History and Examination

A detailed history of recent drug use, including alcohol, must be obtained to establish whether the individual is a currently dependent or recreational user

From: Clinical Forensic Medicine: A Physician's Guide, 2nd Edition Edited by: M. M. Stark © Humana Press Inc., Totowa, NJ

Table 1 Substance Misuse—History

• Period of regular use

• The quantity used per day on a "typical" day

• The frequency of use

• Route of administration

• Prescribed drugs

• Experience of withdrawal_

(Table 1). Street names of substances will vary from country to country, within regions in the same country, with the cultural background of the user, and with time. The examination should look for signs of intoxication, withdrawal, or previous drug use (Table 2). Baseline parameters are useful for re-examination if the detainee is kept in custody. Purity of illicit substances will vary between countries and from year to year; this may be reflected in the drug history obtained, with increasing amounts ingested as drug purity diminishes. Averaged figures from recent seizures (police and customs) available from the United States in 2001 show purity for cocaine at 69%, heroin 50%, and methamphetamine 40% (4), compared with UK figures in 2000 of cocaine 52%, heroin 47%, and amphetamine 5% (5). There were significant differences between the purity of drugs seized by customs and the police, showing the extent to which certain drugs are cut prior to distribution by dealers.

Table 2

Substance Misuse—Examination

Blood pressure Pulse rate Temperature Pupil size

Pupillary reaction to light

Conscious level

(lethargy/stupor/coma)

Glasgow Coma Scale

Orientated in time, place, and person

Speech

Pallor

Flushed

Tremor at rest

Yawning

Lachyrmation

Rhinorrhea

Gooseflesh

Sweating

Bowel sounds

Presence of needle tracks

Restlessness/agitation

Disordered perceptions

Coordination

Gait

Romberg's

Auscultation of the chest

2.2. Harm Minimization

Information and advice should be given to the detainee by the physician on reducing the harm from continued drug misuse. Advice can be provided on a range of issues (3,6):

• Blood-borne viruses (BBVs), including hepatitis B and C and HIV awareness.

• The availability of hepatitis B vaccination.

• The hazards of injecting substances and the greater safety of smoking rather than injecting

• If the individual must inject the preference for hitting a vein rather than injecting into the muscle or skin.

• Avoidance of "shared works," such as needles, syringes, spoons, etc.

• To use different sites for injecting.

• To attend for medical assistance if any pain, redness, or pus collects under the skin at an injection site.

• Information regarding the local services involved in drug counseling and treatment can also be offered.

• Other general health problems may require treatment/referral.

Substance misusers who inject may have experienced a broken needle at some time in their injecting career (7). Central embolization may occur within a few hours up to several days, and this can lead to potentially fatal consequences, including pericarditis, endocarditis, and pulmonary abscesses. Needle fragments must be removed as soon as possible to avoid future complications. This may be done by the users themselves or necessitate attendance at the accident and emergency department.

Brief interventions, whereby it is possible to provide advice about the risks inherent in a range of patterns of substance use and to advise reducing or stopping use as part of screening and assessment, are useful with alcohol consumption (8). A person's motivation to change is important in determining the likelihood of success of any intervention (9), and such motivation may alter depending on a variety of factors. For example, negative life events, such as being arrested for an acquisitive crime motivated by a need to finance a drug habit, can introduce conflict in the detainee's mind about substance misuse and may increase the likelihood of successful intervention.

Arrest referral schemes are partnership initiatives set up to encourage drug misusers brought into contact with the police service to voluntarily participate in confidential help designed to address their drug-related problems. Early evaluation of such projects in the United Kingdom provides good evidence that such schemes can be effective in reducing drug use and drug-related crime (10). In the United States, it has also been recognized that point of arrest is an appropriate stage of intervention for addressing substance misuse (1).

2.3. Prescribing

Although prompt treatment to limit or prevent the withdrawal syndrome is desirable, no central nervous system (CNS) depressant medication should be given if there is evidence of intoxication with other drugs (e.g., alcohol), because many substances have an additive effect. Consideration of whether the detainee is fit for detention is the priority. Most individuals are not detained in police custody for long, and, therefore, medical treatment may not be required. This is particularly so if there is any question that the detainee may have recently ingested substances, the full effects of which may not as yet be obvious. Reassessment after a specific period should be recommended, depending on the history given by the detainee and the examination findings.

Details of medication should be verified whenever possible. It is good practice for all new substitute opiate prescriptions to be taken initially under daily supervision (11). In the custodial situation, if the detainee is on a supervised therapy program, one can be reasonably sure the detainee is dependent on that dose; the detainee may of course be using other illicit substances as well. Recent urine test results may be checked with the clinic to see whether methadone or other drugs are detected on screening.

Particularly with opiate substitution treatment, in the absence of withdrawal signs, confirmation of such treatment should be sought before authorizing continuation. The prescribed dose of opiate substitution therapy may not necessarily indicate accurately the actual amount taken each day if not supervised, because part or all of the dose may be given to other individuals. If there is doubt about the daily dose, it can be divided and given every 12 h. It should be remembered that giving even a small amount of opiates to a nondependent individual may be fatal. Cocaine abuse accelerates the elimination of methadone; therefore, higher doses of methadone must be prescribed to individuals on maintenance regimes who continue to abuse cocaine (12). Any decision to prescribe should be made on the assessment of objective signs as opposed to subjective symptoms, and a detailed record of the history and examination should be made contemporaneously.

Good practice dictates that where treatment can be verified, it should be continued as long as it is clinically safe to do so. Evidence from the National Treatment Outcome Research Study (NTORS), a prospective study of treatment outcome among substance misusers in the United Kingdom, has shown substantial reduction across a range of problem behaviors 4-5 years after pa tients were admitted to national treatment programs delivered and it is important not to disrupt such programs (13).

2.4. Medical Complications of Substance Misuse

Medical complications of substance misuse may give an indication of a problem in the absence of acute symptoms or signs of intoxication. Intravenous injection may result in superficial thrombophlebitis, deep vein thrombosis, and pulmonary embolus and chronic complications of limb swelling and venous ulcers. If injection occurs accidentally into an artery, vascular spasm may occur and result in ischemia, which, if prolonged, can lead to gangrene and amputation.

Cellulitis and abscesses may be seen around injection sites, and deep abscesses may extend into joints, producing septic arthritis. Self-neglect, malnutrition, and dental decay may occur, as may infectious diseases, such as hepatitis B and C, human immunodeficiency virus (HIV), and the acquired immunodeficiency syndrome (AIDS).

Skin manifestations of drug addiction may be seen more commonly in opiate rather than stimulant users, even though stimulant users inject more frequently (14). This is partly because stimulants do not cause histamine release and, therefore, are seldom associated with pruritus and excoriations and also because cutaneous complications are frequently caused by the adulterants injected along with the opiates, rather than the drugs themselves. Fresh puncture sites, tattoos used to cover needle tracks, keloid formation, track marks from chronic inflammation, ulcerated areas and skin popping resulting in atro-phic scars, hyperpigmentation at sites of healed abscess, puffy hands (lymphe-dema with obliteration of anatomic landmarks and pitting edema absent), and histamine-related urticaria (opiates act on mast cells resulting in histamine release) may be seen.

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