Drug Abuse Handbook, Second Edition

1286 Pages·2006·26.45 MB·English

by  Steven B. Karch MD FFFLM

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Half Title Page
SECOND EDITION
Drug Abuse
Handbook
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Title Page
SECOND EDITION
Drug Abuse
Handbook
Editor-in-Chief
Steven B. Karch, MD, FFFLM
Consultant Pathologist and Toxicologist
Berkeley, California
Boca Raton London New York
CRC Press is an imprint of the
Taylor & Francis Group, an informa business
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CRC Press
Taylor & Francis Group
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© 2007 by Taylor & Francis Group, LLC
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Printed in the United States of America on acid-free paper
10 9 8 7 6 5 4 3 2 1
International Standard Book Number-10: 0-8493-1690-1 (Hardcover)
International Standard Book Number-13: 978-0-8493-1690-6 (Hardcover)
This book contains information obtained from authentic and highly regarded sources. Reprinted material is quoted
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Library of Congress Cataloging-in-Publication Data
Drug abuse handbook / [editor-in-chief] Steven B. Karch.-- 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-8493-1690-6 (alk. paper)
ISBN-10: 0-8493-1690-1 (alk. paper)
1. Drugs of abuse--Handbooks, manuals, etc. 2. Drug abuse--Handbooks, manuals, etc. 3. Forensic
toxicology--Handbooks, manuals, etc.
[DNLM: 1. Street Drugs--pharmacology--Handbooks. 2. Forensic Medicine--Handbooks. 3.
Substance
Abuse Detection--Handbooks. 4. Substance-Related Disorders--Handbooks. QV 39 D794 2006]
I. Karch, Steven B.
RM316.D76 2006
615’.19--dc22 2006008334
Visit the Taylor & Francis Web site at
http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
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Preface
By the time this weighty volume is published, more than 10 years will have passed since I first
approached Taylor & Francis (formerly CRC Press) about this project. I was surprised and delighted
when they agreed to undertake this second edition. In the preface to the first edition I told readers
that “a tremendous amount” had been learned about the problem of drug abuse, and I observed
that most of the learning had been done not by pathologists, or even toxicologists, but rather by
molecular biologists and neurochemists. That observation remains true today, even after all of the
opiate receptors have been cloned, at a time when it impossible to look at drug–receptor interactions
in ways that were inconceivable only a decade ago.
In the preface to the first edition I also complained about the slow progress being made in more
traditional, less “exotic” fields. The advent of the phenomenally popular CSI television show helped
raise public awareness of crime scene investigation. Industry is certainly aware of the amazing
progress and has not been slow to capitalize upon it, even to the extent of funding some badly need
research. The same kind of progress in understanding the effects of drug abuse has not occurred
in the field of pathology, or any other medical specialties, for that matter. To the best of my
knowledge, during the last decade, The National Institute of Drug Abuse (NIDA) has not funded
even a single pathologist interested in studying the effects of abused drugs on the heart, or pancreas,
or any other organ in the body; no pathologist sits on any of the NIH review boards. Some might
say this is the very opposite of progress. There is very little difference between the way doctors
treat cases of drug toxicity nowadays and the way they did so 30 years ago. The last really great
advance in this field was the introduction of naloxone. “Compassionate,” or not, the medical
management of sick drug users is no more a priority of our current administration than of the
previous one.
Like it or not, the scientific study of drug abuse–related disease constitutes an important part
of forensic science. When are drugs the cause of death and when do they cause impairment? It
turns out that the metabolism of different drugs varies greatly from individual to individual. Some
of these differences remain apparent even after death, but many, if not most, are not visible to the
naked eye. Not many medical examiners have the training, let alone the equipment, to test for
invisible disease.
Does a very high fluoxetene level in a dead child signify a lethal overdose, or attempted murder,
or is it a fluke of nature? The questions are more than academic, because the answers may determine
whether criminal charges will be filed against the parents. Accordingly, this second edition of the
handbook contains new chapters on both toxicogenetics and on the genetics of sudden cardiac
death. Anyone who felt that they had mastered the art of DNA had best rethink their conclusions.
Far from being a developed discipline, DNA testing is still only in its infancy. Should there be a
third edition of this book, it will no doubt focus largely on DNA-related science; a great deal more
than matching up single nucleotide polymorphisms is involved.
Readers will also note the addition of a section on legal notions of causation. Doctors have
known for years that the search for scientific truth is best carried on outside of the courtroom. What
most doctors do not know is that in the minds of jury members, their opinions carry no more, and
no less, weight than the opinion of any laboratory technician. Worse, both doctor and technician
are likely to have only a vague idea of what constitutes proof, and what constitutes junk science.
But, in fact, there is an easy way to tell: just use the scientific method. Most of this book is
concerned with forensic science, the clinical management of toxic patients, and the management
of addicted patients. At some point there must a convergence of these fields, and at some point all
of these different disciplines become an evidence-based field. Case reports describing possible
episodes of drug toxicity in solitary patients 30 years ago are insufficient to establish causation,
not in the courtroom and not in the laboratory. Isolated post-mortem blood drug levels, no matter
how “significant,” are insufficient to establish the cause of death. A great deal more work and
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knowledge are required before that can be done. No matter how great the scientific advances of
the next decade, there will be no real and lasting impact on everyday practice, at least not until
what we do is, in fact, evidence based.
As should be apparent from the size of this volume, many individuals expended considerable
energy to produce this book. It is probably a good thing that this book took so long to prepare
because most of the truly exciting discoveries have occurred only in the last few years.
My thanks to all of the contributors, and my best wishes to the next editor. I do hope he or she
will have more positive and exciting things to report.
Steven B. Karch, M.D., FFFLM
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The Editor
Steven B. Karch, M.D., FFFLM, received his under-
graduate degree from Brown University. He attended grad-
uate school in anatomy and cell biology at Stanford Univer-
sity. He received his medical degree from Tulane University
School of Medicine. Dr. Karch did postgraduate training in
neuropathology at the Royal London Hospital and in cardiac
pathology at Stanford University. For many years he was a
consultant cardiac pathologist to San Francisco’s Chief Med-
ical Examiner.
In the U.K., Dr. Karch served as a consultant to the
Crown and helped prepare the cases against serial murder
Dr. Harold Shipman, who was subsequently convicted of
murdering 248 of his patients. He has testified on drug
abuse–related matters in courts around the world. He has a special interest in cases of alleged
euthanasia, and in episodes where mothers are accused of murdering their children by the trans-
ference of drugs, either in utero or by breast feeding.
Dr. Karch is the author of nearly 100 papers and book chapters, most of which are concerned
with the effects of drug abuse on the heart. He has published seven books. He is currently completing
the fourth edition of Pathology of Drug Abuse, a widely used textbook. He is also working on a
popular history of Napoleon and his doctors.
Dr. Karch is forensic science editor for Humana Press, and he serves on the editorial boards
of the Journal of Cardiovascular Toxicology, the Journal of Clinical Forensic Medicine (London),
Forensic Science, Medicine and Pathology, and Clarke's Analysis of Drugs and Poisons.
Dr. Karch was elected a fellow of the Faculty of Legal and Forensic Medicine, Royal College
of Physicians (London) in 2006. He is also a fellow of the American Academy of Forensic Sciences,
the Society of Forensic Toxicologists (SOFT), the National Association of Medical Examiners
(NAME), the Royal Society of Medicine in London, and the Forensic Science Society of the U.K.
He is a member of The International Association of Forensic Toxicologists (TIAFT).
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Contributors
Wilmo Andollo, B.S. Neil L. Benowitz, M.D.
Quality Assurance Officer Division of Clinical Pharmacology and
Dade County Medical Examiner Toxicology Experimental Therapeutics
Laboratory University of California
Miami, Florida San Francisco, California
Lidia Avois-Mateus, Ph.D. John W. Boja, Ph.D.
Swiss Laboratory for Doping Analyses U.S. Consumer Product Safety Commission
University Institute of Legal Medicine Directorate for Health Sciences
Lausanne, Switzerland Bethesda, Maryland
Sanjay J. Ayirookuzhi, M.D. Marc D. Bollman, M.D.
Department of Cardiology and Internal University Institute of Legal Medicine
Medicine Lausanne, Switzerland
University of California
Davis, California Joseph P. Bono, M.A.
Supervisory Chemist
Drug Enforcement Administration
Joanna Banbery, M.B.B.S.
Special Testing and Research Laboratory
The Leeds Addiction Unit
McLean, Virginia
Leeds, U.K.
Darlene H. Brunzell, Ph.D.
Michael H. Baumann, Ph.D.
Department of Psychiatry
Clinical Psychopharmacology Section
Yale University School of Medicine
Intramural Research Program
New Haven, Connecticut
National Institute on Drug Abuse
National Institutes of Health
Allen P. Burke, M.D.
Department of Health and Human Services
Professor of Pathology and Medical Director
Baltimore, Maryland
Kernan Hospital Pathology Laboratory
University of Maryland Medical Center
Norbert Baume, Ph.D.
Baltimore, Maryland
Swiss Laboratory for Doping Analyses
University Institute of Legal Medicine
Donna M. Bush, Ph.D., DABFT
Lausanne, Switzerland
Drug Testing Team Leader
Division of Workplace Programs
Michael R. Baylor, Ph.D. Center for Substance Abuse Prevention
Health Sciences Unit Substance Abuse and Mental Health Services
Science and Engineering Group Administration
RTI International Rockville, Maryland
Research Triangle Park, North Carolina
Jonica Calkins, M.D.
Michael D. Bell, M.D. Department of Cardiology and Internal
District Medical Examiner Medicine
Palm Beach Medical Examiner Office University of California
West Palm Beach, Florida Davis, California