CHAPTER 7

POISONING

FORENSIC TOXICOLOGY -is defined as the science that deals with knowledge of source, character
and properties of poisons, their symptoms in the body, their pharmacological actions, and their
treatment. It is the study of the adverse effects of chemicals, such as alcohol, drugs, poisonous gases,
and industrial chemicals on living organisms. It is also concerned with the detection and measurement
of such chemicals through the analysis of samples such as blood, urine. It also involves the use of
toxicology for the purposes of the law, especially when criminal activity is suspected.

The forensic toxicologist is responsible for detecting chemical agents in biological samples, and
providing answers to the following questions in order to assist the medico-legal investigation:

What drug was taken, when, and how?

Was the drug or drugs sufficient to kill or to affect behavior?
Was a substance taken for therapeutic purposes, was it abused recreationally, was it used for suicidal
purposes, or was it administered homicidally?
Was the person intoxicated at the time of the incident?
What are the effects on behavior or performance?
How would a person show intoxication with this substance?
Is there an alternative explanation for the findings?
What additional tests might shed light on these questions?

POISONS - Any substance which when introduced into or absorbed by a living organism, destroys life
or injures health. A poison can be an efficient and deadly instrument of murder, it is toxic enough even
at small quantities, it can be easily disguise (e.g., the taste or odor can be easily masked when mixed in
water, food) and it causes symptoms that are delayed and nonspecific or appear to be due to natural
illness, and if it is readily obtainable and easy to work with.

ARSENIC – is a solid chemical element that is used especially in wood preservatives, alloys, and
semiconductors and is extremely toxic I both pure and combined forms. It is used in insecticides,
pesticides, herbicides, alloys, wood preservatives, additives to animal feed, semiconductors and light-
emitting diodes, homeopathic medicines, paints, and ceramics are the ones that make potent poisons.

Arsenic has been widely used for homicidal purpose as it is cheap, easily available, tasteless and
odorless, and therefore cannot be detected in food or water. Low doses can be given slowly over a long
period of time so that death may appear to be natural.

CYANIDE - are chemical compounds, many of which are highly toxic. These products are used in
several industrial processes, mainly for the mining of gold and silver. It is also employed in several
chemical processes, such as fumigation (disinfection), case hardening of iron and steel, electroplating
and photographic processing.

Cyanide is a rapid-acting and deadly poison that can kill in a matter of minutes. Its use has been
relatively common in suicides and accidents, and has also been used in homicides It has been used for
capital punishment in gas chambers and by terrorists as a chemical weapon.

CARBON MONOXIDE (CO) - is a highly toxic gas produced by the incomplete combustion of organic
materials. It forms when there is insufficient oxygen to produce carbon dioxide. It is colorless, odorless,
tasteless and initially non-irritating; hence, it is very difficult for people to detect.
LEAD - Lead is a soft and malleable metal used in building construction, lead-acid batteries, bullets and
shots, weights, as part of solders, pewters, fusible alloys, and as a radiation shield. Lead acetate is the
most common salt that causes acute poisoning. Immediately upon ingestion, the person will feel sweat,
metallic astringent taste in the mouth along with a burning sensation in the throat and stomach,
salivation and intense thirst. Other symptoms include vomiting, constipation, cold clammy skin, feeble
rapid pulse and shock, drowsiness, headache, muscular cramps and convulsions. Paralysis of lower
limbs may be seen, and death may occur.

DRUGS OF ABUSE

Drug abuse is a growing global problem often resulting in accidents, criminal activity and death. Drug-
related crimes are usually committed either to fund the purchase of drugs or as a consequence of drug
misuse. Examples of such criminal activities include shop-lifting or burglary; offences under the various
acts established to control the possession, distribution and consumption of drugs; and criminal acts
carried out by persons in an abnormal mental state due to drug intoxication or withdrawal, such as
assault or damage to property.

The WHO defines a drug as "any substance, other than those required for the maintenance of normal
health, that, when taken into the living organism may modify one or more of its functions."

Drug misuse is defined as "any taking of a drug which harms or threatens to harm the physical and
mental health or social well-being of an individual.

Drug dependency is defined as "a state, psychic and sometimes also physical, resulting from the
interaction between a living organism and a drug, characterized by behavioral and other responses that
always include a compulsion to take the drug on a continuous or periodic basis in order to experience
its psychic effects and sometimes to avoid discomfort of its absence".

Deaths related to drugs may be from recreational usage of illegal drugs or from deliberate or
inadvertent misuse of over-the-counter preparations or prescription medications. In many cases, a drug
related death scene will include drug paraphernalia, such as syringes, needles, spoon "cookers" with
small foil-cooking sheets, lighters, and so on.

Toxicology reports involving drug-related deaths should be considered in the context of the entire case
investigation, including the person's medical history, drug use/abuse history, scene investigation,
circumstances of the death, and complete autopsy findings. The drugs may have played a primary role
in a death and may, therefore, be listed as the cause of death. Alternatively, the drugs may have played
a minor role in the death and will therefore be listed as a contributory condition.

An autopsy can reveal the following clues that a person may have died of a drug overdose.
a. "Foam cone" over nose and/or mouth;
b. Colorful discoloration of lips, tongue, oral mucosa or stomach;
c. Granular, grainy, or pasty pill material in mouth and/or stomach;
d. Pills in stomach;
e. Pulmonary congestion and/or edema;
f. Frothy (bubbles formed) fluid in bronchi and trachea;
g. Mucus in bronchi; and
h. Increased amount of urine in urinary bladder.

STIMULANTS - (also called "uppers") are psychoactive drugs that stimulate the nervous system,
resulting in euphoria (excitement), increased energy and alertness with loss of appetite. Effects may
also include increased heart rate, blood pressure and respiratory rate; aggressive behavior and
confused thinking leading to exhaustion and sleep; dry mouth delusions and paranoia; and even fits,
coma, and death. Stimulant are widely used as prescription medicines for treatment of narcolepsy (brief
attacks of deep sleep), obesity attentional disorders and clinical depression.

AMPHETAMINE - is the most popular stimulant. It may be taken intravenously, orally or

sniffed/snorted, with effects coming on quickly and lasting for several hours. Other notable stimulants
include caffeine (found in coffee, tea, cocoa, chocolate, soft drinks and energy drinks), nicotine (the
active chemical constituent in tobacco), ephedrine (commonly used as a stimulant, appetite
suppressant, concentration aid and decongestant), and anabolic steroids (used for cosmetic purposes
to develop and maintain masculine characteristics). Abuse of stimulants can lead to insomnia and
severe depression, as well as medical, psychiatric, and psychosocial deterioration.

COCAINE - Cocaine is a strongly addictive controlled substance derived from the leaf of the
Erythroxylon coca bush. It has become an extremely popular drug with some medicinal value
particularly in medical procedure involving nasal passages such as its anesthetic effects during nasal
surgeries and diagnostic procedures although it also has a high potential for abuse.

Cocaine in the form of white crystalline powder can be snorted intranasally or injected intravenously,
while crack cocaine is the less expensive form that can be smoked. Injecting cocaine produces the
most rapid, almost immediate effects. Snorting results in a peak effect within 30-120 minutes; while
smoking effects peak within 5 minutes.

Cocaine makes the user feel euphoric, stimulated, and alert. It also results in difficulty sleeping, loss of
appetite, increased heart rate and blood pressure, and causes the body temperature to rise. Adverse
effects include cardiovascular complications, psychosocial problems, and addiction resulting in powerful
cravings to produce the desired effect. Chronic abusers develop dangerous psychological and
behavioral patterns, and even severe psychosis.

Another unfavorable outcome of cocaine intoxication involves an episode of bizarre (weird) behavior
called "cocaine psychosis" or "excited delirium," which manifests in hyperthermia (elevated body
temperature), delirium, paranoia, abnormally great strength, highly agitated state, cardiorespiratory
arrest, and sudden death.

ECSTACY - is the street name for Methylenedioxymethamphetamine (MDMA). It is a party drug that is
classified as both a stimulant and hallucinogen. It is administered orally as a tablet or capsule, and the
effect last approximately three to six hours. Its popularity in nightclubs and raves is due to its empathy-
enhancing properties, which increases a sense of intimacy and diminished anxiety with others, which
can induce euphoria and mild psychedelia.

High doses of MDMA can damage neurons, resulting in depression, anxiety, memory loss, learning
difficulties, sleep disorders, and sexual dysfunction. It can also lead to increase in heart rate and blood
pressure, fainting, panic attacks, and in severe cases, loss of consciousness and seizures. MDMA-
related deaths have in fact increased markedly, possibly due its wide availability to young people,
especially in parties and clubs.

METHAMPHETAMINE HYDROCHLORIDE OR SHABU - a white odorless powder drug that comes as,
tablet or as crystal that looks like shards of glass with a bitter numbing taste. it can be swallowed,
sniffed/snorted, smoked or injected, resulting in a feeling of physical and mental well-being, as well as a
surge of euphoria and exhilaration (happiness)

When smoked or injected, it produced an instantaneous “rush” and euphoria that can last from 4 to 12
hours. Effects from oral ingestion occur in around 30 minutes and 3 to 5 minutes from snorting and
effects may continue for up to 24 hours, the half-life of the drug is12 hours.

Methamphetamine abuse leads to effects similar to those of cocaine, such as aggressive and violent
behavior, auditory hallucinations, mood disturbances, delusions, psychotic and paranoid that can result
in homicidal and suicidal thoughts. Other potential adverse effects include cardiac and neurological
problems, hypertension, and stroke, if not treated immediately, methamphetamine overdose can result
in death.
HALLUCINOGENS - are drugs that alter the perception of reality. They rarely cause toxicity sufficient
enough to result in death, but may cause convulsions, respiratory depression, coma, hyperthermia and
seizures that may prove fatal. In addition, the effect of altered perceptions, psychosis, and bizarre
(strange) behavior may lead to or contribute in some way to traumatic dead. For example, an abuser
under the influence of LSD may be under the impression that he can fly and thus project himself from a
high window.

Examples of hallucinogens include LSD and cannabis, as PCP (phencyclidine, also called "angel
dust"), Mescaline (from the peyote cactus), and psilocybin (from mushrooms).

LYSERGIC ACID DIETHYLAMIDE (LSD) is a powerful hallucinogenic that is not fatal in itself. It is
usually taken orally with sympathomimetic effects within 5 to 10 minutes and psychological effects
within 30 to 60 minutes, depending on the dose taken. The effects can last for 8 to 12 hours with a
recovery period of 10 to 12 hours. Visual effects such as intensified colors and distorted shapes occur,
as well as distortions of hearing

CANNABIS - or marijuana is a tobacco-like greenish or brownish material made of the dried flowering
tops and leaves of the cannabis (hemp) plant. It is usually smoked or taken orally as "brownies," and
can make users feel pleasurably relaxed or euphoric. It has mood altering properties and is addictive.
When smoked, effects occur within a few minutes and last up to one hour with low doses or 2 to 3 hour
with higher doses. If it is ingested, it may take an hour or more to have an effect which can last 12
hours or more.

The active component in marijuana, which is tetrahydrocannabinol (THC), causes increased heart rate,
dilation of the blood vessels in the whites of the eyes, relaxation and dilation of the bronchial passages,
and euphoria.

Other effects include dry mouth, excessive hunger and thirst sleepiness, and occasionally dysphoria
(anxiety, fear, panic and paranoia). Heavy use impairs memory and alteration. THC also impairs the
areas of the brain that regulate balance, posture, coordination of movement, and reaction time. Proof of
the intake can be obtained from analysis if urine, blood and swab from the lips and fingers.

Marijuana is the most widely used illicit drug in the world. It is not known to cause death via direct drug
toxicity, but THC has been detected in a fairly significant number of deaths, particularly those due to
overdose of other drugs and violent or accidental deaths. Studies have shown that THC alone impairs
driving performance, and the effects are even greater when combined with alcohol.

DEPRESSANTS - (also called "downers) are drugs that slow brain function in a progressive manner
and are most often used in the treatment of anxiety and sleep disorders. These include sedatives,
hypnotics (sleep inducing), and antianxiety drugs (tranquilizers). Depression of the nervous system
leads to sedation and relief of anxiety but, because of disinhibition, may initially result in euphoria,
excitation, and risk-taking.

Physical effects include disorientation, drowsiness, slurred speech, nystagmus (rapid movement of the
eyeballs), loss of co-ordination, ataxia, coma, and death. They should not be used in combination with
other CNS depressing drugs. At high doses, cerebral depression may occur; so the effects are more
dangerous when taken with other cerebral depressants such as alcohol.

The most common depressants are the following:

BARBITURATES - used to treat seizures, anxiety, tension and sleep disorders: particularly dangerous
drugs when taken in overdose can cause a physical and psychological dependence;

BENZODIAZEPINES - prescribed to treat anxiety, sleep disorders and panic attacks (withdrawal
syndrome includes the major complications of fits and psychosis), and

KETAMINE -used as an anesthetic agent that can be taken intranasally, orally or by injection (users
can experience a cocaine like "rush" with psychological association)

ALCOHOL (Ethanol) - is a colorless, flammable, volatile liquid that is soluble in water and has a
characteristic taste and odor. It is commonly referred to simply as alcohol or spirits, and is the principal
type of alcohol found in alcoholic beverages. It is a product of fermentation by the action and yeast cells
on sugars found in fruits and grains.

Deaths due to the toxic effects of acute over-ingestion of ethanol are due to severe respiratory and
CNS depression. It can be caused either by the direct depressive effects or through secondary events
such as aspiration of vomit. Lower alcohol intoxication can also be fatal if the ethanol is combined with
an opiate or other types of depressant drugs.

Alcohol intoxicated persons are also often involved in fatal trauma triggered by their aggressive
behavior. Road accidents often involved alcoholic vulnerability, either caused by drunk drivers or drunk
pedestrians. Other fatal incidents may occur:
.
a. Falling down the stairs resulting in head injuries
b. Falling from high places due to drunken carelessness or unsteady gait
c. Burns and carbon monoxide poisoning (a common scenario is for a drunk to go to bed and fall
asleep while smoking. The cigarette igniting the bedclothes. Sometimes, a gas, electric or kerosene
heater may be knocked over during drunken staggering, which can also start a fatal fire)
d. Drowning especially in river or docking areas (e.g., falling from a bridge or passageway into the
water)

OPIOIDS - are addictive and potentially deadly drugs, in which analgesic (painkiller) effects decrease
the perception of pain and reaction to pain as well as increase pain tolerance. They are also considered
as strong cough suppressants. Side effects include mental clouding, drowsiness, visual disturbances,
sedation, constipation and a strong sense of euphoria. Severe intoxication can result in respiratory,
depression and death.

Examples of opioids include morphine, heroine, codeine, methadone and other opiates. Morphine is the
major representative of the general group of opioids, which comprise natural opium and a whole series
of chemically related derivatives. Heroin is the most abused and the most fatal; it has no medical use
and a high potential for abuse. The most common route of exposure is intravenous injection, but it can
also be snorted or smoked. Side effects include severe itching flushing, dry mouth, nausea and
vomiting.

In cases of fatal heroin abuse, a person may die suddenly sometimes with the needle or the tourniquet
still around the arm Intravenous abusers may have a single scar from a favored injection site or have
multiple needle tracks, usually in the veins of the arm a hands. Other injection sites are the veins in the
leg, groin and even neck. Heroin can also be volatilized and then inhaled by heating a spoon, bottle
cap, portion of a metal beverage can, or on a piece of tinfoil.

POST-MORTEM FORENSIC TOXICOLOGY

In suspected drug and poisoning deaths, the pathologist collects and preserves the specimens for
toxicological analysis subsequent to the autopsy. These cases usually involve toxicological scenarios,
such as drug overdose, homicide by poison, alcohol impairment in an accident or crime, or use of drugs
to commit suicide.

Toxicological analysis is also required in determining if assertions of self-defense against drug-induced

psychotic behavior are plausible, if drugs were used to incapacitate a victim of a crime, or if a patient
was in compliance with their prescribed medicines. Sometimes, the cause of death is unknown, and the
toxicologist has to review the case
history and investigation to narrow the search for a specific poison.

SPECIMEN COLLECTION
Specimen selection, collection, and preservation play an enormously important role in toxicology. It is
important to know which specimens are most useful for yielding drug concentrations that are practical
for interpretation. Furthermore, the proper specimen must be used to assemble all the pieces of the
puzzle when trying to determine a cause and manner of death.

The challenge with post-mortem samples is that the quality and availability of the samples themselves
can vary greatly. Unlike testing clinical samples from living individuals, post-mortem toxicology has the
unique problem of testing samples collected at autopsy that may have undergone varying levels of
decomposition. For example, decomposed bodies may no longer have blood, yet may have vitreous,
urine, and tissue samples. The use of proper preservatives is important to prevent further post-mortem
changes in the samples. Even the selection of the container itself can be important.

BLOOD is the most common and preferable sample to use, when possible. It is a relatively easy
sample to obtain and store. For post-mortem studies, peripheral blood is more desirable than central
blood as it is less affected by post-mortem redistribution.

URINE can be used as a second sample for confirmation of a drug's presence. It is good as a
screening sample as it tends to have less interfering substances, and provides qualitative information
on past exposure or use. It is also relatively easy to obtain and store.

VITREOUS is an excellent specimen to use in the absence of blood. It is leas subject to contamination,
is not affected by embalming, and demonstrates good stability, Vitreous is an excellent specimen for
water-soluble substances, including ethanol and barbiturates.

BILE is usually not a first-line specimen but can be useful in qualitative screening. Bile is not always
present, and when it is available, it is usually in limited quantities. It is most often used for detecting
opiates and morphine.

TISSUE specimens are commonly collected at autopsy and are readily available in large quantities.
However, interpretation of drug concentration can be difficult since data is not often available for
comparison. Tissue concentrations may also be elevated in oral overdoses and chronically
administered drugs. Muscle is a preferred tissue sample. Liver can be used as a secondary sample
when blood is not available; there is extensive data available for comparison of post-mortem drug
concentrations. Kidney specimen is used mainly in heavy-metal testing; lung specimen for inhaled
toxins, such as volatile substances; spleen for cases of carbon monoxide poisoning; and adipose tissue
for pesticide poisonings and volatile analysis.

STOMACH contents are often collected in cases where an oral drug overdose is suspected. Odors may
be present that give a clue of agents present.

HAIR is an excellent screening source for arsenic poisoning and is becoming more commonly used in
screening for the chronic use of illicit drugs, including morphine, cocaine, and amphetamines. Drugs
can be deposited in hair as it grows, allowing hair samples to yield information about drug intake over a
period of several months to years, depending on the length of hair sampled.
Other samples include fly larvae (maggots), blood stains, soil samples and cremation ash, which may
contain drugs or poisons. Tablets, capsules, vials, and various household products may also be
collected at the death scene.

LABORATORY ANALYSIS
Once the samples have been collected and properly preserved the next step is called the extraction
procedure, which involves the separation of the analytes (the substances you want to measure) from
the biological matter. Most specimens require a certain of pretreatment to isolate the drug or poison by
using separation techniques such as distillation, protein precipitation, liquid-liquid extraction and solid-
liquid extraction. This is followed by forensic toxicological analysis using two types of tests: screening
tests and confirmatory test. Samples are usually first screened for the presence of medications and/or
intoxicating substances then a more specific, confirmatory test is performed to determine the exact the
exact substance and often concentration. A confirmatory test should be a different methodology from
the screening test and should be run on a different sample/specimen, if possible.

PRELIMINARY SCREENING TESTS

Screening tests allow the toxicologist to rapidly test for a variety of drugs and toxins. Screening tests
give preliminary results, and then a positive result must be verified with a confirmatory test.
·

a. Immunoassays are popular techniques that can be used to screen a large number of drugs.
The methods are relatively fast and straightforward to use. Immunoassays use antibodies that bind with
a target class of compounds (in this case, drugs). The antibody binds to the drug in question, thereby
yielding a positive screen if the drug is present.

b. Spectrophotometry is easy to use but it is not commonly used in forensic toxicology because of
its lack of sensitivity and specificity. A spectrophotometer can measure the changes in the wavelength
of light (ultraviolet or infrared) passing through a substance to determine the presence or absence of
certain molecules within the matrix.
c. Chromatography can be used as a screening test for a large number of drugs when combined
with a detector. Gas chromatography (GC) and liquid chromatography (LC) are very popular in forensic
toxicology, because they are easy to perform, sensitive, and can provide-good initial separations. Drugs
are dissolved into a mobile phase (gas or liquid), which is then passed through a stationary phase
allowing for separation and isolation of the constituents of the sample. The time taken to traverse the
stationary phase is recorded by a paired detector and compared to internal standard, thus facilitating
the detection of each component within the sample.

CONFIRMATORY TESTS

The process of confirmation involves the use of various methods that give structurally specific
information about a compound in order to eliminate the potential for false positive results. When a drug
has been identified by one of the screening tests, confirmatory tests should be performed using a
different methodology than the screening test and on a different sample, if possible (or at least a
different extract of the same sample).

The confirmatory test should also be more specific than the screening test. The popular method is GC
or LC paired with mass spectrometry. Mass spectrometry is accomplished by fragmenting a molecule
using a barrage of electrons and then analyzing the relative abundance of the fragments or by ionizing
molecules and analyzing the charge transference

Review Questions
What is forensic toxicology and why is it significant in a criminal investigation?
What are the common types of poisons involved in criminal acts?
How is drug misuse different from drug dependency?
What are the different kinds of stimulants and depressants?
What are the major factors to consider in specimen collection and laboratory analysis in aid of
postmortem forensic toxicology?