Top Gun DWI XIX Seminar Book by TCDLA

19th Annual

Course Directors: Danny Easterling, Grant M. Scheiner & Mark Thiessen

TOP GUN DWI XIX SEMINAR INFORMATION Date Location Course Director Total CLE Hours

August 13, 2021 Houston, TX | The Whitehall Hotel 1700 Smith St, Houston, TX 77002 Danny Easterling, Grant Scheiner, and Mark Thiessen 7.5 Ethics: .75

Friday, August 13, 2021 Time

CLE

8:30 am

Daily CLE Hours: 7.5

Ethics: .75

Topic & Speaker Opening Remarks ~ Danny Easterling, Grant Scheiner, and Mark Thiessen

8:45 am

1.0

Chemist and Laboratory Quality Expert Janine Arvizu will launch our combat mission with Top Problems in Texas Blood Testing. This is essential weaponry for building a winning cross-examination of any state’s expert in a DWI blood-test trial.

9:45 am

.75

Houston DWI Lawyer Sean Darvishi will continue our aerial assault with a surgically precise presentation on Voir Dire.

10:30 am

Break

10:45 am

.75

Legislative Expert and Criminal Defense Lawyer Shea Place will mission-brief us on all of the new Texas Criminal Laws Effective September 1, 2021.

11:30 am

.75

Forensic Alcohol Consultant and Breath Testing Expert Matthew Malhiot promises to shoot down the state’s favorite bandit -- Intoxilyzer 9000: Tip to Tail.

12:15 pm 12:30 pm 1:15 pm 1:30 pm 2:15 pm

Lunch Line .75 ETHICS

.75 .75

3:00 pm

Lunch Presentation: Houston DWI Lawyer Doug Murphy will keep our pilots out of an ethical jet wash with a lunchtime presentation you don’t want to miss. Break Dallas Criminal Defense Lawyer Mark Lassiter will show us how to obliterate your enemy without firing a shot, in Sample Motions for Success. Rising star Houston Lawyer Andreea Ionescu prepares to strike an elusive target with Top Tactics on Blood Drug Testing. Break

3:15 pm

1.0

Fort Worth DWI Lawyer Mimi Coffey will show us how it’s done, with a brief lecture and demonstration of Cross-Examination of the Arresting Officers.

4:15 pm

1.0

Nationally renowned, Oklahoma DUI Lawyer Josh Lee brings us up to Mach Speed on an emerging police weapon in Drug Recognition Evaluation: Identifying Drugs with the Draeger DT 5000.

5:15 pm

Adjourn

TCDLA :: 6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

Texas Criminal Defense Lawyers Association

Top Problems in Texas Blood Testing

Sean Darvishi

Voir Dire

Matthew Malhiot Doug Murphy Mark Lassiter Andreea Ionescu

Intoxilyzer 9000: Tip to Tail Ethics Sample Motions for Success Top Tactics on Blood Drug Testing

Mimi Coffey

Cross-Examination of the Arresting Officers

Josh Lee

Identifying Drugs with the Draeger DT 5000

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Top Problems in Texas Blood Testing Speaker:

Janine Arvizu 161 Kuhn Dr Tijeras, NM 87059-8102 (505) 250-7422 Phone (505) 246-5782 Fax Janine.arvizu@gmail.com email

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

7/28/2021

Top Problems in Texas Blood Testing August 13, 2021 Janine Arvizu, CQA Janine.arvizu@gmail.com (505) 250-7422

What matters?

…the amount of ethanol in the tube?

What matters?

…the amount of ethanol in the tube? OR … the amount of ethanol in the person?

7/28/2021

“Highly sophisticated testing technology cannot produce a good result from a poorly collected specimen.” CLSI GP41, 7th ed.

Texas Forensic Toxicology Labs – Alcohol / Toxicology • DPS Abilene A

• DPS Tyler A

• DPS Austin A/T

• DPS Waco A*

• DPS Corpus Christi A*

• DPS Weslaco

• DPS El Paso A

• Bexar County A T

• DPS Garland A

• Brazoria County A T

• DPS Houston A

• Harris County IFS A T

• DPS Lubbock A

• Jefferson County A

• DPS Midland A

*no Alcohol as of 1/1/2021

Texas Forensic Toxicology Labs – Alcohol / Toxicology • SWIFS A T

• Armstrong Forensic A

• TCME A T

• ExperTox T

• Travis Co ME A T

• Firstox T

• Austin PD A

• Fondren Forensics A T

• Fort Worth PD A

• NMS A

• HFSC A T

• Quality Forensic Toxicology A T

7/28/2021

Blood Toxicology Problems 1. The Sample 2. The Method 3. The Testing

Sample Problems Contaminated collection – not aseptic

7/28/2021

Cleansing the puncture site CLSI GP41

“The puncture site must be cleansed to minimize microbial contamination of the specimen.” “Cleanse the site with friction...” back-and-forth friction is superior to circular concentric cleansing.

Cleansing the puncture site CLSI GP41

“Allow the area to air dry. This… allows optimal decontamination.”

Cleansing the puncture site If anything touches the site after application of the antiseptic, the site is contaminated. Start over.

7/28/2021

Evacuated Tube Method

Sample Problems  Contaminated collection – not aseptic

Syringe method

Syringe Method

7/28/2021

Sample Problems  Contaminated collection – not aseptic  Syringe method

Wrong tubes

Wrong tubes ALL tubes < 10 ml ALL Plastic tubes ALL Hemogard closures

7/28/2021

Wrong tubes • Hospital draws • May be serum • No (or too little) preservative • Not certified for blood alcohol

6 ml plastic tubes – NOT certified for alcohol Insufficient preservative (25%) …vulnerable to yeast and bacteria

Sample Problems  Contaminated collection – not aseptic  Syringe method  Wrong tubes

Underfilled tube

7/28/2021

Underfilled tube Tubes should be filled: 10 ml (9.3-10.7 ml) BD (manufacturer) CLSI GP41 (consensus standard in the Federal Register) DPS Crime Laboratory Service Manual

BD Life Sciences – Preanalytical Systems

BD Vacutainer Specimen Collection Products ®

BD Microtainer Capillary Products ®

Product Catalog

BD Life Sciences – Preanalytical Systems

For more than 60 years, BD has advanced the science of specimen collection that has helped enable laboratory tests to become the foundation for 70 percent of all medical decisions.* Today, the BD Vacutainer® product family is a gold standard in sample collection. That is why America’s leading hospitals rely upon it to enhance sample quality and protect their nurses, phlebotomists and other caregivers from costly accidental needlestick injuries. These products—backed by unrivaled customer support and training—help hospitals every day to enhance lab productivity and workflow by reducing retests, recollects and instrument downtime.

70 patients worldwide every second have diagnostic samples collected with BD Vacutainer specimen collection products

To learn about BD Vacutainer® specimen collection products, educational materials or services offered by BD Life Sciences – Preanalytical Systems, please contact your local BD Sales Consultant today. You can also contact us via: BD Technical Services at 1.800.631.0174 or submit an inquiry at www.bd.com/vacutainer/contact BD Customer Service at 1.888.237.2762 or visit us anytime online at www.bd.com/vacutainer * The Lewin Group (2005). The Value of Diagnostics: Innovation, Adoption, and Diffusion into Healthcare. Published for the Advanced Medical Technology Association. Falls Church, VA: Lewin Group; 2005:1.

Table of Contents Venous Products

BD Vacutainer Blood Collection Tubes ®

SST Tubes ................................................................ 3 PST™ Tubes................................................................. 4 RST Tube.................................................................... 4 Fluoride Tubes............................................................ 5 Serum Tubes............................................................... 5 ™

Heparin Tubes............................................................ 6 EDTA Tubes................................................................ 7 Citrate Tubes.............................................................. 8 Specialty Tubes........................................................... 9

BD Vacutainer Molecular Diagnostic Testing / Cell Preparation Tubes ®

Mononuclear Cell Preparation Tubes (CPT™ ).......................................... 10

PAXgene® Blood RNA Tube....................................... 10 Plasma Preparation Tubes (PPT™ )............................... 10

Proteomics Analysis and Protein Preservation P100 Blood Collection System for Plasma Protein Preservation.......................................11 P700 Blood Collection System for Plasma GLP-1 Preservation.........................................11

P800 Blood Collection System for Plasma GLP-1, GIP, Glucagon and Ghrelin Preservation.....................11

BD Vacutainer Blood Collection Needles ®

Eclipse Blood Collection Needles............................. 13 ™

BD Vacutainer Blood Collection Sets ®

Push Button Blood Collection Sets............................ 14

Safety-Lok™ Blood Collection Sets............................. 15

BD Vacutainer Accessories ®

Holder...................................................................... 16 Blood Transfer Device............................................... 16 Luer-Lok™ Access Device........................................... 17

Specimen Collection Assembly.................................. 17 Stretch Latex-Free Tourniquet................................... 17

Capillary Products

BD Microtainer Capillary Blood Collection System ®

Contact-Activated Lancets ....................................... 19 Quikheel™ Lancets.................................................... 19

MAP Microtube for Automated Process.................... 20 Microtainer® Blood Collection Tubes......................... 21

Urine Products

BD Vacutainer Urine Collection System ®

Urine Collection Kits................................................. 23

Urine Bulk Products.................................................. 25

Education Services

Laboratory Consulting Services

Customer Focus

29 Table of Contents – 1

Venous Products

BD Vacutainer Blood Collection Tubes ®

BD Vacutainer ® Blood Collection Tubes are clinically shown and supported with numerous clinical studies on a vast array of analytes and diagnostics platforms to document the efficacy, performance characteristics and ease of use. At BD, we understand that it’s not just a test...it’s a patient and the accuracy of your test result that matter most.

BD Vacutainer SST™ Tubes ®

BD Vacutainer SST™ Tubes contain spray-coated silica to aid in clotting and a polymer gel for serum separation. Samples processed in these tubes are used for serum determinations in chemistry, blood donor screening and infectious disease testing.* BD Vacutainer SST™ Tubes provide an efficient means of serum sample preparation and help to improve laboratory workflow. ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

367981

13 x 75

3.5

Conventional Red/Gray

Paper

Clot Activator/ Polymer Gel

100/1000

367983

13 x 75

3.5

BD Hemogard™ / Gold

Paper

Clot Activator/ Polymer Gel

100/1000

367977

13 x 100

4.0

BD Hemogard™ / Gold

Paper

Clot Activator/ Polymer Gel

100/1000

367989

13 x 100

5.0

BD Hemogard™ / Gold

See Thru

Clot Activator/ Polymer Gel

100/1000

367986

13 x 100

5.0

BD Hemogard™ / Gold

Paper

Clot Activator/ Polymer Gel

100/1000

367987

16 x 100

7.5

Conventional Red/Gray

Paper

Transport Tube Clot Activator/ Double Polymer Gel

100/1000

367988

16 x 100

8.5

Conventional Red/Gray

Paper

Clot Activator/ Polymer Gel

100/1000

367985

16 x 125

10.0

Conventional Red/Gray

Paper

Transport Tube Clot Activator/ Double Polymer Gel

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

* The performance characteristics of these tubes have not been established for infectious disease testing in general; therefore, users must validate the use of these tubes for their specific assay-instrument/reagent system combinations and specimen storage conditions. www.bd.com/vacutainer

Venous Products – 3

BD Vacutainer PST™ Tubes ®

BD Vacutainer PST™ Tubes contain spray-coated lithium heparin and a polymer gel for plasma separation. Samples processed in these tubes are used for plasma determinations in chemistry. BD Vacutainer PST™ Lithium Heparin Tubes eliminate the need to wait for a clot to form, making it an ideal tube for STAT procedures, as well as for patients receiving anticoagulant therapy. They provide the convenience of gel separation with the added advantage of improved turnaround time. ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

368056

13 x 75

3.0

Conventional/ Green/Gray

Paper

Lithium Heparin 56 USP Units with Polymer Gel

100/1000

367960

13 x 75

3.0

BD Hemogard™ / Lt Green

Paper

Lithium Heparin 56 USP Units with Polymer Gel

100/1000

367961

13 x 100

3.5

BD Hemogard™ / Lt Green

Paper

Lithium Heparin 65 USP Units with Polymer Gel

100/1000

368824

16 x 100

4.0

Conventional/ Green/Gray

Paper

Lithium Heparin 64 USP Units with Polymer Gel

100/1000

367962

13 x 100

4.5

BD Hemogard™ / Lt Green

Paper

Lithium Heparin 84 USP Units with Polymer Gel

100/1000

367964

16 x 100

8.0

Conventional/ Green/Gray

Paper

Lithium Heparin 126 USP Units with Polymer Gel

100/1000

BD Vacutainer RST Tube ®

BD Vacutainer Rapid Serum Tubes (RST) contain thrombin-based clot activator and polymer gel for serum separation. Samples processed in these tubes are used for serum determinations in chemistry. A five-minute clotting time makes this tube ideal for STAT testing in the emergency department as well as clinical laboratories striving to improve test turnaround and workflow efficiencies. ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

368774

13 x 100

5.0

BD Hemogard™ / Orange

Paper

Thrombin-based clot activator

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

Venous VenousProducts Products –– 44

BD Vacutainer Fluoride Tubes ®

BD Vacutainer Fluoride Tubes are used to collect samples for glucose determinations. ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

367587

13 x 75

2.0

BD Hemogard™ / Gray

Paper

Sodium Fluoride 3 mg, Na2EDTA 6 mg

100/1000

367921

13 x 75

2.0

BD Hemogard™ / Gray

Paper

Sodium Fluoride 5 mg, Potassium Oxalate 4 mg

100/1000

368587

13 x 75

4.0

Conventional/ Gray

Paper

Sodium Fluoride 10 mg, Potassium Oxalate 8 mg

100/1000

367922

13 x 75

4.0

BD Hemogard™ / Gray

Paper

Sodium Fluoride 10 mg, Potassium Oxalate 8 mg

100/1000

367925

13 x 100

6.0

BD Hemogard™ / Gray

Paper

Sodium Fluoride 15 mg, Potassium Oxalate 12 mg

100/1000

367729

13 x 100

7.0

BD Hemogard™ / Gray

Paper

Sodium Fluoride 30 mg

100/1000

367001

16 x 100

10.0

Conventional/ Gray

Paper

Sodium Fluoride 100 mg, Potassium Oxalate 20 mg

100/1000

BD Vacutainer Serum Tubes ®

BD Vacutainer Plus Plastic Serum Tubes have spray-coated silica and are used for serum determinations in chemistry. Samples processed in these tubes may also be used for routine blood donor screening, immunohematology and diagnostic testing of serum for infectious disease.* ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

366668

13 x 75

3.0

Conventional/Red

Paper

Clot Activator, Silicone Coated

100/1000

367812

13 x 75

4.0

BD Hemogard™ / Red

Paper

Clot Activator, Silicone Coated

100/1000

367814

13 x 100

5.0

BD Hemogard™ / Red

Paper

Clot Activator, Silicone Coated

100/1000

367815

13 x 100

6.0

BD Hemogard™ / Red

Paper

Clot Activator, Silicone Coated

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

Venous Products – 5

BD Vacutainer Serum Tubes – continued ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

368660

13 x 100

6.0

Conventional/Red

Paper

Clot Activator, Silicone Coated

100/1000

366430

16 x 100

10.0

Conventional/Red

Paper

Silicone Coated

100/1000

367820

16 x 100

10.0

Conventional/Red

Paper

Clot Activator, Silicone Coated

100/1000

BD Vacutainer Heparin Tubes ®

BD Vacutainer Heparin Tubes are spray-coated with either lithium heparin or sodium heparin. Samples collected in these tubes are used for plasma determinations in chemistry. ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

366664

13 x 75

2.0

BD Hemogard™ / Green

Paper

Lithium Heparin 37 USP Units

100/1000

367671

13 x 75

2.0

BD Hemogard™ / Green

Paper

Sodium Heparin 33 USP Units

100/1000

366667

13 x 75

3.0

Conventional/ Green

Paper

Lithium Heparin 56 USP Units

100/1000

367884

13 x 75

4.0

BD Hemogard™ / Green

Paper

Lithium Heparin 75 USP Units

100/1000

367871

13 x 75

4.0

BD Hemogard™ / Green

Paper

Sodium Heparin 75 USP Units

100/1000

367886

13 x 100

6.0

BD Hemogard™ / Green

Paper

Lithium Heparin 95 USP Units

100/1000

367880

16 x 100

10.0

Conventional/ Green

Paper

Lithium Heparin 158 USP Units

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

Venous VenousProducts Products –– 66

BD Vacutainer Heparin Tubes – continued ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

367878

13 x 100

6.0

BD Hemogard™ / Green

Paper

Sodium Heparin 95 USP Units

100/1000

366480

16 x 100

10.0

Conventional/ Green

Paper

Sodium Heparin 158 USP Units

100/1000

367874

16 x 100

10.0

Conventional/ Green

Paper

Sodium Heparin 158 USP Units

100/1000

BD Vacutainer EDTA Tubes ®

BD Vacutainer spray-coated EDTA Tubes are used for whole blood hematology determinations, immunohematology testing and blood donor screening.* ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

367842

13 x 75

2.0

BD Hemogard™ / Pink

Crossmatch

K2EDTA 3.6 mg

100/1000

367841

13 x 75

2.0

BD Hemogard™ / Lavender

Paper

K2EDTA 3.6 mg

100/1000

367856

13 x 75

3.0

BD Hemogard™ / Lavender

Paper

K2EDTA 5.4 mg

100/1000

367835

13 x 75

3.0

Conventional/ Lavender

Paper

K2EDTA 5.4 mg

100/1000

367862

13 x 75

4.0

BD Hemogard™ / Lavender

See Thru

K2EDTA 7.2 mg

100/1000

367844

13 x 75

4.0

Conventional/ Lavender

Paper

K2EDTA 7.2 mg

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

Venous Products – 7

BD Vacutainer EDTA Tubes – continued ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

367861

13 x 75

4.0

BD Hemogard™ / Lavender

Paper

K2EDTA 7.2 mg

100/1000

367863

13 x 100

6.0

BD Hemogard™ / Lavender

Paper

K2EDTA 10.8 mg

100/1000

367899

13 x 100

6.0

BD Hemogard™ / Pink

Crossmatch

K2EDTA 10.8 mg

100/1000

368661

13 x 100

6.0

Conventional/ Lavender

Paper

K2EDTA 10.8 mg

100/1000

366450

13 x 100

7.0

Conventional/ Lavender

Paper

K3EDTA 12.15 mg (15% Sol, 0.081 mL)

100/1000

366643

16 x 100

10.0

BD Hemogard™ / Lavender

See Thru

K2EDTA 18 mg

100/1000

368589

16 x 100

10.0

K2EDTA 18 mg

100/1000

Conventional/Pink Crossmatch

BD Vacutainer Citrate Tubes ®

BD Vacutainer Citrate Tubes with 3.2% buffered sodium citrate solution are used for routine coagulation studies. ®

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

363080

13 x 75

1.8

BD Hemogard™ / Lt. Blue

Paper

Buffered Sodium Citrate (0.109M, 3.2%)

100/1000

363083

13 x 75

2.7

BD Hemogard™ / Lt. Blue

Paper

Buffered Sodium Citrate (0.109M, 3.2%)

100/1000

Paper

Buffered Sodium Citrate (0.109M, 3.2%), Theophylline, Adenosine, Dipyridamole (0.3 mL)

100/1000

Paper

Buffered Sodium Citrate (0.105M, 3.2%)

100/1000

367947

13 x 75

4.5

BD Hemogard™ / Lt. Blue

369714

13 x 75

4.5

BD Hemogard™ / Lt. Blue

BD Hemogard™ Closure

Conventional Rubber Stopper

Venous VenousProducts Products –– 88

BD Vacutainer Specialty Tubes ®

BD offers a wide array of tubes to meet your specialty testing requirements. Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

Blood Group Typing, HLA Phenotyping, DNA and Paternity Testing 364816

13 x 100

6.0

Conventional/ Yellow

Paper

Acid Citric Dextrose (ACD) Solution B consists of Trisodium Citrate, 13.2 g/L, Citric Acid, 4.8 g/L, and Dextrose, 14.7 g/L

100/1000

364606

16 x 100

8.5

Conventional/ Yellow

Paper

Acid Citric Dextrose (ACD) Solution A consists of Trisodium Citrate, 22.0 g/L, Citric Acid, 8.0 g/L, and Dextrose, 24.5 g/L

100/1000

3.0

BD Hemogard™ / Tan

Paper

K 2EDTA 5.4 mg

100/1000

Silicone Coated K 3EDTA (12.15 mg)

50/1000

Paper

K 2EDTA 10.8 mg

100/1000

Paper

Serum Clot Activator (Silicone Coated)

100/1000

Lead Testing 367855

13 x 75

Sterile Exterior Pouch 366401

16 x 100

10.0

Conventional/Red

7.0

Conventional/ Lavender

G 13 x 100

Paper Paper

Trace Element Testing 368381

13 x 100

6.0

368380

13 x 100

6.0

BD Hemogard™ / Royal Blue BD Hemogard™ / Royal Blue

Westergren Sedimentation Rate Determination (Buffered Citrate) 369741

13 x 75

2.4

BD Hemogard™ / Black

Paper

Buffered Citrate (32.0 mg Sodium Citrate 4.2 mg Citric Acid/mL) 0.6 mL

100/1000

Whole Blood Microbiology Sodium Polyanethol Sulfonate 364960

16 x 100

8.3

Conventional/ Yellow

See Thru

Sodium Polyanethol Sulfonate (SPS) (0.35% in 0.85% Sodium Chloride) 1.7 mL

100/1000

Discard/No Additive Tubes 366703

13 x 75

3.0

BD Hemogard™ / Clear

Paper

No Additive

100/1000

366704

13 x 75

3.0

Conventional/ Red/Light Gray

Paper

No Additive

100/1000

366408

13 x 100

6.0

BD Hemogard™ / Clear

Paper

No Additive

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

www.bd.com/vacutainer

Venous Products – 9

BD Vacutainer Molecular Diagnostic Testing / Cell Preparation Tubes ®

BD Vacutainer Mononuclear Cell Preparation Tubes (CPT™) ®

The one-step, closed-system tube for blood collection, mononuclear cell separation and transportation offers convenience, safety and reproducibility that may contribute to increased lab productivity. This product is for in vitro diagnostic use.

PAXgene Blood RNA Tube ®

The PAXgene Tube offers a convenient and closed system for the collection, storage and transportation of whole blood that requires intracellular RNA stabilization. The PAXgene tube is for in vitro diagnostic use and is CE-marked. ®

BD Vacutainer Plasma Preparation Tubes (PPT™) ®

The one-step, closed-system tube for blood collection, undiluted plasma preparation and transportation offers convenience, safety and high-quality plasma for molecular diagnostic testing. This product is for in vitro diagnostic use.

Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Label Type

Additive/ Concentration

Packaging Box/Case Quantities

Cell Preparation Tubes (CPT™) 362760

13 x 100

4.0

Conventional/ Lt. Blue/Black

Mylar

Sodium Citrate 0.45 mL of 0.1 Molar

60/Case

362753

16 x 125

8.0

Conventional/ Red/Green

Mylar

Sodium Heparin minimum 198 USP units

60/Case

362761

16 x 125

8.0

Conventional/ Lt. Blue/Black

Mylar

Sodium Citrate 1.0 mL of 0.1 Molar

60/Case

Additive 6.9 mL

100/Case

PAXgene® Blood RNA Tube 762165*

16 x 100

2.5

BD Hemogard™ / Red

Paper

Plasma Preparation Tubes (PPT™) 362788

13 x 100

5.0

BD Hemogard™ / Pearl White

Mylar

K2EDTA 9 mg

100/1000

362799

16 x 100

8.5

BD Hemogard™ / Pearl White

Mylar

K2EDTA 15.8 mg

100/1000

362800

16 x 100

8.5

BD Hemogard™ / Pearl White

Paper

K2EDTA 15.8 mg

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

* PAXgene® Blood RNA Kit (North American Catalog #762164) can be ordered from QIAGEN, or visit http://www.PreAnalytix.com PAXgene is a trademark of PreAnalytix GmbH

Venous VenousProducts Products –– 10 10

Proteomics Analysis and Protein Preservation BD™ P100 Blood Collection System for Plasma Protein Preservation BD™ P100 enables greater recovery and preservation of plasma proteins by the immediate mixing of blood with proprietary protease inhibitors. The on-board stabilizers, specifically formulated for human plasma, provide point-of-collection protection of valuable plasma proteins that are subject to proteolytic degradation and modification after blood collection.* Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Anticoagulant

Additive

Packaging (Tubes/Kit)

366422

13 x 75

~2.0

BD Hemogard™ / Clear

3.6 mg K2EDTA

Proprietary Protein Stabilizers

20 tubes; 10 tubes/foil pouch 2 foil pouches/kit

366448

16 x 100

~8.5

BD Hemogard™ / Clear

15.8 mg K2EDTA

Proprietary Protein Stabilizers

24 tubes; 6 tubes/foil pouch 4 foil pouches/kit

BD™ P700 Blood Collection System for Plasma GLP-1 Preservation BD™ P700 is especially suited as the blood collection tube of choice for assays that require quantitation and measurement of the preproglucagon-derived glucose regulatory peptide, glucagon-like peptide 1 (GLP-1). P700 contains a proprietary dipeptidyl peptidase IV (DPP-IV) protease inhibitor that provides immediate protection of GLP-1 from degradation in plasma.* Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Anticoagulant

Additive

Packaging (Tubes/Kit)

366473

13 x 75

~3.0

BD Hemogard™ / Lavender

5.4 mg K2EDTA

Proprietary DPP-IV Inhibitor

20 tubes; 10 tubes/foil pouch 2 foil pouches/kit

BD™ P800 Blood Collection System for Plasma GLP-1, GIP, Glucagon and Ghrelin Preservation BD™ P800 is especially suited as a blood collection tube of choice for assays that require quantitation and measurement of the glucagon-like peptide 1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP), glucagon and ghrelin. P800 contains a proprietary cocktail of protease, esterase and DPP-IV inhibitors that provides immediate protection of bioactive peptides from degradation in plasma.* Reference Number

Glass (G) or Plastic (P)

Tube Size (mm)

Draw Volume (mL)

Closure Type/Color

Anticoagulant

Additive

Packaging Box/Case

366420

13 x 75

~2.0

BD Hemogard™ / Clear

3.6 mg K2EDTA

Proprietary Cocktail of Protease, Esterase and DPP-IV Inhibitors

100/Case

366421

16 x 100

~8.5

BD Hemogard™ / Clear

15.3 mg K2EDTA

Proprietary Cocktail of Protease, Esterase and DPP-IV Inhibitors

100/Case

BD Hemogard™ Closure * For research use only. Not for use in diagnostic procedures. www.bd.com/vacutainer

Venous Products – 11

Venous Products

BD Vacutainer Eclipse™ Blood Collection Needles ®

The BD Vacutainer® Eclipse™ Blood Collection Needle is a safety-engineered, multi-sample blood collection needle that offers a simple, effective way to collect blood while reducing the possibility of needlestick injuries. It features a safety shield that allows for one-handed activation to cover the needle immediately upon withdrawal from the vein and confirms proper activation with an audible click. BD Vacutainer® Eclipse™ Blood Collection Needle with Pre-Attached Holder is ready to use right out of the package, with no assembly required. Its integrated safety shield and holder maximizes OSHA compliance by protecting clinicians from potential front and back-end needlestick injuries.

Reference Number

Description

Needle Gauge

Needle Length (Inches)

Shield Color

Packaging Box/Case Quantities

368607

BD Vacutainer® Eclipse™ Blood Collection Needle

1.25

Green

48/480

368608

BD Vacutainer® Eclipse™ Blood Collection Needle

1.25

Black

48/480

BD Vacutainer® Eclipse™ Blood Collection Needles with Pre-Attached Holder 368650

BD Vacutainer® Eclipse™ Blood Collection Needle with Pre-Attached Holder

1.25

Green

–/100

368651

BD Vacutainer® Eclipse™ Blood Collection Needle with Pre-Attached Holder

1.25

Black

–/100

www.bd.com/vacutainer

Venous Products – 13

BD Vacutainer Blood Collection Sets ®

A successful venipuncture begins with choosing the appropriate site and equipment for the procedure. Healthcare workers should select safety-engineered products that help contribute to high-quality specimens, patient comfort and healthcare worker safety. The BD line of winged blood collection sets can help you achieve these clinical goals.

BD Vacutainer Push Button Blood Collection Sets ®

The BD Vacutainer Push Button Blood Collection Set offers a clinically demonstrated split-second retracting safety needle to help reduce costly needlestick injuries. It is available with a pre-attached holder for added convenience and to help meet OSHA single-use standards. ®

Reference Number

Needle Gauge

Needle Length (Inches)

Wing Color

Tubing Length (Inches)

Configuration With or Without Luer

Packaging Box/Case Quantities

367344

.75

Green

With

50/200

367342

.75

Light Blue

With

50/200

367341

.75

Royal Blue

With

50/200

367326

.75

Green

Without

50/200

367324

.75

Light Blue

Without

50/200

367323

.75

Royal Blue

Without

50/200

367338

.75

Green

With

50/200

367336

.75

Light Blue

With

50/200

367335

.75

Royal Blue

With

50/200

BD Vacutainer® Push Button Blood Collection Sets with Pre-Attached Holder 367352

.75

Green

Pre-Attached Holder

20/100

368656

.75

Light Blue

Pre-Attached Holder

20/100

368659

.75

Royal Blue

Pre-Attached Holder

20/100

Venous VenousProducts Products –– 14 14

BD Vacutainer Safety-Lok™ Blood Collection Sets ®

The BD Vacutainer Safety-Lok™ Blood Collection Set is simple and easy to use. The safety mechanism can be activated immediately after the blood draw, helping to protect you against needlestick injury. It is also offered with a pre-attached holder for added convenience and to help meet OSHA single-use holder standards. ®

Reference Number

Needle Gauge

Needle Length (Inches)

Wing Color

Tubing Length (Inches)

Configuration With or Without Luer

Packaging Box/Case Quantities

367281

.75

Green

With

50/200

367283

.75

Light Blue

With

50/200

367285

.75

Royal Blue

With

50/200

367296

.75

Green

Without

50/200

367297

.75

Light Blue

Without

50/200

367298

.75

Royal Blue

Without

50/200

367287

.75

Green

With

50/200

367292

.75

Light Blue

With

50/200

367294

.75

Royal Blue

With

50/200

BD Vacutainer® Safety-Lok™ Blood Collection Sets with Pre-Attached Holders 368652

.75

Green

Pre-Attached Holder

25/200

368653

.75

Light Blue

Pre-Attached Holder

25/200

www.bd.com/vacutainer

Venous Products – 15

BD Vacutainer Accessories ®

BD Vacutainer® Accessories are designed for secure and safe specimen sampling. This product offering includes direct-access sampling, transfer devices and tourniquets. These products offer convenience and ease of use and complement the family of BD Vacutainer® and BD Microtainer® products.

BD Vacutainer Holder ®

The BD Vacutainer One Use Holder is compatible with the entire BD Vacutainer Blood Collection System: BD Vacutainer Eclipse Blood Collection Needle, BD Vacutainer Safety-Lok™ Blood Collection Set, BD Vacutainer Push Button Blood Collection Set and BD Vacutainer Multiple Sample Luer Adapter. ®

Reference Number

Description

Packaging Box/Case Quantities

364815

BD Vacutainer® One Use Holder

250/1000

364597

BD Vacutainer® Ribbed Pediatric Tube Adapter

10/100

BD Vacutainer Blood Transfer Device ®

The use of a needle to transfer venous blood from a syringe to a blood collection tube or blood culture bottle is both a dangerous procedure and an OSHA-prohibited practice. The BD Vacutainer Blood Transfer Device was designed with healthcare workers’ safety in mind. This single-use device reduces the risk of transfer-related injuries, while maintaining the specimen integrity required for accurate results. ®

Reference Number

Description

Packaging Box/Case Quantities

364880

BD Vacutainer® Blood Transfer Device

–/200

Venous VenousProducts Products –– 16 16

BD Vacutainer Luer-Lok™ Access Device ®

The BD Vacutainer Luer-Lok™ Access Device is designed for sterile, secure and safer specimen sampling. This device provides the security of a threaded, locking luer connection—the patented BD Vacutainer Luer-Lok™ that replaces a luer slip device. The product is also compatible with a female luer connection or needleless IV site designed for luer-lock access, and luer locking Foley Catheter sampling ports. ®

Reference Number

Description

Packaging Box/Case Quantities

364902

BD Vacutainer® Luer-Lok™ Access Device

–/200

367290

BD Vacutainer® Luer Adapter

100/1000

BD Vacutainer Specimen Collection Assembly ®

Compatible with any split-septum collection port designed for blunt plastic cannula access. Reference Number

Description

Packaging Box/Case Quantities

303380

BD Vacutainer® Specimen Collection Assembly with BD™ Blunt Plastic Cannula

25/200

BD Vacutainer Stretch Latex-Free Tourniquet ®

Concerned about latex sensitivity? The BD Vacutainer Stretch Latex-Free Tourniquet is ideal for practitioners and facilities that want to eliminate latex from their healthcare products. This free-of-latex tourniquet will not cause a latex-induced allergic reaction in latex-sensitive patients or employees. Convenient packaging allows for easy, one-at-a-time dispensing of tourniquets—encouraging a single-use policy that helps reduce the danger of cross-contamination between patients and healthcare workers. ®

Reference Number

Description

Packaging Box/Case Quantities

367203

BD Vacutainer® Stretch Latex-Free Tourniquet

25/500

www.bd.com/vacutainer

Venous Products – 17

Capillary Products

BD Microtainer Capillary Blood Collection System ®

BD Microtainer® Capillary Products feature a complete system designed to provide safety, accuracy and comfort for capillary blood sampling and collection, to meet your varying sample requirements and meet the needs of your most fragile patients.

BD Microtainer Contact-Activated Lancets ®

The BD Microtainer Contact-Activated Lancet has been designed with a positive patient experience in mind. The contact-activation method facilitates a consistent puncture depth and minimizes the likelihood of having to repeat the puncture. It covers only a small area at the contact point, resulting in improved visibility of the puncture site for the clinician and greater accuracy of lancet positioning when performing the puncture. Its innovative ergonomic design allows for a more comfortable grip. The lancet automatically retracts into the device, which prevents the lancet from being reused. In addition, the lot number is laser etched on each lancet for easier tracking. ®

Reference Number

Width and Depth (mm)

Blood Volume

Color

Packaging Box/Case Quantities

366592

30 G x 1.5

Low Flow

Purple

200/2000

366593

21 G x 1.8

Medium Flow

Pink

200/2000

366594

1.5 mm x 2.0

High Flow

Blue

200/2000

BD Microtainer Quikheel™ Lancets ®

Maximize blood flow while minimizing pain in heelsticks on newborns with the safetyengineered BD Microtainer Quikheel™ Lancet. Easy, one-handed activation releases a retractable surgical blade for making a precise, consistent incision that produces sufficient blood flow to conduct PKU testing. A perfect solution for your newborn screening tests. Sizes are color-coded for infant and preemie. ®

Reference Number

Width and Depth (mm)

Blood Volume

Color

Packaging Box/Case Quantities

368100

1.75 x 0.85

Low Flow (Preemie)

Pink

50/200

368101

2.50 x 1.00

High Flow (Infant)

Teal

50/200

www.bd.com/vacutainer

Capillary Products – 19

BD Microtainer MAP Microtube for Automated Process ®

BD Microtainer MAP Microtube for Automated Process is the first one-piece instrument-compatible microtube to offer both standard full-size patient identification labels as well as compatibility with most automated hematology instruments. The BD Microtainer MAP tube is designed to improve the labeling and processing time of capillary blood collection and testing in patients such as infants, children, oncology and the elderly. ®

Reference Number

Glass (G) or Tube Size Plastic (P) (mm)

Color

Additive

Fill Volume (μL)

Packaging Box/Case Quantities

BD Microtainer® MAP Microtube Automated Process 363706

13 x 75

Lavender

1.0 mg K2EDTA

250-500

50/200

Capillary Venous Products Products –– 20 20

Approved for hematology and lead testing!

BD Microtainer Blood Collection Tubes ®

BD Microtainer Blood Collection Tube was designed for ease-of-use and helps to ensure that a quality capillary blood sample is collected. The wider-diameter BD Microtainer Tube with BD Microgard™ Closure features an integrated collector and improved mixing ability. This full array of microcollection tubes is available for hematology and chemistry applications, and is color-coded to match the array of evacuated BD Vacutainer Blood Collection Tubes. ®

Reference Number

Color

Additive

Fill Volume (μL)

Packaging Box/Case Quantities

BD Microtainer® Tubes with BD Microgard Closure ™

365967

Gold

Clot Activator/ SST™ Gel

400-600

50/200

365978

Gold

Clot Activator/ SST™ Gel (Amber)

400-600

50/200

365963

Red

Silicone Coated

250-500

50/200

365974

Lavender

K2EDTA

250-500

50/200

365985

Mint Green

Lithium Heparin/ PST™ Gel

400-600

50/200

365987

Mint Green

Lithium Heparin/ PST™ Gel (Amber)

400-600

50/200

365965

Green

Lithium Heparin

200-400

50/200

365992

Gray

NaFl/Na2EDTA

400-600

50/200

365976

N/A

Tube Extender

N/A

50/200

www.bd.com/vacutainer

Capillary Products – 21

Urine

Products

BD Vacutainer Urine Collection System ®

BD Urine Collection Products offer the advantages of a closed system, for both patients and healthcare workers alike. Patients receive more reliable results, due to decreased preanalytical variability. Healthcare workers derive more safety on the job because they do not need to pour potentially contaminated urine into tubes, while the efficiency of the closed system eliminates the need for re-collections and re-labeling and reduces the potential for preanalytical errors. The preservatives in the BD Urinalysis Tube and the C&S Tube allow for delayed testing and are in compliance with CLSI guidelines.

BD Vacutainer Urine Collection Kits ®

The BD Vacutainer Urine Collection System provides a wide array of urine collection products to meet your everyday urine testing needs. The BD proprietary, mercury-free urinalysis preservative maintains sample integrity for up to 72 hours at room temperature, while the BD microbiology preservative maintains bacterial viability for up to 48 hours at room temperature to help reduce contamination rates. From collection to transport to specimen preservation, BD Vacutainer Urine Products help you handle the most commonly collected and analyzed body fluid. ®

Packaging Box/Case Quantities

Tube Size/ Draw Volume

Closure Type/Color

Additive/Concentration

Complete Kit: Sterile Screw-Cap Collection Cup with Integrated Transfer Device and Plus Plastic Conical Tube with Preservative for Urinalysis and Plus Plastic C&S Preservative Tube and Castile Soap Towelettes

16x100 mm 8.0 mL

Conventional/ Red/Yellow

Ethyl Paraben, Sodium Propionate and Chlorhexidine Preservative

13x75 mm 4.0 mL

Conventional/ Gray

Boric Acid, Sodium Formate and Sodium Borate Preservative

Complete Kit: Sterile Screw-Cap Collection Cup with Integrated Transfer Device and Plus Plastic Conical Tube for Urinalysis and Plus Plastic C&S Preservative Tube and Castile Soap Towelettes

16x100 mm 8.0 mL

Conventional/ Yellow

No Additive

13x75 mm 4.0 mL

Conventional/ Gray

Boric Acid, Sodium Formate and Sodium Borate Preservative

364954

C&S Cup Kit: Sterile Screw-Cap Collection Cup with Integrated Transfer Device and Plus Plastic C&S Preservative Tube and Castile Soap Towelettes

13x75 mm 4.0 mL

Conventional/ Gray

Boric Acid, Sodium Formate and Sodium Borate Preservative

50 Kits/Case

364953

C&S Transfer Straw Kit: Transfer Straw and Plus Plastic C&S Preservative Tube

13x75 mm 4.0 mL

Conventional/ Gray

Boric Acid, Sodium Formate and Sodium Borate Preservative

50/200

Reference Number

364957

364956

Description

50 Kits/Case

Conventional Rubber Stopper

www.bd.com/vacutainer

Urine Products – 23

BD Vacutainer Urine Collection Kits – continued ®

Closure Type/Color

Additive/ Concentration

Packaging Box/Case Quantities

364946

Urinalysis Cup Kit: Sterile Screw-Cap Collection Cup with 16x100 mm Integrated Transfer Device and Plus Plastic 8.0 mL Conical Tube with Preservative for Urinalysis

Conventional/ Red/Yellow

Ethyl Paraben, Sodium Propionate and Chlorhexidine Preservative

50 Kits/Case

364981

Urinalysis Cup Kit: Sterile Screw-Cap Collection Cup with Integrated Transfer Device and Plus Plastic Round Bottom Tube for Urinalysis

16x100 mm 10.0 mL

Conventional/ Yellow

No Additive

50 Kits/Case

364989

Urinalysis Cup Kit: Sterile Screw-Cap Collection Cup with Integrated Transfer Device and Plus Plastic Conical Tube for Urinalysis

16x100 mm 8.0 mL

Conventional/ Yellow

No Additive

50 Kits/Case

364990

Urinalysis Transfer Straw Kit: Transfer Straw and Plus Plastic Round Bottom Tube for Urinalysis

16x100 mm 10.0 mL

Conventional/ Yellow

No Additive

50/200

364991

Urinalysis Transfer Straw Kit: Transfer Straw and Plus Plastic Conical Tube for Urinalysis

16x100 mm 8.0 mL

Conventional/ Yellow

No Additive

50/200

364943

Urinalysis Transfer Straw Kit: Transfer Straw and Plus Plastic Conical Tube with Preservative for Urinalysis

16x100 mm 8.0 mL

Conventional/ Red/Yellow

Ethyl Paraben, Sodium Propionate and Chlorhexidine Preservative

50/200

Reference Number

Tube Size/ Draw Volume

Description

Conventional Rubber Stopper

Venous Urine Products Products– –2424

BD Vacutainer Urine Bulk Products ®

Reference Number

Description

Tube Size/ Draw Volume

Closure Type/Color

Additive/ Concentration

Packaging Box/Case Quantities

364951

Bulk Tube: Plus Plastic C&S Preservative Tube

13x75 mm 4.0 mL

Conventional/ Gray

Boric Acid, Sodium Formate and Sodium Borate Preservative

100/1000

364958*

Bulk Tube: Plus Plastic C&S Preservative Tube

13x75 mm 4.0 mL

BD Hemogard™ / Olive Green

Boric Acid, Sodium Formate and Sodium Borate Preservative

100/1000

364992

Bulk Tube: Plus Plastic Conical Bottom Tube with Preservative for Urinalysis

16x100 mm 8.0 mL

Conventional/Red/ Yellow

Ethyl Paraben, Sodium Propionate and Chlorhexidine Preservative

100/1000

365017

Bulk Tube: Plus Plastic Round Bottom Tube with Preservative for Urinalysis

16x100 mm 8.0 mL

BD Hemogard™ / Yellow

Ethyl Paraben, Sodium Propionate and Chlorhexidine Preservative

100/1000

364980

Bulk Tube: Plus Plastic Conical Tube for Urinalysis

16x100 mm 8.0 mL

Conventional/ Yellow

No Additive

100/1000

364979

Bulk Tube: Plus Plastic Round Bottom Tube for Urinalysis

16x100 mm 10.0 mL

Conventional/ Yellow

No Additive

100/1000

366408

Bulk Tube: Plus Plastic No Additive (Z) Tube

13x100 mm 6.0 mL

BD Hemogard™ / Clear

No Additive

100/1000

364975

Urine Collection Cup with Integrated Transfer Device

—

200/Case

364966

Urine Transfer Straw

—

100/1000

BD Hemogard™ Closure

Conventional Rubber Stopper

* Coming soon www.bd.com/vacutainer

Urine Products – 25

Education Services

At BD,

We pledge to continually support the healthcare professional’s need for high-quality educational tools and training assistance by providing these value-added programs.

Helping You Get the Most Value from Preanalytical Processes

Clinical Documentation

When your facility selects BD Vacutainer specimen collection products, it is getting more than just tools that are shown to provide clinical and economic benefits. Your institution also gains access to world-class technical support and educational services that can help derive maximum value and efficiency from hospital-wide sample collection and transport processes. ®

More than 100 clinical studies on a vast array of BD Vacutainer® and BD Microtainer® products. Also Available: Clinical Documentation Reference Manual

Facts About Needlesticks Prepared especially for nursing and phlebotomy staff members, these brochures contain facts about the dangers of needlesticks and the costs associated with them.

Videos

Training and Educating Your Staff BD recognizes the importance of continuous learning in today’s challenging healthcare environment. That is why we are committed to helping your institution achieve its educational goals and statemandated requirements in a convenient, cost-efficient manner. Our comprehensive portfolio of training and educational tools and services includes: .P.I.R.I.T.® (Safety Product In Service S Resources Initiative Training) provides on-site healthcare workers training on BD Vacutainer® safety-engineered products eb-based product training provides W course-completion certificates to help you maintain training and compliance records Comprehensive educational catalog with products made available through strategic alliances with leading professional associations, authors and publishers, as well as items created exclusively by BD.

Helping You Achieve Quality and Compliance Given the proliferation of technology, instruments, analytes, reagents and methods, your laboratory professionals have a need for information to validate results and comply with CAP and CLSI recommendations.

Instructional videos or CDs designed to aid in training healthcare workers on BD Vacutainer ® specimen collection products.

Sample Collection Pocket Cards Handy laminated pocket cards provide easy reference for: order of draw, tube additive guide, troubleshooting hints for blood collection, best sites for venipuncture and many more.

Quick Reference Cards Handy pocket cards provide easy reference for using BD Vacutainer ® specimen collection products.

Training Aids BD foam baby foot training aid for heelstick technique.

LabNotes® A newsletter, published by BD LifeSciences – Preanalytical Systems, to keep readers current on patient and healthcare worker safety, as well as new preanalytical trends/ issues in the clinical laboratory. For online subscription information, please visit www.bd.com/vacutainer/labnotes.

TechTalk ® A news bulletin to address frequently asked technical questions, with a focus on reducing preanalytical variables.

Wall Charts Instructional wall charts to help educate healthcare professionals.

www.bd.com/vacutainer

Education Services – 27

Laboratory

Consulting Services

BD Laboratory Consulting Services Our experienced consultants review and make recommendations involving all aspects of laboratory medicine to help your institution: Increase revenue Lower operating expenses Improve productivity Enhance patient care

For more information on these customized services, please call BD Technical Services at 1.800.631.0174

Packaging Symbols Services Handling Symbols

Additive Symbols InInVitro VitroDiagnostic Diagnostic Medical MedicalDevice Device

K2E K2E

EDTA EDTA- dipotassium - dipotassiumsalt salt

Temperature TemperatureLimitation Limitation

9NC 9NC

Tri-Sodium Tri-SodiumCitrate Citrate9:1 9:1

Do DoNot NotReuse Reuse

Manufacturer Manufacturer

FX FX

Fluoride Fluorideand andOxalate Oxalate

Catalog CatalogNumber Number

Keep KeepAway AwayFrom FromSunlight Sunlight

FE FE

Fluoride Fluorideand andEDTA EDTA

Method MethodofofSterilization Sterilization Using UsingIrradiation Irradiation

This ThisEnd EndUp Up

LH LH

Lithium LithiumHeparin Heparin

Consult ConsultInstructions Instructions For ForUse Use

Fragile, Fragile,Handle HandleWith WithCare Care

NH NH

Sodium SodiumHeparin Heparin

NoLatex Latex No

No Noadditive additive

Use UseByBy ºcºc

Batch BatchCode Code

oror

ºcºc

Laboratory Consulting Services – 28 Venous Products – 28 Packaging Symbols

Customer BD Vacutainer – The Trusted Leader in Quality and Supply ®

Focus

“Good Enough” is not an option for hospitals, laboratories and clinicians striving to provide optimal and efficient patient care. Medical products must deliver clinical value and meet stringent quality standards. With healthcare budgets tightening, the true cost of poor quality in specimen collection can ripple throughout your institution from the lab to virtually every department in your hospital—adding unwanted cost, inefficiency or even worse, harming patients and caregivers. That is why we strive relentlessly to improve the quality of our products and services—a drive that has made BD the leader and most trusted provider of specimen collection products and services.

Certified and Tested • Two on-site, fully equipped clinical laboratories with a wide range of instrument platforms to ensure compatibility with our products • Four manufacturing facilities around the globe that are ISO 13485:2003 certified

A Disciplined, Data-Driven Approach The foundation of our quality is Six Sigma—a rigorous, data-driven method directed at eliminating errors and defects in the design, production and delivery of our products and services. We also employ other processes to plan, direct, measure and control quality, including: • Robust design controls •C ontrol plan management • L ean daily management • Process validation •C ritical parameter management

In addition, our world-class supply chain management system helps ensure that BD suppliers maintain our quality standards.

Ensuring Total System Performance To better serve our customers and ensure that our specimen collection products work optimally with today’s leading diagnostic instrument platforms and assays, we formed an Instrument Company Liaison function to: • Confirm acceptable mechanical and biochemical performance for new and existing products on all major instrument platforms • Address and resolve potential tube-assay related issues • F oster collaborative market and technology development initiatives

Assuring Supply Product quality means little to clinicians if they do not have timely access to needed specimen collection products. That is why BD has invested extensively in a large manufacturing and distribution network. With four dedicated manufacturing facilities around the world—including two large U.S. plants—BD has the ability to provide customers with unmatched service levels. www.bd.com/vacutainer

Customer Focus – 29

BD Life Sciences – Preanalytical Systems

See the Total Value To learn about BD Vacutainer® specimen collection products, educational materials or services offered by BD Life Sciences – Preanalytical Systems, please contact your local BD Sales Consultant today. You can also contact us via: BD Technical Services at 1.800.631.0174 or www.bd.com/vacutainer/contact BD Customer Service at 1.888.237.2762 or visit us anytime online at www.bd.com/vacutainer

BD Life Sciences Preanalytical Systems 1 Becton Drive Franklin Lakes, NJ 07417 www.bd.com/vacutainer

ANSI/ASB Standard 017, First Edition 2018 Standard Practices for Measurement Traceability in Forensic Toxicology

This document is copyrighted © by the AAFS Standards Board, LLC. 2018 All rights are reserved. 410 North 21st Street, Colorado Springs, CO 80904, asb.aafs.org.

ANSI/ASB Standard 017, 1st Ed. 2018

Standard Practices for Measurement Traceability in Forensic Toxicology ASB Approved February 2018 ANSI Approved June 2018

410 North 21st Street Colorado Springs, CO 80904 This document may be downloaded for free at: http://asb.aafs.org/ This document is provided by the AAFS Standards Board for free. You are permitted to print and download the document and extracts from the document for your own use, provided that: 

you do not modify this document or its related graphics in any way;



you do not use any illustrations or any graphics separately from any accompanying text; and,



you include an acknowledgement alongside the copied material noting the AAFS Standards Board as the copyright holder and publisher.

You expressly agree not to reproduce, duplicate, copy, sell, resell, or exploit for any commercial purposes, this document or any portion of it. You may create a hyperlink to http://asb.aafs.org to allow persons to download their individual, free copy of this document. Your hyperlink must not portray AAFS, the AAFS Standards Board, this document, our agents, associates and affiliates in an offensive manner, or be misleading or false. You may not use our trademarks as part of your link without our written agreement for you to do so. The AAFS Standards Board retains the sole right to submit this document to any other forum for any purpose. Certain commercial entities, equipment or materials may be identified in this document to describe a procedure or concept adequately. Such identification is not intended to imply recommendations or endorsement by the AAFS or the AAFS Standards Board, nor is it intended to imply that the entities, materials, or equipment are necessarily the best available for the purpose.

This document is copyrighted © by the AAFS Standards Board, LLC. 2018 All rights are reserved. 410 North 21st Street, Colorado Springs, CO 80904, asb.aafs.org.

ANSI/ASB Standard 017, 1st Ed. 2018

Foreword This Standard Practices for Measurement Traceability in Forensic Toxicology was developed to provide minimum requirements for establishing measurement traceability in forensic toxicology laboratories. The fundamental reason for establishing traceability of a measurement is to ensure confidence and reliability in forensic toxicological test results. This standard was developed by the Toxicology Subcommittee of the Organizational Scientific Area Committee. It was prepared and finalized as a standard by the Toxicology Consensus Body of the ASB. All hyperlinks and web addresses shown in the document are current as of the publication date of this standard.

Keywords: Measurement Traceability, Calibration, Forensic Toxicology

ANSI/ASB Standard 017, 1st Ed. 2018

Table of Contents 1

Scope ...................................................................................................................................................................................... 1

Normative References .................................................................................................................................................... 1

Terms and Definitions .................................................................................................................................................... 1

4 General Measurement Traceability ........................................................................................................................... 2 4.1 Background ..................................................................................................................................................................... 2 4.2 Requirements for Measurement Traceability................................................................................................... 4 5

Measurement Traceability Requirements for Toxicology ............................................................................... 6

6 Equipment ........................................................................................................................................................................... 7 6.1 General .............................................................................................................................................................................. 7 6.2 Calibration of Analytical Equipment..................................................................................................................... 7 6.3 Other Equipment .......................................................................................................................................................... 8 7

Conformance....................................................................................................................................................................... 8

Annex A (informative) Bibliography ................................................................................................................................ 9

ANSI/ASB Standard 017, 1st Ed. 2018

Standard Practices for Measurement Traceability in Forensic Toxicology 1 Scope This standard defines the minimum requirements for establishing measurement traceability in forensic toxicology laboratories.

2 Normative References The following references are documents that are indispensable for the application of the standard. For dated references, only the edition cited applies. For undated references, the latest edition of the referenced document (including any amendments) applies. International Bureau of Weights and Measures (BIPM)-International Committee for Weights and Measures (CIPM) Mutual Recognition Arrangement 1 International Laboratory Accreditation Cooperation (ILAC), ILAC P10:01/2013 ILAC Policy on Traceability of Measurement Results 2 International Laboratory Accreditation Cooperation (ILAC) Mutual Recognition Arrangement 3 International Organization for Standardization (ISO), ISO/IEC 17025:2005 General requirements for the competence of testing and calibration laboratories (Geneva, Switzerland: ISO, 2005) 3 International Organization for Standardization (ISO), ISO Guide 34:2009 General requirements for the competence of reference material producers (Geneva, Switzerland: ISO, 2009) 4 International Organization for Standardization (ISO), ISO 17034:2016 General requirements for the competence of reference material producers (Geneva, Switzerland: ISO, 2016) 4 Joint Committee for Guides in Metrology (JCGM), International vocabulary of metrology – Basic and general concepts and associated terms (VIM), 3rd ed. (Sèvres, France: International Bureau of Weights and Measures [BIPM]-JCGM 200, 2012) (2008 with minor corrections) 4

3 Terms and Definitions For purposes of this document, the following definitions and acronyms apply. 3.1 accreditation 5 Third party evaluation of a forensic science service provider based on a particular standard(s), other relevant documents and attestation of competence to carry out specific tasks.

More information about the BIPM is available at: http://www.bipm.org/en/cipm-mra/ ILAC document available for download at: http://ilac.org 3 ISO documents available for purchase at: http://www.iso.org/iso/home/store/catalogue_ics.htm or from other authorized distributors 4 VIM available for download at: http://www.bipm.org/en/publications/guides/vim.html 5 From SWGTOX Standard on the Accreditation of Forensic Toxicology Laboratories. 1 2

ANSI/ASB Standard 017, 1st Ed. 2018

3.2 accuracy 6 Closeness of agreement between a measured quantity value and a true quantity value of a measurement. 3.3 calibration Operation that, under specified conditions, establishes a relation between the quantity value and corresponding indications. 3.4 calibrator 7 Measurement standard used in calibration. 3.5 Certified Reference Material 7 CRM Reference material characterized by a metrologically valid procedure for one or more specified properties, accompanied by a certificate that provides the value of the specified property, its associated uncertainty, and a statement of metrological traceability. 3.6 control Material of known composition that is analyzed along with unknown samples(s) in order to evaluate the performance of an analytical procedure. 3.7 decision point Administratively defined cutoff or concentration that is at or above the method’s limit of detection or lower limit of quantitation and is used to discriminate between a negative and positive test result. 3.8 Limit of Detection LOD An estimate of the lowest concentration of an analyte in a sample that can be reliably differentiated from blank matrix and meets identification criteria for the analytical method. 3.9 Lower Limit of Quantitation LLOQ An estimate of the lowest concentration of an analyte in a sample that can be reliably measured with acceptable bias and precision.

From Joint Committee for Guides in Metrology (JCGM), International vocabulary of metrology – Basic and general concepts and associated terms (VIM), 3rd ed. (Sèvres, France: International Bureau of Weights and Measures [BIPM]-JCGM 200, 2012) (2008 with minor corrections) 7 From ISO Guide 30: 2015 6

ANSI/ASB Standard 017, 1st Ed. 2018

3.10 forensic science service provider A forensic science agency or forensic science practitioner providing forensic science services. 3.11 mass reference standard A standard having the highest metrological quality available at a given mass, from which the measurements made at that mass are derived. 3.12 measurement traceability 7 Property of a measurement result whereby the result can be related to a reference through a documented unbroken chain of calibrations, each contributing to the measurement uncertainty. NOTE This is sometime referred to as metrological traceability.

3.13 reference material Material, sufficiently homogeneous and stable with reference to specified properties, which has been established to be fit for its intended use in a measurement or in examination of nominal properties.

4 General Measurement Traceability 4.1

Background

4.1.1 Some measurement processes require only a single step, whereas others may require more than one step. Measurement: process of experimentally obtaining one or more quantity values that can reasonably be attributed to a quantity. 7 Importantly, “process” is the first word in the definition of measurement. Measurement relates to the whole process of obtaining a quantity value. Related terms: Quantity: property of a phenomenon, body, or substance, where the property has a magnitude that can be expressed as a number and a reference. 7 Quantity Value: number and reference together expressing magnitude of a quantity. 7 Quantity Value example (Toxicology): Blood alcohol content: 0.158 grams of ethanol per 100 mL of blood. 4.1.2 Measurements are made in different ways in testing and calibration processes. A measurement may be: a. a reported test result; b. a reported calibration result; or

ANSI/ASB Standard 017, 1st Ed. 2018

c. a quantitative decision point (cutoff) that results in a qualitative test report In all of these scenarios, the measurement(s) may be used as the basis for a conclusion, an interpretation, or an opinion. NOTE A measurement may also be made during the testing or calibration process, but not reported to the customer.

4.1.3

Measurement traceability can be characterized by the following essential elements.8

a. Unbroken Chain of Comparisons – A documented system of comparisons with each step having the essential elements of metrological traceability going back to a stated reference acceptable to the parties, usually a national or international standard. b. Documented Measurement Uncertainty – The measurement uncertainty for each step in the traceability chain must be calculated according to defined methods and must be stated so that an overall uncertainty for the whole chain may be calculated. c. Documented Measurement Procedure – Each step in the chain must be performed according to documented, generally-accepted procedures and the results must be documented. d. Technical Competence – The laboratories or bodies performing one or more steps in the chain must maintain and supply evidence of technical competence (e.g., by maintaining appropriate training records, participating in inter-laboratory comparisons, and by demonstrating that they are accredited by a recognized accreditation body). e. Realization of SI Units – The chain of comparisons must, where possible, end at the realization of the International System of Units (SI). f.

Documented Calibration Intervals – Calibrations must be repeated at established and appropriate intervals to preserve metrological traceability; and

g. Measurement Assurance – A proper measurement assurance program [however named] must be established to ensure the validity of the measurement process and to ensure the calibration status of equipment, reference standards and reference materials. 4.2

Requirements for Measurement Traceability

4.2.1 General Forensic science service providers establish traceability of a measurement process by making one or more measurements using equipment that has been calibrated with established metrological traceability and/or through the use of certified reference materials in the test or calibration method. For equipment and certified reference materials used to establish and maintain measurement traceability, proper handling and storage procedures which meet or exceed manufacturer’s recommendations must be followed. See “Sample Procedure for Method Validation” at https://www.nist.gov/document/sapmethodvalidation2016-12-21doc 8

ANSI/ASB Standard 017, 1st Ed. 2018

4.2.2

Calibration Service Provider

If traceability of a measurement will be established through the calibration of equipment used to make the measurement, then this calibration shall be performed by an appropriately accredited calibration service supplier that, if available, is either:

a. a National Metrology Institute (NMI) that is a signatory to the BIPM - CIPM Mutual Recognition

Arrangement, with the calibration to be performed listed in Appendix C of the BIPM Key Comparison Database (KCDB); or

b. a service supplier accredited to ISO/IEC 17025:2005 by an accrediting body that is a signatory to

the International Laboratory Accreditation Cooperation (ILAC) Mutual Recognition Arrangement, with the calibration to be performed listed in a scope of accreditation.

If an appropriately accredited calibration service supplier is not available (as defined above), then the forensic science service provider shall perform their own evaluation. This evaluation shall ensure the external service supplier meets the competence, measurement traceability, and measurement capability requirements of ISO/IEC 17025:2005 or in the ILAC Policy on the Traceability of Measurement Results.9 The forensic science service provider shall keep objective evidence of this evaluation. The forensic science service provider shall perform a re-evaluation of services at least every two years. 4.2.3

Calibration Program

The forensic science service provider shall identify all equipment in a calibration program, however named, that requires calibration to establish measurement traceability, either totally or partially. The documentation shall: a. establish the interval for calibration; b. delineate if intermediate checks of the calibration status are required between calibrations and if so, the schedule and procedure for those intermediate checks; and c. require calibration of new equipment of this type (e.g., balance, pipette) prior to use of the equipment in testing, calibration or inspection work. See Section 6 for minimum calibration requirements. 4.2.4

Certified Reference Materials

If traceability of a measurement will be established through reference material, the forensic science service provider shall establish it through the use of one or more certified reference material(s) (CRM). If available, the CRM shall be obtained by the forensic science service provider from a supplier that is either: a. a National Metrology Institute (NMI) that is a signatory to the BIPM - CIPM Mutual Recognition Arrangement, with the CRM to be purchased included in the BIPM key comparison database (KCDB); or 9

Reference to ILAC P10.

ANSI/ASB Standard 017, 1st Ed. 2018

b. an accredited Reference Material Producer that is accredited to ISO Guide 34:2009 or ISO 17034:2016 by an accrediting body that is a signatory to a mutual or multilateral recognition arrangement in an ILAC recognized regional accreditation cooperation or the ILAC Mutual Recognition Arrangement, with a scope of accreditation covering the CRM. If a CRM is not available to the forensic science service provider from a supplier that meets the above requirement, then the forensic science service provider shall perform an evaluation of the CRM supplier. This evaluation shall ensure the CRM supplier meets the competence, measurement traceability, and measurement capability requirements of ISO/IEC 17025:2005 or in the ILAC Policy on the Traceability of Measurement Results. The forensic science service provider shall keep objective evidence of this evaluation. The forensic science service provider shall perform a re-evaluation of services at least every two years. 4.2.5

Modifications to Reference Materials

If a reference material used to establish traceability, whether certified or not, is diluted, such as a stock or working solution, then the equipment used shall be calibrated as delineated in Section 6.

5 Measurement Traceability Requirements for Toxicology 5.1 Forensic toxicology methods are typically categorized as screening, qualitative confirmation/identification, or quantitative. Measurement traceability shall be established by the forensic toxicology laboratory through the use of one or more metrologically-prepared calibrators.10 Additionally, a laboratory may choose to use controls that are metrologically-prepared. 5.2 The following (5.2.1 and 5.2.2) measurement traceability requirements shall be followed by forensic toxicology laboratories for their analytical methods. 5.2.1 Measurement traceability shall be established during method validation and routine analysis of cases for: a. all screening procedures with an established decision point concentration; NOTE See 5.2.2 for immunoassay-based screening procedures b. qualitative confirmation/identification concentration;

methods

with

established

decision

point

c. quantitative methods. 5.2.2 Measurement traceability for immunoassay-based screening procedures shall be established during method validation or during routine analysis of cases. Manufacturer kits used in immunoassay-based screening procedures may lack measurement traceability; therefore,

laboratories may establish measurement traceability through use of CRMs while initially validating the method and confirming traceability through use of in-house prepared controls. Calibrators may be undiluted CRM(s) or calibrators prepared using appropriately calibrated equipment and CRMs, or reference material(s) (RM) shown to be fit for purpose, as defined in 4.2.4. 10

ANSI/ASB Standard 017, 1st Ed. 2018

6 Equipment 6.1 General The equipment listed in Section 6.2 is commonly used in forensic toxicology laboratories and shall be calibrated by appropriately accredited calibration service suppliers that meet those requirements in Section 4.2.2. Documentation of the accredited calibration service suppliers shall be maintained by the forensic toxicology laboratory. Equipment shall be calibrated prior to use, and the laboratory shall have a procedure that includes the frequency of calibration and acceptability/tolerance specifications. Calibration documentation shall include the date the calibration is performed, the calibration status and the date the next calibration is due. Equipment shall be calibrated at a point or within a range consistent with typical use. The forensic toxicology laboratory shall evaluate whether intermediate checks of the calibration status are necessary based on, but not limited to, the frequency of use, work volume, occurrence of unexpected shutdown and equipment maintenance. If intermediate checks are performed, the policy and procedure shall include the frequency and specifications for intermediate checks and actions to be taken when the specifications are not met. Intermediate checks shall be carried out using calibrated equipment (e.g., mass reference standards, equipment used to monitor environmental conditions). 6.2 6.2.1

Calibration of Analytical Equipment Analytical Balances

Analytical balances shall be calibrated at least annually by an appropriately accredited calibration service supplier. 6.2.2

Reference Standards

Reference standards (e.g., calipers, rulers, mass reference standards) shall be calibrated at least once every three years by an appropriately accredited calibration service supplier. Any adjustments of reference standards shall only be conducted by an accredited calibration service supplier, and the reference standards shall be calibrated before and after any adjustment. Reference standards used to verify the accuracy of equipment shall be dedicated for this purpose, unless the forensic toxicology laboratory has demonstrated that their integrity as reference standards are maintained. 6.2.3

Volumetric Glassware

Class A volumetric glassware shall be used for the preparation of calibrators and shall be calibrated by an accredited calibration service supplier prior to use. Volumetric glassware used in the preparation of calibrators shall be dedicated for this purpose, and shall be maintained and stored as to protect its integrity. After initial calibration, scheduled recalibration shall recur at least once every ten years by an appropriately accredited calibration service supplier. 6.2.4

Pipettes, Diluters, and Syringes

All pipettes, pipette diluters, automatic diluters, and syringes used for the preparation of calibrator solutions that require measurement traceability or in sample preparation (e.g. sample aliquoting and

ANSI/ASB Standard 017, 1st Ed. 2018

other steps that affect overall measurement uncertainty) shall be calibrated at least annually by an appropriately accredited calibration service supplier. Autosampler syringes used for sample introduction to analytical instrumentation (e.g., gas chromatograph, liquid chromatograph, or immunoassay) do not require calibration. 6.2.5

Thermometers

Thermometers used to verify proper storage of certified reference materials shall be calibrated at least every two years by an appropriately accredited calibration service supplier. Other thermometers that do not significantly affect the accuracy and validity of the test result (e.g., thermometers used in water baths and heat blocks) do not require calibration to establish measurement traceability. 6.2.6

Breath Alcohol Calibration Equipment

Simulator thermometers, multi-meters and barometers, as applicable, shall be calibrated at least every two years by an appropriately accredited calibration service supplier, as defined in 4.2.2. Sections 6.2.1 to 6.2.5 apply to equipment used in preparation of breath alcohol reference materials used in a breath alcohol calibration method. 6.3

Other Equipment

General laboratory equipment used during sample preparation (e.g., centrifuges, rotators, shakers, water baths, evaporators, extraction manifolds, and heating blocks)that does not significantly affect the accuracy and validity of the test result, do not require calibration to establish measurement traceability. A forensic toxicology laboratory may choose to use calibration or verification as a maintenance procedure to ensure proper functioning of the equipment.

7 Conformance Documentation to verify conformance with the above requirements shall be maintained by the forensic toxicology laboratory for a minimum of five years after expiration and shall be made available to auditors upon request.

ANSI/ASB Standard 017, 1st Ed. 2018

Annex A (informative) Bibliography 1] ASCLD/LAB Guidance on Measurement Traceability – Measurement Assurance www.ascld-lab.org/

2] ASCLD/LAB Policy on Measurement Traceability www.ascld-lab.org/ 3] ASTM International E542-01 Standard Practice for Calibration of Laboratory Volumetric Apparatus www.astm.org

4] Eurachem Terminology in Analytical Measurement – Introduction to VIM 3 https://www.eurachem.org/index.php/publications/guides/terminology-in-analyticalmeasurement

5] The National Institute of Standards and Technology (NIST) definition of “internal measurement assurance program” www.nist.gov/traceability/index.cfm

6] The National Institute of Standards and Technology (NIST) Sample Procedure for Method Validation https://www.nist.gov/document/sapmethodvalidation2016-12-21doc

7] The National Institute of Standards and Technology (NIST) Important Technical Guidance on Glassware https://www.nist.gov/sites/default/files/documents/2017/05/09/H-008.pdf

8] International Organization for Standardization (ISO). ISO/IEC 9000:2015 Quality Management Systems—Fundamentals and Vocabulary (Geneva, Switzerland) ISO documents available for purchase at http://www.iso.org/iso/home/store/catalogue_ics.htm or from other authorized distributors

9] International Organization for Standardization (ISO). ISO/IEC 17000:2004 Conformity Assessment—Vocabulary and General Principles (Geneva, Switzerland) ISO documents available for purchase at http://www.iso.org/iso/home/store/catalogue_ics.htm or from other authorized distributors

10] International Organization for Standardization (ISO), ISO Guide 33: 2015 Reference Materials – Good Practice in Using Reference Materials (Geneva, Switzerland) ISO documents available for purchase at http://www.iso.org/iso/home/store/catalogue_ics.htm or from other authorized distributors

11] International Organization for Standardization (ISO), ISO Guide 30: 2015 Reference Materials – Selected Terms and Definitions (Geneva, Switzerland) ISO documents available for purchase at http://www.iso.org/iso/home/store/catalogue_ics.htm or from other authorized distributors

12] International Bureau of Weights and Measures (BIPM) Key Comparison Database (KCDB), Appendix C http://kcdb.bipm.org/appendixC/

ANSI/ASB Standard 017, 1st Ed. 2018

13] National Commission on Forensic Science, Defining Forensic Science and Related Terms https://www.justice.gov/ncfs/file/786571/download

14] Scientific Working Group on Forensic Toxicology (SWGTOX) Standard on the Accreditation of Forensic Toxicology Laboratories (Revision 1), February 22, 2014 http://www.swgtox.org/documents/SWGTOX_Accreditation.pdf

Academy Standards Board 410 North 21st Street Colorado Springs, CO 80904 http://asb.aafs.org/

Vacutainer® Evacuated Blood Collection System For In Vitro Diagnostic Use

INTENDED USE

BD Vacutainer® Tubes, Needles and Holders are used together as a system for the collection of venous blood. BD Vacutainer® Tubes are used to transport and process blood for testing serum, plasma or whole blood in the clinical laboratory.

PRODUCT DESCRIPTION

BD Vacutainer® Tubes are evacuated tubes with color-coded (see table below) conventional stoppers or BD Hemogard™ Closures. BD Vacutainer® Plus Tubes are plastic tubes. Most tube types contain additives in varying concentrations dependent upon the amount of vacuum and the required additive to blood ratio for the tube. See each shelf package or case label for specific additive quantity and approximate draw volume. Additive choice depends on the analytic test method. It is specified by the manufacturer of the test reagents and/or instrument on which the test is performed. Tube interiors are sterile. Tube stoppers are lubricated with silicone or glycerin (see individual shelf package or case label) to facilitate stopper insertion. BD Vacutainer® Tube Closure Color Code Cross Reference*

ADDITIVE GROUP/ADDITIVE Gel Separation Tubes BD SST™ Tubes with Gel and Clot Activator BD PST™ Tubes with Gel and Lithium HeparinN 1 BD SST™ ll Advance Tubes with Gel and Clot Activator** BD PST™ ll Tubes with Gel and Lithium HeparinN 1** Non-Additive Tubes Silicone Coated Uncoated No Additive2 Serum Tubes with Additives Thrombin3** Plus Serum/CAT with Clot Activator Thrombin3, Soybean Trypsin Inhibitor** Sodium Fluoride Whole Blood/Plasma Tubes K2EDTA or K3EDTA K2EDTA Citrate/CTAD (Coagulation) Citrate (ESR) Sodium Fluoride/Sodium EDTA Sodium Fluoride/Potassium Oxalate HeparinN 1 Acid Citrate Dextrose (ACD) Sodium Polyanethol Sulfonate (SPS) Trace Element Tubes Silicone Coated**, HeparinN 1**, K2EDTA or with clot activator Lead Tubes HeparinN 1 K2EDTA

CONVENTIONAL CLOSURE

BD HEMOGARD™ CLOSURE

Red/Gray Green/Gray N/A N/A

Gold Light Green Gold Light Green

Red Red Cherry Red/Light Gray

Red** Pink** Clear

N/A Red N/A Gray**

Orange Red Royal Blue Gray

Lavender*** Pink*** Light Blue Black Gray** Gray Green*** Yellow Yellow

Lavender*** Pink*** Light Blue or Clear Black Gray Gray Green*** N/A N/A

N/A

Royal Blue

N/A N/A

Tan** Tan***

BD Vacutainer® Blood Collection Needles are single-use, double-ended, medical grade stainless steel needles. They have a threaded hub that fits into the threads of all BD Vacutainer® Holders. The venipuncture end of the needle has a point specially designed to enter the skin easily during venipuncture. The needle is lubricated with silicone. The needles are available in 1 and 1-1/2 inch lengths in 20, 21 and 22 gauge*; blood collection sets are available in 3/4 inch lengths in 21, 23 and 25 gauge, BD Vacutainer® Passive Shielding Blood Collection Needles in 1 inch and 21 and 22 gauge and BD Vacutainer® Eclipse™ in 1-1/4 inch and 21 and 22 gauge. Needle size and lot number are printed on each individual needle assembly.

LIMITATIONS OF SYSTEM

The quantity of blood drawn varies with altitude, ambient temperature, barometric pressure, tube age, venous pressure, and filling technique. Tubes with draw volume smaller than the apparent dimensions indicated (partial draw tubes), may fill more slowly than tubes of the same size with greater draw volume. For those tubes subjected to centrifugation to generate plasma or serum for testing, standard processing conditions do not necessarily completely sediment all cells, whether or not barrier gel is present. Cell-based metabolism, as well as natural degradation ex vivo, can continue to affect serum/plasma analyte concentrations/activities after centrifugation. Analyte stability should be evaluated for the storage containers and conditions of each laboratory. BD Vacutainer® PST™ Plus Tubes, BD Vacutainer® PST™ Glass Tubes and BD Vacutainer® PST™ II Tubes are not recommended for the collection of samples for blood banking procedures. BD Vacutainer® SST™ Plus Tubes, BD Vacutainer® SST™ Glass Tubes and BD Vacutainer® SST™ II Advance Tubes are not recommended for immunohematology testing. BD Vacutainer® SST™ Plus Tubes and BD Vacutainer® SST™ II Advance Tubes can be used for certain TDM assays. U.S. customers please contact BD Technical Services Department at 1-800-631-0174 for details, outside the U.S. contact your local representative. Do not use BD Vacutainer® Tubes containing lithium heparin for lithium measurement. For coagulation tests, if patient hematocrit is above 55%, the final citrate concentration in the specimen should be adjusted.

PRECAUTIONS

BD Vacutainer® Serum Tubes

BD Vacutainer® Tubes for Lead and Trace Element Tests

Tubes for lead testing and other trace elements are labeled specifically for these purposes on the shelf package and case label. Use only appropriately labeled tubes for these tests. The tubes for lead and trace element testing have been tested by extraction of the stoppered tube for 4 hours. Inductively Coupled Plasma-Mass Spectrometry (ICP-MS) testing yielded results below these concentration limits: BD Vacutainer® Trace Element Tubes Contamination Upper Limits Analyte Glass µg/L Plus µg/L Analyte Glass µg/L Plus µg/L Antimony 0.8 -* Lead 2.5 0.3 Arsenic 1.0 0.2 Magnesium 60 40 Cadmium 0.6 0.1 Manganese 1.5 1.5 Calcium 400 150 Mercury** - 3.0 Chromium 0.9 0.5 Selenium - 0.6 Copper 8.0 5.0 Zinc 40 40 Iron 60 25 *BD Vacutainer® Trace Element Plus Tubes should not be used for antimony testing. Water extraction analyzed by **Cold Vapor, all others ICP-MS

Plus* µg/L 2.5

0.1N nitric acid extraction analyzed by ICP-MS *Also suitable for routine hematology testing

BD Vacutainer® SST™ Tubes / BD Vacutainer® SST™ II Advance Tubes*

The interior of the tube wall is coated with micronized silica particles to accelerate clotting. A barrier polymer is present at the tube bottom. The density of this material causes it to move upward during centrifugation to the serum-clot interface, where it forms a barrier separating serum from fibrin and cells. Serum may be aspirated directly from the collection tube, eliminating the need for transfer to another container. A silicone coating on the inner tube wall reduces adherence of red cells to tube walls. See Limitations of System, Precautions, Specimen Collection and Handling Sections. *May not be available in the U.S.

BD Vacutainer® PST™ Tubes / BD Vacutainer® PST™ II Tubes*

The interior of the tube wall is coated with lithium heparin to inhibit clotting. Heparin activates antithrombins, thus blocking the coagulation cascade and producing a whole blood/plasma sample instead of clotted blood and serum. A barrier polymer is present at the tube bottom. The density of this material causes it to move upward during centrifugation to the plasma-cell interface, where it forms a barrier separating plasma from cells. Plasma may be aspirated directly from the collection tube, eliminating the need for transfer to another container. See Limitations of System, Precautions, Specimen Collection and Handling Sections. *May not be available in the U.S.

BD Vacutainer® Tubes for Blood Banking

BD Vacutainer® Plus Serum Tubes, BD Vacutainer® Plus K2EDTA Tubes, BD Vacutainer® Glass Serum Tubes, and BD Vacutainer® Glass K3EDTA Tubes, may be used for routine immunohematology testing such as ABO grouping, Rh typing, antibody screening, red cell phenotyping and DAT testing, and blood donor screening for infectious disease such as Syphilis Ab, anti-HIV, anti-HTLV, anti-HCV, anti-HBc, and HBsAg. The performance characteristics of these tubes have not been established for immunohematology testing and infectious disease testing in general; therefore, users must validate the use of these tubes for their specific assay-instrument/reagent system combinations and specimen storage conditions. BD Vacutainer® SST™ Plus Tubes, BD Vacutainer® SST™ Glass Tubes and BD Vacutainer® SST™ II Advance Tubes may be used for routine blood donor screening and diagnostic testing of serum for infectious disease such as ToRCH, Syphilis Ab, anti-HIV, anti-HTLV, anti-HCV, anti-HBc, and HBsAg. The performance characteristics of these tubes have not been established for infectious disease testing in general; therefore, users must validate the use of these tubes for their specific assay-instrument/reagent system combinations and specimen storage conditions.

BD Vacutainer® CTAD Tubes

BD Vacutainer® Blood Collection Needles

BD Vacutainer® Luer Adapter, BD Vacutainer® Luer-Lok™ Access Device, and BD Vacutainer® Blood Transfer Device are products designed with a luer fitting in place of the venipuncture end of the needle. The BD Vacutainer® Luer Adapter is a male slip-luer fitting opposing a multiple sample non-patient (NP) needle. It is designed to be used with a BD Vacutainer® Holder. The BD Vacutainer® Luer-Lok™ Access Device is a holder with an integrated multiple sample NP needle and threaded male luer fitting. The BD Vacutainer® Blood Transfer Device is a holder with an integrated multiple sample NP needle and locking female luer fitting. Products have a latex free sleeve covering the NP needle that prevents leakage of blood into the holder during blood collection. The tubes slide into the holder and are pushed onto the NP needle, allowing the vacuum in the tube to draw blood to a predetermined level.

BD Vacutainer® Plus Serum Tubes / CAT Tubes are coated with silicone and micronized silica particles to accelerate clotting. Particles in the white film on the interior surface activate clotting when tubes are mixed by inversions. A silicone coating on the walls of most serum tubes reduces adherence of red cells to tube walls. See Limitations of System, Precautions, Specimen Collection and Handling Sections.

BD Vacutainer® Tubes for Lead Testing Contamination Upper Limits Glass µg/L 10

The tube component is comprised of two plastic tubes assembled together to maintain the draw volume and liquid additive. The tube contains buffered sodium citrate additive. All tube configurations are full draw and utilize BD Hemogard™ Closures. The fill indicator on the tube represents the minimum volume of blood required for appropriate analysis. See Limitations of System, Precautions, Specimen Collection and Handling Sections. The product performance has been compared to the 4.5mL glass tube for routine coagulation assays on a variety of donor populations with clinically equivalent results obtained. Note: all studies were performed on donors with hematocrits between 25 and 55%.

*Not available in the U.S.

*Closure color may vary for specific reorder numbers. **May not be available in the U.S. 1 HeparinN source is porcine. Devices labeled with a superscript letter ‘N’ indicate that the device contains heparin which has been certified to meet the requirements of USP Heparin Monograph October 1, 2009. 2May only be used as a discard tube or as a secondary specimen collection tube. 3Thrombin source is bovine. ***BD Vacutainer® EDTA tubes (Lavender, Pink and Tan Top tubes) and Lithium Heparin tubes (Green Top tubes) are not recommended for use with Magellan Diagnostics LeadCare® assays, employing the Anodic Stripping Voltammetry (ASV) methodology, or any other assay employing ASV methodology.

Analyte Lead

BD Vacutainer® Plus Citrate Tubes

The CTAD tube is used for the collection and transport of specimens for hemostasis testing. The CTAD solution is a mixture of sodium citrate, theophylline, adenosine and dipyridamole. The purpose of the additive is to anticoagulate the specimen and to minimize in vitro platelet activation. See Precautions, Specimen Collection and Handling Sections.

1. Storage of glass tubes containing blood at or below 0ºC may result in tube breakage. 2. Do not remove conventional rubber stoppers by rolling with thumb. Remove stoppers with a twist and pull motion. 3. Do not use tubes or needles if foreign matter is present. 4. The paper label covering the connection of the needle shields will tear when the needle is opened. Do not use needle if label has been torn before venipuncture. 5. CTAD tubes must be protected from artificial and natural light during storage. Accumulated light exposure in excess of 12 hours can cause additive inactivation. 6. Separation of serum or plasma from the cells should take place within 2 hours of collection to prevent erroneous test results unless conclusive evidence indicates that longer contact times do not contribute to result error. 7. Do not use luer adapters for connection to indwelling catheters/ports; use a BD Vacutainer® Luer-Lok™ Access Device instead. 8. BD Vacutainer® EDTA tubes (Lavender, Pink and Tan Top tubes) and Lithium Heparin tubes (Green Top tubes) are not recommended for use with Magellan Diagnostics LeadCare® assays, employing the Anodic Stripping Voltammetry (ASV) methodology, or any other assay employing ASV methodology.

CAUTION:

1. Practice Universal Precautions. Use gloves, gowns, eye protection, other personal protective equipment, and engineering controls to protect from blood splatter, blood leakage, and potential exposure to bloodborne pathogens. 2. All glass has the potential for breakage. Examine all glass for potential damage in transit before use, and take precautionary measures during handling. 3. Handle all biologic samples and blood collection “sharps” (lancets, needles, luer adapters, and blood collection sets) according to the policies and procedures of your facility. Obtain appropriate medical attention in the event of any exposure to biologic samples (for example, through a puncture injury), since they may transmit viral hepatitis, HIV (AIDS), or other infectious diseases. Utilize any built-inused needle protector, if the blood collection device provides one. BD does not recommend reshielding used needles. However, the policies and procedures of your facility may differ and must always be followed. 4. Discard all blood collection “sharps” in biohazard containers approved for their disposal. 5. Transferring a sample collected using syringe and needle to a tube is not recommended. Additional manipulation of sharps, such as hollow bore needles, increases the potential for needlestick injury. 6. Transferring samples from syringe to an evacuated tube using a non-sharps device should be performed with caution for the reasons described below. • Depressing the syringe plunger during transfer can create a positive pressure, forcefully displacing the stopper and sample, causing splatter and potential blood exposure. • Using a syringe for blood transfer may also cause over or under filling of tubes, resulting in an incorrect blood-to-additive ratio and potentially incorrect analytic results. • Evacuated tubes are designed to draw the volume indicated. Filling is complete when vacuum no longer continues to draw, though some tubes may partially fill due to plunger resistance when filled from a syringe. The laboratory should be consulted regarding the use of these samples. 7. If blood is collected through an intravenous (I.V.) line, ensure that line has been cleared of I.V. solution before beginning to fill blood collection tubes. This is critical to avoid erroneous laboratory data from I.V. fluid contamination. 8. Overfilling or under filling of tubes will result in an incorrect blood-to-additive ratio and may lead to incorrect analytic results or poor product performance. 9. Endotoxin not controlled. Blood and blood components collected and processed in the tube are not intended for infusion or introduction into the human body.

STORAGE

Store tubes at 4-25ºC (39-77ºF), unless otherwise noted on the package label. All liquid preservatives and anticoagulants are clear and colorless, except CTAD which is yellow. Do not use if they are discolored or contain precipitates. Powdered additives such as heparin and thrombin are white; fluoride and fluoride/oxalate may be pale pink. Do not use if color has changed. EDTA spray coated additives may have a white to slightly yellow appearance; this does not affect the performance of the EDTA additive. Do not use tubes after their expiration date. Tubes expire on the last day of the month and year indicated.

SPECIMEN COLLECTION AND HANDLING

READ THIS ENTIRE CIRCULAR BEFORE PERFORMING VENIPUNCTURE.

Required Equipment Not Provided for Specimen Collection

1. Practice Universal Precautions. Use gloves, eye protection, coats or gowns, and other appropriate apparel for protection from exposure to bloodborne pathogens or other potentially infectious materials. 2. Any BD Vacutainer® Needle Holders of the standard size may be used with 13 or 16 mm diameter tubes. A pediatric tube adapter should be used to modify the standard holder to fit the 10.25 mm diameter tubes. 3. Alcohol swab for cleansing site. If additional tubes requiring sterile collections, such as blood cultures, are filled from the same venipuncture, use tincture of iodine or suitable alternative for cleansing. Follow the laboratory policy for sterile sample collection for site preparation and tube handling instructions. Do not use alcohol based cleansing materials when samples are to be used for blood alcohol testing. 4. Dry, clean disposable gauze. 5. Tourniquet. 6. Needle disposal container for used needle or needle/holder combination.

Required Equipment Not Provided for Specimen Processing

1. Disposable transfer pipets if direct sampling from the instrument is not used or if specimen is stored separately. 2. Centrifuge capable of generating the recommended RCF at the tube bottom. A horizontal centrifuge head is preferred for barrier quality with gel tubes and to obtain platelet poor plasma for coagulation studies. 3. Gloves and other personal protective equipment as necessary for protection from exposure to bloodborne pathogens.

Preparation for Specimen Collection

Centrifugation

Be sure the following materials are readily accessible before performing venipuncture: 1. See Required Equipment Not Provided for Specimen Collection above. 2. All necessary tubes, identified for size, draw, and additive. 3. Labels for positive patient identification of samples.

Recommended Order of Draw

1. Tubes for sterile samples. 2. Tubes for coagulation studies (e.g., citrate). 3. BD SST™, BD SST™ II Advance and Serum Tubes. 4. Tubes with other additives (e.g., heparin, EDTA, fluoride). When using a winged blood collection set for venipuncture and a coagulation (citrate) tube is the first specimen tube to be drawn, a discard tube should be used prior to the first specimen collection. The discard tube must be used to fill the blood collection set tubing’s “dead space” with blood. The discard tube does not need to be filled completely. This step will ensure maintenance of the proper bloodadditive-ratio of the specimen. The discard tube should be a non additive or coagulation tube. BD Vacutainer® SST™ Tubes, BD Vacutainer® SST™ II Advance Tubes and BD Vacutainer® Plus Serum Tubes / CAT Tubes contain particulate clot activators and are considered additive tubes. Therefore, Plus Serum Tubes are not to be used as discard tubes before drawing citrate tubes for coagulation studies.

Prevention of Backflow

Since some evacuated blood collection tubes contain chemical additives, it is important to avoid possible backflow from the tube, with the possibility of adverse patient reactions. To guard against backflow, observe the following precautions: 1. Place patient’s arm in a downward position. 2. Hold tube with the stopper uppermost. 3. Release tourniquet as soon as blood starts to flow into tube. 4. Make sure tube additives do not touch stopper or end of the needle during venipuncture.

Venipuncture Technique and Specimen Collection General Instructions

WEAR GLOVES DURING VENIPUNCTURE AND WHEN HANDLING BLOOD COLLECTION TUBES TO MINIMIZE EXPOSURE HAZARD. 1. Select tube or tubes appropriate for required specimen. For sterile collections, see the specific instructions noted in the collection device product circular. 2. Assemble needle in holder. Be sure needle is firmly seated to ensure needle does not unthread during use. 3. Gently tap tubes containing additives to dislodge any material that may be adhering to the stopper. 4. Place tube into holder. Note: Do not puncture stopper. 5. Select site for venipuncture. 6. Apply tourniquet. Prepare venipuncture site with an appropriate antiseptic. DO NOT PALPATE VENIPUNCTURE AREA AFTER CLEANSING. 7. Place patient’s arm in a downward position. 8. Remove needle shield. Perform venipuncture WITH ARM DOWNWARD AND TUBE STOPPER UPPER-MOST. 9. Center tubes in holder when penetrating the stopper to prevent sidewall penetration and resultant premature vacuum loss. Push tube onto needle, puncturing stopper diaphragm. 10. REMOVE TOURNIQUET AS SOON AS BLOOD APPEARS IN TUBE. DO NOT ALLOW CONTENTS OF TUBE TO CONTACT THE STOPPER OR END OF THE NEEDLE DURING PROCEDURE. Note: Blood may occasionally leak from the needle sleeve. Practice Universal Precautions to minimize exposure hazard. If no blood flows into tube or if blood ceases to flow before an adequate specimen is collected, the following steps are suggested to complete satisfactory collection: a. Push tube forward until tube stopper has been penetrated. If necessary, hold in place to ensure complete vacuum draw. b. Confirm correct position of needle cannula in vein. c. REMOVE TUBE AND PLACE NEW TUBE INTO THE HOLDER. d. If second tube does not draw, remove needle and discard. Repeat procedure from Step 1. 11. When first tube has filled to its stated volume and blood flow ceases, remove it from holder. 12. Place succeeding tubes in holder, puncturing diaphragm to begin flow. See Recommended Order of Draw. 13. While each successive tube is filling, turn the filled tube upside-down and return it to upright position. This is one complete inversion. For proper additive performance, invert BD SST™ Tubes or Plus Serum Tubes 5 times. Invert BD CAT Tubes 5-6 times. Invert BD SST™ II Advance Tubes 6 times. Invert Citrate or CTAD tubes 3-4 times. Invert all other filled additive tubes 8-10 times. Do not shake. Vigorous mixing may cause foaming or hemolysis. Insufficient mixing or delayed mixing in serum tubes may result in delayed clotting and incorrect test results. In tubes with anticoagulants, inadequate mixing may result in platelet clumping, clotting and/or incorrect test results. 14. As soon as blood stops flowing in the last tube, remove tube from holder, remove needle from vein, applying pressure to puncture site with dry sterile swab until bleeding stops. 15. Once clotting has occurred, apply bandage if desired. 16. After venipuncture, the top of the stopper may contain residual blood. Take proper precautions when handling tubes to avoid contact with this blood. 17. Dispose of needle and holder per your facility’s policy and guidelines.

Clotting Instructions

Allow blood to clot thoroughly before centrifugation. The following table gives the recommended minimum clotting times for specific tube types or additives. Minimum Clotting Time Recommendations PRODUCT Serum / CAT Tubes BD SST™ / BD SST™ II Advance Tubes Thrombin Tubes

TIME (min) 60 30 5

Recommended times are based upon an intact clotting process. Patients with abnormal clotting due to disease, or those receiving anticoagulant therapy require more time for complete clot formation.

Caution: Do not centrifuge glass tubes at forces above 2200 RCF in a horizontal head (swinging bucket) centrifuge as breakage may occur. Glass tubes may break if centrifuged above 1300 RCF in fixed angle centrifuge heads. BD Vacutainer® Plus Tubes will withstand up to 10,000 RCF in a balanced centrifuge. Always use appropriate carriers or inserts. Use of tubes with cracks or chips or excessive centrifugation speed may cause tube breakage, with release of sample, droplets, and an aerosol into the centrifuge bowl. Release of these potentially hazardous materials can be avoided by using specially designed sealed containers in which tubes are held during centrifugation. Centrifuge carriers and inserts should be of the size specific to the tubes used. Use of carriers too large or too small for the tube may result in breakage. RCF is related to centrifuge speed setting (rpm) using the following equation: where “r”, expressed in cm, is the radial distance from the center of the centrifuge head to the bottom of the tube. The following table gives recommended centrifuge RCF and time: Centrifugation RCF and Time* PRODUCT BD SST™ and BD PST™ Tubes (glass) BD SST™ Plus and BD PST™ Plus Tubes - 13mm BD SST™ Plus and BD PST™ Plus Tubes - 16mm BD SST™ Transport Tubes BD SST™ II Advance and BD PST™ II Tubes All Non-gel Tubes Citrate Tubes

RCF (g) 1000 - 1300 1100 - 1300 1000 - 1300 1100 - 1300 1300 – 2000 ≤ 1300 1500**

TIME (min) 10 10 10 15 10 10 15**

15 minutes for all gel tubes in a fixed angle centrifuge RCF = Relative Centrifuge Force, g’s *Use of alternate centrifugation conditions (e.g., higher RCF and shorter spin time) may also provide acceptable performance; this should be evaluated and validated by the laboratory. **Unless otherwise specified on product labeling. Citrate tubes should be centrifuged at a speed and time to consistently produce platelet-poor plasma (platelet count <10,000/µL) per CLSI Guidelines.

Ensure that tubes are properly seated in the centrifuge carrier. Incomplete seating could result in separation of the BD Hemogard™ Closures from the tube or extension of the tube above the carrier. Tubes extending above the carrier could catch on centrifuge head, resulting in breakage. Balance tubes to minimize the chance of glass breakage. Match tubes to tubes of the same fill level, glass tubes to glass, tubes with BD Hemogard™ Closures to others with the Closure, gel tubes to gel tubes, BD Vacutainer® Plus Tubes with Plus Tubes, and tube size to tube size. Always allow centrifuge to come to a complete stop before attempting to remove tubes. When centrifuge head has stopped, open the lid and examine for possible broken tubes. If breakage is indicated, use mechanical device such as forceps or hemostat to remove tubes. Caution: Do not remove broken tubes by hand. See centrifuge instruction manual for disinfection instructions.

Barrier Information

The flow properties of the barrier material are temperature-related. Flow may be impeded if chilled before or during centrifugation. To optimize flow and prevent heating during centrifugation, set refrigerated centrifuges to 25ºC (77ºF). Tubes should not be re-centrifuged once barrier has formed. Barriers are more stable when tubes are spun in centrifuges with horizontal (swinging bucket) heads than those with fixed angle heads. Separated serum or plasma is ready for use. The tubes may be placed directly on the instrument carrier or serum/plasma may be pipetted into an analyzer cup. Some instruments can sample directly from a separator tube with the stopper in place. Follow the instrument manufacturer’s instructions.

ANALYTIC EQUIVALENCY

Evaluations of BD Vacutainer® Tubes have been performed for an array of analytes over a variety of test methods and time periods. BD Life Sciences - Preanalytical Systems is available to answer questions regarding these studies. Please contact them to obtain references and technical reports on these evaluations and any other information regarding the use of BD Vacutainer® Tubes with your instrument/reagent system.

TECHNICAL SERVICES In the U.S. please contact:

Technical Services

BD Life Sciences - Preanalytical Systems 1 Becton Drive Franklin Lakes, NJ 07417 1-800-631-0174 www.bd.com/vacutainer/referencematerial Outside the U.S. please contact your local BD representative. Whenever changing any manufacturer’s blood collection tube type, size, handling, processing or storage condition for a particular laboratory assay, the laboratory personnel should review the tube manufacturer’s data and their own data to establish/verify the reference range for a specific instrument/reagent system. Based on such information, the laboratory can then decide if a change is appropriate.

REFERENCES

CLSI Document H1-A6. Tubes and Additives for Venous and Capillary Blood Specimen Collection; approved standard, 6th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2010. CLSI Document H3-A6. Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; approved standard, 6th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2007. Landt M, Smith CH and Hortin GL. Evaluation of evacuated blood-collection tubes: Effects of three types of polymeric separators on therapeutic drug-monitoring specimens. Clin Chem 1993; 39:1712-1717. Dasgupta A, Dean R, Saldana S, Kinnaman G and McLawhon RW. Absorption of therapeutic drugs by barrier gels in serum separator blood collection tubes. Am J Clin Path 1994; 101:456-461. Yawn BP, Loge C and Dale J. Prothombin time, one tube or two? Am J Clin Path 1996; 105:794-97. Gottfried, EL and Adachi, MM. Prothrombin time (PT) and activated partial prothrombin time (APTT) can be performed on the first tube. Am J Clin Path 1997; 107:681-683. CLSI Document H21-A5. Collection, Transport, and Processing of Blood Specimens for Testing Plasma-Based Coagulation Assays and Molecular Hemostasis Assays; approved guideline, 5th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2008. CLSI Document H18-A4. Procedures for the Handling and Processing of Blood Specimens for Common Laboratory Tests; approved guideline, 4th ed. Wayne, PA: Clinical and Laboratory Standards Institute; 2010.

Instructions for Removal of BD Hemogard™ Closure

1. Grasp the BD Vacutainer® Tube with one hand, placing the thumb under the BD Hemogard™ Closure. (For added stability, place arm on solid surface). With the other hand, twist the BD Hemogard™ Closure while simultaneously pushing up with the thumb of the other hand ONLY UNTIL THE TUBE STOPPER IS LOOSENED. 2. Move thumb away before lifting closure. DO NOT use thumb to push closure off tube. Caution: Any glass tube has the potential to crack or break. If the tube contains blood, an exposure hazard exists. To help prevent injury during closure removal, it is important that the thumb used to push upward on the closure be removed from contact with the tube as soon as the BD Hemogard™ Closure is loosened. 3. Lift closure off tube. In the unlikely event of the plastic shield separating from the rubber stopper, DO NOT REASSEMBLE CLOSURE. Carefully remove rubber stopper from tube.

Instructions for Reinsertion of BD Hemogard™ Closure

1. Replace closure over tube. 2. Twist and push down firmly until stopper is fully reseated. Complete reinsertion of the stopper is necessary for the closure to remain securely on the tube during handling.

Symbol Key Authorized Representative

Do Not Reuse

Manufacturer

Temperature Limitation

This End Up

Batch Code

Do Not Use If Package Is Damaged

Recyclable

Lower Limit of Temperature

Use By

Biological Risk

For IVD Performance Evaluation Only

Sterile

Fragile, Handle With Care

Method of Sterilization Using Ethylene Oxide

Catalog Number Caution Consult Instructions For Use Date of Manufacture

In Vitro Diagnostic Medical Device Keep Away from Sunlight

Method of Sterilization Using Irradiation Method of Sterilization Using Steam or Dry Heat

Becton, Dickinson and Company, 1 Becton Drive, Franklin Lakes, NJ 07417-1885 USA Becton, Dickinson and Company, Belliver Industrial Estate, Belliver Way, Roborough, Plymouth PL6 7BP United Kingdom 2018 BD. BD, the BD Logo and all other trademarks are property of Becton, Dickinson and Company © Made in USA and UK

Upper Limit of Temperature

CAUTION! CTAD Tubes must be protected from artificial and natural light during storage. Preliminary data indicate unacceptable photoinactivation of dipyridamole after 48 hours exposure to fluorescent light. 03/2018 500030670

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Voir Dire Speaker:

Sean Darvishi 2200 North Loop West Ste 304 Houston, TX 77018-1754 (832) 766-4019 Phone (713) 583-2896 Fax sean@defendmetexas.com email www.defendmetexas.com website

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

Voir Dire in DWI Cases

Voir Dire is quite possibly the most important stage of a trial. With a great case and a bad

jury, things can go South quickly. Figuring out what type of jurors you want, and hone in on creative methods to get some good answers out of them. So how do you do that? Well, it requires you to work outside of the box. The panel will likely be bored as hell after listening to the Judge and the government’s prosecution which consistently across the State of Texas continues to be bland and a bit vanilla. I prefer when there is a break in between the state’s presentation and mine, even if brief. High energy, I believe is one of the most important things you can bring. I almost always start with a couple memes. Lets be real, its 2021, and people are very familiar with them at this point. I talk to the jury about telling the truth and not being afraid to do so. I say this is the time to tell me you think my tie choice is ugly, and that because you think that, you question my defense of my client. Anything will work that is stupid enough to get a giggle. Laughing truly is a medicine that help more than you could imagine. It relaxes the panel, makes them trust you, and you tend to enjoy yourself.

Next, I show a meme or picture from everyone’s favorite movie: My Cousin Vinny. I reveal

to them that I watch this movie before every single trial and that I’ve seen it over 100 times and its worth a trip to the 5 dollar dvd bin at their local Walmart, target or best buy. And I basically use this picture to explain how things work. How, besides how quick the trial was, everything from that movie is pretty spot on. That gets me into explaining how strikes work and how the best 12‐18 people better get talking or else they get to hang out with me, the prosecutor and the Judge for a few days. It is important to be observant at this point and time. You’ll see who truly doesn’t want to be on the jury but most importantly you’ll see who really wants to be on a jury.

Yes, this is generally your retiree who is just excited to have something to do. Look, sometimes that can be the right juror for a case, but 9 times out of 10 you don’t want them. So this is who you may choose to engage in order for them to provide an answer that may get them off the jury.

Next, we address something that I learned from Doug Murphy. That is to tell the jury that

you are not there in opposition of DWI law. Sometimes jurors walk into this situation thinking we are here to bring down the “man” and we are actively fighting the law. Typically I will make that statement and explain that we agree with the law, and the only reason we are here is because we have a genuine dispute of fact and that’s why we need a jury, aka the finder of fact. I usually turn to the prosecutor and make a hand gesture to them which they typically nod in approval. This shows the jury that this is indeed why we are here and certainly makes things a little smoother.

Next up we get into burdens of proof. I find that as many times as we go over this, it does

escape the jurors mind. The stair step burden of proof chart is certainly helpful but we have to be able to explain it with various examples. I start by explaining that someone is innocent UNLESS they are proven guilty not until. Every juror tends to get this wrong but its an easy way to trip them up and make them think. I then speak on the presumption of innocence and talk about what a presumption. I 100% jacked this content from Troy McKinney at a CLE presentation I saw him do a few years back. You discuss what a presumption is and where your bias should be.

I think its important to get philosophical with a juror. Sure, I cant exactly voir dire on

punishment if I am going to the Judge in the unfortunate event of a guilty verdict but I can certainly imply things. So I pose the question “why do we have such a high burden of proof in a criminal case?” I ask this because it makes people think more than with a basic question. I have

people obviously blurt out because they can be convicted. But there is always someone who gets it and says because you are taking away someone’s personal freedoms. I once had someone say because the State was trying to throw my client in a metal cage. So for shock value, I will say that sometimes. That the government wants to label my client a criminal for the rest of their life and lock them away in a metal cage. The DA may not like it, and hell they may even object, but is it untrue? No, its entirely true, and you are the thing that stands between the State and that potential outcome.

Another important thing to address with a jury panel is how things work. How the state

gets to present its evidence first and then you get to respond. How its easy to hear what they have to say and then make up your mind ahead of time. In Harris County, the prosecutors are obsessed with using this puzzle picture demonstrative where they say hey you don’t have the whole picture but you can pretty much tell me what this is beyond a reasonable doubt, right? So credit goes to my former intern and now attorney Tim Rose, but I had him take a picture of a gun and photo shop and orange cap on it and have the puzzle pieces set up and it missing from the cap area. I act as if the state has stole my thunder and show the picture and they all blurt out that it’s a gun. Occasionally I get a smart one who knows where I am going with this. But eventually the big reveal comes up and they all look at each other like, damn tricked again. But I state that I’m not trying to show anyone up or anything like that. Its simply to show you that you need to let the ball drop. That there are two sides to every story and sometimes the state giving you most of the picture is not going to be enough. That’s when you tie this back into burdens of proof. He probably did it, is a not a guilty. Im clearly convinced he did it, is a not guilty. There must be proof beyond a reasonable doubt. So many of us do the burdens and act

like it’s the one above clear and convincing. Its not. It’s the one above reasonable doubt. It makes it that much more imposing.

Now for everyone who has tried a case before you know the power of emotion and how

the state often likes to manipulate this when the have a weaker case. So I make sure to harp on not convicting on maybe’s or because they feel bad for someone or anything like that nature. Its important to knock this down as a theme when speaking to the panel because its human nature to want to give someone the benefit of the doubt but its just something you cannot do here. You have to explain how this is the state of Texas vs your client. How its not your client on trial but the state’s case.

Which leads you to whether someone is a good juror for a case or not. And often times

you have to be honest with the jury about what type of case may not be good for you as a defense attorney. I reference the fact that I will not take burglary of a motor vehicle cases. How it has happened to me too many times to not have some sort of presumption of guilt about a defendant even though I know better. This tends to resonate with jurors as they realize its okay to have these presumptions as long as they are made to be known by the lawyers trying the case.

In my power point I will give various ideas of how to use a dwi investigation to your

advantage and how you can get a juror to think like you.

7/28/2021

The State of Texas v. Innocent Client ATTORNEY SEAN R. DARVISHI

Be 100% Honest With Me (You Won’t Hurt My Feelings)

7/28/2021

What This Process Is and Is Not

We are NOT here in opposition of Texas DWI Law.

Burden of Proof

7/28/2021

Innocent ______ Proven Guilty.

Innocent Unless Proven Guilty.

Presumption of Innocence 

What is a presumption?

7/28/2021

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias, Prejudgment, Strongly Held Belief



Must be True – a State of Mind

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume ______?

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.

7/28/2021

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.



Dark clouds and wet ground…presume it _____?

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.



Dark clouds and wet ground…presume it rained.

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.



Dark clouds and wet ground…presume it rained.



Person in handcuffs on TV….presume ______?

7/28/2021

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.



Dark clouds and wet ground…presume it rained.



Person in handcuffs on TV….presume innocence?

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.



Dark clouds and wet ground…presume it rained.



Person in handcuffs on TV….presume innocence?



Person on the side of the road pulled over by police…presume ________?

Presumption of Innocence Examples of Common Presumptions 

Lightening and Thunder….presume a storm.



Dark clouds and wet ground…presume it rained.



Person in handcuffs on TV….presume innocence?



Person on the side of the road pulled over by police…presume innocent and done nothing illegal?

7/28/2021

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would have to be biased in favor of ________?

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would have to be biased in favor of the State?

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would have to be biased in favor of the State?



Because there is a presumption of innocence, you must be biased in favor of ________?

7/28/2021

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would have to be biased in favor of the State?



Because there is a presumption of innocence, you must be biased in favor of the Citizen Accused?

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would to be biased in favor of the State?



Because there is a presumption of innocence, you must be biased in favor of the Citizen Accused?



To be fair and follow the law (rules of trial) in this case, the law requires that you must be biased in favor of the Citizen Accused.

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would have to be biased in favor of the State?



Because there is a presumption of innocence, you must be biased in favor of the Citizen Accused?



To be fair and follow the law (rules of trial) in this case, the law requires that you must be biased in favor of the Citizen Accused.



Who will not or cannot be biased in favor of (have a strongly held belief in favor of) the Citizen Accused’s innocence?

7/28/2021

Presumption of Innocence 

What is a presumption?



Assumption, Favoritism, Leaning, Bias.



Must be True – a State of Mind.



If there was a presumption of guilt, you would have to be biased in favor of the State?



Because there is a presumption of innocence, you must be biased in favor of The Citizen Accused?



To be fair and follow the law (rules of trial) in this case, the law requires that you must be biased in favor of The Citizen Accused.



Who cannot be biased in favor of (have a strongly held belief in favor of) The Citizen Accused’s innocence?



Who will be biased in favor of the Citizen Accused’s innocence?

Why Do We Have Such a High Burden of Proof in a Criminal Case?

What is Worse? A) Letting a Guilty Person Go B) Convicting an Innocent Person

7/28/2021

Probable Cause to Arrest vs. Beyond A Reasonable Doubt to Convict

7/28/2021

Probable Cause to Arrest vs. Beyond A Reasonable Doubt to Convict

What We Don’t Convict On: *Maybe Did It *Probably Did It *State Hasn’t Proved It But Come On *Lets Send a Message to Others

Who Is On Trial Today?

7/28/2021

Who Is On Trial Today? The State and Their Case

Are You a Good Juror For This Case?

7/28/2021

Because of Life Experiences I Couldn’t Put Those Experiences Aside and be a Fair Juror in a DWI Case.

INTOXICATION AT THE TIME OF DRIVING

Burden of Proof

7/28/2021

Intox at Time of Driving

What If I told you This Guy Can Squat This?

7/28/2021

What if I Brought in a Scientist Who is Never Wrong Who Says That Baby Absolutely Can Lift That Weight?

Thermometer

This Guy Runs a 4.3s 40 Yard Dash?

7/28/2021

Some Drugs Make You Normal Thus, Not Losing Normal Use of Mental/Physical Faculties

Well if He Is On Drugs I Could Tell

What Would You Expect Someone to Look Like on Cocaine?

7/28/2021

Who Will be Intoxicated Off A Single Blunt of Marijuana?

Vs.

Wouldn’t Their THC Levels in Their Blood Be The Same?

Wouldn’t Their THC Levels in Their Blood Be The Same? YES Does That Matter? NO

7/28/2021

How Much Do You Drink? A. Never Have B. Rarely C. Frequently/Socially D. Multiple Times a Week E. Daily

Is Anyone Here Today a Member or Donates to Mothers Against Drunk Driving (MADD) or Any Similar Organization?

Is Anyone Here Today a Member or Former Member of Law Enforcement, Have a Spouse in Law Enforcement or Close Friend/Family Member?

7/28/2021

Do You Know: Client Innocent Officer Donuts Lab Lady Lucy Nurse Nancy Any Employee of DPS Crime Lab The Prosecutor(s) Any Employee of HCDAO or Other Local DAOs

5th Amendment

I Think You Are Guilty of DWI if You Drink Any Amount of Alcohol and Then Get Behind the Wheel of a Vehicle.

7/28/2021

Seen This Before?

NOT The Law

When You Got Your Driver’s License What Kind of Tests Did You Have to Take?

7/28/2021

What Did You Do To Get Your License

7/28/2021

HYPO: You go out with your friends and have 2 small Margaritas. You get pulled over for speeding. You take some field sobriety tests and think you did great. You go and blow a .13. Now what do you tell your lawyer to do if you believe its inaccurate?

Are All Police Officer’s Skill Equal?

A Police Officer Instantly Has More Credibility Than Anyone Else Before He/She Ever Opens Their Mouth to Testify Agree or Disagree?

7/28/2021

What Type of Evidence Will You Require the Defense to Put On?

Will You Require Me to Prove Client was Not Intoxicated?

THANK YOU!

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Intoxilyzer 9000: Tip to Tail Speaker:

Matthew Malhiot 1353 Riverstone Pkwy Ste 120-382 Canton, GA 30114-5634 (678) 880-3171 Phone mmalhiot@forensicalcohol.com email

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

7/22/2021

CMI’S INTOXILYZER® 9000 HOW IT WORKS

Matthew E. Malhiot 678-880-3171 mmalhiot@forensicalcohol.com

Forensic Alcohol Consulting and Training, LLC www.ForensicAlcoholConsulting.com

The Intoxilyzer® 9000

The Intoxilyzer® 9000 1. Mouthpiece storage 2. Magnetic Card Reader 3. Power Button 4. Power Indicator Light 5. Full Color LCD Touch Screen 6. Breath Tube

7/22/2021

From the Side

1. Breath Tube 2. Name Plate 3. Adjustable Stand

From the Back

1. 2. 3. 4. 5.

Breath Flow Port Dry Gas Standard Simulator Port Ethernet Port Two USB Ports

6. 7. 8. 9.

Analog Phone Line Fan 12V DC power 110V AC Power

5 6

From The Right Side



1. External Speaker



2. USB Device



3. Two USB Ports

7/22/2021

The Dry Gas Delivery System

Optical Bench

The Optical Bench

7/22/2021

5000 Vs. 9000

Infrared Finger Print of Ethanol Ethanol Finger Print & the Intoxilyzer 9000

The Subject       

Do they have a fever ? Are they diabetic ? Any kind of diet ? Dental Work ? Breathing problems ? COPD The 2100-1 Ratio

7/22/2021

Breath Test Operator     

15 minute wait Proper Training and Certification Lack of understanding of Instrument Operation No way to tell if internal problems with instrument Instructions given to accused

The Environment     

Breath Test Instrument Location Other subjects in room RFI V.O.C. Power Supply

The Instrument        

10% Accuracy Standard 7% Measurement Uncertainty 4 Filters 0.02 Agreement Mouth Alcohol, SLOPE V.O.C. Internal Control Test Single Point Calibration Check Copyright 2021, Forensic Alcohol Consulting and Training, LLC,

7/22/2021

Statistical Analysis 

90-001305  Ambient

Fail Rate of 0%

 N=338



90-001854  Ambient

Fail Rate of 11%

 n=207

7/28/2021

CMI’S INTOXILYZER® 9000 HOW IT WORKS

Matthew E. Malhiot 678-880-3171 mmalhiot@forensicalcohol.com

Forensic Alcohol Consulting and Training, LLC www.ForensicAlcoholConsulting.com

The Intoxilyzer® 9000

The Intoxilyzer® 9000 1. Mouthpiece storage 2. Magnetic Card Reader 3. Power Button 4. Power Indicator Light 5. Full Color LCD Touch Screen 6. Breath Tube

7/28/2021

From the Side

1. Breath Tube 2. Name Plate 3. Adjustable Stand

From the Back

1. 2. 3. 4. 5.

Breath Flow Port Dry Gas Standard Simulator Port Ethernet Port Two USB Ports

6. 7. 8. 9.

Analog Phone Line Fan 12V DC power 110V AC Power

5 6

From The Right Side



1. External Speaker



2. USB Device



3. Two USB Ports

7/28/2021

The Dry Gas Delivery System

Optical Bench

The Optical Bench

7/28/2021

5000 Vs. 9000

Infrared Finger Print of Ethanol Ethanol Finger Print & the Intoxilyzer 9000

The Subject       

Do they have a fever ? Are they diabetic ? Any kind of diet ? Dental Work ? Breathing problems ? COPD The 2100-1 Ratio

7/28/2021

Breath Test Operator     

15 minute wait Proper Training and Certification Lack of understanding of Instrument Operation No way to tell if internal problems with instrument Instructions given to accused

The Environment     

Breath Test Instrument Location Other subjects in room RFI V.O.C. Power Supply

The Instrument        

7/28/2021

Statistical Analysis 

90-001305  Ambient

Fail Rate of 0%

 N=338



90-001854  Ambient

Fail Rate of 11%

 n=207

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Ethics Speaker:

Doug Murphy

902 Heights Blvd. Houston, Texas 77008 (713) 229-8333 Phone (713) 583-0205 Fax doug@dougmurphylaw.com email dougmurphylaw.com website

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

Ethically & Zealously Representing Clients Top Gun DWI Defense Texas Criminal Defense Lawyers Association August 13, 2021 Presented by:

Doug Murphy Doug Murphy Law Firm, P.C. 902 Heights Blvd. Houston, Texas 77008 (713) 229-8333 doug@dougmurphylaw.com

Special thanks and credit to author of article DUI E.R.

William K. Kirk Cowan Kirk Kattenhorn 4040 Lake Washington Blvd, NE, Suite 300 Kirkland, WA 98033 wkirk@cowanlawfirm.com

D.U.I.E.R.

Managing Your Client’s Trauma William K. Kirk Fellow, NCDD Cowan Kirk Kattenhorn 4040 Lake Washington Blvd, NE, Suite 300 Kirkland, WA 98033 wkirk@cowanlawfirm.com

Empathy. noun. The ability to understand and share the feelings of another. Mindful. adjective. Conscious or aware of something. Focusing one’s awareness on the present moment, especially as part of a therapeutic or meditative relief.

Trauma. noun. Traumatized.

A deeply distressing or disturbing experience.

verb past tense. Subject to lasting shock as a result of an emotionally disturbing experience or physical injury.

The Rules of Professional Conduct Relevant to Our Discussion Today. Rule 1.1 Client-Lawyer Relationship A lawyer shall provide competent representation to a client. Competent representation requires the legal knowledge, skill, thoroughness and preparation reasonably necessary for the representation.

Rule 1.3 Client-Lawyer Relationship A lawyer shall act with reasonable diligence and promptness in representing a client.

Rule 1.4 Client-Lawyer Relationship (a) A lawyer shall: (1) promptly inform the client of any decision or circumstance with respect to which the client's informed consent, as defined in Rule 1.0(e), is required by these Rules; (2) reasonably consult with the client about the means by which the client's objectives are to be accomplished; (3) keep the client reasonably informed about the status of the matter; (4) promptly comply with reasonable requests for information; and (5) consult with the client about any relevant limitation on the lawyer's conduct when the lawyer knows that the client expects assistance not permitted by the Rules of Professional Conduct or other law.

(b) A lawyer shall explain a matter to the extent reasonably necessary to permit the client to make informed decisions regarding the representation.

Rule 2.1 Counselor In representing a client, a lawyer shall exercise independent professional judgment and render candid advice. In rendering advice, a lawyer may refer not only to law but to other considerations such as moral, economic, social and political factors, that may be relevant to the client's situation.

Introduction. We so routinely focus on the outcome of our cases, and often take great pride in the results we obtain for our clients. Since we are accustomed to the day to day battle of administrative hearings, preliminary hearings, motions hearings and trials, we regularly focus on the result and never contemplate the process by which we used to get there. Worse yet, we never truly appreciate, or even consider, the emotional trauma that this entire experience inflicts upon our clients. The mindful lawyer, the empathetic lawyer, is one who not only can achieve great results, but can do it in a manner which helps manage and regulate the client’s emotional experience of the process. By taking this approach, not only do you become a more effective advocate, you form relationships with your clients that will last far beyond your representation of them and will, in the end, lead to long lasting referrals. In today’s short lecture, we will first identify the sheer terror of what many of our client’s experience and what we can do, as mindful and empathetic practitioners, to help manage that emotional experience and lessen the emotional trauma that comes, even with a successful outcome. What It’s Like Getting Arrested. The author can honestly say, but most of you can’t (thankfully) what it’s like getting arrested. It is as horrifying as it is humiliating. The sheer terror of being pulled over is amplified as the officer asks the individual to step from their car. Questions begin about the night’s events including consumption. It does not take long for the driver to realize this is much more than just a speeding ticket. Roadside gymnastics are then performed as cars fly by at 65 mph. Following all of that, the driver is then told to turn around, and put their hands behind their back. They are handcuffed, patted down, items removed from their pocket, usually while the camera is running. Miranda Rights are read like a scene from “Cops.” They are stuffed into the back of a patrol car. A hard plastic tomb for the next 30-60 minutes. After finally arriving at the station, they are dragged out of the car, placed into a overly lit room, with other officers and inmates, in their for a wide array of crimes, and asked to make important decisions in seconds under these circumstances. Many first time offenders never ask for an attorney or even come remotely close to exercising their right to remain silent. The desire to be cooperative and respectful often assists in digging them an evidentiary grave.

Then, with all of this happening, they are then asked to make a decision about whether or not to trust their future to a machine they know nothing about. The choices are: blow and give evidence against yourself, or don’t blow….and give evidence against yourself. Or maybe better yet, the officer just skipped the breath test altogether and got a warrant for their blood instead. Now they meet some nurse they’ve never met before, or worse yet a Phleboto-Cop, who tells them that a judge has signed an order and they are now going to draw blood come hell or highwater. And this is what they get to go through BEFORE they’ve ever had a chance to meet you. Then, after spending a night or two with some of the county’s finest, they begin to search for a lawyer. While they are getting recommendations from friends and family, they are searching the internet and finding that everyone is “_______’s Best DUI Lawyer.” As they begin to make phone calls, they are met by those that don’t have time for them, or those that all they want to do is talk about getting paid, or talk about how great they are. They spend such little time finding out about the client that they not only are disadvantaged should that client choose them, they are doing NOTHING to help manage the emotional trauma that comes with this. Worse yet, some practitioners, may feed on the trauma and use it to a marketing advantage.

Becoming the Empathetic and Mindful Lawyer.

EMPATHY

Empathy is the ability to recognize, understand, and share the thoughts and feelings of another person, animal, or fictional character. Developing empathy is crucial for establishing relationships and behaving compassionately. It involves experiencing another person’s point of view, rather than just one’s own, and enables prosocial or helping behaviors that come from within, rather than being forced.

But for so many of us, we only see the world through our litigated stained glasses. We see the system for what it really is, not what it should be or what we thought it was. We see police for who they truly are. Many times that is good, other times, not so much. We believe in fairness, we fight for fairness, but we know all too often, the system is far from fair. We have become so jaded in our day to day views of the criminal justice system, from weeding through it for years, that we lose our ability to empathize with others. We have heard every story in the book. Sometimes, they were actually true, but we have long forgotten the importance of our client’s experience. Empathy is the key to all of this. Without empathy, we cannot truly relate to our clients, we cannot truly understand our clients, and important for us today, we cannot begin to assist our clients in ways that will benefit them more than any legal ruling. We must re-familiarize ourselves with empathy and practice in our day to day lives. We must engrain that behavior back into our lives so that our clients can prosper and we can become more effective as advocates. There are, three different “types” of empathy. A. Cognitive: “Simply knowing how the other person feels and what they might be thinking. Sometimes called perspective-taking.” If you imagine yourself in your friend’s shoes, you know she is likely to be feeling sad, as well as anxious because she relies on that income to pay her student loans. However, having only cognitive empathy keeps you at a distance from your friend. To truly connect with your friend, you need to share their feelings. This is where emotional empathy comes in. As lawyers we think we know what’s going on in our client’s mind. Even if we don’t, we act like we do anyways. Yes, we know they are scared. Yes, we know they are nervous and anxious. But can you actually share those feelings with your client? Moreover, can you do it in a way that does not compromise your role as an advocate? B. Emotional: “When you feel physically along with the other person, as though their emotions were contagious.” This type of empathy can also extend to physical sensations, which is why we cringe when someone else stubs their toe or why I can NEVER watch the slow motion replay of some dude snapping his leg in a football game. In this case, you would look inwards to identify a situation where you were similarly anxious about the future. The situation itself need not be identical, as each individual is different. What’s important is that the emotions resulting from the situation are the same. Our clients are usually motivated by fear. But the ugly truth is, so are many of us. We are fearful of losing, we are fearful of rejection and we are most fearful of not being good enough. The emotion that you’re feeling, the one of internal terror, is no different than what your client is feeling. Only the stimulus for that sensation is different -- the feeling is the same. So, you’ve successfully understood what your friend is feeling, and put yourself in a similar emotional space. Now what? Well, you can use the insights gleaned from Cognitive and Emotional empathy to have Compassionate Empathy.

C. Compassionate: “With this kind of empathy we not only understand a person’s predicament and feel with them, but are spontaneously moved to help, if needed.” It is the balance between Cognitive and Emotional Empathy that enables us to act without being overcome with feeling or jumping straight into a problem solving process. The latter is the most challenging for us, because that is what we do for a living: we solve problems. Our entire life is defined by that role. But it is only with this type of empathy can we both understand and feel the client’s predicament, yet we are moved and able to help. This is the empathetic and compassionate lawyer who when they truly understands their client’s emotional experience, can assist with that and even influence it at times. The empathetic lawyer can advise the client on what is both best for them legally, and what might be best for them emotionally. Putting it all together Empathy doesn’t just happen naturally for a lot of people. Our fast-paced society does not often encourage us to take a moment to connect with others. In fact, it rarely gives us time to connect with ourselves. It is therefore a conscious choice we have to make, but the more we practice empathy, the more intuitive it becomes. Like any new behavior, we must be very deliberate at first in performing that task. Over time, it becomes literally engrained in us. The benefits cannot be overstated. Professions such as healthcare and teaching, have been the first to accept this approach as they are responsible for the wellbeing of many individuals, both young and old. In healthcare, a 2016 study from Massachusetts General Hospital found empathy to be the distinguishing factor in medical care satisfaction. Empathy enables clinicians to connect on a deeper level with patients, and hence act in their patient’s best interests. Past studies have shown that empathy can also affect healthcare outcomes1 – it can reduce the length of hospital stays2 and even make the common cold go away faster.3 But if that is the case, how could it not help us in our profession? After all, when you consider our industry, it is quite similar to healthcare. Everyone has a specialized education, including post-graduate degrees. The clients/patients have come to us in a state of panic, experiencing mental or physical illness or trauma. They are relying on our expertise and knowledge to help solve the problem. While healthcare is a life or death situation in some instances, DUI defense only seems like a life or death situation for our clients. But those feelings, no matter how overblown they may be, are real for them. We must begin to understand that.

https://journals.sagepub.com/doi/full/10.1177/0141076818769477 https://www.researchgate.net/publication/265005989_Effectiveness_of_psychological_support_based_on_positiv e_suggestion_with_the_ventilated_patient 3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720820/ 2

II.

MINDFULNESS

What Is Mindfulness? Mindfulness means maintaining a moment-by-moment awareness of our thoughts, feelings, bodily sensations, and surrounding environment, through a gentle and objective lens. Mindfulness also involves acceptance, meaning that we pay attention to our thoughts and feelings without judging them—without believing, for instance, that there’s a “right” or “wrong” way to think or feel in a given moment. When we practice mindfulness, our thoughts tune into what we’re sensing in the present moment rather than rehashing the past or imagining the future. Though it has its roots in Buddhist meditation, a secular practice of mindfulness has entered the American mainstream in recent years, in part through the work of Jon Kabat-Zinn4 and his Mindfulness-Based Stress Reduction (MBSR) program, which he launched at the University of Massachusetts Medical School in 1979. Since that time, thousands of studies have documented the physical and mental health benefits of mindfulness in general and MBSR in particular, inspiring countless programs to adapt the MBSR model for schools, prisons, hospitals, veterans centers, and beyond. A lawyer who practices both mindfulness and empathy places themselves in a position where you can understand what your client is experiencing and how it is affecting their experience as well as yours. This practice can help plan for tough meetings or help structure a better way to 4

https://www.mindfulnesscds.com/

deliver bad news. Perhaps the lawyer knows of the client’s succeptability to anxiety or the certain triggers that seem to launch them. The mindful and empathetic lawyer can adjust their approach to better cater to both the client’s legal needs as well as their emotional needs. The mindful lawyer will also know what is motivating the client during certain interactions and/or decisions. The client who seems angry or stressed, is really afraid. The client who is manic is terrified. Lawyers must be mindful of what the client is experiencing AND how it motivates their behaviors and/or decisions.

III.

TRAUMA.

Trauma is an emotional response to a terrible event like an accident, assault, natural disaster or even an arrest. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives. Since trauma can be most acute in the months following the incident, this can greatly affect the attorney-client relationship if not properly addressed. The word “trauma” may be used in two different contexts. In the physical context, it means a physical injury inflicted on a person by some external agent. In a psychological context, the term trauma means an emotional response to a deeply distressing or disturbing event. The event may be the sudden loss of a loved one, an accident, assault or even an arrest. A person subjected to trauma may respond in several ways. They may be in a state of shock, extreme grief, or even denial. Apart from the immediate or short-term response, trauma may also give rise to several longer-term reactions in the form of emotional lability, flashbacks, impulsiveness, and strained relationships. Besides the psychological symptoms, trauma can lead to physical symptoms, such as headaches, lethargy, and nausea. Some people may be affected a lot more than others. Such people may be entrapped in the emotional impact of the trauma and find it difficult to move on with their lives.

Often times, individuals may “self-medicate” themselves from this trauma using alcohol or drugs to numb the emotional pain and anguish brought on by the event. Routinely, clients may actually increase their use of alcohol rather than decrease it following an arrest. The mindful and empathetic lawyer will recognize this and assist the client in overcoming and/or managing this trauma. The Three Types of Trauma. Trauma is divided into three main types: acute, chronic, and complex. Acute Trauma: It mainly results from a single distressing event, such as an accident, assault, natural disaster or in many of our cases, an arrest. The event is extreme enough to threaten the person’s emotional or physical security. The event creates a lasting impression on the person’s mind. If not addressed through medical help, it can affect the way the person thinks and behaves. Acute trauma generally presents in the form of:         

Excessive anxiety or panic Irritation Confusion Inability to have a restful sleep Feeling of disconnection from the surroundings Unreasonable lack of trust Inability to focus on work or studies Lack of self-care or grooming Aggressive behavior

Chronic trauma: It happens when a person is exposed to multiple, long-term, and/or prolonged distressing, traumatic events over an extended period. Chronic trauma may result from a long-term serious illness, sexual abuse, domestic violence, bullying, and exposure to extreme situations, such as a war. These clients can present themselves as having chemical dependency or “addictive-like” behavior. However, in reality, they are self-medicating away chronic trauma (or other mental health ailments). The mindful and empathetic lawyer must learn to spot this and recommend a course of action or treatment to assist this person in coping with these traumatic events. Clients in this category will usually not display signs of trauma when recounting the arrest, it is when you discuss their life in general and their use of substances or overall mental health, that these events will appear. Several events of acute trauma as well as untreated acute trauma may progress into chronic trauma. The symptoms of chronic trauma often appear after a long time, even years after the event. The symptoms are deeply distressing and may manifest as labile or unpredictable

emotional outbursts, anxiety, extreme anger, flashbacks, fatigue, body aches, headaches, and nausea. These individuals may have trust issues, and hence, they do not have stable relationships or jobs. Clients suffering from chronic trauma are literally destined to struggle with personal, professional and social issues unless these issues are resolved through counseling. Complex trauma: It is a result of exposure to varied and multiple traumatic events or experiences. The events are generally within the context of an interpersonal (between people) relationship. It may give the person a feeling of being trapped. Complex trauma often has a severe impact on the person’s mind. It may be seen in individuals who have been victims of childhood abuse, neglect, domestic violence, family disputes, and other repetitive situations, such as civil unrest. It affects the person’s overall health, relationships, and performance at work or school. Whatever be the type of trauma, if a person finds it difficult to recover from the distressing experiences, they must seek timely psychological help. A qualified psychologist can help the person with a traumatic experience lead a fulfilling life.

IV.

BEING “TRAUMATIZED.”

Perhaps the biggest realization that all attorneys must come to grips with is that there is a difference between “trauma” and being traumatized. “Trauma” as we think of it is sever injury, grotesque or violent interactions, the worst of the worst. But being “traumatized” is an emotional state which does not necessarily require our more traditional “trauma” as a comdition precedent. Survivors’ immediate reactions in the aftermath of trauma are quite complicated and are affected by their own experiences, the accessibility of natural supports and healers, their coping and life skills and those of immediate family, and the responses of the larger community in which they live. Although reactions range in severity, even the most acute responses are natural responses to manage trauma— they are not a sign of psychotic issues. Coping styles vary from action oriented to reflective and from emotionally expressive to reticent. Clinically, a response style is less important than the degree to which coping efforts successfully allow one to continue necessary

activities, regulate emotions, sustain self-esteem, and maintain and enjoy interpersonal contacts. Indeed, a past error in traumatic stress psychology, particularly regarding group or mass traumas, was the assumption that all survivors need to express emotions associated with trauma and talk about the trauma; more recent research indicates that survivors who choose not to process their trauma are just as psychologically healthy as those who do. The most recent psychological debriefing approaches emphasize respecting the individual’s style of coping and not valuing one type over another. Foreshortened future: Trauma can affect one’s beliefs about the future via loss of hope, limited expectations about life, fear that life will end abruptly or early, or anticipation that normal life events won’t occur (e.g., access to education, ability to have a significant and committed relationship, good opportunities for work). Initial reactions to trauma can include exhaustion, confusion, sadness, anxiety, agitation, numbness, dissociation, confusion, physical arousal, and blunted affect. Most responses are normal in that they affect most survivors and are socially acceptable, psychologically effective, and self-limited. Indicators of more severe responses include continuous distress without periods of relative calm or rest, severe dissociation symptoms, and intense intrusive recollections that continue despite a return to safety. Delayed responses to trauma can include persistent fatigue, sleep disorders, nightmares, fear of recurrence, anxiety focused on flashbacks, depression, and avoidance of emotions, sensations, or activities that are associated with the trauma, even remotely. A variety of reactions are often reported and/or observed after trauma. Most survivors exhibit immediate reactions, yet these typically resolve without severe long-term consequences. This is because most trauma survivors are highly resilient and develop appropriate coping strategies, including the use of social supports, to deal with the aftermath and effects of trauma. Most recover with time, show minimal distress, and function effectively across major life areas and developmental stages. Even so, clients who show little impairment may still have subclinical symptoms or symptoms that do not fit diagnostic criteria for acute stress disorder (ASD) or PTSD. Only a small percentage of people with a history of trauma show impairment and symptoms that meet criteria for trauma-related stress disorders, including mood and anxiety disorders. The following sections focus on some common reactions across domains (emotional, physical, cognitive, behavioral, social, and developmental) associated with singular, multiple, and enduring traumatic events. These reactions are often normal responses to trauma but can still be distressing to experience. Such responses are not signs of mental illness, nor do they indicate a mental disorder. Traumatic stress-related disorders comprise a specific constellation of symptoms and criteria. Emotional Emotional reactions to trauma can vary greatly and are significantly influenced by the individual’s sociocultural history. Beyond the initial emotional reactions during the event, those most likely to surface include anger, fear, sadness, and shame. However, individuals may encounter difficulty in identifying any of these feelings for various reasons. They might lack experience with or prior exposure to emotional expression in their family or community. They

may associate strong feelings with the past trauma, thus believing that emotional expression is too dangerous or will lead to feeling out of control (e.g., a sense of “losing it” or going crazy). Still others might deny that they have any feelings associated with their traumatic experiences and define their reactions as numbness or lack of emotions. Emotional Dysregulation Some trauma survivors have difficulty regulating emotions such as anger, anxiety, sadness, and shame—this is more so when the trauma occurred at a young age. In individuals who are older and functioning well prior to the trauma, such emotional dysregulation is usually short lived and represents an immediate reaction to the trauma, rather than an ongoing pattern. Self-medication—namely, substance abuse—is one of the methods that traumatized people use in an attempt to regain emotional control, although ultimately it causes even further emotional dysregulation (e.g., substance-induced changes in affect during and after use). Other efforts toward emotional regulation can include engagement in high-risk or self-injurious behaviors, disordered eating, compulsive behaviors such as gambling or overworking, and repression or denial of emotions; however, not all behaviors associated with self-regulation are considered negative. Traumatic stress tends to evoke two emotional extremes: feeling either too much (overwhelmed) or too little (numb) emotion. Treatment can help the client find the optimal level of emotion and assist him or her with appropriately experiencing and regulating difficult emotions. In treatment, the goal is to help clients learn to regulate their emotions without the use of substances or other unsafe behavior. This will likely require learning new coping skills and how to tolerate distressing emotions; some clients may benefit from mindfulness practices, cognitive restructuring, and trauma-specific desensitization approaches, such as exposure therapy and eye movement desensitization and reprocessing (EMDR). Numbing Numbing is a biological process whereby emotions are detached from thoughts, behaviors, and memories. In the following case illustration, Sadhanna’s numbing is evidenced by her limited range of emotions associated with interpersonal interactions and her inability to associate any emotion with her history of abuse. She also possesses a belief in a foreshortened future. A study in 2009 that followed the development of PTSD in disaster workers highlighted the importance of understanding and appreciating numbing as a traumatic stress reaction. Because numbing symptoms hide what is going on inside emotionally, there can be a tendency for family members, counselors, and other behavioral health staff to assess levels of traumatic stress symptoms and the impact of trauma as less severe than they actually are. Cognitions and Trauma The following examples reflect some of the types of cognitive or thought-process changes that can occur in response to traumatic stress. You will see how any of these symptoms could radically and negatively affect the attorney client relationship.

Cognitive errors: Misinterpreting a current situation as dangerous because it resembles, even remotely, a previous trauma (e.g., a client overreacting to an overturned canoe in 8 inches of water, as if she and her paddle companion would drown, due to her previous experience of nearly drowning in a rip current 5 years earlier). Excessive or inappropriate guilt: Attempting to make sense cognitively and gain control over a traumatic experience by assuming responsibility or possessing survivor’s guilt, because others who experienced the same trauma did not survive. We see this in DUI situations, especially involving fatal car accidents, but the defeatist attitude can come from someone even facing a first offense DUI. Trauma-induced hallucinations or delusions: Experiencing hallucinations and delusions that, although they are biological in origin, contain cognitions that are congruent with trauma content (e.g., a woman believes that a person stepping onto her bus is her father, who had sexually abused her repeatedly as child, because he wore shoes similar to those her father once wore). Intrusive thoughts and memories: Experiencing, without warning or desire, thoughts and memories associated with the trauma. These intrusive thoughts and memories can easily trigger strong emotional and behavioral reactions, as if the trauma was recurring in the present. The intrusive thoughts and memories can come rapidly, referred to as flooding, and can be disruptive at the time of their occurrence. If an individual experiences a trigger, he or she may have an increase in intrusive thoughts and memories for a while. For instance, individuals who inadvertently are retraumatized due to program or clinical practices may have a surge of intrusive thoughts of past trauma, thus making it difficult for them to discern what is happening now versus what happened then. Practitioners should be very mindful of this especially when reviewing the video evidence with a client. For that reason, I often send it to the client several days in advance of speaking with them about it allowing them to view it on their terms.

V. PUTTING IT ALL TOGETHER FOR THE LAWYER Now with all of this in mind, what can we, the empathetic and mindful lawyer do to not only assist our clients with their obvious needs (navigating a difficult legal situation) but assist them in managing their emotional experience of your representation? The perfect attorney-client relationship is built on trust and mutual respect for each other. But financially speaking, the perfect attorney-client relationship is one where the client is satisfied with the representation, regardless of outcome, because the emotional experience of working with that attorney was so pleasant and fulfilling. A strong bond is formed between attorney and client who in turn becomes on of the finest referral sources for that client moving forward. Yes, being the empathetic and mindful lawyer helps you become a better advocate, but will benefit you financially as well. Defining Our Goals. Complete representation, one that not only zealously advocates for the client in court, but also helps define and mold the emotional experience of the representation, must first begin with defining what the true goal of our representation is. If this were a live presentation, I would ask several of you, what is our goal when representing a client, and we would hear answers such as:

“to get the best outcome possible for them.” “to ensure that their rights are protected and they are given a fair trial.” “to ensure that Justice has been served.” Whatever that means. But when you really break it down, when we try to sum it up in one word, what best describes our goal?

CONTROL When our clients first call us, or when they first come into our office, their life is completely out of control, or it at least seems that way. For some it seems like its out of control only because of the incident which brought them there to begin with. For others, their life is, in fact, out of control and the underlying legal issue is only a symptom of the larger problem. But they come to our office terrified, and they don’t have control any of it. The entire incident is out of their control. What is the one thing that humans fear the most? A lack of control. The ability to control defines our very existence. It is engrained in all of us. Control is an essential need to humans. It is essential to our survival. It’s just that some need more of it than others. The goal of the defense attorney is gather as much CONTROL of the situation as you possibly can. We want to take our clients from a position of zero control to a position of complete control. Not always is complete control possible, but even in the worst of cases, we can gain control of certain aspects of the case. The more we gather control of the outcome for our clients, the better they feel, the more the trauma dissipates and the attorney-client relationship prospers. Here are some simple ideas to build into your practice, that will help you and your client gain control of the situation and thus better manage the emotional experience of what they are about to endure. 1. Set the Tone and Show that YOU Care. The Initial Consultation. These occur one of two ways: by phone or in person. In my case, most clients call me first, we speak for a few minutes, then we schedule a more formal visit within 24-48 hours of the call. Remember, WE NEVER GET A SECOND CHANCE TO MAKE A FIRST IMPRESSION. So many attorneys are driven by the mighty dollar that they spend these precious first few minutes explaining how great they are, how much they know and why the client needs someone just like them. But the time for that is later. And the best way to sell them on that is to make it obvious to them without ever saying it. If possible, get as much information screened by your office staff so that when you return the call, you are already “up to speed” on the case. Not only does that avoid having to waste time repeating things, your first impression to the client is someone that has taken the time to do their homework and has a handle on things already. Or in better terms, they’re already taking control of the situation.

Take the time to ask open ended questions. Let the client tell their story and not just about what happened, but let them tell you what scares them the most about this case. If they don’t go there…..ask the question yourself. “Tell me, what scares you the most about this case?” Often times the answers I hear from clients are legal impossibilities in their case. It’s not often that you can actually promise something to a client, but when they’re worried about penalties that don’t exist in the case, or would never be imposed in their case, they need to be informed of this. Start asking other questions to see if this is just an “oops” moment, which describes a large majority of our clients or if this incident is really a symptom of a larger problem. If there are larger issues (addiction, addictive-like behavior, mental health) now is the time to empower that client to start taking control of that as well. The more you empower the client early on to take control of those things that they can control, 2. Get the Client Involved. Sometimes we actually have to coach our clients to dial it back a bit. Some think because they can access Google, they now have the letters J.D. behind their name as well. But the opposite is also true sometimes, clients who literally want to drop their entire problem off in your lap, have you fix it, and then call them back when everything is good again. Neither of these approaches work. BUT, client involvement is critical to gaining “control” of the situation. Their involvement gives them a sense of belonging and investment in the case. As you assign tasks to them, and they complete them, they recognize that they are making progress not only in reaching a resolution of the matter, but in gaining control of the situation. Alcohol evaluation, classes, counseling, treatment or Victims’ Panels, they all can be required at a later date in our jurisdiction. Why wait for the Court to order it when you can do it now? Getting the client involved, and explaining the importance of this, help not only the lawyer with case management, but allows the client to garner control of important aspects of their case. 3. Be Transparent…About Everything. Transparency is critical to every relationship. It’s what is sadly lacking in many of our institutions in America right now. No matter what side of the political aisle you come from, we can all agree that our country is in dire need of more transparency. Often times the attorney-client relationship needs more of this as well. We love giving good news. We all love the “two word verdict” or the “I have an amazing plea deal for you,” but we are terrible when it comes to breaking bad news. In many instances, the need to break bad news can be lessened through more transparency. The client should know everything there is to know about the case. In my jurisdiction, the court rules require that “we make available” any discovery for the client to come to our office and review. Instead, we provide the client with EVERYTHING we receive. All reports, every page of them. All videos, all recordings, all photos…all of it.

Even if they’re not participating in the DOL (administrative) hearing, they will listen to every second of it…especially if the officer is testifying. They will be provided with recordings and transcripts of that hearing. They will receive all written rulings from the DOL. And in many instances, if they’re case is one that is truly about damage control, they will come to that conclusion themselves. Sometimes its not about breaking bad news as much as its about being honest with your client. And if you’re totally transparent, right from the first phone call, to the review of discovery, many times there is no news to break at all. This process allows the client to come to grips themselves in what they are dealing with in a more controlled environment. It becomes a realization rather than earth shattering news. 4. Use Your Crystal Ball (When You Can). Every client wants us to tell them how their case is going to turn out. If we were that good at predicting the future, we should all move to Vegas and be retired by the end of the month. Truth is that you can NEVER truly predict how a case will turn out. We have ideas, and often they are based on years and years of experience with similar cases, in the same court, with same prosecutor. And in those instances, educated guesses can be made. But there are many things that we can accurately predict. In fact there are some hearings that we can literally quote the entire hearing, from every party, before the hearing ever happens. These are often mundane, meaningless hearings, but often times we are the only ones who know that. In Washington State, where I practice, we have hearings that occur after the arraignment, and before anything meaningful ever happens called “Pre Trial Conferences.” They sound so important…..they rarely are. However, clients used to call me days before their first pre trial conference freaking out, wanting to know what our strategy was for a hearing that was actually going to take 60 seconds. But for all the things that exist for our clients to stress about, there are many things that they do not need to lose sleep over. Often times, the attorney knows this well in advance. The client should as well. I cannot tell you the power of a phone call the day before to go over the hearing one more time and make sure they have all their questions answered. So yes, use your crystal ball when you can. 5. Make Them Check In With You. There are some clients of mine who literally need to hear from me every day. Others, don’t ever want to hear from me unless I have good news. The important thing is that we have to allow our clients to be who they are. I routinely require my clients to check in with me every week or two even if it’s just for a few minutes to make sure that they are coming along with tasks. By doing this, not only do we ensure that we are constantly moving towards a positive resolution but it demonstrates the clients willingness to stay involved in the case and help garner control of the matter. With the integration of zoom and other video conference platforms into our daily practice, these routine check ins can be quite easy and effective. Even if they last only five minutes sometimes just a face-to-face meeting with the attorney asking the simple

question of “is there any questions I can answer for you right now?” can go a long way in easing the clients anxiety and demonstrating how you are in control of the situation. These routine check cans will also ensure that the client remains accountable for their responsibilities as well. Occurs there should be certain instances in which lengthy and meaningful conversations are mandated. Prior to the case proceeding to court for the first time, upon receipt of any police reports, and upon any receipt of video evidence are usually significant events which require significant attorney-client interaction. Client should be made aware of these and schedules should be adjusted accordingly. But regular communication, no matter what form it may come in, is critical to helping the client survive the emotional trauma of being charged with a crime and having to defend themselves in court 6. Practice, Practice, Practice. While there are many hearings that the attorney will do most if not all of the talking, there are certain hearings that will require our client’s participation. For many people one of their greatest fears is public speaking. Could you think of a worse place to have to engage in public speaking other than a venue which is not only designed to be intimidating but also is the same thing that sits in judgment of the speaker? How many clients have said they were worried that if they said the wrong thing the judge would flip out and thrown in jail? As we know, these are rare instances usually comes from behavior that we would all anticipate swift incarceration from. But in instances where we know our clients are going to need to address the court it is important to tell them that ahead of time and to practice it with them. Once again, the usefulness of zoom and share screen function, goes a long way in having quick yet effective appointments to essentially do dress rehearsals prior to court hearings. The client will find comfort when the attorney tells them that we are going to do an exact dry run of what’s going to occur in court the following day. The anxiety is with going to court will not be eliminated altogether but will be significantly reduced by spending 10 or 15 minutes to do a dress rehearsal. This is especially important for plea and sentencing hearings were often times our client’s choice of words can make a difference in the outcome. In these situations great emphasis should be placed on making sure that our clients effectively communicate with the court. Experience will also show us that there are very specific things that need to be said in very specific situations and certain things that need to be avoided at all costs. I will routinely write out several bullet points for my clients to present at the time of sentencing ensuring them that if they “stick to the script” everything will be okay will, once again, it’s go a long way in reducing the anxiety associated with these very important hearings. 7. Make Sure You Wrap it Up Correctly. In a perfect world, our clients would never have another reason to ever see us again. And certainly we can all this about clients that we could not get rid of fast enough. But wrapping up the active portion of the attorneyclient relationship is a wonderful way to ensure that not only the client succeeds post-

representation of their case, but they have an opportunity to see that the attorney cares about their success in the future as well. Taking another 10 to 20 minutes to do a final wrap up appointment where you go over the specifics of the judgment and sentence and provide a timeline for any remaining obligations proves to the client that the attorney will always have their best interest in mind. 8. Always Take Their Calls. I’ve been doing this for 21 years now and have a pretty good memory but even now I have clients are call me that I cannot recall who they are or anything about their case. I do not even know if they’re calling me to talk about their old case, a new case or something completely unrelated to it. I will always take five minutes to look back in our archive files and learn some of the quick details in dates of my previous representation. In the event that the old case is brought up I will immediately sound like I’m remembering well and the client will feel emotionally more secure during that interaction. In the event they are talking about something new at least the old case is relevant to what might be going on. In the event that they are have questions completely unrelated to it your knowledge of their previous case and ability to recall it will be have instant credibility should he be asking you for advice on other things. This is especially beneficial to your professional colleagues when they call and ask for recommendations for a divorce attorney or a tax lawyer.

VI. CONCLUSION Becoming a more mindful and empathetic lawyer does not happen overnight. It is a learned behavior that we must be intentional about before it becomes part of our sub-conscience being. But there has never been a better time to start than now. Our client go through a horrifying emotional experience. We often define success by the outcome of the case alone, never recognizing the emotional trauma that was added onto the night of the arrest by the justice process itself. We think of it as no big deal, because it is no big deal to us. But to them, the horrified, terrified, petrified souls we call clients, its one of the worst things they’ve ever had to endure. But when we become mindful of this and empathetic to it, we become better advocates in and out of the courtroom and the attorney client relationship prospers.

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Sample Motions for Success Speaker:

Mark Lassiter 3300 Oak Lawn Ave. Suite 700 Dallas, Tx 75219 (214) 845-7007 Phone (214) 845-7006 Fax mark@lomtl.com email www.lomtl.com website

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

CAUSE NO. ________________ § § § § §

STATE OF TEXAS vs.

IN THE COUNTY CRMINAL COURT __________ OF ___________ COUNTY, TEXAS

DEFENDANT’S MOTION TO SUPPRESS COMES NOW the Defendant in the above-styled and numbered cause and files this Motion to Suppress requesting and pleading the following: I. Defendant has been charged with the offense of Driving While Intoxicated ______. II. Law enforcement officials approached, detained, searched, and/or arrested Defendant in DALLAS COUNTY, Texas without a warrant. SPECIFICALLY, __________________________ENTER SPECIFIC REASON FOR MOTION. III. A detention of the Defendant’s person resulted and evidence was obtained. Which Defendant anticipates will be offered as evidence against him in any trial of the charge(s). IV. Defendant would object to the admission of this evidence from any stop, search, detention, warrant, or arrest under the Fourth and Fourteenth Amendments to the United States Constitution. V. Defendant would object to the admission of this evidence from any stop, search, detention, warrant, or arrest under Article I, Section 9 of the Texas Constitution as well as Article 1.06, 14, 18, and Article 38.23 of the Texas Code of Criminal Procedure. VI. Defendant would also request a formal hearing before trial for the Court to consider these issues. REQUEST Defendant’s Motion to Suppress Page 1 of 2

Defendant asks that this Court issue an order suppressing all of the illegally obtained evidence.

Respectfully submitted,

____________________________________

ATTORNEY FOR DEFENDANT

CERTIFICATE OF SERVICE I hereby certify that a true copy of the foregoing motion was personally served upon/mailed to the District Attorney's Office on the same date that it was filed with the trial Court.

__________________________________

Defendant’s Motion to Suppress Page 1 of 2

CAUSE NO. _________ § § § § §

STATE OF TEXAS vs.

IN THE COUNTY CRMINAL COURT ______________ OF ___________ COUNTY, TEXAS

ORDER On ________________________________ , the Court considered Defendant's Motion to Suppress and the Court rules as follows: GRANTED DENIED

(under both State and Federal grounds) to which Defendant objects.

Defendant would request formal written Findings of Fact and Conclusions of Law per State v. West, No. 05-99-00910-CR (Tex.App.-Dallas [5th Dist.] 2000) where Judge Kerry P. Fitzgerald stated, “that the unsuccessful party would be well advised to request findings of facts and conclusions of law from the trial court” and State v. Cullen, 195 S.W. 3d 696 (Tex. Crim. App. 6/28/2006) where the Court states that upon request by the losing party a court SHALL provide finding of fact and conclusions of law. Therefore, the Court makes the following Findings of Fact and Conclusions of Law in a separate memorandum to be provided to Defense Counsel within _________ days for purposes of appeal.

______________________________ JUDGE PRESIDING

Defendant’s Motion to Suppress Page 1 of 2

CAUSE NO. ________________ § § § § §

STATE OF TEXAS vs.

IN THE COUNTY CRMINAL COURT __________ OF ___________ COUNTY, TEXAS

Defendant asks that this Court issue an order suppressing all of the illegally obtained evidence.

Respectfully submitted,

____________________________________

ATTORNEY FOR DEFENDANT

__________________________________

Defendant’s Motion to Suppress Page 1 of 2

CAUSE NO. _________ § § § § §

STATE OF TEXAS vs.

IN THE COUNTY CRMINAL COURT ______________ OF ___________ COUNTY, TEXAS

ORDER On ________________________________ , the Court considered Defendant's Motion to Suppress and the Court rules as follows: GRANTED DENIED

(under both State and Federal grounds) to which Defendant objects.

______________________________ JUDGE PRESIDING

Defendant’s Motion to Suppress Page 1 of 2

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Top Tactics on Blood Drug Testing Speaker:

Andreea Ionescu 15930 Oak Mountain Houston, TX 77095 (832) 509-0222 Phone andreea@aitexaslaw.com email

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

Top Tactics on Drug Blood Testing Andreea Ionescu andreea@aitexaslaw.com

“You cannot get a DWI unless you have alcohol in your system!” I have lost count of how many times I have heard clients, friends, acquaintances, etc say that. And the shocked look on their faces is always the same when they learn that you can get a DWI on prescription medication. DWI drug cases used to be a rarity not too long ago. But nowadays, there are more and more common.

We will talk about areas to challenge in blood analysis when defending DWI drug cases.

1. It all starts in voir dire Because in Texas we don’t have “per se” values in DWI drug cases, it always comes down to not having mental and physical faculties, so it is crucial, that you start laying the ground for what normal is for a person that is/has been using drugs for an extended period of time.

A. How many people are on prescribed medication? At least half the panel will raise their hand. Discuss with them: -

What kind of medication are they taking? (some people will not be comfortable discussing this, but most will) What dose? For how long? What was their starting dose, and what is their current dose?

When you first starting that medication - how did it affect them?

Did that change over time? How?

Did their dose get increased at a certain point?

What happens if you don’t take your medication? 1

Are they fully functional while on their prescribed dose?

Have this conversation with 1-2 people. They will mostly say the same thing which is that they started on a lower dose, it worked in the beginning, and as time went by, they built tolerance and they had to have their dose increased to have the therapeutic benefits of the drug they are taking. They will also tell you that they are fully functional while taking their prescribed dose

But… the most important question is “What happens if you don’t take your medication?” Why? Because majority of time they will tell you that they are not themselves when they don’t take their medication. What does that mean? That means that they have their normal mental and physical faculties when THEY ARE ON THEIR MEDICATION!

Then ask the panel - how many people here believe that you can be arrested for DWI if you take your prescription medication (as prescribed by your doctor), and get in your car and drive? You will get shocked looks every time. Establishing what is normal for a person who takes higher doses of a prescribed medication will help you later when discussing with the analyst about tolerance. The jurors will have already heard from people on their panel that tolerance happens, and people function well on higher medication.

2. What to discuss with the State’s analyst There are many areas that can be addressed during the cross of the analyst, but you cannot possibly cover them all. I always pick 2-3 issues and discuss those. I try to make it as simple as I can for the jurors.

A. Bound vs. unbound drugs in blood When one consumes a drug, the drug will either bind to plasma protein or red blood cell, or remain unbound in plasma water. It is generally assumed that only the unbound drug interacts with the receptor exerting the pharmacological effect.

(Source: The bioanalytical challenge of determining unbound concentration and protein binding for drugs. Bioanalysis. 2013 Dec;5(24):3033-50. doi: 10.4155/bio.13.274. PMID: 24320129.)

Figure 1 illustrates the equilibrium processes between unbound and bound in blood and tissue. The unbound concentration in plasma will be the same as the unbound tissue 3

concentration if transporters, metabolism and bulk flow are not influencing the equilibrium. The equilibrium is affected by changes in PH, temperature, drug concentration, protein concentration, and the concentration of other drugs present

The 2 most common binding proteins are (1) albumin, and (2) 𝞪1-acid glycoprotein (𝞪1-AGP).

Albumin ●

Accounts for almost 60% of the total protein content in plasma

●

It changes based on factors like temperature, pH, and ionic strength

●

The concentration of albumin can be affected by being dehydrated, certain medication (e.g insulin, steroids, hormones), pregnancy, acute and chronic inflammatory responses, as well as severe injuries and surgery

●

Albumin’s 2 main binding sites are warfarin site and benzodiazepine site. The warfarin site is pH dependent.

𝞪1-AGP -

Levels of 𝞪1-AGP can be affected by infection, inflamation, cardiovascular disease, obesity, severe injuries, trauma, burns and steroids and other drugs

Has only one binding site

The levels of albumin and 𝞪1-AGP in blood are very important because they contribute to determining how much of the dose administered has the pharmaceutical effects on the person taking it. The percentage of the dose that binds to protein in the blood has no pharmacological effect.

Levels for both albumin and 𝞪1-AGP are affected by what is going on in our body (medical conditions, pregnancy, injuries, inflammatory responses, etc). So, if the person whose blood is drawn for DWI drug analysis, has a medical condition, let’s say for example, has a high inflammatory response, how is the analyst going to be able to determine (1) the concentration of protein in the person’s blood, and (2) how much of the dose was bound to protein, and how much was unbound? The only way that can be done is for the blood to be analyzed for bound and unbound concentrations immediately after it was drawn.

Effects of temperature and pH on protein binding

The commonly accepted human body temperature is 37 ℃ and the pH in circulating plasma is 7.40±0.05. The blood pH is regulated with dissolved CO2 . When blood is collected, CO2 is immediately lost. In fresh blood, the pH increases 0.1-0.2 units.

After freezing-storage-thawing of the plasma, the pH is often around 8, and after long term storage sometimes even above 9. For both albumin and 𝞪1-AGP the ratio between the unbound concentration and the total concentration increases or decreases based on the pH levels.

Another thing that affects the ratio between the unbound concentration and the total concentration is temperature. An increase in temperature increases the ratio between the unbound concentration and the total concentration.

How is this important for DWI drug blood testing? Considering the fact that the pH levels increase as soon as the blood leaves the body, and sometimes the blood doesn’t get refrigerated until later on, unless the blood is restored to the temperature and pH it was at in 5

the body, it is practically impossible for an analyst to determine what the the ratio between the unbound concentration and the total concentration is at the time of the blood draw. No lab that I have seen during my practice ever tested bound vs unbound drug levels in blood, nor did they acknowledge or differentiate between bound and unbound drug levels in blood

So the question is - is there a way to (1) restore the blood to the way it was when it was drawn and (2) separate the bound to protein (no pharmaceutical effect) from unbound (pharmaceutical effect). Yes there is! 1. Restore the blood to physiological conditions of 37℃ and a pH of 7.40±0.05 A very easy and convenient process is to use CO2,, an incubator with controlled temperature and humidity and simply restore the original CO2 at 37℃. The appropriate concentration and incubation time depend on the surface area/volume ration for the plasma sample and must be determined at every set up 2. The 2 most common methods are (A) Equilibrium Dialysis and (B) Ultrafiltration A. Equilibrium Dialysis (ED) Two chambers are separated by a semipermeable membrane. Plasma is placed in one chamber, and a buffer in the other chamber. The buffer should be as similar as plasma water as possible and usually isotonic phosphate-buffered saline (PBS: pH7.4) is used. After dialysis for 4-24 hours, equilibrium will be reached and the drug concentration in the buffer will be the same as the unbound concentration in the plasma chamber

B. Ultrafiltration

The plasma sample is transferred to the upper part of a two piece container divided by a filter with a molecular weight cut off, and, after centrifugation, the unbound drug concentration is determined in the resulting protein free ultrafiltrate.

We are not going to discuss these methods in detail, as none of the labs I have ever gotten blood tests from use this. I wanted to mention these methods as an illustration that there are ways to separate unbound from bound drug concentrations in the blood, and in order for labs that are doing forensic analysis to be able to accurately report on a number that will be used to establish the pharmacological effect of a drug on person, they should at least try to make sure they test for unbound drug concentrations only.

How can this help us defend drug DWI cases? Well, if there is one thing that is clear, it is that with the way drug blood testing is done in forensic labs, there is no scientifically reliable way for an analyst to say how much of the dose was in fact unbound at the time of the blood draw. And if they can’t determine that, how can that analyst opine with any degree of certainty what effect a certain dosage of the drug ingested has on a person.

B. Therapeutic levels of drugs

The therapeutic range of a drug is the dosage range or blood plasma or serum concentration usually expected to achieve the desired therapeutic effect. This does not mean that patients may not achieve benefit at concentrations below the minimum threshold, or may not experience adverse effects if kept within the range.

Often, when patients take a certain medication for an extended period of time, the dosage they started with is no longer sufficient to obtain the desired therapeutic effect. The dose has to be increased in order to achieve that. As time progresses, 7

many patients require a periodical increase in dose in order to obtain the desired therapeutic effect. (Source: Forest Tennant, M.D. Dr. PH Summary Report: Opioid Blood Levels in High Dose, Chronic Pain Patients. Practical Pain Management Journal, March 2006)

When testifying as to what dosage is considered therapeutic or toxic, most State analysts base their conclusions on therapeutic levels on the Winek Chart. The Winek Chart was compiled by Charles Winek, a former professor at Duquesne University in Pittsburg.

In his article titled “Winek's Drug & Chemical Blood-Level Data 2001”, Winek says that the data has been gathered from literature and from personal experience. Which literature exactly is he referring to? And what personal experience? Then, Winek says that these values can be affected by dose, route of administration, absorption differences, age and sex, tolerance, method of analysis, pathological or disease state, postmortem redistribution, etc. There are a lot of questions that have no answers for how Winek came up with his therapeutic level classifications. What were the age ranges of the subjects used to compile this data? What were their medical conditions? How long have they been taking this medication? What was their starting dosage? What was their current dosage? Were they fully functional while on their higher dosages? Were they able to be fully functional when not on medication?

Professor Forest Tenant, Head of the Arachnoiditis Research and Education Project in West Covina, Ca did a survey, titled “Opioid Levels in High Dose, Chronic 8

Patients” to see what the actual doses of pain medication were for people with chronic pain conditions who were fully functional. He asked a group of physicians to submit a data sheet (excluding the patient’s name) and report opioid blood concentrations in chronic pain patients treated with opiods. All patients were in chronic pain care administered by a physician. Patients had taken opioids for 1 to 50 years, with ages between 25 and 87. Approximately 55% of patients were females and 45% we male. Patients’ functional status included the ability to drive and work. After analyzing the data submitted, Tennant found that many opioid blood concentrations in fully functional patients were above therapeutic levels. Almost all patients demonstrated opioid tolerance since they could fully function and most could drive despite high opioid dosages and blood concentrations. Tenant further concluded that his survey clearly shows that patients become tolerant to high opioid dosages and can physically function well and possibly even work. A high opioid dosage cannot automatically be blamed for an unexpected death or accident based solely on opioid levels in the blood.

Below is a chart of published therapeutic levels, followed by a chart of results summary for opioid tolerant patients

(Source: Forest Tennant, M.D. Dr. PH Summary Report: Opioid Blood Levels in High Dose, Chronic Pain Patients. Practical Pain Management Journal, March 2006)

Looking at Tenant’s study, one can clearly see that saying that a certain dosage is in the therapeutic range, or in the toxic range, without taking into consideration the patient’s medical history, their history with that specific medication, how they tolerate the medication and whether they are fully functional even on higher dosages, is far from scientifically reliable. That is exactly what Winek’s chart is, a bunch of numbers with no context and no literature to back it up. Yet, the State’s analysts rely on it to further their “science.”

C. Drugs and their metabolites When someone consumes a drug, that drug must pass through the liver where it gets metabolized. Once in the liver, enzymes convert prodrugs to active metabolites or active drugs to inactive metabolites.

Knowing what drugs metabolize in is very important when defending DWI drug cases because the presence, or absence of certain metabolites, can not only reveal issues with the testing itself, but can determine the effect that particular dose had on the individual.

A.W. Jones in his study “Concentrations of Scheduled Prescription Drugs in Blood of Impaired Drivers: Considerations for Interpreting the Results” looked at what factors can influence the concentration in blood as a matter of dose, and how is that important to whether a person has overdosed or abused a particular psychoactive medication. (Source: Jones AW, Holmgren A, Kugelberg FC. Concentrations of scheduled prescription drugs in blood of impaired drivers: considerations for interpreting the results. Ther Drug Monit. 2007 Apr;29(2):248-60. doi: 10.1097/FTD.0b013e31803d3c04. PMID: 17417081.)

In this study, A.W. Jones looked at DWI cases from several European countries from 20042005 ( a total of approximately 14500 cases) in order to determine how to establish levels of 11

concentrations in drugs for drug DWIs. His conclusion was that it is difficult to establish threshold limitations (aka therapeutic levels) because of weak concentration effect relationships and because of the development of tolerance over long term therapy.

A.W. Jones also looked at how most common drugs found in DWI drug cases metabolize and what does that mean in interpreting lab testing results. For example, Diazepam metabolites in Nordiazepam. Nordiazepam has a much longer half life than Diazepam, so after repeated use, Nordiazepam levels will accumulate and surpass the levels of Diazepam. Finding low levels of both Diazepam and Nordiazepam suggests fairly recent use. However, Nordiazepam without Diazepam suggests that a significant amount of time has passed since use of Diazepam. As another example, Codeine and Heroin metabolize in Morphine. Morphine is by itself a prescription drug. Nonpharmaceutical heroin contains acetyl codeine as an impurity, and this compound undergoes deacetylation into codeine. The presence of codeine and morphine in blood could mean that a person took a tablet of codeine or had snorted heroin, because both drugs metabolize in morphine. According to A.W. Jones, when both the initial drug metabolizes into a psychoactive metabolite, some labs add the concentration together.

What does all this mean? It means that interpreting the concentration of a prescription drug in someone’s blood can be a difficult task without knowing much more about the person taking the drug, what dosage are they taking, how long have they been taking it, the ratio of unbound to total concentration in blood, the route of administration, etc.

Furthermore, labs that use blood testing to monitor therapeutic levels of drugs so they can properly prescribe a certain dosage to patients, use primarily plasma or serum. However, in forensic testing, labs use whole blood, and blood samples taken in DWI cases contain sodium fluoride as a preservative. That works well when testing for alcohol. It is, however, problematic 12

for drug testing because sodium fluoride causes red cells to hemolysis which makes it impossible to obtain aliquots of cell free plasma for determination of drugs. Considering that most drugs bind to plasma protein, this calls into question the entire result of the blood testing done in a forensic laboratory.

If there is one thing to take from all this, is that an analyst in a state owned and operated lab cannot say with any degree of scientific certainty how a drug affected a person based solely on a blood test using whole blood, without performing all the other steps we discussed above.

ORIGINAL ARTICLE

Concentrations of Scheduled Prescription Drugs in Blood of Impaired Drivers: Considerations for Interpreting the Results A. W. Jones, A. Holmgren, and F. C. Kugelberg

Abstract: We report the concentrations of scheduled prescription drugs in blood samples from people arrested in Sweden for driving under the influence of drugs (DUID). The investigation covered a 2 year period 2004 (N = 7052 cases) and 2005 (N = 7759 cases) and was prompted by recent legislation stipulating zero-concentration limits in blood for controlled substances. However, prescription drugs are exempt from the zero-limit law provided that the medication was being used in accordance with a doctor’s prescription. The blood concentrations of various psychoactive substances were compared with the limits of quantitation of the analytic method used and the socalled therapeutic concentration range according to various reference books and tabulations. Diazepam [N = 1950 (26%)] and nordazepam [N = 2168 (28%)] were the therapeutic agents most frequently identified in these forensic blood samples along with other benzodiazepines such as alprazolam [N = 430 (5.6%)], flunitrazepam [N = 308 (4.0%)], and nitrazepam [N = 222 (2.9%)]. The newer hypnotics, exemplified by zolpidem [N = 148 (1.9%)] and zopiclone [N = 111 (1.5%)], were also high on the list of psychoactive substances identified. Interpreting the concentration of a prescription drug in blood in relation to whether the person had taken an overdose or was abusing the substance in question is not always easy. The age, gender, degree of obesity, and ethnicity of the person concerned; the pharmacokinetic profile of the drug; polymorphism of drugmetabolizing enzymes as well as liver and kidney function and blood hematocrit need to be considered. Among preanalytic factors, stability of the drug in blood after sampling, the type of tubes and preservatives used, the dosage form and route of administration deserve consideration. When therapeutic drug monitoring concentrations are compared with forensic toxicology results, then the plasma-to-whole blood distribution ratio of the drug also needs to be considered. In blood samples from DUID suspects, the concentrations of many commonly used sedatives and hypnotics exceeded the accepted therapeutic limits, which gives an indication of the abuse potential of these types of medications. Key Words: driving, DUID, prescription medication, scheduled drugs, therapeutic drug monitoring (Ther Drug Monit 2007;29:248–260) Received for publication November 14, 2006; accepted January 9, 2007. From the Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, Linköping, Sweden. Supported in part by a grant from the Milan Valverius Foundation. Correspondence: A. W. Jones, Department of Forensic Genetics and Forensic Toxicology, National Board of Forensic Medicine, Artillerigatan 12, SE-581 33 Linköping, Sweden (e-mail: wayne.jones@RMV.se). Copyright Ó 2007 by Lippincott Williams & Wilkins

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n efforts to combat driving under the influence of drugs (DUID) and to simplify the prosecution of offenders, several countries in Europe (eg, Belgium, Finland, France, Germany, Poland, and Sweden) have introduced zero-concentration limits in blood for illicit drugs.1–3 Under this statute, there is no need to prove that a driver was under the influence or impaired by drugs because the evidence in the prosecution case is primarily the analytic toxicology report. If the concentration of an illicit drug in blood is above the limit of quantitation (LOQ) of the analytic method used, this is sufficient evidence to charge a person with DUID.1 Besides driving under the influence of an illicit drug, the Swedish zerotolerance law also includes prescription drugs if these are classified as controlled substances.1 However, a person is exempt from prosecution if the blood concentration of a prescription drug is within the range expected for normal therapeutic use. To convict a person for driving under the influence of a prescription drug, the prosecution has to prove the driver was impaired by drugs or that the concentration in blood was higher than expected for normal therapeutic use, implying that the person had taken an overdose or was abusing the medication in question.1 This requires expert evidence to explain the drug’s pharmacokinetic and pharmacodynamic profile and the factors that can influence the concentration in blood as a function of dose. Such parameters as age, gender, ethnicity, and genetics as well as the role of liver and kidney function, plasma protein binding, and the distribution ratio between plasma and whole blood are considered.4 Controlled dosing studies show large individual variations in peak concentrations (Cmax) and steady-state concentrations (Css) after long-term therapy depending on the half-life of the drug, the dose interval, and other factors.1 We report the spectrum of scheduled prescription drugs identified in blood samples from people arrested in Sweden for DUID. The mean, median, and highest concentration of the various substances are compared with the LOQ of the analytic methods used and the therapeutic concentration range according to various tabulations.5–10 We also discuss issues related to interpretation of the analytic results when a statement is made as to whether a person had overdosed or abused a particular psychoactive medication.

MATERIALS AND METHODS All blood specimens from people suspected of driving under the influence of alcohol and other drugs in Sweden are sent to one central laboratory for toxicologic analysis (National Ther Drug Monit Volume 29, Number 2, April 2007

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Laboratory of Forensic Chemistry, Linköping, Sweden). The first suspicion of impaired driving arises when a motorist is stopped by the police for a traffic violation such as speeding or after involvement in a crash or in connection with a routine sobriety control. The investigation starts with a roadside breathalcohol screening test and if this test is negative, the police have to decide whether the person’s appearance and behavior indicate that other drugs might be involved. Any unusual or erratic behavior along with a negative breath-alcohol test (BAC ,0.2 g/L), suggests that other psychoactive drugs might have been taken. The police also examine the driver’s eyes to record reaction to light and pupil size (dilated or constricted), whether the eyes were bloodshot or glassy, and also the presence of any gaze nystagmus. Specimens of venous whole blood are taken by a nurse or physician with the aid of Vacutainer tubes (2 3 10 mL) that contain 100 mg sodium fluoride and 25 mg potassium oxalate as preservatives (Terumo Europe NV, Leuven, Belgium). Blood is drawn from an elbow vein and two tubes are filled in rapid succession and are immediately inverted several times to mix the blood and chemical preservatives. The police also make an effort to collect a specimen of urine and each suspect is required to empty their bladder into a beaker and a 10 mL aliquot of the specimen is sent for analysis in a tube containing NaF (1%) as preservative. The specimens of urine and/or blood (1 mL) undergo a broad screening analysis for five classes of abused drugs (opiates, cannabinoids, amphetamine analogs, cocaine metabolites, and some benzodiazepines).10,11 Urine is the specimen of choice for drug screening if a sample is available. However, people cannot be forced to urinate and some refuse to comply or fail to void. In this case drug screening is performed on the blood sample instead. If urine is used for screening analysis and the specimen is unusually diluted, as indicated by creatinine content, a decision is made to screen for drugs in the blood sample. Blood samples are subjected to protein precipitation and solvent extraction before analysis by immunoassay using EMIT or CEDIA reagents run on an ADVIA 1650 instrument from Bayer (Health Care Diagnostics, Tarrytown, NY).10,11 All positive results from the screening analysis undergo verification by more specific methods (GC-NPD, LCMS, and GC-MS).11,12 When opiates are detected, the samples are not subjected to hydrolysis, so the free drug concentrations of morphine and codeine are determined in blood samples. Because the immunoassay is not sensitive to many prescription drugs (eg, clomethiazole, zolpidem, zopiclone, and flunitrazepam), these substances are determined in blood samples by capillary gas chromatography with N-P detector as described elsewhere.11,12 The analytic LOQ differ for different substances, and this depends on the laboratory involved and the method of analysis used. If the concentration of an abused drug is found to be above the upper limit of the standard curve, then the analysis is repeated starting with a smaller volume of blood (0.5 or 0.25 mL) after adding drug-free blood to give 1 mL of starting material. Although the aliquots of blood used for analysis of drugs in this project were weighed (1 g), the concentrations are reported here as milligrams per liter to comply with international standards. q 2007 Lippincott Williams & Wilkins

Prescription Drugs in Blood of Impaired Drivers

The material for this study consisted of all cases of DUID over a 2 year period, 2004 (N = 7052) and 2005 (N = 7759). The types of scheduled prescription drugs in the blood samples and the concentrations present were obtained from our in-house database TOXBASE. The search criteria took no account of multidrug use and instead focused on the various prescription medications listed as controlled substances in Sweden. To assess whether the concentrations were high or low, we used information gleaned from compilations of therapeutic and toxic drug concentrations provided by The International Association of Forensic Toxicologists (TIAFT).13 This was done after adjusting for an uneven distribution of drug between serum and whole blood when such information was available.14–16

RESULTS Spectrum of Prescription Drugs in Blood of Drivers Table 1 lists the scheduled prescription drugs identified in blood samples from people apprehended for DUID in Sweden during 2004 and 2005. A few psychoactive drugs are not shown in Table 1 because they occurred only once or twice over the study period (eg, bromazepam, zaleplon). Furthermore, nonscheduled drugs such as caffeine, aspirin, paracetamol, and newer antidepressants (selective serotonin reuptake inhibitors) are also omitted. The drugs are listed in rank order of the number of times they were identified in blood samples at concentrations above LOQ for our laboratory method (also shown). The mean, median, and highest concentration of each drug is given along with the most important indication for prescribing the medication as well as the current Swedish classification as a controlled substance. Sedative/hypnotics, particularly benzodiazepines (diazepam, alprazolam, flunitrazepam, and nitrazepam), dominate (67%) as might be expected from many previous publications dealing with drug-impaired driving.17–20 Highly prevalent too were the newer hypnotics such as zopiclone (1.5%) and zolpidem (1.9%), which are becoming widely prescribed for insomnia and should be taken just before bedtime and never used when skilled tasks such as driving are performed.21,22 Figure 1 gives the frequency distributions for the concentrations of zolpidem (upper plot) and zopiclone (lower plot) in blood samples from DUID suspects. The skewed nature of these distributions is obvious and the mean and median concentrations are fairly high compared with the therapeutic peak concentration (see Appendix).22 Indeed, finding a therapeutic concentration of zolpidem or zopiclone in blood can be considered suspect and suggests that the medication was used at the wrong time of day.22,23 These hypnotic drugs are intended to be taken just before bedtime and their short half-lives ensure that negligible concentrations remain in blood the next morning after an 8 hour sleep.

Concentrations of Parent Drug and Active Metabolite Several of the drugs in Table 1 are metabolized into pharmacologically active products,24 namely diazepam/nordazepam,25 codeine/morphine,26 and carisoprodol/meprobamate.27

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TABLE 1. Concentrations of Scheduled Prescription Drugs in Blood Samples From Driving Under the Influence of Drugs Suspects Apprehended in Sweden During 2004 and 2005 Substance Nordazepam‡ Diazepam Morphine§ Codeine§ Alprazolam Flunitrazepam Nitrazepam Clonazepam Zolpidem Methadone Zopiclone Tramadol Carbamazepine Carisoprodol Meprobamatek Oxazepam Ephedrine Propoxyphene Ethylmorphine Buprenorphine Phenobarbital Alimemazine Hydroxyzine Promethazine Phenytoin Chlordiazepoxide Midazolam Chlorzoxazone Clomethiazole

No. (%) 2168 1950 864 617 430 308 222 164 148 114 111 105 69 66 63 49 47 38 25 16 14 12 10 6 5 4 4 3 3

(28) (26) (11) (8.0) (5.6) (4.0) (3.0) (2.1) (1,9) (1.5) (1.5) (1.4) (0.9) (0.9) (0.8) (0.6) (0.6) (0.5) (0.3) (0.2) (0.2) (0.2) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1) (0.1)

Mean (mg/L)

Median (mg/L)

Highest (mg/L)

LOQ* (mg/L)

0.33 0.36 0.049 0.045 0.09 0.018 0.12 0.05 0.31 0.26 0.10 0.85 3.6 3.9 15.7 1.12 0.21 0.17 0.095 0.0022 9.9 0.16 0.17 0.13 9.7 1.1 0.078 3.0 0.43

0.2 0.2 0.03 0.01 0.06 0.014 0.05 0.04 0.2 0.2 0.06 0.4 2.4 2.8 11 0.8 0.1 0.1 0.03 0.001 3 0.075 0.08 0.09 10 0.3 0.065 1.7 0.4

5.2 6.2 1.6 1.0 3.9 0.12 1.76 0.32 3.48 1.1 0.41 7.6 14 11.9 64 5.7 1.3 0.7 0.82 0.009 48 0.9 0.4 0.3 20 3.5 0.15 5.7 0.7

0.05 0.05 0.005 0.005 0.02 0.005 0.02 0.02 0.03 0.05 0.02 0.05 0.5 0.2 5 0.1 0.05 0.05 0.005 0.0002 1 0.05 0.05 0.05 0.5 0.2 0.02 1 0.02

Therapeutic Drug Category and Classification† Anxiolytic IV Anxiolytic IV Narcotic analgesic II Narcotic analgesic II Anxiolytic IV Hypnotic II Hypnotic IV Anticonvulsant IV Hypnotic IV Narcotic analgesic II Hypnotic V Narcotic analgesic6 Anticonvulsant6 Muscle relaxant IV Anxiolytic/sedative IV Anxiolytic IV Decongestant/bronchodilator{ Narcotic analgesic III Narcotic analgesic III Narcotic analgesic IV Sedative/hypnotic IV Antihistamine, sedative, antipsychotic{ Antihistamine/anxiolytic{ Antihistamine/anxiolytic{ Anticonvulsant{ Anxiolytic IV Anxiolytic, sedative IV Muscle relaxant{ Hypnotic, sedative V

*Limit of quantitation (LOQ) for the analytic method used. †According to the Swedish drug classification system. ‡Active metabolite of diazepam and other benzodiazepines. §Most probably metabolites of illicit heroin. k Active metabolite of carisoprodol. {Not listed as a controlled substance but considered dangerous to use when skilled tasks such as driving are performed.

Nordazepam might have arisen as a metabolite of some other benzodiazepines that are not registered in Sweden (eg, clorazepate). Table 2 gives a breakdown of the results for diazepam (D) or nordazepam (ND) when these substances occurred alone or together in blood samples. ND has a much longer half-life than D so, after repeated intake, concentrations of ND accumulate and surpass those of D.28 Finding D with ND below LOQ suggests fairly recent intake of D and that the metabolite has not had time to accumulate.29 Those instances in which ND was found without D suggest that an appreciable time has elapsed since the last use of the medication containing diazepam.29,30 This follows because of the much longer half-life of ND (approximately 60 hours) compared with D (approximately 30 hours).31 Interpreting the concentrations of morphine and codeine in blood is complicated because morphine itself is a prescription drug and is also a metabolite of both heroin and codeine.32,33 Heroin is a highly addictive illicit drug currently

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used by many DUID suspects in the Nordic countries.34,35 Nonpharmaceutical heroin contains acetyl codeine as an impurity and this compound undergoes deacetylation into codeine.36 Accordingly, the source of morphine and codeine in forensic blood samples is not always easy to resolve. Support for abuse of heroin comes from the unequivocal finding of 6acetylmorphine (6AM) in blood or urine, which is a specific metabolite of heroin and is itself pharmacologically active.37 The number of instances of finding 6AM in blood and/or urine, thus giving convincing proof of the extent of heroin use by DUID suspects, is reported in Table 3. The third example of a prescription drug undergoing conversion to an active metabolite is the centrally active muscle relaxant carisoprodol, which is metabolized by CYP2C19 into meprobamate.38 Meprobamate was once widely prescribed as a sedative but is no longer registered in Sweden. Accordingly, finding meprobamate in blood of DUID suspects invariably means that the person was medicated with the prescription q 2007 Lippincott Williams & Wilkins

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TABLE 2. Interrelationships Between the Concentrations of Diazepam and Its Active Metabolite Nordazepam in Blood Samples From Driving Under the Influence of Drugs Suspects in Sweden Drug Combinations

No.

Mean (mg/L)

Median (mg/L)

Highest (mg/L)

Diazepam (all cases) Nordazepam (all cases) Diazepam with nordazepam Diazepam only* Nordazepam only†

1,950 2,168 1,708 242 460

0.36 0.33 0.39 0.125 0.10

0.2 0.2 0.2 0.09 0.08

6.2 5.2 6.2 1.5 1.1

*Concentration of nordazepam in blood below 0.05 mg/L—the LOQ of the method. †Concentration of diazepam in blood below 0.05 mg/L—the LOQ of the method. LOQ, limit of quantitation.

its derivatives (methamphetamine, ecstasy), cannabis (THC), cocaine, and GHB tend to receive most attention in published surveys of DUID in different countries.34,43–46 Knowledge about legitimate or illicit sources of amphetamine and methamphetamine in blood warrant consideration because some prescription medications are metabolized into these illicit drugs (see review by Musshoff).47 This complicates interpretation of the results when conventional analytical methods are used. Immediately after the zero-limit law was introduced in Sweden, the number of blood samples submitted by the police for toxicologic analysis began to increase and this increase has continued ever since. Statistics show that in approximately 80% to 85% of cases, one or more banned substances is present with illicit drugs such as amphetamine dominating.45 In many drug-negative cases (30–50%), ethanol is present at concentrations above the legal limit for driving in Sweden (0.20 mg/g or 0.20 g/L). Polydrug abuse is the norm among DUID suspects and a scheduled prescription drug often occurs together with an illicit drug such as amphetamine or THC.18 Under these circumstances, the concentration of the prescription drug (eg, diazepam or flunitrazepam) does not need FIGURE 1. Frequency distributions of the concentrations of the newer hypnotic drugs zolpidem (upper plot) and zopiclone (lower plot) in blood samples from impaired drivers apprehended in Sweden.

drug carisoprodol (Table 4).27,38 Because both meprobamate and carisoprodol are pharmacologically active, some investigators add the concentrations together and this information is also included in Table 4.27

DISCUSSION Most previous articles dealing with drug-impaired driving have focused on the various substances identified in blood and the relative frequencies of their occurrence.35,39–41 Much less attention has been given to the actual concentrations present and how these should be interpreted in relation to the dose taken or the impairment of skilled tasks related to driving.4,42 Furthermore, illicit drugs such as amphetamine and q 2007 Lippincott Williams & Wilkins

TABLE 3. Concentrations of Morphine and Codeine Either Alone or Together With 6-acetylmorphine in Blood Samples From Driving Under the Influence of Drugs Suspects Apprehended in Sweden Drug Combinations

No.

Mean (mg/L)

Median (mg/L)

Highest (mg/L)

Morphine (all cases) Morphine only Morphine with 6AM* Morphine with codeine Codeine (all cases) Codeine only Codeine with 6AM* Codeine with morphine

864 365 204 295 617 246 76 295

0.049 0.024 0.053 0.078 0.045 0.063 0.014 0.037

0.03 0.02 0.02 0.06 0.01 0.03 0.01 0.01

1.6 0.43 1.13 1.6 1.0 1.0 0.1 0.93

*6AM, 6-acetylmorphine present in blood above the limit of quantitation of the method—0.005 mg/L.

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TABLE 4. Concentrations of Carisoprodol and Its Metabolite Meprobamate in Blood of Driving Under the Influence of Drugs Suspects and the Sum of the Two Concentrations Drug

No.

Mean (mg/L)

Median (mg/L)

Highest (mg/L)

Carisoprodol Meprobamate Meprobamate only* Sum of carisoprodol + meprobamate

66 63 8 63

3.9 15.7 8.1 19.6

2.8 11.0 8.0 13.8

11.9 64.0 14.0 75.9

*Concentration of carisoprodol below the limit of quantitation of the method—0.2 mg/L.

to be interpreted because the prosecution case focuses on the presence of the illicit drug.1 It is not illegal to drive after legitimate use of a scheduled prescription drug if the concentration is within the therapeutic range and the person shows no evidence of any drug-related impairment. However, many studies have shown that even therapeutic doses of sedative–hypnotics and centrally acting opiate analgesics impair the performance of skilled tasks and have untoward effects on a person’s behavior.48–54 This constitutes a problem for traffic safety, especially when such medication is used for the first time or at inappropriate times of the day in relation to the time of driving. The Swedish government therefore included scheduled prescription drugs in the zero-limit legislation.1 Table 1 lists the 29 most common scheduled prescription drugs in blood samples from DUID suspects apprehended over a 2 year period. Benzodiazepines such as diazepam, alprazolam, flunitrazepam, nitrazepam, clonazepam, and oxazepam dominate this list in terms of the frequency of occurrence. The newer hypnotics zolpidem and zopiclone are also highly prevalent. The presence of morphine and codeine probably originates from the illicit use of heroin (see ‘‘Results’’ for details). The opioids methadone, tramadol, and buprenorphine are also common findings either alone or together with other drugs. Note that methadone and buprenorphine are available on prescription in Sweden as substitution therapy to treat heroin addiction. The other prescription drugs listed in Table 1 represent only a small fraction of the total findings and are, thus, an insignificant problem for road traffic safety. Interpreting the concentration of a prescription drug in blood in relation to the dose taken and the time of last use is fraught with difficulties and many toxicologists shy away from this question. Making an unequivocal statement that the concentration is higher than expected for normal therapeutic usage is not so easy. Controlled dosing studies show large inter- and intraindividual variations in blood or plasma concentrations for the same dose of drug and route of administration.55–58 The peak concentration (Cmax) after a single dose will not necessarily be the same as the steady-state concentration (Css) after repetitive dosing owing to accumulation depending on dose interval and half-life of the drug.59 For drugs with long half-lives, the accumulation in blood is slow but the extent of accumulation is appreciable. After multiple dose therapy, Css ... Cmax after a single dose and the reverse holds for drugs with short half-lives.59

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When the hypnotic flunitrazepam (5 mg) was taken on an empty stomach, Cmax was 0.0107 mg/L compared with 0.004 mg/L when the same dose was taken after a meal.60 Demographics of the patient, including age, gender, obesity, ethnicity as well as various drug–drug interactions should be considered when the analytic results are interpreted.61–64 Liver and kidney function deteriorates with advancing age and this is considered when a physician prescribes medication to the elderly.65,66 People in need of palliative care receiving longterm treatment with strong analgesics can seemingly tolerate unusually high concentrations of, eg, opiates, well above normal therapeutic concentrations and do not necessarily represent a danger for traffic safety.67 Opiates are a diverse group of pharmaceutical agents with high abuse potential and toxicity after taking an overdose.68 Heroin is not available on prescription in Sweden. The presence of codeine and morphine in blood could mean that a person took a tablet of codeine or had snorted heroin, because both drugs are metabolized into morphine.33 Definite proof that heroin was taken comes from finding 6AM in blood or urine as found in 280 instances over a 2 year period.37 Another clue for heroin abuse is given by the finding of a morphine-to-codeine concentration ratio in blood above unity (1.0).33 After subjects received 100 mg codeine phosphate, the morphine-to-codeine concentration ratio in plasma was much less than 1.0 and remained so for up to 23 hours.32 Many of the drugs presented in Table 1 are metabolized by cytochrome P450 (CYP) enzymes, some of which are polymorphic (eg, CYP2D6 and CYP2C19).68–71 Codeine is demethylated by the action of CYP2D6 to produce morphine, which is considered responsible for the analgesic effect of codeine.72 Depending on the genotype inherited, either a strong effect (slow metabolizers) or weak response to medication (rapid metabolizers) is possible.73,74 The particular genotype a person inherits has sometimes had serious clinical consequences after regular use of codeine as a mild analgesic or antitussive medication.75 Other examples of pharmacogenetics include conversion of carisoprodol to meprobamate through CYP2C19, which is also polymorphic.38 Ethnic differences in drug metabolism might be another explanation for finding an unusually high concentration of a prescription drug or its metabolite in blood samples.61,69 The potential for drug–drug interactions should not be overlooked, especially in the elderly in whom polypharmacy is very common. This might be caused by displacement of one drug by another at plasma protein-binding sites or competition for metabolizing enzymes, leading to induction or inhibition of drug metabolism.76–78 Laboratories devoted to therapeutic drug monitoring mostly determine drugs in plasma or serum with a few exceptions (eg, cyclosporine and tacrolimus). This stands in sharp contrast to work performed in forensic toxicology laboratories, particularly those dealing with medical examiner cases. The composition of forensic blood specimens submitted for analysis can vary widely (eg, lipid content, fluidity, water content, and presence of clots).16 The blood samples taken from DUID suspects are also used for determination of ethanol and they therefore contain sodium fluoride (1% w/v) as a preservative. This additive causes red cells to hemolysis q 2007 Lippincott Williams & Wilkins

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making it impossible to obtain aliquots of cell-free plasma for determination of drugs.16 Many of the drugs listed in Table 1, particularly the benzodiazepines, are highly bound to plasma protein, which has implications when forensic toxicology results are compared with therapeutic ranges based on analysis of plasma or serum.14,15 For protein-bound drugs such as diazepam, women will have a somewhat lower concentration in whole blood than men owing to gender-related differences in hematocrit.79,80 Likewise, any medical conditions that results in an abnormal red cell volume such as anemia or polycythemia also deserve consideration when the concentration of drugs are compared and contrasted between plasma and whole blood.81 The small interindividual variations in blood hematocrit have not until now been considered when forensic toxicology results are compared with therapeutic ranges based on therapeutic drug monitoring data. What should be considered when the concentration of a drug in whole blood is compared with the therapeutic range in plasma or serum and a decision made whether the person has overdosed? A good starting point is scientific papers reporting Cmax after a single therapeutic dose and Css after long-term therapy.82–84 Whenever possible, pharmacokinetic parameters should be considered in relation to age, gender, ethnicity, obesity, and any known liver or kidney dysfunction.59,61,62 External factors such as consumption of alcohol, alcohol-induced liver disease, smoking, use of contraceptive steroids, pregnancy, and concomitant use of other drugs might influence Cmax or Css under some circumstances.85–88 Pharmaceutical aspects such as the dosage form, whether tablet, syrup, or sustained-release product, as well as route of administration can have a large impact on Cmax for the same dose of drug administered. Analytic considerations, particularly the condition of the specimen and the type of matrix, whether plasma, serum, or whole blood, are clearly important considerations owing to uneven distribution of drugs between plasma and red cells.14–16 In general, the concentration of a drug in plasma or serum is higher than in whole blood, especially for proteinbound drugs with some obvious exceptions such as the antimalaria drug chloroquine, which is preferentially concentrated in the erythrocytes.80 When the concentration of a drug in whole blood (forensic cases) is compared with the concentration in plasma or serum (therapeutic drug monitoring cases), this gives an advantage to the suspect when one has to decide whether the analytic result is suggestive of an overdose of the medication in question. The Appendix lists in alphabetical order the majority of scheduled prescription drugs found in blood samples from DUID suspects apprehended in Sweden. The structural formula of the drug is given along with the most common registered trade names. The number of occurrences of the various substances over a 2 year period is provided along with the mean, median, and highest concentrations encountered in blood. Drugs identified only once or twice over the study period are not included in the Appendix (eg, bromazepam, zaleplon, temazepam). Also listed are the therapeutic concentration ranges according to information gleaned from the TIAFT web site, which relates mainly to the drug concentration q 2007 Lippincott Williams & Wilkins

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measured in plasma or serum.13 The last column in the Appendix gives the percentage of cases for which the concentrations of specific drugs were judged to be above the therapeutic interval and was thus suggestive of an overdose or abuse of the medication.15,89,90 In compiling this information we have, whenever possible, used information about the distribution of the substance between plasma and whole blood. The concentrations of alprazolam (65%), flunitrazepam (22%), and zolpidem (36%) were often above the therapeutic Cmax concentration for these pharmaceutical agents, giving one indication of the abuse potential for this kind of sedative– hypnotic medication. The use of illicit drugs for pleasure is a criminal offence in most Western nations so the introduction of zeroconcentration limits in blood when driving was politically acceptable and well anchored in public opinion and not opposed by the media. People use recreational drugs to relieve inhibitions, experience euphoria, and escape from reality often with negative effects on performance and behavior. Before the zero-limit law was introduced, a DUID prosecution required tangible evidence that the person was impaired by a drug other than alcohol and was deemed a danger for traffic safety. The main prosecution evidence came from a clinical examination of each suspect in which a physician recorded signs and symptoms of drug influence. The results of the clinical examination often conflicted with the analytic toxicology report and no charges were brought or the person was acquitted if the case went to trial. Accordingly, the introduction of zero-concentration limits in blood for drugs listed as controlled substances has greatly simplified prosecution of DUID offenders.

CONCLUSION Antianxiety agents and sedative–hypnotics, mainly benzodiazepines and also various opiate analgesics, were the scheduled prescription drugs unequivocally identified in blood samples from impaired drivers in Sweden. The contribution of other pharmaceutical agents was relatively small or negligible and did not represent a particular problem for traffic safety. The notion of establishing threshold concentration limits in blood for certain drugs, akin to punishable blood alcohol limits (eg, 0.20 g/L or 0.50 g/L), or enacting graded penalties depending on drug concentration is hard to motivate owing to weak concentration-effect relationships and to the development of tolerance after long-term therapy. Zero-concentration limits or LOQ laws represent a much simpler and more pragmatic way to enforce DUID legislation compared with the traditional impairment laws making it a lot easier to convict an offender. REFERENCES 1. Jones AW. Driving under the influence of drugs in Sweden with zeroconcentration limits in blood for controlled substances. Traffic Inj Prev. 2005;6:317–322. 2. Walsh JM, de Gier JJ, Christopherson AS, et al. Drugs and driving. Traffic Inj Prev. 2004;5:241–253. 3. Moeller MR, Kraemer T. Drugs of abuse monitoring in blood for control of driving under the influence of drugs. Ther Drug Monit. 2002;24: 210–221. 4. Augsburger M, Donze N, Menetrey A, et al. Concentrations of drugs in blood of suspected impaired drivers. Forensic Sci Int. 2005;153:11–15.

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5. Repetto MR, Repetto M. Therapeutic, toxic, and lethal concentrations of 73 drug affecting respiratory system in human fluids. J Toxicol Clin Toxicol. 1998;36:287–293. 6. Repetto MR, Repetto M. Concentrations in human fluids: 101 drugs affecting the digestive system and metabolism. J Toxicol Clin Toxicol. 1999;37:1–8. 7. Winek CL, Wahba WW, Winek CL Jr. Drug and chemical blood level data. Forensic Sci Int. 2001;122:107–123. 8. Stead AH, Moffat AC. A collection of therapeutic, toxic and fatal blood drug concentrations in man. Hum Toxicol. 1983;2:437–464. 9. Uges DRA. Therapeutic and toxic drug concentrations. Bull Int Assoc Forensic Toxicol. 1996;26(Suppl):1–34. 10. Druid H, Holmgren P. A compilation of fatal and control concentrations of drugs in postmortem femoral blood. J Forensic Sci. 1997;42:79–87. 11. Jones AW, Karlsson L. Relation between blood– and urine–amphetamine concentrations in impaired drivers in relation to urinary pH and creatinine. Human Exp Toxicol. 2005;24:615–622. 12. Kronstrand R, Jones AW. Drugs of abuse; analysis. In: Siegel JA, Saukko PJ, Knupfer GC, eds. Encyclopedia of Forensic Sciences. London: Academic Press; 2000:598–610. 13. Uges DRA. TIAFT reference blood level list of therapeutic and toxic substances (last updated 2004). Available at: www.tiaft.org/tmembers/ ttvidx.html. Accessed October 6, 2006. 14. Osselton MD, Hammond MD, Moffat AC. Distribution of drugs and toxic chemicals in blood. J Forensic Sci Soc. 1980;20:187–93. 15. Jones AW, Larson H. Distribution of diazepam and nordiazepam between plasma and whole blood and the influence of hematocrit. Ther Drug Monit. 2004;26:380–385. 16. Skopp G. Preanalytic aspects in post-mortem toxicology. Forensic Sci Int. 2004;142:75–100. 17. Christophersen AS, Ceder G, Kristinsson J, et al. Drugged driving in the Nordic countries—a comparison study between five countries. Forensic Sci Int. 1999;106:173–190. 18. Jones AW, Holmgren A, Holmgren P. High concentrations of diazepam and nordiazepam in blood of impaired drivers: association with age, gender and spectrum of other drugs present. Forensic Sci Int. 2004;146:1–7. 19. Toennes SW, Kauert GF, Steinmeyer S, et al. Driving under the influence of drugs—evaluation of analytical data in oral fluid, serum and urine, and correlation with impairment symptoms. Forensic Sci Int. 2005;152: 149–155. 20. Bramness JG, Skurtveit S, Morland J. Clinical impairment of benzodiazepines—relation between benzodiazepine concentrations and impairment in apprehended drivers. Drug Alcohol Depend. 2002;68: 131–41. 21. Logan BK, Couper FJ. Zolpidem and driving impairment. J Forensic Sci. 2001;46:105–110. 22. Drover DR. Comparative pharmacokinetics and pharmacodynamics of short-acting hypnosedatives: zaleplon, zolpidem and zopiclone. Clin Pharmacokinet. 2004;43:227–238. 23. Rohrig TP, Moore CM. Zolpidem. Forensic aspects for the toxicologist and the pathologist. Forensic Science, Medicine and Pathology. 2005;1-2: 81–90. 24. Garattini S. Active drug metabolites. An overview of their relevance in clinical pharmacokinetics. Clin Pharmacokinet. 1985;10:216–227. 25. Shah JC, Mason WD. Plasma codeine and morphine concentrations after a single oral dose of codeine phosphate. J Clin Pharmacol. 1990;30: 764–766. 26. Inturrisi CE, Max MB, Foley M, et al. The pharmacokinetics of heroin in patients with chronic pain. N Engl J Med. 1984;310:1213–1217. 27. Logan BK, Case GA, Gordon AM. Carisoprodol, meprobamate and driving impairment. J Forensic Sci. 2000;45:619–623. 28. Rutherford DM, Okoko A, Tyrer PJ. Plasma concentrations of diazepam and desmethyldiazepam during chronic diazepam therapy. Br J Clin Pharmacol. 1978;6:69–73. 29. Kuitunen T, Meririnne E, Seppälä T. Correlation between blood diazepam concentrations and performance on the clinical test for drunkenness in acute and chronic diazepam users. J Traffic Med. 1994;22:105–111. 30. Greenblatt DJ, Laughren TP, Allen MD, et al. Plasma diazepam and desmethyldiazepam concentrations during long-term diazepam therapy. Br J Clin Pharmacol. 1981;11:35–40. 31. Mandelli M, Tognoni G, Garattini S. Clinical pharmacokinetics of diazepam. Clin Pharmacokinet. 1978;3:72–91.

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32. Kronstrand R, Jones AW. Concentration ratios of codeine-to-morphine in plasma after a single oral dose (100 mg) of codeine phosphate. J Anal Toxicol. 2001;25:486–487. 33. Ceder G, Jones AW. Concentration ratios of morphine to codeine in blood of impaired drivers as evidence of heroin use and not dedication with codeine. Clin Chem. 2001;47:1980–1984. 34. Hausken AM, Skurtveit S, Christophersen AS. Characteristics of drivers testing positive for heroin or ecstasy in Norway. Traffic Inj Prev. 2004;5: 107–111. 35. Christophersen AS, Ceder G, Kristinsson J, et al. Drugged driving in the Nordic countries—a comparative study between five countries. Forensic Sci Int. 1999;106:173–190. 36. O’Neal CL, Poklis A, Lichtman AH. Acetylcodeine, an impurity of illicitly manufactured heroin, elicits convulsions, antinociception, and locomotor stimulation in mice. Drug Alcohol Depend. 2001;65:37–43. 37. Jones AW. Heroin use by motorists in Sweden verified by analysis of 6-acetyl morphine in urine. J Anal Toxicol. 2001;25:353–355. 38. Bramness JG, Skurtveit S, Fauske L, et al. Association between blood carisoprodol:meprobamate concentration ratios and CYP2C19 genotype in carisoprodol-drugged drivers: decreased metabolic capacity in heterozygous CYP2C19*1/CYP2C19*2 subjects? Pharmacogenetics. 2003;13:383–388. 39. Lillsunde P, Korte T, Michelson L, et al. Drugs usage of drivers suspected of driving under the influence of alcohol and/or drugs. A study of one week’s samples in 1979 and 1993 in Finland. Forensic Sci Int. 1996;77: 119–129. 40. Behrensdorff I, Steentoft A. Medicinal and illegal drugs among Danish car drivers. Accid Anal Prev. 2003;35:851–860. 41. Drummer OH, Gerostamoulos J, Batziris H, et al. The involvement of drugs in drivers of motor vehicles killed in Australian road traffic crashes. Accid Anal Prev. 2004;36:239–248. 42. Longo MC, Hunter CE, Lokan RJ, et al. The prevalence of alcohol, cannabinoids, benzodiazepines and stimulants amongst injured drivers and their role in driver culpability: part II: the relationship between drug prevalence and drug concentration, and driver culpability. Accid Anal Prev. 2000;32:623–632. 43. Brookoff D, Cook CS, Williams C, et al. Testing reckless drivers for cocaine and marijuana. N Engl J Med. 1994;331:318–22. 44. Mura P, Chatelain C, Dumestre V, et al. Use of drugs of abuse in less than 30-year old drivers killed in a road crash in France: a spectacular increase for cannabis, cocaine and amphetamines. Forensic Sci Int. 2006;160: 168–172. 45. Jones AW, Holmgren A. Abnormally high concentrations of amphetamine in blood of impaired drivers. J Forensic Sci. 2005;50:1215–1220. 46. Logan BK. Methamphetamine and driving. J Forensic Sci. 1996;41: 457–465. 47. Musshoff F. Illegal or legitimate use—precursor compounds to amphetamine and methamphetamine. Drug Metab Rev. 2000;32:15–44. 48. Ingum J, Pettersen G, Sager G, et al. Relationship between unbound plasma concentrations and various psychomotor and subjective effects after intakes of diazepam and flunitrazepam. Int Clin Psychopharmacol. 1994;9:115–121. 49. Bramness JG, Skurtveit S, Morland J. Flunitrazepam: psychomotor impairment, agitation and paradoxical reactions. Forensic Sci Int. 2006; 159:83–91. 50. Movig KL, Mathijssen MP, Nagel PH, et al. Psychoactive substance use and the risk of motor vehicle accidents. Accid Anal Prev. 2004;36: 631–636. 51. Fraser AD. Use and abuse of the benzodiazepines. Ther Drug Monit. 1998;20:481–489. 52. Hemmelgarn B, Suissa S, Huang A, et al. Benzodiazepine use and the risk of motor vehicle crash in the elderly. JAMA. 1997;278:27–31. 53. Ray WA, Fought RL, Decker MD. Psychoactive drugs and the risk of injurious motor vehicle crashes in elderly drivers. Am J Epidemiol. 1992; 136:873–883. 54. Barbone F, McMahon AD, Davey PG, et al. Association of road-traffic accidents with benzodiazepine use. Lancet. 1998;352:1331–1336. 55. Greenblatt DJ, Harmatz JS, Friedman HH. A large sample study of diazepam pharmacokinetics. Ther Drug Monit. 1989;11:652–657. 56. Friedman H, Greenblatt DJ, Peters GR, et al. Pharmacokinetics and pharmacodynamics of oral diazepam: effect of dose, plasma concentration, and time. Clin Pharmacol Ther. 1992;52:139–150.

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57. Laurijssens BE, Greenblatt DJ. Pharmacokinetic-pharmacodynamic relationships for benzodiazepines. Clin Pharmacokinet. 1996;30:52–76. 58. Wickstrom E, Amrein R, Haefelfinger P, et al. Pharmacokinetic and clinical observations on prolonged administration of flunitrazepam. Eur J Clin Pharmacol. 1980;17:189–196. 59. Greenblatt DJ, Shaader RI. Pharmacokinetics in Clinical Practice. Philadelphia: WB Saunders Co; 1985:1–125. 60. Bareggi SR, Pirola R, Truci G, et al. Effect of after-dinner administration on the pharmacokinetics of oral flunitrazepam and loprazolam. J Clin Pharmacol. 1988;28:371–375. 61. Klotz U, Avant GR, Hoyumpa A, et al. The effects of age and liver disease on the disposition and elimination of diazepam in adult man. J Clin Invest. 1975;55:347–359. 62. Chen ML. Ethnic or racial differences revisited: impact of dosage regimen and dosage form on pharmacokinetics and pharmacodynamics. Clin Pharmacokinet. 2006;45:957–964. 63. Cheymol G. Effects of obesity on pharmacokinetics: implications for drug therapy. Clin Pharmacokinet. 2000;39:215–231. 64. Cotreau MM, von Moltke LL, Greenblatt DJ. The influence of age and sex on the clearance of cytochrome P450 3A substrates. Clin Pharmacokinet. 2005;44:33–60. 65. Dawling S, Crome P. Clinical pharmacokinetic considerations in the elderly—an update. Clin Pharmacokinet. 1989;17:236–363. 66. Drouet-Coassolo C, Iliadis A, Coassolo P, et al. Pharmacokinetics of flunitrazepam following single dose oral administration in liver disease patients compared with healthy volunteers. Fundam Clin Pharmacol. 1990;4:643–651. 67. Vainio A, Ollila J, Matikainen E, et al. Driving ability in cancer patients receiving long-term morphine analgesia. Lancet. 1995;346 667–670. 68. Burt M, Kloss J, Apple FS. Postmortem blood free and total morphine concentrations in medical examiner cases. J Forensic Sci. 2001;46:1138– 1142. 69. Cascarbi I. Pharmacogenetics of cytochrome P4502D6 genetic background and clinical implications. Eur J Clin Invest. 2003;33(Suppl 2): 17–22. 70. Meyer UA. Pharmacogenetics of adverse drug reactions. Lancet. 2000; 356:1667–1671. 71. Rogers JF, Nafziger AN, Bertino JS Jr. Pharmacogenetics affects dosing, efficacy, and toxicity of cytochrome P450-metabolized drugs. Am J Med. 2002;113:746–750. 72. Fagerlund TH, Braaten O. No pain relief from codeine.? An introduction to pharmacogenomics. Acta Anesthesiol Scand. 2001;45:140–149. 73. Gasche Y, Daali Y, Fathi M, et al. Codeine intoxication associated with ultrarapid CYP2D6 metabolism. N Engl J Med. 2004;351:2827– 2831.

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74. Kirchheiner J, Schmidt H, Tzvetkov M. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomic J. 2006; Jul 4 [Epub ahead of print]. 75. Koren G, Cains J, Chitayat D, et al. Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine-prescribed mother. Lancet. 2006;368:704. 76. Juurlink DN, Mamdani M, Kopp A, et al. Drug-drug interactions among elderly patients hospitalized for drug toxicity. JAMA. 2003;299:1652–1658. 77. Koch-Weser J, Sellers EM. Drug therapy. Binding of drugs to serum albumin (first of two parts). N Engl J Med. 1976;294:311–316. 78. Koch-Weser J, Sellers EM. Drug therapy. Binding of drugs to serum albumin (second of two parts). N Engl J Med. 1976;294:526–531. 79. Maguire KP, Burrows GD, Norman TR, et al. Blood/plasma distribution ratios of psychotropic drugs. Clin Chem. 1980;26:1624–1625. 80. Ingum J, Pettersen G, Sager G, et al. Relationship between unbound plasma concentrations and various psychomotor and subjective effects after intakes of diazepam and flunitrazepam. Int Clin Psychopharmacol. 1994;9:115–121. 81. Hinderling PH. Red blood cells: a neglected compartment in pharmacokinetics and pharmacodynamics. Pharmacol Rev. 1997;49:279–295. 82. Jochemsen R, van Boxtel CJ, Hermans J, et al. Kinetics of five benzodiazepine hypnotics in healthy subjects. Clin Pharmacol Ther. 1983;34:42–47. 83. Greenblatt DJ, Shader RI, Divoll M, et al. Benzodiazepines: a summary of pharmacokinetic properties. Br J Clin Pharmacol. 1981;11(Suppl 1): 11S–16S. 84. Greenblatt DJ, Laughren TP, Divoll Allan M, et al. Plasma diazepam and desmethyldiazepam concentrations during long-term diazepam therapy. Br J Clin Pharmacol. 1981;11:35–40. 85. Olubodun JO, Ochs HR, von Moltke LL, et al. Pharmacokinetic properties of zolpidem in elderly and young adults: possible modulation by testosterone in men. Br J Clin Pharmacol. 2003;56:297–304. 86. Olubodun JO, Ochs HR, Trüten V, et al. Zolpidem pharmacokinetic properties in young females: influence of smoking and oral contraceptive use. J Clin Pharmacol. 2002;42:1142–1146. 87. Fraser AG. Pharmacokinetic interactions between alcohol and other drugs. Clin Pharmacokinet. 1997;33:79–90. 88. Juhl RP, van Thiel DH, Dittert LW, et al. Alprazolam pharmacokinetics in alcoholic liver disease. J Clin Pharmacol. 1984;24:113–119. 89. Bailey DN, Briggs JR. The binding of selected therapeutic drugs to human serum alpha-1 acid glycoprotein and to human serum albumin in vitro. Ther Drug Monit. 2004;26:40–43. 90. Flanagan RJ, Yusufi B, Barnes TRE. Comparability of whole-blood and plasma clozapine and norclozapine concentrations. Br J Clin Pharmacol. 2003;56:135–138.

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APPENDIX. Scheduled Prescription Drugs Identified in Blood Samples From Driving Under the Influence of Drugs Suspects in Sweden

No.*

Mean (median) max concentration (mg/L)

Therapeutic (TIAFT) (mg/L)

No. (%)†

430

0.09 (0.06) 3.9

0.005–0.05 (0.1)‡

279 (65)

Alimemazine (Theralen)

0.16 (0.075) 0.9

0.05–0.4

1 (8.3)

Buprenorphine (Norspan) (Subutex) (Temgesic)

0.0022 (0.001) 0.009

0.001–0.01

None

Carbamazepine (Hermolepsin) (Tegretol) (Trimonil)

3.6 (2.4) 14

Carisoprodol (Somadril)

3.9 (2.8) 11.9

2.5–10

18 (27)

1.1 (0.3) 3.5

0.4–4

1 (25)

Drug (Swedish trade name) Alprazolam (Xanor)

Chlordiazepoxide

256

Structural formulae

4–9 (12)‡

3 (4.3)

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APPENDIX. (continued ) Scheduled Prescription Drugs Identified in Blood Samples From Driving Under the Influence of Drugs Suspects in Sweden

Drug (Swedish trade name)

Structural formulae

No.*

Mean (median) max concentration (mg/L)

Therapeutic (TIAFT) (mg/L)

No. (%)†

Chlorzoxazone (Paraflex)

3 (1.7) 5.7

No info

None

Chlormethiazole (Heminevrin)

0.43 (0.4) 0.7

0.1–2.8

None

0.05 (0.04) 0.32

0.02–0.07

33 (20)

Clonazepam (Iktorivil)

164

Codeine (Ardinex) (Citodon) (Panocod) (Spasmofen) (TreoComp)

617

0.045 (0.01) 1.0

0.05–0.25

11 (1.8)

1950

0.36 (0.2) 6.2

0.125–1.5

224 (12)

Ephedrine

0.21 (0.1) 1.3

0.02–0.2

7 (15)

Ethylmorphine (Cocilana etyfin) (Lepheton)

0.095 (0.03) 0.82

No info

None

Diazepam (Stesolid)

(continued on next page)

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APPENDIX. (continued ) Scheduled Prescription Drugs Identified in Blood Samples From Driving Under the Influence of Drugs Suspects in Sweden

No.*

Mean (median) max concentration (mg/L)

Therapeutic (TIAFT) (mg/L)

308

0.018 (0.014) 0.12

0.005–0.015

Hydroxyzine (Atarax)

0.17 (0.08) 0.4

Meprobamate (Anervan)

15.7 (11) 64

114

0.26 (0.2) 1.1

Drug (Swedish trade name) Flunitrazepam (Rohypnol)

Methadone (Metadon)

Midazolam (Dormicium)

Morphine (Dolcontin) (Depolan)

258

Structural formulae

864

0.05–0.09

10–30

0.05–0.5 (1.0)‡

No. (%)† 67 (22)

5 (50)

11 (17)

1 (0.9)

0.078 (0.065) 0.15

0.08–0.25

None

0.049 (0.03) 1.6

0.01–0.12

78 (9)

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APPENDIX. (continued ) Scheduled Prescription Drugs Identified in Blood Samples From Driving Under the Influence of Drugs Suspects in Sweden

Drug (Swedish trade name) Nitrazepam (Mogadon)

Structural formulae

No.*

Mean (median) max concentration (mg/L)

222

0.12 (0.05) 1.76

Therapeutic (TIAFT) (mg/L) 0.03–0.12

No. (%)† 34 (15)

2168

0.33 (0.2) 5.2

0.2–0.8 (1.8)‡

103 (4.8)

Oxazepam (Sobril)

1.12 (0.8) 5.7

(0.15)‡ 0.5–2.0

5 (10)

Phenobarbital (Fenemal Recip)

9.9 (3) 48

2.0–30 (40)‡

1 (2.8)

Phenytoin (Lehydan) (Epanutin)

9.7 (10) 20

8.0–20

None

Promethazine (Lergigan)

0.13 (0.09) 0.3

(0.05)‡ 0.1–0.4

None

Propoxyphene (Dexofen) (Doloxen)

0.17 (0.1) 0.7

0.1–0.75

Nordazepam

0 (0)

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APPENDIX. (continued ) Scheduled Prescription Drugs Identified in Blood Samples From Driving Under the Influence of Drugs Suspects in Sweden

Drug (Swedish trade name)

Structural formulae

No.*

Mean (median) max concentration (mg/L)

Tramadol (Nobligan) (Tradolan)

105

0.85 (0.4) 7.8

Zopiclone (Imovane)

111

0.099 (0.06) 0.41

Zolpidem (Stilnoct)

148

0.31 (0.2) 3.48

Therapeutic (TIAFT) (mg/L)

No. (%)†

0.1–0.8 (1.0)‡ blood

25 (24)

0.04–0.07

0.08–0.15 (0.2)‡

13 (12)

54 (36)

*Number of positive findings. †Number (and percent) of cases with concentrations in blood considered higher than expected for normal therapeutic use. ‡According to some investigators.

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processes Review

Ultraﬁltration Method for Plasma Protein Binding Studies and Its Limitations Camelia-Maria Toma 1,2 , Silvia Imre 1,2,3, *, Camil-Eugen Vari 4 , Daniela-Lucia Muntean 3 and Amelia Tero-Vescan 5 1

Citation: Toma, C.-M.; Imre, S.; Vari, C.-E.; Muntean, D.-L.; Tero-Vescan, A. Ultraﬁltration Method for Plasma Protein Binding Studies and Its Limitations. Processes 2021, 9, 382. https://doi.org/10.3390/pr9020382 Academic Editor: Ioannis Nikolakakis

Center of Advanced Medical and Pharmaceutical Research, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, RO-540142 Targu Mures, Romania; camelia.toma@umfst.ro Doctoral School of Medicine and Pharmacy, I.O.S.U.D., George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, RO-540142 Targu Mures, Romania Department of Analytical Chemistry and Drug Analysis, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, RO-540142 Targu Mures, Romania; daniela.muntean@umfst.ro Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, RO-540142 Targu Mures, Romania; camil.vari@umfst.ro Department of Chemistry and Medical Biochemistry, Faculty of Medicine in English, George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures, 38 Gheorghe Marinescu Street, RO-540142 Targu Mures, Romania; amelia.tero-vescan@umfst.ro Correspondence: silvia.imre@umfst.ro

Abstract: Plasma protein binding plays a critical role in drug therapy, being a key part in the characterization of any compound. Among other methods, this process is largely studied by ultrafiltration based on its advantages. However, the method also has some limitations that could negatively influence the experimental results. The aim of this study was to underline key aspects regarding the limitations of the ultrafiltration method, and the potential ways to overcome them. The main limitations are given by the non-specific binding of the substances, the effect of the volume ratio obtained, and the need of a rigorous control of the experimental conditions, especially pH and temperature. This review presents a variety of methods that can hypothetically reduce the limitations, and concludes that ultrafiltration remains a reliable method for the study of protein binding. However, the methodology of the study should be carefully chosen. Keywords: ultrafiltration; plasma protein binding; non-specific binding; limitations

Received: 31 January 2021 Accepted: 15 February 2021 Published: 19 February 2021

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Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

Plasma protein binding (PPB) is a reversible process that plays a critical role in drug therapy, influencing both the pharmacokinetic and pharmacodynamic properties of drugs. Binding to plasma proteins is important, especially in the case of drugs with a high affinity to plasma proteins (>99%) and in polytherapy treatments because of the displacement interactions that can occur, which lead to a high risk of adverse drug reactions. Evaluating the degree of PPB is required in the early stages of drug discovery and development, and the existence of an analysis method that can provide accurate and relevant results is essential [1–3]. Regarding the binding to plasma proteins, the interaction with a specific site is determined, on the one hand, by the chemical structure of the drug, the pKa of the substance, and the pH of plasma; on the other hand, the type of protein involved (albumin, alpha-1 acid glycoprotein, lipoproteins, and globulins) is also important. In the case of albumin, of the eight binding sites, the most important are the Sudlow I site (warfarin site) and the Sudlow II site (diazepam site) [1]. Site I forms a pocket of hydrophobic chains that

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contain basic groups in the area of the portal of entry [4]. Binding to site I is reversible, and is achieved by electrostatic bonds (for acidic substances, such as NSAIDs or coumarin anticoagulants, intensely ionized at a plasma pH of about 7.4). For this type of substance, the fraction of binding is significant (98–99%). Moreover, the binding is saturable and sensitive to competition with other drugs, which may have important clinical consequences: the increase in the free fraction and the pharmacodynamic effect with risk of subsequent overdose by displacement interactions; the consistent binding moiety serves as a reservoir: as the free molecules leave the intravascular space by simple diffusion, the equilibrium shifts toward the detachment of the drug–albumin molecules. Site II is similar to site I, but smaller in size, having a polar gateway with affinity for hydrophobic/lipophilic compounds, which possess an electronegative area under the effect of blood pH [4]. Substances that bind non-specifically to albumin (e.g., digoxin) are not affected by the risk of displacement interactions because the binding capacity of albumin is much higher than that obtained at therapeutic concentrations. Alpha-1 acid glycoprotein binds preferentially to basic or neutral molecules (not ionized in the plasma), and since it is an acute-phase protein synthesized in the liver, the pro-inflammatory status can directly influence the bound fraction of the studied drugs [1]. Many methods have been proposed for the study of PPB, including: equilibrium dialysis (ED), ultrafiltration (UF), ultracentrifugation, gel filtration, partition method, spectroscopy, calorimetry, chromatographic techniques, capillary electrophoresis, surface plasmon resonance, etc. [1–8]. However, regarding drug-development, only ED and UF gained widespread acceptance [6,9]. Both UF and ED rely on the physical separation of the unbound and bound fractions of a drug through a semipermeable membrane, followed by the quantification of the free fraction using a suitable analytical technique (usually HPLC-UV or HPLC-MS). Although ED is considered to be the gold standard, UF is becoming increasingly popular due to its main advantage represented by the short analysis time [1,4]. UF is considered to be one of the least time consuming and easiest to apply methods for the determination of the unbound fraction of a drug, having the potential to be used during clinical monitoring. The principle of the UF method is the separation of small volumes of protein-free phase by applying a centrifugal force to a solution containing both proteins and the substance of interest, located in the upper compartment of a special UF device. The UF device is separated into two compartments by a semipermeable membrane, which has different molecular weight limits for protein filtration [1,6,8]. After separation by centrifugation, the free drug concentration is determined from the protein-free ultrafiltrate located in the lower compartment of the UF device. Beside its advantages (speed, simplicity, obtaining accurate and quantitative data, and approximation of physiological conditions), UF also has some disadvantages that may limit its use if not corrected [1,10]. The main disadvantage of the UF technique is the non-specific binding of substances to the semipermeable membrane and the compartment of the UF device, which limits the study of PPB for compounds with high lipophilicity using this particular method [1,4,6,8]. Other limitations of the method to be considered are: the sieve effect, the Gibbs-Donnan effect, protein leakage, the need for rigorous control of pH and temperature [1], and the effect of volume ratio of the ultrafiltrate [11]. Due to the constant interest regarding optimization of the UF method for PPB studies, many research papers describe a variety of methods that can hypothetically reduce the limitations, some of which will be discussed further. 2. Non-Specific Binding The biggest limitation of the UF technique as a study method for the binding of substances to plasma proteins is their non-specific binding (NSB) to the filter membrane and to the material of the UF device, which provides NSB sites due to their characteristic charge and polarity [12,13]. When the analyte shows a high degree of NSB, the concentration

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of the free fraction determined from the ultrafiltrate differs greatly from the actual free concentration in the sample under analysis, thus leading to inaccurate results. This is a growing concern due to the fact that in recent years, more and more lipophilic compounds have been developed, which are adsorbed to a large extent and are associated with a higher degree of NSB. The main parameters that influence the binding of drugs to the filter membrane are the degree of lipophilicity and their molecular mass. The filter material is also important, as its composition modulates the types of interactions. In the case of drugs with marked lipophilicity, adsorption to the filter membrane is very likely, and pre-saturation of the filter may be a solution to avoid NSB, but only if it is performed with a labeled ligand (to avoid errors caused by desorption or competition for binding with the drug that otherwise cannot be quantitatively assessed). The presence of ionizable groups on the surface of the membrane can be a limiting factor in the UF of ionized drug molecules. With regard to molecular weight, its increase (M > 500) may produce a molecular sieving effect, which may lead to lower drug concentrations in the ultrafiltrate than the expected value [13]. Several possibilities have been proposed to eliminate or lower the degree of NSB. One of the methods described in the literature as having the potential to reduce NSB of substances consists of the pre-treatment of the filter units with a solution of Tween 80 [13]. This non-ionic surfactant is applied to the filter membrane in order to reduce potential hydrophobic interactions. In these studies, which were performed on analytical solutions prepared in phosphate buffer, it was observed that the degree of NSB modulation was dependent on the concentration of the Tween solution applied and on the concentration of substance in the sample solutions. Thus, the higher the concentration of Tween 80 solutions used, the lower the degree of NSB observed, and the lower the concentration of the substance in the samples, the higher the degree of NSB. Other studies showed a significant reduction in NSB following a pre-treatment of the filter units with Tween 20 solutions [14]. The chosen working methodology, the characteristics of the UF devices used, and the laboratory equipment are highly important in reducing the degree of NSB by this method. Although efficient in some cases, the pre-treatment with Tween solutions to reduce NSB was not found to be effective for all compounds, and as a result, a pre-treatment with benzalkonium chloride was proposed as a possible and alternative way to further reduce NSB based on its capacity to prevent potential ionic interactions between basic compounds and the filter membrane [13,15]. Studies have shown, however, that although this alternative method is effective for basic compounds, it increases the degree of NSB in the case of acidic compounds and has no effect in the case of neutral and hydrophilic compounds. Considering these results, a selection criterion for choosing the pre-treatment agent of the UF tubes can be stated as follows: Tween 80 reduces NSB of acidic and neutral compounds; benzalkonium chloride reduces NSB of basic compounds [13]. However, the pre-treatment of the UF units with Tween solutions raises some concerns due to having been shown to interact with plasma proteins [16,17] and to interfere with the process of drug binding (as observed with docetaxel, which is extensively bound to proteins) [18]. To lower the impact of NSB on the experimental results, the degree of NSB of substances was usually determined using solutions of the analyte in phosphate buffer saline (PBS), which were subjected to UF. Based on the results, a correction factor was then applied to the results obtained after a sample analysis [6]. However, subsequent studies conducted by Wang and Williams suggested that this is not a feasible alternative, noting that the behavior of some compounds regarding NSB differs when incubated with the UF device in plasma compared to PBS [12]. This is due to serum proteins being adsorbed on the surface of different types of materials, leading to the blocking of most NSB sites. These studies had an approach based on mass balance, and showed that the limitation given by the NSB can be corrected, even in the case of compounds with increased lipophilia, because NSB sites are inactivated in the presence of plasma. However, there is another concern regarding

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NSB that may occur in the ultrafiltrate compartment, where, in the absence of plasma, the risk of NSB increases [6]. Taylor and Harker proposed a modification of the UF technique to eliminate NSB of lipophilic compounds, consisting of the simultaneous UF of the sample being subjected to analysis with a control plasma sample [19]. After centrifugation, the units containing the retentates are exchanged between paired filter units and recentrifuged, thus obtaining two reconstituted samples, one containing the unbound drug, and the other containing the bound drug. Using this modified method of the classical UF technique, NSB was successfully eliminated for some corticosteroid compounds. 3. Effect of Volume Ratio Following the traditional UF, a high volumetric ratio, which cannot be properly controlled, is usually obtained between the ultrafiltrate and the sample solution [11]. It was thought that this volume ratio may affect the protein binding equilibrium and influence the analysis of the free fraction. During UF, the aqueous component of the plasma, which contains the free drug molecules, is forced to pass through the semipermeable membrane due to the pressure gradient. As a result, there is a transient decrease in the free drug concentration, while the protein and protein–drug complex concentrations increase for the remaining sample fraction in the upper compartment of the UF device. Consequently, the initial protein binding equilibrium is considered to be disturbed while a new equilibrium is being established. Some researchers have recommended the volume of ultrafiltrate to be less than 35% of the plasma volume [20], others have recommended it to be less than 20% [21], or even less than 10% [1], to minimize the disturbance of the protein binding equilibrium. Subsequent studies, however, stated that the disturbance of the initial equilibrium due to increased protein concentration in the upper compartment of the UF units is only a misunderstanding of the process that occurs. The explanation is that during UF, balanced sample portions are removed, which do not affect the drug–protein equilibrium above the filter membrane. These data are presented both theoretically and experimentally in a study conducted by Nilsson, in which the same results were obtained for ultrafiltrate volumes between 16% and 47% of the initial plasma volume [6]. Even so, results obtained in some experiments with very large volumes of ultrafiltrate must be considered (up to 80% of the sample volume) in which an increasing concentration of the free drug fraction with an increasing volumetric ratio between the ultrafiltrate and the sample solution was observed [11]. However, this was also considered to be a consequence of the fact that in order to obtain such volumes of ultrafiltrate, it is necessary to apply a very high centrifugal force, which can lead to unwanted protein leakage and increases in temperature, factors that may also affect the experimental results [6]. Because the classical UF method and devices do not allow for such rigorous control of the ultrafiltrate volume and are susceptible to many factors, some researchers have suggested and demonstrated that a hollow fiber centrifugal ultrafiltration (HFCF-UF) is a more accurate alternative for the determination of the unbound drug. HFCF-UF is a more robust method compared to the classical UF, being less affected by experimental conditions and allowing for an exact control of the volume ratio [11,22–24]. HFCF-UF is a more reliable approach, especially in the case of samples with lower serum albumin concentrations, because the influence of the volume ratio on the experimental results was also shown to be dependent on this parameter, being greater with decreasing concentration [25,26]. 4. Influence of Experimental Conditions The experimental conditions in PPB studies are of great importance as they may greatly affect the results of the analysis [27,28]. Among these, the filter device, membrane type, pH, temperature, and relative centrifugal force (RCF) must be considered.

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The Millipore Centrifree UF devices (Merck, Germany) are used in most plasma protein binding studies, but good results using modern devices initially designed for protein or RNA solution concentration (for example, Vivaspin, Vivacon, and Nanosep) were also reported in a study designed by Kratzer et al. [27]. However, these devices require validation to the Centrifree devices, which are used as a reference. Although they are able to be used at a high centrifugal force, in the case of PPB studies, this is not applicable due to the occurrence of the pressure effect. This effect leads to changes in the permeability of the membrane for drugs and water depending on the RCF applied and the molecular weight of the substance. Experiments have shown that the measured free drug fraction decreases as the RCF increases, the effect being more obvious in the case of substances with higher molecular weight. Due to the amplitude of the effect being dependent on the molecular weight of the analyte, it is not possible to establish an optimal value or an upper limit that is generally valid for the RCF. However, the Centrifree user manual recommends a maximum value of 2000× g. Very close attention should be paid when choosing the UF device because different devices can lead to different experimental results for the same compound (as described for imatinib using Amicon vs. Centrifree devices) [15]. Regarding the centrifugation time, the studies performed did not show a significant influence on the results obtained [27,29]. The membrane type of the UF device is also a variable that should be considered when conducting PPB studies because of the possibility of analyte absorbance. Studies have shown that different results can be obtained for the same compound when using devices with a polyethersulfone membrane compared to cellulose; in addition to this, depending on the membrane, the analyte’s behavior can vary greatly [27,28]. Generally, devices with a regenerated cellulose membrane are preferred. However, depending on the compound, good results can also be obtained using other membranes, so this remains a topic of debate. Another important parameter for PPB studies is the pH, which has a significant influence due to the binding of substances to plasma proteins being dependent on its value [6,30–32]. It has been observed that in the case of basic compounds, which normally bind to alpha-1-acid glycoproteins, the free fraction decreases with an increase in the pH due to an increase in the non-ionized fraction. Whereas in the case of acidic compounds, which are mostly bound to albumin, it has been observed that an increase in the pH can either result in an increase or a decrease in the free fraction of the drug. These results are thought to be due to the conformational changes that may occur in the structure of albumin. In the case of neutral compounds, PPB is less affected by changes in the pH [30]. Normally, the pH of the circulating blood has a value between 7.35 and 7.45 maintained especially by the bicarbonate buffer system [6,27]. After collecting the blood, the pH value increases, reaching values even higher than 8, due to a continuous loss of carbon dioxide that occurs during the storage and preparation of the sample. Therefore, restoring the pH to its physiological value is essential. Regarding the temperature, studies have shown there is a decrease in the free fraction of the drug with the temperature falling below the physiological value of 37 ◦ C, and studies conducted at room temperature can give results of even 50% of the unbound fraction determined at 37 ◦ C [6,27]. Considering all these aspects, a rigorous control of both the pH and temperature is required. The values of these parameters must always be adjusted to physiological conditions to obtain relevant results. 5. Conclusions Although UF has its limitations, there are a various number of ways to correct, reduce, or even eliminate them, making it possible to use the method even for more challenging compounds. UF still remains a reliable method for PPB studies, but the methodology of the study should be carefully chosen for each analyte, and very close attention should be paid to the processing and preparation of the samples and experimental conditions.

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Author Contributions: Conceptualization, C.-M.T., S.I., and C.-E.V.; methodology, C.-M.T., S.I., C.-E.V., and D.-L.M.; writing—original draft preparation, C.-M.T.; writing—review and editing, S.I., C.-E.V., D.-L.M., and A.T.-V. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, grant number 10127/5/17.12.2020. Institutional Review Board Statement: Not applicable. Informed Consent Statement: Not applicable. Data Availability Statement: No new data were created or analyzed in this study. Data sharing is not applicable to this article. Conﬂicts of Interest: The authors declare no conﬂict of interest.

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by Forest Tennant, MD, DrPH

TENNANT BLOOD STUDY Summary Report OPIOID BLOOD LEVELS IN HIGH DOSE, CHRONIC PAIN PATIENTS Collaborators: John Conroy, DO John Hoffman, PharmD Art Jordan, MD Gary Kuhns, MD Roger Orman, MD or some time, the medical staff of Practical Pain Management have been aware of the fact that there is a dire need for a method of measuring the effectiveness, tolerance, and proper usage of prescribed opioids, and other aggressive drug therapies. To claim wrongdoing by pain physicians, arbitrary guidelines have been employed by prosecutors, litigants, and medical boards ranging from the total number of pills prescribed, the number of prescriptions, or blood levels to establish legality—all without consideration of the patient’s condition. As a result, physicians are inhibited from properly prescribing opioids to chronic pain patients, stand the risk of prosecution and, in general, are unable to adequately fulfill their obligations to their patients. The author has believed that a correlation between blood level concentrations and proper prescribing could be developed. To do this, Practical Pain Management solicited readers in December 2005, to participate in a survey in which they would submit blood level concentrations and select conditions of patients. The following sections describe the methodology, patient descriptions, major problems addressed, results, and conclusions. Ultimately, it is a goal of this publication to develop guidelines that will protect physicians and permit them to minister to their patients to their fullest ability.

Goals for this Survey This survey was undertaken to accomplish specific goals which are stated below: 1. To prevent the arbitrary application of published, therapeutic opioid blood levels in non-tolerant patients with acute or short term conditions (e.g. post operative or dental; see Table 1) to chronic pain patients who are tolerant and treated with high opioid dosages. 2. To prevent claims of over-prescribing by physicians based solely on an opioid blood level in situations where the

Lawrence Probes, MD David Root, MD Michael Schwartz, MD Joseph Shurman, MD Michael Snyder, MD

patient has had an accident or has died. 3. To encourage physicians to use blood levels to help determine if opioid dosage is appropriate or if malabsorption or rapid metabolism may be present. 4. To encourage the use of opioid blood levels to help determine if tolerance to opioids is present (normal physiologic and mental function in the presence of a significant opioid blood level is diagnostic of opioid tolerance.)

Major Problems Encountered By Physicians Many Physicians have been accused of over prescribing based on prescription amounts without blood level information to determine tolerance. Other physicians have been accused of malpractice based solely on opioid blood level concentrations in patients who have died or been in an accident. One object of this study was to show that chronic pain patients may function well if they are tolerant to high dosages of opioids and maintain a significant blood level. Overall, a lack of background data on opioid dosages and blood concentrations makes it difficult to accurately prescribe as a function of patient tolerance, physical and social functionality.

Methods Selected physician readers of Practical Pain Management in December 2005 were asked to voluntarily submit a data sheet (without the patient’s name) and report opioid blood concentrations in chronic pain patients treated with opioids. All patients were in chronic pain care administered by a physician. Patients had taken opioids for 1 to 50 years. Ages ranged from 25 to 87 years. Approximately 55% of patients were female, and 45% were male. The majority of painful conditions were common and included spine degeneration, neuropathy, arthropathy, and auto-immune disorder. Data collected included age, sex, weight, cause of pain, opioid

Practical PAIN MANAGEMENT, March 2006 ©PPM Communications, Inc. This copy is for personal use only. Do not reproduce, digitally transmit or post without permission.

Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

and daily dosage, and the patient’s functional status including the ability to drive and work. Full ambulatory function generally meant the ability to dress, feed, and ambulate one’s self without assistance. Patients had blood samples taken approximately 1 to 2 hours after a regularly prescribed opioid dosage. The physician utilized his/her usual commercial laboratory.

Opioid Codeine Fentanyl Hydromorphone Meperidine Methadone Morphine Oxycodone Propoxyphene

Results Many opioid blood concentrations in fully functional patients were above the therapeutic and toxic ranges published for nontolerant persons (Table 1). Table 2 presents a summary of survey results, and Tables 3 thru 13 present the associated detail by individual. Essentially all patients demonstrated opioid tolerance since they could fully function and most could drive despite high opioid dosages and blood concentrations. The presence of opioids in the blood was clear evidence that the patients were self- administering opioids and at least in partial compliance with prescribing instructions. Some opioid blood levels were low despite high opioid dosages, indicating that malabsorption or rapid metabolism of opioids may be present. There were also cases that showed significant blood concentrations suggesting that clinical effectiveness had been achieved (see Tables 2 thru 13).

Conclusions Blood concentrations collected in this survey show that an opioid blood level can greatly assist the physician in determining if malabsorption or rapid metabolism may be present or if the therapeutic regimen is appropriate. Opioid blood concentrations in this study clearly show that patients become tolerant to high opioid dosages and can physically function quite well and possibly even work. A high opioid dosage cannot automatically be blamed for an unexpected death or accident based solely on a opioid blood level taken post-accident or at autopsy. The term “over-prescribing” cannot be used without an opioid blood level determination, since a high dosage may not necessarily produce a high blood level. n

Therapeutic Interval (ng/ml)

Toxic Level (over ng/ml)

10-100 1-3 8-32 400-700 100-400 10-80 10-100 100-400

200 8 100 1000 2000 200 200 500

TABLE 1. Previously published Therapeutic and Toxic Reference table for non-tolerant patients.1,2 The therapeutic levels shown here have primarily been determined in non-tolerant dental or post-operative patients rather than chronic, high dose, opioid patients. Acknowledgements Special thanks to Dr. Lawrence Probes for his assistance in compiling the data. Dr. Probes contributed a large number of cases and advised on the structure of the survey. Our thanks also go to all the collaborators (previously listed) for their contributions to this survey. Forest Tennant, MD, DrPH is an internist and addictionologist who specializes in the research and treatment of intractable pain at the Veract Intractable Pain Clinics in West Covina, California. Address any correspondence to Dr. Forest Tennant, 338 S. Glendora Avenue, West Covina, CA 91790-3043; 626-919-7476; fax 626-919-7497; Editor-InChief@PPMjournal.com References 1. Baselt RC. Disposition of Toxic Drugs and Chemicals in Man, 5th Ed. Chemical Toxicology Institute. Foster City, California, 2000. 2. Goldman L and Ausiells D. Reference Intervals and Laboratory Values in Cecil Textbook of Medicine, 22 ed. Eds, Saunders, Philadelphia, 2004.

OPIOID

No.

% Females /Males

Age Range

Weight Range-lbs.

% Full Function

% Drive

Daily Dosage Range

Blood Level ng/ml

Codeine

100/0

135

100%

120mg

408

Fentanyl Transdermal

63/37

28-64

128-375

100%

50%

3-20

50-333mcg

1.2-8.9

Fentanyl Transmucosal

61/39

35-64

112-250

100%

94%

50%

1.5-25

1200-48,000mcg

0.9-9.5

Hydrocodone

64/36

25-74

120-225

100%

73%

1-10

30-300mg

18-396

Hydromorphone

55/45

37-71

115-207

100%

45%

2-50

20-540mg

9.4-230

Methadone

34/66

35-63

105-285

97%

88%

44%

3-20

40-600mg

60-2580

Morphine IR

60/40

37-59

108-430

100%

90%

50%

6-25

100-1800mg

22-828

Morphine SR

61/39

28-73

112-285

94%

83%

39%

2-18

60-2000mg

16-2837

Oxycodone IR

64/36

31-71

108-245

100%

79%

43%

1-50

15-2700mg

5-3077

Oxycodone SR

42/58

26-87

108-270

94%

82%

25%

1.5-13

40-880mg

10-650

Propoxyphene

50/50

36-50

190

100%

8-20

400-1300mg

227-240

TABLE 2. RESULTS SUMMARY

FOR

% Work/ Years on Volunteer Opioid Range

OPIOID-TOLERANT PATIENTS. (Percentages have been rounded to the nearest number.)

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Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

Fentanyl Transdermal

TABLE 3. No. Sex

Cause of Pain

Age

Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

150-50

1.2

Osteoarthritis of Knees

375

Ambulatory Full

Fibromyalgia / Migraine

128

Ambulatory Full

Yes

100-333

8.2

Cervical Spine Degeneration

135

Ambulatory Full

Yes

150-200

4.7

Fibromyalgia

160

Ambulatory Full

Yes

150-200

4.1

Degenerative Spine

270

Ambulatory Full

Yes

100-200

4.3

Systemic Lupus

230

Ambulatory Full

Yes

150-200

3.2

Degenerative Spine

159

Ambulatory Full

Yes

50-100

8.9

Trigeminal Neuralgia

110

Ambulatory Full

Yes

50-100

3.7

Fentanyl Transmucosal

TABLE 4. No. Sex

Cause of Pain

Age Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

8000

7.8

Neuropathies, Post Electrocution

207

Ambulatory Full

Yes

Abdominal Adhesions

270

Ambulatory Full

Yes

4800

Diabetic Neuropathy

170

Ambulatory Full

Yes

1200

2.4

Fibromyalgia / Migraine

128

Ambulatory Full

Yes

4800

9.5

Abdominal Adhesions

250

Ambulatory Full

Yes

1.5

6000

5.3

Migrain, Degenerative Spine, & Knee

180

Ambulatory Full

Yes

4000

4.9

Degenerative Spine/Fusion

150

Ambulatory Full

Yes

9600

2.3

Degenerative Spine, Reflex Sympathetic Dystrophy

225

Ambulatory Full

Yes

7200

8.4

Crohns, Abdominal Adhesions

108

Ambulatory Full

Yes

38,400

3.2

Degenerative Spine

128

Ambulatory Full

Yes

28,800

8.1

Fibromyalgia

175

Ambulatory Full

Yes

19,200

3.4

Headaches

112

Ambulatory Full

Yes

1,800

4.8

Degenerative Spine

205 Ambulatory Full

Yes

25,600

5.1

Fibromyalgia

112

Ambulatory Full

12,000

4.4

Headaches

220

Ambulatory Full

Yes

19,200

0.9

Headaches

150

Ambulatory Full

Yes

14,400

3.6

Degenerative Spine/Fusion

200

Ambulatory Full

Yes

9,600

4.8

Autoimmune/Degenerative Spine

200

Ambulatory Full

Yes

48,000

7.9

Yes

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Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

Codeine

TABLE 5. No. Sex 1

Cause of Pain Fibromyalgia

Age Weight 55

135

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Full Ambulatory

Yes

120

480

Hydrocodone

TABLE 6. No. Sex

Function

Cause of Pain

Age Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Neuropathies

207

Full

Yes

200

150

Lumbar Spine Degeneration

135

Full

Yes

Lumbar Spine Degeneration

207

Full

Yes

Degenerative Arthritis

125

Full

Yes

Degenerative Spine

127

Full

Yes

100

135

Chest Wall Neuropathies

175

Full

Yes

Systemic Lupus/Hip Dysplasia

125

Full

Yes

300

396

Abdominal Adhesions

120

Full

Yes

Systemic Lupus

165

Full

Yes

Thorasic Outlet Neuropathies

225

Full

Yes

Fibromyalgia

130

Full

Yes

Hydromorphone

TABLE 7. No. Sex

Cause of Pain

Age Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Post-electrocution, Neuropathies

207

Full

Yes

200

9.4

Headaches, Porphyria

140

Full

Yes

Fibromyalgia

Full

Yes

Migraine, Degenerative Spine & Knee

180

Full

Yes

Post-Trauma Headache

150

Full

Yes

360

139

Fibromyalgia

134

Full

Yes

Degenerative Spine, Osteoporosis

285

Full

Yes

140

Systemic Lupus

230

Full

Yes

540

230

Fibromyalgia/ Cervical Spine Degeneration

115

Full

Yes

Scleroderma/ Arthritis

240

Full

Yes

360

Headaches

178

Full

Yes

240

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Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

Methadone

TABLE 8. No. SEX

Cause of Pain

Age

Weight

Function

Able to Drive

194

Ambulatory Full

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Yes

400

228

Ambulatory Full

Yes

122

Cervical Spine Degeneration

Post Trauma Headaches

Diabetic Neuropathy

170

Ambulatory Full

Yes

120

130

Peripheral Neuropathy

200

Ambulatory Full

Yes

100

Trigeminal Neuralgia

197

Ambulatory Full

100

280

Facial Neuropathy -Post Trauma

248

Ambulatory Full

Yes

150

156

Lumbar Spine Degeneration

177

Ambulatory Full

Yes

180

234

Fibromyalgia, Migraine

128

Ambulatory Full

Yes

400

Lumbar Spine Disease

193

Ambulatory Full

Yes

100

10 M

Migraine

Ambulatory Full

Yes

320

665

11 M

Diabetic Neuropathy

240

Ambulatory Full

Yes

160

610

12 M

Lumbar Spine Degeneration

240

Ambulatory Full

Yes

180

610

13 M

Lumbar Spine Degeneration

205

Ambulatory Full

Yes

200

499

14 M

Headaches, Shoulder Degeneration

182

Ambulatory Full

Yes

170

349

Scoliosis

105

Ambulatory Full

Yes

16 M

Lumbar Spine Degeneration

250

Ambulatory Full

Yes

200

415

Fibromyalgia, Lumbar Spine Degeneration

180

Ambulatory Full

Yes

120

324

Headaches

220

Ambulatory Full

Yes

274

Cervical Spine Degeneration

Ambulatory Full

Yes

120

1000

Degenerative Spine, Hepatitis C

250

Ambulatory Full

320

808

600

905

600

485

480

2580

160

506

200

273

167

18 M 19

20 M 21

Fibromyalgia, Degenerative Spine

190

Ambulatory Full

Yes

Reflex Sympathetic Dystrophy

245

Ambulatory Full

Yes

Fibromyalgia

235

Ambulatory Full

Yes

24 M

Fibromyalgia

134

Ambulatory Full

Yes

Fibromyalgia

125

Ambulatory Full

Yes

26 M

Spinal Injury/ Paralysis

180

Wheel Chair

Yes

27 M

Fibromyalgia

175

Ambulatory Full

Yes

160

244

28 M Degenerative Spine/ Osteoporosis

285

Ambulatory Full

Yes

400

119

Yes

Degenerative Spine

198

Ambulatory Full

Yes

150

285

30 M

Degenerative Spine

160

Ambulatory Full

Yes

160

182

31 M

Scleroderma/ Arthritis

240

Ambulatory Full

Yes

600

649

32 M

Ulcerative Colitis, Abdominal Adhesions

160

Ambulatory Full

Yes

200

2182

Yes

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Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

Morphine IR

TABLE 9. No. Sex

Cause of Pain

Age

Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Fibromyalgia

134

Full Ambulatory

Yes

960

143

Fibromyalgia

125

Full Ambulatory

Yes

500

156

Degenerative Spine

430

Full Ambulatory

Yes

1500

Degenerative Spine/ Fusion

150

Full Ambulatory

Yes

540

Porphyria

108

Full Ambulatory

1800

828

170

Full Ambulatory

Yes

540

182

150

Full Ambulatory

Yes

100

Systemic Lupus

165

Full Ambulatory

Yes

600

335

Headaches

200

Full Ambulatory

Yes

1200

640

Fibromyalgia

161

Full Ambulatory

Yes

240

Degenerative Spine/ Abdominal Adhesions Autoimmune Disease/ Cervical Spine Degeneration

Morphine SR

TABLE 10. No. Sex

Cause of Pain

Age Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage

Blood Level ng/ml

Lumbar Spine Degeneration

227

Full Ambulatory

Yes

2837

Cervical Spine Degeneration

147

Full Ambulatory

Yes

2.5

240

1300

Neuropathies

157 Full Ambulatory

Yes

400

1635

Lumbar Spine Degeneration

170

2.5

460

190

Cervical Spine Degeneration

98 Full Ambulatory

Yes

600

Lumbar Spine Degeneration

135 Full Ambulatory

Yes

240

182 Full Ambulatory

Yes

160

176 Full Ambulatory

Yes

261

180 Full Ambulatory

Yes

105

8 9

Headaches, Shoulder Degeneration Lumbar Spine Degeneration, M Generative Osteoarthritis Migraine, Degenerative Spine & F Knee

Wheelchair

Metastic Melanoma

165

Full Ambulatory

Yes

900

Cervical Spine Degeneration

168

Full Ambulatory

Yes

400

1335

Abdominal Adhesions

150

Full Ambulatory

Yes

1000

142

Degenerative Spine

192

Full Ambulatory

Yes

1200

181

Degenerative Spine, Osteoporosis

285

Full Ambulatory

Yes

800

247

Degenerative Spine

250

Full Ambulatory

Yes

900

Fibromyalgia

112

Full Ambulatory

2000

184

Fibromyalgia, Cervical Spine Disease

115

Full Ambulatory

Yes

180

140

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Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

TABLE 11.

No. Ssx

Oxycodone Cause of Pain

Age

Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Spine Degeneration, Obesity

285

Full

1520

700

Spine Degeneration

179

Full

1400

226

Spine Degeneration

150

Full

Yes

960

3077

Headaches, Porphyria

140

Full

Yes

195

207

Neuropathy of Chest, PostMastectomy

108

Full

Yes

Degenerative Spine, Fibromyalgia

190

Full

Yes

360

Crohn's, Abdominal Adhesions

108

Full

Yes

480

518

Degenerative Spine

128

Full

Yes

120

Porphyria

108

Full

Hip & Spine Degeneration

125

Full

610

Degenerative Spine

205

Full

Yes

180

Scleroderma, Arthritis

240

Full

Yes

2700

160

Headaches

178

Full

Yes

360

Fibromyalgia

117

Full

Yes

120

149

Degenerative Spine/ Fusion

200

Full

Yes

240

TABLE 12.

No. Sex

Yes

Proproxyphene Cause of Pain

Age Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage mg

Blood Level ng/ml

Abdominal Adhesions

190

Full Ambulatory

Yes

1300

240

Fibromyalgia

190

Full Ambulatory

Yes

400

227

See page 41 for Table 13.

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Te n n a n t B l o o d S t u d y — S u m m a r y R e p o r t

Oxycodone SR

TABLE 13. No. Sex

Cause of Pain

Age

Weight

Function

Able to Drive

Work or Volunteer

Years on Opioids

Daily Dosage

Blood Level ng/ml

Spine Degeneration

191

Full Ambulatory

320

650

Spine Degeneration

132

Full Ambulatory

1.5

880

428

Spine Degeneration

170

Full Ambulatory

960

420

Spine Degeneration

170

Full Ambulatory

Yes

400

Spine Degeneration

270

Full Ambulatory

Yes

480

267

Diabetic Neuropathy

170

Full Ambulatory

Yes

560

120

Peripheral Neuropathy

200

Full Ambulatory

Yes

800

198

Abdominal Adhesions

185

Full Ambulatory

Yes

120

130

Trigeminal Neuralgia

197

Full Ambulatory

480

220

Rheumatiod Arthritis

159

Full Ambulatory

Yes

400

270

Spine Degeneration

240

Full Ambulatory

Yes

480

240

Abdominal Adhesions

201

Wheelchair

Yes

Neuropathies - Post

145

Full Ambulatory

Yes

480

304

Fibromyalgia

190

Full Ambulatory

Yes

240

104

Diabetic Neuropathy

240

Full Ambulatory

Yes

400

386

Lumbar Spine Degeneration

205

Full Ambulatory

Yes

400

114

Migraine

Full Ambulatory

Yes

120

Lumbar Spine Degeneration

Full Ambulatory

Yes

320

134

Cervical Spine Degeneration

Full Ambulatory

Yes

160

196

Fibromyalgia, Cervical Spine Disease

Full Ambulatory

Yes

480

440

Lumbar Spine Degeneration

207

Full Ambulatory

Yes

120

Peripheral Neuropathy

245

Full Ambulatory

Yes

400

278

Generalized Osteoarthritis

257

Full Ambulatory

Yes

320

Headaches

201

Full Ambulatory

Yes

240

103

Shoulder Degeneration

Full Ambulatory

Yes

180

Cervical Spine Degeneration

Full Ambulatory

Yes

120

Degenerative Spine

315

Full Ambulatory

Yes

195

Degenerative Spine, Hip, & Knees

108

Walker

Neuropathy-Inquinal

270

Full Ambulatory

Yes

640

170

Degenrative Lumbar Spine

220

Full Ambulatory

Yes

550

Degenerative Spine

245

Full Ambulatory

600

130

Degenrative Spine/ Fusion

150

Full Ambulatory

Yes

320

179

Degenrative Spine/ Reflex Sympathetic Dystrophy

225

Full Ambulatory

Yes

480

458

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R eview For reprint orders, please contact reprints@future-science.com

The bioanalytical challenge of determining unbound concentration and protein binding for drugs Knowledge regarding unbound concentrations is of vital importance when exploring the PK and PD of a drug. The accurate and reproducible determination of plasma protein binding and unbound concentrations for a compound/drug is a serious challenge for the bioanalytical laboratory. When the drug is in equilibrium with the binding protein(s), this equilibrium will shift when physiological conditions are not met. Furthermore, the true unbound fraction/concentration is unknown, and there are numerous publications in the scientific literature reporting and discussing data that have been produced without sufficient control of the parameters influencing the equilibrium. In this Review, different parameters affecting the equilibrium and analysis are discussed, together with suggestions on how to control these parameters in order to produce as trustworthy results for unbound concentrations/fractions as possible. Drug molecules in vivo are present in blood bound to plasma proteins or to red blood cells (RBCs), or unbound in plasma water. The unbound compound will be distributed to tissues where the compound will either be unbound or bound to proteins. It is generally assumed that only the unbound drug interacts with the receptor exerting the pharmacological effect [1], Figure 1 is an attempt to schematically illustrate the equilibrium processes between unbound and bound drug in blood and tissue. The unbound concentration in plasma will be the same as the unbound tissue concentration if transporters, metabolism and bulk flow are not influencing the equilibrium. The system is in equilibrium in both in vivo and ex vivo samples, and this equilibrium rapidly responds to changes in the environment. Most equilibria will be established within 100 ms, although longer times can be expected for extreme binding, fraction unbound (f u) <0.1% [2]. The equilibrium is affected by changes in pH, temperature, drug concentration, protein concentration and the concentration of other drugs present. The two dominating binding proteins are albumin and a1-acid glycoprotein; their main properties are provided in Table 1. Albumin accounts for almost 60% of the total protein content in plasma, has a molecular weight of 66,000 Da and a typical concentration in human plasma of approximately 650 µmol/l [3,4]. It consists of a single polypeptide chain with 585 amino acids arranged as parallel a-helix structures and no carbohydrate moieties, and the

folding is determined by 17 disulphide bridges. The albumin molecule is very flexible, changing its conformation depending on the environment (e.g., temperature, pH and ionic strength) and with binding of ligands. The albumin concentration in plasma is fairly constant, but can decrease rapidly after severe injuries and surgery. There are two main binding sites with high affinity, usually described as the warfarin site and the benzodiazepine site. Binding to the warfarin site has been shown to be both pH-dependent and species-specific [5]. The other protein, a1-acid glycoprotein (a1-AGP) or orosomucoid, is much more complicated (see [6] for a review). It consists of 59% protein and 41% carbohydrate, including sialic acid (11%). The molecular weight, depending of the method of isolation, is in the range of 38,000 to 48,000 Da while the molecular weight of the commercially available isolated and purified protein is 44,000 Da. The concentration in human plasma from adults is around 15 µM (range 10–30 µM), the concentration in fetuses and newborns is lower but from the age of 1 year the concentration is the about same as for adults. There are also diurnal variations and ethnic differences. Several phenotypes of a1-AGP with different binding properties have been described [7,8]. a1-AGP is an acute-phase protein, the levels increase in various disease states such as infection, inflammation and cardiovascular diseases. Increased levels have also been observed in obese individuals and after severe injuries, trauma and burns. Steroid treatment seems to decrease

Bioanalysis (2013) 5(24), 3033–3050

Lars B Nilsson Analytical Pharmaceutical Chemistry, Dept. of Medicinal Chemistry, Uppsala University, BMC Box 574, SE-75123 Uppsala, Sweden E-mail: larsbnilsson@hotmail.se

ISSN 1757-6180

3033

R eview |

Nilsson Compound focused: studies of the unbound fraction of a drug in plasma;

Cblood

Sample focused: studies of ex vivo unbound concentrations of a drug in actual plasma samples.

Plasma water

Plasma proteins

RBC

Crbc

Crec

Tissue

Response

Figure 1. Description of drug equilibria in blood and tissue. Cb: Concentration bound to plasma proteins; Cblood: Concentration in blood; Cp: Concentration in plasma; Crbc: Concentration bound to red blood cells; Crec: Concentration bound to receptor and giving response; Ct: Concentration bound to tissue; Cu: Unbound concentration.

Key Terms Unbound concentration:

Drug concentration (usually in plasma) that is not bound to proteins and is available for interaction with the receptor.

Unbound fraction: Ratio between the unbound concentration and the total concentration.

3034

a1-AGP levels, while other drug effects have been inconsistent [6]. Altogether, these facts suggest that prediction of unbound concentrations from in vitro data might be less relevant for drugs that mainly bind to a1-AGP. Both proteins exhibit chiral properties, thus enantiomeric drugs might have very different binding properties resulting in stereoselective PK [9,10]. This has also been utilized in chromatographic and capillary electrophoretic separations of drug enantiomers [11]. Lipophilic compounds might also interact with lipoproteins [12,13], the molecular weights of which vary between 200,000 and 2,400,000 Da. This interaction seems to be of a somewhat different character, rather than an equilibrium binding to specific sites on the protein, the drug is distributed between the lipophilic protein and the aqueous part of plasma. The interaction is also different as the fraction distributed to the lipoproteins might be available for cellular uptake [14]. Protein-binding studies could be divided into three different types: Protein focused: studies of how drugs bind to individual proteins;

Bioanalysis (2013) 5(24)

The first approach, usually using an isolated and purified protein linked to a surface [15] or to a chromatographic support [16,17], is of interest from a mechanistic perspective, and possibly for comparing compounds in a structurally related series. The second approach is the most commonly used in drug development; the unbound fraction is determined, usually in vitro, in plasma from different species, populations, and so on, and this unbound fraction is used in transforming determined total drug concentrations to unbound concentrations to help in the interpretation of the drug effects. The third approach is not so common, but would be the ideal information in drug development [18] – the unbound concentration in every sample. It is then possible to directly relate the actual unbound concentration in every sample to PDs and toxicological effects. To determine the extent of plasma protein binding (PPB) and the unbound concentrations for a drug is probably one of the greatest challenges for the bioanalytical scientist; to determine the concentration of a compound in a system in equilibrium without disturbing the equilibrium. The matter is further complicated by the fact that the true unbound fraction/concentration is unknown. There are numerous possibilities to produce false results, and there is no method that can be said to be generally applicable. Many reports on protein binding and unbound concentrations have been published without sufficient control of the different parameters influencing the equilibrium. Furthermore, there are many reports discussing the use of PPB results in the interpretation of the PDs of a drug that neglect, or do not consider, the uncertainties and difficulties involved in the determination of the unbound fractions/concentrations. This review, with added examples from the author’s own work, is an attempt to increase both the awareness of the difficulties and the possibilities to get reproducible and trustworthy results. PK background PPB measurements in drug development are part of the: future science group

Challenge of determining unbound concentration & protein binding for drugs

| R eview

Table 1. General properties of human albumin and a1-AGP. Molecular weight (kD)

Albumin

a1-AGP

Isoelectric point (pH) 5.2 Concentration in plasma (µmol/l) 650

2.7 15

Number of binding sites

6 (2 major)

7 (1 major)

Binds mainly

Acidic compounds (also some neutrals and bases) Basic compounds

PK characterization;

PD characterization (the concentration– response relationship);

Assessment of compound selectivity and safety margin;

Scaling across species and calculation of first dose in humans;

Discrimination between factors altered by disease.

The principal concern with in vivo PPB is related to its concentration-dependent variability within and across different individuals, species, strains and disease models. The equilibrium in plasma between unbound and bound drug for a low molecular weight compound, with rapid on/off rates of binding, is determined by the unbound concentration, the concentration of the binding protein, the number of binding sites per protein molecule and the affinity between drug and protein. The unbound concentration (Cu) at steady state is determined by the (oral) dosing rate and unbound clearance (CLu) (Equation 1). Cu = Dose rate CLu Equation 1

The total plasma concentration C is a consequence of the ratio of Cu to unbound fraction (fu): C = Cu fu Equation 2

where f u is the proportionality factor between the unbound and total plasma concentrations. Equation 2 is often written differently, Cu = C × fu, giving rise to the misunderstanding that the unbound concentration is a consequence of the product of the total concentration and the unbound fraction [19,20]. To avoid misinterpretations the equation should always be written as Equation 2 [21]. Experimentally, the unbound fraction f u is derived by measuring the unbound Cu and total C concentrations at future science group

several concentrations. In a closed (static) system, that is, the in vitro situation, the total drug concentration depends on the amount of drug added to the system, but in the in vivo situation, an open (dynamic) system, the total drug concentration C is a consequence of the unbound concentration Cu and the unbound fraction fu, as discussed above, and the unbound concentration Cu is a consequence of dose rate and unbound clearance CLu. The early characterization of the PK properties of a compound usually comprises the in vitro measurement of PPB. Instead, it is suggested to use data from quantitative ex vivo PPB determinations, obtained at a minimum of two pharmacologically relevant concentrations (low and high), as an integral part of the in vivo PD protocol. This would enable conclusions regarding the impact of binding on potency and the shape of the concentration–response relationship. The unbound fraction in plasma, fu, is constant at lower drug concentrations, but increases as the drug concentration approaches the concentration of the binding plasma protein, assuming the simplest case of a 1:1-binding to one protein. The aspects of concentration-dependent PPB and inter-species differences in PPB for a research compound are visualized in Figure 2 . At an unbound concentration of 0.1 µM there is an almost tenfold inter-species difference in the unbound fraction. The inter-species difference in the unbound fraction then changes with concentration. This makes it difficult to assess the safety margin or the concentration–response relationship across species. In light of these findings it is suggested that inter-species comparisons, and comparisons across compounds or concentrations, should ideally be based on unbound values. Comparisons based on total concentrations will be confounded by the fact that the total plasma concentration is the ratio of the unbound concentration and the unbound fraction. For example, an unbound concentration of 0.1 µM of the compound in Figure 2 will, for rabbit (fu 17%), rat (fu 8.5%), mouse (fu 7.0%), dog (fu 4.2%) and human (fu 2.9%), correspond to www.future-science.com

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Nilsson From a drug-discovery perspective, the use of in vitro unbound fractions as a selection criterion or a parameter for optimization is not very useful, as can be deducted from the reasoning above. What is important is the unbound concentration in vivo and efforts should therefore be focused on synthesizing and selecting compounds with lower unbound clearance and improved membrane permeation [19,25].

Unbound fraction (%)

20 Rabbit 15 Gerbil 10

Rat Mouse

0 0.001

Guinea pig Human

Dog 0.01

0.1 1 Unbound concentration (µM)

Figure 2. Unbound fraction versus unbound plasma concentration for a research compound in mouse, gerbil, rat, guinea pig, rabbit, dog and human.

total plasma concentrations of 590, 1200, 1400, 2400 and 2700 nM, respectively, making concentration–response comparisons across species problematic unless based on unbound concentrations. A good comparison between efficacy and a safety measure can be made by comparing, for example, the estimated unbound concentration giving a 20% change from baseline of the primary effect (Cu20) and the unbound concentrations giving a 10% change from baseline of the secondary effect (e.g., Cu10 for QT-response). Disease states may also alter the unbound concentration (due to changes in the eliminating/metabolic capacity) or the unbound fraction (due to changes in the protein concentration) and, hence, a change in the total plasma concentration. PPB is important to assess in, for example, liver disease, in order to elucidate whether the changes occur in the unbound concentration (metabolism, a change in the dosing rate is needed) or in the unbound fraction (change in total plasma concentrations, no need for a change in dose). The clinical relevance of changes in PPB has been a matter of some controversy [22,23]. Confounding factors known to affect PPB are, for example, species and strain differences, concomitant use of other drugs, anesthetics and surgical stress. Therefore, ex vivo measurements of unbound concentrations/fractions (i.e., measurements from individual study samples rather than pooled samples) in pharmacological or PK in vivo model experiments is suggested in order to avoid quantitative (concentration dependencies) and qualitative differences [24]. 3036

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Techniques for studying protein binding Numerous techniques have been used for studying protein binding, for example, equilibrium dialysis (ED), ultrafiltration (UF), ultracentrifugation, semipermeable membrane extraction, chromatographic techniques including frontal analysis, protein precipitation, negligible extraction, supported liquid membrane extraction, headspace analysis, fluorescence quenching, and surface plasmon resonance. The most common general problems with these techniques are equilibrium disturbance and nonspecific adsorption (NSA). From a drug-development perspective, only ED and UF have gained widespread acceptance and the discussions below will be more or less restricted to these techniques, which is not to say that other techniques cannot be useful; detailed information about the other techniques can be found elsewhere [26–31]. In early drug-discovery settings, where PPB experiments are too time consuming, in silico models for prediction of the protein binding might be a way to better understand the PK/PD properties of a drug [32]. Equilibrium

dialysis In ED, two chambers are separated by a semipermeable membrane. Plasma is placed in one chamber and a buffer in the other chamber. The buffer should be as similar to plasma water as possible and usually isotonic phosphate-buffered saline (PBS; pH 7.4) is used. After dialysis for usually 4–24 h, equilibrium will be reached and the drug concentration in the buffer will be the same as the unbound concentration in the plasma chamber. The time to equilibrium must be verified for each compound and ED manifold. ED is known to be slow and laborious, but there are at least three different commercially available 96-well plates for ED, which makes the technique more convenient. The biggest advantage with ED is that NSA is believed to not affect the unbound fraction; a new equilibrium will be established although at a lower concentration than intended. The main disadvantage is that at future science group

Challenge of determining unbound concentration & protein binding for drugs

Ultrafiltration

UF is a simple method for PPB studies, the plasma sample is transferred to the upper part of a two-piece container divided by a filter with a molecular weight cut-off (MWCO) of 3–30 kD and, after centrifugation, the unbound drug concentration is determined in the resulting protein-free ultrafiltrate. There are single unit UF devices available for different volumes, from several milliliters down to 100 µl, and there are also two 96-well plates available that offer a rational procedure for PPB studies [34]. The big advantage with UF is that protein binding can be studied without disturbing the equilibrium. It is easy to adjust pH and temperature to physiological conditions (see below) prior to future science group

the experiment and easy to maintain pH and temperature during the centrifugation. Another advantage is that the desirable unbound concentration is directly determined in the ultrafiltrate, to calculate the unbound fraction the total concentration in plasma must also be determined. It is mentioned in many articles about UF, that the equilibrium is disturbed as the protein concentration above the filter increases during the UF. This is a misunderstanding, during the filtration process an equilibrated part of the sample is removed and this will not affect the drug–protein equilibrium above the filter. This was recognized early on and verified both theoretically and experimentally [35,36], and experiments in the author’s laboratory with ultrafiltrate volumes of 16–47% of the original plasma volume have given the same result (Figure 3). McMillin et al. studied the influence of centrifugation time and protein concentration on the ultrafiltrate volume and the unbound phenytoin concentrations, and concluded that the equilibrium was maintained [37]. Contradictory results were reported in a recent article studying extreme ultrafiltrate volumes of up to 80% of the initial volume; increasing unbound fractions with increasing ultrafiltrate volumes were seen [38]. The very high g-force (8 g) needed to achieve such ultrafiltrate volumes might, however, result in protein leakage and increased temperature, and this can give similar results to those reported. Unfortunately, UF has one big disadvantage in its susceptibility to NSA. This is mainly, but 5

4 Unbound fraction (%)

equilibrium the concentration is lower than the initial concentration as a part of the compound is now in the buffer chamber. Thus, to get the unbound concentration in an ex vivo sample, the concentration in both the buffer and the plasma chamber at equilibrium must be determined. The ratio between these gives the unbound fraction, and to get the unbound concentration the total concentration is also determined in the ex vivo sample and multiplied with the unbound fraction. This will give a good estimate of the unbound concentration in the sample, as long as the binding is not concentration-dependent (see below). Volume shift due to the osmotic effect of the macromolecules is another often mentioned disadvantage, but according to the author’s experience, the volume shift using PBS is in the range of 2 to 4% and can be regarded as insignificant. It is also important to remember that only proteins cannot cross the membrane. At equilibrium, the components that can cross the membrane will have the same concentration on both sides, although some ions may be unevenly distributed due to the Donnan effect. How this affects the equilibrium is not very well studied. The ideal ED setup for in vitro experiments is probably to first produce ultrafiltrate of the plasma to be studied and then use the ultrafiltrate on the buffer side [33]. This will, however, require rather large volumes of plasma and is of course laborious. In a situation where there is doubt around the equilibrium disturbance when buffer is used, the ultrafiltrate setup might be used as a control. ED has often been regarded as the reference method for PPB determinations, but, as can be seen above, the method has many problems and the results must always be critically scrutinized.

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0 0

10 20 30 40 Ultrafiltration volume as percentage of initial volume

Figure 3. Influence of ultrafiltrate volume on unbound fraction.

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Nilsson not only, adsorption to the UF membrane itself due to its large area. There are different membrane materials available with different properties regarding NSA. Generally, the regenerated cellulose membranes are preferable from an adsorption perspective. To measure the adsorption from plasma is difficult, as the true unbound fraction is unknown, but the filtration of a drug dissolved in pH 7.4 buffer, and analysis of the drug concentration before and after UF might determine if adsorption can be a problem. The use of a correction factor based on the adsorption from buffer has been proposed, but is not a practicable alternative as the adsorption from plasma can be expected to be much lower than from buffer, as the protein-bound drug is not adsorbed and there is also a protective effect of plasma components [39]. A mass balance approach was recently reported, that is, the concentrations and volumes both above and below the filter after centrifugation must be determined [39]. This approach also gave plausible results for compounds with high NSA from buffer. This approach will, however, not compensate for NSA in the ultrafiltrate cup where, in the absence of plasma, the risk for NSA is higher. Efforts have also been made to prevent, reduce or compensate for the nonspecific binding (e.g., [40–42]) but, to the best of the author’s knowledge, there are no generally ef fective procedures. Selective

or nonselective analysis? The PPB experiments can be performed using radiolabeled compounds or nonradiolabeled (cold) compounds. If radiolabeled compounds are used, the compound concentration in the ultrafiltrate or ED chambers can be determined using simple scintillation counting and, thereby, avoiding analytical method development. If cold compounds are used, a selective analysis must be applied, today this usually means LC–MS/MS, and a method must be developed if not already available. Although the radiolabeled alternative might seem attractive at first sight, it must be used with caution as the scintillation counting analysis measures radioactivity regardless of the origin of radioactivity. This means that a very good control of the radiochemical purity and stability of the compound is crucial to be able to judge if the obtained PPB results are trustworthy or not. If it is presumed that the impurity is not bound to proteins, the error induced for 3038

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highly bound compounds might be very large. After determination of radiochemical purity and stability during the PPB experiment, it can be decided if nonselective analysis is a viable alternative. If a 10% error is regarded as acceptable and the compound has 2% radiochemical impurities, nonselective analysis should not be used for compounds with f u below 20%. If f u is 0.5%, the radiochemical purity should be >99.95%. This is illustrated in F igure 4 , which also clearly illustrates the rapid exponential increase of the percentage error at low unbound fractions. It is not unusual to see reports where f u ≤ radiochemical impurity. To avoid confounded results, it has been proposed to always use nonradiolabeled compounds and selective analysis in protein-binding studies for regulatory submissions [43]. When using selective ana l ysis such as LC–MS/MS, an impurity does not affect the results as long as it is chromatographically resolved or has a different molecular ion and/ or product ion. In reality, the biggest risk is when dealing with enantiomeric compounds in nonchiral systems. As mentioned above, enantiomers often have differing PPB properties. When studying the PPB of an enantiomeric compound, it is important to make sure that the right enantiomer is used and that there is no risk for chiral conversion. A small degradation during the experiment is also only a minor problem when using selective analysis. For ED, where the compound is determined at equilibrium in both chambers, the only effect would be that the equilibrium concentration is at a somewhat lower level than planned. For UF the risk is higher, as the chemical stability in ultrafiltrate is sometimes significantly lower than in plasma. This means that 5% degradation in the ultrafiltrate would result in 5% lower determined unbound concentration. Although a PPB UF experiment can be performed in a rather short time, less than 1 h in total, the stability in ultrafiltrate should be checked for compounds with known or anticipated stability problems. Sometimes, immunological methods such as ELISA may also be used for the determinations. These are also nonselective; thus, crossreactivity with metabolites or degradation products must be under control. Even with selective analysis using LC–MS/MS and a stable isotope IS (SILIS), it is possible to get incorrect results. If the SILIS, added at analysis, contains some unlabeled analyte, the future science group

Challenge of determining unbound concentration & protein binding for drugs

Temperature & pH effects on protein binding The normal human body temperature is commonly accepted to be 37°C and the pH in circulating plasma is 7.40 ± 0.05. The blood pH is regulated with dissolved CO2, giving the buffer system H+ - HCO3-. When blood is collected, CO2 is immediately lost, also, in fresh blood the pH increases 0.1–0.2 units. After preparation of plasma and freezing–storage–thawing of the plasma, the pH is often around 8 and after longterm storage sometimes even above 9 [44,45]. The protein binding is often strongly dependent on pH [46,47]. For basic drugs binding primarily to a1-AGP, the unbound fraction decreases with an increase in pH. This is mainly due to the change in the ionization state of basic drugs with pKa values close to pH 7.4 as the nonionized fraction is preferentially bound to the protein. For acidic drugs binding to albumin, the unbound fraction has been found to increase with increasing pH for some drugs, but to decrease for other drugs. Conformational changes of albumin, the neutral-base transition within the pH 6–9 range [48,49], are well known and might explain this behavior. As changes in the ionization state of the compound sometimes cannot fully explain the pH dependence of a1-AGP-binding compounds, conformational changes of this protein have been proposed to modify the binding properties [50], although another study suggests the opposite [51]. Typical pH dependence for basic drugs is future science group

10,000 0.5% unbound inpurities 1% unbound inpurities 2% unbound inpurities 5% unbound inpurities

1000

Error (%)

determined unbound concentration might be overestimated. An 11-times higher unbound concentration would be observed if the SILIS, added at a ten-times higher concentration than the analyte, contains 1% unlabeled analyte and the unbound fraction of the analyte is 1%. There are a few reports in the literature where the unbound fraction increases with decreasing drug concentration, but this anomalous behavior might also be a result of such an analytical error. However, the recommendation must be to always use selective analysis, preferably LC–MS/MS, in PPB studies. Nonselective analysis using a radiolabeled compound and scintillation counting might be used if it is a stable compound with recently determined high radiochemical purity and an expected unbound fraction that is fairly high. PPB results originating from nonselective analysis should not be accepted if the radiochemical purity and the stability are not known/reported.

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100

0.1 0

100

Unbound fraction (%)

Figure 4. Error introduced by unbound labeled impurities (from synthesis or degradation) when determining unbound fraction using labeled compound and nonselective analysis.

demonstrated in Table 2 where the unbound fractions for five local anesthetics with pKa values between 7 and 8 were determined at pH 6.4–9.4 [52]. The influence of temperature is shown in Table 3, where the unbound fractions for the same five local anesthetics were determined at temperatures between 32 and 40°C [52]. Furthermore, according to the author’s experience, the unbound fraction at room temperature is usually approximately 50% of the unbound fraction at 37°C, similar data were reported for phenytoin [53] and a quinine compound [54]. Clearly, strict pH and temperature control are necessary when studying protein binding. How can pH and temperature be restored to physiological conditions of pH 7.4 and 37°C? An easy, physiologically correct and very convenient process for a whole batch of samples is to use a CO2 incubator with controlled temperature and humidity, and simply restore the original CO2 levels at 37°C [44]. The plasma samples, in a 96-well plate or in single units, are placed on a mixer standing in the incubator. Originally, a two-step process was used, but it was later found that for plasma volumes <200 µl (96-well plates for ED and UF and low-volume UF single units) one step, typically 10–15 min at 13% CO2 and 37°C, was sufficient. The appropriate CO2 concentration and incubation time depend on the surface area/volume ratio for the plasma sample and must be determined for every set-up. The process was tested for plasma samples with initial pH varying from 7.8 to >9, and after the CO2 www.future-science.com

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Nilsson Table 2. Influence of pH on unbound fractions. Compound

Unbound fraction (%)

Ropivacaine Bupivacaine Mepivacaine Prilocaine Lidocaine

pH 6.4

pH 7.4

pH 8.4

pH 9.4

28 22 72 70 47

6 5 24 65 25

4 2 13 54 14

5 3 12 52 12

Data taken from [52].

incubation all samples had a pH within the 7.30 to 7.45 range [44]. It is recommended to aim for a pH of 7.30–7.35 after the pH adjustment, as there is usually a small rise in pH during both the UF and ED process. Evaporation during incubation will result in overestimated concentration results, and to prevent this the incubator must have an open water reservoir to keep the humidity high during the process. Using ED, the pH of the plasma has normally not been adjusted prior to the experiment, as it has been assumed that the use of buffer in the opposite chamber would be sufficient to both adjust the pH to 7.4 and maintain the pH during the experiment. However, when pH in the buffer and plasma compartments was measured after dialysis and using Dulbecco´s buffer, a shift of approximately 1.5 pH units was found [55]. Using buffers with higher concentrations, it was possible to adjust and maintain the pH during the dialysis, but unfortunately, the influence of the high ionic strength on the drug–protein equilibrium was not studied. In model experiments, ionic strength has been found to alter the binding constant in drug–protein interaction experiments [56] and the binding of charged ligands to albumin has been found to be clearly dependent on ionic strength and buffer capacity [57]. In the author’s experience with 96-well ED plates (Harvard Bioscience, MA, USA), tightly sealed during dialysis, the pH shift during the experiment is minimal when using Dulbecco’s buffer and when plasma pH is adjusted to 7.3–7.4

(using CO2) in the plate immediately before the start of the dialysis. A similar approach, a combination of a standard buffer and a 5% CO2 atmosphere, was found to give excellent pH control when using the 96-well RED plate (Thermo Scientific) [58]. The variations in unbound fraction at different pH and temperatures clearly show that determinations of unbound fractions and concentrations should, to be relevant from a PK/PD perspective, always be performed at physiological conditions. As it is also very easy to adjust pH and temperature to physiological conditions, there is really no excuse for not doing so. Concentration-dependent binding & species differences In Table 1, the typical concentrations of albumin and a1-AGP in human plasma were stated to be 650 and 15 µmol/l, respectively. Although a1-AGP can vary substantially (see above), these figures can be used as the basis for the discussion below. If a drug binds to the protein as a 1:1 complex, saturation effects will be observed when the drug concentration approaches the protein concentration, that is, the unbound fraction starts to increase. This also means that drug–protein interactions are always dependent on the drug concentration, although this is not observed when the relevant drug concentrations are much lower than the protein concentrations. According to the author’s observations, a noticeable increase in unbound fraction due

Table 3. Influence of temperature on unbound fractions. Compound Ropivacaine Bupivacaine Mepivacaine Prilocaine Lidocaine

Unbound fraction (%) 32°C

37°C

40°C

6 4 21 55 17

6 5 24 65 25

9 13 26 74 23

Data from [52].

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Challenge of determining unbound concentration & protein binding for drugs

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by the binding to albumin and the increase in unbound fraction was not as high as was seen for the a1-AGP solution. When studying the binding to solutions of the isolated and purified proteins, it is generally found that the unbound fractions are significantly higher (typically ~50% higher) than what is observed in plasma, suggesting that the properties of the isolated and purified protein in an aqueous solution is not the same as for the natural protein in plasma [62]. The species differences for this compound were large. The unbound fraction in guinea pig plasma was almost 40-times higher than in rat plasma. Such a large difference is unusual but not extreme; the author has observed differences in unbound fractions between species for the same compound of up to 300-times. Consequently, the unbound fraction in one species cannot be used to estimate the unbound fraction in another species, and to evaluate PK/PD data for the same compound in different species the unbound fraction must be determined for all species (see also the PK background section above). Species differences in protein binding are well known, for example, for tolterodine a f u range of 1.5% (cat) to 39% (rabbit) was found [63]. Less known are the species differences in pH-dependent protein binding, for biperiden there was a difference between f u in rat, dog and human plasma at pH 7.4 that was not seen at a higher pH, whereas for verapamil there was no difference at pH 7.4 but a clear difference at a higher pH [47]. This emphasizes once again the importance of reliable pH control in order to avoid misleading conclusions. 25

20 Unbound fraction (%)

to saturation effects for compounds bound to a1-AGP often starts at a drug concentration of approximately 2–5 µmol/l, and for compounds bound to albumin at approximately 150– 300 µmol/l, well in line with literature data [21]. The saturation effects are seen earlier for compounds with low unbound fractions and later for compounds with high unbound fractions. At very high drug concentrations, the binding protein becomes saturated, f u approaches unity and total and unbound concentrations approach each other asymptotically. More detailed discussions about concentration dependence can be found elsewhere [59–61]. In reality, protein binding is often more complex than a simple 1:1 binding to a single protein. For naproxen, a model with one highaffinity site and five low-affinity sites was found to correlate well with experimental data [59,60]. Many compounds binding to a1-AGP also bind to albumin with lower affinity. An example of concentration- and species-dependent binding for a basic research compound [Nilsson LB, Unpublished Data] can be illustrative. This compound showed similar binding in human albumin and a1-AGP solutions, the unbound fractions were approximately 20–25% for both proteins at drug concentrations of 0.8 and 2 µmol/l. At 20 µmol/l, in accordance with the discussion above, the unbound fraction for a1-AGP increased to 57%, while the unbound fraction for albumin was in the same range as earlier. The in vitro binding in plasma was studied for seven different species (Figure 5). To minimize experimental bias, this experiment was performed in a single batch using a 96-well ED plate (Harvard Bioscience) at pH 7.3–7.4 and 37°C with four replicates for each species and concentration. LC–MS/MS was used for the ana lysis. Large differences were seen between species, both regarding concentration dependence and unbound fractions. In rat, dog and mouse plasma, there were only insignificant changes with concentration. For rabbit and cynomolgus plasma, the changes were rather small – unbound concentration was approximately 50% higher at 20 µmol/l compared with 2 µmol/l. In human plasma the unbound fraction was doubled, while in guinea pig plasma there was a four-times higher unbound fraction at the high drug concentration. Presumably, albumin is the main binding protein in rat, dog and mouse plasma and a1-AGP is the main binding protein in guinea-pig plasma. In human plasma the effect of the saturation of a1-AGP is moderated

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Mouse 15

Rat Guinea pig Rabbit

Dog Cynomolgus Human

0 0,2

2 Drug concentration (µmol/l)

Figure 5. Concentration- and species-dependent unbound fractions for a research compound.

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Nilsson Handling unstable compounds in PPB studies Working with drug discovery and development, it is inevitable to also encounter compounds with limited stability, and PPB data are also important for these compounds. Both the traditional PPB methods are rather demanding regarding stability, for UF the compounds need to be stable in plasma at 37°C for at least 1 h and for ED the equilibration times are usually around 20 h. For some ED devices with a more favorable membrane surface area/sample volume ratio it is possible to achieve shorter equilibration times, but rarely shorter than 4–6 h. The stability must be checked to cover the time for the experiment. For UF, a degradation will directly affect the result. ED is a bit more forgiving and a small decrease in concentration will not affect the unbound fraction as the concentrations at both sides of the membrane are determined at equilibrium (selective analysis is presumed). For bioanalytical purposes, it is often possible to increase the stability by, for example, changing the pH or decreasing the temperature [64], measures that are obviously unsuitable for PPB studies. A major cause of analyte instability in plasma is the enzyme activity of mainly esterases and deamidases. The enzyme activity shows species differences, it is not unusual that a compound is stable in plasma from one species and rapidly degraded in another. As acidification cannot be used to improve the stability, the addition of an enzyme inhibitor can be tried. Fluoride is a classic enzyme inhibitor that has been used for more than a century. Sodium fluoride added to plasma in concentrations of 5–10 mg/ml is an efficient enzyme inhibitor; an example is given in Table 4 [Nilsson LB, Unpublished Data]. Under the conditions investigated, it was found that the compound, a basic drug candidate, was stable in rat, dog, monkey and human plasma, slowly degrading in mouse and rabbit

plasma and rapidly degrading in guinea pig plasma. After addition of sodium fluoride, the stability was also acceptable in the three latter species, but then the question of how a high concentration of Sodium fluoride would affect the sensitive protein-binding equilibrium arose. As the compound was stable in dog and human plasma, a comparison was made of the unbound fractions at three different concentrations, with and without sodium fluoride and using UF. The results showed that sodium fluoride, somewhat surprisingly, did not influence the unbound fractions. Experiences with sodium fluoride for several other compounds, and using both UF and ED, have shown that sodium fluoride is a fairly general enzyme inhibitor that, so far, has not influenced the unbound fractions of any of the studied compounds. The carboxylesterase inhibitor bis-para-nitrophenylphosphate (BNPP), was successfully used to determine the unbound fraction for a hydrolytically unstable amide compound [65]. In addition, for this compound, it was shown that BNPP did not affect the unbound fraction. If sodium fluoride or BNPP are not efficient as inhibitors, there are other agents that might be tested [66,67]. The best advice is to try to understand what enzyme is involved and look for an inhibitor of that enzyme in the literature, then test if it can stabilize the compound and if it affects the unbound fraction. When handling enzyme inhibitors it should be remembered that they are always potentially toxic. If acceptable stability for UF and ED experiments cannot be established, alternative techniques must be used. Both principles discussed below are based on a physical separation of the unbound drug from the rest of the sample and might be questioned as the equilibrium is disturbed. Wenlock et al. recently developed a method for an ester compound rapidly hydrolyzed in rat plasma based on adsorption

Table 4. Stability of research compound in plasma from different species after storage for 145 min at 37°C, with and without sodium fluoride (10 mg/ml). Without sodium fluoride (% remaining) With sodium fluoride (% remaining) Mouse Rat Guinea pig Rabbit Dog Monkey Human

87 99 19 87 103 101 98

95 ND 98 97 ND ND ND

ND: Not determined.

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Challenge of determining unbound concentration & protein binding for drugs on dextran-coated charcoal [68]. The unbound fraction is determined from the compound’s binding rate to dextran-coated charcoal in the presence and absence of plasma along with a determination of the degradation rate in plasma. Another potentially interesting technique is to use extremely fast chromatography in a column packed with large particles (diameter 25–40 µm) and with an aqueous mobile phase at pH 7.4 at a very high flow rate. After direct injection of the pH-adjusted plasma sample, the unbound drug can enter the pores of the column material and be retained, while the large drug–protein complex is excluded from the pores and eluted to waste. The retained fraction is then eluted using a suitable organic modifier to a second analytical column. This has been briefly described in the literature [69]. This was also tried at the author’s laboratory and retention times below 1 s were achieved, but at these high flow rates the chromatographic efficiency was extremely low (theoretical plate number = 1–5). Promising results were obtained, but at that time (2001) the available column material hindered further development. It might be possible to achieve very short separation times using a column a few millimeters long and packed with 2.6 µm core-shell particles. Such a column would produce acceptable chromatographic efficiency at a flow rate and pressure that can be handled by UPLC systems. Absolute unbound concentrations/fractions might not be achievable as long as the time for adjustment of the binding equilibrium is much faster than the separation time, but it might be a useful way to determine relative unbound concentrations/fractions. A similar fast immunoassay approach – flow-based immunoextraction and (reverse) displacement – has been introduced by Hage et al. [70,71]. When determining unbound concentrations in real samples, the possibility that drugs forming metabolites such as glucuronides and N-oxides might convert back to the drug during the experiment must be considered and tested when appropriate; in particular, acylglucuronide metabolites can be a problem. They are usually stable at acidic pH, but at neutral and basic pH they are susceptible to both chemical and enzymatic ester hydrolysis [72]. Thus, to determine the ex vivo unbound concentrations of a compound that has high plasma concentrations of an acylglucuronide using traditional methods would be very demanding. In addition, acylglucuronides are problematic as they might bind covalently to albumin [73]. future science group

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A different type of unstable compound are prodrugs, which are designed to immediately metabolize in plasma forming the active compound. For these compounds, there is rarely a need to study the protein-binding properties of the administered drug, only the active compound. Influence of protein leakage Protein leakage through the ED or UF membrane is seldom measured and, therefore, often a neglected factor, but a factor that might give very misleading results. The specifications from the manufacturers of PPB equipment regarding protein leakage are often vague and imprecise. The effect of protein leakage on the determined unbound fraction is very similar to the effects of impurities in nonselective analysis (Figure 4). A 2% leakage of the binding protein and a f u of 0.1% will give approximately 2000% error while a 5% leakage for a compound with a f u of 20% will give a determined f u of 25% for ED and 24% for UF (errors 25 and 20%, respectively). There are no published comparisons of protein leakage for different ED and UF units. To have a better knowledge of the actual protein leakage, albumin leakage using the ELISA technique (kit for human albumin from Immundiagnostik AG, Bensheim, Germany) was studied [Nilsson LB, Unpublished Data]; the results are presented in Table 5. Human plasma with EDTA as an anticoagulant was used. All utensils were used according to recommendations from the manufacturers and five determinations were made for each device. The detection limit for the leakage varied between 0.0003 and 0.0005%. ELISA is a nonlinear technique and the calibration range depended on the dilution of the ultrafiltrates; therefore, when the samples were not sufficiently diluted the results were above the calibration range. It was not possible to detect any albumin in the ultrafiltrates from single unit UF devices with MWCO <10 kD. With the highest cut-off at 30 kD, low concentrations of albumin were observed in all ultrafiltrates. Leakage was also observed in all ultrafiltrates from the 96-well plates. In one ultrafiltrate from the Ultracel® 10 plate, the leakage was above the calibration range for this experiment, but median leakage was 0.2%. For the ED devices, significant leakage was observed for HTD-96®, the median leakage was 1.2%. This is a re-usable plate with replaceable membranes and insufficient tightening due to wear might have influenced the result. www.future-science.com

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Nilsson Table 5. Albumin leakage in different plasma protein-binding devices. Type

Manufacturer

MWCO (kD)

Conditions

Range for albumin leakage (%)

Millipore Millipore Millipore Millipore

3 5 10 30

6000 g, 20 min 5000 g, 20 min 4000 g, 20 min 4000 g, 20 min

All <0.0003 All <0.0003 All <0.0005 0.0024 – >0.05†

Millipore Millipore

10 10

2000 g, 45 min 2000 g, 45 min

0.07 – 0.23 0.07 – >1†

HTDialysis Harvard Bioscience Thermo Scientific Thermo Scientific

6–8 5 6–8 6–8

6h 20 h 4h 20 h

0.19 – 8.6 All <0.0005 <0.0003 – 0.019 0.0004 – >0.02†

Single-unit UF Microcon® Ultrafree®-MC Ultrafree-MC Ultrafree-MC 96-well UF Ultracel PPB Multiscreen Ultracel® 10 96-well ED HTD-96® Equilibrium Dialyzer-96™ RED‡ RED‡

Above calibration range. 96-well footprint, but can accommodates 48 samples. ED: Equilibrium dialysis; MWCO: Molecular weight cut-off; PPB: Plasma protein binding; RED: Rapid equilibrium dialysis; UF: Ultrafiltration. † ‡

No leakage could be observed for the Harvard plate. Some low leakage was seen for the rapid ED (RED) device after the recommended 4 h dialysis, an observation also made by other researchers [74]. Since equilibrium is usually not reached within 4 h for this plate (also observed elsewhere [39]), a measurement after 20 h dialysis was included and then leakage was observed in four out of five samples. The reported figures must be used with caution, there are only a few observations for a single batch of each device and an enlarged study with several batches of each device might give different results. Nonetheless, this study was used for making the following internal recommendations: for compounds with very low expected unbound fractions; use single-unit UF devices with MWCO <5 kD, or the Harvard ED plate if the NSA is significant. For compounds with unbound fractions above 10–20% and low NSA, the extremely convenient 96-well UF plate is the best choice. Determination of very low unbound fractions/concentrations Drugs showing very low unbound fractions (<1%) are usually lipophilic, acidic drugs, binding to albumin (e.g., naproxen and ibuprofen). The determination of very low unbound fractions poses some special problems. The influence of NSA (UF) and protein leakage (ED and UF), as mentioned above, must be even more carefully controlled. One way to deal with very low unbound fractions is to determine relative unbound fractions [75,76]. In order to compare 3044

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the unbound exposure between two species, it is not necessary to know the absolute unbound fraction for both species, only the ratio between the unbound fractions. A seemingly clever method for this was proposed by Collins and Klecker [76], plasma from one species is dialyzed against plasma from another species. When equilibrium is reached, that is, when the unbound concentrations are the same in both compartments, the total drug concentration in each chamber is determined. The ratio for the total concentrations is inversely proportional to the ratio of the respective unbound concentrations. Thus, an uncertain determination of low concentrations is replaced by a more accurate high concentration determination. When this approach, comparative ED, was studied in detail, several problems were, however, encountered [77]. For a compound with a very low unbound fraction (0.05%), equilibrium could not be reached within an acceptable time. After 40 h the system was still far from equilibrium. In addition, when plasma from two species were dialyzed against each other, the results were not as expected. Analysis of the unbound fraction in each compartment, after UF, showed that the unbound fractions had changed considerably during the experiment, probably due to equilibration of all compounds, except the proteins, between the chambers, resulting in ‘mixed-species’ plasma. In addition, other attempts to use this method for compounds with low unbound fractions failed to give reliable data [75]. Earlier, the analysis of low concentrations in the ultrafiltrate/buffer was hampered by sensitivity future science group

Challenge of determining unbound concentration & protein binding for drugs problems. One way to overcome this was to use serially diluted plasma in order to obtain measurable unbound concentrations; from this the unbound fraction in undiluted plasma was calculated. Dilution might, however, influence the association constant for the drug–protein inter action and this must be controlled. Today, with the highly sensitive LC–MS/MS instruments available, it is usually possible to directly determine unbound concentrations, even for highly bound drugs given in low doses. Yet, the analysis itself is not the main problem; the main problem is the higher risk for anomalous results if the experiments are not carefully undertaken. Thus, the recommendation for highly bound drugs is to use selective LC–MS/MS analysis, to use PPB utensils proven to have low protein leakage and, especially for UF methods, to have control of the NSA. Practical considerations Simultaneous determination of unbound & total concentrations One of the main reasons for not determining unbound concentrations in real samples more often is that it is considered very time consuming. When using 96-well UF and batch adjustment of pH and temperature, this is no longer the case. Furthermore, it is possible to determine total and unbound concentrations in the same run when using LC–MS/MS methodology and two IS [44], one added before the UF and one added after. An IS in the form of the SILIS, preferably 3–5 13C or 15N labels, will have identical protein binding properties as the drug itself. Therefore, if this compound is added to the plasma sample prior to pH and temperature adjustment and UF, it will have the same unbound fraction as the drug itself. The other IS, with a different isotope label compared with the first IS or an analog to the drug, is added to the sample after the UF. After UF and LC–MS/MS analysis, the peak area ratio for drug/SILIS is used to calculate the total concentration and the peak area ratio for the drug/ second IS is used for calculating the unbound concentration. This procedure was tested and found to give results in very good agreement with results determined separately, but has so far not been applied to routine analysis [44]. Different

PPB devices give different results As mentioned in the introduction, the main problem with PPB studies is that the true unbound fraction/concentration is unknown. Using future science group

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different devices for PPB might give rather different results, even in the same laboratory and using standardized procedures. Compared with normal bioanalysis, there is also a bigger risk for batchto-batch variations and the imprecision is usually approximately twice as high. To get an understanding of the inter- and intra-device variation, a study was performed where the unbound fractions for four different model compounds were determined using one ED (ED-96 from Harvard Bioscience) and four UF devices (Ultrafree®-MC 5, 10 and 30 kD and Ultracel™ PPB 96-plate, all from Millipore) [Nilsson LB, Unpublished Data]. The model compounds were warfarin (highly bound to albumin), dexamethasone (moderately bound to albumin), NAD299 (highly bound to a1-AGP) and lidocaine (moderately bound to a1-AGP). All experiments were performed at pH 7.4 and 37°C and at compound concentrations of 5 µmol/l. In Table 6 it can be seen that the 96-well plate gave the highest unbound fraction for all four compounds. Insufficient control of the evaporation during the 45 min centrifugation might have influenced the results. The result for dexamethasone using the 10 kD UF device differs substantially from the other devices. NSA to the 96-well plate was tested for all four compounds prior to the experiments and no significant adsorption was observed. A test of the NSA of dexamethasone to the 10 kD UF device showed, however, that 95% was lost during the UF of this compound in Dulbecco’s buffer. A test of a new batch of the 10 kD UF device gave similar results, while a test of the 30 kD unit showed a loss below 2%. According to the manufacturer, the material and the membrane in the 5, 10 and 30 kD units were the same and the differences in NSA could not be explained. This can be looked upon as an example of the unpredictability of PPB studies and the necessity to always critically examine all results. The CV for the unbound fraction was 5–10% for each device and compound; this is in good agreement with what has been observed in PPB studies for research compounds. The CV of the results for all devices for the same compound was between 16 and 25%. The conclusion for this is that for comparing unbound fractions between species and for calculation of safety margins, all unbound fractions that are compared should be determined using the same method and device. To further increase the precision, it is recommended to determine all unbound fractions in the same experiment. A typical experiment with plasma from five species, albumin and a1-AGP solutions, three drug concentrations and n = 4 www.future-science.com

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Table 6. Unbound fractions determined with different plasma protein-binding devices. Compound Warfarin Dexamethasone Lidocaine NAD299

Unbound fraction (%) ± SD UF 5 kD

UF 10 kD

UF 30 kD

UF 10 kD 96-well ED 96-well

All

0.58 ± 0.07 33.9 ± 3.0 26.6 ± 4.7 2.02 ± 0.19

0.74 ± 0.03 1.10 ± 0.2† 15.3 ± 0.6 2.67 ± 0.29

0.52 ± 0.05 31.2 ± 1.5 24.3 ± 1.9 1.85 ± 0.13

0.76 ± 0.27 45.2 ± 2.4 32.7 ± 2.0 3.32 ± 0.35

0.68 ± 0.17 37.3 ± 6.1 26.7 ± 6.7 2.42 ± 0.55

0.72 ± 0.07 35.2 ± 2.2 31.7 ± 2.6 2.31 ± 0.18

n = 5 for UF and n = 8 for ED. † Results not included in the calculation of mean and SD for all. ED: Equilibrium dialysis; UF: Ultrafiltration.

will result in 84 samples, and can thus be managed using a 96-well plate. Plasma from seven species can be handled if the protein solutions are run in a separate experiment; the precision for the protein solution results is not critical, they are included to determine the main binding protein. High-risk

biological samples Plasma and blood might transmit infectious viruses through contact. In human body fluids, HIV constitutes the highest risk, while for macaque monkey plasma there is a risk for herpes B infections. HIV can be inactivated by heat treatment at 54–56°C for 5 h, at higher temperatures the proteins start to precipitate, and in a study by Mosley and Brouwer [78] it was investigated whether the binding characteristics of albumin and a1-AGP were altered after this treatment. Four different model compounds, binding to different sites, were used. Although the results for two of the compounds were blurred by low radiochemical purity, the general conclusion was that heat treatment did not alter protein binding. An effective milder heat treatment, 56°C for 45 min, to inactivate herpes B virus in macaque plasma has been reported [79]. This has been used by the author and, so far, no significant changes of binding have been observed. Therefore, for most compounds, heat treatment does not seem to change PPB properties, but it is still recommended to always check. Can

separation of plasma from blood at low temperature affect the unbound fraction? A neglected and not very well studied source of error in the determination of both unbound and total concentrations in plasma ex vivo is the separation of plasma from blood. At many laboratories, this separation is often by default performed at 4°C, for stability reasons. As indicated in Figure 1, the fraction bound to blood is in equilibrium with the unbound fraction and the fraction bound to plasma proteins. The 3046

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temperature effect on the unbound fraction has been described above. A 50–100% increase can be expected when going from 20 to 37°C, and the difference between 4 and 37°C can be expected to be much bigger. A higher binding to plasma proteins will generally decrease the partitioning into RBCs [80]. For a compound predominantly present in blood as bound to plasma proteins this is of less importance, but for a compound highly bound to RBCs this means that a much smaller portion of the compound is available for distribution to the RBCs at low temperatures and this would shift the equilibrium unless the temperature dependence for the binding to RBCs mimics the protein binding. For drugs highly distributed to RBCs, for example, tacrolimus [81], it would be interesting to study the unbound plasma concentrations after separation of blood and plasma at different temperatures. Validation of PPB methods The demands on a method used for analyzing samples from protein-binding studies differ from the demands on a method used for determining unbound concentrations ex vivo in samples from regulatory studies. In the first case, a qualified method, preferably with a stable isotope-labeled IS, is sufficient to give good control over the quality of the results. Generic LC–MS/MS methods, sometimes combined with cassette dosing [55], that is, four or more compounds are added to the same plasma samples, are often used when performing in vitro PPB screening at early stages. A generic IS is included as a volume marker, but this IS cannot compensate for the matrix suppression/enhancement effects associated with bioanalysis [82]. The risk for incorrect conclusions is obvious when calculating unbound fractions and comparing results for different compounds and species. For determination of unbound concentrations in GLP studies, validation is necessary both of the method and for each batch of samples [83,84]. A suggested validation scheme is shown in Figure 6. The validation can future science group

Challenge of determining unbound concentration & protein binding for drugs be divided into two parts, validation of the analytical step, that is, the analysis of ultrafiltrate or buffer/plasma, and the validation of the total procedure, that is, the UF/dialysis step plus the analytical step. The validation of the analytical step is the same as for any other bioanalytical method and the same acceptance criteria can be applied. For validation of the total procedure, plasma is spiked with the drug under study and divided into an appropriate number of samples. These QC PPB samples are then used during the method validation to determine the precision of the unbound concentration determinations. Note that accuracy cannot be tested as the true unbound concentration is unknown. The stability of the unbound concentration (freeze–thaw, storage at different temperature) is also studied. For the validation of an analytical run, three QC PPB samples are included in each batch of unknown samples to ensure batch reproducibility; the mean result for these three samples is compared with the mean unbound concentration from the method validation. A suitable concentration level would be an expected typical unbound concentration in the intended study. The acceptance criterion for the mean unbound concentrations should be somewhat more generous than for normal bioanalysis, due to the imprecision added by the UF/ED step, and within ±20% is suggested. Future perspective An increased use of ex vivo unbound concentration determinations in drug development can be expected when interpreting concentration–response relationships and species differences. For decades ED and UF have been the dominating and generally accepted techniques for performing protein-binding studies. Although both techniques have problems, attempts to replace them have so far not been successful. The dream is a new, robust, convenient and generally applicable technique. Blood tends to become a more frequently used matrix for bioanalytical measurements. To determine unbound concentrations in blood is possible but complicated, compared with plasma, as ED and UF are not very suitable due to hemolysis and filter clogging, respectively. In addition, for blood determinations, an alternative new method would be beneficial. To simplify the interpretation of studies of compounds with very low unbound fractions, future science group

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Method validation: Analytical step (LLOQ and three QC levels spiked to ultrafiltrate/dialysate/plasma): Precision (<15%, <20% at LLOQ) Accuracy (±15%, ±20% at LLOQ) Stability Total procedure (QCPPB, one concentration level spiked to plasma): Stability of unbound concentration Precision of unbound concentration (<20%) Run validation: Analytical step: (QCs at three levels, n = 2, in appropriate matrices) >66% within ±15% Total procedure: QCPPB in plasma at one level, n = 3 Mean ± 20% of original determination

Figure 6. Suggested validation for unbound concentration methods. PPB: Plasma protein binding.

better information about and control of protein leakage from the manufacturers of PPB devices, are very important. It is not enough to know that, for example, the total protein content in the ultrafiltrate is less than 2%. For ED devices it is difficult to find any information at all about protein leakage. As albumin is the main binding protein for most compounds exhibiting extremely low unbound fractions, solid information on at least albumin leakage for all devices marketed for PPB studies is anticipated in the future. Acknowledgements The experiments referred to in this review were performed at AstraZeneca R&D, Södertälje, Sweden. M Bath, A Bogstedt and MAL Eriksson are acknowledged for performing many of these experiments. Many thanks to J Gabrielsson, for a lot of interesting discussions on unbound concentrations and their role in drug discovery and development, and to D Westerlund for reviewing the manuscript.

Financial & competing interests disclosure The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. www.future-science.com

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Executive summary General

The determination of unbound concentrations/fractions is of vital importance in drug development, but experiments are often performed without sufficient control of the factors influencing the drug–protein equilibrium.

The true unbound concentration/fraction is unknown. All results must always be critically examined to conclude whether they are trustworthy.

The total drug concentration in vivo is a consequence of the ratio of the unbound concentration to the unbound fraction.

Techniques for studying protein binding

Different techniques have been used, but ultrafiltration and equilibrium dialysis are the techniques preferentially used in drug development. Both techniques have problems that both the analytical chemist and the kineticist should be aware of.

Selective analysis of ultrafiltrates and dialysates using LC–MS/MS is recommended. Nonselective analysis might introduce very large errors.

Factors affecting the drug–protein equilibria

Drug–protein equilibria are pH- and temperature-dependent, and plasma protein binding experiments should always be performed at physiological conditions (pH 7.4 and at 37°C).

Drug–protein equilibria are concentration-dependent. The unbound fraction increases when the drug concentration approaches the protein concentration.

Large species differences in binding are common and comparison of drug effects between species should be based on unbound concentrations.

The possibility of protein leakage through the equilibrium dialysis or ultrafiltration membrane must be controlled for low unbound fractions. The information from manufacturers on protein leakage is often insufficient.

Practical considerations

Simultaneous determination of unbound and total concentrations is possible when using two IS, one of them stable isotope labeled, and LC–MS/MS.

Different devices for plasma protein binding measurements give different results. For best possible results when determining unbound fractions for several species, all experiments should be performed using the same device and preferably in a single batch.

Validation

A guide for validation of plasma protein-binding methods in a GLP environment is provided.

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future science group

Winek's Drug & Chemical Blood-Level Data 2001 Prepared by: Charles L. Winek, Ph.D., Wagdy W. Wahba, Ph.D., Charles L. Winek, Jr., B.S. (Pharm.), M.S., and Tracey Winek Balzer B.S. (Pharm.), M.S.

We have gathered the data in the table from the literature and from personal experience. The values are not considered absolute, but are to be used as a guide in evaluating a given case. The values can be affected by dose, route of administration, absorption differences, age and sex, tolerance, method of analysis, pathological or disease state, postmortem redistribution, etc. Users of the table are referred to Winek's Toxicology Annual and Chapter 72 in Forensic Medicine, Volume III, by Tedeschi, Eckert and Tedeschi for chapters discussing the data, reference to the data, and factors affecting blood-level values. For additional pharmacokinetic information and other tissue levels, users are referred to Baselt’s reference, Disposition of Toxic Drugs and Chemicals in Man. Users are cautioned against pharmacists using pharmacokinetics for interpretation of blood-level data when death is involved. It should be obvious that kinetics, even pharmacokinetics, are not applicable to the moribund state.

Units Drugs and chemicals in the table are reported in both mg% and µg/mL. Drugs are listed by both their trade and generic names. Mg% (milligram percent) is equal to mg/dL (milligram/deciliter); µg/mL (microgram/milliliter) is equal to mg/L (milligram/liter).

NOTE: Divide the mg% level by 100 to obtain mg/mL Divide the µg% level by 100 to obtain µg/mL. To convert mg/L or µg/L to mg% or µg%, divide level by 10. Examples: 1mg/L = 0.1mg% 3µg/L = 0.3µg% µg is the representation for microgram (mcg).

Many therapeutic drugs are reported in nanograms/ milliliter (ng/mL). To convert the listed mcg/mL in this table to ng/mL, multiply the listed value by 1000. For example, digoxin concentration of 0.0022 mcg/mL would be 0.0022 x 1000 = 2.2 ng/mL. Put simply, you move the decimal point three places to the right.

Definition of Blood Levels Therapeutic Blood Level Winek defines a therapeutic blood level as that concentration of drug and/or its active metabolite(s) present in the blood (serum or plasma) following therapeutically effective dosage in humans.

Toxic Blood Level The concentration of drug and/or its active metabolite(s) or chemical present in the blood (serum or plasma) that is associated with serious toxic symptoms in humans.

Lethal Blood Level The concentration of drug and/or its active metabolite(s) or chemical present in the blood (serum or plasma) that has been reported to cause death, or is so far above reported therapeutic or toxic concentrations, that one can judge that it might cause death in humans.

Normal Blood Level Some of the values under normal represent normal body constituents and others represent values related to normal environmental exposure. Values can, and do, vary with geographical location. Suggested additions or corrections can be made by contacting the author at drwinek@aol.com. Recommendations are always welcomed.

Dr. Charles L. Winek Dr. Winek is a professor of toxicology at Duquesne University School of Pharmacy and also teaches for the University's School of Education, Graduate School of Arts and Sciences, and the Law School. He is a diplomate of both American Board of Forensic Toxicology and the Academy of Toxicological Sciences. Dr. Winek is currently the director of Pittsburgh Criminalistics Laboratory and is the former chief toxicologist for the Allegheny County Coroner's Office, positions he held for 32 years. He continues to testify frequently as an expert witness in both criminal and civil cases in Allegheny County and throughout the United States. Dr. Winek has published 119 articles in scientific journals and authored, co-authored or contributed to 29 books. Additionally, Dr. Winek is toxicology editor for the scientific journal Forensic Science International and a member of the editorial boards of The Journal of Applied Toxicology and the journal Analytical Toxicology. (NOTE: Winek's Drug & Chemical Blood-Level Data 2000 is reprinted with written permission as a courtesy to our customers. Fisher HealthCare accepts no responsibility for the accuracy of its contents.)

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG

mg%

Toxic

ug/ml

mg%

Lethal ug/ml

mg%

ug/ml

A Acebutolol (Spectral)

0.05 - 0.12

0.5 - 1.2

*****

Acetaminophen (Tylenol)

1-2

10 - 20

150

>16

>160

Acetazolamide (Diamox)

1.0 - 1.5

10 - 15

*****

Acetohexamide ( Dymelor)

2.1 - 5.6

21 - 56

*****

Acetone

*****

20 - 30

200 - 300

550

Acetonitrile [met: to Cyanide]

*****

0.077

0.77

Acetylsalicylic Acid [as met:

2 - 10

20 - 100

15 - 30

150 - 300

500

2 - 25

20 - 250

*****

Salicylate-for analgesic use] Acetylsalicylic Acid [as met: Salicylate-for rheumatoid arthritis] Actidil (Triprolidine)

0.0004 - 0.0044

0.004 - 0.044

*****

Actifed (Pseudoephedrine)

0.050 - 0.077

0.50 - 0.77

*****

1.9

(Triprolidine) Actron (Ketoprofen)

0.0004 - 0.0044

0.004 - 0.044

*****

0.5 - 0.15

5 - 1.5

*****

Adalat (Nifedipine, Procardia)

0.0015 - 0.0162

0.015 - 0.162

*****

Alcaine (Proparacaine)

*****

1.5

Aldrin

0.00015

0.0015

0.00035

0.0035

*****

Alfenta (Alfentanil)

0.010 - 0.12

0.10 - 1.2

*****

Alfentanil (Alfenta)

0.010 - 0.12

0.10 - 1.2

*****

Allegra (Fexofenadine)

0.018 - 0.021

0.18 - 0.210

*****

Alphaprodine (Nisentil)

0.087 - 0.100

0.87 - 1.00

*****

0.33

3.3

Alprazolam (Xanax)

0.0025 - 0.0102

0.025 - 0.102

*****

0.0122 - 0.039

0.122 - 0.39

Aluminum

0.013

0.13

*****

Amantadine (Symmetrel)

0.006 - 0.031

0.06 - 0.31

0.1 - 0.05

1 - 0.5

0.21 - 0.48

2.1 - 4.8

Ambien (Zolpidem)

0.0029 - 0.0272

0.029 - 0.272

*****

0.05 - 0.112

0.5 - 1.12

Aminophylline (Theophylline)

1-2

10 - 20

3-4

30 - 40

5 - 25

50 - 250

Amitriptyline (Elavil)

0.012 - 0.025

0.12 - 0.25

>0.05

>0.5

0.2 - 2.0

2 - 20

Amitriptyline (Elavil)

0.012 - 0.025

0.12 - 0.25

>0.05

>0.5

*****

0.05 - 0.17

0.5 - 1.7

*****

[+met: Nortriptyline] Ammonia Amobarbital (Amytal)

0.1 - 0.5

1-5

1-3

10 - 30

1.3 - 9.6

13 - 96

Amoxapine (Asendin)

0.0017 - 0.021

0.017 - 0.21

*****

0.295 - 2.0

2.95 - 20

Amoxapine (Asendin)

0.02 - 0.04

0.2 - 0.4

*****

[+met: 8-OH-amoxapine] Amphetamine

0.003 - 0.011

0.03 - 0.11

>0.05

>0.5

>0.1

Amytal (Amobarbital)

0.1 - 0.5

1-5

1-3

10 - 30

1.3 - 9.6

13 - 96

Anafranil (Clomipramine)

0.01 - 0.045

0.1 - 0.45

*****

Anaprox (Naproxen)

3.1 - 12

31 - 120

400

*****

Analeridine (Leritine)

<0.05

<0.5

*****

0.09 - 0.70

0.9 - 7.0

Aniline

*****

0.63

6.3

Ansaid (Flubiprofen)

1 - 2.2

10 - 22

*****

Antabuse (Disulfiram)

0.038 - 0.25

0.38 - 2.5

*****

37 - 58

370 - 580

Antipyrine

0.5 - 2.5

5-25

*****

110

Aralen (Chloroquine)

0.002 - 0.040

0.02 - 0.40

*****

0.3 - 9.9

3 - 99

Arsenic

0.002 - 0.0062

0.02 - 0.062

0.1

0.9 - 1.5

9 - 15

Asendin (Amoxapine)

0.0017 - 0.021

0.017 - 0.21

*****

0.295 - 2.0

2.95 - 20

Page 1

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Asendin (Amoxapine)

mg%

Toxic

ug/ml

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml

0.02 - 0.04

0.2 - 0.4

*****

Astemizole (Hismanal)

0.00004

0.0004

Atarax (Hydroxyzine, Vistaril)

0.0022 - 0.008

0.022 - 0.08

*****

0.4 -3.9

4.2 - 39

Atenolol (Tenorim)

0.02 - 0.07

0.20 - 0.70

3.5

*****

[+met: 8-OH-amoxapine]

Ativan (Lorazepam)

0.001 - 0.024

0.01 - 0.24

0.03 - 0.06

0.3 - 0.6

*****

Atromid (Clofibrate)

12.2

122

*****

Atropine

0.0035 - 0.0200

0.035 - 0.200

*****

0.02

0.2

Avelox (Moxifluxacin)

0.45 - 1.44

4.5 - 14.4

*****

Aventyl (Nortriptyline)

0.005 - 0.0375

0.05 - 0.375

0.05

0.5

1.3

0.027 - 0.08

0.27 - 0.8

*****

[met: Amitriptyline (Elavil)] AZT (Retrovir, Zidovadine) B Baclofen (Lioresal)

0.01 - 0.06

0.1- 0.6

0.11 - 0.35

1.1 - 3.5

*****

Barbital

1 - 2.6

10 - 26

6-8

60 - 80

>10

>100

Barbiturates (intermediate acting)

0.1 - 0.5

1-5

1-3

10 - 30

>30

Barbiturates (long acting)

1-4

10 - 40

4-6

40 - 60

>80

Barbiturates (short acting)

0.1

0.7

Benadryl (Diphenhydramine)

0.0025 - 0.0112

0.025 - 0.112

0.5

>0.8

Benemid (Probenecid)

10 - 20

100 - 200

*****

Bentyl (Dicyclomine)

0.002 - 0.008

0.02 - 0.08

*****

Benzedrex (Propylhexedrine)

0.001

0.01

*****

0.2 - 0.3

2-3

Benzene

*****

0.090 - 0.12

0.90 - 1.2

Benzphetamine (Didrex)

0.0025 - 0.0500

0.025 - 0.500

>0.05

>0.5

1.4

Benztropine (Cogentin)

0.008 - 0.0126

0.08 - 0.126

0.0048

0.048

0.02 - 0.07

0.2 - 0.7

Bethanid (Bethanidine)

0.002 - 0.050

0.02 - 0.50

*****

Bethanidine (Bethanid)

0.002 - 0.050

0.02 - 0.50

*****

Bismuth

0.004 - 0.008

0.04 - 0.08

Blocadren (Timolol)

0.004 - 0.023

0.04 - 0.23

*****

Boron

0.08

0.8

Brethine (Terbutaline)

0.0002 - 0.0006

0.002 - 0.006

*****

0.004

0.04

Brevibloc (Esmolol)

0.11 - 0.159

1.1 - 1.59

*****

Bromide

0.30 - 23

3 - 230

50-150

500-1500

200

2000

Bromide [met: Carbromal (Carbital)]

0.6

40 - 125

400 - 1250

128.5 - 245.0

1285 - 2450

Bropheniramine (Dimetane)

0.0008 - 0.0015

0.008 - 0.015

*****

Bupivacaine (Marcaine)

0.022 - 0.345

0.22 - 3.45

*****

Buprenex (Buprenorphine)

0.0014 - 0.011

0.014 - 0.11

*****

Buprenorphine (Buprenex)

0.0014 - 0.011

0.014 - 0.11

*****

Bupropion (Wellbutrin)

0.0025 - 0.0100

0.025 - 0.100

*****

0.73

7.3

Buspar (Buspirone)

0.0088 - 0.0147

0.088 - 0.147

*****

Buspirone (Buspar)

0.0088 - 0.0147

0.088 - 0.147

*****

0.73

7.3

Butabarbital (Butisol)

0.76 - 1.69

7.6 - 16.9

*****

>30

Butalbital (Sandoptal, Fioricet, Fiorinal)

0.17 - 0.26

1.7 - 2.6

0.7 - 4

7 - 40

1.3 - 2.6

13 - 26

Butanediol

*****

280

Butaperazine (Repoise)

0.002 - 0.069

0.02 - 0.69

*****

Butazolidin (Phenylbutazone)

1.6 - 15.0

16 - 150

200

400

Butisol (Butabarbital)

0.76 - 1.69

7.6 - 16.9

*****

>30

Page 2

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG

mg%

Toxic

ug/ml

mg%

Lethal ug/ml

mg%

ug/ml

Butorphanol (Stadol)

0.00011-0.00017

0.0011 - 0.0017

*****

Butyl Nitrite (Nitrite)

0.05 - 0.40

0.50 - 4

*****

2.2

C Cadmium

0.00005-0.00040

0.0005 - 0.0040

0.005

0.05

0.11

1.1

Caffeine

0.2 - 1.0

2-10

*****

>10

>100

Calan (Isoptin, Verapamil)

0.0055 - 0.0355

0.055 - 0.355

0.09

0.9

0.09 - 8.5

0.9 - 85

Captopril (Capoten)

0.051 - 0.131

0.51 - 1.31

*****

2-6

20 - 60

Capoten (Captopril)

0.051 - 0.131

0.51 - 1.31

*****

2-6

20 - 60

Carbamazepine (Tegretol)

0.14 - 1.2

1.4 - 12

>1.5

>15

>50

Carbital (Carbromal) [as met: Bromide]

0.6

40 - 125

400 - 1250

128.5 - 245.0

1285 - 2450

Carbocaine (Mepivacaine)

0.028 - 0.550

0.28 - 5.50

Carbon Monoxide

1 - 2%

*****

15 - 35%

*****

48-95%

*****

[% Hemoglobin as Carboxyhemoglobin] Carbon Tetrachloride

*****

2-5

20 - 50

10 - 20

100 - 200

Carbromal (Carbital) [as met: Bromide]

0.6

40 - 125

400 - 1250

128.5 - 245.0

1285 - 2450

Cardene (Nicardipine)

0.0036 - 0.015

0.036 - 0.150

*****

Cardizem (Diltiazem)

0.005 - 0.04

0.05 - 0.40

0.37 - 0.61

3.7 - 6.1

0.67

6.7

Carisoprodol (Soma)

1-4

10 - 40

3-5

30 - 50

110

Cataflam (Voltaren, Diclofenac)

0.075 - 0.20

0.75 - 2.0

0.6

*****

Catapres (Clonidine)

0.00003-0.00015

0.0003-0.0015

0.0006

0.006

0.023

0.23

Celexa (Citalopram)

0.0081 - 0.016

0.081 - 0.16

*****

0.024 - 0.13

0.24 - 1.3

Celontin (Methsuximide)

1.0 - 4

10 - 40

4.4

>44

*****

[as met: Desmethylmethsuximide] Centrax (Prazepam)

0.001 - 0.004

0.01 - 0.04

*****

China White (Methylfentanyl)

*****

0.0002 - 0.0011

0.002 - 0.011

Chlor-Trimeton (Chlorpheniramine)

0.0017

0.017

2-3

20 - 30

*****

Chloral Hydrate (Noctec)

0.2 - 1.2

2 - 12

100

250

*****

200

*****

0.015 - 0.055

0.15 - 0.55

[as met: Trichloroethanol] Chloramphenicol (Chloromycetin)

1-2

10 - 20

Chlorcyclizine

0.005 - 0.010

0.05 - 0.10

Chlormepramine

*****

(plus metabolite - Norchlormepramine) Chlordane

0.0001

0.001

0.00025

0.0025

0.17 - 0.49

1.7 - 4.9

Chlordiazepoxide (Librium)

0.067 - 0.31

0.67 - 3.1

0.5

Chlormezanone (Trancopal)

0.25 - 0.88

2.5 - 8.8

*****

Chloromycetin (Chloramphenicol)

1-2

10 - 20

*****

200

Chloroform

2 - 50

20 - 500

7 - 25

70 - 250

390

Chlorophen (Chlorphentermine)

0.032

0.32

*****

Chloroprocaine (Nesacaine)

0.2 - 0.4

2-4

*****

Chloroquine (Aralen)

0.002 - 0.040

0.02 - 0.40

*****

0.3 - 9.9

3 - 99

Chlorothiazide

0.6

*****

Chlorpheniramine (Chlor-Trimeton)

0.001 - 0.0017

0.01 - 0.017

*****

0.05 - 0.11

0.5 - 1.1

Chlorphentermine (Chlorophen)

0.032

0.32

*****

Chlorpromazine (Thorazine)

0.001 - 0.050

0.01 - 0.50

0.1 - 0.2

1-2

0.3 - 1.2

3 - 12

Chlorpropamide (Diabenese)

3.0 - 36.3

30 - 363

20 - 75

200 - 750

*****

Chlorprothixene (Taractan)

0.004 - 0.030

0.04 - 0.30

0.04 - 0.08

0.4 - 0.8

*****

Chlor-Trimeton (Chlorpheniramine)

0.001 - 0.0017

0.01 - 0.017

*****

0.05 - 0.11

0.5 - 1.1

Page 3

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Chlorthalidone (Combipress)

mg% 0.021 - 0.140

Toxic

ug/ml 0.21 - 1.40

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml *****

Cimetidine (Tagamet)

0.05 - 0.45

0.5 - 4.5

*****

Citalopram (Celexa)

0.0081 - 0.016

0.081 - 0.16

*****

0.024 - 0.13

0.24 - 1.3

Citanest (Prilocaine)

0.1 - 0.5

1-5

*****

Claritin (Loratidine)

0.0007 - 0.0028

0.007 - 0.028

0.046

0.46

*****

0.0007 - 0.0028

0.007 - 0.028

0.046

0.46

*****

Clinoril (Sulindac)

[metabolite: descarboethoxyloratadine]

0.4 - 0.5

4-5

*****

Clofibrate (Atromid)

12.2

122

*****

Clomipramine (Anafranil)

0.01 - 0.045

0.1 - 0.45

*****

Clonazepam (Klonopin)

0.0007 - 0.0075

0.007 - 0.075

*****

Clonidine (Catepres)

0.00003-0.00015

0.0003-0.0015

0.0006

0.006

0.023

0.23

Clorazepate (Tranxene)

0.01 - 0.16

0.1 - 1.6

>0.5

>5.0

*****

[as met: N-Desmethyldiazepam Clozapine (Clozaril)

0.0102 - 0.0771

0.102 - 0.771

*****

Clozaril (Clozapine)

0.0102 - 0.0771

0.102 - 0.771

*****

Cocaine

0.005 - 0.093

0.05 - 0.930

0.09

0.9

0.1 - 2.0

1 - 20

Codeine

0.003 - 0.034

0.03 - 0.34

*****

>0.16

>1.6

Cogentin (Benztropine)

0.008 - 0.0126

0.08 - 0.126

0.0048

0.048

0.02 - 0.07

0.2 - 0.7

Colbenemid (Colchicine)

0.00003-0.00300

0.0003-0.0300

*****

0.0021 - 0.025

0.021 - 0.25

Colchicine (Colbenemid)

0.00003-0.00300

0.0003-0.0300

*****

0.0021 - 0.025

0.021 - 0.25

Combipress (Chlorthalidone)

0.021 - 0.140

0.21 - 1.40

*****

Compazine (Prochlorperazine)

*****

>0.1

0.5

Copper

0.10 - 0.15

1.0 - 1.5

0.54

5.4

0.25 - 6.30

2.5 - 63.0

Coumadin (Warfarin)

0.10 - 0.31

1. 0 - 3.1

*****

Cresol

*****

0.90 - 1.90

9-19

Cyanide

0.0004 - 0.0041

0.004 - 0.041

*****

0.11 - 5.3

1.1 - 53

Cylert (Pemoline)

0.07 - 0.62

0.70 - 6.2

*****

Cyclizine

0.003 - 0.030

0.03 - 0.30

0.076

0.76

1.5

Cyclobenzaprine (Flexeril)

0.0015 - 0.0036

0.015 - 0.036

*****

>0.04

>0.4

Cyclopropane

8 - 18

80 - 180

*****

Cyclosporine (Sandimmune)

0.005 - 0.0045

0.05 - 0.045

*****

D Dalmane (Flurazepam)

0.00005-0.00280

0.0005 - 0.0280

0.02

0.2

0.05 - 0.40

0.5 - 4.0

Dalmane (Flurazepam)

0.0033 - 0.0144

0.033 - 0.144

*****

[+met: N-Desalkylflurazepam] Dantrium (Dantrolene)

0.1 - 0.3

1-3

*****

Dantrolene (Dantrium)

0.1 - 0.3

1-3

*****

Darvon (Propoxyphene)

0.023 - 0.107

0.23 - 1.07

0.03 - 0.06

0.3 - 0.6

0.1 - 1.7

1-17

Darvon (Propoxyphene)

0.104 - 0.371

1.04 - 3.71

0.28 - 1.2

2.8 - 12

0.27 - 4.7

2.7 - 47

0.0013

0.013

*****

[+ met: Norpropoxyphene] DDT Demerol (Meperidine)

0.007 - 0.080

0.07 - 0.80

0.5

0.8 - 2.0

8 - 20

Depakene (Valproic Acid)

5 - 10

50 - 100

0.71 - 20.0

7.1 - 200

*****

Desipramine (Norpramin)

0.005 - 0.0684

0.05 - 0.684

>0.05

>0.5

1-2

10 - 20

1.6 - 4

16 - 40

4.4

>44

*****

[met: Imipramine (Tofranil)] Desmethylmethsuximide [met: Celontin (Methsuximide)]

Page 4

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Desyrel (Trazodone)

mg% 0.07 - 0.489

Toxic

ug/ml 0.7 - 4.89

mg% *****

Lethal ug/ml

*****

mg% 1.5

ug/ml 15

Dextromethorphan

0.038

0.38

*****

>0.3

Diabenese (Chlorpropamide)

3.0 - 36.3

30 - 363

20 - 75

200 - 750

*****

Diacetalol

0.063 - 0.433

0.63 - 4.33

*****

Diamox (Acetazolamide)

1.0 - 1.5

10 - 15

*****

Diazepam (Valium)

0.002 - 0.400

0.02 - 4.00

0.5 - 2.0

5 - 20

>30

Diazepam (Valium)

0.031 - 0.600

0.31 - 6.00

*****

>3.4

>34

[+ met: N-Desmethyldiazepam] Diazoxide (Hyperstat)

1.5 - 2.0

15 - 20

>10

>100

*****

Diazinon

*****

0.07 - 27.7

0.7 - 277

Dichloromethane (Methylene Chloride)

*****

9.5 - 60

95 - 600

Diclofenac (Voltaren, Cataflam)

0.075 - 0.20

0.75 - 2.0

0.6

*****

Dicumarol

0.8 - 5.9

8 - 59

*****

Dicyclomine (Bentyl)

0.002 - 0.008

0.02 - 0.08

******

*****

Didrex (Benzphetamine)

0.0025 - 0.0500

0.025 - 0.500

>0.05

>0.5

1.4

Dieldrin

0.00015 - 0.002

0.0015 - 0.02

0.015 - 0.0303

0.15 - 0.303

0.05 - 0.116

0.5 - 1.16

Diethylpropion (Tenuate)

0.0007 - 0.0200

0.007 - 0.200

*****

0.54

5.4

Difenoxin (Motofen)

0.016

0.160

*****

Diflucan (Fluconazol)

0.5 - 1.5

5 - 15

*****

Diflunisal (Dolobid)

0.9 - 13

9 - 130

*****

37 - 58

370 - 580

Digoxin

0.00007-0.0022

0.0007 - 0.022

0.00030-0.00040 0.0030 - 0.0040 0.0035 - 0.02

0.035 - 0.20

Dihydrocodeinone (Hydrocodone)

0.003 - 0.025

0.03 - 0.25

0.05 - 0.2

0.5 - 2

0.07 - 1.2

0.7 - 12

Dilantin (Phenytoin, Diphenylhydantoin)

1-2

10 - 20

2-5

20 - 50

>10

>100

Dilaudid (Hydromorphone)

0.0008 - 0.0049

0.008 - 0.049

****

*****

0.03

0.3

Diltiazem (Cardizem)

0.005 - 0.04

0.05 - 0.40

0.37 - 0.61

3.7 - 6.1

0.67

6.7

Dimetane (Brompheniramine)

0.0008 - 0.0015

0.008 - 0.015

*****

Dimethylsulfoxide (DMSO)

5.04 - 338

50.4 - 3380

*****

160 - 300

1600 - 3000

Dimethyltryptamine

0.0001 - 0.0100

0.001 - 0.100

*****

Dinitro-O-Cresol

*****

3-6

30 - 60

7.5

Diphenhydramine (Benadryl)

0.0025 - 0.0112

0.025 - 0.112

0.5

>0.8

Diphenoxylate (Lomotil)

0.001 - 0.004

0.01 - 0.04

*****

Diphenylhydantoin (Phenytoin, Dilantin)

1-2

10 - 20

2-5

20 - 50

>10

>100

Diprivan (Propofol)

0.2 - 1.6

2 - 16

*****

Disopyramide (Norpace)

0.2 - 0.6

2-6

0.7

2.6

Disulfiram (Antabuse)

0.038 - 0.25

0.38 - 2.5

*****

37 - 58

370 - 580

Divinyl Oxide

*****

700

DMSO (Dimethylsulfoxide)

5.04 - 338

50.4 - 3380

*****

160 - 300

1600 - 3000

Dolobid (Diflunisal)

0.9 - 13

9 - 130

*****

37 - 58

370 - 580

Dolophine (Methadone)

0.0075 - 0.110

0.075 - 1.10

0.02 - 0.2

0.20 - 2.0

0.04 - 0.18

0.4 - 1.8

Dopram (Doxapram)

0.27 - 0.52

2.7 - 5.2

*****

0.04 - 0.8

*****

Doral (Quazepam)

1.1 - 14.8

11 - 148

*****

Doriden (Glutethimide)

0.2 - 1.2

2 - 12

1-8

10 - 80

3 - 10

30 - 100

Dothiepin (Prothiaden)

0.0017 - 0.0420

0.017 - 0.420

*****

0.03 - 0.25

0.3 - 2.5

Doxapram (Dopram)

0.27 - 0.52

2.7 - 5.2

*****

Doxepin (Sinequan)

0.010 - 0.025

0.10 - 0.25

0.012 - 0.43

0.12 - 4.3

0.2 - 2.6

2 -26

Doxepin (Sinequan)

0.010 - 0.025

0.10 - 0.25

>0.05

>0.5

0.8 - 3.5

8 - 35

[+met: N-Desmethyldoxepin

Page 5

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Doxylamine (Unisom)

mg% 0.0069 - 0.0138

Toxic

ug/ml 0.069 - 0.138

mg% *****

Lethal ug/ml

*****

mg% 0.07 - 1.2

ug/ml 0.7 - 12

Duranest (Etidocaine)

0.05 - 0.15

0.5 - 1.5

*****

Dymelor (Acetohexamide)

2.1 - 5.6

21 - 56

*****

Dyphylline

0.65 - 1.43

6.5 - 14.3

3.6

*****

E Effexor (Venlafaxine)

0.007 - 0.393

0.07 - 3.93

*****

0.0061 - 0.075

0.061 - 0.75

0.1 - 0.15

1 - 1.5

*****

Elavil (Amitriptyline)

0.012 - 0.025

0.12 - 0.25

>0.05

>0.5

0.2 - 2.0

2 - 20

Elavil (Amitriptyline)

0.012 - 0.025

0.12 - 0.25

>0.05

>0.5

0.2 - 2.0

2 - 20

0.0009 - 0.0019

0.009 - 0.019

*****

[met: O-Desmethylvenlafaxine]

[+met: Nortriptyline] Eldepryl (Selegiline) Emetine

0.005 - 0.0075

0.05 - 0.075

*****

0.24

2.4

Enalapril (Vasotec)

0.0063 - 0.007

0.063 - 0.070

*****

Encainide (Enkaid)

0.01 - 0.03

0.1 - 0.3

*****

0.006 - 0.028

0.06 - 0.28

*****

0.0003

0.003

0.0007 - 0.0032

0.007 - 0.032

0.045

0.45

{as met: O-Demethylencainide] Encainide (Enkaid) [as met: Methoxy-O-demethylencainide Endrin Ephedrine

0.0068 - 0.01

0.068 - 0.10

*****

0.35 - 2.1

3.5 - 21

Estazolam (Prosom)

0.0042 - 0.0100

0.042 - 0.100

0.125

1.25

*****

Ethanol (listed toxic concentration is legal

*****

80 - 100

800 - 1000

>350

>3500

intoxication for driving in most states) Ethchlorvynol (Placidyl)

0.05 - 0.88

0.5 - 8.8

*****

2.2 - 21.3

22 - 213

Ethinamate (Valmid)

0.4 - 1.1

4 - 11

*****

10 - 20

100 - 200

Ethosuximide (Zarontin)

4 - 10

40 - 100

*****

250

Ethyl Chloride

20 - 30

200 - 300

*****

400

Ethyl Ether

90 - 100

900 - 1000

*****

140 - 189

1400 - 1890

Ethylene Glycol

*****

150.0

1500.0

200 - 400

2000 - 4000

Etidocaine (Duranest)

0.05 - 0.15

0.5 - 1.5

*****

Etodolac (Lodine)

1.2 - 4.7

12 - 47

*****

F Famotidine (Pepcid)

0.0007 - 0.0035

0.007 - 0.035

*****

Felbamate (Felbatol)

0.27 - 3.3

2.7 - 33

14 - 20

140 - 200

*****

Felbatol (Felbamate)

0.27 - 3.3

2.7 - 33

14 - 20

140 - 200

*****

Feldene (Piroxicam)

0.085 - 0.8

0.85 - 8.00

*****

Felodipine (Plendil)

0.00015-0.00088

0.0015 - 0.0088

0.001 - 0.0015

0.01 - 0.015

*****

Fenfluramine (Pondimin)

0.004 - 0.030

0.04 - 0.3

0.07 - 0.09

0.7 - 0.9

0.6 - 1.5

6 - 15

Fenoprofen (Nalfon)

2.7 - 6.6

27 - 6.6

*****

710

Fentanyl (Sublimaze)

0.001 - 0.010

0.01 - 0.10

*****

Fexofenadine (Allegra)

0.018 - 0.021

0.18 - 0.210

*****

Fioricet (Butalbital)

0.17 - 0.26

1.7 - 2.6

0.7 - 4

7 - 40

1.3 - 2.6

13 - 26

Fiorinal (Butalbital)

0.17 - 0.26

1.7 - 2.6

0.7 - 4

7 - 40

1.3 - 2.6

13 - 26

Flecainide (Tambocar)

0.02 - 0.10

0.2 - 1.0

*****

Flexeril (Cyclobenzaprine)

0.0015 - 0.0036

0.015 - 0.036

*****

>0.04

>0.4

Flexin (Zoxazolamine)

0.3 - 1.3

3 - 13

*****

Flubiprofen (Ansaid)

1 - 2.2

10 - 22

*****

Flucanzol (Diflucan)

0.5 - 1.5

5 -15

*****

Page 6

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Flumazenil (Mazicon, Romazicon)

mg% 0.0006 - 0.0039

Toxic

ug/ml 0.006 - 0.039

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml *****

Flunitrazepam (Rohypnol)

0.006 - 0.0052

0.06 - 0.052

0.001 - 0.005

0.01 - 0.05

*****

Fluoride

0.0014 - 0.04

0.014 - 0.4

*****

1.5 - 20

15 - 200

Fluothane (Halothane)

2.2 - 26.0

22 - 260

*****

200

Fluoxetine (Prozac)

0.009 - 0.040

0.09 - 0.40

*****

0.13 - 0.68

1.3 - 6.8

Fluphenazine (Prolixin)

0.00009-0.00170

0.0009 - 0.0170

*****

Flurazepam (Dalmane)

0.00005-0.00280

0.0005 - 0.0280

0.02

0.2

0.05 - 0.40

0.5 - 4.0

Flurazepam (Dalmane)

0.0033 - 0.0144

0.033 - 0.144

*****

[+met: N-Desalkylflurazepam] Fluvoxamine (Luvox)

0.0031 - 0.0087

0.031 - 0.087

*****

Forane (Isoflurane)

2.0 - 7.0

20.0 - 70.0

*****

Furadantoin (Nitrofurantoin)

0.18

1.8

*****

Fortavase, Invirase (Saquinavir)

0.011 - 0.11

0.11 - 1.1

*****

Furosemide (Lasix)

0.1 - 1.0

1 - 10

>20

*****

G Gabapentin (Neurontin)

0.2 - 1.0

2 - 10

*****

Gabitrol (Tiagabine)

0.0001 - 0.0234

0.001 - 0.234

*****

Gamma-Hydroxybutyrate (GHB)

<0.1

<1.0

2.6 - 36

26 - 360

>75

>750

GHB (Gamma-Hydroxybutyrate)

<0.1

<1.0

2.6 - 36

26 - 360

>75

>750

Glucophage (Metformin)

0.1 - 0.4

1-4

4.5 - 7.0

45 - 70

*****

Glutethimide (Doriden)

0.2 - 1.2

2 - 12

1-8

10 - 80

3 - 10

30 - 100

Glycopyrrolate (Robinul)

0.005 - 0.0076

0.050 - 0.076

*****

Gold (Sodium Aurothiomalate)

0.3 - 0.8

3-8

*****

Guaifenesin (Robitussin)

0.04 - 0.14

0.4 - 1.4

210

*****

Guanethidine (Ismelin)

0.001

0.01

*****

H Habitrol (transdermal) (Nicotine)

0.0004 - 0.0444

0.004 - 0.444

*****

0.14

1.4

Halcion (Triazolam)

0.002

0.02

*****

Haldol (Haloperidol)

0.0006 - 0.0245

0.006 - 0.245

0.005 - 0.050

0.05 - 0.50

*****

Haloperidol (Haldol)

0.0006 - 0.0245

0.006 - 0.245

0.005 - 0.050

0.05 - 0.50

*****

Halothane (Fluothane)

2.2 - 26.0

22 - 260

*****

200

Hexachlorophene (Phisohex)

0.0003 - 0.0650

0.003 - 0.650

*****

0.22 - 3.5

2.2 - 35

Hismanol (Astemizole)

0.00004

0.0004

*****

Hydralazine

0.02 - 0.09

0.2 - 0.9

*****

Hydrochlorothiazide (Hydrodiuril)

0.007 - 0.038

0.07 - 0.38

*****

Hydrocodone (Lortab, Vicodin)

0.003 - 0.025

0.03 - 0.25

0.05 - 0.2

0.5 - 2

0.07 - 1.2

0.7 - 12

Hydrodiuril (Hydrochlorothiazide)

0.007 - 0.038

0.07 - 0.38

*****

Hydrogen Sulfide

*****

0.092

0.92

Hydromorphone (Dilaudid)

0.0008 - 0.0049

0.008 - 0.049

****

*****

0.03

0.3

Hydroxychloroquine (Plaquenil)

0.0019 - 0.0210

0.019 - 0.210

*****

6.1

Hydroxyzine (Atarax, Vistaril)

0.0022 - 0.008

0.022 - 0.08

*****

0.4 -3.9

4.2 - 39

Hyoscine (Scopolamine)

0.00003 - 0.0019

0.0003 - 0.019

*****

0.189

1.89

Hyperstat (Diazoxide)

1.5 - 2.0

15 - 20

>10

>100

*****

1.7 - 4.9

17 - 49

8.4 - 70

84 - 700

*****

I Ibuprofen (Motrin) Imitrex (Sumatriptan)

0.0024 - 0.0095

0.024 - 0.095

*****

Imipramine (Tofranil)

0.015 - 0.0105

0.15 - 0.105

0.05 - 0.15

0.5 - 1.5

0.28 - 0.85

2.8 - 8.5

Page 7

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Imipramine (Tofranil)

mg% 0.015 - 0.025

Toxic

ug/ml 0.15 - 0.25

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml *****

[+met: Desipramine] Inderal (Propranolol)

0.001 - 0.034

0.01 - 0.34

0.2

0.8 - 1.2

8 - 12

Indocin (Indomethacin)

0.01 - 0.40

0.1 - 4

0.6

*****

Indomethacin (Indocin)

0.01 - 0.40

0.1 - 4

0.6

*****

INH (Isoniazid)

0.06 - 2.0

0.6 - 20

2 - 14.3

20 - 143

6.5 - 16.8

65 - 168

Invirase, Fortovase (Saquinavir)

0.011 - 0.11

0.11 - 1.1

*****

Ionamin (Phentermine)

0.009 - 0.051

0.09 - 0.51

*****

0.15 - 0.76

1.5 - 7.6

Iron

0.027 - 0.293

0.27 - 2.93

0.28 - 2.5

2.8 - 25

2-5

20 - 50

Ismelin (Guanethidine)

0.001

0.01

*****

Isoflurane (Forane)

2.0 - 7.0

20.0 - 70.0

*****

Isoniazid (INH)

0.06 - 2.0

0.6 - 20

2 - 14.3

20 - 143

6.5 - 16.8

65 - 168

Isopropanol

*****

>40

>400

>150

>1500

Isoptin (Calan, Verapamil)

0.0055 - 0.0355

0.055 - 0.355

0.09

0.9

0.09 - 8.5

0.9 - 85

Isordil (Isosorbide Dinitrate)

0.0008 - 0.0038

0.008 - 0.038

*****

Isosorbide Dinitrate (Isordil)

0.0008 - 0.0038

0.008 - 0.038

*****

0.008 - 0.063

0.08 - 0.63

*****

K Kemadrin (Procyclidine) Ketamine

0.02 - 0.63

0.2 - 6.3

*****

Ketoprofen (Orudis, Actron)

0.5 - 0.15

5 - 1.5

*****

Ketorolac (Toradol)

0.087 - 0.45

0.87 - 4.5

*****

Klonopin (Clonazepam)

0.0007 - 0.0075

0.007 - 0.075

*****

Kwell (Lindane)

0.0001 - 0.0031

0.001 - 0.031

0.05

0.5

0.13

1.3

Labetalol (Normodyne, Trandate)

0.0036 - 0.0271

0.036 - 0.271

*****

Lamactal (Lamotrigine)

0.20 - 1.90

2 - 19

1.5 - 3.6

15 - 36

*****

Lamotrigine (Lamactal)

0.20 - 1.90

2 - 19

1.5 - 3.6

15 - 36

*****

Lasix (Furosemide)

0.1 - 1.0

1 - 10

>20

*****

Lead

0.04

0.4

0.04 - 1.37

0.4 - 13.7

0.11 - 0.53

1.1 - 5.3

Leritine (Anileridine)

<0.05

<0.5

*****

0.09 - 0.70

0.9 - 7.0

Levo-Dromoran (Levorphanol)

0.0007 - 0.0021

0.007 - 0.021

*****

0.08 - 0.27

0.8 - 2.7

Levoprome (Methotrimeprazine)

0.002 - 0.0271

0.02 - 0.271

*****

Levorphanol (Levo-Dromoran)

0.0007 - 0.0021

0.007 - 0.021

*****

0.08 - 0.27

0.8 - 2.7

Librium (Chlordiazepoxide)

0.067 - 0.31

0.67 - 3.1

0.5

Lidocaine (Xylocaine)

0.15 - 0.50

1.5 - 5.0

0.7 - 2

7 - 20

>2.5

>25

Lindane (Kwell)

0.0001 - 0.0031

0.001 - 0.031

0.05

0.5

0.13

1.3

Lioresal (Baclofen)

0.01 - 0.06

0.1 - 0.6

0.11 - 0.35

1.1 - 3.5

*****

Lisinopril (Prinivil, Zestril)

0.002 - 0.0082

0.02 - 0.082

*****

Lithium

0.42 - 0.97

4.2 - 9.7

1.39

13.9

>3.47

>34.7

Lodine (Etodolac)

1.2 - 4.7

12 - 47

*****

Lomotil (Diphenoxylate)

0.001 - 0.004

0.01 - 0.04

*****

Lopressor (Metoprolol)

0.003 - 0.027

0.03 - 0.27

*****

0.47 - 14.2

4.7 - 142

Loratadine (Claritin)

0.0007 - 0.0028

0.007 - 0.028

0.046

0.46

*****

metabolite: descarboethoxyloratadine) Lorazepam (Ativan)

0.0007 - 0.0028

0.007 - 0.028

0.046

0.46

*****

0.001 - 0.024

0.01 - 0.24

0.03 - 0.06

0.3 - 0.6

*****

Lortab (Hydrocodone, Vicodin)

0.003 - 0.025

0.03 - 0.25

0.05 - 0.2

0.5 - 2

0.07 - 1.2

0.7 - 12

Loxapine (Loxitane)

0.001 - 0.003

0.01 - 0.03

*****

0.19 - 0.77

1.9 - 7.7

Page 8

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG

mg%

Toxic

ug/ml

mg%

Lethal ug/ml

mg%

ug/ml

Loxitane (Loxapine)

0.001 - 0.003

0.01 - 0.03

*****

0.19 - 0.77

1.9 - 7.7

LSD (Lysergic Acid Diethylamide,

*****

0.0001 - 0.0009

0.001 - 0.009

*****

0.024 - 0.080

0.24 - 0.80

0.2 - 1.3

2-13

Lysergide) Ludiomil (Maprotiline)

0.005 - 0.0718

0.05 - 0.718

Luvox (Fluvoxamine)

0.0031 - 0.0087

0.031 - 0.087

Lysergic Acid Diethylamide

*****

0.0001 - 0.0009

0.001 - 0.009

*****

******

*****

0.0001 - 0.0009

0.001 - 0.009

*****

1.2 - 3.2

12 -32

8 - 12

80 -120

20 - 32

200 -320

(LSD, Lysergide) Lysergide (LSD, Lysergic Acid Diethylamide) M Magnesium Malathion

0.0 - 0.35

0.0 - 3.5

*****

0.05 - 0.35

0.5 - 3.5

Manganese [serum values]

0.00002-0.00011

0.0002 - 0.0011

0.46

4.6

*****

Maprotiline (Ludiomil)

0.005 - 0.0718

0.05 - 0.718

0.024 - 0.080

0.24 - 0.80

0.2 - 1.3

2-13

Marcaine (Bupivacaine)

0.022 - 0.345

0.22 - 3.45

*****

Mazicon (Flumazenil, Romazicon)

0.0006 - 0.0039

0.006 - 0.039

*****

MDA (3,4-Methylenedioxyamphetamine)

*****

0.18 - 2.6

1.8 - 26

Mebaral (Mephobarbital)

0.05 - 0.35

0.5 - 3.5

*****

Mefenamic Acid (Ponstel)

0.03 - 2.00

0.3 - 20.0

1.1 - 11.0

11 - 110

*****

Mellaril (Thioridazine)

0.01 - 0.26

0.1 - 2.6

0.24 - 1.18

2.4 - 11.8

0.1 - 1.8

1 - 18

Mellaril (Thioridazine)

0.03 - 0.40

0.3 - 4.0

*****

[+met: Mesoridazine] Meperidine (Demerol)

0.007 - 0.080

0.07 - 0.80

0.5

0.8 - 2.0

8 - 20

Mephenytoin (Mesantoin)

2.5 - 4.0

25 - 40

*****

[+met: N-Desmethylmephenytoin] Mephobarbital (Mebaral)

0.05 - 0.35

0.5 - 3.5

*****

Mepivacaine (Carbocaine)

0.028 - 0.550

0.28 - 5.50

Meprobamate

0.2 - 2.6

2 - 26

6 - 10

60 -100

14 - 35

140 - 350

Mercury (Inorganic)

*****

0.018 - 0.062

0.18 - 0.62

0.04 - 2.20

0.4 - 22.0

Mercury (Organic)

<0.008

<0.08

>0.02

>0.2

>0.06

>0.6

Mesantoin (Mephenytoin)

2.5 - 4.0

25 - 40

*****

[+met: N-Desmethylmephenytoin] Mesoridazine (Serentil)

0.118 - 0.352

1.18 - 3.52

*****

0.3

Mestinon (Pyridostigmine)

400

*****

Metaclopramide (Reglan)

0.0072 - 0.075

0.072 - 0.75

*****

Metaxalone (Skelaxin)

29.6

296

*****

Metformin (Glucophage)

0.1 - 0.4

1-4

4.5 - 7.0

45 - 70

*****

Methadone (Dolophine)

0.0075 - 0.110

0.075 - 1.10

0.02 - 0.2

0.20 - 2.0

0.04 - 0.18

0.4 - 1.8

Methamphetamine

0.001 - 0.005

0.01 - 0.05

0.06 - 0.50

0.6 - 5.0

>10

Methanol

*****

200

>89

>890

Methaqualone (Quaalude)

0.04 - 0.80

0.4 - 8.0

1-3

10 - 30

>0.5

Methazolamide (Neptazane)

*****

Methocarbamol (Robaxin)

2.6 - 4.1

26 - 41

*****

Methohexital

0.34 - 1.07

3.4 - 10.7

*****

9.8

Methotrimeprazine (Levoprome)

0.002 - 0.0271

0.02 - 0.271

*****

0.08 - 0.41

0.8 - 4.1

Methoxy-O-demethylencainide

0.006 - 0.028

0.06 - 0.28

*****

[met: Encainide]

Page 9

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Methsuximide (Celontin)

mg% 1.0 - 4

Toxic

ug/ml 10 - 40

mg% 4.4

Lethal ug/ml

>44

mg% *****

ug/ml *****

[as met: Desmethylmethsuximide] Methyldopa

0.10 - 0.75

1.0 - 7.5

*****

Methylene Chloride (Dichloromethane)

*****

9.5 - 60

95 - 600

3-4-Methylenedioxyamphetamines (MDA)

*****

0.18 - 2.6

1.8 - 26

Methylfentanyl (China White)

******

0.0002 - 0.0011

0.002 - 0.011

Methylphenidate (Ritalin)

0.001 - 0.006

0.01 - 0.06

0.08

0.8

0.23

2.3

Methyprylon (Noludar)

0.5 - 1.5

5 - 15

3-6

30 - 60

100

Metoprolol (Lopressor)

0.003 - 0.027

0.03 - 0.27

*****

0.47 - 14.2

4.7 - 142

Mexiletine (Mexitil)

0.05 - 0.20

0.5 - 2.0

*****

2.1 - 4.5

21 - 45

Mexitil (Mexiletine)

0.05 - 0.20

0.5 - 2.0

*****

2.1 - 4.5

21 - 45

Mianserin

0.001 - 0.016

0.01 - 0.16

0.011 - 0.050

0.11 - 0.50

0.01 - 0.26

0.1 - 2.6

Midazolam (Versed)

0.008 - 0.025

0.08 - 0.25

*****

Milontin (Phensuximide)

0.4 - 1.4

4 - 14

8 - 15

80 - 150

*****

Mirtazapine (Remeron)

0.0039 - 0.018

0.039 - 0.18

*****

Moclobemide

0.3

*****

5.6 - 9.0

56 - 90

Molybdenum

0.0015

0.015

*****

Morphine

0.01

0.10

*****

0.005 - 0.400

0.05 - 4.00

Motrin (Ibuprofen)

1.7 - 4.9

17 - 49

8.4 - 70

84 - 700

*****

Motofen (Difenoxin)

0.016

0.160

*****

Moxifluxacin (Avelox)

0.45 - 1.44

4.5 - 14.4

*****

Mysoline (Primidone)

0.2 - 1.9

2 - 19

5-8

50 - 80

100

0.2 - 1.2

2 - 12

1.6

*****

0.001 - 0.014

0.01 - 0.14

*****

0.01 - 0.26

0.1 - 2.6

>0.5

*****

0.002 - 0.180

0.02 - 1.80

*****

N N-Acetylprocainamide (NAPA) [met: Procainamide (Pronestyl) N-Desalkylflurazepam [met: Flurazepam (Dalmane)] N-Desmethyldiazepam (Nordiazepam) [met: Clorazepate (Tranxene)] N-Desmethyldiazepam (Nordiazepam) [met: Diazepam (Valium)] Nalfon (Fenoprofen)

2.7 - 6.6

27 - 66

*****

710

Naloxone (Narcan)

0.001

0.01

*****

NAPA (N-Acetylprocainamide)

0.2 - 1.2

2 - 12

1.6

*****

[met: Procainamide (Pronestyl) Naprosyn (Naproxen)

3.1 - 12

31 - 120

400

*****

Naproxen (Anaprox)

3.1 - 12

31 - 120

400

*****

Narcan (Naloxone)

0.001

0.01

*****

Nardil (Phenelzine)

0.0001 - 0.0002

0.001 - 0.002

*****

>0.15

>1.5

Navane (Thiothixene)

0.001 - 0.010

0.01 - 0.10

*****

Nebcin (Tobramycin)

0.16 - 0.78

1.6 - 7.8

*****

Nefazodone (Serzone)

0.01 - 0.12

0.1 - 1.2

*****

Nembutal (Pentobarbital)

0.1 - 0.3

1-3

>0.5

1.0 - 16.9

10 - 169

Neo-Synephrine (Phenylephrine)

0.003

0.03

*****

Neptazane (Methazolamide)

*****

Nesacaine (Chloroprocaine)

0.2 - 0.4

2-4

*****

Neurontin (Gabapentin)

0.2 - 1.0

2 - 10

*****

Page 10

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Nicardipine (Cardene)

mg% 0.0036 - 0.015

Toxic

ug/ml 0.036 - 0.150

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml *****

Nickel

0.011

0.11

*****

Nicotine

0.0004 - 0.0444

0.004 - 0.444

*****

0.14

1.4

Nicotine (Transdermal)

0.0004 - 0.0031

0.004 - 0.031

*****

(Prostep, Habitrol, Nicotrol) Nicotrol (Transdermal, Nicotine)

0.0004 - 0.0031

0.004 - 0.031

*****

Nifedipine (Adalat, Procardia)

0.0015 - 0.0162

0.015 - 0.162

*****

Nisentil (Alphaprodine)

0.087 - 0.100

0.87 - 1.00

*****

Nitrite (Butyl Nitrite)

0.05 - 0.40

0.5 - 4

*****

2.2

Nitro-Bid (Nitro-Dur, Nitroglycerin)

0.0002 - 0.0013

0.002 - 0.013

*****

Nitro-Dur (Nitro-Bid, Nitroglycerin)

0.0002 - 0.0013

0.002 - 0.013

*****

Nitrofurantoin (Furadantoin)

0.18

1.8

*****

Nitroglycerin (Nitro-Bid, Nitro-Dur)

0.0002 - 0.0013

0.002 - 0.013

*****

Nitroprusside [as met: Thiocyanate]

0.55 - 2.9

5.5 - 29

>10

>100

200

Nitrous Oxide

29 - 44

290 - 440

*****

350

Noctec (Chloral Hydrate)

0.2 - 1.2

2 - 12

100

250

Noludar (Methyprylon)

0.5 - 1.5

5 - 15

3-6

30 - 60

100

Nordiazepam (N-Desmethyldiazepam)

0.01 - 0.26

0.1 - 2.6

>0.5

>5.0

*****

0.002 - 0.180

0.02 - 1.80

*****

[as met: Trichloroethanol]

[met: Clorazepate (Tranxene)] Nordiazepam (N-Desmethyldiazepam) [met: Diazepam (Valium)] Norflex (Orphenadrine)

0.003 - 0.085

0.03 - 0.85

0.2

0.4 - 0.8

4.0 - 8.0

Norfluoxetine [met: Fluoxetine (Prozac)]

0.0018 - 0.0466

0.018 - 0.466

*****

0.09 - 0.5

0.9 - 5.0

Normodyne ( Labetalol, Trandate)

0.0036 - 0.0271

0.036 - 0.271

*****

Norpace (Disopyramide)

0.2 - 0.6

2-6

0.7

2.6

Norpramin (Desipramine)

0.005 - 0.0684

0.05 - 0.684

>0.05

>0.5

1-2

10 - 20

0.005 - 0.0375

0.05 - 0.375

0.05

0.5

1.3

0.0160 - 0.0207

0.160 - 0.207

*****

[met: Imipramine (Tofranil)] Nortriptyline (Aventyl) [met: Amitriptyline (Elavil)] Norverapamil

0.4 - 0.8

4-8

>20

Norvir (Ritonavir)

[met: Verapamil (Calan, Isoptin)]

1.1 - 6.6

11.2 - 66.0

*****

Novocaine (Procaine)

0.02 - 1.30

0.2 - 13.0

>2.1

>21

*****

O O-Demethylencainide [met: Encainide]

0.01 - 0.03

0.1 - 0.3

*****

Olanzapine (Zyprexa)

0.0009 - 0.0023

0.009 - 0.023

*****

0.12

1.2

Ondansetron (Zofran)

0.0022 - 0.0114

0.022 - 0.114

*****

Orinase (Tolbutamide)

4.3 - 9.6

43 - 96

*****

640

Orphenadrine (Norflex)

0.003 - 0.085

0.03 - 0.85

0.2

0.4 - 0.8

4.0 - 8.0

Orudis (Ketoprofen)

0.5 - 0.15

5 - 1.5

*****

1 - 11

10 - 110

Oxalate

0.2

Oxaprozin (Daypro)

0.01 - 0.04

0.1 - 0.4

Oxazepam (Serax)

0.015 - 0.140

0.15 - 1.4

>0.2

*****

Oxycodone (Percodan, Oxycontin)

0.001 - 0.010

0.01 - 0.10

0.02 - 0.50

0.2 - 5.0

*****

Oxycontin (Oxycodone, Percodan)

0.001 - 0.010

0.01 - 0.10

0.02 - 0.50

0.2 - 5.0

*****

Oxyphenbutazone (Tandearil)

1.1 - 11.8

11 - 118

*****

Page 11

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG

mg%

Toxic

ug/ml

mg%

Lethal ug/ml

mg%

ug/ml

P Pancuronium (Pavulon)

0.009 - 0.022

0.09 - 0.22

*****

0.16

1.6

Papaverine

0.025 - 0.400

0.25 - 4.00

*****

Paradione (Paramethadione)

0.11 - 0.50

1.1 - 5.0

*****

Paraldehyde

2.0 - 33.2

20 - 332

20 - 40

200 - 400

>50

>500

Paramethadione (Paradione)

0.11 - 0.50

1.1 - 5.0

*****

Para-Methoxyamphetamine (PMA)

*****

0.02 - 0.49

0.2 - 4.9

Paraquat

*****

0.06 - 0.32

0.6 - 3.2

>1.5

>15

Parathion

*****

0.05 - 3.40

0.5 - 34.0

Parnate (Tranylcypromine)

0.005

0.05

*****

Paroxetine (Paxil)

0.0031 - 0.0062

0.031 - 0.062

*****

0.14 - 0.34

1.4 - 3.4

Pavulon (Pancuronium)

0.009 - 0.022

0.09 - 0.22

*****

0.16

1.6

Paxil (Paroxetine)

0.0031 - 0.0062

0.031 - 0.062

*****

0.14 - 0.34

1.4 - 3.3

PCP (Phencyclidine)

*****

0.0007 - 0.0240

0.007 - 0.240

0.1 - 0.5

1-5

Pemoline (Cylert)

0.07 - 0.62

0.70 - 6.2

*****

Pentachlorophenol

*****

>4.6

>46

Pentazocine (Talwin)

0.003 - 0.100

0.03 - 1.00

0.2 - 0.5

2-5

>0.03

>0.3

Pentobarbital (Nembutal)

0.1 - 0.3

1-3

>0.5

1.0 - 16.9

10 - 169

Pentothal (Thiopental)

0.1 - 4.2

1 - 42

>0.7

1 - 40

10 - 400

Pentoxifylline (Trental)

0.006 - 0.16

0.06 - 1.6

*****

>0.6

>6.0

Pepcid (Famotidine)

0.0007 - 0.0035

0.007 - 0.035

*****

Percodan (Oxycodone)

0.001 - 0.010

0.01 - 0.10

0.02 - 0.50

0.2 - 5.0

*****

Perphenazine (Trilafon)

0.00004-0.00300

0.0004 - 0.0300

0.1

*****

Phenacetin

0.01 - 2.00

0.1 - 20.0

>30

*****

Phencyclidine (PCP)

*****

0.0007 - 0.0240

0.007 - 0.240

0.1 - 0.5

1-5

Phendimetrazine

0.002 - 0.024

0.02 - 0.24

*****

Phenelzine (Nardil)

0.0001 - 0.0002

0.001 - 0.002

*****

>0.15

>1.5

Phenergan (Promethazine)

0.0006 - 0.0099

0.006 - 0.099

*****

0.24 - 1.2

2.4 - 12

Phenmetrazine

0.004 - 0.024

0.04 - 0.24

*****

0.4

Phenobarbital

1-4

10 - 40

4-6

40 - 60

>80

Phenol

*****

>4.6

>46

Phensuximide (Milontin)

0.4 - 1.4

4 - 14

8 - 15

80 - 150

*****

Phentermine (Ionamin)

0.009 - 0.051

0.09 - 0.51

*****

0.15 - 0.76

1.5 - 7.6

Phenylbutazone (Butazolidin)

1.6 - 15.0

16 - 150

200

400

Phenylephrine (Neo-Synephrine)

0.003

0.03

*****

Phenylpropanolamine

0.003 - 0.048

0.03 - 0.48

*****

>10

Phenytoin (Dilantin, Diphenylhydantoin)

1-2

10 - 20

2-5

20 -50

>10

>100

Phisohex (Hexachlorophene)

0.0003 - 0.0650

0.003 - 0.650

*****

0.22 - 3.5

2.2 - 35

Phosphorus (Adult)

2.0 - 4.8

20 - 48

*****

Phosphorus (Child)

4-7

40 -70

*****

Piroxicam (Feldene)

0.085 - 0.8

0.85 - 8.00

*****

Placidyl (Ethchlorvynol)

0.05 - 0.88

0.5 - 8.8

*****

2.2 - 21.3

22 - 213

Plaquenil (Hydroxychloroquine)

0.0019 - 0.0210

0.019 - 0.210

*****

6.1

Plendil (Felodipine)

0.00015-0.00088

0.0015 - 0.0088

0.001 - 0.0015

0.01 - 0.015

*****

PMA (Para-Methoxyamphetamine)

*****

0.02 - 0.49

0.2 - 4.9

Polythiazide (Renese)

0.2 - 0.7

2-7

*****

Pondimin (Fenfluramine)

0.004 - 0.030

0.04 - 0.3

0.07 - 0.09

0.7 - 0.9

0.6 - 1.5

6 - 15

Page 12

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Ponstel (Mefenamic Acid)

mg% 0.03 - 2.00

Toxic

ug/ml 0.3 - 20.0

mg% 1.1 - 11.0

Lethal ug/ml

11 - 110

mg% *****

ug/ml *****

Prazepam (Centrax)

0.001 - 0.004

0.01 - 0.04

*****

Preludin (Phenmetrazine)

0.004 - 0.024

0.04 - 0.24

*****

0.4

Prilocaine (Citanest)

0.1 - 0.5

1-5

*****

Primidone (Mysoline)

0.2 - 1.9

2 - 19

5-8

50 - 80

100

Prinivil (Lisinopril, Zestril)

0.002 - 0.0082

0.02 - 0.082

Probenecid (Benemid)

10 - 20

100 - 200

*****

Procainamide (Pronestyl)

0.4 - 0.8

4-8

>20

Procaine (Novocaine)

0.02 - 1.30

0.2 - 13.0

>2.1

>21

*****

Procardia (Adalat, Nifedipine)

0.0015 - 0.0162

0.015 - 0.162

*****

Prochlorperazine (Compazine)

*****

>0.1

0.5

Procyclidine (Kemadrin)

0.008 - 0.063

0.08 - 0.63

*****

Prolixin (Fluphenazine)

0.00009-0.00170

0.0009 - 0.0170

*****

Prograf (Tacrolimus)

0.0005 - 0.002

0.005 - 0.02

>0.003

>0.03

*****

Promazine (Sparine)

*****

>0.1

>0.5

Promethazine (Phenergan)

0.0006 - 0.0099

0.006 - 0.099

*****

0.24 - 1.2

2.4 - 12

Pronestyl (Procainamide)

0.4 - 0.8

4-8

>20

Propafenone (Rythmol)

0.0176 - 0.165

0.17 - 1.65

*****

Proparacaine (Alcaine)

0.2 - 1.6

2 - 16

*****

Propofal (Diprivan)

0.023 - 0.107

0.23 - 1.07

0.03 - 0.06

0.3 - 0.6

0.1 - 1.7

1-17

Propoxyphene (Darvon)

0.023 - 0.107

0.23 - 1.07

0.03 - 0.06

0.3 - 0.6

0.1 - 1.7

1-17

Propoxyphene (Darvon)

0.104 - 0.371

1.04 - 3.71

0.28 - 1.2

2.8 - 12

0.27 - 4.7

2.7 - 47

[+met: Norpropoxyphene Propranolol (Inderal)

0.6 - 71.1

6 - 711

*****

Propylene Glycol

0.01 - 0.034

0.1 - 0.34

0.2

0.8 - 1.2

8 - 12

Propylhexedrine (Benzedrex)

0.001

0.01

*****

0.2 - 0.3

2-3

Prosom (Estazolam)

0.0042 - 0.0100

0.042 - 0.100

0.125

1.25

*****

Prostep (transdermal) (Nicotine)

0.0004 - 0.0031

0.004 - 0.031

*****

Prothiaden (Dothiepin)

0.0017 - 0.0420

0.017 - 0.420

*****

0.03 - 0.25

0.3 - 2.5

Protriptyline (Vivactil)

0.007 - 0.038

0.07 - 0.38

0.05 - 0.20

0.5 - 2.0

>0.1

Prozac (Fluoxetine)

0.009 - 0.040

0.09 - 0.40

*****

0.13 - 0.68

1.3 - 6.8

Pseudoephedrine (Sudafed)

0.050 - 0.077

0.50 - 0.77

*****

1.9

Pyribenzamine (Tripelennamine)

0.006

0.06

*****

Pyridostigmine (Mestinon)

400

*****

Q Quaalude (Methaqualone)

0.04 - 0.80

0.4 - 8.0

1-3

10 - 30

>0.5

Quazepam

1.1 - 14.8

11 - 148

*****

Quetiapine (Serognel)

0.0195 - 0.0632

0.195 - 0.632

1.3

*****

Quinidine

0.10 - 0.60

1-6

3-5

30 - 50

Quinine

0.17 - 0.97

1.7 - 9.7

>10

1.2

R Rantidine (Zantac)

0.0036 - 0.0094

0.036 - 0.094

*****

Reglan (Metaclopramide)

0.0072 - 0.075

0.072 - 0.75

*****

Remeron (Mirtazapine)

0.0039 - 0.018

0.039 - 0.18

*****

Remifentanil (Ultiva)

0.0003 - 0.005

0.003 - 0.05

*****

Renese (Polythiazide)

0.2 - 0.7

2-7

*****

Repoise (Butaperazine)

0.002 - 0.069

0.02 - 0.69

*****

Page 13

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Restoril (Temazepam )

mg% 0.04 - 0.09

Toxic

ug/ml 0.4 - 0.9

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml *****

Retrovir (AZT, Zidovadine)

0.027 - 0.08

0.27 - 0.8

*****

Rezulin (Troglitazone)

0.1 - 0.3

1-3

*****

Risperdal (Risperidone)

0.0003 - 0.0012

0.003 - 0.012

*****

Risperidone (Risperdal)

0.0003 - 0.0012

0.003 - 0.012

*****

9-Hydroxy Risperidone

0.099

0.990

*****

Ritalin (Methylphenidate)

0.001 - 0.006

0.01 - 0.06

0.08

0.8

0.23

2.3

Ritonavir (Norvir)

1.1 - 6.6

11.2 - 66.0

*****

Robaxin (Methocarbamol)

2.6 - 4.1

26 - 41

*****

Robinul (Glycopyrrolate)

0.005 - 0.0076

0.050 - 0.076

*****

Robitussin (Guaifenesin)

0.04 - 0.14

0.4 - 1.4

210

*****

Rofecoxib (Vioxx)

0.016 - 0.032

0.16 - 0.32

*****

Rohypnol (Flunitrazepam)

0.006 - 0.0052

0.06 - 0.052

0.001 - 0.005

0.01 - 0.05

*****

Romazicon (Flumazenil, Mazicon)

0.0006 - 0.0039

0.006 - 0.039

*****

Rythomol (Propafenone)

0.0176 - 0.165

0.17 - 1.65

*****

S Salicylamide

0.5

5.0

*****

Salicylate

2 - 10

20 - 100

15 - 30

150 - 300

500

2 - 25

20 - 250

*****

[met: Acetylsalicylic Acid - for normal usage] Salicylate [met: Acetylsalicylic Acid-for rheumatoid arthritis] Sandimmune (Cyclosporine)

0.005 - 0.045

0.050 - 0.045

*****

Sandoptal (Butalbital)

0.17 - 0.26

1.7 - 2.6

0.7 - 4

7 - 40

1.3 - 2.6

13 - 26

Saquinavir (Invirase, Fortovase)

0.011 - 0.11

0.11 - 1.1

*****

Scopolamine (Hyoscine)

0.00003 - 0.0019

0.0003 - 0.019

*****

0.189

1.89

Secobarbital (Seconal)

0.1 - 0.22

1 - 2.2

>0.3

0.5 - 5.2

5 - 52

Seconal(Secobarbital)

0.1 - 0.22

1 - 2.2

>0.3

0.5 - 5.2

5 - 52

Sectral (Acebutolol)

0.05 - 0.12

0.5 - 1.2

*****

Seldane (Terfenadine) [as active metabolite]

0.0133 - 0.0423

0.133 - 0.423

*****

Selegine (Eldepryl)

0.0009 - 0.0019

0.009 - 0.019

*****

Serax (Oxazepam)

0.015 - 0.140

0.15 - 1.40

>0.2

*****

Serentil (Mesoridazine)

0.118 - 0.352

1.18 - 3.52

*****

0.3

Seroflurane (Serofrane)

1.34

13.4

*****

Serofrane (Seroflurane)

1.34

13.4

*****

Serognel (Quetiapine)

0.0195 - 0.0632

0.195 - 0.632

1.3

*****

Sertraline (Zoloft)

0.0055 - 0.025

0.055 - 0.25

*****

Serzone (Nefazodone)

0.01 - 0.12

0.1 - 1.2

*****

Sildenafil (Viagra)

0.0127 - 0.115

0.127 - 1.15

*****

Simvastatin (Zocor)

0.00027-0.00056

0.0027 - 0.0056

*****

Sinequan (Doxepin)

0.010 - 0.025

0.10 - 0.25

0.012 - 0.43

0.12 - 4.3

0.2 - 2.6

2 -26

Sinequan (Doxepin)

0.010 - 0.025

0.10 - 0.25

>0.05

>0.5

0.8 - 3.5

8 - 35

[+met: N-Desmethyldoxepin] Skelaxin (Metaxalone)

29.6

296

*****

Sodium Aurothiomalate (Gold)

0.3 - 0.8

3-8

*****

Soma (Carisoprodol)

1-4

10 - 40

3-5

30 - 50

110

Sparine (Promazine)

*****

>0.1

>0.5

Stadol (Butorphanol)

0.00011-0.00017

0.0011 - 0.0017

*****

Page 14

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Stelazine (Trifluoperazine)

mg% 0.05 - 0.20

Toxic

ug/ml 0.5 - 2.0

mg% 0.12 - 0.30

Lethal ug/ml

1.2 - 3.0

mg% 0.3 - 0.8

ug/ml 3-8

Strychnine

*****

0.2

0.28 - 1.20

2.8 - 12.0

Sublimaze (Fentanyl)

0.001 - 0.010

0.01 - 0.10

*****

Sudafed (Pseudoephedrine)

0.050 - 0.077

0.50 - 0.77

*****

1.9

Sufenta (Sufentanil)

0.0001 - 0.0011

0.001 - 0.011

*****

Sufentanil (Sufenta)

0.0001 - 0.0011

0.001 - 0.011

*****

Sulfadiazine

8 - 15

80 - 150

*****

Sulfaguanidine

3-5

30 - 50

*****

Sulfanilamide

10 - 15

100 - 150

*****

Sulfisoxazole

9 - 10

90 - 100

*****

Sulindac (Clinoril)

0.4 - 0.5

4-5

*****

Sumatriptan (Imitrex)

0.0024 - 0.0095

0.024 - 0.095

*****

Surmontil (Trimipramine)

0.001 - 0.030

0.01 - 0.30

*****

0.87 - 1.20

8.7 - 12.0

Symmetrel (Amantadine)

0.006 - 0.031

0.06 - 0.31

0.1 - 0.05

1 - 0.5

0.21 - 0.48

2.1 - 4.8

T Tacrolimus (Prograf)

0.0005 - 0.002

0.005 - 0.02

>0.003

>0.03

*****

Tagamet (Cimetidine)

0.05 - 0.45

0.5 - 4.5

*****

Talwin (Pentazocine)

0.003 - 0.100

0.03 - 1.00

0.2 - 0.5

2-5

>0.03

>0.3

Tambocar (Flecainide)

0.02 - 0.10

0.2 - 1.0

*****

Tandearil (Oxyphenbutazone)

1.1 - 11.8

11 - 118

*****

Taractan (Chlorprothixene)

0.004 - 0.030

0.04 - 0.30

0.04 - 0.08

0.4 - 0.8

*****

Tegretol (Carbamazepine)

0.14 - 1.2

1.4 - 12

>1.5

>15

>50

Temazepam (Restoril)

0.04 - 0.09

0.4 - 0.9

*****

Tenormin (Atenolol)

0.02 - 0.07

0.20 - 0.70

3.5

*****

Tenuate (Diethylpropion)

0.0007 - 0.0200

0.007 - 0.200

*****

0.54

5.4

Terbutaline (Brethine)

0.0002 - 0.0006

0.002 - 0.006

*****

0.004

0.04

Terfenadine (Seldane) [as active metabolite]

0.0133 - 0.0423

0.133 - 0.423

*****

Tetrachloroethylene

*****

0.45 - 4.0

4.5 - 44.0

Tetrahydrocannabinol (THC)

<0.019

<0.19

*****

Thallium

<0.008

<0.08

>0.1

0.05 - 1.10

0.5 - 11.0

THC (Tetrahydrocannabinol)

<0.019

<0.19

*****

Theophylline (Aminophylline)

1-2

10 - 20

3-4

30 - 40

5 - 25

50 - 250

Thiocyanate

0.6 - 2.9

6 - 29

*****

Thiocyanate [met: Nitroprusside]

0.55 - 2.9

5.5 - 29

>10

>100

200

Thiopental (Pentothal)

0.1 - 4.2

1 - 42

>0.7

1 - 40

10 - 400

Thioridazine (Mellaril)

0.01 - 0.26

0.1 - 2.6

>0.5

0.1 - 1.8

1 -18

Thioridazine (Mellaril)

0.03 - 0.40

0.3 - 4.0

*****

[+met: Mesoridazine] Thiothixene (Navane)

0.001 - 0.010

0.01 - 0.10

*****

Thorazine (Chlorpromazine)

0.001 - 0.050

0.01 - 0.50

0.1 - 0.2

1-2

0.3 - 1.2

3 - 12

Tiagabine (Gabitrol)

0.0001 - 0.0234

0.001 - 0.234

*****

Tigan (Trimethobenzamide)

0.1 - 0.2

1-2

*****

Timolol (Blocadren)

0.004 - 0.023

0.04 - 0.23

*****

Tin

0.012 - 0.014

0.12 - 0.14

*****

Tobramycin (Nebcin)

0.16 - 0.78

1.6 - 7.8

*****

Tocainide (Tonocard)

0.4 - 1.0

4 - 10

*****

Tofranil (Imipramine)

0.015 - 0.0105

0.15 - 0.105

0.05 - 0.15

0.5 - 1.5

0.28 - 0.85

2.8 - 8.5

Page 15

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG Tofranil (Imipramine) [+met: Desipramine]

mg% 0.015 - 0.025

Toxic

ug/ml 0.15 - 0.25

mg% *****

Lethal ug/ml

*****

mg% *****

ug/ml *****

Tolbutamide (Orinase)

4.3 - 9.6

43 - 96

*****

640

Tolectin (Tolmetin)

3.7

>60

*****

Tolmetin (Tolectin)

3.7

>60

*****

Toluene

*****

Tonocard (Tocainide)

0.4 - 1.0

4 - 10

*****

Toradol (Ketorolac)

0.087 - 0.45

0.87 - 4.5

*****

Tramadol (Ultram)

0.01 - 0.06

0.1 - 0.6

Trancopal (Chlormezanone)

0.25 - 0.88

2.5 - 8.8

*****

Trandate ( Labetalol, Normodyne)

0.0036 - 0.0271

0.036 - 0.271

*****

Tranxene (Chlorazepate)

0.01 - 0.16

0.1 - 1.6

>0.5

>5.0

*****

[as met: N-Desmethyldiazepam Tranylcypromine (Parnate)

0.005

0.05

*****

Trazodone (Desyrel)

0.07 - 0.489

0.7 - 4.89

*****

1.5

Trental (Pentoxifylline)

0.006 - 0.16

0.06 - 1.6

*****

>0.6

>6.0

Triazolam (Halcion)

0.002

0.02

*****

Tribromoethanol

*****

Trichloroethane

*****

10 - 100

100 - 1000

Trichloroethanol

0.2 - 1.2

2 - 12

100

250

0.1 - 9.0

1 - 90

*****

0.3 - 11.0

3 - 110

[met: Chloral Hydrate (Noctec)] Trichloroethylene Tridione (Trimethadione)

1-3

10 - 30

*****

Trifluoperazine (Stelazine)

0.05 - 0.20

0.5 - 2.0

0.12 - 0.30

1.2 - 3.0

0.3 - 0.8

3-8

Trilafon (Perphenazine)

0.00004-0.00300

0.0004 - 0.0300

0.1

*****

Trimethadione (Tridione)

1-3

10 - 30

*****

Trimethobenzamide (Tigan)

0.1 - 0.2

1-2

*****

Trimethoprim (Trimpex)

0.1 - 0.2

1-2

*****

Trimipramine (Surmontil)

0.001 - 0.030

0.01 - 0.30

*****

0.87 - 1.20

8.7 - 12.0

Trimpex (Trimethoprim)

0.1 - 0.2

1-2

*****

Tripelennamine (Pyribenzamine)

0.006

0.06

*****

Triprolidine (Actidil)

0.0004 - 0.0044

0.004 - 0.044

*****

Tubocurarine

0.004 - 0.600

0.04 - 6.00

*****

Tylenol (Acetaminophen)

1-2

10 - 20

150

>16

>160

Ultiva (Remifentanil)

0.0003 - 0.005

0.003 - 0.05

*****

Ultram (Tramadol)

0.01 - 0.06

0.1 - 0.6

Unisom ( Doxylamine)

0.0069 - 0.0138

0.069 - 0.138

*****

0.07 - 1.2

0.7 - 12

Uric Acid

3-7

30 - 70

*****

V Valium (Diazepam)

0.002 - 0.400

0.02 - 4.00

0.5 - 2.0

5 - 20

>30

Valium (Diazepam)

0.031 - 0.600

0.31 - 6.00

*****

>3.4

>34

[+met: N-Desmethyldiazepam Valmid (Ethinamate)

0.4 - 1.1

4 - 11

*****

10 - 20

100 - 200

Valproic Acid (Depakene)

5 - 10

50 - 100

0.71 - 20.0

7.1 - 200

*****

Vancomycin

3-4

30 - 40

*****

Vasotec (Enalapril)

0.00063 - 0.007

0.0063 - 0.070

*****

Venlafaxine (Effexor)

0.007 - 0.393

0.07 - 3.93

*****

Page 16

Drug and Chemical Blood Level Data - 2001

Therapeutic or Normal DRUG [met: O-Desmethylvenlafaxine]

mg% 0.0061 - 0.075

Toxic

ug/ml 0.061 - 0.75

mg% 0.1 - 0.15

Lethal ug/ml

1 - 1.5

mg% *****

ug/ml *****

Verapamil (Calan, Isoptin)

0.0055 - 0.0355

0.055 - 0.355

0.09

0.9

0.09 - 8.5

0.9 - 85

Versed (Midazolam)

0.008 - 0.025

0.08 - 0.25

*****

Viagra (Sildenafil)

0.0127 - 0.115

0.127 - 1.15

Vicodin (Hydrocodone, Lortab)

0.003 - 0.025

0.03 - 0.25

0.05 - 0.2

0.5 - 2

0.07 - 1.2

0.7 - 12

Vioxx (Rofecoxib)

0.016 - 0.032

0.16 - 0.32

*****

Vivactil (Protriptyline)

0.007 - 0.038

0.07 - 0.38

0.05 - 0.20

0.5 - 2.0

>0.1

Vistaril (Atarax, Hydroxyzine,)

0.0022 - 0.008

0.022 - 0.08

*****

0.4 - 3.9

4.2 - 39

Vistazine (Hydroxyzine)

0.008

0.08

1.3

3.9

Voltaren (Diclofenac, Cataflam)

0.075 - 0.20

0.75 - 2.0

0.6

*****

W Warfarin (Coumadin)

0.10 - 0.31

1. 0 - 3.1

*****

Wellbutrin (Bupropion)

0.0025 - 0.0100

0.025 - 0.100

*****

0.73

7.3

0.0025 - 0.0102

0.025 - 0.102

*****

0.0122 - 0.039

0.122 - 0.390

X Xanax (Alprazolam) Xylene

*****

0.3 - 11.0

3 - 110

Xylocaine (Lidocaine)

0.15 - 0.50

1.5 - 5.0

0.7 - 2

7 - 20

>2.5

>25

Y Yocon (Yohimbine)

0.0046 - 0.029

0.046 - 0.290

*****

Yohimbine (Yocon)

0.0046 - 0.029

0.046 - 0.290

*****

Z Zantac (Rantidine)

0.0036 - 0.0094

0.036 - 0.094

*****

Zarontin (Ethosuximide)

4 - 10

40 - 100

*****

250

Zestril (Lisinopril, Prinivil)

0.002 - 0.0082

0.02 - 0.082

Zidovadine (AZT, Retrovir)

0.027 - 0.08

0.27 - 0.8

*****

Zilenton (Zyflo)

0.04 - 0.31

0.4 - 3.1

*****

Zinc

0.068 - 0.136

0.68 - 1.36

*****

Zocor (Simvastatin)

0.00027-0.00056

0.0027 - 0.0056

*****

Zofran (Ondansetron)

0.0022 - 0.0114

0.022 - 0.114

*****

Zolmitriptan (Zomig)

0.0029 - 0.0272

0.029 - 0.272

*****

0.05 - 0.112

0.5 - 1.12

Zoloft (Sertraline)

0.0055 - 0.025

0.055 - 0.25

*****

Zolpidem (Ambien)

0.0003 - 0.0018

0.003 - 0.018

*****

Zomig (Zolmitriptan)

0.0029 - 0.0272

0.029 - 0.272

*****

0.05 - 0.112

0.5 - 1.12

Zoxazolamine (Flexin)

0.3 - 1.3

3 - 13

*****

Zyflo (Zilenton)

0.04 - 0.31

0.4 - 3.1

*****

Zyprexa (Olanzapine)

0.0009 - 0.0023

0.009 - 0.023

*****

0.12

1.2

Page 17

7/28/2021

TOP TACTICS ON DRUG BLOOD TESTING

ANDREEA IONESCU ANDREEA@AITEXASLAW.COM

IT ALL STARTS IN VOIR DIRE How many people are on prescribed medication? At least half the panel will raise their hand. Discuss with them: -

What kind of medication are they taking?What dose? For how long? What was their starting dose, and what is their current dose?

When you first starting that medication - how did it affect them?

Did that change over time? How?

Did their dose get increased at a certain point?

What happens if you don’t take your medication?

Are they fully functional while on their prescribed dose?

WHAT TO DISCUSS WITH THE STATE ANALYST 1. Bound vs. unbound drugs in blood 2. Therapeutic levels of drugs 3. Drugs and their metabolites

7/28/2021

BOUND VS UNBOUND DRUGS IN BLOOD The 2 most common binding proteins are (1) albumin, and (2) 𝞪1-acid glycoprotein (𝞪1-AGP).

BOUND VS UNBOUND DRUGS IN BLOOD Albumin ● Accounts for almost 60% of the total protein content in plasma ● It changes based on factors like temperature, pH, and ionic strength ● The concentration of albumin can be affected by being dehydrated, certain medication (e.g insulin, steroids, hormones), pregnancy, acute and chronic inflammatory responses, as well as severe injuries and surgery ● Albumin’s 2 main binding sites are warfarin site and benzodiazepine site. The warfarin site is pH dependent.

BOUND VS UNBOUND DRUGS IN BLOOD 𝞪1-AGP -

Levels of 𝞪1-AGP can be affected by infection, inflamation, cardiovascular disease, obesity, severe injuries, trauma, burns and steroids and other drugs

Has only one binding site

7/28/2021

EFFECTS OF TEMPERATURE AND PH ON PROTEIN BINDING - The commonly accepted human body temperature is 37 ℃ and the pH in circulating plasma is 7.40±0.05. The blood pH is regulated with dissolved CO2 . When blood is collected, CO2 is immediately lost. In fresh blood, the pH increases 0.1-0.2 units.

- After freezing-storage-thawing of the plasma, the pH is

often around 8, and after long term storage sometimes even above 9. For both albumin and 𝞪1-AGP the ratio between the unbound concentration and the total concentration increases or decreases based on the pH levels.

EFFECTS OF TEMPERATURE AND PH ON PROTEIN BINDING - An increase in temperature increases the ratio between the unbound concentration and the total concentration.

HOW TO RESTORE BLOOD TO THE WAY IT WAS WHEN IT WAS DRAWN Use CO2,, an incubator with controlled temperature and humidity and simply restore the original CO2 at 37℃. The appropriate concentration and incubation time depend on the surface area/volume ration for the plasma sample and must be determined at every set up

7/28/2021

ONCE BLOOD IS RESTORED - HOW DO YOU TEST FOR BOUND AND UNBOUND DRUGS? The 2 most common methods are: (A) Equilibrium Dialysis and (B) Ultrafiltration

EQUILIBRIUM DIALYSIS Two chambers are separated by a semipermeable membrane. Plasma is placed in one chamber, and a buffer in the other chamber. The buffer should be as similar as plasma water as possible and usually isotonic phosphate-buffered saline (PBS: pH7.4) is used. After dialysis for 4-24 hours, equilibrium will be reached and the drug concentration in the buffer will be the same as the unbound concentration in the plasma chamber

ULTRAFILTRATION The plasma sample is transferred to the upper part of a two piece container divided by a filter with a molecular weight cut off, and, after centrifugation, the unbound drug concentration is determined in the resulting protein free ultrafiltrate.

7/28/2021

THERAPEUTIC LEVELS OF DRUGS Often, when patients take a certain medication for an extended period of time, the dosage they started with is no longer sufficient to obtain the desired therapeutic effect. The dose has to be increased in order to achieve that. As time progresses, many patients require a periodical increase in dose in order to obtain the desired therapeutic effect.

WINEK’S CHART ● How was the data compiled? ● What literature was it gathered from? ● What personal experience?

WINEK’S CHART ● What were the age ranges of the subjects used to compile this data? ● What were their medical conditions? ● How long have they been taking this medication? ● What was their starting dosage? ● What was their current dosage? ● Were they fully functional while on their higher dosages? ● Were they able to be fully functional when not on medication?

7/28/2021

TENANT STUDY ● All patients were in chronic pain care administered by a physician ● Patients had taken opioids for 1 to 50 years, with ages between 25 and 87. ● Approximately 55% of patients were females and 45% we male. ● Patients’ functional status included the ability to drive and work.

TENANT STUDY ● Tenant found that many opioids blood concentrations in fully functional patients were above therapeutic levels ● Almost all patients demonstrated opioid tolerance they could fully function and most could drive

7/28/2021

DRUGS AND THEIR METABOLITES A.W. Jones - Concentrations of Scheduled Prescription Drugs in Blood of Impaired Drivers: Considerations for Interpreting Results ● Looked at how most common drugs found in DWI drug cases metabolize and what does that mean in interpreting lab testing results. ● Diazepam metabolites in Nordiazepam. ❖ Nordiazepam has a much longer half life than Diazepam, so after repeated use, Nordiazepam levels will accumulate and surpass the levels of Diazepam. ❖ Finding low levels of both Diazepam and Nordiazepam suggests fairly recent use. ❖ However, Nordiazepam without Diazepam suggests that a significant amount of time has passed since use of Diazepam.

DRUGS AND THEIR METABOLITES A.W. Jones - Concentrations of Scheduled Prescription Drugs in Blood of Impaired Drivers: Considerations for Interpreting Results

❖ Codeine and Heroin metabolize in Morphine. ❖ Morphine is by itself a prescription drug. ❖ Nonpharmaceutical heroin contains acetyl codeine as an impurity, and this compound undergoes deacetylation into codeine.

❖ The presence of codeine and morphine in blood could mean that a

person took a tablet of codeine or had snorted heroin, because both drugs metabolize in morphine.

DRUGS AND THEIR METABOLITES A.W. Jones - Concentrations of Scheduled Prescription Drugs in Blood of Impaired Drivers: Considerations for Interpreting Results

❖ Labs that use blood testing to monitor therapeutic levels of drugs use plasma or serum ❖ Forensic testing - uses whole blood ❖ DWI cases - vials contain sodium fluoride as a preservative ❖ works well for blood alcohol testing ❖ problematic for drug testing - sodium fluoride causes red cells to hemolysis which makes it impossible to obtain aliquots of cell free plasma to test for drugs

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Cross-Examination of the Arresting Officers Speaker:

Mimi Coffey 4700 Airport Fwy Ste B Fort Worth, TX 76117-6260 (817) 831-3100 Phone (817) 831-3340 Fax mimi@mimicoffey.com email www.mimicoffey.com website

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

Mimi Coffey TCDLA Top GUN DWI Seminar 2021

Included Papers: 1. Cross Examination of the Police Officer in a DWI 2. DWI-Modern Day Salem Witch Hunts 3. The Aging Process and Field Sobriety Tests

Cross Examination of the Police Officer in a DWI Mimi Coffey

Cross Examination of the Police Officer in a DWI By Mimi Coffey, Sr.

The Mindset Perry Mason makes great television, but this is not what wins cases. There is a huge difference between entertainment and justice. Cross examination from a juror’s perspective is a different beast than from a criminal defense lawyer’s. Step one is adopting the right mindset. A professional boxer’s mindset (not training) differs greatly depending on the size, experience and strength of one’s opponent. Not every police officer is a Muhammad Ali in the ring. Whereas strength, strategy and timing determine a boxing match, it is purely the whims and decision making of six to twelve people in a jury box who declare the winner in a trial. The police officer is viewed from the prosecutor’s perspective as the star witness in a DWI. The police officer is viewed from the jury as a respectable public servant who has traded personal gain for the protection of the many. The police officer is regarded as public enemy number one from the defendant’s view. The police officer is considered the most formidable threat (aside from a forensic result or bad video) from the defense lawyer’s perspective. One’s mental mindset of the police officer affects one’s approach to cross examination. It is critical to view the juror’s mindset of the police officer when questioning the officer. The only person in the courtroom who wants to see a bloodbath question and answer session with the cop is the defendant. Unless the jury is giving you an invitation to eviscerate the officer, don’t go there. Step one in a successful cross examination is realizing that you don’t have control over the questioning, the jury does. Lawyers are trained to think in a certain way. The hierarchy is: facts, law and emotions last. The facts combined with the law determine the legal argument. A judge is supposed to apply the facts and law without emotion to determine an outcome. This is the opposite of how jurors think. The key concept to winning a jury trial is to understand that while judges judge, jurors emote. Jurors are taught the law requires a judgment of facts applied to law; however, they cannot separate gut instinct, emotion and life perspective from their decision making. This

requires than any style of cross include the key element- addressing juror’s emotions and sense of equity in the question and answer format.

The Role Having the proper mindset to cross examine a police officer, leads naturally to the next step- role identification. A jury will reject, through their verdict, the defense lawyer who does not properly understand their role. An especially important concept in jury strategy is the drama triangle. A trial naturally lends itself to a protagonist, antagonist, and savior. The jury determines who the protagonist is. Once this is determined, the role of antagonist is naturally assigned. The jury sees their job as the rescuer. Depending on how the roles have been assigned, either the defendant or the State will become the victim they intend to rescue. The beauty of cross examination is that this is the lawyer’s pool cue. How the defense lawyer handles cross examination plays a large part in assigning the roles in a drama triangle. The first rule to remember in the drama triangle is that the bully loses. Cross examinations are fraught with the potential to browbeat and intimidate. The victim of this oppression, whether it is the police officer or the defense lawyer, scores points with the jury in the jurors’ effort to right the aggression. Jurors expect courtrooms to be a scene of respect. A cross examination that oppresses a perceived victim defuses the critical answers obtained on cross. The exception to this rule is when the jury gives the green light to the defense lawyer to go after a stubborn, deceitful or untrustworthy witness. The role of the defense lawyer is to shepherd. Shepherds lead sheep because they learn to think like sheep. This is critical in predicting sheep’s’ responses to various scenarios such as threat, need, and desire. The goal is to lead and herd the jury into a rescue of the defendant by exposing the inequities, injustices and problems that both right the situation according to them and expose the wrongdoings. The prosecutor will automatically assume the role of the protector shepherd protecting the public from the dangers of a wolf. Understanding and appreciating that the prosecutor is donned with such trust from the beginning assists the defense lawyer in knowing when and how to strike. The defense lawyer must know the role that the cross examination itself will take. The defense lawyer shepherd will always don several coats out of necessity: storyteller, anchor watch

on duty, and pathfinder. Upon occasion, the shepherd will have to fight but most of the time it is leading the flock. Jurors view the Judge much as devout Catholics revere the Pope. They will attach much significance to the players of the courtroom according to how they are treated by the Judge. In order for a shepherd to lead, the jurors must trust that the Judge is comfortable with the defense lawyer. Judges innately feel the pulse of the jury. They are much more inclined to react to the instinctive nature of the jurors. For example, where a witness appears to be unduly attacked, it is far likelier the Judge will sustain a prosecutor’s objection where the question offends the reasonableness of the jurors’ if the legality of the ruling is questionable. Leading requires recognition that the Judge plays a protective role to the jury. In those circumstances where the Judge is a Prosecutor with a robe on the bench, the defense lawyer will need to play the drama triangle carefully to appeal as the victim of an unfair system.

The Method The late great jury consultant Catherine Bennett once said, “In order for meaningful perception to occur in the context of a trial, the evidence or testimony must make a lasting impression. The more that you can make the juror feel what is being established, the more lasting the impression will be.” It is easy to internalize the issues in a trial and fail to communicate them effectively on cross. The points that must be made will resonate with the jury if they are told in a storybook format. This involves recreating the scenes that include sight, feel (heat, cold, and weather), smells, sounds and the narrative. Often times, the answers don’t matter as much as the question. For example, “She told you that night that she was cold……….” “She told you that night she wanted her coat…..”

Answer____ Answer____

“At a wind-chill of 3 degrees Fahrenheit, a breeze cut s through you like a knife…” Answer irrelevant When the cross is told in a storybook format, the Judge and Jury are actively placing themselves in the shoes of the defendant. This is the perspective necessary in acclimating them to the victim. Follow through with the wrongs or injustices inflicted on the defendant.

All lawyers dream of the moment that the adversarial witness throws up their hands and gives up. This is not reality. One very effective way in getting points across is to gently lead the police officer down a rosy path by asking simple, non controversial questions that command a “yes” response. Once a trust has been established, it is far easier for the witness to agree with a point that is within reason. The takeaway from the “yes” game is that the jurors are left with the favorable impression that the officer agreed with the defense lawyer most of the time. The ability to do this involves the skill to attack damaging points by agreement or through other means (planting the seeds in voir dire). There is power in a title. Our deference for titles goes back to the middle ages and beyond. We still revere it in the military, corporate structures and most notably the courtroom. The hierarchy is not lost on a jury. To call a police officer, “Officer ____” is to only play to the unspoken deference a jury is expected to give that witness. A police officer is no different than anyone else who takes the stand. It is up to the jury to determine how much weight their testimony is to be given. It is advisable to not use “Officer…..” (“Corporal ____”, Sergeant ____”, “Lieutenant _____” or any such appellation) when questioning the officer. To do so is to give them added credibility. The power of titles is not lost on prosecutors. It is not unusual for them to address defense expert witnesses as “Mr.” or “Ms.” Instead of “Dr.” when such in appropriate. Subtle cues of distinction due have an influence on jurors. It is a complete different story with a recalcitrant witness. The best approach to handle an obstinate witness is to repeat the question using their title and preferably their full name prefacing the exact same question the third time around. Here is an example: “You agree that the light was red?” Answer_____ “You agree that the light was red?” Answer_____ Pause. Take a deep breath. Ask the same question to the intransigent witness a third time but use their full name and make sure to look only at the jury while asking the question. At this point the jury has caught on to the fact that the witness has been caught and their answer is irrelevant. “Officer James Lawrence Cunningham, you agree that the light was red?” Answer irrelevant This method of addressing a deceptive witness conjures up memories of being disciplined as a child. It also provides entertainment, a ray of interest for the jury

amidst a sea of legalities. What is true for Hollywood is very much true in the courtroom. The successful defense lawyer knows and caters their cross examination to a tried truth uttered by Howard Dietz, “The world is a stage; the stage is a world of entertainment.” The points that need to be made on a cross examination cannot be ignored. Cross examination is never an ad hoc exercise. To be effective, every question needs to be placed and delivered with surgical precision. As long as the points are made, the answers are not as critical. High priority is that the defense lawyer keeps an open dialogue with the jury during the question and answer process. This requires moving one’s chair forty-five degrees towards the jury so that there is a forced, yet natural dialogue both spoken and unspoken. With this open dialogue, they will give you permission when there is a rare opportunity to go after a deceptive witness, no holds barred. Last but not least is the length or duration of the cross examination. It is not a one size fits all. As long as all the critical points have been addressed, the rest must comply with the trial’s overall game plan. Often times, less is more. Jurors appreciate a short cross examination opposed to a long, boring, repetitive one where the defense lawyer is caught unawares or unprepared. Where there are no points to be made, skipping cross examination altogether with minor witnesses also comes across as well prepared. Condoleezza Rice said, “Diplomacy, if properly practiced, is not just talking for the sake of talking.” The same can be said of cross examination. It is truly a skill that combines the best of psychology with preparation and strategic entertainment.

DWI – Modern Day Salem Witch Hunts Mimi Coffey

DWI-Modern Day Salem Witch Hunts By Mimi Coffey, Sr.

DWI-Modern Day Salem Witch Hunts Judge Daryl Coffey of County Criminal Court number 8, in Tarrant County, Texas once remarked to me that all a prosecutor has to do to win a DWI case is just make sure that the three letters “DWI” are mentioned at least 15 times in a trial.1 It is this type of environment that has allowed history to repeat itself. All we have to do is look back to the Salem Witch Hunt trials of 1692 where 19 convicted “witches” lost their lives on “specter” evidence.2 Evidence in DWI trials has not come a long way from 1692 where claims of apparitions only visible to their victims were enough to get one hung. The greatest challenge to DWI practitioners these days and to those accused of DWI/DUI related crimes is that courtrooms have not kept pace with the science. Bad science is rubberstamped with approval by the majority of the judiciary as long as the government sponsors it.

Horizontal Gaze Nystagmus The horizontal gaze nystagmus test, or HGN, is alleged to be 77% accurate in determining if a person is .10 BAC3 or more.4 The first problem with this test is the particularity. Police officers are not ophthalmologists trained in the detection of eye movements and or eye pathologies. There are forty-seven types of nystagmus in individuals, separate from Horizontal Nystagmus: (1) Acquired; (2) Anticipatory (induced); (3) Arthrokinetic (induced, somatosensory); (4) Associated (induced, Stransky’s); (5) Audio kinetic (induced); (6) Bartel’s (induced); (7) Brun’s; (8) Centripetal; (9) Cervical (neck torsion, vestibular-basilar artery insufficiency); (10) Circular/Elliptic/Oblique (alternating windmill, circumduction, diagonal, elliptic, gyratory, oblique, radiary); (11) Congenital (fixation, hereditary); (12) Convergence; (13) Convergence-evoked; (14) Dissociated (disjunctive); (15) Downbeat; (16) Drug-induced (barbituate, bow tie, induced); (17) Epileptic (ictal); (18) Flash induced; (19) Gazeevoked (deviational, gaze-paretic, neurasthenic, seducible, setting-in); (20) Horizontal; (21) Induced

(provoked); (22) Intermittent Vertical; (23) Jerk; (24) Latent/Manifest Latent (monocular fixation, unimacular); (25) Lateral Medullary; (26) Lid; (27) Miner’s

(occupational); (28) Muscle-Paretic (myasthenic); (29) Optokinetic (induced, optomotor, panoramic, railway, sigma); (30) Optokinetic After-Induced (postoptokinetic, reverse post-optokinetic); (31) Pendular (talantropia); (32) Periodic/Aperiodic Alternating; (33) Physiologic (end-point, fatigue); (34) Pursuit After-induced; (35) Pursuit Defect; (36) Pseudo spontaneous; (37) Rebound; (38) Reflex (Baer’s); (39) See-Saw; (40) Somatosensory; (41) Spontaneous; (42) Stepping Around; (43) Torsional; (44) Uniocular; (45) Upbeat; (46) Vertical; (47) Vestibular (ageotropic, geotropic, Bechterew’s, caloric, compensatory, electrical/faradic/galvanic, labyrinthine, pneumatic/compression, positional/alcohol, pseudo caloric.5 It is unrealistic given this extensive laundry list -which includes medical conditions- that a police officer can make the important distinction that he is indeed observing horizontal gaze nystagmus. Even if he could, the next issue is causation. Officers jump to an incorrect premise that if they do isolate horizontal gaze nystagmus this must be indicative of ethanol intoxication. There are actually 38 different causes of horizontal gaze nystagmus unrelated to alcohol as judicially recognized in Schultz v. State: (1) problems with the inner ear labyrinth; (2) irrigating the ears with warm or cold water under peculiar weather conditions; (3) influenza; (4) streptococcus infection; (5) vertigo; (6) measles; (7) syphilis; (8) arteriosclerosis; (9) muscular dystrophy; (10) multiple sclerosis; (11) Korchaff’s syndrome; (12) brain hemorrhage; (13) epilepsy; (14) hypertension; (15) motion sickness; (16) sunstroke; (17) eyestrain; (18) eye muscle fatigue; (19) glaucoma; (20) changes in atmospheric pressure; (21) consumption of excessive amounts of caffeine; (22) excessive exposure to nicotine; (23) aspirin; (24) circadian rhythms; (25) acute trauma to the head; (26) chronic trauma to the head; (27) some prescription drugs, tranquilizers, pain medications, anti-convulsants; (28) barbiturates; (29) disorders of the vestibular apparatus and brain stem; (30) cerebellum dysfunction; (31) heredity; (32) diet; (33) toxins; (34) exposure to solvents, PCBs, drycleaning fumes, carbon monoxide; (35) extreme chilling; (36) lesions; (37) continuous movement of the visual field past the eyes; and, (38) antihistamine use.6 Another real problem with the horizontal gaze nystagmus test is the timing of its presence and an actual alcohol concentration. The HGN, as administered by the National Highway Transportation Safety Administration’s (NHTSA) protocol for the Standarized Field Sobriety Tests (SFST) has been cited as the only reliable index of blood alcohol when examined for its ability to distinguish BACs under and over .04% within the .00-.08% range.7 So it is a fallacy to use this test to

determine that someone may be over .08 BAC. What is also alarming is the fact that nystagmus can remain for some time once the BAC has reached .000. In a dose/response study of 89 subjects,8 62% of the dosed subjects exhibited nystagmus in one or both eyes at BAC levels of .00% when tested immediately after all alcohol was cleared from their blood and 56% of those subjects still exhibited nystagmus one hour later.9 In the same study, it was determined from 66 healthy, well-rested subjects10 who did not consume any alcohol and completed 5.5 to 8.0 hours of sleep after being awake for 9 to 14.5 hours (average 11.2) that they had distinct nystagmus in one or both eyes.11 Afterwards these same subjects were re-examined with an average awake time of 24.5 hours and distinct end position nystagmus was observed in one or both eyes in 55% of the group.12 What is particularly troublesome is the stamp of imprimatur by the American Optometrist Association13 touted by prosecutors in laying the foundation for the test=s admissibility.14 It is important to distinguish that no such resolution of acceptance for the HGN exists by the American Academy of Ophthalmology. It is unsettling how eager the American Optometrist Association has been to embrace the possibility of providing expert testimony as a puppet of the government without any legitimate scientific inquiry of their own. The seminal scientific research article on HGN states it best: In an article designed to inform optometrists how to provide expert testimony on the HGNT (HGN), the only evidence of a correlation between BAC and nystagmus given is a reference to the NHTSA’s work. Specifically the article stated “through a series of studies, the National Highway Traffic and Safety Administration (NHTSA) has been able to establish a high correlation between alcohol concentrations in the body and performance on a series of field sobriety tests.” It is interesting, and perhaps revealing, that no other evidence is referenced to support this correlation.15 One only needs to look at the criticism of NHTSA=s foundational research16 -which led to the development of the HGN test- to understand that this is yet another example of agenda government science which misses the mark. It is interesting to note that researchers have determined that percentages generally cited by the courts in support of HGN exist only in NHTSA publications.17 Jurists and prosecutors in the United States have been quick to embrace the HGN test as hardcore science but this component has not been adopted by Great Britain.

Standardized Field Sobriety Tests Outside of the HGN, DWI cases concentrate on psychomotor skills known as standardized field sobriety tests; but just how good are these tests? This requires some basic understanding of testing fundamentals. The first incorrect presumption with this framework is that these tests measure impairment related to driving. They do not.18 The walk and turn and one leg stand are purported to have “face validity,”19 that is the tests relate to actual driving tasks. Face validity is the lowest form of validity a researcher can achieve and is generally not accepted by academia because “face validity rests on the investigator’s subjective evaluation of the appropriateness of the instrument for measuring the concept rather than whether the instrument measures what the researcher wishes to measure.”20 For a test to be valid, there must be high reliability and validity both measured by a correlation coefficient ranging from 0 to 1.0 (highest end of the scale).21 Reliability relates to the consistency of scores based on re-testing. Validity relates to the ability of a test to predict particular benchmarks. Intelligence tests such as the Wechsler Intelligence Test have a reliability of .90. According to the 1977 SCRI study which developed the 3 part standardized field sobriety tests the validity correlation coefficient22 was .48, the walk and turn was .55.23 In layman=s terms what this means is that using a one leg stand to predict a .10 BAC is only 25% better than chance.24 The HGN interestingly enough had only a correlation coefficient of .67 equating to an approximate 33% better prediction than chance.25 Use of the walk and turn is only 27-28% better than chance.26 The overall error rate (wrong percentage of decisions to arrest) was 47%.27 In 1981, laboratory field sobriety tests (this time just the HGN, walk and turn, and one leg stand) were researched again and the error rate was found to be 32%.28 Validity correlation coefficients were not mentioned in this study. Reliability correlation coefficients were given for this study: HGN .66, walk and turn .72.29 For a test to be reliable the coefficient must be .85 or higher.30 When different officers performed the test on the same subject at the same BAC the coefficients dropped down to .59 for the HGN and .34 for the walk and turn, to whit a 66% error rate was indicated for the walk and turn and the one leg stand error rate equated to a

40%.31 Dr. Burns herself indicated that the >77 and >81 error rates were unacceptable.32 In response to a cross-examination question as to whether 32% was acceptable, she replied, “It is getting there.”33 This is the meat and potatoes of what still exists today. Once one gets over the initial shock of how unacceptable these tests are according to government research the next logical step is to look at the relevant scientific peer review community. Dr. Spurgeon Cole and Ronald Nowaczyk did just that in 1994 in a field sobriety study sponsored by Clemson University. According to this study, field sobriety tests which included the walk and turn and one leg stand test were compared to normal tasks such as reciting basic information and walking in normal manner for 21 sober individuals all with a BAC of .000. Forty-six percent of the officers determined the subjects intoxicated by SFST(s) with only fifteen percent of said subjects determined to be intoxicated by normal tests.34 The promulgation of these tests, the HGN, walk and turn and one leg stand may be good enough for government work but are a far cry from reliable, scientific standards. Because of this, innocent people are being convicted every day on these premises, which are taken at face value and not questioned despite their invalidity. When most states lowered legal limits to .08, the government found itself in a quandary of which they still have not been able to solve; hence, the continuation of the misleading 1981 percentages of accuracy: HGN 77%, walk and turn 68%, one leg stand 65%.35 The Colorado,36 Florida37 and San Diego38 studies attempted to quantify accuracy at .08 but none proved worthy of the mission. Such roadblocks as documented by Steve Rubenzer, Ph.D, included but were not limited to the following critiques:

1. The field studies validated the arrest decisions of the officers in the studies, not the SFSTs. 2. The police officers and the degree of supervision in the field studies were not typical of typical DWI stops.

3. The studies were insufficiently documented for scientific papers as cited in U.S. v. Horn, 185 F. Supp.2d 530, 558 (D. Md. 2002).

4. The authors did not report the accuracy of arrest decisions for stops that were observed vs. those that were not, or for SFSTs performed under adverse climate conditions versus those that were not.39

The new purported levels of accuracy in the recent validation studies regarding the same field tests at lower limits are proof of the tests= inherent low reliability correlation coefficient. How these statistically unreliable and invalid tests are somehow more purportedly valid at lower limits is yet proof positive how radical the DWI religion has become to lawmakers and jurists alike in blind disregard of the science.

Leading Jurisdictions Despite ignorant, widespread acceptance of the validity of the HGN, walk and turn and one-leg stand tests, there are some jurisdictions which have started down a very unpopular but judiciously righteous path in respect of scientific principles and constitutional liberty. In Homan v. State, the court determined that in order for the results of a field sobriety test to serve as evidence of probable cause to arrest, the police must have administered the test in strict compliance with standardized testing procedures.40 The court at least recognized that “testing” requires standardization and not haphazard administration if scoring criteria is to be used. What is key in this case is the court=s threshold requirements merely address admissibility at the probable cause level. The mistake in Homan is to give the standardized tests any scientific evidentiary value at all. It however at least recognizes that adherence to protocol is necessary to admissibility as opposed to weight. In U.S. v. Horn, Judge Grimm wrote: There is no factual basis before me to support the NHTSA claims of accuracy for the WAT and OLS tests or to support the conclusions about the total number of standardized clues that should be looked for or that are missing a stated number means the subject failed the test. There is very little before me that suggests that the WAT and OLS tests are anything more than standardized procedures police officers use to enable them to observe a suspect=s coordination, balance, concentration, speech, ability to follow instructions, mood and general physical condition--all of which are visual cues that laypersons, using ordinary experience, associate with reaching opinions about whether someone has been drinking.41 Some of the more notable premises the Horn case stands for are that 1) The results of properly conducted tests may be considered for probable cause.42 2) The SFST(s) cannot be correlated with a specific BAC43 3) The court where requested by counsel should take judicial notice of the fact that there

are many causes of HGN outside of alcohol.44 4) Value added descriptive language regarding the SFST(s) such as “failed the test,” “exhibited” a certain number of “standardized clues” or any other bolstering attempts by the officer is not allowed.45 SFST(s) or any specialized information learned from law enforcement or traffic safety instruction should not be referred to as scientific, technical or specialized.46 Judge Paul Grimm, much like Governor William Phipps of Salem Massachusetts who suspended the special court of Oyer and Terminer,47 which based convictions on specious “specter” evidence, has through his opinion echoed some reason and common sense that is necessary in a court of law in the wake of mass hysteria over DWI prosecutions. Special recognition goes to courts responsible for cases like State v. Doriguzzi,48 where HGN was ruled not admissible because the State had failed to show Frye acceptance and reliability and Young v. City of Brookhaven,49 where the HGN test was ruled as a scientific test but not one generally accepted by the scientific community. These courts provide hope in proving that science is the voice of reason and we have a long way to go in spreading such reason to all parts of the country because science has no jurisdictional bounds.

Special thanks to: Dr. Ron Henson of Beron Consulting and Lab Works, Peoria, Il. Richard Essen of Essen, Essen, Susaneck, Canet, & Goodis P.A., Aventura FL 33180 (and paralegal Jason Hedges), Dr. Joe Citron, Atlanta, Ga. Jason Stinnett, paralegal of the Coffey Firm

Notes 1

Unlike most jurists, Judge Coffey has a scientific background- a Bachelor of Science from Western Kentucky University. 2 See

Rosemary Ellen Guiley, The Encyclopedia of Witches and Witchcraft, 234-299 (1989).

Indicating the chemical concentration of alcohol in the blood as being greater than .10%.

5 6 7 8

9 10

See V. Tharp, M. Burns, and H. Moskowitz, Development and Field Test of Psychophysical Tests for DWI Arrest, DOT-HS-805-864, U.S. Department of Transportation, NHTSA, Washington (1981). Dr. L. F. Dell=Osso, Nystagmus, Saccadic Intrusions/Oscillations and Oscillopsia, 3 Current Neuro-Ophthalmology 147 (1989). Schultz v. State, 664 A.2d 60, 77 (Md. App. 1995). See A.J. McKnight, ET AL., Sobriety Tests for Low Blood Alcohol Concentrations, Accid. Anal. Prev. 2002 May; 34(3): 305-11. See J.L. Booker, End-position nystagmus as an indicator of ethanol intoxication, 41 Science and Justice 113, 115 (2001). (79 men and 10 women between the ages of 22 and 67 who were well rested and in good health, alcohol levels determined by blood and urine assays conducted by gas chromatography and breath concentrations determined by CMI Intoxilyzer 5000 instruments with wet-bath reference units operated at 34 C). See Id. at 115. See Id. at 114-15. (The study consisted of 44 men and 22 women between the ages of 20 and 57 who denied use of alcohol or drugs within the preceding 24 hours).

11 12 13

See Id. at 115. See Id. at 115. See Karl Citek, HGN and the role of the Optometrist, in Admissibility of Horizontal Gaze Nystagmus Evidence: Targeting Hardcore Impaired Drivers, 15 (Am. Prosecutors Research Inst. 2003). (The following resolution was adopted by the American Optometric Association House of Delegates, on June 1993: Whereas drivers under the influence of alcohol pose a significant threat to the public health, safety, and welfare; and

Whereas

optometric scientists and the National Highway and Traffic Safety Administration have shown the Horizontal Gaze Nystagmus (HGN) test to be a scientifically valid and reliable tool for trained police officers to use in field sobriety testing; now therefore be it

Resolved

that the American Optometric Association acknowledges the scientific validity and reliability of the HGN test as a field sobriety test when administered by properly trained and certified police officers; and be it further

Resolved

that the American Optometric Association urges doctors of optometry to become involved as professional consultants in the use of HGN field sobriety testing.)

See Predicate Questions: Optometrist....Appendix K (visited June 18, 2004) <http://nhtsa.com/people/injury/enforce/nystagmus/app_k.html>. (Direct Examination questions for the state’s expert optometrist end with: 88. Are you familiar with the 1993 resolution "Horizontal Gaze Nystagmus as a Field Sobriety Test" passed by the House of Delegates of the American Optometric Association? 89. Is this a copy of the resolution? 90. Please read it to the court).

16 17 18

19 20 21 22 23 24 25 26

Charles R. Honts, Susan L. Amato-Henderson, Horizontal Gaze Nystagmus Test: The State of the Science in 1995, 71 N.D. L.Rev. 671 at 6 (1995). (citing David V. Tiffany, Optometric Expert Testimony: Foundation for the Horizontal Gaze Nystagmus Test, 57 J. of Amer. Optometric Ass=n 705 (1986)). See Id. at 15. See Joseph R. Meaney, Horizontal Gaze Nystagmus: A Closer Look, 36 Jurimetrics J. 383, 385 (1996). Jack Stuster and Marcelline Burns, Validation of the Standardized Field Sobriety Test Battery at BACs Below 0.10 Percent, DOT-HS-808839 6, (1998). See Id. at 27-28. Chava Frankfort-Nachmias & David Nachmias, Research Methods in the Social Sciences, 150 (6th ed. Worth Pub. 2000). See Trial Transcript at 14-16, later reported as State v. Meador, 674 So.2d 826 (Fla. Dist. Ct. App. 1996). See Id. at 21, (The formula is actually the square root of 1.48.). See Id. at 20. See Id. at 21. See Id. at 20, 22. See Id. at 22.

27 28 29 30 31 32 33 34

35 36

38 39 40 41 42 43 44 45 46 47 48 49

See Id. at 29. See Id. at 37. See Id. at 42. See R. Rosenthal & R.L. Rosnow, Essentials of behavioral research: methods and data analysis (2nd ed. McGraw-Hill 1991). See Meador, supra note 21, at 31. See Id. at 141. Id. at 141. See Spurgeon C. Cole & Ronald H. Nowaczyk, Field Sobriety Tests: Are They Designed for Failure?, Perceptual and Motor Skills, 79, 99104, (1994). See Tharp, supra note 4. See Anderson, Ellen and Marcelline Burns, PH.D., A Colorado Validation Study of the Standardized Field Sobriety Test (SFST) Battery, November 1995. See Dioquino, Sgt. Teresa, ET AL., A Florida Validation Study of the Standardized Field Sobriety (SFST) Battery, (date of publication is unknown). See Burns, supra note 18. See Steven Rubenzer, DWI- Part 1 The Psychometrics and Science of Standardized Field Sobriety Tests, The Champion, May 2003, at 24-34. See Homan v. State, 89 Ohio St.3d 421 (2000). U.S. v. Horn, 185 F. Supp. 2d 530, 557 (D. Md. 2002). See Id. at 532-33. See Id. at 533. See Id. at 533. See Id. at 533. See Id. at 533-34. See Guiley, supra note 2 at 299. 334 N.J. Super. 530 (App. Div. 2000) 693 So.2d 1355 (Miss. 1997).

The Aging Process and Field Sobriety Tests Mimi Coffey

The Aging Process and Field Sobriety Tests By Mimi Coffey, Sr.

The Aging Process and Field Sobriety Tests It is not surprising that every year 1.4 million Americans are diagnosed with cancer1, the second leading cause of death next to heart disease. It should be shocking that there are also approximately 1.4 million DWI/DUI arrests (1 of every 139 license drivers) in the country a year with 16,685 alcohol related fatalities in 2005.2 “Alcohol related” fatalities defined as at least one driver or nonoccupant involved in the crash having a blood alcohol concentration of .01 grams per deciliter or higher. These figures include fatalities that were NOT caused by the presence of alcohol.3 Boiled down, NHTSA has led a colossal campaign against DWI/DUI, arresting a disproportionate amount of people compared to the real threat of fatalities on the road (alcohol related fatalities representing 1% of the drivers being arrested). One does not need to be a mathematical genius to understand that this country has a problem, and it’s not what MADD is concerned about. The field sobriety tests are a mechanism to convict people not test whether or not they are sober. The standardized field sobriety tests are a witch-hunt cancer being perpetuated by law enforcement on our own people. Even a recent 2006 NHTSA publication admits, “Road tests have long been considered the gold standard for measuring driving ability. They have widely-recognized limitations.” 4 One would not know this visiting the courtrooms across America. This paper addresses one of the most common sense problems contributing to false convictions, the condition and age of the subject. Dr. Marcelline Burns, developer of the standardized field sobriety tests (sfsts) has conceded that the tests were not designed to determine impairment of driving5. So what relevance do the sfst(s) have in determining whether or not a person is driving while intoxicated or driving while under the influence? Not much, particularly when you factor in their condition and age. It is well documented that the normal aging process is accompanied by deterioration in sensory functions and motor performance.6 Sensory functions necessary in communication also show increased impairment with age 7. Age related slowing in cognitive and motor processes include longer reaction time and movement execution time. This is due to increased neural noise, which results in signals being less well detected in the central nervous system 8. Before the sfsts were developed, in the early decades of experimental psychology, it could already be shown that skill learning ability and motor performance accuracy deteriorate with increasing age9. The original SFST data seemed to take this in to account by setting 65 as the upper limit to sfst usefulness.

Categorizing the effects of age chronologically as the sfst(s) do by stating a 65 year old age limit is both arbitrary and false. Aging actually results in increasing biologic diversity so that we become less alike as we age10. Biologic and chronologic ages are not the same, and body systems do not age at the same rate within an individual11. The biopsychological state of a person is important, including most notably fitness and nutrition. It is empirically well supported that these factors improve attention and psychomotor performance across all age groups12. The National Highway Traffic and Safety Administration (NHTSA), much akin to their arbitrary cutoff, 65 years of age13, also references that an individual 50 lbs or more overweight may have difficulty with the one leg stand14 test. Of relevance is the fact that 64.5% of Americans are overweight and 30.5% are obese15. Regarding physical fitness, the annual number of lives lost through physical inactivity is estimated at more than 250,000 per year16. With respect to the aging process there is a gradual decline in performance. As apposed to an abrupt drop off of cognitive and motor skills, as seen in the case of an acute stroke17. In short, a gradual decline in cognitive and motor processes results from chronological age, fitness, and nutrition in given individual. Changes within the brain are primarily responsible for a loss of motor skills. Poor performance on executive function tasks is associated with a smaller volume of prefrontal cortex mass and increased white matter hyperintensity burden18. Postmortem studies of individuals reveal age related differences in brain structure including reduced brain weight and volume19. Sensory motor integration can be specifically linked to prefrontal activation of the brain. Proving that the prefrontal cortex serves an executive function for motor skills. Age-related deterioration of the prefrontal cortex contributes to cognitive declines, which has significant consequences for motor behavior20. Simply put, the frontal lobes are more sensitive to the effects of and are directly related to motor functions21. Specifically, dopamine receptors within the brain are linked to locomotor functions and learning22. Dopamine neurons account for less than 1% of the total neuronal population of the brain but have a profound effect on motor function23. They act as chemical messengers similar to adrenaline connecting the brain processes that control movement24. Dopamine receptors are reduced up to 50% in the brains of aged humans25. Dopamine neurons in basal ganglia decline 5-10% per decade26. Parkinson’s disease sufferers are a prime example of loss of control of motor activity in regards to dopamine neuron loss27. Early postmortem brain studies in the 1960s revealed significant loss of dopamine in Parkinson patients28. Treatments were developed with the aim of treating Parkinson’s by addressing the prevention of dopamine29 loss, or by stimulating the growth of dopamine receptors not natural in the human aging process30. Aging slows sensory processing, with 95% of the change attributable to aging of the central nervous system and only 5% attributable to slowing outside the brain31.

Declining hormone levels that occur naturally compound the affect of dopamine neuron loss. Several studies have shown that testosterone positively affects performance in certain cognitive domains such as memory and spatial ability32. In an academic study of men aged 48-80 it was shown that older men with less testosterone had lower levels of function in working memory, speed, and attention, as well as spatial relations. For men the use of synthetic hormones did not mediate the performance problem 33. The same proving true for aged women in the administration of synthetic estrogen34. The average rate of decline of testosterone is about 3.2 ng/dL per year for men age 23-9135 36, and 11 ng/dL per year for men aged 61-87. Memory of course becomes relevant under many scenarios of the DWI/DUI investigative process from short-term capacity that includes remembering instructions, to longer-term memory in cooperating with interrogations. The phenomenon of memory aging begins in the 20s among aging adults who report themselves in good health37. Aging memory affects us all, not just those with significant memory disorders such as Alzheimers. In the periods of early and middle adulthood, the memory-aging phenomenon is associated with a shift of the entire distribution of memory. It is not simply attributable to a small percentage of individuals experiencing large memory loss due to pathology, with the remaining individuals maintaining the same level of performance38. With aging, there is a loss of neurons in the gray matter in the cerebellum and hippocampus, which seems to be involved in some aspects of memory function39, with less dramatic changes occurring in the deeper brain structures. In a study using a dualtask combination of walking and memorization it was revealed that older adults prioritized the sensorimotor brain function over the memory task to avoid a loss of balance, resulting in a performance decrease of the memory task40. This explains how the counting may suffer on various field sobriety tasks as the subject focuses more on the physical tasks of balance, regarding the walk and turn and one leg stand tests. There is a distinction in the memory regarding automated and effortful processing where the effects of aging increase the amount of effort required in the performance of new, unlearned or unnatural coordination patterns41. This explains why so many people perform a pivot on the walk and turn exercise versus taking a small series of steps. First, they do not comprehend the turn instructions well because of undue focus on the sensorimotor skills needed to maintain an unnatural and difficult positional stance. The turn itself is a new instruction on an unnatural turn pattern normally encountered in everyday settings. Older adults have much more difficulty with the performance of new tasks, albeit slight, due to the additional cognitive load that must be engaged for learning to occur42. Sensory memory lasts much less than a second and because of sensory changes that occur with aging this puts the aged at a disadvantage43. That explains why older people have much more difficulty in adjusting to the positional stance of the walk and turn, which requires a high level of sensorimotor control. Normally, this level of control is not required unless one is engaged in tightrope walking or gymnastics on the balance beam. Clearly the

sfst(s) are divided attention tests. It’s known that the rate of shifting attention between different sources shows a clear-cut reduction with age44. A research project supported by a seed grant from the Center on Aging and Cognition demonstrated on a simple gripping test combined with recitation, that even after intense practice older adults needed more attentional resources than younger adults to perform a dualtask45. This proves that cognitive performance and force control are interconnected in older adults. In a dual-task bicycling and counting test where the subject had to bicycle in a certain direction and count the number of times an image appeared on a computer screen, it was found that performing the coordination patterns together with the attention task caused a decrease in phasing accuracy and stability in older versus younger people46. Driving is a divided attention task also but does not require the gravitational force control necessary in the one leg stand or memory number recitations to the degree called for in the walk and turn, one leg stand, or manual dexterity tests such as the finger count down. Older adults may experience temporary lapses of attention or executive control, which contributes to greater inconsistency of performance47, as seen in variations of the same field tests both at the roadside and in the station. Higher anxiety has also been associated with poorer divided attention performance in older but not younger adults48. Of course, basic psychomotor functions are required for a divided attention test, but basic too, is the premise that agerelated changes in psychomotor functions will affect the performance scores49.

In a study involving 99 young people from ages 17 to 36, and 763 older people from ages

54-94 on a reaction time test, it was determined that variability between persons (diversity), variability within persons across tasks (dispersion) and variability within persons across time (inconsistency), were greater in older compared to younger adults even when group differences in speed were statistically controlled 50. Studies contrasting younger and older adults have all found increased inconsistency in response time distributions with increasing age51. It has been suggested that more studies need to be conducted in the field of experimental aging research to understand the effects of aging, anxiety and motor control52. An environmental stress study was conducted examining the performance of younger and older skilled miniature golf players during training and competition. Both younger and older adults showed a similar increase in heart rate and self reported anxiety, but whereas younger adults improved their performance during competitive play the older adults’ deteriorated, demonstrating diminished capacity to cope with high arousal conditions due to age-related deficits in cognitive abilities53. This may be explained by the fact that aging is normally associated with neural degeneration in the hippocampus of the brain, which is critical for some forms of memory, and recent research suggests that anxiety and stress may have further detrimental effects on the hippocampus54.

Most DWIs/DUIs occur at night also putting older people at a disadvantage. Across the adult lifespan there is a shift in the self-reported time of peak arousal or attention awareness. This shift reflects a tendency for the optimal time of day (TOD) to become earlier with advancing age55. Since the earliest days of experimental psychology it has been known that TOD can dramatically influence the efficiency of cognitive processing including short-term memory, sustained attention, inhibitory processing and semantic activation56. Age related deficits of working memory are magnified at nonoptimal times of day57. It is undoubtedly obvious, that older subjects who have not been drinking at all will be disadvantaged compared to their younger counterparts. In an experiment regarding reaction time to a stop signal paradigm, there was a 20% difference in stopping efficiency between younger and older folks at nonoptimal times (11% difference at optimal times)58.

Dizziness has been associated with stress. It is

one of the most prominent symptoms of both panic attacks and hyperventilation59. As one grows older; however, the disturbances with balance are greater compared to younger people60. Of more notable concern is the fact that older people are less likely to view their dizzy condition as a self perceived handicap61. People tend not to seek medical treatment for conditions associated with normal aging or ailments of which there are no known treatments. This is particularly true for dizziness. In a study of 100 consecutive outpatients in the United States with dizziness less than one third received a diagnosis for which a treatment plan exists62. The symptomatic prevalence in the community for dizziness has been estimated at more than 20%, yet recorded annual consultation rates of less than 2% indicate this is a significant, silent, untreated problem63. The lifetime prevalence rate of dizziness of Americans resulting from outpatient self reports has been estimated at 25%64. What is alarming is the duration of dizzied impairment. In a London study of citizens aged 18 to 64, it was found that women were more likely to report dizziness than men; people under 36 were more likely to report nonhandicapping dizziness; and handicapping dizziness was significantly more common in individuals aged 36 to 6465. Of more concern is the duration of symptoms: 26% reported less than 6 months, 44% between 6 months and five years, and 30% more than five years66. More than half reported basic postural unsteadiness67. Dizziness is caused by both physical and psychological factors ranging from cardiovascular problems to anxiety68. Vertigo is episodic dizziness considered as an imbalance originating within the vestibular system69. It is interesting to note that several lines of research have suggested that dopamine has a protective role on cochlear70 and vestibular function71, once again spotlighting dopamine’s dramatic role of loss of executive motor control in the natural aging process. Just to maintain a stance requires a greater portion of attentional resources in older compared to younger adults72. Postural stabilization has to do with the role of afferent/efferent signals related to eye movements73. Recent studies74 have shown that postural sway during pursuit of a moving target or when looking straight ahead in the darkness is higher than when fixating on a stationary target or nystagmus is

suppressed. In the latter two, extra-ocular signals are reduced75, resulting in less postural sway. Neck muscles are also involved in stabilizing the head during HGN; yet one’s inability to keep one’s head still is frequently used as a sign of intoxication or inability to follow directions. Horizontal gaze position is associated with head neck muscle activity. It is difficult to not move the head when focusing. In fixed head subjects there is a dynamic coupling of the neck splenius muscle, and horizontal eye position with the oculomotor brain command being distributed to both eye and neck muscles76. In a moving platform experiment comparing: healthy young adults; older adults and older adults with a mild increase in fall risk. Participants were placed on a stationary platform under various conditions, and it was found that healthy older adults had considerable more difficulty maintaining balance both with and without the cognitive task of counting backwards77. Platform conditions varied with side-to-side and front to back movements simulating real world conditions where one might be asked to perform the sfst(s) on inclined, or unleveled surfaces. It is preposterous that in the quest for more convictions, the recent NHTSA sfst manuals goes so far as to say, “Recent field validation studies have indicated that varying environmental conditions have not affected a suspect’s ability to perform this test78.” Motor control and postural control are inextricably linked79. If the surface area or testing conditions do not support basic postural control, performing a walk and turn or one leg stand test is inherently flawed. All motor tasks, unless performed while a subject is fully supported, require complex interactions of postural adjustments to maintain intersegmental coordination and equilibrium during the task80. Although not a standardized test for DWI/DUI, in some jurisdictions the Rhomberg test is still administered. This is a medical test used to detect the presence of brain lesions, and is clearly inappropriate for forensic purposes. Police routinely use the test for sobriety testing purposes. The subject is asked to hold their head back, close their eyes and estimate the passage of 30 seconds. This test is skewed with or without alcohol or drug because one’s natural vestibular system sways to adjust for postural balance, becoming more pronounced with age. Head flexion or extension deteriorates postural stability as a result of vestibular input even where visual information is kept the same81. The peripheral sensory functions of hearing and vision tend to show increased impairment with age, suffering remarkably after age 5082. Many visual changes accompany the aging process even in the absence of known visual pathology83. Among these changes that normal adults exhibit is a loss of contrast sensitivity84, shrinkage of the “useful field of view” (UFOV)85, a decrease in central and peripheral acuity86, spatial vision87, and a weakening of the cognitive control of eye movements88. Translated to the real world practicality of HGN, older adults have difficulty converging their eyes to focus on a target at a close distance89. As far as lack of smooth pursuit, older adults are less able to smoothly pursue a moving stimulus90. Tracking an object shows clear-cut age deficits91. Following the stimulus in general is more difficult because reaction time in dealing with visuo-spatial tasks have been proven to slow for older

adults92. Age differences in oculomotor control translate to saccadic movements (lack of smooth pursuit), which have greater latency and slower peak velocity93. One might argue that the ultimate test in a DWI/DUI investigation is the actual operation of a motor vehicle with vehicle accidents reflecting intoxication. As there are obvious reasons for accidents outside of intoxication, it is important to note age related concerns in automobile accidents. One age related analysis of traffic accidents in Finland showed that attention fatigue is a drastic factor in traffic accidents94. Most DWI/DUIs are not occurring at optimal TOD for older people. One’s useful field of view (UFOV), which diminishes with age, also turns out to be a good predictor of increased driving accidents95. Age related hearing loss (AHL) is the most common type of hearing impairment in humans96. 60 % of people older than 70 years of age have hearing loss of at least 25 decibels97 the prevalence of hearing loss among middle-aged people are not well known. In a comprehensive study of hearing loss in Beaver Dam, Wisconsin of people aged 48-92, 46 % had some form of hearing loss98. It was found that for every 5 years of age the risk of hearing loss increased by almost 90% with men being 4 times more likely to have hearing loss than women99. Education and income level were inversely associated; with people who had not completed high school being 2.42 times more likely to suffer hearing loss compared to those with a college education100. Those earning less than $30k a year were approximately twice as likely as those earning $60k a year to suffer hearing loss largely due to occupational exposure101. Hearing impairment increases with age. The most common hearing loss occurs at higher frequencies making speech especially difficult to understand against background noise102, like the roadside noise of a typical DWI/DUI setting. Temporal resolution is necessary to distinguish the background noise in everyday listening situations103. The precedence effect refers to the finding that short onset-to-onset stimulus delays and leading and lagging sounds will perceptually fuse into a single auditory image104. Even older people with normal hearing sensitivity perform more poorly than younger listeners on a precedence-effect task105. Both temporal resolution and the precedence effect deteriorate with age and hearing loss, with temporal resolution more closely associated with age than hearing loss106. We are all born with a set of sensory cells and at about age 18 we slowly start to lose them107. AHL is also known as presbycusis, or a decrease in hearing loss. Because presbycusis progresses slowly most people do not notice changes until well after age 50108. According to the National Institute on Deafness and other Communication Disorders (NIDCD), presbycusis usually affects both ears equally109. As people age, structures of the ear become less responsive to sound waves contributing to hearing loss110. More specifically, there is a progressive degeneration of the cochlea’s sensory cells and spinal ganglion cells with the outer hair cells the most severely affected111. There are strong psychosocial concerns and consequences due to people not wanting

to obtain hearing aids. One study, which addresses the stigma, estimated only 8% of an elderly population who could benefit from hearing devices requested one after an audiologic evaluation112. Considering the fact that the walk and turn test is not fully demonstrated to 9 steps, people who suffer temporal resolution even without hearing loss as well as those with hearing loss may miss the important instruction of taking only 9 as opposed to 10 steps making them appear intoxicated. A subject is not asked to repeat the instructions on the sfst(s) only that they are understood. The walk and turn is a tightrope exercise requiring an unnatural coordination of muscles and balance. By the time one is aged 60, maximum muscular force is reduced by about 50% and the maximum movement speed up to 90%113. There are both automatic and effortful processes involved in movement control114. When it comes to walking, healthy older people select strategies that maximize stability when balance is perturbed115. For example, in a test where older people were asked to walk a figure 8 in order to maintain balance they shortened their steps116. Normal age-related decline in leg strength may be the primary limiting factor that prevents older people from walking at an equivalent speed to younger people117. Differences of walk are even more pronounced between older and younger people when walking on irregular surfaces118. Just general differences of gait between a younger officer and an older citizen on video reflect age-related declines in body systems, and yet are deceptively portrayed as signs of a slowed central nervous system due to alcohol or other depressants. In a walking coordination stability test comparing older and younger adults, it was proven that along with poorer visual acuity, contrast sensitivity, depth perception and vibration sense, older people also had less ankle dorsiflexion and quadriceps strength for walking119. We know that elderly people show a significant decrease in both cutaneous vibratory and joint sensations120 essential for walking and limb coordination. The attentional cost associated with gait by means of dual-task paradigms have revealed that this common task requires a greater portion of attentional resources in older as compared to younger adults121. This reflects the essential fact that older brains need to recruit additional resources to manage executive functions of otherwise relatively simple tasks122. Miscounting is often offered up as a sign of intoxication or the loss of the normal use of one’s mental faculties. Although it is not a technical clue on the sfst guidelines, optional tests routinely used by officers such as the finger countdown or hand slap test, penalize a citizen for miscounting. In an exercise where the subject, while attempting to maintain balance on a moving platform, was asked to count backwards in threes starting from random numbers with no alcohol or drugs involved, out of 20 younger adults the average number of correct counting responses was 12.5 +/- 2.9, and for 20 older adults it was 9.8 +/- 2.6123. Recent brain imaging data has shown that during performance of repetitive finger or wrist movements, the aging brain must recruit additional sensorimotor regions124. In this way, age-related

proprioceptive processing deficits compromise motor functions for which sensory information is of critical importance125. Regarding the one leg stand, a study in 2 British towns administered the one leg stand to 70 participants upon leaving a bar or nightclub. The majority of those tested ranged in age from 18 to 36 (therefore not even inclusive of the older aged population) with only 23 deemed under the influence of alcohol or a drug, it was determined that the majority of people failed the one leg stand making it an unfit test to determine impairment126. In a massive research project conducted at the Center for Clinical and Lifestyle Research in late 1994 and 1995, involving tests on 349 men and women by Dr. James M. Rippe, M.D. the “Advil Fit over Forty” standards were developed. These standards have since been presented at a variety of national scientific and medical meetings including: The American College of Sports Medicine; The American Heart Association; and the Gerontological Society of America127. Interestingly enough, one of the tests in which a person can assess their health in terms of fitness and balance is the one leg stand test, in which a person merely lifts a leg (simpler than the sfst one leg stand test where one lifts and holds out their leg) for a timed 30 seconds. The following is based on a chart128 that gages one’s level of fitness clearly indicating that the rigid grading criteria of the one leg stand is ludicrous. In the Fit Over Forty book by Dr. James M. Rippe, there is an enlightening chart on page 32 which includes among other things what would be considered average for holding one’s leg back for middle aged people. Surprisingly enough woman in their 40s are considered average if they can hold their foot up in between 7.215.5 seconds. For corresponding males it is in between 4.1-14.7 seconds. This is a far cry from NHTSA’s claim that a BAC can hold up their foot for 25 seconds but seldom 30. In one analysis of the sfst(s) using data over a 4 state area from 1986-1993, it was found that there was a significant trend toward decreased sensitivity with increasing driver age over 44 years129. Sharply contrasting with NHTSA’s 65 years of age. This study referenced some of the misclassification “to be a result of aging”130, and yet it is perilous and ignorant to associate aging by a mere chronological index. When evaluating the walk and turn and one leg stand tests overall, 50 % of doctors in Strathclyde Scotland consulted in a law enforcement study expressed concerns that the tests were inappropriate for use in determining sobriety regardless of age131. The physicians with postgraduate qualifications were significantly more concerned about the tests than doctors without postgraduate qualifications132. The problem with the widespread promulgation of sfst(s) in the alcohol and drug arena by American NHTSA related psychologists, is the lack of true scientific reliability as opposed to purported self serving statistics, which amount to “face validity.” In a study analyzing a sample of 38 papers from 16 journals covering all the major drug types from 1972 to 1988 no papers were found to have documented true scientific reliability or validity133. Although Dr. Marcelline Burns has been widely quoted in her 1995 study, which

claims “validation” for the sfst test battery; the validity of these tests has been questioned134. It is no different than the problem with the DRE validation: “It has to be acknowledged the author of the initial studies which tended to validate the DRE program, was intimately associated with the DRE protocol and involved in the L.A. test which ‘touted’ the DRE accuracy”135. It has been published in the peer reviewed journal: the Journal of Clinical Forensic Medicine, that “No evidence has been presented that there is any correlation between a person’s performance on any aspect of the battery of tests used in FIT (field impairment testing, sfst(s) in the United States) and that person’s ability to drive. It is our belief that the use of these tests has led, and will continue to lead, to the arrest and conviction of motorists whose only crime is that they cannot ‘pass’ the FIT procedures136.” The Association of Forensic Physicians has gone one record stating, “Field Impairment Testing (FIT) as currently performed in the UK has NOT been validated and there is increasing anecdotal evidence that errors of interpretation are being made which could lead to wrongful convictions137.” Put simply, the problems with sfst(s) are that they only account for one variable: the person’s performance at the time of testing, without accounting for any other variables. An experimental design systematically manipulates independent variables to discover their effects on dependent variables138. To attribute cause and effect correctly, all other variables must be controlled, usually by eliminating those that can’t be eliminated, counterbalancing those that cannot, or measuring those that cannot be eliminated or counterbalanced139. The problem with the sfst(s) is that the variables such as age and pathology are not accounted for. Variables that are not accounted for can confound the results in the psychometrics of testing making it impossible to distinguish which variable has caused which effect140. The sfst(s) are an incorrect testing matrix by design. Any psychological test should be valid, reliable, and sensitive in that it should measure what it purports to measure, do so consistently, and be capable in basic design of detecting changes in what it measures141. Although these principles are commonly applied in areas of psychology such as personality, intelligence, and clinical occupational testing, they are rarely applied to performance assessment and hardly at all in the assessment of drugs on performance142, as can be seen with the sfst(s). As we age the rate of decline is intra-individual 143. Individuals become less alike as a function of differences in change144. Age related decreases in performance and increasing intraindividual variability in neurobiological mechanisms in the brain, drive increases in interindividual differences in performance145. Due to the fact that aging is a gradual process and most studies focus on the differences between the elderly and young populations, it is necessary to extrapolate across the ages that the physiologic decay of the body occurs over time. Middle-aged people largely reflect the biologic changes that produce chronic degeneration affecting the body systems. Hypertension (high blood pressure) is one of the most chronic conditions for men and women over the age of 40 with 1 out of every 3 Americans suffering this condition146. Blood pressure affects circulation within the brain, so vital to dopamine

receptor health. High blood pressure has even been judicially recognized as a known cause for HGN147. In terms of circulation health, vital for good brain function, it is known that by the time a man is 50 years of age in the U.S., he has over a 30% chance of having coronary artery disease and by age 60, a 20% chance he has suffered a heart attack148. One of every four people over age 50 suffer from arthritis149, which of course has obvious implications on the walk and turn and one leg stand tests. Even one’s ability to go to the bathroom (as sometimes commented on by police officers in DWI/DUI cases) is significantly affected by aging, as the kidney function of an average 70year is approximately 50% of an average 30 year old150. In conclusion, age and the consumption of alcohol has its benefits. It has been widely recognized by the medical community that alcohol decreases the risk of heart disease by raising the level of healthy HDL cholesterol in one’s blood. 151 Alcohol in the form of flavinoids, common in red wine, has also been proven to impede blood clots, which form in heart attacks152. It is pretty reasonable to assume that alcohol ingestion and driving are issues that shall continue to present themselves; the scientific and law community owe it to society to address the grave injustices currently employed in assessing whether or not one has operated a vehicle while intoxicated or impaired.

Denise Grady, Cancer Patients, Lost in a Maze of Uneven Care, New York Times, www.nytimes.com, (July 29, 2007). 2 NHTSA, DOT HS 810616, Alcohol-Related Crashes and Fatalities, Traffic Safety Facts, www.nhtsa.gov, (2005) 3 See Id. 4 NHTSA, DOT F 1700.7, Identifying Strategies to Study Drug Usage and Driving Functioning Among Older Drivers, Final Report of Polypharmacy and Older Drivers, www.nhtsa.gov, 1-89, (December 2006). 5 Lori Raye Court Reporters, Examination under Oath of Marcelline Burns, 1-62, (April 17 1998). 6 Sofie Heuninckx, Filiep Debaere, Nicole Wenderoth, Sabine Verschueren, & Stephan P. Swinnen, Ipsilateral Coordination Deficits and Central Processing Requirements Associated With Coordination as a Function of Aging, 59B J. of Gerontology 5, 225, (2004). 7 See infra note 9 at 465. 8 Deborah J. Serrien, Stephan P. Swinnen, & George E. Stelmach, Age-Related Dererioration of Coordinated Interlimb Behavior, 55B J. of Gerontology 5, 295, (2000). 9 Konrad Wolfgang Kallus, Jeroen A.J. Schmitt, & David Benton, Attention, psychomotor functions and age, Eur J. Nur, 2005, 44, at 469. 1. Source Cited: Thorndike EL, Bergman EO, Tilton J, and Woodyard E, Adult Learning, (1928), Oxford England. 10 Mark E. Williams M.D., The American Geriatrics Society’s Complete Guide to Aging and Health, Harmony Books, NY, © by the Geriatrics Society, at 15, (1995) 11 See Id. at 14. 12 See supra note 9 at 482. 13 NHSTA, DWI Detection and Standardized Field Sobriety Testing, Participant Manual, (2004), re: WAT at VIII11, re: OLS at VIII-14. 14 See Id. re: 50lbs, at VIII-14. 15 Dixie L Thompson, Jennifer Rakow, & Sara M. Perdue, Relationship between Accumulated Walking and Body Composition in Middle-Aged Women, Official J. of the American College of Sports Medicine, at 914, (Jan. 2004). 1. Source Cirted: Flegal K, M Carroll, C Ogden, and C Johnson, Prevalence and trends in obesity among US adults, 1999-2000, JAMA 288, 1723-27, (2002). 16

Ross C. Brownson PhD, Amy A Eyler PhD, Abby C. King PhD, David R. Brown PhD, Yuh-Ling Shyu MSW, & James F, Sallis PhD, Patterns and Correlates of Physical Activity Among US Women 40 Years and Older, 90 American Journal of Public Health 2, 264, (Feb. 2000). 1. Source Cited: Powell KE, and Blair SN, The public health burden of sedentary living habits: theorectical but realistic estimates, Med Sci Sports Exerc 26, 851-56, (1994). 17 Joanna E. Condron BSc (Hons), & Keith D. Hill PhD Grad Dip Physio BappSc (Physio), Reliability and Validity of Dual-Task Force Platform Assessment of Balance Performance: Effect of Age, Balance Impairment and Cognitive Task, 50 J. of the American Geriatrics Society 1, 161.

Naftali Raz & Karen M. Rodrigue, Differential aging of the brain: Patterns, cognitive correlates and Biobehavioral Reviews, , 741, (2006). 19 See Id. at 731 20 See supra note 8 at 302. 18

modifiers, Neuroscience and

Shannon Robertson, Joel Myerson, & Sandra Hale, Are There Age Differences in Intraindividual Variability in Working Memory Performance?, 61B J. of Gerontology 1, 18, (2006). 23 22 Charles A. Marsden, Dopamine: the rewarding years, British J. of Pharmacology, 140, (2006). See Id. at 136. 24 See supra 25 note 9 at 468 See Id. at 468. 1. Source Cited: Rinne JO, Lonnberg P, and Marjamaki P, Age-dependent decline in human brain dopamine D1 and D2 receptors, 508 Brain Research 2, 349-52, (1990). 26 See Id. at 468. 1. Source Cited: Naoi M, and Maruyama W, Cell death of dopamine neurons in aging and Parkinson’s disease, Mech Aging 111 (2-3), 175-88, (1999). 21

Jackalina M. Van Kampen & Christopher B. Eckman, Dopamine Dз Receptor Agonist Delivery to a Model of Parkinson’s Disease Restores the Nigrostriatal Pathway and Improves Locomotor Behavior, 26 Journal of Neuroscience 2, at 7272, (July 5, 2006). 28 See supra note 22 at 137. 29 See supra note 22. 30 See supra note 27 at 7273. 1. “Interesting to note, rats injected with a form of methamphetamine showed restoration of dopaminergic nigrostriatal circuits.” Baker SA, Baker KA, and Hagg T, Dopaminergic nigrostriatal projections regulate neural precursor cell proliferation in the adult mouse subventricular zone, Eur J Neurosci 20, 575-79, (2004). 31 See supra note 10 at 32. 32 Stephanie J. Fonda, Rosanna Bertrand, Amy O’ Donnell, Christopher Longcope, & John B. McKinlay, Age Hormones, and Cognitive Functioning Among Middle-Aged and Elderly Men: Cross-Sectional Evidence From Massachusetts Male Aging, The Journal of Gerontology Series A: Biological Sciences and Medical Sciences 60, at 385, (2005). 33 See Id. at 388. 34 See Id. at 388. 1. Source Cited: Janowsky JS, Oviatt SK, and Orwoll ES, Testosterone influences spatial cognition in older men 108, 325-32, (1994). 35 See Id. at 387. 1. Source Cited: Harman SM, Metter JE, Tobin JD, Pearson J, and Blackman MR, Longitudinal effects of aging on 36 serum total and free testosterone levels in healthy men, J Clin Endorrinal Metab, 86, 724-3, (2001). See Id. at 387. 1. Source Cited: Morley JE, Kaiser FE, and Perry HM 3 rd, et al, Longitudinal changes in testosterone, luteinizing hormone, and follicle-stimulating hormone in healthy older men, Metabolism 46, 410-3, (1997). 37

Timothy A Salthouse PhD, Memory Aging from 18 to 80, 17 Alzheimer Disease Association Disorder 13, 166, (July-September 2003). 38 See Id. at 166. 39 See supra note 10 at 23. 40 See supra note 6 at 230. 1. Study Cited: Li KZ, Lindenberger U, Freund AM, and Baltes PB, Walking while memorizing: age-related differences in compensatory behavior, Psychological Science 12, 230-37, (2001). 41 Laurie R. Wishart, Timothy D. Lee, Jason E. Murdoch, and Nicola J. Hodges, Effects of Aging on Automatic and Effortful Process in Bimanual Coordination, 55B J. of Gerontology 2, at 93, (2000). 42 See Id. at 93. 43

See supra note 10 at 35. See supra note 9 at 468. 1. Source Cited: Greenwood PM, and Parasutaman R, Scale of attenional focus in visual search, 61 Percept Psychophys 5, 837-59, (1999). 45 Claudia Voelcker-Rehage & Jay L. Alberts, Effect of Motor Practice on Dual-Task Performance in Older Adults, 62B Journal of Gerontology 3, at 147, (2007). 46 See supra note 6 at 230. 47 See supra note 16 at 112. 48 Michael J. Hogan, Divided Attention in Older But Not Younger Adults Is Impaired by Anxiety, Experimental Aging Research, at 111, (2003). 49 See supra note 9 at 463. 50 David F. Hultsch, Stuart W.S. MacDonald, & Roger A. Dixon, Variability in Reaction Time Performance of Younger and Older Adults, 57B J. of Gerontology 2, 101, (2002). 51 See Id. at 102. 52 See supra note 48 at 133. 53 See Id. at 113. 1. Backman L, and Molander B, On the generalizability of the age-related decline in coping with high-arousal conditions in a precision sport: replication and extension, Journal of Gerontology: Psychological Sciences 46, 79-81, (1991). 54 See Id. at 133. 1. Gurvits TG, Shenton MR, Hokama H, Ohta H, Lasko NB, Gilbertson MW, Orr SP, Kikinis R, Lasko FA, McCarley RW, and Pitman RK, Magnetic resonance imaging study of hippocampal volume in chronic combat-related posttraumatic stress disorder, Biological Psychiatry 40, 192-99, (1996). 55 Robert West, Kelly J. Murphy, Maria L. Armilio, Fergus I.M. Craik, & Donald T. Stuss, Effects of Time on Age Differences in Working Memory, 57B J. of Gerontology 1, at 3, (2002). 56 See Id. at 3. 57 See Id. at 4. 58 See Id. at 3. 44

1. May CP, and Hasher L, Synchrony effects in inhibitory control over thought and action, Psychological Science 24, 363-79, (1998).

J. of Experimental

Lucy Yardley, Natalie Owen, Irwin Nazareth, and Linda Luxon, Prevalence and presentation fo dizziness sample of working age people, British J. of General Practice 48, at 1134, (1998). 60 Eva Ekvall Hånsson, Nils-Ove Månsson, and Anders Håkansson, Balance performance and self-perceived primary health care, Scandinavian Journal of Primary Health care 23, at 215, (2005). 61 See Id. at 215. 62 See supra note 59 at 1134.

in a general practice community handicap among dizzy patients in

1. Kroenke K, Lucas CA, and Rosenberg ML, et al, Causes of persistent dizziness: a prospective patients in ambulatory care, Ann Intern Med 117, 898-904, (1992). 63 See Id. at 1134. 64 See Id. at 1131. 65 See Id. at 1133.

study of 100

See Id. at 1133. See Id. at 1133. 68 See Id. at 1131. 69 Kathleen C Horner PhD, Régis Guieu MD, Jacques Magnan MD, André Chays MD, and Yves Cazals PhD, Prolactinoma in Some Ménière’s Patients- Is Stress Involved?, 26 Neuropychopharmacology 1, 135, (2002). 70 See Id. at 138. 1. Study Cited: Eybalin M, Neurotransmitters and neuromodulators of the mammalian cochlea, Physiol Rev 73, 309-73, (1993). 71 See Id. at 138. 1. Study Cited: Petrosini L, and Dell’Anna ME, Vestibular Compensation is affected by treatment with dopamine active agents, Arch Ital Biol 131, 159-71. 72 See supra note 6 at 225. 1. Study Cited: Woollacott M, and Shumway-Cook A, Attention and the control of posture and gait: A review of an emerging area of research, Gait and Posture, 16, 1-14. 73 Zoï Kapoula, and Thanh-Thuan Lê, Effects of distance and gaze position on postural stability in young and old subjects, Exp Brain Res 173, 442, (2006). 74 See Id. at 442. 1. Study Cited: Brandt T, Paulus W, and Strube A, Vision and Posture, In: Bless W, Brandt T (eds) Disorders of posture, Elsewier, Amsterdam, 157-75. 2. Study Cited: Jahn K, Strupp M, Krafczyk S, Schuler O, Glasauer s, and Brandt T, Suppression of eye movement improves balance, Brain 125 (pt 9), 2005-2011, (2002). 3. Study Cited: Struppp M, Glasauer S, Jahn K, Schneider E, Krafczyk S, and Brandt T, Eye movements and balance, Ann NY Acad Sci 1004, 352-58, (2003). 4. Study Cited: Glasauer S, Schneider E, Jahn K, Strupp M, Brandy T, How the eyes move the body 65(8), 1291-93,( 2005). 75 See Id. at 442. 76 See Id. at 442. 67

Study Cited: André-Deshays C, Berthoz A, and Revel M, Eye-head coupling in humans, I. Simultaneous recording of isolated motor units in dorsal neck muscles and horizontal eye movements, 69 Exp Brain Res 2, 399-406, (1998). 2. Study Cited: André-Deshays C, Revel M, and Berthoz A, Eye-head coupling in humans, II. Phasic components, 84 Exp Brain Res 2, 359-66, (1991). 77 See supra note 17 at 157. 78 See supra note 13 at VIII-11. 79 Nataliya Shkuratova BPht, Meg E Morris PhD, and Frances Huxham DipPT, Effects of Age on Balance Control During Walking, 85 Archives of Physical Medicine and Rehabilitation 4, 582, (April 2004). 80 See Id. at 582. 81

See supra note 73 at 443. See supra note 9 at 465. 83 Charles T Scialfa, Static and Dynamic Visual Sensitivity in Older Adults, 30 Canadian Psychology/Psychologie Canadienne 4, at 703, (Oct 1989). 84 See Id. at 703. 85 See supra note 9 at 467. 86 Jochen Laubrock, Reinhold Kliegl, and Ralf Engbert, SWIFT explorations of age differences in eye movements during reading, Neuroscience and Biobehavioral Reviews 30, at 873, (2006). 87 See supra note 83 at 703. 82

See supra note 81 at 879. See supra note 73 at 439. 90 See supra note 83 at 703. 91 See supra note 9 at 469. 92 K Dujardin, JL Bourriez, and JD Guieu, Event-related desynchronization (ERD) patterns during memory processes: effects of aging and task difficulty, Electroencephalography and clinical Neurophysiology 96, 181, (1995). 93 See supra note 86 at 874. 94 See supra note 9 at 466. 1. Source Cited: Summala H and MikkolaT, Fatal accidents among car and truck drivers: effects of fatigue, age and alcohol consumption, 36 Hum Factors 2, 315-26, (1994). 95 See Id. at 467. 89

Source Cited: Sekuler AB, Bennett PJ, and Mamelak M, Effects of aging on the useful field of view, 26 Exp Aging Res 2, 10320, (1994). 96 Michael Anne Gratton and Ana Elena Vázquez, Age-related hearing loss: current research, Current Opinion Otolaryngology and Head and Neck Surgery 11, at 367, (2003). 97 See Id. at 367. 98 Karen J Cruickshanks, Terry L Wiley, Theodore S Tweed, Barbara EK Klein, Ronald Klein, Julie A Mares-Periman, and David M Nondahl, Prevalence of Hearing Loss in Older Adults in Beaver Dam, Wisconsin, 148 American Journal of Epidemiology 9, at 882. 99 See Id. at 881. 100

See Id. at 881. See Id. at 881. 102 Margaret I Wallhagen PhD RN CS, William J Strawbridge PhD, Richard D Cohen MA, and George A Kaplan PhD, An Increasing Prevalence of Hearing Impairment and Associated Risk Factors over Three Decades of the Alameda County Study, 87 American J. of Public Health 3, at 440, (March 1997). 103 Richard A Roberts and Jennifer J Lister, Effects of Age and Hearing Loss on Gap Detection and the Percedence Effect: Broadband Stimuli, 47J. of Speech, Language, and Hearing Research, at 967(Oct 2004). 104 See Id. at 966. 105 See Id. at 966. 106 See Id. at 967. 107 Carol Rados, Sound Advice About Age-Related Hearing Loss, FDA Consumer Magazine, May-June 2005 issue, Pub No. FDA05-1340C. 1. Source statement Cited: Statement by Dr. Hinrich Staecker, M.D., Ph.D, director of the Otology and Neurology Program at the University of Maryland Medical Center in Baltimore. 108 See Id. 109 See Id. 110 See Id. 101

111

See supra note 96 at 368. 112 Renato Peixoto Veras and Leila Couto Mattos, Audiology and Aging : Literature review and current horizons, 73 Rev Bras Otorrinolaringol 1, 126, (2007). 1. Source Cited: Rosenhall ULF, et al, The two faces of presbyacusis: hearing impairment and psychosocial consequences, 41 Int J Audiol 2, 125-35, (2002). 113 See supra note 9 at 466. 114 See supra note 41 at 93. 115 See supra note 79 at 586. 116 See Id. at 586. 117 Hylton B Menz, Stephen R Lord, and Richard C Fitzpatrick, Age-related differences in walking stability, Age and Ageing, 32 British Geriatrics Society 2, at 141, (2003). 118 119

See Id. at 141. See Id. at 139.

120

See supra note 6 at 231. 1. Study Cited: Diener HC, Dichgans J, Gushlbauer B, and Mau H, The significance of proprioception on postural stabilization as assessed by ischemia, Brain Research 269, 103-109, (1984). 121 See Id. at 225. 1. Study Cited: Woollacott M, and Shumway-Cook A, Attention and the control of posture and gait: A review of and emerging area of research, Gait and Posture 16, 1-14, (2002). 122 See supra note 50 at 112.

Study Cited: Dixon RA, and Backman L, Principles of compensation in cognitive neororehabilitation, In: DT Stuss, G Winocur, and IH Robertson (Eds), Cognitive neurorehabilitation, Cambridge England, Cambridge University Press, 59-72, (1999). 2. Dixon RA, Hertzog C, Friesen IC, and Hultsch DF, Assessment of intraindividual change in text recall of elderly adults, In: HH Brownell, and Y Joanette (Eds), Narrative discourse in neurologically impaired and normal aging adults, San Diego CA: Singular,77-101, (1993). 3. Dixon RA, Hultsch DF, and Hertzog C, A manual three-tired structurally equivalent texts for use in aging research (CRGA Tech. Rep. No.2) Victoria, British Columbia, Canada: University of Victoria, Department of Psychology, (1989). 4. Dixon RA, Wahlin A, Maitland SB, Hultsch DF, Hertzog L, and Backman L, (in Press), Episodic memory change in late adulthood: Generalizability across samples and performance indices, Memory and Cognition. 123 See supra note 32 at 159. 124 See supra note 6 at 231. 125 See Id. at 231. 126 Jackson PG, Turnbridge RJ, and Rohe DJ, Drug recognition and field impairment testing: Evolution of trials, In: Larrell Li, and Schlyter F (eds), Alcohol, drugs and traffic safety, Proceeding of the 15 th International conference on alcohol, drugs and traffic safety, Stockholm, Sweden, (May 21-26 2000). 127

James M Rippe MD, Fit Over Forty, William Morah and Company Inc, New York, 17, (Copyright 1996). See Id. at 32. 129 David C Grossman, Beth A Mueller, Tricia Kenaston, Philip Salzberg, William Cooper, and Gregory J Jurkovich, The Validity of Police Assessment of Driver Intoxication in Motor Vehicle Crashes leading to Hospitalization, 28 Accid. Anal. And Prev. 4, Elsevier Science Ltd., at 439, (1996). 130 See Id. at 441. M O’Keefe, Dugs driving-standardized field sobriety tests: a survey of police surgeons in Strathclyde, 8 Journal of Clinical Forensic Medicine 2, 57, (June 2001). 128

132

See Id. at 60. 133 Anthony Wetherell, Performance Tests, 104 Environmental Health Perspectives 2, 252, (April 1996).

1. Study Cited: Parrot AC, Performance tests in psychopharmacology, 2: Content Validity, Human Psychopharmacology, 6:91-98, (1991). 2. Study Cited: Parrot AC, Performance tests in psychopharmacology, 3: Construct Validity and Psychopharmacology, , 6:197-207, (1991). 134

Criterion Validity and Face Validity, Test Interpretation, Human

17 Meeting of the International Council on Alcohol, Drugs, and Traffic Safety (TCADTS), held in Glassier, Scotland, United Kingdom, Aug. 8-13, 2004, and attended by some 400 delegates from around the world, at 5. 135 See Id. at 5. 1. Study Cited: C.J. Trocino, “Drug Recognition Expert (DRE) Testimony Doesn’t Pass Frye Test”, Williams v Judicial Court Florida, (1997). 136 See Id. at 5. 1. Source Cited: Page, TE, The Drug Recognition Expert Response, in the Effects of Drugs (other than alcohol) on Road Safety, 1st Report of the Parliament of Victoria Road Safety Committee, (May 1995). 137 See Id. at 5. 1. Source Cited: AFP News, “AFP’s View and Response: Field impairment Testing” 9, (December 2003). 138 See supra note 133 at 262. 139 See Id. at 262. 140 See Id. at 262. 141 See Id. at 252. 142 See Id. at 252. 143 See supra note 6 at 468. 144 See supra note 50 at 101. 145 See Id. at 112. 146 See supra note 127 at 280. 147 Schultz v. State, 664A. 2d60, 77 (Md. App. 1995). 148 See supra note 127 at 19. 149 See Id. at 277 150 See Id. at 265 151 See Id. at 217 152 See Id. at 217.

Texas Criminal Defense Lawyers Association

Top Gun DWI XIX August 13, 2021

Topic: Identifying Drugs with the Draeger DT 5000 Speaker:

Josh Lee PO Box 352 Vinita, OK 74301 (918) 782-0000 Phone (918) 282-0200 Fax joshlee@leecoats.com email leecoats.com website

6808 Hill Meadow Dr :: Austin, Texas :: 512.478.2514 p :: 512.469.9107 f :: www.tcdla.com

When Sgt. Eddie Bowers first started pulling over impaired drivers in 2000, the great majority were for alcohol abuse. Back then there was no practical way to perform drug testing at the roadside. All that changed in 2009 when his department began to use the Dräger DrugTest® 5000, the leading oral fluid drug testing device.

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Oral Fluid Drug Testing at the Roadside: a Game Changer

THE EVOLUTION OF ROADSIDE IMPAIRMENT CHECKS

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Roadside drug test technology has come a long way since Sgt. Bowers first started making impairment arrests in 2000. “Back then, drug recognition experts carried around urine test kits—that was the only thing out there for us to use. But it’s just not reasonable on any level to request a driver, while in public view, to submit to a urine test. So it wasn’t until the advent of oral fluid testing that we had a viable tool to help us combat drugged driving.”

ABOUT SGT. BOWERS

Sergeant Eddie Bowers has been a law enforcement officer in the state of Nevada since 2000. He received field sobriety test training at the Police Academy and through the National Highway Traffic Safety Administration curriculum. In 2007, Sgt. Bowers became a field sobriety test instructor and in 2013 a field sobriety test instructor trainer. He also participated in the Advanced Roadside Impaired Driving Enforcement (ARIDE) course on how to evaluate drugimpaired drivers. Sgt. Bowers currently teaches standardized field sobriety testing at the Police Academy and conducts seminars at the National Judicial College on field sobriety testing and technology.

Sgt. Bowers continues, “My department started using the Dräger DrugTest® 5000 in 2009 and I will tell you from my own personal experience that it is an absolute game changer. Before then, the lion’s share of my DUIs was for alcohol, and every now and then I’d come across a marijuana DUI that was very distinguishable from the unmistakable odor. The first month I started using the DrugTest 5000 oral fluid machine, I arrested twelve people for DUI. Two of them were for alcohol. The other ten were all DUI drug cases—every one of them tested positive for some type of drug on the Dräger DrugTest 5000.”

“The Dräger DrugTest 5000 is absolutely brilliant for field work.” Sergeant Eddie Bowers

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ORAL FLUID DRUG TESTING

FROM MAINSTREAM MARIJUANA TO OPIATES IN THE SUBURBS

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Sgt. Bowers believes that if marijuana legalization continues to gain traction across the country, more and more people will be using it. “A device like the Dräger DrugTest 5000 is going to be an increasingly important tool at the roadside so we can tell on the spot if the driver has been using marijuana.” Sgt. Bowers adds, “There is also an epidemic in this country of prescription medication abuse. And it’s not just in the very bad neighborhoods or the nefarious parts of town. This is everywhere— this is in the suburbs.” The Dräger DrugTest 5000 helps in those cases because it tests for seven different narcotics. “If you stop the soccer mom with kids in the car and her speech is thick and slow and she says she is overly tired from being up all night with a sick child, it’s very important that I do not send this mom down the road with perhaps everything that is important to her in life—her children in the car—if she were impaired. I now have the ability to find out if a driver is abusing their medication.”

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NON-INVASIVE AND UNINTIMIDATING

Sgt. Bowers considers the Dräger DrugTest easy to use and unintimidating to suspects. To collect an oral sample, Sgt. Bowers hands the test cassette to the suspect and asks them to hold it inside their mouth for about a minute to a minute and a half. “You put the cassette into the machine, turn it on, and it does the rest. The only thing the officer has to do is to type in information when the device asks for it—such as the suspect’s name, birthday, a case number if that is desired, the test location, and so forth.

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“The DrugTest 5000 is elegant in its simplicity. The face of the device has three buttons: an arrow up, a down arrow and a power on button. You can’t get much simpler than that. It’s what we call ‘cop proof,’” says Sgt. Bowers with a laugh. “The Dräger DrugTest 5000 is absolutely brilliant for field work.” How many people have refused to provide a saliva sample? “Since 2009 when I started using this machine, I have not had anybody refuse me. And I’ve tested hundreds of people.” The DrugTest 5000 can also be used to test substances found in a car. “If an officer finds some sort of white powdery substance inside a vehicle, they might wonder, ‘Is this cocaine? Is this methamphetamine?’ It’s not like on TV where they taste it and say ‘Yeah, it’s cocaine.’ We do not do that. So it’s extremely valuable that with the Dräger DrugTest 5000, you can place a sample of the unknown substance onto another test cassette, place it inside the machine, and it’ll tell you what type of narcotic it is.”

ORAL FLUID DRUG TESTING

PROVEN RELIABILITY FROM A TRUSTED BRAND

Sgt. Bowers was familiar with the Dräger brand before he started using the DrugTest 5000. “My agency had been using Dräger preliminary breath testers for alcohol. And when the officers started using those—again, it was a game changer. The Dräger Alcotest PBT was the most reliable preliminary breath tester we had ever used. It would capture a puff of breath from a subject that was perhaps being evasive when they were submitting to the test. The results were very reliable when measured against an evidentiary breath test later on at the jail. So we had a high opinion of Dräger devices and when we saw the availability of an oral fluid tester, we thought ‘Let’s give it a shot. If it’s made by Dräger, it’s likely going to perform very well.’”

in this database, and you can print out a PDF or Excel file if you need paper documentation.” A DEVICE TO HELP SAVE LIVES

Sgt. Bowers summarizes the mission of his profession—which also happens to be his personal passion. “Law enforcement officers are the front line of defense out there in creating a safe environment for people to operate their vehicles on highways. We do that by changing drivers’ behaviors through aggressive enforcement of traffic laws. One of the most profound impacts we can have toward saving lives is arresting impaired drivers, and the Dräger DrugTest 5000 is a piece of technology that can help us do just that. It can help us save lives.”

Sgt. Bowers continues, “The results of the Dräger DrugTest 5000 are extremely relevant when you are making a probable cause determination to make a seizure order for someone’s blood.” Once he has collected a saliva sample and inserted the test cassette into the Dräger DrugTest 5000 to run the test, Sgt. Bowers goes back and tells the driver what he suspects them of using. “I might say, ‘The test that you just submitted to is going to show whether or not you have used any of seven different types of narcotics— and marijuana is one of them.’ Or ‘Methamphetamine is one of them.’ And that’s usually enough to get people to be pretty forthright and say, ‘Well, I did use some marijuana’ or other drug.” In Nevada, audio and video recording devices are used in all patrol vehicles. “Now, we have built our case with their driving, their signs and symptoms in field sobriety testing, their admission to usage, and—the corner piece of the puzzle—the Dräger DrugTest 5000, which gives us very reliable roadside test results.” Back at the station, the coordinator can plug a USB cable into the DrugTest 5000 and download all the test data onto a hard drive on a desktop computer, so the data is always available. “All of the relevant questions that a defense attorney would ask are contained

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When it comes to reliability, the Dräger DrugTest 5000 earns high marks. Sgt. Bowers explains, “We’ve participated in some correlative studies where an oral fluid sample was taken and tested by the Dräger DrugTest 5000, a secondary sample was captured and sent to NMS Labs in Pennsylvania, and then the arrested subject was eventually taken to jail and submitted to an evidentiary test of their blood or urine. We had three pieces of data to look at and all of them married together perfectly—which shows that the reliability of the Dräger DrugTest 5000 is profound.” MAKING A CASE

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Results Cocaine Opiates Benzodiazepines Cannabis-5 Amphetamine Methamphetamine Methadone

005 Negative Negative Negative Positive Negative Negative Negative

DRÄGER DRUGTEST 5000 AT-A-GLANCE

– Tests for 7 different types of narcotics – Shows results in 8 minutes for cannabis; 5 minutes for other types of drugs – Runs on batteries, adapter plugs into cigarette lighter – Stores results of up to 500 drug tests – Uploads results to PC via USB cable for permanent data file – Communicates with wireless, battery-operated printer via infrared sensor

Not all products, features, or services are for sale in all countries. Mentioned Trademarks are only registered in certain countries and not necessarily in the country in which this material is released. Go to www.draeger.com/trademarks to find the current status.

CORPORATE HEADQUARTERS

Drägerwerk AG & Co. KGaA Moislinger Allee 53–55 23558 Lübeck, Germany www.draeger.com

Customer Service: USA

+1 800-4DRAGER (+1 800-437-2437) Technical Service: USA

+1 800-4DRAGER (+1 800-437-2437)

Locate your Regional Sales Representative at: www.draeger.com/contact

Dräger Service When you rely on Dräger breath alcohol and drug screening equipment, you can rest assured you made the right choice. For more than 60 years, we’ve been the global market leader in advanced breath alcohol testing and employ cutting-edge technology to provide devices that are fast, reliable, and easy to use. That’s the Dräger Service Advantage.

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Press Release No. 5 / February 3, 2016

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Test Results from Dräger DrugTest 5000 Found Scientifically Reliable in California Kelly-Frye Hearing Marks the First Scientifically Reliable Ruling for Oral Fluid Drug Test Results in the United States IRVING, Texas – Dräger today announced that oral fluid drug test results from its DrugTest 5000 (DT5000) mobile drug screening system were found to be scientifically reliable in a Kelly-Frye hearing for a vehicular manslaughter case in California. The judge’s decision, which is the first scientific-reliability ruling for a device of this kind in the U.S., allowed for the defendant’s DT5000 results to be presented to the jury. This is a landmark case for the use of admissible oral fluid drug test results in the court of law. In the case of “The People of the State of California v. Junior Salas” (Kern County Superior Court, Bakersfield, Calif.; court case #BF153631A), the jury found the defendant guilty of vehicular manslaughter. Judge Susan M. Gill sentenced Salas on Jan. 19, 2016, to three years in state prison. If there is an appeal, and an appellate court upholds the decision regarding the scientific reliability of the DT5000, the ruling on the admissibility of its results will be made binding throughout California. Dräger’s DT5000 mobile drug screening system uses oral fluid to test for the presence of psychoactive components from seven of the most commonly abused drug types, including cannabinoids (THC), opiates, cocaine, amphetamines, methamphetamines, benzodiazepines and methadone. Accurate, reliable and easy to use, the DT5000 is leveraged by law enforcement personnel in more than a dozen states during roadside stops. Offering quick results, the DT5000 provides a non-invasive alternative to collecting urine or blood samples during driving under the influence of drugs (DUID) investigations. “Dräger understands that DT5000 results need support from policymakers and throughout the criminal justice system, including law enforcement, prosecutors

Contact Local press contact: Marion Varec Tel +1 215 660-2186 marion.varec@draeger.com Dräger 3135 Quarry Road Telford, PA 18969, USA www.draeger.com

Corporate Communications: Melanie Kamann Tel +49 451 882-3998 melanie.kamann@draeger.com Drägerwerk AG & Co. KGaA Moislinger Allee 53-55 23558 Lübeck, Germany www.draeger.com

www.twitter.com/Draeger4Safety www.facebook.com/DraegerSafetyDiagnosticsInc

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Press Release No. 5 / February 3, 2016

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and judges,” said Michael Willis, President, Draeger Safety Diagnostics, Inc. “Due to its broad reach, the DT5000 screening system has undergone extensive, independent, scientific validation and been utilized in approximately one million tests worldwide. This first Kelly-Frye hearing, as well as the push by the Kern County District Attorney’s Office for oral fluid result admissibility in the case, is confirmation that the DT5000 is on its way to becoming a standard screening method for DUID investigations and prosecutions.” Dräger’s DT5000 is broadly used across Europe and Australia and is currently in field use or pilot programs by law enforcement agencies and Drug Recognition Expert (DRE) trained officers in more than a dozen states in the U.S. Due to its extensive testing and scientific validity, the DT5000 is available for immediate placement with law enforcement agencies. Learn more about Dräger’s DT5000 here. Dräger. Technology for Life

Dräger is an international leader in the fields of medical and safety technology. Our products protect, support and save lives. Founded in 1889, Dräger generated revenues of around EUR 2.43 billion in 2014. The Dräger Group is currently present in more than 190 countries and has about 13,500 employees worldwide. Please visit draeger.com for more information.

Contact Local press contact: Marion Varec Tel +1 215 660-2186 marion.varec@draeger.com Dräger 3135 Quarry Road Telford, PA 18969, USA www.draeger.com

Corporate Communications: Melanie Kamann Tel +49 451 882-3998 melanie.kamann@draeger.com Drägerwerk AG & Co. KGaA Moislinger Allee 53-55 23558 Lübeck, Germany www.draeger.com

www.twitter.com/Draeger4Safety www.facebook.com/DraegerSafetyDiagnosticsInc

www.youtube.com/USADraeger

Dräger DrugTest 5000 Drug Testing Device The Dräger DrugTest 5000 system is a fast, accurate means of testing oral ﬂuid samples for drugs of abuse, such as amphetamines, designer amphetamines, opiates, cocaine and metabolites, benzodiazepines, cannabinoids, and methadone. The analyzer oﬀers easy data management with the Dräger Diagnostics Software. FOR LAW ENFORCEMENT USE ONLY.

Convenient carrying handle can easily be carried with one hand―even without bag

Backlit color display clear menu navigation and results display―even in low light conditions

Three-button operation

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Robust housing also suitable for harsh outdoor environments Large analysis chamber opening automatic test run without manual intervention

02 | Dräger DrugTest 5000

Beneﬁts Easy Evaluation The DrugTest 5000 system is designed for easy drug screening and accurate results. ‒ Quick and simple to operate ‒ User-friendly design ‒ On-screen instructions guide you through the drug test

Quick Confirmation The device controls analysis time and internal temperature for accurate results. Positive results can be confirmed with a second oral fluid sample via an independent, third-party laboratory analysis. Results are available online in a matter of days.

Two Step System System components include: ‒ DrugTest 5000 Test Kit: a ready-to-use test cassette with a built-in sample collector and volume adequacy indicator. ‒ DrugTest 5000 Analyzer: a rechargeable, fully automated analyzer providing controlled accurate analysis on site.

Stores, Manages, and Prints Results The analyzer stores the last 500 test results, along with the date and time. You can enter additional subject or test details using the compact keyboard. Data can be downloaded to a PC or printed using the Mobile Printer.

Non-Invasive To protect both you and the donor, sample collection is completely non-invasive. When the cassette is handled correctly, you will not come into contact with the donor’s oral ﬂuid.

Evaluates Unknown Substances You can also evaluate an unknown substance right on the spot. Simply collect a sample with the Surface Sampling Kit (SSK) 5000, transfer it onto the collection tip of the test kit, then analyze the sample for immediate results.

Dräger DrugTest 5000 | 03

Accessories Compact keyboards with PS2 interface, dimensions approx. 28.2 x 13.2 x 2.4 cm. "QWERTZ" - German layout, REF: 8315095 "QWERTY" - English layout, REF: 8315497 "AZERTY" - French layout, REF: 8315142

ST-3451-2003

‒ ‒ ‒ ‒

Carrying case for Analyzer Dräger DrugTest 5000

ST-13321-2008

REF: 8319960

Dräger DrugTest 5000

ST-13212-2007

Transport case REF: 8319925

ST-8404-2006

Dräger Mobile Printer The Dräger Mobile Printer prints breath alcohol and drug test measurement results without using a dedicated power supply. The Mobile Printer documents measurement results of the Dräger Alcotest® 6820, Dräger Alcotest® 7510, as well as some Alcotest® 7410 Plus versions, and the Dräger DrugTest 5000. FOR LAW ENFORCEMENT USE OR USE IN DOT-REGULATED INDUSTRIES ONLY.

04 | Dräger DrugTest 5000

Services Dräger Service

D-19092-2016

When you rely on Dräger breath alcohol and drug screening equipment, you can rest assured you made the right choice. For more than 60 years, we’ve been the global market leader in advanced breath alcohol testing and employ cutting-edge technology to provide devices that are fast, reliable, and easy to use. That’s the Dräger Service Advantage.

Related Products Dräger Alcotest® 9510

ST-430-2006

The Dräger Alcotest® 9510 is an advanced breath alcohol measuring instrument for evidential applications. It is designed to comply with national and international requirements and regulations (OIML R 126). With dual sensor technology, intuitive color touch screen interface, and modern design the Alcotest® 9510 sets superior standards. FOR LAW ENFORCEMENT USE ONLY.

Dräger SSK 5000

D-6296-2009

Ideal for surface drug testing applications, the Dräger SSK 5000 sampling system is quick and easy to use. When used with the Dräger DrugTest 5000, the sample can be transferred to a test cassette and screened for possible drug contamination. The sample can also be stored and transported for further testing. FOR LAW ENFORCEMENT USE ONLY.

Dräger DrugTest 5000 | 05

Related Products Dräger Alcotest® 7510

ST-15093-2008

The Alcotest® 7510 allows for breath alcohol analysis for any application, and is listed on the National Highway Traﬃc Safety Administration's Conforming Product List (NHTSA CPL) as an evidential breath tester. This instrument has received the OIML Certiﬁcate of Conformity. FOR LAW ENFORCEMENT USE ONLY.

06 | Dräger DrugTest 5000

Technical Data Supply Voltage

12 V DC (11 to 15 V DC)

Current Consumption

Typically 3 A

Dimensions (W x H x D)

7.9” x 9.8” x 8.7”

Weight

9.9 lbs

Temperature

Operation: 5 to 40 °C (+41 to +104°F) Storage/Transportation: -20 to +60°C (-4 to +140°F)

Moisture Range

5 to 95%rh, non condensing

Interfaces

Optical IRDA (printer), PS/2, USB Slave

Duration of One Measurement

5 to 10 minutes, depending on type of test

Storage Capacity

500 data sets

Carrying Bag

For Mobile System

Ordering Information Item

Order No.

Dräger DrugTest 5000 Analyzer including power supply, connecting cable and instructions for use.

83 19 900

Consumables Dräger DrugTest 5000 Test Kits - 20/Box (COC, OPI, BZO, THC, AMP, MET, MTD)

83 23 636

Dräger DrugTest Surface Screening Kits - 20/Box

83 20 490

Accessories Compact Keypad (PS/2, dimensions approx. 11.1” x 5.2” x 0.9”) “QWERTY” English Keyboard Layout

44 15 005

Car Cable 12 V (Connecting Cable from car socket/cigarette lighter to DrugTest 5000 Analyzer)

83 12 166

Dräger Mobile Printer

83 19 310

Thermal Paper for Dräger Mobile Printer (1 roll)

44 15 520

Carrying Bag for Dräger DrugTest 5000 Analyzer

83 22 675

USB Connection Cable for Communication with a PC

44 15 001

PC Software Module for Dräger DrugTest 5000

83 19 977

An optional carrying bag is available for the safe transportation of all system components. The keyboard enables information on the test subject and system operator to be entered, allowing a record of this data to be printed out on the spot along with the results.

Dräger DrugTest 5000 | 07

Notes

08 | Dräger DrugTest 5000

CORPORATE HEADQUARTERS

USA

Drägerwerk AG & Co. KGaA Moislinger Allee 53–55 23558 Lübeck, Germany www.draeger.com

Draeger, Inc. 7256 S. Sam Houston Parkway W., Suite 100 Houston, TX 77085 1 800 4DRAGER (1 800 437 2437)

Locate your Regional Sales Representative at: www.draeger.com/contact

Notes

D-9763-2011

Dräger DrugTest® System The new standard in oral fluid screening

D-9764-2011

Accurate, on-the-spot oral fluid drug detection In the past, roadside drug screening has been difficult because it involved the collection of urine or blood samples. The Dräger DrugTest 5000 mobile oral fluid screening system provides an alternative.

D-54723-2012

TWO STEP SYSTEM

D-31773-2011

Now, roadside drug screening can be performed with ease and results are provided within minutes. This non-invasive method lets you screen for seven types of the most commonly abused drugs— while eliminating the embarrassment and hassle of collecting urine or blood samples. System components include: –– Dräger DrugTest 5000 Test Kit: a ready-to-use test cassette with a built-in sample collector and volume adequacy indicator. –– Dräger DrugTest 5000 Analyzer: a rechargeable, fully automated analyzer providing controlled accurate analysis on site.

For Law Enforcement Use Only

D-9765-2011

EASY EVALUATION

The DrugTest 5000 system is designed for ease of use and accurate results. –– Quick and simple to operate –– User-friendly design –– On-screen instructions guide you through the test NON-INVASIVE

Sample collection is completely non-invasive—which is easier for both you and the donor. When the cassette is handled correctly, you will not come into contact with the donor’s oral fluid. QUICK CONFIRMATION

The device controls analysis time and internal temperature for accurate results. Positive results can be confirmed with a second oral fluid sample via an independent, third-party laboratory analysis. Results are available online in a matter of days. STORES, MANAGES AND PRINTS RESULTS

The analyzer stores the last 500 test results, along with the date and time. You can enter additional subject or test details using the compact keyboard. Data can be downloaded to a PC or printed using the Dräger Mobile Printer.

DRUG ANALYTICAL CUT-OFFS Dräger DrugTest® 5000 Test Kit 7 Panel Cut-Off Levels

AMP D-amphetamine

50 ng/mL

MAMP D-methamphetamine

35 ng/mL (MDMA 75)

COC Cocaine

20 ng/mL

THC D9-tetrahydrocannabinol

5 ng/mL

MTD Methadone

20 ng/mL

OPI Morphine

20 ng/mL

BENZO Diazepam

15 ng/mL

EVALUATES UNKNOWN SUBSTANCES

You can also evaluate an unknown substance right on the spot. Simply collect a sample with the Dräger Surface Sampling Kit (SSK) 5000, transfer it onto the collection tip of the test kit, then analyze the sample for immediate results.

D-6296-2009

ST-13221-2007

Collection Tip

Dräger SSK 5000

DrugTest® 5000 Test Kit

PERFORM A TEST 2

D-4780-2011

ST-319-2008

Remove the protective cap from the oral fluid collection tip.

Insert the collection tip into the oral cavity, repeatedly swiping the surface of the cheeks and tongue.

ST-319-2008

ST-322-2008

The indicator tip will turn blue when a sufficient sample volume has been collected. Failure of the indicator to turn blue does not invalidate the test.

Insert the cassette into the analyzer.

ST-319-2008

ST-15164-2008

Insert the buffer cartridge into the analyzer and close the door. The analysis will proceed automatically.

All entered data and results can be printed via the Dräger Mobile Printer. Remove the cassette and attached cartridge from the device.

CORPORATE HEADQUARTERS

Drägerwerk AG & Co. KGaA Moislinger Allee 53–55 23558 Lübeck, Germany

Customer Service: USA

+1 800-4DRAGER (+1 800-437-2437) Technical Service: USA

+1 800-4DRAGER (+1 800-437-2437)

Locate your Regional Sales Representative at: www.draeger.com/contact

www.draeger.com

Dräger DrugTest® 5000

LED Light Source

Detector

Detection Zone

Signal

“Negative”

Signal

“Positive”

+ -

Signal

“Positive”

“Negative”

Dräger DrugTest® 5000

How long it takes

Start up and self-diagnostic time: Collection of Oral Fluid: Keyboard Input: Analysis: Total:

1 minute 4-5 minutes 1-3 minutes 8.5 minutes 14.5-17.5 minutes

To ensure a high degree of Δ9THC sensitivity, an additional incubation step is required for this parameter, and the result is displayed about ten minutes after the start.

Stores 500 samples

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