Forensic Pharmacology

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Forensic Pharmacology Page 9

by B Zedeck


  Dimetapp®, Sudafed® preparations, and Robitussin-DM®. Its

  street names include candy, CCC (or Triple C, for Coricidin

  Cough & Cold), DM, DXM, and Robo. Use of Robitussin-DM®

  is termed “Robo-copping” or “Robo-tripping,” and use of Cori-

  cidin is termed “skittling.”

  Some street names for morphine are cube juice, hard stuff,

  hocus, M, Miss Emma, monkey, and white stuff. Names for

  opium includes big O, black stuff, Chinese tobacco, Dover’s

  powder, joy plant, and zero. Street names for heroin include

  dope, H, horse, junk, skag, and smack. The mixture of heroin

  and cocaine is termed a speedball. Names for codeine include

  Captain Cody, Cody, and schoolboy, and it is found in combi-

  nation with glutethimide.

  Opioids

  83

  Heroin is a Schedule I drug; morphine, codeine, fentanyl,

  hydrocodone, hydromorphone, and oxycodone are Schedule

  II drugs; codeine plus aspirin or acetaminophen is Schedule

  III; propoxyphene is Schedule IV; and codeine sold over the

  counter is Schedule V.

  PHARMACOLOGY OF OPIOIDS

  Depending on the type, opioids can be injected, smoked,

  snorted, or taken orally. Smoking heroin is termed “chas-

  ing the dragon.” Controlled-release oral tablets of morphine

  (MS-Contin®) or of oxycodone (OxyContin®) should never

  be crushed or chewed, as the entire dose of opioid released at

  once may be toxic.

  Oral opiates are absorbed well from the intestinal tract.

  Morphine, however, is significantly metabolized via first-

  pass metabolism and is excreted via enterohepatic circula-

  tion. Heroin crosses the blood-brain barrier much more

  efficiently than morphine, resulting in a greater effect

  (Figure 8.2). Opioids are distributed to many organs and

  are found in breast milk. They cross the placenta, and

  infants born to mothers who abused opioids during preg-

  nancy show signs of dependence and withdrawal. About

  10% of codeine is demethylated to produce morphine that

  is responsible for codeine’s analgesic effect. The half-life of

  morphine, codeine, and heroin is two to four hours. Only

  about 10% of morphine is excreted in urine unchanged, and

  heroin, morphine, oxycodone, and codeine can be detected

  in urine for up to two days after use. Opioids act on sev-

  eral receptors, namely, mu (μ), believed responsible for the

  “high” as well as for the analgesia, sedation, and depres-

  sion of respiration, kappa (κ), delta (δ), and sigma (σ).

  84 Forensic Pharmacology

  Figure 8.2 Heroin is a derivative of morphine. It can be manufactured

  synthetical y by replacing the two hydroxyl (OH) groups in morphine

  with two acetate (CH3COO) groups; thus, an alternate name for heroin is

  diacetylmorphine.

  Dextrorphan, the metabolite of dextromethorphan, blocks

  the NMDA receptor.

  Behavioral effects of opioids include euphoria, sedation

  and mental clouding. Physiological effects include respiratory

  depression, decreased heart rate, contraction of the pupil, con-

  stipation, nausea, and vomiting. Opioids can also release his-

  tamine from body stores, causing severe itching, hypotension,

  sweating, and flushing.

  Opioids

  85

  Overdosing causes stupor and coma. Pulmonary edema

  occurs, and froth can be seen coming from the nose and

  mouth. An antidote for an opioid overdose is naloxone (Nar-

  can®), which can rapidly displace the opioid from the receptor.

  Overuse of dextromethorphan can induce euphoria, sedation,

  ataxia, increased awareness, sweating, elevated blood pressure,

  arrhythmia, hallucinations, and coma. Some of the dextro-

  methorphan effects resemble those of phencyclidine.

  Opioids induce tolerance, and severe withdrawal signs and

  symptoms occur 8 to 12 hours after the last dose. The individual

  begins to yawn, and the eyes begin to tear. Sweating, fever,

  increased blood pressure and heart rate, piloerection (goose

  flesh), dilated pupils, insomnia, chills, gastrointestinal and mus-

  cle cramps, nausea, vomiting, and diarrhea may last for 7 to 10

  days. Thus, to abruptly stop taking opioids, known as “going cold

  turkey,” is a very painful and stressful period for about a week.

  Methadone, distributed at medical centers, is cross-tolerant

  with morphine and heroin and reduces the withdrawal effects.

  Methadone’s effects are long lasting and can be given once daily,

  thereby reducing the time spent trying to obtain drug. The dose

  of methadone is gradually lowered until the individual no lon-

  ger needs any opioid.

  FORENSIC ISSUES

  A positive urine test result for opioids does not necessarily

  mean that the individual used drugs illegally. The GC/MS

  instrument is very sensitive, and any morphine detected

  could have come from the individual having eaten poppy

  seed-containing bagels or pastries shortly before the test.

  Also, many people are prescribed opioid-containing analge-

  sics such as Tylenol® with codeine, Percodan®, and Percocet®,

  and their urine samples will test positive. At the time of urine

  86 Forensic Pharmacology

  collection, it is important to list the foods or drugs taken in the

  prior 24 to 48 hours. Several quinolone antibiotics, including

  levofloxacin (Levaquin®) and ofloxacin (Floxin®), can give

  false-positive results for opioids in screening procedures.

  The initial metabolism of heroin involves loss of one acetyl

  group, forming 6-monoacetylmorphine, or 6-MAM. If 6-MAM

  is detected in body fluids and tissues, it can only have come

  from heroin. When 6-MAM is further metabolized, it loses the

  second acetyl group and forms morphine. At this point, finding

  morphine, is not helpful in determining whether the individual

  had used heroin or morphine, or even codeine, since it also is

  metabolized to morphine.

  Examples of cases involving opioids include murder, acci-

  dental death, positive urine drug test results in child custody

  cases, and medical malpractice. In one medical malpractice

  case against a physician and a pharmacist, a man who had been

  prescribed Tussionex® was found dead. Tussionex® contains

  hydrocodone and an antihistamine, chlorpheniramine, and is

  used to treat cough, cold, and allergy. At autopsy, blood analysis

  revealed the presence of high levels of hydrocodone and also

  the benzodiazepines flurazepam and diazepam. Urine analysis

  indicated the presence of unchanged cocaine, suggesting use

  within the last 8 to 12 hours. All the data led to the conclu-

  sion that the deceased had taken an unusually large amount of

  Tussionex® that by itself might have been lethal, but that the

  combination of hydrocodone and the nonprescribed benzodi-

  azepines depressed the CNS and caused death.

  SUMMARY

  The opioids contain natural and synthetic compounds that are

  medicinally used as analgesic, antidiarrheal, and antitussive

  agents. Opioids are CNS depre
ssants and decrease blood pres-

  Opioids

  87

  sure, heart rate, and respiration. They can cross the placenta

  to affect the fetus. Abuse of opioids can lead to tolerance and

  physical dependence. Withdrawal is severe, and several drugs,

  based on cross-tolerance, have been used to minimize with-

  drawal and to wean the individual off opioids.

  9

  Hallucinogens

  There are two subgroups of hallucinogens: the indolealkyl-

  amine derivatives and the phenethylamine derivatives. The

  indolealkylamine derivatives, which are related to the neu-

  rotransmitter serotonin (5-HT), include lysergic acid diethyl-

  amide (LSD), psilocybin, N,N-dimethyltryptamine (DMT), and

  bufotenine. The phenethylamine derivatives are related to the

  neurotransmitters epinephrine, norepinephrine, and dopamine,

  and include mescaline and methylenedioxymethamphetamine

  (MDMA, also known as ecstasy). All of the hallucinogens are

  Schedule I drugs.

  In 1938, at the Sandoz pharmaceutical firm, a Swiss scientist,

  Dr. Albert Hofmann, synthesized LSD from lysergic acid, which

  is produced by the fungus Claviceps purpurea that infects rye

  and other grains. He took the drug himself and was amazed at

  the psychosis-mimicking (psychotomimetic) effects. The CIA

  secretly tested LSD as a mind-controlling drug, and these experi-

  ments resulted in at least one death and led to congressional and

  presidential investigations.15 Some street names for LSD include

  acid, blotters, California sunshine, Lucy in the sky with diamonds,

  panes, paper, pyramids, stamps, sugar, trips, and white lightning.

  88

  Hallucinogens

  89

  Psilocybin can be found in over 100 species of mushrooms in

  Mexico, Central America, and northwestern and southeastern

  parts of the United States. Some of the common mushroom vari-

  eties are Psilocybe mexicana, Psilocybe cubensis, Psilocybe azure-scens, and Psilocybe cyanescen. Street names include Alice, magic

  mushrooms, purple passion, shrooms, and silly putty.

  DMT is found in the South American plants Virola calophylla

  and Mimosa hostilis, and in grasses, mushrooms, toads, grubs,

  and fish, and has been used by the Amazon natives for spiritual

  effects. DMT was synthesized in 1931.

  Bufotenine was isolated from skin and parotid gland of the

  toad Bufo vulgaris in 1893, and from plants and mushrooms. It

  is also found in the toad Bufo marinus that lives in the southern

  part of the United States and the Caribbean, and in Bufo alvarius,

  found in the southwestern United States. Amazon explorers had

  described poisoning by toad and mushroom preparations more

  than 400 years ago. Street names include black stone, Chan Su,

  Chinese love stones, cohoba, rock hard, Stud 100, and toad.

  Mescaline is an alkaloid isolated from the peyote cactus, spe-

  cies Lophophora williamsii or Anhalonium lewinii, that grows in the southwestern United States and in Mexico. Mescaline

  is found in “buttons” that grow on top of the plant. Aztec and

  Native American Indians used the buttons in religious rites and

  for treatment of snakebite, flu, and arthritis. Some street names

  include bad seed, blue caps, cactus buttons, devils root, mesc,

  moon, peyote, shaman, and tops.

  Methylenedioxymethamphetamine (MDMA) was synthe-

  sized in 1912 and patented in 1914 by Merck as an appetite sup-

  pressant, but was never marketed (Figure 9.1). Since the middle

  1980s, MDMA, which is primarily known as ecstasy, has become

  a popular drug at raves. The final product often contains other

  stimulants such as caffeine or cocaine. Users of ecstasy report

  enhanced communication and empathy with others. A 2002

  90 Forensic Pharmacology

  Figure 9.1 MDMA (3,4-methylenedioxymethamphetamine) is a

  synthetic drug better known by its street name, ecstasy. It has the

  chemical formula C11H15NO2.

  NIDA study found that 4.3% of eighth graders, 6.6% of tenth

  graders, and 10.5% of twelfth graders used ecstasy at least once.

  A 2004 study found that 1.7% of eighth graders, 2.4% of tenth

  graders, and 4% of twelfth graders had used ecstasy at least once

  in the preceding year. 16

  Street names for MDMA, besides ecstasy, include Adam, E,

  ecsta eve, Eve, H-bomb (with heroin), hug drug, love drug, M,

  pikachu (with PCP), psychedelic amphetamine, Versace, X, and

  XTC. Tablets of ecstasy usually have imprinted monograms.

  Some examples include E-mail, D&G, Rolex, Nike, Fred Flint-

  stone, Pokemon, Batman, and cupid.

  PHARMACOLOGY OF HALLUCINOGENS

  LSD is the most potent psychoactive drug and is believed to be

  3,000 to 4,000 times more potent than mescaline. LSD is used

  in tablets (microdots), capsules, sugar cubes, thin squares of

  gelatin (window panes), or liquid form, or it is added to absor-

  bent paper with various designs that is cut into small squares

  Hallucinogens

  91

  and placed on the tongue (Figure 9.2). It is absorbed rapidly

  from the gastrointestinal tract, and effects begin within 5 to

  10 minutes. Animal studies indicate that LSD can pass the pla-

  centa, but reports of birth defects and chromosomal changes

  have not been proven conclusively. The half-life of LSD is about

  three hours. LSD can be detected in urine after one to two

  hours and for about four days.

  Psilocybin mushrooms are chewed or used to make a tea,

  or ground into powder. The effects begin approximately 30

  Figure 9.2 Acid tabs, shown above, are impregnated with

  “acid,” or lysergic acid diethylamide (LSD), a psychedelic drug and

  hallucinogen, illegal in most countries but still commonly used for

  recreational purposes. LSD is colorless and odorless, and its effects

  are unpredictable.

  92 Forensic Pharmacology

  to 60 minutes later and last for about four hours. It is con-

  verted in the liver to psilocin, the biologically active molecule.

  Psilocybin and glucuronidated metabolites are detected in

  urine within several hours after use and for up to three days

  thereafter.

  DMT and bufotenine are destroyed in the intestine, and thus

  cannot be taken orally. Instead, they are smoked or snorted.

  DMT can also be injected, and effects begin in two to five

  minutes. The effects last less than 30 minutes, and, because of

  its short-acting effects, DMT is known as the “businessman’s

  lunch.” Bufotenine’s effects last from 4 to 12 hours.

  Mescaline-containing “buttons” on top of the peyote cactus

  can be chewed or used to make a tea, or ground into a powder.

  Mescaline is absorbed rapidly, and effects begin between one-

  half and two hours after ingestion. Its half-life is six hours. Much

  of mescaline is excreted unchanged in urine as soon as one hour

  after use and for up to four days. In animal studies, there is evi-

  dence that mescaline passes into the fetus and can induce mal-

  formations. Mescaline, LSD, psilocybin, and DMT all activate

  the same serotonin receptor
subtype in the brain.

  Ecstasy is taken orally in pill or capsule form, and effects

  begin about 45 minutes later and last three to six hours (Figure

  9.3). Large amounts of drug can be detected in urine as soon

  as one hour after use and for about three days. The half-life

  of ecstasy is about eight hours. Ecstasy works on serotonin-

  containing neurons. Initially, it leads to an increased release

  of serotonin from nerves and inhibits reuptake, resulting

  in increased serotonin levels in the synapse. Eventually,

  because of depletion and permanent damage to the serotonin

  nerve networks, it results in decreased serotonin levels. It

  also releases dopamine and norepinephrine. Ecstasy causes

  euphoria, an increase in energy, increased communication,

  and increased sexual drive. In addition, ecstasy causes teeth

  Hallucinogens

  93

  Figure 9.3 Ecstasy tablets are manufactured in a variety of colors

  and are often imprinted with a monogram.

  grinding and breakdown of skeletal muscle. Tolerance devel-

  ops rapidly.

  Effects of hallucinogens can be unpredictable, depending on

  the drug and dose, the user’s expectations, and the surround-

  ings in which the drug is used. Physiological effects common

  to all hallucinogens include dilated pupils; increased heart

  rate, blood pressure, and body temperature; sweating; nausea

  and vomiting; headache; loss of appetite; sleeplessness; dry

  mouth; shaking; speech difficulty; loss of coordination; muscle

  rigidity; and visual sensitivity to light. Common psychologi-

  cal effects include delusions and hallucinations, including the

  94 Forensic Pharmacology

  ability to see music and hear colors (an effect called synesthe-

  sia). The user’s sense of time and self can change, and he or she

  may feel several different emotions all at once or swing rapidly

  from one emotion to another, and exhibit impaired concentra-

  tion, judgment, and attention. Paranoia, anxiety, confusion,

  and depression may develop. Tolerance develops, but not signs

  of withdrawal. Cross-tolerance to LSD, mescaline, and psilo-

  cybin has been reported. LSD users refer to their experience

  as a “trip” and to adverse reactions of terrifying thoughts of

  insanity, despair, and death as a “bad trip.” This can last for

  several hours. Many LSD users experience “flashbacks,” recur-

 

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