This case study summarizes a matter in which a window worker was killed while on
the job, resulting in the filing of a lawsuit for negligence. It illustrates how
toxicological interpretation of historical factors and application of peer-reviewed
human studies can play a pivotal role in litigation.
A window washer suddenly and unexpectedly fell to his death.(a)
An experienced window washer working on a 7-story building unhooked his safety belt
to enter the building through an open window when he suddenly fell. Landing headfirst
on the concrete surface of the courtyard below, the man died on impact. A co-worker
immediately called an ambulance but there was nothing that could be done. The two
men had worked as partners for several years prior to the accident. The co-worker
explained to police that the fall was sudden and unexpected and the man had not
yelled out or screamed. He was a highly skilled window washer and there were no apparent
mitigating factors such as wind, water on the ledge or equipment failure.
The deceased man's family alleged negligence on the part of the building owners
and filed a lawsuit for damages. In view of the high settlement demand, attorneys
for defendants retained Dr. Sawyer to conduct an impartial toxicological assessment.
No Apparent Cause
The postmortem examination was unsurprising, clearly indicating the cause of death
as multiple blunt-force injuries sustained from the fall. Toxicological analyses,
however, revealed a peculiar and unexpected finding: a significant level of morphine
was detected in the man's blood.
The co-worker described the deceased worker as a "good-headed" man who
supported his aging parents and a child. He never missed any days of work and was
skilled at his job. However, the co-worker's deposition contained some odd revelations.
At times, he had observed the man exhibiting peculiar physiological conditions
on the job such as sweating, being flushed and disoriented. Although they had
talked about it, the man made no complaints of nausea or pain and insisted that
he was perfectly healthy.
Unexpected Discovery
In the course of preparing a thorough toxicological assessment, Dr. Sawyer reviewed
the sheriff's report, EMT report, medical examiner's report, autopsy analyses and
available postmortem records. He also scrutinized the discovery depositions of
multiple witnesses. Dr. Sawyer then obtained records of the man's medical history
dating back some 15 years and uncovered information which significantly altered
the character of his investigation: The man was a heroin addict.
Some 15 years prior to the accident, the man had begun using heroin. He had later
presented to a health center to discuss substance abuse with a doctor and had been
scheduled for out-patient detoxification, but he failed to appear for treatment.
Ativan and a clonidine patch were prescribed which seemingly had a positive effect
as the man insisted he had abstained from further heroin use. He was scheduled for
further follow-up visits but was a "no-show" for each appointment.
Several years later, the man appeared for follow-up for a gunshot wound to the left
buttock at which time there were indications of continued heroin use. When the man
later presented at the hospital for a testicular neoplasm, he finally admitted continuing
his heroin use. Although in-patient detoxification was scheduled, he again failed
to show up for appointments. He was prescribed clonidine, dicyclomine (for abdominal
cramps) and diphenhydramine (for excessive salivation). Time and again the man indicated
that he wished to beat his addiction, making appointments for which he failed to
appear. This on-again/off-again pattern continued for years. No report indicated
with certainty that his heroin use had ceased.
Heroin and Cognitive Impairment
Heroin impairs the mental and physical abilities required to perform potentially hazardous activities.(a)
Heroin is an opioid drug made from morphine, a natural substance found in the Asian
opium poppy. At doses in excess of the therapeutic range, morphine can impair mental
and physical abilities required for the performance of potentially hazardous tasks.
These include driving, operating machinery or any physical activity involving purposeful
muscular control.
The toxicological literature notes that frequently observed reactions from heroin
use include constipation, nausea, vomiting, lightheadedness, dizziness, sedation,
euphoria and sweating. Significantly, heroin users can also experience clouded mental
functioning and a sudden, unexpected state of semi-consciousness.
The lawsuit alleged that the man was not intoxicated and that the accident was the
result of negligence on the part of the building owners. Since no drug paraphernalia
or drug-related items were found by the police or the medical examiner, Dr. Sawyer
was confronted with a variety of circumstantial factors. These all required appropriate
toxicological context to be interpreted and accepted as evidential by a court.
No "Alternative Facts" Here
In science, objective, generally-accepted, peer-reviewed facts are open to interpretation
only in the sense that they may confound presumptions. Toxicology is based on the
principle that various substances produce causative effects when contacted, inhaled
or ingested. The degree and nature of effects are primarily determined by dose.
Thus, Dr. Sawyer elected to focus upon the causative effects of morphine based on
the blood concentration measured at autopsy. His written toxicological assessment
took the following into account:
- Although some heroin users develop a tolerance for the drug over time, Dr. Sawyer
cited peer-reviewed studies demonstrating that significant cognitive and neuropsychological
impairment remains present regardless of tolerance.
- A study by Bachs,1 et al., 2006, evaluated the relationship between
heroin metabolites and impairment of psychomotor functions. Some individuals selected
from a database of heroin users had morphine present in their blood and some did
not. In the "morphine present" cases, 80% were impaired, but in the "not
present" cases, 86% were unimpaired. This result clearly demonstrated the effects
of psychomotor impairment with morphine present in the blood.
- The prefrontal cortex of the brain is a region responsible for planning complex
cognitive behavior and decision making. A study by Bruin,2 et al., 2001,
found that chronic heroin exposure impairs planning functions of the prefrontal
cortex. This is a consequence of cumulative neuronal damages of prefrontal cortex
and dopamine neurons subsequently demonstrated in experimental and morphological
studies of opiate addicts who died after overdose.
- Plaintiffs contended that the presence of morphine was a result of ingestion of
codeine or poppy seeds. Although the precise source of the morphine in the man's
blood could not be identified with certainty, the forensic evidence and scientific
method ruled out poppy seeds or codeine as sources. Based on the high morphine
blood level, the man would have had to consume unrealistic (impossible) quantities
of poppy seeds to achieve the morphine blood level measured at autopsy. Additionally,
the specific codeine blood level measured 22.6 times lower than the morphine level,
which is inconsistent with morphine converted from codeine administration.
- Although no drug paraphernalia or drug-related supplies were found, the morphine
blood level measured at autopsy was highly suggestive of recent drug abuse. The
generally accepted half-life of morphine is 1.9 + 0.5 hours with an effective concentration
for surgical anesthesia of 65 ng/ml. The morphine level measured in this man at
autopsy was nearly twice this concentration.
Weight of Evidence
Toxicological testimony in the form of a written assessment can carry significant weight in litigation.(a)
Dr. Sawyer's written assessment presented to the court identified the sweating,
dizziness and flushing as consistent with documented reactions from heroin use
(as reported in the toxicological literature). It also noted evidence indicating
heroin self-administration consistent with the documented history of an addict
who had relapsed.
Of particular interest were the findings regarding heroin's long-term cognitive
impairment characteristics. The man's free morphine blood level was within range
for significant impairment regardless of the degree of tolerance that he may have
acquired. Dr. Sawyer cited human studies of heroin addicts which revealed significant
neuropsychological and cognitive impairment critical to a worker's awareness of
structures and distances while requiring precise coordination and accurate footing.
Outcome
It seems the man had managed to keep his heroin addiction a secret for 15 years.
Based upon the available toxicological evidence, Dr. Sawyer offered the opinion
that the man had self-administered heroin that morning and that his chronic heroin
abuse had substantially contributed to his fatal accident. Soon thereafter, the
case settled very favorably for defendant.
Epilogue
The CDC recently reported that heroin overdose deaths have more than quadrupled
in the U.S. and the trend extends backward in time. In 2000, only 6% of drug overdoses
were related to heroin, but 25% of drug overdoses were heroin-related in 2015. The CDC
also warned that adults in the age group of 45-54 years have the highest drug overdose-related
death rate in the nation.
For additional information see: https://www.cdc.gov/drugoverdose/index.html
Notes and References
- Bachs, L. Hoiseth G., Skurtveit S., Morland J., "Heroin-using drivers: importance
of morphine and morphine-6-glucuronide on late clinical impairment," 2006,
European Journal of Clinical Pharmacology, 62(11):905-912.
- Bruin, EA, Gekht, AB, Polunina, AG, Davydov, DM, Gusev, EL, " Neuropsychological
deficit in chronic heroin abusers," 2001, [Russian] Zhurnal Nevrologii i Psikhiatrii
Imeni SS Koraskova, 101(3) 10:9.
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