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The Official Journal of the Australian college of Legal Medicine The Official Journal of the Australian college of Legal Medicine Drug withdrawal, its management and fitness for interview and court Dr Liz Culliford Senior Forensic Medical Officer Queensland Health My name is Liz Culliford. I have been involved in the medical and forensic management of prisoners in police custody since 1987, initially part time as a GP/GMO and for the last 8 years, as a full time GMO. At present I work as a Senior Forensic Medical Officer in the Logan District in South east Queensland. Since the eighties I have seen major changes occur both in the incidence of drug dependence in offenders, the understanding of the medico-legal issues of drug dependence and the quality of care provided to drug dependent prisoners in custody. Criminality and drugs Information available from: Australian Bureau of Statistics (ABS) Australian Bureau of Criminal Intelligence (ABCI) Alcohol and Other Drugs Council of Australia (ADCA) Australian Institute of Health and Welfare (AIHW) Drug Use Monitoring in Australia (DUMA) Illicit Drug Reporting System (IDRS) National Coroners Information System (NCIS) National Drug Strategy Household Survey (NDSHS) Information regarding the statistics of illicit drug use is available in Australia from many sources: I have listed some of the sources above. However, it is difficult to get an accurate assessment of exactly how many criminal and regulatory offences are associated with the use of drugs and alcohol. The sources of information above look at different aspects of crime and drugs because drugs offences statistics look only at offences involving the production, distribution and possession of drugs. Criminal activity in the importation, production, and distribution of drugs 4365kg cannabis, 735kg heroin, 382kg amphetamines and 829kg Criminal activity to support a drug habit DUMA stats confirm 82% test positive after property offences Criminal and regulatory offences committed whilst intoxicated DUMA stats confirm 65% offenders test positive after violent offences Offences committed against persons who are intoxicated 33% homicide victims and 49% sexual assault victims However, there is a general consensus that drugs and alcohol contribute to about three out of four criminal offences in Australia. In 1997 it was determined that 4.9% of Australians aged 18 to 34 years had a drug use disorder (Hall et al, 1998 NDARC). The number of drug offences in Queensland in 2003-2004 was 44610 up 19% on the year before. 119 of these were for trafficking. So it is a major issue. The four areas where drugs and crime are closely linked are seen above. In 2000 for instance a very The Official Journal of the Australian college of Legal Medicine large quantity of drugs were seized by police in Australia. These amounts have already been exceeded in 2004-2005. It is well known that criminal activity accompanies drug use. Drug use is expensive, and in the spiraling use of an expensive habit, there is increasing incidence of stealing, armed robbery, break and enter and fraud. Contributing factors such as the effects of intoxication, are not mentioned in offence statistics, but in the DUMA extended study being performed in four police lockups around the country (in Southport Watchhouse in Qld) 65% of prisoners detained for a violent offence and 82% of those detained for property offences tested positive for amphetamines, benzodiazepines, cannabis, cocaine, methadone or opiates. From the NCIS data, 33% of victims of homicide had consumed alcohol or drugs (or both) at the time of their death. Similarly, from my own statistics for the SER sexual assault forensic service, 38 out of 78 (48.7%) of victims were intoxicated with alcohol or drugs or both at the time of the offence. So the likelihood of arresting an offender with a substance use problem is high. Police Powers and Responsibilities S234 A suspect is allowed to be held for 8 hours with 4 of those hours in ‘time S235 The following must be taken into consideration: Whether questioning is necessary The number of offences The seriousness and complexity of the offences Indicated willingness to make a statement Person’s age, physical capacity and condition and mental capacity After arrest, Police have certain powers and responsibilities regarding interviews undertaken before charges are laid. In Queensland these are set out in the Police Powers and Responsibilities Act 2000. In Section 234 it allows a suspect to be held for questioning for eight hours of which four hours has to be for ‘time out’. However in order to hold a person there must be certain issues taken into consideration. These are stated in Section 235. In this section it states that the person’s physical capacity and condition and mental capacity and condition must be taken into consideration. S236 An extension may be requested for a further 4 hours from a JP or 8 hours S254 ‘When questioning intoxicated persons, there must be a delay until the police are reasonably satisfied the influence of the alcohol or drug no longer affects the person’s ability to understand his or her rights and to decide whether or not to answer questions’. Further time may be requested from a JP or Magistrate but the length of questioning must still not go beyond 4 hours without charging or releasing the suspect. Section 254 also protects a person from being questioned when obviously intoxicated and states that there must be a delay until the police are reasonably satisfied the influence of the alcohol or drug no longer affects the person’s ability to understand his or her rights and to decide whether or not to answer questions’. However, the PPRA does not address the effects of withdrawal. The important question is: does drug withdrawal affect the physical or mental capacity or condition, in a recognizable way? The Official Journal of the Australian college of Legal Medicine Very few obligations definitely stated 4 hours ‘time out’ in eight hours If intoxicated must wait until police ‘reasonably satisfied that intoxication no Physical and mental capacity and condition are taken into consideration. So there are obligations when interviewing a suspect although they are not specifically defined. The interpretation is very broad and it is unlikely that a person who states to the interviewing officer ‘I am hanging out’ is likely to have the interview terminated for the purpose of having that person assessed or treated. Police are aware that the suspect is more vulnerable, and this assists in the process of obtaining information. However having obtained evidence under these circumstances, it is usually left to the suspect’s legal representative to prove that the evidence may have been illegally obtained. This may be relatively easy with a suspect who is obviously intoxicated, but could be a lot more difficult when the symptoms and signs are much more subtle. Drug dependence Characterized by: Withdrawal characterized by an abstinence syndrome if the drug is not taken Increasing tolerance to the drug necessitating increasing doses of the drug to Reduced self care All aspects of life revolving around acquisition and use of the drug and What is drug dependence? I apologize for stating the obvious to the doctors in the room. But it is important to understand the significance of dependence compared with intermittent, non dependant use. Drug dependence is characterized by symptoms of withdrawal if the drug is not taken and tolerance to increasing doses to achieve the same effect. There is also a persistent compulsion and craving to use the drug, with the use assuming more importance to other activities that causes drug seeking. The addict has to acquire the drug and if he or she doesn’t, then goes through the unpleasant withdrawal process characterized by the abstinence syndrome. This is often seen in prisoners in custody any time from a few hours to a couple of days after their last dose (depending on the drug and their level of dependence). Does this withdrawal process affect a person’s ability to represent himself when being interviewed or instructing a lawyer in his initial court attendances? I believe it does. Status when arrested Intoxicated Unaffected Mild withdrawal Severe withdrawal The Official Journal of the Australian college of Legal Medicine At the time of arrest an offender may be anything from intoxicated to withdrawing from their chosen drug. The PPRA states how long the suspect can be held for questioning and that he his medical and mental capacity and condition must be considered. If he or she is intoxicated, time must be allowed for him to sober up. However these are not formal medical assessments, they are police assessments, which may not pick up necessary medical issues which contribute to a person stating things that later, under different circumstances, the suspect would not have stated. This may not have much significance in minor criminal or regulatory offences. Police are used to placing an intoxicated offender in the watchhouse for four hours to allow the effects of alcohol or drugs to wear off. That is as much a procedure to protect a person from himself as to allowing a person to sober up before a formal record of interview can be performed. Many suspects in minor offences are interviewed later and given notices to appear. However, there is much more significance when the suspect of a serious offence needs to be interviewed as soon as possible after the alleged offence. How effective is the police assessment when they fall into one of the categories shown on the slide? What are the concerns? Along a continuum So what are the concerns? Not all offenders who use drugs will be dependent. When they recover from intoxication, they should be fit for interview. Also not all those with dependence will be seen in a state of withdrawal either. They can be arrested at any time along the continuum I have outlined on the slide here. In the watchhouse environment, we see prisoners who have been arrested and they may show clear signs of intoxication or even overdose, at the first consultation, a day later seem remarkably well and the third day be very unwell with vomiting, diarrhoea, muscle cramps and The Official Journal of the Australian college of Legal Medicine extreme anxiety. However, it is possible that they may be interviewed or be required to attend court at any time along this continuum, and it is important that at the stage when they are withdrawing, they are properly assessed and treated so that they can represent themselves properly. There are thus two windows where the suspect is probably fit for interview or instruct a lawyer and these can be seen on the diagram. Symptoms of opioid withdrawal Nausea, vomiting and diarrhoea Muscle and abdominal cramps Sweating and goose-bumps Lethargy Hunger Yawning Intoxication is usually easily recognizable not only by health professionals but by police and the legal fraternity. However, the symptoms and signs of withdrawal are often more subtle, often ignored and the significance not appreciated. The symptoms I have put on this slide are common symptoms that are seen in many addicts going through opioid withdrawal. Any of these symptoms may come on as soon as six hours after the last dose of heroin or take 24 to 48 hours if the opioid drug used has a long half life such as methadone or buprenorphine. So you may have a person who appears well at the beginning of questioning, but over a period of eight or sixteen hours may become increasingly unwell. In Queensland, it would be unusual for a suspect to be seen medically during this period unless he (or she) becomes obviously ill with vomiting or diarrhoea. In the UK and other Australian states, Victoria for instance, many more suspects of serious offences are seen at the beginning and often during the questioning process to determine their fitness for interview. In this state, the fitness for interview is determined by the police. Symptoms of stimulant withdrawal Fatigue and lethargy ‘Crash’ Hungry Anxious Depressed Alteration of mood Muscle cramps There may be confusion as to the expected effects of withdrawal as well. Opioid withdrawal gives a very characteristic syndrome as described on the last slide. However, stimulant withdrawal may present very differently with fatigue and lethargy or simple alteration of mood. To the untrained person, this could be very difficult to recognize. Less recognized effects Anxiety and irritability Slower response to questioning The Official Journal of the Australian college of Legal Medicine Behavioural changes Mood changes Thought content abnormality Attention and concentration difficulties Altered memory for recent and remote events Insight and judgment affected Why is drug withdrawal a problem at all? In addition to the more obvious effects which the police would, or should seek medical assistance, such as the vomiting, there are less recognized effects which are definitely beneficial to the questioner and a disadvantage to the suspect. I have enumerated some of these. All these effects can occur during the period of significant withdrawal from a drug. Drug dependence causes neuro-adaptation predominantly in the dopaminergic receptors in the brain and spinal cord. It is part of the brain reward pathway. When the reward ceases there are inevitable changes to the person’s mood and behaviour. Anxiety, irritability and depressed mood are common accompaniments to any withdrawal state. The ability to answer questions is also often affected as are insight and judgment. There may even be abnormalities to thought content – usually a symptom of psychosis but sometimes merely accompanying the persistent desire to have access to the drug. This is an ideal environment for police to push to get the answers they want to their questions. The suspect becomes very vulnerable. Fitness for interview or court A detainee’s medical or mental wellbeing may affect their competence at Must understand their situation Be able to adequately defend themselves If confessional evidence is improperly obtained, it can result in: improper plea evidence being inadmissible aborted trials dismissal of evidence against co-defendants convictions quashed in the appeal process A suspect’s medical and mental wellbeing may affect their competence at interview. It is the subject’s ability to understand the situation and be able to adequately able to defend himself. This may seem fairly straight forward to establish but in practice there is an element of subjectivity which complicates the determination. However, if the suspect provides confessional evidence when he is obviously unwell, that evidence is deemed to be improperly obtained. That can result in the evidence being inadmissible at the very least, or more serious situations such as aborted trials, dismissal of evidence against co-defendants or convictions being quashed in the appeals process. How does drug withdrawal affect the interview? Onset of withdrawal may be subtle Becomes more vulnerable to suggestion or aggressive questioning Becomes more compliant towards police or plea prematurely The Official Journal of the Australian college of Legal Medicine Become more aggressive or violent towards police or the court Wants the questioning and court process over because of increasing unpleasant Believes will not get treatment until interview or court process is over Both intoxication and withdrawal can be used as a defense for inadmissibility The onset of withdrawal may be quite subtle. At the start of questioning, the suspect may feel reasonably well. It is six hours since his last hit of heroin, and he usually uses two or three times a day. He doesn’t want to draw attention to his addiction status. He thinks ‘I’m OK at the moment’. However as questioning continues and his is given a couple of hours ‘time out’ to have a drink, a meal, a smoke, a toilet break and a sleep, the effects of withdrawal increase. How does this affect the interview? Again the effects may be quite subtle. As a police officer stated to me recently, ‘if they feel a little uncomfortable or unwell, suspects tend to spill the beans much quicker – they are much more vulnerable. That’s what investigation is all about!’ When asked if he would request medical assistance for someone who was unwell from drug withdrawal, he said ‘yes, when we have finished questioning and obtained the information we need’. The assessment Information about the suspect from police and others Observation Medical interview and examination Opinion Information to police with recommendations Fit for interview (or instructing a lawyer) Fit for interview with conditions and treatment Unfit for interview (or instructing a lawyer) What is appropriate medical care? Intoxication is recognized quite well by police and there is regular use of 4 hours time out to recover from the use of drugs or alcohol. Generally, it is recommended that a person’s BAC is below the legal driving level of 0.05% before an interview takes place, but it is rarely tested. However, a person who is repeatedly falling asleep will usually be allowed to do just that. However, the issues of withdrawal are more difficult to assess. Recognition within the custodial environment is usually after questioning regarding specific symptoms. This does not correlate well with the true status of withdrawal, so the signs of tachycardia, hypertension, pilo-erection, dilated pupils, sweating and anxiety are far more accurate to determine the true status of withdrawal, at least in the opioid dependant person. Then of course it is important to also recognize the other medical conditions that occur commonly with substance abuse especially bacterial sepsis, dental problems and blood borne virus infections. They may all impact on the ability to effectively interview a suspect. Treatment Will depend on the drugs used, time of last dose, symptoms, signs, requests from the suspect, likely length of questioning. The Official Journal of the Australian college of Legal Medicine Symptomatic therapy? Replacement therapy? Medications causing sedation may require more breaks for sleep Regular assessment may be needed So we now get around to treatment. This will obviously depend on the drugs used, the time of last dose, symptoms, signs, requests from the suspect and the likely length of question which is often related to the seriousness of the offence. This will range from no treatment, to small amounts of symptomatic treatment to the possibility of using replacement therapy. It must be remembered of course that medications causing sedation may put the suspect to sleep, changing a person who is able to be interviewed to one that is not. Also if treatment is given, regular assessment may be needed. Symptomatic Metaclopramide for nausea and vomiting Loperamide for diarrhoea Brufen or paracetamol for aches and pains Diazepam for anxiety and cramps So I will talk about opioid dependence mainly although stimulant drug dependence is of increasing importance but with less understanding of the best way to treat withdrawal. Most practitioners would know the above regime. It is not very effective but is better than nothing. We no longer use quinine, and although clonidine is very effective in treating the over stimulation of the parasympathetic nervous system, it has the disadvantage of causing significant hypotension and it should probably only be used in a medical environment. Replacement Stat doses with follow-up re-dosing if inadequate symptom response with: Physeptone Buprenorphine Morphine/Delayed release morphine Codeine Endone Obviously if the suspect is on a replacement program, it is important that he or she receives his usual dose ideally at the usual time. This will normalise the suspect and interviewing should then be able to proceed in the normal way. Opioid replacement is a far more sensible method of treating opioid withdrawal in the short term. I have considered the various opioid drugs that could be used and feel that the ideal drug should have a fairly long half life. Small doses may still be given at fairly short intervals and the person reviewed regularly, possibly every four hours. Care has to be taken to determine the optimal dose. The first dose of physeptone may be as low as 10mg but still produce good short term effects. The dose may need to be repeated at 4 or 8 hours, but the likelihood of significant overdose is small but a positive effect should be obtained. MS Contin is absorbed very slowly and be more difficult to The Official Journal of the Australian college of Legal Medicine titrate. Buprenorphine is an excellent drug to assist in the withdrawal process but there is always the risk of precipitating an accelerated withdrawal state because of its mixed agonist and antagonist properties. Both endone and codeine are also possibilities and both are use short term in the UK but they are weak opioids and may not provide much relief. Advantages Would reduce the symptoms of withdrawal more effectively than symptomatic May ‘normalize’ their physical status until appropriate long term management Would improve the quality of information obtained from the interview Could prevent admissions being ‘inadmissible’ or premature pleas being made Offenders’ court behaviour is likely to be better Offenders are easier to manage in the custodial environment if they feel better It may encourage ongoing treatment for offenders’ substance use problems There are definite advantages in providing such a service although I would assume that it would be necessary for the more serious crimes which involve extended periods of interview. Two small doses of physeptone may be all that is needed for the interview process. This may be extended to cover the initial court process as well until formal long term management is arranged. Disadvantages A detailed clinical examination would have to be performed by a suitably qualified doctor (FMO) before a replacement drug is given The dose of drug could be misjudged producing a worsening of the physical The FMO would have to be on hand for reviews as necessary The present legislation does not allow us to provide replacement opioid or stimulant medication to addicts in these circumstances The main disadvantage in providing such a service to police is the lack of is the availability of appropriately trained staff at all hours. They would have to be available not only at the start of the interview but also for periodic reviews. Of course the dose of drug would have to be appropriately titrated, because too much could produce worsening of the suspect’s physical status. Then the main limitation is that the present legislation does not allow us to provide replacement opioid in these circumstances. In the UK, there is no such limitation. However, there have also been a number of overdoses of physeptone given by FMEs in this situation. In conclusion Better assessments performed prior to and during the interview and court Better management of withdrawal with consideration of providing replacement therapy for these two specific purposes The Official Journal of the Australian college of Legal Medicine This would provide a platform to provide ongoing care for offenders both in As I finish, I have presented some of the issues in relation to the fitness of suspects who abuse drugs to be interviewed and attend court. Some of these people may benefit from the judicious use of opioid replacement to ‘normalise’ their medical status and it may allow effective ongoing care to be provided for their substance abuse. Treatment should commence as soon as they are involved with the criminal justice system and continue for as long as they are required to represent themselves. Ideally that should then flow into the health system for long term care both in the community and the correctional system. Dr Liz Culliford Senior Forensic Medical Officer South East Queensland Region Logan District Police Headquarters Civic Parade QLD 4207 Phone: 07 3826 1815 or 0419 706083 Fax: 07 3826 1815 The Official Journal of the Australian college of Legal Medicine

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