.W. Lachenmeier, L. Kroener, and B. Madea. Fully automated determination of amphetamines and synthetic designer drugs in hair samples using headspace solid-phase microextraction and gas chromatography-mass spectrometry. J. Chromatogr. Sci. 40: 359–364 (2002). 249. F. Musshoff, D.W. Lachenmeier, L. Kroener, and B. Madea. Automated headspace solid-phase dynamic extraction for the determination of amphetamines and synthetic designer drugs in hair samples. J. Chromatogr. A 958: 231–238 (2002). 250. P. Kintz and V. Cirimele. Interlaboratory comparison of quantitative determination of amphetamine and related compounds in hair samples. Forensic Sci. Int. 84: 151–156 (1997). 251. D.L. Allen and J.S. Oliver. The use of supercritical fluid extraction for the determination of amphetamines in hair. Forensic Sci. Int. 107: 191–199 (2000). 252. P. Kintz, V. Cirimele, A. Tracqui, and P. Mangin. Simultaneous determination of amphetamine, methamphetamine, 3,4-methylenedioxyamphetamine and 3,4-methylenedioxymethamphetamine in human hair by gas chromatography-mass spectrometry. J. Chromatogr. 670: 162–166 (1995). 253. J. Rohrich and G. Kauert. Determination of amphetamine and methylenedioxy-amphetamine-derivatives in hair. Forensic Sci. Int. 84: 179–188 (1997). 254. O. Suzuki, H. Hattori, and M. Asano. Detection of methamphetamine and amphetamine in a single human hair by gas chromatography/chemical ionization mass spectrometry. J. Forensic Sci. 29: 611–617 (1984). 255. R. Kikura and Y. Nakahara. Distinction between amphetamine-like OTC drug use and illegal amphetamine/methamphetamine use by hair analysis. In Proceedings of the 1994 JOINT TIAFT/SOFT International Meeting, V. Spiehler, Ed. TIAFT/SOFT, 1994, 236–247. 256. B.K. Logan, C.L. Fligner, and T. Haddix. Cause and manner of death in fatalities involving methamphetamine. J. Forensic Sci. 43(1): 28–34 (1998).


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257. B.K. Logan. Methamphetamine and driving impairment. J. Forensic Sci. 41: 457–464 (1996). 258. S. Rasmussen, R. Cole, and V. Spiehler. Methamphetamine in antemortem blood and urine by radioimmunoassay and GC/MS. J. Anal. Toxicol. 13: 263–267 (1989). 259. V.R. Spiehler, I.B. Collison, P.R. Sedgwick, S.L. Perez, S.D. Le, and D.A. Farnin. Validation of an automated microplate enzyme immunoassay for screening of postmortem blood for drugs of abuse. J. Anal. Toxicol. 22: 573–579 (1998). 260. R.C. Driscoll, F.S. Barr, B.J. Gragg, and G.W. Moore. Determination of therapeutic blood levels of methamphetamine and pentobarbital by GC. J. Pharm. Sci. 60(10): 1492–1495 (1971). 261. R.L. Fitzgerald, J.M. Ramos, S.C. Bogema, and A. Poklis. Resolution of methamphetamine stereoisomers in urine drug testing: Urinary excretion of R(–)-methamphetamine following use of nasal inhalers. J. Anal. Toxicol. 12: 255–259 (1988). 262. J.T. Cody. Determination of methamphetamine enantiomer ratios in urine by gas chromatographymass spectrometry. J. Chromatogr. 580: 77–95 (1992). 263. J. Sukbuntherng, A. Hutchaleelaha, H.H. Chow, and M. Mayersohn. Separation and quantitation of the enantiomers of methamphetamine and its metabolites in urine by HPLC: precolumn derivatization and fluorescence detection. J. Anal. Toxicol. 19: 139–147 (1995). 264. C.L. Hornbeck, J.E. Carrig, and R.J. Czarny. Detection of a GC/MS artifact peak as methamphetamine. J. Anal. Toxicol. 17: 257–263 (1993). 265. M.R. Lee, S.C. Yu, C.L. Lin, Y.C. Yeh, Y.L. Chen, and S.H. Hu. Solid-phase extraction in amphetamine and methamphetamine analysis of urine. J. Anal. Toxicol. 21: 278–282 (1997). 266. K. McCambly, R.C. Kelly, T. Johnson, J.E. Johnson, and W.C. Brown. Robotic solid-phase extraction of amphetamines from urine for analysis by gas chromatography-mass spectrometry. J. Anal. Toxicol. 21: 438–444 (1997). 267. A. Poklis and K.A. Moore. Stereoselectivity of the TDxADx/FLx amphetamine/methamphetamine II amphetamine/methamphetamine immunoassays — Response of urine specimens following nasal inhaler use. Clin. Toxicol. 33: 35–41 (1995). 268. J.M. Oyler, E.J. Cone, R.E. Joseph, Jr., E.T. Moolchan, and M.A. Huestis. Duration of detectable methamphetamine and amphetamine excretion in urine after controlled oral administration of methamphetamine to humans. Clin. Chem. 48: 1703–1714 (2002). 269. S. Suzuki, T. Inoue, H. Hori, and S. Inayama. Analysis of methamphetamine in hair, nail, sweat, and saliva by mass fragmentography. J. Anal. Toxicol. 13: 176–178 (1989). 270. J. Fay, R. Fogerson, D. Schoendorfer, R.S. Niedbala, and V. Spiehler. Detection of methamphetamine in sweat by EIA and GC-MS. J. Anal. Toxicol. 20: 398–403 (1996). 271. Y.C. Yoo, H.S. Chung, H.K. Choi, and W.K. Jin. Determination of methamphetamine in the hair of Korean drug abusers by GC/MS. In Proceedings of the 1994 JOINT TIAFT/SOFT International Meeting, V. Spiehler, Ed. TIAFT/SOFT Joint Congress, 1994, 207–214. 272. I. Ishiyama, T. Nagai, and S. Toshida. Detection of basic drugs (methamphetamine, antidepressants, and nicotine) from human hair. J. Forensic Sci. 28: 380–385 (1983). 273. R. Kikura and Y. Nakahara. Hair analysis for drugs of abuse. IX. Comparison of deprenyl use and methamphetamine use by hair analysis. Biol. Pharm. Bull. 18: 267–272 (1995). 274. Y. Nakahara, R. Kikura, M. Yasuhara, and T. Mukai. Hair analysis for Drug Abuse XIV. Identification of substances causing acute poisoning using hair root. I. Methamphetamine. Forensic Sci. Int. 84: 157–164 (1997). 275. S. Suzuki, T. Inoue, T. Yasuda, T. Niwaguchi, H. Hori, and S. Inayama. Analysis of methamphetamine in human hair by fragmentography. Eisei Kagaku 30: 23–26 (1984). 276. M.R. Moeller and M. Hartung. Ecstasy and related substances — Serum levels in impaired drivers. J. Anal. Toxicol. 21: 501–501 (1997). 277. M. Navarro, S. Pichini, M. Farre, J. Ortuno, P.N. Roset, J. Segura, and R. de la Torre. Usefulness of saliva for measurement of 3,4-methylenedioxymethamphetamine and its metabolites: correlation with plasma drug concentrations and effect of salivary pH. Clin. Chem. 47: 1788–1795 (2001). 278. T.P. Rohrig and R.W. Prouty. Tissue distribution of methylenedioxymethamphetamine. J. Anal. Toxicol. 16: 52–53 (1992). 279. R. de la Torre, M. Farre, J. Ortuno, M. Mas, R. Brenneisen, P.N. Roset, J. Segura, and J. Cami. Nonlinear pharmacokinetics of MDMA (“ecstasy”) in humans. Br. J. Clin. Pharmacol. 49: 104–109 (2000).


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280. T. Kraemer and H.H. Maurer. Toxicokinetics of amphetamines: metabolism and toxicokinetic data of designer drugs, amphetamine, methamphetamine, and their N-alkyl derivatives. Ther. Drug Monit. 24: 277–289 (2002). 281. N. Samyn, G. De Boeck, M. Wood, C.T. Lamers, D. De Waard, K.A. Brookhuis, A.G. Verstraete, and W.J. Riedel. Plasma, oral fluid and sweat wipe ecstasy concentrations in controlled and real life conditions. Forensic Sci. Int. 128: 90–97 (2002). 282. A. Poklis, R.L. Fitzgerald, K.V. Hall, and J.J. Saady. EMIT-d.a.u. monoclonal amphetamine/methamphetamine assay. II. Detection of methylenedioxyamphetamine (MDA) and methylenedioxymethamphetamine (MDMA). Forensic Sci. Int. 59: 63–70 (1993). 283. G.W. Kunsman, B. Levine, J.J. Kuhlman, R.L. Jones, R.O. Hughes, C.I. Fujiyama, and M.L. Smith. MDA-MDMA concentrations in urine specimens. J. Anal. Toxicol. 20: 517–521 (1996). 284. J.M. Ramos, Jr., R.L. Fitzgerald, and A. Poklis. MDMA and MDA cross reactivity observed with Abbott TDx amphetamine/methamphetamine reagents. Clin. Chem. 34: 991– (1988). 285. H.H. Maurer, J. Bickeboeller-Friedrich, T. Kraemer, and F.T. Peters. Toxicokinetics and analytical toxicology of amphetamine-derived designer drugs (“Ecstasy”). Toxicol. Lett. 112–113: 133–142 (2000). 286. R. Pacifici, M. Farre, S. Pichini, J. Ortuno, P.N. Roset, P. Zuccaro, J. Segura, and R. de la Torre. Sweat testing of MDMA with the Drugwipe analytical device: a controlled study with two volunteers. J. Anal. Toxicol. 25: 144–146 (2001). 287. S. Pichini, M. Navarro, R. Pacifici, P. Zuccaro, J. Ortuno, M. Farre, P.N. Roset, J. Segura, and R. de la Torre. Usefulness of sweat testing for the detection of MDMA after a single-dose administration. J. Anal. Toxicol. 27: 294–303 (2003). 288. F. Tagliaro, Z. De Battisti, A. Groppi, Y. Nakahara, D. Scarcella, R. Valentini, and M. Marigo. High sensitivity simultaneous determination in hair of the major constituents of ecstasy (3,4-methylenedioxymethamphetamine, 3,4-methylenedioxyamphetamine and 3,4-methylene-dioxyethylamphetamine) by high-performance liquid chromatography with direct fluorescence detection. J. Chromatogr. B Biomed. Sci. Appl. 723: 195–202 (1999). 289. M. Uhl. Tandem mass spectrometry: a helpful tool in hair analysis for the forensic expert. Forensic Sci. Int 107: 169–179 (2000). 290. Y. Nakahara and R. Kikura. Hair analysis for drugs of abuse. XVIII. 3,4-Methylenedioxymethamphetamine (MDMA) disposition in hair roots and use in identification of acute MDMA poisoning. Biol. Pharm. Bull. 20: 969–972 (1997). 291. C. Girod and C. Staub. Analysis of drugs of abuse in hair by automated solid-phase extraction, GC/EI/MS and GC ion trap/CI/MS. Forensic Sci. Int. 107: 261–271 (2000). 292. R. Kikura, Y. Nakahara, T. Mieczkowski, and F. Tagliaro. Hair analysis for Drug Abuse XV. Disposition of 3,4-methylenedioxymethamphetamine (MDMA) and its related compounds into rat hair and application to hair analysis for MDMA abuse. Forensic Sci. Int. 84: 165–177 (1997).

10.7 SPECIMEN VALIDITY TESTING

Yale H. Caplan, Ph.D., DABFT National Scientific Services, Baltimore, Maryland

Urine drug testing is, by its nature and the privacy considerations, decisions, and laws of the federal government and the states, an unobserved process. This is the standard practice unless there is specific individual suspicion that a specimen has been altered or substituted. Although the practice of tampering had been reported prior to the implementation of the federally regulated workplace drug-testing program, the problem became evident in the 1990s with the introduction of “Urine Aid” and later “Klear,” products among others advertised to “Beat a Drug Test.” Earlier methods were crude and often ineffective utilizing more commonly available products such as salt, bleach, soap, and vinegar and sharing information about such products by “word of mouth.” Later a


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significant cottage industry grew through health food stores, advertisements in High Times and other magazines and extensive citation on the Internet. How effective can a drug-testing program be if a magic potion priced at $20 to $30 can provide a person a means to evade detection? In a deterrent-based program, credibility can rapidly decline if users believe they can beat the test. The Department of Health and Human Services (HHS) and the Department of Transportation (DOT) developed countermeasures by causing laboratories to inspect and test specimens, verify their normal composition, and search for foreign chemicals. The term specimen validity testing (SVT) was coined to identify a sequence of testing designed to check if urine was really urine and if the urine was normal or adulterated. This task was not so simple. Laboratories developed credible tests for the five classes of drugs, substances of known composition and predictable outcome, and were now faced with developing tests for a variety of specimen characteristics and an array of unknown compounds. Indeed, the task of comprehensively searching for normal elements that comprise urine and ascertaining that no foreign materials have been added can be more complex and costly than the drug testing itself. The intent of the donor is to subvert the drug testing procedure and create a false negative result. This can be accomplished in three ways: (1) by diluting the urine through excessive fluid intake, (2) by substituting other urine, hopefully drug free urine, in place of the donor’s urine, and (3) adulterating the urine by adding a chemical to the specimen that either destroys the drug in the urine or otherwise interferes with the laboratory immunoassay tests. 10.7.1 Characteristics of Urine Urine is an aqueous solution produced by the kidneys. A review of urine characterization with emphasis on workplace testing has been compiled.1 Urine’s major constituents are primarily electrolytes, metabolic excretory products, and other substances eliminated through the kidneys. The initial characterization of a urine specimen is based on its appearance. Color, clarity, odor, and foaming properties contribute to the appearance of urine. The color of a urine specimen is related to the concentration of its various constituents, most notably urochromes, which exhibit yellow, brown, and red pigments. A normal first morning void has a distinct deep yellow color. It should not be colorless. The characteristic yellow color is predominately caused by the presence of urobilinogen, a hemoglobin breakdown product. After hydration, urine is usually straw-colored, indicating dilute urine. Very dilute urine is essentially colorless and has a water-like appearance. A normal fresh void is clear and transparent. Freshly voided urine that is cloudy or turbid can indicate the presence of white blood cells, red blood cells, epithelial cells, or bacteria. Upon standing, flaky precipitates from urinary tract mucin may appear in the specimen. Aged alkaline urine may become cloudy because of crystal precipitation. After a lipid-rich meal, urine may also become alkaline and cloudy. Freshly voided urine is normally odorless. With age, urine acquires a characteristic aromatic odor. As the constituents in the urine decompose, ammonia, putrefaction compounds, and hydrogen sulfide are detected. Certain foodstuffs, such as coffee, garlic, or asparagus, give a distinctive scent. Patients with poorly controlled diabetes produce ketone bodies such as acetone, which impart a fruity odor to urine. Urine foaming is caused by the presence of protein in the specimen, and foam bubbles should not exhibit the rainbow appearance that is indicative of soap contamination. 10.7.2 Chemical Constituents and Other Characteristics of Urine The kidneys filter plasma, reabsorb most of the dissolved substances that are filtered, secrete some of these substances back into its filtrate, and leave behind a concentrated solution of metabolic waste known as urine. Metabolic waste products are present in urine at high concentrations.


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Creatinine is spontaneously and irreversibly formed from creatine and creatine phosphate in muscle. Creatinine, creatine’s anhydride, is a metabolic waste product that is not reutilized by the body. Because there is a direct relationship between creatinine formation and muscle mass, creatinine production is considered constant from day-to-day provided that muscle mass remains unchanged. In view of this constant production, random creatinine results approximate 24-h collection reference intervals. Creatinine is freely filtered by the renal glomeruli and is not significantly reabsorbed by the renal tubules, but a small amount is excreted by active renal tubular secretion. Creatinine is excreted at a relatively constant rate relatively independent of diuresis, provided kidney function is not impaired. Creatinine production and excretion are age and sex dependent. Normal urine creatinine concentrations are greater than 20 mg/dl. Abnormal levels of creatinine may result from excessive fluid intake, glomerulonephritis, pyleonephritis, reduced renal blood flow, renal failure, myasthenia gravis, or a high meat diet. Specific gravity assesses urine concentration, or amount of dissolved substances present in a solution. As increasing amounts of substances are added to urine, the concentration of these dissolved substances and the density, or the weight of the dissolved substances per unit volume of liquid, increase. Specific gravity varies greatly with fluid intake and state of hydration. Normal values for the specific gravity of human urine range from approximately 1.0020 to 1.0200. Decreased urine specific gravity values may indicate excessive fluid intake, renal failure, glomerulonephritis, pyelonephritis, or diabetes insipidus. Increased urine specific gravity values may result from dehydration, diarrhea, excessive sweating, glucosuria, heart failure, proteinuria, renal arterial stenosis, vomiting, and water restriction. pH is the inverse logarithmic function of the hydrogen ion concentration. It serves as an indicator of the acidity of a solution. The two organs that are primarily responsible for regulating the extremely narrow blood pH range that is compatible with human life are the lungs and the kidneys. The kidneys maintain the blood pH range by eliminating metabolic waste products. The pH of the urine is used clinically to assess the ability of the kidneys to eliminate toxic substances. Urinary pH undergoes physiological fluctuations throughout the day. Urinary pH values are decreased in the early morning followed by an increase in the late morning and early afternoon. In the bacteriacontaminated urine specimen, pH will increase upon standing because of bacterial ammonia formation. Normal urinary pH values range from 4.5 to 9.0. 10.7.3 The Role of HHS and DOT in Specimen Validity Testing HHS through its Mandatory Guidelines for Federal Workplace Drug Testing and other notices has directed laboratories in the conduct of specimen validity tests. The early guidelines permitted testing but did not define the characteristics. When the adulteration and substitution issues became more prominent, HHS and DOT issued guidance. These were considered voluntary. HHS–SAMHSA Program Document (PD) 33 Title: Testing Split (Bottle B) Specimen for Adulterants Dated: March 9, 1998 Summary: The guidance established technical threshold “cutoff” values for pH and nitrates. It required laboratory testing for pH and nitrite concentration in any split specimen that failed to reconfirm. It also authorized additional adulteration testing for the presence of glutaraldehyde, surfactants, bleach, and other adulterants if indicated. HHS–SAMHSA Program Document (PD) 35 Title: Guidelines for Reporting Specimen Validity Test Results Dated: September 28, 1998 Summary: PD 35 replaced the Category I, II, and III reporting protocols established in 1993 with more detailed laboratory test reporting protocols. It established unacceptable limits for nitrite concentration, pH, and substitution. It required further testing when a split specimen failed to reconfirm.


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U.S. DOT–Office of Drug and Alcohol Policy and Compliance (ODAPC) Title: MRO Guidance for Interpreting Specimen Validity Test Results Dated: September 28, 1998 Summary: This companion document to PD 35 contained formal regulatory guidance for MROs, detailing how they were to respond to the various laboratory reporting protocols. HHS–SAMHSA Program Document (PD) 37 Title: Specimen Validity Testing Dated: July 28, 1999 Summary: PD 37 provided specific technical guidelines to the laboratories. The document notes that specimen validity testing may be conducted on Bottle A and must be conducted on Bottle B if Bottle B fails to reconfirm for the requested drug/analyte. Specimen validity tests may include, but are not limited to, tests for creatinine concentration, specific gravity, pH, nitrite concentration, pyridine, glutaraldehyde, bleach, and soap. These tests must be performed using methods that are validated by the laboratory.

Subsequently, DOT published its final rule, 49CFR Part 40, on December 19, 20002 and a technical amendment to the Final Rule on August 1, 2001.3 The 2000 rule mandated validity testing but the 2001 amendment changed this to authorized but not mandated pending future HHS actions. The rule section 40.91 states: What validity tests must laboratories conduct on primary specimens? Creatinine and specific gravity (SG) SG if Creatinine < 20 mg/dl Measure pH Substances that may be used to adulterate urine Send to second laboratory if unable to confirm adulterant New adulterant, report to DOT and HHS Complete testing for drugs Conserve specimen

Most recently HHS published its Revised Mandatory Guidelines for Workplace Drug Testing Programs on April 13, 2004 with an effective date of November 1, 2004.4 It defined the final SVT requirements. Notably it included the following: 1. Creatinine concentration criterion defining a substituted specimen changed to 1.0200 Dilute is a specimen with • Creatinine 2 to 1.020. This testing requirement provides both an analytical and physiological safeguard. The review of the scientific literature including random clinical studies, medical conditions resulting in severe overhydration or polyuria, and water loading studies confirms that the urine criteria of creatinine < 5 mg/dl and urine specific gravity < 1.001 or > 1.020 represent a specimen condition that is not consistent with normal human urine. In the deductive evaluation of 47 studies, no exception to the criteria defining a “substituted” specimen was reported.

However, the review cannot be interpreted as conclusive evidence that it is not possible for anyone to physiologically produce a “substituted” urine, since none of the studies cited was designed to look specifically at the amount of water it takes to produce a substituted specimen. Theoretical physiology suggests a lower value and nephrologists have more recently advised that on a mathe-


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matical basis individuals with low normal serum creatinine values may produce a urine creatinine value slightly below 5 mg/dl. Later that same year, DOT performed a water-loading study that asked the question: How much water does it take to produce a substituted specimen? Or: How much water can a person consume and still not have a “substituted” specimen? 10.7.6.2

DOT Water Loading Study

The DOT study,7 entitled “Paired Measurements of Creatinine and Specific Gravity after Water Loading,” is more on point. The study used 40 female and 13 male volunteers. The first phase was to simulate the shy bladder procedure. The first morning void was collected; then all volunteers were given 40 oz of fluid and were asked to provide a specimen every hour for the first 3 h and to continue with an additional 40 oz or more over the next 3 h. The volunteers were asked to drink as much as they could. Two participants were unable to consume the minimum amount of fluid intended. On the other hand, 11 participants (5 men and 6 women) consumed more than 1 gal of fluid by the end of their test periods. The bottom line was that none of the 480 specimens were identified as “substituted.” The maximal suppression of creatinine values (which is the critical function value) was seen in an individual who had consumed 1.5 gal of water by the 5-h mark. It was reported that the creatinine value approached but was not below 5 mg/dl. Then, interestingly enough, the individual consumed another liter, and in the final hour had an elevated creatinine. Overall, the data showed that many of the volunteers attained levels of specific gravity below the 1.001 threshold value, but did not attain creatinine levels below 5 mg/dl. It, therefore, appeared that individuals cannot consume enough water to have a “substituted” specimen although it may be theoretically possible to do so. The results suggest that it is not physiologically possible to “unintentionally” drink too much water and be confronted with a “refusal to test–substituted specimen.” In the absence of a related medical condition, unintentional ingestion of water seems to be as unlikely as passive inhalation of drugs. (Can a person unintentionally drink 1 1/2 gal of water?) 10.7.6.3

FAA Workplace Urine Specimen Validity Testing Colloquium

In light of several witnessed and documented cases of individuals demonstrating a creatinine concentration slightly below 5 mg/dl, the FAA sponsored a “Workplace Urine Specimen Validity Testing Colloquium,” February 4–6, 2003. The colloquium was organized in direct response to a Congressional mandate to the FAA to prepare a report on whether there were any particular medical conditions, dietary factors, or individual characteristics that could result in a urine specimen meeting the existing criteria of an adulterated or substituted specimen. Participants included, among others, distinguished toxicologists and specific technical experts from the relevant fields of medicine, science, drug testing, and law. The participants had experience in drug-testing programs, medical, and other related fields. Presentations and discussions centered on the physiological impact of medical issues, working conditions, and dietary habits on validity testing conducted on specimens submitted under the DOT workplace program. In April 2004, FAA released its report with the following findings and conclusions: 1. Dietary habits, medical issues, and working conditions do not affect the validity of specimens. 2. The validity testing criteria as currently established for adulteration are appropriate.

Only a few substituted specimens are attributed to physiological concentrations of urine creatinine (a compound in urine) below the HHS established value. However, the established value for creatinine is not appropriate for all people. It made the following recommendations:


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1. Substitution: The creatinine level for determining substituted specimens should be lowered to less than 2 mg/dl. This will prevent any individual who can achieve this concentration through normal physiological means from being improperly labeled as providing a substituted urine specimen. 2. Dilution: The current creatinine and specific gravity levels for determining a dilute specimen are adequate. For federally regulated programs, specimens identified as dilute should be tested for drugs at lower cutoff values in order to overcome the efforts of individuals to hide the presence of drugs. 3. Adulteration: The levels established for pH (11), chromium VI (cutoff concentration of 20 μg/ml or more) and nitrite (greater than or equal to 500 μg/ml) are satisfactory. However, all laboratory testing for adulterants should include two distinct chemical methods to determine the presence of adulterants in the specimens (i.e., one for initial testing and another to confirm the presence of the adulterant). 4. Role of the Medical Review Officer: Supplement current verification process for assessing individuals’ claims that they can produce a specimen meeting the substituted criteria through physiological means. Provide additional guidelines and training for the changes in the verification process.

10.7.7 Adulteration “Adulterated” is the term used for a specimen that has been altered by the donor in an attempt to defeat the drug test. The donor’s goal in this regard is to affect the ability of the laboratory to properly test the specimen for drugs and/or to destroy any drug or drug metabolite that may be present in the specimen.8–10 Many substances can be used to adulterate a urine specimen in vitro, including common household products, commercial chemicals, and commercial products developed specifically for drug test specimen adulteration. Adulterants are therefore readily available, may be easily concealed by the donor during the collection procedure, and can be added to a urine specimen without affecting the temperature or physical appearance of the specimen. To identify adulterated specimens, HHS requires certified laboratories to perform a pH test and a test for one or more oxidizing compounds on all regulated specimens. Laboratories are also allowed to test regulated specimens for any other adulterant, providing they use initial and confirmatory tests that meet the validation and quality control requirements specified by the HHS Guidelines. An adulterant may interfere with a particular test method or analyte, but not affect others. For example, an adulterant may cause a false-negative marijuana (cannabinoids) result using a particular immunoassay reagent, but not affect the test results for other drugs. The same adulterant may not affect the test results obtained using a different immunoassay reagent or method. It is also possible for an adulterant to cause a false-positive drug test result, rather than the intended false negative. The initial drug test required for federal workplace programs (immunoassay) is more sensitive to adulterants than the required confirmatory drug test (gas chromatography/mass spectrometry, GC/MS). Currently, the GC/MS assays for marijuana metabolite (THCA) and opiates appear to be the most affected. An adulterated specimen is defined in 49CFRPart 40.3 as “A specimen that contains a substance that is not expected to be present in human urine, or contains a substance expected to be present but is at a concentration so high that it is not consistent with human urine.” An adulterated specimen may be reported by the laboratory as having a nitrite concentration that is too high, a pH level that is too high or too low, or identified as having a specific adulterant (such as glutaraldehyde) present. The reference in the HHS guidelines to a general oxidant test is new. Most adulterants used are oxidizing agents and the early tests for nitrite and chromate were oxidant tests, although specifically named as either nitrite or chromate. Since the general characteristic of the adulterants was that of an oxidant, it is practical to use a comprehensive general test for screening purposes to be followed by specific confirmation tests, rather than do a series of similar and potentially crossreacting tests to screen for adulterants. HHS allows certified laboratories to test for any adulterant. It is not possible to provide specific program guidance for all substances that may be used as adulterants; however, HHS has included specific requirements in the Guidelines for pH analysis and for the analysis of some known adulterants that follow:


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10.7.7.1

pH

The pH of human urine is usually near neutral (pH 7) although some biomedical conditions affect urine pH. HHS set the program cutoffs for pH based on a physiological range of approximately 4.5 to 9. Specimens with pH results outside this range are reported as invalid. An extremely low pH (i.e., less than 3) or an extremely high pH (i.e., at or above 11) is evidence of an adulterated specimen. Urine specimens that are found to have a pH 11 can be reported as “Specimen Adulterated: pH is too high (or too low).” The establishment and publication of these threshold limits ends the debate and uncertainty that has surrounded the issue of what is a normal urine pH and what margin of safety should be given to upper and lower levels. To the average donor who may be contemplating the addition of a chemical substance to his to her urine, acids and bases seem like good choices. Battery acid and Drano have been used and are generally available. Such compounds have a significant impact on the pH of the specimen and include hydrochloric (muriatic) acid used for swimming pools. Commercial adulterants that affect pH include Amber-13 and THC-free. Amber-13 is a sulfur-smelling liquid sold in a glass vial. When 8 ml of Amber-13 is mixed with 50 to 150 ml of water it produces a pH of about 1. Urine will probably buffer this to some degree. THC-Free lists its formulation as water, muriatic acid, potassium chloride, phosphoric acid, and potassium hydrogen phosphate. One vial of THC-Free added to 50 m of urine will produce a pH of between 1 and 2. 10.7.7.2

Nitrite

Nitrite is an oxidizing agent that has been identified in various commercial adulterant products. Nitrite is produced by reduction of nitrate. Nitrite in high concentrations is toxic to humans, especially infants, causing methemoglobinemia by oxidizing the iron in hemoglobin. Nitrate and to a lesser extent nitrite are present in the environment. Nitrite may be normally present in human urine. There has been a lot of confusion between nitrites and nitrates. It is important to understand the difference between the two compounds. Nitrite is NO2 — Nitrites have a therapeutic use as a vasodilator (oral dose = 30 to 60 mg). Inorganic nitrite can be used in treatment of cyanide poisoning (intravenous dose = 300 to 500 mg). One example of an organic nitrite is nitroglycerin. Nitrite is toxic; after accidental ingestion of nitrite, toxic symptoms include weakness, nausea, numbness, shortness of breath, tachycardia, and cyanosis. One reported case of nitrite overdose resulted in a urine concentration of 340 mg/l. Nitrate is NO3 — Nitrates have a widespread use as fertilizers, which can lead to accumulation in food plants and water supplies.

Both nitrites and nitrates are also used as curing agents in processed meats. They may legally be present in these products in the following concentrations: nitrites up to 200 ppm and nitrates up to 500 ppm. Some pathological conditions (infection, inflammation), medical treatments (cancer), and urinary tract infections may result in nitrites in urine. In whole blood, nitrite is unstable. Whole-blood nitrite is almost completely converted to nitrate within 1 h. The nitrate that is formed is almost completely excreted in the urine. Normal nitrite concentrations in urine are very low and have been demonstrated in a variety of studies to generally be below 100-200 μg/ml. Because low levels of nitrite may be present in human urine, HHS set a cutoff level of 500 μg/ml for adulteration and 200 μg/ml for invalid results. These concentrations are well above levels normally seen in human urine. Therefore, normal exposure does not explain a nitrite-adulterated result. Drug testing laboratories began to study the effects of nitrite in detail when the product Klear came on the market in 1997. A urine specimen would screen positive and then fail confirmation. It would not just fail in the sense that no drug was identified, but it looked like something was destroying all of the organic compounds in the specimen.


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Specimens adulterated with Klear were oxidizing THCA during the extraction process. When aliquots to be tested were acidified, the oxidation process exponentially accelerated. The mass ion peaks on the mass spectral chromatograms were absent. There is no drug and there is no internal standard either. The internal standard is a deuterated version of the drug or metabolite being tested. It is added as a control reference for the analysis and its destruction is diagnostic for an oxidizing adulterant. Some commercial nitrite adulterants include Klear, Whizzies, and Randy’s Klear (I). Klear is a product that comes in a small plastic vial containing 500 to 800 mg of white crystals (potassium nitrite). The cost of two tubes is $29.95. Whizzies (sodium nitrite) appears to be a knockoff product of Klear. It is sold as white powder contained in two vials each containing about 850 mg of the compound. 10.7.7.3

Chromium

Chromium exists in a number of chemical states. The zero valence state, Cr0, is the metallic state. Chromium also exists in nature in a divalent [Cr2+, Cr(II)], trivalent [Cr3+, Cr(III)], and hexavalent [Cr6+, Cr(VI)] state. Understanding the significant differences in the chemistry and toxicology is important in understanding and interpreting adulteration results. The divalent state is very unstable and is rapidly changed to Cr3+. The biologically or toxicologically significant states are the trivalent Cr3+ and hexavalent Cr6+ states. Trivalent chromium Cr3+ is an essential nutrient in diet. It plays a critical role in maintaining normal glucose tolerance. The trivalent chromium is the species found in the dietary supplement chromium picolinate. It is important to realize that even large doses of chromium picolinate will not produce any hexavalent chromium in the urine. It will, naturally, produce a small amount of trivalent chromium in the urine. A literature review shows levels in the low nanogram range. The highest concentration of trivalent chromium reported was 11 ng/ml. Those individuals took 400 μg/day of chromium picolinate for 3 days. The hexavalent chromium Cr6+ is a strong oxidizing agent. Cr6+ is reduced to Cr3+; however, Cr3+ is not converted to Cr6+. Cr6+ is used in chrome plating, dyes and pigments, leather tanning, and wood preserving. Hexavalent chromium is present in the environment and is a carcinogen. It is a very toxic and irritating compound. In studies that looked at dietary or environmental exposure to hexavalent chromium, the maximum level reported was 690 ng/ml. In this instance, 10 mg/day of Cr6+ (in water) were ingested for 3 days. These levels are in stark contrast to what is seen with adulterated urine. In summary, concentrations of Cr3+ in urine are small — in the nanogram per milliliter range. Concentrations of Cr6+ found in adulterated urine specimens are large — in the microgram per milliliter range. In addition, the laboratory adulteration assays are specific for Cr6+ and do not include Cr3+. Urine concentrations of hexavalent chromium found in adulterated urine specimens exceed the highest toxic case reported. (The case was suicide by ingestion of chromic acid solution; 3 days after ingestion, urine contained 5.13 μg/ml. Death occurred 1 month later from injury.) The HHS reporting cutoff is 50 μg/ml. Some chromium containing adulterants include Klear II, LL418, Sweet Pee’s Spoiler (pyridium chlorochromate), UrineLuck, and Ultra Kleen (chromate). Pyridinium chlorochromate is a strong oxidizing agent that has been the agent in some commercial adulterants. This compound is identified by urine drug testing laboratories using a confirmatory test for pyridine. Pyridine at any detectable level in a urine specimen is evidence of adulteration. 10.7.7.4

Hydrogen Peroxide and Peroxidase

The commercial adulterant Stealth comes in a packet that contains two plastic vials. One vial contains a tan solid that does not melt. The other vial contains about 1.7 ml of a clear liquid, with


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a measured pH of 4.5. The user is instructed to pour the solid into the collection cup, add urine, then add the liquid “activator.” The tan solid contains a peroxidase, the enzyme that speeds the oxidation process. The liquid contains peroxide. Stealth goes to work quickly and oxidizes the THC metabolites in a matter of hours, then “self-destructs.” Hence, the name Stealth. 10.7.7.5

Halogens

Halogens are the four elements fluorine, chlorine, bromine, and iodine. Halogen compounds have been used as adulterants. The term “halogen” (from the Greek hals, “salt,” and gennan, “to form or generate”) was given to these elements because they are salt formers. None of the halogens can be found in nature in its elemental form. They are found as salts of the halide ions (F–, Cl–, Br–, and I–). Fluoride ions are found in minerals. Chloride ions are found in rock salt (NaCl), the oceans, and in lakes that have a high salt content. Both bromide and iodide ions are found at low concentrations in the oceans, as well as in brine wells. The assays used by certified laboratories identify halogen compounds that act as oxidants. These do not include the halogen salts that may be present in a urine specimen. The presence of an oxidative halogen in a urine specimen is evidence of adulteration. Iodine/Iodate is a recent adulterant in the halogen class. Molecular iodine (I2) is a blue black solid that sublimes. Iodide (I–) is generally found in the form of potassium or sodium salts (KI, NaI). Iodate (IO3–) also appears as potassium or sodium salts (KIO3, NaIO3) of iodic acid. Iodate is a strong oxidizing agent and is reduced to iodide. Iodide and iodate are used as food and salt additives, in antiradiation products and in thyroid hormones. Normal concentrations are approximately 600 μg/L. 10.7.7.6

Glutaraldehyde

Glutaraldehyde is a clear, colorless liquid with a distinctive pungent odor sometimes compared to rotten apples. One of the first effective commercial adulterants, UrinAid, was found to contain glutaraldehyde. Glutaraldehyde is used as a sterilizing agent and disinfectant, leather tanning agent, tissue fixative, embalming fluid, resin or dye intermediate, and cross-linking agent. It is also used in X-ray film processing, in the preparation of dental materials, and surgical grafts. Glutaraldehyde reacts quickly with body tissues and is rapidly excreted. The most common effect of overexposure to glutaraldehyde is irritation of the eyes, nose, throat, and skin. It can also cause asthma and allergic reactions of the skin. Glutaraldehyde does not normally occur in urine and is readily detectable. It will interfere with the immunochemical screening tests. It may also interfere with the recovery of the drug in GC/MS analysis or it may destroy the metabolite. It is interesting to note that, although this product is sold as a way to guarantee a negative in the urine of marijuana users, it affects the analysis of other drugs as well. It has a chemical aldehyde smell and it will denature proteins in the urine, so that over a 1- or 2-day period of time a brown precipitate will appear. No matter what the preliminary basis may be for suspecting adulteration of a specimen by glutaraldehyde, the presence of glutaraldehyde should be confirmed by reliable chemical analysis such as GC/MS. Glutaraldehyde at any detectable level in a urine specimen is evidence of adulteration. Clear Choice is another adulterant containing glutaraldehyde and squalene. 10.7.7.7

Other Chemicals and Household Products

Surfactants, including ordinary detergents, have been used to adulterate urine specimens. Surfactants have a particular molecular structure made up of a hydrophilic and a hydrophobic component. They greatly reduce the surface tension of water when used in very low concentrations.


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Foaming agents, emulsifiers, and dispersants are surfactants that suspend an immiscible liquid or a solid, respectively, in water or some other liquid. Liquid Soap: Reported to cause false negatives in EIA procedures for THC and PCP. Its addition increases the pH of the specimen. A commercial adulterant called Mary Jane SuperClean 13 was reported to be primarily soap. Sodium Chloride: Reported to cause false negative in EIA procedures. Its addition increases the specific gravity and chloride ion content of the specimen. Bleach: Reported to cause a false negative in EIA procedures for all five drugs tested for by SAMHSA and in FPIA procedures for all but cocaine. Drano: Reported to cause false negatives in EIA procedures. Its addition increases the pH of the specimen. Sodium Bicarbonate: Reported to cause false negatives in EIA procedures for opiates and PCP. Its addition increases the pH of the specimen.

10.7.8 The Invalid Result HHS describes an invalid result as follows: When a laboratory is unable to obtain a valid drug test result or when drug or specimen validity tests indicate a possible unidentified adulterant, the laboratory reports the specimen to the MRO as “invalid result.”

This definition is not a comprehensive. Invalid results also include a category of specimens that can be described as having suspect or abnormal characteristics, such as pH out of the normal range, high nitrite levels, or unusual creatinine and specific gravity levels. It is true that “invalid” results can indicate a possible unidentified adulterant or substitution and that many invalid results could not be physiologically possible. But in many cases there is just an absence of conclusive scientific evidence that the specimen is not physiologically possible, and/or that the analytical method is not definitive, precise, or valid enough to withstand legal challenge. When an MRO receives an “invalid” specimen report, it is incumbent upon him or her to discuss with the laboratory whether additional tests should be performed by the laboratory or by another certified laboratory. It may be possible to obtain definitive drug test results for the specimen using a different drug test method or to confirm adulteration using additional specimen validity tests. The choice of the second laboratory or additional tests will be dependent on the suspect adulterant and the validated characteristics of the different drug test. Laboratory staff should be knowledgeable of their tests’ validated characteristics including effects of known interfering substances, and be able to recommend whether additional testing is worthwhile. The current HHS specimen validity rules require screening of specimens for oxidants, but do not require the laboratory to confirm the screening results. The rationale is that requiring specific confirmation methods for a broad class of defined and undefined adulterants would represent a significant cost increase in laboratory services. The majority of laboratories have decided not to bother with confirming oxidant results, and simply report the screening results as “invalid.” Somewhat unanticipated is that even laboratories that were confirming common oxidants such as nitrites have withdrawn from this practice. The specimen validity rule requires the laboratories to have more comprehensive and definitive confirmatory procedures for nitrites. This likely requires the acquisition of additional laboratory equipment. In addition, there is significant time involved in confirming results of any type. In the wake of increased litigation, there are lingering liability concerns at the laboratories. The end result is that only a small number of laboratories perform confirmatory procedures for nitrites and other oxidants as required by the current rules.


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So today there have evolved three conceptual categories of laboratory results: the positive (drug, adulterated, and/or substituted), the invalid (everything in between), and the negative (dilute and non-dilute). Each requires the focus and attention of the laboratory and the MRO.

10.8 THE ROLE OF THE MEDICAL REVIEW OFFICER IN WORKPLACE DRUG TESTING

Joseph A. Thomasino, M.D., M.S., FACPM JAT MRO, Inc., Jacksonville, Florida

10.8.1 The MRO as the “Gatekeeper” of the Workplace Drug Testing Program A Medical Review Officer (MRO) has come to be defined in U.S. Department of Transportation (DOT) regulations (i.e., 49 CFR Part 40) as a licensed physician (Doctor of Medicine or Osteopathy) who is knowledgeable about and has clinical experience in controlled substance abuse disorders, including detailed knowledge of alternative medical explanations for laboratory confirmed drug test results. The MRO has become an integral part of the workplace drug testing process as federal regulations for workplace drug testing have been developed and implemented, at first for drug testing of federal employees, and then for millions of other workers in private industry for which drug testing was mandated by federal agencies such as the U.S. DOT, The U.S. Coast Guard, and the Nuclear Regulatory Commission. Beginning in the mid-1980s the MRO has been involved in an ever-growing number of drug tests. Federal regulatory requirements for workplace drug testing have expanded and these regulations have further defined and broadened the role of the MRO in the process. Programs for workplace drug testing requiring medical review have been implemented by various states (e.g., Florida, Georgia, others) in connection with worker compensation programs. Some states have required medical review of all workplace drug tests results collected in those states (e.g., Oklahoma and New York). Increasing numbers of private employers have been implementing drug testing programs that include medical review of results absent any regulatory requirement to do so. Although originally all workplace drug testing programs involved the collection of urine drug testing specimens, and most still do, other sampling media including hair, blood, saliva, sweat, and others are beginning to be accepted and used in workplace drug testing programs. All of these factors have led to the emergence of the MRO as the “gatekeeper” of the workplace drug testing process. The identification of the MRO as the “gatekeeper” in the workplace drug testing process was first made in DOT regulations. It is an apt characterization of the overall role of the MRO in this process. One way to conceptualize this role is to consider that the MRO is an “equity agent.” In a sense the MRO oversees all the elements of the process. The MRO ensures that the donor (i.e., the individual providing the drug testing specimen) has had the specimen collected properly, that it has been analyzed correctly, that the result has been reported to the MRO promptly and clearly, that alternative medical explanations for any positive or other non-negative results where appropriate have been sought, that the donor’s technical questions have been answered and the donor’s response to an adverse determination (e.g., a reconfirmation test, substance abuse professional evaluation, etc.) has been facilitated, and that a prompt and clear report of the final determination/verification has been made to the employer or other organization commissioning the drug test. By performing the above functions in reviewing each drug test the MRO helps confer legitimacy and fairness to a process that can become contentious as serious sanctions are often applied to donors with verified non-negative results. A verified positive result, or a determination that the donor has refused to provide an adequate specimen for drug testing, may result in denial or termination of employment,


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loss of other benefits, or other adverse outcomes for the donor. Thus the role of the MRO in allowing the donor due process to explain properly collected and technically valid drug testing results before an adverse determination is made has become vital in maintaining the integrity, value, and effectiveness of workplace drug testing programs. 10.8.2 The MRO and the Collection Process Proper collection of drug testing specimens is the first and arguably the most critical step in the implementation of any workplace drug testing program. Important in this is that chain-of-custody procedures be established and followed in collecting drug testing specimens. Given the serious consequences for the donor that often follow adverse determinations, and the concomitant risk for the organization commissioning the test in applying those consequences inappropriately, it is clear that before becoming involved in the review of any drug test the MRO must be sure that appropriate chain of custody procedures were followed in the collection and further handling of the specimen as it is transported to and analyzed at the laboratory. Strict adherence to the appropriate collection protocol with close attention to properly establishing, maintaining, and documenting the chain of custody for each specimen is therefore vital to the overall success of any drug testing program. The MRO is rarely, if ever, actually present at the time any specimen is collected. In most instances the MRO does not actually know, and has never met the collector for any given specimen. Therefore as the “gatekeeper” of the process the MRO must rely on review of the chain of custody and control form (CCF) that has been completed by the collector and the donor at the time the specimen is collected. Needless to say, prompt provision of a legible copy of the CCF to the MRO by the collector is absolutely vital for the proper management and promulgation of any drug testing program. Practically speaking, assuring that a legible copy of the CCF for each specimen is obtained as rapidly as possible after a specimen has been collected is a major activity for the MRO and staff. The success of most MRO practices, and the ability to gain and maintain clients by the MRO, is largely determined by how rapidly the MRO is able to provide reports of final determination/verification to the organization commissioning a test, once a test has been collected. Once received, the CCF for each specimen is reviewed by the MRO or staff to ensure that it is legible and that it has been appropriately completed by the collector and the donor. The legible, properly completed CCF is then matched with the result received from the laboratory and the MRO and/or staff complete the review and make report to the organization commissioning the test. Any deficiencies in the CCF should be corrected, if possible, by the MRO before the final determination is made. Often deficiencies will have been detected and corrected by the laboratory before the result is reported to the MRO. However, if it becomes apparent that the laboratory has failed to detect or correct a deficiency it falls to the MRO to do so. Certain flaws on the CCF are “fatal.” The most common of these are quantity of specimen insufficient for testing; no collector printed name or collector signature in the collector certification portion of the CCF; tamper-evident seal broken or missing on the specimen container upon arrival at the laboratory; and donor identification on the specimen container not matching the donor identification on the CCF submitted with the specimen. When these “fatal” deficiencies or flaws are detected the laboratory will not perform the analysis. When this condition is reported to the MRO the final determination/verification must be that the test was canceled due to the flaw. However, for other deficiencies, if the laboratory has not corrected them, the MRO must do so. These include, among others, a CCF on which the collector’s name is printed but the collector has failed to sign that section of CCF in which the collector certifies that the specimen was submitted by the donor in question and that the specimen was collected, labeled, and sealed in accordance with the appropriate protocol; the certifying scientist has failed to sign the laboratory copy of the CCF when reporting the result (this becomes apparent to the MRO only in the case of a nonnegative result for which the laboratory copy of the CCF must be provided to and reviewed by the MRO prior to making a final determination/verification); and times and/or dates on the CCF missing


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or contradictory. There is at least one flaw or deficiency that cannot ordinarily be corrected by the laboratory prior to analysis. This is failure of the donor to sign that section of the CCF in which the donor certifies that the specimen was actually submitted by the donor, that it has not been adulterated or tampered with, that the specimen container was sealed with a tamper-evident seal in the donor’s presence, and that the information on the CCF and the label affixed to the specimen container is correct. As the laboratory ordinarily does not receive a copy of the CCF that bears the donor’s signature, it is the MRO’s responsibility to check for and correct this deficiency when it arises. Unless the collector has noted in the remarks section of the CCF that the donor has refused to sign, or that the collector forgot to have the donor sign before leaving the collection site, an attempt should be made to correct the flaw. This flaw, like other flaws that can be corrected, is corrected by having the collector sign an affidavit, certificate of correction, or memorandum for record (these are synonymous terms). This document should indicate that despite the flaw, the specimen was, in fact, submitted by the donor in question, the specimen was otherwise collected, handled, and transported to the laboratory properly, and that this is a true and accurate statement on the part of the collector. Once the properly executed document is received by the MRO it is maintained with the other documentation for the specimen, and review proceeds as for any other specimen. If the deficiency is not corrected in a reasonable time, usually considered to be no more than 1 to 2 weeks from when the flaw was detected and the certificate of correction was presented to the collector, the specimen is reported as canceled due to the uncorrected flaw. When “fatal” or uncorrected flaws result in the cancellation of a specimen, it is the responsibility of the MRO to document and point this out to the collector in question, urge the collector to ensure that the situation is not repeated, and suggest that if additional training or education is needed to address the situation and prevent recurrences that it be promptly obtained by the collector. Even minor deficiencies or administrative mistakes that do not cause cancellation of the test, or require formal correction per se, in order to make a final determination/verification, should be documented and pointed out to the collector for corrective action. Errors of this sort that have no significant adverse effect on the donor’s ability to have a fair and accurate drug test include among others: failure of the collector to indicate whether the specimen temperature was read within 4 min of collection and/or whether or not the temperature was within range; minor mistakes in recording the donor identification number on the CCF; reason for test inappropriate or unmarked on the CCF; failure to directly observe a specimen in instances where observation was called for; and delay in the collection process. By careful review of the CCF for each specimen the MRO helps ensure the integrity of the collection process, and by extension the entire drug testing process, as proper collection is the foundation of any successful workplace drug testing program. By correcting deficiencies that are detected and making collectors aware of them, the MRO strengthens and fosters this most important element of workplace drug testing programs. 10.8.3 The MRO and the Analytical Laboratory In a sense the MRO is one of the main “customers” of the analytical laboratory performing toxicological testing in the drug testing process. Although the organization commissioning the test may actually originally arrange for and pay for drug testing, in most instances the analytical laboratory reports results directly to the MRO who makes a final verification of the results before reporting them to the organization commissioning the test that has engaged the MRO for this purpose. In most instances where an organization has engaged an MRO the organization is not made aware of the laboratory confirmed result by the laboratory and the laboratory will not reveal the laboratory confirmed result to the organization, insisting that the MRO report all results to the organization. This arrangement is required for federally mandated testing and by some statesponsored testing programs, e.g., in Florida. In other states either all results or only laboratory confirmed positive results (e.g., in Maryland), must be reviewed by the MRO before they are


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reported to the organization commissioning the test. Therefore, in practice, the MRO and staff usually develop close working relationships with their counterparts at the analytical laboratories, i.e., the toxicologists, certifying scientists, and client service representatives. This is necessary to ensure prompt receipt of results by the MRO once analysis has been completed and for the MRO and staff to clarify and fully understand all aspects of the laboratory report. As the “gatekeeper” in the drug testing process the MRO has a responsibility to correct any flaws in the testing process that may be discovered on the part of the analytical laboratory before making a final determination for any given test result. Failure of the certifying scientist to provide necessary documentation (e.g., the properly completed laboratory copy of the CCF for non-negative results on federal testing), failure of the certifying scientist to sign or otherwise fully and properly complete necessary documentation, and correction of flaws in the collection process not detected by the analytical laboratory prior to release of results to the MRO are examples of this. The MRO has a responsibility to ensure that all aspects of the laboratory report are understood before making a final verification. This is particularly important when invalid drug test results are reported by the laboratory. In these instances, where for a variety of technical reasons the toxicologist does not feel that a reliable analysis can be made (e.g., presence of an interfering substance the exact nature of which is unknown, urine specimen colored blue or having some other unusual color or appearance, urine creatinine low with normal specific gravity, among others), the MRO must interview the donor to establish whether or not a legitimate medical explanation can be established to explain these circumstances. It is incumbent on the MRO to fully understand why the specimen was deemed unsuitable for analysis rendering the invalid result, and to consult with appropriate laboratory personnel in this regard, so as to properly direct the interview with the donor. Similarly, there are instances where it is not clear to the MRO whether a donor’s explanation for any non-negative result would in fact explain the result. The MRO can and should consult with appropriate laboratory personnel in these instances and make reliance on the information and guidance they provide in these matters. Finally, the MRO often has a responsibility to offer the donor the option to have a drug testing specimen with a non-negative result sent to a different analytical laboratory for reconfirmation testing after an adverse determination has been made for that result by the MRO. This is required for federally mandated drug testing, by some state sponsored drug testing programs, by state law in some states, and as a matter of organizational policy for some organizations commissioning drug testing. As the “gatekeeper” of this process, if a specimen fails to reconfirm for the result in question, the MRO has a responsibility to then amend the final determination/verification for that specimen. The MRO must also notify the donor and the organization commissioning the test of this, and depending on the type of testing, e.g., federally mandated, state sponsored, etc., may also have to make a report to a governmental or other body overseeing the drug testing process. Such a report may have serious consequences for the analytical laboratory found to have reported a “false positive” or other erroneous result in terms of the laboratory’s ability to continue to provide drug testing services. In practice the MRO and staff must develop and maintain good communications and close working relationships with their counterparts at the analytical laboratories. This is essential for the proper conduct of any drug testing program. 10.8.4 The MRO and the Verification of Drug Testing Results The primary role of the MRO in workplace drug testing programs has always been to verify the results of the drug tests collected. When federally mandated drug testing programs were first implemented in the 1980s it was considered essential that donors with laboratory-confirmed positive drug testing results be afforded an opportunity to confidentially provide a legitimate alternative medical examination, if one existed, before the commissioning organization learned of the result. In the event that a legitimate alternative medical explanation could be established, the laboratory-confirmed positive result would be “downgraded,” i.e., reported as negative to the


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commissioning organization by the MRO in such a way that it would appear to be no different from any other laboratory-confirmed negative result. As part of allowing “due process” before sanctions were applied to the donor as a result of a laboratory-confirmed positive result, the role of the MRO as the finder of fact, interpreter of information offered, and maker of the final determination was conceived. A large portion of the time an MRO devotes to MRO practice is spent conducting and interpreting the results of interviews conducted with donors with laboratory-confirmed non-negative results. Originally, these were individuals with laboratory-confirmed positive results for the five drugs or classes of drugs tested for in federally mandated testing, i.e., amphetamine and methamphetamine, cocaine metabolites, marijuana metabolites, opiates (specifically codeine, morphine, and 6-acetylmorphine), and phencyclidine. As non-federally regulated drug testing programs were implemented, expanded, and in some cases tailored to the needs of individual organizations, other substances including alcohol, barbiturates, benzodiazepines, methadone, methaqualone, other opiates, propoxyphene, and others have been included in workplace drug testing programs, and naturally the MRO has had to deal with laboratory-confirmed positive results for these as well. In this process the MRO confidentially conducts and documents the interview; explains the result to the donor and the MRO’s role in the process; allows the donor the opportunity to present an explanation; gives the donor reasonable time to develop and provide any evidence supporting any explanation offered; and promptly reviews, interprets, confirms, and verifies any information received before making the final determination/verification. Besides laboratory-confirmed positive results, other non-negative results have also come to require an interview of the donor and interpretation of information gathered prior to verification by the MRO. For federally mandated testing, urine specimens that have been adulterated with a foreign substance that can be specifically and reliably identified are reported as such to the MRO by the laboratory. The MRO conducts an interview to determine if a legitimate alternative medical explanation can be established for the presence of the adulterant in the specimen. If this cannot be established, the result is reported as a “refusal to test” to the organization commissioning the test with resultant sanctions applied to the donor as prescribed in federal regulations. For federally mandated testing, urine specimens with extremely low creatinine levels (i.e., 2 mg/dl or less) and specific gravity of 1.001 or less or 1.020 or greater are reported as substituted (i.e., not consistent with normal human urine) to the MRO. Similar to adulterated specimens, for substituted specimens the MRO must also conduct an interview to determine if a legitimate alternative medical explanation can be established to explain these abnormal creatinine and specific gravity values. If it appears to the MRO that such an explanation may exist, the donor is then required to demonstrate under observed and controlled conditions that urine with these abnormal characteristics can once again be produced. The MRO reviews the results of this procedure in making the final determination. Once again, failure to establish an acceptable explanation or to demonstrate the production of urine meeting these criteria under observed and controlled circumstances will result in a final verification of the result and report to the commissioning organization as a “refusal to test.” Invalid drug test results, as discussed above, also require an interview with the donor. In these if a legitimate alternative medical explanation can be established, the result is simply verified as canceled with no further action required unless a negative result is required (on federally mandated testing this is for pre-employment, return to duty, or follow-up testing). If a legitimate alternative medical explanation cannot be established, the test is verified as canceled but on federally mandated testing the organization commissioning the test is informed that an immediate re-collection directly observed by an individual of the same sexual gender as the donor must be conducted with minimal advance notice to the donor. There are some additional circumstances that require review by the MRO of information not gathered directly from the donor or provided by the analytical laboratory. Results of evaluations conducted in response to substituted specimens were mentioned above. For opiate positive results (i.e., codeine or morphine) the MRO in some circumstances (6-acetylmorphine negative, and


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codeine or morphine level less than 15,000 ng/ml on federally mandated urine drug testing) the MRO must have clinical evidence of opioid abuse before making a final determination/verification that the test is positive. This involves in some cases a “hands on” physical examination conducted by the MRO, or review by the MRO of an examination conducted by another physician acceptable to the MRO, to establish whether or not there is clinical evidence of opioid abuse (e.g., needle marks or tracks, disturbance of the sensorium, neurological abnormalities, etc.) before making the final determination/verification. Individuals who do not provide sufficient urine for testing even when provided extra time and fluids to do so are putatively demonstrating so-called “shy bladder.” In these cases, on federally mandated testing, the donor is required to undergo an examination by the MRO or other qualified physician acceptable to the MRO to establish whether or not an ascertainable physiologic condition (e.g., a urinary system dysfunction) or a documented preexisting psychological disorder had or with a high degree of probability could have prevented the donor from providing a sufficient quantity of urine for testing. The MRO must review the results of this evaluation, seriously consider the opinion of the examiner if the examination was conducted by another, and render a final determination. If there is an acceptable explanation established as a result of the examination the test is verified as canceled unless a negative result is required; if there is no acceptable explanation established it is reported as a “refusal to test.” On federally mandated testing where a negative result is required and the test is canceled due to an established legitimate explanation, an additional examination of the donor is required to establish whether not clinical evidence of illicit drug use also exists. The results of this examination, conducted once again either by the MRO or another physician acceptable to the MRO, are reviewed by the MRO and a final determination is rendered. This evaluation may also include drug testing using another medium such as blood, saliva, hair, etc. If there is no evidence of illicit drug use, the test is verified as negative and is so reported to the organization commissioning the test. If there is evidence of illicit drug use, the test is reported as canceled and the evidence of illicit drug use is also reported to the organization commissioning the test. Although the personal focus of the MRO is naturally on non-negative results, the vast majority of results reviewed by the MRO and staff are negative. The MRO has a responsibility to ensure that negative results are also properly reviewed and promptly verified and reported as negative. The concerns expressed above concerning collection and laboratory issues apply to negative results as well. Regular, periodic review by the MRO of negative results verified by staff is required for federally mandated testing, and is an essential element of good MRO practice in general. The heart of the MRO’s practice and professional responsibility is timely, accurate, and equitable review, verification, and reporting of drug testing results. The integrity, credibility, and success of this vital public safety and health program depend on the responsible and proper performance of this function by professionals dedicated to it. 10.8.5 The MRO and Safety Issues Often, during the interviews conducted for non-negative results, the MRO will be informed by the donor, or will otherwise learn through other information provided as part of this process, of a condition the donor is suffering or a medication the donor is taking, that either renders the donor medically unqualified for safety-sensitive work in terms of the federal regulation in response to which drug testing is being conducted or which otherwise poses a potential safety hazard to the worker, co-workers, or the general public. Many of these federal regulations, e.g., those of the DOT, require the MRO to report these circumstances to the employer or other organization commissioning the drug test, without the consent of the donor. Some state-sponsored drug testing programs, e.g., the Florida Drug-Free Workplace Program, include similar provisions. In general, it is common for the MRO to feel obligated to report such circumstances to the organization commissioning drug testing even when not required or encouraged to do so by any extant federal or state law, regulation, or guideline.


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Obviously, such a report will usually have serious consequences for the donor as it may result in the donor being prohibited from performing all or part of the donor’s work duties until the situation is resolved. DOT regulations, for example, currently require the MRO to report the safety issue to the employer. However, these regulations also require the MRO to instruct the donor that if additional information is provided to the MRO in a timely fashion from the donor’s treating health practitioner that modifies the situation the MRO must then share that with the employer for the employer’s further consideration of the matter. A similar approach may be adopted by the MRO for non-federally mandated testing in an attempt to resolve these potentially serious and often contentious issues. This issue has been complicated by the Health Insurance Portability and Accountability Act (HIPAA). Some information obtained during the MRO interview or other portions of the drug testing process may be considered “protected health information” and therefore under HIPAA would require specific consent or authorization from the donor before it was released by the MRO to the organization commissioning the test. The DOT has opined that such information gathered as part of the drug testing regulated by that agency is exempt from the provisions of HIPAA, and that the MRO, and other service providers, need no consent or authorization to release information gathered during this process in accordance with the federal regulation. However, for state-sponsored programs, or other non-federally mandated testing, it is not at all clear that “protected health information” gathered during the process of drug testing can be released by the MRO or other service providers to the organization commissioning the test in the absence of the consent or authorization of the donor without running afoul of HIPAA. In some states, for example, Maryland, certain information gathered as part of the drug testing process cannot be released to the organization commissioning the test without the donor’s consent or authorization as a matter of state law, over and above any requirements imposed by HIPAA. Until this issue is clarified, and in some states regardless of any interpretations or modifications of HIPAA, it would appear most prudent for the MRO to obtain specific written consent from the donor before releasing “protected health information” to the organization commissioning the test, unless as is the case for DOT testing the issue has been specifically and definitively addressed. In practice, this may be accomplished ad hoc on a case-by-case basis as the need arises, or by advising the organization commissioning the test to require an appropriate written consent or authorization be executed by the donor before drug testing is performed. 10.8.6 The MRO and Other Administrative Functions in Workplace Drug Testing The MRO may be called upon to perform a number of administrative functions beyond simply reviewing and reporting of results. As discussed above, additional examinations of donors may be required before the MRO can make a final determination/verification in certain instances. For federally mandated testing donors with shy bladders (i.e., not able to produce a sufficient quantity of urine for testing), donors whose inability to produce a sufficient quantity of urine for testing is due to a permanent or long-term condition and for whom a negative result is required (i.e., on pre-employment, follow-up, or return to duty testing), those with adulterated or substituted specimens under certain circumstances, and donors for whom clinical evidence of opioid abuse must be obtained, will require the MRO to approve of the selection of the referral physician other than the MRO for these examinations, and in some instances help either the organization commissioning the test or the donor to locate a suitable examiner. On federally mandated testing the MRO has a responsibility to cooperate with the Substance Abuse Professional (SAP) working with a donor for whom the MRO has verified a result as positive, or refusal to test. The MRO must also provide available information that the SAP requests, e.g., quantitative test results, information gathered during the MRO interview, etc. The requirement on federally mandated testing for the MRO to report medical information to the organization commissioning the test that is likely to result in the donor being determined to be


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medically unqualified for safety-sensitive duties, or otherwise indicates that continued performance of safety-sensitive duties by the donor is like to pose a significant safety risk, has also been mentioned above. Prompt sharing of additional information received from the donor’s physician that might modify such a situation with the organization commissioning the test is an important administrative function the MRO is called upon to perform. For all forms of testing the MRO has a responsibility to preserve the confidentiality of all information gathered and maintain records of MRO activities for varying periods of time depending upon regulatory requirements, state laws, contractual obligations, and professional guidelines. The MRO may also be called upon to provide these records to individual donors and produce them in various court or other legal or administrative proceedings. Finally, in practice, the MRO is often called upon as a general consultant source for all matters dealing with drug and alcohol testing, not only by employers, but also by labor organizations and individual donors with concerns about drug testing. The MRO may be called upon by the organization commissioning the test to help arrange and review specialized toxicological testing tailored to some particular circumstance or situation in the workplace. Perhaps the most important administrative function for the MRO is to be knowledgeable and available to employers and donors to address their questions and concerns so as to support the integrity and credibility of the drug testing process. 10.8.7 Emerging Issues for the MRO A number of issues are currently emerging that will affect MRO practice. These include specimen validity issues, alternative testing matrices, expanding the scope of toxicological testing on federally mandated and other testing, and on-site testing. Concerns have been raised as to the level of creatinine in the urine that when present with a specific gravity of 1.001 or less or 1.020 or greater is to be considered evidence of a substituted specimen, not consistent with normal human urine, and thus exposing the donor to sanctions if such a specimen is verified as a refusal to test on this basis. Formerly this level was 5 mg/dl or less. However, quite recently, in response to scientific review of this issue and demonstrated ability on the part of donors to produce creatinine levels of 3 to 4 mg/dl simply by ingesting fluids, with no underlying physiologic disorder, DOT has lowered the level at which the specimen is to be considered substituted by the MRO to 2 mg/dl. Formerly, negative specimens were considered substituted with levels of creatinine between 2 and 5 mg/dl. These required the MRO to interview the donor, and in the absence of conditions that would lead the MRO to believe there was a reasonable probability that such levels of creatinine and specific gravity could be produced physiologically by the donor, verify the result as a refusal to test. These are now to be verified by the MRO as negative and dilute with the requirement that the specimen be re-collected immediately under direct observation by an observer of the same gender as the donor. This issue will continue to be controversial and additional changes to the approach to the problem of ultradilute specimens may very well be forthcoming as experience and research expand. Needless to say, any such changes are bound to affect MRO practice. As noted above, urine has been the traditional medium or matrix for drug testing. Most workplace drug testing programs still collect urine. Currently, federally mandated alcohol testing utilizes breath or oral fluid (i.e., saliva) specimens. At present, for federally mandated drug testing only urine specimens may be collected, with the exception of instances where the donor is unable to produce sufficient urine for testing due to a permanent or long-term medical condition and a negative result is required. However, additional matrices are emerging that are gaining greater acceptance and wider use. Blood has always been available, but the invasive collection method and the greater expenses involved have relegated it to a very minor role in workplace drug testing programs. More recently, hair testing has been implemented in a number of state-sponsored (e.g., Florida) or other unregulated programs. Oral fluid testing is being offered by analytical laboratories


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for unregulated testing and some companies are starting to adopt it. On the horizon are other matrices, including sweat, that may also emerge as practical media for drug testing. The MRO will have to become familiar with the pitfalls and nuances of interpretation of results obtained from these alternative matrices. The scope of workplace drug testing has largely been confined to the ten drugs or classes of drugs mentioned above. However, changes in the drug of choice of some members of industrial populations over time are being noted and calls for an expansion of the drugs tested for on regulated and unregulated testing are being increasingly made by employers and other organizations commissioning testing. At present there is pressure to include methylenedioxymethamphetamine (MDMA or “ecstasy”), gamma-hydroxybutyric acid (GHB or “Georgia home boy”), Rohypnol (flunitrazepam or “the date rape drug”), OxyContin (oxycodone), and others in standard drug testing panels. Obviously as the scope of drug testing expands this will increase the challenges faced by the MRO. Workplace drug testing has traditionally been based on collecting a specimen at or near the workplace. The specimen is then sent to an analytical laboratory distant from the workplace. The results of the analysis have then been reported to the MRO who has reviewed them before they are released to the employer or other organization commissioning the test. Currently, federally mandated drug testing must be done in this way. However, new systems of testing have been developed that permit reading of the result immediately after collection at the workplace. In practice, most organizations performing this on-site drug testing will immediately act on negative results without any further testing, e.g., permitting a pre-placement applicant to begin work immediately, etc. Specimens demonstrating non-negative results upon on-site testing are usually sent to an analytical laboratory for confirmatory testing. If results are confirmed as non-negative, definitive action is then taken in response to the confirmatory testing done off-site. The accuracy, sensitivity, and specificity of the various on-site testing systems currently available vary, and approach the accuracy, sensitivity, and specificity of traditional analytical laboratory testing to varying degrees depending on the system used. Depending on the design of the system there may be no role at all for the MRO in the review of negative results of on-site testing, with MRO review being reserved for non-negative results that are confirmed as non-negative as described above. To what degree and in what fashion the MRO is to be integrated in on-site testing will obviously be of great interest as use of on-site testing grows.

10.9 QUALITY PRACTICES IN WORKPLACE TESTING

John M. Mitchell, Ph.D. and Francis M. Esposito, Ph.D. Health Science Unit, Science and Engineering Group, RTI International, Research Triangle Park, North Carolina

10.9.1 History The roots of workplace drug testing lie in the U.S. military’s drug testing program. The military began drug testing military personnel in response to the rise in drug abuse that accompanied the Vietnam War. Initially, it was designed to identify “at risk” individuals and to present an opportunity for treatment. By 1980, drug abuse in the U.S. military was rampant. A survey found that approximately 50% of enlisted personnel had used illicit drugs within the past 10 days.1 It was obvious that more stringent measures were necessary. At first, the military turned to the resources available in the civilian laboratory community, but it soon recognized that the methodologies available for the testing of the large number of specimens needed to support military goals were woefully


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inadequate. A taskforce consisting of civilian advisors, testing industry representatives, and military personnel was organized to develop a system that would allow testing of large numbers of urine specimens in a forensically defensible manner. It was through these measures that modern-day forensic urine drug testing laboratories were created. These efforts are notable, because the military system established the basis for legal and scientific acceptance of the methods and procedures utilized in today’s workplace drug testing. Important innovations in the military’s program include random testing of personnel and instrumented on-site testing. This integrated program resulted in a reduction in drug use by enlisted personnel such that by 1982 a survey found that the number of personnel who used drugs in the past 30 days had dropped to less than 30%. By 1988, the number dropped to less than 10%.2 The military drug testing program was built upon the experience obtained from mass testing of biological samples in the clinical laboratory and forensic principles. While the primary purpose of the military’s program was to maintain national security by removing personnel who were abusing drugs, it incorporated a quality system to protect service members from inaccurate results. The quality system that provided reliable testing included: observed collection of urine specimens, written standard operating procedures (SOPs), separate testing methods for initial and confirmatory tests, mass screening with immunoassay tests, confirmation of immunoassay positives by gas chromatography/mass spectrometry detector (GC/MS), utilization of deuterated analytes as internal standards for GC/MS procedures, internal and external quality control systems, independent assessment of laboratory performance by a team of experienced scientists, and the right of an accused to have a portion of the specimen retested. Workplace programs mandated by the federal government and many state governments have incorporated most of the quality assurance components from the military’s system. One component, routine observed collections, has not been incorporated into these systems, and this omission has proved to be a problem for “urine only” based workplace programs. Unobserved collections have fostered an industry dedicated to the subversion of these programs by the provision of synthetic urine, negative human urine, prosthetic devices for the delivery of substitution products, oxidants, fixatives, peroxidases, acids, bases, and other substances that are intended to interfere with the testing methods. 10.9.2 The Need for Quality Assurance The necessity for maintaining quality in current workplace drug testing programs becomes apparent when the potential impact of this testing is considered. In 2002, laboratories certified by the Department of Health and Human Services (HHS) tested an estimated 6 million urine specimens collected from donors under federal mandate and an additional estimated 23 million specimens collected under other workplace programs (source: data supplied by federally regulated laboratories that participate in the National Laboratory Certification Program, NLCP). With estimated positive rates of 2.5% in regulated programs and 4.8% in nonregulated programs,3 this would mean that in 2002, these laboratories reported an estimated 1 million results consistent with drug use. In order that innocent individuals do not lose their jobs, and are not denied gainful employment or placed under suspicion of drug use, the goal for quality assurance (QA) in workplace testing programs must be zero tolerance for errors. In the following sections, we review the parts of workplace drug testing programs that are critical to success, examine the programs and methods currently in place to measure the quality of the system, and provide some suggestions for future measurements. 10.9.3 Parts of the Workplace Drug Testing Quality System To obtain a goal of zero errors, the quality system must encompass all parts of the workplace drug testing program. The people, the equipment and instruments, the materials, the methods, and the facilities utilized in all phases of the program must be considered.


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10.9.3.1


The Employer

In workplace drug testing, the quality system begins and ends with the employer. Without proper planning, training, and guidance, the program developed by an employer may not meet the requirements mandated by law and other guidelines. The choices an employer makes in selecting collection sites, testing facilities, and Medical Review Officers (MROs) will undoubtedly influence program effectiveness. While cost is a consideration in making these selections, it should not be the only factor considered. It is important that each test result be supported by proper collection, accurate and legally supportable testing, and appropriate determination of drug abuse. Without these elements, the actions taken by the employer as a result of a drug test may not be in accordance with the law or other guidance, may place the employer in jeopardy, and may wrongly accuse a valued employee or a qualified candidate for employment. 10.9.3.2

The Donor

The donor is an important part of the quality process, but the controls that can be placed on the donor are limited in most programs by considerations of privacy and personal rights. While most donors are conscientious and trustworthy, the quality system must limit the opportunity for a small drug-using minority to subvert the test by substituting their specimen with another urine or other aqueous solution, diluting their specimen by adding water or drinking large amounts of water before collection, or adulterating the specimen with substances that are meant to interfere with testing. 10.9.3.3

The Collection

A specimen must be properly collected to ensure an accurate test. Quality practices need to be followed to ensure the identity and integrity of the specimen. The identity of the donor must be determined, and the link between the specimen and the donor must be maintained throughout the process. Once obtained, the specimen must be secure from tampering and handled under forensic guidelines. There should be no opportunity for subversion of the drug test by the donor, the collector, or the two in collusion. These practices apply to specimens collected for on-site testing or shipped to a testing facility. Specimens collected for workplace drug testing must be closely scrutinized for the quality of the collection. A positive drug test or an abnormal specimen validity test must be able to withstand the challenges of an MRO, a donor, or a legal review. Components of a quality collection include the collector, collection site, collection materials, and collection protocol. One source of guidance for urine specimen collection may be found in the handbook published by the Substance Abuse and Mental Health Services Administration (SAMHSA).4 Some of the information in this section was obtained from this handbook, with a focus on the items critical to the quality of the collection process. The Collector A key element in a quality performance by a collector is training. A collector may be responsible for collecting one or more specimen matrices (i.e., hair, urine, sweat, and oral fluid) and may conduct on-site tests on some of these matrices. Collectors must be thoroughly trained in the collection process for each matrix. They must be trained not only for the routine collection, but also for problems that might arise during the collection (e.g., unacceptable specimen temperature, apparent adulterated specimen, insufficient amount of specimen). For collectors also conducting on-site testing, training must be specific for each on-site testing device. The training should include when and how to conduct the test, demonstration of testing proficiency, actions to take for borderline results, how to package specimens for shipment to a testing facility for additional testing, completion of documentation, and reporting of negative results.


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Proper collector training begins with a qualified trainer. For urine collection, which is the most common matrix in workplace testing, a supervisor of the collection facility with previous experience typically assumes this responsibility; however, there are organizations such as the Drug and Alcohol Testing Industry Association (DATIA) that will also provide a standard course on specimen collection. With the introduction of other matrices and on-site testing into federal and state programs, all training programs may require changes. New initiatives between the testing and collection industries and controlling agencies will become necessary to ensure the validity of the specimens and the results of on-site tests. Training will need to be provided for each specimen type and each on-site test device. Training should go beyond the standard classroom lecture format. Error-free mock collections should be demonstrated for each specimen type, and testing proficiency using blind controls should be demonstrated with each type of on-site testing device. Written exams may also be part of the training program. All training must be documented in a manner that can be easily reviewed and understood by an outside auditor. Minimally, documentation would include a description of the training, time of conduction, identification of the trainer, results of all examinations, and criteria for acceptable performance. Beyond the initial training, a collector should be monitored for performance. Errors that occur during specimen collection or with the use of on-site testing devices require error correction training. For example, the Department of Transportation (DOT) requires collector correction training when errors in the collection process of urine specimens cause a test to be canceled.5 The DOT requires the collector to demonstrate proficiency in the collection procedure by completing one uneventful mock collection and two mock collections related to the error. The person providing the retraining attests in writing that the mock collections were performed correctly with no errors. However, this process fails to address frequency of errors, which is an indicator of the collector’s overall performance and the potential for test-canceling errors. Within the urine drug testing industry, the collection site is perceived to be the weak link in the quality system. To correct this perception, it is recommended that the performance of all collectors be monitored and training requirements be standardized. Within federal programs, one approach to monitoring collector performance would be to examine the chain-of-custody documents, commonly referred to as custody and control forms (CCF), completed by a collector. CCFs failing to conform to federal guidelines would initiate further assessment of the collector’s performance and appropriate corrective actions. Examples of collector noncompliance would be submission of a single specimen when a split specimen is required, submission of two specimens with differing physical appearance as a split specimen collection, or submission of CCFs containing multiple administrative errors. Collectors for non-federal programs might be monitored by professional groups such as DATIA. A collector’s proficiency with on-site testing devices should be measured with periodic performance testing (PT) samples for each on-site device utilized, as well as routine submission of a percentage of the on-site negatives to a laboratory conducting instrumented immunoassay testing and confirmatory testing of immunoassay positives. Abnormal numbers of false negatives should then be investigated to determine if the cause is the on-site device or the performance of the tester. Federal programs should be able to monitor on-site devices and tester performance; however, other programs may have to rely on professional groups for this function. Collection Site A collection site must meet certain requirements to ensure a quality collection. The site must have restricted access. Collection materials, records, and specimens must be properly stored and secured from unauthorized individuals. Materials (e.g., controls, reagents, testing devices) must be kept in acceptable temperature and humidity conditions for proper performance. Secure storage must be provided for specimens until they are tested or shipped to a testing facility, and records


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must be retained as required by applicable regulations. As part of its records, a collection site must maintain copies of current and past SOPs, a copy of each CCF, log books or log sheets, temperature logs from storage areas for specimens and perishable supplies, inventory of supplies/materials, donor information, and chain-of-custody handling. These records should be retained for the length of time required by governing regulations, usually 2 years or more. Urine collection sites should place bluing agent in the toilet bowl and tank and restrict access to soap, water, cleaning agents, and other materials that could be used to adulterate a specimen. Collection Materials A quality collection requires a collection kit designed for the matrix to be collected. The kit should contain a single-use collection device, container(s) for shipment of the specimen to a testing facility, CCFs, and tamper-evident seal(s). Kits for some matrices may require additional materials (e.g., scissors for a hair collection, wipes for a sweat collection). If on-site testing is to be conducted, the kit may also contain an on-site device. All materials must be proved not to affect the testing of the specimen. Containers used for storage/shipment must be capable of holding a tamper-evident security seal at room and frozen temperatures. Additional security can be provided to transported specimens with the use of individual sealable bags or boxes. Shipping containers can be used to protect the specimen from physical damage during transport. Collection Protocol A detailed written protocol (SOP) must be followed for every type of specimen collection. The basic requirements of a collection are the following: Preparation of the collection site (discussed above) Verification of donor identity Preparation of donor for specimen collection (e.g., removal of coats and hats for unobserved collections) Inspection of the specimen to ensure proper amount (and correct temperature of urine) and inspect for evidence of adulteration or substitution Preparation of the specimen for testing, storage, or shipment (e.g., sealing the specimen with tamperevident labels) Completion of the CCF

The CCF is used to identify the donor, collector, employer, and MRO; to provide a unique specimen identification number; to account for handling of the specimen; and to report results and remarks in a uniform manner. 10.9.3.4

The Testing Facility

Testing facilities should establish QA programs to ensure the quality of their processes. Central to the quality assurance program is an SOP manual that details all procedures and processes. This manual and the documentation generated from a QA program in a workplace drug testing facility must be available for review by client auditors, certification agencies, lawyers, judges, etc. Users of the testing services in these facilities need to be assured that the results are high quality and legally defensible. A comprehensive QA program must include the handling, testing, and reporting processes. Components of QA practices include training personnel; validating and maintaining analytical instruments, analytical equipment, and computer systems; validating analytical methods; monitoring chain-of-custody procedures; using quality control samples; and participating in PT programs.


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Personnel Testing facility personnel must be well trained and motivated. They must not be allowed to succumb to the routine nature of the procedures utilized in today’s high-throughput facilities. They must be knowledgeable of the scientific principles underlying the analytical procedures, the capabilities and limitations of the equipment they utilize to perform their work, and the regulatory requirements related to their work. They must be well versed in forensic principles and procedures, and their qualifications, training, and proficiency must be well documented. Equipment and Instrumentation The equipment and instruments utilized to test specimens are an intrinsic part of the quality system. They must be appropriate for the task and proven to perform the tasks through validation processes. This also includes the facility’s management information system (MIS) and other computer-controlled equipment. Materials The importance of quality materials is often overlooked until a problem develops. As with equipment, the quality of the materials must be proven, not assumed. Quality facilities should perform acceptance tests on materials prior to their use and monitor their performance as a part of routine operations. Methods The methods utilized by a facility for all aspects of specimen handling and testing are a critical part of the quality system. A facility may have the best equipment available, highly motivated and trained personnel, and proven materials, but if the method is poorly designed, it will fail more often than a scientifically sound, operationally rugged method. Analytical methods and procedures utilized in workplace drug testing must be validated and characterized to provide timely results that will withstand the scrutiny of legal and administrative proceedings. Their continued performance at the desired level must be monitored by internal and external quality systems. Basic Quality Assurance Practices Method Validation — The quality of an analytical procedure is documented during its validation. Performance parameters commonly determined during validation of initial test procedures are linearity, specificity, precision, accuracy, and carryover studies. Validation of quantitative confirmatory procedures also includes sensitivity, limits of detection, and quantitation and ruggedness. Validation samples are prepared in the matrix to be tested and within the concentration range of interest. At a minimum, these tests are performed annually and when major changes (e.g., change in extraction procedure, new instrumentation) are made to an existing method. Validation records must be organized for an auditor’s review and should include the purpose, scientific principle, method, results, discussion, summary, and review with approval by the facility director. Quality Control — Quality control (QC) is a subsection of QA. QC is used to determine if all components of an analytical process are performing correctly. QC samples of known content are analyzed with the test specimens. Their purpose is to monitor the performance of an analytical procedure within defined limits of variation.


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Calibrators are samples of known content by which the identification and concentration of an analyte in a specimen is determined. Calibration of a device or instrument can be established with a single calibrator or a series of calibrators at varying concentrations. It is common to find initial and confirmatory workplace drug tests evaluated with a single calibrator, but this approach requires the concentration to be determined at the administrative cutoff concentration or decision point. Multiple calibrators can be used to extend the limits of accurate quantitation on an instrument. Calibrators and controls (often referred to as QC samples) are routinely prepared in the matrix of interest to minimize matrix effects. A quality practice is to prepare QC samples from a reference material of documented purity and content. Additionally, calibrators and controls should be prepared with reference materials from different suppliers; otherwise, a bias may occur. If both types of QC samples must be prepared from a single reference material, then they must be prepared independently. QC samples must be validated before they are placed into use. The quantitative criteria for acceptance of calibrators should be more stringent than the criteria applied to other QC samples. Typically, calibrators should not differ by more than 10% from the target value, whereas controls may differ up to 20%. The primary method of validating new QC samples is by parallel testing with QC samples in use. If available, externally certified reference samples should be included in the validation process. The history and use of QC samples should be documented with information that includes the lot number, date of preparation and first use, expiration date, individual preparing the sample, preparation procedure, and validation data. Workplace drug testing utilizes administrative cutoffs. QC samples at concentrations above and below the cutoff are used to demonstrate linearity around the cutoff, allowing clear differentiation of positive and negative specimens. These controls should be within the linear range of the assay and near the cutoff (±25%). Analytical batches should also contain a negative control to demonstrate the response of the assay in the absence of an analyte and a blind sample to demonstrate that the analytical batch has been properly prepared and analyzed. Other controls may be included to demonstrate extended linearity, lack of carryover, completeness of hydrolysis steps, lack of interference from structurally related analytes, and adherence to dilution protocols. Typically, a minimum of 5 to 10% of QC samples are required in each batch of specimens, some of which should be distributed throughout the batch. Internal standards are essential to accurate quantitative analysis of QC samples and donor specimens. Ideally, the concentration of the internal standard should be close to the cutoff. Deuterated analogues of the analyte of interest are best for GC/MS selected ion monitoring as they have similar fragmentation patterns. However, structurally similar analytes can serve as the internal standard if the available deuterated internal standards are unsuitable (e.g., coelute with the analyte of interest and have the same major ion fragments). Quantitative and qualitative acceptance criteria for initial and confirmatory tests must be established and adhered to during analysis. QC results, acceptable and unacceptable, must be documented as a complete record of QC performance. Systems for monitoring QC results should be established to detect shifts, trends, and biases. Actions to be taken to correct these anomalies should be contained in the facility’s SOP. Physical Plant The physical plant in which testing occurs must be sufficient to meet requirements for security, habitability, safety, and performance of the work required. It must provide security for the specimen, the testing, and the results such that the linkage of the result with a donor is never in doubt. It must provide adequate space, ventilation, and other features to ensure a safe environment for employees and an optimum environment to conduct testing. Errors can be introduced in the testing process when the physical plant is inadequate.


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It is important that an alternative source of power be available during prolonged power outages. At a minimum, there must be a plan to ensure proper temperature conditions for stored specimens. Management Information Systems An MIS is designed to improve the reliability, efficiency, and productivity of the testing facility. It may exist as a centralized data system with workstations tied into analytical equipment or standalone personal computers. It is used to log in and track samples, order tests, receive and manage data, report results, and handle routine administrative tasks. The MIS must be independently validated before being utilized for any task associated with the receipt, handling, testing, data review, or result reporting. All software and hardware added after the initial validation should be validated prior to use. Security must be in place to prevent unauthorized access, inappropriate release of information, and introduction of unauthorized, unvalidated software. The MIS must be monitored for problems, and audit trails must be established for all functions. Backup and disaster recovery procedures should be in place to prevent loss of information entered into the system. MIS procedures should be subjected to routine audits as part of an inspection process. An MIS SOP manual describing the items above must be established and available during inspections. The person responsible for management of the MIS may not be the testing facility director; however, the director must be knowledgeable of the functions performed by the MIS, have input into its functions, and ensure that the forensic testing is supported. The testing facility director and MIS manager must work together to establish procedures for requesting changes to the MIS, validate changes, and determine end-user acceptance. 10.9.3.5

The Medical Review Officer

Testing facilities in all federal and many nonregulated workplace programs report test results directly to an MRO. Both DOT regulations5 and HHS Mandatory Guidelines6 contain requirements for MROs. To meet these requirements, physicians may obtain training and certification from any one of three organizations: American Association of Medical Review Officers, American College of Occupational and Environmental Medicine, and American Society of Addiction Medicine. To correctly interpret test results, MROs use their medical knowledge and their understanding of the applicable laws and regulations, the testing process, the collection process, and information provided by the donor. The properly trained and motivated MRO must be willing to question not only the donor, but also the collection site and the testing facility to ensure that the employer is provided a determination that considers the applicable science and regulations. MROs are often called gatekeepers because they are able to query the entire process to ensure that the quality system was intact. The MRO practice should have a detailed SOP to ensure the quality of the MRO process, consistency of procedures, and adherence to governing guidelines and regulations. A more complete description of the MRO practice is described elsewhere in this volume. Currently, MROs are not routinely monitored for the quality of their review. One approach to an MRO review program could be based on the documentation received by testing facilities. CCFs containing results for specimens reported as adulterated, substituted, invalid, and drug positive could be audited to determine the final disposition of the test. Reviews that revealed noncompliance with regulations would require an in-depth audit of other non-negative results reported by that MRO. Reports of these reviews could then be provided to the employer and other agencies, as appropriate. 10.9.4 Measuring Quality in the Workplace System Measuring the quality of workplace testing requires the establishment of standards against which the measurement may be performed. Currently, there are four programs that establish


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standards for testing facilities and conduct measurements against those standards. While there are programs that accredit or certify MROs and collectors, none conduct measurements beyond the initial certification or accreditation. Subsequent sections will describe some of the tools utilized by organizations to measure the quality of testing facilities. 10.9.4.1

Testing Facility Certifying and Accrediting Organizations

NLCP The reliability of facilities that test specimens for drugs in the workplace will always be of concern. A high degree of certainty of results is required of drug testing facilities to prevent false accusations against those undergoing testing. For this reason, the “Mandatory Guidelines for Federal Workplace Drug Testing Programs”6 were developed to provide guidance to federal agencies for the collection and analysis of urine specimens collected from federal employees. With these Guidelines, HHS established standards for certification that have made HHS-certified urine drug testing laboratories the “gold standard” in the drug testing industry. Regulations issued by the DOT for the drug testing of safety-sensitive private sector employees in its operating modes, as well as the Nuclear Regulatory Commission for fitness for duty employees require the use of HHS-certified laboratories to perform their mandated drug testing. The NLCP was developed for the establishment of initial and ongoing certification of forensic urine drug testing laboratories. The NLCP is designed to examine laboratories for compliance to the Mandatory Guidelines. In doing so, it examines the laboratory quality practices discussed above. Two of the major components of the NLCP are the PT program and the inspection program. Other components of the NLCP are described elsewhere in this volume. The NLCP PT program emphasizes the laboratory’s ability to accurately quantify drug concentrations in urine and report the results following Federal requirements. Strict scoring policies mean that a certified laboratory’s failure to successfully test the PT samples may result in suspension or revocation of its certification. The NLCP challenges laboratories with PT samples formulated to mimic real specimens from donors in order to identify problems and to ensure appropriate actions are taken to correct those problems. Laboratories are expected to investigate all PT errors and must submit documentation of investigation and completed corrective action, as directed. The NLCP categorizes laboratories (Category 1–smallest to Category 5–largest), using an objective system based in part on laboratory size, regulated specimen workload, and number of non-negative specimens reported in a 6-month period. Depending on category, semiannual maintenance inspections last 2 or 3 days and consist of one or two inspectors performing a general inspection (i.e., reviewing procedures and observing practice) and one to six inspectors performing a records audit. The NLCP focuses inspections on the procedures of the laboratory and on examination of the laboratory’s forensic product through the audit component. The teams use two checklists: the General Laboratory Procedures Checklist and the Records Audit Checklist. The inspection team submits two summary reports, one from the general inspectors and one from the auditors. The inspection reports are reviewed by the NLCP technical staff. An Inspection Final Report is returned to the laboratory listing the deficiencies. Major deficiencies require a remedial action plan within 5 business days. All others must complete the remedial process within 30 days. Remedial actions are reviewed at the next inspection. College of American Pathologists The College of American Pathologists (CAP) has developed a Forensic Urine Drug Testing (FUDT) Accreditation Program that parallels the NLCP but is directed at non-federal workplace drug testing. Although this is a voluntary program, many clients require this accreditation for their non-federal employee drug testing.


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The CAP program requires completion of a self-inspection checklist between on-site inspections that are conducted by a group of volunteers in the forensic toxicology field. Inspectors, guided by a checklist, focus on laboratory procedures and processes that include specimen handling, analytical instruments and procedures, quality control, personnel, computer operations, safety, facilities, records, and reporting. Laboratories are also required to participate in at least the Urine Drug Testing Confirmation PT program. Acceptable performance is based on correctly identifying and quantifying drugs and obtaining a minimum score of 80%. A false-positive drug report is a survey failure with accreditation probation. Continued failures result in loss of accreditation. The FUDT program differs from the NLCP in that the laboratory is evaluated for drugs other than the illicit drugs used in the federal program. In addition, the laboratory may use initial and confirmatory cutoffs unlike those stated in the Mandatory Guidelines. A more detailed description of the FUDT program can be found in a previous edition of this textbook.7 State of Florida The State of Florida has established a Drug-Free Workplace program similar to the HHS Program for Federal Employees.8 It regulates workplace testing for state employees and private workplace drug testing programs seeking discounts on Florida workers’ compensation insurance premiums. Oversight of the program is maintained by the State Agency for Health Care Administration.9 It allows the testing of biological samples (primarily urine and hair) for ten drugs/drug classes and their metabolites and alcohol (blood). It requires laboratories to conduct initial and confirmatory testing of positive specimens using two different scientific methods, to participate in proficiency testing programs, and to report test results to an MRO. Laboratories must participate in a proficiency testing program that tests for all of the required drugs. Inspections of licensed laboratories are semiannual and are conducted by the state. An HHS-certified laboratory may request to substitute one of the state inspections with an NLCP inspection and is required to submit the results of all NLCP inspections. Blind PT specimens are not required as part of the QA program. State of New York The State of New York amended its public health laws in 1966 to require the licensure of clinical laboratories by establishing minimum qualifications for directors and by requiring that the performance of all procedures employed by clinical laboratories meet minimum standards accepted and approved by the state department of health.10 The laboratory licensure program is managed by the state’s public health laboratory for 27 specialties of laboratory science, including forensic toxicology. The laboratory director must hold a certificate of qualification from the state department of health; minimum qualifications include a doctoral degree and 4 years of postdoctoral laboratory experience, 2 of which must be in the toxicology specialty. Laboratories engaged in the toxicological analysis of biological specimens are required to participate successfully in the state’s proficiency testing program and must be in substantial compliance with standards of practice as assessed through biennial inspections. Laboratory standards and proficiency testing performance requirements in the forensic toxicology specialty are comparable to those of the NLCP. However, the State of New York has not imposed limitations on the specimen matrix, the drugs to be tested for in workplace programs, or the assay cutoff concentrations. These service characteristics are established through laboratory-client contracts. Performance in proficiency testing is evaluated in the context of the assay cutoff concentrations that are reported to the program. The proficiency testing specimen matrix is urine. Blind PT specimens are not required as part of the laboratory licensure program.


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10.9.4.2


Methods of Measuring Quality

There are four primary systems for measuring the quality of a drug testing program: inspections, PT, blind specimens, and retests of non-negative specimens (conducted under most programs at the request of the donor). Inspections The inspection process is essential for improving and maintaining the quality of a testing facility, collection site, collector, and MRO. An inspection should represent an independent review of operations and be conducted by trained and knowledgeable professionals. It provides a means of peer review and feedback. Inspections provide a snapshot of the operations at the time they are conducted and are not a substitute for other quality systems. Since each part of the workplace drug testing system is dynamic, constantly changing to improve quality, increase efficiency, and reduce expenses, it is important that inspections occur on a regular basis. Although accreditation/certification may not be mandatory or available for each part of the system, it would provide additional assurance to clients that quality services and results are being provided. Currently there are no provisions for routine inspections of collection sites, collectors, and MROs. Typically, inspections of a testing facility are a requirement for initial accreditation or certification, as are periodic maintenance inspections by certifying or accreditation organizations such as those previously described. Technically and professionally qualified inspectors receive training and continuing education sponsored by those organizations. The inspectors review all of the relevant administrative and technical functions of the site to ensure they are in accordance with prescribed regulations and industry practices. Inspectors, guided by an inspection checklist, review and evaluate testing processes to include: SOP manual, specimen handling, analytical equipment and maintenance, computer operations, analytical procedures, review and reporting of results, QCs, and personnel qualifications and training. Inspectors also review records that include specimen data, method validation data, PT data, chain-of-custody documentation, and reports transmitting results to the client or MRO. Deficiencies noted during the inspection must be corrected and reviewed at the next inspection. A critical issue in any testing facility inspection is the amount of data that should be reviewed. The data should be carefully selected to optimize the detection of possible administrative, technical, and forensic issues. This is best accomplished by reviewing documentation and results for specimens that were reported as non-negatives. Non-negative specimens include drug positives, abnormal specimens (i.e., adulterated, diluted, and substituted), and specimens received but not tested. The resources required for an inspection should be determined by the testing facility’s workload, the number of non-negative results reported, and the amount of review necessary to determine that all procedures have been adequately evaluated. Inspections meeting these criteria consume large amounts of time and resources, but are essential to maintaining quality. Proficiency/Performance Testing (PT) Participation in PT programs is an important quality practice for all testing entities, including testing facilities and personnel conducting on-site tests. They provide a mechanism for assessing the accuracy of the handling, testing, and reporting processes. They can be used to identify and test modifications to operating procedures, methods, and equipment. Regulatory agencies now require testing facilities to maintain acceptable performance in designated PT programs as a condition for initial and continued accreditation/certification. Although there are no regulatory requirements for routine PTs for on-site tests in workplace drug testing, some on-site testing facilities are using available PT programs to monitor performance. PT samples are prepared by fortifying the matrix of interest (e.g., urine, oral fluids, hair) to the desired drug analyte concentration. Within workplace drug testing, PT samples are normally


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formulated to determine the ability of the testing facility to accurately identify and quantify drug analytes alone or in the presence of possible interfering substances, to identify abnormal or adulterated specimens, and to determine the dynamic range of the testing methods. PT samples should be handled in the same manner as donor specimens. This includes not using replicate analysis if routine samples are not run in replicate. Criteria used to identify and quantify specimens should be the same for donor and PT specimens. It is ideal for a testing facility to include PT samples among donor specimens when testing the samples. Reported PT results from participating facilities are compared to a reference value (normally the average of all results excluding outliers) to determine acceptable quantitative performance. If different analytical methods are used, means for each method are sometimes determined for comparison. Appropriate ranges for each method’s mean can be standard deviations, percentage from the mean, or both. Method means can be further used to determine acceptable methods and/or instrumentation when compared to established reference methods. The number of specimens in a PT cycle is small in comparison to the total specimens analyzed in a facility. For this reason, a quality practice is to participate in as many PT programs as possible. It is desirable to spread these PT sets over the entire year. Testing facilities should review the information returned by the PT program. Any trends that are developing should be examined. Unacceptable results are to be investigated and corrective action taken to prevent reoccurrence. For major errors (e.g., false positives, large variations from the reference value), immediate resolution of the error through remedial action should be required by the certifying/accreditation agency. Do PT programs make a difference in performance? Analysis of data from the NLCP PT program indicates that a PT program can enforce an initial level of performance and over time improve the performance of conforming facilities. In Figure 10.9.1A, bar graphs depict, through average coefficients of variation (CV), the performance of laboratories that applied for certification and certified laboratories in 1990. The variation within the population of certified laboratories was less than that of the candidate population for all drug analytes. In Figure 10.9.1B, it can be seen that since 1990, the average CV for most drug analytes has decreased. Not shown are the average CVs for codeine and phencyclidine, which have remained at 9 to 12% since 1990. Blind Specimens QA specimens presented to a testing facility in the same manner as donor specimens are referred to as blind specimens. They are submitted with fictitious information on the required custody documents and specimen bottles. These specimens should not be readily identifiable as blind specimens. The drug content of a blind specimen should be validated before use. The HHS Mandatory Guidelines and DOT regulations require that employers submit blind specimens to certified laboratories as part of their drug testing program. Many testing facilities have QA programs that submit blind specimens to the facility as part of their quality practices. Blind specimens provide an excellent means of monitoring all of a facility’s procedures. In addition to checking the technical processes of a testing facility, blind samples submitted with broken seals, incomplete CCF, etc., can also challenge the facility’s procedures for handling of administrative errors. The results of blind specimens should be closely monitored, and an investigation should be initiated when the results are inconsistent with target analyte identification or concentration. This investigation should evaluate the supplier and testing facility, identify the source of the inconsistent results, and require corrective actions. Retests of Non-Negative Specimens In many programs, the donor of a specimen found to be non-negative may request that an aliquot of the original specimen, in the case of a single specimen collection, or the unopened bottle,


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Analytical Variation of Candidate and Certified Laboratories 1990–1991 50% 45%

Average CV (percent)

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20% 15% 10% 5% 0% AMP

MAMP

BZE

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COD

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A Analytical Variation for HHS Certified Laboratories 1990–2003 30%

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Average CV (percent)

THCA

20%

15%

10%

5%

0% 1990

1993

1997

1999

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Year

B Figure 10.9.1 (A) Comparison of the average CV of GC/MS values reported by NLCP candidate and certified laboratories in 1990–1991 for amphetamine (AMP), methamphetamine (MAMP), benzoylecgonine (BZE), morphine (MOR), codeine (COD), phencyclidine (PCP), and 11-nor-9-carboxy THC (THCA). (B) Average CV for amphetamine (AMP), methamphetamine (MAMP), benzoylecgonine (BZE), morphine (MOR), 6-acetylmorphine (6-AM), and 11-nor-9-carboxy THC (THCA).


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in the case of a split specimen collection, be retested. The retest is normally conducted at a testing facility different from the one reporting the non-negative result. Failure of the second testing facility to confirm the original result provides an opportunity to investigate the data from both facilities. Investigations of these incidences most often point to an issue with the collection process, usually the addition of an adulterant or a lack of a proper collection, rather than a testing facility error. 10.9.5 Conclusion Workplace drug testing programs have become well established over the past 20-plus years. They have grown from a modest beginning in the military to become a program much larger than any imagined. The science and testing methodologies for urine drug testing have been well established. Now, it appears that the structure of workplace testing will change. The pressures from efforts to subvert a urine drug test have generated a need for solutions. Specimen validity testing cannot detect all efforts to suborn drug testing. Civil rights issues associated with observed collections make it clear that they can only be used under specific circumstances. Workplace drug testing using matrices such as hair, oral fluids, and sweat are being offered as a solution. While it would appear that these matrices are less subject to undetectable attempts to circumvent a valid test, there is still discussion within the scientific and legal communities about interpretation of results from these tests and their appropriate use. It is believed that these issues will be clarified and in the future the effectiveness of workplace drug testing will be enhanced as a result of their implementation. However, as a word of caution, this is possible only if the lessons learned about the quality requirements of the urine drug testing system are appropriately applied to the testing of new matrices. Acknowledgments The authors express their appreciation to Donna M. Bush, Ph.D., Walter F. Vogl, Ph.D., and Charles Lodico, M.S., of the Division of Workplace Programs, Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services; Richard W. Jenny, Ph.D., of the State of New York Department of Health; and Patricia L. James, B.S., M.A., the State of Florida Agency for Health Care Administration for regulatory insight.

REFERENCES 1. Department of Defense. Urinalysis test results analysis. Naval Military Personnel Command Contract N00600-82-D-2956, October 22, 1982. 2. Brey, R.M. et al. Highlights of the 1988 worldwide survey of substance abuse and health behaviors among military personnel. Department of Defense Contract MDA903-87-C-0854, 1989. 3. Quest Diagnostics, Inc. 2003 drug testing index. http://www.questdiagnostics.com/. 4. Urine Specimen Collection Handbook for the New Federal Drug Testing Custody and Control Form. Division of Workplace Programs, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services. http://www.drugfreeworkplace.gov/DrugTesting/SpecimenCollection/UrnSpcmnHndbk.html. 5. Procedures for Transportation Workplace Drug and Alcohol Testing Programs, 49 CFR Part 40, Department of Transportation, 65 Federal Register 79462, December 19, 2000 and 65 Federal Register 41944, August 9, 2001. 6. Mandatory Guidelines for Federal Workplace Drug Testing Programs, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, 59 Federal Register 29908, June 9, 1994.


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7. Baenziger, J., The College of American Pathologists voluntary laboratory accreditation program, in Drug Abuse Handbook, Karch, S.B., Ed., CRC Press, Boca Raton, FL, 1998, chap. 10.2.2. 8. Florida Statutes Section 112.0455. 9. Florida Administrative Code Chapter 59A-24. 10. New York State Public Health Law Article 5, Title V.

10.10 CURRENT LEGAL ISSUES OF WORKPLACE DRUG TESTING

Theodore F. Shults, J.D., M.S. Chairman, American Association of Medical Review Officers, Research Triangle Park, North Carolina

Over the 20-year life of modern workplace drug testing, a body of law has been created that is directly related to and directly influences its practice. It is an expansive body, stretching from the constitutional limits on the government’s ability to require testing under the Fourth Amendment; it involves a large and expanding matrix of state drug testing laws and legal cases, and travels all the way down to local rules establishing how to introduce drug test results in an unemployment security case.1 Over this timeframe, fundamental federal laws such as the Americans with Disabilities Act, the Omnibus Transportation Employee Testing Act of 1991, and more recently the Health Insurance Portability and Accountability Act (HIPAA) came into existence. All of these laws affect and shape drug testing practices, the drug testing industry, employment practices, and social policy. There are a number of legal treatises that deal with employment drug testing and that cover federal and state drug testing laws. This chapter focuses on current key legal issues with a particular perspective of a drug testing service provider and employer. Regardless of the reader’s knowledge of and facility with the specific laws of workplace drug testing, the following are broad issues that all employers and providers of drug testing services such as collectors, laboratories, third-party administrators, and medical review officers (MROs) will be dealing with directly in the years ahead. 10.10.1

Liability of Drug Testing

Over these 20 years or so of modern workplace drug testing there have been literally millions of drug tests performed, tens of thousands of positive tests reported, and relatively few lawsuits. There are many reasons for this, but perhaps the most significant is that the analytical procedures are reliable and defendable. Mistakes happen, and mistakes have happened, but there is a very low incidence of error considering the large number of tests performed. Other historical factors contributing to the relatively low level of litigation are that it is often difficult for a donor to bring an action against an employer or a service agent alleging negligence, and the damages of such alleged negligence are often low. One of the great concerns of drug testing has been the fact that often the only evidence of drug use is the laboratory test, and for many donors it is easier to deny illicit drug use and claim the results are a “false positive” than to acquiesce to the results and reality. Thus, there has always been a great deal of potential for litigation, which would cripple drug testing programs. From the perspective of an employer, the greatest liability is not from drug testing but rather from the damages caused by an impaired employee to a third party. If an employee, acting within the scope of employment, causes injury to customers or to the public after consuming alcohol or drugs, liability may be imputed to the employer under the doctrine of respondeat superior. This vicarious liability can occur in commonplace situations, such as an accident caused by an impaired employee driving a company vehicle.2 The actual costs of a drug- or alcohol-related accident can be astronomical, e.g., the Exxon Valdez environmental catastrophe and damage awards. Employers


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involved in hazardous or safety-sensitive work have understandable concern over the drug use, fitness, and qualifications of their employees. One of the greatest misconceptions in drug testing is that employers who drug-test are at a great risk for lawsuits from employees over the results and adverse employment consequences. That’s not true — or at least, it is an overstatement. Certainly, if an employer discriminates against an employee or applicant there are legal consequences, but courts do not want to get into routine hiring and firing decisions, or second-guessing business decisions. Thus, there is the judicial doctrine of employment-at-will, which broadly protects employers from direct suits from employees over drug testing. Essentially, the employment-at-will doctrine stands for the premise that in the absence of an employment contract there is no “temporal” relationship between employer and employee. In other words, the employer–employee relationship can be terminated without notice, and without cause. Since there is no need for a reason to terminate the relationship, it is irrelevant whether the reason for the termination is reasonable, unreasonable, fair, unfair, right or wrong, as long as it is not illegal or against public policy. (An illegal reason is discrimination based on race, age, or sex, retaliation for filing a workers’ compensation claim, or termination for certain types of “whistleblowing.”) Thus, in the absence of any state law to the contrary, employers have a great deal of insulation from lawsuits arising from employment decisions based on drug test results, even if the results are not accurate. An important distinction is when there is a collective bargaining agreement (CBA). This is a type of employment contract. The key distinction between a CBA and employment-at-will is that an employer cannot terminate a covered employee unless there is a reason, which is usually phrased as “just cause.”3 With unionized employees, the union has a duty to defend its members, and there is a right to a grievance process and arbitration. The employer may have to reinstate a terminated employee following arbitration, and pay back wages, but there are no monetary damages. From the service provider’s perspective, liability issues are more complex. First, there is contractual liability, which is the service provider’s responsibility for performing drug testing services appropriately for the client (the employer). For the laboratory, it involves the accurate handling, analysis, and reporting of specimens. For collectors, it is the proper performance of the collection process. For MROs, it is fulfilling the verification process correctly. But this contractual liability exists between the service providers and the client (i.e., the parties to the contract). There have been a few situations where employers have sought damages against a service provider for breach of contract, but this has been relatively rare. Second, the doctrine of employment-at-will has not been extended to cover service agents, even though they are acting in many cases as the “agent” of an employer. What has historically protected service agents from lawsuits from donors is the fact that the law has not recognized a duty of care existing between the third-party service agent and the donor of a specimen. Historically, the service provider did not owe a “legal duty” to the donor. Thus, a donor who alleged that the specimen was mishandled or was a “false positive” could not bring a negligence claim against the service provider, because an essential element of negligence law is the existence of a legal duty. To be a bit more accurate, the donor could bring a suit against the service provider, but it would be quickly dismissed. That has been changing on a state-by-state basis since the mid-1990s. That historical protection or legal insulation is eroding, and has been eliminated in a number of jurisdictions. A good illustration of how the law looks differently at employers and service providers is the case of Jane Doe v. SmithKline. In this 1994 case, the Quaker Oats Company made an offer to an applicant (Jane Doe) for a marketing job. The job offer was contingent on passing a drug test. The drug test was reported to Quaker as positive for a low level of morphine. Apparently there was no MRO verification, and no clinical evidence of abuse. When it learned that the laboratory had identified morphine in the specimen, Quaker simply withdrew the offer.4 The applicant, who had quit her job and was in the process of relocating, brought suit against Quaker and the laboratory. Even though Quaker did not use an MRO and withdrew the offer of employment, the court quickly


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dismissed Quaker as a defendant under the employment-at-will doctrine. It was not so easy, however, for the lab. The trial court found that it was liable. The Texas Court of Appeals ruled that, given these facts, a laboratory had a legal duty to warn test subjects of possible influences on results (e.g., poppy seed ingestion). The Texas Supreme Court, however, overruled this decision. The laboratory analysis was correct — there was morphine in the urine. That was what the laboratory was asked to determine, and it did. In the end, a divided court found that the laboratory has no legal duty to warn donors.5 The failure to mention poppy seeds to the employer, and the employer’s reliance on the test results, may still be a basis for a suit alleging willful and intentional interference with the conditional offer of employment between the employer and employee. No wrong goes without a right, as plaintiffs’ lawyers like to say. Thus, with employment-atwill protecting the employer and with no legal duty attaching to the provider, the donor might not have any legal recourse. Naturally, with drug testing an almost universal employment practice, this insulation was not going to last forever. The law adapts, and it is in that process. Over the past few years there has been a case-by-case, jurisdiction-by-jurisdiction expansion of what is essentially the scope of legal liability to cover various drug test providers. There is an expanding body of law that allows employees to bring direct actions against laboratories (and theoretically against MROs, third-party administrators, and specimen collectors). In the first significant case, Stinson v. Physicians Immediate Care, Limited, Stinson alleged that the laboratory had been negligent in performing a drug test on him and had reported a false-positive result for cocaine. Stinson alleged that the test result was false or, in the alternative, the report of the test result was false. As is characteristic in this type of case, the allegations were general in nature. The plaintiff alleged the defendant was negligent. The trial court dismissed Stinson’s case on the grounds that a laboratory does not have any legal duty to the donor of the specimen. The appellate court in Illinois, however, reversed this decision and held that a drug testing laboratory owes a duty of reasonable care to persons whose specimens it tests for employers or prospective employers. The appellate court view was that it is reasonably foreseeable that the tested person will be harmed if the laboratory negligently reports the test results to the employer, that the laboratory is in the best position to guard against injury, and that the laboratory is better able to bear the burden financially than an individual who is wrongly maligned by a false-positive report. Thus a terminated employee, and presumably a frustrated applicant, has a basis to state a claim against a laboratory by alleging that the laboratory has a duty to the donor to act with reasonable care in collecting, handling, and testing the specimen, and reporting the results accurately. Several appellate decisions have defined the legal responsibility of laboratories.6 This expansion of legal duty is not limited to the laboratories. In November 1999, the Wyoming Supreme Court cited the Stinson case when it held not only that a collector (and a collection company) owes a duty of care to the donor, but that it also has a duty of care as a consultant, where the collection company recommended a urine alcohol test. (And this duty to the donor essentially extends to all of the service providers.) The Wyoming case was Duncan v. Afton, Inc.7 It is another example of a court finding that a drug test provider (in this case, a third-party administrator, a collector, a laboratory, and an MRO) owes a duty of care when collecting, handling, and processing urine specimens for the purpose of performing substance abuse testing. This duty is not only to the employer, but to employees and applicants as well. All of the above cases deal with the duty of drug and alcohol service providers in regard to allegations of “false-positives” and protecting the donor’s interests. A question that has been in the background is whether service providers such as MROs owe a duty to third parties for “false negatives” or “undue delay” in reporting results, or the failure to notify an employer that an employee may be unfit for a safety-sensitive position. In other words, is there exposure for a service


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provider who fails to report a “positive” test for whatever reason, and there is a drug-related catastrophic accident? Such circumstances are rare, but one court case has dealt with such an occurrence. The case, Turley v. Taylor Clinic, went to trial in late 2005 in the Aniston, Alabama state court, the first reported case of a drug-related catastrophic accident occurring while the MRO verification process was under way. It is the first case where an MRO has been charged with causing harm to a “third party” — not the donor, but individuals harmed by the donor (a drug-impaired truck driver). The case illustrates the relatively indefensible position the MRO and the MRO’s employer, Taylor Clinic, were placed in by the failure of the regulations to address a fundamental flaw in drug testing analysis and the intrinsic regulatory conflict between “safety” and the prohibition of removing a presumptive positive donor from safety-sensitive tasks until the verification process is complete. Methamphetamine exists in two forms called isomers, with significantly different clinical and pharmacological properties. Both forms look identical to a mass spectrometer. The l isomer, levmetamfetamine, is found in over-the-counter inhalers like Vicks Inhaler®. The d isomer is the form of methamphetamine that acts as a potent CNS stimulant and is the form that is a controlled substance and is abused. The l and d forms of methamphetamine can be differentiated analytically, but there is no regulatory requirement to do so. Therefore, most laboratories that must compete on price in this mandatory testing program do not do the analysis. The risk to all MROs is that if they do not order the d and l test for a methamphetamine positive (in cases where there is no other medical explanation), the MRO is exposed to a future claim from the donor that the results were in fact due to legal use of a nasal inhaler.8 The positive methamphetamine donor will allege that the MRO negligently or intentionally failed to order the isomer identification analysis. Thus, under the current regulatory scheme the laboratory’s report of undifferentiated methamphetamine presents MROs with the Hobson’s choice of either verifying a methamphetamine-positive without objective laboratory evidence of whether the drug reported is d methamphetamine or l levmetamfetamine, or delaying the verification to perform the d and l testing. A regulatory conflict exists in addition to this technical deficiency. DOT regulations place a legal duty on MROs to remove donors who present safety risks, and yet also prohibit removal of a donor with a positive test until the result is verified by the MRO.9 What happened in the Turley case is that the laboratory reported a positive undifferentiated methamphetamine to the MRO. The MRO immediately contacted the truck driver. The truck driver first claimed that the result was due to prescription use of Didrex®, then to Adipex®.10 He strongly denied use of illegal methamphetamine. The MRO determined that there was no prescription use and ordered the d and l analysis. The MRO promptly contacted the employer representative as soon as the laboratory analysis came back as d methamphetamine. While the MRO was waiting for the d and l analysis, the truck driver was seen driving his rig erratically on a major highway. Before the state police could intercept him, the driver exited the highway and ran the stop sign at the end of the exit ramp. A pickup truck collided with the side of his tractor-trailer, resulting in the immediate death of the passenger and the subsequent death of the driver. The truck driver was uninjured. The police arrested the driver, who could not stay awake. A police-requested blood test for drugs and alcohol was positive for methamphetamine. The truck driver was found to have grossly overextended his time on the road. He had doctored his logbooks and was suffering from fatigue. He pled guilty to vehicular homicide and was given an active jail sentence. In the discovery process of the wrongful death suits filed against the trucking firm, the plaintiffs’ attorneys discovered that the random DOT drug test for methamphetamine had not been reported to the employer at the time of the accident. To the plaintiffs, this simply looked like negligence. The plaintiffs alleged in their respective complaints that the MRO should have contacted the employer and had the driver removed the moment the lab result came in (although this would have


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violated DOT’s regulations), and subsequently that the MRO should not have ordered the d and l isomer test, which caused a delay in reporting the result.11 What the plaintiffs presented at trial were the bad acts of the truck driver and his guilty plea for drug-related vehicular homicide. They pointed out to the jury that DOT regulations refer to the MRO as the “gatekeeper” for the program. This was creatively interpreted to mean the MRO is supposed to protect the public from illegal drug users — specifically, from methamphetaminecrazed truckers. The plaintiffs also read the provisions from Part 40 that state the donor has the “burden of proof” as meaning that if on the first telephone call the donor cannot prove he has an alternative medical explanation, he must be found to be positive and/or removed from service. It mattered little that these were fundamental misinterpretations of the regulations. It did not seem to matter that the MRO role is also to protect individuals who are not illegal drug users from being falsely accused or losing employment because they use an over-the-counter inhaler. It was quite simple for the plaintiffs: local fellows are dead, an out-of-town doctor failed to report the results — bad outcome, bad MRO. These issues could have been addressed. However, the defense was essentially forced to settle this case by following the informal guidance (or as it was described, the bombshell) that was dropped by DOT’s Office of Drug and Alcohol Policy and Compliance (ODAPC). The defense counsel for Taylor Clinic asked ODAPC its view on the actions of the MRO and presented the office with a “hypothetical” synopsis of the facts. The defense counsel was surprised to learn from ODAPC that: … the MRO had no compelling medical reason to order the d,l isomer test and delay reporting. The donor offered no medication or explanation in the hypothetical that gave a reason for delaying the final verification decision waiting for that particular additional test.

The new concept of requiring a compelling medical reason to order a d and l test is without any regulatory basis and is in frank conflict with the guidance DOT has given for over a decade. It also raises the question of whether an MRO, in the absence of a compelling medical reason, should delay reporting of any positive results where the purported explanation is unlikely. For example, it is common for a donor to claim that he or she is positive for cocaine because his or her dentist used cocaine in a recent procedure. It is generally understood in the MRO community, the general medical community, and the dental community that cocaine is not used in routine dental procedures in the U.S. The standard of practice has been, however, for the MRO to give the donor some reasonable amount of time to get information from the dentist. Some MROs even contact the dentist directly to verify the information. If there is a drug-related accident or injury while this aspect of the verification process is under way, can it now be alleged that the MRO was negligent because there was no compelling medical reason to verify the donor’s claim? DOT has certainly opened the door for such allegations. ODAPC further exacerbated its guidance to Taylor Clinic in respect to verification of methamphetamine by subsequently proposing that MROs go ahead and report positive methamphetamine results without the d and l analysis. The MRO is then free to decide whether to order the additional test. In the event the d and l results are reported back as all l isomer, the MRO can issue a “revised” report. This sounds reasonable, except that in most cases the donor will have already been fired, and most employers who are not governed by collective bargaining agreements will be under no legal obligation to rehire them. It is doubtful that this “guidance” is even constitutional, as it is simply an unreasonable rule with unreasonable results. At the time of this writing, these concerns have been expressed to DOT without satisfactory response. Turley v. Taylor Clinic is the worst-case scenario for an MRO and for the government. It all stems from the failure of the HHS Mandatory Guidelines to require laboratories to identify which form of methamphetamine they are reporting. If the trend is toward holding the service provider


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liable for the shortcomings of policy and regulatory schizophrenia, MRO verification of DOT results will begin to present unacceptable levels of risk. Some legislative relief would be appropriate. 10.10.2

Specimen Validity: Managing the Integrity of Specimens and the Question of Federal Preemption

Workplace drug testing has historically been based on the analysis of urine specimens. There are many advantages to using urine. There is sufficient quantity, it is easy for a laboratory to handle and manipulate the specimen, urine is mostly water, and the physiologic processes and kidneys provide a first pass at concentrating the metabolites and drugs of interest in the urine. The development of high-speed automated immunoassay instruments in the 1980s facilitated the ability to quickly and effectively screen urine specimens and made large-scale urinalysis programs practical. Urine gives a 2- to 3-day window of detection using typical workplace drug testing cutoff levels. The disadvantage of urine is, frankly, that it is urine. Urine collection involves a personal and private process that requires a reasonable degree of privacy. A legal (and social) constraint of urinalysis testing is the premise that in the absence of individualized suspicion of adulteration or other subterfuge of the collection process, it is unreasonable to witness or directly observe the production of a urine specimen.12 This “reasonable” degree of privacy in the collection process has provided a reasonable opportunity for a drug user to adulterate, substitute, or otherwise attempt to undermine the drug testing process, and many have. Adulteration and substitution have challenged the integrity, technology, and economics of urine drug testing. The very principles and legal foundation of drug testing have been challenged by the adulteration industry and their willing accomplices: drug users who have no interest in changing their behavior. In 2004, HHS implemented a technical strategy that required certified laboratories to screen all specimens received from federal agencies for the presence of oxidants, check the pH, and determine the level of creatinine.13 The new standard is known as the specimen validity testing (SVT) rule. It establishes a technical protocol that provides a level of screening and confirmation for adulterants and the identification of substituted specimens equivalent to the identification of prohibited drugs and metabolites. The rule was framed as the ultimate solution for the war on adulterants. However, in developing its SVT rule, HHS made a fundamental policy decision to require only a generic screening for adulterants, and not to require any laboratory to have a confirmation procedure for the screen. A survey of laboratories in 2005 indicated that the certified laboratories have essentially abandoned the process of adulterant confirmation.14 One presumes that the extent of the laboratory retreat from this area was unanticipated, but the consequence has been the precipitous drop in the number of adulterated specimen reports. A specimen that meets the screening criteria for a tampered or suspect specimen is then reported as an “invalid” result. Following the implementation of the SVT rule, all adulterated specimens became invalids. These “invalid” results trigger requirements for the MRO to have discussions with the laboratory, call the donor to discuss the results, and in most every case call the donor back for an observed recollection. In addition, now the MRO must even “verify” that the observed collection was indeed observed. This approach begs the question: What are the results of these second observed collections? How many are positive? No systematic data has been released to support the fundamental premise of the SVT rule. Is the return visit of the donor with an invalid any better than requiring a second drug test of anyone for no reason? Under this rule, the mandatory recollection of specimens under observed conditions is not productive. Unfortunately, the HHS specimen validity testing rule has been implemented and serves as a standard and template for testing federal agency employees. It has become the de facto standard, being authorized under DOT and NRC for regulated industry. In late 2005, DOT formally proposed


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adopting these rules without modification.15 However, DOT and NRC are still evaluating the merits of the overall approach, and may ultimately decide not to follow this protocol. A recurring pattern of specimen validity testing has been that when laboratories begin to test for a particular adulterant, such testing has a profound impact on the use of the identified adulterant. In the 1990s glutaraldehyde was one of the more common urine adulterants. Its use dropped off sharply and in a relatively short period of time after the laboratories began to identify the compound. Unfortunately, this lesson has not been incorporated into the HHS SVT rule. There are now no more confirmed adulterated test results, only invalids. Current thinking is that alternative tests such as oral fluid, sweat patches, and even hair testing provide a better specimen because the collection is essentially one that is observed. But the adulteration industry sees these “alternative” specimens merely as new markets and opportunities ahead. Adulteration products are already available to “clean toxins” out of hair. One can foresee a line of products to “detoxify” the mouth and breath and to purify sweat. Like so many products in this genre, the product does not have to work to be successfully sold in this market. To date, the legal issues of specimen validity testing have not involved the question of whether it is appropriate to test for adulterants or for substitution. The focus has been on the integrity of the analysis and the validity of the cutoff levels. Although laboratories are not actually performing confirmation testing of adulterants, they are reporting creatinine and specific gravity results. The creatinine cutoff level for a substituted specimen was initially established by HHS at 5 ng/ml. This was, however, found to be high enough for some individuals to achieve. In other words, it was not medically or physiologically impossible to produce a “substituted” specimen at or around this level. Although a donor could challenge the substituted results and engage what was called a “referral physician” and demonstrate their ability to produce creatinine at such low levels, it was a burdensome process. In February 2003, a colloquium funded by Congress and hosted by the FAA Civil Aerospace Medical Institute (CAMI) specifically convened to assess the soundness of the specimen validity rules in effect at that time.16 One result of the research and findings of this colloquium was the decision to lower the creatinine cutoff level for substituted specimens. The change from 5 ng/ml creatinine to 50%) and possibly even the higher “clear and convincing” evidence standard. Certainly this would be the case for assays for cannabis or cocaine, where crossreacting substances are minimal and accordingly interpretation of test results is relatively straightforward. However, it is unlikely that these devices alone would be held to meet the beyond a reasonable doubt standard (95% or higher). It is important to note that these devices would be expected to demonstrate accuracies well beyond the 70% observed with near-cutoff specimens, when testing specimens within the criminal justice context with a less-challenging concentration distribution. Furthermore, when examining the performance of these devices against the criteria of drug presence or absence (rather than GC/MS confirmation cutoff criteria) these devices have demonstrated positive predictive values of virtually 1. That is, a positive on-site, non-instrumented

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drug test result, at least for cocaine or cannabinoids, can be relied on to indicate the presence of drug in the specimen, even though there may be insufficient amounts to be confirmed positive when using standard confirmation cutoffs. 11.2.9 Conclusions There is no question that several of the non-instrumented drug testing devices are not only rapid and easy to use, but also are sufficiently accurate and reliable for use within a variety of criminal justice programs. There is ample peer-reviewed scientific literature supporting the accuracy of these devices as well as many studies demonstrating their utility within a wide variety of criminal justice settings. That they are being considered for use within the federally regulated workplace testing programs is also a testament to their level of scientific and regulatory acceptance. Furthermore, there is a growing body of case law addressing these devices’ levels of accuracy and reliability and how they comport with various due process requirements. However, these devices will still likely need to be used with some form of confirmation testing if significant sanctions are to be imposed.

REFERENCES 1. 2000 Arrestee Drug Abuse Monitoring: Annual Report, National Institute of Justice, NCJ 193013, 2003. www.adam-nij.net. 2. Kadehjian, L. and Baer, J., On-Site Testing Devices in the Criminal Justice System, On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, chap. 5. 3. Robinson, J. and Jones, J., Drug Testing in a Drug Court Environment: Common Issues to Address, NCJ 181103, 2000. 4. Crowe, A. and Sydney, L., Ten Steps for Implementing a Program of Controlled Substance Testing of Juveniles, NCJ 178897, 2000. 5. Crowe, A. and Sydney, L., Developing a Policy for Controlled Substance Testing of Juveniles. June, NCJ 178896, 2000. 6. Torres, S., The use of a credible drug testing program for accountability and intervention, Fed. Prob., 60(4), 18, 1996. 7. Carver, J.A., Using drug testing to reduce detention, Fed. Prob., 57(1), 42, 1993. 8. The Impact of Systemwide Drug Testing in Multnomah County, Oregon, National Institute of Justice, 1995. 9. Stephens, R. and Feucht, T., Reliability of self-reported drug use and urinalysis in the drug use forecasting system, Prison J., 73 (3–4), 279, 1993. 10. Visher, C. and McFadden, K., A Comparison of Urinalysis Technologies for Drug Testing in Criminal Justice, National Institute of Justice, 1991. 11. Wish, E. and Gropper, B., Drug Testing by the Criminal Justice System: Method, Research, and Application, in Crime and Justice, Vol. 13: Drugs and Crime. University of Chicago Press, Chicago, 1990. 12. BJA Monograph, Urinalysis as a Part of a Treatment Alternative to Street Crime Program, Bureau of Justice Assistance, NCJ 115416, 1988. 13. Wish, E., et al. Identifying Drug Users and Monitoring Them during Conditional Release, National Institute of Justice, NCJ 108560, 1988. 14. Carver, J., Drugs and Crime: Controlling Use and Reducing Risk through Testing, National Institute of Justice, 1986. 15. Wish, E., Drug Testing, National Institute of Justice, NCJ 104556, n.d. 16. Integrating Drug Testing into a Pretrial Services System: 1999 Update, NCJ 176340, 1999. 17. Henry, D. and Clark, J., Pretrial Drug Testing: An Overview of Issues and Practices, NCJ 176341, 1999. 18. Rhodes, W. et al., Predicting Pretrial Misconduct with Drug Tests of Arrestees. Evidence from Six Sites, National Institute of Justice, Research in Brief, NCJ 157108, 1996.


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19. Rhodes, W. et al., Predicting pretrial misconduct with drug tests of arrestees: evidence from eight settings, J. Quant. Criminol., 12(3), 315, 1996. 20. Drug Testing. Guidelines for Pretrial Release and Diversion, National Association of Pretrial Services Agencies, 1995. 21. BJA Monograph, Integrating Drug Testing into a Pretrial Services System, Bureau of Justice Assistance, NCJ 142414, 1993. 22. Jones, P.R. and Goldkamp, J.S., Implementing pretrial drug testing programs in two experimental sites: some deterrence and jail bed implications, Prison J., 73(2), 199–219, 1993. 23. Britt, C.L., Gottfredson, M.R., and Goldkamp, J.S., Drug testing and pretrial misconduct: an experiment on the specific deterrent effects of drug monitoring defendants on pretrial release, J. Res. Crime Delinquency, 29(1), 62, 1992. 24. Goldkamp, J.S. and Jones, P.R., Pretrial drug testing experiments in Milwaukee and Prince George’s County: the context of implementation, J. Res. Crime Delinquency, 29(4), 430–465, 1992. 25. Smith, D. and Polsenberg, C., Specifying the relationship between arrestee drug use test results and recidivism, J. Crim. Law Criminol., 83(2), 364, 1992. 26. Visher, C., Pretrial drug testing: panacea or Pandora’s box? Ann. Am. Acad., 521, 112, 1992. 27. Visher, C., Pretrial Drug Testing, National Institute of Justice, 1992. 28. Carver, J., Pretrial drug testing: an essential step in bail reform, B.Y.U. J. Pub. Law, 5(2), 371, 1991. 29. Nielson, D., Consenting to searches after being arrested: pretrial drug testing, B.Y.U. J. Pub. Law, 5(2), 439, 1991. 30. Meyers, P., Pretrial drug testing: is it vulnerable to due process challenges? B.Y.U. J. Pub. Law, 5(2), 285, 1991. 31. Walton R., et al., Pretrial drug testing — an essential component of the national drug control strategy, B.Y.U. J. Pub. Law, 5(2), 341, 1991. 32. Jensen, C., Survey of current and prior pretrial drug testing sites, B.Y.U. J. Pub. Law, 5(2), 451, 1991. 33. Skousen, R., A special needs exception to the warrant and probable cause requirements for mandatory and uniform pre-arraignment drug testing in the wake of Skinner v. Railway Labor Executives’ Association and National Treasury Employees’ Union v. Von Raab, B.Y.U. J. Pub. Law, 5(2), 409, 1991. 34. Goldkamp, J.S., Gottfredson, M.R., and Weiland, D., Pretrial drug testing and defendant risk, J. Crim. Law Criminol., 81(3), 585, 1990. 35. Visher, C., Using drug testing to identify high-risk defendants on release: a study in the District of Columbia, J. Crim. Justice, 18, 321, 1990. 36. Toborg, M. et al., Assessment of Pretrial Urine Testing in the District of Columbia, National Institute of Justice, 1989. 37. BJA Monograph, Estimating the Cost of Drug Testing for a Pretrial Services Program, Bureau of Justice Assistance, 1989. 38. Rosen, C. and Goldkamp, J., The constitutionality of drug testing at the bail stage, J. Crim. Law Criminol., 80(1), 114, 1989. 39. Abell, R., Pretrial drug testing: expanding rights and protecting public safety, Geo. Wash. Law Rev., 57(4), 943, 1989. 40. BJA Monograph, Drug Testing Guidelines and Practices for Adult Probation and Parole Agencies, Bureau of Justice Assistance, NCJ 129199, 1991. 41. Rosen, C., The Fourth Amendment implications of urine testing for evidence of drug use in probation, Brooklyn Law Rev., 55, 1159, 1990. 42. delCarmen, R. and Sorensen, J., Legal Issues in Drug Testing Probation and Parole Clients and Employees, Department of Justice, National Institute of Corrections, 1989. 43. delCarmen, R. and Sorensen, J., Legal issues in drug testing probationers and parolees, Fed. Prob., 19, 1988. 44. Wilson, D., Drug Use, Testing, and Treatment in Jails, NCJ 179999, 2000. 45. Bird, A. et al., Harm reduction measures and injecting inside prison versus mandatory drug testing: results of a cross sectional anonymous questionnaire survey, Br. Med. J., 315, 21, 1997. 46. Gore, S. and Bird, A., Cost implications of random mandatory drug tests in prisons, Lancet, 348, 1124, 1996.



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47. Gore, S. et al., Prison rights: mandatory drug tests and performance indicators for prisons, Br. Med. J., 312, 1411, 1966. 48. Gore, S. and Bird, A., Mandatory drug tests in prisons, Br. Med. J., 310, 595, 1995. 49. Epstein, R., Urinalysis testing in correctional facilities, Boston Univ. Law Rev., 67, 475, 1987. 50. Kadehjian, L., Performance of five non-instrumented urine drug-testing devices with challenging nearcutoff specimens, J. Anal. Toxicol., 25, 670, 2001. 51. Willette, R. and Kadehjian, L., Drugs-of-Abuse Test Devices, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, chap. 17. 52. Crouch, D. et al., A field evaluation of five on-site drug-testing devices, J. Anal. Toxicol., 26, 493, 2002. 53. Yacoubian, G.S., Wish, E.D., and Choyka, J.D., A comparison of the ONTRAK TesTcup-5 to laboratory urinalysis among arrestees, J. Psychoactive Drugs, 34(3), 325, 2002. 54. Mandatory Guidelines for Federal Workplace Drug Testing Programs, SAMHSA, Draft 4, Sept. 5, 2001. www.workplace.samhsa.gov. 55. Walsh, J.M. et al., An evaluation of rapid point-of-collection oral fluid drug-testing devices, J. Anal. Toxicol., 27, 429, 2003. 56. Yacoubian, G.S., Wish, E.D., and Perez, D.M., A comparison of saliva testing to urinalysis in an arrestee population, J. Psychoactive Drugs, 33(3), 289, 2001. 57. www.passpoint.org. 58. www.mcjeyecheck.com. 59. Crucilla, C. and Pickworth, W., Eye evaluations as pre-screening for drugs, presented at the College on Problems of Drug Dependence Annual Meeting, Scottsdale, AZ, June, 2001. Abstract available at http://views.vcu.edu/cpdd/index.htm. 60. Mieczkowski, T., The utilization of ion mobility spectrometry in a criminal justice field application, in Drug Testing Technology. Assessment of Field Applications, T. Mieczkowski, Ed., CRC Press, Boca Raton, FL, 1999, chap 4.

11.3 REGULATORY CONCERNS FOR POINT OF COLLECTION TESTING IN THE WORKPLACE

Michael R. Baylor, Ph.D., Craig A. Sutheimer, Ph.D., and Susan D. Crumpton, M.S. Health Sciences Unit, Science and Engineering Group, RTI International, Research Triangle Park, North Carolina

11.3.1 Introduction Point of collection (POC) testing is relatively new in workplace and other areas of forensic drug testing. As with laboratory-based workplace drug testing, POC test users must implement procedures that ensure accurate and reliable test results while protecting donor rights to privacy and confidentiality. Many procedures for the collection, handling, and reporting of workplace drug test specimens are common to both POC testing and laboratory-based testing. However, some aspects of POC testing are unique. These are further discussed below. At the time of this writing, the federal government is revising the Department of Health and Human Services (HHS) Mandatory Guidelines for Federal Workplace Drug Testing Programs.1,2 The purpose of the Guidelines is to ensure that the regulated drug testing programs under this umbrella meet stringent forensic and scientific/technical standards. The original Guidelines addressed only laboratory-based urine drug testing. With the new Guidelines, the government plans to allow POC testing, as well as testing of other specimen matrices (i.e., hair, oral fluid, sweat). The final revised Guidelines are to be published following public comment and any revisions made after consideration of those comments.


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11.3.2 POC Testing Techniques 11.3.2.1

POC Testing Devices for Drugs of Abuse

POC devices for drugs of abuse were first available in the mid-1980s and early 1990s. POC devices include both non-instrumented devices with visually detected end points as well as semiautomated or automated instrumented testing devices with instrument-read end points. POC testing can be performed in the workplace with little or no prior notice and provides information that supports decisions about hiring or continued employment. Drug tests conducted with POC devices utilize a chromatographic migration of the specimen in addition to competitive binding immunoassays, the same general scientific principle used in the initial tests conducted by certified laboratories on their regulated specimens. The devices use either a negative indicating reaction (i.e., the absence of a band indicates a presumptive positive result) or a positive indicating reaction (i.e., the presence of a band indicates a presumptive positive result). There is a wide variation in the testing panels and cutoffs available for POC devices. Although their ability to perform at some administrative cutoffs has been questioned,3 commercially available devices meet minimal technical requirements. A number of the devices have been cleared by the Food and Drug Administration (FDA). The FDA Center for Devices and Radiological Health provides information on test categorization and approval/clearance of test devices (searchable databases are available at http://www.fda.gov/cdrh/ consumer/mda/index.html#databases). Investigators, independent of the manufacturers, have evaluated urine non-instrumented POC devices and have found them to perform similarly to the instrumented immunoassay tests conducted in certified laboratories3–6 using current cutoffs. The investigators conducted tests on both drug-free urine and donor specimens. The drug-free urine was tested with and without drug analytes and the donor specimens were selected from specimens that had previously been analyzed and determined to be drug-free or to contain varying amounts of target analyte. Little device performance difference was noted between tests conducted by laboratory technicians and laypersons who had been trained in the proper procedures for conducting and reading the test.3,4 To date, only one group of independent investigators7 has evaluated non-instrumented POC devices for oral fluid. In their study, fortified oral fluids at concentrations consistent with the proposed HHS cutoffs were analyzed. The study found device variability and noted device difficulty in detecting cannabinoids. The investigators suggest that the rapid evolution of the device technology should be able to overcome any current problems relating to targeted analyte and manufacturer’s cutoff and be able to provide assays consistent with proposed HHS cutoffs. The investigators felt that “there is every reason to be optimistic about the future for drug testing using the oral fluid matrix.” To date, independent evaluations of instrumented POC devices have not been available for review. 11.3.2.2

POC Testing Devices for Specimen Validity

Specimen validity test (SVT) POC devices for the detection of products used to suborn urine drug testing have become more widely used in the past several years. POC devices include noninstrumented devices with visually read end points as well as semiautomated instrumented testing devices with instrument-read end points. Specimen validity tests conducted with these devices utilize colorimetric assays, the same technology utilized by certified laboratories on their instrumented testing equipment used for at least initial SVT procedures. Both independent investigators and manufacturers have evaluated urine non-instrumented SVT POC devices for the detection of abnormal urine specimens.8–10 The studies evaluated drug-containing specimens to which were added adulterating chemicals or adulterants that had been purchased. Results from these preliminary studies were variable; however, the studies did demonstrate



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the ability of the varying devices to detect creatinine, as well as some oxidizing adulterants, and to measure pH. 11.3.3 Regulatory Issues for POC Testing 11.3.3.1

Evidentiary Value

POC testing must be scientifically and forensically sound. At this time, POC test results do not meet the forensic and scientific standards that have been deemed necessary for regulated workplace drug testing. The proposed HHS Guidelines allow POC testing to identify the absence of drugs or to identify a specimen as valid. According to the proposed Guidelines, only valid negative drug test results can be reported from a POC testing site by a trained tester. All presumptive non-negative specimens must be sent under chain-of-custody to a certified laboratory for initial and confirmatory testing. A POC test specimen is considered a presumptive non-negative specimen if the POC test result is positive or invalid (i.e., a specimen with an unacceptable POC SVT result, an abnormal POC drug test response, or an abnormal physical characteristic identified by the collector or trained tester). 11.3.3.2

Regulatory Oversight

It is anticipated that monitoring POC testing would necessitate an extensive program that cannot be easily managed by a single regulatory entity. While one regulatory body could retain overall responsibility for regulated testing, it might be necessary for other organizations, designated as POC Oversight Groups (POGs), to take an active part in the direct oversight of POC testing sites and trained testers. Possible oversight groups could be the individual federal agencies under whose regulations specimens are tested, a contractor, or a nongovernment training/certifying organization (e.g., industry group). In turn, the regulatory body could monitor the POG’s procedures and records. 11.3.3.3

POC Devices

Certified laboratories are expected to validate their initial and confirmatory testing instruments and assays prior to use with regulated specimens. Their validation studies address variables that exist in and among laboratories. The variables include the instruments (e.g., manufacturer, model, condition, settings), analysts (e.g., variation in practices including measurement and pipetting techniques), quality control materials, and reagents (e.g., different materials and/or mixtures, as well as differences in preparation and/or storage conditions). Due to the multiple variables, the regulatory emphasis is on the user’s validation, as well as the product manufacturer’s validation. The regulatory focus on POC test validation at least in part can be shifted from the user to the manufacturer of the device. POC testing involves discrete non-instrumented devices that have fewer testing variables than the instrumented assays used by laboratories. Unlike laboratory-based instrumented tests, an individual with little or no scientific/technical knowledge and experience can utilize a POC device, without extensive training. At least two published studies have documented comparable performance between individuals with nonscientific backgrounds and those with scientific/technical experience.3,4 Non-instrumented POC devices are configured by the manufacturer and most include manufacturer’s controls (i.e., QC integrated into the device or QC samples provided by the device manufacturer). This process should reduce variability in QC among testers, as opposed to QC samples prepared by individual users or purchased from various suppliers. POC devices require no specimen pretreatment (e.g., extraction) and no user-prepared reagents are needed for POC testing. The validation of POC devices by manufactured lot would be the basis for approved use in regulated drug testing programs.


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Regulatory Body

POC Device Manufacturer

POC Oversight Group

Figure 11.3.1 Regulatory Issues: POC device manufacturer, regulatory body and POG. POC manufacturer submits application and device lot validation data to the regulatory body; regulatory body forwards application and validation data to the POG for review; POG forwards PT set to the manufacturer; manufacturer reports PT results to POG for review; if acceptable the POG recommends approval of the device lot to the regulatory body; regulatory body places approved device lot on CPL.

To set some baseline level of performance, POC devices used in a regulated program must be cleared by the FDA through its regulatory processes. These processes include review and evaluation of the manufacturer’s validation records for the device supporting the stated purpose (i.e., drug detection). The forensic requirements of workplace drug testing necessitate evaluation beyond that required by the FDA. This additional evaluation should involve review by the regulatory body or a POG designated by the Body. Under this evaluation structure, the POC device manufacturer would submit an application to the regulatory body, along with data that support the manufactured lot’s performance at and around specified cutoffs, as well as data supporting the lot’s specificity to detect the target analyte(s) in the presence of analogous compounds. The regulatory body would forward the application and supporting data to the POG for technical review. The POG would send a performance testing (PT) set to the manufacturer. The manufacturer would report PT results back to the POG for review. If the application, validation data, and PT performance are found to be acceptable, the POG recommends approval of the device lot to the regulatory body and requests that the manufacturer submit a predetermined number of devices that could be used to assess problems that might arise during the life of the device lot. The regulatory body would issue a certificate of acceptability and place the device lot on a Conforming Products List (CPL) that would be published and updated periodically. The relationships between the POC device manufacturer, POG, and regulatory body as described above are schematically depicted in Figure 11.3.1. 11.3.3.4

Trained Testers and POC Testing Sites

The regulatory body should specify training and performance requirements for POC testers. This training must address chain-of-custody documentation, confidentiality of test results and donor information, record keeping, and testing procedures that ensure proper operation, storage, QC procedures, result interpretation, and any maintenance procedures for each type of POC device used. Individuals should also successfully complete a set of proficiency testing samples. A certificate of qualification program would identify individuals allowed to test regulated specimens. Individuals seeking certification for testing regulated specimens would be required to submit an application and documentation of appropriate training to the regulatory body. Qualified applicants



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Regulatory Body

POC Oversight Group

POC Trained Tester

Figure 11.3.2 Regulatory Issues: POC trained testers, regulatory body, and POG. POC trained tester submits an application and training documentation to the regulatory body; regulatory body forwards application and training documentation to the POG for review; POG forwards PT set to the trained tester; trained tester reports PT results to the POG for review. If acceptable, the POG recommends certification of the trained tester to the regulatory body; regulatory body issues certificate to trained tester; trained tester provides copy of certification to the POG.

would be sent a set of proficiency samples by the POG. Individuals reporting acceptable results would be issued a trained tester certificate with a specified expiration date (e.g., 1 year). Prior to the expiration date, the POG would send a set of proficiency samples to the trained tester for certification renewal. Training records must be available for review, and should be maintained by the POG and updated as appropriate. Ongoing compliance must also be monitored. Direct oversight of POC testing sites/trained testers could be accomplished by a POG in a manner similar to the current National Laboratory Certification Program (NLCP) for urine drug testing laboratories, with on-site inspections and PT challenges. As is currently required of certified laboratories, the POC testing sites/trained testers must use a written standard operating procedures (SOP) manual that incorporates procedures required for regulated workplace testing. To ensure consistency among the various POC testing sites/trained testers, it may be practical for entities under whose regulations testing is performed (e.g., individual federal agencies) to write and distribute the SOP manuals. Any procedural deficiencies or discrepant test results identified through the inspection, PT, or a specimen QA program (as described below) or reported by a Medical Review Officer (MRO) could be addressed through remediation by the POG with the POC testing site. Remediation would involve investigation and corrective actions to correct identified problems. Based on identified deficiencies, a POC testing site or a trained tester could be suspended from testing regulated specimens. Any errors attributed to a POC device itself could be referred for remediation by the POG with the POC device manufacturer. Based on identified deficiencies, a device lot could be removed from the CPL. The timing of the suspension or device lot removal would be dependent on the degree and imminence of harm to the tested population and general public. The relationships between the trained tester, POG, and regulatory body as described above are outlined in Figure 11.3.2. 11.3.3.5

Specimens

As noted above, when the revised Guidelines go into effect, federal agencies and regulated employers will be allowed to test different specimen matrices (i.e., urine, hair, oral fluid, sweat)


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in their workplace drug testing programs. These matrices are already being tested in the private sector. The choice of specimen matrix depends on several factors, especially the drug detection time using a particular specimen matrix and the reason for the test (e.g., pre-employment, postaccident, reasonable suspicion, return to duty, follow-up, random). Currently, POC devices are available for testing urine or oral fluid specimens. Devices for other specimen matrices may be developed in the future. POC testing of urine is most suited for situations that require quick, negative results such as in emergency/crisis management. It can be used for random, reasonable suspicion/cause, and postaccident testing if drug use occurred more than 3 h prior to the incident. This type of testing may be least suited for pre-employment, return-to-duty, and follow-up testing. POC testing of oral fluid also is most suited for situations that require quick, negative results such as in emergency/crisis management. Therefore, in a workplace setting, it is most suited for reasonable suspicion/cause and post-accident testing. It may be least suited for random testing. Oral fluid is not suited for return-to-duty, follow-up, and pre-employment testing. 11.3.3.6

Collection Sites and Specimen Collection

Specimen collection requirements should closely parallel those procedures already established for laboratory-based workplace drug testing.11,12 These procedures were developed to ensure a consistent, forensically defensible collection using strict chain-of-custody procedures, thereby ensuring that the integrity and identity of each specimen are maintained. A brief summary of specimen collection requirements follows. A collection site may be a permanent or temporary facility. All sites where regulated specimens are collected must be equipped with security features limiting access to appropriate collection site personnel. A dedicated collection facility must be secured at all times. Temporary collection facilities, at a minimum, must be secured during collections. Collection sites must tailor the facility and operations to the specimen type(s) collected. For example, oral fluid specimen collections require only direct observation. Urine specimen collections require facilities that provide donor privacy during collection and also enable observed collections. Measures must be taken to prevent specimen adulteration or substitution (e.g., turning off water supply or securing faucets, coloring the water in the toilet, preventing access to items that may be used to adulterate a specimen). All facilities must have a means for donors to wash their hands, preferably in the area where the collection takes place. Essential elements of a proper collection include procedures for verifying donor identity; maintaining specimen identification and integrity throughout the collection process, subsequent storage, and transfers; documenting the collection and chain-of-custody using a standardized custody and control form (CCF); and examining the specimen for adequate volume and other characteristics (e.g., temperature of a urine specimen). Specimen containers should be sealed in the presence of the donor. The collection container must be tamper-evident and prevent contamination of the specimen. Some current POC devices are incorporated into the collection container. Collection site record-keeping procedures must ensure the accuracy, security, and confidentiality of drug test information. 11.3.3.7

POC Testing Procedures and Reporting Results

POC testing differs from laboratory-based testing in that the same individual may collect and test the specimen. To avoid confrontation, testing should not occur in the presence of the donor and the collector should not reveal any test results to the donor. Presumptive non-negative specimens should be resealed with tamper-evident tape to ensure the integrity of the specimen. Both primary and split specimens should be placed into secured temporary



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Regulatory Body

Employer

MRO

POC Oversight Group

POC Trained Tester

Certified Laboratory

Figure 11.3.3 Regulatory Issues: POC non-negative confirmation testing, reporting results and quality assurance. Trained tester reports negative results to the MRO; trained tester forwards non-negative specimens to the laboratory for confirmation testing; a percentage of negative specimens are forwarded to laboratory for QA testing; laboratory reports non-negative results to the MRO; laboratory reports QA results to the POG; MRO reports results to the employer.

storage and be under chain-of-custody until the specimen is transferred to a certified laboratory for initial and confirmatory testing. Specimens with negative POC drug test results and acceptable responses for POC specimen validity tests should be reported by the trained tester directly to the MRO. These specimens should be discarded immediately after testing (unless the negative specimen is to be sent to a certified laboratory for QA purposes). Valid negative results must be reported to the MRO by sending a completed CCF or electronic report. Measures must be taken to ensure the security and confidentiality of donor information. The relationships between the trained testers, laboratory, MRO, and POG for reporting results from POC sites are depicted in Figure 11.3.3. 11.3.3.8

Quality Control/Quality Assurance

Due to the forensic aspects of workplace drug testing, QC requirements for workplace POC testing will be more stringent than those for nonregulated on-site testing in clinical environments (i.e., “point of care testing”).13 However, quality control requirements for POC testing will also differ from those required for laboratory-based instrumented tests in a regulated workplace testing program. Certified laboratories are required to document the validity of specimen results in each initial and confirmatory test batch by analyzing a specified type and percentage of QC samples. POC testing using discrete POC devices has fewer testing variables. In addition, many, if not most, devices include a test line or control line that indicates proper test performance. Therefore, it would appear sufficient to document acceptable performance for each trained tester on each day that the individual tests specimens with a specific test device. As previously noted, POC testing will be used only as a screening test, with any presumptive non-negative specimens tested and confirmed in a certified laboratory in accordance with stringent QC policies. The HHS Mandatory Guidelines for Workplace Drug Testing Programs require federally regulated programs to have an external QA program. Federal agencies and regulated employers are required to submit blind proficiency samples to certified laboratories (i.e., a specified percentage of the donor specimens they submit for testing) to demonstrate the laboratory’s ability to obtain and report results correctly. A QA program for POC testing sites/trained testers could require a


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Regulatory Body

Employer

POC Device Manufacturer MRO

POC Oversight Group

POC Trained Tester

Certified Laboratory

Figure 11.3.4 The regulatory oversight of POC testing: The interaction of all components.

specified percentage of POC test-negative donor specimens to be sent to a certified laboratory for testing (with donor identification and demographic information redacted). The laboratory would then report its results to the POG for review. This QA process involving the interactions of the trained tester, laboratory, and POG is incorporated into Figure 11.3.4. 11.3.4 POC Testing Advantages and Disadvantages The major advantage of POC testing is the almost immediate identification of negative test results. POC testing is performed as a discrete analysis, not requiring batch configuration, so individual specimens can be analyzed without delay. Employer costs for negative POC test specimens are comparable to costs of laboratory-based testing. Due to the additional testing performed, it would appear that the employer costs for nonnegative specimens will be greater than current costs for laboratory testing. POC test devices have a shelf life of 12 to 18 months. This relatively short time may be a major disadvantage to testing sites with a limited specimen volume to be analyzed, as the tendency of manufacturers to package devices in multiples could result in numbers of the devices expiring before use. Another disadvantage of POC testing may be the fees associated with the complex oversight/regulatory program needed for an extremely decentralized population of sites/testers. Procedural disadvantages that have been noted for POC testing in other fields, such as clinical testing,14 would not appear to be of concern in a regulated workplace setting with POC testing used only as a presumptive test method. For example, the potential for misinterpretation of results would be unlikely. A POC device that is prone to inconclusive results probably would not meet criteria for placement on the CPL. Additionally, training requirements for testers and regulatory oversight as previously described (e.g., proficiency testing, QA program using POC test-negative specimens) should reveal systemic problems. 11.3.5 Role of the Medical Review Officer The MRO plays an essential part in regulated workplace drug testing. In POC testing, the MRO would provide the final interpretation of test results and serve as the liaison among the various parties involved in a drug test (e.g., the regulatory body, federal agency, the employer, the donor, the collection site, the POC testing site and POC trained tester, and the laboratory). The MRO must report negative



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drug test results from a POC testing site to the employer/agency in the same manner as results obtained from a laboratory. Non-negative specimens must be treated by the MRO in the same manner regardless of whether they were first tested using POC tests or tested only by a laboratory. MROs must be knowledgeable about the capabilities of the POC tests and laboratory-based test methods that were used for specimens that they review. The MRO must report any discrepant or erroneous test results to the regulatory body, so an investigation can be conducted to identify and address the cause of the problem. Due to conflict of interest concerns, some relationships between MROs and certified laboratories are considered inappropriate and are prohibited (i.e., the MRO must not be an employee, agent of, or have any financial interest in a certified laboratory). Similar prohibitions should be instituted for the relationship between MROs and POC device manufacturers and for the relationship between MROs and POC testing sites for which the MRO reviews drug test results. 11.3.6 Regulatory Oversight The unique challenges for the regulatory body are that the POC testing sites may be numerous and decentralized and that many trained testers may have little forensic background or training. As proposed, another oversight group (POG) could provide administrative and technical support to a regulatory body. It is conceived that delegated functions could include reviewing and approving POC devices, providing training (i.e., initial training for users or “train-the-trainer” courses), and maintaining administrative oversight of testers and POC testing sites. Records are an essential component in any forensic field. A POG could maintain the records for workplace drug testing programs such as a registry of trained testers, records of results by tester for each device as part of a QA program, and other documentation demonstrating the acceptability of testing, reporting, and record keeping. POC testing has both technical-scientific issues and administrative-policy issues that need to be incorporated into the regulatory process.15 The Substance Abuse and Mental Health Services Administration and the Department of Health and Human Services (SAMHSA/HHS) currently certifies laboratories to perform federal workplace urine drug testing and monitors federal workplace drug testing through the National Laboratory Certification Program (NLCP) via on-site inspections and quarterly PT challenges. Similar direct oversight may be required to ensure that regulated workplace drug testing using POC testing is conducted with the equivalent integrity and technical standards as testing in a certified laboratory. With proper safeguards and regulatory oversight in place, it is envisioned that POC testing has the potential to become a significant part of regulated workplace drug testing. Acknowledgments The authors express their appreciation to Donna M. Bush, Ph.D., Walter F. Vogl, Ph. D., and Charles LoDico, M.S. (Division of Workplace Programs, Center for Substance Abuse Prevention, SAMHSA) for regulatory insight and to Robert Dow (RTI staff member) for graphic and editorial support.

REFERENCES 1. Mandatory Guidelines for Workplace Drug Testing Programs, Substance Abuse and Mental Health Services Administration, Department of Health and Human Services, 59 Federal Register (FR) 29916 (June 9, 1994). 2. Draft 4, Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Mandatory Guidelines for Workplace Drug Testing Programs, September 5, 2001, available at URL http://www.workplace.samhsa.gov.


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3. Kadehjian, L.J., Performance of five non-instrumented urine drug-testing devices with challenging near-cutoff specimens. J. Anal. Toxicol., 25, 670, 2001. 4. Crouch, D.J. et al., A field evaluation of five on-site drug-testing devices. J. Anal. Toxicol., 26, 493, 2002. 5. Peace, M.R, Tarnai, L.D., and Poklis, A., Performance evaluation of four on-site drug-testing devices for detection of drugs of abuse in urine. J. Anal. Toxicol., 24, 589, 2002. 6. SAMHSA, On-site Testing: An Evaluation of Non-Instrumented Drug Test Devices, January 29, 1999, available at URL http://www.workplace.samhsa.gov. 7. Walsh, J.M. et. al., An evaluation of rapid point-of-collection oral fluid drug-testing devices. J. Anal. Toxicol., 27, 429, 2003. 8. Peace, M.R. and Tarnai, L.D., Performance evaluation of three on-site adulterant detection devices for urine specimens. J. Anal. Toxicol., 26, 464, 2002. 9. Wong, B. et. al., Adulterants: its detection and effects on urine drug screens. Abstract: Society of Forensic Toxicologists 2003 Meeting. 10. Wong, R. The effect of adulterants on urine screen for drugs of abuse: detection by an on-site dipstick device. Am. Clin. Lab., 21, 37, 2002. 11. HHS, Urine Specimen Collection Handbook for the New Federal Drug Testing Custody and Control Form, OMB Number 0930-0158, Exp Date: June 30, 2003. 12. DOT Urine Specimen Collection Guidelines for the U.S. Department of Transportation Workplace Drug Testing Programs, 49 CFR Part 40, available at URL http://www.dot.gov/ost/index.html. 13. Wu, A.H.B., On-site tests for therapeutic drugs, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, chap. 2. 14. George, S. and Braithwaite, R., Use of on-site testing for drugs of abuse. Clin. Chem., 48, 10, 2002. 15. Shults, T.F. and Caplan, Y.H., Program requirements, standards, and legal considerations for on-site drug testing devices in workplace testing programs, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, chap 4.

11.4 ALCOHOL DETERMINATION IN POINT OF COLLECTION TESTING

J. Robert Zettl, B.S., M.P.A., DABFE Forensic Consultants, Inc., Centennial, Colorado

The section covers five topics: general considerations; pharmacology and toxicology of alcohol; organizational policies and procedures for specimen collection and testing; governmental regulations; and devices for testing of breath, saliva, and urine. A comprehensive discussion of alcohol pharmacology and toxicology and evidentiary breath testing can be found in other sections of this text. The material presented in those areas serves to assist the reader in understanding this chapter. Devices used for human subject alcohol determination can be separated into four broad categories: (1) law enforcement — driving under the influence (DUI); (2) diagnostic for treatment or other medical purposes; (3) pre-employment and workplace for compliance; and (4) for cause and random for governmental compliance. This chapter focuses on devices used in the last two venues. 11.4.1 General Considerations The primary focus of this section is alcohol point of collection test devices and procedures, but it is appropriate to discuss briefly how and why alcohol testing is important in point of collection testing. According to information from the National Highway Traffic Safety Administration, there were 41,471 motor vehicle traffic fatalities in the U.S. in 2000.1 Of those 41,471 fatalities, 15,935 or 38.4% were alcohol related. This represents an average of one alcohol-related fatality every 31 min.



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The National Safety Council2 estimates the economic loss to society from a single highway fatality to be $90,000, and the corresponding total economic loss exceeding $4 billion annually.3 The drinking driver affects every one of us through increased taxes for additional law enforcement needs, medical facilities, incarceration, rehabilitation, social security and welfare for survivors, as well as increased insurance rates. In the U.S., alcohol accounts for two thirds of all workplace substance abuse complaints and depletes a similar percentage from their health care benefit budgets. The results of a 2002 study4 released by the Substance Abuse and Mental Health Services Administration (SAMHSA) showed drug use trends in the U.S. Of interest is that most alcohol and drug users are employed. Alcohol abuse and its related problems cost society many billions of dollars each year.5–8 Estimates of the economic costs of alcohol abuse attempt to assess in monetary terms the damage that results from the misuse of alcohol. These costs include expenditures on alcohol-related problems and opportunities that are lost because of alcohol. In a 1985 cost study, Rice and co-workers9 estimated that the cost to society of alcohol abuse was $70.3 billion. By adjusting cost estimates for the effects of inflation and the growth of the population over time, that cost today could be well over $100 billion. 11.4.2 Pharmacology and Toxicology of Alcohol Alcohol is commonly ingested orally and passes from the mouth, through the esophagus, into the stomach, and then into the small intestine. From here, alcohol is absorbed into the blood and distributed by the circulatory system to all parts of the body. As alcohol is transported through the body by the blood flow, it passes through the liver, which is primarily responsible for its metabolism, then to the kidneys where it is eliminated into the urine, then to the brain where it elicits its primary effect, and finally to the lungs where some alcohol passes unaltered out of the body. This unaltered alcohol permits the determination of a breath alcohol concentration (BrAC) from the alveolar or deep lung air.10 Alcohol is a low-molecular-weight organic molecule that is sufficiently similar to water to be miscible with water in all proportions. In addition, alcohol is able to cross cell membranes by a simple diffusion process; therefore, it can quickly achieve equilibrium throughout the body. The result of these properties is that alcohol rapidly becomes associated with all parts of the body, including oral fluid, and concentrations of alcohol will be found in proportion to body water content. 11.4.3 Organizational Policies and Procedures 11.4.3.1

Collection and Testing

Although it is the quantity of alcohol present in the brain that actually affects a person’s normal functions, practicality necessitates a specimen that is in equilibrium with the brain be used to reflect alcohol concentration. Therefore, most studies center on the use of blood to correlate the degree of alcohol impairment; however, over the last 30-plus years, breath testing has supplemented blood as the specimen of choice. Due to the difficulty in the collection of urine, its use as a specimen has fallen into some disfavor. Blood is more likely to be used in defining driving under the influence of alcohol and blood and/or urine in defining driving under the influence of drugs. Serum or plasma is often used in clinical situations where alcohol is tested. Since the water content of serum or plasma is greater than that of whole blood, serum/plasma alcohol concentrations are typically 10 to 20% greater than the corresponding blood specimen. Therefore, if serum/plasma tests are to be utilized where blood alcohol concentrations (BACs) define legal penalties, the serum/plasma concentrations must be corrected. Serum to blood ratios vary from 1.12 to 1.17 while plasma averages 1.18. A ratio of 1.16 is commonly used to make the conversion.11


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Blood or urine is seldom used in alcohol point of collection testing (APOCT) because of difficulties that hinder their ease of collection. In most instances, existing regulations or statutes will dictate the choice of specimen. At present breath and saliva are the specimens collected in the majority of APOCT venues.12 11.4.3.2

Specimens for Analysis

The most commonly used specimen for APOCT is breath for the two venues covered in this chapter: (a) pre-employment and workplace for compliance and (2) for cause and random for governmental compliance. With recent technological advances, saliva is taking on a new dimension and is pressing breath as the “new” specimen of choice. Saliva can, with appropriate care in specimen procurement and application of the accepted distribution ratios, be correlated with blood and a blood alcohol equivalent can be reported. 11.4.4 Breath Testing for Alcohol 11.4.4.1

Principles

Breath tests to determine the alcohol concentration present in a person’s body are by far the most frequently utilized tests in cases involving driving under the influence of alcohol. States today have universally adopted legislation that permits reporting of a subject’s alcohol concentration in breath units of alcohol per 210 L of breath. Breath alcohol analysis is the method of choice of law enforcement and many others due to ease and operational simplicity of new generation breath testing equipment, speed with which analyses may be conducted, convenience of being able to perform the analysis at or near the scene of an incident, and the convenience of having the subjects’ test results immediately available. (A complete discussion of breath alcohol testing can be found elsewhere in this volume.) 11.4.4.2

Breath Alcohol Testing Devices

Introduction The National Highway Traffic Administration has established a conforming products list for instruments that conform to the “Model Specifications for Devices to Measure Breath Alcohol.”13 This list contains all devices currently approved to perform breath alcohol testing within the U.S. Although many of the devices found on the present conforming products list are no longer manufactured, many are still in use. In 1995, Zettl in conjunction with the Colorado Department of Public Health and Environment conducted a national survey of alcohol programs.14 Some “electronic” devices listed in the 1995 Colorado Department of Public Health survey are no longer manufactured and newer-generation devices have been introduced since that survey was completed. Refer to the National Highway Traffic Administration conforming products list for a complete listing of all “electronic” instruments that can be used for point of collection testing. Electronic Devices — Evidentiary Electronic devices are generally classified into two distinct categories: (1) tabletop devices, which are larger and more expensive units originally designed for use in DUI testing, and (2) handheld or preliminary breath (alcohol) testers (PBTs), which are smaller units originally designed for use as screening devices by law enforcement to determine a suspected DUI’s approximate



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BrAC level at the time of stop. PBTs are now used extensively as evidentiary units in workplace and DUI testing. Both types of devices are designed to analyze a breath sample and determine the amount of alcohol present in such a manner that the results have a degree of scientific accuracy and specificity sufficient to be reliable for presentation in court as evidence. They are self-contained portable laboratories in which the underlying principle, mode of operation, and safeguards are such that the end user can effectively operate the instruments and develop reproducible results. Electronic Tabletop Devices Infrared (IR) technology utilizes the principle that alcohol present as a vapor in breath absorbs specific wavelengths of IR light. Alveolar air is trapped in a sample chamber. IR light is directed through the sample cell and finally reaches a detector that measures the amount of light absorbed. As the concentration of alcohol vapor increases in the chamber, the amount of IR energy reaching the detector falls in a predictable exponential manner; hence, IR devices measure alcohol by detecting the decrease in the intensity of IR energy as it passes through the chamber. The Draeger Corporation, Breathalyzer Division (Durango, CO) and Intoximeters, Inc. (St. Louis, MO) have developed breath test instruments that incorporate IR technology combined with an electrochemical (EC) fuel cell. Use of dual technology enhances both the quality and integrity of the sample and the accuracy of the alcohol test result. Fuel cell technology is discussed later in this chapter under Electronic Handhelds. The most recent device, the Intoxilyzer 8000, uses dual IR (two separate wavelengths), one for alcohol concentration and the other for interferent detection. Electronic Gas Chromatographic Tabletop Devices These devices are no longer being manufactured but may still be in use. They are the Gas Chromatograph Intoximeter (GCI) Mark II and Mark IV manufactured by Intoximeters, Inc. and the Alco-Analyzer Gas Chromatograph, models 1000, 2000, and 2100, manufactured by Luckey Laboratories and later US Alcohol Testing. Although the instruments used different methods of detection, they were of equal specificity and accuracy. They could be used as either direct measurement devices or they could analyze collected samples such as blood, delayed breath, saliva, and urine by means of headspace chromatography. They were excellent for use in a centralized facility setting; that is, samples could be collected in the field and forwarded to a centralized processing facility where technical personnel conducted the testing. Electronic Handheld Devices: PBTs Handheld “electronic screening devices” are small, portable, relatively inexpensive, may cost only a few hundred dollars, and were originally designed to estimate the BAC or BrAC of an individual. Some of the devices may be prone to erroneous readings both falsely high and low. The electrical sensor instruments — fuel cell — are generally more accurate (±10% range or better) and some are more specific for alcohol than others with printer attachments to be used in evidential settings. As stated, they were originally intended to assist in quickly determining the approximate alcohol concentration in an individual and were referred to as PBTs. The devices are useful for monitoring and controlling alcohol abuse and or intoxication in various workplace, alcohol abuse programs, and correctional institutions. Evidentiary handhelds utilize an EC sensor — generally a fuel cell — to measure the amount of alcohol present in the sample. All of the devices in this category use alveolar air and may be calibrated for BrAC concentration.


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Table 11.4.1

Pass–Warn–Fail PBTs

1. B.A.T. III by Century Systems, Inc. uses catalytic combustion for alcohol analysis. Pointer indicates Warn or Fail. 2. Alcohalt Detector by Mine Safety Appliance Company uses catalytic combustion for alcohol analysis and two indicator lights for Pass or Fail. 3. A.L.E.R.T. Model J3AD by Alcohol Counter Measures, Inc. Uses a Taguchi semiconductor detector to analyze the alcohol and a series of green, amber, and red lights to indicate Pass, Warn, or Fail. 4. Older generation Alco-Sensor by Intoximeters, Inc. Used a cluster of light-emitting diodes to indicate Pass, Warn, Fail (later models use a digital display for a direct readout of the % alcohol present). Table 11.4.2 1. 2. 3. 4.

Digital Display PBTs

Alco-Sensors II through IV by Intoximeters, Inc. The Alco Sensor IV is shown in Figure 11.4.1. Phoenix by Life Loc. See Figure 11.4.2. CMI Corporations S-D2 and Models 200, 300, and 400. See Figure 11.4.3 for the S-D2. National Draeger’s Alcotest 7410. See Figure 11.4.4.

Because the devices were originally intended for screening, they should be used carefully and only for their intended purpose by trained personnel. Some of the older-generation devices are not sufficiently accurate for evidentiary purposes and if the subject tested is placed at risk pending the results of such tests, then the initial “screening” test should be confirmed by an evidentiary test. PBTs are extremely useful because they are generally less expensive than tabletop units and training and upkeep is less involved. Newer-generation PBTs, when used according to manufacturer specifications, can yield an accurate BrAC. Pass–Warn–Fail Devices These devices are calibrated to determine into which of three likely broad-range categories of BrAC an individual will likely fall. PASS — Alcohol concentration below a predetermined level. Usually a level at which the individual is considered able to drive safely. Usually less than 0.05% except for underage drinkers. WARN — Alcohol concentration above the level where a person would pass but below a level where the individual is considered intoxicated. Usually at or above 0.05% but less than the state’s legal limit for per se. FAIL — Alcohol concentration above the level where the individual is considered intoxicated. Usually at or above 0.08% or 0.10%. Depends on the state’s level for DUI.

The concentrations at each level may be arbitrarily set as desired. Refer to Table 11.4.1 for a listing of some of the Pass–Warn–Fail devices and Table 11.4.2 for a listing of some of the digital display devices. Digital Display Devices There are many digital display devices on the NHTSA conforming products list. Some are shown in Table 11.4.2 (Figures 11.4.1 through 11.4.4). All use a fuel cell to determine the amount of alcohol present and %BrAC is digitally displayed. Handheld — Non-Evidentiary According to the manufacturer’s product information the Alco-Scan Model AL-2500 (Figure 11.4.5), is a very versatile device that measures %BAC. The user gently blows at the sensor’s intake and within 2 s the LCD displays a BrAC. The AL2500 is a compact and ideal device for use in social gatherings and for group testing.15



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Figure 11.4.1 Intoximeters, Alco Sensor IV.

Figure 11.4.2 Lifeloc, Phoenix.

Figure 11.4.3 CMI SD-2.

Figure 11.4.4 Draeger 7410.


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Figure 11.4.5 Alco-Scan Model AL-2500.

There are many devices like the Alco-Scan Model AL-2500, many priced under $100, but the end user should be cautioned that many are non-evidentiary and may not be suitable for some testing venues. Screening Devices NHTSA establishes which devices can be used as screening devices under its “Conforming Products List of Screening Devices to Measure Alcohol in Body Fluids.16” 11.4.4.3

Saliva-Based Technology

Analytical Principle Saliva collection for alcohol testing is regularly employed in POCT facilities but is not used in DUI testing due to its practical constraints in court. Although saliva may be impractical for DUI enforcement because significant subject cooperation is needed to facilitate collection, recent advances in collection technology hold great promise for its use in POCT on-site (roadside) drug detection. For additional information, visit the RoadSIdeTestingAssessment Web site.17 Saliva alcohol results can be compared to the amount of alcohol contained in a person’s blood. If collected properly by observing a waiting period after a person has consumed his or her last alcoholic beverage, usually 10 to 15 min, then any residual alcohol will have been absorbed, swallowed, or evaporated, and the person’s mouth is “clear.” According to one manufacturer’s



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information the relationship between the amount of saliva alcohol and blood alcohol is 1:1 whereas with breath it is 000048:1, making saliva a more sensitive testing medium than breath.18 There are two prominent saliva-based alcohol test procedures. The QED saliva alcohol test procedure will not react with ketones often found in the saliva of patients with diabetes. Unlike some breath analyzers and other saliva tests, the QED is specific to ethyl alcohol and will not crossreact with acetone and ketones produced by diabetics. The second type of disposable tester, strip test technology, does not have a great correlation between a person’s true BAC and saliva alcohol concentration. Strip-based saliva testers are treated with an enzyme alcohol oxidase, which responds to alcohol in proportion to the concentration of alcohol in a mixed saliva sample placed on it. The user estimates the BAC by comparing the color change on the test strip patch to standard colors calibrated to correspond to different BACs. Although some saliva testers seem to indicate the presence of alcohol well, the enzyme alcohol oxidize used in these testers is easily affected by hot and cold temperatures. Hot temperatures will tend to indicate falsely high readings, while cold temperatures will tend to indicate falsely low readings. Exposure to temperatures above 80°F or to ambient air will destroy the enzyme alcohol oxidase, rendering the tester useless. Most saliva testers give no indication if contamination has occurred, and if it has, they may not work effectively. Saliva testers generally have a shelf life of 1 year or less. The technology and chemical reaction employed in the QED or the test strip technology is not as precise, accurate, or reliable as breath alcohol testing. Saliva-based alcohol tests require an evidential breath test (EBT) to confirm positive test results. Saliva alcohol testing is much less expensive to operate than a breath test, and unless a POCT facility conducts a very high volume of tests in a central location, then saliva testing instead of breath may be more cost-effective. Since most employees do not test positive for alcohol, simple screening is generally more cost-effective for POCT facilities. Saliva-Based Devices QED Saliva Alcohol Test — The QED (Figure 11.4.6) is a quantitative test device for the rapid determination of equivalent BAC using a non-invasive saliva sample. Approved by the Federal Department of Transportation (DOT) for commercial alcohol testing programs, the QED uses a unique patented lateral flow method to rapidly determine alcohol presence in saliva expressed as %BAC and milliliter per deciliter concentration. It is as simple as reading a thermometer.19 The QED Saliva Alcohol test uses a preset chemical reactive process that requires no user intervention; a color bar rises to the level of alcohol present in the system in much the same way as a mercury thermometer. In extensive clinical trials, saliva alcohol levels measured by the QED

Figure 11.4.6 QED Saliva Alcohol Test.


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Saliva Alcohol test demonstrated a high correlation rate of 98% (r = 0.98) to blood analyzed by sophisticated laboratory gas chromatography methods.20 The QED Saliva Alcohol Test (Figure 11.4.6) is an easy-to-use diagnostic procedure with everything required contained in a sealed foil package. Total time required for the test is between 3 and 5 min. The three basic steps are as follows: 1. Using the cotton swab included, actively swab around the cheeks, gums, and tongue for 30 to 60 s or until the cotton swab is completely saturated with saliva. 2. Place the test device on a flat surface. Gently twist the swab with the collected saliva sample into the entry port and apply steady pressure to activate the capillary action until the pink fluid passes the QA Spot™ located at the top of the test device. 3. Allow the test device to develop for 2 min. A distinct purple bar will form within the marked scale region. The highest point of the purple bar represents the level of alcohol expressed either as a percentage or as grams per 100 ml or milligrams per deciliter concentration.

According to product information, the QED Saliva Alcohol Test will accurately measure a range of BAC of 0 to 145 mg/dl or 0.000% to 0.145% equivalent BAC.20 POCT facilities using the saliva alcohol test in very remote areas can comply with the DOT requirement that confirmation tests on positive screening tests must be conducted within 30 min. DOT will accept results of confirmation tests conducted more than 30 min after a positive screening test (49 CFR Part 40 section 40.65, paragraph (b)).20 The DOT added a sentence, which directs the Breath Alcohol Technician (BAT) to simply explain “why?” if a confirmation test is done more than 30 min after a screening test. Saliva-Based Test Strip — Alco-Screen: The ALCO-Screen™ (Figure 11.4.7) saliva alcohol test is intended for use as a rapid, highly sensitive method to detect the presence of alcohol in saliva and to provide a semiquantitative approximation of BAC. For applications where a quantitative determination of BAC is required, a positive ALCO-Screen result must be verified using an acceptable quantitative alcohol analysis procedure. ALCO-Screen requires no special training provided instructions are followed carefully. However, a qualified professional should perform

Figure 11.4.7 ALCO-Screen.



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quantitative follow-up testing. ALCO-Screen is not intended as a measurement of mental or physical impairment but rather a screening test for the presence of alcohol in semiquantitative amounts. As with any saliva-based or breath alcohol tester, a deprivation period of at least 15 min must be observed before beginning the test. This includes non-alcoholic drinks, tobacco products, coffee, breath mints, food, etc. The ALCO-Screen is used by saturating a reactive pad with saliva from the test individual’s mouth or sputum cup. At exactly 2 min, a change in color is observed in the reactive pad. A color change of green or blue indicates the presence of alcohol and a positive result. Results obtained after more than 2 min and 30 s (2.5 min) may be erroneous and should not be used. A BAC is estimated by comparing the color of the reactive pad to the color chart on the back of the test package (Figure 11.4.7). The ALCO-Screen produces a color change in the presence of saliva alcohol ranging from a light green-gray color at 0.02% BAC to a dark blue-gray color near 0.30% BAC. ALCO-Screen is designed and calibrated to be interpreted 2 min after saturation of the reactive pad. Waiting longer than 2 min to interpret the test can result in erroneous or falsepositive results. ALCO-Screen is a visually interpreted test; as such, exact interpretation of results is not required in most cases. However, persons who are color blind or visually impaired may experience difficulty when a more specific interpretation is required. Furthermore, where test interpretation may be biased for whatever reason, it is suggested that another person’s opinion of test results or color matching be obtained.20 ALCO Screen 2: ALCO-Screen 2 is a simple and cost-effective method of monitoring for alcohol consumption in a zero tolerance testing program. According to its product information, the ALCO-Screen 2 has been tested and approved by the U.S. DOT for required testing of all transportation and safety-sensitive employees for BACs above the federally mandated zero tolerance level of 0.02% (Figure 11.4.8). ALCO-Screen 2 is a simple one-step saliva-screening test that works in a clean, non-invasive manner and provides results in 4 min. Simply wet the test pad with saliva and wait 4 min. The development of a line on the test pad at 4 min indicates a BAC exceeding 0.02%. Any line, no matter how faint, developing on the reactive test pad at 4 min is a positive

Figure 11.4.8 ALCO-Screen 2.


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test. The Alco-Screen 2 is highly sensitive and can be used for evidentiary purposes. Completed test results can be photocopied for permanent filing.20 11.4.4.4

Chemical–Color-Change-Based Devices

Subcategories of screening devices, which are not electronic, make a determination of alcohol concentration by use of a chemical reaction. The first type of non-electronic device consists of either dichromate or permanganate salts in acid-impregnated crystals, which are placed in glass tubes. The individual being tested blows into a balloon or plastic bag or through the tube. After a certain volume of air or time has transpired, a measurement of the length of stain on the crystals in the tube (color change) is used to approximate the BrAC. The color change is a result of the chemical reaction occurring between alcohol and the chromate or permanganate salts in the crystals. Examples of older devices of this type include the Alcolyzer, several varieties distributed by Intoximeters, Inc., the Becton-Dickinson devices, Kitigawa Drunk-O-Tester by the Komo Chemical Industrial Company, Sober-Meters (Mobats) by US Alcohol and AlcoPro (Knoxville, TN). These screening devices use a mixed expired breath sample with the exception of the Becton-Dickinson device, which uses a two-chambered plastic bag to obtain alveolar air for the screening test. The results obtained from using these devices should be read according to time requirements expressed by the manufacturer. Other oxidizable components of breath will continue to react with the chemicals and may produce false positives. Screening devices that utilize a color change reaction for alcohol detection are disposable and good for only one test whereas electronic devices have an extended life and can be used repeatedly after resetting; hence they may be more cost-effective if an agency is doing multiple testing. One of the more popular disposable screeners is the BreathScan® Alcohol Detector (Figure 11.4.9).20 According to the manufacturer’s promotional material, “it is a disposable breath-alcohol indicator designed for one-time use” and according to its manufacturer it provides an accurate measure of the alcohol present in the exhaled breath of a test subject. By measuring the alcohol content in the breath, a reliable indication of the blood alcohol level is achieved. The BreathScan detector employs a new, patented technology for simple, on-the-spot screening for the presence of alcohol. The BreathScan tester can only be used once and then disposed of, minimizing contamination associated with repeated use of nondisposable units (no AIDS cross transmission). The BreathScan’s low cost and ease of use make the tester ideal for screening to determine whether an individual should submit to a forensic-quality blood test for confirmation. Just break the internal capsule, shake, and blow hard into the test cylinder of breath alcohol detector for a few seconds. Then read the color change of the chemical crystals in 2 min or less. Approved by the DOT, the detectors are available in five BAC levels for a complete range of sensitivity: 0.10%, 0.08%, 0.05%, 0.04%, and 0.02% (for zero tolerance testing), and they are very light and easy to carry around, weighing 0.16 oz each.

Figure 11.4.9 BreathScan Alcohol Detector.



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Figure 11.4.10 PAS IV “Sniffer.”

11.4.4.5

Passive Alcohol Sensor Devices

“Passive” alcohol sensing (PAS) devices are designed to detect the presence of alcohol in a person’s normally expelled breath; that is, the subject being tested is not required to blow into a mouthpiece as with conventional breath test devices. Passive alcohol sensing devices pull, through the use of a fan or other mechanical means, the vapor from the subject’s normal breathing when the device is activated and held in close proximity to the subject’s mouth. The device can also be held over open containers of an alcohol beverage to see if an underage person is drinking illegally. The present distributor of the PAS Systems is LLC (Fredericksburg, VA). It markets the PAS III, non-invasive alcohol-screening instrument, which has a built-in high-intensity flashlight (Figure 11.4.10). Their product information refers to the device as a “sniffer” for overt or covert alcohol detection. This device uses fuel cell technology for determining alcohol concentration. Another PAS device, the Alcometer, is currently available from Lions Laboratories (Cardiff, Wales, U.K.). Passive alcohol sensors have had a varied history — first introduced in the early 1970s without much success. In a recent DOT/NHTSA study (DOT HS 807 394), one such device was able to discriminate among differing alcohol air samples under laboratory conditions. The user has to be cognizant that passive alcohol sensors are influenced by wind disturbances. Wind or any air movement tends to invalidate their proficiency. 11.4.5 Blood and Urine — Collection, Identification, and Preservation of Specimens This issue is addressed only briefly here. Other treatises and handbooks can be found that will assist the reader in understanding this area of alcohol testing.21,22 Blood or urine specimens must be collected in a manner to maintain the chain of custody as in any other forensic case. However, additional precautions are required since the specimens are biological in nature, namely, removal of blood by qualified medical persons in an alcohol-free manner, and preservation of the specimen to permit mailing and long-term storage. Before establishing a system for collection, one should consult with the certifying state or other agency in control of specimen collection and testing to prevent unnecessary problems. 11.4.6 Quality Assurance and Proficiency Testing 11.4.6.1

Saliva

Quality control (QC) requirements for the Saliva Alcohol test can be conducted using control checks, with the Saliva Alcohol Ethanol Control from OraSure Technologies.23 Saliva alcohol ethanol control solutions should be run once per lot number of saliva alcohol tests.


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Saliva-based devices such as the ALCO-Screen may be qualitatively verified using a test solution prepared by adding 4 drops of 80-proof distilled spirits to 8 oz (1 glass) of water. This solution should provide a color reaction equal to or higher (darker) than the 0.04% color block. The color reaction with alcohol in saliva is somewhat slower and less intense than with alcohol in aqueous solutions. 11.4.6.2

Body Fluids

A laboratory conducting blood alcohol determinations whether for clinical or forensic purposes should maintain an internal system designed to assure the reliability of all laboratory data and should participate in an external proficiency testing program, where available, that evaluates the laboratory on the basis of the comparability of its results with those of several reference laboratories analyzing the same sample. The quality assurance program should include maintenance and periodic testing of equipment, validation and recalibration of methods, reagent evaluation, and surveillance of results. In-house reference calibrators and controls may be prepared from outdated whole human blood targeting concentrations of 0.000, 0.050, 0.100, 0.200, and 0.400% ethanol. Various reference materials are available to prepare or serve as standards, calibrators, and controls, e.g., the National Institute of Standards and Testing (NIST) material, SRM 1821 Ethanol (formerly National Bureau of Standards), and the College of American Pathologists (CAP) alcohol reference materials. Many states, private entities, and reagent manufacturers provide reference, calibrator, and control materials. For standardization, calibrators are assayed in triplicate and an appropriate standard curve prepared. Standardization should be repeated periodically or as dictated by changes in operational protocol. One or more quality control blood specimens (0.080, 0.015%, etc.) should be prepared and the mean and standard deviation determined for a total of 20 samples analyzed over a period of 10 days. The quality control sample should then be analyzed with every run of unknown alcohol samples and the result should fall within 95% confidence limits. The American Academy of Forensic Sciences, Toxicology Section and the Society of Forensic Toxicologists, Inc. have approved a quality assurance program titled, “Forensic Toxicology Laboratory Guidelines.”24 These same quality control procedures should be used for the testing of any other body fluids such as urine, serum, saliva, and post-mortem samples. An excellent resource for quality assurance can be found in Garriott’s Medicolegal Aspects of Alcohol22 or by obtaining the “Forensic Toxicology Laboratory Guidelines” from the American Academy of Forensic Sciences, Toxicology Section or the Society of Forensic Toxicologists, Inc.24 Duplicate aliquoting and testing of forensic biological specimens is an important part of any quality assurance procedure or program. In general, the results of the two independent tests should fall within a range of each other by ±10% or 0.02% BAC. Other accuracy or precision criteria may be used, but an increased degree of confidence in the reported results is achieved by duplicate testing.25 11.4.6.3

Breath

Although correlation between alcohol concentrations calculated using breath testing instruments and alcohol concentrations determined directly from blood have been well documented in the literature and accepted by the courts, it is necessary to have a method for the standardization and quality control of breath test devices. For scientific and legal reasons, it is necessary to demonstrate that a particular device was functioning properly at the time a subject was tested. Wet Bath Breath Alcohol Simulation The relationship between the concentration of alcohol in air as compared to blood at 34°C is discussed in other chapters of this text. The partition ratio for air/blood is greater than that of



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air/water; therefore, if an aqueous alcohol solution is heated to 34°C the amount of alcohol in the air space at equilibrium will be less than that of blood. To produce a breath sample that simulates a given BAC, it is therefore necessary that the aqueous (water and alcohol solution) be of an alcohol concentration greater than the expected reading value. If an expected BrAC of 0.100% at 34°C is required, then the aqueous water and alcohol concentration must be 0.121%. Simulation Units for Breath Alcohol Testers There are several manufactures of breath alcohol simulation devices. A complete list of companies and their devices can be obtained by contacting the National Highway Traffic Safety Administration, Office of Alcohol and State Programs, at 400 Seventh Street, S.W., Washington, D.C., 20590, (202) 366-5593 and asking for the current Model Specifications for Calibrating Units for Breath Alcohol Testers. The Simulator maintains the temperature at a constant 34 ± 0.2°C. The simulator contains several basic components: the first is the jar that holds the solution; the second is the head, which serves as a seal to the jar and contains the thermostat, thermometer, propeller, and motor, an air inlet tube that is attached to a bubbler tube, an air outlet tube, and a wire mesh baffle to prevent the solution from escaping through the outlet tube. The simulator solution is the most critical component. It should be carefully prepared and its accuracy checked by a competent laboratory and standardized by chemical and chromatographic analysis, comparing the results to a primary reference standard material (e.g., potassium dichromate, NIST Alcohol Standard). Gas Breath Alcohol Simulation Breath alcohol simulation is achieved by using a dry gas mixture. Several manufactures prepare or sell gaseous ethanol products. The device consists of a tank of pressurized air containing a specified alcohol concentration; a button is depressed and the alcohol/air mixture is released into the breath-testing device. These gaseous standards are useful if the breath test instrument utilizes a relatively small sample volume. For breath testing instruments with large sample volumes, use of these gaseous standards may or may not be practical. Any pressurized gas mixture of alcohol and air is subject to variation due to atmospheric pressure; hence, the mixture should be standardized against a wet solution of known alcohol concentration prior to use in a field situation. For a complete listing of the dry gas ethanol manufactures, contact DOT/NHTSA and obtain its most recent listing of these units, contained in the conforming products list of calibrating units.26 11.4.7 Concluding Remarks The abbreviation BAC refers to blood alcohol concentration, with concentrations expressed as percent weight to volume, % (w/v) or grams of alcohol per 100 ml of blood. The abbreviation BrAC refers to breath alcohol concentration expressed as percent weight to volume, % (w/v) or grams of alcohol per 210 L of deep lung or alveolar breath. The term alcohol refers to ethyl alcohol or ethanol. There are many excellent resources for forensic alcohol information; those by Garriott and Saferstein are especially helpful. In addition to printed documentation, numerous Internet sites are available. Table 11.4.3 provides a list of some of these. Acknowledgments The author thanks Yale Caplan, Ph.D., and the manufacturers of alcohol test equipment for providing assistance, information, and photographs.


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Table 11.4.3

Alcohol and Traffic Safety-Related Sites on the Internet

Air Products American Academy of Forensic Sciences AAA Foundation for Traffic Safety Alcohol Countermeasure Systems Bureau of Transportation Statistics Canadian Safety Council CMI, Inc. Drug and Alcohol Testing Industry Association Draeger Breathalyzer Division Guth Laboratories Health and Human Services Drug Testing Insurance Institute for Highway Safety International Association for Chemical Testing International Council on Alcohol, Drugs and Traffic Safety Intoximeters, Inc. Lifeloc Lion Laboratories Mothers Against Drunk Driving National Clearinghouse for Alcohol and Drug Information National Committee for Clinical Laboratory Standards National Highway Traffic Safety Administration National Institute of Health National Institute on Alcohol Abuse and Alcoholism National Institute on Drug Abuse National Motorists Association National Safety Council, Committee on Alcohol & Other Drugs NPAS DataMaster PAS Systems International Road Side Testing Assessment Scott Specialty Gasses Society of Forensic Toxicologists Substance Abuse and Mental Health Services Administration Transportation Research Board U.S. Department of Health and Human Services U.S. Department of Transportation

www.airproducts.com www.aafs.org www.aaafts.org www.acs-corp.com www.bts.gov www.safety-council.org www.alcoholtest.com www.datia.com www.drager-breathalyzer.com www.guthlabs.com www.health.org/workpl.htm www.carsafety.org www.iactonline.org raru.adelaide.edu.au/icadts/ www.intox.com www.lifeloc.com www.lionlaboratories.com www.madd.org www.health.org www.nccls.org www.nhtsa.dot.gov www.nih.gov www.niaaa.nih.gov www.nida.nih.gov www.motorists.org www.nsc.org www.npas.com www.sniffalcohol.com www.rosita.org www.scottgas.com www.soft-tox.org www.samhsa.gov www.nas.edu/trb www.hhs.gov www.dot.gov

REFERENCES 1. January 2000 Impaired Driving Program Update, National Highway Traffic Safety Administration, Traffic Safety Programs, Impaired Driving Division, Washington, D.C., 2000. 2. National Safety Council, 1121 Spring Lake Drive, Itasca, IL. 3. Colorado Association of Chiefs of Police, D.U.I. Enforcement Manual for the State of Colorado (August, 1977). 4. Results from the 2002 National Survey on Drug Use and Health: National Findings. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Washington, D.C., 2002. 5. Berry, R.E., Boland, J.P., Smart, C., and Kanak, J., The Economic Cost of Alcohol Abuse: 1975. Policy Analysis, Brookline, MA, 1977. 6. Cruze, A.M., Harwood, H.J., Kristiansen, P.L., Collins, J.J., and Jones, D.C., Economic Costs to Society of Alcohol and Drug Abuse and Mental Illness: 1977. Research Triangle Institute, Research Triangle Park, NC, 1981. 7. Harwood, H.J., Napolitano, D.M., Kristiansen, P.L., and Collins, J.J., Economic Costs to Society of Alcohol and Drug Abuse and Mental Illness: 1980. Research Triangle Institute, Research Triangle Park, NC, 1984.



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8. Rice, D.P., Estimating the Cost of Illness. Health Economics Series, No. 6. DHEW Pub. No. (PHS) 947-6, 1966. U.S. Department of Health, Education and Welfare, Rockville, MD, 1966. 9. Rice, D.P., Kelman, S., Miller, L.S., and Dunmeyer, S., The Economic Costs of Alcohol and Drug Abuse and Mental Illness: 1985. National Institute on Drug Abuse, Rockville, MD, 1990. 10. Zettl, J.R., Prosecution of driving while under the influence student manual, in Toxicology and the Forensic Analysis of Alcohol. American Prosecutors Research Institute, National Traffic Law Center, Washington, D.C. USDOT/NHTSA Project Number 004NTLC and 0922 Drug Driver. 11. Payne, J.P., Hill, D.W., and King, N.W., Observations on the distribution of alcohol in blood, breath and urine, Br. Med. J., 1, 196, 1996. 12. Dubowski, K.M. and Caplan, Y.H., Alcohol testing in the workplace, in Medicolegal Aspects of Alcohol, 3rd ed., J.C. Garriott, Ed., Lawyers & Judges Publishing, Tucson, 1996, 439–475. 13. National Highway Traffic Safety Administration, Highway Safety Programs, Model specifications for devices to measure breath alcohol, amended, Fed. Regis., 67(192), 2002. 14. Zettl, J.R., Colorado Alcohol Test Program Survey — Update, Colorado Department of Public Health and Environment, Laboratory and Radiation Services Division, February 27, 1997. 15. Advance Safety Devices, 21000 Osborne Street, Suite 4, Canoga Park, CA 91304. 16. National Highway Traffic Safety Administration, Highway Safety Programs, Conforming products list for screening devices to measure alcohol in body fluids, amended, Fed. Regis., 66(87), 2001. 17. www.rosita.org//. 18. Craig Medical Distribution, Inc. 185 Park Center Drive, Building P, Vista, CA 92801. 19. OraSure Technologies, Inc. Bethlehem, PA (Formerly STC Technologies, Inc.). 20. STC Technologies, Inc. 1745 Eaton Avenue, Bethlehem PA 18018-1799. 21. Caplan, Y.A. and Zettl, J.R., The determination of alcohol in blood and breath, in Forensic Science Handbook, Vol. 1, 2nd ed., R.E. Saferstein, Ed., Prentice Hall, Upper Saddle River, NJ, 2001, chap. 12. 22. Garriott, J.C., Ed., Medicolegal Aspects of Alcohol, 3rd ed., Lawyers & Judges Publishing, Tucson, 1996. 23. OraSure Technologies, Inc. 220 East First Street Bethlehem, PA 18015. 24. Forensic Toxicology Laboratory Guidelines, American Academy of Forensic Sciences, Toxicology Section and Society of Forensic Toxicologists, Inc., 1997–98. 25. Jones, A.W. and Logan, B.K., DUI defenses, in Drug Abuse Handbook, S. Karch, Ed., CRC Press, Boca Raton, FL, 1998, 1006–1045. 26. Department of Transportation, National Highway Traffic Safety Administration, Model specifications for calibrating units for breath alcohol testers; conforming products list of calibrating units, Fed. Regis., 62(156), August 13, 1997.

11.5 ON-SITE POINT-OF-COLLECTION DRUG TESTING: HISTORY, DEVELOPMENT, AND APPLICATIONS

Jane S.C. Tsai, M.D. Roche Diagnostics, Indianapolis, Indiana

The advantage or projected benefit of prompt analytical investigations near the site of specimen collection has aggrandized the development of point-of-care products in diverse fields of in vitro diagnostics. POC is used in clinical or diagnostic tests as an abbreviation for point-of-care testing. A variety of descriptions have been used to describe diagnostic POC testing (POCT), including on-site testing, near patient testing (NPT), and decentralized testing. The term POC is also cited in the literature for drugs of abuse testing and clinical toxicology.1–3 In contrast to general clinical diagnostic assays, testing for drugs of abuse involves the considerations of specimen collection, chain-of-custody, specimen validity, two-tier screening and confirmation testing, and the reporting process. Therefore, SAMHSA (Substance Abuse and Mental Health Services Administration) and


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DTAB (Drug Testing Advisory Board) have adopted the term point of collection testing (POCT) for POC drug testing during the drafting process for the new “Mandatory Guidelines for Federal Workplace Drug Testing Programs.”4 Although both the concept and practice of POCT have been evolving over an extended period of time, technological advances in the past two decades have greatly expanded the role of POCT in health care. An assortment of POC tests, ranging from urinalysis strips to handheld sensor systems and sophisticated bench-top analyzers, are currently in active use,1 especially for applications that require fast turn-around time (TAT). In the areas where the availability of an immediate test result could influence the outcome management or patient care, the use of POCT is desirable even though there are important considerations regarding the reliability, accuracy, and cost-effectiveness of these tests. Testing for drug abuse or misuse is an example of areas where the immediacy of a test result could contribute to enhance the efficiency of the testing program. Therefore, POCT has been applied in workplace drug testing programs to facilitate the decision-making process5,6 and evaluated in the field for road-side testing or traffic safety.7,8 POC drugs of abuse testing is also widely used in various compliance programs (e.g., criminal justice, psychiatric, rehabilitation, and drug treatment testing) to aid in behavior modification for higher admission of use and better sanctions of ongoing drug use.9,10 When used appropriately, POC substance abuse testing can be utilized in clinics or the emergency department to help rule out or rule in drug exposure.1,3 In Subpart L of the draft of new mandatory guidelines,4 POCT will be defined as “an initial test conducted at the collection site either to determine the presence of drugs and/or to determine the validity of a specimen.” The proposed guidelines specify two types of POCT devices: (1) Noninstrumented for which the end-point result is obtained by visual evaluation (i.e., read by human eye); or (2) instrumented for which the result is obtained by instrumental evaluation (e.g., densitometer, spectrophotometer, fluorometer). The majority of publications have used the expression “on-site” instead of “POC” for drugs of abuse testing. In addition to the terms “on-site,” “point-of-care,” and “point-of-collection,” an assortment of terminology has been used to describe single-use, disposable, commercial immunoassay kits for drugs of abuse screening. Trade names that contain or imply the words “rapid,” “quick,” “fast,” “instant,” “express,” “simple,” “screen,” “scan,” “no-step,” or “one-step” have been used in commercial drug POCT products. 11.5.1 Evolution of On-Site/POC Drug Testing During the early phases of drug testing, “on-site” urine drug tests were carried out on the premises as compared to those sent to an “off-site” laboratory. The first court-based testing laboratory was established in 1971.9 On-site urine drug testing using “instrumented” immunoassays could also be carried out in a clinic with immediate feedback of results to patients and staff. In 1977, Goldstein et al.11 evaluated on-site vs. off-site urine testing in a methadone treatment program. The authors concluded that there were negligibly small differences between the on-site or off-site urine testing groups with respect to illicit drug use although other advantages might justify the adoption of on-site testing in methadone programs. At the early stage of workplace drug testing implementation, the term “on-site” urine testing for drugs of abuse was generally used to refer to tests “done at the place of business.”12 In the 1986 NIDA Research monograph 73, Willette12 wrote that “the first major consideration” to be reviewed when selecting a system for drug testing is to decide if testing will be done on-site or by an outside laboratory. The horizon of on-site drug testing has since been expanded far beyond the defined “on-site equipment at on-site testing area” to an array of “non-instrumented” devices used by various substance abuse testing programs. In the monograph, however, the described advantages and disadvantages of on-site vs. laboratory screening remain coetaneous considerations for current on-site drug testing.



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The historical milestones for the development of the federal guidelines have been for laboratory drug testing, and the drafting of guidelines that will formally permit on-site testing4 was still in process as of early 2004. Subsequent to the publication of the 1988 mandatory guidelines,13 NIDA sponsored a “Consensus Conference” in 1989 to assess and evaluate such programs and to develop recommendations for change.14 The seven working groups and the participants of this conference were able to reach a consensus as recorded in the Consensus Report.14 The issue of on-site testing was one of four issues considered by multiple working groups. In this Consensus Report, the “onsite initial screening only testing facilities” should “only be allowed where safety issues demand the most rapid turn-around time, justifying the risk to the client inherent in unconfirmed tests, and the considerable difficulties in achieving accurate testing that such facilities create.” It was agreed that on-site urine screening “can reliably identify negative specimens, provided appropriate safeguards are built into the procedure.” A NIDA-funded evaluation of 11 laboratory-based on-site drug testing facilities15 concluded that on-site drug testing was technically possible for screening in the private sector, military, and criminal justice systems. However, recommendations were made to address the flaws identified in personnel, specimen handling, security, standard operating procedure manual, testing method, quality control and assurance programs, and policies.15,16 It was recommended that guidelines should be developed to establish operational consistency and analytical accuracy among on-site drug testing facilities. Meanwhile, the 1989 Nuclear Regulatory Commission (NRC) “Fitness for Duty” rule permitted NRC licensees to have their own on-site testing program.17 Licensees were permitted to conduct initial screening tests of an aliquot before forwarding selected specimens to a laboratory certified by the Department of Health and Human Services (HHS), provided the licensee’s and testing facilities meet the stated quality criteria for conducting the tests.. Similarly, a 1991 National Institute of Justice (NIJ) study on urinalysis technology comparison reported that on-site instrumented drug testing demonstrated equal performance to commercial laboratory-based testing.9,18 In parallel with instrumented testing, non-instrumented-based “on-site testing devices” that can be used without the need of a laboratory were launched into a few nonregulated drug testing fields but did not become a viable alternative of regulated workplace drug testing when the federalmandated testing was initiated. The revision of mandatory guidelines in 199419 also did not specify rules for on-site testing; however, several departments of the U.S. government have since sponsored evaluations and working groups to assess the reliability of, and to address issues associated with, these on-site testing devices.20–23 During the SAMHSA-sponsored On-Site Drug Testing Workgroup Meeting in 1999,16 the consensus recommendations from 1989 were reviewed again. It was recognized that the main elements remain the same but the “grid” would be revised to take into consideration the non-instrumented-based and instrumented-based techniques, to add oral fluids, and to leave out “elements that are clearly laboratory based.” A laboratory for conducting “only instrumented initial drug and validity tests” will be called an Instrumented Initial Test Facility (IITF) as described in Subpart M of the draft of new mandatory guidelines.4 Four types of specimen can be tested at an IITF (hair, oral fluid/saliva, sweat/patch, and urine). In comparison, a POCT will be “an initial test conducted at the collection site” using either non-instrumented or instrumented assays for urine or oral fluid drug testing. In addition to the SAMHSA mandatory guidelines for workplace drug testing, several other organizations have developed their recommended “guidelines” for forensic, athletic, or clinical drug testing. The National Academy of Clinical Biochemistry (NACB) Laboratory Medicine Practice Guidelines addressed the “major limitations” of immunoassays for drug testing in emergency department and clinical laboratories to support the diagnosis and management of the poisoned patients.24 Issues associated with the nature of antibody-based drug screening and the different cutoff requirements for workplace vs. compliance or clinical testing are applied to both laboratorybased and POC drug testing. Some of the countries that develop their drug testing guidelines take into consideration the different drug testing segments. For example, the Swiss guidelines for drug


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testing (non-legally binding) defined four areas of application: clinical sector, substitution or withdraw treatment, forensic investigations, and “non-traditional” environment (workplace, physicals, military, school).25 The application of non-instrumental immunoassays in each of the four areas is addressed in the document; however, the use of rapid tests is generally not preferred. Despite that on-site drug testing has not been permitted in mandated testing programs and is not preferred in many settings, there has been a significant growth of on-site drug testing in the past few years.16,26 Compared to off-site urinalysis, on-site drug testing was shown to have lower variable costs, and total costs were lower once a threshold of 27 employees tested was attained.27 Mastrovitch et al.28 evaluated the POCT screening approach in an emergency department of a tertiary-care, urban medical center and showed at least 37.5% cost saving per analyte using POCT as compared to laboratory-based urine screening. The widespread interest in on-site drug testing can also be measured from the arrays of comparative studies conducted in the past decade that evaluated various combinations of “currently available on-site drug testing devices” under a variety of conditions.20–23,29 The business models for on-site drug testing are very complex due to multiple customer types with multiple requirements and expectations. With few examples of federal agency preemption, on-site testing has been subject to different U.S. state laws and various levels of restrictions. The manner in which a drug testing program is managed in private sectors can be quite client-driven. The recent explosion of on-site testing products and the Internet has further complicated the fields of on-site drug testing. Therefore, the examples described in this chapter are general representations and are not all-inclusive for these very diverse fields. 11.5.2 History of Technology and Product Development Significant strides in the development of technologies and products for competitive immunoassays of small molecules have been made in the past 30 years. There have also been substantial research and development investments in drug screening technologies. Generally, the instrumented immunoassays played a role in supporting the commercialization of non-instrumented immunoassays. One example of such can be demonstrated by the FDA (Food and Drug Administration) 510(k) pre-market clearance review process whereby a new product gains approval by demonstrating substantial equivalency to one or more “predicate devices” on the market. Confirmation technologies, especially GC/MS, are used as the gold reference for immunoassay studies for 510(k) submission and are occasionally used as the predicate methods. Although increasing numbers of teststrip products have obtained clearance utilizing similar test-strip products as predicate devices, the first phases of on-site products were comparatively evaluated with instrumented, laboratory-based immunoassays to attain FDA approval. 11.5.2.1

Instrumented Immunoassays

The early concept of the “two-stage field testing procedure” involved the on-site collection of samples that could be preserved and transported in a convenient way for completing the instrumented testing in a laboratory. For “field” application, the samples can be absorbed onto paper disks such as a paper loaded with cation-exchange resin, dried, and mailed to the laboratory for radioimmunoassay (RIA).30 The locally collected, sample-treated paper with ion-exchange resin could also be tested with hemagglutination-inhibition and spectrophotofluorimetry.31 In a 1976 review article, Cleeland et al.32 reported that the RIAs appear to be equally applicable to detection of drugs in urine, blood, saliva, and tissues, and “can be used equally well for emergency (STAT) tests or mass screening.” Nonetheless, the most commonly utilized urine drug testing methodology for on-site facilities has been homogeneous immunoassays that can be easily performed using small automated analyzers. Reagents based on the principles of EMIT (enzyme multiplied immunoassay technique), and to a lesser degree, FPIA (fluorescent polarization immunoassay), and KIMS (kinetic interaction of



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particles in solution), have all been utilized in the context of on-site laboratory testing. Examples of bench-top analyzers or newer analyzer families that offer models suitable for small- to mediumsize laboratories include Dade Behring (Deerfield, IL) ETS-Plus, Viva, 30Rand V-Twin; Abbott (Abbott Park, IL) TDx, TDxFLx; Olympus (Melville, NY) AU series, and Roche (Indianapolis, IN) Hitachi Systems, Cobas MIRA-Plus, and Cobas Integra systems. 11.5.2.2

Non-Instrumented Drug Testing Products

Microparticle-Based On-Site Immunoassays The utilization of hemagglutination-inhibition methods to detect abused drugs was reported in 1971.33 Early versions of a non-instrumented testing device for abused drugs included a latex agglutination-inhibition-based testing device (Abutex) made available for investigation by Hoffmann-La Roche in the 1970s. By 1981, several Roche Agglutex products for abused drug screening had received FDA 510(k) approval. The Agglutex assays were available from the mid-1970s until the early 1990s; the method was reported to be easy to use and could accommodate analysis of “approximately a hundred specimens per hour without sophisticated instrumentation” although the results were available after a 2-h incubation period.34 By contrast, the next generation of latex agglutination-inhibition based products, Roche Abuscreen OnTrak,35–44 produced results in approximately 4 min. The first wave of OnTrak products received FDA approval in 1988. A multianalyte agglutination assay was reported in 1993 by Abbott researchers45 as a 10-min assay system for five classes of abused drugs. Slide or capillary-flow microparticle-based POCT immunoassay products have the advantage of better-controlled reaction kinetics (liquid-phase, thorough reagent mixing, and incubation) and relatively easy visual interpretation of a positive or negative result. However, these assays are less versatile due to the requirements of liquid reagent storage and handling and were gradually replaced by membrane-based products in the past few years. Membrane-Based Assays for Urine Drug Testing — One-Step Lateral Flow Immunochromatography Paper strip-based immunochromatographic assays or “dipstick” assays have been explored for drug immunoassay development. The first application of lateral flow paper strip was disclosed in a 1978 patent that utilized immunochromatography to carry out an RIA.46 In 1983, Litman et al.47 reported “an internally referenced test strip immunoassay for morphine.” Enzyme-channeling immunoassay that involved sequential incubation of the strip in the sample and developer solution could “score the test as positive or negative for drug” based on the ratio of the color formed on the indicator pad to that formed on the reference pad. An enzyme immunochromatography based on “the spatial distribution of enzyme label” for analyte quantification48 was used in the Syva AccuLevel product for therapeutic drug monitoring.49,50 Earlier evaluations of paper chromatography tests for drugs of abuse screening in urine, such as the 1980 Technology Resources, Inc., TRI dipstick and the 1987 Keystone Diagnostic Inc. Quik Test, all indicated that the tests were inaccurate, unreliable, and unacceptable.51–54 By the mid-1990s, approximately a dozen membrane-based on-site products for screening drugs of abuse in urine were launched either by established companies in the drug testing business or by new companies founded to enter POC or drug testing markets. Examples of products marketed or evaluated during this time period include (in alphabetical order) Abusign (Princeton Biomeditech, Princeton, NJ),55,56 accuPINCH (Hycor Biomedical Inc., Garden Grove, CA),57 EZ-Screen (Environmental Diagnostics, Burlington, NC),58–61 Frontline (Boehringer Mannheim/Roche),62,63 microLine (DSSI, later CascoNerl, Portland, ME), OnTrak TesTcup and OnTrak TesTstik (Roche Diagnostics, now Varian, Inc., Irvine, CA),64–71 Rapid Drug Screening (American Bio Medica Corp. Kinderhook, NY), Triage


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(BioSite, San Diego, CA),72–78 Verdict (Editek, Inc., now MedTox, Burlington, NC), Visualine (Sun Biomedical, Cherry Hill, NJ),79 etc. Over time a number of POCT products or brands were either “on and off the market” — or completely changed product configurations. From the late 1990s into the early 2000s, there has been a rapid proliferation in both the numbers and distributors of on-site drug testing products. Besides those in the U.S., the number of overseas manufacturers of POC drug testing products has also increased in recent years. Several of the onsite testing investigation projects either inventoried or evaluated the contemporaneous on-site testing products.20–23,28 The reports list descriptions of selected products and some of the different products that are in fact identical products. From published information and government databases, it can be noted that many products either share the same strip manufacturer or are essentially the same devices under different packaging or labeling. For products marketed under different trade names, their package inserts typically contain the same data because no additional studies are needed for FDA “Add-to-file” approval for selling the device with different trade names or labeling. Collectively, divergent factors have contributed to the explosion of the number and types of POC drug testing products. Among the contributing factors are increased acceptance of on-site testing by the marketplaces, more recognition of the on-site testing benefits, more new companies and new alliances, and more “menu configurations” comprising various combinations of single and panel tests. Conversely, the lack of mandated or standardized regulations, the significant price erosion, and the promulgation of the Internet also contributed to bluring the entry barriers into the on-site drug testing markets. Membrane-Based Drug Assays for Alternative Matrices In addition to urine drug testing, some of the on-site testing products were evaluated for blood or post-mortem blood testing following blood extraction or acetone precipitation.80,81 However, the performance is different. In recent years, one-step lateral flow immunochromatography has also been the format of choice for most of the on-site drug testing for alternative matrices. Examples of on-site saliva testing products82–89 include (in alphabetical order) Drugwipe and DrugwipeII (Securetec, Ottobrunn, Germany), OralLab (Varian, Inc., Irvine, CA), OralScreen (Avitar, Inc., Canton, MA), RapiScan Cozart Bioscience Ltd. (Cozart Bioscience Ltd., U.K.), and SalivaScreen (Ulti-Med, Ahrensberg, Germany). The Drugwipe products are also marketed for drug detection in sweat or on the skin. These products are discussed in another chapter of this section. However, with more of the on-site urine test manufacturers expanding into the oral fluid testing field, the number of oral fluid testing products is likely to increase in the coming years. 11.5.2.3

Hybrid of Instrumented and Non-Instrumented On-Site Drug Testing

The “hybrid” system usually consists of a handheld “reader” to help interpret the color development result of an on-site testing strip. There are bench-top readers that can integrate sample-handling or testing procedures. Many of the test strip developers have developed readers for internal use or for products; moreover, a few generic strip readers are commercially available. Nevertheless, not all companies make the commercialization decision. Examples of on-site tests that have to be used in conjunction with an instrument include RapiScan (Cozart Biosciences), eScreen (eScreen, Inc., Overland Park, KS), etc. Currently, there are companies that can offer connectivity and multivendor information management for POCT. Some of the on-site device or service providers may offer customized data management for the needs of chain-of-custody and data entry, reporting, and storage. The sensitivity of the reader depends on the quality of the optical components, resulting in a trade-off between the quality, the price, and the portability of the readers. Instruments that employ light reflectance or optical scanners may not achieve greater sensitivity than the human eye. Because the “gray zone” of color reading (weakly positive vs. weakly negative) also falls on the analytical gray zone of the testing result (around cutoff region of the calibration curve), the overall interpre-



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tation accuracy is not significantly affected by human or machine reading. However, the human subjectivity and lighting issues can both be minimized by instrument reading. The instrument reading also offers benefits in result recording and processing, although it carries additional cost and handling and quality control of the readers. Therefore, the choice of adopting the hybrid system is at the discretion of the users for their drug testing program budget and goals. Specific readers are required for assays that utilize fluorescence or phosphor particles to achieve lower detection limits for certain analytes, especially for oral fluid drug testing. The Uplink analyzer developed by OraSure Technologies, Inc. (OTI) is a portable instrument containing a laser source that “interrogates” the test strip based on Up-Converting Phosphor Technology (UPT).90 A few research reports have shown the feasibility of applying immunosensor technology to drug testing.91,92 The future development of immunosensor-based on-site drug testing may potentially be applied to “smart” handheld devices with more digital capability in result processing, wireless transmission, and data management. 11.5.3 Principles of Detection Reactions The majority of on-site drug testing products utilize microparticles to maximize reagent reaction surfaces and to allow detection of the outcome of the competitive immunoassays. Microparticle agglutination-inhibition assays such as Abuscreen OnTrak assays use relatively large white microparticles with coated drug-conjugate to bind antibody and produce visible latex aggregates in the absence of drugs. The presence of drugs above the designated cutoff level prevents the agglutination and produces a milky appearance, indicating a screening positive result. Membrane-based assays utilize smaller colored nanoparticles with attached antibody to bind pre-immobilized drug conjugate and produce a color signal. The binding can be inhibited by drugs in the sample so the absence of the color signal indicates a screening positive result. Membranes such as nitrocellulose or nylon membrane have become the key component of POC immunoassays. In rapid POC immunoassays, membranes not only provide means for separation of the bound and unbound but also serve as solid-phase reaction chambers. There are two major forms of membrane-based tests: lateral-flow and flow-through. Lateral flow is the most commonly used “one-step assay” because of its ease of use. The “convective mass transfer” of the immunoreactant to the binding partner allows the assay to be performed upon the initiation of sample flow. However, immunoreactions in a lateral flow strip are not carried out under an equilibrium condition, which results in certain degree of compromise in reaction kinetics when compared with assays performed in an equilibrium mode. Various chemical, reagent, and process optimizations, most of them proprietary, have been actively sought to enhance performance and manufacturing consistency while maintaining the one-step advantage. The plastic housing for lateral flow test strips is typically a self-contained device that has all the reagents necessary to complete a test. The flow-through tests typically involve the handling of liquid solution and require more than one step of user intervention. Thus the flow-through form can require more manual manipulation and need more time to carry out tests for the same groups of analytes; however, the trade-off allows incubation of immunoreaction components in liquid state until they reach a predetermined nearequilibrium state. The system with sequential incubations and washing may help to reduce residual nonspecific binding and can be more forgiving of potential sample matrix effects. The assembly of flow-through assays usually is a single device designed to allow for wicking of the sample and excess reagents. 11.5.3.1

One-Step Lateral Flow Immunochromatography

Typically, the basic test configuration comprises a nitrocellulose membrane strip with an immobilized capture reagent, which contains one member of the antigen–antibody binding pairs. The detection reagent consists of colored nanoparticles, which have been sensitized with the comple-


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mentary binding partner. The strip also contains other components to modulate optimal immunoreactions. For drugs of abuse testing, the immobilized reagent is usually a drug derivative that has been covalently attached to a large molecular carrier protein (i.e., drug conjugate). There are two types of nanoparticles used in the reaction of visual-read lateral flow assays: metal sol (usually colloidal gold) or colored latex nanoparticles. The particle size and uniformity of colloidal gold require optimal manufacturing control with an ideal diameter of gold particles for lateral flow assays of around 40 nm. In contrast, the choice of colored uniform latex particles is typically in the 100- to 300-nm range. The constructions of lateral flow strips have previously been described in detail, as the examples include a representative colloidal gold-based test strip configuration93 and a blue latex-enhanced immunochromatography.94 In brief, lateral flow immunoassays are based on competition between the drug, which may be present in the sample being tested, and the immobilized drug conjugate for binding to specific antibodies on the surface of the nanoparticles. If drug is present in the sample being tested, it binds with the antibody and inhibits the antibody reaction with the drug conjugate. Subsequently, no color is observed in the test results area. If the sample being tested contains drug below the cutoff concentration or is drug-free, the antibody is free to bind with the drug conjugate and a color band develops in the test results area. A second line, a control, may also be formed on the membrane by excess nanoparticles, indicating the test is complete or valid. Lateral flow strips can be designed to test for one or more analytes in a single strip or for panel testing in a single housing containing several strips. For drugs of abuse assays, the test can be completed within 3 to 5 min of sample application. The results of colloidal gold-based strips need to be interpreted within a few minutes of assay completion (most package inserts specify the results reading time limits). The results of blue latex-based strips can stay stable for longer periods of time and the results can be read upon tester convenience for up to a few hours after assay completion. Lateral flow assays have also been applied to use with up-converting phosphor reporters and the UPlink reader for detecting drugs in oral fluid.90 UPT nanoparticles are lanthanide-containing ceramic particles that can absorb infrared light and emit visible light. The UPlink reader contains a miniaturized infrared laser and can measure the signal intensity of the lines for conversion to qualitative results. 11.5.3.2

Multistep, Liquid Reagent, and Membrane-Based Assays

One example of a membrane-based enzyme immunoassay is EZ-SCREEN.61 The testing card contains antibody immobilized in the reactive area. Testing sample, along with positive and negative controls, is added to the reactive area as indicated on the card. Then the enzyme conjugate solution, wash reagent, and substrate reagents are added sequentially. The presence of drug in the testing sample competes with the drug–enzyme conjugate for binding to the membrane-embedded antibody and thereby reduces the color development after the substrate is added. The results are interpreted in 3 min by comparing color in the sample reaction site to that of the positive control site. The color differentiation of positive and negative control sites serves to indicate if the test is valid or not. Another example is ASCEND MultImmunoAssay (AMIA) that employs two reaction phases and a wash step for Triage drug panel testing.72,78 The first step involves the incubation of a predefined sample volume in a reaction well that contains three lyophilized reagent beads. After 10 min, the reaction mixture is transferred to a membrane solid phase with immobilized antibodies in discrete drug detection lines. The results can be interpreted visually after allowing the complete soaking of the reaction mixture and a subsequent wash of the membrane. The three reagent beads contain the set of antibodies for the analytes of interest, the corresponding drug derivative-colloidal gold conjugates, and reaction buffer, respectively. The drug conjugate competes with the corresponding drug in the donor urine for limited antibody binding sites. Competition of drug conjugate and drug in the urine for antibody binding occurs in the solution phase. When the reaction mixture is transferred to the testing area, freed drug conjugate can bind to its respective antibody on the



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test-plate membrane. After washing, positive result produces a reddish-colored bar in the drug detection zone adjacent to the drug name whereas negative sample produces no color. The results are read within 5 min of completion. 11.5.4 General Operational Considerations 11.5.4.1

Testing Flow and Confirmation

In general, workplace programs that use POCT are more likely to follow the same chain-ofcustody and testing flow as laboratory-based drug testing programs. Depending on the industrial sectors, company size, and local and state regulations, however, the actual practice of workplace testing can vary dramatically. In contrast to workplace testing, NACB discourages the maintenance of chain-of-custody documentation for clinical toxicological purposes24 unless it is known in advance that a specimen will likely be involved in a medicolegal matter. For compliance testing programs, the practice can range from those following regulated testing flow to those conducting tests in front of the person being tested. All the drug testing immunoassays are required by the FDA to clearly emphasize on product labeling that screen results are only preliminary and a more specific alternative chemical method must be used to obtain a confirmed analytical result. For the diverse end users of on-site drug immunoassays, however, the decision to confirm is at user discretion. The two-tier screening and confirmation system has not yet been a “mandate” for non-federal-regulated testing programs; however, many of the workplace testing programs do establish the confirmation requirements. Testing programs that employ full-service providers can have service bundled from collection to confirmation and reporting. For clinical testing, however, NACB considers the need for obtaining STAT results as negating the value of confirmation in emergency cases and recommends against routinely performing confirmative analyses on positive screening results.24 If the clinician anticipates subsequent involvement with medicolegal or social services or clinical need to identify a specific drug, the staff should notify the laboratory for a confirmation analysis.24 In criminal justice and drug treatment programs, user admission of drug use following a positive on-site screening result may be sufficient to waive further confirmation. However, in many cases confirmation is required for legal reasons and specific regulations. 11.5.4.2

Training

Similar to other aspects of on-site drug testing, training for using the products and interpreting the results can vary from program to program. The most popular mode of training is for the manufacturers/device providers to develop the training materials, audio-visual aids, and documentations. The manufacturers provide the first tier of training directly or through a third-party organization. The customers may have the option to set up a “training the trainers” program. The training typically involves presentations and reading materials, live demonstrations, and hands-on training using known controls and blind samples. Written examinations and certificates are mechanisms to certify the completion of training. The manufacturers can also develop interactive web-based elearning training. With the wide spectrum of device providers, however, the quality, delivery, and outcome of the training may vary considerably. 11.5.4.3

Quality Control and Quality Assurance

Unlike the instrumented laboratory-based immunoassays that employ on-board calibrations and controls, single-use POC test strips are precalibrated during the manufacturing process. Manufacturers that follow good manufacturing practices with validated procedures typically specify multiple


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steps of batch- and lot-based quality controls at both the test strip production phase and the finishedgoods stage. In theory, the majority of on-site drug testing devices have built-in procedural controls that should not be confused with analytical controls. One-step, competitive lateral flow assays contain one antigen–antibody pair of reagents and employ one control line downstream from the result zone. Multistep assays such as AMIA require two control lines to ensure that the test procedure is valid. In reality, these built-in controls do not verify the actual immunoreactions of the devices to target drug(s) and the only method of true “control” is via the use of externally prepared and validated drug-containing and drug-negative controls. The built-in test valid zones can be designed to visually correspond to the positive and negative results; however, the quality control recommendation in all device package inserts includes running external controls. Quality assurance (QA) is a comprehensive program that provides constant surveillance of all aspects of a laboratory or a testing facility. Quality control is an important part of a QA program and is used to ensure the accuracy of the tests. The implementation of a QA program and the use of quality control for POC drug testing are both client-driven. Although Clinical Laboratory Improvement Amendments (CLIA) exempt drug testing, many clinical testing and some state workplace testing regulations have requirements that are equivalent to or stricter than CLIA. Most of the clinical testing and some of the testing programs require daily run of external positive and negative controls unless special exemption is granted. In nonclinical testing, the more typical practice is to run quality controls either at fixed time intervals or when starting to use a new shipment or new lot of devices. A number of testing programs and devices also participate in open and blind proficiency testing. 11.5.5 Product Comparison Studies A number of studies have evaluated and compared the performance of rapid POC drug tests. Reports investigating the performance of POCT devices generally fall into five categories: 1. Detailed description and performance summary of one particular or two similar device types34–40,43,49–54,51–80,82–88,95,96 2. General comparative evaluation of a number of different on-site devices and/or laboratory-based immunoassays28,41,42,44,55,81,89,97–101 3. Comparative challenges of the devices with samples specifically selected to test the limits of immunoassay screens, such as near-cutoff performance or challenge of potential cross-reactivity issues20,21,103,104 4. General comments or reviews3,5,9,10,27,105,106 5. Field studies7,8,22,23,29,102

When comparing results from these studies, it is always crucial to recognize that different study goals, sample selections, and protocols can dramatically influence the outcome and interpretation of these studies. It is also important to take into consideration the target analyte and cutoff selections of the assays as well as the type and prevalence of the testing population. There are voluminous references but only examples of cutoff-challenge studies or field studies are briefly reviewed in this chapter. 11.5.5.1

Studies That Emphasized Near-Cutoff Challenges

In 1999, SAMHSA published a Division of Workplace Programs-sponsored evaluation of onsite testing that was designed to challenge 15 non-instrumented devices and an instrument-immunoassay on their accuracy near the cutoff.20 The DWP-sponsored evaluation and its predecessor,



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a study carried out for the Administrative Office of the U.S. Courts, were subsequently published as a book chapter.21 Although there are trade-offs of sensitivity vs. specificity when the majority of the samples evaluated are within ±25% of the cutoff values, the report stated that performance of most on-site devices was comparable to that of an instrument-based immunoassay. The overall accuracy of all drug test results vs. GC/MS (HHS cutoffs) ranged from 63% (PharmScreen DS) to 78% (OnTrak TesTstik), as compared to the accuracy of 76% for instrumented EMIT assays. The authors commented that the “favorable performance” of these devices was “encouraging.” Moreover, “it is expected that specimens encountered in most workplace testing situations will have fewer specimens with drug concentrations near the cutoff.”20 Therefore, “a much higher percentage of confirmed positive results and fewer false negative results should occur during actual testing in the field.” With the similar principle of “using challenging clinical sample sets” containing drug concentrations close to the screening cutoffs, Kadehjian104 compared the performance of five on-site drugsof-abuse testing devices (microLine, TesTcup5, RapidTest, RapidCup, and Triage) and an instrumented test (Emit d.a.u.). In this study, 298 specimens were tested on each of five devices and each result was independently read by two operators. There was little difference in overall accuracy between the scientist and nonscientist readers. The percent borderline results ranged from 10% (RapidCup) to 32% (microLine), whereas the accuracy of borderline results ranged from 34% (Triage) to 82% (TesTcup). More importantly, the author reported that accuracy generally improved with all devices demonstrating predictive values between 0.98 and 1.0 when device performance was assessed according to drug presence/absence criteria. 11.5.5.2

Field Evaluations

In 2000, the U.S. DOT published a study sponsored by the National Highway Safety Administration (NHTSA), “Field Test of On-Site Drug Testing Devices.”22,23 In this study, 30 on-site products were identified and 16 devices were rated based on 14 criteria. From the rating results, five devices (AccuSign, TesTcup5, TesTstik, Rapid Drug Screen, and Triage) were selected to evaluate 800 samples in two high drug prevalence counties in New York and Texas. The study had police officers participate in the actual use of the devices. Samples that showed positive results for any assay from any of the devices and 5% of the samples that showed negative results on all devices were sent to a laboratory for confirmation. The unconfirmed positive rates as a percentage of all samples tested (drug present in concentrations below the MS confirmation cutoff) were as follows: 0.12% for amphetamines, 1.0 to 1.12% for cannabinoids, 0.5 to 1.37% for cocaine metabolites, 0.25 to 0.37% for opiates and PCP, respectively. The false negative rates were as follows: 0% for amphetamines, 0.25 to 0.87% for cannabinoids, 0.12 to 0.37% for cocaine metabolites, 0 to 0.12% for opiates, and 0 to 0.25% for PCP. The report indicated that, when cutoff concentration and additional drugs are taken into consideration, the POCT devices were accurate in identifying positive samples and rarely failed to identify a driver with the target drugs in urine. Participating police officers generally favored the use of on-site devices in the enforcement of impaired driving laws. Nonetheless, the use of these devices should not supplant the officer’s judgment regarding impairment. Another field evaluation of on-site, multi-analyte drug testing devices as tools to identify drivers under the influence of drugs was funded by HHS/NIDS and reported by Buchan et al.8 During the 4-month study in a Florida county, voluntary and legal urine specimens were collected from suspects placed under arrest for suspicion of DUI and 303 samples contained a sufficient volume of urine for testing and confirmation. Specimens were tested in a university laboratory using four different POCT kits (AbuSign, TesTcup, Abuscreen OnTrak, and Triage). Results indicated that the accuracy ranged from 97.4 to 98.0% for THC, 97.4 to 98.0% for cocaine, and 99.7 to 100% for opiates. The authors observed that the four kits were in very close agreement on prevalence (15.5 to 15.8% for THC, all at 13.2% for cocaine, and all at 0.7% for opiates).


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11.5.6 Examples of POC Drug Testing Applications 11.5.6.1

Testing in the Workplace

Technical standards established for federally mandated workplace testing have withstood a number of constitutional challenges and served as a model for some state statutes for Drug-Free Workplace and for voluntary employer drug testing programs. Ideally, POC workplace drug testing by and large should follow this model. The portable and qualitative nature of on-site drug testing devices, however, can be a serious challenge to the “safeguards” that were built into the mandated program. In private sector workplace testing, employers may use their discretion on how to conduct POC testing or to contract to third-party or comprehensive drug testing service providers. Regardless of where and how a test is performed, a reliable workplace testing program has to take into consideration specimen collection (site, personnel, device, and procedure), donor and specimen (integrity, security, privacy, chain-of-custody, storage or transfer), result (handling and reporting), quality (QC, QA), and outcome management (confirmation, medical review officer). The most prominent example of large-scale application of on-site drug testing in the workplace has been the U.S. Postal Service (USPS) drug testing program.16 USPS started a pilot program in 1997. The pilot study involved a variety of different validation studies using both clinical and spiked specimens that involved four collection sites and large numbers of side-by-side studies over several months. In 1999, USPS decided to make the pilot project a full-time program. USPS has now implemented POCT in more than 1000 collection sites nationwide. The USPS example demonstrates that a well-planned and well-structured on-site workplace drug testing program can be effective and sustainable even when it involves a large number of geographically diverse sites. 11.5.6.2

Testing in Clinical Settings

Controversies continue to exist regarding the value of urine drug testing in clinical settings. The cited reasons for the controversies include the drugs involved, the sample, the methods utilized to perform the tests, and the level of understanding of the physician using the data.107 Despite the demand for rapid results in emergency situations, the immunoassays “are often designed for, or adapted from, workplace testing and are not necessarily optimized for clinical applications.” The study authors concluded that “While the literature is replete with studies concerning new methods and a few regarding physician understanding, there are none that we could find that thoroughly, objectively, and fully addressed the issues of utility and cost-effectiveness.”107 Likewise, NACB considers that immunoassays, although rapid, have major limitations in sensitivity and specificity.24 Even so, the features of fast TAT and panel screening have helped POC drug testing to become a viable technology in clinical settings. In comparison to the SAMHSA-5 panel for workplace testing, on-site testing devices for the clinical settings contain additional assays for benzodiazepines, barbiturates, and/or tricyclic antidepressants. Although assays for cannabinoids and phencyclidine are considered not useful in general clinical testing, on-site products for the clinical market generally contain a menu of eight to ten assays. Examples of products evaluated for on-site clinical testing include the market leader Triage DOA panel as well as ABMC Rapid Drug Screen, Dade Behring RapidTest, Abbott Signify-ER, Roche TesTcard 9, TesTcup-ER, BioRad Tox-See, etc.28,38–40,69,72–78,95–96 According to the Biosite promotional material, on-site drug testing has been used in over 2500 U.S. hospitals, indicating that on-site devices also can be effective and sustainable in the clinical market. 11.5.6.3

Testing in the Criminal Justice Systems

The utility of urine drug testing as an objective and effective tool to identify and treat substance abusers within the criminal justice systems has been well-recognized and is fully documented in



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another chapter of this section.9 The major market segments for drug testing within the criminal justice systems include community corrections, institutions and prisons, rehabilitation, and law enforcement. Community corrections, such as probation and parole, security, pre-trial services, and drug courts, are among the largest of the four segments to adopt non-instrumented devices for POC drug testing. Road-side drug testing and DUI programs can be categorized in the law enforcement segment. These applications have been thoroughly evaluated in studies sponsored by government or organizations such as DOT, HHS/NIDS, and ROSITA.8,22,23,29,102 11.5.6.4

Other Applications — Testing at School, Home, and Direct Consumer Testing

Examples of more recent uses of POCT include school and home testing. These applications are still evolving and will not be discussed at this time. Regardless of the sources of on-site testing devices (e.g., over-the-counter retails, pharmacy, or Internet), the direct consumer sales of both onsite drug testing device and drug testing adulterants signal an intriguing era of drug testing. Together with the drug and drug testing “knowledge” from Internet and multimedia information sources, people have the means to test themselves before reporting to a drug test or to titer or experiment with the use of both drugs and adulterants. There are a number of ethical questions regarding lay misuse of the devices and non-consent testing but the topics are beyond the scope of this chapter. Recently, the U.S. FDA established a specific Web site for home drug tests;108 this is a resourceful online tool that provides clear yet comprehensive explanations of the two-step drugs of abuse tests. 11.5.7 Continuing Evolution and Future Trends The evolution of on-site drug testing has truly come a long way. Since the 1980s, the challenges of exploring the “new” POCT markets have included the diverse marketing requirements, different laws and individual state legislation constraints, lack of permission in regulated testing, legal and interpretation considerations, and various market acceptance criteria and customer expectations. To date, some of the challenges remain critical but the tests continue to be popular for several reasons. The simple operation to produce visible results within a few minutes has been an attractive feature. Most importantly, the major products have had proven performance for customer needs that not only established customer and legislative acceptance but increased the practical utility of POCT as part of the drug testing programs. In general, these rapid assays can provide comparable performance with conventional immunoassays in most drug-screening settings. The near-cutoff precision is typically better with laboratory instrumented assays; however, on-site assays are useful for routine drug screening in the markets that demand rapid, qualitative determination. The trend of adopting POC drug testing appears to continue into the foreseeable future even though the market growth has been leveling off. Considering the dynamics of the diagnostic industry and drug testing business, the description of POCT product development in this chapter is not an attempt to be all-inclusive. Companies often make business decisions concerning alliances, divestiture, and acquisition to best meet their strategic considerations and goals. Naturally the business activities will continue into the future and can influence not only existing products but also future development of on-site drug testing. In addition, the World Wide Web and globalization will continue to influence on-site drug testing. Besides regular e-commerce activities of product providers, there are plenty of independent Web sites selling assortments of trade-name and generic on-site drug testing devices on the Internet. Additionally, many drug testing “full service providers” and “re-sellers” (third-party administrators, labs, distributors, medical review officers) have bundled into their service on-site drug testing devices from a variety of device manufacturers. Ironically, the Internet era also considerably boosts the adulter-


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ation industry, and most of the Web sites that sell drug testing adulterants also sell on-site drug testing devices for self-titration of drug use and for user self-testing. Because drug testing can have decisive medicolegal and social consequences, the industry is closely affected by regulatory and legislative issues and decisions. In general, most of the companies that are active in the on-site drug testing business are members of major industrial associations such as NOTA (National On-Site Testing Association) and DATIA (Drug and Alcohol Testing Industry Association). NOTA is an advocacy and resource center for on-site drug and alcohol testing. DATIA was founded in 1995 as the National Association of Collection Sites, and has since expanded its scope to represent the entire spectrum of drug and alcohol service providers, including collection sites, laboratories, consortiums/third party administrators, medical review officers, and testing equipment manufacturers. The two associations have worked independently or collaborated on behalf of on-site drug testing and will continue to play important roles in the future of on-site drug testing. The limitations of immunoassay for drug screening apply to both laboratory-based instrumented testing and on-site testing. Because the understanding of antibody cross-reactivity issues and various cutoff decisions requires knowledge of immunoassay and drug testing, interpreting and reporting results can continue to be issues with on-site drug screening unless safeguard requirements are built into the testing program. There is more to a drug testing program than just results and the success of an on-site testing program relates to how it is structured and implemented. The draft for the next versions of SAMHSA federal guidelines takes into considerations many of these requirements for conducting POCT.4 Meanwhile, the FDA is revising its guidance of pre-market submission for drugs of abuse screening tests by combining the previous drafts for prescription and over-the-counter drug screening into one draft.109 These new regulatory developments both recognize the co-existence of conventional laboratory tests and on-site screening for drugs of abuse. All of these developments will continue to shape the future of on-site drug testing.

REFERENCES 1. 2. 3. 4. 5. 6.

7. 8.

9. 10. 11. 12.

Price, C.P. and Hicks, J.M., Eds., Point-of-Care Testing, AACC Press, Washington, D.C., 1999. Bissell, M., Point-of-care testing at the millennium, Crit. Care Nurs. Q. 24, 39, 2001. Yang, J.M., Toxicology and drugs of abuse testing at the point of care. Clin. Lab. Med. 21, 363, 2001. Draft Mandatory Guidelines for Federal Workplace Drug Testing Programs, Draft 4, 2001. http://workplace.samhsa.gov/ResourceCenter/DT/FA/GuidelinesDraft4.htm. Armbruster, D.A., On-site workplace drug testing, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 25. Shults, T.F. and Caplan, Y.H., Program requirements, standards, and legal considerations for on-site drug testing devices in workplace testing programs, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 37. Walsh, J.M., On-site testing devices and driving-under-the-influence cases, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 67. Buchan, B.J., Walsh, J.M. and Leaverton, P.E., Evaluation of the accuracy of on-site multi-analyte drug testing devices in the determination of the prevalence of illicit drugs in drivers, J. Forensic Sci. 43, 395, 1998. Kadehjian, L.J. and Baer, J., On-site testing devices in the criminal justice system, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 55. Valentine, J.L., Clinical point-of-care testing for drugs of abuse, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 1. Goldstein, A., Horns, W.H., and Hansteen, R.W., Is on-site urine testing of therapeutic value in a methadone treatment program? Int. J. Addict. 12, 717, 1977. Willette, R.E., Choosing a Laboratory, NIDA Res Monograph 73, Hawks, R.L. and Chiang, C.N., Eds., 1986, 13.



955

13. Mandatory guidelines for federal workplace drug testing programs, Fed. Regis. 53, 1988, 11970. 14. NIDA Technical, Scientific and Procedural Issues of Employee Drug Testing Consensus Report, Finkle, B.S., Blanke, R.V., and Walsh, J.M., Eds., NIDA, 1990. 15. Rollins, D., On-site drug testing in the workplace. Final Report to the National Institute on Drug Abuse. Division of Workplace Programs, 1992. 16. Transcript On-Site Drug Testing Workgroup Meeting, 1999. http://workplace.samhsa.gov/ResourceCenter/r382.htm. 17. U.S. Nuclear Regulatory Commissions Fitness-for-Duty Program, 10 CFR Part 26, 1989. http://www.nrc.gov/reading-rm/doc-collections/cfr/part026/full-text.html. 18. Visher, C. and McFadden, K., A comparison of urinalysis technologies for drug testing in criminal justice, National Institute of Justice, 1991. 19. Mandatory guidelines for federal workplace drug testing programs, 1994, Fed. Regis. 59, 29908 http://www.health.org/workplace/GDLNS-94.htm or http://workplace.samhsa.gov/fedprograms/MandatoryGuidelines/HHS09011994.pdf. 20. An Evaluation of Non-Instrumented Drug Test Devices, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Prevention, Division of Workplace Programs, 1999. http://workplace.samhsa.gov/ResourceCenter/r409.htm. 21. Willette, R.E. and Kadehjian, L.J., Drugs-of-abuse test devices: a review, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 219. 22. DOT HS 809 192. Field test of on-site drug detection devices, 2000. http://www.nhtsa.dot.gov/ people/ injury/research/pub/onsitedetection/Drug_index.htm or http://www.nhtsa.dot.gov/people/injury/research/ pub/onsitedetection/On-SiteDrugDetection.pdf. 23. Crouch, D.J., Hersch, R.K., Cook, R.F., Frank, J.F., and Walsh, J.M., A field evaluation of five onsite drug-testing devices, J. Anal. Toxicol. 26, 493, 2002. 24. Wu, A.H., McKay, C., Broussard, L.A., Hoffman, R.S., Kwong, T.C., Moyer, T.P., Otten, E.M., Welch, S.L., and Wax, P., National academy of clinical biochemistry laboratory medicine practice guidelines: recommendations for the use of laboratory tests to support poisoned patients who present to the emergency department, Clin. Chem. 49, 357, 2003. 25. AGSA Swiss Working Group for Drugs of Abuse Testing Guidelines. http://www.consiliasa.ch/agsa/E/AGSA%20Guidelines_E_rev3.pdf. 26. Armbruster, D.A., On-site drug testing on the rise and growing strong, MLO Med. Lab. Obs. 29, 40, 1997. 27. Ozminkowski, R.J., Mark, T., Cangianelli, L., Walsh, J.M., Davidson, R., Blank, D., Flegel, R.R., and Goetzel, R.Z., The cost of on-site versus off-site workplace urinalysis testing for illicit drug use, Health Care Manage. (Frederick) 20, 59, 2001. 28. Mastrovitch, T.A., Bithoney, W.G., DeBari, V.A. and Nina, A.G., Point-of-care testing for drugs of abuse in an urban emergency department, Ann. Clin. Lab. Sci. 32, 383, 2002. 29. ROSITA Deliverable D2, Inventory of state-of-the-art roadside drug testing equipment, 1999. www.rosita.org. 30. Alexander, G.J. and Machiz, S., Simplified radioimmunoassay of urinary drugs of abuse adsorbed on ion-exchange papers, Clin. Chem. 23, 1921, 1977. 31. Alexander, G.J., A procedure for drug screening without the need to transport urines: use of ion exchange papers and hemagglutination inhibition, Clin. Toxicol. 9, 435, 1976. 32. Cleeland, R., Christenson, J., Usategui-Gomez, M., Heveran, J., Davis, R., and Grunberg, E., Detection of drugs of abuse by radioimmunoassay: a summary of published data and some new information, Clin. Chem. 22, 712, 1976. 33. Adler, F.L. and Liu, C.T., Detection of morphine by hemagglutination-inhibition, J. Immunol. 106, 1684, 1971. 34. Deom, A., Evaluation of a new latex agglutination inhibition test, Agglutex, for the demonstration of opiates in urine, Ann. Biol. Clin. (Paris), 42, 317, 1984. 35. Schwartz, J.G., Zollars, P.R., Okorodudu, A.O., Carnahan, J.J., Wallace, J.E., and Briggs, J.E., Accuracy of common drug screen tests, Am. J. Emerg. Med. 9, 166, 1991. 36. Armbruster, D.A. and Krolak, J.M., Screening for drugs of abuse with the Roche ONTRAK assays, J. Anal. Toxicol. 16, 172, 1992.


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37. Welch, E., Fleming, L.E., Peyser, I., Greenfield, W., Steele, B.W., and Bandstra, E.S., Rapid cocaine screening of urine in a newborn nursery, J. Pediatr. 123, 468, 1993. 38. Westdorp, E.J., Salomone, J.A., III, Roberts, D.K., McIntyre, M.K., and Watson, W.A., Validation of a rapid urine screening assay for cocaine use among pregnant emergency patients, Acad. Emerg. Med. 2, 795, 1995. 39. Belfer, R.A., Klein, B.L., Boenning, D.A., and Soldin, S.J., Emergency department evaluation of a rapid assay for detection of cocaine metabolites in urine specimens, Pediatr. Emerg. Care 12, 113, 1996. 40. Birnbach, D.J., Stein, D.J., Grunebaum, A., Danzer, B.I., and Thys, D.M., Cocaine screening of parturients without prenatal care: an evaluation of a rapid screening assay, Anesth. Analg. 84, 76, 1997. 41. Crouch, D.J., Frank, J.F., Farrell, L.J., Karsch, H.M., and Klaunig, J.E., A multiple-site laboratory evaluation of three on-site urinalysis drug-testing devices, J. Anal. Toxicol. 22, 493, 1998. 42. Crouch, D.J., Cheever, M.L., Andrenyak, D.M., Kuntz, D.J., and Loughmiller, D.L., A comparison of ONTRAK TESTCUP, abuscreen ONTRAK, abuscreen ONLINE, and GC/MS urinalysis test results, J. Forensic Sci. 43, 35, 1998. 43. Farrell, L.J. Abuscreen ONTRAK tests for drugs of abuse, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 153. 44. Schilling, R.F., Bidassie, B., and El-Bassel, N., Detecting cocaine and opiates in urine: comparing three commercial assays. J. Psychoactive Drugs 31, 305, 1999. 45. Parsons, R.G., Kowal, R., LeBlond, D., Yue, V.T., Neargarder, L., Bond, L., Garcia, D., Slater, D., and Rogers, P., Multianalyte assay system developed for drugs of abuse. Clin. Chem. 39, 1899, 1993. 46. Deutsch, M. and Mead, L.W., Test device U.S. patent, 4,094,647, 1978. 47. Litman, D.J., Lee, R.H., Jeong, H.J., Tom, H.K., Stiso, S.N., Sizto, N.C., and Ullman, E.F., An internally referenced test strip immunoassay for morphine. Clin. Chem. 29, 1598, 1983. 48. Zuk, R.F., Ginsberg, V.K., Houts, T., Rabbie, J., Merrick, H., Ullman, E.F., Fischer, M.M., Sizto, C.C., Stiso, S.N., and Litman, D.J. Enzyme immunochromatography — a quantitative immunoassay requiring no instrumentation, Clin. Chem. 31, 1144, 1985. 49. Opheim, K.E., Statland, B.E., Tillson, S.A., and Litman, D.J., Calibration, quality control, and stability of a quantitative enzyme immunochromatographic method for therapeutic drug monitoring, Ther. Drug Monit. 9, 190, 1987. 50. Morris, R.G. and Schapel, G.J., Phenytoin and phenobarbital assayed by the ACCULEVEL method compared with EMIT in an outpatient clinic setting, Ther. Drug Monit. 10, 469, 1988. 51. Jukofsky, D., Kramer, A., and Mule, S.J., Evaluation of the TRI “dipstick” test for the detection of drugs of abuse in urine, J. Anal. Toxicol. 5, 14, 1981. 52. Cone, E.J. and Menchen, S.L., Lack of validity of the KDI Quik Test Drug Screen for detection of benzoylecgonine in urine, J. Anal. Toxicol. 11, 276, 1987. 53. Kaplan, R.M., Fochtman, F., Brunett, P., White, C., and Heller, M.B., An analysis of clinical toxicology urine specimens using the KDI Quik test, J. Toxicol. Clin. Toxicol. 27, 369, 1989. 54. Schwartz, R.H., Bogema, S., and Thorne, M.M., Evaluation of the Keystone Diagnostic Quik Test. A paper chromatography test for drugs of abuse in urine, Arch. Pathol. Lab. Med., 113, 363, 1989. 55. Ros, J.J., Pelders, M.G., and Egberts, A.C., Performance of Abusign drugs-of-abuse slide tests with particular emphasis on concentrations near the cutoff: comparison with FPIA-ADx and confirmation of results with GC-MS, J. Anal. Toxicol. 22, 40, 1998. 56. Ros, J.J.W. and Pelders, M.G., AccuSign drugs of abuse test, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 111. 57. Jenkins, A.J., Darwin, W.D, Heustis, M.A., Cone, E.J., and Mitchell, J.M., Validity testing of the accuPINCHTM THC test, J. Anal. Toxicol. 19, 5, 1995. 58. Schwartz, R.H., Bogema, S., and Thorne, M.M., Evaluation of the EZ-SCREEN enzyme immunoassay test for detection of cocaine and marijuana metabolites in urine specimens, Pediatr. Emerg. Care 6, 147, 1990. 59. Jenkins, A.J., Mills, L.C., Darwin, W.D., Huestis, M.A., Cone, E.J., and Mitchell, J.M., Validity testing of the EZ-SCREEN cannabinoid test, J. Anal. Toxicol. 17, 292, 1993. 60. Kranzler, H.R., Stone, J., and McLaughlin, L., Evaluation of a point-of-care testing product for drugs of abuse; testing site is a key variable, Drug Alcohol Depend. 40, 55, 1995.



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61. Ferrara, S.D., Tedeschi, L., and Castagna, F., The EZ-SCREEN and RapidTest devices for drugs of abuse, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 123. 62. Wennig, R., Moeller, M.R., Haguenoer, J.M., Marocchi, A., Zoppi, F., Smith, B.L., de la Torre, R., Carstensen, C.A., Goerlach-Graw, A., Schaeffler, J., and Leinberger, R. Development and evaluation of immunochromatographic rapid tests for screening of cannabinoids, cocaine, and opiates in urine, J. Anal. Toxicol. 22, 148, 1998. 63. Schneider, S. and Wennig, R., Frontline testing for drugs of abuse, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 143. 64. Towt, J., Tsai, S.C.J., Hernandez, M.R., Klimov, A.D., Kravec, C.V., Rouse, S.L., Subuhi, H.S., Twarowska, B., and Salamone, S.J., ONTRACT TESTCUP: A novel, on-site, multi-analyte screen for the detection of abused drugs, J. Anal. Toxicol. 19, 504, 1995. 65. Tsai, J.S.C., Towt, J., Kravec, C., Oades, B., Rashid, F., Talbot, L.A., Twarowska, B., and Salamone, S.J., ONTRAK TESTCUP-5: A multianalyte immunoassay device for onsite drug testing, Proc. TIAFT 35, 466, 1997. 66. Crouch, D.J.. The OnTrak TesTcup system, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 163. 67. Birnbach, D.J., Browne, I.M., Kim, A., Stein, D.J., and Thys, D.M., Identification of polysubstance abuse in the parturient, Br. J. Anaesth. 87, 488, 2001. 68. Yacoubian, G.S., Jr., Wish, E.D., and Choyka, J.D., A comparison of the OnTrak Testcup-5 to laboratory urinalysis among arrestees, J. Psychoactive Drugs 34, 325, 2002. 69. Peace, M.R., Poklis, J.L., Tarnai, L.D., and Poklis, A., An evaluation of the OnTrak Testcup-er onsite urine drug-testing device for drugs commonly encountered from emergency departments, J. Anal. Toxicol. 26, 500, 2002. 70. Tsai, J.S.C., Oades, B., Demirtzoglou, D., Zhao, H., and Salamone, S., Simultaneous evaluation of OnTrak TesTstik Amphetamines Assay and TesTstik Methamphetamine Assay for the screening of amphetamines in urine, Proc. TIAFT 39, 160, 2001. 71. Salamone, S.J. and Tsai, J.S.C., OnTrak TesTstik device, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 185. 72. Buechler, K.F., Moi, S., Noar, B., McGrath, D., Villela, J., Clancy, M., Shenhav, A., Colleymore, A., Valkirs, G., Lee, T., Bruni, J.F.., Walsh, M., Hoffman, R., Ahmuty, F., Nowakowski, M., Buechler, J., Mitchell, M., Boyd, D., Stiso, N., and Anderson, R., Simultaneous detection of seven drugs of abuse by the Triage panel for drugs of abuse, Clin. Chem. 38, 1678, 1992. 73. Wu, A.H., Wong, S.S., Johnson, K.G., Callies, J., Shu, D.X., Dunn, W.E., and Wong, S.H., Evaluation of the Triage system for emergency drugs-of-abuse testing in urine, J. Anal. Toxicol. 17, 241, 1993. 74. de la Torre, R., Domingo-Salvany, A., Badia, R., Gonzalez, G., McFarlane, D., San, L., and Torrens, M., Clinical evaluation of the Triage analytic device for drugs-of-abuse testing, Clin. Chem. 42, 1433, 1996. 75. Valentine, J.L. and Komoroski, E.M., Use of a visual panel detection method for drugs of abuse: clinical and laboratory experience with children and adolescents, J. Pediatr. 126, 135, 1995. 76. Poklis, A. and O’Neal, C.L., Potential for false-positive results by the TRIAGE panel of drugs-ofabuse immunoassay, J. Anal. Toxicol. 20, 209, 1996. 77. Poklis, A., Edinboro, L.E., Lee, J.S., and Crooks, C.R., Evaluation of a colloidal metal immunoassay device for the detection of tricyclic antidepressants in urine, J. Toxicol. Clin. Toxicol. 35, 77, 1997. 78. de la Torre, R., Triage device for drug analysis, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 199. 79. Kuzdzal, S.A. and Nichols, J.H., Visualine II drugs-of-abuse test kits, in On-Site Drug Testing, Jenkins, A.J. and Goldberger, B.A., Eds., Humana Press, Totowa, NJ, 2002, 213. 80. Moriya, F. and Hashimoto, Y., Application of the Triage panel for drugs of abuse to forensic blood samples, Nippon Hoigaku Zasshi 50, 50, 1996. 81. Hino, Y., Ojanpera, I., Rasanen, I., and Vuori, E., Performance of immunoassays in screening for opiates, cannabinoids and amphetamines in post-mortem blood, Forensic Sci. Int. 131, 148, 2003. 82. Kintz, P., Cirimele, V., and Ludes, B., Codeine testing in sweat and saliva with the Drugwipe, Int. J. Legal Med. 111, 82, 1998.


958


83. Barrett, C., Good, C., and Moore, C., Comparison of point-of-collection screening of drugs of abuse in oral fluid with a laboratory-based urine screen, Forensic Sci. Int. 122, 163, 2001. 84. Yacoubian, G.S., Jr., Wish, E.D., and Perez, D.M., A comparison of saliva testing to urinalysis in an arrestee population, J. Psychoactive Drugs 33, 289, 2001. 85. De Giovanni, N., Fucci, N., Chiarotti, M., and Scarlata, S., Cozart Rapiscan system: our experience with saliva tests, J. Chromatogr. B Anal. Technol. Biomed. Life Sci. 773, 1, 2002. 86. Samyn, N. and van Haeren, C., On-site testing of saliva and sweat with Drugwipe and determination of concentrations of drugs of abuse in saliva, plasma and urine of suspected users, Int. J. Legal Med. 113, 150, 2000. 87. Jehanli, A., Brannan, S., Moore, L., and Spiehler, V.R., Blind trials of an onsite saliva drug test for marijuana and opiates, J. Forensic Sci. 46, 1214, 2001. 88. Kolbrich, E.A., Kim, I., Barnes, A.J., Moolchan, E.T., Wilson, L., Cooper, G.A., Reid, C., Baldwin, D., Hand, C.W., and Huestis, M.A., Cozart RapiScan Oral Fluid Drug Testing System: an evaluation of sensitivity, specificity, and efficiency for cocaine detection compared with ELISA and GC-MS following controlled cocaine administration, J. Anal. Toxicol. 27, 407, 2003. 89. Walsh, J.M., Flegel, R., Crouch, D.J., Cangianelli, L., and Baudys, J., An evaluation of rapid pointof-collection oral fluid drug-testing devices, J. Anal. Toxicol. 27, 429, 2003. 90. Niedbala, R.S., Feindt, H., Kardos, K., Vail, T., Burton, J., Bielska, B., Li, S., Milunic, D., Bourdelle, P., and Vallejo, R., Detection of analytes by immunoassay using up-converting phosphor technology, Anal. Biochem. 293, 22, 2001. 91. Nath, N., Eldefrawi, M., Wright, J., Darwin, D., and Huestis, M., A rapid reusable fiber optic biosensor for detecting cocaine metabolites in urine, J. Anal. Toxicol. 23, 460, 1999. 92. Tsai, J.S.C., Deng, D., Diebold, E., Smith, A., Wentzel, C., and Franzke, S., The latest development in biosensor immunoassay technology for drug assays, LABOLife, 4/02, 17, 2002. 93. Weiss, A., Concurrent Engineering for Lateral-Flow Diagnostics, IVD Technol. 5, 48, 1999. 94. Klimov, A.D., Tsai, S.-C.J., Towt, J., and Salamone, S.J., Improved immuno-chromatographic format for competitive-type assays. Clin. Chem. 41, 1360, 1995. 95. Yang, J.M. and Lewandrowski, K.B., Urine drugs of abuse testing at the point-of-care: clinical interpretation and programmatic considerations with specific reference to the Syva Rapid Test (SRT), Clin. Chim. Acta 307, 27, 2001. 96. Phillips, J.E., Bogema, S., Fu, P., Furmaga, W., Wu, A.H., Zic, V., and Hammett-Stabler, C., Signify ER Drug Screen Test evaluation: comparison to Triage Drug of Abuse Panel plus tricyclic antidepressants, Clin. Chim. Acta 328, 31, 2003. 97. Ferrara, S.D., Tedeschi, L., Frison, G., Brusini, G., Castagna, F., Bernardelli, B., and Soregaroli, D., Drugs-of-abuse testing in urine: statistical approach and experimental comparison of immunochemical and chromatographic techniques, J. Anal. Toxicol. 18, 278, 1994. 98. George, S. and Braithwaite, R.A., A preliminary evaluation of five rapid detection kits for on site drugs of abuse screening, Addiction 90, 227, 1995. 99. Peace, M.R., Tarnai, L.D., and Poklis, A., Performance evaluation of four on-site drug-testing devices for detection of drugs of abuse in urine, J. Anal. Toxicol. 24, 589, 2000. 100. Gronholm, M. and Lillsunde, P., A comparison between on-site immunoassay drug-testing devices and laboratory results, Forensic Sci. Int. 121, 37, 2001. 101. Leino, A., Saarimies, J., Gronholm, M., and Lillsunde, P., Comparison of eight commercial on-site screening devices for drugs-of-abuse testing, Scand. J. Clin. Lab. Invest. 61, 325, 2001. 102. ROSITA Deliverable D4, Evaluation of different roadside drug tests, 2000. (www.rosita.org) 103. Taylor, E.H., Oertli, E.H., Wolfgang, J.W., and Mueller, E., Accuracy of five on-site immunoassay drugs-of-abuse testing devices, J. Anal. Toxicol. 23, 119, 1999. 104. Kadehjian, L.J. Performance of five non-instrumented urine drug-testing devices with challenging near-cutoff specimens, J. Anal. Toxicol. 25, 670, 2001. 105. Schwartz, R.H., Clark, H.W., and Meek, P.S., Laboratory tests for rapid screening of drugs of abuse in the workplace: a review, J. Addict. Dis. 12, 43, 1993. 106. George, S. and Braithwaite, R.A., Use of on-site testing for drugs of abuse, Clin. Chem. 48, 1639, 2002. 107. Hammett-Stabler, C.A., Pesce, A.J., and Cannon, D.J., Urine drug screening in the medical setting, Clin. Chim. Acta 315, 125, 2002.



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108. U.S. Food and Drug Administration, Home use test, Drugs of abuse (two-step tests), 2003. http://www.fda.gov/cdrh/oivd/homeuse-drug-2step.html. 109. U.S. Food and Drug Administration, Draft Guidance: Premarket Submissions and Labeling Recommendations for Drugs of Abuse Screening Tests, 2003. http://www.fda.gov/cdrh/oivd/guidance/152.html.



CHAPTER

12

Post-Mortem Toxicology Edited by Henrik Druid, M.D., Ph.D. Associate Professor, Department of Forensic Medicine, Karolinska Institute, Stockholm, Sweden

CONTENTS 12.1 Introduction to Post-Mortem Toxicology ...........................................................................965 12.1.1 Medicolegal Death Investigation ...........................................................................965 12.1.1.1 The Role of Police and Medical Examiner Investigators ....................965 12.1.1.2 Role of the Forensic Pathologist...........................................................967 12.1.2 Certification of Death.............................................................................................967 12.1.3 The Role of Toxicology in Death Investigation ....................................................968 12.1.3.1 Homicides..............................................................................................969 12.1.3.2 Suicides..................................................................................................969 12.1.3.3 Accidents ...............................................................................................969 12.1.3.4 Natural Deaths.......................................................................................970 12.1.3.5 Unclassified, Undetermined, or Pending ..............................................970 12.1.3.6 Pending Toxicology (Overdose)............................................................970 12.1.4 The Toxicology Examination.................................................................................971 12.1.4.1 Poisons...................................................................................................971 12.1.4.2 Comprehensive Toxicology Screening..................................................971 12.1.4.3 Case Review ..........................................................................................972 12.1.4.4 Quality Assurance .................................................................................972 12.1.4.5 The Toxicology Report .........................................................................972 12.1.4.6 Toxicological Interpretation ..................................................................973 References ...........................................................................................................................973 12.2 Specimen Selection, Collection, Preservation, and Security..............................................975 12.2.1 Chain of Custody ...................................................................................................976 12.2.2 Specimen Collection ..............................................................................................976 12.2.2.1 Specimen Containers.............................................................................976 12.2.2.2 Specimen Preservatives .........................................................................977 12.2.3 Sampling.................................................................................................................977 12.2.3.1 Blood .....................................................................................................978 12.2.3.2 Urine ......................................................................................................979 12.2.3.3 Bile ........................................................................................................979 12.2.3.4 Vitreous Humor .....................................................................................979 961


962


12.2.3.5 Gastric Contents ....................................................................................979 12.2.3.6 Hair ........................................................................................................980 12.2.3.7 Tissues ...................................................................................................980 12.2.3.8 Labeling.................................................................................................980 12.2.4 Selection of Post-Mortem Specimens....................................................................981 12.2.4.1 Blood .....................................................................................................981 12.2.4.2 Urine ......................................................................................................982 12.2.4.3 Bile ........................................................................................................982 12.2.4.4 Vitreous Humor .....................................................................................983 12.2.4.5 Gastric Contents ....................................................................................983 12.2.4.6 Tissues ...................................................................................................984 12.2.4.7 Hair ........................................................................................................984 12.2.4.8 Bone and Bone Marrow ........................................................................985 12.2.4.9 Skeletal Muscle .....................................................................................985 12.2.4.10 Larvae ....................................................................................................986 12.2.4.11 Meconium..............................................................................................986 12.2.4.12 Other Specimens ...................................................................................987 12.2.5 Nonbiological Evidence.........................................................................................987 References ...........................................................................................................................988 12.3 Common Methods in Post-Mortem Toxicology .................................................................991 12.3.1 Analytical Chemistry in Post-Mortem Toxicology ...............................................991 12.3.2 Simple Chemical Tests...........................................................................................992 12.3.2.1 Useful Color Tests.................................................................................993 12.3.2.2 Other Color Tests That May Be Included in a Screen.........................994 12.3.3 Reinsch Test for Heavy Metals..............................................................................994 12.3.4 Microdiffusion Tests ..............................................................................................994 12.3.4.1 Cyanide Test ..........................................................................................994 12.3.4.2 Carbon Monoxide..................................................................................994 12.3.5 Other Simple Tests.................................................................................................994 12.3.5.1 Glucose, Ketones, Protein, and pH via a Diagnostic Reagent Strip (Dip-Stick)....................................................................................994 12.3.5.2 Odor, Color, and pH of Gastric Contents.............................................995 12.3.6 Immunoassays ........................................................................................................995 12.3.6.1 Enzyme Immunoassay...........................................................................996 12.3.6.2 Fluoresence Polarization Immunoassay................................................997 12.3.6.3 Radioimmunoassay................................................................................997 12.3.6.4 Kinetic Interaction of Microparticles in Solution ................................997 12.3.6.5 Useful Immunoassays for Post-Mortem Toxicology Screening ...............................................................................................997 12.3.7 Chromatography.....................................................................................................999 12.3.7.1 Thin-Layer Chromatography.................................................................999 12.3.7.2 Gas Chromatography...........................................................................1000 12.3.7.3 Gas Chromatography/Mass Spectrometry ..........................................1002 12.3.7.4 High-Performance Liquid Chromatography .......................................1003 12.3.8 Ultraviolet-Visible Spectrophotometry ................................................................1004 12.3.9 Spectroscopic Methods for Analysis of Toxic Metals and Metaloids ................1005 12.3.10 Sample Preparation ..............................................................................................1005 12.3.10.1 Extraction Methods .............................................................................1005 12.3.10.2 Hydrolysis to Release Drugs in Sample Pretreatment .......................1008 12.3.10.3 Applications.........................................................................................1008 References .........................................................................................................................1008


POST-MORTEM TOXICOLOGY

963

12.4 Strategies for Post-Mortem Toxicology Investigation ......................................................1026 12.4.1 Screening Strategy ...............................................................................................1026 12.4.2 General Concepts .................................................................................................1026 12.4.3 Basic Strategies ....................................................................................................1027 12.4.3.1 Amphetamines.....................................................................................1027 12.4.3.2 Barbiturates..........................................................................................1028 12.4.3.3 Benzodiazepines ..................................................................................1029 12.4.3.4 Cocaine ................................................................................................1029 12.4.3.5 Opiates.................................................................................................1029 12.4.3.6 Phencyclidine.......................................................................................1029 12.4.3.7 Immunoassays for Other Illegal Drugs...............................................1029 12.4.3.8 Chromatographic Methods..................................................................1030 12.4.3.9 Gastric Contents vs. Urine ..................................................................1030 12.4.3.10 Screening with Gas Chromatography .................................................1031 12.4.3.11 Screening with Liquid Chromatography ............................................1032 12.4.4 The General Unknown.........................................................................................1032 12.4.5 Confirmation.........................................................................................................1033 12.4.5.1 What Confirmation Is Necessary, and Why .......................................1033 12.4.5.2 When Is Confirmation Necessary? .....................................................1036 12.4.5.3 When Is Confirmation Unnecessary? .................................................1036 12.4.6 Gas Chromatography-Mass Spectrometry...........................................................1036 12.4.6.1 Qualitative GC/MS-SIM Determination Criteria................................1037 12.4.6.2 Potential Problems with GC/MS Analyses.........................................1038 12.4.7 Liquid Chromatography-Mass Spectrometry ......................................................1038 12.4.8 Method Validation ................................................................................................1039 12.4.9 Quantification of Drugs and Poisons...................................................................1039 12.4.9.1 What Should Be Quantified? ..............................................................1039 12.4.9.2 Specimens for Quantification of Drugs and Poisons .........................1040 12.4.9.3 Quantification: Procedural Issues........................................................1041 12.4.10 The Review Process .............................................................................................1042 12.4.11 Pending Toxicology Conference..........................................................................1042 References .........................................................................................................................1042 12.5 Quality Assurance in Post-Mortem Toxicology ...............................................................1052 12.5.1 Introduction ..........................................................................................................1052 12.5.2 Standard Operating Procedures ...........................................................................1053 12.5.3 Personnel ..............................................................................................................1053 12.5.3.1 Continuing Education..........................................................................1053 12.5.4 Measuring Devices...............................................................................................1054 12.5.5 Reagents ...............................................................................................................1054 12.5.6 Reference Materials .............................................................................................1054 12.5.6.1 Calibrators ...........................................................................................1055 12.5.6.2 Internal Standards................................................................................1057 12.5.6.3 Controls ...............................................................................................1058 12.5.7 Samples and Sampling.........................................................................................1060 12.5.8 Analytical Methods and Procedures ....................................................................1061 12.5.8.1 Quality of an Analytical Procedure ....................................................1061 12.5.8.2 Qualitative Methods ............................................................................1062 12.5.8.3 Quantitative Methods ..........................................................................1063 12.5.8.4 Method Development and Validation..................................................1063 12.5.9 Instruments ...........................................................................................................1064 12.5.9.1 Installation ...........................................................................................1064


964


12.5.9.2 Preventive Maintenance ......................................................................1064 12.5.9.3 Pre-Analysis Checklist ........................................................................1064 12.5.10 Data ......................................................................................................................1065 12.5.10.1 Chain-of-Custody Data .......................................................................1065 12.5.10.2 Analytical Data....................................................................................1065 12.5.10.3 Quality Control Data...........................................................................1065 12.5.11 Reports .................................................................................................................1066 12.5.12 Proficiency Programs ...........................................................................................1066 12.5.13 Accreditation Programs........................................................................................1067 References .........................................................................................................................1067 12.6 Interpretation of Post-Mortem Drug Levels .....................................................................1069 12.6.1 Introduction ..........................................................................................................1069 12.6.2 General Considerations ........................................................................................1070 12.6.2.1 The Analytical Result..........................................................................1070 12.6.2.2 Post-Mortem Specimens .....................................................................1070 12.6.3 Pharmacokinetics .................................................................................................1076 12.6.3.1 Absorption and Distribution................................................................1076 12.6.3.2 Metabolism and Pharmacogenetics.....................................................1077 12.6.3.3 Calculation of Total Body Burden......................................................1077 12.6.3.4 Estimation of Amount Ingested from Blood Levels ..........................1078 12.6.4 Post-Mortem Redistribution and Other Changes ................................................1078 12.6.4.1 Incomplete Distribution.......................................................................1078 12.6.4.2 Post-Mortem Redistribution and Post-Mortem Diffusion ..................1079 12.6.5 Other Considerations............................................................................................1080 12.6.5.1 Trauma.................................................................................................1080 12.6.5.2 Artifacts of Medication Delivery ........................................................1081 12.6.5.3 Additive and Synergistic Toxicity.......................................................1081 12.6.5.4 Adverse Reactions...............................................................................1082 12.6.5.5 Drug Instability ...................................................................................1082 12.6.5.6 Interpretation Using Tables of Values.................................................1082 12.6.6 Conclusion............................................................................................................1083 References .........................................................................................................................1083

Due to the continuous increase in availability and use of pharmaceuticals and illicit drugs, postmortem toxicology has become more and more important in death investigations. The introduction of new substances on the market requires a high awareness among pathologists and toxicologists and necessitates the development of methods that encompasses the newcomers. Fortunately, many important achievements have been made in methodology, and the application of novel techniques, such as modifications of solid phase extraction and LC/MS techniques, now offers better conditions for efficient and sensitive analyses of numerous substances. Many important contributions regarding the impact of various post-mortem changes that may influence the toxicological results have been published. Pharmacogenetic analyses, e.g., to identify poor metablizers, may now be applied on post-mortem material and assist in the determination of the manner of death, and studies on post-mortem redistribution of drugs have resulted in a widespread appreciation of the influence of the specimen type on the drug concentrations. In recent years, the specific detection of many compounds and their metabolites in various matrices has improved substantially. However, the interpretation of their concentrations remains a difficult task. Hence, despite the progress in post-mortem toxicology, information about previous drug use and the circumstances surrounding death, and the autopsy findings are still very important



965

in order to arrive at correct conclusions when interpreting the analytical results. An intimate collaboration between toxicologists and pathologists is therefore desirable.

12.1 INTRODUCTION TO POST-MORTEM TOXICOLOGY

W. Lee Hearn, Ph.D.1 and H. Chip Walls, B.S.2 1

2

Director, Dade County Medical Examiner Toxicology Laboratory, Miami, Florida Department of Pathology, Forensic Toxicology Laboratory, University of Miami, Miami, Florida

12.1.1 Medicolegal Death Investigation The medical examiner’s office investigates sudden, violent, unnatural, or unexpected deaths,1–3 and the medical examiner, coroner, or pathologist is responsible for determining the cause and manner of death. The cause of death is the injury, intoxication, or disease that initiates a process leading to death, and if that initial event had not occurred, the individual would not have died. Death may follow years after the causal event. The manner of death is the circumstances in which the cause of death occurred. Five classifications are used to categorize the manner of death: homicide, suicide, accident, natural, and undetermined. Anatomic findings elicited at autopsy are often insufficient to determine the manner of death. To determine the manner of death, all available information pertaining to a particular case, including the terminal events, scene investigation, police reports, social and medical history, autopsy findings, and results of histologic and toxicologic testing, must be considered. The question “Did alcohol, other drugs, or poisons cause or contribute to this person’s death?” must always be answered. Success in arriving at the correct conclusion depends on the combined efforts of the pathologist, the investigators, and the toxicologist. The process of death investigation and the role of the laboratory are outlined in Figure 12.1.1. 12.1.1.1

The Role of Police and Medical Examiner Investigators

When a death is reported to the medical examiner’s office, a case investigator will obtain certain information to determine whether the case falls under the jurisdiction of the medical examiner. The following is a list of important topics to consider, which may vary according to jurisdiction: Cases Requiring Medicolegal Death Investigation 1. Any death where any form of violence, whether criminal, suicidal, or accidental, was directly responsible or contributory. 2. Any death caused by an unlawful act or criminal neglect. 3. Any death occurring in a suspicious, unusual, or unexplained fashion. 4. Any death where there is no attending physician. 5. Any death of a person confined to a public institution. 6. The death of any prisoner even though both the cause and manner appear to be natural. 7. Any death caused by or contributed to by drugs or other chemical poisoning or overdose. 8. Any sudden death of a person in apparent good health. 9. Any death occurring during diagnostic or therapeutic procedures. 10. Any fetal stillbirth in the absence of a physician. 11. Any death where there is insufficient medical information to explain the individual’s demise.


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Scene Observations

Terminal Events

Medical/Social History

Police Report

Autopsy vs. External Exam

External Exam Only

Autopsy - Gross external/internal exam - Diagrams/photographs - Microscopic studies - Toxicology specimens - Selection - Collection - Preservation - Other physical evidence

- Gross external exam - Diagrams/photographs - Toxicology specimens (limited) - Other physical evidence

Investigative Correlation YES

NO COD/MOD pending

COD & MOD Toxicology Assays

+/– Findings

Positive Findings

Further Investigation - Additional testing - Police reports - Consults

Possible COD Case Evaluation/Interpretation anatomy, toxicology, histopathology, investigation Final Report COD & MOD Sign Death Certificate Figure 12.1.1 Overview of death investigation.

An unnatural death is any death that is not a direct result of a natural, medically recognized disease process. Any death where an outside, intervening influence, either directly or indirectly, is contributory to the individual’s demise, or accelerates and exacerbates an underlying disease process to such a degree as to cause death, would also fall into the category of unnatural death. Investigators are the eyes and ears of the medical examiner, especially in cases where the body is removed prior to the pathologist’s involvement. The importance of an adequate investigation into past social and medical history cannot be overemphasized. Police reports and investigations provide scene documentation. Typically, a report will include a description and identification of the body, time and place of death, eyewitness accounts, drugs present, and photographs. Investigators assigned by the medical examiner collect all items and information pertaining to establishing the cause and manner of death. Investigators contact the



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family and friends of the deceased for information regarding, for example, past medical and social history and prescribed medications. Many cases have histories of prescription drugs to guide the investigation. All medication bottles should be verified as to content and count, in addition to performing a routine pharmacy check of the person’s medication usage. Medical examiner investigators must also contact hospitals and treating physicians to obtain copies of medical records and police agencies to obtain arrest records. Progressively, a file is assembled that contains all of the relevant background information to assist the pathologist in understanding the medical and social history of the deceased. The medicolegal systems in countries outside the U.S. vary, but the selection of cases subjected to a forensic pathology examination is usually similar. However, in several countries the police are responsible for the investigation even in noncriminal cases. It is therefore important that the pathologists and toxicologists stay in good contact with the investigating police officer to obtain all relevant information outlined above. 12.1.1.2

Role of the Forensic Pathologist

The principal role of the forensic pathologist is to investigate sudden, unexpected, and violent deaths in order to determine the cause and manner of death. In suspected drug-related deaths or poisonings, the pathologist must both exclude traumatic or pathological mechanisms as possible causes of death and select and preserve appropriate specimens for toxicologic analysis. After autopsy, cases can often be divided into two categories: those with an anatomical cause of death and those without. Few drugs leave telltale signs so obvious that the pathologist can determine a manner and cause of death without additional testing. Obvious exceptions include liver necrosis caused by acetaminophen, or the severely hemorrhagic gastric mucosa and smell from cyanide exposure, or coronary artery disease and cardiac enlargement in a cocaine user. Negative findings require toxicological analyses. Approximately 10% of the cases submitted for toxicology do not have any guiding features. However, many of the thousands of potential compounds that could have caused death will have already been eliminated after history and autopsy results are correlated. Since the majority of drugs and poisons do not produce characteristic pathological lesions, their presence in the body can be demonstrated only by chemical methods. Collection and preservation of appropriate specimens is a critical component of the autopsy examination.4–9 Just what is collected depends, at least partly, on the policy and finances of the department. The utility of these specimens depends not only on the condition of the body, but also on the pathologist’s technique. Specimens must be large enough, the correct preservative must be used, and they must be placed in appropriate, clearly and correctly labeled containers. Specimen collection is the first link in the chain of custody. Sample integrity within the chain of custody is an essential requirement for the rest of the forensic investigation. In cases where autopsy fails to determine a cause of death, or where there is an incomplete investigation, it is imperative to collect an adequate variety of specimens. Subsequent findings may modify or narrow the field of search, and make it unnecessary to examine each specimen, but they can always be discarded. However, many toxins are completely lost in the embalming process, so if the appropriate specimens are not collected at the time of the initial post-mortem examination, the cause of death may never be determined. 12.1.2 Certification of Death Each state requires a medical and legal document known as the Death Certificate be filed with the Bureau of Vital Statistics. The certificate contains demographic information as well the cause


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and manner of death as determined by the medical examiner. Five different classifications are recognized: (1) homicide, (2) suicide, (3) accident, (4) natural, and (5) undetermined. The results from toxicological analyses of post-mortem specimens are applied to determine whether drugs or toxins are a cause of death, or whether they may have been a contributing factor in the death. Negative toxicological results may be equally important as positive results, and sometimes even more meaningful as in the case of antiseizure medicines not detected in a suspected seizure death as compared to a positive marijuana test in the urine of a shooting victim. 12.1.3 The Role of Toxicology in Death Investigation Most toxicology offices have established routines for specific types of cases, and the pathologist often provides some indication of what toxicological testing should be performed on each case (Figure 12.1.2). It would appear that cases of suspected homicide require much more thorough testing than obvious cases of accidental or natural death, but that is not really the case. Alcohol and other sedative hypnotic drugs, for example, are often detected in fire victims and may well have contributed to the cause of death.

Is the involvement of toxic substance(s)∗ a possible factor in death?

YES Is the likely toxic agent known?

YES Proceed with specific methods for the agent

YES Proceed with analysis for most likely agents.

NO Why was analysis requested?

NO Are history and circumstances leading to death known?

NO Proceed with comprehensive analysis (general unknown).

∗Forensic Questions Relative to Poisoning: 1. Was the death or illness due to a poison? 2. What toxin produced the illness? 3. Was the substance employed capable of producing death? 4. Was a sufficient quantity taken to produce death or toxic results? 5. When and how was the toxin taken? 6. Could a poisoning have occurred and the poison either be or have become undetectable? 7. Could the detected poison have an origin other than in poisoning? 8. Was the poisoning SUICIDAL, ACCIDENTAL, OR HOMICIDAL? 9. Were the correct specimens collected and preserved, analyzed in such a manner to answer the question at hand? Figure 12.1.2 Identification of a toxicology issue in the death investigation.



12.1.3.1

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Homicides

The relationship between intoxication and violence is well recognized.10–12 Toxicological studies in cases of traumatic homicide should include tests for alcohol, prescribed medications, and other drugs. Negative findings can be used in court to rebut assertions of self-defense against a “drugcrazed” attacker. Positive findings may help explain how the victim became involved in a physical altercation. In addition, results of drug screening provide information about the deceased’s lifestyle that may prove useful to police as they search for the murderer. Toxicological investigations may also reveal evidence that a victim was drugged to incapacitation and then murdered. 12.1.3.2

Suicides

In cases of suicide, investigators try to discover an explanation for the act.13–15 People may be driven to suicide by failing health, financial problems, loss of a loved one, severe mental depression, or other causes. Drugs that can potentiate or exacerbate depression are commonly detected in suicides. A well-recognized drawback with antidepressants is that they neutralize passivity and inhibition before they affect the mood, and thereby confer an increased risk for suicide during the first weeks of treatment.16,17 Drugs commonly found in suicide victims include alcohol, sedatives (particularly benzodiazepines), analgesics, and hypnotics, and sometimes even illicit drugs. Therefore, toxicological investigations should encompass a large number of intoxicants. Occasionally, a suicide victim employs multiple means to reduce the chances of survival, implying that intake of drugs should not be overlooked even if another suicidal method is apparent. 12.1.3.3

Accidents

For fatal accidents, highway crashes immediately come to mind; however, accidental deaths occur in many other circumstances.9,11,18–22 Drownings, falls, fires, electrocutions, boating accidents, and aircraft crashes, as well as accidental drug overdoses, are included in this classification. Accidents often result from carelessness or the impairment of mental or motor function on the part of the victim or another person. In apparent cases of accidental death, it is important to confirm or rule out alcohol- or other drug-induced impairment. Many insurance policies exclude death or injury resulting from the misuse of intoxicating substances, although in some cases quite the opposite is true. In those jurisdictions where drug deaths are considered accidents, double indemnity clauses may come into play. The families of victims dying from cocaine toxicity could, in some instances, be entitled to twice the face value of the decedent’s life insurance. Parties injured in an accident may litigate to recover damages. The sobriety or intoxication of the deceased can be a factor in efforts to assign blame. And, of course, apparent accidental deaths may actually turn out to be suicides, or they may be natural deaths occurring in circumstances that suggest an accident. When a driver becomes incapacitated by a heart attack, for example, and loss of control results in an accident, toxicological studies may play a part in the investigation. Detection of intoxicants, together with other evidence, may indicate that an apparent accident was actually intentional. For example, finding large quantities of a drug in a deceased person’s stomach suggests that an overdose was intentional (i.e., suicide) rather than accidental. If post-mortem investigation fails to detect carbon monoxide in the blood of a burn victim, or soot in the airway, it may be that the victim had already died when the fire started. Such cases may be deaths from natural causes, or attempts to destroy evidence of a murder. Further investigation may discover evidence of illness or trauma. Workplace accidents must always be investigated for the possible involvement of alcohol or other drugs, since there are likely to be insurance claims against the employer. If the victim is shown to have intoxicants in the body, the employer may be held blameless. Another aspect of workplace-related accidents concerns exposure to toxic chemicals. The potential for such exposures varies with the nature of the business. If exposure to a toxic


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chemical is alleged or suspected, investigators should obtain a list of chemicals in the workplace, and the toxicology laboratory of the medical examiner should analyze for those chemicals whose toxicity is consistent with the circumstances of death. 12.1.3.4

Natural Deaths

Apparent natural deaths may or may not require toxicological study. If the autopsy clearly reveals the cause of death, and no history of drug or alcohol misuse is known, the pathologist may decide that further toxicological study is not necessary.23,25 Sometimes studies are ordered to evaluate compliance with required pharmacotherapy, such as measurement of anticonvulsant drug levels in an person with epilepsy who has a seizure and then dies. When the apparent cause of death may be related to drug or alcohol misuse, testing should be done to determine whether or not relevant drugs are present. For example, acute myocardial infarctions, cerebral hemorrhages, ruptured berry aneurysms, and dissecting aortic aneurysms are often associated with recent cocaine use. Such cases should be tested for cocaine and other drugs, particularly when this occurs in young people or when there is a history of drug use. A diagnosis of alcoholism should call for a blood alcohol analysis. The diagnosis of sudden infant death syndrome (SIDS) is a diagnosis of exclusion. All apparent SIDS cases should be tested for alcohol and other drugs. Child abuse can include drugging a restless infant, where even a small dose of drug may be fatal. When there is any uncertainty regarding the cause of death, testing should be done to rule out an overdose. Terminally ill people sometimes commit suicide, and hospice patients are occasionally poisoned by their caregivers. When samples for apparent natural deaths are submitted to the toxicology laboratory for testing, unrecognized poisoning cases are sometimes discovered. 12.1.3.5

Unclassified, Undetermined, or Pending

When the cause or manner of death remains elusive at the completion of investigations and autopsy, the case is left unclassified, pending further studies.4,23 Additional inquiries, microscopic examinations, and toxicological studies are initiated to find sufficient evidence for a diagnosis. The primary goal for the toxicology laboratory is to determine whether or not toxic substances are present in the deceased in sufficient quantities to kill. If a probable toxic cause of death is identified, the laboratory gathers additional evidence to assist the pathologist in deciding how it was administered, and estimating how much was used, and how long before death. The results of toxicology testing are considered along with other evidence to formulate an opinion regarding the manner of death. 12.1.3.6

Pending Toxicology (Overdose)

Death by poisoning or overdose may be accidental, suicidal, or homicidal.15,20,23,25–27 Various clues indicating poisoning may be observed during the autopsy. In some cases, a large amount of partially degraded medicinal tablets is found in the stomach, esophagus, mouth, and nostrils, or a typical strong smell of alcohol is noticed. However, other unusual odors or abnormal colors of stomach contents, urine, or tissues, and specific lesions may suggest to the experienced forensic pathologist that a drug or poison was the cause of death. Evidence from the death scene, such as a suicide note or empty containers, may point to a poisoning or drug overdose in some cases. However, most drug-related deaths do not leave such telltale markers as those found in heart attacks, cancer, or trauma. Often the only clue from the autopsy is pulmonary congestion and edema. The pathologist calls upon the toxicology laboratory to confirm the suspicion by identifying the poison or poisons and gathering enough quantitative data to support a conclusion that the detected poison was sufficient to cause death.



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In addition, the laboratory may sometimes be able to shed light on the issues of how much was taken and the route of administration. The assignment of manner of death is based on the totality of the evidence, including the pharmacology and toxicology of the substance, the route of administration and quantity taken, the social and medical history of the deceased, and evidence collected from the death scene.7,20,28,29 Drug-related death certification is by a process of compilation and evaluation of all findings during the death investigation, where elimination of a number of other possible causes of death (COD) is as important as the detection of a toxic substance in sufficient concentrations to have caused or contributed to the death.28 12.1.4 The Toxicology Examination The toxicologic investigation typically begins with the preliminary identification of drugs or chemicals present in post-mortem specimens.30–39 Confirmatory testing is then performed to conclusively identify the substance(s) present in the post-mortem specimens. In a forensic laboratory, positive identification must be established by at least two independent analyses, each based on a different analytic principle. The next step in the process is to determine the quantity of substance in the appropriate specimens. Identifying drugs in waste fluids, such as bile and urine, is a useful undertaking, but quantifying drugs in these fluids usually has limited interpretive value. Drug quantification in peripheral blood, along with quantification in samples from liver, gastric contents, or other specimens, as dictated by the case, provides more meaningful interpretive information. Therapeutic and toxic ranges have been established for many compounds,28 but it should be recognized that “therapeutic” concentrations rarely can be determined in the post-mortem setting.40 All cases cannot be tested for all drugs. A number of factors, some not immediately obvious, determine what kind, and how many, tests will be done. The importance of the medicolegal classification of death and specimen collection has already been mentioned. But other factors, such as geographic patterns of drug use and laboratory capabilities, must also be considered. Occasionally, mere detection of a drug is sufficient. But, in the case of some prescription medications, the actual amount present must be quantified. A request for “therapeutic” drug analysis may be made even if the autopsy has already determined the cause of death. If a history of seizure is obtained, the pathologist may request an antiepileptic drug screen to determine whether or not the person was taking any such medication. The same holds true for, e.g., theophylline in individuals with asthma. An individual who has committed suicide may have been prescribed therapeutic drugs for depression or other mental illness. A test for these drugs may indicate the degree of patient compliance. In forensic toxicology, a negative laboratory result carries the same weight as a positive result. 12.1.4.1

Poisons

Often the nature of a suspected toxin is unknown. This type of case is termed a “general unknown.”41,42 In cases of this nature, a full analysis of all available specimens by as many techniques as possible may be required to reach a conclusion. The most common approach involves first testing for volatile agents, and then performing drug screens. The drug screen is usually confined to those drugs that are commonly seen in the casework. When the most common substances have been ruled out, the laboratory proceeds to test for more exotic drugs and poisons. 12.1.4.2

Comprehensive Toxicology Screening

It is impossible to consider the topic of forensic toxicology without discussing analytical toxicology in detail.43–46 Screening methods should provide presumptive identification, or at least class identification while also giving an indication of concentration. An adequate screening protocol, capable of detecting or eliminating the majority of the commonly encountered toxins, usually


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requires a combination of three or more chemically unrelated techniques. In general, some toxins are so common that, no matter the type of case, they should always be included for analysis; e.g., ethanol, salicylate, acetaminophen, sedatives, hypnotics, and other drugs such as cocaine, opiates, and antidepressants. All screening tests that are positive for substances relevant to the case must then be confirmed, and analytes of significance submitted for quantification in several tissues. Later sections in this chapter discuss testing methods and how they are combined to yield effective analytical strategies. 12.1.4.3

Case Review

During the toxicological investigation, each case is subjected to periodic review, its status evaluated, and the need for additional testing determined. Based on what is known about the death and the specimens available, a panel of screening tests is designed to quickly detect or rule out the most common drugs and, when appropriate, poisons.33,37,38,43,47 New tests may be ordered to expand the initial search, or to confirm preliminary findings. The flow of information in forensic toxicology must be in two directions48 — from pathologist to laboratory, then back to the physician who will integrate all of the findings. Laboratory personnel must effectively communicate with the pathologist concerning the scope (and limitations) of the services they can provide, suggest the proper selection of specimens, and assist with interpretation of the results. In particular, when drug screens are used, the pathologist should know which drugs they cover — and which drugs will go undetected. To operate effectively, the toxicologist must be provided with enough information about the history and autopsy findings to rationally select the most appropriate tests. 12.1.4.4

Quality Assurance

Each laboratory must formulate and adhere to a quality assurance (QA) program. QA provides safeguards to ensure that the toxicology report contains results that are accurate and reproducible, and that the chain of custody has been preserved. A written QA plan sets out the procedures employed to ensure reliability, and provides the means to document that those procedures were correctly followed. The laboratory’s strict adherence to a proper QA program induces confidence in the laboratory’s work product and prevents or overcomes potential legal challenges. Before a new or improved method is introduced into a laboratory, it must be selected with care and its performance must be rigorously and impartially evaluated under laboratory conditions. 12.1.4.5

The Toxicology Report

When all toxicological testing is completed, the results are summarized in a report that is sent to the pathologist. This report becomes a part of the autopsy report. It specifies the name of the deceased, if known, and the medical examiner case number. The specimens tested, the substances detected in each specimen, and the measured concentrations of those substances are presented in tabular form. The report should also list substances tested for, but not found, especially if they were named in the toxicology request. If any drug was detected, but not confirmed, a note to that effect should be on the report. In addition, any information about the specimens, such as the date and time of collection of ante-mortem blood or any unusual condition of a specimen, should also be noted on the report. Because of the well-known difficulties associated with the post-mortem redistribution of many drugs, the report should always indicate where in the body the blood specimen was obtained. Toxicology reports are usually signed or initialed by the issuing toxicologist, and in some jurisdictions may be signed by the pathologist as well.



12.1.4.6

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Toxicological Interpretation

All substances are poisons; there is none which is not a poison. The right dose differentiates a poison and a remedy. Paracelsus (1493–1541) Poisons and medicines are oftentimes the same substance given with different intents. Peter Mere Latham (1789–1875)

The significance of the reported results must be explained, often to a jury.5,28,43,48–51 The pharmacology, toxicology, local patterns of drug abuse, and post-mortem changes all can affect toxicological results. In any given case, a toxicologist may be asked the following questions (even though a definitive answer may not be possible in all instances): 1. 2. 3. 4. 5. 6. 7. 8.

What was taken, when and how? Was the drug or combination of drugs sufficient to kill or to affect behavior? What are its effects on behavior? Does the evidence indicate if a substance was taken for therapeutic purposes, as a manifestation of drug misuse, for suicidal purposes or was it administered homicidally? Was the deceased intoxicated at the time of the incident that caused death? How would intoxication by the particular drug manifest? Is there any alternative explanation for the findings? What additional tests might shed light on the questions?

REFERENCES 1. Mason, J.K., Forensic medicine [review]. Injury 21: 325–327, 1990. 2. Prahlow, J.A. and Lantz, P.E., Medical examiner/death investigator training requirements in state medical examiner systems. J. Forensic Sci. 40: 55–58, 1995. 3. Gross, E.M., The Model Postmortem Examinations Act in the State of Connecticut, 1969–1974. Legal Med. Annu. 51–66, 1975. 4. Norton, L.E., Garriott, J.C., and DiMaio, V.J., Drug detection at autopsy: a prospective study of 247 cases. J. Forensic Sci., 27: 66–71, 1982. 5. Margot, P.A., Finkle, B.S., and Peat, M.A., Analysis and problems of interpretation of digoxin in postmortem blood and tissues. Proc. West. Pharmacol. Soc. 26: 393–396, 1983. 6. Patel, F., Ancillary autopsy — forensic histopathology and toxicology. Med. Sci. Law 35: 25–30, 1995. 7. Prouty, R.W. and Anderson, W.H., The forensic science implications of site and temporal influences on postmortem blood-drug concentrations. J. Forensic Sci. 35: 243–270, 1990. 8. McCurdy, W.C., Postmortem specimen collection. Forensic Sci. Int. 35: 61–65, 1987. 9. Nagata, T., Significance of toxicological examination in the practice of forensic medicine [Japanese]. Fukuoka Igaku Zasshi Fukuoka Acta Medica 77: 173–177, 1986. 10. Garriott, J.C., Drug use among homicide victims. Am. J. Forensic Med. Pathol. 14: 234–237, 1993. 11. Ladewig, D. Drugs and violence [German]. Ther. Umschau 50: 194–198, 1993. 12. Poklis, A., Graham, M., Maginn, D., Branch, C.A., and Gantner, G.E., Phencyclidine and violent deaths in St. Louis, Missouri: a survey of medical examiners’ cases from 1977 through 1986. Am. J. Drug Alcohol Abuse 16: 265–274, 1990. 13. Derby, L.E., Jick, H., and Dean, A.D., Antidepressant drugs and suicide. J. Clin. Psychopharmacol. 12: 235–240, 1992. 14. Nielsen, A.S., Stenager, E., and Brahe, U.B., Attempted suicide, suicidal intent, and alcohol. Crisis 14: 32–38, 1993.


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15. Marzuk, P.M., Tardiff, K., and Leon, A.C., Final exit and suicide assessment in a forensic setting — reply. Am. J. Psychiatry 152: 1833, 1995. 16. Stahl, S.M., Nierenberg, A.A., and Gorman, J.M., Evidence of early onset of antidepressant effect in randomized controlled trials. J. Clin. Psychiatry 62(Suppl. 4): 17–23, discussion 37, 2001. 17. Licinio, J. and Wong, M.L., Depression, antidepressants and suicidality: a critical appraisal. Nat. Rev. Drug Discov. 4: 165–171, 2005. 18. Alleyne, B.C., Stuart, P., and Copes, R., Alcohol and other drug use in occupational fatalities. J. Occup. Med. 33: 496–500, 1991. 19. Caplan, Y.H., Ottinger, W.E., Park, J., and Smith, T.D., Drug and chemical related deaths: incidence in the state of Maryland — 1975 to 1980. J. Forensic Sci. 30: 1012–1021, 1985. 20. Hammersley, R., Cassidy, M.T., and Oliver, J., Drugs associated with drug-related deaths in Edinburgh and Glasgow, November 1990 to October 1992. Addiction 90: 959–965, 1995. 21. Marx, J., Alcohol and trauma. Emerg. Med. Clin. North Am. 8: 929–938, 1990. 22. Lewis, R.J. and Cooper, S.P., Alcohol, other drugs, and fatal work-related injuries. J. Occup. Med. 31: 23–28, 1989. 23. Mcginnis, J.M. and Foege, W.H., Actual causes of death in the United States [see comments]. J. Am. Med. Assoc. 270: 2207–2212, 1993. 24. Hanzlick, R., National Association of Medical Examiners Pediatric Toxicology (PedTox) Registry Report 3. Am. J. Forensic Med. Pathol. 16: 270–277, 1995. 25. Briglia, E.J., Davis, P.L., Katz, M., and Dal Cortivo, L.A., Attempted murder with pancuronium. J. Forensic Sci. 35: 1468–1476, 1990. 26. Bogan, J., Rentoul, E., Smith, H., and Weir, W.P., Homicidal poisoning by strychnine. J. Forensic Sci. Soc. 6: 166–169, 1966. 27. Moffat, A.C., Interpretation of post mortem serum levels of cardiac glycosides after suspected overdosage. Acta Pharmacol. Toxicol. 35: 386–394, 1974. 28. Stead, A.H. and Moffat, A.C., A collection of therapeutic, toxic and fatal blood drug concentrations in man. Hum. Toxicol. 2: 437–464, 1983. 29. Brettel, H.F. and Dobbertin, T., Multifactorial studies of 154 fatalities of psychotropic drug poisoning [German]. Beitr. Gerichtl. Med. 50: 127–130, 1992. 30. Sunshine, I., Basic toxicology. Pediatr. Clin. North Am. 17: 509–513, 1970. 31. Levine, B., Forensic toxicology [review]. Anal. Chem. 65: 272A–276A, 1993. 32. Jentzen, J.M., Forensic toxicology. An overview and an algorithmic approach. Am. J. Clin. Pathol. 92: S48–55, 1989. 33. Levine, B.S., Smith, M.L., and Froede, R.C., Postmortem forensic toxicology [review]. Clin. Lab. Med. 10: 571–589, 1990. 34. Flanagan, R.J., Widdop, B., Ramsey, J.D., and Loveland, M., Analytical toxicology [review]. Hum. Toxicol. 7: 489–502, 1988. 35. Chollet, D. and Kunstner, P., Fast systematic approach for the determination of drugs in biological fluids by fully automated high-performance liquid chromatography with on-line solid-phase extraction and automated cartridge exchange. J. Chromatogr. 577: 335–340, 1992. 36. Maurer, H.H., Systematic toxicological analysis of drugs and their metabolites by gas chromatographymass spectrometry. J. Chromatogr. 580: 3–41, 1992. 37. Nagata, T., Fukui, Y., Kojima, T., Yamada, T., Suzuki, O., Takahama, K. et al., Trace analysis for drugs and poisons in human tissues [Japanese]. Nippon Hoigaku Zasshi Jpn. J. Legal Med. 46: 212–224, 1992. 38. Stewart, C.P. and Stollman, A., The toxicologist and his work, in Toxicology: Mechanisms and Analytical Methods, Stewart, C.P. and Stollman, A., Eds., Academic Press, New York, 1960, chap. 1. 39. Puopolo, P.R., Volpicelli, S.A., Johnson, D.M., and Flood, J.G., Emergency toxicology testing (detection, confirmation, and quantification) of basic drugs in serum by liquid chromatography with photodiode array detection. Clin. Chem. 37: 2124–2130, 1991. 40. Druid, H. and Holmgren, P., Compilations of therapeutic, toxic, and fatal concentrations of drugs, J. Toxicol. Clin. Toxicol. 36:133–134, 1998. 41. Wu Chen, N.B., Schaffer, M.I., Lin, R.L., Kurland, M.L, Donoghue, E.R., Jr., and Stein, R.J., The general toxicology unknown. I. The systematic approach. J. Forensic Sci. 28: 391–397, 1983.



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42. Wu Chen, N.B., Schaffer, M.I., Lin, R.L., Kurland, M.L., Donoghue, E.R., Jr., and Stein, R.J., The general toxicology unknown. II. A case report: doxylamine and pyrilamine intoxication. J. Forensic Sci. 28: 398–403, 1983. 43. Osselton, M.D., Analytical forensic toxicology [review]. Arch. Toxicol. Suppl. 15: 259–267, 1992. 44. Drummer, O.H., Kotsos, A., and Mcintyre, I.M., A class-independent drug screen in forensic toxicology using a photodiode array detector. J. Anal. Toxicol. 17: 225–229, 1993. 45. Bailey, D.N., Comprehensive toxicology screening in patients admitted to a university trauma center. J. Anal. Toxicol. 10: 147–149, 1986. 46. Chen, J.S., Chang, K.J., Charng, R.C., Lai, S.J., Binder, S.R., and Essien, H., The development of a broad-spectrum toxicology screening program in Taiwan. J. Toxicol. Clin. Toxicol. 33: 581–589, 1995. 47. De Zeeuw, R.A., Procedures and responsibilities in forensic toxicology [letter]. J. Forensic Sci. 27: 749–753, 1982. 48. Stafford, D.T., Prouty, R.W., and Anderson, W.H., Current conundrums facing forensic pathologists and toxicologists [editorial]. Am. J. Forensic Med. Pathol. 4: 103–104, 1983. 49. Lokan, R.J., James, R.A., and Dymock, R.B., Apparent post-mortem production of high levels of cyanide in blood. J. Forensic Sci. Soc. 27: 253–259, 1987. 50. Heatley, M.K. and Crane, J., The blood alcohol concentration at post-mortem in 175 fatal cases of alcohol intoxication. Med. Sci. Law 30: 101–105, 1990. 51. Schulz, M. and Schmoldt, A., A compilation of therapeutic and toxic plasma drug concentrations. Anaesthesist 43: 835–844, 1994.

12.2 SPECIMEN SELECTION, COLLECTION, PRESERVATION, AND SECURITY

Bradford R. Hepler, Ph.D. and Daniel S. Isenschmid, Ph.D. Toxicology Laboratory, Wayne County Medical Examiner’s Office, Detroit, Michigan

Specimen selection, collection, preservation, and security place unique demands on the postmortem forensic toxicologist. The quality of results expected from the post-mortem laboratory today is high and reflects the research advances and continued improvements in instrumentation and analytical methods seen since the origins of modern forensic toxicology in the early 20th century.1–3 However, it must be recognized that — even with technological advances — accurate, forensically defensible results are predicated on the quality and type of specimens provided, and the documentation of each specimen’s origin and history. As important are issues relating to security and evidence control during the collection and storage process. Finally, in considering data available from publications and databases, it is important to recognize that the quality and the “comparability” of data between institutions are only as good as the consistency of approach in specimen collection, storage, and analysis between these organizations. Many major references in forensic pathology have, each in their own manner, sought to provide information about specimen collection issues.1,4–9 More recently, the literature has focused on novel and more intriguing issues such as post-mortem release and/or redistribution of drugs from tissues into blood as mechanisms that can lead to legitimate debates about the meaning of a reported value.10–17 Thus, even an analytically “accurate value” may be subject to misinterpretation when the drug concentration in a single blood specimen is used to explain the circumstances surrounding a drug intoxication death, particularly when the drug concentrations are not excessively high or low. This and other specimen collection and documentation issues are the subjects for discussion in this chapter.


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12.2.1 Chain of Custody One major difference between forensic and clinical toxicology is that institutions performing forensic work are held legally accountable for documenting the handling of specific evidence within the organization. This means that all evidence associated with a specific case must be kept in a secure area at all times and be accounted for during its lifetime by using a record or chain of custody (COC). Documentation should include who handled the evidence, what evidence was handled, when and why the evidence was handled, and where the evidence was located at all times. This documentation is central to the demonstration that the evidence has remained intact, and not been adulterated, changed, mishandled, or misplaced in any fashion that would compromise its integrity. Evidence ties together people, places, actions, and things, which have important impact on circumstances surrounding events in which individuals are held legally accountable. In criminal actions the importance of the evidence may truly involve a “life or death” determination, while in civil litigation large sums of money or property may be at stake. The biological specimens collected during the autopsy are evidence and must be legally accounted for. Specimens must be maintained in secure, limited-access areas at all times with access restricted to only those individuals designated in the institution’s standard operating procedure. Specimen handling has been and will continue to be legally scrutinized by the courts. Properly maintained COC documentation rules out any period of time in which a specimen may be left vulnerable to adulteration or tampering. Failure to properly document the COC may compromise not only the integrity of the specimen, but also the credibility of the institution handling the specimen. Labor-intensive documentation can be tedious and a natural deterrent to the consistent maintenance of records, including the COC. The use of computers for documenting COC and other specimen transactions within the post-mortem forensic toxicology laboratory has recently been demonstrated.18–20 The ability of the computer to routinely maintain and monitor predictable and consistently occurring events make it an ideal tool for tracking of forensic events. 12.2.2 Specimen Collection 12.2.2.1

Specimen Containers

There are several unique challenges to collecting post-mortem forensic toxicology specimens compared with specimen collection in other forensic toxicology disciplines such as human performance toxicology and employment drug testing. Post-mortem specimen quality can be quite variable, making specimen collection and subsequent reproducibility in aliquoting of the specimen difficult at times. Specimen quantity, or availability, will vary considerably from one case to another, yet the laboratory must attempt to provide a comprehensive toxicological analysis for a general unknown. In the latter regard, detection limits are pressed, and trace findings may have a major bearing on issues of compliance and proper patient care in hospitalized or extended care facilities and the potential for civil litigation. The use of appropriate specimen containers and preservatives can be critical in the toxicologists’ ability to ultimately identify a substance in a given specimen. Usually, the best container to utilize when collecting and storing post-mortem biological fluids is glass.1,9,21 Glass is inert, does not contain any plasticizer contaminants, and maximizes storage space. Plasticizer contamination is further reduced with Teflon-lined caps. If drug concentrations of less than 0.010 μg/mL are expected, silation of glassware may be indicated.1 Disposable Pyrex glass culture tubes are suitable for long-term frozen storage and come in a variety of sizes. It is important that the container size chosen for each specimen will allow it to be as close to full as possible in order to minimize concerns about oxidative losses due to air trapped in the top of the container, volatile drug evaporation, and “salting-out” effects from preservatives that may be added to the tube.1 Generally, 50-mL culture tubes represent the best choice for blood and urine specimens.



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Smaller tubes (e.g., 15, 20, and 30 mL) can be used for the collection of small amounts of blood, vitreous humor, and bile specimens. Most types of plastic containers are suitable for the collection of solid tissue specimens and gastric contents. The nature of solid tissue reduces direct contact with the plastic container, and the relative amount of drug(s) present in gastric contents will minimize the influence of plasticizer interference. The principal argument that can be made against glass containers is the possibility of breakage. However, this can be minimized by using appropriate storage racks and carrying totes. Some laboratories have successfully used plastic containers by identifying a product that reduces plasticizer contribution and adsorption of drug to the container. Nalgene® containers have been recommended for collection of post-mortem biological fluids.22 While drug stability in these containers was not determined to be a problem, the evaluation of contaminants was not reported. Whether a facility chooses glass or plastic, it is important that the laboratory carefully evaluate the container before routinely collecting specimens in it. The nature and potential for contamination can be evaluated by analyzing drug-negative biological fluids stored over time in the container. In addition, the plastic must be chosen carefully to ensure that it does not crack when frozen. For example, polystyrene is subject to cracking under these conditions whereas polypropylene is not. 12.2.2.2

Specimen Preservatives

Blood specimens should be preserved by adding 2% w/v sodium fluoride to the collection container. Sodium fluoride is added to inhibit microorganism conversion of glucose to ethanol, microorganism oxidation of ethanol,23,24 post-mortem conversion of cocaine to ecgonine methyl ester by cholinesterases,25 and enzymatic loss of other esters such as 6-acetylmorphine.1,26 Esters, subject to alkaline hydrolysis, are more stable in post-mortem blood than ante-mortem blood because the pH of blood falls after death; therefore acidification of blood is not indicated. Some laboratories may choose to add an anticoagulant such as potassium oxalate, EDTA, or sodium citrate at a concentration of 5 mg/mL in addition to the fluoride preservative.21,23,24 Preservatives and anticoagulants may be added to collection containers designated for blood ahead of time. However, if only a small amount of blood is collected, the excess fluoride may affect headspace volatile assays by altering the vapor pressure of the analyte.11 Ideally, one preserved and one unpreserved blood specimen should be taken for comparison, if needed.22 Once collected, blood specimens should be stored in tightly sealed containers at low temperatures (4°C short term and –20°C long term). The low temperatures inhibit bacterial growth and generally slow reaction kinetics such as the conversion of ethanol to acetaldehyde.25 In addition, an aliquot of preserved blood, sufficient in quantity to fill the secondary container, should be removed from the primary specimen at the time of specimen accessioning and stored at -20°C in a frost-free freezer. This aliquot should be saved for the quantitative confirmation of unstable analytes such as cocaine and olanzapine and for ethanol reanalysis, if needed. Specimen preservatives are generally not required for other specimens (e.g., urine, bile, vitreous, tissues, etc.); however, to all samples subject to alcohol analysis, sodium (or potassium) fluoride should be added. As for blood, these specimens should be stored sealed at 4°C until testing is completed and then frozen at –20°C if long-term storage is required. 12.2.3 Sampling Biological fluids are collected using new or chemically clean hypodermic syringes using appropriate needle gauges and lengths for the specimen to be collected. One needle and syringe should be used per specimen taken. If syringes and needles are to be reused, then care must be taken to scrupulously clean and disinfect these devices between uses. A typical cleansing procedure should include a minimum of 30 min of soaking in a disinfectant, e.g., 10% solution of household


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Table 12.2.1

Guide to the Collection of Routine Toxicology Specimens

Specimen

Amount

When to Obtain

Blood, heart

50–100 mL

Always

Blood, peripheral

5–10 mL

Blood, clot Urine

Whole clot All

For complete toxicology testing Trauma cases Always

Bile

All

Always

Vitreous humor Gastric contents

All All

Liver Kidney Spleen Brain, fat

50 50 50 50

Always For complete toxicology testing Always Metals, ethylene glycol CO, CN Lipophilic drugs

Lung

50 g

Volatile poisons

Hair

Pen-sized bundle

Drug history, metals

g g g g

Comments Identify source; preserve with 2% sodium fluoride and potassium oxalate; reserve an aliquot without preservative, if possible Identify source; use femoral or subclavian blood if possible Submit any quantity, even if 450 ms) on the ECG. However, up to 30% of gene-positive patients may have a normal or only borderline prolonged QTC interval, making diagnosis impossible in some cases.10–14,18 Exercise testing may reveal an otherwise concealed form of LQTS.19,20 There is a weak association in the literature between SIDS (sudden infant death syndrome) and LQTS, although probably fewer than 5% of all SIDS cases are due to ion channel mutations.21,22 Other, more common causes of SIDS include placing the infant prone, co-sleeping with overlaying by adults, and inborn errors of metabolism. As with many ion channelopathies causing unexplained sudden death, autopsy findings are unremarkable. Venous blood saved in an EDTA-tube (or perhaps snap-frozen myocardial tissue) can be tested at a research laboratory for the presence of LQTS ion channel mutations. Table 13.2.1

Long QT Syndrome Genes

Disease

Chromosome Locus

Gene

Gene Product

LQT1 LQT2 LQT3 LQT4 LQT5 LQT6 LQT7

11p15.5 7q35-36 3p21-23 4q25-27 21p22.1 21p22.1 17q23

KVLQT1 HERG SCN5A ankyrin 2 minK (KCNE1) MiRP1 (KCNE2) KCNJ2

IKs, subunit IKr, subunit Na channel ankyrin-B IKs, subunit IKr, subunit IKr, subunit


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Pathophysiology The fundamental defect in LQTS is prolonged ventricular repolarization and a tendency toward the occurrence of torsades de pointes (polymorphic ventricular tachycardia) and ventricular fibrillation.4,5 The LQTS ion channel mutation leads to this abnormality in repolarization, and evidence of it can be seen on the ECG as a prolonged QT interval. Beta-blocker medications (described below) do not shorten the QT interval; they are believed to act, in part, by blocking EADs (early after-depolarizations), which initiate the ventricular arrhythmias. Genetics To date, a total of seven genes have been identified as causing long QT syndrome.23–26 The mutant ion channel that causes clinical LQTS is inherited in an autosomal dominant fashion with incomplete penetrance and was originally known as the “Romano-Ward Syndrome.” With the advent of genetic testing, it has become clear that each LQTS genetic subtype represents a unique disease, with different triggers to arrhythmias. The genes that encode the potassium channels KVLQT1 (on chromosome 11) and minK (on chromosome 21) interact to form the cardiac IKs (inward slow potassium) current; mutations in each cause LQT1 and LQT5, respectively.5,23,24 The potassium channels HERG (on chromosome 7) and MiRP1 (on chromosome 21) interact to form the IKr (inward rapid potassium) current, and defects in each cause LQT2 and LQT6, respectively.25 Mutations in the sodium cardiac channel SCN5A cause LQT3 (on chromosome 3).26 The gene responsible for LQT4 was recently identified as a mutation in the ankyrin-B protein.27 The potassium channel mutations cause a “loss of function” in the channel (or a “dominant-negative effect,” in the case of the HERG mutation), whereas defects in the sodium channel cause a “gain of function.”4,5 LQT7 is due to a defect in the α-subunit of the IKr channel (gene product KCNJ2). In the unlikely event that a mutant copy of the IKs channel is inherited from each parent (mutations in the KVLQT1 and minK genes), the child will suffer from a clinically severe form of autosomal dominant LQTS, and from autosomal recessive congenital deafness. This condition is known as the “Jervell and Lange-Nielsen syndrome” (JLNS).28,29 JLNS was first described in 1957 in a Norwegian family in which three congenitally deaf children died suddenly before the age of 10.30 It is actually quite rare, with an estimated incidence of 1.6 to 6 cases per million.29 In a somewhat more likely event, it is possible that an individual carrying a KCNH2 mutation on a mutant allele might also carry a different KCNH2 polymorphism on the nonmutant allele. Relatives who inherit the one without the other would be asymptomatic, but when both mutations are simultaneously present, reduction of Ik would be substantial and result in a clinically significant form of LQTS. This situation has actually been demonstrated to occur in humans, raising the possibility that compound mutations may be more common than had previously been suspected.31 Treatment There is no consensus on how to treat patients with LQTS.4,13,32 Most physicians would advocate an implantable defibrillator (ICD) for those patients who have survived a cardiac arrest, or possibly even in those with syncopal events.33 Dual chamber pacemakers, even with beta-blocker therapy, have been shown to be ineffective in symptomatic patients.34 It is generally recommended that beta-blocker therapy should be initiated in asymptomatic LQTS patients.11–14 The exact dose or type of beta-blocker medication to be used is unclear. In patients unable (or unwilling) to take medications, an ICD may then be recommended. Restriction from heavy physical activity is also suggested in affected patients. Data from the International LQTS Registry have shown that symptomatic LQT1 patients have a low recurrence rate after starting beta-blocker medication (19% recurrence), LQT2 patients have an intermediate rate (41% recur-


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rence), and LQT3 patients a higher rate (50%).10 Sympathectomy to modify the effect of adrenaline upon the heart has been shown to be ineffective at preventing events.34 13.2.1.2

Brugada Syndrome

The Brugada syndrome (BS) is another inherited ion channelopathy that causes unexplained sudden death, particularly in middle-aged males.35–37 It is relatively common in southeast Asia and should particularly be considered in the autopsy of subjects with this ethnicity.38 Epidemiology A Brugada syndrome consensus report published in 2002 estimated the incidence of the disease worldwide at up to 66 cases per 10,000 people.39 Although it is an autosomal dominant disease, it affects males more commonly than females, in an 8:1 male:female ratio. The reason for this gender difference is unknown. The gene is much more prevalent in Southeast Asia than in the U.S., and Brugada syndrome is thought to cause the entity known as Lai Tai (“death during sleep”) in Thailand, a relatively common cause of sudden unexplained death among young healthy men.38 Clinical Features The Brugada brothers reported eight cases of cardiac arrest in 1992, in young healthy patients with right bundle branch block patterns on ECG.40 Since then, more has been learned about BS, although much about the disease remains a mystery.41,42 It is not known why some patients with Brugada become symptomatic and others remain clinically silent. However, once BS subjects experience a symptom (syncope or aborted cardiac arrest), it becomes a very lethal disease with a high clinical penetrance.43–45 Several studies have found that the 5-year recurrence rate following a resuscitated cardiac arrest was 62%.39,41,43–45 Most arrhythmic events occur for the first time when patients are in their early 40s, but episodes have been described over a wide age range (2 to 77 years). Symptomatic patients with Brugada experience polymorphic ventricular tachycardia degenerating into ventricular fibrillation, leading to syncope or even death. The episodes occur most commonly during sleep but may also happen with exercise or at rest. The ECG in a patient with Brugada is frequently abnormal and provides the best way to diagnose BS. A right bundle branch block-type pattern is often noted in right precordial leads V1–V3 with concomitant ST segment elevation.35–37,46 In many patients with BS, the ECG abnormalities can normalize or be unmasked by pharmacologic challenge with a sodium channel blocking drug such as procainamide, flecainide, or ajmaline.47,48 Many patients with Brugada will have abnormal test results during invasive electrophysiology (EP) studies.49,50 Inducibility of malignant ventricular arrhythmias in this group of patients is not rare, and it may portend a worse clinical prognosis than for those patients who have normal EP studies.35–37,49,50 The usual cardiac tests in BS are normal including echocardiogram, cardiac magnetic resonance imaging (MRI), and biopsy. Autopsy findings of the heart in patients with BS are also unremarkable. Pathophysiology The mutation in the SCN5A gene results in either a reduced sodium channel current or failure of the sodium channel to express. The disease is caused by a defect in the α-subunit of the cardiac sodium channel gene (SCN5A).37,41,51,52 Numerous SCN5A mutations have been described that produce BS, but most lead to a “loss of function” in the cardiac sodium channel. Interestingly, LQT3 (a completely different disease) is also due to mutations in the SCN5A gene but leads to a “gain of function” in the sodium channel.51–55


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The mutant sodium channel demonstrates more abnormal function at higher temperatures. There are numerous reports in the literature of patients with BS experiencing symptoms during febrile illnesses.35–37 Recently it has been shown that the Y1102 polymorphism of the SCN5A gene is present in 13% of African Americans, and that its presence has been linked to the occurrence of lethal arrhythmias in African American families with ventricular tachycardia. The prevalence of the Y1102 polymorphism in a series of sudden deaths in this population has been established; it is present in 28% of African Americans who die of unexplained arrhythmias. Adjusted for age and sex, the relative risk of an unexplained arrhythmic death in individuals with this polymorphism was 8.4 (95% CI 2.1 to 28.6, P = 0.001) when compared with noncardiac deaths in this subgroup. The presence of the Y1102 allele appears to be a risk factor in African Americans for sudden cardiac death even in the absence of obvious morphological findings.56 Genetics BS is an ion channelopathy inherited in an autosomal dominant fashion. To date, only 20% of Brugada cases have been linked to the SCN5A gene; the precise ion channel mutations causing the remaining 80% of cases are unknown.40–42 The SCN5A gene is one of the largest ion channel genes known, with at least 28 exons identified thus far.51,52 Treatment Medications are largely ineffective at treating BS.39 Amiodarone, beta-blocker, and calcium channel blocking agents have all been tried and do not prevent sudden death in high-risk patients, although sotalol may be useful.57 The recommended treatment for symptomatic patients with BS is ICD implantation, particularly as the recurrence rate for such subjects is high. Patients who have not yet experienced an arrhythmic event but spontaneously exhibit the abnormal ECG findings are at intermediate risk for an episode and may benefit from prophylactic implantation of a defibrillator.49,50,58 13.2.1.3

Catecholaminergic Polymorphic Ventricular Tachycardia

CPMVT is a newly described inherited disorder of cardiac calcium channels. It is another arrhythmogenic disorder characterized by sudden unexplained death associated with exercise. Epidemiology The disease has thus far been described in several Finnish and Italian families.59–62 The epidemiology of this disorder has not yet been fully characterized and is so far limited to small case series. Its true incidence is likely much higher than is currently appreciated since most cases are undiagnosed. Clinical Features CPMVT was first described by Leenhardt et al. in 1995 in 21 children.63 This disorder is characterized by syncopal spells in childhood and adolescence, which are often triggered by exercise or stress (catecholamines). Cardiac arrest and sudden death also occur. The disease has a mortality of 30 to 50% by the age of 30 in affected individuals.62 Due to its autosomal dominant nature, there is often a family history of unexplained sudden death. The resting ECG of a patient with this disorder is usually unremarkable, as are cardiac imaging studies (echocardiogram, angiogram, cardiac MRI, etc.).62–65 Patients with CPMVT may experience bi-directional or polymorphic ventricular tachycardia with exercise stress testing, with emotional stress, or during infusion of adrenaline (isoproterenol).64,65 Up to 30% of such patients have been


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initially misdiagnosed as having LQTS in one study.61 Autopsy findings in subjects with CPMVT are generally normal. Pathophysiology Defective calcium channels formed as a result of the mutations in the ryanodine receptor gene RyR2 lead to abnormal conduction, which predispose the heart to ventricular tachycardia and sudden death.59–62,66 RyR2, the gene encoding the cardiac calcium channel, is responsible for mediating the coupling of the cell’s electrical excitation and mechanical contraction. Cellular depolarization leads to release of Ca2+ from the sarcoplasmic reticulum via RyR2 and mechanical contraction. Sudden death is hypothesized to occur as the result of torsades de pointes or ventricular fibrillation due to the abnormal calcium channel handling. Genetics CPMVT is due to a defect in the cardiac ryanodine receptor (RyR2) gene, which is inherited in an autosomal dominant fashion.59–62,66 Ryanodine receptors are intracellular calcium channels that regulate the release of calcium from different cell sites. Three different isoforms of the ryanodine receptor are known, and a different gene encodes each. They are the largest ion channels yet described. RyR2 (encoded by 105 exons) is characteristically found in the heart while RyR1 is found in skeletal muscle. Because this entity is newly described and the genes encoding the mutant calcium channel are so large, no commercial genetic screening is currently available for CPMVT. Treatment Beta-blockers form the mainstay of therapy in this condition. In patients who have survived cardiac arrest or are felt to be at particularly high risk for sudden death, an ICD is offered.61,65 13.2.2 Disorders of the Heart Muscle 13.2.2.1

Arrhythmogenic Right Ventricular Dysplasia

ARVD is a newly recognized disorder that is a cause of unexplained sudden death in otherwise healthy young adults, particularly young athletic men.67–69 Particularly in the early stages, affected patients may have grossly normal heart function. Epidemiology The true incidence of ARVD is unknown. In a prospective, detailed autopsy-based study in the Veneto region of northern Italy, 20% of unexplained sudden deaths in subjects under age 35 were found to have ARVD, including 22% of young athletic men who died suddenly in the region.70 It is unclear if northern Italy simply has an abnormally high incidence of the disease, or if this reflects the true incidence of the disease. However, it is likely a much more common entity than initially appreciated as most cases go undetected. Clinical Features Unfortunately, the initial presentation of ARVD clinically is often the unexplained sudden death in a healthy, athletic male. Patients experience ventricular arrhythmias from the diseased right ventricle. These range from benign premature ventricular complexes (PVCs) to ventricular tachy-


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Table 13.2.2

ARVD Diagnostic Criteria

ECG Findings Epsilon wave of QRS in leads V1–V3 Late potentials on signal-averaged ECG Arrhythmias Right ventricular tachycardia or premature beats Family history Confirmed at autopsy Structural findings RV global hypokinesis with preserved LV function

cardia or even ventricular fibrillation and cardiac arrest.71–74 ARVD was first described briefly in 1961, and in greater detail in 1977.75,76 The Study Group on ARVD/C has defined specific criteria to aid in the diagnosis of ARVD (Table 13.2.2).77 ECG findings include a complete or incomplete right bundle branch block during normal sinus rhythm with T wave inversion in leads V1 to V3. An epsilon wave, a terminal notch in the QRS, may also be present.67–69,71–73 A signal-averaged ECG (SAECG) is also characteristically abnormal.77 Echocardiographic findings may be normal or reveal a variety of abnormalities in the right ventricle including RV wall thinning, dilatation, or dysfunction.67–69,71–73,78 Cardiac MRI can sometimes be useful as it may reveal the fibrofatty infiltration of the RV free wall.79,80 Biopsy of the RV septum (done in the septum and not in the free wall, due to free wall thinning) is often not helpful because involvement of the septum in ARVD is sporadic. ARVD represents one of the few genetically based causes of sudden death that can be identified at autopsy, at least in grossly abnormal cases. The pathologist may find diffuse or segmental loss of myocardium in the right ventricular free wall, with concomitant replacement with fibrofatty tissue.67–69 Two thirds of such patients have patchy, acute myocarditis-type of findings with lymphocytic infiltration and cell death.71–73 Up to 50% of patients with ARVD have right ventricular aneurysms at autopsy.71–73,77 Patients can have progressive dilatation and failure of the right ventricle over time, which can also occasionally involve the left ventricle, leading to a diffuse cardiomyopathy. One study found that 76% of ARVD subjects had histologic involvement of the left ventricle.77 Pathophysiology The pathophysiology of ARVD is unclear. It likely represents a complex interplay among genetic predisposition, cellular mechanisms, and unknown environmental factors.67–69,77 Several consistent features of ARVD can be noted: apoptosis (programmed cell death), a component of inflammatory heart disease (e.g., acute myocarditis), and myocardial dystrophy. The disease is progressive over decades in some patients, whereas it is relatively quiescent, for unknown reasons, in others. Genetics At least seven distinct chromosomal loci for ARVD have so far been located.81–85 These loci include two on chromosome 10, two on chromosome 14, and one each on chromosomes 1, 2, and 3. One autosomal recessive form of ARVD is associated with palmoplantar keratoderma and woolly hair.86 It is due to a mutation in the gene for plakoglobin. Another syndrome found in Ecuador involves a recessive mutation in the gene for desmoplakin.87 Both are components of desmosomes, which form the major cell adhesion junctions. Currently, there is no commercial genetic testing available to diagnose ARVD. For most cases of ARVD, the genetic linkage is unclear. Up to 30 to 50% of the cases will have an associated family history consistent with ARVD (including sudden death).71–73,77


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Treatment There is no consensus for how to treat ARVD.77 In those patients who have survived cardiac arrest, implantation of an ICD is generally recommended to avoid sudden death.88 Pharmacologic therapy with beta-blocker or antiarrhythmic medications has also been suggested.77 Radiofrequency ablation during electrophysiology study of ventricular arrhythmias has also been attempted.89 13.2.2.2

Hypertrophic Cardiomyopathy

HCM is one of the oldest known non-atherosclerotic causes of sudden death. It was first described in 1958.90 It has been called HOCM (hypertrophic obstructive cardiomyopathy) and also IHSS (idiopathic hypertrophic subaortic stenosis) despite that 75% of affected patients do not have a sizable resting outflow gradient.91,92 It is a polygenic, relatively common, genetic cause of sudden death, particularly in young athletes. Epidemiology HCM is actually the most common genetically associated form of sudden cardiac death. It is estimated that 1 in 500 people (0.2% of the general population) carry an HCM genetic mutation.93,94 However, the phenotypic presentation or clinical penetrance of the disease is much lower. Most patients with an HCM mutation will not demonstrate clinical manifestations of the disease during life. Clinical Features The hallmark feature of HCM, when present, is myocyte disarray.92,95,96 The clinical diagnosis of HCM during life is made most reliably by echocardiography. Severe ventricular wall thickening can be noted. A normal left ventricular wall thickness is generally 30 mm are not unusual in severe cases of HCM.97–101 Marked septal hypertrophy is often an agedependent effect and may not be seen initially in young patients. In most cases, the left ventricle is affected diffusely, or it may demonstrate ASH (asymmetric septal hypertrophy).95–101 In contrast, in the Japanese variant of HCM, the apical left ventricle is primarily affected and shows abnormal thickening.92,95–101 At autopsy using detailed pathologic examination, one can frequently see hypertrophied myocytes with bizarre shapes, chaotic cellular alignment, and gross cellular disarray in the left ventricle.102–106 The disarray is most evident in the mid-portion of the septum. Patchy areas of myocardial scarring and fibrosis can be seen, a lesion that is thought to be due to the presence of abnormal intramural coronary arteries.107,108 Pathophysiology Syncope in these subjects may occur due to arrhythmias, or it may be the result of outlet obstruction due to ventricular hypertrophy and cavitary obliteration.90,97,98 Dehydration can trigger syncopal events in such patients. Sudden death in HCM is primarily due to electrical abnormalities generating ventricular arrhythmias.92,97,109–112 In support of this view, one large study of patients with HCM, in whom defibrillators were implanted, demonstrated that nearly 25% of the patients had documented ventricular arrhythmias over a 3-year follow-up period.113 The disease may be progressive in certain individuals. Cardiomyocytes continue to hypertrophy over years, but in a clinically silent manner that may lead ultimately to an end-stage, dilated cardiomyopathic picture.92,97,98 Depending on the timeframe during which the patient is evaluated, the HCM-affected heart could appear grossly normal, markedly hypertrophied, or dilated, which makes the diagnosis difficult.


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Genetics The polygenic and multicellular nature of HCM makes it a frustratingly difficult disease to diagnose unless gross histopathologic abnormalities are found on ECG or at autopsy. At least ten different genes encoding the cardiac sarcomere have been implicated in HCM.92,97,98,114 More than 150 unique mutations have been reported since the first genetic cause for HCM was identified in 1990.115 Most such mutations are missense mutations found in the proteins of the cardiac sarcomere and are located in the β-myosin heavy chain, cardiac troponin T, or myosin binding protein-C.111–119 Although the disease is autosomal dominant, a family history of syncope or sudden death may be lacking, and the disease has variable clinical penetrance. Within the β-myosin heavy chain gene (MYH7), numerous mutations have been described as malignant mutations associated with a poor clinical prognosis.118–121 These particular mutations seemed to be associated with a severe clinical phenotype including progression to end-stage heart failure or sudden death, a relatively high penetrance of the disease, and extreme left ventricular wall thickness.92,97,98,112,117,118 Treatment There are no formal guidelines for treating asymptomatic patients with HCM.92,97,98 In symptomatic patients with shortness of breath, treatment with medications that reduce the outflow gradient remains the mainstay of therapy.92,97,98,122,123 Such medications include beta-blockers or calcium channel blockers. In very symptomatic patients with a large (>50 mm) gradient, the outflow gradient can be reduced by surgical myomectomy or by catheter-based alcohol ablation.92,97,98,124,125 The latter is a relatively new technique, which causes a controlled myocardial infarction and thus reduces the obstruction to outflow. In those patients deemed at high risk for an arrhythmic event, an ICD may be implanted to avert sudden death. 13.2.3 Drug Causes of Sudden Death Clearly, many medications and drugs of abuse can lead to cardiac arrhythmias and sudden death. A detailed description of these topics is beyond the scope of this chapter. However, we consider three major causes of sudden death that should be considered by the pathologist at autopsy: ephedra (or ma huang), methamphetamine, and cocaine. 13.2.3.1

Ephedra

Ma huang is a popular herb derived from the genus Ephedra used for over 5000 years in Chinese folk remedies.126 It is a natural source of ephedrine taken in various vitamin or other supplements to promote weight loss and boost energy. Ephedrine and its derivatives function in the body by increasing the availability of naturally released catecholamines.127 Its physiologic effects on the body include increasing the heart rate, raising the cardiac output, and elevating the vascular resistance.128 It is excreted in the urine and has a serum half-life of 2.7 to 3.6 h.129 Before the supplements were withdrawn from the market, it was one of the most widely used herbal supplements in the world. Even though ephedra-containing supplements are no longer for sale, millions of consumers still use ephedrine on a daily basis in the form of over-the-counter asthma preparations. It is puzzling that these asthma preparations, which have been available for more than 50 years, were never associated with any of the complications attributed to the supplements. An estimated 12 million consumers in the U.S. alone purchased over-the-counter ephedracontaining preparations in 1999.130–132 Caffeine is also a common ingredient in ephedra preparations;


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the combination of the two drugs, when taken in excess, clearly can cause ventricular arrhythmias, hypertension, or cardiovascular collapse. Numerous case reports have linked ma huang to cases of cardiovascular disorders, sudden death, and hemorrhagic stroke.133 One analysis of adverse event reports evaluated 926 possible cases of ephedra toxicity reported to the FDA from 1995 through 1997.130 The authors identified 37 major cardiovascular events they thought likely to be ma huang related, including 16 strokes, 11 cardiac arrests, and 10 myocardial infarctions. The average age of the 37 patients was only 43 ± 13 years and included 23 women. Pathologists should consider testing for ephedra/ma huang particularly in young, otherwise healthy subjects who die suddenly with a normal autopsy, or if autopsy reveals early-onset vascular disease such as strokes or myocardial infarction.134–137 Particular attention should be paid to a history of vitamin supplement ingestion in such patients. 13.2.3.2

Methamphetamine

Methamphetamine is a central nervous stimulant that was first synthesized by a German chemist in 1887.138 It is an odorless, crystalline powder that is soluble in alcohol or water. Its precursors are ephedrine and pseudoephedrine. Its sympathomimetic actions produce hypertension, elevated heart rate, ischemia, vasoconstriction, and other adrenergic-type of stimuli upon the heart. Acute aortic dissection has been described at autopsy in methamphetamine users.139 Myocardial infarction, chest pain syndromes, and coronary artery disease have been found in such patients, and a direct toxic effect on myocytes has been implicated for methamphetamine.140–142 Methamphetamine may promote ventricular arrhythmias and sudden death with its use.143 Chronic use may lead to a dilated cardiomyopathy.144–147 Methamphetamine use is increasingly popular and should be considered in the autopsy evaluation when present, but usually there are other stigmata present suggesting the diagnosis, and sudden cardiac death with a negative autopsy is rare in a methamphetamine abuser. 13.2.3.3

Cocaine

Cocaine (benzoylmethylecgonine) is an alkaloid originally extracted from the leaves of the Erythroxylon coca plant.147 It is estimated that at least 30 million people in the U.S. have used cocaine at some point. Cocaine acts at both the central and peripheral adrenergic nervous system by blocking the reuptake of norephinephrine and dopamine from presynaptic terminals. These effects lead to a net stimulatory effect upon the cardiovascular system.148,149 Cocaine causes a variety of cardiac complications. Its basic pathophysiologic effect is to induce an adrenergic overload leading to acceleration of the heart rate, proarrhythmic effects, and even cardiac collapse.147,148,150,151 Cocaine increases myocardial oxygen demand acutely while concomitantly reducing myocardial oxygen supply with its direct vasoconstrictive effects on the coronary arteries. It promotes intracoronary thrombosis and platelet aggregation in the absence of coronary atherosclerosis, leading to vascular injury.147,148,150–152 Finally, long-term cocaine use has been associated with premature and accelerated atherosclerosis.155 The pathologist should consider cocaine toxicity as an adjunctive diagnosis in the unexplained sudden death of seemingly healthy subjects. However, as is true for methamphetamine abusers, sudden death with a negative autopsy is an uncommon finding in a cocaine abuser. In addition to its direct cardiac effects (e.g., myocardial infarction, stroke, aortic dissection, cardiac arrhythmias), cocaine has been found to directly block the HERG potassium channel.157 This finding represents yet another way cocaine may cause sudden cardiac death, and is particularly important, since HERG blockade would not be associated with any identifiable anatomic markers.


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13.2.4 Molecular Diagnosis of Cardiovascular Disease With the explosion of molecular techniques, DNA testing on peripheral blood and tissue has revolutionized the diagnosis of genetic causes of sudden death. We describe the basic methods of tissue preparation and DNA analysis as a useful overview for the clinical pathologist and coroner. 13.2.4.1

Collection of DNA from Blood Samples

It is easiest to amplify DNA that will be used for genetic testing when it is taken from blood samples.158,159 Ideally, the medical examiner or pathologist would collect the samples at the time of autopsy. At least 15 ml of blood should be collected in EDTA-containing tubes, in order to prevent coagulation and degradation of the DNA. The tubes are then stored at 4°C until the DNA can be extracted for analysis, which should be within 1 week, although sometimes DNA can be extracted up to 4 months after collection. If the blood samples are collected in tubes that do not contain an anticoagulant, the DNA should be extracted promptly (within days of the initial collection). 13.2.4.2

Collection of DNA from Tissue Samples

Extraction of high-quality DNA from tissue that can be used for PCR (polymerase chain reaction) amplification is much more problematic than using blood samples. It is often difficult to amplify long fragments of DNA from formalin-fixed and paraffin-embedded tissue because formalin fixation may damage the DNA, as may long storage in the tissue blocks prior to analysis. Formic acid may also form in the sample making PCR difficult, if not impossible160,161 Formic acid hydrolyzes the DNA and creates single-strand nicks in the DNA. In post-mortem tissues fixed in nonbuffered formalin (usually in tissue preserved more than 20 years ago), DNA fragments longer than 90 base pairs cannot be amplified. There are a variety of published methods to extract DNA from preserved tissue.162,163 Many involve a phenol-chloroform digestion and washing step. Commercial kits are also available that may simplify the methodology. One recent paper described a “pre-PCR restoration process” in which the single-stranded DNA nicks are repaired with Taq polymerase prior to PCR amplification, greatly enhancing the length of DNA pieces that could be amplified.164 An alternative method for obtaining usable DNA from tissue collected at autopsy is to snapfreeze fresh myocardial tissue in liquid nitrogen, and store it at –80°C until DNA extraction is performed. Using this method allows the extraction process to be deferred for many months. Clearly, collection and preservation of tissue or blood samples for future DNA analysis is cumbersome, time-intensive, and costly. However, it may be of great assistance in determining the cause of death if tissue is carefully preserved for future DNA testing, especially in those cases where a genetic cause of sudden death is suspected. Acknowledgments This work was funded in part by an American Heart Association Beginning-Grant-in-Aid, Western States Affiliates, to Dr. Glatter.

REFERENCES 1. Escobedo LG, Zack MM. Comparisons of sudden and nonsudden coronary deaths in the United States. Circulation 1996;93:2033–6.


TOXICOGENETICS

1109

2. Goraya TY, Jacobsen SJ, Kottke TE, et al. Coronary heart disease death and sudden cardiac death. Am J Epidemiol 2003;157:763–70. 3. Zheng ZJ, Croft BJ, Giles WH, et al. Sudden cardiac death in the United States, 1989 to 1998. Circulation 2001;104:2158–63. 4. Wehrens XH, Vos MA, Doevendans PA, et al. Novel insights in the congenital long QT syndrome. Ann Intern Med 2002;137:981–92. 5. Vincent GM. The molecular genetics of the long QT syndrome: genes causing fainting and sudden death. Annu Rev Med 1998;49:263–74. 6. Zeltser D, Justo D, Halkin A, et al. Torsade de pointes due to noncardiac drugs: most patients have easily identifiable risk factors. Medicine 2003;82:282–90. 7. Al-Khatib SM, LaPointe NM, Kramer JM, et al. What clinicians should know about the QT interval. JAMA 2003;289:2120–7. 8. Yang P, Kanki H, Drolet B, et al. Allelic variants in long-QT disease genes in patients with drugassociated torsades de pointes. Circulation 2002;105:1943–8. 9. Roden DM. Pharmacogenetics and drug-induced arrhythmias. Cardiovasc Res 2001;50;224–31. 10. Schwartz PJ, Priori SG, Spazzolini C, et al. Genotype-phenotype correlation in the long-QT syndrome: gene-specific triggers for life-threatening arrhythmias. Circulation 2001;103:89–95. 11. Moss AJ, Schwartz PJ, Crampton RS, et al. The long QT syndrome: a prospective international study. Circulation 1985; 71:17–21. 12. Moss AJ, Schwartz PJ, Crampton RS, et al. The long QT syndrome. Prospective longitudinal study of 328 families. Circulation 1991;84:1136–44. 13. Zareba W, Moss AJ, Schwartz PJ, et al. Influence of genotype on the clinical course of the long-QT syndrome. International Long-QT Syndrome Registry Research Group. N Engl J Med 1998;339:960–5. 14. Locati EH, Zareba W, Moss AJ, et al. Age- and sex-related differences in clinical manifestations in patients with congenital long-QT syndrome. Circulation 1998;97:2237–44. 15. Moss AJ, Robinson JL, Gessman L, et al. Comparison of clinical and genetic variables of cardiac events associated with loud noise versus swimming among subjects with the long QT syndrome. Am J Cardiol 1999;84:876–9. 16. Ali RH, Zareba W, Moss AJ, et al. Clinical and genetic variables associated with acute arousal and nonarousal-related cardiac events among subjects with long QT syndrome. Am J Cardiol 2000;85:457–61. 17. Wilde AA, Jongbloed RJ, Doevendans PA, et al. Auditory stimuli as a trigger for arrhythmic events differentiate HERG-related (LQTS2) patients from KVLQT1-related patients (LQTS1). J Am Coll Cardiol 1999;33:327–32. 18. Priori SG, Napolitano C, Schwartz PJ. Low penetrance in the long-QT syndrome: clinical impact. Circulation 1999;99:529–33. 19. Swan H, Viitasalo M, Piippo K, et al. Sinus node function and ventricular repolarization during exercise stress test in long QT syndrome patients with KvLQT1 and HERG potassium channel defects. J Am Coll Cardiol 1999;34:823–9. 20. Swan H, Toivonen L, Viitasalo M. Rate adaptation of QT intervals during and after exercise in children with congenital long QT syndrome. Eur Heart J 1998;19:508–13. 21. Schwartz PJ, Priori SG, Dumaine R, et al. A molecular link between the sudden infant death syndrome and the long-QT syndrome. N Engl J Med 2000;343:262–7. 22. Ackerman MJ, Siu BL, Sturner WQ, et al. Postmortem molecular analysis of SCN5A defects in sudden infant death syndrome. JAMA 2001;286:2264–9. 23. Keating M, Atkinson D, Dunn C, et al. Linkage of a cardiac arrhythmia, the long QT syndrome, and the Harvey ras-1 gene. Science 1991;252:704–6. 24. Jiang C, Atkinson D, Towbin JA, et al. Two long QT syndrome loci map to chromosomes 3 and 7 with evidence for further heterogeneity. Nat Genet 1994;8:141–7. 25. Abbott GW, Sesti F, Splawski I, et al. MiRP1 forms IKr potassium channels with HERG and is associated with cardiac arrhythmia. Cell 1999;97:175–87. 26. Wang Q, Li Z, Shen J, et al. Genomic organization of the human SCN5A gene encoding the cardiac sodium channel. Genomics 1996;34:9–16.


1110


27. Mohler PJ, Schott JJ, Gramolini AO, et al. Ankyrin-B mutation causes type 4 long-QT cardiac arrhythmia sudden cardiac death. Nature 2003;421:634–9. 28. Chen Q, Zhang D, Gingell RL, et al. Homozygous deletion in KVLQT1 associated with Jervell and Lange-Nielsen syndrome. Circulation 1999;99:1344–7. 29. Splawski I, Timothy KW, Vincent GM, et al. Molecular basis of the long-QT syndrome associated with deafness. N Engl J Med 1997;336:1562–7. 30. Jervell A, Lange-Nielsen F. Congenital deaf-mutism, functional heart disease with prolongation of the Q-T interval, and sudden death. Am Heart J 1957;54:59–68. 31. Crotti L, Lundquist AL, Insolia R, et al. KNCH2-K897T is a genetic modifier of latent congenital long-QT syndrome. Circulation 2005;222:1251–8. 32. Chiang CE and Roden DM. The long QT syndromes: genetic basis and clinical implications. J Am Coll Cardiol 2000;36:1–12. 33. Groh WJ, Silka MJ, Oliver RP, et al. Use of implantable cardioverter-defibrillators in the congenital long QT syndrome. Am J Cardiol 1996;78:703–6. 34. Dorostkar PC, Eldar M, Belhassen B, et al. Long-term follow-up of patients with long-QT syndrome treated with beta-blockers and continuous pacing. Circulation 1999;100:2431–6. 35. Antzelevitch C, Brugada P, Brugada J, et al. Brugada syndrome: a decade of progress. Circ Res 2002;91:1114–8. 36. Gussak I, Antzelevitch C, Bjerregaard P, et al. The Brugada syndrome: clinical, electrophysiologic, and genetic aspects. J Am Coll Cardiol 1999;33:5–15. 37. Antzelevitch C. The Brugada syndrome: ionic basis and arrhythmia mechanisms. J Cardiovasc Electrophysiol 2001;12:268–72. 38. Nademanee K, Veerakul G, Nimmannit S, et al. Arrhythmogenic marker for the sudden unexplained death syndrome in Thai men. Circulation 1997;96:2595–2600. 39. Wilde AAM, Antzelevitch C, Borggrefe M, et al. The Study Group on the Molecular Basis of Arrhythmias of the European Society of Cardiology. Proposed diagnostic criteria for the Brugada syndrome: consensus report. Circulation 2002;106:2514–9. 40. Priori SG, Napolitano C, Gasparini M, et al. Natural history of Brugada syndrome: insights for risk stratification and management. Circulation 2002;105:1342–7. 41. Alings M and Wilde A. “Brugada” syndrome: clinical data and suggested pathophysiological mechanism. Circulation 1999;99:666–73. 42. Brugada P, Brugada J. Right bundle branch block, persistent ST segment elevation and sudden cardiac death: a distinct clinical and electrocardiographic syndrome. J Am Coll Cardiol 1992;20:1391–6. 43. Brugada J, Brugada R, Antzelevitch C, et al. Long-term follow-up of individuals with the electrocardiographic pattern of right bundle-branch block and ST-segment elevation in precordial leads V1 to V3. Circulation 2002;105:73–8. 44. Brugada J, Brugada R, and Brugada P. Right bundle-branch block and ST-segment elevation in leads V1 through V3. Circulation 1998;97:457–60. 45. Priori SG, Napolitano C, Gasparini M, et al. Clinical and genetic heterogeneity of right bundle branch block and ST-segment elevation syndrome. Circulation 2000;102:2509–15. 46. Smits JP, Eckardt L, Probst V, et al. Genotype-phenotype relationship in Brugada syndrome: electrocardiographic features differentiate SCN5A-related patients from non-SCN5A-related patients. J Am Coll Cardiol 2002;40:350–6. 47. Brugada R, Brugada J, Antzelevitch C, et al. Sodium channel blockers identify risk for sudden death in patients with ST-segment elevation and right bundle branch block but structurally normal hearts. Circulation 2000;101:510–5. 48. Priori SG, Napolitano C, Schwartz PJ, et al. The elusive link between LQT3 and Brugada syndrome: the role of flecainide challenge. Circulation 2000;102:945–7. 49. Brugada P, Brugada R, Mont L, et al. Natural history of Brugada syndrome: the prognostic value of programmed electrical stimulation of the heart. J Cardiovasc Electrophysiol 2003;14:455–7. 50. Kanda M, Shimizu W, Matsuo K, et al. Electrophysiologic characteristics and implications of induced ventricular fibrillation in symptomatic patients with Brugada syndrome. J Am Coll Cardiol 2002;39:1799–805. 51. Chen Q, Kirsch GE, Zhang D, et al. Genetic basis and molecular mechanism for idiopathic ventricular fibrillation. Nature 1998;392:293–6.


TOXICOGENETICS

1111

52. Balser JR, The cardiac sodium channel: gating function and molecular pharmacology. J Mol Cell Cardiol 2001;33:599–613. 53. Kurita T, Shimizu W, Inagaki M, et al. The electrophysiologic mechanism of ST-segment elevation in Brugada syndrome. J Am Coll Cardiol 2002;40:330–4. 54. Yan GX and Antzelevitch C. Cellular basis for the Brugada syndrome and other mechanisms of arrhythmogenesis associated with ST-segment elevation. Circulation 1999;100:1660–6. 55. Clancy CE and Rudy Y. Na+ channel mutation that causes both Brugada and long-QT syndrome phenotypes: a simulation study of mechanism. Circulation 2002;105:1208–13. 56. Burke A, Creighton W, Mont E, et al. Role of SCN5A Y1102 polymorphism in sudden cardiac death in blacks. Circulation 2005;112:798–802. 57. Glatter KA, Wang Q, Keating M, et al. Effectiveness of sotalol treatment in symptomatic Brugada syndrome. Am J Cardiol 2004;93:1320–2. 58. Kakishita M, Kurita T, Matsuo K, et al. Mode of onset of ventricular fibrillation in patients with Brugada syndrome detected by implantable cardioverter defibrillator therapy. J Am Coll Cardiol 2000;36:1646–53. 59. Laitinen PJ, Brown KM, Piippo K, et al. Mutations of the cardiac ryanodine receptor (RyR2) gene in familial polymorphic ventricular tachycardia. Circulation 2001;103:485–90. 60. Swan H, Piippo K, Viitasalo M, et al. Arrhythmic disorder mapped to chromosome 1q42-q43 causes malignant polymorphic ventricular tachycardia in structurally normal hearts. J Am Coll Cardiol 1999;34:2035–42. 61. Priori SG, Napolitano C, Memmi M, et al. Clinical and molecular characterization of patients with catecholaminergic polymorphic ventricular tachycardia. Circulation 2002;106:69–74. 62. Priori SG, Napolitano C, Tiso N, et al. Mutations in the cardiac ryanodine receptor gene (hRyR2) underlie catecholaminergic polymorphic ventricular tachycardia. Circulation 2001;103:196–200. 63. Leenhardt A, Lucet V, Denjoy I, et al. Catecholaminergic polymorphic ventricular tachycardia in children. A 7-year follow-up of 21 patients. Circulation 1995;91:1512–9. 64. Lahat H, Eldar M, Levy-Nissenbaum E, et al. Autosomal recessive catecholamine- or exercise-induced polymorphic ventricular tachycardia. Circulation 2001;103:2822–7. 65. Fisher JD, Krikler D, Hallidie-Smith KA. Familial polymorphic ventricular arrhythmias: a quarter century of successful medical treatment based on serial exercise-pharmacologic testing. J Am Coll Cardiol 1999;34:2015–22. 66. Tunwell RE, Wickenden C, Bertrand BM, et al. The human cardiac muscle ryanodine receptor-calcium release channel: identification, primary structure and topological analysis. Biochem J 1996;318:477–87. 67. Corrado D, Basso C, Thiene G. Arrhythmogenic right ventricular cardiomyopathy: diagnosis, prognosis, and treatment. Heart 2000;83:588–95. 68. Fontaine G, Fontaliran F, Hebert JL, et al. Arrhythmogenic right ventricular dysplasia. Annu Rev Med 1999;50:17–35. 69. Thiene G, Basso C. Arrhythmogenic right ventricular cardiomyopathy: an update. Cardiovasc Pathol 2001;May–Jun;10:109–17. 70. Thiene G, Nava A, Corrado D, et al. Right ventricular cardiomyopathy and sudden death in young people. N Engl J Med 1988;318:129–33. 71. Nava A, Bauce B, Basso C, et al. Clinical profile and long-term follow-up of 37 families with arrhythmogenic right ventricular cardiomyopathy. J Am Coll Cardiol 2000;36:2226–33. 72. Corrado D, Basso C, Thiene G, et al. Spectrum of clinicopathologic manifestations of arrhythmogenic right ventricular cardiomyopathy/dysplasia: a multicenter study. J Am Coll Cardiol 1997; 30:1512–20. 73. McKenna WJ, Thiene G, Nava A, et al. Diagnosis of arrhythmogenic right ventricular dysplasia/cardiomyopathy. Br Heart J 1994;71:215–8. 74. Obata H, Mitsuoka T, Kikuchi Y, et al. Twenty-seven-year follow-up of arrhythmogenic right ventricular dysplasia. Pacing Clin Electrophysiol 2001;24:510–1. 75. Dalla Volta S, Battaglia G, Zerbini E. “Auricularization” of right ventricular pressure curve. Am Heart J 1961;61:25–33. 76. Fontaine G, Guiraudon G, Frank R, et al. Stimulation studies and epicardial mapping in ventricular tachycardia: study of mechanisms and selection for surgery. In: Kulbertus HE, ed. Reentrant Arrhythmias: Mechanisms and Treatment. Lancaster: MTP Press;1977:334–50.


1112


77. Corrado D, Fontaine G, Marcus FI, et al. Arrhythmogenic right ventricular dysplasia/cardiomyopathy: need for an international registry. Circulation 2000;101:E101–6. 78. Basso C, Thiene G, Corrado D, et al. Arrhythmogenic right ventricular cardiomyopathy. Dysplasia, dystrophy, or myocarditis? Circulation 1996;94:983–91. 79. Midiri M, Finazzo M, Brancato M, et al. Arrhythmogenic right ventricular dysplasia: MR features. Eur Radiol 1997;7:307–12. 80. Tandri H, Calkins H, Nasir K, et al. Magnetic resonance imaging findings in patients meeting task force criteria for arrhythmogenic right ventricular dysplasia. J Cardiovasc Electrophysiol 2003;14: 476–82. 81. Danieli GA and Rampazzo A. Genetics of arrhythmogenic right ventricular cardiomyopathy. Curr Opin Cardiol 2002;17:218–21. 82. Rampazzo A, Nava A, Danieli GA, et al. The gene for arrhythmogenic right ventricular cardiomyopathy maps to chromosome 14q23-q24. Hum Mol Genet 1994;3:959–62. 83. Ahmad F, Li D, Karibe A, et al. Localization of a gene responsible for arrhythmogenic right ventricular dysplasia to chromosome 3p23. Circulation 1998;98:2791–5. 84. Li D, Ahmad F, Gardner MJ, et al. The locus of a novel gene responsible for arrhythmogenic rightventricular dysplasia characterized by early onset and high penetrance maps to chromosome 10p12p14. Am J Hum Genet 2000;66:148–56. 85. Melberg A, Oldfors A, Blomstrom-Lundqvist C, et al. Autosomal dominant myofibrillar myopathy with arrhythmogenic right ventricular cardiomyopathy linked to chromosome 10q. Ann Neurol 1999;46:684–92. 86. Protonotarios N, Tsatsopoulou A, Patsourakos P, et al. Cardiac abnormalities in familial palmoplantar keratosis. Br Heart J 1986;56:321–6. 87. Norgett EE, Hatsell SJ, Carvajal-Huerta L, et al. Recessive mutation in desmoplakin disrupts desmoplakin-intermediate filament interactions and causes dilated cardiomyopathy, woolly hair and keratoderma. Hum Mol Genet 2000;9:2761–6. 88. Link MS, Wang PJ, Haugh CJ, et al. Arrhythmogenic right ventricular dysplasia: clinical results with implantable cardioverter defibrillators. J Interv Card Electrophysiol 1997;1:41–8. 89. Fontaine G, Tonet J, Gallais Y, et al. Ventricular tachycardia catheter ablation in arrhythmogenic right ventricular dysplasia: a 16-year experience. Curr Cardiol Rep 2000;2:498–506. 90. Teare D. Asymmetrical hypertrophy of the heart in young adults. Br Heart J 1958;20:1–18. 91. Braunwald E, Lambrew CT, Rockoff D, et al. Idiopathic hypertrophic subaortic stenosis. Circulation 1964;30 (suppl IV):3–217. 92. Maron BJ. Hypertrophic cardiomyopathy: A systematic review. JAMA 2002;287:1308–20. 93. Maron BJ, Bonow RO, Cannon RO, et al. Hypertrophic cardiomyopathy. Interrelations of clinical manifestations, pathophysiology, and therapy. N Engl J Med 1987;316:780–9. 94. Maron BJ, Gardin JM, Flack JM, et al. Prevalence of hypertrophic cardiomyopathy in a general population of young adults. Circulation 1995;92:785–9. 95. Maron BJ, Epstein SE. Hypertrophic cardiomyopathy: a discussion of nomenclature. Am J Cardiol 1979;43:1242–4. 96. Klues HG, Schiffers A, Maron BJ. Phenotypic spectrum and patterns of left ventricular hypertrophy in hypertrophic cardiomyopathy. J Am Coll Cardiol 1995;26:1699–1708. 97. Spirito P, Seidman CE, McKenna WJ, et al. The management of hypertrophic cardiomyopathy. N Engl J Med 1997;336:775–85. 98. Maron BJ. Hypertrophic cardiomyopathy. Lancet 1997;350:127–33. 99. Spirito P, Bellone P, Harris KM, et al. Magnitude of left ventricular hypertrophy predicts the risk of sudden death in hypertrophic cardiomyopathy. N Engl J Med 2000;342:1778–85. 100. Louie EK, Maron BJ. Hypertrophic cardiomyopathy with extreme increase in left ventricular wall thickness. J Am Coll Cardiol 1986;8:57–65. 101. Elliott PM, Gimeno Blanes JR, Mahon NG, et al. Relation between severity of left-ventricular hypertrophy and prognosis in patients with hypertrophic cardiomyopathy. Lancet 2001;357:420–4. 102. Maron BJ, Roberts WC. Quantitative analysis of cardiac muscle cell disorganization in the ventricular septum of patients with hypertrophic cardiomyopathy. Circulation 1979;59:689–706. 103. Ferrans VJ, Morrow AG, Roberts WC. Myocardial ultrastructure in idiopathic hypertrophic subaortic stenosis. Circulation 1972;45:769–92.


TOXICOGENETICS

1113

104. St. John Sutton MG, Lie JT, Anderson KR, et al. Histopathological specificity of hypertrophic obstructive cardiomyopathy. Br Heart J 1980;44:433–43. 105. Varnava AM, Elliott PM, Mahon N, et al. Relation between myocyte disarray and outcome in hypertrophic cardiomyopathy. Am J Cardiol 2001;88:275–9. 106. Maron BJ, Anan TJ, Roberts WC. Quantitative analysis of the distribution of cardiac muscle cell disorganization in the left ventricular wall of patients with hypertrophic cardiomyopathy. Circulation 1981;63:882–94. 107. Maron BJ, Epstein SE, Roberts WC. Hypertrophic cardiomyopathy and transmural myocardial infarction without significant atherosclerosis of the extramural coronary arteries. Am J Cardiol 1979;43:1086–1102. 108. Basso C, Thiene G, Corrado D, et al. Hypertrophic cardiomyopathy and sudden death in the young: pathologic evidence of myocardial ischemia. Hum Pathol 2000;31:988–98. 109. Elliott PM, Poloniecki J, Dickie S, et al. Sudden death in hypertrophic cardiomyopathy: identification of high risk patients. J Am Coll Cardiol 2000;36:2212–8. 110. Maron BJ, Olivotto I, Spirito P, et al. Epidemiology of hypertrophic cardiomyopathy-related death: revisited in a large non-referral-based patient population. Circulation 2000;102:858–64. 111. McKenna WJ, England D, Doi YL, et al. Arrhythmia in hypertrophic cardiomyopathy. Br Heart J 1981;46:168–72. 112. Watkins H. Sudden death in hypertrophic cardiomyopathy. N Engl J Med 2000;342:422–4. 113. Maron BJ, Shen WK, Link MS, et al. Efficacy of implantable cardioverter-defibrillators for the prevention of sudden death in patients with hypertrophic cardiomyopathy. N Engl J Med 2000;342:365–73. 114. Seidman JG, Seidman C. The genetic basis for cardiomyopathy: from mutation identification to mechanistic paradigms. Cell 2001;104:557–67. 115. Geisterfer-Lowrance AA, Kass S, Tanigawa G, et al. A molecular basis for familial hypertrophic cardiomyopathy: a beta-cardiac myosin heavy chain gene missense mutation. Cell 1990;62:999–1006. 116. Watkins H, McKenna WJ, Thierfelder L, et al. Mutations in the genes for cardiac troponin T and alpha-tropomyosin in hypertrophic cardiomyopathy. N Engl J Med 1995;332:1058–64. 117. Watkins H, Rosenzweig A, Hwang DS, et al. Characteristics and prognostic implications of myosin missense mutations in familial hypertrophic cardiomyopathy. N Engl J Med 1992;326:1108–14. 118. Marian AJ. Pathogenesis of diverse clinical and pathological phenotypes in hypertrophic cardiomyopathy. Lancet 2000;355:58–60. 119. Moolman JC, Corfield VA, Posen B, et al. Sudden death due to troponin T mutations. J Am Coll Cardiol 1997;29:549–55. 120. Enjuto M, Francino A, Navarro-Lopez F, et al. Malignant hypertrophic cardiomyopathy caused by Arg723Gly mutation in beta-myosin heavy chain gene. J Mol Cell Cardiol 2000;32:2307–13. 121. Tesson F, Richard P, Charron P, et al. Genotype-phenotype analysis in four families with mutations in the beta-myosin heavy chain gene responsible for familial hypertrophic cardiomyopathy. Hum Mutat 1998;12:385–92. 122. Spicer RL, Rocchini AP, Crowley DC, et al. Chronic verapamil therapy in pediatric and young adult patients with hypertrophic cardiomyopathy. Am J Cardiol 1984;53:1614–9. 123. Gilligan DM, Chan WL, Joshi J, et al. A double-blind, placebo-controlled crossover trial of nadolol and verapamil in mild and moderately symptomatic hypertrophic cardiomyopathy. J Am Coll Cardiol 1993;21:1672–9. 124. Lakkis NM, Nagueh SF, Dunn JK, et al. Nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy: one-year follow-up. J Am Coll Cardiol 2000;36:852–5. 125. Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery. J Am Coll Cardiol 2001;38:1994–2000. 126. Tyler VE. The Honest Herbal: A Sensible Guide to the Use of Herbs and Related Remedies. 3rd ed. New York: Pharmaceutical Products Press;1993:119–20. 127. Sapru HN, Theoharides TC. Autonomic nervous system. In: Theoharides TC, ed. Essentials of Pharmacology. 2nd ed. Boston: Little, Brown; 1996:58. 128. Hoffman BB, Lefkowitz RJ. Catecholamines, sympathomimetic drugs, and adrenergic receptor antagonists. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 9th ed. New York: McGraw-Hill;1996:221.


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129. Pentel P. Toxicity of over-the-counter stimulants. JAMA 1984;252:1898–1903. 130. Samenuk D, Link MS, Homoud MK, et al. Adverse cardiovascular events temporally associated with ma huang, an herbal source of ephedrine. Mayo Clin Proc 2002;77:12–6. 131. Haller CA, Benowitz NL. Adverse cardiovascular and central nervous system events associated with dietary supplements containing ephedra alkaloids. N Engl J Med 2000;343:1833–8. 132. Gurley BJ, Gardner SF, Hubbard MA. Content versus label claims in ephedra-containing dietary supplements. Am J Health Syst Pharm 2000;57:963–9. 133. Karch SB. Use of ephedra-containing products and risk for hemorrhagic stroke. Neurology 2003;61:724–5. 134. Shekelle PG, Hardy ML, Morton SC, et al. Efficacy and safety of ephedra and ephedrine for weight loss and athletic performance. JAMA 2003;289:1537–45. 135. Foxford RJ, Sahlas D, Wingfeld KA. Vasospasm-induced stroke in a varsity athlete secondary to ephedrine ingestion. Clin J Sport Med 2003;13:183–5. 136. Wooltorton E, Sibbald B. Ephedra/ephedrine: cardiovascular and CNS effects. CMAJ 2002;166:633. 137. Blechman KM, Karch SB, Stephens BG. Demographic, pathologic, and toxicological profiles of 127 decedents testing positive for ephedrine alkaloids. Forensic Sci Int 2004;139:61–9. 138. Yu Q, Larson DF, Watson RR. Heart disease, methamphetamine, and AIDS. Life Sci 2003;73:129–40. 139. Swalwell CI, Davis GG. Methamphetamine as a risk factor for acute aortic dissection. J Forensic Sci 1999;44:23–6. 140. Turnipseed SD, Richards JR, Kirk JD, et al. Frequency of acute coronary syndrome in patients presenting to the emergency department with chest pain after methamphetamine use. J Emerg Med 2003;24:369–73. 141. Carson P, Oldroyd K, Phadke K. Myocardial infarction due to amphetamine. Br Med J 1987;294:1524–6. 142. Furst SR, Fallon SP, Reznik GN, et al. Myocardial infarction after inhalation of methamphetamine. N Engl J Med 1990;323:1147–8. 143. Bashour TT. Acute myocardial infarction resulting from amphetamine abuse: a spasm-thrombus interplay? Am Heart J 1994;128:1237–9. 144. Hong R, Matsuyama E, Nur K. Cardiomyopathy associated with the smoking of crystal methamphetamine. JAMA 1991;265:1152–4. 145. Call TD, Hartneck J, Dickinson WA, et al. Acute cardiomyopathy secondary to intravenous amphetamine abuse. Ann Internal Med 1982;97:559–60. 146. Karch SB, Stephens BG, Ho CH. Methamphetamine-related deaths in San Francisco: demographic, pathologic, and toxicologic profiles. J Forensic Sci 1999;44:359–68. 147. Benzaquen BS, Cohen V, Eisenberg MJ. Effects of cocaine on the coronary arteries. Am Heart J 2001;142:402–10. 148. Kloner RA, Hale S, Alker K, et al. The effects of acute and chronic cocaine use on the heart. Circulation 1992;85:407–19. 149. O’Brien CP. Drug addiction and drug abuse. In: JG Hardman and LE Limbird, Eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 10th ed. New York: McGraw-Hill: 2001, 621–42. 150. Minor RL, Scott BD, Brown DD, et al. Cocaine-induced myocardial infarction in patients with normal coronary arteries. Ann Intern Med 1991;115:797–806. 151. Mittleman RE, Wetli CV. Cocaine and sudden “natural” death. J Forensic Sci 1987;32:11–9. 152. Rod JL, Zucker RP. Acute myocardial infarction shortly after cocaine inhalation. Am J Cardiol 1987;59:161. 153. Simpson RW, Edwards WD. Pathogenesis of cocaine-induced ischemic heart disease. Arch Pathol Lab Med 1986;110:479–84. 154. Cooke CT, Dowling GP. Cocaine-associated coronary thrombosis and myocardial ischemia. Pathology 1988;20:242, 305–6. 155. Kolodgie FD, Virmani R, Cornhill JF, et al. Increase in atherosclerosis and adventitial mast cells in cocaine abusers: an alternative mechanism of cocaine-associated coronary vasospasm and thrombosis. J Am Coll Cardiol 1991;17:1553–60. 156. Kogan MJ, Verebey KG, DePace AC, et al. Quantitative determination of benzoylecgonine and cocaine in human biofluids by gas-liquid chromatography. Anal Chem 1977;49:1965–9.


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157. Zhang S, Rajamani S, Chen Y, et al. Cocaine blocks HERG, but not KvLQT1 + minK, potassium channels. Mol Pharmacol 2001;59;1069–76. 158. Higuchi R. Simple and rapid preparation of samples for PCR. In HA Ehrlich, Ed. PCR Technology: Principles and Applications for DNA Amplification. New York: Stockton Press: 1989, 31–38. 159. Bajanowski T, Rossi L, Biondo B, et al. Prolonged QT interval and sudden infant death — report of two cases. Forensic Sci Int 2001;115:147–53. 160. Sato Y, Sugie R, Tsuchiya B, et al. Comparison of the DNA extraction methods for polymerase chain reaction amplification from formalin-fixed and paraffin-embedded tissues. Diagn Mol Pathol 2001;10:265–71. 161. Cao W, Hashibe M, Rao JY, et al. Comparison of methods for DNA extraction from paraffin-embedded tissues and buccal cells. Cancer Detect Prev 2003;27;397–404. 162. Mygind T, Ostergaard L, Birkelund S, et al. Evaluation of five DNA extraction methods for purification of DNA from atherosclerotic tissue and estimation of prevalence of Chlamydia pneumoniae in tissue from a Danish population undergoing vascular repair. BMC Microbiol 2003;3:19. 163. Konomi N, Lebwohl E, Zhang D. Comparison of DNA and RNA extraction methods for mummified tissues. Mol Cell Probes 2002;16:445–51. 164. Bonin S, Petrera F, Niccolini B, et al. PCR analysis in archival postmortem tissues. Mol Pathol 2003;56:184–6.



CHAPTER

14

Drug Law CONTENTS 14.1 DUI Defenses ....................................................................................................................1118 14.1.1 General Challenges ..............................................................................................1119 14.1.1.1 Drinking after the Offense ..................................................................1119 14.1.1.2 Laced Drinks .......................................................................................1121 14.1.1.3 Rising Blood-Alcohol Concentration .................................................1122 14.1.1.4 Pathological States and Ethanol Pharmacokinetics ............................1124 14.1.1.5 Drug-Alcohol Interactions...................................................................1126 14.1.1.6 Gastric Alcohol Dehydrogenase..........................................................1126 14.1.1.7 Endogenous Ethanol and the Autobrewery Syndrome.......................1127 14.1.2 Urine Samples ......................................................................................................1128 14.1.3 Blood Samples .....................................................................................................1130 14.1.3.1 Use of Alcohol Swabs for Skin Disinfection .....................................1130 14.1.3.2 Trauma and Intravenous Fluids...........................................................1131 14.1.3.3 Blood-Water Content and Hematocrit ................................................1132 14.1.4 Breath-Alcohol Analysis ......................................................................................1133 14.1.4.1 Mouth Alcohol and Use of Mouthwash Preparations ........................1134 14.1.4.2 Regurgitation and Gastro Esophageal Reflux Disease (GERD) ........1135 14.1.4.3 Dentures and Denture Adhesives ........................................................1136 14.1.4.4 Alleged Interfering Substances in Breath...........................................1137 14.1.4.5 Variability in the Blood/Breath Alcohol Ratio ...................................1140 14.1.4.6 Pulmonary Function (Chronic Obstructive Pulmonary Disease) .......1142 14.1.4.7 Breathing Pattern and Hypo- and Hyperthermia................................1143 14.1.5 Concluding Remarks............................................................................................1144 References .........................................................................................................................1145 14.2 Testing Claims of Adverse Drug Effects in the Courtroom.............................................1156 14.2.1 The Supreme Court’s Directive: Expert Testimony Must Be Derived by the Scientific Method ...........................................................................................1157 14.2.2 Evaluating General Causation Evidence under the Scientific Method...............1159 14.2.2.1 Epidemiology ......................................................................................1159 14.2.2.2 Animal Research .................................................................................1163 14.2.2.3 Chemical Analogies.............................................................................1165 14.2.2.4 Case Reports/Case Series....................................................................1165 14.2.2.5 Secondary Source Materials................................................................1167

1117


1118


14.2.3 Causation Opinions Based on Clinical Reasoning..............................................1167 14.2.3.1 Clinical Reasoning and General Causation ........................................1168 14.2.3.2 Clinical Reasoning and Specific Causation........................................1169 14.2.4 The Parlodel Litigation ........................................................................................1170 14.2.4.1 Plaintiffs’ Allegations Regarding Parlodel..........................................1171 14.2.4.2 Opinions Admitting Plaintiffs’ Experts’ Causation Opinions ............1171 14.2.4.3 Opinions Excluding Plaintiffs’ Experts’ Opinions .............................1172 14.2.5 Conclusion............................................................................................................1173

14.1 DUI DEFENSES

Alan Wayne Jones, D.Sc.1 and Barry K. Logan, Ph.D.2 1

Department of Forensic Toxicology, University Hospital, Linköping, Sweden Director, Washington State Toxicology Laboratory, Department of Laboratory Medicine, University of Washington, Seattle, Washington 2

After prohibition was abolished in the United States in 1933, consumption of alcohol escalated as did many of the negative consequences associated with too much drinking. Among other things, the number of alcohol-related accidents within the home, at work, and on the roads increased alarmingly.1,2 Alcohol and transportation made a poor mix, and in efforts to curb this new wave of road-traffic accidents and deaths on the highways, more effective legislative measures were urgently needed.3,4 The first laws prohibiting driving under the influence of alcohol (DUI) appeared in the 1920s, but the criteria used to demonstrate impairment and unfitness to drive were not very sophisticated. These included the smell of alcohol on the breath, the ability of a person to walk a chalk line, and various behavioral signs and symptoms of inebriation.5 Gaining a conviction for drunk driving was by no means certain, unless the suspect showed obvious signs and symptoms of gross intoxication.6 It was strikingly obvious that more sensitive and more objective methods were needed to decide whether a person was under the influence of alcohol. Following the lead of some European countries, efforts in the U.S. were directed toward measuring the concentration of alcohol in blood and other body fluids as evidence of intoxication.7 However, quantitative studies of the relationship between blood-alcohol and impairment were virtually nonexistent at this time. These efforts led to the first statutory limits of blood alcohol concentration (BAC) for driving being set at 150 mg/dL (0.15 g/dL), a conservatively high level.8,9 Subsequently, this threshold BAC for driving has progressively been lowered, first to 100 mg/dL (0.10 g/dL) and in all U.S. states the limit is now set at 80 mg/dL (0.08 g/dL).10 For young (< 21 y) drivers an even lower BAC, so-called zero tolerance limits, has been sanctioned (0.00 to 0.02 g/dL).11 Legal limits of blood alcohol concentration differ from country to country and also within regions of the same country, e.g. the various states in Australia.12 Lowering the legal alcohol limits for driving even further is supported by many national and international medical societies including the American Medical Association.13 Judging by recent trends in Europe, it seems that most countries are aiming for a threshold BAC limit of 50 mg/dL (0.05 g/dL); France approved a 0.05 g/dL limit in 1995, whereas Sweden adopted 0.02 g/dL in 1990.12 Punishment and sanctions for those found guilty of drunk driving have become increasingly severe and include suspension of the driver’s license, heavy fines, and sometimes a mandatory term of imprisonment.14–16 The first DUI statutes stipulated that the concentration of alcohol present in body fluids (blood, breath, or urine) was admissible as presumptive evidence of unfitness to drive, but that this was a rebuttable presumption.4,6 In contrast, most of the DUI statutes in operation


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today are the so-called per se laws, under which the person’s BAC or breath alcohol concentration (BrAC) is the sole deciding factor necessary as proof of unfitness to drive.15,16 In short, a person can be found guilty of drunk driving without exhibiting visible signs of intoxication when alcohol concentration per se statutes are in operation.16 This legal framework, whereby the concentration of alcohol in a specimen of blood or breath determines guilt or innocence, places high demands on the analytical methods used for forensic purposes. Moreover, pre-analytical factors such as sampling, transportation, storage and handling of specimens needs to be carefully regulated and controlled. The combined influences of per se legislation, the compelling objective standard of proof provided to juries in the numerical value of the BAC or BrAC result, and the increasingly harsh penalties imposed on those found guilty of DUI explain, at least in part, the vigorous defense attacks against prosecution evidence based on results of BAC or BrAC determinations. Soon after chemical tests for intoxication were introduced and used on a large scale, the reliability of the approved methods and the results obtained were increasingly being questioned.4 The practice of running duplicate determinations on the same specimen or obtaining two or more specimens of the same or different body fluids (e.g., blood and urine) and testing these by different analytical methods has much to recommend it.14,15 Defending drinking drivers has become a popular business and many lawyers specialize in this area of jurisprudence. A plethora of textbooks and newsletters are available that provide detailed information about the science and law of DUI litigation.17-21 These typically present recent examples of DUI case law, reviews and opinion of articles published in scientific peer-review journals, and hints and tips for developing more effective strategies for defending and also for prosecuting drunk drivers.22 This review article discusses the strengths and weaknesses of common DUI defense challenges. The work is subdivided into four main sections. The first deals with general attacks on potentially incriminating evidence, the second focuses on challenging results of urine alcohol analysis, the third deals with scrutiny of blood sampling and analysis, and the fourth section is concerned with the use of evidential breath-alcohol instruments. Procedural aspects of the DUI offense, such as whether the arresting police officer followed the correct protocol when the driver was apprehended, had reasonable suspicion or probable cause for making the arrest, conducted the field sobriety tests properly, or gave the appropriate warnings demanded by the local rules and regulations prior to administering the chemical test, are not considered. The chemistry and physiology of forensic alcohol testing are the main focus of this review and much of the perpetual nit-picking about procedural issues often raised in DUI litigation are omitted. An extensive list of references is provided, and most citations refer to articles published in peer-review U.S. and European English language journals. However, a bimonthly journal from Germany called Blutalkohol (blood-alcohol), is worthy of note. Blutalkohol is published by Steintor-Verlag, Lübeck and the first volume appeared in 1962/63. This periodical contains a wealth of information about forensic aspects of alcohol with direct relevance to the defense and prosecution of DUI suspects. Although most of the articles are written in German, English summaries are provided. 14.1.1 General Challenges 14.1.1.1

Drinking after the Offense

A frequent defense tactic is one in which the suspect claims to have consumed alcohol after driving or being involved in an accident such as a single-vehicle crash; this approach is sometimes called the hip-flask ploy.23,24 Prosecution for DUI must necessarily relate driving with the consumption of alcohol at a time before or during the driving. In these cases however it is alleged that the drinking took place after the driving, but prior to obtaining a specimen of blood or breath for forensic analysis. For example, hit-and-run drivers often manage to drive home. When eventually apprehended by the police, they might claim to have been sober during the driving but


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needed alcohol to “calm their nerves” or alleviate the condition of shock caused by “hitting a bird or cat,” and the resulting damage to the car. Subjects will often insist they drank alcohol after driving, even when they cannot produce any empty or opened bottle of liquor or any other credible evidence such as eye witnesses to support their story. Some of the more experienced DUI offenders, especially repeat offenders, may carry a bottle of alcohol in their coat pocket or glove compartment, for the express purpose of being able to drink after driving; hence the origin of the term hip-flask defense. In some jurisdictions the prosecutor must prove beyond a reasonable doubt that the allegation of drinking after the offense was untrue, or that in spite of the alcohol consumed after driving the suspect’s BAC or BrAC at the time of driving still exceeded the legal limit. This is often a difficult task. To deal with alleged drinking after the offense, the prosecutor has several options available and should seek help from qualified forensic experts when preparing the case. First, it is important to consider the testimony of the police or other witnesses who might have observed the actual driving, or the behavior and general appearance of the suspect when arrested. Such observations as the smell of alcohol on the breath, slurred speech, or unsteady gait are important to document before the driver has had the opportunity to drink any more alcohol. In cases where the subject has allegedly consumed a large quantity of alcohol immediately before being apprehended by the police, one would also expect to see a dramatic and progressive onset of symptoms of intoxication. Second, information regarding the quantity of alcohol allegedly consumed after driving, the time of intake and the sex, age, height, and body weight of the suspect can be used to calculate the expected BAC.22 If this approach is used, the suspect should be given the “benefit of any doubt” by assuming that at the time of sampling blood and breath, absorption and distribution from the post-incident ethanol consumption was complete. The Widmark equation (see Chapter 5.2) is commonly used to calculate the expected BAC on the basis of the person’s body weight and drinking pattern.25,26 Making an adjustment for elimination of alcohol through metabolism between the time of starting to drink and the time of sampling blood is usually warranted, especially when several hours have elapsed between the time of the driving and the time of obtaining a blood-sample. In this way, a theoretical mean BAC and its 95% confidence interval can be compared with the analytical report from the forensic laboratory. The resulting difference in BAC, if any, should reflect the BAC that existed prior to the post-incident drinking, and therefore the BAC before or during driving. The use of a 95% confidence interval is a safeguard to allow for inter-individual variations in absorption, distribution, and elimination patterns of alcohol (see Chapter 5.2 for details). Grossly exaggerated claims of the amount of alcohol consumed after the offense, such as drinking a whole bottle of liquor in a relatively short time span, are clearly unrealistic and should be given little credibility. The limitations of urine alcohol concentration (UAC) are dealt with in the next section; however, if the police manage to obtain samples of urine and blood shortly after driving, the magnitude of the UAC/BAC ratio can help resolve whether alcohol was ingested within approximately 1 h of taking the samples. This approach was tested empirically by Iffland et al.27 who found that UAC/BAC ratios between 1.0 to 1.15 indicated fairly recent drinking whereas ratios larger than 1.2:1 indicate that the drinking began much earlier. This fits with the observation that during the absorption phase of alcohol kinetics, before equilibration has been reached, UAC is generally less than or equal to BAC. In the post-absorptive phase of alcohol metabolism, UAC is usually 1.3 to 1.5 times higher than BAC.28,29 The concentration of alcohol in pooled bladder urine mirrors the average concentration prevailing in the blood during the formation of urine in the kidneys and storage in the bladder.28 Because urine has about 20% more water than an equal volume of whole blood, the concentration of alcohol in newly secreted urine is about 20% higher than BAC and a urine/blood ratio of 1.2:1 should be expected. Dividing the measured UAC by 1.2 gives an estimate of the lowest BAC at the time of voiding or since the bladder was last emptied. Moreover, a UAC/BAC ratio exceeding 1.3 suggests that the bulk of the alcohol was already absorbed into the blood and distributed throughout total body water. Whenever the police suspect that a person will


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assert consumption of alcohol after driving, efforts should be made to obtain two specimens of urine about 30 to 60 min apart. If the UAC of the second void is higher than the first void then it seems reasonable to assume that absorption of alcohol from the stomach is not complete at the time of sampling. Such a finding would support the claim of recent consumption of alcohol. If the UAC decreases between the first and second void 30 to 60 min later, this suggests that the postabsorptive phase has become well established and the main part of the alcohol was imbibed at least 1 to 2 h earlier. 28,29 If the ratio of UAC/BAC is less than or close to unity, this supports the contention of recent consumption of alcohol and the BAC curve was probably still rising, or near the peak. If an alcoholfree pool of urine existed in the bladder before drinking started, this would tend to dilute the concentration of alcohol in primary urine secreted into the bladder and might suggest a rising UAC between the two successive voids, even though in reality the BAC curve was in the post-peak phase. Alternatively, evaluating the change in BAC between the times of taking two blood samples 30 to 60 min apart gives a good indication of whether a rising or falling BAC existed at the time of sampling.30 Forensic toxicologists in Germany have developed another way to deal with allegations of drinking after the offense and this method has become known as congener analysis.31–34 In brief, this method entails analyzing the alcoholic beverage the suspect claims to have consumed after driving with the aim of identifying other volatile constituents besides ethanol. Pure ethanol does have a distinctive odor, although these other congeners (non-ethanol volatiles) produced during the fermentation process help impart the distinctive smell and flavor to the drink.31 The results of the congener analysis are then compared with the volatiles present in a sample of blood or urine taken from the suspect in an attempt to match the components. Methanol, 1-propanol, 2-butanol, and 2methyl-1-propanol are typical examples of congener alcohols that can be identified in body fluids depending on the particular kind of beverage consumed.32 The results of congener analysis, together with other information, has been accepted by the courts in Germany when dealing with hit-andrun drivers who frequently claim drinking after the offense.31–34 The usefulness of analyzing methanol as a congener in forensic casework is limited by the fact that this alcohol is produced naturally in the body and its concentration in body fluids increases after ingestion of ethanol because of competition for the metabolizing enzyme alcohol dehydrogenase.35–37 Furthermore, if the beverage consumed before the incident is the same as that allegedly consumed afterwards, the congeners will be the same and this approach would not work. Claims of drinking after the offense can be counteracted by appropriate legislation. For example, in Norway it is a separate offense for a motorist to consume alcohol within 6 hours of driving if there is good reason to believe that the police will want to investigate some event related to the driving. Thus, drinking within 6 h of an accident to reach a BAC in excess of the legal limit carries the same penalty as being found guilty of drunk driving (Norwegian traffic law, paragraph 22). Without this kind of legislation, the magnitude of the UAC/BAC ratio and the change in BAC between successive samples, or UAC between two successive voids, provides useful information to evaluate whether or not a person has consumed alcohol within an hour or so before taking the samples. Knowledge of the stage of alcohol kinetics is important not only in cases of alleged drinking after the offense but also when asked to engage in retrograde extrapolation of BAC to an earlier time. Accurate back-tracking of BAC to the time of driving is fraught with difficulties, and only an approximate result, and likely range of values is possible, based on known population averages for rate of alcohol elimination. Again, the need to back extrapolate can be avoided by statutory definition of the relevant BAC for prosecution as that existing at the time of sampling or within 2 to 3 h of the driving. 14.1.1.2

Laced Drinks

The “laced drinks” defense is another challenge that arises during prosecution of drunk drivers in their attempts to avoid punishment for DUI.17,19–21 The usual story is that a friend or associate


1122


has added liquor (usually vodka) to a non-alcoholic drink or to beer when the person concerned was otherwise engaged or distracted. Another spin on this scenario is where the suspect has been invited to consume some kind of homemade beverage which was not recognized as containing a high alcohol content because the taste was masked by strong fruit flavoring. Unintentional intoxication through the over-consumption of alcohol-containing chocolates or alcohol-soaked fruit have also been documented. Only later, after being apprehended for DUI, was it apparent to the people in these cases that the drink must have contained an unusually high concentration of alcohol, which was not obvious from the taste. The subjective intoxication effects of alcohol differ widely among different individuals and this allows the defendant to argue that he or she was driving with a BAC above the limit but without intent, which although not a complete defense, may have some mitigating value. Widmark calculations (see Chapter 5.2) are commonly used to estimate the BAC expected from the amount of alcohol inadvertently consumed in the laced drink.24,25 However, relating a given BAC to a precise degree of intoxication is difficult because of the wide variations in consumption and concentration tolerance between different individuals. Dram-shop laws in the U.S. place responsibility on the host at the party, or the owner of the bar for damages caused by a drunk driver if that person was served alcohol while he or she was visibly intoxicated.17–22 In a well-documented laced drinks case, a woman was acquitted after driving with a BAC of 0.17 g/dL. She admitted drinking from a “punch bowl” when visiting the home of some friends, although she denied knowledge of the fact that the drink was laced with 96% v/v ethanol, and claimed not to feel any definite impairment effects of alcohol despite the high BAC. The medicolegal experts called by the court refused to state with certainty that the woman must have felt under the influence of alcohol at a BAC of 0.17 g/dL. On appeal to the high court, the woman was acquitted of willfully driving under the influence. The prosecutor approached the supreme court but permission to review the case was refused.38 The trend toward introducing lower legal limits and zero tolerance laws for young people should make the laced drinks defense, and thus driving over the limit without intent, a much more common defense tactic. This follows because of the great difficulty in recognizing symptoms of intoxication at very low BAC levels such as 0.02 g/dL where impairment may be minimal. The same applies to driving in the morning following an evening of heavy drinking, when low per se illegal concentrations of alcohol are enforced. 14.1.1.3

Rising Blood-Alcohol Concentration

Some DUI suspects argue that their BAC or BrAC was below the legal limit at the time of driving, but that the concentration of alcohol had risen to exceed the legal alcohol limit at the time of obtaining the samples for analysis. In short, if the prosecution BAC was 0.12 g/dL at the time of the test, it might be suggested that it was below 0.08 g/dL at the time of driving some time earlier.39,40 The key question here is by how much can the BAC or BrAC rise after the last drink? To answer this question, details of the subject’s drinking pattern before or during the driving, as well as the various time elements and intake of food, should be carefully investigated. The pharmacokinetics of alcohol show large inter-individual variations especially when small doses are taken after a meal.41,42 This challenge is known as the rising BAC defense and the usual scenario according to the defendant is that he or she was engaged in moderate social drinking for several hours after work, perhaps with a meal or eating bar snacks. For some unexplained, and physiologically improbable reason, the alcohol ingested during the evening remained unabsorbed in the stomach until the person decided to leave for home or drive to the next bar. Shortly after driving the person is either involved in a collision or pulled over by the police because of a moving traffic offense, and in this connection is arrested for DUI. The defendant then claims that between the time of being apprehended and the time of providing the blood or breath-alcohol test, the alcohol in the stomach became absorbed into the blood, bringing the person over the legal limit.


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Obviously, this scenario is unreasonable because alcohol, unlike many other drugs, starts to become absorbed from the stomach immediately following ingestion. Gastric emptying accelerates this process and leads to a rapid onset of the effects of alcohol on the brain. Indeed, people indulge in drinking primarily to experience alcohol’s enjoyable pharmacological effects such as euphoria, relaxation, and diminished social inhibitions. In order for this to happen, the alcohol must become absorbed into the bloodstream and transported to the brain. The intoxicating effects of alcohol are more pronounced during the rising limb of the BAC profile, and people would surely be surprised if they had been consuming drinks for several hours without experiencing any effect! Unfortunately, only a handful of studies have looked at the pharmacokinetics of alcohol under real-world drinking conditions to establish, for a large number of subjects, the degree of rise in BAC and the time needed to reach the peak after the last drink. Gullberg43 reported a study in which 39 subjects drank various quantities of alcohol under realworld drinking conditions. The mean time required to reach the peak BAC after end of drinking was 19 min (span 0 to 80 min) and 81% of subjects reached a peak within 30 min. A study reported by Shajani and Dinn44 also gives a clue to the time needed to reach peak BAC under social drinking conditions. In 8 men and 8 women who consumed known amounts of alcohol according to choice, the maximum BAC was reached 35 min (span 17 to 68 min) after end of intake. Taken together these studies and a few others suggest the low probability that the result of a blood or breath-alcohol test made some time after driving will be higher than at the time of driving which is often 1 to 2 h earlier. Zink and Reinhardt45 made an important contribution when they allowed heavy drinkers to consume very large amounts of alcohol over periods of 6 to 10 h, resulting in peak BAC’s in the range 0.10 to 0.38 g/dL. Venous blood was taken for analysis of alcohol at 15 min intervals during and after the drinking spree. In this way accurate information was obtained about the shape of the concentration-time profile and the time of reaching the peak as well as rise in BAC after the last drink. Importantly, they found that half the individuals had reached their peak BAC even before the last drink was taken (i.e., the rate of elimination exceeds the rate of consumption). The longest time necessary to reach a peak was 50 min after end of drinking (mean ± SD, 7.7 ± 22.9 minutes), and when a rise in BAC occurred between the end of drinking and the peak BAC it was invariably less than 0.02 g/dL. This study has important ramifications because many DUI suspects have bloodalcohol concentrations in this high range when they are apprehended. Drinking alcohol together with a large meal was studied by Jones and Neri42 who found that under these conditions, although the peak BAC was attained soon after the end of drinking for most subjects, a BAC plateau developed, and for some the BAC remained fairly constant for 2 to 3 h. Interestingly, in 10 of these subjects, 70% of the peak BAC had been attained within 15 min after the end of drinking. More studies are needed delineating the absorption kinetics of alcohol for different drinking conditions, with different beverages and formulations and with fast and slow ingestion of alcohol, on an empty stomach and after a meal. Although a person’s BAC or BrAC at the time of driving or when a road-traffic accident occurred might be considered the most relevant result for prosecution, it is fairly obvious that estimating this value can involve much uncertainty. This follows because the blood or breath-test is often made 1 to 2 h after the driving and there is a wide variation in absorption, distribution, and elimination patterns of alcohol in individual DUI suspects. Much can be gained by statutory definition of the relevant BAC or BrAC as that prevailing at the time of the chemical test and not at the time of driving. Unfortunately, many jurisdictions persist with using the BAC or BrAC at the time of driving as the relevant figure needed for prosecution of DUI suspects. Other jurisdictions accept the chemical test result, provided it was obtained within 2 h of the driving, as being equivalent to the BAC at the time of driving. Samples of blood or breath taken outside this time frame require the prosecution to estimate the BAC or BrAC prevailing at the time of driving. This entails making a back extrapolation of BAC from time of sampling to the time of driving and this calculation is always subject to much uncertainty. In cases where the statutory period of 2 or 3 h between the


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driving and the time of the test is exceeded, error in back extrapolation can be minimized (in the defendant’s favor), by only extrapolating back to the end of the 2- or 3-h period. Provided the subject was in the post-peak phase of alcohol absorption-distribution at the time of driving and at the time of sampling blood, extrapolating back with a conservative alcohol burnoff rate, such as 0.008 to 0.010 g/dL per hour, can be defended. Other safeguards against overestimation include an adjustment for absorption of alcohol contained in the last drink, and allowing for the possibility of a BAC concentration plateau existing, during which time the BAC remains more or less constant for several hours, as sometimes happens if alcohol is ingested together with a large meal. Other reasonable approaches include the use of population mean elimination rates, with 95% confidence intervals to establish the most likely upper and lower limits of BAC. A recent study of double blood samples from 1090 DUI suspects arrived at a mean alcohol burn-off rate of 0.019 g/dL per hour with 95% limits of agreement, spanning from 0.009 to 0.029 g/dL/h.46 These results suggest that making a back estimation of a person’s BAC over long periods of time and assuming a relatively low and constant burn-off rate such as 0.008 to 0.01 g/dL/h will lead to a large underestimate of the BAC at the time in question, but always in the defendant’s favor. While this approach gives a definite advantage to the suspect, the practice of making a back estimation of a person’s BAC is inevitably a controversial issue in DUI litigation and should be avoided whenever possible.47–50 14.1.1.4

Pathological States and Ethanol Pharmacokinetics

The pharmacokinetics of many prescription drugs have been carefully investigated in patients suffering from various diseases.51–53 Much less work has been done concerning the influence of disease states on absorption, distribution, and metabolism of the social drug ethanol. DUI suspects sometimes claim however that they suffer from certain medical conditions or pathological states, which they hope might explain their BAC being above the legal limit for driving. Various claims of this kind have been documented such as liver cirrhosis, kidney failure, or absence of a kidney or one lobe of the lung. Because only 2 to 5% of the total quantity of alcohol consumed is excreted in urine and breath, reduced efficiency of the lungs or kidney has marginal effect on the total amount of alcohol eliminated from the body. The rate of alcohol elimination from blood in patients with kidney failure scheduled for hemodialysis was no different from the burn-off rate in healthy control subjects.54 Major surgery to the gastro-intestinal tract, such as gastrectomy, is known to cause a more rapid absorption of alcohol leading to an overshoot peak, which tends to be somewhat higher than the maximum BAC expected.55–57 A similar phenomenon is often observed when drinking neat liquor on an empty stomach.41 However, 1 to 2 h after drinking ends, the BAC should approach the value expected for the dose of alcohol ingested and the person’s gender and body weight because alcohol has now had sufficient time to equilibrate in the total body water. The rate of absorption of alcohol shows wide inter-individual variations even in apparently healthy individuals, and estimating the peak BAC from amount consumed is subject to considerable uncertainty.41 Jokipii58 devoted his thesis work to comparing blood-alcohol profiles under controlled conditions in healthy subjects and in those with various diseases (liver cirrhosis, acute hepatitis, hyperthyreosis, diabetes mellitus, and neurocirculatory asthenia or dystonia). This publication is unfortunately not widely available, although its salient features were reviewed with the conclusion that these particular pathological states did not cause distorted alcohol burn-off rates or abnormal distribution volumes of ethanol compared with healthy control subjects.59 Drunk drivers with de facto diseased liver, such as alcohol hepatitis or cirrhosis, insist that this renders them slow metabolizers of ethanol compared with individuals having normal liver function. Controlled studies of the effect of various liver diseases on the rate of disappearance of alcohol from blood are rather sparse. Ethical issues preclude embarking on detailed investigations of this topic. Those few studies available do not support the notion of a slower rate of metabolism outside the limits of 0.009 to 0.025 g/dL/h seen in healthy individuals.60–63 Moreover, results of alcohol


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drinking experiments in patients with cirrhosis are often confounded by the problem of malnutrition in these binge drinkers. This also leads to a slower elimination rate of alcohol from blood.52,63 In patients with cirrhosis and severe portal hypertension, where part of the blood is forced to bypass the liver, there is some evidence to suggest a slower rate of ethanol disappearance (0.007 g/dL/h). The reason for this finding is probably diminished flow of blood to the alcohol metabolizing enzymes, and not so much necrosis of the liver tissue.64 People suffering from chronic liver disease often accumulate a fluid in the peritoneal cavity called ascites.65,66 Indeed, ascites is one consequence of long-term abuse of alcohol and alcoholinduced cirrhosis. Because the ascites fluid is mainly water, this furnishes a body fluid reservoir for ethanol, thus increasing the person’s volume of distribution. The volume of ascites fluid can vary widely between different individuals, and up to 5 liters is not uncommon. An increased total body water in patients with ascites raises the volume of distribution for other hydrophilic drugs besides ethanol. The concentration of alcohol in ascites will be closer to the concentration in plasma and serum than in whole blood. When alcohol has been cleared from the blood circulation the pool of alcohol in the ascites fluid can redistribute back into the bloodstream. However, alcohol cannot concentrate in this fluid space and ascites fluid should therefore contain approximately 10 to 20% more alcohol than an equal volume of whole blood. Like the situation with urine (see Chapter 5.2), there should also be a time-lag in the clearance of the alcohol from ascites fluid compared with blood. Most of the scientific evidence indicates that alcoholics generally tend to metabolize alcohol faster than moderate drinkers owing to induction of the microsomal enzyme denoted P4502E1, sd one of the consequences of long-term heavy drinking.67 In a recent study in alcoholics undergoing detoxification with initial BACs of 0.20 to 0.45 g/dL, the burn-off rate (β-slopes) ranged from 0.013 to 0.036 g/dL/h with an average of 0.022 g/dL/h.68 A similar mean value was reported when the work of several research groups based in Germany were compiled together; average elimination rate 0.022 ± 0.005 g/dL/h (mean ± SD).69 Many DUI suspects are clearly alcoholics, and in a study of 1090 apprehended drunk drivers from whom two blood samples were taken 60 min apart, the mean β-slope was 0.019 g/dL/h with 95% limits of agreement of 0.009 to 0.029 g/dL/h, being in close agreement with values for alcoholics during detoxification.46 Individuals suffering from diabetes mellitus with impaired glucose metabolism might have elevated concentrations of ketone bodies, including acetone, circulating in their blood. Note that the acetone produced can also become reduced to isopropanol in the liver through the alcohol dehydrogenase pathway.70 However, when modern gas chromatographic (GC) methods are used for blood alcohol analysis, acetone and isopropanol are easily distinguished, so defense challenges directed at the lack of specificity of GC methods are therefore pointless if two or more different stationary phases are used for the chromatography.71 There is no evidence to suggest that the rate of ethanol metabolism should be any different in people suffering from diabetes compared with healthy control subjects.72,73 The metabolic disturbances associated with insulin-dependent diabetes are not related to the enzymes involved in the disposal of ethanol.74 Total body water and activity of alcohol dehydrogenase enzymes decreases in states of malnutrition and protein deficiency, and this is reflected in slower burn-off rates of alcohol.75,76 However, moderate losses of body water after prolonged sauna bathing did not result in any marked differences in the shape of blood-alcohol profiles.77 A low relative TBW/kg body weight is associated with a smaller volume of distribution for ethanol and this explains the well known male-female difference in peak BAC and area under the curve for the same dose of alcohol administered per kg body weight.78 The distribution volume of ethanol was shown to decrease in male subjects between the ages of 20 to 60 years along with a decrease in total body water in the elderly.79 People involved in traffic accidents might be badly injured and suffer from shock and hemorrhage owing to massive losses of blood. This raises the question about the influence of trauma and shock on the hepatic metabolism of alcohol and the resulting blood-alcohol profiles.80–82 In a recent study with 10 subjects involved in accidents when under the influence of alcohol, and suffering from poly-traumatic shock, a series of venous and arterial blood samples were obtained for


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determination of ethanol.83 The rate of alcohol disappearance from blood ranged from 0.017 to 0.021 g/dL/h (mean 0.018 g/dL/h) and these values were the same regardless of whether arterial or venous blood sampling sites were used. The results of this study confirm many other anecdotes and case reports regarding alcohol pharmacokinetics in people injured when drunk.80–82 Hypovolemic shock following massive loss of blood will result in a redistribution of body fluids and higher proportions of plasma enter the intravascular space to maintain an effective circulation and tissue perfusion.84 This might alter the relative distribution of some protein-bound drugs and endogenous substances between body compartments, but the concentration of alcohol in the blood is not markedly influenced.85,86 Nevertheless, some people continue to speculate about the impact of trauma on blood-alcohol concentrations and alcohol burn-off rates, even though a careful review of the literature shows that there is no substance to these opinions.87 14.1.1.5

Drug-Alcohol Interactions

The intake of various tonics (elixirs), cough syrups, over-the-counter medications, or even foodstuffs that might contain alcohol, will obviously result in alcohol appearing in the blood.88 Some cough medicines, vitamin mixtures, pick-me-ups, and other health-store products may contain considerable quantities of alcohol (>10% v/v), and overdosing with these products will obviously elevate a person’s BAC. By how much the BAC rises will depend on the quantities consumed and the time frame in relation to driving. Medication taken in tablet form or drugs applied externally can hardly be expected to lead to alcohol appearing in the blood. Psycho-pharmacological agents such as benzodiazepine derivatives may cause increased impairment when taken together with alcohol because of interaction at the GABA receptor complex in the brain.89 However, there is no evidence to suggest that the resulting BAC will be any different from that expected if the same dose of alcohol had been taken without the drug.90 Intake of alcohol can modify the pharmacokinetics and behavioral effects of drugs that are metabolized by P4502E1 enzymes or that interact with the GABA receptor to elicit their effects on the central nervous system.91 However, these changes do not result in an altered alcohol pharmacokinetics or a raised BAC above that obtained in control experiments when the same dose of alcohol was consumed on an empty stomach. One drug that does block the metabolism of alcohol is 4-methyl pyrazole (4-MP), which competes with ethanol for binding sites on the primary metabolizing enzyme ADH.92 However 4-MP is not prescribed by physicians even though it may have legitimate therapeutic uses in the treatment of patients poisoned with methanol or ethylene glycol.93,94 14.1.1.6

Gastric Alcohol Dehydrogenase

The enzyme mainly responsible for the metabolism of alcohol is called alcohol dehydrogenase (ADH) and this is located primarily in the liver and to a minor extent also in other organs and tissue such as the kidney and the mucosa of the stomach.95 Recent studies have shown that gastric ADH is seemingly less active in women compared with men and also in alcoholics compared with moderate drinkers, and the overall activity decreases with advancing age.96 About 20 years ago the suspicion arose that part of the dose of alcohol consumed was metabolized in the stomach by gastric ADH. This process was known as pre-systemic metabolism or first-pass effect. This meant that the effective dose of alcohol reaching the systemic circulation depended on the efficacy of gastric ADH enzymes. Sex-related differences in gastric ADH offered another mechanism to explain why women reach a higher peak BAC than men for the same dose of alcohol.97 If a part of the dose of ethanol is metabolized by gastric ADH, this would also explain the observation of a smaller area under the BAC-time profile after oral intake compared with intravenous administration of the same dose. Prolonged retention of alcohol in the stomach, such as after drinking together with or after a meal, allows more opportunity for pre-systemic oxidation by gastric ADH to occur.98,99


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Interest in the role played by gastric ADH in the overall metabolism of ethanol received a boost when in vitro studies showed that the enzyme extracted from gastric biopsies was inhibited by certain commonly prescribed drugs. Among others, aspirin and the H2-receptor antagonists, ranitidine and cimetidine, used in the treatment of gastric ulcers and inhibition of secretion of excess stomach acid, were capable of blocking the action of gastric ADH.100,101 This led to the suggestion that people taking this medication, which is widely used in society, and now available without prescription, run the risk of obtaining higher than expected BAC’s and, therefore, a potentially more pronounced impairment from the alcohol they consume.102,103 The drugs seemingly promote the bioavailability of ethanol by removing the potential for oxidation of some of the alcohol already in the stomach.102–104 Media coverage of this much publicized research triggered a large number of defense challenges from individuals who claimed to combine their H2-receptor blocking drugs with intake of alcohol.105 Studies purporting to show an enhanced bioavailability of ethanol, and a higher peak BAC from this drug–alcohol interaction were not very convincing. The number of volunteer subjects was often limited (N = 6) and very low doses of alcohol (0.15 to 0.3 g/kg) were ingested 1 h after a fat-rich meal. Moreover, the methods of alcohol analysis were not appropriate considering that the maximum BACs reached were only 0.015 to 0.025 g/dL, being far removed from the statutory limits for driving in most countries, namely, 0.05 to 0.08 g/dL.106 Many subsequent studies involving larger numbers of subjects and a better experimental design failed to confirm the enhanced bioavailability of alcohol when H2-receptor antagonist drugs were taken together with a moderate doses of ethanol 0.15, 0.30, or 0.60 g/kg.106–111 Accordingly, this defense challenge holds little merit to explain a person’s BAC being above the legal limit for driving without intent. Many factors influence the rate of absorption of alcohol from the gut and the bioavailability, particularly the amount of food in the stomach before drinking.98,99 It is always good advice not to drink alcohol on an empty stomach. 14.1.1.7

Endogenous Ethanol and the Autobrewery Syndrome

With the help of sensitive and specific methods of analysis, very low concentrations of ethanol (0.5 to 1.5 mg/L) can be determined in body fluids from people who have not consumed any alcoholic beverages.112–114 It seems that endogenous ethanol (EE) is produced in the gut by microbes, bacteria and/or yeasts acting on dietary carbohydrates, but other biochemical pathways also exist according to a comprehensive review of this subject.115 Indeed, the existence of other metabolic precursors of EE was confirmed when ethanol was identified in blood and tissue samples from germ-free rats, because in these animals fermentation of carbohydrates by microflora inhabiting the gut cannot be invoked as an explanation.116 Because the portal blood draining the stomach and intestine must pass through the liver before reaching the heart, lungs, and systemic circulation, any EE formed in the gut is probably eliminated through the action of alcohol metabolizing enzymes located in the liver.117 Abnormally high (0.05 g/dL) concentrations of EE were measured in blood and cerebrospinal fluid from hospitalized patients who had allegedly abstained from drinking alcohol.118,119 The reports of this work were published in peer-reviewed journals, so these unusual findings give some cause for concern and warrant a carefully scrutiny. It seems that the methodology used for measuring ethanol in biological specimens was rather primitive involving wet-chemistry and oxidation, which is not a specific means of identifying ethanol. Whether dietary factors or even the medication prescribed to the patients were oxidized by the chemical reagents used in the assay, producing falsely elevated concentrations of EE needs to be explored.120 If for some reason large quantities of ethanol are synthesized in the gastro-intestinal tract and overwhelm the capacity of the alcohol-metabolizing enzymes in the liver, then much higher concentrations of EE could appear in the peripheral venous blood. This is exactly what was described in a group of Japanese subjects who were suffering from various disorders of the gut. Some had previously complained of experiencing feelings of drunkenness even without consumption of


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alcohol.121–122 This condition seemed to appear after the subjects had eaten a carbohydrate-rich meal, such as rice. This study from Japan was difficult to fault because ethanol was identified in blood, urine, and breath with the aid of a reliable gas chromatographic method used for quantitative analysis.121 The term used to describe this abnormal production of EE was “autobrewery syndrome” and to our knowledge this has been observed only in Japanese subjects.123 It is widely known that the activity of alcohol metabolizing enzymes, especially aldehyde dehydrogenase, is diminished in Oriental populations compared with Caucasians, which might render Japanese and other Asians less able to clear ethanol from the portal blood.59 Other requirements before “autobrewery syndrome” that should be seriously considered as contributing to a person’s BAC include genetic predisposition (Oriental origin), a past history of gastrointestinal ailments, documented medical treatment for the problem, low tolerance to alcohol, and reports of fatigue and drunkenness after eating meals. The occurrence of EE has also attracted interest in clinical and diagnostic medicine as an indirect way to furnish evidence of yeast infections in the gut.123 After obtaining a control pre-treatment blood sample, the fasted patient receives a 5 g glucose load orally and a second blood sample is taken again after 1 h. If the concentration of EE in the second blood sample is significantly higher than in the first, this indicates the possibility of a bacteria or yeast overgrowth in the stomach or small intestine causing a gut-fermentation reaction. Many studies from various countries have confirmed the existence of EE in blood and other biological media from healthy human subjects, but the concentrations rarely exceed 1.0 mg/L, which is over 1000 times less than the statutory BAC for unfitness to drive in most countries (0.08 g/dL = 0.8 g/L = 800 mg/L). These vanishingly small concentrations lack any forensic significance except in exceptional circumstances such as that described for Japanese subjects suffering from gastrointestinal disorders (autobrewery syndrome).121 Concentrations of EE in blood samples from people with diabetes mellitus, as well as other metabolic disorders, were not much different from the values in healthy control subjects.113 14.1.2 Urine Samples It has been known for more than a century that only a small fraction (about 1 to 2%) of the quantity of alcohol a person consumes is excreted unchanged in the urine.124,125 Indeed, collection and analysis of urine was recommended by Widmark as a chemical test to prove that a person had been drinking and as an aid in the clinical diagnosis of drunkenness.125 When urine is used as a body fluid for analysis of alcohol in traffic law enforcement, great care is needed with the sampling protocol to ensure correct interpretation of results.28,29,126,127 This follows because the concentration of alcohol in urine does not relate to the concentration in the blood at the time of emptying the bladder.29 Instead, the UAC reflects the average BAC during the time period in which the urine is being produced and stored in the bladder after the previous void.128 During this storage time, the BAC might have changed appreciably and even reached a zero concentration. In the morning after an evening of drinking it is not uncommon to find that the first urinary void contains a relatively high concentration of alcohol, whereas blood or breath-alcohol content are below the limits of detection with conventional analytical methods.129 The morning UAC reflects the person’s average BAC during the night after the last void before bedtime. In the U.K. urine specimens were approved for evidential purposes after the Road Traffic Act of 1967, when an alcohol concentration of 80 mg/dl blood or 107 mg/dL urine was accepted as per se evidence of unfitness to drive safely.14 However, the rules and regulations required the collection of two samples of urine about 30–60 min apart.14 The first void empties the bladder of old urine, and the concentration of alcohol measured in the second void reflects the person’s bloodalcohol concentration at the mid-point of the collection period. Because urine contains about 20% more water than an equal volume of whole blood, the concentration of alcohol in the urine entering the ureter will always be higher than the concentration in blood flowing to the kidney.28,29 The urine/blood ratio in the post-peak phase of alcohol metabolism is about 1.33:1 on the average,


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Table 14.1.1

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Evidential Breath-Alcohol Instruments Currently Used for Forensic Purposes in Europe and North America; the Statutory Limits of BloodAlcohol (BAC) and Breath-Alcohol (BrAC) Concentration Are Also Reported

Country

Breath analyzer

BrAC limit

Swedena Finlanda Norway Great Britain

Evidenzer Alcotest 7110 Intoxilyzer 5000N Intoxylizer 6000 Intoximeter EC/IR Intoxilyzer 6000 DataMaster Alcotest 7110 Ethylométer 679T Alcotest 7110 Intoxilyzer 5000 & 8000 Intoximeter EC/IR DataMaster Intoxilyzer 5000C DataMaster C Alcotest 7110 None at present

0.10 mg/L and 0.50 mg/L 0.22 mg/L and 0.53 mg/L 0.10 mg/L 35 µg/100 mL

0.20 and 1.0 mg/g 0.50 and 1.2 mg/g 0.20 mg/g 80 mg/100 mL

35 µg/100 mL 220 µg/L 0.25 mg/L 0.25 mg/L 0.08 g/210 L

80 mg/100 mL 0.50 mg/mL 0.50 mg/mL 0.50 mg/mL 0.08 g/100 mL

0.08 g/210 L

80 mg/100 mL

0.25 mg/L 0.25 mg/L

0.50 mg/g 0.50 mg/g

Ireland Holland Austria France U.S.A.b

Canada Germany Denmark a

b

BAC Limit

Sweden and Finland have a two-tier legal limit with more severe penalties for a DUI suspect with a high BAC. In some U.S. states several different breath-alcohol instruments are approved for forensic purposes.

although large inter- and intra-individual variations exist.128 Studies have shown that the urine/blood ratio of alcohol as well as its variability increases as the blood-alcohol concentration decreases.28,29 The mean ratio of 1.33:1 is higher than expected on the basis of water content differences (1.2:1), in part because of the time-lag between formation of urine in the ureter and storage in the bladder before voiding (see Chapter 5.2). With relatively short storage times the UAC/BAC ratio might be close to the value expected theoretically of 1.2:1. Note that in UK traffic-law enforcement, the DUI suspect’s BAC is not estimated indirectly from the measured UAC. Instead, the legislature has adopted an alcohol concentration of 107 mg/dL in urine as being equivalent to 80 mg/dL in blood (107/80 = 1.33). This approach is similar to the way that the threshold limits of BrAC have been derived from the existing BAC, by dividing by the blood/breath conversion factor adopted by the legislature in the respective countries (see Table 14.1.1). Indeed, because of individual variations in the urine/blood and breath/blood ratios of alcohol, it is strongly recommended that UAC or BrAC not be converted into a presumed BAC as a measure of guilt in DUI prosecution. Instead, the threshold concentration of alcohol should be defined in terms of the substance analyzed whether this is breath or urine.15,16 Not many jurisdictions allow the concentrations of alcohol determined in urine specimens as binding evidence for prosecution in DUI, especially when per se statutes operate. This caution is well founded if the measured UAC has to be translated into the presumed BAC because the urine/blood ratio is highly variable between and within individuals and also changes as a function of the BAC. However, unlike most other drugs, the UAC/BAC ratio is not influenced by diuresis because alcohol is handled by the kidneys exactly like water in a passive diffusion process.126 Increasing the volume of urine excreted by drinking large volumes of water may dilute the urine as reflected by its osmolality and creatinine content but the concentration of alcohol in the specimen will remain unchanged.130 One objection often raised against the use of urine-alcohol evidence in prosecution of DUI suspects is that some people cannot completely empty their bladders on demand. The retention of old urine with a higher content of alcohol than expected for the prevailing BAC at the time of voiding introduces uncertainty.131 The prevalence of urine retention in the population at large is hard to estimate although this problem is seemingly more common in elder men, and


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some studies have detected as much as 25 mL of residual urine.131 However, the impact of urine retention on the concentration of alcohol determined in successive voids and the magnitude of error incurred if the UAC is converted into presumed BAC has not been demonstrated experimentally. Because some people might have glucose in their urine,132 especially those suffering from diabetes mellitus,133 there is always a risk that ethanol can be produced in vitro through the fermentation of sugar by micro-organisms or yeasts infecting the bladder or urinary tract.134,135 Some reports claim that ethanol can be produced in the bladder itself, so-called bladder beer.136 This makes it important to include chemical preservatives such as sodium or potassium fluoride at a concentration of at least 1% w/v or sodium azide in the collecting tubes to inhibit microbial synthesis of ethanol.136,137 Storage of urine specimens in a refrigerator immediately after collection will also help to hinder the synthesis of ethanol through the action of candida albicans acting on glucose as substrate.137 Some new research findings have demonstrated that production of alcohol directly in the bladder or in the collecting tubes in vitro after sampling can be detected by measuring in the urine the concentration of 5-hydroxytryptophol (5HTOL), a minor metabolite of serotonin.138 The concentration of 5HTOL increases in blood and urine during hepatic oxidation of ethanol, so a normal concentration of 5HTOL in urine and an elevated concentration of ethanol suggest that the alcohol was synthesized after voiding from the action of bacteria or yeasts on carbohydrate or other substrates.139 14.1.3 Blood Samples 14.1.3.1

Use of Alcohol Swabs for Skin Disinfection

Blood specimens collected for alcohol analysis in traffic law enforcement are generally taken from an antecubital vein with the aid of sterile equipment such as evacuated tubes (Vacutainer) or a disposable plastic syringe and needle. Preparation of the skin at the site of blood sampling with disinfectants such as ethanol (70% v/v) or isopropanol (70% v/v) should obviously be avoided if specimens are intended for clinical or forensic alcohol testing. Because sterile equipment is used, disinfection of the skin at the site of sampling is not really necessary and, instead, cleaning the skin with saline or soap and water is sufficient. Nevertheless, alleged contamination by ethanol or isopropanol in the swabs used to disinfect the skin is sometimes raised as a defense challenge in attempts to invalidate results of blood-alcohol analysis.140,141 Note, however, that the methods used for forensic alcohol analysis should be able to distinguish between ethanol and isopropanol. Many studies have been done to evaluate the risk of carry-over of alcohol from the antiseptic used to swab the skin before the specimen of venous blood was taken for analysis.142,143 A classic example of giving the benefit of the doubt was demonstrated when several hundred convictions for DUI in the U.K. were deemed invalid and the sentences overturned. This was felt necessary because the swabs normally issued with kits used for blood-sampling from DUI suspects had been inadvertently switched to another brand, which contained isopropanol.144 The legal alcohol limit in the U.K. is 35 µg/100 mL breath and if the result is between 40 and 50 µg/100 mL the suspect can opt to provide a blood sample instead and the BAC is then used as evidence for prosecution (threshold BAC = 80 mg/100 mL). Because of reported large discrepancies between BAC and BrAC in this kind of paired test, the swabs used to clean the skin before drawing blood became suspect. This suspicion was strengthened when the swabs were shown to contain alcohol (isopropanol). This led to an official investigation. The convictions of several hundred individuals who had pleaded guilty to DUI and had received their sentences were considered unsound and quashed. It appears that this decision was reached by the court of appeals because the integrity of the blood specimen was cast in doubt, and the defendants were not aware of this when they were asked to plead guilt or not guilty to DUI. This led to several controlled studies into the risk of carry-over of alcohol from the swabs used to disinfect the skin. The results, however, showed that


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contamination of the blood sample with various alcohols during venipuncture was highly unlikely and in most studies, only traces or no alcohol at all could be detected in the specimens.145–149 If evacuated tubes are used for sampling blood, then two tubes should be filled with blood in rapid succession and gently inverted several times to mix with the chemical preservatives. If some coagulation does occur, the sample should be homogenized prior to sampling to prevent inadvertent aliquoting of the serum fraction which would contain more alcohol than a specimen of whole blood. The chemical preservatives are typically sodium fluoride (NaF), which prevents glycolysis and inhibits certain enzymes and micro-organisms that might be present in the blood, and potassium oxalate which serves as an anticoagulant. These substances are already in the tubes as supplied by the manufacturer, although the necessity of having sodium fluoride in sterile Vacutainer tubes is open to discussion because contamination with bacteria can, in reality, only arise from the skin at the point of inserting the needle. Nevertheless, NaF should be included if only to prevent this defense challenge from being raised; the amount of NaF recommended for blood specimens taken from living subjects is 100 mg/10 mL blood (1% w/v). If the amount actually present is challenged then methods are available to assay blood samples for fluoride ions such as by using ion-sensitive electrodes or by other means.150 In the event that alcohol-containing swabs are used, the practice of always taking two tubes of blood for analysis has the advantage that any unusually large discrepancies in the results of BAC between the two tubes can be detected. If present, this might suggest carryover or some other problem. However, the studies from the UK cited above confirm several earlier reports, which demonstrated that the risk of carryover of alcohol, even when 70% ethanol was used as an antiseptic, is virtually non-existent.149,151 Another safeguard when filling evacuated tubes with blood is to remove each tube from the collecting needle and holder before withdrawing the needle from the puncture site.151 The concentration of alcohol in stored blood samples decreases on storage at 4°C despite the inclusion of 1% w/v NaF as preservative.152 The rate of loss of alcohol is only about 0.003 g/dL per month, and evidently occurs by a non-enzymatic oxidation reaction that involves oxyhemoglobin.152,153 If blood specimens are contaminated with microorganisms when the Vacutainer tubes are opened to remove aliquots for analysis, this can lead to a much more rapid disappearance of alcohol during storage compared with unopened tubes. It seems that various species of microorganism utilize alcohol as a food.140 Other considerations regarding specimen collection include filling the tube with as much blood as possible, to avoid having a large airspace. Volatiles, including ethanol, will accumulate in the headspace and will be lost when the tube is opened. In the event that a tube is opened and closed repeatedly, this could result in appreciable losses of alcohol. The question of uptake of alcohol through the skin as a mode of entry into the body to produce elevated BAC has been raised as a defense challenge by people working with large volumes of solvents. In fact, the absorption of ethanol through the skin was investigated many years ago by Bowers et al.154 in controlled experiments with several children and one adult. The legs of the test subjects were wrapped in cotton soaked in 200 mL of 95% ethanol and secured with rubber sheeting and sealed with adhesive tapes. Blood samples were taken before and at various times after this treatment but neither clinical signs of inebriation nor raised BAC were noted. It seems safe to conclude that ethanol cannot accumulate in the body, and BAC is not increased by absorption through intact skin. 14.1.3.2

Trauma and Intravenous Fluids

Drunk drivers are often involved in serious road-traffic crashes causing injury and sometimes death. Trauma resulting in massive losses of blood precipitate a hypovolemic shock and this requires swift emergency treatment. This might involve administering medication at the site of the accident such as pain killers and intravenous fluids to counteract shock and replace depleted body fluids. More intensive treatment can be given on arrival at a surgical emergency unit and it is usually at


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this point that a blood sample is taken for clinical and/or medicolegal purposes. The sampling of blood for analysis of alcohol in a critically injured patient requires considerable deliberation to safeguard the integrity of the patient and the specimen. Errors incurred in sampling blood from trauma patients are not uncommon, and they are beyond the control of the forensic laboratory.155 Care is needed if intravenous fluids are administered as a first aid for treatment of shock, and it is important that the blood sample for alcohol analysis is not taken downstream from the same vein used for infusion. Otherwise, this can result in a marked dilution of the specimen and a decrease in the concentration of alcohol. If dilution of the specimen is suspected, this can sometimes be verified by determination of hemoglobin.155 Routinely analyzing aliquots of blood from two Vacutainer tubes that are filled in rapid succession furnishes a useful way to reveal discrepant results and problems associated with blood sampling. If the tube-to-tube difference in BAC exceeds that expected from knowledge of random analytical errors and past experiences, this points to other influences such as pre-analytical factors. Abnormally large differences in BAC between the two tubes can often be traced to dilution or coagulation of one or both of the samples because of inadequate mixing after collection. Note that the concentration of alcohol measured in plasma or serum will be higher than in whole blood by about 10 to 15% as discussed in detail elsewhere.156 14.1.3.3

Blood-Water Content and Hematocrit

The water content of whole blood is easily determined by weighing an aliquot and heating overnight at 105 to 110°C to reach a constant weight.156 The change in weight after desiccation can be used to calculate the water content of the blood specimen. According to the scientific literature whole blood contains 85 g water per 100 mL (95% range 83.0 to 86.5 g/100 mL).157 The specific gravity of blood is 1.055 so the water content is 5.5% less when expressed in mass/mass units; 85.0% w/v corresponds to 80.6 % w/w.157 Women tend to have approximately 1 to 2% more water than men for the same volume of whole blood owing to loss of red cells during periods of menstruation.158 Whole blood is composed of a plasma fraction, red blood cells (erythrocytes), white blood cells (leukocytes), and platelets. Blood hematocrit is defined as the volume of packed cells per 100 mL of whole blood when expressed as a percentage. Normal values for hematocrit in men are 42 to 50% compared with 37 to 47% in women.159 The red cells (erythrocytes) carry the hemoglobin and contain about 73 mL of water/100 mL cells whereas plasma contains 93 mL of water/100 mL plasma. Assuming a hematocrit of 40%, the water content of whole blood should be (0.40 × 73) + (0.60 × 93) or 85 mL water/100 mL of whole blood. This value agrees well with gravimetric determinations of blood-water by desiccation and a mean value of 85.6% w/v was reported.156 Because the red cells contain so much water and because alcohol distributes in blood according to the water content of the various components, it must be obvious that even fairly wide variations in hematocrit will not make much difference to the concentration of alcohol per unit volume of whole blood. This was confirmed empirically when blood was prepared in-vitro with hematocrit values of 18, 31, 39, and 60.160 The specimens were spiked with the same amount of ethanol to give a BAC of 0.212 g/dL and the actual concentration in each blood sample was determined by gas chromatography to be 0.211, 0.211, 0.207, and 0.208 g/dL respectively. Thus, no influence of varying hematocrit from 18 to 60 on the alcohol concentration in the whole blood was observed.160 However, if equilibrated headspace vapor above the same blood specimens had been analyzed, the specimen with lowest hematocrit (large plasma portion and more water per unit volume) would have had a lower headspace concentration of ethanol compared with the specimens with higher hematocrit (low plasma portion and therefore less water content per unit volume).158 This follows because the


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concentration of alcohol in the vapor phase will be higher for the blood specimen with least water and therefore will contain a higher concentration of alcohol per mL blood-water.158 A blood sample with abnormally low hematocrit means a low number of blood cells and also a low hemoglobin content, which might be associated with a patient suffering from anemia. The other extreme is polycythemia, which is an overabundance of red cells per unit volume of blood and therefore an abnormally high hematocrit in this condition. The question of whether variations in hematocrit influence the maximum BAC reached from intake of a known amount of alcohol is difficult to answer because large changes in hematocrit are often associated with changes in the distribution of body water in general and therefore with an altered volume of distribution for ethanol.161 14.1.4 Breath-Alcohol Analysis Historical developments in testing for alcohol intoxication by use of chemical analysis of blood or breath were recently reviewed.162 Breath-tests for alcohol are currently used in forensic science practice and traffic law enforcement for two main purposes. The first and least controversial application involves roadside pre-arrest screening to furnish an objective indication of alcohol involvement and whether or not the driver might be above the critical legal limit for driving. In many situations, the police require probable cause before a chemical test for alcohol can be administered. This necessitates observations about the way the person was driving, and evidence of impairment from use of field-sobriety tests, which are important concerns before making an arrest and administering the chemical test for alcohol. Various hand-held devices are currently available for measuring breath-alcohol concentration at the roadside (Table 14.1.2). The most popular method of roadside breath testing involves the principle of electrochemical oxidation of alcohol with a fuel cell sensor and this technology is fairly selective because endogenous volatiles such as acetone and methane do not react with this kind of detector. However, if acetone is reduced in the body to isopropanol, this secondary alcohol is oxidized with the fuel cell sensor and can give a response that cannot be distinguished from ethanol.163 The results of roadside breath-testing might be displayed as colored lights such as pass (green), warn (yellow), or fail (red), or as a digital display of breath-alcohol concentration in units such as mg/L or g/210L depending on the particular jurisdiction (Table 14.1.1). If the screening test gives a positive response this indicates the driver has been drinking and may be over the legal limit, which is sufficient probable cause to demand a specimen of blood or breath for evidential forensic analysis. The suspect is then taken to a police station where an evidential breath-alcohol test is conducted; examples of instruments used in various countries are given in Table 14.1.1. When properly calibrated and operated, the hand-held screening devices can be as accurate as any other breath test instrument. Some of the limitations of screening devices when used for quantitative Table 14.1.2

Examples of the Most Commonly Used Hand-Held Breath-Alcohol Devices for Roadside Breath-Alcohol Screening Purposes and for Estimating the Coexisting Blood-Alcohol Concentrationa

Breath-test instrument

Method of alcohol analysis

Manufacturer and country

Alcolmeter SD-2 Alcolmeter SD-400 Alcotest 7410 Alcotest 6510 Alcosensor III and IV Alcodoose II Lifeloc FC10

Electrochemical oxidation Electrochemical oxidation Electrochemical oxidation Electrochemical oxidation Electrochemical oxidation Infrared Absorption (9.5 µm) Electrochemical oxidation

Lion Laboratories, U.K. Lion Laboratories, U.K. Dräger, Germany Dräger, Germany Intoximeters Inc., U.S.A. Seres, France Lifeloc Inc., U.S.A.

a

To estimate BAC from BrAC, the breath analyzers must be pre-calibrated with a blood:breath conversion factor such as 2100:1 or 2300:1.


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evidential purposes include: the lack of protection they provide against interference from mouth alcohol, the lack of blank tests or calibration control tests, the fact that they can generate low results at low temperatures, and also that for some older devices (Alcosensor III, Alcolmeter SD-2) the results are operator dependent; releasing the button before the reading has stabilized will generate a low result. Breath-alcohol instruments used for quantitative evidential purposes are generally more sophisticated than the hand-held screening devices and provide a printed record of results with date, time, location of the test as well as computer-storage of results for generating statistical reports. Moreover, these devices ensure that end-expired breath is being sampled and that residual alcohol in the mouth from recent drinking or regurgitation has not biased the result. A critical element in performing an evidential breath-alcohol test is always to observe the suspect for at least 15 min before making the breath test. During this time he or she should not be allowed to drink, eat, smoke, or place anything in the mouth prior to completing the test. Moreover, a duplicate test should be made not less than 3 min and not more than 15 min after completion of the first test. The instrument calibration must be controlled in conjunction with testing the subject and this is accomplished with a breath-alcohol simulator device or alcohol contained in compressed gas tanks. Analysis of the room-air provides a blank test result before and between making the duplicate tests with the subject. All these requirements have been described in detail elsewhere and are important for ensuring a successful evidential breath testing program that will withstand scrutiny.164 Regardless of these many new developments and improvements in the technology of breath-alcohol testing, challenges against the reliability of the results are far more common than against the results of blood-alcohol analysis. This probably stems from the fact that breath-testing is performed by police officers whereas blood-alcohol analysis is done at government laboratories by chemists, some of whom have research experience or a Ph.D. degree. Furthermore, the blood sample is usually retained and can be re-tested if there is any doubt about the results, whereas breath samples are generally not preserved and therefore cannot be re-tested. 14.1.4.1

Mouth Alcohol and Use of Mouthwash Preparations

Even during the first studies of breath-alcohol analysis as a test for intoxication, it was emphasized that testing should not be conducted too soon after the last drink.165 Thus, Emil Bogen in his landmark article, which was published in 1927, made the following statement; “As soon as the disturbing factor of alcoholic liquor still in the mouth is removed, which occurs usually within fifteen minutes after imbibition, in the absence of hiccuping or belching, the alcoholic content of 2 liters of expired air was a little greater than 1 cc of urine.”

A multitude of studies have been done since the 1930s to confirm the importance of a 15-min deprivation period after the last drink even though this problem is sometimes rediscovered from time to time.166 Most experiments on the influence of residual mouth alcohol on breath-test results have generally involved human subjects initially alcohol-free who are required to hold solutions of alcohol (40% v/v) in their mouths for 1 to 2 min without swallowing.167,168 Immediately after expelling the alcohol, the test subject undergoes a series of breath tests at 1- to 2-min intervals for 20 to 30 min. The results show that within 15 to 20 min after ejecting a strong solution of alcohol from the mouth, the response of the breath-alcohol analyzer is always less than 0.01 g/210 L, which is generally considered the threshold for baseline readings. Other study designs have involved measuring breath-alcohol in subjects after they drink alcohol to reach a certain BAC level.169 After rinsing the mouth with more alcohol, breath tests are made repeatedly until the results recover to the pre-drinking BrAC. Under these test conditions, the time needed to clear the residual alcohol from the mouth was even less than 10 min.169 Accordingly, on the basis of experiments such as these, rules and regulations for evidential breath-alcohol testing stipulate a 15- to 20-min observation period before conducting an evidential


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breath-alcohol test. During this time the suspect should not be allowed to smoke or drink or place any material in the mouth, and if he or she regurgitates or vomits, the observation period must be started again. Although a 15-min observation period is not mandated prior to conducting roadside breath-alcohol screening tests, in practice, a considerably longer time will usually have elapsed since the last drink was taken, unless the drinking took place while the person was driving. The time involved in stopping the vehicle, and contacting the driver, as well as any necessary field sobriety testing will usually take longer than 15 min. For reliable quantitative determinations, however, the 15-min deprivation period should be observed and documented. Many mouth-wash preparations contain alcohol as well as other organic solvents, and the concentrations sometimes are as high as 50 to 60% v/v. Obviously the use of these materials prior to conducting a breath-alcohol test would produce similar disturbances on breath-test results as having alcoholic beverages in the mouth. Provided that the 15 to 20 min observation time is maintained, use of breath fresheners containing alcohol will not have any negative impact on the reliability of the test result.170 However, if these preparations are intentionally or unintentionally consumed, this will be a source of alcohol just like drinking an alcoholic beverage. In a recent study with commercial mouthwash products, Listerine (29.6% alcohol), Scope (18.9% alcohol), and Lavoris (6.0% alcohol), tests were made on a breath-alcohol analyzer after rinsing the mouth with these preparations. Within 2 min of rinsing the mouth, breath-test results were as high as 240 mg/dL (expressed as BAC equivalent) but within 10 min this had dropped dramatically and was well below the threshold limits for driving (0.08 to 0.10 g/dL). By 15 min post-rinsing, the readings were below 0.01 g/dL. Similar results, namely no significant response with an infrared breathalcohol analyzer, were obtained 15 to 20 min or more after various mouthwashes, aftershave lotions, and perfumes in common use in Germany were tested.171 14.1.4.2

Regurgitation and Gastro Esophageal Reflux Disease (GERD)

The pioneer work by Bogen165 indicated that hiccuping, burping, and belching might present a problem in connection with breath-alcohol analysis. Only very limited investigations of this problem have been made, and these indicate that the risk of elevating breath-alcohol readings is greatest shortly after the end of drinking as might be expected because the concentration of alcohol in the stomach is then at its highest.172,173 A closely related problem is gastro-esophageal reflux disease (GERD).174–177 Many people suffer from acid-reflux disorders, known as reflux esophagitis, whereby gastric secretions as well as other liquid contents erupt from the stomach into the esophagus and sometimes reach the mouth.178–180 Indeed, this condition might be aggravated after drinking certain alcoholic beverages.181,182 The impact of GERD on results of evidential breathalcohol testing has not yet been investigated in any controlled studies. Nevertheless, this medical condition has been raised as a defense challenge from DUI suspects who maintain they experienced a reflux from the stomach into the mouth immediately prior to providing a breath-alcohol sample.183 The higher the concentration of alcohol prevailing in the stomach during a reflux, the greater the risk of contaminating the breath-sample in a similar mechanism to the mouth-alcohol effect. From this follows the contention that GERD is the cause of a person’s BrAC being above the legal limit for driving, and medical experts have testified to this effect, which has led to the acquittal of a DUI suspect.184 However, the validity of this defense argument was strongly questioned by another expert as being one of the least convincing, and he also noted that the doctors appearing for the defense “ignored one of the basic maxims in the business,” namely “what the subject says he has drunk is not evidence.”185 Although most evidential breath test instruments feature “slope detection” to disclose the presence of mouth alcohol, in some cases these may not detect small contributions resulting from belching or burping. A far better approach to counter the GERD defense challenge is always to observe the subject carefully, and to perform duplicate breath-alcohol analyses, that is two separate exhalations 3 to 5 min apart.185 Obtaining close agreement between the two independent results


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speaks against the influence of regurgitation of stomach contents having a high concentration of alcohol just prior to making the first breath-test or between the first and the second test. Also the risk of GERD elevating the breath test result decreases as the time after ingestion of alcohol increases because of the ongoing absorption of alcohol from the stomach and the emptying of the stomach contents into the duodenum. Evidential breath-alcohol programs that require only a single breath-alcohol test are out of date and should be abandoned especially if GERD is a recurring defense argument. The single chemical test for alcohol has no place in jurisdictions where per se statutes operate, regardless of whether blood or breath analysis is used for forensic purposes. 14.1.4.3

Dentures and Denture Adhesives

The question of people with dentures or individuals who might be fitted with special bridgework where alcohol can be trapped has arisen as a possible cause of obtaining a falsely elevated breath-alcohol reading.186,187 This challenge is therefore akin to having residual alcohol in the mouth from recent drinking. The empirical evidence supporting the notion that sufficient alcohol becomes trapped under denture plates or in other structures or cavities in the mouth for long periods of time is not very convincing, although a few isolated case reports support this defense argument.188 A person suspected for DUI in the U.K. was acquitted when expert testimony raised a reasonable doubt about the validity of the evidential breath test performed using an Intoximeter 3000 breath alcohol analyzer. Alcohol allegedly was trapped in cavities in the mouth as a result of dental treatment.186 However, the experiments and reasoning presented to support this defense argument were speculative, not very convincing, and were easy to fault.187 An acquittal in a DUI case in the U.S. was obtained when expert evidence suggested that the breath-test results were suspect because of alcohol being absorbed by the particular kind of denture adhesive used by the defendant.188 The most convincing study appearing in a peer-reviewed journal dealing with breath-alcohol testing and the use of dentures involved the participation of 24 subjects.189 They were tested under various conditions; with dentures intact, with dentures removed, and with dentures held loosely in place both with and without adhesives. The volunteers held 30 mL of 80 proof brandy in their mouths for 2 min without swallowing. After ejecting the alcohol, breath-alcohol tests were made with an Intoxilyzer 5000 instrument at regular intervals. After an elapsed time of 20 min, no results were above 0.01 g/210 L.189 This argues convincingly against the idea of people who wear dentures obtaining falsely elevated breath-alcohol concentrations. The widely practiced deprivation period and observation time of 15 to 20 min seems adequate to eliminate the risk of mouth-alcohol invalidating results even in people with dentures.190 A recent report described experiments in a person with dentures who was suspected of DUI. The defendant alleged that the brand of denture adhesive used was responsible for the breath alcohol reading being above the legal limit of 0.10 g/210 L breath.188 In one set of tests with a Breathalyzer model 900, which is not equipped with a slope detector, prolonged retention of alcohol was observed remarkably for several hours after 86 proof whisky was held in the mouth and when a certain brand of dental adhesive was used. These results suggest that some kinds of denture adhesives might retain alcohol for longer and lead to false high breath-alcohol readings. However, no corroborative reports of this have been published, and more controlled studies are necessary making use of duplicate measurements of blood and breath-alcohol concentration, weaker solutions of ethanol, and monitoring the shape of the BrAC exhalation profile in order to substantiate these surprising observations and conclusions. Many of the latest generation of breath-alcohol analyzers used for evidential purposes are equipped with a slope-detector mechanism, which is designed to monitor the time-course of BrAC during a prolonged exhalation.191,192 If the BrAC is higher at the start of an exhalation compared with at the end of the exhalation, this causes a negative slope and suggests a possible mouth alcohol effect or perhaps regurgitation of stomach contents or GERD. More work is necessary to evaluate


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the effectiveness of the slope detectors fitted to evidential breath-alcohol analyzers over a wide range of concentrations of alcohol in the mouth, and at various times after the end of drinking. 14.1.4.4

Alleged Interfering Substances in Breath

The alleged response of breath-alcohol instruments to interfering substances is a common DUI defense argument in many countries.193 The interferents in question are either claimed to have been produced naturally in the body, so called endogenous breath volatiles, or volatile organic compounds (VOC) inhaled with the ambient air during occupational exposure. The question of whether substances other than ethanol give a response on evidential breath-alcohol instruments escalated dramatically in the early 1970s after infra-red absorptiometry started to become the technology of choice for evidential purposes.194 Hitherto, the Breathalyzer model 900 dominated the field of breathalcohol testing in the U.S. and this device incorporates wet-chemistry oxidation with photometric endpoint for determination of BrAC.195 Although this represents a non-specific chemical oxidation reaction for the analysis of alcohol, provided the galvanometer on the Breathalyzer was read after exactly 90 seconds as per the instructions, the presence of acetone, toluene and other substances in the breath do not present a serious interference problem.196,197 Most infrared evidential breath alcohol devices provide some control for the presence of interfering substances with the use of either multiple filters, or dual technology, such as electrochemical oxidation in conjunction with infrared. Endogenous Breath Volatiles Human expired air consists of a mixture of gases including oxygen, nitrogen, carbon dioxide, water, vapor, and in extremely small amounts a multitude of volatile organic compounds (VOCs).198–200 The major endogenous breath volatiles are acetone, methane, and the unsaturated hydrocarbon isoprene (2-methyl-1,3-butadiene).201–204 The concentration of acetone expelled in breath is usually between 0.5 and 5 µg/L but this can increase appreciably if a person is deprived of food or engages in a prolonged fast.205 Moreover, during ketoacidosis, a condition often associated with hyperglycemia, diabetes mellitus, or alcohol withdrawal, the concentration of ketone bodies (acetone, acetoacetate and beta-hydroxybutyrate) circulating in the blood increases appreciably along with the concentration of acetone expelled in the breath.205–208 The question of whether VOCs other than ethanol might interfere with the results of evidential breath-alcohol testing started to become an issue of debate and concern shortly after the first Intoxilyzer instrument, a single wavelength (3.39 µm) analyzer, appeared for use in law enforcement.194 The Intoxilyzer measures the C-H bond stretching and vibrational frequencies in ethanol molecules, which means that abnormally high concentrations of acetone (blood/air distribution ratio approximately 300:1) in breath becomes a major candidate as an interfering substance. However, this problem was quickly solved by monitoring the absorption of infrared radiation at two wavelengths such as 3.39 and 3.48 µm as currently used with the Intoxilyzer 5000.193 Another approach to enhance selectivity is to incorporate two independent methods of analysis such as IR and electrochemical oxidation in the same unit as is used with the Alcotest 7110.209 When properly adjusted, the Intoxilyzer 5000 instrument corrects the ethanol signal for the presence of acetone in the breath. Moreover, if the concentration of breath-acetone exceeds 300 to 600 µg/L, corresponding to a blood concentration of 0.009 to 0.018 g/dL, the imbalance between the two filter signals exceeds a pre-set threshold value and the evidential test is aborted.193 The instrument reports an interferant detected and the “apparent ethanol” concentration is stored in an internal memory of the software. If very high concentrations of acetone are present in the blood, this ketone can be reduced by alcohol dehydrogenase in the liver to produce isopropanol, which also absorbs infrared radiation at the wavelengths used and can masquerade as ethanol.163 Methanol, which has highly toxic metabolites, presents a special problem if high concentrations are present in blood and breath because infrared breath-alcohol analyzers cannot easily distinguish this one-carbon


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alcohol from ethanol if only two infrared wavelengths are used. The potential for methanol to interfere with a breath test can best be addressed by a consideration of its toxicological properties.94 Isoprene is another endogenous VOC expelled in the breath. In experiments with 16 healthy subjects, the breath isoprene concentration ranged from 0.11 to 0.70 µg/L as determined by thermal desorption gas chromatography and UV detection.201 These concentrations are much too low to interfere with the measurement of breath-alcohol with the infrared technology currently used for evidential purposes. Methane is produced in the gut by the action of colonic bacteria on disaccharides and this VOC can be detected in human expired air. It seems that some individuals are more prone than others to generate methane in the large intestine and the concentration of this hydrocarbon expelled in breath under different conditions requires more documentation.204 Methane should perhaps be considered as a potential interfering substance in connection with forensic breath-alcohol testing by infrared methods, but more research is necessary on this topic before raising an alarm.203 Acetaldehyde is a VOC produced during the metabolism of ethanol by all known enzymatic pathways and is also a major constituent of cigarette smoke. The high volatility and low blood/air partition coefficient of acetaldehyde (190:1) means that this substance crosses the alveolar-capillary membrane of the lungs and enters the breath.210 Because acetaldehyde absorbs IR radiation in the same region as ethanol (3.4 to 3.5 µm) this VOC might be considered a potential interfering substance in connection with evidential breath-alcohol testing. This problem was investigated empirically in tests with a single wavelength (3.39 µm) infrared analyzer under conditions when abnormally high concentrations of breath-acetaldehyde (50 µg/L) existed.211 This was accomplished by inhibiting the metabolism of acetaldehyde by pretreatment of subjects with Antabuse-like drugs before they drank alcohol. Even under these extreme conditions, no false-high apparent ethanol readings were obtained. In recent reviews of the biomedical alcohol research literature, it seems that the concentrations of acetaldehyde in blood are very low during oxidation of ethanol (< 88 µg/L corresponding to 0.46 µg/L in breath) that this metabolite of ethanol cannot be seriously considered an interfering VOC when testing drunk drivers with the aid of infrared analyzers.210,212 Occupational Exposure to Organic Solvents A few studies have dealt with the response of infrared breath-alcohol instruments after occupational exposure to solvent vapors, although no convincing evidence of an interference problem has emerged, provided that at least 20 min elapses after leaving the work environment.213 In an effort to investigate the claims from two convicted drunk drivers that inhalation of solvents caused false high readings on an infrared breath-alcohol instrument, the men volunteered to spray cars with toluene/xylene/methanol-based paint thinner under extreme working conditions and without the use of protective clothing or face masks.214 They worked for several hours in a small poorly ventilated room making use of 5 to 7 liters of paint during this time. It was noted that their eyes were watering and they were suffering from severe irritation, coughing regularly and complaining of sore throats. Tests with one of the subjects gave measurable apparent ethanol responses during the exposure. Results with an infrared breath analyzer (Intoximeter 3000) were consistently higher than those obtained with an electrochemical instrument (Alcolmeter S-D2). At times of 0 min, 15 min, and 30 min after leaving the small working environment, one subject gave BrAC results of 0.019, 0.010, and 0.002 g/210 L on the IR analyzer. The lack of any instrument responses for the other subject was explained by a considerably lower environmental temperature on the day of the testing, and this presumably led to a less efficient vaporization of the solvents. Inhalation of gasoline fumes as might occur if a person sniffs this liquid or engages in siphoning gasoline between cars can cause falsely elevated readings on the Intoxilyzer 5000.215,216 In an actual DUI case scenario, the Intoxilyzer reacted by aborting the test because an interfering substance or substances were detected.193 Gasoline contains, among other things, a complex mixture of aliphatic and aromatic hydrocarbons and these were also qualitatively identified in a blood sample taken from the suspect whose blood-alcohol concentration was zero. Abuse of organic solvents such as


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thinner or glue is another source of interfering substances in connection with evidential breathalcohol testing.217 People who abuse these materials often tend to smell of the solvents they inhale, and may display characteristic symptoms of intoxication. If there is evidence to suggest solvent abuse, or extended exposure to solvent fumes, arrangements should be made for obtaining blood samples instead. Diethyl ether is another solvent capable of interfering with the response of dual wavelength infrared breath-alcohol instruments and being mistakenly reported as ethanol.218 This solvent is no longer widely used in industry or hospitals, so the risk of being exposed to ether in everyday life is not very high, although it is present in carburetor or starting fluid. Several other case reports have appeared suggesting that work-related inhalation of toluene and lacquer fumes in conjunction with normal occupational exposure gives readings on IR analyzers exceeding 0.10 g/210L.219,220 However, the test subject who had been apprehended for DUI sometimes showed behavioral manifestations of solvent inhalation or abuse and was chronically exposed to these agents over a period of many years, so accumulation of toluene in body fat depots cannot be excluded. Some drunk drivers use technical spirits for intoxication purposes and these solvents contain ethanol, methanol, methyl ethyl ketone, ethyl acetate, and isopropanol as well as other VOCs. These substances absorb IR radiation and can be mistakenly identified as ethanol with some IR breathalcohol analyzers.221 By comparing the results from a pre-arrest roadside test utilizing an electrochemical sensor for ethanol determination, with the results from infrared evidential analyzers, useful information can be gleaned about the presence of an interfering substance. The two detector systems (IR and Fuel cell) respond differently to different VOCs in the breath; electrochemical sensors don’t respond to acetone or hydrocarbons.222,223 A comprehensive series of experiments on the subject of evidential breath-alcohol testing and the response to organic solvents was made in the U.K., where two infrared analyzers have been used for legal purposes since 1983.224–226 Human volunteers were exposed on different occasions to toluene, 1,1,1-trichlorethane, butane, white spirit, and nonane under controlled conditions, and blood and breath were sampled at regular intervals after ending the exposure. The volunteers assumed a resting position talking and playing cards during a 4-h period of exposure to the solvents at concentrations close to the upper limits prescribed for the workplaces in the U.K. After inhalation of butane vapor a response was seen on the infrared breath analyzers lasting for 1 to 5 min after exposure, before rapidly declining to zero.224 Exposure to toluene and 1,1,1-trichloroethane did not give any response on the IR analyzers although these substances were identified in blood samples for up to 8 h after exposure ended.224 The concentration of the solvents in blood and breath decreased rapidly on ending the exposure, which supports the conclusion that normal occupational use of solvents would be unlikely to contribute to false high results on IR breathalcohol analyzers. Similar negative findings on evidential breath-test results were reported after inhalation of nonane and white spirit.225 Elevation of blood and breath-alcohol concentrations as a result of inhalation of ethanol vapors by brewery or distillery workers or industrial workers required to handle ethanol-based solvents has been a recurring argument in DUI trials.227 One of the first controlled studies was done in 1951 with subjects being exposed to varying concentrations of ethanol vapor for up to 6 h.227 The results showed that alcohol could be absorbed into the blood by inhalation through the lungs, and that the BAC attained was proportional to the concentration of ethanol in the inhaled air and the rate of ventilation. However, extreme conditions were necessary to build-up a BAC exceeding 0.01 g/dL, and the methods of blood and breath-alcohol analysis were fairly primitive.227 Note that between 6 to 8 g of ethanol can be metabolized per hour so uptake by inhalation and absorption through the lungs must exceed this amount before the BAC will increase above base-line levels. Moreover, it was noted that inhalation of air-alcohol concentrations of 10 to 20 mg/L caused coughing and smarting of the eyes and nose. Untoward effects were more pronounced at concentrations of 30 mg/L, and at 40 mg/L the situation was barely tolerable, making it impossible to remain in this atmosphere for any length of time.


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Several more recent studies have looked in theory and practice at the reality of generating an elevated BAC from inhalation of ethanol vapor.228–230 From these experiments we conclude that obtaining a BAC exceeding 0.003-0.005 g/dL is highly unlikely as a result of normal occupational exposure owing to the metabolism of ethanol that occurs during and immediately after ending the exposure.231 However, if a person already has an elevated BAC before entering an atmosphere with a very high alcohol vapor concentration (simply sitting in a bar is not sufficient!), then the metabolism of alcohol and clearance of BAC might be delayed during the inhalation period. This would lead to a shallower β-slope than expected if the intake of alcohol by inhalation is sufficient to balance the amount eliminated by metabolism.232 In short, caution should be exercised in interpreting breath test results from subjects with extensive solvent exposure immediately prior to the breath test. Most solvents are rapidly distributed and eliminated following environmental exposure. There is no evidence that casual exposure to solvents or solvent-containing products will exert an effect on an evidential breath test administered an hour or more later. 14.1.4.5

Variability in the Blood/Breath Alcohol Ratio

Historically, the first breath-alcohol instruments were developed and used as an indirect way of measuring a person’s blood alcohol concentration. Breath-testing was considered more practical than blood-testing for traffic-law enforcement purposes,162 because of the noninvasive sampling technique and the fact that an immediate indication of the person’s blood-alcohol concentration and state of inebriation were obtained.233 Conversion of a measured BrAC into the expected BAC was accomplished by calibrating the breath-analyzers with a constant factor (2100:1), which was known as the blood/breath ratio of alcohol. The figure of 2100:1 had been determined empirically by equilibration of blood and air at constant temperatures in vitro and also in vivo by taking samples of breath and venous blood at nearly the same time from a large number of volunteer subjects.234,235 In the post-absorptive phase of alcohol metabolism, studies showed that the blood/breath ratio of alcohol was approximately 2100:1, and this figure was subsequently endorsed by several meetings of experts with international representation.162 However, the blood/breath ratio is not a constant for all individuals and varies within the same individual from time to time and during different phases of alcohol metabolism.236 This variability needs to be considered when the results of breath-alcohol testing are used in criminal litigation to estimate a person’s blood-alcohol concentration. All analytical results have inherent uncertainty, resulting from a combination of human error, systematic errors in calibration, random instrument error, etc. In a forensic context, the extent of any error should be known by analysis of appropriate standards and controls, and the contribution of error or uncertainty in the measurement should be considered when the result is interpreted. When measurements are being made of dynamic systems, such as exhaled human breath samples, further biological variation outside of the control of the analyst is introduced. The inherent variability in the blood/breath alcohol ratio among different individuals is an excellent example of this, and has emerged as a hot topic of discussion and debate in the scientific literature and in the courts.17–22 For many years, the results of breath-alcohol analysis in law enforcement were overshadowed by inherent variations in blood/breath ratio and allegations that BAC had been overestimated by use of breath-test instruments. Obtaining an estimated BAC that was too high was more likely during the absorption phase, when BAC was still rising, because of the existence of arterial-venous (A-V) differences in alcohol concentration. The time course of breath-alcohol concentration follows more closely the arterial BAC than the venous BAC, with the arterial BAC exceeding the venous during the absorptive phase, and vice versa during the elimination phase. Moreover, the 2100:1 ratio was originally determined by comparing venous BAC and BrAC in samples taken during the post-absorptive phase of alcohol metabolism when A-V differences are small or negligible.234 The actual blood/breath conversion factor is clearly a moving target, and its value depends on many factors that are impossible to know or control in any individual subject at the time of testing. Several more recent studies comparing blood and breath-alcohol in DUI suspects show that in the field,


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the blood/breath ratio is closer to 2400:1 with a 95% range from 1900 to 2900, indicating a strong bias in favor of the suspect being breath-tested in comparison with the same person providing a specimen of blood for analysis at a forensic laboratory.237–240 In an attempt to quell much of the troublesome debate that was erupting over the continued use of a constant blood/breath ratio, experts in the field of chemical tests for intoxication met to discuss the scientific and legal issues involved. The fruits of this meeting came in the form of a signed statement endorsing the continued use of the 2100:1 ratio for clinical and forensic purposes. Several new studies verified that the 2100:1 ratio gives a generous margin of safety in favor of the subject by about 10% compared with venous BAC analyzed directly.241,242 In controlled laboratory studies, with blood and breath samples taken during the post-absorptive phase of alcohol metabolism, a blood/breath ratio of 2300:1 was more appropriate to give unbiased estimates of venous BAC.241 To eliminate the entire problem of variability in the blood/breath ratio and the need to convert BrAC to BAC, Mason and Dubowski suggested that the threshold alcohol limit for driving should be defined in terms of the person’s BrAC at the time of the test.242 This approach was clearly similar to the use of UACs in Great Britain, where the statutory limits for motorists are 80 mg/dL in blood or 107 mg/dL in urine, which implies a UAC/BAC of 1.33:1.14 Because a blood-alcohol concentration limit of 0.10 g/dL was already widely accepted in the U.S., the corresponding threshold BrAC limit was set at 0.10 g/210 liters of breath. By including the 210 liters in the wording of the statute, the weight of alcohol (0.10 g) remained the same regardless of whether blood or breath-alcohol testing were used for analysis. Much is often made over these units given the fact that 210 L is a larger volume than any human could exhale. This is clearly a spurious issue, however, since only a portion of the breath (typically around 50 mL) is being tested, and the units used are g/210L. The results could equally well be expressed in µg/L, mg/mL, micromoles per liter, or any other concentration units. Any units can be used, provided that the instrument is calibrated with the appropriate standards, having concentrations of alcohol similar to the unknown breath samples. Accordingly, a person’s BAC or BrAC are now considered equivalent for the purpose of generating evidence of impairment at the wheel. Eliminating the need to convert BrAC into BAC in every single case led to a dramatic reduction in spurious litigation concerning blood/breath ratios of alcohol and inherent variability. Furthermore, the effects of alcohol on psychomotor performance, as well as roadside surveys of the risk of involvement in traffic accidents, have been conducted with breath-test instruments (e.g., the Grand Rapids survey) and not by the analysis of BAC directly. However, several U.S. states, among others New Jersey, still persist in translating the breath-alcohol readings into a presumed BAC. Indeed, the use of breath-alcohol testing was the subject of a vigorous defense challenge in 1989 in the State of New Jersey, where the Breathalyzer was well established for testing drinking drivers. The DUI statute in New Jersey stipulated that a person’s blood-alcohol concentration should be estimated indirectly by analysis of the breath. The gist of the defense argument was that the 2100:1 blood/breath ratio was biased against the person being tested. Considerable expert testimony was called to answer questions about variation in the blood/breath conversion factor used. This “Downie case” was eventually settled by the Supreme Court of New Jersey ruling in favor of the continued use of the Breathalyzer 900 in law enforcement and also keeping the 2100:1 conversion factor unchanged. The bulk of the expert testimony and the most credible witnesses took the stance that breath-tests involving a 2100:1 ratio tended to underestimate the venous blood-alcohol concentration for samples taken in the post-absorptive phase of alcohol metabolism and when results are truncated to two decimal places. When the countries in Europe introduced evidential breath-alcohol testing in the early 1980s, the threshold BrAC limits were derived from the pre-existing BAC limits on the basis of a presumed blood/breath ratio, either 2000:1, 2100:1, or 2300:1 depending on the country. Thus, 0.50 mg/mL, which is the statutory BAC limit in the Netherlands, became 220 µg/L in breath, being derived from 0.50/2300 = 0.000217 and rounding to 0.00022, before moving the decimal point to obtain appropriate units of μg and liters. The threshold BrAC limits corresponding to already established BAC limits in different countries are shown in Table 14.1.1.


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14.1.4.6


Pulmonary Function (Chronic Obstructive Pulmonary Disease)

The basic premise of breath-alcohol testing is that the concentration of alcohol in pulmonary capillary blood equilibrates with alveolar air at normal body temperature.243 However, the air in the upper airways and dead-space regions of the lungs also contains alcohol by a diffusion process from the mucous membranes receiving alcohol from blood supplying the tissue in the upper respiratory tract. Furthermore, alcohol from the upper respiratory tract may be picked up in the inspired air and deposited further down the tract during inspiration, only to be redistributed again during expiration, with some of the alveolar alcohol being deposited back into the depleted tissues of the upper airways.244 The net effect is that the alcohol which appears on the expired breath does so as a result of a complex dynamic process, which varies in degree from individual to individual. As indicated in the previous section, however, where the law specifies a BrAC per se offense, the actual mechanism is not relevant, and the per se BrAC offense is readily justified in terms of impairment associated with BrAC. Modern breath-alcohol instruments are equipped with automated procedures for sampling breath and these monitor the volume exhaled and the concentration of alcohol during a prolonged exhalation. If a person manages to exhale a certain minimum volume of breath for a given length of time to satisfy the sampling requirements, a portion of the end-expired air is captured for analysis of alcohol. Some individuals, particularly those with impaired lung function, will genuinely be unable to satisfy the sampling parameters of some evidential breath-alcohol analyzers currently being used.245,246 Indeed, even subjects with healthy lungs, especially women of small stature and those who habitually smoke cigarettes, might have insufficient lung capacity to exhale for the minimum required time. Moreover, at high blood-alcohol concentration, the ability of a person to provide an approved sample of breath might be reduced compared with the sober state.247 The rules and regulations pertaining to evidential breath-alcohol testing should therefore contain an option for the suspect to provide a blood sample if he or she fails to satisfy the sampling requirements because of pulmonary limitations. In Great Britain, the policeman operating the instrument has to decide whether the suspect is not cooperating properly in providing the required sample. If this happens, the person can be charged with “failing to provide” as a separate offense that carries the same punishment as if the BrAC had been above the legal limit for driving.14,245 Many people charged and prosecuted for “failing to provide” in the U.K. have later been vindicated by seeking medical advice and undergoing pulmonary function tests.248,249 This prompted the British Home Office scientists to embark on a series of studies into the ability of people with small stature and impaired lung function to satisfy the sampling requirements of various breath-alcohol testing instruments.245,250 Those individuals with forced expiratory volume in one second (FEV1.0) of less than 2.0 L and forced vital capacity (FVC) of less than 2.6 L were unable to use some of the breath-testing equipment evaluated. In another study with healthy subjects less than 5 ft 5 in. (165 cm) tall, some were unable to provide the required breath sample.250 This report, however, fails to specify the ages of the subjects, whether they were tested under the influence of alcohol, and whether they smoked cigarettes. These variables are important when the ability of a person to provide an approved breath sample has to be judged. Asthma is an inflammatory disease of the airways causing obstruction to breathing and a reduction in air flow. Respiratory inhalers used by asthmatics contain salbutamol (β2-adrenergic bronchodilator) as the active ingredient. It is the mainstay treatment for acute attacks of asthma. The use of this inhaled medication just prior to being breath-tested with Intoximeter 3000 (infrared) and Alcolmeter S-D2 (electrochemistry) failed to produce a response of apparent alcohol.251 A similar lack of response was reported for a number of nasal sprays used by people with impaired lung function.252 Some asthma inhalers contain ethanol as an ingredient and this means that a response is more likely to occur immediately after their use. However, within 2 to 9 min after using a wide range of inhalers and sprays, the small positive response on the breath analyzers was eliminated.253


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To test the influence of chronic obstructive pulmonary disease (COPD) on breath-alcohol analysis, patients suffering from COPD received 60 to 70 g ethanol and their blood-alcohol concentration was compared with results using the Breathalyzer model 900 at various times after drinking. The resulting blood/breath ratios were consistently higher than the 2100:1 calibration factor used with the Breathalyzer 900 instrument, so breath-tests for alcohol are not detrimental to those individuals who suffer from COPD.254 In a more recent study with 12 COPD patients as well as an age matched control group of subjects, alcohol (0.60 g/kg) was given by intravenous infusion and blood and breath-alcohol concentrations were determined for up to 4 h.255 The blood/breath ratios of alcohol in the control group and patients with COPD varied with time after infusion of alcohol and in the post-peak phase of metabolism of alcohol, the values were mostly in excess of 2400:1.255 Summing up these experiments in patients with pulmonary disease, there is no solid evidence to suggest that impaired lung function (asthma, COPD, emphysema) puts them at risk of being unfairly prosecuted for drunk driving when per se alcohol limits operate.256,257 If people with these pulmonary limitations manage to provide an approved breath sample, there is no reason to believe that the test result will be greater than for people with healthy lungs having the same blood-alcohol concentration. On the contrary, because of the higher blood/breath ratios in people suffering from COPD compared with age-matched control subjects, those with COPD who might be breath-tested have an advantage.255 14.1.4.7

Breathing Pattern and Hypo- and Hyperthermia

For a given individual, the concentration of alcohol expelled in the breath depends on the concentration existing in the pulmonary blood, which depends on the amount of alcohol consumed and the time after drinking when breath-tests are made.243 However, the concentration of alcohol measured in the breath at a given blood-alcohol concentration depends on numerous factors, especially the person’s pattern of breathing prior to exhalation and body temperature. Also, various design features of the breath-alcohol analyzer, such as the resistance to exhalation and the geometry of the breath-inlet tube, and also the kind of mouthpiece and spit-trap fitted to the instrument, are important to consider when variations in test results have to be explained.258–260 The influence of a person’s breathing pattern prior to exhalation has been evaluated in several studies and variables such as breath-holding, hyper- and hypoventilation, as well as shallow breathing were investigated.258 Most changes in the pre-exhalation maneuver decrease the BrAC in the final exhalation compared with a control sample comprising a moderately deep inhalation and forced end-exhalation. However, breath-holding or hypoventilation before providing breath for analysis increases the concentration of alcohol in the breath-sample by about 10 to 20%.261,262 This higher BrAC is caused in part by a higher breath temperature and the longer time available for equilibration of alcohol with the mucous surfaces in the upper airways.263 Body temperature has an important influence on BrAC because the temperature coefficient of alcohol solubility is ± 6.5% per degree centigrade.264 Local cooling of the mouth and upper-airway by breathing cold air will decrease breath-temperature and breath-alcohol concentration.265 Keeping ice in the mouth before and during exhalation leads to a marked lowering in the person’s BrAC, in part because of the high solubility of alcohol in water condensing from the ice, and condensation of ethanol vapor in the mouth.266 Isothermal re-breathing devices have been described for use with breath alcohol equipment.267 The net effect of this device is to allow better equilibriation of alcohol with all the tissues in the respiratory tract, thus raising the breath test result by about 10%, and showing a closer agreement to the blood alcohol result when a blood/breath ratio of 2100:1 is assumed.267 Controlled studies of the influence of hypo- and hyperthermia on breath-alcohol test results with Breathalyzer model 900 were reported by Fox and Hayward.268,269 The deep-core body temperature was raised by keeping volunteer subjects immersed up to their necks in water at 42°C for 45 min. This caused a 2.5°C rise in body temperature and a 23% distortion (increase) in the breath-alcohol


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concentration. Immersion of the subjects up to the neck in cold water at 10°C for 45 min caused mild hypothermia and the breath-alcohol concentration decay curve was distorted downwards by 22%. When subjects were returned to normothermic conditions, the BrAC readings recovered to reach the values expected from past experience with the Breathalyzer 900, that is, results were about 10% less than the corresponding blood-alcohol concentration directly determined. 14.1.5 Concluding Remarks The widespread use of statutory alcohol concentration limits for motorists simplifies the prosecution of drunken drivers and makes this process more effective. Accordingly, a person’s blood or breath-alcohol concentration has become the single most important evidence for successfully prosecuting DUI suspects. It should, however, always be considered in the context of other evidence, such as observations about the subject’s driving ability, outward behavior, and response to questions and performance in field sobriety tests. This has meant that defense arguments focus heavily on trying to discredit and cast doubt on the reliability of the result of analyzing alcohol in blood and/or breath. Of the two, it seems that results of measuring blood-alcohol are much less frequently questioned than those obtained by analyzing the breath. This probably stems from the earlier tradition of translating a measured BrAC into a presumed BAC for forensic purposes. The magnitude of variation in the conversion factor (blood/breath ratio) from person to person and in the same person over time triggered many defense challenges, which still persist today. The uncertainty in the sampling and analysis of breath and the conversion factors used have attracted much debate in the scientific literature and in the courts. The entire problem with blood/breath ratios should have been eliminated after defining the statutory alcohol limits for driving as the BrAC per se and thus sidestepping the need to convert BrAC into BAC. Furthermore, mostly under the control of a built-in microprocessor, evidential breath-alcohol instruments are typically operated by police officers and not by chemists. This apparent vested interest in the outcome of the test result tends to make breath-alcohol testing more suspect according to some critics, and vulnerable to defense attacks compared with blood alcohol measurements performed at a forensic laboratory. Much could be done to improve forensic alcohol analysis by paying more attention to pre-analytical factors, in particular the methods and procedures used to obtain samples of body fluids (blood, breath, or urine). The responsibility for sampling, transport, and initial storage of specimens is usually in the hands of the police and other personnel who lack training in clinical laboratory methods.270 The use of a checklist to document certain key aspects of the sampling protocol and the various precautions taken is highly recommended.271 Any mishaps or unusual incidents that occur during sampling, as well as the behavior and appearance of the suspect, should be carefully noted. These might become important later when the results of alcohol analysis are interpreted by the court. The trend toward accreditation of clinical and forensic laboratories will help to standardize and document analytical procedures and establish acceptable standards of performance that minimize the risk of laboratory blunders. Forensic tests for alcohol, however, should always be held to a high standard, and where there is error, mistakes, or uncertainty, this should be honestly recognized and accrue to the defendant’s favor. As long as there is a lot of money to be made in defending drunk drivers, or testifying on their behalf, there will always be lawyers and expert witnesses prepared to embark on crusades to discredit the police, the laboratory, or both. To focus an attack on the scientific background of forensic alcohol testing, a defense lawyer requires the services of an expert witness.272 There are plenty of these individuals available, many of whom can be located through professional directory listings of their names, addresses, academic qualifications, experience, and often their fee. Most of these experts are willing to testify for the defense, the prosecution, or both and will generally testify in either criminal or civil litigation. During the highly publicized Daubert decision from the U.S. Supreme Court, much was written about the use of scientific evidence and how best to judge the testimony of expert witnesses.273 At


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about this time, an editorial in the scientific journal Nature made the following statement about expert witnesses:274 The so-called expert witness in court may be a hired-gun, willing to testify to anything for a fee, or a crackpot whose insupportable ideas are masked by an advanced degree (Ph.D.) often from a respectable university.

William S. Lovell (chemist and district attorney) made the following observation about the use and abuse of expert testimony in DUI litigation as long ago as 1972:275 Courts are indeed plagued by the instant expert, who whether out of a misguided eagerness to earn his fee or an overreaction to his own self-described credentials, may expound far reaching opinions.

The courtroom can be a cruel place and skillful use of expert testimony plays a much bigger role in deciding the outcome of DUI trials held in the U.S. and Britain than in continental Europe. In Britain and the U.S., the adversarial system of justice operates, which aims to establish the truth by probing the strengths and weaknesses of defense and prosecution cases.276 This opens the door for selecting expert witnesses known for their strong opinions and outspoken views about key elements of the scientific evidence crucial for the case. This is somewhat different from the situation in continental Europe and Scandinavia where the inquisitorial system operates and an investigating judge or judges appoint the necessary forensic experts who conduct tests and make investigations independent of the prosecution.277,278 This gives the impression that forensic experts evaluate the scientific evidence in a more impartial way and arrive at an opinion based on their findings. This takes the form of a written report to the court, similar to a deposition, but occasionally the expert is also expected to appear in person to present his conclusions and receive questioning from the defense and prosecution attorney. As far as possible, expert witnesses should base their testimony on personal experience and studies they have conducted themselves and the results of which have been published in the peerreviewed literature. But even peer-reviewers make mistakes and publication per se does not make the results gospel. Scientists are not infallible and unsubstantiated opinion is no substitute for personal experience and well designed experiments. If scientific evidence is important in criminal or civil litigation, it might be better for the judge to appoint suitably qualified experts instead of relying on witnesses chosen by the opposing sides.279 This was one of the recommendations of the Daubert decision of the U.S. Supreme Court, and has already been put into practice in Oregon, in a case concerning the health hazards of silicone breast implants.280 Unfortunately, the demeanor and manner of the witness often determines whether or not the evidence they present is accepted by the jury, rather than the validity of the science on which the opinion is based.281 Complex scientific issues can usually not be satisfactorily discussed and debated in the courtroom by lawyers posing set-piece questions to expert witnesses, many of whom have poor or inappropriate qualifications and questionable motives.281,282 Other complicating factors are that the attorneys are often prepared to use any available means, including confusing the jury, obfuscating the issues, and impugning the expert testimony, in order to gain an acquittal, rather than pursuing an objective search for the truth. REFERENCES 1. 2. 3. 4.

Heise, H.A., Alcohol and automobile accidents. JAMA 103, 739, 1934. Heise, H.A., Halporn, B., Medicolegal aspects of drunkenness. Penn Med J 36, 190, 1932. Holcomb, R.L., Alcohol in relation to traffic accidents. JAMA 111, 1076, 1938. Borkenstein, R.F., Historical perspective: North American traditional and experimental response. J Stud Alc Supp. 10, 3, 1985.


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5. Andréasson, R., Jones, A.W., Historical anecdote related to chemical tests for intoxication. J Anal Toxicol 20, 207, 1996. 6. Ladd, M., Gibson, R.B., The medicolegal aspects of the blood test to determine intoxication. The Iowa State Law Review 24, 1, 1939. 7. Bavis, D.F., Arnholt, M.F., Tests of blood and urine of drunken drivers. Nebraska State Med J 24, 220, 1939. 8. Newman, H.W., Fletcher, E., The effect of alcohol on driving skill. JAMA 115, 1600, 1940. 9. Newman, H.W., Acute Alcoholic Intoxication; A Critical Review. Stanford University Press, Stanford, CA, 1941. 10. Hingson, R., Heeren, T., Winter, M., Lowering state legal blood alcohol limits to 0.08%: The effect on fatal motor vehicle crashes. Am J Pub Health 86, 1297, 1996. 11. Wagenaar, A.C., O’Malley, P.M., LaFond, C. Lowered legal blood alcohol limits for young drivers: effects on drinking, driving, and driving after drinking behaviors in 30 states. Am J Pub Health 91, 801, 2001. 12. Jones, A.W., Blood and breath-alcohol concentrations. Br Med J 305, 955, 1992. 13. Council on Scientific Affairs, American Medical Association Council Report. Alcohol and the driver. JAMA 255, 522, 1986. 14. Walls, H.J., Brownlie, A.R., Drink, Drugs and Driving. Sweet & Maxwell, London, 1985. 15. Jones, A.W., Enforcement of drink-driving laws by use of per se legal alcohol limits: Blood and/or breath concentration as evidence of impairment. Alc Drugs and Driving 4, 99, 1988. 16. Ziporyn, T., Definition of impairment essential for prosecuting drunken drivers. JAMA 253, 3509, 1985. 17. Tarantino, J., Defending Drinking Drivers. James Publishing Inc., Santa Ana, CA, 1986. 18. Head, W.C., Joye, Jr. R.I., 101 ways to avoid a drunk driving conviction. Maximar Publishing Company, Atlanta, 1991. 19. Fitzgerald, E.F., Hume, D.N., Intoxication test evidence: Criminal and Civil. The Lawyers Cooperative Publishing Company, 1987. 20. Nichols, D.H., Drinking/Driving litigation: Criminal and Civil. Callaghan, Deerfield, Il., 1985. 21. Erwin, R., Defense of Drunk Driving Cases, Criminal/Civil. Matthew Bender, New York, 1996. 22. Cohen, H.M., Green, J.B., Apprehending and prosecuting the drunk driver. Matthew Bender, New York, 1995. 23. Denney, R.C., The use of breath and blood alcohol values in evaluating hip flask defences. New Law Journal, Sept. 26, 923, 1986. 24. Lewis, M.J., The individual and the estimation of his blood alcohol concentration from intake with particular reference to the hip-flask drink. J Forens Sci Soc 26, 19, 1985. 25. Jones, A.W., Widmark’s equation; Determining amounts of alcohol consumed from blood alcohol concentration. DWI Journal; Law and Science 3, 8, 1989. 26. Forrest, A.R.W., The estimation of Widmark’s factor. J Forens Sci Soc 26, 249, 1986. 27. Iffland, R., Staak, M., Rieger, S., Experimentelle Untersuchungen zur Überprüfung von Nachtrunkbehauptungen. Blutalkohol 19, 235, 1982. 28. Biasotti, A.A., Valentine, T.E., Blood alcohol concentration determined from urine samples as a practical equivalent or alternative to blood and breath alcohol tests. J Forens Sci 30, 194, 1985. 29. Jones, A.W., Ethanol distribution ratios between urine and capillary blood in controlled experiments and in apprehended drinking drivers. J Forens Sci 37, 21, 1992. 30. Grüner, O., Ludwig, O., Rockenfeller, K., Die Bedeutung der Doppelblutentnahmen für die Beurteilung von Nachtrunkbehauptungen. Blutalkohol 17, 26, 1980. 31. Bonte, W., Begleitstoffe alkoholischer Getränke. Verlag Max Schmidt-Röshild, Lübeck, FRG, 1988. 32. Iffland, R., Congener analysis of blood in legal proceedings: Possibilities and problems. In: W. Bonte, editor, Proc. In: Workshop on Congener Alcohols and Their Medicolegal Significance. University of Düsseldorf, 1987, p 236. 33. Bilzer, N., Grüner, O., Methodenkritische Betrachtungen zum Nachweis aliphatischer Alkohole im Blut mit Hilfe der Headspace-Analyze. Blutalkohol 20, 411, 1983. 34. Bonte, W., Contributions to congener analysis. J Traffic Med 18, 5, 1990. 35. Roine, R.P., Eriksson, C.J.P., Ylikahri, R., Penttilä, A.M., Salaspuro, M., Methanol as a marker of alcohol abuse. Alcoholism Clin Exp Res 13, 172, 1989. 36. Buchholtz, U., Blutmethanol als Alkoholismusmarker. Blutalkohol 30, 43, 1993.


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37. Haffner, H.Th., Graw, M., Besserer, K., Blickle, U., Henssge, C., Endogenous methanol: variability in concentration and rate of production. Evidence of a deep compartment. Forens Sci Intern 79, 145, 1996. 38. Jones, A.W., Top-ten defence challenges among drinking drivers in Sweden. Med Sci Law 31, 429, 1991. 39. Jones, A.W., Status of alcohol absorption in drinking drivers. J Anal Toxicol 14, 198, 1990. 40. Jones, A.W., Jönsson, K.Å., Neri, A., Peak blood-alcohol concentration and the time of its occurrence after rapid drinking on an empty stomach. J Forensic Sci 36, 376, 1991. 41. Jones, A.W., Interindividual variations in the disposition and metabolism of ethanol in healthy men. Alcohol 1, 385, 1984. 42. Jones, A.W., Neri, A., Evaluation of blood-ethanol profiles after consumption of alcohol together with a large meal. Can Soc Forens Sci J 24, 165, 1991. 43. Gullberg, R.G., Variations in blood alcohol concentration following the last drink. J Police Sci Admin 10, 289, 1982. 44. Shajani, N.K., Dinn, H.N., Blood alcohol concentrations reached in human subjects after consumption of alcohol in a social setting. Can J Forens Sci Soc 18, 38, 1985. 45. Zink, P., Reinhardt, G., Der Verlauf der Blutalkoholkurve bei großen Trinkmengen. Blutalkohol 21, 422, 1984. 46. Jones, A.W., Andersson, L., Influence of age, gender, and blood-alcohol concentration on the disappearance rate of alcohol from blood in drinking drivers. J Forens Sci 41, 922, 1996. 47. Allanowai, Y., Moreland, T.A., McEwen, J., Halliday, F., Durnin, C.J., Stevenson, I.H., Ethanol kinetics — extent of error in back extrapolation procedures. Br J Clin Pharmacol 34, 316, 1992. 48. Lewis, K.O., Back calculation of blood alcohol concentration. Br Med J 295, 800, 1987. 49. Montgomery, M.R., Reasor, M.J., Retrograde extrapolation of blood alcohol data; An applied approach. J Toxicol Environ Health 36, 281, 1992. 50. Dossett, J.A., Breath tests, blood tests and back calculations. The Law Society’s Gassett, 15 October, 2925, 1987. 51. McLean, A.J., Morgan, D.J., Clinical pharmacokinetics in patients with liver disease. Clin Pharmacokinet 21, 42, 1991. 52. Hoyumpa, A.M., Schenker, S., Major drug interactions: Effect of liver disease, alcohol, and malnutrition. Ann Rev Med 33, 113, 1982. 53. Koltz, U., Pathophysiological and disease-induced changes in drug distribution volume: Pharmacokinetic implications. Clin Pharmacokinet 1, 204, 1976. 54. Grüner, O., Bilzer, N., Walle, A.J., Blutalkoholkurve und Widmark-Werte bei dialyseabhängigen Patienten. Blutalkohol 17, 371, 1980. 55. Cotton, P.B,, Walker, G., Ethanol absorption after gastric operations and in the coeliac syndrome. Postgrad Med J 49, 27, 1973. 56. Griffiths, G.H., Owen, G.M., Camphell, H., Shields, R., Gastric emptying in health and in gastroduodenal disease. Gastroenterology 54, 1, 1968. 57. Elmslie, R.G., Davis, R.A., Magee, D.F., White, T.T., Absorption of alcohol after gastrectomy. Surg Gynacol Obstet 119, 1256, 1964. 58. Jokipii, S.G., Experimental studies on blood alcohol in healthy subjects and in some diseases. Thesis for MD degree, University of Helsinki, 1951. 59. Jones, A.W., Biochemistry and physiology of alcohol: Applications to foresnic science and toxicology. In: Medicolegal aspects of alcohol, edited by J.C. Garriott, Lawyers & Judges Publishing Company, Inc., Tuson, 1996, p 85. 60. Lieberman, F.L., The effect of liver disease on the rate of ethanol metabolism in man. Gastroenterology 44, 261, 1968. 61. Ugarte, G., Insunza, I., Altschiller, H., Iturriage, H., Clinical and metabolic disorders in alcoholic hepatic damage. Chapter 29, In: Alcohol and Alcoholism, edited by R.E. Popham, Addiction Research Foundation, Toronto, 1969; p 230. 62. Mezey, E., Tobon, F., Rates of ethanol clearance and activities of the ethanol-oxidizing enzymes in chronic alcoholic patients. Gastroenterology 61, 707, 1971. 63. Bode, J.Ch., The metabolism of alcohol: Physiological and pathophysiological aspects. J Roy Coll Phycns 12, 122, 1978.


1148


64. Mallach, H.J., von Oldershausen, H.F., Springer, E., Der Einfluß oraler Alkoholzufuhr auf den Blutalkoholspiegel von Gewohnheitstrinkern und Leberkranken unter verschiedenen alimentären Bedingungen. Klin Wschr 50, 732, 1972 65. Runyon, B.A., Care of patients with ascites. N Eng J Med 330, 337, 1994. 66. Aiza, I., Perez, G.O., Schiff, E.R., Management of ascites in patients with chronic liver disease. Am J Gastroenterol 89, 1949, 1994. 67. Teschke, R., Gellert, J., Hepatic microsomal ethanol-oxidizing system (MEOS): metabolic aspects and clinical implications. Alcoholism; Clin Exp Res 10, 20S, 1986. 68. Jones, A.W., Sternebring, B., Kinetics of ethanol and methanol in alcoholics during detoxification. Alc Alcohol 27, 641, 1992. 69. Haffner, H.T., Batra, A., Bilzer, N., Dietz, K., Gilg, T., Graw, M., et al., Statistische Annäherung an forensische Rückrechnungswerte für Alkoholiker. Blutalkohol 29, 53, 1992. 70. Monaghan, M.S., Olsen, K.M., Ackerman, B.H., Fuller, G.L., Porter, W.H., Pappas, A.A., Measurement of serum isopropanol and the acetone metabolite by proton nuclear magnetic resonance; Application to pharmacokinetic evaluation in a simulated overdose model. Clin Toxicol 33, 141. 1995. 71. Jones, A.W., Schuberth, J., Computer-aided headspace gas chromatography applied to blood-alcohol analysis: Importance of online process control. J Forensic Sci 34, 1116, 1989. 72. Coldwell, B.B., Grant, G.L., The disappearance of alcohol from the blood of diabetics. J Forensic Sci 8, 220, 1963. 73. Coldwell, B.B., A note on the estimation and disappearance of alcohol in blood, breath and urine from obese and diabetic patients. J Forensic Sci 10, 480, 1965. 74. Taylor, R., Agius, L., The biochemistry of diabetes. Biochem J 250, 625, 1988. 75. Bode, Ch., Buchwald, B., Goebell, H., Hemmung des Äthanolabbaues durch Proteinmangel beim Menschen. Dtsch Med Wschr 96, 1576, 1971. 76. Bode, Ch., Thiel, D., Hemmung des Äthanolabbaus beim Menschen durch Fasten: Reversibilität durch Fructose-Infusion. Dtsch Med Wschr 100, 1849, 1975. 77. Willner, K., Kretschmar, R., Die Veränderung des Verteilyngsfaktors nach akuten Körperwasserverlusten. Blutalkohol 2, 99, 1963. 78. Marshall, A.W., Kingstone, D., Boss, A.M., Morgan, M.Y., Ethanol elimination in males and females; relationship to menstrual cycle and body composition. Hepatology 3, 701, 1983. 79. Jones, A.W., Neri, A., Age-related changes in blood-alcohol parameters and subjective feelings of intoxication. Alc Alcohol 20, 45, 1985. 80. Brettel, H.F., Maske, B., Zur Alkoholbestimmung bei Blutnahme in Schockzustand. Blutalkohol 8, 360, 1971. 81. Brettel, H.F., Die Alkoholbegutachtung bei Traumatisierten und Narkotisierten. Blutalkohol 11, 1, 1974. 82. Brettel, H.F. and Henrich, M., Die Rückrechnung auf die sog, Tatzeitalkoholkonzentration bei Schockfällen. Blutalkohol 16, 145, 1979. 83. Kleemann, W.J., Seibert, M., Tempka, A., Wolf, M., Weller, J-P., Tröger, H-D., Arterielle und venöse Alkoholelimination bei 10 polytraumatisierten Patienten. Blutalkohol 33, 162, 1995. 84. Baskett, P.J.F., Management of hypovolemic shock. Br Med J 300, 1453, 1990. 85. Flordal, P.A., The plasma dilution factor: Predicting how concentrations in plasma and serum are affected by blood volume variations and blood loss. J Lab Clin Med 126, 353, 1995. 86. Ditt, J., and Schulze, G., Blutverlust und Blutalkoholkonzentration. Blutalkohol 1, 183, 1962. 87. Wigmore, J.G., Mammoliti, D.N., Comments on Medicolegal alcohol determination: Implications and consequences of irregularities in blood alcohol concentration vs time curves. J Anal Toxicol 17, 317, 1993. 88. Goldberger, B.A., Cone, E.J., Kadehjian, L., Unexpected ethanol ingestion through soft drinks and flavored beverages. J Anal Toxicol 20, 332, 1996. 89. Linnoila, M., Mattila, M.J., Kitchell, B.S., Drug interactions with alcohol. Drugs 18, 299, 1979. 90. Lane, E.A., Guthrie, S., Linnoila, M., Effects of ethanol on drug and metabolite pharmacokinetics. Clin Pharmacokinet 10, 228, 1985. 91. Lieber, C.S., Interaction of alcohol with other drugs and nutrients: Implications for the therapy of alcoholic liver disease. Drugs, 40 (suppl 3) 23, 1990. 92. Blomstrand, R., Theorell, H., Inhibitory effect on ethanol oxidation in man after administration of 4methyl pyrazole. Life Sci 9, 631, 1970.


DRUG LAW

1149

93. Blomstrand, R., Östling-Wintzell, H., Löf, A., McMartin, K., Tolf, B.R., Hedström, K.G., Pyrazoles as inhibitors of alcohol oxidation and as important tools in alcohol research: An approach to therapy against methanol poisoning. Proc Natl Acad Sci 76, 3499, 1979. 94. Jacobsen, D., McMartin, K.E., Methanol and ethylene glycol poisonings — mechanism of toxicity, clinical course, diagnosis and treatment. Med Toxicol 1, 309, 1986. 95. Estonius, M., Svensson, S., Höög, J.O., Alcohol dehydrogenase in human tissues: localisation of transcripts coding for five classes of the enzyme. FEBS Letters 397, 338, 1996. 96. Seitz, H.K., Egerer, G., Simanowski, U.A., Waldherr, R., Eckey, R., Agarwal, D.P., Goedde, H.W., Von Wartburg, J.P., Human gastric alcohol dehydrogenase activity; effect of age, sex, and alcoholism. Gut 34, 1433, 1993. 97. Frezza, M., DePadova, C., Pozzato, G., Terpin, M., Baraona, E., Lieber, C.S., High blood alcohol levels in women: the role of decreased gastric alcohol dehydrogenase activity and first-pass metabolism. N Engl J Med 322, 95, 1990. 98. Welling, P.G., Pharmacokinetics of alcohol following single low doses to fasted and non-fasted subjects. J. Clin. Pharmacol. 17, 199–206, 1977. 99. Wilkinson, P.K., Sedman, A.J., Sakmar, E., Lin, Y.J., Wagner, J.G., Fasting and non-fasting blood ethanol concentration following repeated oral administration of ethanol to one adult male subject. J. Pharmacokinet. Biopharm. 5, 41, 1977. 100. Roine, R., Gentry, T., Hernandez-Munoz, R., Baraona, E., Lieber, C.S., Aspirin increases blood alcohol concentration in humans after ingestion of ethanol. JAMA 264, 2406, 1990. 101 Julkunen, R.J.K., Tannenbaum, L., Baraona, E., Lieber, C.S., First-pass metabolism of ethanol: an important determinant of blood levels after alcohol consumption. Alcohol 2, 437, 1985. 102. Seitz, H.K., Bösche, J., Czygan, P., Veith, S., Simon, B., Kommerell, B., Increased blood ethanol levels following cimetidine but not ranitidine. Lancet 2 700, 1982. 103. Feely, J., Wood, A.J., Effects of cimetidine on the elimination and actions of ethanol. JAMA 247, 2819, 1982. 104. Caballeria, J., Baraona, E., Rodamilans, M., Lieber, C.S., Effects of cimetidine on gastric alcohol dehydrogenase activity and blood ethanol levels. Gastroenterology 96, 388, 1989. 105. Westenbrink, W., Cimetidine and the blood alcohol curve: A case study and review. Can Soc Forens Sci J 28, 165, 1995. 106. Bye, A., Lacey, L.F., Gupta, S., Powell, J.R., Effect of ranitidine hydrochloride (150 mg twice daily) on the pharmacokinetics of increasing doses of ethanol (0.15, 0.3, 0.6 g/kg). Br. J. Clin. Pharmacol. 41, 129, 1996. 107. Dauncey, H., Chesher, G.B., Palmer, R.H., Cimetidine and ranitidine; Lack of effect on the pharmacokinetics of an acute ethanol dose. J Clin Gastroenterol. 17, 189, 1993. 108. Fraser, A.G., Hudson, M., Sawyerr, A.M., Smith, M., Rosalki, S.B., Pounder, R.E., Ranitidine, cimetidine, famotidine have no effect on post-prandial absorption of ethanol 0.8 g/kg taken after an evening meal. Aliment. Pharmacol. Therapeut. 6, 693, 1992. 109. Raufman, J.P., Notar-Francesco, V., Raffaniello, R.D., Straus, E.W., Histamine-2 receptor antagonists do not alter serum ethanol levels in fed, nonalcoholic men. Ann Int Med. 118, 488, 1993. 110. Pedrosa, M.C., Russell, R.M., Saltzman, J.R., Golner, B.B., Dallal, G.E., Sepe, T.E., Oates, E., Egerier, G., Seitz, H.K., Gastric emptying and first-pass metabolism of ethanol in elderly subjects with and without atrophic gastritis. Scand J Gastroenterol. 31, 671, 1996. 111. Toon, S., Khan, A.Z., Holt, B.J., Mullins, F.G.P., Langley, S.J., and Rowland, M.M., Absence of effect of ranitidine on blood alcohol concentrations when taken morning, midday, or evening with or without food. Clin Pharmacol Therap 55, 385, 1994. 112. Lester, D., The concentration of apparent endogenous ethanol. J. Stud. Alcohol 23, 17, 1962. 113. Sprung, R., Bonte, W., Rüdell, E., Domke, M., Frauenrath, C., Zum Problem des endogenen Alkohols. Blutalkohol 18, 65, 1981. 114. Jones, A.W., Mårdh, G., Änggård, E., Determination of endogenous ethanol in blood and breath by gas chromatography-mass spectrometry. Pharmacol. Biochem. Behav. 18 Suppl. 1, 267, 1983. 115. Ostrovsky, Y. M., Endogenous ethanol — Its metabolic, behavioral and biomedical significance. Alcohol 3, 239, 1986. 116. Jones, A.W., Ostrovsky, Y.M., Wallin, A., Midtvedt, T., Lack of differences in blood and tissue concentrations of endogenous ethanol in conventional and germfree rats. Alcohol 1, 393, 1984.


1150


117. Blomstrand, R., Observations on the formation of ethanol in the intestinal tract in man. Life Sci. 10, 575, 1971. 118. Agapejev, S., Vassilieff, I., Curi, P.R., Alcohol levels in cerebrospinal fluid and blood samples from patients under pathological conditions. Acta Neurol Scand 86, 496, 1992. 119. Agapejev, S., Vassilieff, I., Curi, P.R., Alcohol in cerebrospinal fluid (CSF) and alcoholism. Hum Exper Toxicol 11, 237, 1992. 120. Jones, A. W., Concentration of endogenous ethanol in blood and CSF. Acta Neurol. Scand. 89, 149, 1994. 121. Kaji, H., Asanuma, Y., Yahara, O., Shibue, H., Hisamura, M., Saito, N., Kawakami, Y., Murao, M., Intragastrointestinal alcohol fermentation syndrome; report of two cases and review of the literature. J Forens Sci Soc 24, 461, 1984. 122. Kaji, H., Asanumo, Y., Saito, N., Hisamura, M., Murao, M., Yoshida, T., Takahashi, K., The autobrewery syndrome — the repeated attacks of alcoholic intoxication due to the overgrowth of Candida (albicans) in the gastrointestinal tract, Materia Medica Polona, 8, 429, 1976. 123. Hunnisett, A., Howard, J., Davies, S., Gut fermentation (or the ‘Auto-brewery’) syndrome: A new clinical test with initial observations and discussion of clinical and biochemical implications. J Nutr Med 1, 33, 1990. 124. Jones, A.W., Excretion of alcohol in urine and diuresis in healthy men in relation to their age, the dose administered, and the time after drinking. Forens Sci Intern 45, 217, 1990. 125. Widmark, E.M.P., Uber die Konzentration des genossenen Alkohols in Blut und Harn unter verschiedenen Umständen. Skand Arch Physiol 33, 85, 1915. 126. Blackmore, D.J., Mason, J.K., Renal clearance of urea, creatinine and alcohol. Med Sci Law 8, 51, 1968. 127. Miles, W.R., The comparative concentrations of alcohol in human blood and urine at intervals after ingestion. J Pharmacol Exp Therap 20, 265, 1922. 128. Lundquist, F., The urinary excretion of ethanol in man. Acta Pharmacol Toxicol 18, 231, 161. 129. Jones, A.W., Helander, A., Disclosing recent drinking after alcohol has been cleared from the body. J Anal Toxicol 20, 141, 1996. 130. Widmark, E.M.P., Principles and application of medicolegal alcohol analysis. Biomedical Publications, Davis, 1981, pp 1–163. 131. Mulrow, P.J., Huvos, A., Buchanan, D.L., Measurement of residual urine with I123 labeled diodrast. J Lab Clin Med 57, 109, 1961. 132. Fine, J., Glucose content of normal urine. Br Med J 1, 1209, 1965. 133. Alexander, W.D., Wills, P.D., Eldred, N., Urinary ethanol and diabetes mellitus. Diab. Med. 5, 463, 1988. 134. Sulkowski, H.A., Wu, A.H.B., McCarter, Y.S., In-vitro production of ethanol in urine by fermentation. J Forens Sci 40, 990, 1995. 135. Saady, J.J., Poklis, A., Dalton, H.P., Production of urinary ethanol after sample collection. J Forens Sci 38, 1467, 1993. 136. Muholland, J.H., Townsend, F.J., Bladder Beer: a new clinical observation. Trans Am Clin Climatol Ass 95, 34, 1983. 137. Chang, J., Kollman, S.E., The effect of temperature on the formation of ethanol by candida albicans. J Forensic Sci 34, 105, 1989. 138. Beck, O., Helander, A., Jones, A.W., Serotonin metabolism marks alcohol intake. Forensic Urine Drug Testing, September 1996, p 1–4. 139. Helander, A., Beck, O., Jones, A.W., 5HTOL/5HIAA as biochemical marker of post-mortem ethanol synthesis. Lancet 340, 1159, 1992. 140. Dick, G.L., Stone, H.M., Alcohol loss arising from microbial contamination of drivers’ blood specimens. Forens Sci Intern 34, 17, 1987. 141. Heise, H.A., How extraneous alcohol affects the blood test for alcohol. Am J Clin Pathol 32, 169, 1959. 142. Goldfinger, T.M., Schaber, D., A comparison of blood alcohol concentration using non-alcohol and alcohol-containing skin antiseptics. Ann Emerg Med 36, 665, 1982. 143. Times Law Report. Power to quash convictions after guilty pleas., The Times, October 4, 1990. 144. Taberner, P.V., A source of error in blood alcohol analysis. Alc Alcohol 24, 489, 1989. 145. Peek, G.J., March, A., Keating, J., Ward, R.J., Peters, T.J., The effects of swabbing the skin on apparent blood alcohol concentration. Alc Alcohol 25, 639, 1990.


DRUG LAW

1151

146. McIvor, R.A., Cosbey, S.H., Effect of using alcoholic and non-alcoholic skin cleansing swabs when sampling blood for alcohol estimation using gas chromatography. Brit J Clin Prac 44, 235, 1990. 147. Ogden, E.J.D., Gerstner-Stevens, J., Burke J., Young, S.J., Venous blood alcohol sampling and the alcohol swab. The Police Surgeon, October, 4, 1992. 148. Carter. P.G., McConnell, A.A., Venous blood sampling in drink driving offences and English law. Alc Drugs and Driving 6, 27, 1990. 149. Ryder, K.W,, Glick, M.R., The effect of skin cleansing agents on ethanol results measured with the Du Pont automatic clinical analyzer. J Forensic Sci 31, 574, 1986. 150. Kissa, E., Determination of inorganic fluoride in blood with a fluoride ion-sensitive electrode. Clin Chem 33, 253, 1987. 151. Dubowski, K.M., Essary, N.A., Contamination of blood specimens for alcohol analysis during collection. Abs & Rev in Alcohol and Driving 4, 3, 1983. 152. Brown, G.A., Neylan, D., Reynolds, W.J., and Smalldon, K.W., The stability of ethanol in stored blood. Part 1: Important variables and interpretation of results. Anal Chim Acta 66, 271, 1973. 153. Smalldon, K.W. and Brown, G.A., The stability of ethanol in stored blood. Part II: The mechanism of ethanol oxidation. Anal Chim Acta 66, 285, 1973. 154. Bowers, R.V., Burleson, W.D., Blades, J.F., Alcohol absorption from the skin in man. Quart J Stud Alc 3, 31, 1942. 155. Riley, D., Wigmore J.G., Yen, B., Dilution of blood collected for medicolegal alcohol analysis by intravenous fluids. J Anal Toxicol 20, 330, 1996. 156. Jones, A.W., Hahn, R., Stalberg, H., Distribution of ethanol and water between plasma and whole blood; Inter- and intra-individual variations after administration of ethanol by intravenous infusion. Scand J Clin Lab Invest 50, 775, 1990. 157. Lenter, C., Geigy Scientific Tables, Geigy Pharmaceuticals, Basel, 1992. 158. Jones, A.W., Determination of liquid/air partition coefficients for dilute solutions of ethanol in water, whole blood, and plasma. J Anal Toxicol 7, 193, 1983. 159. Ganong, W.F., Review of Medical Physiology. Lange Medical Publications, Los Altos, 1979. 160. Wilkinson, D.R., Haines, P., Morgner, R., Sockrider, D., Wilkinson, C.L., Spartz, M., The 2100/1 ratio used in alcohol programs is once again under attack. In: Alcohol, Drugs and Traffic Safety, Eds P.C. Noordzij and R. Roszbach, Elsevier Science Publishers, Amstedam, 1987, p 391. 161. Wright, B.M., Distribution of ethanol between plasma and erythrocytes in whole blood. Nature 218, 1263, 1968. 162. Jones, A.W., Measuring alcohol in blood and breath for forensic purposes — A historical review. Forens Sci Rev 8, 13, 1996. 163. Jones, A.W., Andersson, L., Biotransformation of acetone to isopropanol observed in a motorist involved in a sobriety control. J Forensic Sci 40, 686, 1995. 164. Dubowski, K.M., Essary, N., Quality assurance in breath alcohol analysis. J Analyt Toxicol 18, 306, 1994. 165. Bogen, E., Drunkenness; A quantitative study of acute alcohol intoxication. JAMA 89, 1508, 1927. 166. Spector, N.H., Alcohol breath tests: Gross errors in current methods of measuring alveolar gas concentrations. Science 172, 57, 1971. 167. Dubowski, K.M., Studies in breath-alcohol analysis: Biological factors. Z Rechtsmed 76, 93, 1975. 168. Caddy, G.R., Sobell, M.B. and Sobell, L.C., Alcohol breath tests: Criterion times for avoiding contamination by mouth alcohol. Behav Res Meth Instr 10, 814, 1978. 169. Gullberg, R.G., The elimination rate of mouth alcohol: mathematical modeling and implications in breath alcohol analysis. J Forensic Sci 37, 1363, 1992. 170. Modell, J.G., Taylor, J.P. and Lee, J.Y., Breath alcohol values following mouthwash use. JAMA 270, 2955, 1993. 171. Grüner, O., Bilzer, N., Untersuchungen zur Beeinflu barkeit der Alkomat — Atemalkoholmessungen durch verschiedene Stoffe des täglichen Gebrauchs (Mundwässer, parfüms, Rasierwässer, etc.). Blutalkohol 27, 119, 1990. 172. Denney, R.C. and Williams, P.M., Mouth alcohol: Some theoretical and practical considerations. In: Proceedings, 10th International Conference on Alcohol, Drugs and Traffic Safety, edited by Noordzij, P.C. and Roszbach, R. Amsterdam: Elsevier, 1987, p. 355-358. 173. Penners, B.M. and Bilzer, N., Aufsto en (Eruktation) und Atemalkoholkonzentration. Blutalkohol 24, 172, 1987.


1152


174. Kahrilas, P.J., Gastroesophageal reflux disorders. JAMA 276, 983, 1996. 175. Fraser, A.G., Gastro-oesophageal reflux and laryngeal symptoms. Aliment Pharmacol Therapeut 8, 265, 1994. 176. Schoeman, M.N., Tippett, M., Akkermans, L.M.A., Dent, J., Holloway, R.H., Mechanisms of gastroesophageal reflux in ambulant healthy human subjects. Gastroenterology 108, 83, 1995. 177. Klauser, A.G., Schindlbeck, N.E., Müller-Lissner, S.A., Symptoms in gastro-oesophageal reflux disease. Lancet 335, 205, 1990. 178. Cohen, S., The pathogenesis of gastroesophageal reflux disease; A challenge in clinical physiology. Ann Int Med 117, 1051, 1992. 179. Pope, C.E., Acid-reflux disorders. N Eng J Med 331, 656, 1994. 180. Weinberg, D.S. and Kadish, S.L., The diagnosis and management of gastroesophageal reflux disease. Med Clin North Am. 80:411 1996. 181. Kaufman, S.E., Kaye, M.D., Induction of gastro-oesophageal reflux by alcohol. Gut 19, 336, 1978. 182. Pehl, C., Wendl, B., Pfeiffer, A., Schmidt, T., Kaess, H., Low-proof alcoholic beverages and gastroesophageal reflux. Dig Dis Sci 38, 93, 1993. 183. Wells, D., Farrar, J., Breath-alcohol analysis of a subject with gastric regurgitation. In Abstracts of the 11th International Conference on Alcohol, Drugs, and Traffic Safety, Chicago, 1989. 185. Wright, B.M., Medical problems with breath testing of drunk drivers. Br Med J 289, 1071, 1984. 184. Duffus, P., Dunbar J.A., Medical problems with breath testing of drunk drivers. Br Med J 289, 831, 186. Trafford, D.J.H., and Makin, H.L.J., Breath-alcohol concentration may not always reflect the concentration of alcohol in blood. J Anal Toxicol. 18;225-228, 1994. 187. Cowan, J.M., Apparent flaws in a breath-alcohol case report. J Anal Toxicol 19;128, 1995. 188. Cohen, H.M., Saferstein, R., Mouth alcohol, denture adhesives and breath-alcohol testing. Drunk Driving Liquor Liability Reporter, 6, 24, 1992. 189. Harding, P.M., McMurray, M.C., Laessig, R.H., Simley, D.O., Correll, P.J., Tsunehiro, J.K., The effect of dentures and denture adhesives on mouth alcohol retention. J Forens Sci 37, 999, 1992. 190. Katzgraber, F., Rabl, W., Stainer, M., Wehinger, G., Die Zahnprothese — ein Alkoholdepot? Blutalkohol 32, 274, 1995. 191. Dubowski, K.M., The technology of breath-alcohol analysis. US Department of Transportation Report No. (ADM) 92-1728, U.S. Goverment Printing Office, Wahington, DC, 1992. 192. Kramer, M., Haffner, H.T., Cramer, Y. and Ulrich, L., Untersuchungen zur Funktion der Restalkoholanzeige beim Atemalkoholtestgerät — Alcomat. Blutalkohol 24, 49, 1987. 193. Jones, A.W., Andersson, L., Berglund, K., Interfering substances identified in the breath of drinking drivers with Intoxilyzer 5000S. J Anal Toxicol 20, 522, 1996. 194. Harte, R.A., An instrument for the determination of ethanol in breath in law enforcement practice. J Forensic Sci 16, 167, 1971. 195. Borkenstein, R.B., Smith, H.W., The Breathalyzer and its applications. Med Sci Law 2, 13, 1961. 196. Oliver, R.D., Garriott, J.C., The effects of acetone and toluene on Breathalyzer results. J Anal Toxicol 3, 99, 1979. 197. Brick, J., Diabetes, breath acetone and Breathalyzer accuracy: A case study. Alc Drugs Driving 9, 27, 1993. 198. Manolis, A., The diagnostic potential of breath analysis. Clin Chem 29, 5, 1985. 199. Jones, A.W., Excretion of low molecular weight volatile substances in human breath: Focus on endogenous ethanol. J Anal Toxicol 9, 246, 1985. 200. Krotoszynski, B.K., Bruneau, G.M., O Neill, H.J., Measurement of chemical inhalation exposure in urban populations in the presence of endogenous effluents. J Anal Toxicol 3, 225, 1979. 201. Jones, A.W., Lagersson, W., Tagesson, C., Determination of isoprene in human breath by gas chromatography with ultraviolet detection. J Chromatog 672, 1, 1995. 202. Flores, A., Franks, J.F., The likelihood of acetone interference in breath alcohol measurement. Alc Drugs and Driving 3, 1, 1987. 203. Marks, V., Methane and the infrared breath-alcohol analyzer. Lancet ii, 50, 1984. 204. Peled, Y., Weinberg, D., Hallak, A., Gilat, T., Factors affecting methane production in humans. Dig Dis Sci 32, 267, 1987. 205. Dubowski, K.M., and Essary, N.A., Response of breath-alcohol analyzers to acetone. J Anal Toxicol 7, 231, 1983.


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206. Mebs, D., Gerchow, J., Schmidt, K., Interference of acetone with breath-alcohol testing. Blutalkohol 21, 193, 1984. 207. Levey, S., Balchum, O.J., Medrando, V., Jung, R., Studies of metabolic products in expired air. 11 Acetone. J Lab Clin Med 63, 574, 1964. 208. Tassopoulos, C.N., Barnett, D., Fraser, T.R., Breath-acetone and blood-sugar measurements in diabetes. Lancet i, 1282, 1969. 209. Schoknecht, G., Hahlbrauck, B., Erkennung von Fremdgasen bei der Atemalkoholanalyse. Blutalkohol 29, 193, 1992. 210. Jones, A.W., Measuring and reporting the concentration of acetaldehyde in human breath. Alc Alcohol 30, 271, 1995. 211. Jones, A.W., Drug alcohol flush reaction and breath acetaldehyde concentration: No interference with an infrared breath alcohol analyzer. J Anal Toxicol 10, 98, 1986. 212. Eriksson, C.J.P., Fukunaga, T., Human blood acetaldehyde (Update 1992). In Advances in Biomedical Alcohol Research, eds P.V. Taberner and A.A. Badaway, Pergamon Press, Oxford, 1995, p 9. 213. Imobersteg, A.D., King, A., Cardema, M. and Mulrine, E., The effects of occupational exposure to paint solvents on the Intoxilyzer-5000 — a field study. J Anal Toxicol 17, 254, 1993. 214. Denney, R.C., Solvent inhalation and ‘apparent’ alcohol studies on the Lion Intoximeter 3000. J Forens Sci Soc 30, 357, 1990. 215. Cooper, S., Infrared breath-alcohol analysis following inhalation of gasoline fumes. J Anal Toxicol 5, 198, 1981. 216. Hümpener, R., Hein, P.M., Untersuchungen zur Beeinflußbarkeit der Alcomat-Atemalkoholmessung durch Benzin. Blutalkohol 29, 365, 1992. 217. Aderian R., Schmitt, G., Wu, M., Klebstoff-Lösemittel als Ursache eines Atemalkohol-Wertes von 1.96 promille. Blutalkohol 29, 360, 1992. 218. Bell, C.M., Gutowski, S.J., Young, S. and Wells, D., Technical Note — Diethyl Ether Interference with Infrared Breath Analysis. J Anal Toxicol 16, 166, 1992. 219. Edwards, M.A., Giguiere, W., Lewis, D., Baselt, R., Intoxilyzer interference by solvents. J Anal Toxicol 10, 125, 1986. 220. Giguiere, W., Lewis, D., Baselt, R., Chang, R., Lacquer fumes and the Intoxilyzer. J Anal Toxicol 12, 168, 1988. 221. Jones, A.W., Observations on the specificity of breath-alcohol analyzers used for clinical and medicolegal purposes. J Forensic Sci 34, 842, 1989. 222. Logan, B.K., Gullberg, R.G., Elenbaas, J.K., Isopropanol interference with breath alcohol analysis: A case report. J Forensic Sci 39, 1107, 1994. 223. Pennington, J.C., The effect of non-ethanolic substancs on the alcolmeter S-L2. Can Soc Forens Sci J 28, 131, 1995. 224. Gill, R., Hatchett, S.E., Broster, C.G., Osselton, M.D., Ramsey, J.D., Wilson, H.K., Wilcox, A.H., The response of evidential breath alcohol testing instruments with subjects exposed to organic solvents and gases. 1. Toluene, 1,1,1-trichloroethane and butane. Med Sci Law 31, 187, 1991a. 225. Gill, R., Warner, H.E., Broster, C.G., Osselton, M.D., Ramsey, J.D., Wilson, H.K., Wilcox, A.H., The response of evidential breath alcohol testing instruments with subjects exposed to organic solvents and gases. 11 White spirit and nonane. Med Sci Law 31, 201, 1991b. 226. Gill, R., Osselton, M.D., Broad, J.E., Ramsey, J.D., The response of evidential breath alcohol testing instruments with subjects exposed to organic solvents and gases. 111. White spirit exposure during domestic painting. Med Sci Law 31, 214, 1991c. 227. Lester, D., Greenberg, L.A., The inhalation of ethyl alcohol by man. J Stud Alcohol 12, 167, 1951. 228. Mason, J.K., Blackmore, D.J., Experimental inhalation of ethanol vapor. Med Sci Law 12, 205, 1972. 229. Lewis, M.J., Inhalation of ethanol vapor; A case report and experimental test involving the spraying of shellac lacquer. J Forens Sci Soc 25, 5, 1985. 230. Lewis, M.J., A theoretical treatment for the estimation of blood alcohol concentration arising from inhalation of ethanol vapor. J Forens Sci Soc 25, 11, 1985. 231. Campbell, I., Wilson, H.K., Blood alcohol concentration following the inhalation of ethanol vapor under controlled conditions. J Forens Sci Soc 26, 129, 1986. 232. Kruhoffer, P.W., Handling of inspired vaporized ethanol in the airways and lungs with comments on forensic aspects. Forens Sci Intern 21, 1, 1983.


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233. Harger, R.N., Lamb, E.B., Hulpieu, H.R., A rapid chemical test for intoxication employing breath. JAMA 110, 779, 1938. 234. Harger, R.N., Forney, R.B., Barker, H.B., Estimation of the level of blood alcohol from analysis of breath. J Lab Clin Med 36, 318, 1950. 235. Harger, R.N., Raney, B.B., Bridwell, E.G., Kitchel, M.F., The partition ratio of alcohol between air and water, urine and blood; estimation and identification of alcohol in these liquids from analysis of air equilibrated with them. J Biol Chem 183, 197, 1950. 236. Jones, A.W., Variability of the blood/breath alcohol ratio in vivo. J Stud Alc 39, 1931, 1978. 237. Harding, P.M., Field, P.H., Breathalyzer accuracy in actual law enforcement practice; A comparison of blood- and breath-alcohol results in Wisconsin drivers. J Forensic Sci 32, 1235, 1987. 238. Harding, P.M., Laessig, R.H., Field, P.H., Field performance of the Intoxilyzer 5000: A comparison of blood- and breath-alcohol results in Wisconsin drivers. J Forensic Sci 35,1022, 1990. 239. Taylor, M.D., Hodgson, B.T., Blood/breath correlations: Intoxilyzer 5000C, Alcotest 7110, and Breathalyzer 900A breath alcohol analyzers. Can Soc Forens Sci J 28, 153, 1995. 240. Jones, A.W., Andersson, L., Variability of the blood/breath alcohol ratio in drinking drivers. J Forensic Sci 41, 922, 1996. 241. Dubowski, K.M., O Neill, B., The blood/breath ratio of ethanol. Clin Chem 25, 1144, 1979. 242. Mason, M.F., Dubowski, K.M., Breath-alcohol analysis: Uses, methods, and some forensic problems — Review and opinion. J Forensic Sci 21, 9, 1976. 243. Jones, A.W. Physiological aspects of breath-alcohol measurement. Alc Drugs and Driving 6, 1, 1990. 244. George S.C., Babb, A.L., Hlastala, M.P., Dynamics of soluble gas exchange in the airways III. Single exhalation breathing maneuver. J Appl Physiol 75, 2439, 1993. 245. Gomm, P.J., Broster, C.G., Johnson, N.M., Hammond, K., Study into the ability of healthy people of small stature to satisfy the sampling requirements of breath alcohol testing instruments. Med Sci Law 33, 311, 1993. 246. Morris, M.J., Alcohol breath testing in patients with respiratory disease. Thorax 45, 717, 1990. 247. Neukirch, F., Liard, R., Korobaeff, M., Pariente, R., Pulmonary function and alcohol consumption. Chest 98, 1546, 1990. 248. Prabhu, M.B., Hurst, T.S., Cockcroft, D.W., Baule, C., Semenoff, J., Airflow obstruction and roadside breath alcohol testing. Chest 100, 585, 1991. 249. Morris, M.J., Taylor, A.G., Failure to provide a sample for breath alcohol analysis. Lancet i, 37, 1987. 250. Gomm, P.J., Osselton, M.D., Broster, C.G., Johnson, N.M., Upton, K. Study into the ability of patients with impaired lung function to use breath alcohol testing devices. Med Sci Law 31, 221, 1991a. 251. Gomm, P.J., Osselton, M.D., Broster, C.G., Johnson, N.M., Upton, K., The effect of salbutamol on breath alcohol testing in asthmatics. Med Sci Law 31, 226, 1991b. 252. Gomm, P.J., Weston, S.I., Osselton, M.D., The effect of respiratory aerosol inhalers and nasal sprays on breath alcohol testing devices used in Great Britain. Med Sci Law 30, 203, 1990. 253. Westenbrink, W., Sauve, L.T., The effect of asthma inhalers on the ALERT J3A, Breathalyzer 900A, and mark IV GC Intoximeter. Can J Forens Sci Soc 24, 23, 1991. 254. Haas, H., Morris, J.F., Breath-alcohol analysis and chronic bronchopulmonary disease. Arch Environ Health 25, 114, 1972. 255. Hahn, R.G., Jones, A.W., Billing, B., Stalberg, H.P., Expired-breath ethanol measurement in chronic obstructive pulmonary disease: implications for transurethral surgery. Acta Anaesthesiol Scand 35, 393, 1991. 256. Briggs, J.E., Patel, H., Butterfield, K., Noneybourne, D., The effects of chronic obstructive airway disease on the ability to drive and to use a roadside Alcolmeter. Respir Med 84, 43, 1990. 257. Crockett, A.J., Schembri, D.A., Smith, D.J., Laslett, R., Alpers, J.H., Minimum respiratory function for breath alcohol testing in South Australia. J Forens Sci Soc 32, 349, 1992. 258. Jones, A.W., How breathing technique can influence the results of breath alcohol analysis. Med Sci Law 22, 275, 1982. 259. Bell, C.M., Flack, H.J., Examining variables associated with sampling for breath alcohol analysis. In: Proc 13th Intern Conf Alcohol, Drugs, and Traffic Safety, Eds C.N. Kloeden and A.J. McLean, NHMRC Road Accident Research Unit, University of Adelaide, Australia, 1995, p 111.


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260. Bell, C.M., What about the humble mouthpiece? Breath sample modification and implications for breath-alcohol analysis. Proceedings 13th Intern Conf Alcohol, Drugs, and Traffic Safety, Eds C.N. Kloeden and A.J. McLean, NHMRC Road Accident Research Unit, University of Adelaide, Australia, 1995, p 945. 261. Mulder, J.A.G., Neuteboom, W., The effects of hypo- and hyperventilation on breath alcohol measurements. Blutalkohol 24, 341, 1987. 262. Schmutte, P., Stromeyer, H., Naeve, W., Vergleichende Untersuchungen von Atem- und Blutalkoholkonzentration nach körperlicher Belastung und besonderer Atemtechnik (Hyperventilation). Blutalkohol 10, 34, 1973. 263. Jones, A.W., Quantitative relationships of the alcohol concentration and the temperature of breath during a prolonged exhalation. Acta Physiol Scand 114, 407, 1992. 264. Gatt, J.A., The effect of temperature and blood:breath ratio on the interpretation of breath alcohol results. New Law Journal March 16, 249, 1984. 265. Jones, A.W., Effects of temperature and humidity of inhaled air on the concentration of ethanol in a man’s exhaled breath. Clin Sci 63, 441, 1982. 266. Gaylarde, P.M., Stambuk, D., Morgan, M.Y., Reduction in breath ethanol readings in normal male volunteers following mouth rinsing with water at differing temperatures. Alc Alcohol 22, 113, 1987. 267. Ohlson, J., Ralph, D.D., Mandelkorn M.A., Babb, A.L., Hlastala, M.P., Accurate measurement of blood alcohol concentration with isothermal rebreathing. J. Stud. Alc. 51, 6, 1990 268. Fox, G.R., Hayward, J.S., Effect of hypothermia on breath-alcohol analysis. J Forens Sci 32, 320, 1987. 269. Fox, G.R., Hayward, J.S., Effect of hyperthermia on breath-alcohol analysis. J Forens Sci 34. 836, 1989. 270. Chamberlain, R.T., Chain of custody: Its importance and requirements for clinical laboratory specimens. Lab Med, June: 477, 1989. 271. Dubowski, K.M., The role of the scientist in litigation involving drug-use testing. Clin Chem 34, 788, 1988. 272. Ayala F.J., Black, B., Science and the courts. Am Sci 81, 230, 1993. 273. Gold, J.A., Zaremski, M.J., Rappaport, E., Shefrin, D.H., Daubert v. Merrel Dow; The Supreme Court tackles scientific evidence in the courtroom. JAMA 270, 2964, 1993. 274. Editorial, Criteria for science in the courts. Nature 362, 481, 1993. 275. Lovell, W.S., Breath tests for determining alcohol in the blood. Science 178, 264, 1972. 276. Iwwinkelried, E.J., The evolution of the American test for admissibility of scientific evidence. Med Sci Law 30, 60, 1990. 277. Neufeld, P.J. and Colman, N., When science takes the witness stand. Sci Am 262, 46, 1990. 278. Havard, J.D.J, Expert scientific evidence under the adversarial system. A travesty of justice. J For Sci Soc 32, 225, 1992. 279. Annas, G.J., Scientific evidence in the courtroom; the death of the Frye rule. N Eng J Med 330, 1018, 1994. 280. Culliton, B.J., Scientific “experts” and the law. Nature Med. 3, 123, 1997 281. Eaton, D.L., Kalman, D., Scientists in the courtroom: basic pointers for the expert scientific witness. Environ Health Perspect 102, 668, 1994. 282. Kuffner Jr., C.A., Marchi, E., Morgado, J.M., Rubio, C.R., Capillary electrophoresis and Daubert; Time for admission, Anal Chem, April 1, 241A, 1996.


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14.2 TESTING CLAIMS OF ADVERSE DRUG EFFECTS IN THE COURTROOM

Joe G. Hollingsworth, J.D. and Eric G. Lasker, J.D.* Spriggs & Hollingsworth, Washington, D.C.

There is something fascinating about science. One gets such wholesale returns of conjecture out of such a trifling investment of fact. — Mark Twain, Life on the Mississippi (1874) Editor’s note: This section on testing claims is a new, much-needed addition to this second edition. It can be almost guaranteed that anyone who has attended a forensic conference at any time in the last 10 years has been forced to sit through a lecture on the implications of the Daubert decision. It can also be guaranteed with equal certainty that most of those attending the lecture neither understood nor cared a great deal about what was being said. That is unfortunate, because this is a very important ruling, and it should have an enormous effect on the way we work and testify. Readers are very fortunate to have access to this section. By illustrating the problem with a real case and real plaintiff’s arguments, the authors have made the magnitude of our problem frighteningly clear.

In today’s litigious society, no textbook on the potential adverse health effects of drugs would be complete without a discussion of how claims of alleged adverse drug reactions are evaluated in the courtroom. While there are many examples of licit and illicit drugs that have scientifically established adverse effects, there are also many examples of medically indicated drugs that have been pulled from the market, in whole or in part, based on perceived risks that are not borne out by the objective scientific data. Over the past 20 years, the courts have been inundated with scientifically unfounded claims that pharmaceuticals or medical devices caused adverse health effects, starting with the allegations in the 1980s that the morning sickness drug Bendectin caused birth defects and continuing in the 1990s and 2000s with claims of autoimmune disease from silicone breast implants, and claims of strokes and cardiovascular diseases from the postpartum lactation drug Parlodel. These cases have led the courts to develop important evidentiary rules that — when properly applied — prevent such unfounded claims from reaching the jury. Ever since the U.S. Supreme Court’s landmark ruling in the Bendectin case Daubert v. Merrell Dow Pharmaceuticals, Inc.,1 judges have been tasked with the obligation to serve as gatekeepers to keep scientifically unreliable and irrelevant expert testimony out of the courtroom. The standards set forth in Daubert, which the Supreme Court has described as “exacting,”2 have had a significant impact on numerous areas of legal dispute, but perhaps no area has been more affected than toxic tort and pharmaceutical product liability litigation. Under Daubert and its progeny, General Electric v. Joiner3 and Kumho Tire Co., Ltd. v. Carmichael,4 a plaintiff can no longer get a product liability claim before a jury based solely on an expert’s subjective opinion that the plaintiff’s injury was caused by a particular drug. Rather, the plaintiff must demonstrate that the expert’s opinion is scientifically valid, both on the general causation question of whether the drug could potentially cause the injury in any patient and the specific causation question of whether the drug in fact did cause the particular plaintiff’s injury.5 * Messrs. Hollingsworth and Lasker are partners in the Washington, D.C. law firm Spriggs & Hollingsworth, where they specialize in pharmaceutical and toxic tort litigation. 1

509 U.S. 579 (1993). Weisgram v. Marley Co., 528 U.S. 440, 455 (2000). 3 522 U.S. 136 (1997). 4 526 U.S. 137 (1999). 5 See, e.g., Raynor v. Merrell Pharms. Inc., 104 F. 3d 1371, 1376 (D.C. Cir. 1997). 2


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Daubert has imposed a significant new obligation on trial courts, and many judges have struggled to understand the scientific principles that they must follow in their new role.6 Plaintiffs’ counsel and like-minded legal observers have sought to take advantage of this uncertainty by arguing that the Supreme Court provided ambiguous guidance regarding the admissibility of medical causation testimony and that courts should defer to the judgment of medical experts so long as they follow the same “differential diagnosis” reasoning in their expert testimony as they do in their clinical practice.7 These arguments are wrong. The guidance provided by the Supreme Court is clear: expert testimony that a drug caused an adverse event is admissible only if it is based on the scientific method, i.e., evidence properly derived through the generating and testing of hypotheses. This guidance provides a simple framework for courts considering the variety of evidence generally put forth by causation experts in drug product liability litigation, whether it be epidemiology, animal research, chemical analogies, anecdotal information, or differential diagnosis. In this chapter, we review the Supreme Court’s adoption of the scientific method as the standard for admissibility of expert testimony and analyze how a court’s proper understanding of the scientific method can guide it in evaluating the different types of causation evidence presented in pharmaceutical product liability litigation, both with respect to general and specific causation. Throughout this discussion and in the concluding section, we draw on our firm’s experience as national defense counsel in a series of product liability cases involving the prescription drug Parlodel, in which these evidentiary issues have been analyzed in-depth in judicial opinions across the country. The Parlodel litigation has been described in another recent textbook as “the first significant products liability causation debate of the 21st century” and one that “will serve as a guide to understanding the significant causation issues that will continue to be involved, at increased rates of complexity, in the 21st century products cases.”8 14.2.1 The Supreme Court’s Directive: Expert Testimony Must Be Derived by the Scientific Method In Daubert, the Supreme Court held that scientific testimony is not admissible unless it satisfies the dual requirements of scientific reliability and relevance. Scholarly debate regarding Daubert has often focused on the four factors suggested by the Court in determining scientific reliability: (1) testing, (2) peer review, (3) error rate and standards, and (4) general acceptance. However, a rote discussion of these factors misses the point. These factors are relevant only insofar as they assist the trial court in applying the overarching directive of Daubert that expert testimony must be based on the scientific method. The Supreme Court explained that “in order to qualify as ‘scientific knowledge’ an inference must be derived by the scientific method.”9 The Court defined the scientific method as follows: “Scientific methodology today is based on generating hypotheses and testing them to see if they can be falsified; indeed, this methodology is what distinguishes science from other fields of human inquiry.”10 Moreover, “[s]cientific validity for one purpose is

6

A recent survey of 400 state trial judges found that while a large majority of judges agreed that the role of “gatekeeper” was an appropriate one for a judge, most judges did not have a proper understanding of the scientific principles set forth in Daubert. See Sophia I. Gatowski, et al., Asking the gatekeepers: a national survey of judges on judging expert evidence in a post-Daubert world, 25(5) Law and Human Behavior 433 (2001). 7 See, e.g., J. Kassirer and J. Cecil, Inconsistency in evidentiary standards for medical testimony: disorder in the courts, 288(11) JAMA 1382–87 (Sept. 2002); M. Berger, Upsetting the balance between adverse interests: the impact of the Supreme Court’s trilogy on expert testimony in toxic tort litigation, 64 SUM Law & Contemp. Probs. 289 (Spring/Summer 2001). 8 Terence F. Kiely, Science and Litigation: Products Liability in Theory and Practice 177 (CRC Press, Boca Raton, FL, 2002). 9 509 U.S. at 590. 10 Id. at 593. The Supreme Court cited to two philosophical texts on the nature of scientific evidence. See id. (citing C. Hempel, The Philosophy of Natural Science 49 (1966) (“[T]he statements constituting a scientific explanation must be capable of an empirical test”); K. Popper, Conjectures and Refutations: The Growth of Scientific Knowledge 37 (5th ed. 1989) (“[T]he criterion of the scientific status of a theory is its falsifiability, or refutability, or testability”)).


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not necessarily scientific validity for other, unrelated purposes.”11 In other words, expert testimony is admissible only if empirical testing validates the specific theory to which the expert opines.12 Daubert also explains that while admissible expert testimony must be based on the scientific method, “there are important differences between the quest for truth in a courtroom and the quest for truth in the laboratory.”13 “[S]cientific conclusions are subject to perpetual revision. Law on the other hand, must resolve disputes finally and quickly.”14 Accordingly, expert testimony must be judged based on the current state of scientific knowledge, not on the possibility that additional knowledge may emerge in the future. The Court recognized that the requirement of existing empirical evidence “on occasion will prevent the jury from learning of authentic insights and innovation” but held that this “is the balance struck by Rules of Evidence designed not for the exhaustive search for cosmic understanding but for particularized resolution of legal disputes.”15 Four years after Daubert, the Supreme Court provided further guidance on how judges should use the scientific method in evaluating expert testimony. In Joiner, the plaintiffs’ experts contended that their opinion (that PCBs can cause lung cancer) should be admitted because they relied on epidemiology and animal studies, which are standard tools used by scientists in testing causal hypotheses. The Court rejected this contention, explaining that a faithful application of the scientific method requires more: “whether animal studies can ever be the proper foundation for an expert’s testimony was not the issue. The issue was whether these experts’ opinions were sufficiently supported by the animal studies on which they purport to rely.”16 In other words, expert testimony must be based on empirical testing that validates the conclusions reached.17 The Joiner Court held that the research cited by plaintiffs’ experts did not validate their conclusions because the epidemiological studies did not report a statistically significant causal link between PCBs and lung cancer, lacked proper controls, and examined substances other than PCBs, and because the animal studies involved massive doses of PCBs and a different type of cancer and could not be properly extrapolated to humans. Plaintiffs’ experts could not support their opinions under the scientific method because their conclusions ultimately rested on subjective leaps from the scientific evidence. “[N]othing in either Daubert or the Federal Rules of Evidence requires a district court to admit evidence that is connected to existing data only by the ipse dixit of the expert. A court may conclude that there is simply too great an analytical gap between the data and opinion proffered.”18 Two years later, in Kumho Tire, the Supreme Court held that the Daubert requirements of reliability and relevance apply to all expert testimony, including experience-based testimony. Even in areas where the four factors proposed in Daubert are inapplicable, the Court explained that the overarching question remains the same: Is the expert’s testimony supported by a methodology that has been objectively validated and supports the conclusions offered?19 In evaluating this question, 11

Id. at 591. The four factors discussed in Daubert provide different methods by which an expert’s opinion can be analyzed for adherence to the scientific method. Two of the factors, testing and error rates, are integral parts of the scientific method itself. The other two factors, peer review and general acceptance, can provide independent support that the opinion was properly derived by the scientific method. Peer review, however, should not be mindlessly equated with publication. As the Supreme Court noted, publication “is but one element of peer review.” Daubert, 509 U.S. at 593. Peer review, like general acceptance, refers more broadly to the concept that the theory at issue has been subjected to and found valid through empirical testing by the broader scientific community. See generally W. Anderson, et al., Daubert’s backwash: litigationgenerated science, 34 U. Mich. J.L. Reform 619 (2001); E. Chan, The “Brave New World” of Daubert: true peer review, editorial peer review, and scientific validity, 70 N.Y.U. L. Rev. 100 (1995). 13 Id. at 596–97. 14 Id. at 597. 15 Id. 16 522 U.S. at 145. 17 See id. at 146 (“conclusions and methodology are not entirely distinct from one another”). 18 Id. 19 See 526 U.S. at 157 (noting with respect to challenged tire expert’s testimony that “despite the prevalence of tire testing,” plaintiffs did not “refer to any articles or papers that validate [the expert’s] approach”). 12


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the Court instructed that courts should consider whether the expert “employs in the courtroom the same level of intellectual rigor that characterizes the practice of the expert in the relevant field.”20 14.2.2 Evaluating General Causation Evidence under the Scientific Method General causation opinions in drug product liability litigation may be based on a wide variety of evidence of differing scientific value, including, inter alia, epidemiology, animal studies, chemical analogies, case reports, and regulatory findings and other secondary sources. Some legal observers have argued that a medical expert’s evaluation of this evidence involves a “complex inferential process” and that the expert accordingly should be allowed to simply lump this evidence together and reach “a subjective judgment about the strength of the evidence.”21 However, Daubert clearly requires more. Under Daubert, a trial court must consider each of these categories of evidence in light of the scientific method, and the expert’s testimony may only be admitted if the expert can establish through scientific evidence that her causal hypothesis has been reliably tested and validated. Further, causation experts cannot satisfy their Daubert burden by arguing that the scientific research necessary to test their hypothesis has not been or cannot be performed. Daubert requires trial judges to evaluate expert testimony based on the science that exists at the time, not the possibility of new scientific discoveries in the future or guesswork as to what those discoveries might show.22 As Judge Posner of the U.S. Court of Appeal for the Seventh Circuit explained, “the courtroom is not the place for scientific guesswork, even of the inspired sort. Law lags science, it does not lead it.”23 14.2.2.1

Epidemiology

Controlled epidemiological studies are generally considered the most reliable evidence for testing a hypothesis that a particular substance causes a particular injury in humans.24 Epidemiological studies can be especially important in cases where the drug or substance at issue is widely used or where there is a measurable background rate of the alleged injury regardless of exposure. In these situations, epidemiology may be the only way to test the hypothesis that observed injuries in exposed individuals are reflective of an increased risk and a causal connection rather than pure statistical chance.25 While the absence of epidemiology may not be fatal to a plaintiff’s case, 20

Id. at 152. Kassirer and Cecil, supra note 7, at 1384, 1386; see also Berger, supra note 7. 22 509 U.S. at 597. 23 Rosen v. Ciba-Geigy Corp., 78 F.3d 316, 319 (7th Cir. 1996). 24 See, e.g., Soldo v. Sandoz Pharms. Corp., 244 F. Supp. 2d 434, 532 (W.D. Pa. 2003) (epidemiology is “the primary generally accepted methodology for demonstrating a causal relation between a chemical compound and a set of symptoms or a disease”) (quoting Conde v. Velsicol Chem. Corp., 804 F. Supp. 972, 1025–26 (S.D. Ohio 1992), aff’d, 24 F.3d 809 (6th Cir. 1994)); Hollander v. Sandoz Pharms. Corp., 95 F. Supp. 2d 1230, 1235, n.14 (W.D. Okla. 2000) (“In the absence of an understanding of the biological and pathological mechanisms by which disease develops, epidemiological evidence is the most valid type of scientific evidence of toxic causation”), aff’d, 289 F.3d 1193 (10th Cir. 2002); Breast Implant Litig., 11 F. Supp. 2d 1217, 1224–25 (D. Colo. 1998) (same, citing cases). 25 There has been recent controversy regarding whether certain types of epidemiological studies should be considered inherently more reliable than others in establishing causation. Historically, courts have understood that randomized controlled clinical trials are less likely to report erroneous associations than observational epidemiological studies, like cohort or case control studies. See In re Rezulin Prod. Liab. Litig., 369 F. Supp. 2d 398, 406 (S.D.N.Y. 2005); see also David H. Kaye and David A. Freeman, Reference Guide on Statistics, Reference Manual on Scientific Evidence (2d ed. 2000) at 94–95. However, recent research suggests that this understanding may be mistaken, see John Concato, et al., Randomized, controlled trials, observational studies, and the hierarchy of research design, 342(25) N. Engl. J. Med. 1887 (2000); John Concato, Observational versus experimental studies: what’s the evidence for a hierarchy? 1 J. Am. Soc. Exp. NeuroTherapeutics 341 (2004). In a recent review of the most highly cited clinical research (defined as studies cited more than 1000 times in the literature), a scientist concluded that 16% of the top-cited clinical research studies relating to medical interventions had been contradicted within the following 15 years and another 16% were followed by subsequent research suggesting that the initial findings may have been overstated. John P.A. Ioannidis, Contradicted and initially stronger effects in highly cited clinical research, 294(2) JAMA 218 (2005). While epidemiological evidence can provide the best evidence of causation, as explained below, even the best study cannot establish that causation in fact exists. 21


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numerous courts have held that a plaintiff seeking to establish causation without such evidence will face a high evidentiary hurdle.26 When causation experts rely on epidemiological studies to support their opinions, a trial court must analyze those studies to determine whether they provide a proper foundation for the expert’s testimony under the scientific method. The finding in an epidemiological study of an association between a substance and an injury is not equivalent to causation.27 There are three reasons that a positive association may be observed in an epidemiological study: (1) chance, (2) bias, and (3) real effect.28 As the Supreme Court recognized in Joiner, epidemiological research cannot provide a scientifically reliable basis for an affirmative causation opinion if it is statistically insignificant or inadequately controlled for bias.29 Epidemiologists attempt to account for the possibility of chance by calculating “confidence intervals” around point estimates of potential increased risk derived from epidemiological studies. An epidemiological study is considered to show a statistically significant association with an increased risk if the confidence interval of upper- and lower-bound estimates of risk does not include the possibility of no increased risk in the exposed population. The possibility of no increased risk is referred to as the “null” hypothesis, which is generally indicated by a relative risk or odds ratio of 1.0.30 The generally accepted confidence interval in epidemiological studies is 95%, meaning that a study is not statistically significant unless the “null” hypothesis of no increased (or decreased) risk can be excluded with 95% confidence.31 If an epidemiological study is not statistically significant, it cannot provide scientifically reliable evidence of an association, let alone causation.32 Further, numerous courts have held that epidemiological evidence can only support a conclusion that a substance is more likely than not the cause of disease if it establishes a doubling of the risk of the disease.33 The reasoning behind this requirement is that if exposure does not at least double the risk of injury, then more than half of the exposed population suffering from injuries allegedly caused by the substance would have been injured anyway through pure chance (based on the background risk of injury) thereby disproving “more likely than not” legal causation. Courts have also cautioned against reliance on statistically significant subgroup analyses, given the likelihood that numerous subgroup analyses will result in spurious statistical associations in some end points through chance alone.34 Bias in epidemiology is any systematic error that makes the two groups being compared different in more ways than just the variable being studied.35 Common sources of bias include confounding factors (other factors associated with the studied factor that might account for a perceived increased risk), selection bias (uncontrolled differences between the studied populations), and information 26 See, e.g., Siharath v. Sandoz Pharms. Corp., 131 F. Supp. 2d 1347, 1358 ((N.D. Ga. 2001), aff’d sub., nom Rider v. Sandoz Pharms. Corp., 295 F.3d 1194 (11th Cir. 2002). 27 See Michael D. Green, Reference Guide on Epidemiology, Reference Manual on Scientific Evidence (2d ed. 2000) at 336. 28 See Magistrini v. One Hour Martinizing Dry Cleaning, 180 F. Supp. 2d 584, 591 (D.N.J. 2002), aff’d, 68 Fed. Appx. 356 (3d Cir. 2003)); Caraker v. Sandoz Pharms. Corp., 188 F. Supp. 2d 1026, 1032 (S.D. Ill 2001); see also Eddy A. Bresnitz, Principles of research design, in Goldfrank’s Toxicologic Emergencies 1827–28 (Goldfrank, et al. eds. 6th ed. 1998). 29 See Joiner, 522 U.S. at 145–46. 30 See Turpin v. Merrell Dow Pharms., Inc., 959 F.2d 1349, 1353 n.1 (6th Cir. 1992). 31 Id., at 723 (citing DeLuca v. Merrell Dow Pharms., Inc., 791 F. Supp. 1042, 1046 (D.N.J. 1992), aff’d, 6 F.3d 778 (3d Cir. 1993)). 32 See Joiner, 522 U.S. at 145; see also Dunn v. Sandoz Pharms. Corp., 275 F. Supp. 2d 672, 681 (M.D.N.C. 2003) (“statistically insignificant results do not constitute proof” of causation); Soldo, 244 F. Supp. 2d at 533 (“Courts have emphasized that epidemiologic proof must be statistically significant,”) (citing cases); Caraker, 188 F. Supp. 2d at 1034 (rejecting experts’ causation opinions “inasmuch as they rely on selective use of statistically insignificant data from epidemiological studies”). 33 See Magistrini, 180 F. Supp. 2d at 591; Siharath, 131 F. Supp. 2d at 1356; In re Breast Implant Litig., 11 F. Supp. 2d at 1225-26; Hall v. Baxter Healthcare Corp., 947 F. Supp. 1387, 1403-04 (D. Or. 1996); see also Daubert v. Merrell Dow Pharms., Inc, 43 F.3d 1311, 1321 (9th Cir. 1995) (“Daubert II”) (“A relative risk of less than two may suggest teratogenicity, but it actually tends to disprove legal causation as it shows that Bendectin does not double the likelihood of birth defects”). But cf. In re Hanford Nuclear Reservation Litig., 292 F.3d 1124, 1137 (9th Cir. 2002) (plaintiffs did not need to present epidemiological evidence showing a doubling of risk of cancer from ionizing radiation at specific exposure levels because capability of ionizing radiation to cause cancer generally has been recognized by scientific and legal authority). 34 See Newman v. Motorola, Inc., 218 F. Supp. 2d 769, 779 (D. Md. 2002), aff’d 62 Fed. R. Evid. Serv. 1289 (4th Cir. 2003). 35 See Magistrini, 180 F. Supp. 2d at 592.


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bias (systematic error in measuring data that results in differential accuracy of information).36 A court must consider each of these sources of bias in interpreting an epidemiological study because bias can produce an erroneous association.37 Thus, for example, courts have excluded expert causation testimony based on purported statistically significant epidemiologic evidence where the study failed to account for other confounding exposures that could have accounted for the apparent association.38 Courts have rejected expert opinions that relied on epidemiological studies where the subjects were not blinded to the study hypothesis.39 Courts have rejected expert testimony based on epidemiological studies that failed to adequately address the possibility that injured subjects would be more likely to recall a preceding exposure than healthy controls (“recall bias”).40 Courts have also rejected expert testimony that relied upon epidemiological studies that failed to articulate selection criteria for participants in the study and thus could not account for selection biases “that could lead to erroneous inferences regarding causation.”41 The existence of a well-controlled epidemiological study that reports a statistically significant increased association with a specific injury does not, by itself, provide scientifically reliable evidence establishing causation.42 “The strong consensus among epidemiologists is that conclusions about causation should not be drawn, if at all, until a number of criteria have been considered.”43 In analyzing the scientific reliability of epidemiological evidence under Daubert, a number of courts have been guided by a set of criteria published by the noted epidemiologist, Sir Austin Bradford Hill in 1965 (“the Bradford Hill criteria”).44 The Bradford Hill criteria can be summarized as follows: (1) strength of association, (2) consistency and replication of findings, (3) specificity with respect to both the substance and injury at issue; (4) evidence of a doseresponse relationship, (5) temporal relationship, (6) biological plausibility, and (7) consideration of alternative explanations.45 In light of these criteria, courts have rejected statistically significant epidemiological research under Daubert where the reported relative risk is only slightly elevated46 and have suggested that epidemiological research reporting a relative increased risk of less than three times indicates only a weak association (strength of association).47 Courts have also rejected isolated, statistically 36 See Merrell Dow Pharms. v. Havner, 953 S.W.2d 706, 719 (Tex. 1997); see also Bresnitz, supra note 28, at 1831–32; Michael D. Green, et al., Reference Guide on Epidemiology, Reference Manual on Scientific Evidence at 389, 392, & 395 (2d ed. 2000) (discussing sources of bias); David A. Grimes and Kenneth F. Schuls, Bias and causal associations in observational research, 359 Lancet 248 (Jan. 19, 2002) (same, including real-world examples of confounding errors). 37 Magistrini, 180 F. Supp. 2d at 591; Caraker, 188 F. Supp. 2d at 1032; see also Havner, 953 S.W.2d at 719 (“Bias can dramatically affect the scientific reliability of an epidemiological study.”). 38 Nelson v. Tennessee Gas Pipeline Co., 243 F.3d 244, 252–54 (6th Cir. 2001) (expert’s failure to account for confounding factors in cohort study or alleged PCB exposures rendered his opinion unreliable). 39 See Allison v McGhan Med. Corp., 184 F.3d 1300, 1315 (11th Cir. 1999) (noting that the women participating in the study at issue “were aware of the hypothesis, a factor which could have created bias, skewing the results and ultimately making the conclusions suspect”). 40 See Newman, 218 F. Supp. 2d at 778; see also Maras v. Avis Rent A Car Sys., Inc., No. Civ. 03-6191, 2005 WL 83828, * 5 (D. Minn. Jan. 14, 2005) (rejecting expert testimony based on epidemiological study that, among other failures, may have been influenced by recall bias). 41 In re TMI Litig., 193 F.3d 613, 707–08 (3d Cir. 1999); see also Bouchard v. Am. Home Prods. Corp., 213 F. Supp. 2d 802, 809–10 (N.D. Ohio 2002) (excluding expert causation testimony to the extent based on epidemiological study tainted with selection bias). 42 See, e.g., Amorgianos v. Nat’l R.R. Passenger Corp., 137 F. Supp. 2d 147, 168 (E.D.N.Y. 2001), aff’d, 303 F.3d 256 (2d Cir. 2002). 43 Havner, 953 S.W.2d at 718. 44 See Dunn, 275 F. Supp 2d at 677–78; Magistrini, 180 F. Supp. 2d at 592–93; Amorgianos, 137 F. Supp. 2d at 168; Castellow v. Chevron USA, 97 F. Supp. 2d 780, 786–87 & n.2 (S.D. Tex. 2000); In re Breast Implants, 11 F. Supp. 2d at 1233 n.5; Havner, 953 S.W.2d at 718 & n.2. 45 Id.; see also Bresnitz, supra note 28 at 1827–28 (describing Bradford Hill criteria in detail); Grimes and Schulz, supra note 36 (same); Douglas L. Weed, Underdetermination and incommensurability in contemporary epidemiology, 7(2) Kennedy Inst. Ethics J. 107, 113–15 (1997) (same). 46 See Allison, 184 F.3d at 1315 (noting that statistically significant epidemiological study reporting an increased risk of marker of disease of 1.24 times in patients with breast implants was so close to 1.0 that it “was not worth serious consideration for proving causation.”); In re Breast Implants Litig., 11 F. Supp. 2d at 1227 (same). 47 See Havner, 953 S.W.2d at 719.


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significant epidemiological findings that are not replicated in other epidemiological research (consistency).48 Courts have rejected epidemiological studies reporting statistically significant associations with allegedly similar substances or allegedly similar injuries (specificity).49 And courts have rejected alleged associations in epidemiological studies that did not demonstrate a dose–response relationship (dose response).50 Moreover, courts have not accepted the mere incantation of the name of Bradford Hill as establishing the reliability of a causation hypothesis.51 These criteria must be applied faithfully or they can also generate unreliable conclusions,52 as demonstrated by two review papers published in 1989–1990 that both purported to use the Bradford Hill criteria to assess the epidemiological evidence regarding an association between alcohol consumption and breast cancer, but reached dramatically different conclusions.53 Causation experts sometimes attempt to bolster individually weak epidemiological studies by relying on “meta-analyses” in which otherwise insignificant or inconsistent findings are pooled to generate a single purportedly significant finding. This approach was rejected by courts in the Bendectin litigation,54 and rightfully so. While meta-analyses can provide useful information if conducted pursuant to proper scientific methodology, they have frequently reported causal relationships that do not survive scientific scrutiny.55 By pooling data from different studies, meta-analyses can paper over biases and other weaknesses in the underlying studies, disregard inconsistent findings, and improperly combine divergent population groups. As one commentator has explained, “[m]eta-analyses begin with scientific studies, usually performed by academics or government agencies, and sometimes incomplete or disputed. The data from these studies are then run through computer models of bewildering complexity, which produces results of implausible precision.”56 After finding that meta-analyses were frequently contradicted by subsequent large, randomized controlled trials, another investigator cautioned: “The popularity of meta-analysis may at least partly come from the fact that it makes life simpler and easier for reviewers as well as readers. However, simplification may lead to inappropriate conclusions.”57 Pursuant to Daubert, a court 48

See, e.g., Miller v. Pfizer, Inc., 196 F. Supp. 2d 1062, (D. Kan. 2002) (expert failed to address “fact that other research is contrary to his conclusion), aff’d, 356 F.3d 1326 (10th Cir.), cert denied, 125 S. Ct. 40 (2004); Havner, 953 S.W.2d at 727 (“if scientific methodology is followed, a single study would not be viewed as indicating that it is ‘more probable than not’ that an association exists”). 49 See Joiner, 522 U.S. at 145–46 (studies proffered as evidence of PCB-lung cancer link involved exposures to mineral oils or other potential carcinogens); Burleson v. Tex. Dep’t. of Criminal Justice, 393 F.3d 577, 585–86 (5th Cir. 2004) (rejecting expert testimony where expert could not point to epidemiological studies demonstrating statistically significant link between thorium dioxide exposure and plaintiff’s type of lung or throat cancer); Allison, 184 F.3d at 1315 (studies reported link to injuries not suffered by plaintiff); Schudel v. Gen. Elec. Co., 120 F.3d 991, 997 (9th Cir. 1997) (studies involved exposures to organic solvents other than those at issue); Magistrini, 180 F. Supp. 2d at 603–04 (to same effect). 50 See Newman, 218 F. Supp. 2d at 778 (no dose–response relationship found in study involving cell phone use and cancer); Kelley v. Am. Heyer-Schulte Corp., 957 F. Supp. 873, 879 (W.D. Tex. 1997). 51 See Hollander, 289 F.3d at 1204 (rejecting expert’s causation testimony despite his claimed adherence to the Bradford Hill methodology): Dunn, 275 F. Supp. 2d at 677–78 (same). 52 See Lust v. Merrell Dow Pharms. Inc., 89 F.3d 594, 598 (9th Cir 1996) (“the district court should be wary that the [expert’s] method has not been faithfully applied”); O’Conner v. Commonwealth Edison Co., 13 F.3d 1090, 1106–07 (7th Cir. 1994) (excluding opinion where expert did not follow his own expressed methodology for establishing causation); Knight v. Kirby Inland Marine, Inc., 363 F. Supp. 2d 859, 864 (N.D. Miss. 2005) (expert’s “Bradford-Hill analysis is only as reliable as the underlying data upon which it is based”); Hall, 947 F. Supp. at 1400 (quoting Lust). 53 See Weed (1997) supra note 45 at 115, 116–18 (discussing Robert A. Hiatt, Alcohol consumption and breast cancer, 7 Med. Oncol. Tumor Pharmacother. 143 (1990) (concluding that women with risk factors for breast cancer should limit alcohol use) and Ernst L. Wynder and Randall E. Harris, Does alcohol consumption influence the risk of developing breast cancer? in Important Advances in Oncology 283 (V.T. Devita, S. Hellman, and S.A. Rosenberg eds. 1989) (concluding that there was no evidence of a causal link)). 54 See, e.g., DeLuca v. Merrell Dow Pharms., Inc., 791 F. Supp. 1042, 1046-59 (D.N.J. 1992), aff’d without op., 6 F.3d 778 (3d Cir. 1993); see also Knight, 363 F. Supp. 2d at 866 (rejecting causation opinion based on meta-analyses of cancer risks to chemical industry employees). 55 For examples, see Douglas L. Weed, Interpreting epidemiological evidence; how meta-analysis and causal inference methods are related, 29 Int. J. Epidemiol. 387 (2000); Jacques LeLorier, et al., Discrepancies between meta-analyses and subsequent large randomized, controlled trials, 337(8) N. Engl. J. Med. 336 (1997); Samuel Shapiro, Is meta-analysis a valid approach to the evaluation of small effects in observational studies? 50(3) J. Clin. Epidemiol. 223 (1997); Samuel Shapiro, Meta-analysis/Shmeta-analysis, 140(9) Am. J. Epidiol. 771 (Nov. 1994). 56 Shapiro (1994), at 771, supra note 55. 57 LeLorier (1997), at 541, supra note 55.


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must look behind the “bewildering complexity” of meta-analysis and protect against “inappropriate conclusions” by requiring the expert to establish the reliability and relevance both of the different pieces of information going into the meta-analysis and the calculations used to combine the information into a single result. 14.2.2.2

Animal Research

Animal research may be a useful tool for raising suspicions that can then be tested in humans, but there are significant differences in humans and laboratory animals that limit the degree to which animal research can validate a causation hypothesis in humans.58 There are numerous examples of apparent positive findings in animal studies that have subsequently been found inapplicable to humans. The most commonly cited example, perhaps, is saccharine, which was linked to bladder cancer in rats over 20 years ago but was recently removed from the National Toxicology Program list of potential human carcinogens after years of subsequent research failed to find any health risk in humans. Similarly, scientists have determined that a common insecticide, carbaryl, causes fetal abnormalities in dogs because dogs lack a specific enzyme involved in metabolizing carbaryl. Humans have the enzyme at issue and are accordingly not believed to be at risk.59 Because of numerous such problems of extrapolation, courts repeatedly have held that animal studies alone cannot prove causation in humans.60 At a minimum, extrapolations from animal studies to humans are not considered reliable in the absence of a credible scientific explanation why such extrapolation is warranted.61 In evaluating whether animal studies can form a reliable foundation for a causation opinion, trial courts should consider such factors as (1) whether the results followed a dose–response curve; (2) whether the animal studies involved massive doses, (3) whether the studies involved different routes of administration, (4) whether the studies are conducted in intact animals (as opposed, e.g., to isolated animal parts), (5) whether the results have been replicated in different animal species, and (6) whether the animal models have been shown to be reliable predictors of human experience.62 Animal toxicology studies are not designed to establish whether a substance is safe in humans but rather to allow scientists to study the types of effects a substance can produce under specified conditions.63 Accordingly, animal studies are often conducted with the goal of inducing the greatest number of adverse effects. This is accomplished in a number of ways, including the use of extremely high doses and exposures through special routes designed to deliver the substance directly to a particular organ without allowing for normal absorption and metabolization.64 While these models are useful and appropriate in the laboratory as a means to generate hypotheses for further testing, they create additional problems for extrapolating study findings to humans.

58

See, e.g., Irva Hertz-Picciotto, Epidemiology and quantitative risk assessment: a bridge from science to policy, 85(4) Am. J. Public Health. 484, 485 (1995) (“The uncertainty stemming from interspecies extrapolation is far larger than the uncertainty resulting from uncontrolled bias or errors in exposure information in epidemiological studies”). 59 See Bernard D. Goldstein and Mary Sue Henifen, Reference Guide on Toxicology, Reference Manual on Scientific Evidence 420 n.48 (2d ed. 2000). For additional examples of the often dramatic differences in responses among animal species and between animals and humans, see David L. Eaton and Curtis D. Klaassen, Principles of toxicology, in Casarett & Doull’s Toxicology: The Basic Science of Poisons 25–26 (Curtis D. Klaassen ed., 6th ed. 2001); Elaine M. Faustman and Gilbert S. Omenn, Risk assessment, in Casarett & Doull’s Toxicology: The Basic Science of Poisons, supra, at 88–90; Lorenz Rhomberg, Risk assessment and the use of information on underlying biological mechanisms: A perspective, 365 Mutat. Res. 175, 179–80 (1996); Jan M. M. Meijers, et al., The predictive value of animal data in human cancer risk assessment, 25 Regul. Toxicol. Pharmacol. 94 (1997). 60 See Siharath, 131 F. Supp. 2d at 1367 (quoting Bell v. Swift Adhesives, Inc., 804 F. Supp. 1577, 1579–80 (S.D. Ga. 1992)); Wade-Greaux v. Whitehall Labs.,Inc., 874 F. Supp. 1441, 1483–84 (D.V.I. 1994), aff’d without op., 46 F.3d 1120 (3d Cir. 1994). 61 See Soldo, 244 F. Supp. 2d at 565; Siharath, 131 F. Supp. 2d at 1366–67 (citing cases). 62 See, e.g., Joiner, 522 U.S. at 144; Hollander, 289 F.3d at 1209; Turpin, 959 F.2d at 1358–61; In re Rezulin Prod. Liab. Litig., 369 F. Supp. 2d at 406–07; Caraker, 188 F. Supp. 2d at 1037; Wade-Greaux, 874 F. Supp. at 1477. 63 See Eaton and Klaassen, at 27, supra note 59. 64 See Eaton and Klaassen, at 27, supra note 59; Karl K. Rozman and Curtis D. Klaassen, Absorption, distribution, and excretion of toxicants, in Casarett & Doull’s Toxicology: The Basic Science of Poisons, at 111.


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The existence of a dose–response relationship has been described as the most fundamental and pervasive concept in toxicology.65 All substances, even water, become toxic at a high enough dose. Conversely, however, “it has long been recognized that acute toxicological responses are associated with thresholds; that is, there is some dose below which the probability of an individual responding is zero.”66 As stated by the oft-described father of chemical pharmacology, Paracelsus (1493–1541), “What is there that is not poison? All things are poison and nothing [is] without poison. Solely a dose determines that a thing is not a poison.”67 Accordingly, even leaving to one side the issue of inter-species variations, the fact that a high-dose study results in adverse effects in animals cannot be extrapolated into a scientifically reliable conclusion that the substance can cause such effects at normal exposure levels in humans.68 To the contrary, because toxic effects in humans are generally expected to appear in the same range on the basis of dose per unit of body surface as in experimental animals, a finding of adverse events in animals at only very high doses may be more indicative of the safety of the substance in normal use.69 The route by which a substance enters the body can also have a significant effect on its toxicity. Animal researchers frequently administer chemical agents through special routes, including, inter alia, (1) intraperitoneal, (2) subcutaneous, (3) intramuscular, and (4) intravenous.70 These routes of administration may bypass the normal mechanisms through which potential toxins are removed before reaching the general circulation. For example, many substances are biotransformed and detoxified by the liver; while these substances may demonstrate toxic effects when injected intravenously, intramuscularly, or subcutaneously, they are perfectly safe if ingested orally.71 Likewise, animal researchers also use genetically designed or physically altered animals in which normal protective body mechanisms are removed.72 These types of animal studies can be useful in studying how an animal’s normal body mechanisms interact and how substances can affect isolated physiological systems, but they do not reflect real-world risks, even in the species being studied. In conducting its Daubert inquiry, a trial court also must determine whether the findings in the animal studies “fit” the opinions being offered in the case. Thus, an expert cannot rely on animal research that relates to a different injury than the one at issue. For example, animal carcinogenicity studies indicate that animals “react differently and in much more diverse ways than man” and that “compared to humans much more variation occurs in the cancer sites in animals.”73 However, in cases in which a chemical has been associated with cancers in both animal studies and epidemiological studies, “the target organ is usually identical.”74 In Joiner, the Supreme Court thus rejected animal research in part because the animals had developed a different type of cancer than the cancer at issue in the plaintiff.75

65

See Eaton and Klaassen, at 17–18, supra note 59. Id., at 21. Id., at 13. 68 See, e.g., Meijers, supra note 59, at 100 (concluding based on a comparison of animal and epidemiological studies for specific chemicals that “chemicals with little or no cancer potential in humans have been tested at too high concentrations in rodents... which resulted in the observed carcinogenic effect”). 69 Id., at 27. Federal regulatory agencies such as the Environmental Protection Agency thus use high-dose animal research as a basis for establishing conservative regulatory safe exposure levels for humans (albeit at levels several multiples below that found to have no effect in animals). See, e.g., Faustman and Omenn, supra note 59, at 92–94. 70 See Rozman and Klaassen, supra note 64, at 111; see also Meijers, supra note 59 at 95–98; Irva Hertz-Picciotto, supra note 58, at 485. 71 See Eaton and Klaassen, supra note 59, at 14; Rozman & Klaassen, supra note 64, at 111–14. 72 See, e.g., Rhomberg, supra note 59, at 181–83 (discussing carcinogenicity testing in animals engineered to be more susceptible to tumors). 73 Meijers, supra note 59, at 98. 74 Id. 75 See Joiner, 522 U.S. at 145; see also Glastetter v. Novartis Pharms. Corp., 252 F.3d 986, 991 (8th Cir. 2001). 66 67


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Chemical Analogies

Causation opinions derived from chemical analogies rely on the hypothesis that a substance’s effects can be predicted based on the established effects of similarly structured compounds. Trial courts should be very wary of such “guilt-by-association” evidence,76 particularly where there is scientific research involving the actual substance at issue that demonstrates differences between it and its purported chemical cousins. Because even small changes in molecular structure can radically change a particular substance’s properties and propensities, research in analogous substances does not reliably test the causal hypothesis at issue.77 The difficulty in relying on chemical analogies has been demonstrated by attempts to create computerized programs to assess the toxicity of chemical agents based on structure–activity relationships (SARs). These computerized models are far more sophisticated than the simplistic chemical analogies often relied on by causation experts in toxic tort litigation, and often rely on additional information regarding a substance beyond its chemical structure. Even so, while these models ultimately may prove helpful in setting research priorities or generating hypotheses, they have failed to provide reliable predictions as to a chemical’s toxic effect.78 As reported in a recent survey article, two prediction toxicity exercises conducted in recent years under the aegis of the National Toxicology Program have found that models that attempt to predict carcinogenicity “based solely on information derived from chemical structure” have been particularly unreliable, with the first exercise reporting that “overall accuracy in terms of positive or negative predictions was in the range 50–65%” and the ongoing second exercise reporting even higher error rates in preliminary results.79 Moreover, “[a] clear limitation of almost all the prediction systems … was their excessive sensitivity, i.e., incorrectly predicting many non-carcinogens as positive.”80 Efforts to predict toxicity based on structure activity relationships have resulted in similar problems.81 14.2.2.4

Case Reports/Case Series

Case reports and case series are anecdotal observations of adverse effects occurring in coincidence with exposure to a given substance. If a sufficient body of similar case reports appear in the literature, they can spur epidemiological or other controlled research to test the hypothesis that a causal link exists.82 However, as most courts have properly recognized, case reports themselves do 76 Caraker, 188 F. Supp. 2d at 1038; see also Soldo, 244 F. Supp. 2d at 549 (“Other federal courts facing proffered expert testimony based on the effects of allegedly similar compounds have reached the same conclusion and rejected such contentions: these courts have found that consideration of the effects of other drugs can only lead away from the truth.”) (citing cases). 77 See McClain v. Metabolife Int’l, Inc., 401 F.3d 1233, 1246 (11th Cir. 2005); Rider, 295 F.3d at 1200–01; Glastetter, 252 F.3d at 990; Schudel, 120 F.3d at 996–97. 78 See, e.g., Faustman and Omenn, supra note 59, at 86–87; A.M. Richard and R. Benigni, AI and SAR Approaches for Predicting Chemical Carcinogenicity: Survey and Status Report, 13(1) SAR and QSAR in Environmental Research 1 (2002); J. Ashby and R.W. Tenant, Prediction of rodent carcinogenicity for 44 chemicals: results, 9(1) Mutagenesis 7 (1994). 79 See Richard and Benigni, supra note 78, at 8, 10. 80 Richard and Benigni, supra note 78, at 8; see also Ashby and Tenant, supra note 78, at abstract (“carcinogenicity tends to be overpredicted by this integrated technique” of basing predictions on chemical structure, genotoxicity and rodent toxicity). 81 See James D. McKinney, et al., Forum: the practice of structure activity relationships (SAR) in toxicology, 56 Toxicol. Sci. 8, 15 (2000) (“Given the huge range and variability of possible interactions of chemicals in biological systems, it is highly unlikely that SAR models will ever achieve absolute certainty in predicting a toxicity outcome, particularly in a whole-animal system.”). 82 See Howard Hu and Frank E. Speizer, Influence of environmental and occupational hazards on disease, in Harrison’s Principles of Internal Medicine 19 (Braunwald, et al. eds. 15th ed. 2001) (“Case reports either sent to local authorities or published in the literature often prompt follow-up studies that can lead to the identification of new hazards”); David A. Grimes and Kenneth F. Schulz, Descriptive studies: what they can and cannot do, 359 Lancet 145 (Jan. 12, 2002) (“epidemiologists and clinicians generally use descriptive reports to search for clues of cause of disease — i.e., generation of hypotheses”); J.A. Arnaiz, et al., The use of evidence in pharmacovigilance: case reports as the reference source for drug withdrawals, 57 Eur. J. Clin. Pharmacol. 89–91 (2001).


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not test the causal hypothesis and accordingly cannot support a causation opinion under Daubert.83 Case reports are merely anecdotal accounts of observations in particular individuals; they are not controlled tests, frequently lack analyses, and frequently make little attempt to screen out alternative causes for a patient’s condition.84 As discussed above, when the substance at issue is widely used, it is statistically certain given general background rates of injury that there will be case reports in which an exposure and an injury coincidentally coincide. Accordingly, the existence of such case reports is of little scientific value.85 In drug product liability cases, causation experts may rely on so-called “causality assessments” of individual case reports. Causality assessments are algorithms used in some European pharmacovigilance regulatory schemes that seek to impose some structure on evaluation of individual case reports by creating standardized questions to be used in the review of such reports, such as: • • • • •

Was the adverse event a known consequence of the drug? Did the event occur in temporal proximity to the use of the drug? Did the symptoms disappear upon withdrawal of the drug (“dechallenge”)? Did the symptoms reappear following reintroduction of the drug (rechallenge)? Are there alternative causes for the adverse event?

Reviewers then grade individual case reports using such terms as “not possible,” “unlikely,” “possible,” and “probable.”86 Causality assessments are used by some regulatory agencies as a signaling tool, but “they have no objective reliability which would render them useful in a wider environment.”87 “None of the available causality assessment systems has been validated.… In other words the uncertainty [inherent in case reports] is not reduced, but categorized (at best in a semiquantitative way).”88 Studies of standardized causality assessments have repeatedly found significant disagreements between graders using the same assessment methodology.89 Accordingly, causality assessments carry no greater scientific weight than other case reports and likewise cannot provide the type of evidence required under Daubert.90 Some case reports include information regarding purported dechallenges or rechallenges, i.e., reports that a patient’s condition improved when the substance was removed or worsened when the substance was reintroduced. Where the dechallenge/rechallenge report is merely an after-thefact account of an anecdotal observation, it suffers from similar reliability problems as other case reports. Many medical conditions result in fluctuations in symptomology in the ordinary course, and apparent temporal associations with exposure may be due to pure chance. Even if the dechallenge or rechallenge is conducted prospectively with the intent of testing a causal hypothesis, a 83 See McClain, 401 F.3d at 1253–54; Norris v. Baxter Healthcare Corp., 397 F.3d 878, 885 (10th Cir. 2005); Rider, 295 F.3d at 1199; Hollander, 289 F.3d at 1211; Glastetter, 252 F.3d at 989–90; Soldo, 244 F. Supp. 2d at 541; Caraker, 188 F. Supp. 2d at 1034–35; Brumbaugh v. Sandoz Pharm. Corp., 77 F. Supp. 2d 1153, 1156 (D. Mont. 1999), see also Siharath, 131 F. Supp. 2d at 1361–62 (citing cases). 84 See Rider, 295 F.3d at 1199; Glastetter, 252 F.3d at 989–90; Soldo, 244 F. Supp. 2d at 539–40; see also Ellenhorn’s Medical Toxicology: Diagnosis and Treatment of Human Poisoning 1 (Ellenhorn ed. 2d ed. 1997) (“Case reports demonstrate a temporal but not necessarily causative relationship between exposure and health effects. This information is often confounded by the inability to exclude other causes of illness.”). 85 See Grimes & Schulz, supra note 82, at 148 (case reports, case series, and other descriptive studies “do not allow conclusions about cause of disease”). 86 See M.N.G. Dukes, et al., Responsibility for Drug-Induced Injury: A Reference Book for Lawyers, the Health Professionals and manufacturers 45–46 (2d ed. 1998); Ronald H.B. Meyboom, et al., Causal or casual? The role of causality assessments in pharmacovigilance, 17(6) Drug Saf. 374, 375–81 (1997). 87 M.N.G. Dukes, supra note 86 at 46. 88 Mayboom, supra note 86, at 382. 89 See Mayboom, supra note 86 at 381; G. Miremont, et al., Adverse drug reactions: physicians’ opinions versus a causality assessment method, 46 Eur. J. Clin. Pharmacol. 285, 288 (1994). 90 See Glastetter v. Novartis Pharms. Corp., 107 F. Supp. 2d 1015, 1037 n. 21 (E.D. Mo. 2000) (“like case reports … a causality assessment involves only one individual, and, in any event, is not sufficient to establish causation”) aff’d, 252 F.3d 986 (8th Cir. 2001); Soldo, 244 F. Supp. 2d at 545 (plaintiff has failed to show that the causality assessment “methodology — adopted for foreign regulatory purposes — meets any of the Daubert criteria, nor has plaintiff shown any other indicia of reliability.”).


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perceived effect in one person has limited scientific value at best.91 Because the data are limited to a single observation, a trial court must be particularly diligent in determining whether the dechallenge/rechallenge was conducted under strict controls to account for potential confounding influences. Prospective dechallenge/rechallenge experiments — sometimes referred to as “single subject” or “n of 1” experiments — have numerous limitations that preclude general causation conclusions.92 “[W]ithout strong assumptions regarding how an intervention on one individual relates to its effects on others, the results from a single-subject design provide little useful information … [and e]xamination of a single subject cannot verify those assumptions.”93 As courts have explained, a prospective dechallenge/rechallenge report “constitutes but one single, uncontrolled experiment.”94 14.2.2.5

Secondary Source Materials

In addition to actual scientific or anecdotal data, causation experts will sometimes rely on secondary source materials that cite to the primary evidence, such as regulatory materials, textbooks, and internal company documents. These secondary materials do not add any additional scientific knowledge and are no more reliable than the evidence they cite.95 They do not test a causal hypothesis; they merely report the findings of others. In particular, regulatory findings do not provide relevant “peer review” for a causation opinion, because they are based on a risk–utility analysis that involves a much lower standard of proof than that which is demanded by a court of law.96 For example, a recent article reported that the vast majority of regulatory withdrawals of approvals for drugs in Spain during the 1990s were based solely on case reports.97 As one commentary observed, “law, societal considerations, costs, politics, and the likelihood of litigation challenging a given regulation all influence the level of scientific proof required by the regulator decision-maker in setting regulatory standards and make such standards problematic as reference points in litigation.”98 14.2.3 Causation Opinions Based on Clinical Reasoning The question whether clinical reasoning can reliably support a causation opinion must be considered separately with respect to general causation and specific causation. Doctors do not in their ordinary clinical practice reach scientifically reliable determinations regarding general causation; they make individualized treatment decisions based on the exigencies of the moment. Accordingly, clinical reasoning cannot reliably support a general causation opinion. On the other hand, clinical reasoning through a differential diagnosis may provide reliable support for a specific causation opinion, so long as the diagnosis is reached in a manner that it is faithful to the scientific 91

See Dunn, 275 F. Supp 2d at 683; Soldo, 244 F. Supp. 2d at 541–42; Caraker, 188 F. Supp. 2d at 1035–36; see also Revels v. Novartis Pharms. Corp., No. 03-98-00231-CV, 1999 WL 644732, *5 (Tex. App. Aug. 26, 1999). 92 See David M. Reboussin and Timothy M. Morgan, Statistical considerations in the use and analysis of single-subject designs, Med. Sci. Sports Exerc. 639, 640–642 (1996) (discussing limitations). 93 Reboussin and Morgan, supra note 92, abstract. 94 Soldo, 244 F. Supp. 2d at 541 (quoting Revels, 1999 WL 644732, at *5); see also McClain, 401 F.3d at 1254–55 (“dechallenge/re-challenge tests are still case reports and do not purport to offer definitive conclusions as to causation”) (quoting Rider, 295 F.3d at 1200). 95 See Soldo, 244 F. Supp. 2d at 513, 542; Caraker, 188 F. Supp. 2d at 1039; Siharath, 131 F. Supp. 2d at 1370; Glastetter, 107 F. Supp. 2d at 1034 n.18. 96 See McLain, 401 F.3d at 1248–50; Rider, 295 F.3d at 1201; Glastetter, 252 F.3d at 991; Hollander, 289 F.3d at 1215; Conde, 24 F.3d at 814; Dunn, 2003 WL 21856420, at * 10; Soldo, 244 F. Supp. 2d at 513; see also Richard A. Merrill, Regulatory toxicology, in Casarett & Doull’s Toxicology: The Basic Science of Poisons 1041–43 (discussing federal regulator’s conservative risk-utility analysis); Joseph V. Rodricks and Susan H. Rieth, Toxicological risk assessment in the courtroom: are available methodologies suitable for evaluating toxic tort and product liability claims?, 27 Regul. Toxicol. Pharmacol. 21, 27 (“The public health-oriented resolution of scientific uncertainty [used by regulators] is not especially helpful to the problem faced by a court.”). 97 See Arnaiz, supra note 82. 98 Rodricks and Rieth, supra note 96, at 30.


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method. Differential diagnoses conducted for tort litigation purposes raise unique issues of reliability, however, because they generally are conducted post hoc and not in the context of medical treatment. 14.2.3.1

Clinical Reasoning and General Causation

Doctors in their day-to-day practice are required to make treatment decisions for individual patients based on the clinical information before them. These clinical judgments do not provide a reliable basis for a general causation opinion.99 Doctors do not conduct scientific testing in their daily practice to determine whether particular substances can cause particular injuries. Indeed, few doctors have more than a rudimentary training in the scientific methods used to determine causation.100 Instead, they reach working diagnoses and make conservative medical judgments based on their Hippocratic oath to “first, do no harm.”101 Thus, for example, if a patient reports a recent exposure to a new medication or chemical substance, the doctor may order the patient to avoid further exposures based not on a scientific determination of causality but simply as a no-risk prophylactic measure.102 While doctors may reach tentative opinions regarding causation in the course of providing treatment, their opinions are not reached pursuant to the scientific method, but are instead based on inferential leaps that allow them to provide immediate therapeutic care. Clinical causation opinions based on differential diagnosis are “a mixture of science and art, far too complicated for its accuracy to be assessed quantitatively or for a meaningful error rate to be calculated.”103 Moreover, differential diagnosis only “follow[s] the causal stream up to a point where intervention is possible” because, typically, physicians “do not care about a disease’s etiology … unless understanding causation would assist in diagnosis and treatment.”104 As one court recently explained, Doctors in their day-to-day practices stumble upon coincidental occurrences and random events and often follow human nature, which is to confuse association and causation. They are programmed by human nature and the rigors and necessities of clinical practices to conclude that temporal association equals causation, or at least that it provides an adequate proxy in the chaotic and sometimes inconclusive world of medicine. This shortcut aids doctors in their clinical practices because the most important objective day-to-day is to help their patients and “first do no harm,” as their Hippocratic oath requires. Consequently, they make leaps of faith.… [This type of] clinical impression is not the sort of scientific methodology that Daubert demands.105

Plaintiffs’ counsel seeking to rely on clinical reasoning to support a general causation opinion will often cite to the language in Kumho Tire that an expert must “employ in the courtroom the same level of intellectual rigor that characterizes the practice of the expert in the relevant field.”106 This argument is misplaced, because, as explained above, “the relevant field[s]” for a general causation opinion are epidemiology and toxicology, not clinical medicine.107 Plaintiffs’ counsel will also argue that differential diagnosis is a well-recognized, scientifically reliable technique. But differential 99

See Soldo, 244 F. Supp. 2d at 508; Siharath, 131 F. Supp. 2d at 1362; In re Breast Implant Litig., 11 F. Supp. 2d at 1230; Hall, 947 F. Supp. at 1413. 100 See Hu and Speizer, supra note 82. 101 See Siharath, 131 F. Supp. 2d at 1371; see also Miremont, supra note 89 at 288 (explaining finding that physicians are more likely to attribute causation to a drug as being due to their “necessarily more pragmatic approach to patients and diseases”). 102 See Kassirer and Cecil, at 1384. 103 John M. Conley and John B. Garver, III, William C. Keady and the law of scientific evidence, 68 Miss. L.J. 39, 51 (1998). 104 Herbert A. Simon, Artificial-intelligence approaches to problem solving and clinical diagnosis, in Logic of Discovery and Diagnosis in Medicine 72, 87 (Kenneth F. Schaffner ed. 1985). 105 Siharath, 131 F. Supp. 2d at 1372. 106 526 U.S. at 152. 107 See Siharath, 131 F. Supp. 2d at 1362; Michael B. Kent, Jr., Daubert, doctors and differential diagnosis: treating medical causation testimony as evidence, 66 Def. Couns. J. 525, 532–33 (1999).


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diagnosis is a reliable methodology only for “ruling out” alternative causes of injury from a list of possible causes; it does not “rule in” a substance as a potential cause in the first instance.108 14.2.3.2

Clinical Reasoning and Specific Causation

Although insufficient for purposes of general causation, a differential diagnosis may provide a scientifically reliable basis for a specific causation opinion — i.e., that an established toxin in fact caused a plaintiff’s injury. However, an expert’s bare assertion that the expert applied a differential diagnosis is not sufficient to satisfy Daubert. A trial court must determine whether the differential diagnosis is based on a reliable methodology. Accordingly, the expert must demonstrate that the differential diagnosis was based on a sufficient and valid clinical investigation.109 The expert also must have a scientifically reliable basis for excluding alternative causes of the plaintiff’s injury, including the possibility that the injury was idiopathic.110 In analyzing the reliability of a specific causation opinion based on differential diagnosis, trial courts must ensure that the expert employs “the same level of intellectual rigor” in the courtroom as a treating physician would employ in the ordinary care of patients.111 An expert cannot simply look for all possible causes of a person’s illness from the universe of potential causes and declare that each of them — including the exposure at issue — should be considered actual but for causes for purposes of tort liability.112 Even if an expert can show reliable scientific evidence supporting some level of increased risk from a drug, the expert cannot reliably point to the drug as the cause of an individual plaintiff’s injury if that plaintiff has other independent risk factors that are more strongly associated with the injury in question. For example, assume that there is scientifically reliable epidemiological evidence showing a three times statistically significant increased risk of stroke in patients who used a given drug X. That evidence may be sufficient to support an expert’s specific causation opinion with regard to a plaintiff who has no other risk factor for stroke. However, it would not be sufficient to support a specific causation opinion with regard to a patient who also suffers from uncontrolled hypertension and has smoked a pack of cigarettes a day for the past 20 years, given the greater risks posed by those comorbid conditions. Where a plaintiff has other established risk factors that could have caused the plaintiff’s injury, the expert must explain how he ruled out these other potential causes to reliably support an opinion that the injury was due instead to a drug exposure.113 A trial court also needs to evaluate an expert’s differential diagnosis in light of the artificial circumstances in which it is reached. Unlike differential diagnoses conducted by doctors in their day-to-day practice, a differential diagnosis in a litigation context is often conducted in support of an already asserted legal claim of causation. This raises myriad possibilities of bias, both intentional and unintentional. Consider a hypothetical example of typical large-scale drug product liability litigation. Based on anecdotal reports of adverse events and possibly pressure from special interest organizations like Public Citizen, the FDA recommends labeling changes or withdraws approval of a drug.114 The same day, if not before, plaintiffs’ firms will begin advertising for potential plaintiffs through 108

See Norris, 397 F.3d at 885; Soldo, 244 F. Supp. 2d at 524; Siharath, 131 F. Supp. 2d at 1362–63; Glastetter, 107 F. Supp. 2d at 1027. 109 See Soldo, 244 F. Supp. 2d at 551; Pick v. Am. Med. Sys. Inc., 958 F. Supp. 1151, 1168–69 (E.D. La. 1997). 110 See Daubert, 43 F.3d at 1319; Soldo, 244 F. Supp. 2d at 551–52; Magistrini,180 F. Supp. 2d at 608–10 (D.N.J. 2002); Nelson v. Am. Home Prods. Corp., 92 F. Supp. 2d 954, 971 (W.D. Mo. 2000). 111 Kumho Tire, 536 U.S. at 152. 112 See Cano v. Everest Minerals Corp., 362 F. Supp. 2d 814, 846 (W.D. Tex. 2005). 113 See Wills v. Amerada Hess Corp., 379 F.3d 32, 50 (2d Cir. 2004) (excluding expert’s specific causation opinion that plaintiff’s squamous cell carcinoma had been caused by polycyclic aromatic hydrocarbons where plaintiff was a smoker and heavy consumer of alcohol); Easter v. Aventis Pasteur, Inc., 358 F. Supp. 2d 574, 577 (E.D. Tex. 2005) (expert could not reliably point to thimerosal in vaccine as a cause of plaintiff’s neurological injuries where plaintiff had autism that could not be linked to vaccine and was independently associated with such injuries). 114 As discussed supra at 1160, such regulatory action is not the equivalent of a finding of causation.


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various forms of media, including the Internet, television, radio, and print media. Provided that the drug has been used by a relatively large number of patients, there will be a ready population of patients who had adverse events while taking the drug based solely on statistical chance due to the background rates of such events regardless of drug use. Accordingly, plaintiffs’ counsel can quickly gather a large pool of potential plaintiffs. Plaintiffs’ counsel will then start weeding through that pool to exclude individuals with obvious alternative causes for their injuries and patients whose injury did not emerge in temporal proximity to their ingestion of the drug. At first blush, this might appear to be a reliable method for determining those individuals whose injuries were more likely due to the drug. That interpretation, however, is based on the false premise that medicine can always find a cause for an injury. In fact, there are many conditions for which medicine frequently cannot find a cause.115 In other words, there is often a measurable background rate of idiopathic injuries, i.e., injuries with unknown causes. Plaintiffs’ counsel’s weeding out process, accordingly, often merely identifies the statistically expected population of patients who coincidentally had adverse events of unknown cause while taking the drug. At the same time plaintiffs’ counsel are reviewing their potential plaintiff population, they will also be looking for an expert witness to provide a specific causation opinion. Generally, plaintiffs’ counsel will select an expert who is already prepared to offer a favorable general causation opinion. Plaintiffs’ counsel will also select an expert witness who is predisposed toward providing a favorable specific causation opinion. This does not mean that the expert is intentionally biased or insincere in his or her opinion, but it does mean that the expert will enter the process with a preconceived assumption of causality. By the time the expert and plaintiff are brought together for purposes of a differential diagnosis, the result is effectively preordained. The expert will start the examination from the premise that the substance at issue is dangerous and a likely cause of injury regardless of potential alternative causes. The plaintiff will not present with obvious alternative causes of injury sufficient to shake the expert from the initial presumption. Moreover, in cases where the expert is not the patient’s treating physician, the expert will not test the initial diagnosis through ongoing observation and medical treatment. This “differential diagnosis” bears little resemblance to a differential diagnosis conducted by treating physicians in their regular practice, and cannot provide the type of objective validation that Daubert requires for admissibility of an expert specific causation opinion. Trial courts must recognize that there is an inherent “selection bias” at work in mass drug product liability litigation and carefully evaluate the expert’s specific causation opinion with this artificial background in mind. 14.2.4 The Parlodel Litigation Over the past decade, a number of product liability cases involving the prescription drug Parlodel have been working their way through the courts. The Parlodel litigation has resulted in a body of Daubert case law that squarely addresses the issues of medical causation expert testimony discussed above and provides a detailed analysis of “all of the components of the ‘causation’ argument that are available to experts in the most contentious of products liability case[s].”116 There is now an emerging judicial consensus that plaintiffs’ experts’ causation opinions in the Parlodel litigation do not satisfy the requirements of Daubert. Three federal appellate courts, the Eighth, Tenth, and Eleventh Circuits, have unanimously affirmed district court opinions excluding the causation opinions of plaintiffs’ experts, and four other published district court opinions 115

See, e.g., Steven A. Kittner, et al, Cerebral infarction in young adults, 50 Neurology 890–94 (1998) (despite neurologists’ careful review, in 50.5% of cases, no probable cause of stroke in young adults could be identified). Kiely, supra note 8. In addition to being used as a case study for legal scholars, the Parlodel litigation was discussed in an article published in the Journal of the American Medical Association by an unsuccessful amicus for plaintiffs appealing a Parlodel Daubert exclusionary ruling to the Eleventh Circuit Court of Appeals in Rider. See J. Kassirer and J. Cecil, supra note 7.

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excluding this testimony were not appealed.117 A few earlier district court opinions, two of which were drafted by the same magistrate judge, have gone the other way.118 The Parlodel opinions thus provide a useful Daubert case study of courts that properly evaluated medical causation testimony based on the scientific method and those that do not. 14.2.4.1

Plaintiffs’ Allegations Regarding Parlodel

Parlodel (bromocriptine mesylate) is an FDA-approved drug used for a variety of indications, including Parkinson’s disease, amenorrhea/galactorrhea (lack of menses), infertility, and acromegaly (a growth disorder). From 1980 to 1994, Parlodel was also approved for the prevention of postpartum lactation (“PPL”) in women who elected not to breast-feed. The manufacturer of Parlodel withdrew the drug from the market for this PPL indication following receipt of a number of case reports of strokes, seizures, and myocardial infarctions and an FDA advisory committee determination that there was limited need for pharmaceutical treatment for PPL. The FDA withdrew its approval of Parlodel for the PPL indication in 1995, based on its conclusion that the limited utility of the drug for PPL did not outweigh the possible risks.119 Plaintiffs’ experts allege that Parlodel causes vasoconstriction (a narrowing of blood vessels), which they allege can cause stroke, seizures, and myocardial infarction. Plaintiffs’ experts concede that the epidemiological studies conducted on the drug have not established a causal link with these injuries and that there is a body of controlled clinical research in humans that has found that Parlodel has the exact opposite effect of causing vasodilation (a widening of blood vessels). Plaintiffs’ experts also concede that controlled intact animal research has not shown a causal link between Parlodel and strokes, seizures, or myocardial infarctions in animals. Plaintiffs’ experts base their causation opinion on anecdotal case reports (including alleged dechallenge/rechallenge reports), animal research involving limited end points, chemical analogies, a variety of secondary source materials, and differential diagnoses.120 14.2.4.2

Opinions Admitting Plaintiffs’ Experts’ Causation Opinions

The district courts that have admitted plaintiffs’ experts’ causation opinions have relied primarily on differential diagnoses and the determination that lesser scientific evidence of general causation should be accepted because it allegedly would not be possible to conduct an epidemiological study of sufficient strength to adequately test plaintiffs’ experts’ causation hypothesis. Thus, one magistrate judge dismissed the lack of any direct scientific evidence supporting plaintiffs’ experts’ causation opinion, reasoning that “[s]cience, like many other human endeavors, draws conclusions from circumstantial evidence, when other, better forms of evidence [are] not available.”121 In a subsequent opinion, the same magistrate judge sounded a similar theme: “In science, as in life, where there is smoke, fire can be inferred, subject to debate and further testing.”122 The court was similarly deferential in its review of plaintiffs’ experts’ specific causation opinions. While noting that there were a number of alternative causes for the injuries at issue, the court found that the “debate creates a question about the weight to be accorded the plaintiffs’ experts’ opinions, but it does not affect the admissibility.”123 117 Rider, 295 F.3d 1194; Hollander, 289 F.3d 1193; Glastetter, 252 F.3d 986; Dunn, 275 F. Supp 2d 672; Soldo, 244 F. Supp. 2d 434; Caraker, 188 F. Supp. 2d 1026; Brumbaugh, 77 F. Supp. 2d 1153; see also Revels, 1999 WL 644732 (excluding Parlodel causation opinions on Texas analog of Daubert). 118 Brasher v. Sandoz Pharms. Corp., 160 F. Supp. 2d 1291 (N.D. Ala. 2001) (Putnam, M.J.); Globetti v. Sandoz Pharms. Corp., 111 F. Supp. 2d 1174 (N.D. Ala. 2000) (Putnam, M.J.); Eve v. Sandoz Pharms. Corp., 2001 U.S. Dist. LEXIS 4531 (S.D. Ind. Mar. 7, 2001). 119 See Caraker, 188 F. Supp. 2d at 1028, 1040. 120 See generally Rider, 295 F.3d 1194; Glastetter, 252 F.3d 986; Caraker, 188 F. Supp. 2d 1026. 121 Globetti, 111 F. Supp. 2d at 1180; see also Eve, 2001 U.S. Dist. LEXIS 4531, at *75 (quoting Globetti). 122 Brasher, 160 F. Supp. 2d at 1296; see also id. at 1297 (“Given the practical unavailability of other forms of scientific evidence, reliance on those that are available is all the more reasonable.”). 123 Id. at 1299.


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Missing in these opinions is any recognition of the requirement in Daubert that the experts’ causation opinions be based on the scientific method of testing and validating hypotheses. Daubert does not permit expert testimony to be admitted based on the smoke of anecdotal reports and inferences, nor does it allow courts to lower the bar of scientific reliability based on a perceived lack of relevant scientific evidence. In accepting plaintiffs’ experts’ lower showing of evidence, these courts abdicated their gatekeeping responsibility. 14.2.4.3

Opinions Excluding Plaintiffs’ Experts’ Causation Opinions

By contrast, in the Parlodel cases in which courts have evaluated plaintiffs’ experts’ opinions based on the scientific method, the experts’ testimony has been excluded. These courts have conducted detailed analyses of each of the different categories of evidence discussed above, and their reasoning and conclusions are incorporated in that discussion. The overarching theme in these opinions is the courts’ recognition that medical causation opinions are not admissible unless they are based on scientifically tested and validated hypotheses. As these courts have explained, Daubert does not establish a “best efforts” test.124 An expert cannot satisfy Daubert by arguing that the expert has “used the best methodology available under the circumstance,”125 or that the expert has “done the best [the expert] could with the available data and the scientific literature.”126 Rather, the expert must answer the “key question,” whether the “theory being advanced by the expert is testable or has been tested, the methodology of which is what distinguishes science from other fields of human inquiry.”127 “The hallmark of [Daubert’s] reliability prong is the scientific method, i.e., the generation of testable hypotheses that are then subjected to the real world crucible of experimentation, falsification/validation, and replication.”128 The “testing of hypotheses” is “a critical aspect of the application of the scientific method.”129 Expert opinions “reposed in the realm of ‘may cause’ or ‘possibly could cause’” must be excluded.130 “While hypothesis is essential in the scientific community because it leads to advances in science, speculation in the courtroom cannot aid the fact finder in making a determination of whether liability exists.”131 These Parlodel cases forcefully answer critics of Daubert who argue for a lower standard based on deferential review of medical causation testimony: The Daubert trilogy, in shifting the focus to the kind of empirically supported, rationally explained reasoning required in science, has greatly improved the quality of the evidence upon which juries base their verdicts. Although making determinations of reliability may present the court with the difficult task of ruling on matters that are outside its field of expertise, this is less objectionable than dumping a barrage of scientific evidence on a jury, who would likely be less equipped than a judge to make reliability and relevancy determinations.132

The scientific method serves as a bulwark against subjective judgments and inspired guesswork masquerading as scientific knowledge. Courts that ignore the scientific method in their review of medical causation opinions do a disservice to the legal system and disregard the Supreme Court’s mandate.

124

Siharath, 131 F. Supp. 2d at 1373. Id. at 1371. 126 Hollander, 289 F.3d at 1213. 127 Brumbaugh, 77 F. Supp. 2d at 1156. 128 Caraker, 188 F. Supp. 2d at 1030. 129 Soldo, 244 F. Supp. 2d at 529. 130 Glastetter, 107 F. Supp. 2d at 1025. 131 Dunn, 275 F. Supp. 2d at 684. 132 Rider, 295 F.3d at 1197. 125


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14.2.5 Conclusion Faced with the exacting standards of Daubert, plaintiffs’ causation experts will often respond with a spaghetti-on-the-wall strategy in the hope that something will stick. The Supreme Court’s adoption of the scientific method as the central guide to admissibility provides district courts with the solution they need to untangle the mess. For each strand in plaintiffs’ expert’s analysis, the questions are the same: Is the expert relying on evidence that has been tested and validated, and does the evidence fit the question at issue? Unless experts can answer both of these questions in the affirmative, they should not be allowed to serve up their opinions to a jury. As Supreme Court Justice Breyer explained in his concurring opinion in Joiner, the evidentiary safeguards imposed by the courts against unreliable science provides an important bulwark against unfounded litigation that can threaten access to needed health care: [M]odern life, including good health as well as economic well-being, depends upon the use of artificial or manufactured substances.… [I]t may, therefore, prove particularly important to see that judges fulfill their Daubert gatekeeping function, so that they help assure that the powerful engine of tort liability, which can generate strong financial incentives to reduce, or to eliminate, production, points toward the right substances and does not destroy the wrong ones.133

While this book has focused primarily on the dangers of drug abuse, the potential dangers of litigation abuse on the availability of medically indicated pharmaceutical products also poses a threat to patient health that must not be ignored.

133

Joiner, 522 U.S. at 148–49 (Breyer, J., concurring).


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Appendices CONTENTS Appendix IA: Glossary of Terms in Forensic Toxicology..........................................................1175 Appendix IB: Common Abbreviations ........................................................................................1179 Appendix IC: References for Methods of Drug Quantitative Analysis......................................1182 References ....................................................................................................................................1188 Appendix II: Sample Calculations...............................................................................................1220 Appendix III: Predicted Normal Heart Weight (g) as a Function of Body Height in 392 Women and 373 Men ..............................................................................................................1223

APPENDIX IA: GLOSSARY OF TERMS IN FORENSIC TOXICOLOGY Compiled by H. Chip Walls, B.S. Department of Pathology, Forensic Toxicology Laboratory, University of Miami, Miami, Florida

Absolute Method A method in which characterization is based on physically defined (absolute) standards. Accreditation (l) A formal process by which a laboratory is evaluated, with respect to established criteria, for its competence to perform a specified kind(s) of measurement(s); (2) the decision based upon such a process; (3) formal recognition that a testing laboratory is competent to carry out specific tests or specific types of tests. Accuracy Closeness of the agreement between the result of a measurement and a true value of the measured quantity. Acetaldehyde The first product of ethanol metabolism. Acute Severe, usually crucial, often dangerous in which relatively rapid changes are occurring. An acute exposure runs a comparatively short course. Acute tolerance The development of tolerance within the course of a single exposure to a drug. Alcohol dehydrogenase (ADH) The main enzyme that catalyzes the conversion of ethanol to acetaldehyde. Aldehyde dehydrogenase (ALDH) The enzyme that converts acetaldehyde to acetate. Aliquot (1) A divisor that does not divide a sample into a number of equal parts without leaving a remainder; (2) a sample resulting from such a divisor. Analyte The specific component measured in a chemical analysis. Analytical run (series) A set of measurements carried out successively by one analyst using the same measuring system, at the same location, under the same conditions, and during the same short period of time. Analytical sensitivity The ability of a method or instrument to discriminate between samples having different concentrations or containing different amounts of the analyte. Slope of the analytical calibration function. 1175


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Analytical specificity Ability of a measurement procedure to determine solely the measurable quantity (desired substance) it purports to measure and not others.

Analytical wavelength Any wavelength at which an absorbance measurement is made for the purpose of the determination of a constituent of a sample.

Antemortem Before death, occurring before death. Ascites An abnormal accumulation of fluid in the peritoneal cavity of the abdomen. Assignable cause A cause believed to be responsible for an identifiable change in precision or accuracy of a measurement process.

Beer’s law The absorbance of a homogeneous sample containing an absorbing substance is directly proportional to the concentration of the absorbing substance.

Bias A systematic error inherent in a method or caused by some artifact or idiosyncrasy of the measurement system. Temperature effects and extraction inefficiencies are examples of errors inherent in the method. Blanks, contamination, mechanical losses, and calibration errors are examples of artifact errors. Bias can be either positive or negative, and several kinds of error can exist concurrently. Therefore, net bias is all that can be evaluated. Blank (1) The measured value obtained when a specified component of a sample is not present during the measurement. In such a case, the measured value (or signal) for the component is believed to be due to artifacts and should be deducted from a measured value to give a net value due solely to the component contained in the sample. The blank measurement must be made so that the correction process is valid. (2) Biological specimen with no detectable drugs added, routinely analyzed to ensure that no false-positive results are obtained. Blind sample A control sample submitted for analysis as a routine specimen whose composition is known to the submitter but unknown to the analyst. A blind sample is one way to test the proficiency of a measurement process. Calibrant Substance used to calibrate, or to establish the analytical response of, a measurement system. Calibration Comparison of a measurement standard or instrument with another standard or instrument to report or eliminate, by adjustment, any variation or deviation in the accuracy of the item being compared. Central line The long-term expected value of a variable displayed on a control chart. Certification A written declaration that a particular product or service complies with stated criteria. Certified value The value that appears in a certificate as the best estimate of the value for a property of a certified reference material. Certified reference material (CRM) A reference material one or more of whose property values are certified by a technically valid procedure, accompanied by or traceable to a certificate or other documentation that is issued by a certifying body. [ISO Guide 30: 1981 (E)] Chain of custody (COC) Handling samples in a way that supports legal testimony to prove that the sample integrity and identification of the sample have not been violated as well as the documentation describing these procedures. Chance cause A cause for variability of a measurement process that occurs unpredictably, for unknown reasons, and is believed to happen by chance alone. Check standard (in physical calibration) An artifact measured periodically, the results of which typically are plotted on a control chart to evaluate the measurement process. Chronic Persistent, prolonged, repeated. Chronic tolerance The gradual decrease in degree of effect produced at the same blood concentration in the course of repeated exposures to that drug. Coefficient of variation The standard deviation divided by the value of the parameter measured. Comparative method A method that is based on the intercomparison of the sample with a chemical standard. Composite sample A sample composed of two or more components selected to represent a population of interest. Concentration Amount of a drug in a unit volume of biological fluid, expressed as weight/volume. Urine concentrations are usually expressed either as nanograms per milliliter (ng/ml), micrograms per milliliter (µg/ml), or milligrams per liter (mg/l). (There are 28,000,000 micrograms in an ounce, and l,000 nanograms in a microgram.)


APPENDICES

1177

Confidence interval That range of values, calculated from an estimate of the mean and the standard deviation, which is expected to include the population mean with a stated level of confidence. In the same manner, confidence intervals can also be calculated for standard deviations, lines, slopes, and points. Confirmation A second test by an alternate chemical method to positively identify a drug or metabolite. Confirmations are carried out on presumptive positives from initial screens. Control chart A graphical plot of test results with respect to time or sequence of measurement together with limits in which they are expected to lie when the system is in a state of statistical control. Control limits The limits shown on a control chart beyond which it is highly improbable that a point could lie while the system remains in a state of statistical control. Control sample A material of known composition that is analyzed concurrently with test samples to evaluate a measurement process. (See also Check standard.) Correlation coefficient Measures the strength of the relation between two sets of numbers, such as instrument response and standard concentration. Cross sensitivity A quantitative measure of the response for an undesired constituent or interferent as compared to that for a constituent of interest. Cross-reacting substances In immunoassays, refers to substances that react with antiserum produced specifically for other substances. Cutoff level (threshold) Value serving as an administrative breakpoint (or cutoff point) for labeling a screening test result positive or negative. Cytochrome P450 A detoxifying enzyme found in liver cells. Detection limit or limit of detection (LOD) The lowest concentration of a drug that can reliably be detected. Smallest result of a measurement by a given measurement procedure that can be accepted with a stated confidence level as being different from the value of the measurable quantity obtained on blank material. Double blind A sample, known by the submitter but supplied to an analyst in such a way that neither its composition nor its identification as a check sample or standard is known to the analyst. Duplicate measurement A second measurement made on the same or identical sample of material to assist in the evaluation of measurement variance. Endogenous Produced or originating within the body by natural processes such as intermediary metabolism. Enzymes Proteins whose function is to drive the chemical reactions of the body — a catalyst of biochemical reactions. False negative An erroneous result in an assay that indicates the absence of a drug that is actually present. False negative rate The proportion of true positive samples that give a negative result. False positive An erroneous result in an assay that indicates the presence of a drug that is actually not present. False positive rate The proportion of true negative samples that give a positive test result. Fume Gas-like emanation containing minute solid particles arising from the heating of a solid body such as lead, in distinctions to a gas or vapor. This physical change is often accompanied by a chemical reaction such as oxidation. Fumes flocculate and sometimes coalesce. Odorous gases and vapors are not fumes. Hepatocyte Name given to cells within the liver. Hyperglycemia An excessive amount of glucose in the blood. Hypoglycemia An abnormally low concentration of glucose in the circulating blood. Impairment Decreased ability to perform safely a given task. Infrared Pertaining to the region of the electromagnetic spectrum from approximately 0.78 to 300 microns (780 to 300,000 nanometers). Insulin A hormone produced in the islets of Langerhans in the pancreas as a response to elevated blood sugar levels. The hormone permits the metabolism and utilization of glucose. Interferant A chemical compound or substance other than the substance of interest (e.g., ethanol) to which the measuring instrument responds to give a falsely elevated result. Interfering substances Substances other than the analyte that give a similar analytical response or alter the analytical result.


1178


Interindividual variation Distribution of the values of a type of quantity in individuals of a given set. Intraindividual variation Distribution of the values of a type of quantity in a given individual. Limit of quantification (LOQ) The lower limit of concentration or amount of substance that must be present before a method is considered to provide quantitative results. By convention, LOQ = 10 x so, where so = the estimate of the standard deviation at the lowest level of measurement. Matrix The composition of the biological sample being analyzed, consisting of proteins, lipids and other biomolecules that can affect analyte recovery. Matrix effects Influence of a component in the analytical sample other than the component being investigated on the measurement being made. MEOS The microsomal ethanol oxidizing system, an enzyme system in liver that converts ethanol to acetaldehyde. Metabolite A compound produced from chemical changes of a drug in the body. Microsomal enzymes Detoxifying enzymes associated with certain membranes (smooth endoplasmic reticulum) within cells. Ordinal scale Ordered set of measurements consisting of words and/or numbers indicating the magnitude of the possible values that a type of quantity can take. Outlier A value in a sample of values so far separated from the remainder as to suggest that it may be from a different population. Perimortem At or near the time of death. Pharmacodynamics The study of the relationship of drug concentration to drug effects. Pharmacokinetics The study of the time course of the processes (absorption, distribution, metabolism, and excretion) a drug undergoes in the body. Physical dependence A state that develops in parallel with chronic tolerance and is revealed by the occurrence of serious disturbances (abstinence syndrome) when drug intake is terminated. Postmortem After death, occurring after death, of or pertaining to a postmortem examination, an autopsy. Precision Closeness of agreement between independent results of measurements obtained by a measurement procedure under prescribed conditions (standard deviation). Presumptive positive Sample that has been flagged as positive by screening but that has not been confirmed by an equally sensitive alternative chemical method. Proficiency-testing specimen A specimen whose expected results are unknown to anyone in the laboratory, known only by an external agency, and later revealed to the laboratory as an aid to laboratory improvement and/or a condition of licensure. Psycho Pertaining to the mind and mental processes. Psychoactive Affecting the mind or mental processes. Psychochemical A substance affecting the mind or mental processes. Psychology The science of mental processes and behavior. Psychomotor Of or pertaining to muscular activity associated with the mental process. Psychomotor functions Matters of mental and motor function. Psychosis Severe mental disorder, with or without organic damage, characterized by deterioration of normal intellectual and social functioning and by partial or complete withdrawal from reality. Psychotomimetic Pertaining to or inducing symptoms of a psychotic state. Psychotropic Having a mind-altering effect. Qualitative test Chemical analysis to identify one or more components of a mixture. Quality assurance (QA) Practices that assure accurate laboratory results. Quality control (QC) Those techniques used to monitor errors that can cause a deterioration in the quality of laboratory results. Control material most often refers to a specimen, the expected results of which are known to the analyst, that is routinely analyzed to ensure that the expected results are obtained. Quantitative test Chemical analysis to determine the amounts or concentrations of one or more components of a mixture. Repeatability Closeness of agreement between the results of successive measurements during a short time (within run standard deviation).


APPENDICES

1179

Reproducibility Closeness of agreement between the results of measurements of the same measurable quantity on different occasions, made by different observers, using different calibrations, at different times (between run standard deviation). Screen A series of initial tests designed to separate samples containing drugs at or above a particular minimum concentration from those below that minimum concentration (positive vs. negative). Sensitivity The detection limit, expressed as a concentration of the analyte in the specimen. Specificity Quality of an analytical technique that tends to exclude all substances but the analyte from affecting the result. Split specimen Laboratory specimen that is divided and submitted to the analyst, unknown to him or her, as two different specimens with different identifications. Standard Authentic sample of the analyte of known purity, or a solution of the analyte of a known concentration. Substrate The substance (molecule) acted upon by an enzyme; its conversion to a particular product is catalyzed by a specific enzyme. Tolerance A state that develops after long-term exposure to a drug. Metabolic tolerance infers a faster removal, oxidation by the liver. Functional tolerance infers a change in sensitivity of the organ to the effects of the drug. Tolerance interval That range of values within which a specified percentage of individual values of a population, measurements, or sample are expected to lie with a stated level of confidence. Ultraviolet Pertaining to the region of the electromagnetic spectrum from approximately 10 to 380 nm. Visible Pertaining to radiant energy in the electromagnetic spectral range visible to the human eye, approximately 380 to 780 nm. Wavelength A property of radiant energy, such as IR, visible, or UV. The distance measured along the line of propagation, between two points that are in phase on adjacent waves.

APPENDIX IB: COMMON ABBREVIATIONS Compiled by H. Chip Walls, B.S. Department of Pathology, Forensic Toxicology Laboratory, University of Miami, Miami, Florida

ABS AM AMPH AP APAP ASA ASCVD ASHD BAC BDS BE BENZO Bld BP BSV CAP CBC CI CID CN CO Co c/o

Absorbance error (EMIT) Morning, antemortem Amphetamines Attending physician Acetaminophen Salicylates Arteriosclerotic cardiovascular disease Arteriosclerotic heart disease Blood alcohol concentration Basic drug screen Benzoylecgonine Benzodiazepine(s) Blood Blood pressure Blue-stoppered vacutainer College of American Pathologists Complete blood count Chemical ionization (in mass spectrometry) Criminal investigation department Cyanide Carbon monoxide County Complain(-ing), (-ed), (-t) of


1180


COPD DC Decd DM DNR DOH D/T DUI DUID DWI dx EB ECD EI EMIT ER ET EtOH Ext Extn FH FID FS FTD Fx g g% GC GC/MS gm GSV GSW H2O HCT Hgb HIV HPLC HTN Hx ICU L, l LLQ LUQ MC MCT MCV Meds MEO MeOH mg ml, mL MSDS MVA n NB ND NDD Neg ng NOK NP

Chronic obstructive pulmonary disease Death certificate Decedent/deceased Diabetes melitus Do not resuscitate Department of Health Due to Driving under the influence DUI for drugs Driving while intoxicated Diagnosed Eastbound Electron capture detector (GC) Electron impact ionization (in mass spectrometry) Enzyme-multiplied immunoassay testing Emergency room Evidence technician Ethanol/alcohol Extract Extraction Funeral home Flame ionization detector (GC) Fingerstick Failed to detect Fracture Gram Gram percent Gastric contents, gas chromatography Gas chromatography/mass spectrometry Gram Gray-stoppered vacutainer Gunshot wound Water Hematocrit Hemoglobin Human immunodeficiency virus High performance liquid chromatograph(y) Hypertension History Intensive care unit Liter Left lower quadrant Left upper quadrant Mixed volatiles Micro color test Mean cell volume Medications Medical Examiner’s Office Methanol Milligram Milliliter Material safety data sheet Motor vehicle accident Number Northbound None detected No drugs detected Negative Nanogram Next of kin Nurse practitioner


APPENDICES

1181

NPD NR O2 OF Opi p P Pb PCC PCP pg PM PMH PO Pos PSV p/u QA QC QNS QS QS to _ R RB RBC RIA RLQ R/O RSV RUQ Rx s S/A SB SD Ser SMA S/O SOB SOP Sp Gr SST STD TAT THC TLC Tx U VD VP w/ WAN WB WBC w/o x y/o µL µg 4-Br % sat

Nitrogen phosphorus detector Not requested Oxygen Ocular fluid (vitreous) Opiates After Probation Lead Poison Control Center Phencyclidine Picogram Postmortem, in the evening Previous medical history Police officer, probation officer Positive Purple-stoppered vacutainer Pick(ed) up Quality assurance Quality control Quantity not sufficient Quantity sufficient Dilute to volume Referral Reagent blank Red blood cells Radio immunoassay Right lower quadrant Rule out Red-stoppered vacutainer Right upper quadrant Prescription Without Same address Southbound Standard deviation Serum Sympathomimetic amines Sign-out Shortness of breath Standard operating procedure Specific gravity Serum separator tube Sexually transmitted disease turn-around time Tetrahydrocannabinol Thin-layer chromatography Taken Urine Venereal disease Venipuncture With Weak acid/neutral Westbound White blood cells Without Average Year old Microliter (also uL) Microgram (also ug, ugm, µgm) Tetrabromophenolphthalein ethyl ester (a color test) Percent saturation


1182


APPENDIX IC: REFERENCES FOR METHODS OF DRUG QUANTITATIVE ANALYSIS Drug Name

Class

Fraction

11-Hydroxy delta-9-THC DELTA-9-THC Acebutolol Acetaminophen Acetazolamide Acetylcarbromal Acetylsalicyclic acid Albuterol Alfentanil Allobarbital Allopurinol Alphaprodine Alprazolam Amantadine Amiodarone Amitriptyline Amlodipine Amobarbital Amoxapine Amphetamine Amyl nitrite Aprobarbital Astemizole Atenolol Atracurium Atropine (Hyoscyamine-D,L) Azatadine Baclofen Barbital Barbiturates

3 3 2 1 5 3 1 2 1 3 5 1 3 1 2 3 3 3 3 3 3 3 4 2 3 3 3 1 3 3

B B B WAN B WAN A B B WAN WAN B B/N B B B B WAN B B G WAN B B Q B B B WAN WAN

Benzephetamine Benzocaine Benzoylecgonine Benzphetamine Benztropine Bepridil Betaxolol Biperiden Bisoprolol Bretylium Bromazepam Bromocriptine Bromdiphen-hydramine Bupivacaine Buprenorphine Bupropion Buspirone Butabarbital Butalbital

3 3 3 3 3 2 2 3 3 2 3 3 4 3 1 3 3 3 3

B B AMPHO B B B B B B O B B B B B B B WAN WAN

Butorphanol Caffeine Camazepam Carbamazepine Carbinoxamine

1 3 3 3 3

B WAN B B B

UV

GC [1]

[18−20]

LC

GC/MS

[2]

[3−9]

[13] [21−24]

[14]

General [10−12] [10−12] [15−17] [25−29]

[30] [31−33]

[45]

[34,35] [39]

[41] [46−55]

[46,56−60]

[42]

[62 63]

[64,65]

[66]

[71−76] [81] [82−85]

[77−80]

[91–93]

[94−101]

[36−38] [40] [43,44]

[61]

[67,68] [69,70]

[86,87]

[88–90] [102–106] [50]

[107] [108] [109] [111,112] [114, 115] [116] [118–123]

[110] [113]

[117] [51,120, 124–129] [130–134] [135] [140–145]

[136–139] [146] [147]

[67]

[148] [151,152] [155–157] [170] [62]

[158] [162,163] [175] [176]

[149] [150] [153,154] [164–166] [171,172] [175] [86,107,12 0,126] [177]

[185–187]

[159–161] [167–169] [173,174]

[179–181]

[178] [182–184]

[188–190]

[191,192]


APPENDICES

Drug Name

1183

Class

Fraction

Carfentanil Carisoprodol Chlopropamide Chloral Hydrate Chlordiazepoxide

1 3 5 3 3

B WAN WAN O B

UV

GC

LC

Chloropromazine Chloroquine Chlorpheniramine Chlorphentermine Chlorpromazine Chlorpropamide Chlorprothixene Chlorzoxazone Cimetidine Clemastine Clobazam Clomipramine Clonazepam Clonidine Clorazepate Clotiazepam Clozapine Cocaethylene

3 5 3 3 3 5 3 3 5 3 3 3 3 2 3 3 3 3

B B B B B WAN B WAN, B B B B B B B B B B B

Cocaine

3

B

[248]

[250–253]

Codeine Colchicine Cotinine Cyclizine Cyclobenzaprine Cyclopane Cyproheptadine delta-9-THC- Carboxylic acid Demoxepam

1 5 5 3 3 5 3 3

B B B B B WAN B A

[258]

[259] [266,267]

3

B

Desalkylflurazepam Desflurane Desipramine Dextromethorphan Dextrorphan Diazepam

3 5 3 4 4 3

B G B B B B

Diclofenac Dicyclomine Diethylpropion Diflunisal Dihydrocodeine Diltiazem Diphenhydramine Diphenoxin Diphenoxylate Disopyramide Doxepin Doxylamine Ecgonine methyl ester

1 5 3 1 1 2 4 1 1 2 3 4 3

A B B WAN B B B B B B B B B

[195] [197]

General [194]

[198] [199–202] [202,204–2 06] [207]

[212]

GC/MS [124,193] [196] [203]

[201,202] [208] [210,211]

[209]

[213] [214,215]

[208,216] [197]

[217]

[225–228]

[218,219] [221–224] [229–231]

[234,235] [237–239]

[240–243] [245]

[268] [72]

[220] [227] [232,233] [236]

[140,245– 248] [140,145, 254–257] [260–264] [269–271] [272] [73,273]

[244] [138,249]

[265]

[274] [275]

[276] [201,280, 281] [283]

[234,235, 290]]

[288,289] [288,289] [283,291, 292] [293,294]

[3,7,10, 277–279] [202,282] [284,285] [287]

[286]

[236]

[295] [296] [297] [298,299] [300] [153]

[152] [301] [301] [302,303] [306] [250, 251, 309–311]

[304,305] [308] [254,312– 315]

[300] [307]


1184


Class

Fraction

Encainide Enflurane Ephedrin Esmolol Estazolam Ethanol Ethchlorvynol Ethinamate Ethosuximide Ethylene Ethylflurazepam Etodolac Etomidate Famotidine Felbamate

Drug Name

2 5 4 2 3 5 3 3 3 5 3 1 3 3 3

B G B B B G O WAN WAN G B A WAN B WAN, B

Felodipine Fenfluramine Fenoprofen Fentanyl

2 3 1 1

B B A B

Flecainide Flunitrazepam Fluoxetine Fluphenazine Flurazepam Flurbiprofen Freon Gasoline Glipizide Glutethimide Glyburide Halazepam Haloperidol Hexobarbital

2 3 3 3 3 1 5 5 5 3 5 3 3 3

B B B B B A G G WAN WAN WAN B B WAN

Hydrocodone Hydromorphone Hydroxychloroquine Hydroxyzine Ibuprofen Imipramine Indomethacin

1 1 5 3 1 3 1

B AMPHO B B WAN B WAN

Insulin Iso-metheptene Isoflurane Isopropanol Isoxsuprine Isradipine Ketamin Ketazolam Ketoprofen Ketorolac l-methamphetamine Lamotrigine Levallorphan Levodopa Levorphanol

5 5 3 5 2 2 3 3 1 1 3 3 1 5 1

O B G G B B B B WAN B B B B O AMPHO

UV

GC

LC

GC/MS

[320]

[318] [183]

[321]

[149]

[322–329] [330–334]

General [316,317] [319]

[335,336] [337–339]

[340,341]

[342] [343] [344]

[189,345, 346]

[347]

[348] [349] [350] [351]

[62, 63] [364–367]

[357–359] [360–363] [368]

[124,193, 352–355] [300]

[356]

[369] [370]

[371] [372,373]

[374,375] [371] [376–379]

[129,383, 384]

[380–382] [120,125, 126]

[385] [386]

[387–389] [211,391]

[264,390]

[294,393] [398–401] [350,405– 407]

[394–397] [402]

[392] [398] [403,404]

[408–412] [318] [413–419] [420] [421]

[422] [425–427] [428–431]

[423,424]

[432] [433–435] [436–438] [439] [440]


APPENDICES

Drug Name

1185

Class

Fraction

Lidocaine

5,2

B

UV

GC

Lithium Loperamide Lorantadine Lorazepam Loxapine LSD Maprotiline Mazindol MDEA Meclizine Medazepam Mefenamic Acid Meperidine (Pethidine) Mephentermine Mephenytoin Mephobarbital Mepivacaine Meprobamate

3 1 3 3 3 3 3 3 3 3 3 1 1 3 3 3 3 3

O B B B B B B B B B B A B B B B B WAN

[195,452]

Mescaline (Peyote) Mesoridazine Methadone and metabolite Methamphetamine

3 3 1 3

B B B B

[459] [463]

Methanol

5

G

Methapyrilene Methaqualone Methocarbamol Methohexital Methsuximide Methylenedioxy amphetamine (MDA) Methylenedioxymethamphetamine (MDMA; Ecstasy) Methylphenidate Methyprylon Methysergide Metoclopramide Metoprolol Mexiletine Midazolam

3 3 3 3 3 3

B WAN,B WAN WAN WAN B

3

B

3 3 3 5 2 2 3

B WAN B B B B B

Molindone Monoacetylmorphine

1 1

B B

Moricizine Morphine Morphine-3-glucuronide Nadolol Nalbuphine Naproxen Nicotine

2 3 3 2 1 1 5

B AMPHO AMPHO B B WAN B

Nifedipine Nitrazepam

2 3

B B

LC

GC/MS

General

[155,156, 441]

[281]

[442–444]

[445–447]

[448,449] [450,451] [132] [361] [157]

[453]

[457]

[375,454, 455] [456] [458]

[460–462] [133,464, 465]

[418,466– 468] [235,469]

[470]

[471]

[340] [132,472] [132,472]

[473] [475]

[474] [422,477, 478]

[480]

[474] [300,476] [479]

[481]

299,482– 484]

[485–487] [491–494]

[488–490]

[178,495] [294] [496] [499]

[500,501] [149,321, 360,363]

[269,497, 498] [502]


1186


Drug Name

Class

Fraction

3 3 3 3 1 1 3 2 3 3 3 3 1 3 3 3 3 3 3

G B B B B B B Q B O B B B B WAN B B B B WAN

Phensuximide Phentermine Phenylpropanolamine Phenyltoloxamine Phenytoin (Diphenylhydantoin) Piroxicam Prazepam

3 3 3 4 3

WAN B B B WAN

1 3

A B

Primidone

3

WAN

Procainamide Procaine Promazine Promethazine Propafenone Propanolol Propofol Propoxyphene

2 5 3 3 3 2 3 1

B B B B B B B B

Protriptyline

3

B

Pseudoephedrine Psycylobin Pyrilamine Quazepam Quinidine Quinine Ranitidine Risperidone Scopolamine Secobarbital Selegiline Sertraline Sotalol Strychnine

4 3 4 3 2 5 5 3 3 3 3 3 2 5

B O B B B B B B B WAN B B B B

Nitrous oxide Nomifensine Nylidrin Orphenadrine Oxazepam Oxycodone Oxymorphone Pancuraonium Papaverine Paradehyde Paroxetine PCP Pemoline Pentazocine Pentobarbital Pergolide Perphenazine Phendimetrazine Phenelazine Phenobarbital

UV

GC

LC

[292]

GC/MS

[503] [504,505] [505]

General

[506] [507,508]

[509] [510] [511–513]

[514,515] [516]

[517–519] [49,54]

[520]

[521–524] [525] [526]

[189,339, 527–529] [530]

[134,531]

[532] [528,533, 534,338] [62,321, 360,535] [189,527, 529] [303]

[473]

[540] [541] [542–544] [547]

[469,549– 552]

[536,537] [538,539]

[545,546] [548] [553–556]

[74,222, 376,560]

[557–559] [385,561– 564] [94,565]

[308,566] [567]

[568] [570]

[569] [538] [571]

[572,573] [574,575]

[576,577] [578,579]

[582]

[580] [583]

[584,585] [587]

[581] [586] [510] [588]


APPENDICES

Drug Name

1187

Class

Fraction

Succinylcholine Sufentanil Sumatriptan Talbutal

3 1 1 3

Q B B WAN

Temazepam Terbutaline Terfenadine Tetracaine Tetrazepam Theophylline

3 4 4 5 3 4

B B B B B WAN

Thiamylal Thiopental Thioridazine Thiothixene Tocainide Tolazamide Tolmetin Toluene Tolutamide Tramadol Tranylcypromine Trazodone Triazolam

3 3 3 3 2 3 1 5 3 1 3 3 3

WAN WAN B B B WAN WAN G WAN B B B B

Trichloroethylene Trifluoperazine Triflupromazine Trihexyphenidyl Trimethadione Trimethobenzamide Trimipramine Tripelennamine

5 3 3 3 3 3 3 4

G B B B WAN B B N

Triprolidine Tubocurarine Valproic acid Venlafaxine Verapamil Xylene

4 5 3 3 2 5

N Q WAN B N G

Zolpidem

3

B

UV

GC

LC

GC/MS

General [589,590] [193,591] [592]

[86,593, 594] [595] [598]

[596,597] [599,600] [601]

[610]

[83,338, 602, 603] [608,609] [405] [399,457]

[603–607]

[300]

[611]

[612–614]

[126] [615–617] [618]

[619–621] [321]

[66,622– 624]

[625] [67] [626]

[398] [517,518, 632]

[630]

[402]

[633–635]

[636,637]

[638]

[642–644]

[627] [628,629] [631]

[639] [640,641] [645,646] [102,647– 650]

[651–655]

KEY: Fraction (extraction): A = acid, B = Base, WAN = weak acid neutral, Ampho = amphoteric, Q = quantanary, O = Other


1188


Pharmacological Classification 1 Analgesics and Antiinflamatory Nonsteroidal antiinflammatories Opioids Central analgesics 2 Cardiovascular/DiureticDrugs Antiarrhythmics Antihypertensives Beta blockers Calcium channel blockers Inotropic Nitrates 3 Central Nervous System Drugs Anticonvulsants Antiemetics/ antivertigo Depressants Hallucinogens Psychotherapeutic agents Antianxiety Antidepressants Antipsychotics Sedatives and hypnotics General anesthetics Barbiturates Nonbarbiturates Gases Volatile liquids Muscle relaxants Parkinsonism drugs Stimulants Analeptics Amphetamines Anorexiants 4 Respiratory Drugs Antihistamines and antiallergics Bronchodilators Cough and cold 5 Other

REFERENCES 1. Ritchie, L.K., Caplan, Y.H., and Park, J., delta-9-Tetrahydrocannabinol analysis in forensic blood specimens using capillary column gas chromatography with nitrogen sensitive detection, Journal of Analytical Toxicology, 11, 205–209, 1987. 2. Moffat, A.C., Williams, P.L., and King, L.J., Combined high-performance liquid chromatography and radioimmunoassay method for the analysis of delta 9-tetrahydrocannabinol and its metabolites in plasma and urine, NIDA Research Monograph, 42, 56–68, 1982. 3. Hattori, H., Detection of cannabinoids by GC/MS. Part I. Quantitation of delta-9-THC in human urine and blood plasma., Nippon Hoigaku Zasshi, 35, 67–72, 1981. 4. Huestis, M.A., Mitchell, J.M., and Cone, E.J., Detection times of marijuana metabolites in urine by immunoassay and GC-MS, Journal of Analytical Toxicology, 19, 443–449, 1995. 5. McCurdy, H.H., Lewellen, L.J., Callahan, L.S., and Childs, P.S., Evaluation of the Ion Trap Detector for the detection of 11-nor-delta 9-THC-9-carboxylic acid in urine after extraction by bonded-phase adsorption, Journal of Analytical Toxicology, 10, 175–177, 1986. 6. Clatworthy, A.J., Oon, M.C., Smith, R.N., and Whitehouse, M.J., Gas chromatographic-mass spectrometric confirmation of radioimmunoassay results for cannabinoids in blood and urine, Forensic Science International, 46, 219–230, 1990.


APPENDICES

1189

7. Wilkins, D., Haughey, H., Cone, E., Huestis, M., Foltz, R., and Rollins, D., Quantitative analysis of THC, 11-OH-THC, and THCCOOH in human hair by negative ion chemical ionization mass spectrometry, Journal of Analytical Toxicology, 19, 483–491, 1995. 8. Kudo, K., Nagata, T., Kimura, K., Imamura, T., and Jitsufuchi, N., Sensitive determination of delta9-tetrahydrocannabinol in human tissue by GC/MS, Journal of Analytical Toxicology, 19, 87–90, 1995. 9. Moeller, M.R., Doerr, G., and Warth, S., Simultaneous quantitation of delta-9-tetrahydrocannabinol (THC) and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH) in serum by GC/MS using deuterated internal standards and its application to a smoking study and forensic cases, Journal of Forensic Sciences, 37, 969–983, 1992. 10. Huestis, M.A., Henningfield, J.E., and Cone, E.J., Blood cannabinoids. I. Absorption of THC and formation of 11-OH-THC and THCCOOH during and after smoking marijuana [see comments], Journal of Analytical Toxicology, 16, 276–282, 1992. 11. Huestis, M.A., Henningfield, J.E., and Cone, E.J., Blood cannabinoids. II. Models for the prediction of time of marijuana exposure from plasma concentrations of delta 9-tetrahydrocannabinol (THC) and 11-nor-9-carboxy-delta 9-tetrahydrocannabinol (THCCOOH) [see comments], Journal of Analytical Toxicology, 16, 283–290, 1992. 12. Kemp, P.M., Abukhalaf, I.K., Manno, J.E., Manno, B.R., Alford, D.D., and Abusada, G.A., Cannabinoids in humans, Journal of Analytical Toxicology, 19, 285–291, 1995. 13. Meffin, P.J., Harapat, S.R., Yee, Y.G., and Harrison, D.C., High-pressure liquid chromatographic analysis of drugs in biological fluids. V. Analysis of acebutolol and its major metabolite, Journal of Chromatography, 138, 183–191, 1977. 14. Siren, H., Saarinen, M., Hainari, S., Lukkari, P., and Riekkola, M., Screening of beta-blockers in human serum by ion-pair chromatography and their identification as methyl or acetyl derivatives by gas chromatography-mass spectrometry, Journal of Chromatography, 632, 215–227, 1993. 15. Leloux, M., Niessen, W., and van der Hoeven, R., Thermospray liquid chromatography/mass spectrometry of polar beta-blocking drugs: preliminary results, Biological Mass Spectrometry, 20, 647–649, 1991. 16. Ghanem, R., Bello, M.A., Callejon, M., and Guiraum, A., Determination of beta-blocker drugs in pharmaceutical preparations by non-suppressed ion chromatography, Journal of Pharmaceutical & Biomedical Analysis, 15, 383–388, 1996. 17. Segura, J., Pascual, J.A., Ventura, R., Ustaran, J.I., Cuevas, A., and Gonzalez, R., International cooperation in analytical chemistry: experience of antidoping control at the XI Pan American Games, Clinical Chemistry, 39, 836–845, 1993. 18. Davey, L. and Naidoo, D, Urinary screen for acetaminophen (paracetamol) in the presence of Nacetylcysteine, Clinical Chemistry, 39, 2348–2349, 1993. 19. Novotny, P.E. and Elser, R.C, Indophenol method for acetaminophen in serum examined, Clinical Chemistry, 30, 884–886, 1984. 20. Bailey, D.N., Colorimetry of serum acetaminophen (paracetamol) in uremia, Clinical Chemistry, 28, 187–190, 1982. 21. Wong, A.S., An evaluation of HPLC for the screening and quantitation of benzodiazepines and acetaminophen in post mortem blood, Journal of Analytical Toxicology, 7, 33–36, 1983. 22. West, J.C., Rapid HPLC analysis of paracetamol (acetaminophen) in blood and postmortem viscera, Journal of Analytical Toxicology, 5, 118–121, 1981. 23. Manno, B.R., Manno, J.E., Dempsey, C.A., and Wood, M. A., A high-pressure liquid chromatographic method for the determination of N-acetyl-p-aminophenol (acetaminophen) in serum or plasma using a direct injection technique, Journal of Analytical Toxicology, 5, 24–28, 1981. 24. Colin, P., Sirois, G., and Chakrabarti, S., Rapid high-performance liquid chromatographic assay of acetaminophen in serum and tissue homogenates, Journal of Chromatography, 413, 151–160, 1987. 25. Ashbourne, J.F., Olson, K.R., and Khayam-Bashi, H., Value of rapid screening for acetaminophen in all patients with intentional drug overdose, Annals of Emergency Medicine, 18, 1035–1038, 1989. 26. Campbell, R.S. and Price, C.P., Experience with an homogeneous immunoassay for paracetamol (acetaminophen), Journal of Clinical Chemistry & Clinical Biochemistry, 24, 155–159, 1986. 27. Dasgupta, A. and Kinnaman, G, Microwave-induced rapid hydrolysis of acetaminophen and its conjugates in urine for emergency toxicological screen, Clinical Chemistry, 39, 2349–2350, 1993. 28. Price, L.M., Poklis, A., and Johnson, D.E., Fatal acetaminophen poisoning with evidence of subendocardial necrosis of the heart, Journal of Forensic Sciences, 36, 930–935, 1991.


1190


29. Slattery, J.T., Nelson, S.D., and Thummel, K.E., The complex interaction between ethanol and acetaminophen. [Review], Clinical Pharmacology & Therapeutics, 60, 241–246, 1996. 30. Wallace, S.M., Shah, V.P., and Riegelman, S., GLC analysis of acetazolamide in blood, plasma, and saliva following oral administration to normal subjects, Journal of Pharmaceutical Sciences, 66, 527–530, 1977. 31. Asselin, W.M. and Caughlin, J.D., A rapid and simple color test for detection of salicylate in whole hemolyzed blood, Journal of Analytical Toxicology, 14, 254–255, 1990. 32. Morris, H.C., Overton, P.D., Ramsay, J.R., Campbell, R.S., Hammond, P.M., Atkinson, T., et al., Development and validation of an automated, enzyme-mediated colorimetric assay of salicylate in serum, Clinical Chemistry, 36, 131–135, 1990. 33. Trinder, P., Rapid determination of salicylates in biological materials, Biochemical Journal, 57, 1954 34. Levine, B. and Caplan, Y.H., Liquid chromatographic determination of salicylate and methyl salicylate in blood and application to a postmortem case, Journal of Analytical Toxicology, 8, 239–241, 1984. 35. Dipietra, A.M., Gatti, R., Andrisano, V., and Cavrini, V., Application of high-performance liquid chromatography with diode-array detection and on-line post-column photochemical derivatization to the determination of analgesics, Journal of Chromatography, 729, 355–361, 1996. 36. Chan, T.Y., Chan, A.Y., Ho, C.S., and Critchley, J.A., The clinical value of screening for salicylates in acute poisoning, Veterinary & Human Toxicology, 37, 37–38, 1995. 37. Asselin, W.M. and Caughlin, J.D., A rapid and simple color test for detection of salicylate in whole hemolyzed blood, Journal of Analytical Toxicology, 14, 254–255, 1990. 38. Jammehdiabadi, M. and Tierney, M., Impact of toxicology screens in the diagnosis of a suspected overdose: salicylates, tricyclic antidepressants, and benzodiazepines, Veterinary & Human Toxicology, 33, 40–43, 1991. 39. Bland, R.E., Tanner, R.J., Chern, W.H., Lang, J.R., and Powell, J.R., Determination of albuterol concentrations in human plasma using solid-phase extraction and high-performance liquid chromatography with fluorescence detection, Journal of Pharmaceutical & Biomedical Analysis, 8, 591–596, 1990. 40. King, W.D., Holloway, M., and Palmisano, P.A., Albuterol overdose: a case report and differential diagnosis. [Review], Pediatric Emergency Care, 8, 268–271, 1992. 41. Bjorkman, S. and Stanski, D.R., Simultaneous determination of fentanyl and alfentanil in rat tissues by capillary column gas chromatography, Journal of Chromatography, 433, 95–104, 1988. 42. Mautz, D., Labroo, R., and Kharasch, E., Determination of alfentanil and noralfentanil in human plasma by gas chromatography-mass spectrometry, Journal of Chromatography B: Biomedical Applications, 658, 149–153, 1994. 43. Van, B.H., Van, P.A., Gasparini, R., Woestenborghs, R., Heykants, J., Noorduin, H., et al., Pharmacokinetics of alfentanil during and after a fixed rate infusion, British Journal of Anaesthesia, 62, 610–615, 1989. 44. Meistelman, C., Saint-Maurice, C., Lepaul, M., Levron, J., Loose, J., and Mac, G.K., A comparison of alfentanil pharmacokinetics in children and adults, Anesthesiology, 66, 13–16, 1987. 45. Schumann, G.B., Lauenstein, K., LeFever, D., and Henry, J.B., Ultraviolet spectrophotometric analysis of barbiturates, American Journal of Clinical Pathology, 66, 823–830, 1976. 46. Gill, R., Stead, A.H., and Moffat, A.C., Analytical aspects of barbiturate abuse: identification of drugs by the effective combination of gas-liquid, high-performance liquid and thin-layer chromatographic techniques, Journal of Chromatography, 204, 275–284, 1981. 47. Lillsunde, P., Michelson, L., Forsstrom, T., Korte, T., Schultz, E., Ariniemi, K., et al., Comprehensive drug screening in blood for detecting abused drugs or drugs potentially hazardous for traffic safety, Forensic Science International, 77, 191–210, 1996. 48. Mule, S. and Casella, G., Confirmation and quantitation of barbiturates in human urine by gas chromatography/mass spectrometry, Journal of Analytical Toxicology, 13, 13–16, 1989. 49. Wallace, J.E., Hall, L.R., and Harris, S.C., Determination of pentobarbital and certain other barbiturates by capillary gas-liquid chromatography, Journal of Analytical Toxicology, 7, 178–180, 1983. 50. Budd, R.D., Gas chromatographic properties of 1,3-dialkyl barbiturate derivatives, Clinical Toxicology, 17, 375–382, 1980. 51. Barbour, A. D., GC/MS analysis of propylated barbiturates, Journal of Analytical Toxicology, 15, 214–215, 1991.


APPENDICES

1191

52. Christophersen, A. S. and Rasmussen, K. E., Glass capillary column gas chromatography of barbiturates after flash-heater derivatization with dimethylformamide dimethylacetal, Journal of Chromatography, 192, 363–374, 1980. 53. Budd, R. D. and Mathis, D. F., GLC screening and confirmation of barbiturates in post mortem blood specimens, Journal of Analytical Toxicology, 6, 317–320, 1982. 54. Sun, S. R. and Hoffman, D. J., Rapid, sensitive GLC determination of pentobarbital and other barbiturates in serum using nitrogen-specific detector, Journal of Pharmaceutical Sciences, 68, 386–388, 1979. 55. Marigo, M., Ferrara, S. D., and Tedeschi, L., A sensitive method for gas-chromatographic assay of barbiturates in body fluids, Archives of Toxicology, 37, 107–112, 1977. 56. Gill, R., Lopes, A. A., and Moffat, A. C., Analysis of barbiturates in blood by high-performance liquid chromatography, Journal of Chromatography, 226, 117–123, 1981. 57. Drummer, O. H., Kotsos, A., and McIntyre, I. M., A class-independent drug screen in forensic toxicology using a photodiode array detector, Journal of Analytical Toxicology, 17, 225–229, 1993. 58. Chan, E. M. and Chan, S. C., Screening for acidic and neutral drugs by high performance liquid chromatography in post-mortem blood, Journal of Analytical Toxicology, 8, 173–176, 1984. 59. Ferrara, S. D., Tedeschi, L., Frison, G., and Castagna, F., Solid-phase extraction and HPLC-UV confirmation of drugs of abuse in urine, Journal of Analytical Toxicology, 16, 217–222, 1992. 60. Lehane, D. P., Menyharth, P., Lum, G., and Levy, A. L., Therapeutic drug monitoring: measurements of antiepileptic and barbiturate drug levels in blood by gas chromatography with nitrogen - selective detector, Annals of Clinical & Laboratory Science, 6, 404–410, 1976. 61. Van Vunakis, H., Freeman, D. S., and Gjika, H. B., Radioimmunoassay for anileridine, meperidine and other N-substituted phenylpiperidine carboxylic acid esters, Research Communications in Chemical Pathology & Pharmacology, 12, 379–387, 1975. 62. Gaillard, Y., Gay-Montchamp, J. P., and Ollagnier, M., Simultaneous screening and quantitation of alpidem, zolpidem, buspirone and benzodiazepines by dual-channel gas chromatography using electron-capture and nitrogen-phosphorus detection after solid-phase extraction, Journal of Chromatography, 622, 197–208, 1993. 63. Lillsunde, P. and Seppala, T., Simultaneous screening and quantitative analysis of benzodiazepines by dual-channel gas chromatography using electron-capture and nitrogen-phosphorus detection, Journal of Chromatography, 533, 97–110, 1990. 64. Akerman, K. K., Jolkkonen, J., Parviainen, M., and Penttila, I., Analysis of low-dose benzodiazepines by HPLC with automated solid-phase extraction, Clinical Chemistry, 42, 1412–1416, 1996. 65. Shimamine, M., Masunari, T., and Nakahara, Y., [Studies on identification of drugs of abuse by diode array detection. I. Screening-test and identification of benzodiazepines by HPLC-DAD with ICOS software system], Eisei Shikenjo Hokoku—Bulletin of National Institute of Hygienic Sciences, 47–56, 1993. 66. Cairns, E. R., Dent, B. R., Ouwerkerk, J. C., and Porter, L. J., Quantitative analysis of alprazolam and triazolam in hemolysed whole blood and liver digest by GC/MS/NICI with deuterated internal standards, Journal of Analytical Toxicology, 18, 1–6, 1994. 67. Pollak, P. T., A systematic review and critical comparison of internal standards for the routine liquid chromatographic assay of amiodarone and desethylamiodarone, Therapeutic Drug Monitoring, 18, 168–178, 1996. 68. Flanagan, R. J., Storey, G. C., and Holt, D. W., Rapid high-performance liquid chromatographic method for the measurement of amiodarone in blood plasma or serum at the concentrations attained during therapy, Journal of Chromatography, 187, 391–398, 1980. 69. Fernandez, G. S., Witherington, T. L., and Stafford, D. T., Effective column extraction from decomposed tissue in a suspected overdose case involving maprotiline and amitriptyline, Journal of Analytical Toxicology, 9, 230–231, 1985. 70. Bailey, D. N. and Jatlow, P. I., Gas-chromatographic analysis for therapeutic concentrations of amitriptyline and nortriptyline in plasma, with use of a nitrogen detector, Clinical Chemistry, 22, 777–781, 1976. 71. Vandel, S., Vincent, F., Prudhon, F., Nezelof, S., Bonin, B., and Bertschy, G., [Comparative study of two techniques for the determination of amitriptyline and nortriptyline: EMIT and gas chromatography]. [French], Therapie, 47, 41–45, 1992.


1192


72. Poklis, A. and Edinboro, L. E., REMEDi drug profiling system readily distinguishes between cyclobenzaprine and amitriptyline in emergency toxicology urine specimens [letter], Clinical Chemistry, 38, 2349–2350, 1992. 73. Wong, E. C., Koenig, J., and Turk, J., Potential interference of cyclobenzaprine and norcyclobenzaprine with HPLC measurement of amitriptyline and nortriptyline: resolution by GC-MS analysis, Journal of Analytical Toxicology, 19, 218–224, 1995. 74. Attapolitou, J., Tsarpalis, K., and Koutselinis, A., A modified simple and rapid reversed phase high performance liquid chromatographic method for quantification of amitriptyline and nortriptyline in plasma, Journal of Liquid Chromatography, 17, 3969–3982, 1994. 75. Rop, P. P., Viala, A., Durand, A., and Conquy, T., Determination of citalopram, amitriptyline and clomipramine in plasma by reversed-phase high-performance liquid chromatography, Journal of Chromatography, 338, 171–178, 1985. 76. Hartter, S. and Hiemke, C., Column switching and high-performance liquid chromatography in the analysis of amitriptyline, nortriptyline and hydroxylated metabolites in human plasma or serum, Journal of Chromatography, 578, 273–282, 1992. 77. Oliver, J. S. and Smith, H., Amitriptyline and metabolites in biological fluids, Forensic Science, 3, 181–187, 1974. 78. Spiehler, V., Spiehler, E., and Osselton, M. D., Application of expert systems analysis to interpretation of fatal cases involving amitriptyline, Journal of Analytical Toxicology, 12, 216–224, 1988. 79. Bolster, M., Curran, J., and Busuttil, A., A five year review of fatal self-ingested overdoses involving amitriptyline in Edinburgh 1983–’87, Human & Experimental Toxicology, 13, 29–31, 1994. 80. Bailey, D. N. and Shaw, R. F., Interpretation of blood and tissue concentrations in fatal self-ingested overdose involving amitriptyline: an update (1978–1979), Journal of Analytical Toxicology, 4, 232–236, 1980. 81. Pandya, K. K., satia, M., Gandhi, T. P., Modi, I. A., Modi, R. I., and Chakravarthy, B. K., Detection and determination of total amlodipine by high-performance thin-layer chromatography: a useful technique for pharmacokinetic studies, Journal of Chromatography B: Biomedical Applications, 667, 315–320, 1995. 82. Svinarov, D. A. and Dotchev, D. C., Simultaneous liquid-chromatographic determination of some bronchodilators, anticonvulsants, chloramphenicol, and hypnotic agents, with Chromosorb P columns used for sample preparation, Clinical Chemistry, 35, 1615–1618, 1989. 83. Meatherall, R. and Ford, D., Isocratic liquid chromatographic determination of theophylline, acetaminophen, chloramphenicol, caffeine, anticonvulsants, and barbiturates in serum, Therapeutic Drug Monitoring, 10, 101–115, 1988. 84. Kabra, P. M., Stafford, B. E., and Marton, L. J., Rapid method for screening toxic drugs in serum with liquid chromatography, Journal of Analytical Toxicology, 5, 177–182, 1981. 85. Kabra, P. M., Koo, H. Y., and Marton, L. J., Simultaneous liquid-chromatographic determination of 12 common sedatives and hypnotics in serum, Clinical Chemistry, 24, 657–662, 1978. 86. Liu, R. H., McKeehan, A. M., Edwards, C., Foster, G., Bensley, W. D., Langner, J. G., et al., Improved gas chromatography/mass spectrometry analysis of barbiturates in urine using centrifuge- based solidphase extraction, methylation, with d5-pentobarbital as internal standard, Journal of Forensic Sciences, 39, 1504–1514, 1994. 87. Pocci, R., Dixit, V., and Dixit, V., Solid-phase extraction and GC/MS confirmation of barbiturates from human urine, Journal of Analytical Toxicology, 16, 45–47, 1992. 88. Osiewicz, R. J. and Middleberg, R., Detection of a novel compound after overdoses of aspirin and amoxapine, Journal of Analytical Toxicology, 13, 97–99, 1989. 89. Taylor, R. L., Crooks, C. R., and Caplan, Y. H., The determination of amoxapine in human fatal overdoses, Journal of Analytical Toxicology, 6, 309–311, 1982. 90. Wu Chen, N. B., Schaffer, M. I., Lin, R. L., Hadac, J. P., and Stein, R. J., Analysis of blood and tissue for amoxapine and trimipramine, Journal of Forensic Sciences, 28, 116–121, 1983. 91. Bourque, A. J., Krull, I. S., and Feibush, B., Automated HPLC analyses of drugs of abuse via direct injection of biological fluids followed by simultaneous solid-phase extraction and derivatization with fluorescence detection, Biomedical Chromatography, 8, 53–62, 1994. 92. Achilli, G., Cellerino, G. P., Deril, G. V. M., and Tagliaro, F., Determination of illicit drugs and related substances by high-performance liquid chromatography with an electrochemical coulometric-array detector, Journal of Chromatography, 729, 273–277, 1996.


APPENDICES

1193

93. Michel, R. E., Rege, A. B., and George, W. J., High-pressure liquid chromatography/electrochemical detection method for monitoring MDA and MDMA in whole blood and other biological tissues, Journal of Neuroscience Methods, 50, 61–66, 1993. 94. Paul, B. D., Past, M. R., McKinley, R. M., Foreman, J. D., McWhorter, L. K., and Snyder, J. J., Amphetamine as an artifact of methamphetamine during periodate degradation of interfering ephedrine, pseudoephedrine, and phenylpropanolamine: an improved procedure for accurate quantitation of amphetamines in urine, Journal of Analytical Toxicology, 18, 331–336, 1994. 95. Suzuki, S., Inoue, T., Hori, H., and Inayama, S., Analysis of methamphetamine in hair, nail, sweat, and saliva by mass fragmentography, Journal of Analytical Toxicology, 13, 176–178, 1989. 96. Hornbeck, C. L., Carrig, J. E., and Czarny, R. J., Detection of a GC/MS artifact peak as methamphetamine, Journal of Analytical Toxicology, 17, 257–263, 1993. 97. Nakahara, Y., Detection and diagnostic interpretation of amphetamines in hair. [Review], Forensic Science International, 70, 135–153, 1995. 98. Kalasinsky, K. S., Levine, B., Smith, M. L., Magluilo, J., Jr., and Schaefer, T., Detection of amphetamine and methamphetamine in urine by gas chromatography/Fourier transform infrared (GC/FTIR) spectroscopy, Journal of Analytical Toxicology, 17, 359–364, 1993. 99. Lillsunde, P. and Korte, T., Determination of ring- and N-substituted amphetamines as heptafluorobutyryl derivatives, Forensic Science International, 49, 205–213, 1991. 100. Logan, B. K., Methamphetamine and driving impairment. [Review], Journal of Forensic Sciences, 41, 457–464, 1996. 101. Rasmussen, S., Cole, R., and Spiehler, V., Methamphetamine in antemortem blood and urine by RIA and GC/MS, Journal of Analytical Toxicology, 13, 263–267, 1989. 102. Premel-Cabic, A., Cailleux, A., and Allain, P., [A gas chromatographic assay of fifteen volatile organic solvents in blood (author’s transl)]. [French], Clinica Chimica Acta, 56, 5–11, 1974. 103. Astier, A., Chromatographic determination of volatile solvents and their metabolites in urine for monitoring occupational exposure, Journal of Chromatography, 643, 389–398, 1993. 104. Oliver, J. S. and Watson, J. M., Abuse of solvents “for kicks,” Lancet, 1, 84–86, 1977. 105. Ghittori, S., Fiorentino, M. L., and Imbriani, M., [Use of gas chromatography with flame ionization (GC-FID) in the measurement of solvents in the urine], Giornale Italiano di Medicina del Lavoro, 9, 21–24, 1987. 106. Houghton, E., Teale, P., and Dumasia, M. C., Improved capillary GC/MS method for the determination of anabolic steroid and corticosteroid metabolites in horse urine using on-column injection with highboiling solvents, Analyst (London), 109, 273–275, 1984. 107. Maurer, H. H., Identification and differentiation of barbiturates, other sedative-hypnotics and their metabolites in urine integrated in a general screening procedure using computerized gas chromatography-mass spectrometry, Journal of Chromatography, 530, 307–326, 1990. 108. Kingswood, J. C., Routledge, P. A., and Lazarus, J. H., A report of overdose with astemizole, Human Toxicology, 5, 43–44, 1986. 109. Law, B. and Weir, S., Fundamental studies in reversed-phase liquid-solid extraction of basic drugs; II: Hydrogen bonding effects, Journal of Pharmaceutical & Biomedical Analysis, 10, 181–186, 1992. 110. Logan, B. K. and Case, G. A., Identification of laudanosine, an atracurium metabolite, following a fatal drug-related shooting, Journal of Analytical Toxicology, 17, 117–119, 1993. 111. Xu, A., Havel, J., Linderholm, K., and Hulse, J., Development and validation of an LC/MS/MS method for the determination of L-hyoscyamine in human plasma, Journal of Pharmaceutical & Biomedical Analysis, 14, 33–42, 1995. 112. Saady, J. J. and Poklis, A., Determination of atropine in blood by gas chromatography/mass spectrometry, Journal of Analytical Toxicology, 13, 296–299, 1989. 113. Cugell, D. W., Clinical pharmacology and toxicology of ipratropium bromide. [Review], American Journal of Medicine, 81, 18–22, 1986. 114. Fraser, A. D., MacNeil, W., and Isner, A. F., Toxicological analysis of a fatal baclofen (Lioresal) ingestion, Journal of Forensic Sciences, 36, 1596–1602, 1991. 115. Millerioux, L., Brault, M., Gualano, V., and Mignot, A., High-performance liquid chromatographic determination of baclofen in human plasma, Journal of Chromatography 729, 309–314, 1996. 116. Bailey, D. N. and Jatlow, P. I., Barbital overdose and abuse, American Journal of Clinical Pathology, 64, 291–296, 1975.


1194


117. Varin, F., Marchand, C., Larochelle, P., and Midha, K. K., GLC-mass spectrometric procedure with selected-ion monitoring for determination of plasma concentrations of unlabeled and labeled barbital following simultaneous oral and intravenous administration, Journal of Pharmaceutical Sciences, 69, 640–643, 1980. 118. Moriya, F. and Hashimoto, Y., Application of the Triage panel for drugs of abuse to forensic blood samples, Nippon Hoigaku Zasshi—Japanese Journal of Legal Medicine, 50, 50–56, 1996. 119. Chankvetadze, B., Chankvetadze, L., Sidamonidze, S., Yashima, E., and Okamoto, Y., High performance liquid chromatography enantioseparation of chiral pharmaceuticals using tris(chloro- methylphenylcarbamate)s of cellulose, Journal of Pharmaceutical & Biomedical Analysis, 14, 1295–1303, 1996. 120. Qiu, F. H., Liu, L., Guo, L., Luo, Y., and Lu, Y. Q., [Rapid identification and quantitation of barbiturates in plasma using solid-phase extraction combined with GC-FID and GC-MS method], Yao Hsueh Hsueh Pao—Acta Pharmaceutica Sinica, 30, 372–377, 1995. 121. Thormann, W., Meier, P., Marcolli, C., and Binder, F., Analysis of barbiturates in human serum and urine by high-performance capillary electrophoresis-micellar electrokinetic capillary chromatography with on-column multi-wavelength detection, Journal of Chromatography, 545, 445–460, 1991. 122. Minder, E. I., Schaubhut, R., and Vonderschmitt, D. J., Screening for drugs in clinical toxicology by high-performance liquid chromatography: identification of barbiturates by post-column ionization and detection by a multiplace photodiode array spectrophotometer, Journal of Chromatography, 428, 369–376, 1988. 123. Mangin, P., Lugnier, A. A., and Chaumont, A. J., A polyvalent method using HPLC for screening and quantification of 12 common barbiturates in various biological materials, Journal of Analytical Toxicology, 11, 27–30, 1987. 124. Cody, J. T. and Foltz, R. L., GC/MS analysis of body fluids for drugs of abuse, in Forensic Applications of Mass Spectrometry, Yinon, J., CRC Press, Boca Raton, FL, 1995, pp. 1–59. 125. Kojima, T., Taniguchi, T., Yashiki, M., Miyazaki, T., Iwasaki, Y., Mikami, T., et al., A rapid method for detecting barbiturates in serum using EI-SIM, International Journal of Legal Medicine, 107, 21–24, 1994. 126. Abadi, M. and Solomon, H. M., Detection of tolmetin and oxaprozin by a GC/MS method for barbiturates [letter], Journal of Analytical Toxicology, 18, 62, 1994. 127. Gibb, R. P., Cockerham, H., Goldfogel, G. A., Lawson, G. M., and Raisys, V. A., Substance abuse testing of urine by GC/MS in scanning mode evaluated by proficiency studies, TLC/GC, and EMIT, Journal of Forensic Sciences, 38, 124–133, 1993. 128. Pocci, R., Dixit, V., and Dixit, V. M., Solid-phase extraction and GC/MS confirmation of barbiturates from human urine, Journal of Analytical Toxicology, 16, 45–47, 1992. 129. Chen, X. H., Wijsbeek, J., van Veen, J., Franke, J. P., and de Zeeuw, R. A., Solid-phase extraction for the screening of acidic, neutral and basic drugs in plasma using a single-column procedure on Bond Elut Certify, Journal of Chromatography, 529, 161–166, 1990. 130. Logan, B. K., Methamphetamine and driving impairment. [Review] [37 refs], Journal of Forensic Sciences, 41, 457–464, 1996. 131. Long, C. and Crifasi, J., Methamphetamine identification in four forensic cases, Journal of Forensic Sciences, 41, 713–714, 1996. 132. Ensslin, H. K., Kovar, K. A., and Maurer, H. H., Toxicological detection of the designer drug 3,4methylenedioxyethylamphetamine (Mde, Eve) and its metabolites in urine by gas chromatography mass spectrometry and fluorescence polarization immunoassay, Journal of Chromatography B: Biomedical Applications, 683, 189–197, 1996. 133. Valentine, J. L., Kearns, G. L., Sparks, C., Letzig, L. G., Valentine, C. R., Shappell, S. A., et al., GC-MS determination of amphetamine and methamphetamine in human urine for 12 hours following oral administration of dextro-methamphetamine: lack of evidence supporting the established forensic guidelines for methamphetamine confirmation, Journal of Analytical Toxicology, 19, 581–590, 1995. 134. Meatherall, R., Rapid GC-MS confirmation of urinary amphetamine and methamphetamine as their propylchloroformate derivatives, Journal of Analytical Toxicology, 19, 316–322, 1995. 135. Arufe-Martinez, M. I. and Romero-Palanco, J. L., Identification of cocaine in cocaine-lidocaine mixtures (“rock cocaine”) and other illicit cocaine preparations using derivative absorption spectroscopy, Journal of Analytical Toxicology, 12, 192–196, 1988.


APPENDICES

1195

136. Clauwaert, K. M., Vanbocxlaer, J. F., Lambert, W. E., and Deleenheer, A. P., Analysis of cocaine, benzoylecgonine, and cocaethylene in urine by HPLC with diode array detection, Analytical Chemistry, 68, 3021–3028, 1996. 137. Fernandez, P., Lafuente, N., Bermejo, A. M., Lopezrivadulla, M., and Cruz, A., HPLC determination of cocaine and benzoylecgonine in plasma and urine from drug abusers, Journal of Analytical Toxicology, 20, 224–228, 1996. 138. Logan, B. K., Smirnow, D., and Gullberg, R. G., Lack of predictable site-dependent differences and time-dependent changes in postmortem concentrations of cocaine, benzoylecgonine, and cocaethylene in humans, Journal of Analytical Toxicology, 21, 23–31, 1997. 139. Sosnoff, C. S., Ann, Q., Bernert, J. T., Jr., Powell, M. K., Miller, B. B., Henderson, L. O., et al., Analysis of benzoylecgonine in dried blood spots by liquid chromatography—atmospheric pressure chemical ionization tandem mass spectrometry, Journal of Analytical Toxicology, 20, 179–184, 1996. 140. Thompson, W. C. and Dasgupta, A., Confirmation and quantitation of cocaine, benzoylecgonine, ecgonine methyl ester, and cocaethylene by gas chromatography/mass spectrometry, American Journal of Clinical Pathology, 104, 187–192, 1995. 141. Corburt, M. R. and Koves, E. M., Gas chromatography/mass spectrometry for the determination of cocaine and benzoylecgonine over a wide concentration range, Journal of Forensic Sciences, 39, 136–149, 1994. 142. Okeke, C. C., Wynn, J. E., and Patrick, K. S., Simultaneous analysis of cocaine, benzoylecgonine, methylecgonine, and ecgonine in plasma using an exchange resin and GC/MS, Chromatographia, 38, 52–56, 1994. 143. Gerlits, J., GC/MS quantitation of benzoylecgonine following liquid–liquid extraction of urine, Journal of Forensic Sciences, 38, 1210–1214, 1993. 144. Aderjan, R. E., Schmitt, G., Wu, M., and Meyer, C., Determination of cocaine and benzoylecgonine by derivatization with iodomethane-D3 or PFPA/HFIP in human blood and urine using GC/MS (EI or PCI mode), Journal of Analytical Toxicology, 17, 51–55, 1993. 145. Abusada, G. M., Abukhalaf, I. K., Alford, D. D., Vinzon-Bautista, I., Pramanik, A. K., Ansari, N. A., et al., Solid-phase extraction and GC/MS quantitation of cocaine, ecgonine methyl ester, benzoylecgonine, and cocaethylene from meconium, whole blood, and plasma, Journal of Analytical Toxicology, 17, 353–358, 1993. 146. Kikura, R. and Nakahara, Y., Hair analysis for drugs of abuse. XI. Disposition of benzphetamine and its metabolites into hair and comparison of benzphetamine use and methamphetamine use by hair analysis, Biological & Pharmaceutical Bulletin, 18, 1694–1699, 1995. 147. Rosano, T. G., Meola, J. M., Wolf, B. C., Guisti, L. W., and Jindal, S. P., Benztropine identification and quantitation in a suicidal overdose, Journal of Analytical Toxicology, 18, 348–353, 1994. 148. Le Solleu, H., Demotes-Mainard, F., Vincon, G., and Bannwarth, B., The determination of bromazepam in plasma by reversed-phase high-performance liquid chromatography, Journal of Pharmaceutical & Biomedical Analysis, 11, 771–775, 1993. 149. Yoshida, M., Watabiki, T., Tokiyasu, T., Saito, I., and Ishida, N., [Determination of benzodiazepines by thermospray liquid chromatograph-mass spectrometer. Part 1. Nitrazepam, estazolam, bromazepam, flunitrazepam]. [Japanese], Nippon Hoigaku Zasshi Japanese Journal of Legal Medicine, 47, 220–226, 1993. 150. Haring, N., Salama, Z., and Jaeger, H., Triple stage quadrupole mass spectrometric determination of bromocriptine in human plasma with negative ion chemical ionization, Arzneimittel Forschung, 38, 1529–1532, 1988. 151. Hindmarsh, K. W., Hamon, N. W., and LeGatt, D. F., Simultaneous identification and quantitation of diphenhydramine and methaqualone, Clinical Toxicology, 11, 245–255, 1977. 152. Meatherall, R. C. and Guay, D. R., Isothermal gas chromatographic analysis of diphenhydramine after direct injection onto a fused-silica capillary column, Journal of Chromatography, 307, 295–304, 1984. 153. Tonn, G. R., Mutlib, A., Abbott, F. S., Rurak, D. W., and Axelson, J. E., Simultaneous analysis of diphenhydramine and a stable isotope analog (2H10)diphenhydramine using capillary gas chromatography with mass selective detection in biological fluids from chronically instrumented pregnant ewes, Biological Mass Spectrometry, 22, 633–642, 1993. 154. Vycudilik, W. and Pollak, S., [Detection of diphenhydramine in autolytic brain tissue in poisoninduced brain death syndrome], Zeitschrift für Rechtsmedizin—Journal of Legal Medicine, 95, 129–135, 1985.


1196


155. Lorec, A. M., Bruguerolle, B., Attolini, L., and Roucoules, X., Rapid simultaneous determination of lidocaine, bupivacaine, and their two main metabolites using capillary gas-liquid chromatography with nitrogen phosphorus detector, Therapeutic Drug Monitoring, 16, 592–595, 1994. 156. Demedts, P., Wauters, A., Franck, F., and Neels, H., Simultaneous determination of lidocaine, bupivacaine, and their two main metabolites using gas chromatography and a nitrogen–phosphorus detector —selection of stationary phase and chromatographic conditions, Therapeutic Drug Monitoring, 18, 208–209, 1996. 157. Coyle, D. E. and Denson, D. D., Simultaneous measurement of bupivacaine, etidocaine, lidocaine, meperidine, mepivacaine, and methadone, Therapeutic Drug Monitoring, 8, 98–101, 1986. 158. Clark, B. J., Hamdi, A., Berrisford, R. G., Sabanathan, S., and Mearns, A. J., Reversed-phase and chiral high-performance liquid chromatographic assay of bupivacaine and its enantiomers in clinical samples after continuous extraplural infusion, Journal of Chromatography, 553, 383–390, 1991. 159. Zakowski, M. I., Ramanathan, S., Sharnick, S., and Turndorf, H., Uptake and distribution of bupivacaine and morphine after intrathecal administration in parturients: effects of epinephrine, Anesthesia & Analgesia, 74, 664–669, 1992. 160. Bailey, C. R., Ruggier, R., and Findley, I. L., Diamorphine-bupivacaine mixture compared with plain bupivacaine for analgesia, British Journal of Anaesthesia, 72, 58–61, 1994. 161. Martin, J. and Neill, R. S., Venous plasma (total) bupivacaine concentrations following lower abdominal field block, British Journal of Anaesthesia, 59, 1425–1430, 1987. 162. Kintz, P., Cirimele, V., Edel, Y., Jamey, C., and Mangin, P., Hair analysis for buprenorphine and its dealkylated metabolite by RIA and confirmation by LC/ECD, Journal of Forensic Sciences, 39, 1497–1503, 1994. 163. Debrabandere, L., Van Boven, M., and Daenens, P., Analysis of buprenorphine in urine specimens, Journal of Forensic Sciences, 37, 82–89, 1992. 164. Kuhlman, J. J., Magluilo, J., Cone, E., and Levine, B., Simultaneous assay of buprenorphine and norbuprenorphine by negative chemical ionization tandem mass spectrometry, Journal of Analytical Toxicology, 20, 229–235, 1996. 165. Shiraishi, Y., Sakai, S., Yokoyama, J., Hayatsu, K., Mochizuki, T., Moriwaki, G., et al., [The plasma concentration of buprenorphine during its continuous epidural infusion after catheterization at different vertebral levels], Masui—Japanese Journal of Anesthesiology, 42, 371–375, 1993. 166. Battah, A.-K. and Anderson, R. A., Comparison of silyl derivatives for GC/MS analysis of morphine and buprenorphine in blood. in 26th International Meeting of the International Association of Forensic Toxicologists. 1989. Glasgow, Scotland. 167. Kuhlman, J. J., Lalani, S., Magluilo, J., Levine, B., Darwin, W. D., Johnson, R. E., et al., Human pharmacokinetics of intravenous, sublingual, and buccal buprenorphine, Journal of Analytical Toxicology, 20, 369–378, 1996. 168. Ohtani, M., Kotaki, H., Uchino, K., Sawada, Y., and Iga, T., Pharmacokinetic analysis of enterohepatic circulation of buprenorphine and its active metabolite, norbuprenorphine, in rats, Drug Metabolism & Disposition, 22, 2–7, 1994. 169. San, L., Torrens, M., Castillo, C., Porta, M., and de la Torre, R., Consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment: results from cross-sectional studies in 1988 and 1990, Addiction, 88, 1341–1349, 1993. 170. Rohrig, T. P. and Ray, N. G., Tissue distribution of bupropion in a fatal overdose, Journal of Analytical Toxicology, 16, 343–345, 1992. 171. Fogel, P., Mamer, O. A., Chouinard, G., and Farrell, P. G., Determination of plasma bupropion and its relationship to therapeutic effect, Biomedical Mass Spectrometry, 11, 629–632, 1984. 172. Friel, P. N., Logan, B. K., and Fligner, C. L., Three fatal drug overdoses involving bupropion, Journal of Analytical Toxicology, 17, 436–438, 1993. 173. Spiller, H. A., Ramoska, E. A., Krenzelok, E. P., Sheen, S. R., Borys, D. J., Villalobos, D., et al., Bupropion overdose: a 3-year multi-center retrospective analysis, American Journal of Emergency Medicine, 12, 43–45, 1994. 174. Butz, R. F., Welch, R. M., and Findlay, J. W., Relationship between bupropion disposition and dopamine uptake inhibition in rats and mice, Journal of Pharmacology & Experimental Therapeutics, 221, 676–685, 1982.


APPENDICES

1197

175. Jajoo, H. K., Mayol, R. F., LaBudde, J. A., and Blair, I. A., Metabolism of the antianxiety drug buspirone in human subjects, Drug Metabolism & Disposition, 17, 634–640, 1989. 176. Scott, E. P., Application of postcolumn ionization in the high-performance liquid chromatographic analysis of butabarbital sodium elixir, Journal of Pharmaceutical Sciences, 72, 1089–1091, 1983. 177. Mulvana, D. E., Duncan, G. F., Shyu, W. C., Tay, L. K., and Barbhaiya, R. H., Quantitative determination of butorphanol and its metabolites in human plasma by gas chromatography electron capture negative-ion chemical ionization mass spectrometry, Journal of Chromatography B: Biomedical Applications, 682, 289–300, 1996. 178. Combie, J., Blake, J. W., Nugent, T. E., and Tobin, T., Furosemide, Patella vulgata beta-glucuronidase and drug analysis: conditions for enhancement of the TLC detection of apomorphine, butorphanol, hydromorphone, nalbuphine, oxymorphone and pentazocine in equine urine, Research Communications in Chemical Pathology & Pharmacology, 35, 27–41, 1982. 179. Rodopoulos, N. and Norman, A., Determination of caffeine and its metabolites in urine by highperformance liquid chromatography and capillary electrophoresis, Scandinavian Journal of Clinical & Laboratory Investigation, 54, 305–315, 1994. 180. Jin, X., Zhou, Z. H., He, X. F., Zhang, Z. H., and Wang, M. Z., [Solid-phase extraction and RP-HPLC screening procedure for diuretics, probenecid, caffeine and pemoline in urine], Yao Hsueh Hsueh Pao —Acta Pharmaceutica Sinica, 27, 875–880, 1992. 181. Leakey, T. E., Simultaneous analysis of theophylline, caffeine and eight of their metabolic products in human plasma by gradient high-performance liquid chromatography, Journal of Chromatography, 507, 199–220, 1990. 182. Fligner, C. L. and Opheim, K. E., Caffeine and its dimethylxanthine metabolites in two cases of caffeine overdose: a cause of falsely elevated theophylline concentrations in serum, Journal of Analytical Toxicology, 12, 339–343, 1988. 183. Garriott, J. C., Simmons, L. M., Poklis, A., and Mackell, M. A., Five cases of fatal overdose from caffeine-containing “look-alike” drugs, Journal of Analytical Toxicology, 9, 141–143, 1985. 184. Miceli, J. N., Aravind, M. K., and Ferrell, W. J., Analysis of caffeine: comparison of the manual enzyme multiplied immunoassay (EMIT), automated EMIT, and high-performance liquid chromatography procedures, Therapeutic Drug Monitoring, 6, 344–347, 1984. 185. Lensmeyer, G. L., Isothermal gas chromatographic method for the rapid determination of carbamazepine (“tegretol”) as its TMS derivative, Clinical Toxicology, 11, 443–454, 1977. 186. Schwertner, H. A., Hamilton, H. E., and Wallace, J. E., Analysis for carbamazepine in serum by electron-capture gas chromatography, Clinical Chemistry, 24, 895–899, 1978. 187. Toseland, P. A., Grove, J., and Berry, D. J., An isothermal GLC determination of the plasma levels of carbamazepine, diphenylhydantoin, phenobarbitone and primidone, Clinica Chimica Acta, 38, 321–328, 1972. 188. Martens, J. and Banditt, P., Validation of the analysis of carbamazepine and its 10,11-epoxide metabolite by high-performance liquid chromatography from plasma: comparison with gas chromatography and the enzyme-multiplied immunoassay technique, Journal of Chromatography, 620, 169–173, 1993. 189. Romanyshyn, L. A., Wichmann, J. K., Kucharczyk, N., Shumaker, R. C., Ward, D., and Sofia, R. D., Simultaneous determination of felbamate, primidone, phenobarbital, carbamazepine, two carbamazepine metabolites, phenytoin, and one phenytoin metabolite in human plasma by high-performance liquid chromatography, Therapeutic Drug Monitoring, 16, 90–99, 1994. 190. Rainbow, S. J., Dawson, C. M., and Tickner, T. R., Direct serum injection high-performance liquid chromatographic method for the simultaneous determination of phenobarbital, carbamazepine and phenytoin, Journal of Chromatography, 527, 389–396, 1990. 191. Schmidt, S. and Schmitz-Buhl, M., Signs and symptoms of carbamazepine overdose, Journal of Neurology, 242, 169–173, 1995. 192. Chai, C. and Killeen, A. A., Carbamazepine measurement in samples from the emergency room, Therapeutic Drug Monitoring, 16, 407–412, 1994. 193. Schwartz, J. G., Garriott, J. C., Somerset, J. S., Igler, E. J., Rodriguez, R., and Orr, M. D., Measurements of fentanyl and sufentanil in blood and urine after surgical application. Implication in detection of abuse, American Journal of Forensic Medicine & Pathology, 15, 236–241, 1994.


1198


194. Tobin, T., Kwiatkowski, S., Watt, D., Tai, H., Tai, C., Woods, W., et al., Immunoassay detection of drugs in racing horses. XI. ELISA and RIA detection of fentanyl, alfentanil, sufentanil and carfentanil in equine blood and urine, Research Communications in Chemical Pathology & Pharmacology, 63, 129–152, 1989. 195. Kintz, P., Mangin, P., Lugnier, A. A., and Chaumont, A. J., A rapid and sensitive gas chromatographic analysis of meprobamate or carisoprodol in urine and plasma, Journal of Analytical Toxicology, 12, 73–74, 1988. 196. Backer, R. C., Zumwalt, R., McFeeley, P., Veasey, S., and Wohlenberg, N., Carisoprodol concentrations from different anatomical sites: three overdose cases, Journal of Analytical Toxicology, 14, 332–334, 1990. 197. Kaistha, K. K., Selective assay procedure for chlorpropamide in the presence of its decomposition products, Journal of Pharmaceutical Sciences, 58, 235–237, 1969. 198. Meatherall, R. C., Green, P. T., Kenick, S., and Donen, N., Diazoxide in the management of chlorpropamide overdose, Journal of Analytical Toxicology, 5, 287–291, 1981. 199. Levine, B., Park, J., Smith, T. D., and Caplan, Y. H., Chloral hydrate: unusually high concentrations in a fatal overdose, Journal of Analytical Toxicology, 9, 232–233, 1985. 200. Meyer, E., Van Bocxlaer, J. F., Lambert, W. E., Piette, M., and De Leenheer, A. P., Determination of chloral hydrate and metabolites in a fatal intoxication, Journal of Analytical Toxicology, 19, 124–126, 1995. 201. Lister, R. G., Abernethy, D. R., Greenblatt, D. J., and File, S. E., Methods for the determination of lorazepam and chlordiazepoxide and metabolites in brain tissue, Journal of Chromatography, 277, 201–208, 1983. 202. Song, D., Zhang, S., and Kohlhof, K., Determination of chlordiazepoxide in mouse plasma by gas chromatography-negative-ion chemical ionization mass spectrometry, Journal of Chromatography B: Biomedical Applications, 660, 95–101, 1994. 203. Heller, P. F., Goldberger, B. A., and Caplan, Y. H., Chloral hydrate overdose: trichloroethanol detection by gas chromatography/mass spectrometry, Forensic Science International, 52, 231–234, 1992. 204. Bailey, D. N., Blood concentrations and clinical findings following overdose of chlordiazepoxide alone and chlordiazepoxide plus ethanol, Journal of Toxicology—Clinical Toxicology, 22, 433–446, 1984. 205. Dixon, R., Brooks, M. A., Postma, E., Hackman, M. R., Spector, S., Moore, J. D., et al., N-desmethyldiazepam: a new metabolite of chlordiazepoxide in man, Clinical Pharmacology & Therapeutics, 20, 450–457, 1976. 206. Stronjny, N., Bratin, K., Brooks, M. A., and de Silva, J. A., Determination of chlordiazepoxide, diazepam, and their major metabolites in blood or plasma by spectrophotodensitometry, Journal of Chromatography, 143, 363–374, 1977. 207. Bailey, D. N. and Guba, J. J., Gas-chromatographic analysis for chlorpromazine and some of its metabolites in human serum, with use of a nitrogen detector, Clinical Chemistry, 25, 1211–1215, 1979. 208. Ohkubo, T., Shimoyama, R., and Sugawara, K., Determination of chlorpromazine in human breast milk and serum by high-performance liquid chromatography, Journal of Chromatography, 614, 328–332, 1993. 209. Nishigami, J., Takayasu, T., and Ohshima, T., Toxicological analysis of the psychotropic drugs chlorpromazine and diazepam using chemically fixed organ tissues, International Journal of Legal Medicine, 107, 165–170, 1995. 210. Walker, O. and Ademowo, O. G., A Rapid, Cost-effective liquid chromatographic method for the determination of chloroquine and desethylchloroquine in biological fluids, Therapeutic Drug Monitoring, 18, 92–96, 1996. 211. Volin, P., Simple and specific reversed-phase liquid chromatographic method with diode-array detection for simultaneous determination of serum hydroxychloroquine, chloroquine and some corticosteroids, Journal of Chromatography B: Biomedical Applications, 666, 347–353, 1995. 212. Murtha, J. L., Julian, T. N., and Radebaugh, G. W., Simultaneous determination of pseudoephedrine hydrochloride, chlorpheniramine maleate, and dextromethorphan hydrobromide by second-derivative photodiode array spectroscopy, Journal of Pharmaceutical Sciences, 77, 715–718, 1988.


APPENDICES

1199

213. Masumoto, K., Tashiro, Y., Matsumoto, K., Yoshida, A., Hirayama, M., and Hayashi, S., Simultaneous determination of codeine and chlorpheniramine in human plasma by capillary column gas chromatography, Journal of Chromatography, 381, 323–329, 1986. 214. Bailey, D. N. and Guba, J. J., Gas-chromatographic analysis for chlorpromazine and some of its metabolites in human serum, with use of a nitrogen detector, Clinical Chemistry, 25, 1211–1215, 1979. 215. Garriott, J. C. and Stolman, A., Detection of some psychotherapeutic drugs and their metabolites in urine, Clinical Toxicology, 4, 225–243, 1971. 216. Fenimore, D. C., Meyer, C. J., Davis, C. M., Hsu, F., and Zlatkis, A., High-performance thin-layer chromatographic determination of psychopharmacologic agents in blood serum, Journal of Chromatography, 142, 399–409, 1977. 217. Lin, Q., Lensmeyer, G. L., and Larson, F. C., Quantitation of cimetidine and cimetidine sulfoxide in serum by solid-phase extraction and solvent-recycled liquid chromatography, Journal of Analytical Toxicology, 9, 161–166, 1985. 218. Borel, A. G. and Abbott, F. S., Metabolic profiling of clobazam, a 1,5-benzodiazepine, in rats, Drug Metabolism & Disposition, 21, 415–427, 1993. 219. Streete, J. M., Berry, D. J., and Newbery, J. E., The analysis of clobazam and its metabolite desmethylclobazam by high-performance liquid chromatography, Therapeutic Drug Monitoring, 13, 339–344, 1991. 220. Schutz, H., [A screening test for Nor-clobazam, a principal metabolite of the new 1,5 benzodiazepine clobazam (Frisium)], Archiv für Kriminologie, 163, 91–94, 1979. 221. Coudore, F., Hourcade, F., Moliniermanoukian, C., Eschalier, A., and Lavarenne, E., Application of HPLC with silica-phase and reversed-phase eluents for the determination of clomipramine and demethylated and 8-hydroxylated metabolites, Journal of Analytical Toxicology, 20, 101–105, 1996. 222. Altieri, I., Pichini, S., Pacifici, R., and Zuccaro, P., Improved clean-up procedure for the highperformance liquid chromatographic assay of clomipramine and its demethylated metabolite in human plasma, Journal of Chromatography B: Biomedical Applications, 669, 416–417, 1995. 223. McIntyre, I. M., King, C. V., Cordner, S. M., and Drummer, O. H., Postmortem clomipramine: therapeutic or toxic concentrations? Journal of Forensic Sciences, 39, 486–493, 1994. 224. Nielsen, K. K. and Brosen, K., High-performance liquid chromatography of clomipramine and metabolites in human plasma and urine, Therapeutic Drug Monitoring, 15, 122–128, 1993. 225. Marliac, Y. and Barazi, S., [Determination of unchanged clonazepam in plasma by gas-liquid chromatography]. [French], Annales de Biologie Clinique, 47, 503–506, 1989. 226. Miller, L. G., Friedman, H., and Greenblatt, D. J., Measurement of clonazepam by electron-capture gas-liquid chromatography with application to single-dose pharmacokinetics, Journal of Analytical Toxicology, 11, 55–57, 1987. 227. Wilson, J. M., Friel, P. N., Wilensky, A. J., and Raisys, V. A., A methods comparison: clonazepam by GC-electron capture and GC/MS, Therapeutic Drug Monitoring, 1, 387–397, 1979. 228. Petters, I., Peng, D. R., and Rane, A., Quantitation of clonazepam and its 7-amino and 7-acetamido metabolites in plasma by high-performance liquid chromatography, Journal of Chromatography, 306, 241–248, 1984. 229. Shaw, W., Long, G., and McHan, J., An HPLC method for analysis of clonazepam in serum, Journal of Analytical Toxicology, 7, 119–122, 1983. 230. Haver, V. M., Porter, W. H., Dorie, L. D., and Lea, J. R., Simplified high performance liquid chromatographic method for the determination of clonazepam and other benzodiazepines in serum, Therapeutic Drug Monitoring, 8, 352–357, 1986. 231. Doran, T. C., Liquid chromatographic assay for serum clonazepam, Therapeutic Drug Monitoring, 10, 474–479, 1988. 232. Haering, N., Salama, Z., Reif, G., and Jaeger, H., GC/MS determination of clonidine in body fluids. Application to pharmacokinetics, Arzneimittel-Forschung, 38, 404–407, 1988. 233. Arrendale, R. F., Stewart, J. T., and Tackett, R. L., Determination of clonidine in human plasma by cold on-column injection capillary GC/MS, Journal of Chromatography, 432, 165–175, 1988. 234. Linnoila, M. and Dorrity, F., Jr., Rapid gas chromatographic assay of serum diazepam, N-desmethyldiazepam, and N-desalkylflurazepam, Acta Pharmacologica et Toxicologica, 41, 458–464, 1977.


1200


235. McCurdy, H. H., Lewellen, L. J., Cagle, J. C., and Solomons, E. T., A rapid procedure for the screening and quantitation of barbiturates, diazepam, desmethyldiazepam and methaqualone, Journal of Analytical Toxicology, 5, 253–257, 1981. 236. Kudo, K., Nagata, T., Kimura, K., Imamura, T., and Noda, M., Sensitive determination of diazepam and N-desmethyldiazepam in human material using capillary GC/MS, Journal of Chromatography, 431, 353–359, 1988. 237. Lovdahl, M. J., Perry, P. J., and Miller, D. D., The assay of clozapine and N-desmethylclozapine in human plasma by high-performance liquid chromatography, Therapeutic Drug Monitoring, 13, 69–72, 1991. 238. Jennison, T. A., Brown, P., Crossett, J., Kushnir, M., and Urry, F. M., A rapid gas chromatographic method quantitating clozapine in human plasma or serum for the purpose of therapeutic monitoring, Journal of Analytical Toxicology, 19, 537–541, 1995. 239. Lin, G., McKay, G., Hubbard, J. W., and Midha, K. K., Decomposition of clozapine N-oxide in the qualitative and quantitative analysis of clozapine and its metabolites, Journal of Pharmaceutical Sciences, 83, 1412–1417, 1994. 240. McCarthy, P. T., Hughes, S., and Paton, C., Measurement of clozapine and norclozapine in plasma/serum by high performance liquid chromatography with ultraviolet detection, Biomedical Chromatography, 9, 36–41, 1995. 241. Gupta, R. N., Column liquid chromatographic determination of clozapine and N-desmethylclozapine in human serum using solid-phase extraction, Journal of Chromatography B: Biomedical Applications, 673, 311–315, 1995. 242. Olesen, O. V. and Poulsen, B., On-line fully automated determination of clozapine and desmethylclozapine in human serum by solid-phase extraction on exchangeable cartridges and liquid chromatography using a methanol buffer mobile phase on unmodified silica, Journal of Chromatography, 622, 39–46, 1993. 243. Chung, M. C., Lin, S. K., Chang, W. H., and Jann, M. W., Determination of clozapine and desmethylclozapine in human plasma by high-performance liquid chromatography with ultraviolet detection, Journal of Chromatography, 613, 168–173, 1993. 244. Liu, H. C., Chang, W. H., Wei, F. C., Lin, S. K., Lin, S. K., and Jann, M. W., Monitoring of plasma clozapine levels and its metabolites in refractory schizophrenic patients, Therapeutic Drug Monitoring, 18, 200–207, 1996. 245. Clauwaert, K. M., Van Bocxlaer, J. F., Lambert, W. E., and De Leenheer, A. P., Analysis of cocaine, benzoylecgonine, and cocaethylene in urine by HPLC with diode array detection, Analytical Chemistry, 68, 3021–3028, 1996. 246. Bailey, D. N., Cocaethylene (ethylcocaine) detection during toxicological screening of a university medical center patient population, Journal of Analytical Toxicology, 19, 247–250, 1995. 247. Cone, E. J., Hillsgrove, M., and Darwin, W. D., Simultaneous measurement of cocaine, cocaethylene, their metabolites, and “crack” pyrolysis products by gas chromatography-mass spectrometry, Clinical Chemistry, 40, 1299–1305, 1994. 248. Hime, G. W., Hearn, W. L., Rose, S., and Cofino, J., Analysis of cocaine and cocaethylene in blood and tissues by GC-NPD and GC-ion trap mass spectrometry, Journal of Analytical Toxicology, 15, 241–245, 1991. 249. Bailey, D. N., Comprehensive review of cocaethylene and cocaine concentrations in patients, American Journal of Clinical Pathology, 106, 701–704, 1996. 250. Nishikawa, M., Nakajima, K., Tatsuno, M., Kasuya, F., Igarashi, K., Fukui, M., et al., The analysis of cocaine and its metabolites by liquid chromatography/atmospheric pressure chemical ionizationmass spectrometry (LC/APCI-MS), Forensic Science International, 66, 149–158, 1994. 251. Peterson, K. L., Logan, B. K., Christian, G. D., and Ruzicka, J. Analysis of polar cocaine metabolites in urine and spinal fluid, in 46th Annual Meeting of the American Academy of Forensic Sciences, San Antonio, TX, 1994. 252. Logan, B. K. and Stafford, D. T., High-performance liquid chromatography with column switching for the determination of cocaine and benzoylecgonine concentrations in vitreous humor, Journal of Forensic Sciences, 35, 1303–1309, 1990. 253. Masoud, A. N. and Krupski, D. M., High-performance liquid chromatographic analysis of cocaine in human plasma, Journal of Analytical Toxicology, 4, 305–310, 1980.


APPENDICES

1201

254. Thompson, W. C. and Dasgupta, A., Confirmation and quantitation of cocaine, benzoylecgonine, ecgonine methyl ester, and cocaethylene by gas chromatography/mass spectrometry. Use of microwave irradiation for rapid preparation of trimethylsilyl and T-butyldimethylsilyl derivatives [see comments], American Journal of Clinical Pathology, 104, 187–192, 1995. 255. Cardenas, S., Gallego, M., and Valcarcel, M., An automated preconcentration-derivatization system for the determination of cocaine and its metabolites in urine and illicit cocaine samples by gas chromatography/mass spectrometry, Rapid Communications in Mass Spectrometry, 10, 631–636, 1996. 256. Kintz, P. and Mangin, P., Simultaneous determination of opiates, cocaine and major metabolites of cocaine in human hair by gas chromotography/mass spectrometry (GC/MS), Forensic Science International, 73, 93–100, 1995. 257. Hearn, W. L., Keran, E. E., Wei, H. A., and Hime, G., Site-dependent postmortem changes in blood cocaine concentrations, Journal of Forensic Sciences, 36, 673–684, 1991. 258. Delbeke, F. T. and Debackere, M., Influence of hydrolysis procedures on the urinary concentrations of codeine and morphine in relation to doping analysis, Journal of Pharmaceutical & Biomedical Analysis, 11, 339–343, 1993. 259. Posey, B. L. and Kimble, S. N., High-performance liquid chromatographic study of codeine, norcodeine, and morphine as indicators of codeine ingestion, Journal of Analytical Toxicology, 8, 68–74, 1984. 260. Vu-Duc, T. and Vernay, A., Simultaneous detection and quantitation of O6-monoacetylmorphine, morphine and codeine in urine by gas chromatography with nitrogen specific and/or flame ionization detection, Biomedical Chromatography, 4, 65–69, 1990. 261. Bowie, L. J. and Kirkpatrick, P. B., Simultaneous determination of monoacetylmorphine, morphine, codeine, and other opiates by GC/MS, Journal of Analytical Toxicology, 13, 326–329, 1989. 262. elSohly, H. N., Stanford, D. F., Jones, A. B., elSohly, M. A., Snyder, H., and Pedersen, C., Gas chromatographic/mass spectrometric analysis of morphine and codeine in human urine of poppy seed eaters, Journal of Forensic Sciences, 33, 347–356, 1988. 263. Wu Chen, N. B., Schaffer, M. I., Lin, R. L., and Stein, R. J., Simultaneous quantitation of morphine and codeine in biological samples by electron impact mass fragmentography, Journal of Analytical Toxicology, 6, 231–234, 1982. 264. Saady, J. J., Narasimhachari, N., and Blanke, R. V., Rapid, simultaneous quantification of morphine, codeine, and hydromorphone by GC/MS, Journal of Analytical Toxicology, 6, 235–237, 1982. 265. Gygi, S. P., Colon, F., Raftogianis, R. B., Galinsky, R. E., Wilkins, D. G., and Rollins, D. E., Doserelated distribution of codeine and its metabolites into rat hair, Drug Metabolism & Disposition, 24, 282–287, 1996. 266. Tracqui, A., Kintz, P., Ludes, B., Rouge, C., Douibi, H., and Mangin, P., High-performance liquid chromatography coupled to ion spray mass spectrometry for the determination of colchicine at ppb levels in human biofluids, Journal of Chromatography B: Biomedical Applications, 675, 235–242, 1996. 267. Clevenger, C. V., August, T. F., and Shaw, L. M., Colchicine poisoning: report of a fatal case with body fluid analysis by GC/MS and histopathologic examination of postmortem tissues, Journal of Analytical Toxicology, 15, 151–154, 1991. 268. Thompson, J. A., Ho, M. S., and Petersen, D. R., Analysis of nicotine and cotinine in tissues by capillary GC and GC/MS, Journal of Chromatography, 231, 53–63, 1982. 269. Urakawa, N., Nagata, T., Kudo, K., Kimura, K., and Imamura, T., Simultaneous determination of nicotine and cotinine in various human tissues using capillary gas chromatography/mass spectrometry, International Journal of Legal Medicine, 106, 232–236, 1994. 270. Deutsch, J., Hegedus, L., Greig, N. H., Rapoport, S. I., and Soncrant, T. T., Electron-impact and chemical ionization detection of nicotine and cotinine by gas chromatography-mass spectrometry in rat plasma and brain, Journal of Chromatography, 579, 93–98, 1992. 271. Jacob, P. d., Yu, L., Wilson, M., and Benowitz, N. L., Selected ion monitoring method for determination of nicotine, cotinine and deuterium-labeled analogs: absence of an isotope effect in the clearance of (S)-nicotine-3′,3′-d2 in humans, Biological Mass Spectrometry, 20, 247–252, 1991. 272. Backer, R. C., McFeeley, P., and Wohlenberg, N., Fatality resulting from cyclizine overdose, Journal of Analytical Toxicology, 13, 308–309, 1989.


1202


273. Tasset, J. J., Schroeder, T. J., and Pesce, A. J., Cyclobenzaprine overdose: the importance of a clinical history in analytical toxicology [letter], Journal of Analytical Toxicology, 10, 258, 1986. 274. Levine, B., Jones, R., Smith, M. L., Gudewicz, T. M., and Peterson, B., A multiple drug intoxication involving cyclobenzaprine and ibuprofen, American Journal of Forensic Medicine & Pathology, 14, 246–248, 1993. 275. Baehr, G. R., Romano, M., and Young, J. M., An unusual case of cyproheptadine (Periactin) overdose in an adolescent female, Pediatric Emergency Care, 2, 183–185, 1986. 276. Law, B., Mason, P. A., Moffat, A. C., Gleadle, R. I., and King, L. J., Forensic aspects of the metabolism and excretion of cannabinoids following oral ingestion of cannabis resin, Journal of Pharmacy and Pharmacology, 36, 289–294, 1983. 277. elSohly, M. A., Little, T. L., Jr., and Stanford, D. F., Hexadeutero-11-nor-delta 9-tetrahydrocannabinol9-carboxylic acid: a superior internal standard for the GC/MS analysis of delta 9-THC acid metabolite in biological specimens, Journal of Analytical Toxicology, 16, 188–191, 1992. 278. Moeller, M., Doerr, G., and Warth, S., Simultaneous quantitation of delta-9-tetrahydrocannabinol (THC) and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol (THC-COOH) in serum by GC/MS using deuterated internal standards and its application to a smoking study and forensic cases, Journal of Forensic Sciences, 37, 969–983, 1992. 279. Kemp, P. M., Abukhalaf, I. K., Manno, J. E., Manno, B. R., Alford, D. D., McWilliams, M. E., et al., Cannabinoids in humans. II. The influence of three methods of hydrolysis on the concentration of THC and two metabolites in urine, Journal of Analytical Toxicology, 19, 292–298, 1995. 280. Wolff, K., Garretty, D., and Hay, A. W. M., Micro-extraction of commonly abused benzodiazepines for urinary screening by liquid chromatography, Annals of Clinical Biochemistry, 34, 61–67, 1997. 281. Tanaka, E., Terada, M., Misawa, S., and Wakasugi, C., Simultaneous determination of twelve benzodiazepines in human serum using a new reversed-phase chromatographic column on a 2-mu-m porous microspherical silica gel, Journal of Chromatography B: Biomedical Applications, 682, 173–178, 1996. 282. Needleman, S. B. and Porvaznik, M., Identification of parent benzodiazepines by gas chromotography/mass spectroscopy (GC/MS) from urinary extracts treated with B-glucuronidase, Forensic Science International, 73, 49–60, 1995. 283. Peat, M. A. and Kopjak, L., The screening and quantitation of diazepam, flurazepam, chloridazepoxide, and their metabolites in blood and plasma by electron-capture gas chromatography and high pressure liquid chromatography, Journal of Forensic Sciences, 24, 46–54, 1979. 284. Song, D., Zhang, S., and Kohlhof, K., Gas chromatographic-mass spectrometric method for the determination of flurazepam and its major metabolites in mouse and rat plasma, Journal of Chromatography B: Biomedical Applications, 658, 142–148, 1994. 285. Clatworthy, A. J., Jones, L. V., and Whitehouse, M. J., The GC/MS of the major metabolites of flurazepam., Biomedical Mass Spectronomy, 4, 248–254, 1977. 286. Aderjan, R. and Mattern, R., [A fatal monointoxication by flurazepam (Dalmadorm). Problems of the toxicological interpretation (author’s transl.)]. [German], Archives of Toxicology, 43, 69–75, 1979. 287. Abel, M. and Eisenkraft, J. B., Erroneous mass spectrometer readings caused by desflurane and sevoflurane, Journal of Clinical Monitoring, 11, 152–158, 1995. 288. Hartter, S., Baier, D., Dingemanse, J., Ziegler, G., and Hiemke, C., Automated determination of dextromethorphan and its main metabolites in human plasma by high-performance liquid chromatography and column switching, Therapeutic Drug Monitoring, 18, 297–303, 1996. 289. Lam, Y. W. and Rodriguez, S. Y., High-performance liquid chromatography determination of dextromethorphan and dextrorphan for oxidation phenotyping by fluorescence and ultraviolet detection, Therapeutic Drug Monitoring, 15, 300–304, 1993. 290. Wallace, J. E., Schwertner, H. A., and Shimek, E. L. j., Analysis for diazepam and nordiazepam by electron-capture gas chromatography and by liquid chromatography, Clinical Chemistry, 25, 1296–1300, 1979. 291. St-Pierre, M. V. and Pang, K. S., Determination of diazepam and its metabolites by high-performance liquid chromatography and thin-layer chromatography, Journal of Chromatography, 421, 291–307, 1987. 292. MacKichan, J. J., Jusko, W. J., Duffner, P. K., and Cohen, M. E., Liquid-chromatographic assay of diazepam and its major metabolites in plasma, Clinical Chemistry, 25, 856–859, 1979.


APPENDICES

1203

293. Plavsic, F. and Culig, J., Determination of serum diclofenac by high-performance liquid chromatography by electromechanical detection, Human Toxicology, 4, 317–322, 1985. 294. Blagbrough, I. S., Daykin, M. M., Doherty, M., Pattrick, M., and Shaw, P. N., High-performance liquid chromatographic determination of naproxen, ibuprofen and diclofenac in plasma and synovial fluid in man, Journal of Chromatography, 578, 251–257, 1992. 295. Garriott, J. C., Rodriquez, R., and Norton, L. E., Two cases of death involving dicyclomine in infants, Journal of Toxicology—Clinical Toxicology, 22, 455–462, 1984. 296. Shimamine, M., Takahashi, K., and Nakahara, Y., [Studies on the identification of psychotropic substances, Eisei Shikenjo Hokoku—Bulletin of National Institute of Hygienic Sciences, 67–73, 1992. 297. Levine, B., Smyth, D., and Caplan, Y., A diflunisal related fatality: a case report, Forensic Science International, 35, 45–50, 1987. 298. Hofmann, U., Fromm, M. F., Johnson, S., and Mikus, G., Simultaneous determination of dihydrocodeine and dihydromorphine in serum by gas chromatography-tandem mass spectrometry, Journal of Chromatography B: Biomedical Applications, 663, 59–65, 1995. 299. Musshoff, F. and Daldrup, T., Evaluation of a method for simultaneous quantification of codeine, dihydrocodeine, morphine, and 6-monoacetylmorphine in serum, blood, and postmortem blood, International Journal of Legal Medicine, 106, 107–109, 1993. 300. Maurer, H. H., Identification of antiarrhythmic drugs and their metabolites in urine, Archives of Toxicology, 64, 218–230, 1990. 301. Pierce, T. L., Murray, A. G., and Hope, W., Determination of methadone and its metabolites by high performance liquid chromatography following solid-phase extraction in rat plasma, Journal of Chromatographic Science, 30, 443–447, 1992. 302. Angelo, H. R., Bonde, J., Kampmann, J. P., and Kastrup, J., A HPLC method for the simultaneous determination of disopyramide, lidocaine and their monodealkylated metabolites, Scandinavian Journal of Clinical & Laboratory Investigation, 46, 623–627, 1986. 303. Proelss, H. F. and Townsend, T. B., Simultaneous liquid-chromatographic determination of five antiarrhythmic drugs and their major active metabolites in serum, Clinical Chemistry, 32, 1311–1317, 1986. 304. Anderson, W. H., Stafford, D. T., and Bell, J. S., Disopyramide (Norpace) distribution at autopsy of an overdose case, Journal of Forensic Sciences, 25, 33–39, 1980. 305. Kapil, R. P., Abbott, F. S., Kerr, C. R., Edwards, D. J., Lalka, D., and Axelson, J. E., Simultaneous quantitation of disopyramide and its mono-dealkylated metabolite in human plasma by fused-silica capillary gas chromatography using nitrogen-phosphorus specific detection, Journal of Chromatography, 307, 305–321, 1984. 306. McIntyre, I. M., King, C. V., Skafidis, S., and Drummer, O. H., Dual ultraviolet wavelength highperformance liquid chromatographic method for the forensic or clinical analysis of seventeen antidepressants and some selected metabolites, Journal of Chromatography, 621, 215–223, 1993. 307. Pounder, D. J. and Jones, G. R., Post-mortem drug redistribution—a toxicological nightmare, Forensic Science International, 45, 253–263, 1990. 308. Wu Chen, N. B., Schaffer, M. I., Lin, R. L., Kurland, M. L., Donoghue, E. R., Jr., and Stein, R. J., The general toxicology unknown. II. A case report: doxylamine and pyrilamine intoxication, Journal of Forensic Sciences, 28, 398–403, 1983. 309. Virag, L., Mets, B., and Jamdar, S., Determination of cocaine, norcocaine, benzoylecgonine and ecgonine methyl ester in rat plasma by high-performance liquid chromatography with ultraviolet detection, Journal of Chromatography B: Biomedical Applications, 681, 263–269, 1996. 310. Peterson, K. L., Logan, B. K., and Christian, G. D., Detection of cocaine and its polar transformation products and metabolites in human urine, Forensic Science International, 73, 183–196, 1995. 311. Balikova, M. and Vecerkova, J., High-performance liquid chromatographic confirmation of cocaine and benzoylecgonine in biological samples using photodiode-array detection after toxicological screening, Journal of Chromatography B: Biomedical Applications, 656, 267–273, 1994. 312. Crouch, D. J., Alburges, M. E., Spanbauer, A. C., Rollins, D. E., and Moody, D. E., Analysis of cocaine and its metabolites from biological specimens using solid-phase extraction and positive ion chemical ionization mass spectrometry, Journal of Analytical Toxicology, 19, 352–358, 1995. 313. Wang, W. L., Darwin, W. D., and Cone, E. J., Simultaneous assay of cocaine, heroin and metabolites in hair, plasma, saliva and urine by gas chromatography-mass spectrometry, Journal of Chromatography B: Biomedical Applications, 660, 279–290, 1994.


1204


314. Mule, S. J. and Casella, G. A., Confirmation and quantitation of cocaine, benzoylecgonine, ecgonine methyl ester in human urine by GC/MS, Journal of Analytical Toxicology, 12, 153–155, 1988. 315. Matsubara, K., Maseda, C., and Fukui, Y., Quantitation of cocaine, benzoylecgonine and ecgonine methyl ester by GC-CI-SIM after Extrelut extraction, Forensic Science International, 26, 181–192, 1984. 316. Ahnoff, M., Ervik, M., Lagerstrom, P. O., Persson, B. A., and Vessman, J., Drug level monitoring: cardiovascular drugs. [Review], Journal of Chromatography, 340, 73–138, 1985. 317. Braggio, S., Sartori, S., Angeri, F., and Pellegatti, M., Automation and validation of the high-performance liquid chromatographic-radioimmunoassay method for the determination of lacidipine in plasma, Journal of Chromatography B: Biomedical Applications, 669, 383–389, 1995. 318. Saito, K., Takayasu, T., Nishigami, J., Kondo, T., Ohtsuji, M., Lin, Z., et al., Determination of the volatile anesthetics halothane, enflurane, isoflurane, and sevoflurane in biological specimens by pulseheating GC-MS, Journal of Analytical Toxicology, 19, 115–119, 1995. 319. Heusler, H., Quantitative analysis of common anaesthetic agents, Journal of Chromatography, 340, 273–319, 1985. 320. Ohtsuji, M., Lai, J. S., Binder, S. R., Kondo, T., Takayasu, T., and Ohshima, T., Use of REMEDi HS in emergency toxicology for a rapid estimate of drug concentrations in urine, serum, and gastric samples, Journal of Forensic Sciences, 41, 881–886, 1996. 321. Boukhabza, A., Lugnier, A. A., Kintz, P., and Mangin, P., Simultaneous HPLC analysis of the hypnotic benzodiazepines nitrazepam, estazolam, flunitrazepam, and triazolam in plasma, Journal of Analytical Toxicology, 15, 319–322, 1991. 322. Charlebois, R. C., Corbett, M. R., and Wigmore, J. G., Comparison of ethanol concentrations in blood, serum, and blood cells for forensic application, Journal of Analytical Toxicology, 20, 171–178, 1996. 323. O’ Neal, C., Wolf, C. E., 2nd, Levine, B., Kunsman, G., and Poklis, A., Gas chromatographic procedures for determination of ethanol in postmortem blood using t-butanol and methyl ethyl ketone as internal standards, Forensic Science International, 83, 31–38, 1996. 324. Macchia, T., Mancinelli, R., Gentili, S., Lugaresi, E. C., Raponi, A., and Taggi, F., Ethanol in biological fluids: headspace GC measurement, Journal of Analytical Toxicology, 19, 241–246, 1995. 325. Skrupskii, V. A., [Gas chromatographic analysis of ethanol and acetone in the air exhaled by patients]. [RUSSIAN], Klinicheskaia Laboratornaia Diagnostika, 4, 35–38, 1995. 326. Jones, A. W., Edman-Falkensson, M., and Nilsson, L., Reliability of blood alcohol determinations at clinical chemistry laboratories in Sweden, Scandinavian Journal of Clinical & Laboratory Investigation, 55, 463–468, 1995. 327. Clerc, Y., Huart, B., Charotte, J. M., and Pailler, F. M., [Validation of blood ethanol determination method by gas chromatography (letter)]. [French], Annales de Biologie Clinique, 53, 233–238, 1995. 328. Cox, R. A. and Crifasi, J. A., A comparison of a commercial microdiffusion method and gas chromatography for ethanol analysis, Journal of Analytical Toxicology, 14, 211–212, 1990. 329. Jones, A. W. and Schuberth, J., Computer-aided headspace gas chromatography applied to blood-alcohol analysis: importance of online process control, Journal of Forensic Sciences, 34, 1116–1127, 1989. 330. Bridges, R. R. and Jennison, T. A., Analysis of ethchlorvynol (Placidyl): evaluation of a comparison performed in a clinical laboratory, Journal of Analytical Toxicology, 8, 263–268, 1984. 331. Winek, C. L., Wahba, W. W., Rozin, L., and Winek, C. L., Jr., Determination of ethchlorvynol in body tissues and fluids after embalmment, Forensic Science International, 37, 161–166, 1988. 332. Winek, C. L., Wahba, W. W., and Winek, C. L., Jr., Body distribution of ethchlorvynol, Journal of Forensic Sciences, 34, 687–690, 1989. 333. Flanagan, R. J., Lee, T. D., and Rutherford, D. M., Analysis of chlormethiazole, ethchlorvynol and trichloroethanol in biological fluids by gas-liquid chromatography as an aid to the diagnosis of acute poisoning, Journal of Chromatography, 153, 473–479, 1978. 334. Flanagan, R. J. and Lee, T. D., Rapid micro-method for the measurement of ethchlorvynol in blood plasma and in urine by gas-liquid chromatography, Journal of Chromatography, 137, 119–126, 1977. 335. Bailey, D. N. and Shaw, R. F., Ethchlorvynol ingestion in San Diego County: a 14-year review of cases with blood concentrations and findings. [Review], Journal of Analytical Toxicology, 14, 348–352, 1990. 336. Kelner, M. J. and Bailey, D. N., Ethchlorvynol ingestion: interpretation of blood concentrations and clinical findings, Journal of Toxicology—Clinical Toxicology, 21, 399–408, 1983.


APPENDICES

1205

337. Berry, D. J. and Clarke, L. A., Gas chromatographic analysis of ethosuximide (2-ethyl-2-methyl succinimide) in plasma at therapeutic concentrations, Journal of Chromatography, 150, 537–541, 1978. 338. Richard, L., Leducq, B., Baty, C., and Jambou, J., [Plasma determination of 7 common drugs by high performance liquid chromatography], Annales de Biologie Clinique, 47, 79–84, 1989. 339. Schmutz, A. and Thormann, W., Determination of phenobarbital, ethosuximide, and primidone in human serum by micellar electrokinetic capillary chromatography with direct sample injection, Therapeutic Drug Monitoring, 15, 310–316, 1993. 340. Miles, M. V., Howlett, C. M., Tennison, M. B., Greenwood, R. S., and Cross, R. E., Determination of N-desmethylmethsuximide serum concentrations using enzyme-multiplied and fluorescence polarization immunoassays, Therapeutic Drug Monitoring, 11, 337–342, 1989. 341. Stewart, C. F. and Bottorff, M. B., Fluorescence polarization immunoassay for ethosuximide evaluated and compared with two other immunoassay techniques, Clinical Chemistry, 32, 1781–1783, 1986. 342. Haring, C. M., Dijkhuis, I. C., and van Dijk, B., A rapid method of determining serum levels of etomidate by gas chromatography with the aid of a nitrogen detector, Acta Anaesthesiologica Belgica, 31, 107–112, 1980. 343. Qin, X. Z., Ip, D. P., Chang, K. H., Dradransky, P. M., Brooks, M. A., and Sakuma, T., Pharmaceutical application of LC-MS. 1—Characterization of a famotidine degradate in a package screening study by LC-APCI MS, Journal of Pharmaceutical & Biomedical Analysis, 12, 221–233, 1994. 344. Poquette, M. A., Isothermal gas chromatographic method for the rapid determination of felbamate concentration in human serum, Therapeutic Drug Monitoring, 17, 168–173, 1995. 345. Wong, S. H. Y., Sasse, E. A., Schroeder, J. M., Rodgers, J. K., Pearson, M. L., Neicheril, J. C., et al., Totally automated analysis by robotized prepstation and liquid chromatography—direct-sample analysis of felbamate, Therapeutic Drug Monitoring, 18, 573–580, 1996. 346. Annesley, T. M. and Clayton, L. T., Determination of felbamate in human serum by high-performance liquid chromatography, Therapeutic Drug Monitoring, 16, 419–424, 1994. 347. Friel, P. N., Formoso, E. J., and Logan, B. K. GC/MS analysis of felbamate, a new antiepileptic drug, in postmortem specimens, in American Academy of Forensic Science, Seattle, WA, 1995. 348. Nishioka, R., Umeda, I., Oi, N., Tabata, S., and Uno, K., Determination of felodipine and its metabolites in plasma using capillary gas chromatography with electron-capture detection and their identification by gas chromatography-mass spectrometry, Journal of Chromatography, 565, 237–246, 1991. 349. Ferretti, R., Gallinella, B., Latorre, F., and Lusi, A., Direct high-performance liquid chromatography resolution on a chiral column of dexfenfluramine and its impurities, in bulk raw drug and pharmaceutical formulations, Journal of Chromatography, 731(1–2): 340–345, 1996. 350. Moore, C. M. and Tebbett, I. R., Rapid extraction of anti-inflammatory drugs in whole blood for HPLC analysis, Forensic Science International, 34, 155–158, 1987. 351. Watts, V. and Caplan, Y., Determination of fentanyl in whole blood at subnanogram concentrations by dual capillary column gas chromatography with nitrogen sensitive detectors and gas chromatography/mass spectrometry, Journal of Analytical Toxicology, 12, 246–254, 1988. 352. Mautz, D. S., Labroo, R., and Kharasch, E. D., Determination of alfentanil and noralfentanil in human plasma by gas chromatography-mass spectrometry, Journal of Chromatography B: Biomedical Applications, 658, 149–153, 1994. 353. Smialek, J. E., Levine, B., Chin, L., Wu, S. C., and Jenkins, A. J., A fentanyl epidemic in Maryland 1992, Journal of Forensic Sciences, 39, 159–164, 1994. 354. Levine, B., Goodin, J. C., and Caplan, Y. H., A fentanyl fatality involving midazolam, Forensic Science International, 45, 247–251, 1990. 355. Ferslew, K., Hagardorn, A., and McCormick, W., Postmortem determination of the biological distribution of sufentanil and midazolam after an acute intoxication, Journal of Forensic Sciences, 34, 249–257, 1989. 356. Poklis, A., Fentanyl: A review for clinical and analytical toxicologists [Review], Journal of Toxicology Clinical Toxicology, 33, 439–447, 1995. 357. Hoppe, U., Krudewagen, B., Stein, H., Hertrampf, R., and Gundert-Remy, U., Comparison of fluorescence polarisation immunoassay (FPIA) and high performance liquid chromatography (HPLC) methods for the measurement of flecainide in human plasma, International Journal of Clinical Pharmacology, Therapy, & Toxicology, 31, 142–147, 1993.


1206


358. Stas, C. M., Jacqmin, P. A., and Pellegrin, P. L., Comparison of gas-liquid chromatography and fluorescence polarization immunoassay for therapeutic drug monitoring of flecainide acetate, Journal of Pharmaceutical & Biomedical Analysis, 7, 1651–1656, 1989. 359. Straka, R. J., Hoon, T. J., Lalonde, R. L., Pieper, J. A., and Bottorff, M. B., Liquid chromatography and fluorescence polarization immunoassay methods compared for measuring flecainide acetate in serum, Clinical Chemistry, 33, 1898–1900, 1987. 360. Berthault, F., Kintz, P., and Mangin, P., Simultaneous high-performance liquid chromatographic analysis of flunitrazepam and four metabolites in serum, Journal of Chromatography B: Biomedical Applications, 685, 383–387, 1996. 361. Kleinschnitz, M., Herderich, M., and Schreier, P., Determination of 1,4-benzodiazepines by highperformance liquid chromatography electrospray tandem mass spectrometry, Journal of Chromatography B: Biomedical Applications, 676, 61–67, 1996. 362. Robertson, M. D. and Drummer, O. H., High-performance liquid chromatographic procedure for the measurement of nitrobenzodiazepines and their 7-amino metabolites in blood, Journal of Chromatography B: Biomedical Applications, 667, 179–184, 1995. 363. Benhamou-Batut, F., Demotes-Mainard, F., Labat, L., Vincon, G., and Bannwarth, B., Determination of flunitrazepam in plasma by liquid chromatography, Journal of Pharmaceutical & Biomedical Analysis, 12, 931–936, 1994. 364. Lantz, R. J., Farid, K. Z., Koons, J., Tenbarge, J. B., and Bopp, R. J., Determination of fluoxetine and norfluoxetine in human plasma by capillary gas chromatography with electron-capture detection, Journal of Chromatography, 614, 175–179, 1993. 365. Rohrig, T. P. and Prouty, R. W., Fluoxetine overdose: a case report [published erratum appears in Journal of Analytical Toxicology 14, 63, 1990], Journal of Analytical Toxicology, 13, 305–307, 1989. 366. Orsulak, P. J., Kenney, J. T., Debus, J. R., Crowley, G., and Wittman, P. D., Determination of the antidepressant fluoxetine and its metabolite norfluoxetine in serum by reversed-phase HPLC with ultraviolet detection, Clinical Chemistry, 34, 1875–1878, 1988. 367. Nash, J. F., Bopp, R. J., Carmichael, R. H., Farid, K. Z., and Lemberger, L., Determination of fluoxetine and norfluoxetine in plasma by gas chromatography with electron-capture detection, Clinical Chemistry, 28, 2100–2102, 1982. 368. Nichols, J. H., Charlson, J. R., and Lawson, G. M., Automated HPLC assay of fluoxetine and norfluoxetine in serum, Clinical Chemistry, 40, 1312–1316, 1994. 369. Eap, C. B., Gaillard, N., Powell, K., and Baumann, P., Simultaneous determination of plasma levels of fluvoxamine and of the enantiomers of fluoxetine and norfluoxetine by gas chromatography mass spectrometry, Journal of Chromatography B: Biomedical Applications, 682, 265–272, 1996. 370. Miller, R. S., Peterson, G. M., McLean, S., Westhead, T. T., and Gillies, P., Monitoring plasma levels of fluphenazine during chronic therapy with fluphenazine decanoate, Journal of Clinical Pharmacy & Therapeutics, 20, 55–62, 1995. 371. Sener, A., Akkan, A. G., and Malaisse, W. J., Standardized procedure for the assay and identification of hypoglycemic sulfonylureas in human plasma, Acta Diabetologica, 32, 64–68, 1995. 372. Flanagan, R. J. and Withers, G., A rapid micro-method for the screening and measurement of barbiturates and related compounds in plasma by gas-liquid chromatography, Journal of Clinical Pathology, 25, 899–904, 1972. 373. Shipe, J. R. and Savory, J., A comprehensive gas chromatography procedure for measurement of drugs in biological materials, Annals of Clinical & Laboratory Science, 5, 57–64, 1975. 374. Bailey, D. N. and Shaw, R. F., Blood concentrations and clinical findings in nonfatal and fatal intoxications involving glutethimide and codeine, Journal of Toxicology Clinical Toxicology, 23, 557–570, 1985. 375. Bailey, D. N. and Shaw, R. F., Interpretation of blood glutethimide, meprobamate, and methyprylon concentrations in nonfatal and fatal intoxications involving a single drug, Journal of Toxicology Clinical Toxicology, 20, 133–145, 1983. 376. Hoffman, D. W. and Edkins, R. D., Solid-phase extraction and high-performance liquid chromatography for therapeutic monitoring of haloperidol levels, Therapeutic Drug Monitoring, 16, 504–508, 1994.


APPENDICES

1207

377. Aravagiri, M., Marder, S. R., Van Putten, T., and Marshall, B. D., Simultaneous determination of plasma haloperidol and its metabolite reduced haloperidol by liquid chromatography with electrochemical detection. Plasma levels in schizophrenic patients treated with oral or intramuscular depot haloperidol, Journal of Chromatography B: Biomedical Applications, 656, 373–381, 1994. 378. Jann, M. W., Chang, W. H., Lam, Y. W., Hwu, H. G., Lin, H. N., Chen, H., et al., Comparison of haloperidol and reduced haloperidol plasma levels in four different ethnic populations, Progress in Neuro Psychopharmacology & Biological Psychiatry, 16, 193–202, 1992. 379. Park, K. H., Lee, M. H., and Lee, M. G., Simultaneous determination of haloperidol and its metabolite, reduced haloperidol, in plasma, blood, urine and tissue homogenates by high-performance liquid chromatography, Journal of Chromatography, 572, 259–267, 1991. 380. Haering, N., Salama, Z., Todesko, L., and Jaeger, H., GC/MS determination of haloperidol in plasma. Application to pharmacokinetics, Arzneimittel-Forschung, 37, 1402–1404, 1987. 381. van Leeuwen, P. A., Improved GC/MS assay for haloperidol utilizing ammonia CI and SIM, Journal of Chromatography and Biomedical Applications, 40, 321–330, 1985. 382. Hornbeck, C. L., Griffiths, J. C., Neborsky, R. J., and Faulkner, M. A., GC/MS chemical ionization assay for haloperidol with SIM, Biomedical Mass Spectrometry, 6, 427–430, 1979. 383. Coudore, F., Alazard, J. M., Paire, M., Andraud, G., and Lavarenne, J., Rapid toxicological screening of barbiturates in plasma by wide-bore capillary gas chromatography and nitrogen-phosphorus detection, Journal of Analytical Toxicology, 17, 109–113, 1993. 384. Soo, V. A., Bergert, R. J., and Deutsch, D. G., Screening and quantification of hypnotic sedatives in serum by capillary gas chromatography with a nitrogen-phosphorus detector, and confirmation by capillary gas chromatography-mass spectrometry, Clinical Chemistry, 32, 325–328, 1986. 385. Mahoney, J. D., Gross, P. L., Stern, T. A., Browne, B. J., Pollack, M. H., Reder, V., et al., Quantitative serum toxic screening in the management of suspected drug overdose, American Journal of Emergency Medicine, 8, 16–22, 1990. 386. Meeker, J. E., Som, C. W., Macapagal, E. C., and Benson, P. A., Zolpidem tissue concentrations in a multiple drug related death involving Ambien, Journal of Analytical Toxicology, 19, 531–534, 1995. 387. Bouquillon, A. I., Freeman, D., and Moulin, D. E., Simultaneous solid-phase extraction and chromatographic analysis of morphine and hydromorphone in plasma by high-performance liquid chromatography with electrochemical detection, Journal of Chromatography, 577, 354–357, 1992. 388. Sawyer, W. R., Waterhouse, G. A., Doedens, D. J., and Forney, R. B., Heroin, morphine, and hydromorphone determination in postmortem material by high performance liquid chromatography [see comments], Journal of Forensic Sciences, 33, 1146–1155, 1988. 389. O’ Connor, E. F., Cheng, S. W., and North, W. G., Simultaneous extraction and chromatographic analysis of morphine, dilaudid, naltrexone and naloxone in biological fluids by high-performance liquid chromatography with electrochemical detection, Journal of Chromatography, 491, 240–247, 1989. 390. Cone, E. J. and Darwin, W. D., Simultaneous determination of hydromorphone, hydrocodone and their 6alpha- and 6beta-hydroxy metabolites in urine using selected ion recording with methane chemical ionization, Biomedical Mass Spectrometry, 5, 291, 1978. 391. Croes, K., McCarthy, P. T., and Flanagan, R. J., Simple and rapid HPLC of quinine, hydroxychloroquine, chloroquine, and desethylchloroquine in serum, whole blood, and filter paper- adsorbed dry blood, Journal of Analytical Toxicology, 18, 255–260, 1994. 392. Kintz, P., Godelar, B., and Mangin, P., Gas chromatographic identification and quantification of hydroxyzine: application in a fatal self-poisoning, Forensic Science International, 48, 139–143, 1990. 393. Naidong, W. and Lee, J. W., Development and validation of a liquid chromatographic method for the quantitation of ibuprofen enantiomers in human plasma, Journal of Pharmaceutical & Biomedical Analysis, 12, 551–556, 1994. 394. Maurer, H. H., Kraemer, T., and Weber, A., Toxicological detection of ibuprofen and its metabolites in urine using gas chromatography-mass spectrometry (GC-MS), Pharmazie, 49, 148–155, 1994. 395. Zhao, M. J., Peter, C., Holtz, M. C., Hugenell, N., Koffel, J. C., and Jung, L., GC/MS determination of ibuprofen enantiomers in human plasma using r(-)-2,2,2-trifluoro-1-(9-anthryl)ethanol as derivatizing reagent, Journal of Chromatography B: Biomedical Applications, 656, 441–446, 1994.


1208


396. Seideman, P., Lohrer, F., Graham, G. G., Duncan, M. W., Williams, K. M., and Day, R. O., The stereoselective disposition of the enantiomers of ibuprofen in blood, blister and synovial fluid, British Journal of Clinical Pharmacology, 38, 221–227, 1994. 397. Theis, D. L., Halstead, G. W., and Halm, K. A., Development of capillary GC/MS methodology for the simultaneous determination of ibuprofen and deuterated ibuprofen in serum, Journal of Chromatography, 380, 77–87, 1986. 398. Jourdil, N., Pinteur, B., Vincent, F., Marka, C., and Bessard, G., Simultaneous determination of trimipramine and desmethyl- and hydroxytrimipramine in plasma and red blood cells by capillary gas chromatography with nitrogen-selective detection, Journal of Chromatography, 613, 59–65, 1993. 399. Maynard, G. L. and Soni, P., Thioridazine interferences with imipramine metabolism and measurement, Therapeutic Drug Monitoring, 18, 729–731, 1996. 400. Nielsen, K. K. and Brosen, K., High-performance liquid chromatography of imipramine and six metabolites in human plasma and urine, Journal of Chromatography, 612, 87–94, 1993. 401. Koyama, E., Kikuchi, Y., Echizen, H., Chiba, K., and Ishizaki, T., Simultaneous high-performance liquid chromatography-electrochemical detection determination of imipramine, desipramine, their 2hydroxylated metabolites, and imipramine N-oxide in human plasma and urine: preliminary application to oxidation pharmacogenetics, Therapeutic Drug Monitoring, 15, 224–235, 1993. 402. Eap, C. B., Koeb, L., and Baumann, P., Determination of trimipramine and its demethylated and hydroxylated metabolites in plasma by gas chromatography-mass spectrometry, Journal of Chromatography, 652, 97–103, 1994. 403. Hunt, J. P., Haywood, P. E., and Moss, M. S., A gas chromatographic screening procedure for the detection of non-steroidal anti-inflammatory drugs in horse urine, Equine Veterinary Journal, 11, 259–263, 1979. 404. Sibeon, R. G., Baty, J. D., Baber, N., Chan, K., and Orme, M. L., Quantitative gas-liquid chromatographic method for the determination of indomethacin in biological fluids, Journal of Chromatography, 153, 189–194, 1978. 405. Hannak, D., Scharbert, F., and Kattermann, R., Stepwise binary gradient high-performance liquid chromatographic system for routine drug monitoring, Journal of Chromatography A, 728, 307–310, 1996. 406. Caturla, M. C. and Cusido, E., Solid-phase extraction for the high-performance liquid chromatographic determination of indomethacin, suxibuzone, phenylbutazone and oxyphenbutazone in plasma, avoiding degradation of compounds, Journal of Chromatography, 581, 101–107, 1992. 407. Cosolo, W., Drummer, O. H., and Christophidis, N., Comparison of high-performance liquid chromatography and the Abbott fluorescent polarization radioimmunoassay in the measurement of methotrexate, Journal of Chromatography, 494, 201–208, 1989. 408. Bauernfeind, M. and Wood, W. G., Evaluation of a fully mechanised immunoassay—Enzymun-Test System ES 300—and comparison with in-house methods for 8 analytes, European Journal of Clinical Chemistry & Clinical Biochemistry, 31, 165–172, 1993. 409. Patel, F., Fatal self-induced hyperinsulinaemia: a delayed post-mortem analytical detection, Medicine, Science & the Law, 32, 151–159, 1992. 410. Fletcher, S. M., Insulin. A forensic primer. [Review], Journal Forensic Science Society, 23, 5–17, 1983. 411. Heyndrickx, A., Van Peteghem, C., Majelyne, W., and Timperman, J., Detection of insulin in cadavers, Acta Pharmaceutica Hungarica, 50, 201–206, 1980. 412. Dickson, S. J., Cairns, E. R., and Blazey, N. D., The isolation and quantitation of insulin in postmortem specimens—a case report, Forensic Science, 9, 37–42, 1977. 413. Jones, A. W., Severe isopropanolemia without acetonemia: contamination of specimens during venipuncture? [letter; comment], Clinical Chemistry, 41, 123–124, 1995. 414. Chan, K. M., Wong, E. T., and Matthews, W. S., Severe isopropanolemia without acetonemia or clinical manifestations of isopropanol intoxication [see comments], Clinical Chemistry, 39, 1922–1925, 1993. 415. Jerrard, D., Verdile, V., Yealy, D., Krenzelok, E., and Menegazzi, J., Serum determinations in toxic isopropanol ingestion, American Journal of Emergency Medicine, 10, 200–202, 1992. 416. Davis, P. L., Dal Cortivo, L. A., and Maturo, J., Endogenous isopropanol: forensic and biochemical implications, Journal of Analytical Toxicology, 8, 209–212, 1984.


APPENDICES

1209

417. Kelner, M. and Bailey, D. N., Isopropanol ingestion: interpretation of blood concentrations and clinical findings, Journal of Toxicology Clinical Toxicology, 20, 497–507, 1983. 418. Baker, R. N., Alenty, A. L., and Zack, J. F., Jr., Toxic volatiles in alcoholic coma. A report of simultaneous determination of blood methanol, ethanol, isopropanol, acetaldehyde and acetone by gas chromatography, Bulletin of the Los Angeles Neurological Societies, 33, 140–144, 1968. 419. Alexander, C. B., McBay, A. J., and Hudson, R. P., Isopropanol and isopropanol deaths-ten years’ experience, Journal of Forensic Sciences, 27, 541–548, 1982. 420. Brogden, R. N. and Sorkin, E. M., Isradipine. An update of its pharmacodynamic and pharmacokinetic properties and therapeutic efficacy in the treatment of mild to moderate hypertension. [Review], Drugs, 49, 618–649, 1995. 421. Kochhar, M. M., Bavda, L. T., and Bhushan, R. S., Thin-layer and gas chromatographic determination of ketamine and its biotransformed products in biological fluids, Research Communications in Chemical Pathology & Pharmacology, 14, 367–376, 1976. 422. Adams, H. A., Weber, B., Bachmann, M. B., Guerin, M., and Hempelmann, G., [The simultaneous determination of ketamine and midazolam using high pressure liquid chromatography and UV detection (HPLC/UV)], Anaesthesist, 41, 619–624, 1992. 423. Feng, N., Vollenweider, F. X., Minder, E. I., Rentsch, K., Grampp, T., and Vonderschmitt, D. J., Development of a gas chromatography-mass spectrometry method for determination of ketamine in plasma and its application to human samples, Therapeutic Drug Monitoring, 17, 95–100, 1995. 424. Lau, S. S. and Domino, E. F., Gas chromatography mass spectrometry assay for ketamine and its metabolites in plasma, Biomedical Mass Spectrometry, 4, 317–321, 1977. 425. Carr, R. A., Caille, G., Ngoc, A. H., and Foster, R. T., Stereospecific high-performance liquid chromatographic assay of ketoprofen in human plasma and urine, Journal of Chromatography B: Biomedical Applications, 668, 175–181, 1995. 426. Lovlin, R., Vakily, M., and Jamali, F., Rapid, sensitive and direct chiral high-performance liquid chromatographic method for ketoprofen enantiomers, Journal of Chromatography B: Biomedical Applications, 679, 196–198, 1996. 427. Palylyk, E. L. and Jamali, F., Simultaneous determination of ketoprofen enantiomers and probenecid in plasma and urine by high-performance liquid chromatography, Journal of Chromatography, 568, 187–196, 1991. 428. Chun, I. K., Kang, H. H., and Gwak, H. S., Determination of ketorolac in human serum by highperformance liquid chromatography, Archives of Pharmacal Research, 19, 529–534, 1996, 429. Tsina, I., Tam, Y. L., Boyd, A., Rocha, C., Massey, I., and Tarnowski, T., An indirect (derivatization) and a direct hplc method for the determination of the enantiomers of ketorolac in plasma, Journal of Pharmaceutical & Biomedical Analysis, 15, 403–417, 1996. 430. Tsina, I., Chu, F., Kaloostian, M., Pettibone, M., and Wu, A., Hplc method for the determination of ketorolac in human plasma, Journal of Liquid Chromatography & Related Technologies, 19, 957–967, 1996. 431. Sola, J., Prunonosa, J., Colom, H., Peraire, C., and Obach, R., Determination of ketorolac in human plasma by high performance liquid chromatography after automated online solid phase extraction, Journal of Liquid Chromatography & Related Technologies, 19, 89–99, 1996. 432. Logan, B. K., Friel, P. N., Peterson, K. L., and Predmore, D. B., Analysis of ketorolac in postmortem blood, Journal of Analytical Toxicology, 19, 61–64, 1995. 433. Sievert, H. J. P., Determination of amphetamine and methamphetamine enantiomers by chiral derivatization and GC/MS as a test case for an automated sample preparation system, Chirality, 6, 295–301, 1994. 434. Cooke, B. J., Chirality of methamphetamine and amphetamine from workplace urine samples, Journal of Analytical Toxicology, 18, 49–51, 1994. 435. Nagai, T., Kamiyama, S., Kurosu, A., and Iwamoto, F., [Identification of optical isomers of methamphetamine and its application to forensic medicine]. [Japanese], Nippon Hoigaku Zasshi Japanese Journal of Legal Medicine, 46, 244–253, 1992. 436. Wallace, S. J., Lamotrigine—a clinical overview, Seizure, 3, 47–51, 1994. 437. Rambeck, B. and Wolf, P., Lamotrigine clinical pharmacokinetics. [Review], Clinical Pharmacokinetics, 25, 433–443, 1993.


1210


438. May, T. W., Rambeck, B., and Jurgens, U., Serum concentrations of lamotrigine in epileptic patients —the influence of dose and comedication, Therapeutic Drug Monitoring, 18, 523–531, 1996. 439. Kintz, P., Flesch, F., Jaeger, A., and Mangin, P., GC-MS procedure for the analysis of zipeprol, Journal of Pharmaceutical & Biomedical Analysis, 11, 335–338, 1993. 440. Xu, Y. Q., Fang, H. J., Xu, Y. X., Duan, H. J., and Wu, Y., [Studies on the analysis of anileridine, levorphanol, nalbuphine and ethamivan in urine], Yao Hsueh Hsueh Pao—Acta Pharmaceutica Sinica, 26, 606–610, 1991. 441. Benko, A. and Kimura, K., Toxicological analysis of lidocaine in biological materials by using HPLC, Forensic Science International, 49, 65–73, 1991. 442. Cirimele, V., Kintz, P., and Mangin, P., Detection and quantification of lorazepam in human hair by GC-MS/NCI in a case of traffic accident, International Journal of Legal Medicine, 108, 265–267, 1996. 443. Higuchi, S., Urabe, H., and Shiobara, Y., Simplified determination of lorazepam and oxazepam in biological fluids by gas chromatography-mass spectrometry, Journal of Chromatography, 164, 55–61, 1979. 444. Koves, E. M. and Yen, B., The use of gas chromatography/negative ion chemical ionization mass spectrometry for the determination of lorazepam in whole blood, Journal of Analytical Toxicology, 13, 69–72, 1989. 445. Twitchett, P. J., Fletcher, S. M., Sullivan, A. T., and Moffat, A. C., Analysis of LSD in human body fluids by high-performance liquid chromatography, fluorescence spectroscopy and radioimmunoassay, Journal of Chromatography, 150, 73–84, 1978. 446. Veress, T., Study of the extraction of LSD from illicit blotters for HPLC determination, Journal of Forensic Sciences, 38, 1105–1110, 1993. 447. Cai, J. and Henion, J., On-line immunoaffinity extraction-coupled column capillary liquid chromatography/tandem mass spectrometry: trace analysis of LSD analogs and metabolites in human urine, Analytical Chemistry, 68, 72–78, 1996. 448. Nelson, C. C. and Foltz, R. L., Determination of lysergic acid diethylamide (LSD), iso-LSD, and Ndemethyl-LSD in body fluids by gas chromatography/tandem mass spectrometry, Analytical Chemistry, 64, 1578–1585, 1992. 449. Bukowski, N. and Eaton, A. N., The confirmation and quantitation of LSD in urine using GC/MS, Rapid Communication Mass Spectrometry, 7, 106–108, 1993. 450. Ackermann, R., Kaiser, G., Schueller, F., and Dieterle, W., Determination of the antidepressant levoprotiline and its N-desmethyl metabolite in biological fluids by gas chromatography/mass spectrometry, Biological Mass Spectrometry, 20, 709–716, 1991. 451. Alkalay, D., Carlsen, S., Khemani, L., and Bartlett, M. F., Selected ion monitoring assay for the antidepressant maprotiline, Biomedical Mass Spectrometry, 6, 435–438, 1979. 452. Stidman, J., Taylor, E. H., Simmons, H. F., Gandy, J., and Pappas, A. A., Determination of meprobamate in serum by alkaline hydrolysis, trimethylsilyl derivatization and detection by GC/MS, Journal of Chromatography, 494, 318–323, 1989. 453. Kintz, P. and Mangin, P., Determination of meprobamate in human plasma, urine, and hair by gas chromatography and electron impact mass spectrometry, Journal of Analytical Toxicology, 17, 408–410, 1993. 454. Bailey, D. N., The present status of meprobamate ingestion. A five-year review of cases with serum concentrations and clinical findings, American Journal of Clinical Pathology, 75, 102–106, 1981. 455. Hamman, B., Meprobamate, in Methodology for Analytical Toxicology: Volume I, Sunshine, I., Ed., CRC Press, Boca Raton, FL, 1984, 219–221. 456. Foltz, R. L., Fentiman, A. F., Jr., and Foltz, R. B., GC/MS assays for abused drugs in body fluids. [Review], NIDA Research Monograph, 32, 1–198, 1980. 457. Poklis, A., Wells, C. E., and Juenge, E. C., Thioridazine and its metabolites in post mortem blood, including two stereoisomeric ring sulfoxides, Journal of Analytical Toxicology, 6, 250–252, 1982. 458. Schurch, F., Meier, P. J., and Wyss, P. A., Acute poisoning with thioridazine [German], Deutsche Medizinische Wochenschrift, 121, 1003–1008, 1996. 459. Kintz, P., Mangin, P., Lugnier, A. A., and Chaumont, A. J., A rapid and sensitive gas chromatographic analysis of methadone and its primary metabolite, Journal de Toxicologie Clinique et Experimentale, 10, 15–20, 1990.


APPENDICES

1211

460. Alburges, M. E., Huang, W., Foltz, R. L., and Moody, D. E., Determination of methadone and its Ndemethylation metabolites in biological specimens by GC-PICI-MS, Journal of Analytical Toxicology, 20, 362–368, 1996. 461. Wilkins, D. G., Nagasawa, P. R., Gygi, S. P., Foltz, R. L., and Rollins, D. E., Quantitative analysis of methadone and two major metabolites in hair by positive chemical ionization ion trap mass spectrometry, Journal of Analytical Toxicology, 20, 355–361, 1996. 462. Baugh, L. D., Liu, R. H., and Walia, A. S., Simultaneous gas chromatography/mass spectrometry assay of methadone and 2-ethyl-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP) in urine, Journal of Forensic Sciences, 36, 548–555, 1991. 463. Jacob, P., 3rd, Tisdale, E. C., Panganiban, K., Cannon, D., Zabel, K., Mendelson, J. E., et al., Gas chromatographic determination of methamphetamine and its metabolite amphetamine in human plasma and urine following conversion to N-propyl derivatives, Journal of Chromatography B: Biomedical Applications, 664, 449–457, 1995. 464. Dallakian, P., Budzikiewicz, H., and Brzezinka, H., Detection and quantitation of amphetamine and methamphetamine—electron impact and chemical ionization with ammonia-comparative investigation on Shimadzu Qp 5000 GC-MS System, Journal of Analytical Toxicology, 20, 255–261, 1996. 465. Valtier, S. and Cody, J. T., Evaluation of internal standards for the analysis of amphetamine and methamphetamine, Journal of Analytical Toxicology, 19, 375–380, 1995. 466. Wu, A. H., Kelly, T., McKay, C., Ostheimer, D., Forte, E., and Hill, D., Definitive identification of an exceptionally high methanol concentration in an intoxication of a surviving infant: methanol metabolism by first-order elimination kinetics, Journal of Forensic Sciences, 40, 315–320, 1995. 467. Pla, A., Hernandez, A. F., Gil, F., Garcia-Alonso, M., and Villanueva, E., A fatal case of oral ingestion of methanol. Distribution in postmortem tissues and fluids including pericardial fluid and vitreous humor, Forensic Science International, 49, 193–196, 1991. 468. Winkel, D. R. and Hendrick, S. A., Detection limits for a GC determination of methanol and methylene chloride residues on film-coated tablets, Journal of Pharmaceutical Sciences, 73, 115–117, 1984. 469. Kintz, P., Tracqui, A., Mangin, P., Lugnier, A. A., and Chaumont, A. A., Simultaneous determination of dextropropoxyphene, norpropoxyphene and methaqualone in plasma by gas chromatography with selective nitrogen detection, Journal de Toxicologie Clinique et Experimentale, 10, 89–94, 1990. 470. Liu, F., Liu, Y. T., Feng, C. L., and Luo, Y., Determination of methaqualone and its metabolites in urine and blood by UV, GC/FID and GC/MS, Yao Hsueh Hsueh Pao Acta Pharmaceutica Sinica, 29, 610–616, 1994. 471. Streete, J. M., Berry, D. J., Clarke, L. A., and Newbery, J. E., Analysis of desmethylmethsuximide using high-performance liquid chromatography, Therapeutic Drug Monitoring, 17, 280–286, 1995. 472. Poklis, A., Mackell, M. A., and Drake, W. K., Fatal intoxication from 3,4-methylenedioxyamphetamine, Journal of Forensic Science, 24, 70–75, 1979. 473. Quaglio, M. P., Bellini, A. M., and Minozzi, L., Simultaneous determination of propranolol or metoprolol in the presence of benzodiazepines in the plasma by gas chromatography, Farmaco, 47, 799–809, 1992. 474. Li, F., Cooper, S. F., and Cote, M., Determination of the enantiomers of metoprolol and its major acidic metabolite in human urine by high-performance liquid chromatography with fluorescence detection, Journal of Chromatography B: Biomedical Applications, 668, 67–75, 1995. 475. Holt, D. W., Flanagan, R. J., Hayler, A. M., and Loizou, M., Simple gas-liquid chromatographic method for the measurement of mexiletine and lignocaine in blood-plasma or serum, Journal of Chromatography, 169, 295–301, 1979. 476. Minnigh, M. B., Alvin, J. D., and Zemaitis, M. A., Determination of plasma mexiletine levels with gas chromatography-mass spectrometry and selected-ion monitoring, Journal of Chromatography B: Biomedical Applications, 662, 118–22, 1994. 477. Bourget, P., Bouton, V., Lesnehulin, A., Amstutz, P., Benayed, M., Benhamou, D., et al., Comparison of high-performance liquid chromatography and polyclonal fluorescence polarization immunoassay for the monitoring of midazolam in the plasma of intensive care unit patients, Therapeutic Drug Monitoring, 18, 610–619, 1996. 478. Mastey, V., Panneton, A. C., Donati, F., and Varin, F., Determination of midazolam and two of its metabolites in human plasma by high-performance liquid chromatography, Journal of Chromatography B: Biomedical Applications, 655, 305–310, 1994.


1212


479. de Vries, J. X., Rudi, J., Walter-Sack, I., and Conradi, R., The determination of total and unbound midazolam in human plasma, Biomedical Chromatography, 4, 28–33, 1990. 480. Vu-Duc, T. and Vernay, A., Simultaneous detection and quantitation of O6-monoacetylmorphine, morphine and codeine in urine by gas chromatography with nitrogen specific and/or flame ionization detection, Biomedical Chromatography, 4, 65–69, 1990. 481. Hanisch, W. and Meyer, L. V., Determination of the heroin metabolite 6-monoacetyl-morphine in urine by high-performance liquid chromatography with electrochemical detection, Journal of Analytical Toxicology, 17, 48–50, 1993. 482. Kintz, P., Mangin, P., Lugnier, A. A., and Chaumont, A. J., Identification by GC/MS of 6-monoacetylmorphine as an indicator of heroin abuse, European Journal of Clinical Pharmacology, 37, 531–532, 1989. 483. Schuberth, J. and Schuberth, J., GC/MS determination of morphine, codeine and 6-monoacetylmorphine in blood extracted by solid phase, Journal of Chromatography, 490, 444–449, 1989. 484. Wasels, R. and Belleville, F., Gas chromatographic-mass spectrometric procedures used for the identification and determination of morphine, codeine and 6-monoacetylmorphine, Journal of Chromatography A, 674, 225–234, 1994. 485. Rotshteyn, Y. and Weingarten, B., A highly sensitive assay for the simultaneous determination of morphine, morphine-3-glucuronide, and morphine-6-glucuronide in human plasma by high-performance liquid chromatography with electrochemical and fluorescence detection, Therapeutic Drug Monitoring, 18, 179–188, 1996. 486. Pacifici, R., Pichini, S., Altieri, I., Caronna, A., Passa, A. R., and Zuccaro, P., HPLC electrospray mass spectrometric determination of morphine and its 3- and 6-glucuronides: application to pharmacokinetic studies, Journal of Chromatography B: Biomedical Applications, 664, 329–334, 1995. 487. Pacifici, R., Pichini, S., Altieri, I., Caronna, A., Passa, A. R., and Zuccaro, P., High-performance liquid chromatographic-electrospray mass spectrometric determination of morphine and its 3- and 6-glucuronides: application to pharmacokinetic studies, Journal of Chromatography B: Biomedical Applications, 664, 329–334, 1995. 488. Tyrefors, N., Hyllbrant, B., Ekman, L., Johansson, M., and Langstrom, B., Determination of morphine, morphine-3-glucuronide and morphine-6-glucuronide in human serum by solid-phase extraction and liquid chromatography mass spectrometry with electrospray ionisation, Journal of Chromatography, 729, 279–285, 1996. 489. Moeller, M. R. and Mueller, C., The detection of 6-monoacetylmorphine in urine, serum and hair by GC/MS and RIA, Forensic Science International, 70, 125–133, 1995. 490. Levine, B., Wu, S., Dixon, A., and Smialek, J., An unusual morphine fatality, Forensic Science International, 65, 7–11, 1994. 491. Romberg, R. W. and Lee, L., Comparison of the hydrolysis rates of morphine-3-glucuronide and morphine-6-glucuronide with acid and beta-glucuronidase, Journal of Analytical Toxicology, 19, 157–162, 1995. 492. Aderjan, R., Hofmann, S., Schmitt, G., and Skopp, G., Morphine and morphine glucuronides in serum of heroin consumers and in heroin-related deaths determined by HPLC with native fluorescence detection, Journal of Analytical Toxicology, 19, 163–168, 1995. 493. Wright, A. W., Watt, J. A., Kennedy, M., Cramond, T., and Smith, M. T., Quantitation of morphine, morphine-3-glucuronide, and morphine-6-glucuronide in plasma and cerebrospinal fluid using solidphase extraction and high-performance liquid chromatography with electrochemical detection, Therapeutic Drug Monitoring, 16, 200–208, 1994. 494. Rop, P. P., Grimaldi, F., Burle, J., De Saint Leger, M. N., and Viala, A., Determination of 6monoacetylmorphine and morphine in plasma, whole blood and urine using high-performance liquid chromatography with electrochemical detection, Journal of Chromatography B: Biomedical Applications, 661, 245–253, 1994. 495. Yoo, Y. C., Chung, H. S., Kim, I. S., Jin, W. T., and Kim, M. K., Determination of nalbuphine in drug abusers’ urine, Journal of Analytical Toxicology, 19, 120–123, 1995. 496. McManus, K. T., deBethizy, J. D., Garteiz, D. A., Kyerematen, G. A., and Vesell, E. S., A new quantitative thermospray LC-MS method for nicotine and its metabolites in biological fluids, Journal of Chromatographic Science, 28, 510–516, 1990.


APPENDICES

1213

497. Cooper, D. A. and Moore, J. M., Femtogram on-column detection of nicotine by isotope dilution gas chromatography/negative ion detection mass spectrometry, Biological Mass Spectrometry, 22, 590–594, 1993. 498. Deutsch, J., Hegedus, L., Greig, N. H., Rapoport, S. I., and Soncrant, T. T., Electron-impact and chemical ionization detection of nicotine and cotinine by gas chromatography-mass spectrometry in rat plasma and brain, Journal of Chromatography, 579, 93–98, 1992. 499. Lesko, L. and Miller, A., Rapid GC method for quantitation of nifedipine in serum using electroncapture detection, Journal of Chromatographic Science, 21, 415–419, 1983. 500. Ohkubo, T., Noro, H., and Sugawara, K., High-performance liquid chromatographic determination of nifedipine and a trace photodegradation product in hospital prescriptions, Journal of Pharmaceutical & Biomedical Analysis, 10, 67–70, 1992. 501. Nitsche, V., Schuetz, H., and Eichinger, A., Rapid high-performance liquid chromatographic determination of nifedipine in plasma with on-line precolumn solid-phase extraction, Journal of Chromatography, 420, 207–211, 1987. 502. Martens, J., Banditt, P., and Meyer, F. P., Determination of nifedipine in human serum by gas chromatography-mass spectrometry: validation of the method and its use in bioavailability studies, Journal of Chromatography B: Biomedical Applications, 660, 297–302, 1994. 503. Kintz, P., Cirimele, V., Vayssette, F., and Mangin, P., Hair analysis for nordiazepam and oxazepam by gas chromatography—negative-ion chemical ionization mass spectrometry, Journal of Chromatography B: Biomedical Applications, 677, 241–244, 1996. 504. Dickson, P. H., Lind, A., Studts, P., Nipper, H. C., Makoid, M., and Therkildsen, D., The routine analysis of breast milk for drugs of abuse in a clinical toxicology laboratory, Journal of Forensic Sciences, 39, 207–214, 1994. 505. Smith, M. L., Hughes, R. O., Levine, B., Dickerson, S., Darwin, W. D., and Cone, E. J., Forensic drug testing for opiates. VI. Urine testing for hydromorphone, hydrocodone, oxymorphone, and oxycodone with commercial opiate immunoassays and gas chromatography-mass spectrometry, Journal of Analytical Toxicology, 19, 18–26, 1995. 506. Drummer, O. H., Syrjanen, M. L., Phelan, M., and Cordner, S. M., A study of deaths involving oxycodone, Journal of Forensic Sciences, 39, 1069–1075, 1994. 507. Poklis, A. and Melanson, E. G., A suicide by pancuronium bromide injection: evaluation of the fluorometric determination of pancuronium in postmortem blood, serum and urine, Journal of Analytical Toxicology, 4, 275–280, 1980. 508. Briglia, E. J., Davis, P. L., Katz, M., and Dal Cortivo, L. A., Attempted murder with pancuronium, Journal of Forensic Sciences, 35, 1468–1476, 1990. 509. Paul, B. D., Dreka, C., Knight, E. S., and Smith, M. L., Gas chromatographic mass spectrometric detection of narcotine, papaverine, and thebaine in seeds of Papaver somniferum, Planta Medica, 62, 544–547, 1996. 510. Eap, C. B. and Baumann, P., Analytical methods for the quantitative determination of selective serotonin reuptake inhibitors for therapeutic drug monitoring purposes in patients [Review], Journal of Chromatography B: Biomedical Applications, 686, 51–63, 1996. 511. Miceli, J. N., Bowman, D. B., and Aravind, M. K., An improved method for the quantitation of phencyclidine (PCP) in biological samples utilizing nitrogen-detection gas chromatography, Journal of Analytical Toxicology, 5, 29–32, 1981. 512. Kintz, P., Tracqui, A., Lugnier, A. J., Mangin, P., and Chaumont, A. A., Simultaneous screening and quantification of several nonopiate narcotic analgesics and phencyclidine in human plasma using capillary gas chromatography, Methods & Findings in Experimental & Clinical Pharmacology, 12, 193–196, 1990. 513. Holsztynska, E. J. and Domino, E. F., Quantitation of phencyclidine, its metabolites, and derivatives by gas chromatography with nitrogen-phosphorus detection: application for in vivo and in vitro biotransformation studies, Journal of Analytical Toxicology, 10, 107–115, 1986. 514. Slawson, M. H., Wilkins, D. G., Foltz, R. L., and Rollins, D. E., Quantitative determination of phencyclidine in pigmented and nonpigmented hair by ion-trap mass spectrometry, Journal of Analytical Toxicology, 20, 350–354, 1996. 515. Kidwell, D. A., Analysis of phencyclidine and cocaine in human hair by tandem mass spectrometry, Journal of Forensic Sciences, 38, 272–284, 1993.


1214


516. Jin, X., Zhou, Z. H., He, X. F., Zhang, Z. H., and Wang, M. Z., [Solid-phase extraction and RP-HPLC screening procedure for diuretics, probenecid, caffeine and pemoline in urine]. [Chinese], Yao Hsueh Hsueh Pao—Acta Pharmaceutica Sinica, 27, 875–880, 1992. 517. Mackell, M. A. and Poklis, A., Determination of pentazocine and tripelennamine in blood of T’s and Blue addicts by gas-liquid chromatography with a nitrogen detector, Journal of Chromatography, 235, 445–452, 1982. 518. Poklis, A. and Mackell, M. A., Pentazocine and tripelennamine (T’s and Blues) abuse: toxicological findings in 39 cases, Journal of Analytical Toxicology, 6, 109–114, 1982. 519. Poklis, A. and Mackell, M. A., Toxicological findings in deaths due to ingestion of pentazocine: a report of two cases, Forensic Science International, 20, 89–95, 1982. 520. Liu, R. H., McKeehan, A. M., Edwards, C., Foster, G., Bensley, W. D., Langner, J. G., et al., Improved GC/MS analysis of barbiturates in urine using centrifuge-based solid-phase extraction, methylation, with d5-pentobarbital as internal standard, Journal of Forensic Science, 39, 1504–1514, 1994. 521. Turley, C. P., Pentobarbital quantitation using immunoassays in Reye’s syndrome patient serum, Therapeutic Drug Monitoring, 11, 343–346, 1989. 522. Earl, R., Sobeski, L., Timko, D., and Markin, R., Pentobarbital quantification in the presence of phenobarbital by fluorescence polarization immunoassay, Clinical Chemistry, 37, 1774–1777, 1991. 523. Li, P. K., Lee, J. T., and Schreiber, R. M., Rapid quantification of pentobarbital in serum by fluorescence polarization immunoassay, Clinical Chemistry, 30, 307–308, 1984. 524. Sarandis, S., Pichon, R., Miyada, D., and Pirkle, H., Quantitation of pentobarbital in serum by enzyme immunoassay, Journal of Analytical Toxicology, 8, 59–60, 1984. 525. Bowsher, R. R., Apathy, J. M., Compton, J. A., Wolen, R. L., Carlson, K. H., and DeSante, K. A., Sensitive, specific radioimmunoassay for quantifying pergolide in plasma, Clinical Chemistry, 38, 1975–1980, 1992 526. Shimamine, M., Takahashi, K., and Nakahara, Y., [Studies on the identification of psychotropic substances. IX. Preparation and various analytical data of reference standard of new psychotropic substances, N-ethyl methylenedioxyamphetamine, N-hydroxy methylenedioxyamphetamine, mecloqualone, 4-methylaminorex, phendimetrazine and phenmetrazine], Eisei Shikenjo Hokoku—Bulletin of National Institute of Hygienic Sciences, 66–74, 1993. 527. Moriyama, M., Furuno, K., Oishi, R., and Gomita, Y., Simultaneous determination of primidone and its active metabolites in rat plasma by high-performance liquid chromatography using a solid-phase extraction technique, Journal of Pharmaceutical Sciences, 83, 1751–1753, 1994. 528. Kouno, Y., Ishikura, C., Homma, M., and Oka, K., Simple and accurate high-performance liquid chromatographic method for the measurement of three antiepileptics in therapeutic drug monitoring, Journal of Chromatography, 622, 47–52, 1993. 529. Liu, H., Delgado, M., Forman, L. J., Eggers, C. M., and Montoya, J. L., Simultaneous determination of carbamazepine, phenytoin, phenobarbital, primidone and their principal metabolites by highperformance liquid chromatography with photodiode-array detection, Journal of Chromatography, 616, 105–115, 1993. 530. Binder, S. R., Adams, A. K., Regalia, M., Essien, H., and Rosenblum, R., Standardization of a multiwavelength UV detector for liquid chromatography-based toxicological analysis, Journal of Chromatography, 550, 449–459, 1991. 531. Wu, A. H., Onigbinde, T. A., Wong, S. S., and Johnson, K. G., Identification of methamphetamines and over-the-counter sympathometic amines by full-scan GC-ion trap MS with electron impact and chemical ionization, Journal of Analytical Toxicology, 16, 137–141, 1992. 532. Cui, J. F., Zhou, Y., Cui, K. R., Li, L., and Zhou, T. H., [Study on metabolism of phenmetrazine-like drugs and their metabolites], Yao Hsueh Hsueh Pao—Acta Pharmaceutica Sinica, 25, 632–636, 1990. 533. Rambeck, B., May, T. W., Jurgens, M. U., Blankenhorn, V., Jurges, U., Korn-Merker, E., et al., Comparison of phenytoin and carbamazepine serum concentrations measured by high-performance liquid chromatography, the standard TDx assay, the enzyme multiplied immunoassay technique, and a new patient-side immunoassay cartridge system, Therapeutic Drug Monitoring, 16, 608–612, 1994. 534. Logan, B. K. and Stafford, D. T., Direct analysis of anticonvulsant drugs in vitreous humour by HPLC using a column switching technique, Forensic Science International, 41, 125–134, 1989. 535. Lensmeyer, G. L., Rajani, C., and Evenson, M. A., Liquid-chromatographic procedure for simultaneous analysis for eight benzodiazepines in serum, Clinical Chemistry, 28, 2274–2278, 1982.


APPENDICES

1215

536. Eadie, M. J., Formation of active metabolites of anticonvulsant drugs. A review of their pharmacokinetic and therapeutic significance. [Review] [86 refs.], Clinical Pharmacokinetics, 21, 27–41, 1991. 537. Streete, J. M. and Berry, D. J., Gas chromatographic analysis of phenylethylmalonamide in human plasma, Journal of Chromatography, 416, 281–291, 1987. 538. Kim, S. Y. and Benowitz, N. L., Poisoning due to class IA antiarrhythmic drugs. Quinidine, procainamide and disopyramide. [Review], Drug Safety, 5, 393–420, 1990. 539. Sonsalla, P. K., Bridges, R. R., Jennison, T. A., and Smith, C. M., An evaluation of the TDX fluorescence polarization immunoassays for procainamide and n-acetylprocainamide, Journal of Analytical Toxicology, 9, 152–155, 1985. 540. Bagli, M., Rao, M. L., and Hoflich, G., Quantification of chlorprothixene, levomepromazine and promethazine in human serum using high-performance liquid chromatography with coulometric electrochemical detection, Journal of Chromatography B: Biomedical Applications, 657, 141–148, 1994. 541. Bohm, R., Ellrich, R., and Koytchev, R., Quantitation of R- and S-propafenone and of the main metabolite in plasma, Pharmazie, 50, 542–545, 1995. 542. Botterblom, M. H., Feenstra, M. G., and Erdtsieck-Ernste, E. B., Determination of propranolol, labetalol and clenbuterol in rat brain by high-performance liquid chromatography, Journal of Chromatography, 613, 121–126, 1993. 543. Kwong, E. C. and Shen, D. D., Versatile isocratic high-performance liquid chromatographic assay for propranolol and its basic, neutral and acidic metabolites in biological fluids, Journal of Chromatography, 414, 365–379, 1987. 544. Lindner, W., Rath, M., Stoschitzky, K., and Uray, G., Enantioselective drug monitoring of (R)- and (S)- propranolol in human plasma via derivatization with optically active (R,R)-O,O-diacetyl tartaric acid anhydride, Journal of Chromatography, 487, 375–383, 1989. 545. Ehrsson, H., Identification of diastereomeric propranolol-o-glucuronides by GC/MS., Journal of Pharmacy and Pharmacology, 27, 971–973, 1975. 546. Ehrsson, H., Simultaneous determination of (–)- and (+)- propranolol by GC/MS using a deuterium labeling technique, Journal of Pharmacy and Pharmacology, 28, 662, 1976. 547. Altmayer, P., Buch, U., Buch, H. P., and Larsen, R., Rapid and sensitive pre-column extraction highperformance liquid chromatographic assay for propofol in biological fluids, Journal of Chromatography, 612, 326–330, 1993. 548. Guitton, J., Desage, M., Lepape, A., Degoute, C. S., Manchon, M., and Brazier, J. L., Quantitation of propofol in whole blood by gas chromatography-mass spectrometry, Journal of Chromatography B: Biomedical Applications, 669, 358–365, 1995. 549. Amalfitano, G., Bessard, J., Vincent, F., Eysseric, H., and Bessard, G., Gas chromatographic quantitation of dextropropoxyphene and norpropoxyphene in urine after solid-phase extraction, Journal of Analytical Toxicology, 20, 547–554, 1996. 550. Margot, P. A., Crouch, D. J., Finkle, B. S., Johnson, J. R., and Deyman, M. E., Capillary and packed column GC determination of propoxyphene and norpropoxyphene in biological specimens: analytical problems and improvements, Journal of Chromatographic Science, 21, 201–204, 1983. 551. Wolen, R. L., Gruber, C. M., Jr., Baptisti, A., Jr., and Scholz, N. E., The concentration of propoxyphene in the plasma and analgesia scores in postpartum patients, Toxicology & Applied Pharmacology, 19, 498–503, 1971. 552. Wolen, R. L. and Gruber, C. M., Jr., Determination of propoxyphene in human plasma by gas chromatography, Analytical Chemistry, 40, 1243–1246, 1968. 553. Wolen, R. L., Obermeyer, B. D., Ziege, E. A., Black, H. R., and Gruber, C. M., Jr., Drug metabolism and pharmacokinetic studies in man utilising nitrogen-15- and deuterium-labelled drugs: the metabolic fate of cinoxacin and the metabolism and pharmacokinetics of propoxyphene, In: Baillie, T. A., Ed., Stable Isotopes, Baltimore, University Park Press, QV, 20, 1978. 554. Wolen, R. L., Ziege, E. A., and Gruber, C., Jr., Determination of propoxyphene and norpropoxyphene by chemical ionization mass fragmentography, Clinical Pharmacology & Therapeutics, 17, 15–20, 1975. 555. Nash, J. F., Bennett, I. F., Bopp, R. J., Brunson, M. K., and Sullivan, H. R., Quantitation of propoxyphene and its major metabolites in heroin addict plasma after large dose administration of propoxyphene napsylate, Journal of Pharmaceutical Sciences, 64, 429–433, 1975. 556. Wolen, R. L., Ziege, E. A., and Gruber, C. M., Determination of propoxyphene and norpropoxyphene by chemical ionization mass fragmentography., Clinical Pharmacological Therapy, 17, 15–20, 1974.


1216


557. Flanagan, R. J., Johnston, A., White, A. S., and Crome, P., Pharmacokinetics of dextropropoxyphene and nordextropropoxyphene in young and elderly volunteers after single and multiple dextropropoxyphene dosage, British Journal of Clinical Pharmacology, 28, 463–469, 1989. 558. Kaa, E. and Dalgaard, J. B., Fatal dextropropoxyphene poisonings in Jutland, Denmark, Zeitschrift für Rechtsmedizin—Journal of Legal Medicine, 102, 107–115, 1989. 559. Kintz, P. and Mangin, P., Abbott propoxyphene assay: evaluation and comparison of TDx FPIA and GC/MS methods, Journal of Analytical Toxicology, 17, 222–224, 1993. 560. Preskorn, S. H. and Fast, G. A., Therapeutic drug monitoring for antidepressants: efficacy, safety, and cost effectiveness [published erratum appears in Journal of Clinical Psychiatry, 52, 353, 1992]. [Review], Journal of Clinical Psychiatry, 52, 23–33, 1991. 561. Power, B. M., Hackett, L. P., Dusci, L. J., and Ilett, K. F., Antidepressant toxicity and the need for identification and concentration monitoring in overdose. [Review], Clinical Pharmacokinetics, 29, 154–171, 1995. 562. Henry, J. A., Alexander, C. A., and Sener, E. K., Relative mortality from overdose of antidepressants [see comments] [published erratum appears in British Medical Journal, 8, 310(6984):911, 1995], British Medical Journal, 310, 221–224, 1995. 563. Rao, M. L., Staberock, U., Baumann, P., Hiemke, C., Deister, A., Cuendet, C., et al., Monitoring tricyclic antidepressant concentrations in serum by fluorescence polarization immunoassay compared with gas chromatography and HPLC, Clinical Chemistry, 40, 929–933, 1994. 564. Poklis, A., Soghoian, D., Crooks, C. R., and Saady, J. J., Evaluation of the Abbott ADx total serum tricyclic immunoassay, Journal of Toxicology Clinical Toxicology, 28, 235–248, 1990. 565. Brooks, K. E. and Smith, N. S., Lack of formation of methamphetamine-like artifacts by the monoacetates of pseudoephedrine and related compounds in the GC/MS analysis of urine extracts [letter], Journal of Analytical Toxicology, 17, 441–442, 1993. 566. Yeh, S. Y., N-depyridination and N-dedimethylaminoethylation of tripelennamine and pyrilamine in the rat, Drug Metabolism & Disposition, 18, 453–461, 1990. 567. Bun, H., Coassolo, P., Ba, B., Aubert, C., and Cano, J. P., Plasma quantification of quazepam and its 2-oxo and N-desmethyl metabolites by capillary gas chromatography, Journal of Chromatography, 378, 137–145, 1986. 568. Gupta, S. K. and Ellinwood, E. H., Jr., Liquid chromatographic assay and pharmacokinetics of quazepam and its metabolites following sublingual administration of quazepam, Pharmaceutical Research, 5, 365–368, 1988. 569. Kales, A., Quazepam: hypnotic efficacy and side effects. [Review] [137 refs.], Pharmacotherapy, 10, 1–10, 1990. 570. Brandsteterova, E., Romanova, D., Kralikova, D., Bozekova, L., and Kriska, M., Automatic solidphase extraction and high-performance liquid chromatographic determination of quinidine in plasma, Journal of Chromatography A, 665, 101–104, 1994. 571. Cosbey, S. H., Craig, I., and Gill, R., Novel solid-phase extraction strategy for the isolation of basic drugs from whole blood, Journal of Chromatography B: Biomedical Applications, 669, 229–235, 1995. 572. Lloyd, T. L., Perschy, T. B., Gooding, A. E., and Tomlinson, J. J., Robotic solid phase extraction and high performance liquid chromatographic analysis of ranitidine in serum or plasma, Biomedical Chromatography, 6, 311–316, 1992. 573. Karnes, H. T., Opong-Mensah, K., Farthing, D., and Beightol, L. A., Automated solid-phase extraction and high-performance liquid chromatographic determination of ranitidine from urine, plasma and peritoneal dialysate, Journal of Chromatography, 422, 165–173, 1987. 574. Aravagiri, M., Marder, S. R., Van Putten, T., and Midha, K. K., Determination of risperidone in plasma by high-performance liquid chromatography with electrochemical detection: application to therapeutic drug monitoring in schizophrenic patients, Journal of Pharmaceutical Sciences, 82, 447–449, 1993. 575. Le Moing, J. P., Edouard, S., and Levron, J. C., Determination of risperidone and 9-hydroxyrisperidone in human plasma by high-performance liquid chromatography with electrochemical detection, Journal of Chromatography, 614, 333–339, 1993. 576. Borison, R. L., Diamond, B., Pathiraja, A., and Meibach, R. C., Pharmacokinetics of risperidone in chronic schizophrenic patients, Psychopharmacology Bulletin, 30, 193–197, 1994. 577. Springfield, A. C. and Bodiford, E., An overdose of risperidone, Journal of Analytical Toxicology, 20, 202–203, 1996.


APPENDICES

1217

578. Deutsch, J., Soncrant, T. T., Greig, N. H., and Rapoport, S. I., Electron-impact ionization detection of scopolamine by gas chromatography-mass spectrometry in rat plasma and brain, Journal of Chromatography, 528, 325–331, 1990. 579. Oertel, R., Richter, K., Ebert, U., and Kirch, W., Determination of scopolamine in human serum by gas chromatography ion trap tandem mass spectrometry, Journal of Chromatography B: Biomedical Applications, 682, 259–264, 1996. 580. Quatrehomme, G., Bourret, F., Zhioua, M., Lapalus, P., and Ollier, A., Post mortem kinetics of secobarbital, Forensic Science International, 44, 117–123, 1990. 581. Sharp, M. E., Wallace, S. M., Hindmarsh, K. W., and Peel, H. W., Monitoring saliva concentrations of methaqualone, codeine, secobarbital, diphenhydramine and diazepam after single oral doses, Journal of Analytical Toxicology, 7, 11–14, 1983. 582. Paetsch, P. R., Baker, G. B., Caffaro, L. E., Greenshaw, A. J., Rauw, G. A., and Coutts, R. T., Electroncapture gas chromatographic procedure for simultaneous determination of amphetamine and Nmethylamphetamine, Journal of Chromatography, 573, 313–317, 1992. 583. La Croix, R., Pianezzola, E., and Strolin Benedetti, M., Sensitive high-performance liquid chromatographic method for the determination of the three main metabolites of selegiline (L-deprenyl) in human plasma, Journal of Chromatography B: Biomedical Applications, 656, 251–258, 1994. 584. Maurer, H. H. and Kraemer, T., Toxicological detection of selegiline and its metabolites in urine using fluorescence polarization immunoassay (FPIA) and gas chromatography-mass spectrometry (GC-MS) and differentiation by enantioselective GC-MS of the intake of selegiline from abuse of methamphetamine or amphetamine, Archives of Toxicology, 66, 675–678, 1992. 585. Reimer, M. L., Mamer, O. A., Zavitsanos, A. P., Siddiqui, A. W., and Dadgar, D., Determination of amphetamine, methamphetamine and desmethyldeprenyl in human plasma by gas chromatography/negative ion chemical ionization mass spectrometry, Biological Mass Spectrometry, 22, 235–242, 1993, 586. Meeker, J. E. and Reynolds, P. C., Postmortem tissue methamphetamine concentrations following selegiline administration, Journal of Analytical Toxicology, 14, 330–331, 1990. 587. Rogowsky, D., Marr, M., Long, G., and Moore, C., Determination of sertraline and desmethylsertraline in human serum using copolymeric bonded-phase extraction, liquid chromatography and GC/MS, Journal of Chromatography B: Biomedical Applications, 655, 138–141, 1994. 588. De Saqui-Sannes, P., Nups, P., Le Bars, P., and Burgat, V., Evaluation of an HPTLC method for the determination of strychnine and crimidine in biological samples, Journal of Analytical Toxicology, 20, 185–188, 1996. 589. Stevens, H. M. and Moffat, A. C., A rapid screening procedure for quaternary ammonium compounds in fluids and tissues with special reference to suxamethonium (succinylcholine), Journal of the Forensic Science Society, 14, 141–148, 1974. 590. Forney, R. B., Jr., Carroll, F. T., Nordgren, I. K., Pettersson, B. M., and Holmstedt, B., Extraction, identification and quantitation of succinylcholine in embalmed tissue, Journal of Analytical Toxicology, 6, 115–119, 1982. 591. Woestenborghs, R. J., Timmerman, P. M., Cornelissen, M. L., Van Rompaey, F. A., Gepts, E., Camu, F., et al., Assay methods for sufentanil in plasma. Radioimmunoassay versus gas chromatographymass spectrometry, Anesthesiology, 80, 666–670, 1994. 592. Rochholz, G., Ahrens, B., Konig, F., Schutz, H. W., Schutz, H., and Seno, H., Screening and identification of sumatriptan and its main metabolite by means of thin-layer chromatography, ultraviolet spectroscopy and gas chromatography/mass spectrometry, Arzneimittel-Forschung, 45, 941–946, 1995. 593. Qiu, F. H., Liu, L., Guo, L., Luo, Y., and Lu, Y. Q., [Rapid identification and quantitation of barbiturates in plasma using solid-phase extraction combined with GC-FID and GC-MS method]. [Chinese], Yao Hsueh Hsueh Pao—Acta Pharmaceutica Sinica, 30, 372–377, 1995. 594. Laakkonen, U. M., Leinonen, A., and Savonen, L., Screening of non-steroidal anti-inflammatory drugs, barbiturates and methyl xanthines in equine urine by gas chromatography-mass spectrometry, Analyst, 119, 2695–2696, 1994. 595. Tjaden, U. R., Meeles, M. T., Thys, C. P., and van der Kaay, M., Determination of some benzodiazepines and metabolites in serum, urine and saliva by high-performance liquid chromatography, Journal of Chromatography, 181, 227–241, 1980. 596. Pounder, D. J., Adams, E., Fuke, C., and Langford, A. M., Site to site variability of postmortem drug concentrations in liver and lung, Journal of Forensic Sciences, 41, 927–932, 1996.


1218


597. Walash, M. I., Belal, F., Metwally, M. E., and Hefnawy, M. M., A selective fluorimetric method for the determination of some 1,4-benzodiazepine drugs containing a hydroxyl group at C-3, Journal of Pharmaceutical & Biomedical Analysis, 12, 1417–1423, 1994. 598. McCarthy, P., Atwal, S., Sykes, A., and Ayres, J., Measurement of terbutaline and salbutamol in plasma by high performance liquid chromatography with fluorescence detection, Biomedical Chromatography, 7, 25–28, 1993. 599. Van Vyncht, G., Preece, S., Gaspar, P., Maghuin-Rogister, G., and DePauw, E., Gas and liquid chromatography coupled to tandem mass spectrometry for the multiresidue analysis of beta-agonists in biological matrices, Journal of Chromatography A, 750, 43–49, 1996. 600. Lindberg, C., Paulson, J., and Blomqvist, A., Evaluation of an automated thermospray liquid chromatography-mass spectrometry system for quantitative use in bioanalytical chemistry, Journal of Chromatography, 554, 215–226, 1991. 601. Altieri, M., Bogema, S., and Schwartz, R. H., TAC topical anesthesia produces positive urine tests for cocaine, Annals of Emergency Medicine, 19, 577–579, 1990. 602. Hannak, D., Haux, P., Scharbert, F., and Kattermann, R., Liquid chromatographic analysis of phenobarbital, phenytoin, and theophylline, Wiener Klinische Wochenschrift. Supplementum, 191, 27–31, 1992. 603. Mounie, J., Richard, L., Ribon, B., Hersant, J., Sarmini, H., Houin, G., et al., Methods of theophylline assay and therapeutic monitoring of this drug [published erratum appears in Annales de Biologie Clinique (Paris) 48, 447, 1990]. [Review], Annales de Biologie Clinique, 48, 287–293, 1990. 604. Zaninotto, M., Secchiero, S., Paleari, C. D., and Burlina, A., Performance of a fluorescence polarization immunoassay system evaluated by therapeutic monitoring of four drugs, Therapeutic Drug Monitoring, 14, 301–305, 1992. 605. Jones, L. A., Gonzalez, E. R., Venitz, J., Edinboro, L. E., and Poklis, A., Evaluation of the Vision Theophylline assays in the emergency department setting, Annals of Emergency Medicine, 21, 777–781, 1992. 606. Sessler, C. N., Theophylline toxicity: clinical features of 116 consecutive cases. [Review], American Journal of Medicine, 88, 567–576, 1990. 607. el-Sayed, Y. M. and Islam, S. I., Comparison of fluorescence polarization immunoassay and HPLC for the determination of theophylline in serum, Journal of Clinical Pharmacy & Therapeutics, 14, 127–134, 1989. 608. Costantino, A. G., Caplan, Y. H., Levine, B. S., Dixon, A. M., and Smialek, J. E., Thiamylal: review of the literature and report of a suicide, Journal of Forensic Sciences, 35, 89–96, 1990. 609. Stockham, T. L., McGee, M. P., and Stajic, M., Report of a fatal thiamylal intoxication, Journal of Analytical Toxicology, 15, 155–156, 1991. 610. Yashiki, M., Kojima, T., and Okamoto, I., Toxicological study on intravenous thiopental anesthesia—interrelation between rate of injection and distribution of thiopental, Forensic Science International, 33, 169–175, 1987. 611. Garriott, J. C., Foerster, E., Juarez, L., de la Garza, F., Mendiola, I., and Curoe, J., Measurement of toluene in blood and breath in cases of solvent abuse, Clinical Toxicology, 18, 471–479, 1981. 612. Inoue, H., Iwasa, M., Maeno, Y., Koyama, H., Sato, Y., and Matoba, R., Detection of toluene in an adipoceratous body, Forensic Science International, 78, 119–124, 1996. 613. Kawai, T., Mizunuma, K., Yasugi, T., Horiguchi, S., and Ikeda, M., Toluene in blood as a marker of choice for low-level exposure to toluene, International Archives of Occupational & Environmental Health, 66, 309–315, 1994. 614. Jones, A. D., Dunlap, M. R., and Gospe, S. M., Jr., Stable-isotope dilution GC-MS for determination of toluene in submilliliter volumes of whole blood, Journal of Analytical Toxicology, 18, 251–254, 1994. 615. Von Burg, R., Toluene. [Review] [85 refs.], Journal of Applied Toxicology, 13, 441–446, 1993. 616. Lof, A., Wigaeus Hjelm, E., Colmsjo, A., Lundmark, B. O., Norstrom, A., and Sato, A., Toxicokinetics of toluene and urinary excretion of hippuric acid after human exposure to 2H8-toluene, British Journal of Industrial Medicine, 50, 55–59, 1993. 617. Saker, E. G., Eskew, A. E., and Panter, J. W., Stability of toluene in blood: its forensic relevance, Journal of Analytical Toxicology, 15, 246–249, 1991. 618. Xu, Y. X., Xu, Y. Q., Zhang, C. J., and Shen, L., [Analysis of tramadol and its metabolites in human urine]. [Chinese], Yao Hsueh Hsueh Pao—Acta Pharmaceutica Sinica, 28, 379–383, 1993.


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619. Anderson, W. H. and Archuleta, M. M., The capillary gas chromatographic determination of trazodone in biological specimens, Journal of Analytical Toxicology, 8, 217–219, 1984. 620. Caccia, S., Ballabio, M., Fanelli, R., Guiso, G., and Zanini, M. G., Determination of plasma and brain concentrations of trazodone and its metabolite, 1-m-chlorophenylpiperazine, by gas-liquid chromatography, Journal of Chromatography, 210, 311–318, 1981. 621. Lambert, W., Van Bocxlaer, J., Piette, M., and De Leenheer, A., A fatal case of trazodone and dothiepin poisoning: toxicological findings, Journal of Analytical Toxicology, 18, 176–179, 1994. 622. Senda, N., Kohta, K., Takahashi, T., Shizukuishi, K., Mimura, T., Fujita, T., et al., A highly sensitive method to quantify triazolam and its metabolites with liquid chromatography—mass spectrometry, Biomedical Chromatography, 9, 48–51, 1995. 623. Joynt, B. P., Triazolam blood concentrations in forensic cases in Canada, Journal of Analytical Toxicology, 17, 171–177, 1993. 624. Koves, G. and Wells, J., The quantitation of triazolam in postmortem blood by gas chromatography/negative ion chemical ionization mass spectrometry, Journal of Analytical Toxicology, 10, 241–244, 1986. 625. Kostrzewski, P., Jakubowski, M., and Kolacinski, Z., Kinetics of trichloroethylene elimination from venous blood after acute inhalation poisoning, Journal of Toxicology—Clinical Toxicology, 31, 353–363, 1993. 626. Kintz, P., Godelar, B., Mangin, P., Chaumont, A. J., and Lugnier, A. A., Identification and quantification of trihexyphenidyl and its hydroxylated metabolite by gas chromatography with nitrogen-phosphorus detection, Journal of Analytical Toxicology, 13, 47–49, 1989. 627. Maurer, H. H., Detection of anticonvulsants and their metabolites in urine within a “general unknown” analytical procedure using computerized GC/MS, Archives of Toxicology, 64, 554–561, 1990. 628. Jones, R., Klette, K., Kuhlman, J. J., Levine, B., Smith, M. L., Watson, C. V., et al., Trimethobenzamide cross-reacts in immunoassays of amphetamine/methamphetamine [letter; see comments], Clinical Chemistry, 39, 699–700, 1993. 629. Colbert, D. L., Possible explanation for trimethobenzamide cross-reaction in immunoassays of amphetamine/methamphetamine [letter; comment], Clinical Chemistry, 40, 948–949, 1994. 630. Pok Phak, R., Conquy, T., Gouezo, F., Viala, A., and Grimaldi, F., Determination of metapramine, imipramine, trimipramine and their major metabolites in plasma by reversed-phase column liquid chromatography, Journal of Chromatography, 375, 339–347, 1986. 631. Fraser, A. D., Isner, A. F., and Perry, R. A., Distribution of trimipramine and its major metabolites in a fatal overdose case, Journal of Analytical Toxicology, 11, 168–170, 1987. 632. Poklis, A., Case, M. E., and Ridenour, G. C., Abuse of pentazocine/tripelennamine combination. Ts and Blues in the city of St. Louis, Missouri Medicine, 80, 21–23, 1983. 633. Pokrajac, M., Miljkovic, B., Spiridonovic, D., and Varagic, V. M., An improved gas chromatographic determination of valproic acid and valpromide in plasma, Pharmaceutica Acta Helvetiae, 67, 237–240, 1992. 634. Vajda, F. J., Drummer, O. H., Morris, P. M., McNeil, J. J., and Bladin, P. F., Gas chromatographic measurement of plasma levels of sodium valproate: tentative therapeutic range of a new anticonvulsant in the treatment of refractory epileptics, Clinical & Experimental Pharmacology & Physiology, 5, 67–73, 1978. 635. Berry, D. J. and Clarke, L. A., Determination of valproic acid (dipropylacetic acid) in plasma by gasliquid chromatography, Journal of Chromatography, 156, 301–307, 1978. 636. Liu, H., Montoya, J. L., Forman, L. J., Eggers, C. M., Barham, C. F., and Delgado, M., Determination of free valproic acid: evaluation of the Centrifree system and comparison between high-performance liquid chromatography and enzyme immunoassay, Therapeutic Drug Monitoring, 14, 513–521, 1992. 637. Liu, H., Forman, L. J., Montoya, J., Eggers, C., Barham, C., and Delgado, M., Determination of valproic acid by high-performance liquid chromatography with photodiode-array and fluorescence detection, Journal of Chromatography, 576, 163–169, 1992. 638. Yu, D., Gordon, J. D., Zheng, J., Panesar, S. K., Riggs, K. W., Rurak, D. W., et al., Determination of valproic acid and its metabolites using gas chromatography with mass-selective detection: application to serum and urine samples from sheep, Journal of Chromatography B: Biomedical Applications, 666, 269–281, 1995. 639. Dupuis, R. E., Lichtman, S. N., and Pollack, G. M., Acute valproic acid overdose, Drug Safety, 5, 65–71, 1990.


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640. Levine, B., Jenkins, A. J., Queen, M., Jufer, R., and Smialek, J. E., Distribution of venlafaxine in three postmortem cases, Journal of Analytical Toxicology, 20, 502–505, 1996. 641. Parsons, A. T., Anthony, R. M., and Meeker, J. E., Two fatal cases of venlafaxine poisoning, Journal of Analytical Toxicology, 20, 266–268, 1996. 642. Shin, H. S., Ohshin, Y. S., Kim, H. J., and Kang, Y. K., Sensitive assay for verapamil in plasma using gas-liquid chromatography with nitrogen-phosphorus detection, Journal of Chromatography B: Biomedical Applications, 677, 369–373, 1996. 643. Levine, B., Jones, R., Klette, K., Smith, M. L., and Kilbane, E., An intoxication involving BRON and verapamil, Journal of Analytical Toxicology, 17, 381–383, 1993. 644. Crouch, D. J., Crompton, C., Rollins, D. E., Peat, M. A., and Francom, P., Toxicological findings in a fatal overdose of verapamil, Journal of Forensic Sciences, 31, 1505–1508, 1986. 645. Ashraf, M., Chaudhary, K., Nelson, J., and Thompson, W., Massive overdose of sustained-release verapamil—a case report and review of literature, American Journal of the Medical Sciences, 310, 258–263, 1995. 646. Brogden, R. N. and Benfield, P., Verapamil—a review of its pharmacological properties and therapeutic use in coronary artery disease [review], Drugs, 51, 792–819, 1996. 647. Akisu, M., Mir, S., Genc, B., and Cura, A., Severe acute thinner intoxication, Turkish Journal of Pediatrics, 38, 223–225, 1996. 648. Etzel, R. A. and Ashley, D. L., Volatile organic compounds in the blood of persons in Kuwait during the oil fires, International Archives of Occupational & Environmental Health, 66, 125–129, 1994. 649. Mannino, D. M., Schreiber, J., Aldous, K., Ashley, D., Moolenaar, R., and Almaguer, D., Human exposure to volatile organic compounds: a comparison of organic vapor monitoring badge levels with blood levels, International Archives of Occupational & Environmental Health, 67, 59–64, 1995. 650. Ramsey, J., Anderson, H. R., Bloor, K., and Flanagan, R. J., An introduction to the practice, prevalence and chemical toxicology of volatile substance abuse, Human Toxicology, 8, 261–269, 1989. 651. Stanke, F., Jourdil, N., Lauby, V., and Bessard, G., Zopiclone and zolpidem quantification in human plasma by high performance liquid chromatography with photodiode-array detection, Journal of Liquid Chromatography & Related Technologies, 19, 2623–2633, 1996. 652. Meeker, J. E., Som, C. W., Macapagal, E. C., and Benson, P. A., Zolpidem tissue concentrations in a multiple drug related death involving Ambien, Journal of Analytical Toxicology, 19, 531–534, 1995. 653. Ahrens, B., Schutz, H., Seno, H., and Weiler, G., Screening, identification and determination of the two new hypnotics zolpidem and zopiclone, Arzneimittel-Forschung, 44, 799–802, 1994. 654. Tracqui, A., Kintz, P., and Mangin, P., High-performance liquid chromatographic assay with diodearray detection for toxicological screening of zopiclone, zolpidem, suriclone and alpidem in human plasma, Journal of Chromatography, 616, 95–103, 1993. 655. Debailleul, G., Khalil, F. A., and Lheureux, P., HPLC quantification of zolpidem and prothipendyl in a voluntary intoxication, Journal of Analytical Toxicology, 15, 35–37, 1991.

APPENDIX II: SAMPLE CALCULATIONS

Barry K. Logan, Ph.D. Director, Washington State Toxicology Laboratory, Department of Laboratory Medicine, University of Washington, Seattle, Washington

Alan Wayne Jones, D.Sc. Department of Forensic Toxicology, University Hospital, Linköping, Sweden

This section presents some typical scenarios based on authentic DUI cases, and the application of some of the issues discussed in Chapter 13. Bear in mind that statutory “per se” alcohol limits are somewhat arbitrary, and that a person’s driving might be influenced below the so-called “legal


APPENDICES

1221

limit.” For this reason, the quantitative measurement of blood or breath alcohol, and related calculations, should be one element of any DUI case, and not the entire case. Example 1. The defendant (male, 175 lb) had been drinking for 3 h, but gulps down a “double vodka,” (assumed to be 2 oz of 40% v/v) immediately before leaving the bar, and is arrested for DUI 15 min later. His BrAC 30 min after arrest is 0.10 g/210 L. Could his BrAC have been below 0.08 at the time of driving? This question relates to the significance of the last drink as a factor in raising the BrAC. Since this pattern of drinking represents a small bolus on top of a pre-existing BrAC, it is likely that the last drink was substantially absorbed within 15 min, i.e., at the time of the arrest. The small amount of alcohol unabsorbed would not be enough to account for the difference between 0.08 and 0.10 g/210 L. Note that no allowance was made for alcohol metabolism (often called burn-off) in this example. Assuming some alcohol elimination occurred between the time of the arrest and the breath test, this would make it even less likely that the BrAC at the time of the arrest was below 0.08 g/210 L. It is possible to construct a scenario whereby the defendant’s version could be supported, and might involve some kind of delayed gastric emptying, an unusually low volume of distribution for the alcohol, and a low alcohol elimination rate. This latter scenario, however, is much less likely than the former, and needs to be evaluated in the context of other available information in the case. For example, what was the reason for the driver being stopped in the first place? These situations require the application of some scientific common sense, and the principle of Occam’s razor, namely that the fewer assumptions one has to invoke to explain a set of facts, the more likely that explanation is. Note also that intra-individual variations in absorption and elimination of alcohol make any kind of reconstruction or repeat of the circumstances in question of dubious value. Example 2. The defendant (male, 230 lb) claims he consumed ten 12-oz beers of 4.2% v/v alcohol content in 1 h, then drove immediately afterward, and was arrested 10 min after his last drink. The BrAC was 0.17 g/210 L, 1 h later. Could the suspect’s BrAC have been below 0.10 g/210 L at the time of driving? In this scenario, one has to make fewer assumptions in order for the defendant’s BrAC to be below 0.10 g/210 L at the time of driving. Absorption of alcohol after drinking so much beer could result in a delayed peak. The drinking pattern is unusual, however, based on Widmark’s formula it could account for the measured BrAC. Credible corroboration of the defendant’s story would be important in presenting this case to the jury, and would have to be considered in the context of other evidence of his behavior, his driving, his statements at the time of arrest, etc. It has to be said that even if true, this pattern of drinking followed by driving is not likely to engender much sympathy from the jury. Example 3. The defendant (male, 150 lb) admits to having a few drinks before an accident, but alleges he drank 4 oz of 40% v/v whisky to steady his nerves after the accident. His BAC at the time of blood sampling about 1 h later was 0.15 g/dL. Could his BAC at the time of the accident have been below 0.08 g/dL? This scenario relates to whether the contribution from post-accident drinking can account for the difference between the measured BAC and an administrative legal limit. According to Widmark’s formula, the contribution to BAC from the post-accident drinking would be approximately 0.08 g/dL. Given the uncertainty in this estimate (~0.06 to 0.09 g/dL), there is a significant possibility that he could have been below 0.08 g/dL at the time of the accident. Important factors to consider would be the accuracy of the estimate of how much post-accident drinking actually took place (if indeed it did), the actual times of the accident and blood sampling, and some corroboration of the pre-accident drinking pattern. A large amount of drinking immediately before the accident could further raise the likelihood of the BAC being below 0.08 at the time of the accident. In some countries, drinking within a certain time period after an accident is itself considered a punishable offense, and certainly displays poor judgment on the part of the defendant. Example 4. Defendant (male, 230 lb) is arrested and an evidential breath test shows 0.21 g/210 L. He claims he only consumed two 16-oz beers over a 3-h period. Application of Widmark’s


1222


formula shows that the volume of beer required to produce this BrAC is about 230 oz of 3.5% v/v beer. How can this discrepancy be resolved? The defendant maintains that the discrepancy suggests a malfunction in the breath test instrument. This comes down to an evaluation of the credibility of the defendant’s story against the accuracy and reliability of the breath test. Safeguards followed when conducting the breath test, such as duplicate testing, room air blank tests, and simulator control tests with each subject test, will help to validate the accuracy of the result. Again, other factors such as the defendant’s driving pattern, performance in field sobriety tests, and behavior at the time of the arrest will either help or hurt his story. It is the experience of most people working in this field that defendants will invariably underestimate their actual consumption, and may not recall the brand of beer or liquor they were drinking. Example 5. The defendant (female 120 lb) leaves the scene of an accident, but is eventually arrested and a blood sample is collected 4 h later. Her BAC at the time of sampling is 0.05 g/dL. What was her BAC at the time of the accident ? This is a clear-cut case regarding the validity of retrograde extrapolation, or estimating back. If one assumes that the defendant was fully post-absorptive at the time of the accident, estimating back 4 h and allowing a mean burn-off rate of 0.019 g/dL/h (with a range from 0.009 g/dL/h to 0.030 g/dL/h) would produce a most likely BAC of 0.126 g/dL (range 0.086 to 0.170 g/dL). However, since a BAC plateau might have occurred, especially with food in the stomach, the validity of this assumption of a decreasing blood alcohol curve for 4 h is perhaps open to question. Another approach, which is more defensible, can be applied if there is a statutory time limit that applies to the measured BAC. For example, there may be a presumption in the law that a BAC within 2 h of driving is representative of the BAC at the time of driving. In this case, estimating back only 2 h, to place the defendant within the 2-h statutory window, is more reliable and produces a most likely BAC of 0.088 g/dL within a range of 0.068 to 0.110 g/dL. The larger question in this case would be whether the woman was under the influence of alcohol at the time of the accident, and the estimated BAC is only one element of that determination. Example 6. The defendant has a breath alcohol concentration of 0.16 g/210L. An expert called by the defense claims that the suspect’s elevated body temperature (102.9°F) resulting from a fever, raised his breath level over his blood level by 20%. He claims that the defendant held his breath before exhaling into the instrument, raising his BrAC by 10%. He claims that the defendant may have had some acetone on his breath, but not enough to trigger the interference detector on the instrument, resulting in up to 0.009 g/dL apparent ethanol response from acetone. He notes the “margin of error” on the instrument is 0.01 g/210 L. He also claims that alcohol from the defendant’s upper airways was picked up by his breath during the expiration, suggesting that the alcohol entering the instrument did not come from alveoli, or deep lung regions of the airway. The net effect is that the defendant’s “actual” BrAC could have been as low as 0.08 g/210 L. This shotgun approach, perhaps tied to one of the other rising BAC scenarios discussed above, is very common in DUI litigation, as it seeks to present a barrage of details attacking the validity of breath testing in general, and this defendant’s test in particular. The various assertions need to be evaluated individually. First, if the jurisdiction has separate blood and breath statutes, the blood/breath ratio resulting from elevated temperature is not relevant. Breath holding will elevate breath alcohol concentrations compared with rapid, repeated inspiration and expiration. However, breath holding is not part of the breath test protocol, and a well-documented 15-min observation period can challenge this assertion. The acetone issue is discussed in detail in Chapter 13; however, the amount of acetone required to produce an apparent BrAC of 0.009 g/210 L, would result only from extreme fasting (including abstinence from alcoholic beverages) or diabetes, which is not a transient condition. The defendant’s medical records can determine whether he or she is diabetic. The “margin of error” issue is frequently raised when the result is close to the legal limit. What “margin of error” means is not clear; it is certainly not a scientific term. Most instrument protocols that include a control with each breath test will require that the control is within ±0.01 g/210 L of


APPENDICES

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a reference value; however, these same instruments will also include optical controls which typically must meet much more stringent parameters. The kinetics of alcohol deposition and evaporation from the airways during inspiration and expiration have been alluded to in Chapter 13; however, the bottom line is that breath testing is recognized as a valid measurement of impairment, and breath alcohol concentration, regardless of the complexity of the respiration physiology, is a valid indicator of intoxication. The best approach in these cases is again to contrast the contrived circumstances that are required for the defendant’s version to be valid, with the generally more straightforward explanation that the defendant had consumed too much alcohol, was arrested because of impaired driving, failed field sobriety tests, and gave a breath test that reflects his true breath alcohol concentration and is consistent with his impairment. Example 7. The defendant has a BrAC of 0.05 g/210 L, and performs field sobriety tests well. To what extent was the subject’s driving affected? One can say with some confidence that certain elements of the driving task are influenced at fairly low BrAC levels even in experienced drinkers. However, certain kinds of driving tasks are more likely to be affected than others. Driving down a straight, country road with no other traffic, in good weather, during daylight hours requires less skill than driving on a busy city street at night, in the rain, with pedestrians around, and distractions in the car such as intoxicated companions or loud music. In a case such as this, one must look at the driver’s actual driving performance and determine first if it was impaired, then second if other explanations exist for that impairment besides drinking, including possibly fatigue, drug use, or inattention. This BrAC on its own says relatively little about the extent of driving impairment.

APPENDIX III: PREDICTED NORMAL HEART WEIGHT (G) AS A FUNCTION OF BODY HEIGHT IN 392 WOMEN AND 373 MENa Body height (cm)

(in.)

Women L95

P

U95

L95

Men P

U95

130 132 134 136 138 140 142 144 146 148 150 152 154 156 158 160 162 164 166 168 170 172 174 176 178 180 182

51 52 53 54 54 55 56 57 57 58 59 60 61 61 62 63 64 65 65 66 67 68 69 69 70 71 72

133 135 137 139 141 143 145 147 149 151 153 155 157 159 161 163 165 167 169 171 173 176 178 180 182 184 186

204 207 210 214 217 220 223 226 229 232 236 239 242 245 248 251 254 258 261 264 267 270 273 277 280 283 286

314 319 324 329 334 338 343 348 353 358 363 368 372 377 382 387 392 397 401 406 411 416 421 426 431 435 440

164 167 170 173 175 178 181 184 187 189 192 195 198 201 204 207 209 212 215 218 221 224 227 230 233 235 238

232 236 240 243 247 251 255 259 263 267 271 275 280 284 288 292 296 300 304 308 312 316 320 324 328 332 336

327 333 338 344 349 355 361 366 372 378 383 389 395 400 406 412 417 423 429 435 440 446 452 458 463 469 475


1224


a

Body height (cm)

(in.)

Women L95

P

U95

L95

Men P

U95

184 186 188 190 192 194 196 198 200 202 204 206 208 210

72 73 74 75 76 76 77 78 79 80 80 81 82 83

188 190 192 194 196 198 200 202 204 206 208 210 212 214

289 292 295 299 302 305 308 311 314 318 321 324 327 330

445 450 455 460 465 469 474 479 484 489 494 499 508 508

241 244 247 250 253 256 259 262 265 268 271 274 276 279

341 345 349 353 357 361 365 369 374 378 382 386 394 394

481 487 492 498 504 510 516 522 527 533 539 545 557 557

P = predicted normal heart weight; L95 = lower 95% confidence limit; U95 = upper 95% confidence limit. From Kitzman, D. et al., Age related changes in normal human hearts during the first 10 decades of life. Part II (Maturity): A quantitive anatomic study of 765 specimens from subjects 20 to 99 years old, Mayo Clinic Proc., 63:137–146, 1988. With permission.

1690_IDX.fm Page 1225 Thursday, November 16, 2006 10:06 AM

Index A Abnormal blood profiles, doping, 710–711 Absorption alternative matrix test interpretation, workplaces, 815–816 amphetamines, 169 barbiturates, 175 biological membrane transfer, 151–153 drug levels interpretation, post-mortem, 1076–1077 methamphetamines, 171–172 Abuse, marketed medications alteration, 288 assessment, pharmacological entity, 282–287 availability, 288–289 butorphanol, 290, 291–295, 296 case studies, 290–303 control, 282 dextromethorphan, 298, 299–302, 303 drug discrimination, 284–285 fentanyl, 296, 297, 298 fundamentals, 281–282 pharmacokinetics, 288 physical-dependence capacity, 287 postmarketing surveillance, 289–290 premarketing abuse-liability testing, 282–289 preparation assessment, 288–289 self-administration, 283–284 subjective effects, 285–287 Abuse markers, 391–393 Abuse/use characteristics, 479 Accelerated atherosclerosis, 101–102 Accidents, post-mortem toxicology, 969 Accreditation programs, 1067 Accuracy confirmatory testing, workplace, 786 quality assurance, post-mortem toxicology, 1062 Acetaldehyde adducts, 413–414 Action mechanisms, 479–482 Activated charcoal, 668–669 Active metabolites, 161 Acute conditions and effects hypertension, 665 ingestion, alcohol, 403–411 intoxication, 316–321 3,4-methylenedioxymethamphetamine, 540–542

renal failure, 651 tolerance, alcohol, 322–323 Adams studies, 132 Addiction medicine, comorbidity management, 584–586 Addiction medicine, principles dependence, 561–564 fundamentals, 560 motivation, 564–565 pharmacokinetics, 563–564 plasticity, 564 precautions, 565–566 prescribing in context, 565 principles, 560–566 psychoactive effect, 562–563 Addiction medicine, replacement prescribing antisensitizing agents, 583–584 clinical approach, 583–584 dopaminergic agents, 582–583 neurochemical approach, 582–583 new approaches, 584 opioid-specific prescribing, 580–581 serotonin-reuptake inhibitors, 582–583 stimulant-specific prescribing, 582–584 tricyclic antidepressants, 583–584 Addiction medicine, substitute prescribing benzodiazepine specific, 572 buprenorphine maintenance prescribing, 569–571 drug monitoring, 568 fundamentals, 566–567, 572–574 methadone, 567–568 monitoring, 568 opioid-specific prescribing, 567–569 outcomes, 572 pharmacokinetics, 570–571, 571 plasma methadone monitoring, 568–569 stimulant specific, 571 treatment compliance, 567 withdrawal syndromes treatment, 572–580 Addiction medicine, toxicologic issues, 587–589, 588 Addiction medicine, withdrawal syndromes adrenergic agonists, 577 buprenorphine, 575–577, 576 detoxification, 573–578 fundamentals, 572–574 hypnotic withdrawal syndrome, 579–580 management of withdrawal, 580 methadone, 574

1225


1226

naltrexone-assisted detoxification, 577–578 opiate-specific withdrawal syndrome, 574–578 sedative withdrawal syndrome, 579–580 stimulant-specific withdrawal syndrome, 578–579 Addition method, 1057, 1057 Additive toxicity, 1081 Administrative functions, MRO, 862–863 Administrative interface, testing technologies, 244 Adrenergic agonists, withdrawal syndromes treatment, 577 Adulterants and adulteration, see also Dilutions and diluents cocaine, 14 controlled substances examination, 50–51 specimen validity testing, 851–855 workplace testing legal issues, 885–886 Advantages point of collection testing, 924 specimens, 906–907 Adverse reactions, drug levels interpretation, 1082 Advisory Group for Aerospace Research and DevelopmentStandardized Test for Research with Environmental Stressors Battery (AGARDSTRES), 254, 255 Age, pharmacokinetics, 167 Agitation fundamentals, 636–637 immediate interventions, 638 secondary interventions, 638–640 Alanine aminotransferase, 411–412 Albertson studies, 667 Alcohol biochemical tests, 401–417 central nervous system, 132, 132–133, 134 clinical analysis, 333–365 DOT workplace testing, 753, 756–757, 757 fitness-for-duty rules, 763 forensic analysis, 333–365 fundamentals, 315 impairment measurement, 316–328 measuring impairment, 316–328 nuclear power industry workplace testing, 763 post-mortem, 376–395 testing, 753, 756–757, 757, 763 Alcohol, biochemical tests acetaldehyde adducts, 413–414 acute ingestion, 403–411 alanine aminotransferase, 411–412 aspartate, 411–412 carbohydrate-deficient transferrin, 412–413, 413 chronic ingestion, 411–414 clinical use, 415–416 combinations, 415 erythrocyte mean corpuscular volume, 412 ethanol, 403–409, 405–407, 409 fatty-acid ethyl esters, 409–410 follow-up treatment, 416 fundamentals, 401–402, 402, 417 gamma-glutamyl transferase, 411 mean corpuscular volume, 412 methanol, 407–408, 408 phosphatidylethanol, 413


potential tests and markers, 414 sensitivity, 403 serotonin metabolites, 410, 410–411 single tests, 415 specificity, 403 trait markers, 416 treatment follow-up, 416 unselected population screening, 415 Alcohol, clinical and forensic analysis analytical factors, 352 blood/breath ratio, 349–350, 350 blood concentrations, 336–338, 337–338 blood water content, 335–336, 336 body fluids, alcohol measurement, 339–346 breath-alcohol analysis, 346–350, 347 chemical oxidation methods, 339 concentration units, 335 enzymatic methods, 339–341, 341 ethanol pharmacokinetics, 356–363 evidential breath-testing instruments, 347–349, 347–349 fate, alcohol, 354, 354–356, 357 first-pass metabolism, 361–362 food effects, 362–363, 362–363 fundamentals, 333–335, 334–335, 363–365 gas chromatographic methods, 341–345, 343–344 gastric ADH, 361–362 handheld screening instruments, 346–347, 347 hematocrit and hemoglobin, 336–337, 337 interlaboratory proficiency tests, 353, 353–354 measuring, 339–346 Michaelis-Menten model, 360–361 pharmacokinetics, 356–363 plasma, concentrations, 336–338, 337–338 post-analytical factors, 352–353 pre-analytical factors, 351–352 quality assurance aspects, 350–354 serum water content, 335–336, 336 specimens, 335–339 uncertainty allowance, 338–339 Widmark model, 356, 357–358, 358–360 Alcohol, measuring impairment acute intoxication, 316–321 acute tolerance, 322–323 behavioral correlates, 316–321 blood alcohol concentration variations, 322 cognitive functioning, 316–318 dual-task performance, 317–318 field sobriety tests, 326–327 fundamentals, 327–328 hangover, 323–324 horizontal gaze nystagmus, 320–321 impairment testing, 324–327 individual differences, 321 ingestion time, 321–324 motor control, 316–318 positional alcohol nystagmus, 319–320 reaction time, 317 reliability, 325 sensitivity, 325 specificity, 325–326


INDEX

speech, 318–319 time of ingestion, 321–324 validity, 325 vestibular functioning, 319–321 Alcohol, post-mortem abuse markers, 391–393 alternative biological samples, 383–384 blood alcohol concentration, 378–381 fundamentals, 376–377, 394–395 hematomas, 389–390, 389–390 isopropyl alcohol, 394 ketoacidosis, 390–391 markers, 391–393 methanol, 393–394 residual gastric alcohol, 384–385 sequestered hematomas, 389–390, 389–390 specimens, 377 stability and synthesis, alcohol, 385–389, 388 urinary alcohol, 382–383 vitreous alcohol, 381–382, 382 Alcohol determination, point of collection testing (POCT) blood, 937 body fluids, 938 breath, 928–939 chemical-color-change-based devices, 936, 936 collection, 927–928 considerations, 926–927 devices, 928–932 fundamentals, 926, 939, 940 organizational policies and procedures, 927–928 passive alcohol sensor devices, 937, 937 pharmacology, alcohol, 927 proficiency testing, 937–939 quality assurance, 937–939 saliva, 937–938 saliva-based technology, 932–936 specimens, 928 testing, 927–928 toxicology, alcohol, 927 urine, 937 Alcohol swabs, 1130–1131 ALCO Screen 2 test, 935, 935–936 Alexander and Perry studies, 580 Alkalinization, rhabdomyolysis, 652 Allan studies, 585 Alleged interfering substances, 1137–1140 Alles, Gordon, 478 Allometric scaling, 541, 545 Alteration, 288 Alternative biological samples, 383–384, see also Alternative specimens Alternative matrices interpretation, workplaces absorption, 815–816 analytical considerations, 822–823, 824–826 blood, 816–818, 817–818 chemical considerations, 822–823, 824–826 circumstances of exposure, 815, 815 clearance, 816 detection time course, 823, 827, 827 disposition, 815–816 distribution, 815–816

1227

elimination, 816 exposure circumstances, 815, 815 fundamentals, 814 guidance for interpretation, 827–828, 829 hair, 820–822, 822 matrices interpretation, 823–828 multiple specimen testing, 827 oral fluid, 819, 819–820 pharmacokinetics, 822–823, 824–826 physiologic considerations, 816–822 point of collection testing, 946 sweat, 820, 821 time course of detection, 823, 827, 827 urine, 818, 819 Alternative specimens alternative specimens, 898, 898–907 developing technologies, 907 devices and techniques, 899–906 evaluation of devices, 901, 902–903, 903–906 fundamentals, 897, 907 operation of devices, 899–901, 900–901 point of collection testing, 898, 898–907 saliva specimens, 906–907 sweat specimens, 906–907 Amantadine (Symmetrel), 582 Ambre studies, 182 Aminoergolines (Terguride and SD208911), 583 D-Amphetamine, 210–212 Amphetamines absorption, 169 action, 704 common methods, post-mortem toxicology, 997 confirmatory testing, workplace, 792–795 distribution, 169–170 dopamine transporter, 434 excretion, 170, 170 hair specimen, 804 immunoassay testing, workplace, 780–781 investigation strategies, post-mortem toxicology, 1027–1028 metabolism, 170, 170, 704 non-urine workplace testing approaches, 804, 808 oral fluids, 808 pharmacokinetics, 169–170 post-mortem toxicology, 997, 1027–1028 sports and blood doping, 704–705, 718 workplace testing, 780–781, 792–795 Anabolic-adrogenic steroids, 716–719 Anabolic steroids forensic analysis, 33–34 regulatory history, 30–31, 31 sports and blood doping, 700–702 structure-activity relationship, 32, 32–33 Analysis and analytical issues alternative matrix test interpretation, workplaces, 822–823, 824–826 common methods, post-mortem toxicology, 991–992, 992 confirmatory testing, workplace, 791–795 drug levels interpretation, post-mortem, 1070 factors, alcohol, 352


1228

Medical Review Officer, 858–859 non-urine workplace testing approaches, 802–803, 802–803, 807–809 post-mortem toxicology, 991–992, 992 quality assurance, post-mortem toxicology, 1061–1063, 1065 workplace testing, 791–795 ANAM, see Automated Neurophysical Assessment Metrics (ANAM) Anderson studies, 326 Andollo studies, 1052–1067 Anesthesia, seizures, 644 Anggard, Franksson and, studies, 169 Anglin, McGlothlin and, studies, 563 Angrist studies, 529 Animal research, 1163–1164 Anoxic ischemic encephalopathy, 140–141 Antibiotics, stroke, 664 Antidote attributes, medical complications, 630 Antisensitizing agents, 583–584 Aorta examination techniques, 91, 92–93 Applications common methods, post-mortem toxicology, 1008 consumer, point of collection testing, 953 criminal justice system, 952–953 law enforcement, 249–251 National Laboratory Certification Program, 741 occupational, 259–262 point of collection testing, 952–953 post-mortem toxicology, 1008 school, 953 testing technologies, 248–262 toxicogenetics, 1092–1095 workplace, 952 Applied settings, testing technologies, 259–261 APTS, see Automated Portable Test System (APTS) Argentina, 774 Arrhythmias, cardiac care, 659–660 Arrhythmogenic right ventricular dysplasia, 1103–1105 Aspartate, 411–412 Aspiration pneumonia, 129, 129–130 Aspirin, cardiac care, 658 Assay calibration, 788–789, see also Immunoassays Assessment, pharmacological entity, 282–287 Atheletes, see Sports and blood doping Attentional abilities benzodiazepines, 218–220 cocaine and D-amphetamine, 211 marijuana, 226 3,4-methylenedioxymethamphetamine, 213 nicotine and tobacco, 215–216 opioids, 223 Attitude surveys, 770 Attwood studies, 318 Australia, 771–774 Autobrewery syndrome, 1127–1128 Automated Neurophysical Assessment Metrics (ANAM), 254–255, 255 Automated Portable Test System (APTS), 257, 257–258 Autopsy body packers, 76


excited delirium, 75 fundamentals, 73–75, 74 scene of death, 76–79, 77–79 Availability, assessment of preparation, 288–289 Avitar ORALscreen, 904 Avois-Mateus studies, 703–706 Ayestas, Mario, 551 Ayirookuzhi studies, 1098–1108 Azzazy studies, 721

B BAC, see Blood-alcohol concentration (BAC) Bailey studies, 124–125 Baker studies, 256 Banbery studies, 572–580 Barbiturates absorption, 175 common methods, post-mortem toxicology, 998 confirmatory testing, workplace, 795 distribution, 175–176 elimination, 176, 176–177 immunoassay testing, workplace, 783–784 investigation strategies, post-mortem toxicology, 1028 metabolism, 176, 176–177 pharmacodynamics, 274 pharmacokinetics, 174–177 pharmacology, 174–175 post-mortem toxicology, 998, 1028 pupillometry, 274 seizures, 617, 618–619, 643 workplace testing, 783–784, 795 Barnett, Chiang and, studies, 563 Barrett studies, 904 Basile, Margaret, 534 Baumann, Michael H., 536–551 Baumann studies, 536–551 Baume studies, 700–702 Baumgartner and Hill studies, 801 Baumgartner studies, 801 Baylor studies, 317, 917–925 Bearn studies, 577 Beckett, G.H., 6 Behavioral assessment alcohol, measuring impairment, 316–321 3,4-methylenedioxymethamphetamine, 550–551 Behavioral impairment assessment, occupational settings administrative interface, 244 Advisory Group for Aerospace Research and Development-Standardized Test for Research with Environmental Stressors Battery, 254, 255 applications, 248–262 applied settings, 259–261 Automated Neurophysical Assessment Metrics, 254–255, 255 Automated Portable Test System, 257, 257–258 CogScreen-Aeromedical Edition, 261 computerized performance test batteries, 251–259


INDEX

cost, 246 Delta (Essex Corporation), 260 drug evaluation and classification program, 249–251 evaluation norms, 243–244 fitness of duty tests, 251–259 frequency, testing, 247 fundamentals, 238–240, 262–263 government application, 251–259 handheld personal digital assistants, 245–246 implementation, testing, 246–248 individual tests, 242–243 law enforcement applications, 249–251 legal issues, 247–248 Memory Assessment Clinics Battery, 258, 258 MiniCog, 259 misuse potential, 248 Naval Medical Research Institute Performance Assessment Battery, 253–254, 254 Neurobehavioral Evaluation System 2, 256, 256 NovaScan (Nova Technology, Inc), 259–260 occupational applications, 259–262 Performance-on-Line (SEDIcorp), 260–261 performance stability, 247 personal computers, 245 Psychomotor Vigilance Task, 259 selection, 240–244 simulation, 261–262 Synwork, 258–259 test frequency, 247 test implementation, 246–248 testing platform, 245–246 Unified Tri-Service Cognitive Performance Assessment Battery, 251–252, 252 user acceptance, 247 user interface, 244 Walter Reed Army Institute Performance Assessment Battery, 252–253, 253 web-based systems, 246 Beirness and Vogel-Sprott studies, 317 Belgium, 769 Bell, Michael D., 120–129, 132–143 Benmansour, Frazer and, studies, 543 Benowitz studies, 597–675 Benzodiazepines absorption, 178 agitation, 636–637 attentional abilities, 218–220 cardiac care, 658 cognitive abilities, 220–221 common methods, post-mortem toxicology, 998 confirmatory testing, workplace, 793, 795 delirium, 636–637 distribution, 178 elimination, 179, 179–180 fundamentals, 35 human performance effects, 217–221 immunoassay testing, workplace, 784 investigation strategies, post-mortem toxicology, 1029 medical complications, 616–618, 617–618 metabolism, 179, 179–180 motor abilities, 218

1229

neuroleptics comparison, 636–637 pharmacodynamics, 217–221 pharmacokinetics, 177–180 pharmacology, 177–178 post-mortem toxicology, 998, 1029 psychomotor stimulants, 217–221 psychosis, 636–637 seizures, 641, 643 sensory abilities, 218 substitute prescribing, 572 workplace testing, 784, 793, 795 Benzoylecgonine, 998 Benzoylecgonine ethyl ester (cocaethylene), 438 Beta-blockers, 656, 659–661 Bickel studies, 221, 562 Bile, 979, 982 Binding, tissue constituents, 153–154 Bioavailability, parameters, 158 Biochemical tests, alcohol acetaldehyde adducts, 413–414 acute ingestion, 403–411 alanine aminotransferase, 411–412 aspartate, 411–412 carbohydrate-deficient transferrin, 412–413, 413 chronic ingestion, 411–414 clinical use, 415–416 combinations, 415 erythrocyte mean corpuscular volume, 412 ethanol, 403–409, 405–407, 409 fatty-acid ethyl esters, 409–410 follow-up treatment, 416 fundamentals, 401–402, 402, 417 gamma-glutamyl transferase, 411 mean corpuscular volume, 412 methanol, 407–408, 408 phosphatidylethanol, 413 potential tests and markers, 414 sensitivity, 403 serotonin metabolites, 410, 410–411 single tests, 415 specificity, 403 trait markers, 416 treatment follow-up, 416 unselected population screening, 415 Biological membrane transfer absorption, 151–153 binding, tissue constituents, 153–154 blood-brain-barrier, 154 dermal absorption, 152 distribution, 153–154 fundamentals, 149–150 gastrointestinal absorption, 151 parenteral injection, 152–153 pregnancy, 154 pulmonary absorption, 152 Biotransformation, pharmacokinetics, 154–156 Bisgrove, Mills and, studies, 317, 321 Bishop studies, 220 Blind specimens, 875 Block studies, 225, 227 Blom studies, 218


1230

Blood-alcohol concentration (BAC) alcohol analysis specimens, 336–338, 337–338 blood/breath ratio, 349–350, 350 post-mortem alcohol interpretation, 378–381 time of ingestion, 322 Blood and blood samples alternative matrix test interpretation, workplaces, 816–818, 817–818 DNA collection, toxicogenetics, 1108 drug levels interpretation, post-mortem, 1070–1071 DUI defenses, 1130–1133 point of collection testing, 937 specimens, post-mortem toxicology, 978–979, 981–982 Blood-brain-barrier, 154, see also Brain Blood doping, see Sports and blood doping Blood profiles, 710–711, see also Sports and blood doping Blood-water content alcohol analysis specimens, 335–336, 336 DUI defenses, 1132–1133 Blotter paper LSD, 39, see also Lysergic acid diethylamide (LSD) Body burden calculation, 1077–1078 Body fluids alcohol measurement, 339–346 methanol, biochemical tests, alcohol, 407–408 point of collection testing, 938 Body packers and stuffers, 76, 670–671 Boehrer studies, 656 Bogen studies, 355, 1134–1135 Boja, John W., 431–440 Boja studies, 431–440 Bolivia, 774 Bolla studies, 225 Bollmann studies, 695–721 Bond studies, 218 Bone and bone marrow, 985, 1075 Bono, Joseph P., 1–69 Bowel irrigation, 669 Bowen studies, 733 Bowers studies, 1131 Brain, 1073–1074, see also Blood-brain-barrier Braithwaite, George and, studies, 906 Branan Medical Oratect, 899–900, 904 Brazil, 774 Breath-alcohol analysis alcohol, clinical and forensic analysis, 346–350, 347 alleged interfering substances, 1137–1140 blood samples, 1130–1133 breath-alcohol analysis, 1133, 1133–1145 breathing pattern, 1143–1144 chronic obstructive pulmonary disease, 1142–1143 dentures and denture adhesives, 1136 DUI defenses, 1129, 1133, 1133–1145 fundamentals, 1129, 1133, 1133, 1144–1145 gastro esophageal reflux disease, 1135–1136 hyperthermia, 1143–1144 hypothermia, 1143–1144 mouthwash preparations, 1134–1135 pulmonary function, 1142–1143 ratio variability, 1140–1141 regurgitation, 1135–1136


testing devices, point of collection testing, 928–932, 938–939 Breath/blood ratio, 349–350, see also Blood-alcohol concentration (BAC) Breathing pattern, 1143–1144 Brewer and Sandow studies, 318 Breyer (Supreme Court Justice), 1173 Bromocriptine (Parlodel), 582, 1170–1172 Brookhuis studies, 219 Brown studies, 219 Brugada syndrome, 1100–1102 Bruns and Moskowitz studies, 321 Brunzell, Darlene, 452–460 Brunzell studies, 452–460 Buchanan studies, 220 Buchan studies, 951 Bull studies, 551 Bunker, Ed, 279 Buprenorphine pharmacokinetics, 198–199 replacement prescribing, 583 substitute prescribing, 569–571 withdrawal syndromes treatment, 575–577, 576 Burke, Allen P., 97–108 Bush, Donna, 736–765, 877, 925 Bush, George H.W. (President), 748 Bush studies, 659 Butorphanol, 290, 291–295, 296

C Caffeine, 703 Calcium-channel blockers, 658–659 Calibrators confirmatory testing, workplace, 788–790 quality assurance, post-mortem toxicology, 1055–1057 Calkins studies, 1098–1108 Callaham studies, 643 Callaway studies, 636 Cami studies, 275 Cannabis and cannabinoids, see also Marijuana common methods, post-mortem toxicology, 998 hair specimen, 804 immunoassay testing, workplace, 781–782 non-urine workplace testing approaches, 804, 808 oral fluids, 808 post-mortem toxicology, 998 sports and blood doping, 714–715 workplace testing, 781–782 Capacity for alteration, see Alteration Capillary electrophoresis (CE), 44 Caplan studies, 727–893, 939 Capsule imprints, 38–39 Carbohydrate-deficient transferrin, 412–413, 413 Carbon monoxide, 994 Cardiac care, see also Heart; Myocardial alterations cardiomyopathy, 86–87, 88–89 coronary interventions, 83–86, 84–85 death, examination techniques, 91–92, 93–95, 94


INDEX

examination techniques, 83–86 hypertrophy, 95–96 immediate interventions, 661–662 medical complications, 658–663 secondary interventions, 662–663 Cardiovascular considerations molecular diagnosis, 1108 sports and blood doping, 716–717, 717 Carlezon and Wise studies, 436 Carrera studies, 584 Carryover, 787–788 Case review, post-mortem toxicology, 972 Case studies case reports and series, 1165–1167 marketed medications abuse, 290–303 3,4-methylenedioxymethamphetamine, 537–540 pharmacodynamics, 290–293 pupillometry, 269–273, 275–278 Catch-up provisions, 763–764 Catecholaminergic polymorphic ventricular tachycardia, 1102–1103 Catha edulis (Khat), 29 Catravas and Waters studies, 647 Causation evidence evaluation, 1159–1167 Causation opinions, 1167–1172 CE, see Capillary electrophoresis (CE) CEDIA common methods, post-mortem toxicology, 996 post-mortem toxicology, 996 Central nervous system alcohol effects, 132, 132–133, 134 anoxic ischemic encephalopathy, 140–141 cerebral vasculitis, 137–138, 139 cerebrovascular disease, 135–137, 136–138 depressants, 35–36, 36 encephalopathy, 142–143 excited delirium, 133–135, 135 heroin smokers encephalopathy, 142–143 infections, 141–142, 141–142 movement disorders, 140 seizure disorder, 138, 140, 140 stimulants, 37 Cerebral vasculitis, 137–138, 139 Cerebrovascular disease, 135–137, 136–138 Certification of death, 967–968 Certification revocation and suspension, 746 Chain of custody, 976, 1065 Chait and Pierri studies, 225 Characteristics of use/abuse, 479 Chemical analogies, courtroom testing, 1165 Chemical-color-change-based devices, 936, 936 Chemical oxidation methods, 339 Chemicals, clandestine laboratories, 58, 58–60 Chemical tests alternative matrix test interpretation, 822–823, 824–826 common methods, post-mortem toxicology, 992–994 Chiang and Barnett studies, 563 Chile, 774 Chiles, Collins and, studies, 324 Chiulli studies, 643 Cholinergic adaptations, 466, 466–468

1231

Chromatography common methods, post-mortem toxicology, 999–1004 confirmatory testing, workplace, 789 diode array detectors, 1003 electron capture detector, 1001–1002 flame ionization detector, 1001 fluorescence detectors, 1003 fundamentals, 999 gas chromatography, 1000–1003 high-performance liquid chromatography, 1003–1004 mass spectrometry, 1002–1003 nitrogen/phosphorus detector, 1001 performance, 789 post-mortem toxicology, 999–1004, 1030 REMEDi HS HPLC, 1004 thin-layer chromatography, 999–1000 Toxi-Lab TLC, 999–1000 ultraviolet absorption detectors, 1003 workplace testing, 789 Chromium, 853 Chronic ingestion, 411–414, see also Ingestion Chronic obstructive pulmonary disease, 1142–1143 CIPD survey, 770 Circular lights task, pupillometry, 272, 273 Circulatory support, 649 Circumstances of exposure, 815, 815 Cirimele studies, 800–813 Claims, courtroom testing animal research, 1163–1164 case reports and series, 1165–1167 causation evidence evaluation, 1159–1167 causation opinions, 1167–1172 chemical analogies, 1165 clinical reasoning, 1167–1170 epidemiology, 1159–1162 expert testimony, 1157–1158, 1171–1172 fundamentals, 1156–1157, 1173 general causation evidence evaluation, 1159–1167 opinions, causation, 1167–1172 Parlodel litigation, 1170–1172 plaintiffs’ allegations, 1171 scientific method, 1157–1167 secondary source material, 1167 Clandestine laboratories chemicals commonly encountered, 58, 58–60 fundamentals, 55–56 safety concerns, 57–58 Clark, Robert, 551 Clearance alternative matrix test interpretation, workplaces, 816 parameters, 157–158 Cleeland studies, 944 Clinical and forensic analysis, alcohol analytical factors, 352 blood/breath ratio, 349–350, 350 blood concentrations, 336–338, 337–338 blood water content, 335–336, 336 body fluids, alcohol measurement, 339–346 breath-alcohol analysis, 346–350, 347 chemical oxidation methods, 339 concentration units, 335


1232

enzymatic methods, 339–341, 341 ethanol pharmacokinetics, 356–363 evidential breath-testing instruments, 347–349, 347–349 fate, alcohol, 354, 354–356, 357 first-pass metabolism, 361–362 food effects, 362–363, 362–363 fundamentals, 333–335, 334–335, 363–365 gas chromatographic methods, 341–345, 343–344 gastric ADH, 361–362 handheld screening instruments, 346–347, 347 hematocrit and hemoglobin, 336–337, 337 interlaboratory proficiency tests, 353, 353–354 measuring, 339–346 Michaelis-Menten model, 360–361 pharmacokinetics, 356–363 plasma, concentrations, 336–338, 337–338 post-analytical factors, 352–353 pre-analytical factors, 351–352 quality assurance aspects, 350–354 serum water content, 335–336, 336 specimens, 335–339 uncertainty allowance, 338–339 Widmark model, 356, 357–358, 358–360 Clinical applications, see also Applications point of collection testing, 952 toxicogenetics, 1092–1095 Clinical approach, replacement prescribing, 583–584 Clinical considerations biochemical tests, alcohol, 415–416 Brugada syndrome, 1101 catecholaminergic polymorphic ventricular tachycardia, 1102–1103 heart muscle disorders, 1103–1104 hypertrophic cardiomyopathy, 1105 long QT syndromes, 1099 nicotine dependence, 459–460 reasoning, courtroom testing, 1167–1170 Club drugs, 275, see also specific drug Coca alkaloids, 13–14 Cocaethylene (benzoylecgonine ethyl ester), 438 Cocaine absorption, 181–182 accelerated atherosclerosis, 101–102 actions, 705 adulterants, 14 attentional abilities, 211 coca alkaloids, 13–14 cognitive abilities, 211–212 crack conversion, 12–13 D-amphetamine, 210–212 distribution, 182 dopamine transporter, 433 drug synergy, 104 elimination, 183–184 endothelial dysfunction, 102 exhibit comparison, 54–55 fundamentals, 9–10, 14 hair specimen, 804 hemodynamic alterations, 103, 103 historical developments, 11


human performance effects, 210–212 immunoassay testing, workplace, 782–783 investigation strategies, post-mortem toxicology, 1029 isolation, 11–12 medical complications, 599–603, 601 metabolism, 182–183, 183 microvascular resistance, 100–101 motor abilities, 210–211 non-urine workplace testing approaches, 804, 809 oral fluids, 809 pharmacokinetics, 181–184 pharmacology, 181 post-mortem toxicology, 1029 psychomotor stimulants, 210–212 purification, 11–12 sensory abilities, 210 sources, 10, 10–11 sports and blood doping, 705, 718 sudden death, 1107 synergy, drugs, 104 thrombosis, 101, 102 toxicogenetics, 1107 vascular effects, 100–104 vasculitis, 104 vasospasticity, 100–101 workplace testing, 782–783 Cocaine, neurochemical adaptations dopamine receptors, 509–512 dopamine transporter, 505–508 D2 receptor adaptations, 510 D3 receptor adaptations, 506, 510–511 fundamentals, 503–505, 518 GABA receptors, 516–517 glutamate receptors, 516 5-HT transporter, 515–516 ibogaine, 517–518 kappa (κ) opioid receptors, 513–515 multitarget pharmacotherapeutic agents, 517–518 pharmacotherapies, 507–508, 511–512, 514–517 reinforcement, 507 serotonin transporter, 515–516 vaccines, 508 Cocaine, neuropsychiatric consequences delirium, 530–531, 530–534, 533 differential diagnosis, 529, 529 fundamentals, 528–529, 534 Cody and Foltz studies, 1037 Cognitive abilities and functioning behavioral correlates, intoxication, 316–318 benzodiazepines, 220–221 cocaine and D-amphetamine, 211–212 marijuana, 226–227 3,4-methylenedioxymethamphetamine, 213 nicotine and tobacco, 216–217 opioids, 224 CogScreen-Aeromedical Edition, 261 Cohen studies, 473 Collection, see also Point of collection testing (POTC) Medical Review Officer, 857–858 quality practices, workplace testing, 866–868 specimens, post-mortem toxicology, 976–977


INDEX

Collector, quality practices, 866–867 College of American Pathologists, 872–873 Collins and Chiles studies, 324 Colombia, 774 Color considerations and tests, 41, 993–995 Coma, 630–636 Combinations, alcohol biochemical tests, 415 Commins studies, 544 Commonality source determination, 53–54 Comorbidity management, 584–586 Comparative analysis cocaine exhibit comparison, 54–55 heroin exhibit comparison, 54 source commonality determination, 53–54 Compartmental modeling, 161–164, 162 Comprehensive screening, 971–972 Computerized performance test batteries Advisory Group for Aerospace Research and Development-Standardized Test for Research with Environmental Stressors Battery (AGARD-STRES), 254, 255 Automated Neurophysical Assessment Metrics (ANAM), 254–255, 255 Automated Portable Test System (APTS), 257–258 CogScreen-Aeromedical Edition, 261 Delta (Essex Corporation), 252, 260 Memory Assessment Clinics Battery (MAC), 258, 258 MiniCog, 259 Naval Medical Research Institute Performance Assessment Battery (NMRI-PAB), 253–254, 254 Neurobehavioral Evaluation System 2 (NES2), 256, 256 NovaScan (Nova Technology, Inc), 259–260 Performance-on-Line (SEDIcorp), 260–261 Psychomotor Vigilance Task (PVT), 259 Synwork, 258–259 Unified Tri-Service Cognitive Performance Assessment Battery (UTC-PAB), 251–252, 252 Walter Reed Army Institute Performance Assessment Battery (WRPAB), 252–253, 253 Concentration units, 335 Concomitant drug use, 275–278 Conditions of measurement, pupillometry, 278 Cone studies alternative matrix test results interpretation, 814–828 distribution, 182 heroin, 195 metabolism and excretion, 190 motor abilities, 226 Conference, pending, 1042 Confidentiality, 758–759 Confirmation investigation strategies, post-mortem toxicology, 1033–1036 point of collection testing, 949 Confirmation cutoffs, 771, 772 Confirmatory chemical tests capillary electrophoresis, 44 drug analysis, 42–47 gas chromatography, 42–43

1233

gas chromatography/mass spectrometry, 45–46 high-performance liquid chromatography, 43–44 infrared spectrophotometry, 44–45 microcrystal identifications, 42 nuclear magnetic resonance spectroscopy, 46–47 Confirmatory testing accuracy, 786 amphetamines, 792–795 analytical issues, 791–795 assay calibration, 788–789 barbiturates, 795 benzodiazepines, 793, 795 calibrators, 788–790 carryover, 787–788 chromatographic performance, 789 controls, 788–790 data review, 791 derivative selection, 791–794, 792 fundamentals, 785, 785 internal standards selection, 794 ions selection, 794–795 linearity, 786–787 materials verification, 789–790 methadone, 795 method validation, 785–788 opiates, 793–794 phencyclidine, 795 positive test results, criteria, 790–791 precision, 786 propoxyphene, 795 qualitative criteria, 790 quality assurance, 785–788 quality control, 789–790 quantitative criteria, 791 results evaluation, 790 sensitivity, 786–787 specificity, 787 workplace testing, 785, 785–795 Congressional interest (2005), 885–886 Conjugates, ethanol metabolism, 408–409, 409 Connolly studies, 123 Connors and Maisto studies, 317 Consortium administrators, 759 Constriction amplitude, 270, 271–272 Constriction velocity, 270, 271–272 Consumer applications, point of collection testing, 953 Containers, specimens, 976–977 Content of consciousness, 630 Continuing education, 1053 Contraindications, 672–673 Control, marketed medications, 282 Controlled substances, see also specific substance defined, 3 legislation, 4–5 medical uses, 60–62 physiological effects, 60–62 Schedule I, 62–64 Schedule II, 64–65 Schedule III, 65–67 Schedule IV, 67–68 Schedule V, 69


1234

scheduling, 3–4 synonyms, 62–69 Controlled substances, examinations adulterants, 50–51 diluents, 50–51 fundamentals, 47–48 identification, 48–49 quantitating, 48–49, 51–52 reference standards, 52–53 Controls confirmatory testing, workplace, 788–790 quality assurance, post-mortem toxicology, 1058–1060 Cook studies, 172, 203 Cope studies, 906 Cormier, Renaud and, studies, 715 Coronary arteries, 81–83, 82–83, see also Cardiac care Correlational analyses, 271–273, 273 Correlations, pharmacokinetics, 164–165 Cosgrove, Kelly P., 429–551 Cosgrove studies, 503–518 Cost, testing technologies, 246 Courtroom, testing claims animal research, 1163–1164 case reports and series, 1165–1167 causation evidence evaluation, 1159–1167 causation opinions, 1167–1172 chemical analogies, 1165 clinical reasoning, 1167–1170 epidemiology, 1159–1162 expert testimony, 1157–1158, 1171–1172 fundamentals, 1156–1157, 1173 general causation evidence evaluation, 1159–1167 opinions, causation, 1167–1172 Parlodel litigation, 1170–1172 plaintiffs’ allegations, 1171 scientific method, 1157–1167 secondary source material, 1167 Cozart Bioscience Rapiscan, 904–905 Crack conversion, 12–13, see also Cocaine Criminal justice, point of collection testing (POCT) applications, 952–953 detection, adulteration/dilution, 912 fundamentals, 909–910, 910 legal issues, 914 non-instrumented tests, 910–912 regulatory issues, 913–914 technologies, 913 Crippen, Harvey, 1077 Crouch, Heishman, Singleton and, studies, 249 Crouch studies, 895–954 Crumpton studies, 917–925 Crystalloids, rhabdomyolysis, 651 Cue-driven behaviors, 457–458, 458 Curran studies, 227 Curry studies, 652–653 Cyanide test, 994 Cyclic antidepressants, 998 Cyclophosphamide (vasculitis), 665


D D-Amphetamine, 210–212 Danforth, John (Senator), 748 Das studies, 434 Data confirmatory testing, workplace, 791 quality assurance, post-mortem toxicology, 1065–1066 David studies, 472 Davis studies, 188, 647 Decisions regarding prescribing, 585–586 Decontamination fundamentals, 667–669 immediate interventions, 669–670 non-urine workplace testing approaches, 801–802 secondary interventions, 670–671 Decreased mental status fundamentals, 630–632 immediate interventions, 632–635 secondary interventions, 635–636 Defenses, see DUI defenses De Giovanni studies, 905 de la Torre studies, 542 Delirium cocaine, 530–531, 530–534, 533 fundamentals, 636–637 immediate interventions, 638 secondary interventions, 638–640 Delta (Essex Corporation), 252, 260 Denmark, 769 Dentures and denture adhesives, 1136, see also Mouthwash preparations Department of Transportation (DOT) alcohol testing, 753, 756–757, 757 confidentiality, 758–759 consortium administrators, 759 Health and Human Services relationship, 749–750 laboratory testing, 754–755 Medical Review Officer, 755–756 professional, substance abuse, 757–758 public interest exclusion, 759–760 reasons for testing, 751–752 release of information, 758–759 responsibility, 750 safety-sensitive employees, 750, 750 specimen collection, 739, 752–754, 753 specimen validity testing, 844–846, 847 substance abuse professional, 757–758 third-party administrators, 759 violation consequences, 752 water loading study, 850 Dependence, addiction medicine, 561–564 Depression, toxicogenetics, 1093 Derivative selection, 791–794, 792 Derlet studies, 658 Dermal absorption, 152 Dersch, Chris, 551 Design of studies, pupillometry, 269, 275 Desipramine (Pertofran), 584 Detection adulteration/dilution, 912


INDEX

limits, quality assurance, 1061 reactions, point of collection testing, 947–949 time course, 823, 827, 827 Detoxification adrenergic agonist usage, 577 buprenorphine, 575–577, 576 fundamentals, 573–574 methadone usage, 575 naltrexone assistance, 577–578 opiate-specific withdrawal syndrome, 575–577, 577 Developing technologies, 907 Devices and techniques, see also Instrumentation breath alcohol testing, 928–932 evaluations, 901, 902–906, 903–906 examples, 899, 899 fundamentals, 918 methods, 899 operation, 899–901, 900–901 regulatory issues, 919–920, 920 specimen validity, 918 Dextromethorphan, 298, 299–302, 303 Dextrose, medical complications, 630 Diagnostic reagent strips, 994 Di Chiara and Imperato studies, 431 DiClemente, Prochaska and, studies, 564 Differential diagnosis, 529, 529 Diffusion, post-mortem, 1079–1080 Digital display devices, 930, 930–931, see also Breathalcohol analysis; Devices and techniques Digit symbol substitution task, 272, 273 Dilation velocity, 270, 272 Dilutions and diluents, 50–51, 848–849, see also Adulterants and adulteration Dinges and Powell studies, 259 Dinn, Shajani and, studies, 1123 Diode array detectors, 1003 Diphenylamine test, 993 Direct consumer applications, 953 Disadvantages point of collection testing, 924 specimens, 906–907 Disassociative anesthetics, 610–611 Diseases interactions, pharmacokinetics, 167 pupillometry, 278–279 Disposition, 815–816 Distribution alternative matrix test interpretation, workplaces, 815–816 amphetamines, 169–170 barbiturates, 175–176 biological membrane transfer, 153–154 drug levels interpretation, post-mortem, 1076–1077 volume, parameters, 158 DNA collection, toxicogenetics, 1108 Dole and Nyswander studies, 567 Domino studies, 204 Donor role, 866 Dopamine adaptations, tobacco smoking, 468–470 methamphetamines, 479–483

1235

receptors, cocaine, 509–512 replacement prescribing, 582–583 transporter and addiction, 505–508 Dopamine transporter and addiction, neurochemistry amphetamine, 434 cocaine, 433 ethanol, 437–438 fundamentals, 431–432, 439–440, 440 genetic polymorphism, 439 marijuana, 436–437 nicotine, 438 opiates, 434–435 phencyclidine, 435–436 uptake, 432, 432–433 Doping, see Sports and blood doping Dosages fundamentals, 159–160 loading, 159–160 3,4-methylenedioxymethamphetamine, 545–546 rate, 160 DOT, see Department of Transportation (DOT) Dow, Robert, 925 Doyle, Sir Arthur Conan, 11 Dräger Safety Drugtest, 900–901 D2 receptor adaptations, 510 D3 receptor adaptations, 506, 510–511 Driessen studies, 585 Drinking after offense, 1119–1121 “Driving under the influence” defenses, see DUI defenses Drug abuse, see also Point of collection testing; specific drug abuse markers, 391–393 abuse/use characteristics, 479 eventuality, methamphetamines, 478–479 point of collection testing, 918 Drug abuse, marketed medications alteration, 288 assessment, pharmacological entity, 282–287 availability, 288–289 butorphanol, 290, 291–295, 296 case studies, 290–303 control, 282 dextromethorphan, 298, 299–302, 303 drug discrimination, 284–285 fentanyl, 296, 297, 298 fundamentals, 281–282 pharmacokinetics, 288 physical-dependence capacity, 287 postmarketing surveillance, 289–290 premarketing abuse-liability testing, 282–289 preparation assessment, 288–289 self-administration, 283–284 subjective effects, 285–287 Drug abuse, pathology, see also specific disease autopsy, 73–80 central nervous system, 132–143 fundamentals, 72–73 heart disease, 80–108 lung disease, 124–129 myocardial alterations, 113–117


1236

scene of death, 73–80 valvular heart disease, 120–123 Drug-alcohol interactions, 1126, see also Breath-alcohol analysis Drug analysis capillary electrophoresis, 44 color tests, 41 confirmatory chemical tests, 42–47 gas chromatography, 42–43 gas chromatography/mass spectrometry, 45–46 high-performance liquid chromatography, 43–44 infrared spectrophotometry, 44–45 microcrystal identifications, 42 nuclear magnetic resonance spectroscopy, 46–47 physical characteristics, 40–41 screening tests, 40–42 thin layer chromatography, 41–42 Drug discrimination, 284–285 Drug evaluation and classification program, 249–251 Drug instability, 1082, see also Stability Drug interactions, see Interactions; specific drugs Drug law alcohol swabs, 1130–1131 alleged interfering substances, 1137–1140 autobrewery syndrome, 1127–1128 blood samples, 1130–1133 blood-water content, 1132–1133 breath-alcohol analysis, 1129, 1133, 1133–1145 breathing pattern, 1143–1144 chronic obstructive pulmonary disease, 1142–1143 dentures and denture adhesives, 1136 drinking after offense, 1119–1121 drug-alcohol interactions, 1126 endogenous ethanol, 1127–1128 ethanol pharmacokinetics, 1124–1126 fundamentals, 1118–1119, 1144–1145 gastric alcohol dehydrogenase, 1126–1127 gastro esophageal reflux disease, 1135–1136 general challenges, 1119–1128 hematocrit, 1132–1133 hyperthermia, 1143–1144 hypothermia, 1143–1144 intravenous fluids, 1131–1132 laced drinks, 1121–1122 mouthwash preparations, 1134–1135 pathological states, 1124–1126 pulmonary function, 1142–1143 ratio variability, 1140–1141 regurgitation, 1135–1136 rising blood-alcohol concentration, 1122–1124 trauma, 1131–1132 urine samples, 1128–1130, 1129 Drug levels interpretation, post-mortem absorption, 1076–1077 additive toxicity, 1081 adverse reactions, 1082 analytical results, 1070 blood, 1070–1071 body burden calculation, 1077–1078 bone, 1075 brain, 1073–1074


considerations, 1070–1076 diffusion, post-mortem, 1079–1080 distribution, 1076–1077 drug instability, 1082 fluids, 1074 fundamentals, 1069–1070, 1083 gastric contents, 1072–1073 glasses, 1075–1076 hair, 1075 incomplete distribution, 1078–1079 ingestion estimation, 1078 injection sites, 1074–1075 liver, 1072 medication delivery artifacts, 1081 metabolism, 1077 nails, 1075 nasal swabs, 1074–1075 paraphernalia, 1075–1076 pharmacogenetics, 1077 pharmacokinetics, 1076–1078 post-mortem specimens, 1070–1076 redistribution and changes, 1078–1080 soft tissues, 1074 specimens, post-mortem, 1070–1076 spoons, 1075–1076 stability, lack of, 1082 synergistic toxicity, 1081 syringes, 1075–1076 tables of values, 1082–1083 total body burden calculation, 1077–1078 trauma, 1080–1081 urine, 1073 vitreous humor, 1071–1072 Drug monitoring, substitute prescribing, 568 Drug-positive/drug-negative days, 277, 277 Drug solubilization, 802 Drug stability, see Stability Drug synergy, cocaine, 104 Druid studies, 961–1083 Dual-task performance, 317–318 Dubowski, Mason and, studies, 1141 DUI defenses alcohol swabs, 1130–1131 alleged interfering substances, 1137–1140 autobrewery syndrome, 1127–1128 blood samples, 1130–1133 blood-water content, 1132–1133 breath-alcohol analysis, 1129, 1133, 1133–1145 breathing pattern, 1143–1144 chronic obstructive pulmonary disease, 1142–1143 dentures and denture adhesives, 1136 drinking after offense, 1119–1121 drug-alcohol interactions, 1126 endogenous ethanol, 1127–1128 ethanol pharmacokinetics, 1124–1126 fundamentals, 1118–1119, 1144–1145 gastric alcohol dehydrogenase, 1126–1127 gastro esophageal reflux disease, 1135–1136 general challenges, 1119–1128 hematocrit, 1132–1133 hyperthermia, 1143–1144


INDEX

1237

hypothermia, 1143–1144 intravenous fluids, 1131–1132 laced drinks, 1121–1122 mouthwash preparations, 1134–1135 pathological states, 1124–1126 pulmonary function, 1142–1143 ratio variability, 1140–1141 regurgitation, 1135–1136 rising blood-alcohol concentration, 1122–1124 trauma, 1131–1132 urine samples, 1128–1130, 1129

E Earnest studies, 645 Ecstasy, see 3,4-Methylenedioxymethamphetamine Ecuador, 774 Edeleanu, Lazar, 478 Edwards and Gross studies, 561 Effects, human performance, see Human performance effects Effect scaling, 545–546, 546–547 Elad and Ginsburg studies, 8 Electron capture detector, 1001–1002 Electronic testing devices, 928–929 Elimination, see also Excretion alternative matrix test interpretation, workplaces, 816 barbiturates, 176, 176–177 compartmental modeling, 163–164 fundamentals, 156 ELISA, 996–997 Ellis studies, 715 Elsmore studies, 259 ElSohly studies, 190 Emergency care, immediate interventions agitation, 638 cardiac care, 661–662 decontaminations, 669–670 decreased mental status, 632–635 delirium, 638 heat stroke, 647–650 hypertension, 657 hyperthermia, 647–650 ingestions, 669–670 psychosis, 638 rhabdomyolysis, 653 seizures, 644–645 stroke, 665–666 Emergency care, secondary interventions agitation, 638–640 cardiac care, 662–663 decontaminations, 670–671 decreased mental status, 635–636 delirium, 638–640 heat stroke, 650 hypertension, 657–658 hyperthermia, 650 ingestions, 670–671 psychosis, 638–640

rhabdomyolysis, 653–654 seizures, 645 stroke, 666–667 Emergency management, medical complications activated charcoal, 668–669 acute hypertension, 665 acute renal failure, 651 agitation, 636–640 airway, 632 alkalinization, 652 anesthesia, 644 antibiotics, 664 antidote attributes, 630 arrhythmias, 659–660 aspirin, 658 barbiturates, 643 benzodiazepines, 636–637, 641, 643, 658 beta-blockers, 656, 659–661 breathing, 632 calcium-channel blockers, 658–659 cardiac care, 658–663 circulation, 632 circulatory support, 649 coma, 630–636 content of consciousness, 630 crystalloids, 651 cyclophosphamide (vasculitis), 665 decontamination, 667–671 decreased mental status, 630–636 delirium, 636–640 dextrose, 630, 633 emergency management, 629–675 epinephrine, 660 esmolol, 656–657 flumazenil, 632, 634–635 fosphenytoin, 643–644 furosemide, 652 gastric lavage, 667 glucocorticoids, 665 hallucinogens, 674–675 heat stroke, 645–650 heparin, 664 hypertensive emergencies, 654–658 hyperthermia, 645–650 immersion, 649 ingestions, 667–671 labetalol, 656 lethargy, 630–636 level of consciousness, 630 lidocaine, 659 mannitol, 652 mental status, 630–636 nalmefene, 631, 633–634 naloxone, 631, 633–634, 673 neuroleptic malignant syndrome, 646–647 neuroleptics, 636–637 nimodipine, 664–665 nitroglycerin, 658 opiates, 672–673 phentolamine, 659 propranolol, 660–661


1238

psychosis, 636–640 psychostimulants, 671–672 rhabdomyolysis, 650–654 sedative-hypnotics, 673–674 seizures, 640–645 serotonin syndrome, 647 shivering, 649 stroke, 656, 663–667 stupor, 630–636 superventricular arrhythmias, 660 surgery, 664 thermometry, 649 thiamine, 630, 632–633 thrombolytics, 659, 664 ventricular arrhythmias, 660 whole bowel irrigation, 669 Emerging issues, MRO, 863–864, see also Future trends Employee attitudes survey, 770 Employer role, 866 Encephalopathy, 142–143 Endocarditis, see Infective endocarditis Endocrine effects, doping, 717 Endogenous ethanol, 1127–1128 Endothelial dysfunction, 102 Eneas studies, 651 Envitec-Wismar SmartClip, 905–906 Enzymatic methods, 339–341, 341 Enzyme immunoassays, see also Immunoassays common methods, post-mortem toxicology, 996–997 immunoassay testing, workplace, 778–779 Enzymes, see Phase I and II enzymes Ephedra and ephedrine sports and blood doping, 706, 719 sudden death, 1106–1107 toxicogenetics, 1106–1107 vascular effects, 107 Epidemiology Brugada syndrome, 1101 catecholaminergic polymorphic ventricular tachycardia, 1102 claims, courtroom testing, 1159–1162 heart muscle disorders, 1103 hypertrophic cardiomyopathy, 1105 long QT syndromes, 1099 myocardial alterations, 114 Epinephrine, cardiac care, 660 Epperson studies, 470 Epstein, David H., 281–303 Equipment, quality practices, 869 Ergot alkaloids, 106, 106–107 Erythrocyte mean corpuscular volume, 412 Erythropoietin action mechanism, 708 blood profiles, 710–711 detection, 708–711 fundamentals, 707 morbidity, 719 production, 707–708 Esmolol, hypertension, 656–657 Esposito studies, 864–877 Esterlis, Irina, 465–473


Esterlis studies, 465–473 Esters, see Fatty-acid ethyl esters Ethanol dopamine transporter, 437–438 DUI defenses, 1124–1126 measuring, 403–406, 405 metabolism, 406–407, 406–409, 409 pharmacodynamics, 274 pharmacokinetics, 356–363 pupillometry, 274 sports and blood doping, 716 Ethyl esters, see Fatty-acid ethyl esters Europe, 766–769 European Union comparison, 771 European Workplace Drug Testing Society, 767 Evaluation norms, 243–244 Evaluation of devices, 901, 902–903, 903–906 Evidential breath-testing instruments, 347–349, 347–349, see also Breath-alcohol analysis Evidentiary electronic devices, 928–929 Evidentiary value, 906, 919 Examination, post-mortem toxicology, 971–973 Examination techniques, heart disease aorta, 91, 92–93 cardiac death, 91–92, 93–95, 94 cardiac hypertrophy, 95–96 cardiomyopathy, 86–87, 88–89 coronary arteries, 81–83, 82–83 coronary interventions, 83–86, 84–85 fundamentals, 96 heart valves, 88–90, 90–91 ischemic heart disease, 86, 87 myocardium, 86, 87 prosthetic heart valves, 91 removal of heart, 81 vascular effects, 98–100 Excited delirium central nervous system, 133–135, 135 scene of death, 75 Excretion, see also Elimination amphetamines, 170, 170 methamphetamines, 171–172 Exercise, sports and blood doping, 711 Expanding technology, legal issues, 886–888 Expert testimony, 1157–1158, 1171–1172 Exposure circumstances, 815, 815 Exposure duration, 161 Extraction methods, 1005–1007 Eye tracking, pharmacodynamics, 266–279

F FAA (Federal Aviation Administration) Workplace Urine Specimen Validity Testing Colloquium, 850–851, see also Department of Transportation (DOT) Factors, pharmacokinetic, 165–167 Fagan studies, 317 Fank, Michelle, 279


INDEX

Fant, Reginald, 279 Farasat, Sharifeh, 279 Farrell, Munn and, studies, 644 Farre studies, 173 Fate of alcohol, 354, 354–356, 357 Fatigue fitness-for-duty rules, 765 pupillometry, 278–279 Fatty-acid ethyl esters, 409–410 Fault analyses, pupillometry, 276 Federal Aviation Administration (FAA) Workplace Urine Specimen Validity Testing Colloquium, 850–851, see also Department of Transportation (DOT) Federal Highway Administration, see Department of Transportation (DOT) Federal Railroad Administration, see Department of Transportation (DOT) Federal Register, see Department of Transportation (DOT) Federal regulation, workplace testing alcohol testing, 753, 756–757, 757, 763 catch-up provisions, 763–764 confidentiality, 758–759 consortium administrators, 759 fatigue, 765 federal preemption, 883–885 fundamentals, 746, 761–762 Health and Human Services relationship, 749–750 historical developments, 736–737 laboratory testing, 754–755 Medical Review Officer, 755–756 MROs, 764 National Laboratory Certification Program, 741–746 professional, substance abuse, 757–758 2005 proposed amendments, 762–765 public interest exclusion, 759–760 reasons for testing, 751–752 release of information, 758–759 reporting, 741 responsibility, 750 results reporting, 741 return to duty, 764–765 safety-sensitive employees, 750, 750 sanctions, 763 specimen collection, 737–738, 739, 752–754, 753 specimen testing, 738, 740–741 substance abuse professional, 757–758 third-party administrators, 759 violation consequences, 752 Feinfeld studies, 651 Fellner, S., 905–906 Fenfluramine-associated regurgitant value disease, 123 Feng studies, 467 Fentanyl fundamentals, 21–22, 24–25 marketed medications abuse, 296, 297, 298 medical complications, 615 pharmacodynamics, 296, 297, 298 pharmacokinetics, 198 FHWA, see Department of Transportation (DOT) Field evaluations, 951

1239

Field sobriety tests, 326–327 Finland, 769 First aid, see Emergency care, immediate interventions First-pass metabolism, 361–362 Fishbain, Wetli and, studies, 530 FIT equation, 277–278 Fitness-for-duty alcohol testing, 763 catch-up provisions, 763–764 fatigue, 765 fundamentals, 761–762 MROs, 764 2005 proposed amendments, 762–765 return to duty, 764–765 sanctions, 763 testing technologies, 251–259 Fitzgerald studies, 781 5-HT 3,4-methylenedioxymethamphetamine, 542, 542–543, 546–551, 548 transporter, cocaine, 515–516 Flame ionization detector, 1001 Florida, 873 Flow, point of collection testing, 949 Fluids, drug levels interpretation, 1074 Flumazenil, 632, 634–635 Fluorescence detectors, 1003 Fluorescence polarization immunoassay, 997 Fluorescence polarization immunoassays, 779 Flupenthixol, 583 Follow-up treatment, 416 Foltin studies, 211 Foltz, Cody and, studies, 1037 Foltz, Rodger, 1038 Fone studies, 551 Food effects, 362–363, 362–363 Forensic analysis, anabolic steroids, 33–34 Forensic and clinical analysis, alcohol analytical factors, 352 blood/breath ratio, 349–350, 350 blood concentrations, 336–338, 337–338 blood water content, 335–336, 336 body fluids, alcohol measurement, 339–346 breath-alcohol analysis, 346–350, 347 chemical oxidation methods, 339 concentration units, 335 enzymatic methods, 339–341, 341 ethanol pharmacokinetics, 356–363 evidential breath-testing instruments, 347–349, 347–349 fate, alcohol, 354, 354–356, 357 first-pass metabolism, 361–362 food effects, 362–363, 362–363 fundamentals, 333–335, 334–335, 363–365 gas chromatographic methods, 341–345, 343–344 gastric ADH, 361–362 handheld screening instruments, 346–347, 347 hematocrit and hemoglobin, 336–337, 337 interlaboratory proficiency tests, 353, 353–354 measuring, 339–346 Michaelis-Menten model, 360–361


1240


pharmacokinetics, 356–363 plasma, concentrations, 336–338, 337–338 post-analytical factors, 352–353 pre-analytical factors, 351–352 quality assurance aspects, 350–354 serum water content, 335–336, 336 specimens, 335–339 uncertainty allowance, 338–339 Widmark model, 356, 357–358, 358–360 Forensic pathologist role, 967 Forensic toxicology, 1094, 1095 Fosnaugh studies, 278 Fosphenytoin, 643–644 Foulds studies, 215–217 Fowler studies, 468 Fox and Hayward studies, 1143 FRA, see Department of Transportation (DOT) France, 768 Franken, Fred, 551 Franksson and Anggard studies, 169 Frazer and Benmansour studies, 543 French Guyana, 774 Freud, Sigmund, 11 Fujiwara test, 993 Funderburk studies, 563 Furosemide, 652 Future trends Medical Review Officer, 863–864 point of collection testing, 953–954 sports and blood doping, 721

G GABAergic adaptations, 470 GABA receptors, 516–517 Gabow studies, 650 Galski studies, 223 Gamma-glutamyl transferase, 411 Gas chromatography (GC) body fluids alcohol measurement, 341–345, 343–344 common methods, post-mortem toxicology, 1000–1003 confirmatory chemical tests, 42–43 investigation strategies, post-mortem toxicology, 1027, 1031–1032 tabletop devices, electronic, 929 Gas chromatography/mass spectrometry (GC/MS) confirmatory chemical tests, 45–46 investigation strategies, post-mortem toxicology, 1036–1038 post-mortem toxicology, 1036–1038 Gastric considerations ADH, ethanol clinical pharmacokinetics, 361–362 alcohol dehydrogenase, DUI defenses, 1126–1127 Gastric contents common methods, post-mortem toxicology, 995 drug levels interpretation, post-mortem, 1072–1073 investigation strategies, post-mortem toxicology, 1030–1031 specimens, post-mortem toxicology, 979, 983–984

Gastric lavage, 667 Gastro esophageal reflux disease, 1135–1136 Gastrointestinal absorption, 151 Gates and Tschudi studies, 8 GC, see Gas chromatography (GC) GC/MS, see Gas chromatography/mass spectrometry (GC/MS) General causation evidence evaluation, 1159–1167 General challenges, DUI defenses, 1119–1128 Generic products, identification, 37 Genetic doping, 721 Genetic factors, pharmacokinetics, 166 Genetic polymorphism, 439 Genetics Brugada syndrome, 1102 catecholaminergic polymorphic ventricular tachycardia, 1104 heart muscle disorders, 1104 hypertrophic cardiomyopathy, 1106 George and Braithwaite studies, 906 Germany, 768 GH, see Human growth hormone (GH) Ginsburg, Elad and, studies, 8 Girardin studies, 195 Giroud studies, 714–715, 721 Glasses, drug levels interpretation, 1075–1076 Glatter studies, 1098–1108 Global workplace testing Argentina, 774 attitude surveys, 770 Australia, 771–774 Belgium, 769 Bolivia, 774 Brazil, 774 Chile, 774 CIPD survey, 770 Colombia, 774 confirmation cutoffs, 771, 772 Denmark, 769 Ecuador, 774 employee attitudes survey, 770 Europe, 766–769 European Union comparison, 771 European Workplace Drug Testing Society, 767 Finland, 769 France, 768 French Guyana, 774 fundamentals, 765–766, 774 Germany, 768 Greece, 768 guidelines, legally defensible testing, 770–771 Guyanas, 774 historical background, 766 Ireland, 768–769 legally defensible testing guidelines, 770–771 Luxembourg, 768 mining industry, Australia, 772–773 Netherlands, the, 767–768 New Zealand, 771–774 Paraguay, 774 Peru, 774


INDEX

1241

Portugal, 768 prisons, 770 scope, 766 screening cutoffs, 771 South America, 774 Spain, 768 Suriname, 774 Sweden, 767 United Kingdom, 769–770 United States comparison, 771 Uruguay, 774 Venezuela, 774 Glucocorticoids, stroke, 665 Glucose, 994 Glue sniffing, 105 Glutamate and glutamate receptors, 484, 516 Glutaraldehyde, 854 Golby studies, 317 Goldberger studies, 775–795 Goldfrank studies, 635 Goldstein studies, 942 Gorelick studies, 512 Gouzoulis-Mayfrank studies, 550 Government application, 251–259 Granulomatous pneumonitis/arteriopathy, 127–129, 127–129 Greece, 768 Greenblatt studies, 166, 632 Green studies, 204 Greenwood, Seivewright and, studies, 577 Griesar studies, 215 Griffiths, Roache and, studies, 221 Gross, Edwards and, studies, 561 Growth hormone, see Human growth hormone (GH) Gudelsky, Shankaran and, studies, 548 Guidance for interpretation, 827–828, 829 Guidelines, legally defensible testing, 770–771 Gullberg studies, 1123 Gurtman studies, 551 Guyanas, 774

H Hadfield studies, 434 Haile, Colin N., 478–490 Haile studies, 478–490 Hair alternative matrix test interpretation, workplaces, 820–822, 822 drug levels interpretation, post-mortem, 1075 non-urine workplace testing approaches, 800–805 specimens, post-mortem toxicology, 980, 984–985 workplace testing legal issues, 886–888 Half-life parameters, 159 Hallucinogens, see also specific drug fundamentals, 674–675 medical complications, 606–611 pupillometry, 274 Halogens, specimen validity testing, 854

Hanbauer, Kennedy and, studies, 433 Handheld PDAs, see Personal digital assistants (PDAs) Handheld screening instruments, 346–347, 347, 929–930, see also Devices and techniques Hangover, ingestion time, 323–324 Harris studies, 183 Hartnoll studies, 563 Hart studies, 226–227 Harvey studies, 189 Hayward, Fox and, studies, 1143 Health and Human Services (HHS) DOT relationship, 749–750 immunoassay testing, workplace, 780–783 specimen validity testing, 844–846 Hearn studies benzoylecgonine ethyl ester (cocaethylene), 438 investigation strategies, post-mortem toxicology, 1026–1042 methods, post-mortem toxicology, 991–1008 post-mortem toxicology, 965–973 Heart, see also Cardiac care; Myocardial alterations muscle disorders, 1103–1106 removal, examination techniques, 81 valves, examination techniques, 88–90, 90–91 Heart disease, examination techniques aorta, 91, 92–93 cardiac death, 91–92, 93–95, 94 cardiac hypertrophy, 95–96 cardiomyopathy, 86–87, 88–89 coronary arteries, 81–83, 82–83 coronary interventions, 83–86, 84–85 fundamentals, 96 heart valves, 88–90, 90–91 ischemic heart disease, 86, 87 myocardium, 86, 87 prosthetic heart valves, 91 removal of heart, 81 vascular effects, 97, 98–100, 99–108 Heather studies, 561 Heat stroke, see also Hyperthermia fundamentals, 645–647 immediate interventions, 647–650 secondary interventions, 650 Heavy metals, 994 Heffter, A., 17 Hegge, Fred, 252 Heim, Roger, 18 Heishman, Singleton and Crouch studies, 249 Heishman and Henningfield studies, 215 Heishman studies, 209–228, 238–263 Helander, Anders, 401–417 Helmlin studies, 172 Helpern, Siegel and, studies, 113 Hematocrit and hemoglobin alcohol analysis specimens, 336–337, 337 DUI defenses, 1132–1133 Hematomas, 389–390, 389–390 Hemodynamic alterations, 103, 103 Hendelson studies, 582 Henderson studies, 821 Henningfield, Heishman and, studies, 215


1242

Henningfield, Snyder and, studies, 216 Heparin, stroke, 664 Hepatic effects, 717 Hepler studies, 975–987 Heritable channelopathies and myopathies, 1098–1108 Heroin exhibit comparison, 54 fundamentals, 5–6 medical complications, 614–615 morphine isolation, 7–9 pharmacokinetics, 194, 195–196 production, 7–9 sources by region, 6–7 vascular effects, 105 Heroin smokers encephalopathy, 142–143 HGN, see Horizontal gaze nystagmus (HGN) Hicks, Thomas, 696 Higgins studies, 211 High-performance liquid chromatography (HPLC), 43–44, 1003–1004 Hill, Baumgartner and, studies, 801 Hill, Sir Austin Bradford, 1161 Hindbrain inputs, 456 Hindmarch studies, 215, 221 Historical developments anabolic steroids, regulatory, 30–31 cocaine, 11 marijuana, 15–16 quality practices, workplace testing, 864–865 workplace testing, 732–734, 736–737, 766 Hoffman, Albert, 185 Hoffman-La Roche studies, 945 Hoffman studies, 633, 637 Hofmann, Albert, 18, 20 Hojer studies, 635 Hollander studies, 659 Holland studies, 645 Hollings, Earnest (Senator), 748 Hollingsworth studies, 1156–1173 Home applications, 854–855, 953 Homicides, 969 Horizontal gaze nystagmus (HGN), 320–321 Hotchkiss, Ed, 279 Houghton, Wilkinson and, studies, 259 Household products, 854–855 Houston studies, 216 Howland, Jonathan, 238–263 Howland studies, 262 HPLC, see High-performance liquid chromatography (HPLC) 5-HT 3,4-methylenedioxymethamphetamine, 542, 542–543, 546–551, 548 transporter, cocaine, 515–516 Huestis studies, 715, 727–893 Human growth hormone (GH), 711–714, 719 Human performance effects attentional abilities, 211, 213, 215–216, 218–220, 223, 226 benzodiazepines, 217–221 cocaine, 210–212


cognitive abilities, 211–213, 216–217, 220–221, 224, 226–227 D-amphetamine, 210–212 fundamentals, 209–210, 227 marijuana, 224–227 3,4-methylenedioxymethamphetamine, 212–214 motor abilities, 210–211, 215, 218, 223, 225–226 nicotine, 214–217 opioids, 222–224 psychomotor stimulants, 210–214 sedative-hypnotics, 217–221 sensorimotor abilities, 212 sensory abilities, 210, 214–215, 218, 222, 225 tobacco, 214–217 Humans, intracellular messenger systems, 487–488, 488 Hunt and Jones studies, 189 Huntley studies, 318 Hybrid systems, 946–947 Hydrocodone medical complications, 615 pharmacokinetics, 197–198 Hydrogen peroxide, 853–854 Hydrolysis, 1008 Hydromorphone medical complications, 615 pharmacokinetics, 199–200 Hypertension fundamentals, 654–657 immediate interventions, 657 secondary interventions, 657–658 Hyperthermia DUI defenses, 1143–1144 fundamentals, 645–647 immediate interventions, 647–650 secondary interventions, 650 Hypertrophic cardiomyopathy, 1105–1106 Hypertrophy, myocardial alterations, 114–115 Hypnotic withdrawal syndrome, 579–580 Hypothermia, DUI defenses, 1143–1144

I Ibogaine, 517–518 Identification blotter paper LSD, 39 capsule imprints, 38–39 controlled substances examination, 48–49 non-urine workplace testing approaches, 803–804 packaging loops, 37–38 tablet markings, 38–39 Imaging studies, methamphetamines, 489–490 Imipramine (Tofranil), 584 Immediate interventions, see also Secondary interventions agitation, 638 cardiac care, 661–662 decontaminations, 669–670 decreased mental status, 632–635 delirium, 638 heat stroke, 647–650


INDEX

hypertension, 657 hyperthermia, 647–650 ingestions, 669–670 psychosis, 638 rhabdomyolysis, 653 seizures, 644–645 stroke, 665–666 Immersion, hyperthermia/heat stroke, 649 Immunoassays assay calibration, 788–789 common methods, post-mortem toxicology, 995–998 investigation strategies, post-mortem toxicology, 1029 Immunoassay testing, workplace amphetamines, 780–781 barbiturates, 783–784 benzodiazepines, 784 cannabinoids, 781–782 cocaine, 782–783 enzyme immunoassays, 778–779 fluorescence polarization immunoassays, 779 fundamentals, 776–777, 777 HHS-regulated drugs, 780–783 methadone, 784 methaqualone, 784 on-site drug testing, 779–780 opiates, 783 particle immunoassays, 779 phencyclidine, 783 propoxyphene, 784 radioimmunoassays, 777–778 Immunochromatography, 945–948 Impairment due to alcohol, measuring acute intoxication, 316–321 acute tolerance, 322–323 behavioral correlates, 316–321 blood alcohol concentration variations, 322 cognitive functioning, 316–318 dual-task performance, 317–318 field sobriety tests, 326–327 fundamentals, 327–328 hangover, 323–324 horizontal gaze nystagmus, 320–321 impairment testing, 324–327 individual differences, 321 ingestion time, 321–324 motor control, 316–318 positional alcohol nystagmus, 319–320 reaction time, 317 reliability, 325 sensitivity, 325 specificity, 325–326 speech, 318–319 time of ingestion, 321–324 validity, 325 vestibular functioning, 319–321 Impairment testing, 324–327 Imperato, Di Chiara and, studies, 431 Incidence of drugs, 734, 734 Incomplete distribution, 1078–1079 Individual considerations behavioral correlates, 321

1243

pupillometry, 277, 277 testing technologies, 242–243 Infections, central nervous system, 141–142, 141–142 Infective endocarditis, 120–123 Infrared (IR) spectrophotometry, 44–45 Ingestion estimation, 1078 fundamentals, 667–669, 668 immediate interventions, 669–670 secondary interventions, 670–671 time, measuring impairment, 321–324 Injection sites, 1074–1075 Inputs, see Hindbrain inputs Inspections, 742–746, 874 Instability, 1082, see also Stability Installation, quality assurance, 1064 Instrumentation, see also Devices and techniques immunoassays, 944–945 investigation strategies, post-mortem toxicology, 1041 post-mortem toxicology, 1041 pupillometry, 267–268 quality assurance, post-mortem toxicology, 1064 quality practices, workplace testing, 869 Interactions, 167, 1126 Interlaboratory proficiency tests, alcohol, 353, 353–354 Internal standards investigation strategies, post-mortem toxicology, 1041 post-mortem toxicology, 1041 quality assurance, post-mortem toxicology, 1057–1058 selection, confirmatory testing, 794 International Standards for Testing, 698–699 Interpretation, post-mortem toxicology, 973 Interspecies scaling, 545–546 Interventions, immediate agitation, 638 cardiac care, 661–662 decontaminations, 669–670 decreased mental status, 632–635 delirium, 638 heat stroke, 647–650 hypertension, 657 hyperthermia, 647–650 ingestions, 669–670 psychosis, 638 rhabdomyolysis, 653 seizures, 644–645 stroke, 665–666 Interventions, secondary agitation, 638–640 cardiac care, 662–663 decontaminations, 670–671 decreased mental status, 635–636 delirium, 638–640 heat stroke, 650 hypertension, 657–658 hyperthermia, 650 ingestions, 670–671 psychosis, 638–640 rhabdomyolysis, 653–654 seizures, 645 stroke, 666–667


1244


Intoxication behavioral correlates, 316–321 Intracellular messenger systems, 485–488, 488 Intracellular signaling, 457, 459 Intravenous fluids, DUI defenses, 1131–1132 Inturrisi and Verebely studies, 196 Invalid results, specimens, 855–856 Investigation of death, 968, 968–971, see also Post-mortem toxicology In vitro studies, 537–538, 537–539 In vivo microdialysis studies, 539, 539–540, 548–549 Ion channel disorder, 1099–1103 Ions selection, 794–795 IR, see Infrared (IR) spectrophotometry Ireland, 768–769 Ischemic heart disease, 86, 87 Isenschmid studies, 775–795, 975–987 Isolation, cocaine, 11–12 Isopropyl alcohol, 394

J James, Patricia L., 877 Jehanli studies, 904–905 Jenkins, Amanda J., 147–205 Jenkins studies, 195, 223 Jenny, Richard W., 877 Jensen, Knut, 718 Jensen studies, 544 Johanson, Tancer and, studies, 546 Johanson and Uhlenbuth studies, 562 Johnson studies, 563 Jones, Alan Wayne alcohol fundamentals, 315 biomedical tests, alcohol consumption, 401–417 clinical and forensic analysis, alcohol, 333–365 DUI defenses, 1118–1145 post-mortem alcohol, 376–395 Jones, Hunt and, studies, 189 Jones and Neri studies, 1123 Jones studies, 1069–1083 Josephs, Steele and, studies, 318

K Kadehjian studies, 909–915, 951 Kahlig studies, 434 Kaku and Lowenstein studies, 663 Kalant studies, 363 Kappa (κ) opioid receptors, 513–515 Karch, Steven B., 113–117 Kateman and Pijpers studies, 1061, 1065 Kato studies, 807 Kelly, Thomas H., 238–263 Kelly studies, 219, 221, 226–228 Kennedy and Hanbauer studies, 433 Kennedy studies, 257 Kerr studies, 223–224

Ketamine, 205 Ketoacidosis, 390–391 Ketones, 994 Khat, see Catha edulis (Khat) Kidwell and Van Wie studies, 907 Kidwell studies, 811 Kinetic interaction, microparticles, 997 Kintz, Mangin and, studies, 821 Kintz studies, 800–813, 903 Kirby studies, 548 Kleber, Kosten and, studies, 531, 533 Kleiber studies, 545 Knight studies, 167 Knochel studies, 652–653 Kolbrich studies, 905 Koller, Karl, 11 Kolodgie, Frank D., 97–108 Kolodgie studies, 101 Κ opioid receptors, 513–515 Kosten and Kleber studies, 531, 533 Krebs studies, 216 Krishnan-Sarin, Suchitra, 465–473 Krishnan-Sarin studies, 465–473 Kroll, Levy and, studies, 643 Krueger studies, 432 Kulig studies, 667 Kumar studies, 218 Kunsman studies, 218

L Labeling, 980 Labeling specimens, 980 Labetalol, hypertension, 656 Laboratory analysis and studies attentional abilities, 211, 213, 215–216, 218–220, 223, 226 benzodiazepines, 217–221 cocaine, 210–212 cognitive abilities, 211–213, 216–217, 220–221, 224, 226–227 D-amphetamine, 210–212 fundamentals, 209–210, 227 marijuana, 16–17, 224–227 3,4-methylenedioxymethamphetamine, 212–214 motor abilities, 210–211, 215, 218, 223, 225–226 nicotine, 214–217 opioids, 222–224 psychomotor stimulants, 210–214 pupillometry, 269–273 sedative-hypnotics, 217–221 sensorimotor abilities, 212 sensory abilities, 210, 214–215, 218, 222, 225 tobacco, 214–217 Laboratory inspections, 742–746, see also Inspections Laboratory testing, 754–755 Laced drinks, DUI defenses, 1121–1122 Lam studies, 180 Lange studies, 656


INDEX

Larvae, 986 Lasker studies, 1156–1173 Lasne studies, 721 Law enforcement applications, 249–251 Lawrence, Judy, 69 Lebish studies, 171 Legal drugs, 278–279, see also Legitimate medications; Medical uses; Prescription drugs Legal issues 2005 Congressional interest, 885–886 adulteration, 885–886 expanding technology, 886–888 federal preemption, 883–885 fundamentals, 878 hair, 886–888 liability, 878–883 medical marijuana, 889–890 oral fluid, 886–888 point of collection testing, 914 prescription drugs, 888–889 screen-only drug testing, 890–892 specimen validity, 883–885 substitution, 885–886 sweat testing, 886–888 testing technologies, 247–248 Legally defensible testing guidelines, 770–771 Legislation, controlled substances, 4–5, see also Regulatory issues Legitimate medications, see also Legal drugs; Medical uses; Prescription drugs benzodiazepines, 35 central nervous depressants, 35–36, 36 fundamentals, 35 narcotic analgesics, 36–37 vascular effects, 106–107 Le Houezec studies, 215 Lehti studies, 320 Leirer, Yesavage and, studies, 324 Leppik studies, 643 Lerman studies, 471 Lester studies, 182 Lethargy, medical complications, 630–636 Level of consciousness, 630 Levin studies, 216 Levy and Kroll studies, 643 Liability, workplace testing legal issues, 878–883 Libman studies, 664 Lidocaine, cardiac care, 659 Lifepoint Impact Test System, 904 Light reflex, 268, 268, see also Pupillometry Liguori studies, 225–226 Limitations pupillometry, 278–279 specimens, 906–907 Lindstrom studies, 467 Linearity confirmatory testing, workplace, 786–787 quality assurance, post-mortem toxicology, 1061 Linnoila studies, 220, 317, 321 Lintzeris studies, 569–571 Liquid chromatography (LC), 1032

1245

Liquid chromatography/mass spectrometry (LC/MS), 1038–1039 Liquid-liquid extraction, 1005–1006 Liquid reagent assays, 948–949 Li studies, 470 Litman studies, 945 Liver, drug levels interpretation, 1072 Loading, dosage regimens, 159–160 LoDico, Charles, 877, 925 Logan studies, 1118–1145 Long QT syndromes, 1099–1101 Long-term effects, 3,4-methylenedioxymethamphetamine, 542–544 Lorente studies, 715 Lott studies, 439 Louria studies, 113 Lovell, William S., 1145 Lowenfeld, Lowenstein and, studies, 268 Lowenstein, Kaku and, studies, 663 Lowenstein and Lowenfeld studies, 268 LSD, see Blotter paper LSD; Lysergic acid diethylamide (LSD) L-tryptophan, vascular effects, 107 Lundquist and Wolthers studies, 360 Lung disease, see also Pulmonary considerations aspiration pneumonia, 129, 129–130 fundamentals, 124–126, 125–126 granulomatous pneumonitis/arteriopathy, 127–129, 127–129 Luxembourg, 768 Lysergic acid diethylamide (LSD), see also Blotter paper LSD absorption, 185 distribution, 185–186 excretion, 186, 186 fundamentals, 20, 20 medical complications, 609–610 metabolism, 186, 186 pharmacokinetics, 185–186 pharmacology, 185

M MAC, see Memory Assessment Clinics Battery (MAC) Maisto, Connors and, studies, 317 Management information systems, 871 Management of withdrawal, 580 Mangin and Kintz studies, 821 Mangin studies, 716–719 Mannitol, rhabdomyolysis, 652 Manno studies, 715 Mariani, Angelo, 11 Marijuana, see also Cannabis and cannabinoids absorption, 188–189 attentional abilities, 226 cognitive abilities, 226–227 distribution, 189 dopamine transporter, 436–437 excretion, 189–190, 190


1246

fundamentals, 15–16, 16 historical developments, 15–16 human performance effects, 224–227 laboratory analysis, 16–17 medical complications, 611–612 metabolism, 189–190, 190 motor abilities, 225–226 pharmacodynamics, 224–227, 274 pharmacokinetics, 187–190 pharmacology, 187–188 psychomotor stimulants, 224–227 pupillometry, 274 sensory abilities, 225 workplace testing legal issues, 889–890 Markers alcohol, 414 3,4-methylenedioxymethamphetamine, 542, 543–544, 544 post-mortem alcohol interpretation, 391–393 traits, 416 Marketed medications, abuse alteration, 288 assessment, pharmacological entity, 282–287 availability, 288–289 butorphanol, 290, 291–295, 296 case studies, 290–303 control, 282 dextromethorphan, 298, 299–302, 303 drug discrimination, 284–285 fentanyl, 296, 297, 298 fundamentals, 281–282 pharmacokinetics, 288 physical-dependence capacity, 287 postmarketing surveillance, 289–290 premarketing abuse-liability testing, 282–289 preparation assessment, 288–289 self-administration, 283–284 subjective effects, 285–287 Marston studies, 550 Martin, Christopher S., 316–328 Martin, Pisoni and, studies, 318 Martin and Moss studies, 323 Mash, Deborah C., 528–534 Mash studies, 506, 528–534 Mason and Dubowski studies, 1141 Mass spectrometry (MS), 1002–1003 Mastrovitch studies, 944 Materials, workplace testing confirmatory testing, 789–790 quality practices, 868–869 Matrices interpretation, 823–828 Maylor studies, 317 McCarron studies, 646 McElvain and Schenk studies, 432 McGlothlin and Anglin studies, 563 McGregor studies, 551 McMillen studies, 318 MCV, see Mean corpuscular volume (MCV) MDMA, see 3,4-Methylenedioxymethamphetamine Mean corpuscular volume (MCV), 412


Measurements alcohol, clinical and forensic analysis, 339–346 pupillometry, 269–270, 276, 278 quality practices, workplace testing, 871–877 Measurements, alcohol impairment acute intoxication, 316–321 acute tolerance, 322–323 behavioral correlates, 316–321 blood alcohol concentration variations, 322 cognitive functioning, 316–318 dual-task performance, 317–318 field sobriety tests, 326–327 fundamentals, 327–328 hangover, 323–324 horizontal gaze nystagmus, 320–321 impairment testing, 324–327 individual differences, 321 ingestion time, 321–324 motor control, 316–318 positional alcohol nystagmus, 319–320 reaction time, 317 reliability, 325 sensitivity, 325 specificity, 325–326 speech, 318–319 time of ingestion, 321–324 validity, 325 vestibular functioning, 319–321 Measuring devices, quality assurance, 1054, see also Devices and techniques; Instrumentation Meconium, 986–987 Medical complications activated charcoal, 668–669 acute hypertension, 665 acute renal failure, 651 agitation, 636–640 airway, 632 alkalinization, 652 anesthesia, 644 antibiotics, 664 antidote attributes, 630 arrhythmias, 659–660 aspirin, 658 barbiturates, 617, 618–619, 643 benzodiazepines, 616–618, 617–618, 636–637, 641, 643, 658 beta-blockers, 656, 659–661 breathing, 632 calcium-channel blockers, 658–659 cardiac care, 658–663 circulation, 632 circulatory support, 649 cocaine, 599–603, 601 coma, 630–636 content of consciousness, 630 crystalloids, 651 cyclophosphamide (vasculitis), 665 decontamination, 667–671 decreased mental status, 630–636 delirium, 636–640 dextrose, 630, 633


INDEX

disassociative anesthetics, 610–611 emergency management, 629–675 epinephrine, 660 esmolol, 656–657 fentanyl, 615 flumazenil, 632, 634–635 fosphenytoin, 643–644 fundamentals, 598, 599 furosemide, 652 gastric lavage, 667 glucocorticoids, 665 hallucinogens, 606–611, 674–675 heat stroke, 645–650 heparin, 664 heroin, 614–615 hydrocodone, 615 hydromorphone, 615 hypertensive emergencies, 654–658 hyperthermia, 645–650 immersion, 649 ingestions, 667–671 labetalol, 656 lethargy, 630–636 level of consciousness, 630 lidocaine, 659 lysergic acid diethylamide, 609–610 mannitol, 652 marijuana, 611–612 mental status, 630–636 mepridine, 615–616 methadone, 615 morphine, 614 nalmefene, 631, 633–634 naloxone, 631, 633–634, 673 natural stimulants, 603–604 neuroleptic malignant syndrome, 646–647 neuroleptics, 636–637 nimodipine, 664–665 nitroglycerin, 658 opiates, 672–673 opioids, 612–613, 612–616 oxycodone, 615 oxymorphone, 615 pentazocine, 616 phentolamine, 659 phenylethylamine derivatives, 606–609 propoxyphene, 615 propranolol, 660–661 psychosis, 636–640 psychostimulants, 671–672 rhabdomyolysis, 650–654 sedative-hypnotics, 616–620, 673–674 seizures, 640–645 serotonin syndrome, 647 shivering, 649 solvents, 619, 619–620 stimulants, 599–606, 600 stroke, 656, 663–667 stupor, 630–636 superventricular arrhythmias, 660 surgery, 664

1247

synthetic stimulants, 604–606 thermometry, 649 thiamine, 630, 632–633 thrombolytics, 664 thrombolytic therapy, 659 ventricular arrhythmias, 660 whole bowel irrigation, 669 Medical Examiner Investigator, 965–967 Medical Review Officer (MRO) administrative functions, 862–863 analytical laboratory, 858–859 collection process, 857–858 DOT workplace testing, 755–756 emerging issues, 863–864 fitness-for-duty rules, 764 fundamentals, 856–857 future trends, 863–864 nuclear power industry workplace testing, 764 point of collection testing, 924–925 quality practices, workplace testing, 871 results verification, 859–861 safety issues, 861–862 specimen validity testing, 846, 848 Medical uses, see also Legal drugs; Legitimate medications; Prescription drugs controlled substances, 60–62 marijuana, 889–890 methamphetamines, 478–479 Medication delivery artifacts, 1081 Medicolegal death investigation, 965–967, 966 Meil, William M., 431–440 Meil studies, 431–440 Mellanby studies, 322 Mello studies, 563 Membrane-based assays, 945–946, 948–949 Membranes, see Biological membrane transfer Memory Assessment Clinics Battery (MAC), 258, 258 Mental status, 630–636 Mepridine, 615–616 Merigian studies, 667 Mesocorticolimbic dopamine system, 454–456, 455 Metabolism amphetamines, 170, 170 barbiturates, 176, 176–177 drug levels interpretation, post-mortem, 1077 methamphetamines, 171–172 3,4-methylenedioxymethamphetamine, 539, 541, 541–542 Metabolites serotonin, alcohol biochemical tests, 410 therapeutic drug monitoring, 161 Metals and metaloids, 1005 Methadone confirmatory testing, workplace, 795 immunoassay testing, workplace, 784 medical complications, 615 pharmacokinetics, 196–197 substitute prescribing, 567–568 withdrawal syndromes treatment, 574 workplace testing, 784, 795


1248

Methamphetamines absorption, 171–172 abuse eventuality, 478–479 action mechanisms, 479–482 characteristics of use/abuse, 479 dopamine, 479–483 excretion, 171–172 fundamentals, 478, 490 glutamate, 484 humans, intracellular messenger systems, 487–488, 488 imaging studies, 489–490 intracellular messenger systems, 485–488, 488 medical use, 478–479 metabolism, 171–172 military use, 478–479 neurotoxicity, 488–490 norepinephrine, 481–482 novel therapeutic targets, 484–485 oxidative stress, 489 patterns of use/abuse, 479 pharmacokinetics, 171–172 pharmacotherapeutic targets, 482–488 reinforcement, 479–483, 485–487 serotonin, 481, 483 sudden death, 1107 vascular effects, 100, 104–108 Methanol biochemical tests, alcohol, 407–408, 408 post-mortem alcohol interpretation, 393–394 Methaqualone, 784 Methcathinone, 28, 28–29 Methodology quality assurance, post-mortem toxicology, 1063 quality practices, workplace testing, 869 validation, 785–788 3,4-Methylenedioxyamphetamine, 172, 172 3,4-Methylenedioxymethamphetamine acute effects, 540–542 allometric scaling, 541, 545 attentional abilities, 213 behavioral assessments, 550–551 cognitive abilities, 213 dosing, 545–546 effect scaling, 545–546, 546–547 fundamentals, 536–537, 551 5-HT, 542, 542–543, 546–551, 548 human performance effects, 212–214 interspecies scaling, 545–546 long-term effects, 542–544 markers of neurotoxicity, 542, 543–544, 544 metabolism, 539, 541, 541–542 microdialysis studies, 539, 539–540, 548–549 monoamine transporters, 537–539, 537–540 neuroendocrine studies, 549, 549–550 pharmacokinetics, 172, 172–173 pharmacological effects, 539–540, 540–541 psychomotor stimulants, 212–214 sensorimotor abilities, 212 studies, 537–540 in vitro studies, 537–538, 537–539 in vivo microdialysis studies, 539, 539–540, 548–549


Methylphenidate (Ritalin), 583 Michaelis-Menten model, 360–361 Microcrystal identifications, 42 Microdialysis studies, 539, 539–540, 548–549 Microdiffusion tests, 994 Microparticle-based on-site immunoassays, 945 Microparticle kinetic interaction, 997 Microvascular resistance, 100–101 Military use, methamphetamines, 478–479 Mills and Bisgrove studies, 317, 321 MiniCog, 259 Mining industry, Australia, 772–773 Misuse potential, 248 Mitchell studies, 864–877 Mizoguchi studies, 487 Models, 161–164 Molecular diagnosis, cardiovascular disease, 1108 Moliteno studies, 104 Mongrain and Standing studies, 318 Monitoring, substitute prescribing, 568 Monks studies, 542 Monoamine transporters, 537–539, 537–540 Mooney, James, 17 Moore studies, 905 Morbidity of doping, 716–719 Morley studies, 551 Morphine absorption, 193 distribution, 193–194 excretion, 194, 194–195 isolation, heroin, 7–9 medical complications, 614 metabolism, 194, 194–195 pharmacokinetics, 192–195 pharmacology, 192–193 Mortality of doping, 720–721 Mortimer, W.G., 11 Moskowitz, Bruns and, studies, 321 Moskowitz studies, 220 Moss, Martin and, studies, 323 Motivation, addiction medicine, 564–565 Motor abilities and control behavioral correlates, intoxication, 316–318 benzodiazepines, 218 cocaine and D-amphetamine, 210–211 marijuana, 225–226 nicotine and tobacco, 215 opioids, 223 Mouthwash preparations, 1134–1135, see also Dentures and denture adhesives Movement disorders, 140 MRO, see Medical Review Officer (MRO) Mudge, Weiner and, studies, 156 Mullick, Florabel G., 97–108 Multilevel calibration, 1055–1056, 1056 Multiple specimen testing, 827, see also specimens and specimen collection Multistep assays, 948–949 Multitarget pharmacotherapeutic agents, 517–518 Munn and Farrell studies, 644 Munzar studies, 483


INDEX

1249

Murillo, Rudy, 266–279 Murphy studies, 586 Murray studies, 124 Mushrooms, see Psilocybin mushrooms Myers, Carol S., 209–228 Myocardial alterations, see also Cardiac care epidemiology, 114 fundamentals, 113 hypertrophy, 114–115 opiate abusers, 116–117 stimulant-related disorders, 115–116 Myocardium, examination techniques, 86, 87 Myrsten studies, 323

N Nagai, Nagayoshi, 478 Nahas studies, 659 Nails, 1075 Nalmefene, 631 Naloxone, 631, 673 Naltrexone-assisted detoxification, 577–578 Narcotic analgesics, 36–37 Narula, Jagat, 97–108 Nasal swabs, 1074–1075 National Institute on Drug Abuse, see Department of Transportation (DOT) National Laboratory Certification Program (NLCP), see also Department of Transportation (DOT) laboratory participation, 741–746 quality practices, workplace testing, 872 specimen validity testing, 848–850 State of the Science-Update 1, 848–850 National Transportation Safety Board, see Department of Transportation (DOT) Natural deaths, post-mortem toxicology, 970 Natural stimulants, medical complications, 603–604 Naval Medical Research Institute Performance Assessment Battery (NMRI-PAB), 253–254, 254 Near-cutoff challenges, 950–951 Neri, Jones and, studies, 1123 NES2, see Neurobehavioral Evaluation System 2 (NES2) Netherlands, the, 767–768 Neurobehavioral Evaluation System 2 (NES2), 256, 256 Neurochemical approach, replacement prescribing, 582–583 Neurochemistry cocaine, 503–518, 528–534 dopamine transporter and addiction, 431–440 methamphetamine abuse, 478–490 3,4-methylenedioxymethamphetamine, 536–551 neuropsychiatry, cocaine abuse, 528–534 nicotine dependence, 452–460 tobacco smoking, habitual, 465–473 Neuroendocrine studies, 549, 549–550 Neuroleptic malignant syndrome, 646–647 Neuroleptics, 636–637 Neuropsychiatry, cocaine abuse, 528–534 Neurotoxicity, 488–490

New York, 873 New Zealand, 771–774 Niaura studies, 317, 321 Nicotine and tobacco attentional abilities, 215–216 cognitive abilities, 216–217 dopamine transporter, 438 human performance effects, 214–217 motor abilities, 215 pharmacodynamics, 214–217, 275 psychomotor stimulants, 214–217 pupillometry, 275 receptor composition, 452–453 sensory abilities, 214–215 vascular effects, 105 Nicotine dependence, neurochemistry clinical implications, 459–460 cue-driven behaviors, 457–458, 458 fundamentals, 452, 459–460 hindbrain inputs, 456 intracellular signaling, 457, 459 mesocorticolimbic dopamine system, 454–456, 455 receptor composition, 452–453, 453 reinforcement, 454–457 supporting neurochemical systems, 453–458 ventral tegmental area, 454–456 Nicotinic receptor composition, 452–453, 453 NIDA, see Department of Transportation (DOT) Niedbala, S., 903 Nimodipine, stroke, 664–665 Nitrite, specimen validity testing, 852–853 Nitrogen/phosphorus detector, 1001 Nitroglycerin, cardiac care, 658 Niyogi studies, 378 NMR, see Nuclear magnetic resonance (NMR) spectroscopy NMRI-PAB, see Naval Medical Research Institute Performance Assessment Battery (NMRIPAB) Noble, Parker and, studies, 321 Nonbiological evidence, 987 Noncommercial assays, 906 Non-evidentiary devices, 930, 932, 932, see also Breathalcohol analysis Non-instrumented tests and testing products, 910–912, 945–946 Non-negative specimen retests, 875, 877 Non-patch collection, 811 Non-urine workplace testing approaches amphetamines, 804, 808 analysis of drugs, 802–803, 802–803, 807–809 cannabis, 804, 808 cocaine, 804, 809 decontamination procedures, 801–802 drug solubilization, 802 fundamentals, 800, 813 hair, 800–805 identification of drugs, 803–804 location of hair, 804–805 non-patch collection, 811 opiates, 803–804, 809


1250


oral fluid, 806–809 patch collection, 811–812 sampling, 806–807 screening tests, 807 solubilization, drugs, 802 specimen collection, 801, 806–807, 810–811 sweat, 810–812 Norepinephrine, 481–482 Norms, see Evaluation norms NovaScan (Nova Technology, Inc), 259–260 Novel therapeutic targets, 484–485 NRC, see Nuclear power industry workplace testing NTSB, see Department of Transportation (DOT) Nuclear magnetic resonance (NMR) spectroscopy, 46–47 Nuclear power industry workplace testing alcohol testing, 763 catch-up provisions, 763–764 fatigue, 765 fundamentals, 761–762 MROs, 764 2005 proposed amendments, 762–765 return to duty, 764–765 sanctions, 763 Nyswander, Dole and, studies, 567

O O’Callaghan studies, 544 Occupational applications, 259–262 Occupational settings, behavioral impairment administrative interface, 244 Advisory Group for Aerospace Research and Development-Standardized Test for Research with Environmental Stressors Battery, 254, 255 applications, 248–262 applied settings, 259–261 Automated Neurophysical Assessment Metrics, 254–255, 255 Automated Portable Test System, 257, 257–258 CogScreen-Aeromedical Edition, 261 computerized performance test batteries, 251–259 cost, 246 Delta (Essex Corporation), 260 drug evaluation and classification program, 249–251 evaluation norms, 243–244 fitness of duty tests, 251–259 frequency, testing, 247 fundamentals, 238–240, 262–263 government application, 251–259 handheld personal digital assistants, 245–246 implementation, testing, 246–248 individual tests, 242–243 law enforcement applications, 249–251 legal issues, 247–248 Memory Assessment Clinics Battery, 258, 258 MiniCog, 259 misuse potential, 248

Naval Medical Research Institute Performance Assessment Battery, 253–254, 254 Neurobehavioral Evaluation System 2, 256, 256 NovaScan (Nova Technology, Inc), 259–260 occupational applications, 259–262 Performance-on-Line (SEDIcorp), 260–261 performance stability, 247 personal computers, 245 Psychomotor Vigilance Task, 259 selection, 240–244 simulation, 261–262 Synwork, 258–259 test frequency, 247 test implementation, 246–248 testing platform, 245–246 Unified Tri-Service Cognitive Performance Assessment Battery, 251–252, 252 user acceptance, 247 user interface, 244 Walter Reed Army Institute Performance Assessment Battery, 252–253, 253 web-based systems, 246 Odor, 995 O’Hearn studies, 543 O’Leary studies, 226 Olson studies, 629–675 One-compartment models, 162, 162 One-step lateral flow immunochromatography, 945–948 On-site drug testing, 779–780 On-Site OraLab, 904 On-site point of collection testing (POCT) alternative matrices, 946 applications, 952–953 clinical applications, 952 confirmation, 949 consumer applications, 953 criminal justice system application, 952–953 detection reactions, 947–949 direct consumer applications, 953 evolution, 942–944 field evaluations, 951 flow, 949 fundamentals, 941–942 future trends, 953–954 home applications, 953 hybrid systems, 946–947 immunochromatography, 945–948 instrumented immunoassays, 944–945 liquid reagent assays, 948–949 membrane-based assays, 945–946, 948–949 microparticle-based on-site immunoassays, 945 multistep assays, 948–949 near-cutoff challenges, 950–951 non-instrumented testing products, 945–946 one-step lateral flow immunochromatography, 945–948 operational considerations, 949–950 product comparison studies, 950–951 product development, 944–947 quality assurance and quality control, 949–950 school applications, 953 technology history, 944–947


INDEX

testing flow and confirmation, 949 training, 949 workplace applications, 952 Operation of devices, 899–901, 900–901 Opiates and opioids, see also specific type attentional abilities, 223 cognitive abilities, 224 common methods, post-mortem toxicology, 998 confirmatory testing, workplace, 793–794 contraindications, 675 dopamine transporter, 434–435 fundamentals, 672–673 hair specimen, 803–804 human performance effects, 222–224 immunoassay testing, workplace, 783 investigation strategies, post-mortem toxicology, 1029 medical complications, 612–613, 612–616, 672–673 motor abilities, 223 myocardial alterations, 116–117 naloxone infusion, 675 non-urine workplace testing approaches, 803–804, 809 opioidergic adaptations, 471 oral fluids, 809 pharmacodynamics, 222–224, 273–274 pharmacokinetics, 191–200 post-mortem toxicology, 998, 1029 psychomotor stimulants, 222–224 pupillometry, 273–274 replacement prescribing, 580–581 sensory abilities, 222 substitute prescribing, 567–569 tobacco smoking, 471 toxicogenetics, 1093–1094 withdrawal syndromes treatment, 574–578 workplace testing, 783, 793–794 Opinions, causation, 1167–1172 Oral fluid alternative matrix test interpretation, workplaces, 819, 819–820 non-urine workplace testing approaches, 806–809 workplace testing legal issues, 886–888 OraLine s.a.t. Test, 904 ORALscreen, 904 OraSure Technologies Uplink, 900–901, 903 Organizational policies and procedures, 927–928 Organizations, 872–873 Osselton, D., 905 Outcomes, substitute prescribing, 572 Ouyand, Qinjie, 534 Overdose, death by, 970–971 Oxidative stress, methamphetamines, 489 Oxidizing agents, 993 Oxycodone medical complications, 615 pharmacokinetics, 196–197 Oxymorphone, medical complications, 615 Oyler studies, 171

1251

P Packaging loops, 37–38 Packers, see Body packers and stuffers PAN, see Positional alcohol nystagmus (PAN) Paracelsus (historical figure), 1164 Paraguay, 774 Parameters age, 167 bioavailability, 158 clearance, 157–158 disease interactions, 167 distribution volume, 158 drug interactions, 167 factors, pharmacokinetic, 165–167 fundamentals, 157 genetic factors, 166 half-life, 159 interactions, 167 pharmacokinetic factors, 165–167 sex differences, 166–167 volume of distribution, 158 Paraphernalia, drug levels interpretation, 1075–1076 Parenteral injection, 152–153 Parker and Noble studies, 321 Parlodel (bromocriptine), 582, 1170–1172 Participants of studies, 269, 275 Particle immunoassays, 779 Partilla, John, 551 Pascual-Leone studies, 645 Passive alcohol sensor devices, 937, 937 Pass-warn-fail devices, 930, 930, see also Breath-alcohol analysis Patch collection, 811–812 Patel studies, 125 Pathological states, DUI defenses, 1124–1126 Pathology, drug abuse, see also specific disease autopsy, 73–80 central nervous system, 132–143 fundamentals, 72–73 heart disease, 80–108 lung disease, 124–129 myocardial alterations, 113–117 scene of death, 73–80 valvular heart disease, 120–123 Pathophysiology Brugada syndrome, 1101–1102 catecholaminergic polymorphic ventricular tachycardia, 1102–1103 heart muscle disorders, 1104 hypertrophic cardiomyopathy, 1105 long QT syndromes, 1100 Patterns of use/abuse, 479 PBTs, 929, see also Breath-alcohol analysis PDAs, see Personal digital assistants (PDAs) Pemberton, John, 11 Pending conference, 1042 Pending deaths, 970 Pending toxicology, 970–971 Pentazocine, 616 Perez-Reyes, Wall and, studies, 188


1252

Perez-Reyes studies, 182, 188 Performance measures, 269–270, 272 Performance-on-Line (SEDIcorp), 260–261 Performance stability, 247 Performance testing, 742, see also Proficiency/performance testing Perkins studies, 215 Peroxidase, 853–854 Perrine studies, 326–327 Perri studies, 652 Perry, Alexander and, studies, 580 Personal computers, 245, see also Technologies Personal digital assistants (PDAs), 245–246, see also Technologies Personnel, 869, 1053 Pertofran (desipramine), 584 Peru, 774 Pervin studies, 562 Peyote, 17–18, 18 pH, 852, 994–995, 1007 Pharmacodynamics barbiturates, 274 behavioral impairment, occupational settings, 238–263 benzodiazepines, 217–221 butorphanol, 290, 291–295, 296 case studies, 290–293 club drugs, 275 concomitant drug use, 275 dextromethorphan, 298, 299–302, 303 effects, human performance, 209–228 ethanol, 274 eye tracking, 266–279 fentanyl, 296, 297, 298 fundamentals, 209 hallucinogens, 274 marijuana, 224–227, 274 marketed medications abuse, 281–303 nicotine, 214–217, 275 occupational settings, behavioral impairment, 238–263 opiates, 273–274 opioids, 222–224 pharmacokinetic correlations, 164–165 postmarket surveillance, 289–290 premarketing abuse-liability testing, 282–289 psychomotor stimulants, 210–214 pupillometry, 266–279 sedative-hypnotics, 217–221 stimulants, 274 testing technologies, 240–262 tobacco, 214–217 Pharmacogenetics, 1077 Pharmacogenomics, 1088–1096, 1089, 1091 Pharmacokinetics addiction medicine, 563–564 age, 167 alcohol, clinical and forensic analysis, 356–363 alternative matrix test interpretation, workplaces, 822–823, 824–826 amphetamine, 169–170 assessment of preparation, 288 barbiturates, 174–177


benzodiazepines, 177–180 biological membrane transfer, 149–154 biotransformation, 154–156 buprenorphine, 198–199, 570–571, 571 cocaine, 181–184 compartmental modeling, 161–164 correlations, 164–165 disease interactions, 167 dosage regimens, 159–160 drug interactions, 167 drug levels interpretation, post-mortem, 1076–1078 elimination, 156 factors, parameters, 165–167 fentanyl, 198 fundamentals, 149 genetic factors, 166 heroin, 194, 195–196 hydrocodone, 197–198 hydromorphone, 199–200 interactions, 167 ketamine, 205 lysergic acid diethylamide, 185–186 marijuana, 187–190 marketed medications, 288 methadone, 196–197 methamphetamine, 171–172 3,4-methylenedioxyamphetamine, 172, 172 3,4-methylenedioxymethamphetamine, 172, 172–173 modeling, 161–164 morphine, 192–195 opioids, 191–200 oxycodone, 196–197 parameters, 157–159, 165–167 pharmacodynamic correlations, 164–165 phencylidine, 202–204 physiological models, 164 preparation assessment, 288 sex differences, 166–167 specific drugs, 169–205 substitute prescribing, 570–571, 571 therapeutic drug monitoring, 160–161 toxicokinetics, 165 tramadol, 199 transfer, biological membrane, 149–154 Pharmacological effects, 539–540, 540–541 Pharmacology, alcohol, 927 Pharmacotherapies dopamine receptors, cocaine, 511–512 dopamine transporter, cocaine, 507–508 glutamate receptors, cocaine, 517 5-HT transporter, cocaine, 516 kappa-opioid receptors, 514–515 targets, methamphetamines, 482–488 Phase I and II enzymes, 155–156 Phencyclidine absorption, 203 common methods, post-mortem toxicology, 998 confirmatory testing, workplace, 795 distribution, 203–204 dopamine transporter, 435–436 excretion, 204


INDEX

fundamentals, 20–21, 22–23 immunoassay testing, workplace, 783 investigation strategies, post-mortem toxicology, 1029 metabolism, 204 pharmacokinetics, 202–204 pharmacology, 203 post-mortem toxicology, 998, 1029 workplace testing, 783, 795 Phenethylamines, 22–23, 25–28, 28 Phentolamine, 659 Phenylethylamine derivatives, 606–609 Phenylpropanolamine, 107 Phosphatidylethanol, 413 Physical characteristics, screening tests, 40–41 Physical-dependence capacity, 287 Physical plant, quality practices, 870–871 Physiological considerations alternative matrix test interpretation, workplaces, 816–822 effects, controlled substances, 60–62 models, pharmacokinetics, 164 Pickworth, Wallace B., 266–279 Pierce studies, 765–774 Pierri, Chait and, studies, 225 Pifl studies, 434 Pijpers, Kateman and, studies, 1061, 1065 Pinheiro studies, 768 Pisoni and Martin studies, 318 Plaintiffs’ allegations, 1171 Plasma concentrations, alcohol analysis specimens, 336–338, 337–338 methadone monitoring, substitute prescribing, 568–569 therapeutic drug monitoring, 160–161 Plasticity, addiction medicine, 564 Point of collection testing (POCT), alcohol determination blood, 937 body fluids, 938 breath, 928–939 chemical-color-change-based devices, 936, 936 collection, 927–928 considerations, 926–927 devices, 928–932 fundamentals, 926, 939, 940 organizational policies and procedures, 927–928 passive alcohol sensor devices, 937, 937 pharmacology, alcohol, 927 proficiency testing, 937–939 quality assurance, 937–939 saliva, 937–938 saliva-based technology, 932–936 specimens, 928 testing, 927–928 toxicology, alcohol, 927 urine, 937 Point of collection testing (POCT), alternative specimens alternative specimens, 898, 898–907 developing technologies, 907 devices and techniques, 899–906 evaluation of devices, 901, 902–903, 903–906 fundamentals, 897, 907

1253

operation of devices, 899–901, 900–901 saliva specimens, 906–907 sweat specimens, 906–907 Point of collection testing (POCT), criminal justice detection, adulteration/dilution, 912 fundamentals, 909–910, 910 legal issues, 914 non-instrumented tests, 910–912 regulatory issues, 913–914 technologies, 913 Point of collection testing (POCT), on-site alternative matrices, 946 applications, 952–953 clinical applications, 952 confirmation, 949 consumer applications, 953 criminal justice system application, 952–953 detection reactions, 947–949 direct consumer applications, 953 evolution, 942–944 field evaluations, 951 flow, 949 fundamentals, 941–942 future trends, 953–954 home applications, 953 hybrid systems, 946–947 immunochromatography, 945–948 instrumented immunoassays, 944–945 liquid reagent assays, 948–949 membrane-based assays, 945–946, 948–949 microparticle-based on-site immunoassays, 945 multistep assays, 948–949 near-cutoff challenges, 950–951 non-instrumented testing products, 945–946 one-step lateral flow immunochromatography, 945–948 operational considerations, 949–950 product comparison studies, 950–951 product development, 944–947 quality assurance and quality control, 949–950 school applications, 953 technology history, 944–947 testing flow and confirmation, 949 training, 949 workplace applications, 952 Point of collection testing (POCT), workplace advantages and disadvantages, 924 collection sites, 922 devices, 918–920, 920 drug abuse testing, 918 evidentiary value, 919 fundamentals, 917 medical review officer role, 924–925 quality control and quality assurance, 923–924, 924 regulatory issues, 919–924 regulatory oversight, 925 reporting procedures, 923 specimens, 918, 921–922 techniques, 918 testing procedures, 922–923, 923 trained testers, 920–921, 921 Poisons, post-mortem toxicology, 971


1254

Poland studies, 549–550 Police role, 965–967 Pollan studies, 656 Pompeia studies, 219 Pond studies, 667–668 Pope studies, 225 Portugal, 768 Positional alcohol nystagmus (PAN), 319–320 Positive test results, criteria, 790–791 Posner (Judge), 1159 Post-analytical factors, alcohol, 352–353 Postmarket surveillance, 289–290 Post-mortem alcohol interpretation abuse markers, 391–393 alternative biological samples, 383–384 blood alcohol concentration, 378–381 fundamentals, 376–377, 394–395 hematomas, 389–390, 389–390 isopropyl alcohol, 394 ketoacidosis, 390–391 markers, 391–393 methanol, 393–394 residual gastric alcohol, 384–385 sequestered hematomas, 389–390, 389–390 specimens, 377 stability and synthesis, alcohol, 385–389, 388 urinary alcohol, 382–383 vitreous alcohol, 381–382, 382 Post-mortem drug levels interpretation absorption, 1076–1077 additive toxicity, 1081 adverse reactions, 1082 analytical results, 1070 blood, 1070–1071 body burden calculation, 1077–1078 bone, 1075 brain, 1073–1074 considerations, 1070–1076 diffusion, post-mortem, 1079–1080 distribution, 1076–1077 drug instability, 1082 fluids, 1074 fundamentals, 1069–1070, 1083 gastric contents, 1072–1073 glasses, 1075–1076 hair, 1075 incomplete distribution, 1078–1079 ingestion estimation, 1078 injection sites, 1074–1075 liver, 1072 medication delivery artifacts, 1081 metabolism, 1077 nails, 1075 nasal swabs, 1074–1075 paraphernalia, 1075–1076 pharmacogenetics, 1077 pharmacokinetics, 1076–1078 post-mortem specimens, 1070–1076 redistribution and changes, 1078–1080 soft tissues, 1074 specimens, post-mortem, 1070–1076


spoons, 1075–1076 stability, lack of, 1082 synergistic toxicity, 1081 syringes, 1075–1076 tables of values, 1082–1083 total body burden calculation, 1077–1078 trauma, 1080–1801 urine, 1073 vitreous humor, 1071–1072 Post-mortem specimens, 1070–1076, see also Post-mortem toxicology, specimens Post-mortem toxicology accidents, 969 case review, 972 certification of death, 967–968 comprehensive screening, 971–972 examination, 971–973 forensic pathologist role, 967 fundamentals, 964–965 homicides, 969 interpretation, 973 investigation of death, 968, 968–971 medical examiner investigators role, 965–967 medicolegal death investigation, 965–967, 966 natural deaths, 970 overdose, death by, 970–971 pending deaths, 970 pending toxicology, 970–971 poisons, 971 police role, 965–967 quality assurance and quality control, 972 reports, 972 roles, 965–971, 968 suicides, 969 toxicology role, 968, 698–971 unclassified deaths, 970 undetermined deaths, 970 Post-mortem toxicology, common methods amphetamines, 997 analytical chemistry, 991–992, 992 applications, 1008 barbiturates, 998 benzodiazepines, 998 benzoylecgonine, 998 cannabinoids, 998 carbon monoxide, 994 CEDIA, 996 chemical tests, 992–994 chromatography, 999–1004 color, 995 color tests, 993–994 cyanide test, 994 cyclic antidepressants, 998 diagnostic reagent strips, 994 diode array detectors, 1003 diphenylamine test, 993 electron capture detector, 1001–1002 ELISA, 996–997 enzyme immunoassays, 996–997 extraction methods, 1005–1007 flame ionization detector, 1001


INDEX

fluorescence detectors, 1003 fluorescence polarization immunoassay, 997 Fujiwara test, 993 gas chromatography, 1000–1003 gastric contents, 995 glucose, 994 heavy metals, 994 high-performance liquid chromatography, 1003–1004 hydrolysis, 1008 immunoassays, 995–998 ketones, 994 kinetic interaction, microparticles, 997 liquid-liquid extraction, 1005–1006 mass spectrometry, 1002–1003 metals and metaloids, 1005 microdiffusion tests, 994 microparticle kinetic interaction, 997 nitrogen/phosphorus detector, 1001 odor, 995 opiates, 998 oxidizing agents, 993 pH, 994–995, 1007 phencyclidine, 998 propoxyphene, 998 protein, 994 radioimmunoassay, 997 Reinsch test, 994 REMEDi HS HPLC, 1004 sample preparation, 1005–1008 screening, 997–998 solid phase extraction, 1006–1007 thin-layer chromatography, 999–1000 Toxi-Lab TLC, 999–1000 trichloro compounds, 993 Trinder’s reagent, 993 ultraviolet absorption detectors, 1003 ultraviolet -visible spectrophotometry, 1004–1005 Post-mortem toxicology, investigation strategies alternatives to ToxiLab, 1030 amphetamines, 1027–1028 barbiturates, 1028 benzodiazepines, 1029 chromatographic methods, 1030 cocaine, 1029 conference, pending, 1042 confirmation, 1033–1036 fundamentals, 1026–1027, 1027–1028 gas chromatography, 1027, 1031–1032 gas chromatography/mass spectrometry, 1036–1038 gastric contents, 1030–1031 immunoassays, 1029 instruments, 1041 internal standard, 1041 liquid chromatography, 1032 liquid chromatography/mass spectrometry, 1038–1039 opiates, 1029 pending conference, 1042 phencyclidine, 1029 quantification, 1039–1041 review process, 1042 sample preparation, 1041

1255

selected ion monitoring, 1037–1038 specimens, 1040 ToxiLab A, 1030 unknown toxic agents, 1032–1033, 1034 urine, 1030–1031 validation of methods, 1039 Post-mortem toxicology, quality assurance accreditation programs, 1067 accuracy, 1062 addition method, 1057, 1057 analytical data, 1065 analytical methods and procedures, 1061–1063 calibrators, 1055–1057 chain-of-custody data, 1065 continuing education, 1053 controls, 1058–1060 data, 1065–1066 detection limits, 1061 fundamentals, 1052–1053 installation, 1064 instruments, 1064 internal standards, 1057–1058 linearity, 1061 measuring devices, 1054 method development, 1063 multilevel calibration, 1055–1056, 1056 personnel, 1053 pre-analysis checklist, 1064 precision, 1061–1062, 1062 preventative maintenance, 1064 proficiency programs, 1066–1067 qualitative methods, 1062–1063 quality control data, 1065–1066, 1066 quantitative methods, 1063 reagents, 1054 reference materials, 1054–1060 reports, 1066 samples and sampling, 1060 selectivity, 1062 sensitivity, 1061 specificity, 1062 standard operating procedures, 1053 validation, 1063 Post-mortem toxicology, specimens bile, 979, 982 blood, 978–979, 981–982 bone and bone marrow, 985 chain of custody, 976 collection, 976–977 containers, 976–977 fundamentals, 975 gastric contents, 979, 983–984 hair, 980, 984–985 labeling, 980 larvae, 986 meconium, 986–987 nonbiological evidence, 987 preservatives, 977 sampling, 977–980, 978 selection, 981–987 skeletal muscle, 985–986


1256

tissues, 980, 984 urine, 979, 982 vitreous humor, 979, 983 Potential tests and markers, 414, see also Markers Pötsch, Skopp and, studies, 907 Pounder, Derrick J., 333–365, 376–395 Powell, Dinges and, studies, 259 Pre-analysis checklist, 1064 Pre-analytical factors, alcohol, 351–352 Precautions, addiction medicine, 565–566 Precision confirmatory testing, workplace, 786 quality assurance, post-mortem toxicology, 1061–1062, 1062 workplace testing, 786 Pregnancy, 154 Premarketing abuse-liability testing, 282–289 Preparation assessment, marketed medications, 288–289 Prescribing comorbidity management, 585–586 in context, 565 substitute, addiction medicine, 580–584 Prescribing, replacement antisensitizing agents, 583–584 clinical approach, 583–584 dopaminergic agents, 582–583 neurochemical approach, 582–583 new approaches, 584 opioid-specific prescribing, 580–581 serotonin-reuptake inhibitors, 582–583 stimulant-specific prescribing, 582–584 tricyclic antidepressants, 583–584 Prescribing, substitute benzodiazepine specific, 572 buprenorphine maintenance prescribing, 569–571 drug monitoring, 568 methadone, 567–568 monitoring, 568 opioid-specific prescribing, 567–569 outcomes, 572 pharmacokinetics, 570–571, 571 plasma methadone monitoring, 568–569 stimulant specific, 571 Prescription drugs, 888–889, see also Legal drugs; Legitimate medications; Medical uses Preservatives, 977 Preston, Kenzie L., 281–303 Preston studies, 223 Preventative maintenance, 1064 Primary interventions, see also Secondary interventions agitation, 638 cardiac care, 661–662 decontaminations, 669–670 decreased mental status, 632–635 delirium, 638 heat stroke, 647–650 hypertension, 657 hyperthermia, 647–650 ingestions, 669–670 psychosis, 638 rhabdomyolysis, 653


seizures, 644–645 stroke, 665–666 Prisons, workplace testing, 770 Prochaska and DiClemente studies, 564 Product comparison studies, 950–951 Product development, 944–947 Professional, substance abuse, 757–758 Proficiency/performance testing NLCP, 742 point of collection testing, 937–939 quality assurance, post-mortem toxicology, 1066–1067 quality practices, workplace testing, 874–875, 876 specimens, 906 Prohibited list, sports, 697–698 Proposed amendments (2005), 762–765 Propoxyphene common methods, post-mortem toxicology, 998 confirmatory testing, workplace, 795 immunoassay testing, workplace, 784 medical complications, 615 post-mortem toxicology, 998 workplace testing, 784, 795 Propranolol, cardiac care, 660–661 Prosthetic heart valves, examination techniques, 91 Protein, 994 Protocol, quality practices, 868 Provost and Woodward studies, 215 Pseudoephedrine, vascular effects, 107 Psilocybin mushrooms, 18, 18–19 Psychoactive effect, addiction medicine, 562–563 Psychological effects, 717 Psychomotor stimulants, 210–214 Psychomotor Vigilance Task (PVT), 259 Psychosis fundamentals, 636–637 immediate interventions, 638 secondary interventions, 638–640 Psychostimulants, 671–672, 672 Public interest exclusion, 759–760 Pulmonary considerations, see also Lung disease absorption, biological membrane transfer, 152 function, DUI defenses, 1142–1143 Pupil diameter, 270, 271–272 Pupillary measures, 269–270, 271–272 Pupillometry barbiturate effects, 274 circular lights task, 272, 273 club drug effects, 275 concomitant drug use effects, 275–278 conditions of measurement, 278 constriction amplitude, 270, 271–272 constriction velocity, 270, 271–272 correlational analyses, 271–273, 273 design of studies, 269, 275 digit symbol substitution task, 272, 273 dilation velocity, 270, 272 disease, 278–279 drug-positive/drug-negative days, 277, 277 ethanol effects, 274 fatigue, 278–279 fault analyses, 276


INDEX

1257

FIT equation, 277–278 fundamentals, 266–267, 279 hallucinogens effects, 274 individual comparison, 277, 277 instrumentation, 267–268 laboratory study, 269–273 legal drugs, 278–279 light reflex, 268, 268 limitations, 278–279 marijuana effects, 274 measurement conditions, 278 measures used in studies, 269–270, 276 nicotine effects, 275 opiate effects, 273–274 participants of studies, 269, 275 performance measures, 269–270, 272 pupil diameter, 270, 271–272 pupillary measures, 269–270, 271–272 results of studies, 270–273, 276–278 size of pupils, 267 statistical analyses, 270, 276 stimulant effects, 274 studies, 269–273, 275–278 subjective measures, 269, 271, 272 subject variability, 278 utility, 278–279 Purification, cocaine, 11–12 PVT, see Psychomotor Vigilance Task (PVT)

Q QED Saliva Alcohol Test, 933–934 Qualitative criteria, confirmatory testing, 790 Qualitative methods criteria, workplace testing, 790 quality assurance, post-mortem toxicology, 1062–1063 Quality assurance, post-mortem toxicology accreditation programs, 1067 accuracy, 1062 addition method, 1057, 1057 analytical data, 1065 analytical methods and procedures, 1061–1063 calibrators, 1055–1057 chain-of-custody data, 1065 continuing education, 1053 controls, 1058–1060 data, 1065–1066 detection limits, 1061 fundamentals, 1052–1053 installation, 1064 instruments, 1064 internal standards, 1057–1058 linearity, 1061 measuring devices, 1054 method development, 1063 multilevel calibration, 1055–1056, 1056 personnel, 1053 pre-analysis checklist, 1064 precision, 1061–1062, 1062

preventative maintenance, 1064 proficiency programs, 1066–1067 qualitative methods, 1062–1063 quality control data, 1065–1066, 1066 quantitative methods, 1063 reagents, 1054 reference materials, 1054–1060 reports, 1066 samples and sampling, 1060 selectivity, 1062 sensitivity, 1061 specificity, 1062 standard operating procedures, 1053 validation, 1063 Quality assurance and quality control alcohol, clinical and forensic analysis, 350–354 confirmatory testing, workplace, 785–790 data, post-mortem toxicology, 1065–1066, 1066 point of collection testing, 923–924, 924, 937–939, 949–950 post-mortem toxicology, 972 quality practices, workplace testing, 865, 869–870 specimens, 906 workplace testing, 785–790 Quality practices, workplace testing blind specimens, 875 collection, 866–868 collector, 866–867 College of American Pathologists, 872–873 donor role, 866 employer role, 866 equipment, 869 Florida, 873 fundamentals, 877 historical developments, 864–865 inspections, 874 instrumentation, 869 management information systems, 871 materials, 868–869 measurements, quality, 871–877 Medical Review Officer, 871 methodology, 869 New York, 873 NLCP, 872 non-negative specimen retests, 875, 877 organizations, 872–873 personnel, 869 physical plant, 870–871 proficiency/performance testing, 874–875, 876 protocol, 868 quality assurance and quality control, 865, 869–870 quality system, 865–871 site of collection, 867–868 testing facility, 868–871 validation of method, 869 Quality system, workplace testing blind specimens, 875 collection, 866–868 collector, 866–867 College of American Pathologists, 872–873 donor role, 866


1258


employer role, 866 equipment, 869 Florida, 873 inspections, 874 instrumentation, 869 management information systems, 871 materials, 868–869 measurements, quality, 871–877 Medical Review Officer, 871 methodology, 869 New York, 873 NLCP, 872 non-negative specimen retests, 875, 877 organizations, 872–873 personnel, 869 physical plant, 870–871 proficiency/performance testing, 874–875, 876 protocol, 868 quality assurance and quality control, 869–870 site of collection, 867–868 testing facility, 868–871 validation of method, 869 Quantification, 1039–1041 Quantitative methods controlled substances examination, 48–49, 51–52 criteria, confirmatory testing, 791 quality assurance, post-mortem toxicology, 1063

R Radioimmunoassays, see also Immunoassays common methods, post-mortem toxicology, 997 immunoassay testing, workplace, 777–778 Rainey studies, 338 Raistrick studies, 560–566, 584–586 Rapoport studies, 8 Rate, dosage regimens, 160 Ratio variability, DUI defenses, 1140–1141 Reaction time, behavioral correlates, 317 Reagan, Ronald (President), see Department of Transportation (DOT) Reagents, quality assurance, 1054 Reasons for testing, 751–752 Recombinant EPO detection, 708–711 Redistribution and changes, 1078–1080 Reference materials, 1054–1060 Reference standards, 52–53 Regional sources, 6–7, see also Sources Regulatory history, 30–31, 31 Regulatory issues, 913–914, 919–924, see also Legislation, controlled substances Regulatory oversight, 925 Regurgitant value disease, 123 Regurgitation, DUI defenses, 1135–1136 Reinforcement cocaine, 507 methamphetamines, 479–483, 485–487 nicotine dependence, 454–457 Reinhardt, Zink and, studies, 356, 1123

Reinsch test, 994 Reith studies, 433 Release of information, 758–759 Reliability impairment testing, 325 testing technologies, 242–243 Relling studies, 166 REMEDi HS HPLC, 1004 Removal of heart, examination techniques, 81 Renal failure, rhabdomyolysis, 650–651 Renaud and Cormier studies, 715 Replacement prescribing, addiction medicine antisensitizing agents, 583–584 clinical approach, 583–584 dopaminergic agents, 582–583 neurochemical approach, 582–583 new approaches, 584 opioid-specific prescribing, 580–581 serotonin-reuptake inhibitors, 582–583 stimulant-specific prescribing, 582–584 tricyclic antidepressants, 583–584 Reports and reporting point of collection testing, 923 post-mortem toxicology, 972 quality assurance, post-mortem toxicology, 1066 workplace testing, 741 Reproductive effects, 717 Residual gastric alcohol, 384–385 Responsibility, DOT workplace testing, 750 Results evaluation, workplace testing, 790 pupillometry, 270–273, 276–278 reporting, workplace testing, 741 verification, MRO, 859–861 Rettig studies, 218 Return to duty, 764–765 Revell, Wesnes and, studies, 215 Review process, 1042 Revocation of certification, 746 Rhabdomyolysis fundamentals, 650–652 immediate interventions, 653 secondary interventions, 653–654 Rice studies, 8, 927 Rising blood-alcohol concentration, 1122–1124 Ritalin (methylphenidate), 583 Roache and Griffiths studies, 221 Robinson studies, 550, 707–711 Rodgers studies, 898 Roles, post-mortem toxicology, 965–971, 968 Ron studies, 650, 652 Rosenberg studies, 646, 669 Rothman, Richard B., 536–551 Rothman studies, 536–551 Rothrock studies, 664 Roth studies, 629–675 Rowland studies, 169 Roy-Byrne studies, 220 Rusby, H.H., 11 Rush, Stoops and, studies, 218 Rusted studies, 221


INDEX

1259

Ruttenber studies, 531 Rutter, John, 551

S Saano studies, 219 Safety concerns, clandestine laboratories, 57–58 Safety issues, MRO, 861–862 Safety-sensitive employees, 750, 750 Saliva point of collection testing, 906–907, 932–938 therapeutic drug monitoring, 161 Saliva-Based Test Strip, 934, 934–936 SAM-HSA, see Department of Transportation (DOT) Samples and sampling common methods, post-mortem toxicology, 1005–1008 investigation strategies, post-mortem toxicology, 1041 non-urine workplace testing approaches, 806–807 quality assurance, post-mortem toxicology, 1060 specimens, post-mortem toxicology, 977–980, 978 Sampson-Cone studies, 814–828 Samyn, N., 907 Sanctions, fitness-for-duty rules, 763 Sandow, Brewer and, studies, 318 Satel studies, 529 Saudan studies, 700–702 Saugy studies, 695–721 Scene of death autopsy, 76–79, 77–79 body packers, 76 excited delirium, 75 fundamentals, 73–74 Scheduling controlled substances fundamentals, 3–4 Schedule I, 62–64 Schedule II, 64–65 Schedule III, 65–67 Schedule IV, 67–68 Schedule V, 69 Schenk, McElvain and, studies, 432 Schenk studies, 545 Schepers studies, 171 Schmittner, John P., 281–303 Schoemaker studies, 433 School applications, 953 Science of substitutions, 849–851 Scientific method, 1157–1167 Scope, workplace testing, 766 Scott studies, 471 Screening, 997–998 Screening cutoffs, 771 Screening devices, 932, see also Breath-alcohol analysis; Devices and techniques Screening tests color tests, 41 fundamentals, 40 non-urine workplace testing approaches, 807 physical characteristics, 40–41 thin layer chromatography, 41–42

Screen-only drug testing, 890–892 SD208911 (aminoergolines), 583 Secondary interventions, see also Immediate interventions agitation, 638–640 cardiac care, 662–663 decontaminations, 670–671 decreased mental status, 635–636 delirium, 638–640 heat stroke, 650 hypertension, 657–658 hyperthermia, 650 ingestions, 670–671 psychosis, 638–640 rhabdomyolysis, 653–654 seizures, 645 stroke, 666–667 Secondary source material, 1167 Securetec Drugwipe, 900, 903–904 Sedative-hypnotics, see also specific drug barbiturates, 617, 618–619 benzodiazepines, 616–618, 617–618 fundamentals, 673–674 human performance effects, 217–221 medical complications, 616–620 solvents, 619, 619–620 Sedatives, withdrawal syndromes treatment, 579–580 Seivewright and Greenwood studies, 577 Seizures central nervous system, 138, 140, 140 fundamentals, 640–644 immediate interventions, 644–645 secondary interventions, 645 Selected ion monitoring, 1037–1038 Selection specimens, post-mortem toxicology, 981–987 testing technologies, 240–244 Selectivity, quality assurance, 1062 Self-administration, premarketing abuse-liability testing, 283–284 Sensitivity biochemical tests, alcohol, 403 confirmatory testing, workplace, 786–787 impairment testing, 325 quality assurance, post-mortem toxicology, 1061 workplace testing, 786–787 Sensorimotor abilities, 212 Sensory abilities benzodiazepines, 218 cocaine and D-amphetamine, 210 marijuana, 225 nicotine and tobacco, 214–215 opioids, 222 Sequestered hematomas, 389–390, 389–390 Series studies, 548 Serotonin adaptations, tobacco smoking, 471–472 metabolites, biochemical tests, 410, 410–411 methamphetamines, 481, 483 replacement prescribing, 582–583 reuptake inhibitors, 582–583 transporter, cocaine, 515–516


1260

Serotonin syndrome, 647 Serum water content, 335–336, 336 Sex differences, pharmacokinetics, 166–167 Shajani and Dinn studies, 1123 Shankaran and Gudelsky studies, 548 Sherwood studies, 214–215 Shippenberg studies, 514 Shiran studies, 196 Shivering, 649 Shults studies, 878–892 Siegel and Helpern studies, 113 Signaling, see Intracellular signaling Simpson, Tom, 718 Simulations, testing technologies, 261–262 Single tests, biochemical tests, 415 Singleton and Crouch, Heishman, studies, 249 Site of collection, 867–868 Size of pupils, 267 Skeletal muscle, 985–986 Skopp and Pötsch studies, 907 Smith, Onterrio, 885 Smoking cessation treatments, 472–473 Snyder and Henningfield studies, 216 Soetens studies, 212 Soft tissues, drug levels interpretation, 1074 Solid phase extraction, 1006–1007 Solubilization, drugs, 802 Solvents medical complications, 619, 619–620 vascular effects, 105 Source commonality determination, 53–54 Sources cocaine, 10, 10–11 heroin, 6–7 South America, 774 Spain, 768 Späth, E., 17 Specificity biochemical tests, alcohol, 403 confirmatory testing, workplace, 787 impairment testing, 325–326 quality assurance, post-mortem toxicology, 1062 workplace testing, 787 Specimens, post-mortem toxicology bile, 979, 982 blood, 978–979, 981–982 bone and bone marrow, 985 chain of custody, 976 collection, 976–977 containers, 976–977 fundamentals, 975 gastric contents, 979, 983–984 hair, 980, 984–985 labeling, 980 larvae, 986 meconium, 986–987 nonbiological evidence, 987 preservatives, 977 sampling, 977–980, 978 selection, 981–987 skeletal muscle, 985–986


tissues, 980, 984 urine, 979, 982 vitreous humor, 979, 983 Specimens, validity testing adulteration, 851–855 chromium, 853 dilutions, 848–849 DOT, 844–846, 847, 850 FAA Workplace Urine Specimen Validity Testing Colloquium, 850–851 fundamentals, 842–843 glutaraldehyde, 854 halogens, 854 Health and Human Services, 844–846, 847 household products, 854–855 hydrogen peroxide, 853–854 invalid results, 855–856 Medical Review Officer role, 846, 848 nitrite, 852–853 NLCP: State of the Science-Update 1, 848–850 peroxidase, 853–854 pH, 852 science of substitutions, 849–851 substitutions, 848–851 urine, 843–844 water loading study, 850 Specimens and specimen collection alcohol, 335–339, 377 containers, 976–977 DOT workplace testing, 739, 752–754, 753 drug levels interpretation, post-mortem, 1070–1076 investigation strategies, post-mortem toxicology, 1040 multiple specimen testing, 827 non-urine workplace testing approaches, 801, 806–807, 810–811 point of collection testing, 918, 921–922, 928 specimens, post-mortem, 1070–1076 toxicology, post-mortem, 1040 validity, 918 workplace testing, 737–738, 739, 740–741, 883–885 Speech, behavioral correlates, 318–319 Spoons, drug levels interpretation, 1075–1076 Sports and blood doping abnormal blood profiles, 710–711 amphetamine, 704–705, 718 anabolic-adrogenic steroids, 716–719 anabolic steroids, 700–702 blood doping, 707–711 caffeine, 703 cannabinoids, 714–715 cardiovascular effects, 717 cocaine, 705, 718–719 endocrine effects, 717 ephedrine, 706, 719 erythropoietin, 707–711, 719 ethanol, 716 exercise, 711 fundamentals, 696–697 future trends, 721 genetic doping, 721 hepatic effects, 717


INDEX

human growth hormone, 711–714, 719 International Standards for Testing, 698–699 morbidity of doping, 716–719 mortality of doping, 720–721 prohibited list, 697–698 psychological effects, 717 recombinant EPO detection, 708–711 reproductive effects, 717 stimulants, 703–706, 718–719 sudden death, 720–721 synthetic anabolic steroids, 700–702 tendon injuries, 718 testosterone, 700–702 urine strategy, 713 Stability drug levels interpretation, post-mortem, 1082 post-mortem alcohol interpretation, 385–389, 388 toxicologic issues, 587 Staley, Julie K., 429–551 Staley studies, 465–473, 503–518 Standard operating procedures, 1053 Standing, Mongrain and, studies, 318 Statistical analyses, pupillometry, 270, 276 Steele, Trice and, studies, 244, 247–248, 262 Steele and Josephs studies, 318 Steinmeyer, S., 903 Steroids, anabolic, 30–34 Stimulant-related disorders, 115–116 Stimulants medical complications, 599–606, 600 pharmacodynamics, 274 pupillometry, 274 replacement prescribing, 582–584 sports and blood doping, 703–706, 718–719 substitute prescribing, 571 withdrawal syndromes treatment, 578–579 Stoops and Rush studies, 218 Stroke fundamentals, 663–667 hypertension, 656 immediate interventions, 665–666 secondary interventions, 666–667 Structure-activity relationship, 32, 32–33 Studies marketed medications abuse, 290–303 3,4-methylenedioxymethamphetamine, 537–540 pharmacodynamics, 290–293 pupillometry, 269–273, 275–278 Stuffers, see Body packers and stuffers Stupor, medical complications, 630–636 Subjective effects, premarketing abuse-liability testing, 285–287 Subjective measures, pupillometry, 269, 271, 272 Subject variability, pupillometry, 278 Substance Abuse and Mental Health Services Administration, see Department of Transportation (DOT) Substance abuse professional, 757–758 Substitute prescribing, addiction medicine benzodiazepine specific, 572 buprenorphine maintenance prescribing, 569–571

1261

drug monitoring, 568 methadone, 567–568 monitoring, 568 opioid-specific prescribing, 567–569 outcomes, 572 pharmacokinetics, 570–571, 571 plasma methadone monitoring, 568–569 stimulant specific, 571 Substitutions specimen validity testing, 848–851 workplace testing legal issues, 885–886 Sudden death sports and blood doping, 720–721 toxicogenetics, 1106–1107 Suicides, 969 Sun Biomedical Laboratories OraLine s.a.t. Test, 904 Superventricular arrhythmias, 660 Supporting neurochemical systems, 453–458 Surgery, stroke, 664 Suriname, 774 Suspension of certification, 746 Sutheimer studies, 917–925 Swabs, see Alcohol swabs Sweat alternative matrix test interpretation, workplaces, 820, 821 non-urine workplace testing approaches, 810–812 point of collection testing, 906–907 workplace testing legal issues, 886–888 Sweden, 767 Symmetrel (amantadine), 582 Synergistic toxicity, 1081 Synergy, drugs, 104 Synonyms, controlled substances, 62–69 Synthesis, alcohol, 385–389, 388 Synthetic anabolic steroids, 699–702 Synthetic stimulants, 604–606 Synwork, 258–259 Syringes, 1075–1076

T Taberner studies, 317 Tables of values, 1082–1083 Tablet markings, 38–39 Tabletop testing devices, electronic, 929, see also Breathalcohol analysis Tancer and Johanson studies, 546 Tan studies, 437 Taylor, Richard C., 238–263 Technologies developing, 907 history, 944–947 legal issues, 886–888 personal computers, 245 personal digital assistants, 245–246 point of collection testing, 913 Tendon injuries, 718 Tenenbein studies, 669


1262

Tennant studies, 274 Terguride (aminoergolines), 583 Test batteries, computerized performance Advisory Group for Aerospace Research and Development-Standardized Test for Research with Environmental Stressors Battery (AGARD-STRES), 254, 255 Automated Neurophysical Assessment Metrics (ANAM), 254–255, 255 Automated Portable Test System (APTS), 257–258 CogScreen-Aeromedical Edition, 261 Delta (Essex Corporation), 252, 260 Memory Assessment Clinics Battery (MAC), 258, 258 MiniCog, 259 Naval Medical Research Institute Performance Assessment Battery (NMRI-PAB), 253–254, 254 Neurobehavioral Evaluation System 2 (NES2), 256, 256 NovaScan (Nova Technology, Inc), 259–260 Performance-on-Line (SEDIcorp), 260–261 Psychomotor Vigilance Task (PVT), 259 Synwork, 258–259 Unified Tri-Service Cognitive Performance Assessment Battery (UTC-PAB), 251–252, 252 Walter Reed Army Institute Performance Assessment Battery (WRPAB), 252–253, 253 Testers, trained, 920–921, 921 Testing, see also Point of collection testing (POCT) facilities, quality practices, 868–871 flow and confirmation, 949 platform, 245–246 point of collection testing, 927–928 procedures, 922–923, 923 Testing claims, courtroom animal research, 1163–1164 case reports and series, 1165–1167 causation evidence evaluation, 1159–1167 causation opinions, 1167–1172 chemical analogies, 1165 clinical reasoning, 1167–1170 epidemiology, 1159–1162 expert testimony, 1157–1158, 1171–1172 fundamentals, 1156–1157, 1173 general causation evidence evaluation, 1159–1167 opinions, causation, 1167–1172 Parlodel litigation, 1170–1172 plaintiffs’ allegations, 1171 scientific method, 1157–1167 secondary source material, 1167 Testing technologies, behavioral impairment in occupational settings administrative interface, 244 Advisory Group for Aerospace Research and Development-Standardized Test for Research with Environmental Stressors Battery, 254, 255 applications, 248–262 applied settings, 259–261 Automated Neurophysical Assessment Metrics, 254–255, 255


Automated Portable Test System, 257, 257–258 CogScreen-Aeromedical Edition, 261 computerized performance test batteries, 251–259 cost, 246 Delta (Essex Corporation), 260 drug evaluation and classification program, 249–251 evaluation norms, 243–244 fitness of duty tests, 251–259 fundamentals, 238–240, 262–263 government application, 251–259 handheld personal digital assistants, 245–246 individual tests, 242–243 law enforcement applications, 249–251 legal issues, 247–248 Memory Assessment Clinics Battery, 258, 258 MiniCog, 259 misuse potential, 248 Naval Medical Research Institute Performance Assessment Battery, 253–254, 254 Neurobehavioral Evaluation System 2, 256, 256 NovaScan (Nova Technology, Inc), 259–260 occupational applications, 259–262 Performance-on-Line (SEDIcorp), 260–261 performance stability, 247 personal computers, 245 Psychomotor Vigilance Task, 259 selection, 240–244 simulation, 261–262 Synwork, 258–259 test frequency, 247 test implementation, 246–248 testing platform, 245–246 Unified Tri-Service Cognitive Performance Assessment Battery, 251–252, 252 user acceptance, 247 user interface, 244 Walter Reed Army Institute Performance Assessment Battery, 252–253, 253 web-based systems, 246 Testosterone, 700–702 Tharp studies, 320, 326 Therapeutic drug monitoring, 160–161 Thermometry, 649 The Whizzinator, 885 Thiamine, medical complications, 630 Thin-layer chromatography (TLC), 41–42, 999–1000 Third-party administrators, 759 Thomasino studies, 856–864 Thorne, David, 252 Thrombolytics, 659, 664 Thrombosis, 101, 102 Time course of detection, 823, 827, 827 Time delays, therapeutic drug monitoring, 160 Time of ingestion, alcohol, 321–324 Tissues, 980, 984 Tissue sample DNA collection, 1108 TLC, see Thin-layer chromatography (TLC) Tobacco smoking, neurochemistry, see also Nicotine and tobacco cholinergic adaptations, 466, 466–468 dopaminergic adaptations, 468–470


INDEX

fundamentals, 465–466 GABAergic adaptations, 470 opioidergic adaptations, 471 serotonergic adaptations, 471–472 smoking cessation treatments, 472–473 Tobler studies, 218 Tofranil (imipramine), 584 Tolerance alcohol, time of ingestion, 322–323 therapeutic drug monitoring, 161 Tolliver, James, 34 Torre studies, 173 Total body burden calculation, 1077–1078 Toxicogenetics applications, 1092–1095 arrhythmogenic right ventricular dysplasia, 1103–1105 blood sample DNA collection, 1108 Brugada syndrome, 1101–1102 cardiovascular disease, molecular diagnosis, 1108 catecholaminergic polymorphic ventricular tachycardia, 1102–1103 clinical applications, 1092–1095 cocaine, 1107 depression, 1093 DNA collection, 1108 ephedra, 1106–1107 forensic toxicology, 1094, 1095 fundamentals, 1087–1088 heart muscle disorders, 1103–1106 heritable channelopathies and myopathies, 1098–1108 hypertrophic cardiomyopathy, 1105–1106 ion channel disorder, 1099–1103 long QT syndromes, 1099–1101 methamphetamine, 1107 molecular diagnosis, cardiovascular disease, 1108 opiate toxicity, 1093–1094 pharmacogenomics, 1088–1096, 1089, 1091 sudden death, 1106–1107 tissue sample DNA collection, 1108 Toxicokinetics, 165 Toxicology alcohol, 927 body fluids, 588, 588–589 post-mortem toxicology, 968, 968–971 stability, drug and heat, 587 ToxiLab alternatives, 1030 common methods, post-mortem toxicology, 999–1000 investigation strategies, post-mortem toxicology, 1030 post-mortem toxicology, 999–1000, 1030 Trained testers, 920–921, 921 Training, 906, 949 Trait markers, 416 Tramadol, 199 Transfer, biological membrane, 149–154 Trauma drug levels interpretation, post-mortem, 1080–1081 DUI defenses, 1131–1132

1263

Treatment Brugada syndrome, 1102 catecholaminergic polymorphic ventricular tachycardia, 1105 compliance, 567 follow-up, 416 heart muscle disorders, 1105 hypertrophic cardiomyopathy, 1106 long QT syndromes, 1100–1101 Treatment, withdrawal syndromes adrenergic agonists, 577 buprenorphine, 575–577, 576 detoxification, 573–578 fundamentals, 572–574 hypnotic withdrawal syndrome, 579–580 management of withdrawal, 580 methadone, 574 naltrexone-assisted detoxification, 577–578 opiate-specific withdrawal syndrome, 574–578 sedative withdrawal syndrome, 579–580 stimulant-specific withdrawal syndrome, 578–579 Trends, see Future trends Trice and Steele studies, 244, 247–248, 262 Trichloro compounds, 993 Tricyclic antidepressants, 583–584 Trinder’s reagent, 993 Tsai studies, 941–954 Tschudi, Gates and, studies, 8 Two-compartment models, 162, 163

U Uhlenbuth, Johanson and, studies, 562 ulti med Products Salivascreen, 905 Ultraviolet absorption detectors, 1003 Ultraviolet -visible spectrophotometry, 1004–1005 Uncertainty allowance, 338–339 Unclassified and undetermined deaths, 970 Unified Tri-Service Cognitive Performance Assessment Battery (UTC-PAB), 251–252, 252 United Kingdom, 769–770 United States comparison, 771 Unknown toxic agents, 1032–1033, 1034 Unselected population screening, 415 Uptake, dopamine transporter, 432, 432–433 Urinary alcohol, post-mortem interpretation, 382–383 Urine alternative matrix test interpretation, workplaces, 818, 819 drug levels interpretation, post-mortem, 1073 DUI defenses, 1128–1130, 1129 investigation strategies, post-mortem toxicology, 1030–1031 point of collection testing, 937 post-mortem toxicology, 979, 982, 1030–1031 specimen validity testing, 843–844 sports and blood doping, 713 Uruguay, 774 U.S. Coast Guard, see Department of Transportation (DOT)


1264


Use/abuse characteristics, 479 User acceptance, testing technologies, 247 User interface, testing technologies, 244 UTC-PAB, see Unified Tri-Service Cognitive Performance Assessment Battery (UTC-PAB) Utecht studies, 669 Utility, pupillometry, 278–279

V Vaccines, cocaine, 508 Validation, quality assurance, 1063 Validity and validation of methods impairment testing, 325 investigation strategies, post-mortem toxicology, 1039 post-mortem toxicology, 1039 quality practices, workplace testing, 869 testing technologies, 242–243 Validity testing, specimens adulteration, 851–855 chromium, 853 dilutions, 848–849 DOT, 844–846, 847, 850 FAA Workplace Urine Specimen Validity Testing Colloquium, 850–851 fundamentals, 842–843 glutaraldehyde, 854 halogens, 854 Health and Human Services, 844–846, 847 household products, 854–855 hydrogen peroxide, 853–854 invalid results, 855–856 Medical Review Officer role, 846, 848 nitrite, 852–853 NLCP: State of the Science-Update 1, 848–850 peroxidase, 853–854 pH, 852 science of substitutions, 849–851 substitutions, 848–851 urine, 843–844 water loading study, 850 Valvular heart disease, 120–123, 121–122, 123 Van der Venne, Marie Therese, 766 Van Wie, Kidwell and, studies, 907 Varian On-Site OraLab, 904 Vascular effects accelerated atherosclerosis, 101–102 cocaine, 100–104 drug synergy, 104 endothelial dysfunction, 102 ephedrine, 107 ergot alkaloids, 106, 106–107 fundamentals, 97, 98, 99 glue sniffing, 105 hemodynamic alterations, 103, 103 heroin, 105 legitimate medications, 106–107 L-tryptophan, 107 methamphetamine, 100, 104–108

microvascular resistance, 100–101 nicotine, 105 phenylpropanolamine, 107 pseudoephedrine, 107 solvents, 105 synergy, drugs, 104 thrombosis, 101, 102 vasculitis, 104 vasospasticity, 100–101 Vasculitis, 104 Vasospasticity, 100–101 Venezuela, 774 Ventral tegmental area (VTA), 454–456 Ventricular arrhythmias, 660 Verebely, Inturrisi and, studies, 196 Verstraete studies, 898–907 Veselis studies, 222 Vestibular functioning, 319–321 Villain studies, 800–813 Villegier studies, 468 Violation consequences, 752 Virmani, Renu, 80–108 Vitòria studies, 768 Vitreous alcohol, 381–382, 382 Vitreous humor drug levels interpretation, post-mortem, 1071–1072 post-mortem toxicology, specimens, 983 specimens, post-mortem toxicology, 979, 983 Vogel-Sprott, Beirness and, studies, 317 Vogel-Sprott studies, 317, 323 Vogl, Walter, 877, 925 Volkerts studies, 219 Volume of distribution, 158 VTA, see Ventral tegmental area (VTA)

W Wagner studies, 186, 360 Walker studies, 224 Wall and Perez-Reyes studies, 188 Walls studies, 965–973, 991–1008 Wall studies, 204 Walsh, J. Michael, studies, 898–907 Walsh, Sharon L., 281–303 Walter Reed Army Institute Performance Assessment Battery (WRPAB), 252–253, 253 Wang studies, 721, 904 Ward studies, 651 Washburn, Robert, 890 Wassen, R.G., 18 Wasson, V.P., 18 Water content, serum and blood, 335–336, 336 Water loading study, 850 Waters, Catravas and, studies, 647 Web-based systems, 246 Weiner and Mudge studies, 156 Wesnes and Revell studies, 215 Wesnes studies, 216 Wetli, Charles V., 71–79


INDEX

Wetli and Fishbain studies, 530 Wetli studies, 113 White studies, 1088–1096 The Whizzinator, 885 Whole bowel irrigation, 669 Widmark, Erik M.P., 339 Widmark model, 356, 357–358, 358–360 Widmark studies, 359, 362 Wilkinson and Houghton studies, 259 Wilkinson studies, 181, 360 Willette studies, 942 Willstatter, Richard, 11 Wilson studies, 317, 652 Wise, Carlezon and, studies, 436 Withdrawal syndromes treatment addiction medicine, 572–580 adrenergic agonists, 577 buprenorphine, 575–577, 576 detoxification, 573–578 fundamentals, 572–574 hypnotic withdrawal syndrome, 579–580 management, 580 methadone, 574 naltrexone-assisted detoxification, 577–578 opiate-specific withdrawal syndrome, 574–578 sedative withdrawal syndrome, 579–580 stimulant-specific withdrawal syndrome, 578–579 Wittchen studies, 584 Wolff studies, 559–589 Wolthers, Lundquist and, studies, 360 Wong, R., 904 Wong studies, 1088–1096 Woodward, Provost and, studies, 215 Workplace point of collection testing (POCT) advantages and disadvantages, 924 collection sites, 922 devices, 918–920, 920 drug abuse testing, 918 evidentiary value, 919 fundamentals, 917 medical review officer role, 924–925 quality control and quality assurance, 923–924, 924 regulatory issues, 919–924 regulatory oversight, 925 reporting procedures, 923 specimens, 921–922 specimen validity, 918 techniques, 918 testing procedures, 922–923, 923 trained testers, 920–921, 921 Workplace testing fundamentals, 731–732, 746 historical developments, 732–734, 736–737 incidence of drugs, 734, 734 National Laboratory Certification Program, 741–746 reporting, 741 results reporting, 741 specimen collection, 737–738, 739 specimen testing, 738, 740–741 Workplace testing, alternative matrix test interpretation absorption, 815–816

1265

analytical considerations, 822–823, 824–826 blood, 816–818, 817–818 chemical considerations, 822–823, 824–826 circumstances of exposure, 815, 815 clearance, 816 detection time course, 823, 827, 827 disposition, 815–816 distribution, 815–816 elimination, 816 exposure circumstances, 815, 815 fundamentals, 814 guidance for interpretation, 827–828, 829 hair, 820–822, 822 matrices interpretation, 823–828 multiple specimen testing, 827 oral fluid, 819, 819–820 pharmacokinetics, 822–823, 824–826 physiologic considerations, 816–822 sweat, 820, 821 time course of detection, 823, 827, 827 urine, 818, 819 Workplace testing, approaches and considerations accuracy, 786 amphetamines, 780–781, 792–795 analytical issues, 791–795 assay calibration, 788–789 barbiturates, 783–784, 795 benzodiazepines, 784, 793, 795 calibrators, 788–790 cannabinoids, 781–782 carryover, 787–788 chromatographic performance, 789 cocaine, 782–783 confirmatory testing, 785, 785–795 controls, 788–790 data review, 791 derivative selection, 791–794, 792 enzyme immunoassays, 778–779 fluorescence polarization immunoassays, 779 fundamentals, 775–776, 777 HHS-regulated drugs, 780–783 immunoassay testing, 776–784, 777 internal standards selection, 794 ions selection, 794–795 linearity, 786–787 materials verification, 789–790 methadone, 784, 795 methaqualone, 784 method validation, 785–788 on-site drug testing, 779–780 opiates, 783, 793–794 particle immunoassays, 779 phencyclidine, 783, 795 positive test results, criteria, 790–791 precision, 786 propoxyphene, 784, 795 qualitative criteria, 790 quality assurance, 785–788 quality control, 789–790 quantitative criteria, 791 radioimmunoassays, 777–778


1266

results evaluation, 790 sensitivity, 786–787 specificity, 787 Workplace testing, Department of Transportation alcohol testing, 753, 756–757, 757 confidentiality, 758–759 consortium administrators, 759 Health and Human Services relationship, 749–750 laboratory testing, 754–755 Medical Review Officer, 755–756 professional, substance abuse, 757–758 public interest exclusion, 759–760 reasons for testing, 751–752 release of information, 758–759 responsibility, 750 safety-sensitive employees, 750, 750 specimen collection, 739, 752–754, 753 substance abuse professional, 757–758 third-party administrators, 759 violation consequences, 752 Workplace testing, Federal regulation alcohol testing, 753, 756–757, 757, 763 catch-up provisions, 763–764 confidentiality, 758–759 consortium administrators, 759 fatigue, 765 fundamentals, 746, 761–762 Health and Human Services relationship, 749–750 historical developments, 736–737 laboratory testing, 754–755 Medical Review Officer, 755–756 MROs, 764 National Laboratory Certification Program, 741–746 professional, substance abuse, 757–758 2005 proposed amendments, 762–765 public interest exclusion, 759–760 reasons for testing, 751–752 release of information, 758–759 reporting, 741 responsibility, 750 results reporting, 741 return to duty, 764–765 safety-sensitive employees, 750, 750 sanctions, 763 specimen collection, 737–738, 739, 752–754, 753 specimen testing, 738, 740–741 substance abuse professional, 757–758 third-party administrators, 759 violation consequences, 752 Workplace testing, global Argentina, 774 attitude surveys, 770 Australia, 771–774 Belgium, 769 Bolivia, 774 Brazil, 774 Chile, 774 CIPD survey, 770 Colombia, 774 confirmation cutoffs, 771, 772 Denmark, 769


Ecuador, 774 employee attitudes survey, 770 Europe, 766–769 European Union comparison, 771 European Workplace Drug Testing Society, 767 Finland, 769 France, 768 French Guyana, 774 fundamentals, 765–766, 774 Germany, 768 Greece, 768 guidelines, legally defensible testing, 770–771 Guyanas, 774 historical background, 766 Ireland, 768–769 legally defensible testing guidelines, 770–771 Luxembourg, 768 mining industry, Australia, 772–773 Netherlands, the, 767–768 New Zealand, 771–774 Paraguay, 774 Peru, 774 Portugal, 768 prisons, 770 scope, 766 screening cutoffs, 771 South America, 774 Spain, 768 Suriname, 774 Sweden, 767 United Kingdom, 769–770 United States comparison, 771 Uruguay, 774 Venezuela, 774 Workplace testing, legal issues adulteration, 885–886 2005 Congressional interest, 885–886 expanding technology, 886–888 federal preemption, 883–885 fundamentals, 878 hair, 886–888 liability, 878–883 medical marijuana, 889–890 oral fluid, 886–888 prescription drugs, 888–889 screen-only drug testing, 890–892 specimen validity, 883–885 substitution, 885–886 sweat testing, 886–888 Workplace testing, Medical Review Officer administrative functions, 862–863 analytical laboratory, 858–859 collection process, 857–858 emerging issues, 863–864 fundamentals, 856–857 results verification, 859–861 safety issues, 861–862 Workplace testing, non-urine approaches amphetamines, 804, 808 analysis of drugs, 802–803, 802–803, 807–809 cannabis, 804, 808


INDEX

cocaine, 804, 809 decontamination procedures, 801–802 drug solubilization, 802 fundamentals, 800, 813 hair, 800–805 identification of drugs, 803–804 location of hair, 804–805 non-patch collection, 811 opiates, 803–804, 809 oral fluid, 806–809 patch collection, 811–812 sampling, 806–807 screening tests, 807 solubilization, drugs, 802 specimen collection, 801, 806–807, 810–811 sweat, 810–812 Workplace testing, nuclear power industry alcohol testing, 763 catch-up provisions, 763–764 fatigue, 765 fundamentals, 761–762 MROs, 764 2005 proposed amendments, 762–765 return to duty, 764–765 sanctions, 763 Workplace testing, quality practices blind specimens, 875 collection, 866–868 collector, 866–867 College of American Pathologists, 872–873 donor role, 866 employer role, 866 equipment, 869 Florida, 873 fundamentals, 877 historical developments, 864–865 inspections, 874 instrumentation, 869 management information systems, 871 materials, 868–869 measurements, quality, 871–877

1267

Medical Review Officer, 871 methodology, 869 New York, 873 NLCP, 872 non-negative specimen retests, 875, 877 organizations, 872–873 personnel, 869 physical plant, 870–871 proficiency/performance testing, 874–875, 876 protocol, 868 quality assurance and quality control, 865, 869–870 quality system, 865–871 site of collection, 867–868 testing facility, 868–871 validation of method, 869 Wrenn studies, 633 Wright, C.P. Alder, 6 Wright, C.R., 195 WRPAB, see Walter Reed Army Institute Performance Assessment Battery (WRPAB)

Y Yamashita studies, 438 Yesavage and Leirer studies, 324 York, Heide, 279 Youden studies, 1062

Z Zacny studies, 222 Zalis studies, 647 Zettl studies, 926–939 Zevin studies, 598–620 Zink and Reinhardt studies, 356, 1123 Zurovsky studies, 651


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