Journal of Pharmacy Practice

Forensic pharmacists engage in work relating to litigation, the regulatory process, or the criminal justice system. Forensic pharmacy overlaps with many other forensic fields. Pharmacists hold a variety of positions with local, state, and federal governments. Many pharmacists do freelance work as forensic litigation consultants. A forensic pharmacist can be a valuable resource in legal cases relating to malpractice, adverse drug reactions, drunk and drugged driving, and numerous other types of civil and criminal cases. There are no specific training programs or certifications for forensic pharmacists. However, certification in clinical areas does enhance the status of an expert.

Many concerns to society are relevant to forensic pharmacists. Specific applications of forensic pharmacy include death investigation, professional malpractice, drug-induced violence, competency to stand trial, acquaintance rape, child abuse, drug testing, fraud & white collar crime, worker's compensation, and medication errors. Effects of the drug on either the victim or the defendant can be an issue in civil or criminal cases. Pharmacokinetics calculations can be useful in legal cases relating to drunk driving and adverse drug events.

While a student at Massachusetts College of Pharmacy, I did an externship with the Massachusetts Attorney General's Office Medicaid Fraud Control Unit. The unit investigates suspected fraud by health professionals and health care organizations. The director of pharmacy investigations, my preceptor, is a pharmacist and a Certified Fraud Examiner. This is a valuable combination when working on cases involving pharmaceuticals and durable medical equipment. Working at the Attorney General's Office has broadened my understanding of career options available to pharmacists. I would highly recommend this to any pharmacy student who may be doing externship work in the near future.

About 15% of accident-involved drivers have drugs detected in their system. The Drug Evaluation and Classification (DEC) Program was designed to give police officers a systematic, standardized twelve-step method to enable them to look for signs and symptoms of drug use from a group of seven drugs. The classes of drugs covered by the program are phencyclidine, inhalants, narcotic analgesics, cannabis, CNS depressants, CNS stimulants, and hallucinogens. The DEC program certifies the police officer as a Drug Recognition Expert (DRE) to evaluate the behavior and physical signs of the drug use such as blood pressure, pulse, nystagmus, strabismus, and pupil size. Since the procedures and methods of the program have a medical basis, the pharmacist, toxicologist or other similarly trained scientist with knowledge of physiology, pharmacology, disease states, chemistry, and physical assessment would be an ideal DRE. It is suggested that the future role of the pharmacist in the DEC program be one of final interpretation of the results noted by the DRE, or training the DRE to recognize the full spectrum of factors which may be causing the symptoms observed.

Although there are over 20,000 species of spiders in the United States serious complications from envenomation is restricted to only two genera: Loxoceles species (i.e., brown recluse type spiders) and Latrodectus species (i.e., black widow type spiders). Loxoceles species venom is primarily cyto/hemo toxic. It produces local necrotic lesions and occasionally systemic reactions including disseminated intravascular coagulation. Latrodectus species venom is primarily neurotoxic with little more than local erythema at the bite site, but with serious systemic effects from paresthesias to paralysis. A horse serum derived antivenin is available for Latrodectus envenomation while surgical intervention is often necessary for large necrotic lesions associated with Loxoceles envenomation.

This report will present a case of neonatal propylene glycol poisoning from the use of intravenous lorazepam and also discuss the toxicity of diluents in general. Although used as a diluent in many pharmaceuticals and generally considered safe, propylene glycol can cause serious side effects: hyperosmolality in burn victims due to silver sulfadiazine products containing propylene glycol and in premature babies due to particular multivitamin preparations, irreversible perception deafness, skin irritation, high anion gap acidosis due to elevated lactate levels, and reversible neurological disturbances. Toxicity caused by propylene glycol may be manifested by hyperosmolality, lactic acidosis, hemolysis and hemoglobinuria, skin irritation, deafness, and other neurological disturbances.¹ Historically, the toxicity of diluents played an important role in the development of toxicity testing before the release of new drugs. The topic is current, as evidenced by the Important Drug Warning letter recently issued by Glaxo Wellcome, the manufacturer of Agenerase, warning about the toxicities and drug interactions associated with the propylene glycol diluent in the oral solution, as well as by competitive interference with the aldehyde dehydrogenase enzyme pathway. This report and discussion is included in the Forensic Pharmacist issue because the case investigation arose out of retention of one of the authors (O'Donnell) as an expert witness and consultant on behalf of the child/subject of the case report.

Forensic urine drug testing (FUDT) is a tool of many employers to assess drug use in employees. Collegiate and professional sports test for banned substances. Immunoassays are often the screening test. Gas chromatography/mass spectrometry is the confirmatory test. Numerous foods and medications interfere with test results. Safeguards in FUDT include chain of custody procedures, certification of laboratories and personnel, cutoff values, quality assurance and quality control procedures, and medical review officers. Breath analysis is used in drunk-driving cases. Blood and hair can also be analyzed for substances of abuse. Pharmacists can be an asset in drug testing issues.