Tag Archives: Toxicology

WAS MARILYN MONROE MURDERED?

A1No movie star lived on after death like Marilyn Monroe. She was far more than a bleached-blonde bombshell with a voluptuous frame and a lusty voice—she intuitively knew her craft. Born in poverty as Norma Jean Mortenson (aka Baker) to a mentally unstable mother, Marilyn Monroe rose to Hollywood glamor, fame, and idolization beyond what few ever reached. Tragically, by the time she died at age thirty-six, her performing career had spiraled into the same abyss her personal relationships and head space were already in.

MM10Marilyn Monroe was found dead in her Beverly Hills bed at 3 a.m. on Sunday, August 5, 1962. The scene suggested nothing suspicious—no foul play, that is—and the toxicology results from her autopsy proved she’d succumbed to a lethal dose of prescription drugs. The coroner ruled her death as “probable suicide” but, like the deaths of other uber-celebrities, many mumbled murder. Monroe’s death was reinvestigated in 1992 by the Los Angeles District Attorney who came to the same conclusion—“probable suicide”.

In today’s coroner-speak, “probable” is not in the official vocabulary. Neither is “possibly”. Everywhere in the civilized world, coroners are mandated by legislation to rule a manner of death as being in one of five categories: natural, homicide, accidental, suicide, or undetermined. Now, fifty-four years later, an impartial look at Monroe’s case facts indicate her manner of death should not be ruled as a suicide.

But was Marilyn Munroe actually murdered?

A7On the day of her death, Marilyn Monroe was in the company of many people, none of who reported any immediately implied threat or perceived action from Monroe that suggested an imminent danger of suicide, nor any behavior that was outside of her already troubled mental state of manic highs and depressive lows. She’d a history of emotional instability that, today, would likely be classified as Bipolar II Disorder and she was under the continual care of a general physician and a psychiatrist. Monroe was no stranger to prescription pharmaceuticals, specifically anti-depressants and sleeping pills, but she was a relatively light alcohol drinker.

Marilyn Monroe had a difficult year in 1961. She worked very little due to health issues. Besides her emotional imbalance and substance dependency, she underwent surgery for endometriosis (uterus ailment) and a cholecystectomy (gall bladder removal), then suffered a painful attack of sinusitis. Her stress level soared from a lawsuit with 20th Century Fox where they sued Monroe for breach of contract—her erratic behavior led to delays in filming, disputes with cast and crew, then finally a stop of production.

A14On Saturday morning, August 4, Marilyn Monroe met with her official photographer and discussed an upcoming Playboy deal, then kept a massage appointment, a meeting with her publicist, talked with friends on the phone, and signed for deliveries for her house renovation. She was visited by her psychiatrist, Dr. Ralph Greenson, in the late afternoon for a scheduled therapy session. Greenson left around 7 p.m. and reported no alarming behavior, however he ensured that Monroe’s housekeeper, Eunice Murray, would be staying overnight.

Marilyn Monroe retired to her bedroom around 8 p.m. The last person to have contact with Monroe was actor Peter Lawford who invited her to a Hollywood party. He reported that in their phone conversation Monroe sounded tired—sleepy—as under the influence of drugs. After their call, Lawford became alarmed and phoned back to the house where he got Murray. She assured him everything was fine with Monroe.

A22At 3 a.m. on Sunday morning, Eunice Murray woke and noticed light coming from under Monroe’s bedroom door. Sensing something not right, Murray tapped on the door. There was no response so she tried the handle and found it locked, which she stated was unusual.

Now alarmed, Murray phoned Dr. Greenson who instructed her to go outside and look through the bedroom window. She did and observed Marilyn Monroe lying facedown on the bed, covered in a sheet, and clutching a telephone receiver in her right hand.

Greenson arrived at approximately 3:20 a.m., broke the window with a fireplace poker, and climbed in. Immediately he could tell Monroe had been dead for some time and it was pointless to call an ambulance or attempt resuscitation. Greenson phoned Monroe’s physician, Dr. Hyman Engelberg, who arrived at around 3:50 a.m. Engelberg examined Monroe by removing the phone receiver and rolling her over, officially pronouncing death. At 4:25 a.m. they notified the LAPD.

MM2The attending detective agreed with the two doctors that there was nothing to indicate foul play and the death was most likely a drug overdose. The detective photographed the scene and recorded the “pill count” of the pharmaceutical vials on Monroe’s nightstand. Dr. Engelberg noted a vial containing twenty-five capsules of the barbiturate Nembutal that he’d prescribed two days earlier was empty. Vials with other prescriptions appeared in order including one containing the sleeping sedative Chloral Hydrate.

Marilyn Monroe was autopsied on the morning of August 6 by pathologist Dr. Thomas Noguchi who would later be known as “Coroner To The Stars” for his many postmortem exams on celebrities. His original autopsy report is on the public record and can be downloaded. Click Here.

A20Noguchi is very clear in his report and many subsequent interviews that he found no evidence of physical trauma—specifically needle marks—on Monroe’s body. Based on his observations and those of Drs. Greenson and Engelberg regarding Monroe’s rigor, livor, algor, and palor mortis conditions, he felt reasonable to estimate her time of death between 8 and no later than 10 p.m. the previous night. Noguchi found no natural cause of death and waited for the toxicology report before forming his final conclusions.

The tox screen was done by the LA County Coroner’s laboratory and released on August 13. The results concluded  Monroe’s blood contained 4.5 milligrams (percent) of Nembutal and 8.0 milligrams (percent) of Chloral Hydrate. Her liver contained 13.0 milligrams (percent) of Pentobarbital. Blood ethanol (alcohol) was absent.

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Noguchi was satisfied the combination of Nembutal and Chloral Hydrate levels in Monroe was sufficiently high to cause her death through respiratory and central nervous system failure and he knew the Pentobarbital stored in her liver was simply indicative of someone who had long exposure to barbiturates and developed a “tolerance”. Noguchi certified the cause as “acute barbiturate poisoning due to ingestion of overdose” but he was reluctant to rule the classification as “suicide”. Though Noguchi was certain no evidence existed to suggest the death was an intentional homicide, he was uncomfortable with there being no clear evidence that Monroe intended to take her own life.

There were no immediate threats, no suicide note, no warning behavior, and not all the Chloral Hydrate pills were consumed, not like the Nembutal.

A23It might be an accidental OD, Noguchi thought, and he was troubled by the fact Monroe had been prescribed the amounts of Nembutal and Chloral Hydrate at the same time—her physician had to have known they’d be lethal if mixed a large quantity.

Noguchi was under pressure—political pressure, if you will—from the elected Chief Coroner of Los Angeles County to shut down media speculation that there might be more to Monroe’s death than a sad case of a despondent star intentionally extinguishing her light. The Chief and Noguchi reached a temporary compromise that they’d say Monroe’s death was a “probable” suicide.

A21Noguchi didn’t go so far as to insinuate negligence by Monroe’s caregivers might be the smoking gun, yet he requested a “psychological autopsy” to investigate Marilyn Monroe’s mental state leading to her death. Without clear evidence of an intentional suicide, the pattern of Monroe’s behavior was crucial in corroborating a suicide rule.

This statement was issued by LA County Chief Coroner Theodore J. Curphey. It’s an addendum to Noguchi’s final autopsy report:

“Following is the summary report by the Psychiatric Investigative Team which assisted me in collecting information in this case. The team was headed by Robert Litman, M.D., Norman Farberow. Ph. D., and Norman Tabachnick, M.D.:

‘Marilyn Monroe died on the night of August 4th or the early morning of August 5th, 1962. Examination by the toxicology laboratory indicates that death was due to a self-administered overdose of sedative drugs. We have been asked, as consultants, to examine the life situation of the deceased and to give an opinion of the intent of Miss Monroe when she ingested the sedative drugs which caused her death. From the data obtained, the following points are the most important and relevant:
Miss Monroe suffered from psychiatric disturbance for a long time. She experienced severe fears and frequent depressions. Mood changes were abrupt and unpredictable. Among symptoms of disorganization, sleep disturbance was prominent, for which she had been taking sedative drugs for many years. She was thus familiar with and experienced in the use of sedative drugs and well aware of their dangers.
Recently, one of the main objectives of her psychiatric treatment had been the reduction of her intake of drugs. This has been partly successful during the last two months. She was reported to be following doctor’s orders in her use of drugs; and the amount of drugs found in her home at the time of her death was not unusual.
In our investigation, we have learned that Miss Monroe had often expressed wishes to give up, to withdraw, and even to die. On more than one occasion in the past, when disappointed and depressed, she made a suicide attempt using sedative drugs. On these occasions, she had called for help and had been rescued.
From the information collected about the events on the evening of August 4th, it is our opinion that the same pattern was repeated except for the rescue. It has been our practice with similar information collected in other cases in the past to recommend a certification for such deaths as a probable suicide.
Additional clues for suicide provided by the physical evidence are:
(1) the high level of barbiturates and chloral hydrate in the blood, which, with other evidence from the autopsy, indicate the probable ingestion of a large amount of drugs in a short period of time;
(2) the completely empty bottle of Nembutal, the prescription for which was filled the day before the ingestion of drugs; and
(3) the locked door which was unusual.’

MM7

Now that the final toxicological report and that of the psychiatric consultants have been received and considered, it is my conclusion that the death of Marilyn Monroe was caused by a self-administered overdose of sedative drugs and that the mode of death is probable suicide.

– Theodore J. Curphey, M.D. Chief Medical Examiner-Coroner for the County of Los Angeles, August 13, 1962.”

There’s that word “probable” again.

A24In my time as a police officer and coroner, I’ve attended many drug overdose deaths. Some were clearly suicides, backed-up by threats and notes. Some were accidents by misadventure, usually mixed with alcohol. And some were undetermined—not shown to have a definite intent by the decedent to take their own life.

I’d say some of the undetermined deaths were probably suicides—if I could say it. But a coroner doesn’t have the legal option to say “probably”. There’s a long-held  court ruling called the Beckon Test that states a death can only be classified as a suicide if it can be determined that the individual knew the consequences of their actions would end in death and intentionally carried them out. There is a high standard of proof required for a finding of suicide as the ruling states:

A25

“In most legal cases the test to be satisfied is a balance of probability. But a determination of suicide can only be made where there is clear and convincing evidence. There is to be a presumption against suicide at the outset and one must be certain beyond a high degree of probability that the death was a suicide. Where one cannot be absolutely certain, the death must be classified as undetermined.”

Based on my death investigation experience, there are three points about Marilyn Monroe’s suicide ruling that bother me.

First, in all the polypharmacy overdoses I’ve seen where suicide was obvious, the deceased downed the whole darned stash.

A30In Monroe’s case, Dr. Engelberg prescribed her 50 caps of 500 mg Chloral Hydrate on July 31 as a refill for a previous Chloral Hydrate order on July 25. She was taking 10 per day. At her death scene, there were still 10 Chloral Hydrate caps left in her bedside vial. 40 were gone and, at a rate of 10 per day from July 31 till August 4, the pill count is right in order.

In the toxicology world, the effects of drugs are rated on a range scale of Therapeutic, Toxic, and Lethal. In the Lethal range, the substance is given a value called LD50 where it’s expected that 50 percent of the population would be expected to die from the drug’s effect at a certain point based upon the drug’s milligram blood content per the kilogram weight of the person.

MM17

Marilyn Monroe’s autopsy report recorded her weight at 117 pounds or 53.2 kilograms. The Chloral Hydrate level in her blood was determined to be 8.0 milligrams (percent) based on her weight or 80 parts per million (ppm). Looking at my toxicology scale from my coroner days, I see that Chloral Hydrate has a Therapeutic range to 30 ppm and an LD50 value at 100 ppm, so Monroe was 20% under the Chloral Hydrate lethal bar.

MM15

Looking at her barbiturate blood content from the Nembutal, it’s recorded to be 4.5 mg (percent) or 45 ppm. My chart says the barbiturate Pentobarbital, which is what’s in Nembutal, has a Therapeutic range to 12 ppm and an LD50 at 40 ppm. So Monroe was only 12.5 % over the average barbiturate lethal threshold, not taking into account that she was a very “tolerant” user.

However, the combination of Chloral Hydrate and Nembutal was deadly and this had to be known by Dr. Engelberg when he ordered Monroe’s prescription. This brings me to my second point.

A29A physician has a professional duty of care to their patient, especially when prescribing medication to a person with Monroe’s mental history. I find it irresponsible, actually negligent, that Dr. Engelberg failed to ensure Monroe no longer had Chloral Hydrate in her possession when he issued her a prescription for 25, 1500 mg caps of Nembutal four days later, knowing her supply of Chloral Hydrate wasn’t exhausted based on her prescribed consumption.

My third point deals with the “rescue” issue.

This very much applies to the Beckon Test. Intentional overdoses as attention-getting devices are common and always rely on the person’s backup plan that someone will intervene. This was part of Monroe’s previous overdose episodes as noted in the “psychological autopsy” report. And they referenced Monroe’s locked door as being unusual.

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I think the locked door issue is completely negated by the fact that Monroe was found with her telephone receiver in hand. This was stated by Eunice Murray, Dr. Greenson, Dr. Engelberg, and corroborated by the investigating detective who verified they reported this to him and suggested she was phoning for rescue—which was her pattern—but was overcome.

If I were the coroner ruling on the manner of Marilyn Monroe’s death, I’d be legally bound to consider how the facts apply to the parameter of categories.

MM1A natural cause determination is completely eliminated by the autopsy and toxicology evidence. Monroe clearly died as the result of a drug overdose.

Despite kooky conspiracy theories that Bobby Kennedy snuck in and injected Marilyn Monroe to cover up her alleged affair with President Jack or that mobsters Jimmy Hoffa and Sam Giancana knocked her off to keep from ratting them out, no sensible person can make a case that Monroe was intentionally murdered. But a homicide ruling doesn’t just apply to murder. The definition of homicide is “the killing of a human being due to the act or omission of another”.

I believe Dr. Engelberg was professionally negligent in his duty of care to Marilyn Monroe. He had to know—certainly ought to have known—that he was treating an emotionally unstable patient with a history of suicide attempts through polypharmacy. By giving Monroe a potentially lethal amount of barbiturates and not ensuring her chloral hydrate was gone, Engelberg effectively signed her death warrant.

However negligent Engelberg may have been, though, my suspicion falls far short of the burden necessary for establishing a homicide conclusion.

A3That Monroe accidently died from a self-administered overdose is a distinct probability but, again, the Coroners Act and court precedents won’t allow me the liberty to rely on probabilities regarding suicide. I have to come to a clear conclusion based on facts.

Setting aside the locked door and phone receiver in hand—these two negate each other—I must defer to one other glaring fact. There were still 10 caps of Chloral Hydrate left in her pill vial. Marilyn Monroe was a very experienced and tolerant prescription pill user. She knew exactly what she was taking, what their effects were, and she failed to down her whole darned stash which is always proof of a polypharmacy overdose suicide.

A4So deferring to the Beckon Test, I have to presume against Marilyn Monroe’s suicide from the outset and must be satisfied beyond a high degree of probability that her death was a suicide—I must be certain—and I can’t—because no clear evidence exists that Monroe’s death was an intentional act to end her own life. It may well have been an unfortunate, unrescued accident.

Therefore, I find Marilyn Monroe’s manner of death as Undetermined.

THE EXCRUCIATING DEATH OF MISTER RED PEPPER PASTE MAN

A17“Sounded like someone was skinning a live cat,” the neighbor told us. She sniffed, wiping her eyes. “Then loud crashing and banging, then… everything went quiet. I waited a while, didn’t hear nothing more, so I went and checked and found him dead on the floor.” 

I was in my first year of coroner understudy and shadowing my mentor, senior coroner Barbara McCormick. We were in the kitchen of a tiny suite on the poor side of town, standing over this skinny, old guy who was in a semi-fetal position with one arm wrapped around his abdomen and his other hand clutching his throat. I’ll never forget his wide-open eyes or the gritting grimace of teeth—the expression of excruciating pain etched in a cold, deathly stare.

“Heart attack or brain aneurysm, Barb?” I asked, ready to flip a coin. I was new to the coroner service, but no stranger to dead bodies after a career as a homicide cop. There was zero sign of foul play at this scene and my experience told me people only drop dead from one of these two natural events.

A19Barb was bent over, starting the head-to-toe examination that coroners do before removing a body for a thorough autopsy back at the morgue. “Wouldn’t bet on either.” Barb was trying to pry his jaw for a look down the throat. “Check his color. Blue-gray. He’s asphyxiated. I’m thinking he might have choked on something but, for the life of me, I don’t know how he could let out a curdling cat-scream if something was stuck in his yap.”

While Barb was messing with his head, I snooped around. It was typical digs for a single pensioner—a bachelor suite crammed with junk. Empty booze bottles and overflowing ashtrays testified to a lifestyle that suggested he should be dead of something by now. I checked for meds, which was routine. The pathologist would want to know what was likely in his system and the toxicology lab would want it for sure.

A20I found the usual pill vials indicating treatment for coronary and respiratory ailments that heavy drinkers and smokers all have. The place was relatively clean, although cluttered, and didn’t reek of garbage and bodily waste like most of these places do. I saw a part-eaten sandwich on the table and a freshly cracked beer—seemed like the old boy was doing lunch when violently seized by the death monster and taken down hard to the mat.

Barb stood up, looking puzzled. “I have no idea. Should be an interesting postmortem.” We finished photographs, bagged the man, then stretchered him out to the transport van and drove him off to the morgue.

We’d recorded his personal details, which is part of a death investigation, but his real name never stayed with me. Most are like that. In the death business it’s not a good idea to get too close to your clients, but some you never forget because of how they checked out.

A15It’s normal—in black humor behind the scenes—for coroners to name their files by earned handles. I’ll always remember Capn’ Crab Bait, Voltage Vern, Methlab Mikey, Arachnoid Ann, Lawn Tractor Guy, Tarzan of the Caterpillars, Freight Train Ference, The Krosswalk Kidd, The Drill Sergeant, Pole Dancer, Cats-Sup, and… as long as I live… I’ll never forget The Electric Carving Knife Lady.

And, it came to pass, I’ll also never forget the dead little man we’d just rolled into the cooler. 

Next morning my favorite pathologist, Dr. Elvira Esikanian, was on the roster to autopsy our guy from the kitchen floor. I loved dealing with Elvira. She’s Bosnian with a wicked sense of dry humor and an equally wicked curriculum vitae, including exhuming mass graves for the UN and serving in some of the busiest morgues around the world where she’d often do a dozen different cuttings per day.

A21Although Elvira was exceptionally thorough, she was a go-to-the-throat prosector. She’d assess the circumstances, then head straight to the most likely cause.

“I’m suspecting an acute respiratory event,” Elvira stated. “Note the petechiae in the eyes.” She pointed to pricks of blood in his whites. “We normally see petechiae in cases of sudden and severe loss of oxygen, such as in strangulation, although on this man I see no sign of exterior trauma.”

We Y-incisioned the thorax/abdominal cavities and began removing organs.

A16“His lungs are clear, with the exception of tobacco effects.” Elvira had cross-sectioned them. “And his airway is unobstructed. This man did not choke, nor was he suffocated by fluid.” She examined the heart, which showed expected signs of advanced coronary artery disease. “And he did not suffer a heart attack.” Elvira placed the gastro-intestinal tract in a plastic tub and set it aside on her bench.

She proceeded straight to a cranial exam, inspecting for the tell-tale bleed of a cerebral hemorrhage. “Nothing obvious here.” Elvira put the brain in a stainless bowl. “You indicated this man was eating lunch when he expired.” She looked at me. I nodded. She reached for her plastic tub. “I’m going to examine the stomach.”

A22For most pathologists and coroners, digging in the digestive tract is the most unpleasant part of the job. It was no different with this man. Elvira incised the stomach and poured its contents into a clear, glass tray. She flipped on her magnifiers and bent a gooseneck light overtop. Immediately, she let out a wolf-whistle. “Look at this!”

To me, it was a messy slime-goo of chewed bread mixed with some rude and red, pasty substance.

To Elvira, it was the smoking gun.

A25I watched Elvira excise a culture, fix it in a slide, and examine it under her microscope. “Have a look.” She directed me to the eyepieces.

What I saw was a squiggling biological mass of sub-terrain aliens—looking out-of-this-world like agitated, animated, turquoise tampons breathlessly mingling in a magnified mess of greenish-gray snot.

I swear they had heads, horns, and hoofs.

Clostridium  Botulinum,” Elvira announced. “Botulism. I’m sure this man died from the deadliest food poison known.” 

Now, I’d heard of botulism. Everyone has. That’s why my mum would sniff the tin cans when she opened them and why she’d boiled preserves for four hours. But this was the first time I’d seen a real case of botulism.

A12“We won’t know the strain or the severity level until we get toxicology results but I can tell you, given how quickly this poor fellow expired, it must be an extremely toxic ratio.” Elvira went on. “What happens is the neurotoxin produced by the botulinum bacteria acts as a blocking agent preventing neurotransmitters from issuing instructions to the muscles. Once this poison hit his system, every nerve in his body would have felt on fire and he’d quickly fall into total paralysis. That would soon stop his lungs and he’d fall into a state of anoxia, or lack of oxygenated blood to the brain. He’d be conscious throughout and would feel everything… but would be unable to react.”

She glanced at the cut-open cadaver on her examining table. “What a positively excruciating way to die.”

A8Barb McCormick already had her digital camera out and was scrolling through shots from the scene. “This might be it.” Barb enlarged a photo showing the kitchen. Evident was a jar with its top off, containing a reddish substance.

Realizing the lethality of the situation and the danger to others, Barb and I immediately went back to the apartment. There, on the counter, was a jar of red pepper paste with a label indicating it originated in China and was far past its expiry date. A tag showed it’d been purchased at the Dollar Store.

Cautiously, we peered inside.

And—I’m here to tell you—that red, peppery, pasty scum was actually moving.

A26It took over a month for the toxicology results to come back. They proved positive for Botulinum toxin—Type E—and the dosage was staggering.

Toxicology measures the presumed lethal dose of a substance in digital units of LD50/ (mg/kg) which translates to the Lethal Dose (LD) required to kill half of the tested laboratory animals in a controlled volume and time.

The LD for Botulinum toxin is 0.00001. Our red pepper paste man’s reading was over 0.02000—two thousand times the amount needed to kill a human being.

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A27It’s been a few years since the red pepper paste case and I thought I’d review the pathology around Botulinum toxin. Here’s a quote from a paper by the World Health Organization on the medical process of how botulism works on the human body:

To understand the role of Botulinum toxin, it is necessary first to understand how the brain initiates a muscle contraction as it is in this process that Botulinum toxin intervenes.
Muscles are connected to the brain by the nervous system which is a complex network of neurons – these are long cells that can pass information using either electrical or chemical signals. Chemical signals pass between neurons and muscles through synapses, which are specialized connections linking cells. The chemicals that are used to pass these messages are called neurotransmitters.
A30In the case of a muscle contraction, the chemical signal is passed using a neurotransmitter called acetylcholine. This sits in the neuron in a vesicle, a small bubble surrounded by a membrane, until it is required. When the neuron receives a message from the nervous system to initiate a muscle contraction, the acetylcholine is released from the vesicle and passes through the synapse into the muscle fiber.
To achieve this, the vesicles need to be transported to, and fuse with, the neuron membrane that adjoins the synapse between the nerve and the muscle. This process is controlled by a group of proteins called the SNARE complex.
A29The three main proteins involved are Syntaxin (which connects to the nerve membrane), Synaptobrevin (which connects to the vesicle) and SNAP-25 (which helps the other SNARE proteins link up). These proteins join together to cause the vesicle to move to the nerve membrane and fuse with it. The acetylcholine can then be released across the synapse and pass into the muscle. This then triggers a chain of events that causes the muscle contraction.
Botulinum toxin prevents the release of acetylcholine through the synapse.
Botulinum toxin is produced by a bacterium called Clostridium Botulinum. This bacterium is associated with causing botulism, a rare but deadly form of food poisoning.
A33Botulinum toxin is exceptionally toxic but, when purified and used in tiny, medically controlled doses, it can be used effectively to relax excessive muscle contraction and is now commonly used in cosmetic surgery.

Hmmm… BOtulinum TOXin… BoTox. 

A23The same gruesome stuff in the red pepper paste that painfully killed our old man is commonly stuck into people’s faces to make them look younger and pretty.

I’m sure, for the most part, BoTox injections are perfectly safe. But… if you’re thinking of cosmetically shedding some years, remember the Excruciating Death of Mister Red Pepper Paste Man.

MARIJUANA: DRIVING HIGH

Sabra Botch-Jones, M.S., M.A., D-ABFT-FT, is a forensic toxicologist at Boston University School of Medicine/fTox Consulting, LLC. With the move towards decriminalization of marijuana across North America comes the issue of legal DUI tolerances with cannabis impairment. Sabra wrote this accredited, scientific article specifically for DyingWords. Thanks, Sabra!

Introduction

AA1ASeveral States have moved into a new era with the legalization of medical and/or recreational use of marijuana. With this shift we must stop and ask the question of “are we ready”?

With the year 2014 behind us, we have 24 states with legislation allowing the use of marijuana for certain medical conditions and two states (Colorado and Washington) having passed laws allowing its use recreationally. This is a historical shift for a substance that has had a world-wide presence since 28th century B.C.

AA2Safety-sensitive functions such as operating a motor vehicle require our full attention and distracted or impaired operation can be catastrophic. Driving under the influence of an impairing substance, including legal recreational (i.e alcohol) and prescription drugs, puts our lives and those around us at risk.

Therefore, let us explore the risk posed by driving “high” and what research is telling us.

What We Know

AA3A multitude of studies exist on cannabis intoxication and its effect on the skills needed to drive safely. With this magnitude of information, the answer to our previous question “are we ready” should be yes, but is it?

We know that drug use, alone or in combination with alcohol, increases our risk of being involved in a motor vehicle accident; however, the level(s) (if any) of tetrahydrocannabinol (THC) used to determine impairment is the subject of debate.

Research shows inter-individual variation in impairment, with some individuals being dangerously impaired at very low levels. Conversely, there are individuals who showing no appreciable cognitive effects test well above the suggested levels.1-7

AA4This variability makes passing legislation based on compound levels extremely difficult and may lead to erroneous perceptions that driving while high is not dangerous.

Complex tasks such as driving require attentiveness, accurate perception of speed and timing as well as altertness.1-6 These are all areas that THC can negatively effect.1-6

In a placebo-controlled cross-over study investigating the acute effects of smoking high-potency cannabis joints on psychomotor skills related to driving, researchers found that subjects still reported experiencing a “high” or “feelings of intoxication” well past peak levels, with measured concentrations dropping below the legal level 5 ng/mL set by some states.1

AA6It is challenging to correlate what this level means to actual impairment due to the fact that THC levels in the blood peak quickly following inhalation and decline rapidly based on pharmacokinetics.6 Adding to the complexity of analytical interpretation of THC in the blood is time, with subjective effects felt as soon as after 1 to 2 inhalations.8

Researchers have also shown that significant impairment of tracking skills (used as an indication of accurate motor control) accompanies marijuana use.1 Ultimately these authors concluded “that smoking cannabis significantly decreases psychomotor skills and globally alters the activity of the main brain networks involved in cognition even at low concentrations of THC in the blood.”1

AA7In addition to these skills, attention alone, divided attention, visual functions, and reaction time are all areas impaired when an individual drives “high”.1-3 The impairment of each of these skills differs depending on the dose and potency of the drug. Therefore the effects of marijuana and the detrimental consequence on a particular skill varies depending on the particular function being employed.

What Should We Do?

AA8AEstablishing levels of THC in which a jurisdiction considers an individual impaired is challenging. Some countries have established a zero-tolerance approach to compensate for individual-to-individual impairment. In the United States, we have created similar laws for certain drugs to account for lack of scientific knowledge and/or user variability and this may be an approach to consider.

Regardless of what approach is taken, as with all drugs (recreational or prescription) ultimately it is the individual that must be responsible for their actions.

Refrain from operating a motor vehicle when impaired and be aware that negative effects can continue well past the feeling of being “high”. 

References:
  1. Battistella, Giovanni et al. “Weed or Wheel! fMRI, Behavioural, and Toxicological Investigations of How Cannabis Smoking Affects Skills Necessary for Driving.” Ed. Lin Lu. PLoS ONE 8.1 (2013): e52545. PMC. Web. 5 Jan. 2015.
  2. Walsh, J. Michael et al. “Drugs and Driving”. Traffic Injury Prevention. Vol. 5, Iss. 3, 2004
  3. Sewell, R. Andrew, James Poling, and Mehmet Sofuoglu. “THE EFFECT OF CANNABIS COMPARED WITH ALCOHOL ON DRIVING.” The American journal on addictions / American Academy of Psychiatrists in Alcoholism and Addictions 18.3 (2009): 185–193. PMC. Web. 5 Jan. 2015
  4. Moskowitz H. Marihuana and driving. Accid Anal Prev. 1985;17:323– 345.
  5. Hall W. The Health and Psychological Consequences of Cannabis Use. Canberra: Australian Government Publication Service; 1994.
  6. Kurzthaler I, Hummer M, Miller C, et al. Effect of cannabis use on cognitive functions and driving ability. J Clin Psychiatry. 1999;60:395– 399.
  7. Liguori A, Gatto CP, Robinson JH. Effects of marijuana on equilibrium, psychomotor performance, and simulated driving. Behav Pharmacol. 1998;9:599–609.
  8. Berghaus G, Scheer N, Schmidt P. Effects of Cannabis on Psychomotor Skills and Driving Performance-A Metaanalysis of Experimental Studies. Schafer Library of Drug Policy. Accessed Jan. 08, 2015
    http://druglibrary.org/schaffer/misc/driving/s16p2.htm

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AA9Sabra Botch-Jones, M.S., M.A., D-ABFT-FT of Boston University School of Medicine/fTox Consulting, LLC, is a Forensic Toxicologist and full-time faculty member at Boston University’s Biomedical Forensic Sciences graduate program. She teaches courses in Drug Chemistry, Forensic Toxicology and Instrumental Analysis in Forensic Laboratories.

She began her career with the Federal Aviation Administration’s Bioaeronautical Sciences Research Laboratory at the Civil Aerospace Medical Institute and was a Senior Forensic Toxicologist/Quality Manager at the Tarrant County Medical Examiner’s Office.

AA9ASabra is board certified as a Diplomate by the American Board of Forensic Toxicology. She earned her Master of Science degrees in Drug Chemistry and Forensic Toxicology from the University of Florida as well as undergraduate and graduate degrees in Criminal Justice from the University of Central Oklahoma. She conducts research in the areas of forensic toxicology, analytical chemistry, as well as epidemiological studies on drug use.

AA9BSabra has authored and co-authored 14 scientific articles. She is active in a number of professional organizations including the National Safety Council’s Alcohol, Drugs and Impairment Division (Executive Board), Society of Forensic Toxicologists, Southwestern Association of Toxicologists, Association for Women in Science (Writer-AWIS Magazine), and the American Academy of Forensic Sciences.

Sabra was recently selected to be a member of the toxicology subcommittee of the Organization for Scientific Area Committees.

Her Boston University Faculty Link is: http://www.bumc.bu.edu/gms/biomedforensic/faculty-and-staff/faculty/sabra-r-botch-jones-instructor/

fTox Consulting link is: http://ftoxconsulting.com

fTox Consulting Facebook link is: www.facebook.com/FtoxConsult

Sabra’s Twitter Handle is: @sabraruvera