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Forensic Toxicology Of Drugs That Affect Performance And Behaviour

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Drugs That Affect Behaviour: the people

criminal victim

criminal

law

civil

law

doctor patient

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Drugs That Affect Behaviour: pharmacology

• drugs affecting neurotransmission

• drugs affecting the endocrine system

• other exogenous drugs

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GABA: major inhibitory neurotransmitter

• GABA agonists include

ethanol

benzodiazepine

barbiturates

ghb

GABA receptor

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GABA inhibitory effects

higher centre control disinhibition

cerebellum ataxia nystagmus

sensory pathways anaesthesia

reticular activating sys unconsciousness

brain stem respiratory arrest

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The dopamine pathway

• The reward pathway: neural hedonism

VTA = ventral tegmental areaNIDA©

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Classical addictive drugs and other drugs of abuse

• opioids

• ethanol

• amphetamines

• cocaine

• lysergide

• cannabis

• gammahydroxybutyrate

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Drugs affecting the endocrine system

• testosterone

• insulin

• corticosteroids

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Other exogenous drugs

Many predictable agents– anticholinergics, stimulants, hallucinogens

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

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Hallucinogens - 1968

volatile carbon compounds

nutmeg morning glory seeds

skin of toadsnight-shade

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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

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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

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Drug-induced hallucination

R -v- Lipman [1970]

• charged with manslaughter

• Guilty

• 'voluntary intoxication’

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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

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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

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Drug-induced disinhibition

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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

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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

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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

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Guardian July 27 1991

Drug-induced aggression

Drug turned husband into a double killer

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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

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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

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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

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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

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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.

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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…

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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 …

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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

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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

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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

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Zolpidem, amnesia, and unconsciousness

Take it off shelves

Call for Stilnox ban after leg lost in incident

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Drug-induced confession

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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

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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

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Not just the customers …Independent 4th Sept 1998

Doctors’ drinking ‘out of control’

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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

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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

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Making the victim do what you want: helplessness

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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

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Making the victim do what you want: unconsciousness

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Making the victim do what you want: unconsciousness

GP took his assistant with him

• ‘smell my aftershave’

• rape

• facial burn

• evidence

• conviction

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How to give chloroform

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Rape doctor gets 10 years

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The victim: helpless

R -v- Khan; Khan

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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

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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

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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

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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

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Conclusion

• Many drugs– ethanol– benzodiazepines– opioids

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

• Many more problems to come

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