Toxicology, medical education, & more

Opioids: Five Facts for Attorneys

More now than ever, I am consulted as a toxicologist to opine on criminal and civil cases that involve opioids (prescription and illicit). Although there are countless case-specific questions, there are a few facts to give attorneys insight into their opioid-related cases from a scientific-perspective. There are actually more than a few facts (and lots of science to explain!) so I am looking forward to presenting a one-hour continuing legal education talk in June at the 2019 Pennsylvania Bar Institute Criminal Law Symposium entitled “Opioids: A Primer in Toxicology for Attorneys”.

Just to shed light on some terminology, opiates are compounds derived from the opium poppy plant, namely morphine and codeine. (Side note: who said natural products were necessarily safe? That’s a topic for another time.) Opioids are synthetic (eg, fentanyl) or semi-synthetic drugs (eg, heroin, oxycodone, hydrocodone). However, the term opioid is now used to encompass both of these families of drugs that bind to opioid receptors in the body.

1. The dose makes the poison. Well, the dose also makes the toxicology screen positive or negative (there are minimum detection limits on toxicology screens). Yes, poppy seeds are from the opium poppy plant. But one poppy seed bagel is not going to give a positive opioid drug screen. How many will? Let’s just say more than your stomach would care to digest.
2. Naloxone is not the only opioid-antagonist (meaning, it kicks an opioid off the opioid receptors in the body and reverses its effects). But it is the one that works the fastest (which is key for acting as a life-saving antidote). Naloxone does not affect opioid blood levels. It is structurally related to the opioid oxymorphone (with some modification), interestingly enough, but its presence is unlikely to yield a positive opioid drug screen (note that a “drug screen” is different than a confirmatory test). There are reports in the literature of this happening. However, it’s uncommon and if there is a question, dig into the laboratory testing data or check with the laboratory. More on naloxone from my CLE talk at Jenkins Law Library. 
3. Levels of opioids (blood, urine, antemortem, postmortem) are all over the map in terms of what reflects a fatal dose. Why? Simply put, tolerance, the presence of other drugs in the patient’s system (eg, benzodiazepines), and the source of testing (more relevant in postmortem toxicology testing) are all factors to consider when interpreting opioid levels and their relation to toxicity.
4. Naloxone does not work 100% of the time. This antidote may not have been given early enough in the downward spiral of the opioid-poisoned patient’s clinical course, the dose was not high enough (eg, large dose of fentanyl), or a combination of the two.
5. Being in the mere presence of fentanyl will not put someone at risk for fentanyl poisoning (despite reports in the media). Now, if someone gets it on their hands and then eats without washing their hands or licks their hands, or if the fentanyl becomes aerosolized, then there is risk for great harm. Dermal exposure is risky but more so because the person may not realize they have the fentanyl on their skin and allow it to slowly absorb (fentanyl does not instantly absorb through the skin and enter the bloodstream). The fentanyl has to get into the blood and in order to do so it must cross our skin barrier (again, not instant) or get through one of our mucous membranes (eg, mouth, nasal passage). The ways on-scene responders can stay safe in such situations is beyond the scope of this article.

Dr. Muller is available to present seminars to attorneys on drugs of abuse and other toxicology-related topics. She has presented numerous continuing legal education programs to attorneys with an interest in learning the science behind their drug, chemical, and alcohol cases. She can be reached at Allison@AcriMullerConsulting.com.

Spice: A Seasoned Overview for Attorneys

Lately I’ve been presented with several legal cases involving “Spice”. A person may have used Spice and was involved in a criminal-related case or presented to medical care for the treatment of symptoms related to Spice. This is not a new street drug, as recreational use of Spice in the United States started in 2009. But due to Spice’s evolving presentation and misconceptions about its properties, this drug’s toxicology warrants an introduction and review for attorneys.

Spice is just one of the many names for synthetic cannabinoids (SCs). Other names include K2, Fubinaca, Fake Weed, Mr. Nice Guy, Black Magic, Scooby Snax…and the list goes on. SCs are sprayed onto dry plant material and sold in bags that look like “potpourri” or “herbal incense”. They may even be labeled as such – but the buyer knows that the contents are not for freshening their kitchen after cooking, however.

The actual chemical compounds found in samples of Spice will vary. SCs were originally developed for medicinal purposes to increase the pain-relieving effects that marijuana would deliver. However, Spice has no accepted medicinal use and according to a 2017 Drug Enforcement Administration report, 26 SCs are Schedule I substances under the Controlled Substances Act. There are more than 26 SCs out there as the SC formulations keep evolving.

SCs are not structurally related to marijuana. The two substances are similar in that they hit the same receptors in the body. However, SCs have more potent receptor-activity than marijuana and SCs do not contain the substances found in marijuana that “blunt” many adverse effects.

A urine drug screen, unless specifically designed to pick up synthetic cannabinoids, will not automatically pick up SCs. The drug is not similar to marijuana (cannabis) in structure, nor does it produce the same metabolites (breakdown products), so a positive result will not be produced by SCs if the drug screen only picks up marijuana. There are laboratories that can test specifically for SCs. These tests, even if geared to pick up SCs, will not pick up all SCs as different iterations of these compounds are continuing to be produced.

SCs are smoked or ingested and acute effects include increased breathing rate, increased heart rate, wide pupils, acute renal failure, nausea, vomiting, agitation, anxiety, and hallucinations (auditory and visual). Other possible acute effects include stroke, seizures, and serotonin syndrome. Serious reactions can manifest as schizophrenic in nature (hence the term “Spiceophrenia”), especially in those with a pre-existing psychiatric disorder or a predisposition for such, and include hallucinations, paranoia, agitation, and violent behavior. Marijuana can do this too but SCs can have greater psychoactive effects compared to natural cannabis. The duration of SC-related psychiatric effects varies from weeks to months and researchers continue to collect data on the long-term effects of these chemical compounds. The withdrawal symptoms following abrupt discontinuation of long-term SC use may present as severe anxiety, restlessness, nightmares, muscle twitches, increased heart rate, and increased blood pressure. Studies are also ongoing regarding the long-term effects of SCs and withdrawal patterns. The take-home message here is that there is not a black-and-white template for determining if a specific behavior is related to SC usage. As with all clinically-related cases, careful assessment of all background information and history is needed.

It is difficult to predict drug interactions with SCs as the amount and type of chemical in one batch of SCs to another vary. As a result, the metabolites formed and the pathways they are enhancing or inhibiting will vary.

The treatment of acute toxicity/withdrawal-related symptoms from SC involves emergency department and/or hospital admission for supportive care, benzodiazepines, and intravenous fluids. Antipsychotic drugs are also sometimes used and continued on an outpatient basis once the patient is stabilized. There is no reversal agent (antidote) for the effects of SCs so treatment is guided by the patient’s signs and symptoms. Of important note, there have been numerous reports of SCs being contaminated with a rodenticide, brodifacoum, that thins the blood. Patients using SCs would then present not only with some of the symptoms associated with SC previously described but also unexplained bleeding.

Dr. Muller is available to present seminars to attorneys on drugs of abuse and other toxicology-related topics. She has presented numerous continuing legal education programs to attorneys with an interest in learning the science behind their drug, chemical, and alcohol cases. She can be reached at Allison@AcriMullerConsulting.com.

Medication-Related Cases: 5 Questions for Attorneys to Ponder

There are some scenarios that may send red flags up that harm to a patient occurred due to a medication. The simplest (but unfortunately, least likely) scenario is when a healthy patient, taking no other medications, says “I just started taking this medication and as soon as I started taking it, something went wrong”. And, the “what went wrong” part has been well-documented in the medical literature. But harm from medications is not usually that easy to sort-out. 

Medication adverse events are not always obvious, even to the trained medical professional. There are reasons for this. A patient may have medical conditions that cloud the picture of an adverse drug reaction. There may have been a medication error (that is, wrong drug, wrong dose, or wrong patient) but it went unnoticed. Or, the medication error was noticed but not reported by the health care provider for fear of retribution or poor documentation. 

As a toxicologist, the first thing I am looking for when reviewing medical records is if any of the drugs given to a patient could have contributed to the patient’s medical condition. And of course, if a medication harmed a patient, how can this harm could have been prevented. 

For attorneys, there are the “top 5” things to think about when reviewing details of a medical case, which may or may not be a medication-related case from the get-go. Of course, a toxicology or other medical expert may be at your fingertips, but here are some tips for attorneys before that step is even a thought: 

1. Did a patient receive too much medication? 

The dose makes the poison. As a toxicologist, this is one of my favorite adages. There is so much truth to it. Yes, a drug or even a chemical can have a lot of dangerous effects associated with it. But the question becomes, how much was the patient actually exposed to? That is not always easy to answer. In the case of a hospitalized patient, we can only go by what is documented in the chart and we hope that the documentation is accurate. In the case of a patient who returns home with prescriptions, we don’t know with certainty if the patient was taking the drug as prescribed. Or, perhaps the patient was taking a drug not even intended for them. 

1. Was a medication appropriate for a patient? 

Even a “normal” dose of a drug may be harmful to a patient. How can this be? Didn’t we just ascertain that the dose makes the poison? Some other scenarios can be at play here. For example, were there other medical conditions that made a certain drug less tolerable and more toxic to a particular patient? Were there medications that interacted with one another, intensifying the effect of one or more of the drugs or extending the time the drug stayed in the body? As an attorney, don’t write off a possible medication adverse reaction just because the dose was acceptable. 

1. The dose of the drug was fine. Or…was it? 

What is an acceptable dose of a drug? Sometimes the answer is very patient-specific. There are drugs with very narrow margins of safety (drugs like lithium, phenytoin, warfarin). That is, a little bit off from an acceptable dose can lead to harm. Some drugs are based on the patient’s weight. Is there a weight documented in the medical records? Or was an “average adult” weight used to calculate the dose? Did the patient change their diet or have a recent gastrointestinal illness? This area is a little trickier and probably warrants a call to a toxicology expert. 

1. Were any antidotes included on a patient’s drug list? If so, why was it used? 

An antidote is used to reverse the effects of a drug. An attorney may not know why an antidote was used when it is encountered in a medical record. For example, was it simply to reverse the effects of anesthesia? Or was a drug given in an excessive amount and now its effect needs to be reversed by an antidote? Or did a patient have an adverse reaction to a drug that needs to be treated? Examples of antidotes are naloxone and flumazenil. It’s helpful to know why each and every drug on a medical record was used. You may be surprised what you find out. 

1. I see drug levels. Why are they here and what do they mean? 

Keep an eye out for drug levels in medical records. Why were they performed? Was it for routine monitoring of a patient or was it because there was an adverse medication event? Interpreting drug levels is challenging. Drug levels do not always correlate with how sick a patient is, or will become. Drug levels are measured in different ways and the interpretations of these tests is a science in itself. Keep your radar up when you see drug levels in a medical chart. But discuss them with a medical expert to help you connect the dots. Connecting the dots is what experts are there for.

Postmortem Toxicology: The Basics

Most often, I am asked by attorneys to review cases that involve the living. But at times, I am asked to review cases that involve the dead, and the question becomes: what happened before death? Specifically, what was the role, if any, of the drugs/chemicals/toxins found in the decedent’s body according to postmortem toxicology testing? Examples of such cases include those involving death following drug delivery, medication-related deaths, and fatal accidents (motor vehicle or workplace) following drug or alcohol use.

When it comes to drugs, it’s not straightforward (and at times, not possible) to determine what amount of drug was used prior to death. In my CLE talk “Postmortem Toxicology for Attorneys: What Can Dead People Tell Us?”, one of my main take-home points is that if all you have are postmortem drug levels, then all you have are … postmortem drug levels. I know, that sounds simplistic. But, it sums up the main point I want to make regarding such levels. There are published tables of postmortem blood concentrations for numerous drugs in the medical and forensic literature. The existence of such tables have created the expectation that one can simply look up drug levels on these tables, compare them with those from a postmortem toxicology report, and voilà! … determine if the drug was taken antemortem (before death) in a therapeutic, toxic, or fatal dose. Those tables have their time and place. However, they are not meant to be used in isolation but rather simply as the starting point of a toxicologic investigation. “User beware”.

There are numerous variables that can influence postmortem drug levels, making these published tables only a reference source. As a toxicologist interpreting postmortem drug levels, I want to hear a “story”. This story should include as many of these chapters as possible: the decedent’s medical history (eg, medical conditions, medication history, drug abuse history), information from the scene (eg, drugs, drug paraphernalia), witness accounts (what was the decedent’s behavior prior to death?), police reports, autopsy findings, when the postmortem samples were collected, the location from which the postmortem samples were collected, and the circumstances of death. There of course can be other chapters to this story (these are just a few). But I list these to illustrate that reliable interpretation of postmortem drug testing results hinges on more than just drug levels. 

Naloxone: The Antidote to the Opioid Epidemic? What Lawyers Need to Know

It’s not everyday that I get a room full of attorneys, who after a long day, want to learn some toxicology. But this week, I had not only a full room, but an engaged audience ready to learn about naloxone. This talk covered questions including: What is naloxone? How does it work? What are the reasons behind the opioid epidemic and how does naloxone fit in? How can this information help me with opioid-related cases (and how do I know if my case involves an opioid to begin with?) All these questions, and more, were covered in this 1-hour CLE course at Jenkins Law Library in Philadelphia.