yellowCard Centre WM Forensic Toxicology Of Drugs That Affect Performance And Behaviour
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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
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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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