Margaret M Stark

Drug misuse and dependence — guidelines on clinical management

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Drug-mediated sexual assault.

Psychoactive substances may be given to a potential victim to alter their behaviour or conscious state. This problem is not new; alcohol has been used alone or in combination with other substances to the same effect. Doctors involved in the examination of complainants of sexual assault need to be aware of the effects of the drugs that may be used and ensure that a detailed history, examination and the appropriate specimens are taken. This report describes a series of incidents involving drug-mediated sexual assault and outlines the dilemmas that accompany such incidents.

Is CS spray dangerous? : CS is a particulate spray, not a gas

Editor—The most recent edition of the British National Formulary reviews the emergency treatment of patients exposed to 2-chlorobenzylidene malononitrile (CS) spray. 1 It is important to note that as used in the United Kingdom CS is not a gas but a particulate spray formulated for use against a violent individual. Law enforcement agencies have expressed concern about the use of CS spray.2,3 The Department of Health has issued a comprehensive report on CS spray, concluding that there are no health concerns about the effects of CS when used appropriately.4 In the context of law enforcement, using chemical restraints is safer than hands-on contact or using other weapons that have a higher probability of causing death.5 CS has been used in the United States and has a long history of safe and effective use. No consistent adverse effects from acute exposure have been documented, nor has excessive or unfounded use been a problem. In Memphis, Tennessee, the introduction of chemical restraints in the police department dramatically decreased the number of injuries to police officers and to prisoners as well as decreasing the number of complaints of excessive force made against officers.5 In Tennessee all officers undergo training in which they are exposed to both CS and oleum capsicum, and no significant injuries from exposure have been reported. The most important aspect of managing a patient who has been exposed to CS is to practise good hygiene by removing any contaminated clothing and to ensure that the individual is exposed to air and is not placed in a confined space before decontamination. Special attention should be paid to limiting secondary exposure by using protective clothing such as gloves and by putting contaminated clothing into bags. In most cases this is all the treatment that is needed. Left untreated, most symptoms will resolve within minutes of exposure. Washing with soap and water is not recommended unless symptoms persist. The particulate form of CS can dissolve in the irrigant and exacerbate irritation or contaminate other surfaces, such as the eyes. In the rare instances when irrigation is required, normal saline, not water, is the best choice. If symptoms persist then evaluation by a physician is warranted. The most common persistent complaint is ocular irritation, and this is usually the result of a particle of CS becoming embedded in the ocular surface. In this instance, copious irrigation with saline and a thorough slit lamp examination should be carried out.

Management of drug misusers in police custody.

Police surgeons are increasingly being asked by the police to assess whether drug misusers held in police custody are fit to be detained and fit for interview. There has been little published on how they manage these questions, furthermore the management appears to vary in different parts of the country. This study sets out to determine the attitudes and practise of police surgeons to the management of drug misusers in police custody. A questionnaire was sent to the full members of the Association of Police Surgeons of Great Britain (APSGB) in March 1993. It was found that police surgeons are very aware of the increasing drug problem, indeed 76% reported that they were seeing an increasing number of drug misusers. However, they exhibit significantly negative attitudes to drug misusers and there is no common practice for prescribing controlled drugs. Fifty-two per cent said that on average they notified no drug misusers each month. Seventy-six per cent of respondents said they had received a hepatitis B immunization. The majority of respondents called for more training on drug problems. Therefore, there is an urgent need for specific guidelines for police surgeons on the management of drug misusers in police custody to address the arbitrary nature of the current practice.

MEDICAL CARE IN CUSTODY: The medical care of detainees and the prevention of tragedy - the role of the forensic medical examiner

(FMEs), also known as police surgeons, forensic medical officers or forensic physicians, are registered medical practitioners, usually general practitioners, with an interest in clinical forensic medicine, working part time in the field. A few doctors, mainly in busy metropolitan areas, work exclusively as forensic physicians. These doctors, who are self-employed, independent contractors to a police service, offer medical care to detainees and, when required, forensic assessment of prisoners and suspects in police custody, and the complainants (victims) of crime. They provide interpretation of their findings to police, courts and social services, and they have a vital role in the prevention of deaths in custody. This paper explains how the role has changed and developed in recent years and discusses the importance of the specialty of clinical forensic medicine being fully recognised in the future.

Use of a pupillometer to assess change in pupillary size post-cannabis

With a view to evaluating reports of increased pupillary size in cannabis users noted by police, male volunteers aged over 18 years were given one of four doses of cannabis (placebo, 4.7mg resin, or 11.5 or 18mg tetrahydrocannabinol in a grass based cannabis cigarette). Pupillary size was measured using a Procyon Pupillometer model P2000SA before dosing and at 30min after dosing. Average pupil size increased form the baseline measurement at 30min at both low and high dose but was more significant at low dose. While there is a difference in the mean pupil size when participants had received the low dose of cannabis, there is considerable variation among participants under both the low dose and under the influence of cannabis resin. This effect was not apparent under the high dose of cannabis.

Violence in clinical forensic medicine.

Objective: to investigate the levels of physical and verbal violence experienced in the preceding year by doctors working in clinical forensic medicine. Design and subjects: anonymised questionnaire sent to all full members of the Association of Police Surgeons. Results: 517 eligible questionnaires were returned; 18.2 per cent of respondents had experienced physical violence, a total of 150 incidents. Of those incidents ‘warning signs’ of violence had been present in only 25 per cent. A total of 54 working days were lost. Injuries included a fractured wrist and corneal scarring. Of the respondents, 65.5 per cent had experienced verbal violence (of which the most common type was obscenity); 11.8 per cent had received training in dealing with verbal violence and 10.4 per cent in dealing with physical violence; 88 per cent believed that training on how to deal with violence should be part of police surgeon/forensic medicine training. Conclusion: verbal and physical violence are common in clinical forensic medicine. Training in dealing with these issues should be introduced.

Care of Detainees

Healthcare professionals (HCPs) may be asked by the police to assess the fitness for detention in police custody of adults and juveniles arrested in connection with an offense; those detained by immigration; individuals requiring a place of safety (children and the mentally ill); remanded or sentenced (convicted) prisoners; or those detained under terrorism legislation. A person in police custody is referred to as a detainee in this chapter. Detainees may have to be interviewed regarding their involvement in an offense and possibly further detained overnight for court; guidance may therefore have to be given to the custodians regarding their care.

DRUGS, DRIVING AND SOBRIETY TESTS - A REVIEW OF RECENT DEVELOPMENTS

Research by TRL, UK in 1997 showed a six-fold increase in illicit drug consumption by fatally injured drivers compared with a comparable study carried out ten years earlier. The low level of prosecutions for drug driving indicate that significant numbers of drivers impaired by drugs go undetected by police. This hass because there is no readily available roadside screening device and because of lack of police training in this subject. Trials in the Strathclyde Police area after a training course for police officers and surgeons led to the arrest of suspects failing a field impairment test, and of those subsequently tested for drugs, 92% proved positive. Further quantification of impairment testing is considered necessary. Medical examination procedures are discussed including the relative merits of blood and urine samples. The assessment of the effect of the drugs will depend on individual tolerance levels and the setting of legislative drug driving levels is not considered possible. A testing procedure reliant on a sample of perspiration from the suspects forehead is described, but only one drug can be tested for at a time. Another test relies on a sample of saliva. Over 98% of drivers returning a questionnaire were in favour of roadside testing for drugs.

The use of an alcometer in clinical forensic practice

Forensic physicians are at times required to provide a professional opinion on a persons degree of intoxication through alcohol, particularly with regard to fitness for interview by the police. Inherent to these assessments is an estimation of the blood alcohol concentration (BAC). Most forensic physicians rely on taking a history regarding recent alcohol consumption and a clinical assessment to estimate the BAC. We report a study in which the BAC of 118 detainees was estimated and compared with the BAC measured by an alcometer. Our estimations were accurate in 66% of cases. Most errors resulted from underestimating the BAC. Additionally, we attempted to determine fitness for interview using a single measurement of the BAC without a clinical assessment. 19% of those who were assessed as unfit for interview had a BAC of less than the UK legal limit for driving (currently 80 mg%) and 37% considered fit, had a BAC above that level. We conclude that the routine use of alcometers would enhance the practice of forensic medicine but could not replace its role in the assessment of levels of alcohol intoxication.