Supervisor Forensic Toxicology Rhode Island Department of Health Overview Introduction to FT Impaired Driving Program Local and National Statutes FT DUI Testing Protocol Process Analytical Instruments ID: 1032347
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1. Forensic Toxicology Robert Almeida, MS, D-ABFT-FT, TC-NRCCSupervisor, Forensic ToxicologyRhode Island Department of Health
2. OverviewIntroduction to FTImpaired Driving ProgramLocal and National StatutesFT DUI Testing Protocol/ ProcessAnalytical InstrumentsPharmacology of Drugs and Ethanol
3. Forensic ToxicologyThe analysis of biological specimens (ex. body fluids, tissues & organs) to determine the presence or absence of drugs and/or poisons for medico-legal purposes.
4. Forensic ToxicologyDid drugs and/or alcohol cause or contribute to an individual’s death or behavior?
5. Forensic ToxicologyDrugs and Poisons in Biological SamplesThree Sub-disciplines:Post-mortem toxicology:Autopsy specimensManner and cause of deathUrine drug testing:Pre-employment or on the job drug useDrug maintenance programHuman performance toxicology
6. Human Performance Toxicology“Behavioral toxicology”How drugs influence human performance or behaviorPhysically and psychologicallyLegal consequences of alcohol and drug useLaw Enforcement:Impaired-drivingDrug facilitated sexual assaultOther criminal acts while under the influence of a drug
7. “Drunk” Driving Alcohol/ Ethanol RelatedCorrelation between ethanol in the blood and the level of impairmentStatutes: Motor Vehicle OffensesAll fifty statesBlood Alcohol Concentrations/ set measurements:Driving Under the Influence (DUI): 0.08%Driving While Impaired: 0.02%D.O.T./Federal: 0.04%Additional/Aggravated Offenses per StatutesProposed legislation
8. “Drunk” Flying March 2016 @ 7:00 AMDetroit to PhiladelphiaFifty year old AA co-pilot arrested in the cockpitOperating an aircraft while under the influence of alcoholLegal limit: 0.04%Breathalyzer: 0.08%Misdemeanor
9. Drugged Driving LawsAll states have laws against drugged-driving*No set measurements for DUID.Why?Alcohol is a simpler compound and therefore processed more easily than drugs.No close link between blood and drug levels and measured impairment.Interactions occur with drug-drug and drug-alcohol combinations.Emergence of new designer drugs and their effects.
10. Rhode Island DUID StatuteZero tolerance per se lawTook effect July 1, 2006Guilty of DUID: “…operates a vehicle while under the influence of any intoxicating liquor, drugs, or any controlled substance...”Guilty of DUID: “…blood presence of any controlled substances”
11. DEA Controlled SubstancesUniform Controlled Substances ActCategorize drugs according to their potential danger to the publicFive tiers (I-V) Accepted medical use and potential for abuse/ dependenceInclude illicit and prescription drugs
12. Impaired Driving Operation of a motor vehicle while under the influence of alcohol and/or drugsDUI, OUI, DWI, DUIDDrugged driving: use of impairing substances:Illegal drugsChemicals/InhalantsMisuse of prescription drugsMisuse of over the counter medications
13. Effects of OH and Drugs on DrivingReaction time: increased or decreasedImpaired judgement/decision makingImpaired visionInability to multi-taskImpaired coordinationInability to process information or detect hazards
14. Effects of Drugs on DrivingAttention:Divided, not focusedTracking:Staying in lane of travel: Weaving/ Wrong-wayMaintaining proper distancePerception:Predominately visualEnvironmentGlareDark and light
15. Pharmacodynamics/ -kineticsPharmacodynamics:The study of effects of drugs in the body“what a drug does to us”Categories
16. Drug ClassificationsClasses of drugs and/or metabolites:CNS StimulantsCNS DepressantsNarcoticsHallucinogensInhalantsOverlap with CNS effects
17. CNS StimulantsCocaineAmphetamine (Adderall), MDA (Sally), Methamphetamine, MDMA (Ecstasy, Molly)Methylphenidate (Ritalin)Schedule II drugs
18. CNS StimulantsPhysiological and psychological effects:Increased brain activity/alertnessQuick speech/ movementsRestlessness/ agitation/ fidgety/ pacingHyperactivityIncreased BP, HRFeelings of euphoria/ superiority/ paranoiaHighly addictiveWithdrawal symptoms
19. Cocaine DUID Case35 YO male driverPO observed MV approaching at a high rate of speedEstimated 60 mphTailgatingAggressive behavior: Yelling and argumentativeDilated pupilsToxicology findings:Positive cocaine
20. CNS DepressantsPsychological/ Behavioral Effects:Sleeping, lessen anxietyDifficulty thinking and processing thoughtsImpaired judgementDiminished concentration, memory, attentionDrowsinessPhysiological Effects:Slurred speechIncreased reaction timeMuscular incoordination/ loss of balance
21. Ethanol/ Ethyl AlcoholC2H5OHColorless liquid, generally diluted in waterMost frequently seen drug in FTLCNS DepressantPotentiation with other CNS depressants, ex. narcotics, barbiturates, tranquilizersMay mask other drugs presentBlood alcohol level is proportional to the concentration of ethanol in the brain
22. CNS DepressantsReduce anxiety, induce sleep, or dull sensesDrugs:BarbituratesBenzodiazepinesNarcoticsAnti-histamines/Allery: Diphenhydramine (Benadryl) Sleeping aids- Ambien, SominexMuscle relaxants- Soma, FlexerilCold/Flu meds
23. BenzodiazepinesAnti-anxietyOCDPanic disordersTablet or IV formMost commonly seen Rx med. Diazepam/ ValiumAlprazolam/ XanaxClonazepam/ KlonopinBenzene ring, Diazepine ring Long or short actingDesigner “Benzos”
24. Narcotic AnalgesicsMost commonly prescribed drugPotent painkillersOpiates/ OpioidsStrong CNS depressantsHighly addictiveSedation/ sleepiness, nodding offRespiratory suppressionReceptorsSchedule II Schedule I
25. Opiates/ OpioidsRx or illicit:Morphine/ heroinCodeineOxycodoneHydrocodoneMethadoneTramadolFentanylFentanyl analogs
26. ZolpidemPrescription DrugTrade name: AmbienCNS depressantFast acting sedative hypnoticPrescribed for short-term treatment of insomniaDose taken immediately before bedtimeDo not take with alcohol or CNS depressantsDEA Schedule IV controlled substanceKnown to cause sleep-walking, -eating, -drivingTop 10 drugs found in impaired motorists
27. Zolpidem DUI Case 2014Fifty-four year old femaleReports of a MV operator driving over neighborhood lawns and striking her SUV into her garageOfficers report female sitting in the driver’s seat with the engine running and MV pinned up against the garage doorThe gear was in “Drive”Driver staring straight ahead in a trance-like state.PO request that the SUV be put into “Park” and she stated “It is and my friend is driving”
28. Zolpidem DUI Case 2014She then put the SUV into reverse.DisorientedMumbled speechIncapable of answering simple questionsUnsteady on her feetDenied using alcohol or drugs that dayToxicology finding: Negative alcoholPositive ZolpidemRepeat offender from two years prior
29. InhalantsChemical productsMore frequently used by younger people“Huffing”Used to change one’s mental stateEffects on driving:Impaired thought processHallucinationsDelusionsDizzinessMuscular incoordinationDisorientation
30. InhalantsGlueGasolinePaint thinnerDust-offSharpiesSpray PaintNitrous oxide
31. “Huffing” Case23 YO male driverSlumped over steering wheelDriving through a parking lotA witness honked her hornAccelerated the MV, went over a curb, and hit a parked carPO found computer dusting sprayToxicology finding:1,1-difluoroethane
32. HallucinogensAltered perception of realityVisualAuditoryEmotionsMarijuana (THC)Synthetic CannabinoidsBath SaltsLSDPCPPsilocybin/ Psilocin
33. MarijuanaCannabis plantTHC active componentHashish, hash oilSmoked or eatenUsed for treating chronic pain and nauseaAddictiveWithdrawal Attributed to decreased motivationIncreased inactivityHallucinogen and CNS depressant
34. MarijuanaTargets cannabinoid receptors in the brain:Effect:PerceptionMemoryMoodSleepAppetiteMost frequently found illicit drug in drivers involved in a motor vehicle accident
35. Pharmacodynamics/ -kineticsPharmacodynamics:The study of effects of drugs in the body“what a drug does to us”Pharmacokinetics:The study of drugs in the body“what we do to a drug”ADME:
36. Absorption- EthanolAlcohol appears in the blood within minutes after consumption:Stomach and small intestinesComplete in generally 30-90 minutesMaximum BAC is reachedPost-absorption
37. Absorption Rate- EthanolDepends on:Amount of alcohol consumedType of drinkTime of consumptionPresence of food in the stomachHealth of the individual
38. Absorption- DrugsMost concentrated at the point of entryRoutes of administration:Oral:GI tract, stomach, intestines, and liverInhalation:Through the lungs; “huffing” solvents, gases, smokingRapid absorptionIntravenous: Most efficient; drug administered directly into the bloodstream; bypass the stomach and liver
39. Absorption- DrugsIntranasal:Insufflation; snorting; cocaine, heroinIntramuscular:Less efficient; slower transfer to the bloodstreamSublingual:Oral mucosa, tongueRapid absorptionDermal:Patches: fentanyl, nicotine
40. DistributionEthanol: Carried to watery parts of the bodyBlood, brain, vitreous humorTransfer from blood into the tissuesDistributes to heart, liver, kidney, and brain Muscle and fat more slowlyVolume of distribution: theoretical valueVd= D/CEx: Alcohol: <1; Amitriptyline: 11-18
41. MetabolismProcess of altering the drug to eliminate it from the bodyDetoxification processPrimarily in the liverPhase I:Transform functional groupsMay form other active compounds (metabolites)Ex. Diaxepam/ Valium; NordiazepamPhase II:Mostly inactive, water soluble compounds
42. EliminationExcretionFinal removal from the bodyKidney and liverException:EtOH: also eliminated through the lungs and sweatDrugs also eliminated into breast milkElimination rates:Zero order: constant amount cleared from the blood per unit time; ex. EtOHFirst order: constant fraction of drug is removed from the blood per unit time; half-lives
43. Elimination- EthanolOxidation: Liver enzymes 95% to CO2 and waterExcretion: 5% unchanged stateBreath, sweat, and urineAmount of alcohol exhaled in breath is proportional to BACHenry’s Law2100:1 mL
44. The Process of a RI DUID CaseEstablish probable cause:Observation of improper driving or equipment violation by a PO Evaluation /interview of the driverStandardized Field Sobriety Tests performed outside of MVBlood collectionBlood samples taken and submitted to the FTL
45. Blood vs. UrineBlood specimen necessary to determine impaired drivingBlood is circulating throughout the bodyIn equilibrium with the brainPresent in the CNSUrine is an end-product of biological processes:Absorption, Distribution, and MetabolismPooled sample over timeDrugs present for days-weeksMay not be present in the blood
46. Blood vs. BreathBreath is an easily obtainable, non-invasive sample for testing alcohol use.Provides a fast and accurate result.Breathalyzer instrument cannot detect drugs
47. FTL Evidence
48. Specimen Tubes
49. DUI Scope of TestingEthanol/Volatiles/InhalantsDrugs: 2 stepsPreliminary screeningPresumptive resultClasses of drugsConfirmatory testing:Specific/directed testingTwo different test methods necessary to report a positive result
50. Alcohol TestingHeadspace Gas chromatography Separation techniquePartition effect:Stationary phaseMobile phaseFlame ionization detectorRTWell established and acceptedHighly specific and sensitive
51. Gas Chromatograph
52. GC Volatiles Chromatogram
53. Headspace Gas Chromatograph
54. TerminologySensitivity:Measure of the method’s ability to detect an analyteDistinquish true negatives from true positivesLimits of detection and quantification Specificity:Measure of the method’s ability to correctly identify an analyteCross-reactivityEx. Immunoassays, Confirmatory tests
55. Forensic Drug Testing A two step process:Preliminary screening:ImmunoassayConfirmatory testing:GCGC/MS LC/MSWell established and accepted techniques
56. Comprehensive Drug TestingClasses of drugs and/or metabolites:CNS StimulantsCNS DepressantsNarcoticsHallucinogensInhalantsIllicit and Rx
57. Prescription and OTC DrugsAnti-depressantsAnti-psychoticsMuscle relaxantsAnti-seizure CardiovascularCold/Flu MedsCough syrupsAnti-histaminesSleeping aids
58. Preliminary TestsFirst step in forensic drug testing“Immunoassay”Presumptive ScreensQualitative assaysClasses of drugsDisadvantages:Limited scope of testingFalse negatives and positives are possibleNot forensically defensible without confirmation
59. ELISA TestEnzyme linked immunosorbent assayCompetitive bindingAntibody-Antigen reactionAdvantage:AutomatedHigh sensitivityApplicable to blood and post-mortem specimensDisadvantage:Low specificity
60. ELISA Screening TestAntibody-Antigen Reaction
61. ELISA Process Antibody coated platesSample + ConjugateIncubation/ competitive bindingWashSubstrateReaderMeasures absorbance of conjugate in sample and standardsInversely Proportional
62. ELISA Principle
63. ELISA Preliminary Testing
64. ELISA Tecan System
65. Confirmatory Testing Second phase of forensic drug testingAll positive screening tests require confirmatory test utilizing a more specific and sensitive chemical principle.Qualitative or quantitative analysisGas or liquid chromatograph Mass spectrophotometer detectorGC/MS or LC/MS
66. Confirmatory TestingDetect and identify specific drugs presentBroad scope of analytes, including metabolitesDetect minute amountsForensically defensibleWidely accepted methodologyExtensive scientific literature and informationRequires separation of the drug from the sample matrixLabor intensiveExpensive instrumentation
67. Analytical OverviewBlood specimenIsolate the drug/analyte of interestChemical property of the drugLiquid-liquid extractionSolid phase extractionAnalysis:HPLC, GC, GC/MSData Processing/Review/Interpretation
68. Liquid-liquid ExtractionMost frequently used techniquepH adjustment with buffer, acid, or baseExtract with an organic solventHexane, chloroform, dichloromethaneProperty of the drug of interest:? Acidic, neutral, or basic drug/ functional groupsGood recoveries but time consuming
69. Solid Pase ExtractionCommercially prepared columnsContains sorbent/ resin/ silicaSeries of stepsAcid, neutral, basic drugsFully automatedAnalyze
70. Solid Pase Extraction
71. Solid Phase Auto-extractor
72. Mass Spectrometer DetectorCoupled with GC or LCIdentifying techniqueInlet, electron ionization, bond breaking and fragmentation, analyzer, detectorResulting in a drug “fingerprint”MS database/ libraryHighly accurate, sensitive, and specific
73. GC/MS System
74. GC/MS TICSKF-525A:ProadifenInternal Standard2 unknown peaks
75. GC Mass SpectraGC/MS Cocaine chromatogram
76. GC/MS System
77. InterpretationA toxicologist can:Test the sampleInterpret the analytical resultTestify clearly to the effects of drug present in the driver
78. InterpretationA toxicologist cannot:Determine impairment in a specific individual from a single blood resultDetermine how much drug was takenDetermine exactly when a drug was taken
79. InterpretationIs the driver impaired?Cannot give an opinion based solely on positive toxicology resultsNeed information gathered by the investigator at the sceneObservations, situation, environment, SFSTs
80. Drug Interpretation IssuesNo legal guidelinesCase-by-case basisPolypharmacy/multiple drug use:Synergistic effect with other like drugsMixed classesIndividual toleranceMetabolites
81. 2018 Toxicology Stats188 DUI cases submitted96.3% DUI cases positive for ethanol or drugs 50% Positive EthanolAve. BAC= 0.18 g% ethanol66% Positive DrugsDrugs: THC, Fentanyl, Cocaine, Methadone, Benzodiazepines 22%: Ethanol + Drugs
82. ConclusionIndividual impairment increases as a drug’s concentration increases in the bodyEthanol and drugs effect a driver’s ability to safely operate a MV and increase the risk of a MV crashDo not mix alcohol and drugs
83. Robert Almeida, MS, D-ABFT-FT, TC-NRCCSupervisor, Forensic Toxicology401.222.5565robert.almeida@health.ri.gov