316 F.

Mußhoff

• Epilepsy
• Heart conditions
• Fluid retention
• Nausea
• Stomach problems
• Diabetes
• Several types of infections
As a general guideline some of the effects of medicines that can affect a person’s
driving ability include the following
• Drowsiness or tiredness
• Dizziness or feeling light-headed
• Difficulty to concentrate
• Feeling edgy, angry or aggressive
• Feeling nauseous or otherwise unwell
• Reduced coordination or feeling shaky and unstable
Using benzodiazepines and driving, for example may cause an increase in the risk
of a person to have an accident [3]. People on higher doses or those who just began
to take higher doses are the most at risk of impaired driving and to have a resulting
accident which is due to some of the effects of benzodiazepines that may affect driv-
ing ability such as drowsiness and fatigue, blurred vision, lack of muscular coordina-
tion, slower reaction time, slower information processing, reduced concentration
and impaired judgement.

Effects of Mixing Drugs on Driving

Taking more than one drug at the same time or taking one drug followed by another
can have unpredictable results [21]. This includes mixing illegal drugs and legal
drugs such as alcohol and medicines (prescribed and over-the-counter medication).
If a person takes multiple drugs (including alcohol, medicines and illegal drugs)
each drug could alter the effects of the other, often in an unpredictable way. The
effects of mixing drugs are influenced by a range of factors and can be different for
each person. Things to consider include the following:
• Type of drugs
• Dose of each drug
• Intake of drugs (taken at the same time, at different times and in which order)
• Consumer’s psychological and physical attributes (person’s mental or emotional
state and physical health)
The risk of a crash while someone is under the influence of two or more drugs
(illicit, licit or pharmaceutical) may be even higher than under the influence of
one drug.
15  Alcohol and Drug Fatalities in Transportation: Forensic-Toxicological Implications 317

Combining drugs with similar effects such as alcohol and cannabis, alcohol and
benzodiazepines, or amphetamines and ecstasy can increase the effects of each
drug. Depressant drugs like alcohol, cannabis, heroin or other opioids, and benzodi-
azepines slow down brain activity and other parts of the central nervous system.
Combining depressants can multiply the depressant effects (slowing down) in an
additive as well as in an exponential way. Stimulant drugs like amphetamines,
cocaine and ecstasy speed up brain activity and other parts of the CNS and combina-
tion of stimulants can multiply the stimulant effects. This lead to greater stress on
the body, particularly on the heart and other vital organs, and can impair a person’s
driving ability more than in the case that only one drug was consumed.
Combining drugs with different effects like alcohol and ecstasy or cocaine and
benzodiazepines seem to “cancel each other out.” This makes it difficult for some-
one to estimate how much his driving ability has been impaired. If a person has been
drinking alcohol and using amphetamines, for example, he may not feel the depres-
sant effects of the alcohol as they have been masked by the stimulant effects of
amphetamines. The person may feel capable of driving when he might be drunk in
fact. These combinations also put a lot of stress on the body since it tries to balance
the different effects of the drugs which simultaneously exert their effects.

Forensic-Toxicological Analysis

As described above, in the epidemiological aspect alcohol, drugs and medicines

play an important role especially in (fatal) traffic accidents. Therefore, a chemical-
toxicological analysis should be performed in every case of traffic accident. Not
only drivers responsible for the crash but also pedestrians or others persons who
were recognized as victims can be affected. During the course of clarification
drug-related mistakes of victims could be interpreted as jointly responsible for an
event. After an accident without injuries or fatalities drug analysis is performed,
as routinely done in every case that is suspicious of DUI using routine laboratory
procedures. Analysis is complicated if injured or fatal persons have to be tested
due to some specifics which have to be considered like potential influences of
emergency medical aid (medication, infusions, loss of blood), a longer time period
between event and sampling of material for analyses (also between the time
of death and sampling) or no availability of definite sample material even in fatal-
ities (e.g. blood).

Matrices

In principle, various matrices are useful for chemical-toxicological analysis to

investigate cases of drugged driving. Generally, urine is the sample of choice for
screening and identification of unknown drugs because concentrations of substances
318 F. Mußhoff

are relatively high compared with other matrices such as blood, saliva or sweat.
Saliva and sweat are potentially useful for on-site drug-testing procedures in living
persons but not in fatalities. In urine, the window of detection for a preceding
consumption of drugs is markedly enhanced compared to blood. Additionally, the
sometimes active or inactive metabolites of drugs in urine samples can be identified
in addition, or even exclusively. Otherwise, a positive result in a urine sample does
not necessarily prove an actual impairment. The dose of a drug and as a general rule
impairments due to drug consumption are most closely correlated with its concen-
tration in blood. For this purpose, the relevant matrices that should be analyzed for
quantification are whole blood or rather serum or plasma. In these matrices, the
unchanged drug is detectable in most cases and the sample material is relatively
homogenous because physiologic parameters vary only within narrow limits. In
addition, blood or plasma samples are mandatory in cases of DUI in a relevant
number of countries all over the world. Difficulties arise when only aged or haemo-
lysed or post-mortem blood is available, even in cases of fatal traffic accidents.

Post-mortem Material for Toxicological Analysis

in Traffic Fatalities

In general, specimens available in post-mortem toxicology investigations can be

numerous and variable and may be selected based on case history, requests, legal
aspects and availability in a given case. Further information about post-mortem
toxicology is given in some excellent reviews [43, 44].

Body Fluids

Urine

As described above, the accumulation of drugs and metabolites in urine usually

results in high concentrations facilitating detection of drug use. Therefore, urine has
a great potential to provide information on ante-mortem drug exposure and is
frequently used as a screening specimen. However, there is no correlation between
urine drug concentration and pharmacological effects and urine may not always be
indicative for acute poisoning and impairment.

Bile

Even in post-mortem cases in which urine is not available bile may be substituted.
Bile represents a collection and storage depot for many drugs and corresponding
metabolites that have a biliary excretion and are subject to enterohepatic circulation.
15  Alcohol and Drug Fatalities in Transportation: Forensic-Toxicological Implications 319

Many drugs have been shown to accumulate in bile and the detection of drugs and/
or major metabolites in bile may indicate previous or chronic exposure to a drug.

Cerebrospinal Fluid and Vitreous Humour

Cerebrospinal fluid and vitreous humour are thought to be closer to the site of action
of drugs than blood and are useful to screen for a variety of drugs. They are less
subject to contamination and bacterial invasion by virtue of their protected environ-
ment inside the brain, the spinal column or the eye. Both cerebrospinal fluid and
vitreous humour also contain very little enzymes and proteins. Therefore, drugs
which are highly protein bound or those which are lipophilic tend to be found in
lower concentrations in these fluids than in blood. Vitreous humour is also useful for
alcohol analysis and has been used to distinguish ante-mortem alcohol ingestion
from post-mortem alcohol formation.

Gastric and Intestinal Contents

Oral ingestion remains the most popular means of exposure, especially to medi-
cines. Therefore, the gastrointestinal contents are essential for screening. Undigested
pills and tablets are often present.

Blood

As described above, blood is the specimen of choice for quantifying and inter-
preting concentrations of drugs and corresponding metabolites. For further interpre-
tation quantitation is usually performed on specimens from peripheral sites, for
example from the femoral vein, because post-mortem drug concentration can vary
from site to site. Caution has to be made concerning samples labelled as “heart
blood.” Samples may not have been collected from the heart itself but drawn blind
through the chest wall and may include pleural or chest fluid, pericardial fluid and
even gastric content if the death was traumatic. Following severe injury or trauma,
samples from defined sources are often not available and blood may be collected
only from the thoracic or abdominal cavity. The composition of these specimens
markedly differs from whole blood. Therefore, these “blood” samples only provide
a qualitative documentation of the presence of a drug. Tables  15.12 and 15.13
summarize factors that should be taken into consideration when interpreting blood
analysis results.

Tissue Samples

Tissues usually collected for post-mortem toxicological investigations include liver,

kidney, lung, brain and skeletal muscle specimens, as well as adipose tissue. Drug
320 F. Mußhoff

Table 15.12  Special considerations in the interpretation of blood analysis results in post-mortem
toxicology
1. Cardiac vs. peripheral blood: site dependence and distribution/redistribution phenomena
•  Cardiac blood is usually more abundant than peripheral blood
•  In contrast to concentrations derived from peripheral sources, reference data of cardiac
blood drug concentrations (from living persons) are not available
•  Important factors affecting the concentration ratio cardiac/peripheral blood are the type
of drug, its volume of distribution, concentration range, protein binding, pKa-value and
the post-mortem interval between death and autopsy (sampling)
•  Site-dependent differences can also arise from an incomplete distribution of the drug at
the time of death, and/or from post-mortem redistribution at the cellular level by passive
diffusion or via the vascular pathway from the major organs; the vascular pathway may
depend on the blood remaining fluid after death
•  The ante-mortem interval may be of importance, as one of the main factors behind the
redistribution phenomena: during the distribution phase, the arterial blood concentration
can be appreciably higher than the venous blood concentration
  To consider:
•  Drug levels in heart blood are mainly higher than in femoral venous blood and often
there is a wide range of ratios of drug concentrations in cardiac vs. peripheral blood
(basic drugs with a large volume of distribution showed the greatest range)
Heart blood is only useful for qualitative screening procedures!
2. Blood to serum/plasma ratios
•  Blood is a complex mixture containing solubilized proteins, dissolved fats, solids, and
suspended cells but drug concentrations provided in literature are usually determined in
serum
•  The water content and pH of a post-mortem blood sample may also differ significantly
from physiological ranges; samples are often haemolysed, putrefied, and may be quite
inhomogeneous mixtures
  To consider:
•  Literature data of serum/plasma concentrations cannot be absolutely used to classify the
concentrations determined from post-mortem blood
•  Blood to plasma concentration ratios for drugs of forensic interest has to be taken into
consideration
Be careful in interpretation of quantitative data with respect to the characteristics of the drug
of interest!
3. Post-mortem instability of substances and metabolic production (Table 15.14)
•  Bioconversion in situ after death as well as in collection vessels can occur
•  Decomposition and bacterial production occur dependent on time intervals and
temperature
  To consider:
•  Target analytes in living and deceased can vary
•  Possible influences of storage conditions prior to sampling as well as between sampling
and analysis has to be taken into consideration
Special target analytes and artefacts due to storage have to be considered in post-mortem
toxicology!

detection in tissue specimens may be considered whenever drugs are involved that
are highly lipophilic in nature and are preferably bound to tissue. Tissue samples
may also be useful in cases with extended post-mortem time period (time interval
between accident and time of death) and whenever body fluids are not available or
difficult to obtain.
15  Alcohol and Drug Fatalities in Transportation: Forensic-Toxicological Implications 321

Table 15.13  Special mechanisms in post-mortem samples between time of death and sampling
and during further storage, modified according to [42, 59]
Mechanisms Example(s)
Chemical instability
• Hydrolysis • Heroin, cocaine, acetyl salicylic acid
• Oxidation • Oxidation of sulphur containing drugs, morphine
Metabolic instability
• Esterases (endogenous) • Hydrolysis of ester type drugs or prodrugs
• Enzyme activities derived from • Hydrolysis of glucuronides, e.g. morphine glucuronides
bacteria • Reduction, e.g. nitrobenzodiazepines, THCCOOH
• Oxidation, e.g. thioridazine
Metabolic production Ethanol, GHB, carbon monoxide, cyanide

Kidney

Even in cases without urine samples a kidney specimen can be useful for screening
purposes since most drugs and metabolites are excreted into urine and will pass
through the kidneys.

Liver

Liver is favoured as a specimen when blood is not available due to exsanguination,

fire or decomposition. Since most drugs are metabolized in the liver, both the parent
compound and its metabolites may be present in high concentrations. Analysis of a
liver tissue specimen may also help to differentiate acute overdose from therapeutic
use of drugs with a narrow dosing window.

Lungs

Often high drug concentrations can be found in lung tissue, especially in cases of
inhalation or intravenous poisoning.

Brain

Brain is a useful specimen for the measurement of drugs because it is the principal
site of action for many drugs. Additionally, lipophilic substances like, for example
antidepressants, narcotics and halogenated hydrocarbons accumulate in central
nervous tissue. According to Mura et al. [45], THC for example can be detected in
brain regions that are influenced by its effects even if the substance is no longer
detectable in blood. This could be of special interest in traffic fatalities.
322 F. Mußhoff

Skeletal Muscle

Skeletal muscle as a post-mortem sample for analysis is used when blood is not
available, for example due to exsanguination. It is present in large quantities and
less affected by decomposition than the internal organs. However, the muscle to
blood ratio is influenced by the time lapse between drug exposure and death as well
as by the volume of distribution of the drug and drug analysis on skeletal muscle is
rather qualitative than quantitative in nature. Muscle specimens had also been con-
sidered as an alternative sample for alcohol analysis but the muscle to blood ethanol
concentration ratio was found to depend on the time course of ethanol absorption,
distribution and elimination.

Hair Samples

Hair samples may provide retrospective information about drug (ab)use [46, 47].
The amounts deposited in hair are functions of both ingestion/exposure and of the
metabolic regimen. There are various factors that influence drug concentrations in
hair. However, hair analysis revealed information about previous drug consumption
and tolerance.

Laboratory Approaches to Drug Testing in DUI Cases

In cases with suspicion of driving while impaired by drugs and especially in traffic
fatalities samples should be subjected to a broad screen for common drugs not only
relevant to the patterns of recreational drug use in jurisdiction but also for common
CNS-acting prescription and over-the-counter drugs [48].
Analysis starts with an immunoassay screening procedure in most cases. These
assays are often class-specific rather than drug-specific and their value is to rule out
the presence of certain drug classes in form of presumptive tests without further
forensic relevance, especially at court. Positive immunoassay results should not be
considered as proof of identification of a compound without complementary confir-
matory analysis. Furthermore, it has to be taken into consideration that immunoas-
says will not detect all types of drugs that are present; it may produce different
intensities of response to members of the same drug class and may fail to identify
important members of drug classes completely. Due to cross-reactivity and consid-
ering interferences false-negative and false-positive immunoassay results can be
revealed, especially in biological samples of road casualties (after medical treat-
ment with various drugs and infusions or if sample material is available after a crash
that is poorly defined). Especially in cases of fatal traffic injuries immunoassay tests
should be supplemented by chromatographic tests to include as many of the relevant
drugs as possible. Without this procedure there is significant possibility that the
drug or the metabolite that has caused impairment is not identified.