Glossary of Terms Used by Pathologists for Cause of Death in Drug Related Cases

Version 1.2 (September 2005)

Purpose

This glossary is provided as a resource for users of the National Coroners Information System (NCIS). It is intended to assist users of the database in the interpretation of pathology reports, particularly those for deaths relating to drugs, poisons or alcohol.

The definitions of terms were provided by forensic pathologists around Australia and generally represent their individual professional opinions. As such, more than one interpretation is provided some terms. The definitions provided are not intended to be collectively exhaustive and other interpretations of the term may be relevant. While the glossary is provided to assist NCIS users, you should be aware that a given definition may not reflect the view of a pathologist who reported a particular case. In addition, the list of terms is not intended to include all terms used by pathologists in reporting cause of death in drug related cases. The definitions are in no way intended to be prescriptive to pathologists. The NCIS (previously referred to as MUNCCI) collated this glossary in good faith and assumes no responsibility for the accuracy of the definitions provided.

The NCIS and Australian forensic pathologists have made this glossary available for the personal, non-commercial use of NCIS users. The glossary may not be used for any commercial purpose. Further, the glossary may not be used for any legal purpose. The definitions may not be taken from the glossary and reprinted in any form without the express written permission of the NCIS.

Acknowledgments

This glossary was collated by Natasha Redman, Project Officer – Drugs Module, in March 2001 based on definitions provided by forensic pathologists around Australia. The NCIS wishes to thank all pathologists who contributed to the glossary, in particular:

Prof Stephen Cordner, Victorian Institute of Forensic Medicine, VIC Dr Peter Ellis, Institute of Clinical Pathology and Medical Research, NSW Prof Peter Herdson, Consultant Forensic Pathologist, ACT Dr Ross James, Forensic Science Centre, SA Dr Robert Kelsall, Dept of Forensic Pathology, Royal Hobart Hospital, TAS Dr Dianne Little, Institute of Clinical Pathology and Medical Research, NSW Dr Matthew Lynch, Victorian Institute of Forensic Medicine, VIC Dr Charles Naylor, John Tonge Centre, QLD Assoc Prof David Ranson, Victorian Institute of Forensic Medicine, VIC The Role of the Forensic Pathologist by Associate Professor David L Ranson 1 and Natasha C Redman 2 1 Victorian Institute of Forensic Medicine; 2 Monash University National Centre for Coronial Information

Today, much of the function of the office of coroners in Australia is focused on prevention, with the coroner empowered to make broad recommendations surrounding the issues of public health and safety and judicial administration. Such an approach gives the coroner a dynamic function in contributing to the welfare of the community. In this modern framework the role of the forensic pathologist has been revitalised. The forensic pathologist is not involved only with the investigation of suspicious deaths that may have a criminal connotation. Rather, the forensic pathologist's role has been widened to include a wide range of natural and unintentional deaths, investigation of which can lead to improvements in the health and safety of the community. In conjunction with the coroner, the forensic pathologist is a watchdog who maintains a constant surveillance on potential fatal hazards in our society and ensures that preventable deaths are recognised and the issues surrounding them addressed.

Legal jurisdictions differ in the way they organise death investigation services and the relationship between a coroner and police investigators is at times complex. Some general rules, however, appear to be common. The authority to investigate a death lies with a coroner and it is the coroner who institutes and authorises a pathologist to perform a post-mortem examination. The police have a similar duty to investigate a death and, with respect to certain aspects of the death investigation, they act as agents of investigation for the coroner. In this situation, the forensic pathologist is another co- investigator for the coroner.

Traditionally, the forensic pathologist has been considered to be involved solely in the conduct of an autopsy. In practice, however, forensic pathologists play a much wider role. For example, they may become involved in the examination of scenes of death, or, in the case of criminal investigations, in the examination of suspects who may have inflicted injuries on the victim. They may evaluate medical records for both criminal and civil medico-legal purposes, and examine the statements of witnesses with regard to medical matters before a wide variety of tribunals.

Despite this varied role, the forensic pathologist’s main task is still the conduct of autopsies for the coroner. The vast majority of autopsies conducted by forensic pathologists involve unconfirmed natural deaths which society requires to be scrutinised and confirmed. The investigation of non-suspicious natural deaths, accidents (fatal incidents), deaths from suicide, deaths from drugs and deaths from other forms of intentional and non-intentional injury form the vast majority of their case work. The information that can be gained from investigating these deaths is potentially very significant for the community. The investigation of suspicious deaths is another vital role of the forensic pathologist. In such cases, they are involved in the compilation of a brief of evidence that may form part of a prosecution within the criminal justice system. In such cases, the forensic pathologist assists with the evaluation and presentation of that evidence both before and during court proceedings, in addition to the other elements of the standard death investigation.

One of the responsibilities of the forensic pathologist is to determine issues relating to the cause of death and circumstances of death of individuals. In this context, forensic pathologists have a specific interest in forensic toxicology. Where deaths are apparently the result of toxic substances, a forensic pathologist must collect the appropriate body samples and, together with a forensic toxicologist, arrange for the most appropriate analysis.

Toxicological analysis is a routine part of most of forensic autopsies. The toxicologist analyses human tissues for the presence of drugs and other chemical agents that may have been taken into the body. Homicides, suicides and motor vehicle accidents are perhaps the most common cases in which drug analysis is involved. However, there is a wide variety of apparently accidental deaths, including those associated with work and recreation, where toxicology and drug analysis are important in analysing the circumstances of the death.

An environment that provides a high level of communication between the disciplines of forensic pathology and forensic toxicology is ideal for the investigation of problematic suspicious deaths. Ultimately, the forensic pathologist must integrate the result of the autopsy and results of toxicology testing together with other laboratory tests to arrive at an overall expert opinion regarding the medical cause of death.

Recommended Reading (Brodrick Committee Report.) Cmnd. 4810. Report Of The Committee On Death Certification And Coroners. November 1971. Published by the Home Office in the United Kingdom, London 1971. Busuttil, A. and Jones, J. S. P. Deaths in Major Disasters : The pathologist's role . The Royal College of Pathologists, London 1990. Crowther, M. Anne, and White, Brenda. On Soul and Conscience : The medical expert and crime: 150 years of forensic medicine in Glasgow . Aberdeen University Press, Aberdeen 1988. Gonzalez-Crussi, F. Three Forms Of Sudden Death : And other reflections on the grandeur and misery of the body . Picador, London 1987. Hill, Rolla B; and Anderson, Robert E. The Autopsy : Medical practice and public policy . Butterworths, Boston 1988. Knight, Bernard. Forensic Pathology. Edward Arnold, London 1991. Plueckhahn, V. D. and Cordner, S. M. Ethics, Legal Medicine & Forensic Pathology . 2nd Edition. Melbourne University Press, Melbourne 1991. Selby, Hugh. (ed.). The Aftermath of Death: Coronials. Federation Press, Leichhardt, NSW, 1992. Spitz, Werner U. (ed.) and Fisher, Russell S. Spitz And Fisher's Medicolegal Investigation Of Death: Guidelines for the application of pathology to crime investigation. Charles C. Thomas, Springfield, Ill. 1993. A ABUSE (eg. alcohol, ethanol, cigarettes, tobacco, drug, specific drug) To take a drug for non-therapeutic reasons; Non-therapeutic use; The excessive use of drugs without regard for health and wellbeing; Use of an illicit substance or overuse of a licit substance; May be used when there is a background of “abuse” but no significant toxicity. ACUTE ABUSE (eg. intravenous morphine) Acute toxicity / non-therapeutic use; The taking of a single dose of a drug without regard to health or wellbeing; Recent abuse (no evidence of chronic abuse). CHRONIC ABUSE (eg. alcohol, drug) Long term use of an agent resulting in a deleterious effect; To take a drug non-therapeutically over a long period of time; Long term non-therapeutic use; Long term excessive use of drugs without regard for health and wellbeing; Longstanding abuse. ABUSER One who uses a certain drug; Somebody who uses drugs to an extent that it could affect their health and wellbeing. ACCIDENTAL OVERDOSE See Overdose. ACUTE ABUSE See Abuse. ACUTE NARCOTISM Sudden death following administration of a narcotic opiate, from any mechanism; Death following ingestion (usually by injection) of heroin; Acute narcotic toxicity; The acute toxic effects of a narcotic drug. ACUTE ON CHRONIC ALCOHOLISM High blood alcohol in someone with pathological evidence of alcohol-related disease; Acute alcohol toxicity on a background of chronic alcohol abuse; Recent bout of drinking in a known chronic alcoholic; Acute alcoholic intoxication against a background of chronic alcoholism. ACUTE ON CHRONIC DRUG ABUSE Recent ingestion of a drug or drugs where there is previously known chronic drug abuse of that drug or drugs. ACUTE OVERDOSE See Overdose. ACUTE POISONING See Poisoning. ACUTE TOXICITY See Toxicity. ACUTE WITHDRAWAL See Withdrawal. ADDICT A person who habitually uses a drug, where there is diminished control over their use of the drug. ADDICTION Repeated need for a drug over and above primary clinical / other necessity; The habitual use of a drug where there is diminished control over the drug use. ADMINISTRATION / ADMINISTERED To give (a drug); Given by self or somebody else. SELF-ADMINISTRATION Given (by any means) by the subject; To give (a drug) to oneself; Given by oneself. ADVERSE EFFECTS OF . . . See Effects Of . . . AFFECTED BY . . . (eg. alcohol, cannabis) Clinical behaviour alterations caused by . . . ; Altered physical and mental function caused by a drug. ALCOHOLIC Alcoholism; Someone dependent on alcohol; Somebody who habitually uses alcohol; Usually concluded on the basis of history provided by the police. KNOWN ALCOHOLIC Person who is a recognised alcoholic; Usually concluded on the basis of history provided by the police. ALCOHOLIC CIRRHOSIS See Cirrhosis. ALCOHOLIC LIVER DISEASE Any of a number of conditions of the liver that result from overuse or long term ingestion of alcohol; Pathological changes in the liver typical of those seen due to chronic alcohol intake; Where liver disease caused by alcohol is identified; Disease, not drug, is the direct cause of the death. ALCOHOLIC SEIZURE Seizure related to alcohol use; Seizure caused by alcohol; Probably not the same as Alcohol Withdrawal seizure; The drug is an indirect factor in death. ALCOHOLISM Physical / psychological dependence on alcohol; The abuse of alcohol; Usually concluded on the basis of history provided by the police. CHRONIC ALCOHOL ABUSE Alcoholism; The long term abuse of alcohol; Usually concluded on the basis of history provided by the police plus supporting pathological evidence. CHRONIC ALCOHOLISM Alcoholism; Long term (not specified) use of alcoholic drink; Physical / psychological dependence on alcohol; The long term abuse of alcohol; Usually concluded on the basis of history provided by the police plus supporting pathological evidence; Used to describe disease when there is historical and post mortem evidence of this. ALCOHOL WITHDRAWAL SEIZURE Seizure related to alcohol withdrawal; Seizure caused by withdrawal of alcohol; Probably not the same as Alcohol Seizure; The drug is an indirect factor. ASPHYXIA The mechanical obstruction of oxygen intake; Generic term for lack of oxygen; Hypoxia due to external factors, but not related to drugs.

B BINGE DRINKER Alcoholism; One who indulges in repeated episodes of heavy drinking, separated by periods of reduced or absent alcohol drinking.

C CARBON MONOXIDE POISONING / OVERDOSE / TOXICITY A toxic level of carbon monoxide in the blood by toxicological examination. CARBON MONOXIDE POISONING; CAR EXHAUST Toxicity due to CO from car exhaust fumes; CO toxicity from car exhaust; A toxic level of carbon monoxide in the blood detected by toxicology resulting from the intake of car exhaust fumes; Toxicological evidence of toxic / fatal CO levels (from car exhaust); Toxic effects of carbon monoxide. CHRONIC ABUSE See Abuse. CHRONIC ALCOHOL ABUSE See Alcoholism. CHRONIC ALCOHOLISM See Alcoholism. CHRONIC INGESTION See Ingestion. CHRONIC LIVER DISEASE (ALCOHOL RELATED) Alcoholic liver disease; Where chronic liver disease caused by alcohol is identified; Disease, not drug, is the direct cause of the death. CHRONIC POISONING See Poisoning. CHRONIC TOXICITY See Toxicity CHRONIC USE See Use. CIRRHOSIS Alcoholic liver disease (presuming alcohol is the cause); Literally excessive fibrosis and includes the syndrome of chronic liver disease, often caused by alcohol, characterised by excessive fibrosis and other changes in the liver; Diffuse liver disease with regenerative nodules separated by fibrous scars; Disease, not drug, is the direct cause of the death. ALCOHOLIC CIRRHOSIS Cirrhosis associated with chronic alcohol abuse; Cirrhosis which can be directly attributed to alcohol; Cirrhosis due to alcohol; Disease, not drug, is the direct cause of the death.

COMBINED DRUG TOXICITY (also Mixed or Multiple Drug Toxicity) Combined toxic effects of substances; Acute or chronic toxicity using more than one drug; Combined effect of drugs is toxic even if individually each drug is at therapeutic level; The combination of drugs is a direct or an indirect cause of the death; Where more than one drug may have contributed to death. COMBINED EFFECTS OF . . . See Effects Of . . . CONSUMPTION / CONSUMED Probably swallowed; Administration / taking of a substance; The intake of a substance. EXCESSIVE CONSUMPTION The inappropriate consumption of an agent.

D DEPENDENCE / DEPENDENT (eg. drug, nicotine, tobacco, specific drug) Repeated need for a drug over and above primary clinical / other necessity; Physical / psychological need for a drug; History of withdrawal syndrome; The situation in which a person believes that he/she is unable to function without a particular drug. KNOWN DRUG DEPENDENCE History of withdrawal syndrome; Where someone is known to have a drug addiction. DUST EXPOSURE The exposure to dust or dusts of the type known to produce human disease.

E EFFECTS OF . . . Biochemical or clinical results of exposure to drug; Consequences of . . . ; The effects produced by any particular noxious or traumatic agent. ADVERSE EFFECTS OF . . . Untoward consequences of . . . ; Effects of a drug, not intended by the manufacturer and which can produce alterations in physical and mental function. COMBINED EFFECTS OF . . . Biochemical or clinical results of exposure to multiple drugs; Interaction of . . . ; Combined toxicity of . . . ; The effects produced by more than one particular noxious or traumatic agent. TOXIC EFFECTS OF . . . Untoward consequences of . . . ; The effects produced by any particular noxious or traumatic agent, where toxic levels of drugs are involved. See Toxicity. EXCESS (eg. alcohol) More than is considered necessary / safe / healthy; Too much; Drug intake in excess of that recommended for health and wellbeing. EXCESSIVE ALCOHOL Alcohol toxicity; The abuse of alcohol. EXCESSIVE ALCOHOL BLOOD LEVEL Alcohol toxicity; Where the level of alcohol in the blood detected by toxicology is at a level considered to impair physical and mental performance. EXCESSIVE CONSUMPTION See Consumption. EXCESSIVE INTAKE See Intake. EXCESSIVE INTOXICATION See Intoxication. EXCESSIVE USE See Use.

F FREQUENT DRUG USER See User.

H HEAVY ALCOHOL CONSUMPTION Alcoholism; The abuse of alcohol. HEAVY ALCOHOL INTAKE Alcoholism; The abuse of alcohol. HEAVY DRINKING Alcoholism; Drinking alcohol to a level well above the standard, generally regarded as 4 units of alcohol for men and 2 for women. HEAVY INTOXICATION See Intoxication. HIGH BLOOD ALCOHOL High level of alcohol in the blood; Alcohol toxicity; Where the level of alcohol in the blood detected by toxicology is at a level considered to impair physical and mental performance. HISTORY OF ABUSE / USE History given by police / hospital that person used a particular drug (non-therapeutic); One who uses a certain drug; Where there is a known history of drug abuse or usage. HISTORY OF ALCOHOL ABUSE Alcoholism; Where alcohol abuse is indicated in the circumstances surrounding the case as provided. HISTORY OF ALCOHOLISM Alcoholism; Where alcohol abuse is indicated in the circumstances surrounding the case as provided; Usually concluded on the basis of history provided by the police plus supporting pathological evidence.

I INGESTION (eg. alcohol, ethanol, drug, marijuana) Swallowed; Administration / taking of a substance; The intake of a drug or other substance orally. CHRONIC INGESTION (eg. alcohol) Administration / taking of a substance over a prolonged period; Long term ingestion. INHALATION OF GAS & AEROSOL Toxicity of gas / aerosol; Ingestion of gas or aerosol by inhalation. INHALATION OF TOXIC FUMES (eg. carbon monoxide) To breathe in poisonous gases; Toxicity from inhaled substances; Ingestion by inhalation of chemical substances which could have an adverse effect on physical or mental function; eg. “Inhalation of fire fumes” may be interpreted as carbon monoxide poisoning in a fire. INTAKE Oral exposure; Ingestion; Things taken in by the body. EXCESSIVE INTAKE (eg. alcohol) Ingestion of large amounts; Intake to excess. INTERACTION Where two drugs interact with one another to produce an effect which is not designed for either of the drugs alone. INTOXICATION Clinical manifestation of harmful effect of drug / poison; Presence of a drug detected by toxicological analysis at a level which could impede normal physical functions, such as coordination, consciousness etc. See Toxicity. HEAVY INTOXICATION Well above the therapeutic level on toxicological analysis. EXCESSIVE INTOXICATION Well above the therapeutic level on toxicological analysis.

K KNOWN ALCOHOLIC See Alcoholic. KNOWN DRUG DEPENDENCE See Dependence / Dependent . KNOWN USER See User. KNOWN DRUG USER See User.

L LEVEL (DRUG) Concentration (of drug); Level detected by toxicological estimation using standard chemical procedures and reported accordingly. LONG TERM DRUG USER See User.

M MIXED DRUG OVERDOSE See Overdose. MIXED DRUG TOXICITY (also Combined or Multiple Drug Toxicity) Combined toxic effects of substances; Acute or chronic toxicity using more than one drug; Combined effect of drugs is toxic even if individually each drug is at therapeutic level; The combination of drugs is a direct or an indirect cause of the death; Where more than one drug may have contributed to death. MULTIPLE DRUG OVERDOSE See Overdose. MULTIPLE DRUG TOXICITY (also Combined or Mixed Drug Toxicity) Combined toxic effects of substances; Acute or chronic toxicity using more than one drug; Combined effect of drugs is toxic even if individually each drug is at therapeutic level; The combination of drugs is a direct or an indirect cause of the death; Where more than one drug may have contributed to death. MULTIPLE SUBSTANCE DRUG OVERDOSE See Overdose. MULTI SUBSTANCE ABUSE See Substance Abuse.

O OVERDOSE (eg. drug, accidental, specific drug) Administration of drug above safe or therapeutic level; Excessive amount of drug causing deleterious effect; Presence of a drug in the blood stream by toxicological analysis at a greater than therapeutic or lethal level; Deliberate or inadvertent drug administration obviously in excess of therapeutic amounts. See Toxicity. ACCIDENTAL OVERDOSE An overdose which is accidental. ACUTE OVERDOSE See Overdose, Toxicity. MULTIPLE DRUG OVERDOSE Overdose using multiple drugs. See Toxicity – Chronic toxicity. MIXED DRUG OVERDOSE Overdose using multiple drugs. See Toxicity – Chronic toxicity. MULTIPLE SUBSTANCE DRUG OVERDOSE Overdose using multiple drugs. See Toxicity – Chronic toxicity. OVERINDULGENCE (eg. alcohol) See Intake – Excessive Intake. OVERUSE (eg. alcohol ) Drug intake in excess of that recommended for health and wellbeing.

P POISONING (drugs, chemicals, CO, etc) Direct harmful effect of a chemical usually by virtue of an abnormally high quantity; Adverse effects of the substance on the body; The presence of a drug or drugs detected in the blood stream by toxicological analysis at a toxic or lethal level; Drug or chemical is a direct or an indirect cause of the death; Death due to adverse effects of exposure. See also Toxicity. ACUTE POISONING Direct harmful effect of a chemical usually by virtue of an abnormally high quantity, occurring soon after drug administered . See Toxicity, Toxicity – Acute Toxicity, Poisoning. CHRONIC POISONING (eg. alcohol) Chronic abuse at a toxic level . See Toxicity – Chronic toxicity. PREVIOUS HIGH ALCOHOL INTAKE Alcohol abuse in the past.

R RECENT CANNABIS USE Where they are known to have smoked cannabis within recent days or show toxicological evidence of having used cannabis.

S SELF-ADMINISTRATION See Administration. STEROID TREATMENT Treatment using cortisone or its related compounds. STEROID USE Usually refers to administration of anabolic steroid (for any cause); Use of cortisone or related compounds. SUBSTANCE Drug or other socially abused material - marijuana, petrol fumes etc. SUBSTANCE ABUSE Non-therapeutic use of drugs / toxins; The excessive use of drugs without regard for health and wellbeing; May be used when there is a background of “abuse” but no significant toxicity. MULTI SUBSTANCE ABUSE Non-therapeutic use of multiple drugs / toxins; The excessive use of more than one substance without regard for health and wellbeing; Abuse of more than one substance.

T THERAPY (eg. warfarin, anticoagulant) Treatment; Medical use of agent; Use of drugs for a medical purpose. TOXIC EFFECTS OF . . . See Effects Of . . . TOXICITY (eg. alcohol, cannabis, drug, specific drug, acid) Harmful effect of a drug (not specific to nature of harm); Poisonous effects of the substance on the body; Adverse effect of substance; Intake of drugs producing blood levels in the known toxic range as detected by toxicological analysis; Toxicological evidence of drug level above therapeutic or unknown toxic range at time of death; The drug is a direct or an indirect cause of the death; Death attributed to an adverse effect of the substance in question; The level of the drug / substance has somehow caused the death. ACUTE TOXICITY (eg. alcohol, cannabis) Poisonous effects of the substance on the body over a short period of time; Acute adverse effect of substance; Intake of drugs producing blood levels in the known toxic range as detected by toxicological analysis; Toxicological evidence of drug level above therapeutic or unknown toxic range at time of death. CHRONIC TOXICITY (eg. alcohol) Adverse effect of chronic use of substance; Continued use of a drug so that it is at a level of toxicity for a long period of time; Long term exposure – may be abuse or not. See also Combined Drug Toxicity, Mixed Drug Toxicity and Multiple Drug Toxicity.

U UNDER THE INFLUENCE OF . . . Affected by a drug; eg. Death due to multiple injuries consistent with being involved in a MVA "whilst under the influence of …". USE (eg. alcohol, cigarettes, cannabis, kava, drug, specific drug) To take a drug; The intake of drugs by whatever means are appropriate; Specific drug identified toxicologically. EXCESSIVE USE The excessive intake of drugs by whatever means are appropriate. CHRONIC USE (eg. alcohol) To take a drug over a long period of time; Long term usage. USER (eg. drug user, user of a specific drug) One who uses a certain drug; A person who uses drugs. KNOWN USER One who uses a certain drug; Someone who is known to use drugs. KNOWN DRUG USER One who uses a certain drug; Someone who is known to use drugs. LONG TERM DRUG USER One who uses a certain drug; Where drug use is continued for a long period of time (time unspecified). FREQUENT DRUG USER One who uses a certain drug; Somebody who frequently uses drugs.

W WITHDRAWAL (eg. alcohol) Clinical effect of ceasing or reducing drug exposure in individual previously tolerant; Adverse effect(s) of discontinuation of drug/substance; Those symptoms produced by the withdrawal from a drug of dependence. ACUTE WITHDRAWAL (eg. alcohol) Acute effects of withdrawal.