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The Drug Evaluation Classification Program: using ocular and other signs to detect drug intoxication
Abstract
A systematic approach to determining drug intoxication has been developed for use by police officers. By considering specific physiological signs, trained officers can detect the effects of seven major drug types.
Officers follow a 12-step testing sequence and evaluate signs such as pupil sizes and responses, eye movements, heart rate, body temperature, mental timing, and balance. A matrix is then used to compare that subject's signs to those that would be produced by the seven types of drugs. If a pattern match is found, the officer concludes that the subject is under the influence of a drug and specifies the drug type.
Several field and laboratory validation studies have been conducted using these procedures. In general, officers were 70% to 90% accurate in determining intoxication status and drug classification, but poly-drug use and drug rebound effects can sometimes cause problems in interpretation.
Ocular and other physiological signs can be used to detect drug intoxication and classify the type of drug taken. Knowledge of the procedures used in the Drug Recognition Program can enable optometrists to serve as consultants to the police and as expert witnesses in cases involving the use of ocular signs that indicate illicit drug use.
... The following divided attention tests were performed by the 10 subjects: Romberg balance test, walk-and-turn (WAT) test and the one-leg stand (OLS) test (3,4). Subjects were further assessed for the lack of convergence, pupil size and reaction to light, bloodshot eyes and horizontal and vertical gaze nystagmus (HGN and VGN). ...
... The time interval between smoking and blood sample collection undoubtedly contributed to the observed discrepancies between observed effects at the time of arrest and concentration at the time of the blood draw, and is being evaluated in ongoing studies. Nystagmus is not typical of marijuana use (3,4,16), and it was absent in seven of nine synthetic cannabinoid users in this series also. Recently, Musshoff et al. (17) described a series of seven subjects some of whom exhibited impairment in their driving following toxicologically confirmed synthetic cannabinoid use. ...
Twelve cases of suspected impaired driving are discussed in which the drivers who subsequently tested positive for synthetic cannabinoid drugs underwent a psychophysical assessment. The attitude of the drivers was described as cooperative and relaxed, speech was slow and slurred and coordination was poor. Pulse and blood pressure were generally elevated. Horizontal gaze nystagmus was assessed in nine of the subjects, but was present in only two. The most consistent indicator was a marked lack of convergence. In all cases where a Drug Recognition Expert (DRE) officer evaluated and documented impairment (10 cases), it was attributed to the DRE cannabis category. Performance in field sobriety tests was variable, ranging from poor to minimal observable effect. Synthetic cannabinoid testing was performed by LC-MS-MS. Positive results included: JWH-018 (n = 4), 0.1-1.1 ng/mL; JWH-081 (n = 2) qualitative only; JWH-122 (n = 3), 2.5 ng/mL; JWH-210 (n = 4), 0.1 ng/mL; JWH-250 (n = 1), 0.38 ng/mL and AM-2201 (n = 6), 0.43-4.0 ng/mL. While there is good evidence of psychophysical impairment in these subjects, further structured data collection is needed to fully assess the relationship between synthetic cannabinoid use and psychomotor and cognitive impairment.
... A number of studies have demonstrated the ability of pupillometry to differentiate between potentially drug impaired and normal subjects with 70-100% accuracy [113,114]. The most significant parameters were RPA and MCV [112]. ...
The pupillary light reflex (PLR) describes the constriction and subsequent dilation of the pupil in response to light as a result of the antagonistic actions of the iris sphincter and dilator muscles. Since these muscles are innervated by the parasympathetic and sympathetic nervous systems, respectively, different parameters of the PLR can be used as indicators for either sympathetic or parasympathetic modulation. Thus, the PLR provides an important metric of autonomic nervous system function that has been exploited for a wide range of clinical applications. Measurement of the PLR using dynamic pupillometry is now an established quantitative, non-invasive tool in assessment of traumatic head injuries. This review examines the more recent application of dynamic pupillometry as a diagnostic tool for a wide range of clinical conditions, varying from neurodegenerative disease to exposure to toxic chemicals, as well as its potential in the non-invasive diagnosis of infectious disease.
... HGN in DRE evaluations likewise indicates impairment associated with select categories of drugs, e.g. alcohol, CNS depressants, dissociative anesthetics, inhalants, and/or medical conditions affecting driving ability, but is not typically associated with cannabis in these protocols (Couper and Logan, 2014;Kosnoski et al., 1998;McLane and Carroll, 1986;Richman and Jakobowski, 1994). Thus, the lack of significant HGN differences in our study was expected. ...
Background:
The Drug Evaluation and Classification Program (DECP) is commonly utilized in driving under the influence (DUI) cases to help determine category(ies) of impairing drug(s) present in drivers. Cannabis, one of the categories, is associated with approximately doubled crash risk. Our objective was to determine the most reliable DECP metrics for identifying cannabis-driving impairment.
Methods:
We evaluated 302 toxicologically-confirmed (blood Δ(9)-tetrahydrocannabinol [THC] ≥1μg/L) cannabis-only DECP cases, wherein examiners successfully identified cannabis, compared to normative data (302 non-impaired individuals). Physiological measures, pupil size/light reaction, and performance on psychophysical tests (one leg stand [OLS], walk and turn [WAT], finger to nose [FTN], Modified Romberg Balance [MRB]) were included.
Results:
Cases significantly differed from controls (p<0.05) in pulse (increased), systolic blood pressure (elevated), and pupil size (dilated). Blood collection time after arrest significantly decreased THC concentrations; no significant differences were detected between cases with blood THC <5μg/L versus ≥5μg/L. The FTN best predicted cannabis impairment (sensitivity, specificity, positive/negative predictive value, and efficiency ≥87.1%) utilizing ≥3 misses as the deciding criterion; MRB eyelid tremors produced ≥86.1% for all diagnostic characteristics. Other strong indicators included OLS sway, ≥2 WAT clues, and pupil rebound dilation. Requiring ≥2/4 of: ≥3 FTN misses, MRB eyelid tremors, ≥2 OLS clues, and/or ≥2 WAT clues produced the best results (all characteristics ≥96.7%).
Conclusions:
Blood specimens should be collected as early as possible. The frequently-debated 5μg/L blood THC per se cutoff showed limited relevance. Combined observations on psychophysical and eye exams produced the best cannabis-impairment indicators.
... Changes in pupillary size are seen in various poisonings and can, together with other symptoms, give important clues regarding the nature of the toxin [1,2]. Dilated pupils (mydriasis) result from intoxication with substances which either increase the sympathomimetic tone (e.g., amphetamines, cocaine) or decrease the cholinergic tone (e.g., antihistamines, antidepressants). ...
Background:
Miosis occurs following exposure to toxins that decrease the sympathomimetic tone, increase the cholinergic tone, or exert sedative-hypnotic effects, but has not been reported in insulin poisoning.
Case report:
A 64-year- old woman without co-morbidities was found unconscious next to an empty insulin pen. Her Glasgow Coma Scale was 3 with absent reflexes, bilateral reactive miosis, and injection marks across the abdominal wall. The patient was endotracheally intubated, mechanically ventilated, and transferred to this hospital. At admission, the blood glucose level was 34 mg/dL. Glasgow Coma Scale remained at 3, with persistent bilateral reactive miosis. The toxicology screening was negative for ethanol, barbiturates, tricyclic antidepressants, phenothiazines, amphetamines, cannabinoids, salicylates, acetaminophen, and cocaine. Cranial computed tomography with angiography and magnetic resonance imaging (MRI) did not show any structural brain lesions. Intravenous glucose was continued at 6-14 g/h for 3 days. On repeated neurological examinations, the patient remained deeply comatose, with partial loss of cranial nerve function. Bilateral reactive miosis persisted for 4 days. From day 5 on, the patient awoke progressively. At discharge, the patient was fully alert and orientated, without a focal neurological deficit.
Conclusions:
Prolonged bilateral reactive miosis can be a clinical symptom accompanying metabolic encephalopathy in severe insulin poisoning. Functional impairment of the pons due to relative hypoperfusion during hypoglycemia may serve as a reasonable pathophysiologic explanation for this phenomenon.
... Sin embargo, su uso por vía parenteral, ha sido un método de autólisis poco frecuente. (4)(5) Incorporar a la práctica diaria nuestra experiencia en el diagnóstico, seguimiento y tratamiento de estos pacientes, motivó la realización del presente trabajo. ...
Suicide or suicidal intend is a very old procedure, carried out by the human being against himself. We presented the descriptive study of three patients who inoculated themselves kerosene, a domestic combustible, in a suicidal intend, unleashing severe tissue necrosis and acute pulmonary lesion in one of them. In the study it was clear the lack of prevision on the reach of the complications that lately appeared, from the part of the medical staff. We made suggestions for the persons injured for this cause in the future. Key words: suicidal intend, kerosene, tissue necrosis.
Articles published in Biomed Rev 2021; 32
Community corrections practitioners generally conceptualize “substance abuse technologies” to mean those things that are used to detect the use of some substance that an offender is prohibited from using as a condition of pretrial release, probation, parole, work release, or any other correctional options that involve an alternative to traditional incarceration (e.g., day reporting programs, electronic monitoring, or community-based residential and treatment programs for inmates reentering the community after a period of incarceration). In this chapter, we broaden the focus of “technologies” in order to give due diligence to substance abuse testing technologies from their traditionally narrow focus on detection to include technologies associated with delivering services that produce reductions in substance abuse and ultimately in individual offender recidivism.
Background:
Emergency Departments (EDs) care for thousands of alcohol-intoxicated patients annually. No clinically relevant bedside measures currently exist to describe degree of impairment.
Objectives:
To assess a group of bedside tests ("Hack's Impairment Index [HII] score") that applies a numerical value to the degree of alcohol-induced impairment in ED patients.
Methods:
A six-month retrospective review of HII score data was performed in a convenience sample of 293 intoxicated ED patients. Patients were scored 0-4 on five tasks, divided by the maximum score (20 if all tasks completed), every 2 hours; and classified by the number of visits: Low-frequency (1 visit); Medium-frequency (2 visits); High-frequency (≥3 visits). Correlations were assessed between HII score, healthcare provider judgment of intoxication, and measured alcohol levels.
Results:
Study patients had 513 visits; 236 were low-frequency, 26 middle-frequency and 31 high-frequency. Clinical assessment and HII score were strongly correlated (Spearman's rho = 0.82, p < 0.001); clinical assessment and alcohol level less strongly so (rho = 0.49, p < 0.001). Among low-frequency patients, HII score and alcohol level were weakly correlated (r = 0.324, p < 0.001), with no such correlation among high-frequency visitors (r = -0.04, p = 0.89). The mean decline between serial HII scores was 0.126 (95% CI: 0.098-0.154).
Conclusion:
This pilot study shows the HII score can be performed at the bedside of alcohol-intoxicated patients. The HII declines in a reasonably predictable manner over time; and applies a quantitative, objective assessment of alcohol impairment.
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