The Northwest Evaluator, February 1998

"THE NORTHWEST EVALUATOR"

The Pacific Northwest Drug Recognition Expert Newsletter

February 1998 Volume 3, Issue 8

"When Is Pupil Size Not Really The Pupil Size"

Robert L. Yolton, PhD, OD, and Karl Citek, PhD, OD
Pacific University, College of Optometry
Forest Grove, OR

So you think that when you measure pupil size with your pupilometer you are really obtaining a valid indication of the true size of the pupil? Wrong! If the defense attorney wants to play trivial pursuit with you, he or she might point to the optical effects of the cornea which can cause the pupil you observe to appear 5-10% larger than it actually is. Is this fact of any real importance except in a game of trivial pursuit? Nope, because all pupil measurements are made from outside the eye and no one really worries about what the true size of the pupil is.

Since pupil size is important in DRE work, a good understanding of what affects pupil size is important in those "unusual" cases or when persistent defense attorneys want to test your knowledge. First, the pupil is not a "thing." It is an empty hole in the center of the iris. The iris, which forms the pupil, consists of a layer of cells containing the pigment melanin, which blocks the light, and two sets of muscles. A ring shaped muscle called the sphincter closes the pupil, and a radial set of muscle fibers called the dilator opens it. Primary input to the sphincter is from the parasympathetic (relaxing) branch of the autonomic nervous system, whereas the dilator is controlled by the sympathetic branch (fighting). Pupil size is primarily determined by the balance between actions of the two branches of the autonomic nervous system.

The most important factor that affects pupil size is light. When light is detected by the photoreceptors in the eyes, information is sent via the optic nerve and tract to nuclei in the mid-brain and then on to the Edinger-Wesphal nucleus. Signals to the dilator and sphincter muscles are generated as a result to activity in this nucleus, but other sources of neural innervation beyond those produced by light can also alter activity in this nucleus.

Because the coordination required to keep the two systems in balance is not perfect, the pupil is in a constant state of unrest. This is called hippus. Normal hippus is difficult to detect, but exaggerated hippus can result from various pathological states including drug intoxication. It is well known that cocaine affects the sympathetic nervous system and causes dilation, whereas the narcotic analgesics affect the parasympathetic system and cause constriction.

Light, drugs, and disease of the visual system are not the only factors that affect pupil size. Age, fatigue, emotional excitement, and viewing distance also has effects. Based on a survey of 1,263 subjects, Lowenfeld found that typical pupil sizes in the dark range from about 7 mm at age 15 years to about 5 mm at age 60. Extreme fatigue can cause some pupillary constriction and exaggerated hippus, but the amounts are difficult to specify. Conversely, as persons become excited or aroused, the actions of the sympathetic branch predominate and the pupils dilate. This is well known to sales persons who watch for the customer's pupils to dilate when shown an object of great interest.

Another factor that affects pupil size is where the person is looking. To understand this effect, we need to review a bit of optics. Those who are old enough to recall the early pinhole cameras know that these cameras did not have a lens. The image was formed by passing light through a simple pinhole on the front of the camera. Using this method, it demonstrates that it is easier to focus on things if you look through a small hole -- like a small pupil.

Mother nature knew about the small hole effect when she designed our eyes and knew that when we want to look at something up close we need really sharp vision. Three things need to happen when we look up close. We need to converge our eyes, we need to use the muscle inside of the eyes to focus the lens, and we need sharp vision. How do we get sharp vision? We constrict the pupil, partially by spill-over of parasympathetic nervous activity directed toward the muscles controlling the lens shape.

This group of three actions is called the near triad: convergence, accommodation, and miosis. So, what does this mean to the DRE? Your instructions for administering the pupil size test require the suspect to look at a distant object (2.5 meters or more in my opinion). If you do not do this and the suspect looks at your nose or forehead, which is about 0.5 meter away, the test is done incorrectly. The pupil size you record will be artificially small. Try it yourself by placing a person in dim light and having the person look from distant to near. You should be able to see the pupil open and close as focus is changed.

All of this might sound fairly complicated so maybe you have to have a medical degree as some claim. Perhaps this is the case if you are going to diagnose brain tumors using unequal pupil sizes, but this is not your job. The things that make use of pupil sizes appropriate for the DRE are standardization, standardization, and standardization. You place the suspect in a standardized environment for a standardized length of time to become accustomed to the light and surroundings. In the dark room, you estimate pupil sizes in a standardized method using a standardized pupilometer. Finally, you compare your results to standards that have been established by researchers as being related to intoxicated with certain types of drugs. If testing is done in a standardized manner, then most or all of the complicating factors become of little importance to you as you draw your primary conclusions about the suspect. But, as with any test, do it wrong and your results are meaningless.

If you have comments or questions, contact Dr. Yolton or Dr. Citek at Pacific University, College of Optometry, Forest Grove, OR 97116 or by e-mail at: yoltonr@pacificu.edu

St. John's Wort -- Can It Impair?

By DRE Officer Tim Lenihan
Myrtle Creek, Oregon, P.D.

St. John's Wort (Hypericum Perforatum) is fast becoming a popular treatment for mild depression. In the past 10 years the compound has been used successfully by prescription in Germany. A division of the German government, Commission E, has sponsored numerous studies on the drug. In the U.S., the drug is available with a prescription and is not regulated by the Food and Drug Administration. Recent claims by the proponents for use the drug state that the drug is effective and without major side effects.

St. John's Wort has been available in crude forms for several centuries. In biblical times the drug was used to induce a general feeling of well being. It is also used as an effective topical anti-biotic. In crude form, the plant is mixed with olive oil for preparation as an anti-biotic.

St. John's Wort refers most commonly to a derivative of the plant Hypericum Perforatum and is sometimes referred as hypericum. The specific extract from the plant that is believed to be the most active component is hypericin, which is named after the plant itself. The plant grows commonly in North America and is an annual flowering ground cover. The plant is commonly used as landscaping in shaded areas.

The most common method for removing the hypericin from the plant is to boil the plant in water. A more effective and simple method is to dry the leaves, crush them, combine with alcohol and place them with an open dish. As the alcohol evaporates a compound of about 3% hypericin is left as a white powder around the edge of the dish. The compound is the most common used in the over-the-counter medicines.

Hypericin enters into the Central Nervous System (CNS) through the benzodiazepene receptor sites. The drug acts as a CNS depressant. Proponents of the drug claim that it has no negative effect on the CNS or a user's ability to operate heavy machinery, including an automobile. Proponents also claim there is no inter-action with alcohol.

As a DRE, I have evaluated several persons claiming to have used St. John's Wort. The common factors are that the persons had a lack of smooth pursuit and distinct nystagmus at maximum deviation. The angle of onset was well outside 45 degrees. As with alcohol, the blood pressure was above the normal range. Other indicators were also consistent with the CNS Depressant category.

Health care professionals that I have consulted have told me they believe hypericum would have an additive effect with other depressants. One professional, who uses the drug regularly, believes there is no negative effect from the drug. He also proclaimed my research was a "witch hunt." When asked about the drug, most professionals will tell you they have heard of the drug and they admit that they don't know much about it.

Most DRE's, including myself, have limited experience with users of this drug. I cannot say without a doubt that this drug, alone, impairs a person ability to safely operate a vehicle. I have conducted portions of an evaluation on persons claiming they ingested no other drugs than St. John's Wort and have found a very slight impairment. I have also conducted evaluations on persons that consumed the drug in combination with other drugs.

One subject evaluated had ingested hypericum with Jimson Weed in a brewed tea. Both indicators of a CNS Depressant and a Hallucinogen were present. The Hallucinogen effect was considerably stronger than the depressant effect. It was difficult to determine during the evaluation which drug was more psychoactive.

One preparation of St. John's Wort combines the 3% hypericin compound with Kava. As a DRE, I find it very interesting that the combination is finding its way into the consumer market.

In this early stage of hypericum's popularity, it seems prudent that user's should at least be cautioned about the possible negative effects. This statement seems to be agreeable to most health care professionals that know much about the drug. Most health care professionals believe that more evaluation of the drug is needed before the popularity increases.

Herbal medications are not regulated in the U.S., and I recommend that persons claiming to have ingested St. John's Wort still have a toxicological test performed. There have been reports of substances being marketed as St. John's Wort that actually contain benzodiazepenes. Serum levels of hypericin can also be tested although they can only be tested in blood samples.

Much of my research was obtained from the text: Hypericum (St. John's Wort) and Depression, Prelude Press, 1966. A free copy of the text and other information is available on the internet at http://www.hypericum.com. The author, Dr. Harold Bloomfield, is most definitely a proponent of hypericum's use.

I encourage other DRE's to review materials regarding St. John's Wort and its effects. If you have comments or knowledge/experience with the drug, please contact me at: Officer Tim Lenihan, Myrtle Creek Police Department, PO Box 940, Myrtle Creek, OR 97457.

Heroin Problems in Pacific Northwest

Unlike many major cities in U.S., the cities of Portland, Oregon, and Seattle, Washington, are experiencing increasing problems associated with heroin. In Seattle, drug abuse generally is sending fewer people to the emergency rooms, however, there was a 15% increase in heroin-related ER visits. Since 1990, heroin use by people seeking medical help in Seattle-area ER's has quadrupled. In 1996, drug-related cases reportedly dropped by 4%, however, was the drug most often mentioned by those seeking medical attention. On a per capita basis, heroin led to ER visits more often in only three other metropolitan areas; Baltimore, Newark, NJ, and San Francisco. Although final data has not been completed, the 1997 death rate from drug overdoses appears to have changed little from 1996. About 10 deaths a month are tied to heroin use.

In Portland, Oregon, deaths continued to increase related to heroin use. Nine people died from suspected heroin overdose in one week. Some officials believe the sudden rise of deaths may be related to potent batch of heroin in the area. Most users have been used to using heroin that is 7-10% pure, but overdose victims apparently bought and used heroin that could be as much as 90% pure.

More than 150 people in Portland have died from heroin overdoses in 1997. In 1996, 155 of the 205 drug-overdose deaths in the state were tied to heroin. More than half of those occurred in the Portland metro area.

Impact of Marijuana Intoxication
on the Brain Studied

Blood flow to the brain was studied in 32 volunteers who had a mean age of 32.5 years and a history of exposure to marijuana (Mathew, et al., Life Sciences, 1997). This was a double-blind study performed before and after intravenous injection of THC at the rate of either 0.25 mg/min or 0.15 mg/min, compared to placebo. The results showed that THC, but not the placebo, increased brain blood flow, particularly in the frontal part of the brain and correlated with the volunteers' analysis of whether or not they were high. Changes in the higher dose group could be detected sooner (within 30 minutes) than those in the lower dose group. This study shows that THC impacts activity in the part of the brain that is associated with memory and stress-induced cardiovascular responses, and particularly in the part of the brain involved in emotion and short-term memory. This study may provide a physiologic basis for the brain side effects seen with cannabis use.

Source: Marijuana Research Review, Sept. 1997

What Makes Cocaine Users Feel Good?

Federally sponsored researchers at the Brookhaven National Laboratory have used positron emission tomograph (PET scanning) to characterize the relationship between cocaine-induced euphoria and the degree to which cocaine blocks the actions of an important molecule in the brain called the dopamine transporter. The results of the study are described in articles published in the April 24, 1997, issue of Nature.

In the brain, signals are carried from neuron to neuron by the release of small amounts of chemicals called neurotransmitters. The impulse is terminated when the neurotransmitter is pumped out of the synapses (the connection between the two neurons), and back into the nerve that released it. This process, called "reuptake," is blocked by the cocaine. The result is that dopamine accumulates. It had always been presumed that it was this accumulation of dopamine that caused the "high," but the hypothesis had never completely been proven.

The Brookhaven researcher gave cocaine injections to 17 cocaine abusers, then used PET scanning to measure the concentration of cocaine that had combined with the dopamine transporters. At the same time they were asked to describe the effects they were feeling as the cocaine was injected. The scans and the psychological measurements were then correlated.

They found that no symptoms were perceived at all, unless at least 47% of the dopamine transporters were attached to cocaine molecules. They also found that, with doses commonly taken by abusers, the cocaine blocked 60% to 77% of the transporters.

In a related study in the same issue of Nature, the Brookhaven group compared the dopamine systems in the brains of chronic cocaine-users and non-cocaine users. Both groups were treated with methylphenidate (Ritalin, which also causes increases in brain dopamine levels). In the chronic users, they found decreased responsiveness in a part of the brain called the striatum, the area that is generally thought to be associated with experiencing feelings of pleasure. At the same time, they found increased dopamine levels in the thalamus, a region of the brain concerned with the transmission of sensory input.

The largest correlated thalamic increases were seen during periods of intense cocaine craving. None of these changes were seen in the control group. Nora Volkow, the lead researcher, concludes that "the dopamine pathways in the thalamus, as well as the striatum, are critically involved in cocaine addition."

Source: Forensic Abuse Advisor Vol. 9 (5) May 1997

"Ask the DRE Doctor" is a regular feature of the "Northwest Evaluator" and utilizes medical background and experience of Dr. Richard Smith Jr. Richard is employed by the California Highway Patrol as their academy physician and medical director. He has been a practicing emergency physician for over 25 years after graduating from Stanford University Medical School in 1969. He is also an instructor at the CHP and Oregon DRE schools.
"Which Is It, CNS Depressant or Stroke"

Question: Several times I have conducted evaluations on an elderly person whom I suspected of using a CNS Depressant. When reviewing the evaluation and forming my opinion, I noticed that many of the signs were similar to someone who may have had a stroke. In what ways can I usually be assured that I am not evaluating someone who may be suffering from a recent stroke and are there tests I can do to screen for that?

Answer: A stroke is a blockage of an artery or bleeding in a portion leading to some kind of neurological deficit. The resulting signs and symptoms will depend on which part of the brain is damaged. If the injury is deep in the primitive parts of the brain then the individual will be severely impaired. The more common presentation involves blockage of the middle cerebral artery and results in lateralizing signs. What is often seen is slurred speech in the sense of having difficulty forming the words while the person otherwise seems fully aware, unlike someone impaired on drugs. Next look for lateralizing signs of the face, such as a droopy eyelid, or sagging corner of the mouth. If you ask someone suffering from a stroke to stick out their tongue it should deviate to the effected side. Having them grin or asking the subject to show their teeth will often show the facial asymmetry. I would look for the asymmetry in the face first is because the face innervations map out to the largest area of the Cerebrum. The hands and feet map out to the next largest areas of the brain.

That is why some experts suggest having the person smile, have the person squeeze your hand, or have the person raise their arms above their head. I have a suspected stroke victim raise and hold their arms up in front of them for 10 seconds. You will notice the weakened side drifting down. If you ask the person to grip your hand, have the person squeeze your index and middle fingers at the same time, giving you more sensitivity. What I am describing only works if the bigger thinking of the brain (cerebrum) is effected. Strokes involving other parts of the brain will give many varied presentations and the above comments work best for the most common strokes. The stroke patient has an affect of being very concerned and within the limits of their injury. Above all, if you conduct some of these simple checks and suspect a stroke victim, immediately consult medical attention for the person.

If you have a specific question about medical disorders or other medical issues which may effect your drug evaluation opinion, please contact Dr. Richard Smith by E-mail at 71045.1770@CompuServe.com.

THE OREGON DECP UPDATE

By Lt. Chuck Hayes
Oregon DECP Coordinator

Oregon DRE Training

Oregon will begin training 22 officers in the states 5th DRE school beginning April 7, 1998. The 22 officers were selected from over 50 applications statewide. The applicants were reviewed and selected by the State's newly formed DRE Steering Committee. The new 22 officers will aid the placement of new DRE's in many rural areas of the state that have not had the services of a DRE in the past.

The Oregon training will feature the 9-day Pre-School and DRE School format. However, several of the sessions have been expanded for additional instruction by Dr. Richard Smith and Dr. Robert Yolton.

1997 Oregon DRE Evaluation Highlights

Although the final numbers are still coming in, it appears that the 102 Oregon DRE's have once again made a tremendous impact in the state. A total of 779 evaluations were conducted in the state and it appears the DRE's are again in the 88-90% accuracy rate. Of the 779 evaluations, 212 of those suspects were also charged with Possession a Controlled Substance (PCS), and 76 of the drivers were arrested after being involved in a motor vehicle accident.

Two Oregon DRE officers who made a tremendous impact on the program in 1997 were Deputy Jo Gardiner of the Jackson County Sheriff's Office and Officer Jeff Durbin of the Gresham Police Department. Deputy Gardiner lead the state with 65 drug evaluations while Officer Durbin accounted for 63 evaluations. Great Job!!

IDAHO DECP REPORT

By Cpl. Dean Matlock
Idaho State Police/DECP Coordinator

"New State DECP Coordinator"

Rob Storm, Idaho's first DECP Coordinator was promoted to Patrol Sergeant. He has relocated to the Twin Falls office of the Idaho State Police. Rob was the first DRE in Idaho and became the DECP Coordinator soon after his certification in 1995. He was very instrumental in getting the program started and building it into what it is today. We all wish Rob the best of luck in his new position.

Idaho is entering the final phase of the thrust of the DRE program. The next DRE school is April 20-30, 1998, in Meridian, Idaho. This class will bring Idaho's number of DRE's to 62 officers. After this school, the program will be in a maintenance mode until a permanent funding source is located to assist with the lab costs of the increased urine toxicologies. Overall, the program has been a tremendous success and is slowing winning judicial approval.

"DWI Death Rate Decreases With New .08"

Idaho's new DWI law is delivering what backers had hoped for, fewer deaths and injuries from alcohol-related crashes. On July 1, 1997, the Idaho blood alcohol level for DWI was lowered from .10% to .08%. The law change now makes Idaho one of 15 states nationwide to adopt the lower BAC.

According to the office of Idaho Highway Safety, alcohol related traffic deaths dropped 14% in the first five months of the new law. During the same period, alcohol-related injuries decreased 25 percent.

WASHINGTON DECP REPORT

By Lt. Kim Zangar
Washington State Patrol/DECP Coordinator

"DUID Arrests Climb in Seattle Area"

As the number of DRE's increase in Washington State, so do the number of arrests under the influence of drugs. In the past 6 months of 1997, troopers made 106 arrests for drug-impaired driving. During January 1998, troopers made 16 arrests. Additional arrests have been made by officers from other agencies.

Las month, a 28-year old man who plowed a tractor-trailer into 14 parked cars was found guilty of driving while under the influence of drugs. The DRE in this case testified for three hours. The defense flew in an expert witness to counter the DRE's testimony. The driver was under the influence of methamphetamine at the time of the collision.

NATIONAL DECP NEWS

By Ernie Floegel
IACP DECP Coordinator

"1998 DRE, Drugs, Alcohol, and Impaired Driving Training Conference"

Finishing touches are underway for the 1998 IACP DRE, Drugs, Alcohol, and Impaired Driving Training Conference. The conference will be held in Portland, Oregon, June 28-30, 1998. The Double Tree Inn at Jantzen Beach is the host facility, located along I-5, on the Columbia River, separating Oregon and Washington.

In February, registration information was mailed out to each State Coordinator and DRE's nationwide. The registration deadline is May 15, 1998. Besides the conference registration fee for those attending, there will also be a spouse's fee, allowing a spouse to attend portions of the conference activities.

The conference will include an excellent training agenda that includes Drs. Marcelline Burns, Gary Kay, and Barry Logan, Phyllis Good, and others. There will be numerous social events during the conference, including a Friday golf tournament, a Saturday evening welcoming reception, a Sunday evening sight-seeing tour of the Columbia River Gorge and Multnomah Falls, a Monday evening casino night, and a day-time downtown shopping and sight-seeing tour for the spouses. Tuesday evening the conference will conclude with a banquet hosted by Sheering-Plough Pharmaceutical Company.

The fourth annual conference appears that it will be one of the best yet. If you need registration information or have questions about the conference, please contact me at (914) 682-6162.

"DRE E-Mail List"

Fellow DRE's, I would like to invite you to join DRUG-RECOGNITION-L, an e-mail list for Drug Recognition Experts. Subscription is free and will remain free thanks to C.A.N.D.I.D., Citizens Against Drug Impaired Driving.

The list provides a discussion forum for DRE's and is a valuable resource for the DRE. It was started for DRE's. Most members are DRE's, however, there are also some toxicologists and non-DRE police officers on the list.

The list is restricted to certified DRE's, toxicologists and police officers who have an interest in drug impaired driving/drug symptomology issues. Karen Tarney, founding director of CANDID, is also a list member. Pharmacists, prosecutors, and others who would be a good resource for the list will be considered.

If you would like to join the list, you can contact me or you can also use the on-line registration form at: http://www.geocities.com/CapitolHill/8862/Form.htm. This may also default to the geocities page, delete that page and the DRE registration form will be there.

I look forward to hearing from you and adding you to the list and having you join in our discussions.

Charlie Ferry
DRE, New Castle PD, NY

Test Your DRE Knowledge:

This Newsletter Study Questions:

1. The Efferent Nerves are also known as the _____________________ Nerves.

2. How many carbon atoms does a molecule of ethanol have?

3. Every chemical that is called an "alcohol" is composed of carbon, oxygen, and ___________________.

4. The pulse point located in the crease of the wrist nearest the thumb is called the ___________ pulse point.

5. The term for an abnormally rapid pulse rate is _____________________.

6. Where is the Carotid Pulse point located?

7. Demoral and Percodan are drugs from what drug category?

8. Anti-Depressants are sometimes referred to as ___________ ___________.

9. Anti-Anxiety depressants are referred to as the _________ tranquilizers.

10. Volatile solvents and Aerosols ___________ blood pressure.

Questions and Answers from the last issue of the "Northwest Evaluator"

1. Dopamine, Serotonin and GABA are types of neurotransmitters ?

2. Homeostasis is the dynamic balance or steady state involving levels of salt, water, sugar, or other materials in the body fluids.

3. The Korotkoff sounds are heard with the use of a stethoscope.

4 "Skin popping" a drug is also referred to as a subcutaneous injection.

5. The Axon carries messages away from the cell body.

6. The Artery carries blood from the heart.

7. The Pyloric Value control alcohol (etoh) moving into the intestines.

8. LSD was discovered in 1938 by Dr. Albert Hoffman.

9. LSD is manufactured from Lysergic Acid, which is found in ergot.

10. Phencyclidine (PCP) was developed in 1959 as an anesthetic and later used in veterinary medicine.