yellowcard centre wm forensic toxicology of drugs that affect performance and behaviour

yellow

Card

Cen

tre WM

Forensic Toxicology Of Drugs That Affect Performance And Behaviour

yellow

Card

Cen

tre WM

Drugs That Affect Behaviour: the people

criminal victim

criminal

law

civil

law

doctor patient

yellow

Card

Cen

tre WM

Drugs That Affect Behaviour: pharmacology

• drugs affecting neurotransmission

• drugs affecting the endocrine system

• other exogenous drugs

yellow

Card

Cen

tre WM

GABA: major inhibitory neurotransmitter

• GABA agonists include

ethanol

benzodiazepine

barbiturates

ghb

GABA receptor

yellow

Card

Cen

tre WM

GABA inhibitory effects

higher centre control disinhibition

cerebellum ataxia nystagmus

sensory pathways anaesthesia

reticular activating sys unconsciousness

brain stem respiratory arrest

yellow

Card

Cen

tre WM

The dopamine pathway

• The reward pathway: neural hedonism

VTA = ventral tegmental areaNIDA©

yellow

Card

Cen

tre WM

Classical addictive drugs and other drugs of abuse

• opioids

• ethanol

• amphetamines

• cocaine

• lysergide

• cannabis

• gammahydroxybutyrate

yellow

Card

Cen

tre WM

Drugs affecting the endocrine system

• testosterone

• insulin

• corticosteroids

yellow

Card

Cen

tre WM

Other exogenous drugs

Many predictable agents– anticholinergics, stimulants, hallucinogens

Some unexpected drugs, e.g. – infliximab– montelukast– pizotifen– ribavirin– tibolone

yellow

Card

Cen

tre WM

Hallucinogens - 1968

volatile carbon compounds

nutmeg morning glory seeds

skin of toadsnight-shade

yellow

Card

Cen

tre WM

What the drug effects mean

Effect on the perpetrator

• drug-induced hallucination

• drug-induced aggression

• drug-induced disinhibition

• drug-induced amnesia

• drug-induced confession

• drug-induced incompetence

yellow

Card

Cen

tre WM

Drug-induced hallucination

R -v- Lipman [1970]

• man took LSD

• believed his girlfriend was serpent at the centre of the Earth

• attacked her with a sword and killed her

yellow

Card

Cen

tre WM

Drug-induced hallucination

R -v- Lipman [1970]

• charged with manslaughter

• Guilty

• 'voluntary intoxication’

yellow

Card

Cen

tre WM

Not drug-induced hallucinationR -v- Francis 2000

Defendant sexually assaulted boy of 16Boy was taking tramadol

• expert 1: ‘tramadol can cause hallucinations, so boy’s evidence unreliable’

• experts 2, 3: ‘Tramadol for years, no hallucination ever’

• so – expert 1 criticised, appeal dismissed

yellow

Card

Cen

tre WM

Drug-induced hallucination? Or religious duty?

• defendant was going into Rasta Temple with 36g cannabis for ‘act of worship’

• convicted• ‘No statutory defence of religious use in

the Misuse of Drugs Act 1971 and prosecution did not infringe the accused's rights under ECHR’

Worshiping with weed R -v- Paul Simon Taylor 2001

yellow

Card

Cen

tre WM

Drug-induced disinhibition

yellow

Card

Cen

tre WM

Drug-induced disinhibition

A rich 51-year-old business man

• prolactinoma

• Rx bromocriptine, then quinagolide

• pursued women and neglected business

• after 3 years bankrupt

• sued makers of quinagolide

• settled out of court

yellow

Card

Cen

tre WM

Drug-induced disinhibitionR -v- Lee Heard 2007

Some crimes can only be committed if the criminal had ‘intent’ {mens rea}

• A drunken man rubbed himself lewdly against the leg of a police officer

• convicted under Sexual Offences Act 2003: the rubbing was intended at the time, even if he would not have done it sober, or could not remember it

yellow

Card

Cen

tre WM

Drug-induced disinhibition

Know what you are drinking

R -v- Allen (Kevin) 1988 • committed sexual assault while drunk• admitted to 4 pints beer + two bottles

unknown, ‘tasting of aniseed’• intoxication not involuntary simply by not

knowing precise nature and strength of the alcohol

• appeal dismissed

yellow

Card

Cen

tre WM

Guardian July 27 1991

Drug-induced aggression

Drug turned husband into a double killer

yellow

Card

Cen

tre WM

Drug-induced aggression: adverse effect

44-year-old depressed man went beserk

• hit wife and friend over the head with an iron bar

• then tried to cut their heads off with a kitchen knife

• drug poisoning + mania from amitriptyline

yellow

Card

Cen

tre WM

Steroid suicide

• asthma• corticosteroids• suicide

Guardian 26th November 1996

The down side of drugs

Judy Jones reports on a tragic result of taking legally prescribed steroids

yellow

Card

Cen

tre WM

Drug-induced aggression: adverse effect

Arson after diazepam

R -v- Hardie 1984 • a man took 5 diazepam tablets ‘to calm his

nerves,’ then set light to his girlfriend’s flat• no evidence that he knew… that this would

render a person aggressive or incapable of appreciating risks

• appeal allowed

yellow

Card

Cen

tre WM

Drug-induced aggression

Hypoglycaemia: no bar to conviction for murder R -v- Bailey 1983

• man with IDDM • hit a rival lover over the head with an iron bar• ‘hypo’• if a patient knew there was a risk that failure to

take food after insulin could make him aggressive, then he was reckless

• ample evidence that he left home armed with an iron bar intent on teaching his rival a lesson

• convicted

yellow

Card

Cen

tre WM

Anabolic steroids

‘Some individuals may experience mental status and behavioral changes with anabolic steroid use, including irritability, aggressiveness, euphoria, depression, mood swings, altered libido, and even psychosis’ Kashkin and Kleber, 1989; Bahrke et al., 1990; Middleman

and DuRant, 1996; Clark and Henderson, 2003.

yellow

Card

Cen

tre WM

Drug-induced aggression: anabolic steroids

Klotz et al, 2006 • 241 anabolic steroid positive• 1199 anabolic steroid negative

• RR of carrying a weapon x 2, but • RR of violent crime x 1and• the wrong study…

yellow

Card

Cen

tre WM

Drug-induced aggression?

Sgt Colin Murray, Royal Engineers

• 22 years of blameless service

• two pints of beer in Nairobi nightclub

• bit a stranger on the nose

• Court martial

• Pleaded guilty, but …

yellow

Card

Cen

tre WM

Drug-induced aggression?

• completely out of character• taking mefloquine as an antimalarial • having nightmares• nightmares, neuropsychiatric troubles

and aggression recognized ADRs to mefloquine

• so: ‘? involuntary intoxication’• Appeal upheld

yellow

Card

Cen

tre WM

Drug-induced aggression?

Murder under the influenceR -v- Catling (2006)

• man took alcohol + paroxetine• put daughter and bag in car, ransacked house• stabbed sleeping ex-girlfriend to death • drove to police• Court accepted that paroxetine could cause

violence• BUT clearly premeditated, so appeal dismissed

yellow

Card

Cen

tre WM

I really can’t remember, officer • 29-year-old took heroin + 30 x 20mg

temazepam• tried to rob 2 garages, a store, and a

fish-and-chip shop• can’t remember the next day• entirely consistent with effects of

temazepam• convicted

Drug-induced amnesia

yellow

Card

Cen

tre WM

Zolpidem, amnesia, and unconsciousness

Take it off shelves

Call for Stilnox ban after leg lost in incident

yellow

Card

Cen

tre WM

Drug-induced confession

yellow

Card

Cen

tre WM

Drug-induced confession

Thiopental (Pentothal®)1948 Raymond Cens • tried as Nazi collaborator• “aphasic and amnesia after stroke”• given thiopental and answered questions

coherently• ‘memory unimpaired, aphasia feigned’…• Cens sues psychiatrists for assault and

breach of confidentiality• Cens censured

yellow

Card

Cen

tre WM

Hypos, death, and pardonR -v- G

Mr M IDDM• many hypos; car accident 3/12 before• fatal car accident while hypo• convicted

Mrs G IDDM for > 40 years• hypo while driving > killed another driver• never previously had serious hypo• hypo couldn’t have been expected• acquitted

yellow

Card

Cen

tre WM

Not just the customers …Independent 4th Sept 1998

Doctors’ drinking ‘out of control’

yellow

Card

Cen

tre WM

Testing for benzodiazepine inebriation

Bramness, Skurtveit, Mørland

• Norwegian tests for impairment • 818 drivers +ve for benzodiazepines

• ‘Standardized field sobriety test’

• Romberg’s, eye tests, and general look correlate with benzo concentration

• 2–3 times worse in those with highest concentrations

yellow

Card

Cen

tre WM

Drugs and the victim

State of mind

making the victim do what you want

unconsciousness

helplessness – physical or mental

amnesia

making the ‘victim’ imagine a crime

yellow

Card

Cen

tre WM

Making the victim do what you want: helplessness

yellow

Card

Cen

tre WM

0

10

20

30

40

50

60

70

80

90

Percent amnesic after diazepam-D or flunitazepam-F

D20F1

D10

F0.5

0D5

5’ 20’ 40’ 60’ 90’

% amnesic

Time from dose

yellow

Card

Cen

tre WM

Making the victim do what you want: unconsciousness

yellow

Card

Cen

tre WM

Making the victim do what you want: unconsciousness

GP took his assistant with him

• ‘smell my aftershave’

• rape

• facial burn

• evidence

• conviction

yellow

Card

Cen

tre WM

How to give chloroform

yellow

Card

Cen

tre WM

Rape doctor gets 10 years

yellow

Card

Cen

tre WM

The victim: helpless

R -v- Khan; Khan

yellow

Card

Cen

tre WM

Not murder, but ?manslaughter by omission

Khan & Khan gave LB heroin

• LB took heroin

• the heroin killed her

• she would have survived if treated…

• Khan & Khan charged with murder

• no clear intention, so manslaughter

• convicted, but

yellow

Card

Cen

tre WM

Not according to English law

‘Stephen's Digest of the Criminal Law (3rd edition 1887):

• "A sees B drowning and is able to save him by holding out his hand.

• A abstains from doing so in order that B may be drowned, and B is drowned.

• A has committed no offence.”

• Pardoned on appeal

yellow

Card

Cen

tre WM

The victim: helpless

Chaotic 25-year-old drug user and shoplifter• briefly arrested, then left by police in field• body found a month later• toxicology: dextroproxyphene, morphine, and

procyclidine; • police charged with manslaughter • opinion: possibly relevant, but not certainly• verdict: not guilty

yellow

Card

Cen

tre WM

Making the ‘victim’ imagine a crime

A 70-year-old man given midazolam for GI endoscopy

• Shortly afterwards: ‘sexually assaulted by two nurses’

• One hour later: remembers nothing

yellow

Card

Cen

tre WM

Conclusion

• Many drugs– ethanol– benzodiazepines– opioids

• Many forensic problems– adverse effects, toxic effects– perpetrator, victim– crime, damages

• Many more problems to come

yellow

Card

Cen

tre WM