Joey Gareri, M.Sc. response to Dr. Chatterton witness statement

8/10/2019 Joey Gareri, M.Sc. response to Dr. Chatterton witness statement

1/11

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January

18,2013

Randy

Schwartz,

Crown

Counsel

Ministry

of the

Attomey

General

Crown Law

Office,

Criminal

10'h

Floor,720

Bay

Street

Toronto,

Ontario

c/o Detective

Tim

Johnstone

Detective

#456

Toronto Police

Service, 43

Division

'lirn.

J

ohnstone(41 o_rolteipo

Ii ce. on. ca

RE: Hair

analysis

in.R.

v.

BroomJield,

Tamara

Dear Mr.

Schwartz,

ffi

This report

is being

provided,

at

your

request,

in

order

to

respond to the items

raised by

Dr. Craig

Chatterton

inhis lTitness

Statement,

submitted

as

Exhibit I

to

his affidavit

(Court

File

No.

C52434),

dated

November 2,2012.

I will respond

as directly

as

possible

to

each

specific

item contained

within

Dr.

Chatterson's opinion

on a

page

by

page

basis:

LABORATORY

ACCREDITATION

(p.

6

of

22)

Our laboratory

in

iicensed

through

Ontario Laboratory

Accreditation

(OLA)

under

the

Ontario

Medical

Association's

Quality

Management

Program

for Laboratory

Services

(QMP-LS).

OLA is

a

partner

of

the

Standards

Council

of

Canada

and

OLA

requirements

are based

on Intemational

Organization

for

Standardization (ISO)

criteria,

augmented

with additionai

criteria

pertaining

to government

regulation

and

generally

accepted

principles

of

good practice

tll.

A11 methods

used

by

the

Motherisk

Laboratory

in

clinical

reporting

have been

vaiidated.

o,

Regarding

our

proficiency

testing, we

have

participated

in

the

intemational

proficiency

testing

program

provided

by the

Society of Hair Testing

(SOHT)

for

over

ten

years.

The

international

SOHT

program

is

the

only

available proficiency

testing

program

for hair analysis

of

drugs

in

Canada.

To address

Dr.

Chatterton's

concern

regarding our

proficiency

testing performance,

I

have

inciuded in

my report

our

proficiency

testing results

from

2005

(see

Appendix

1).

You will

note that

our laboratory's

performance

for

cocaine

analyses

show

ow test

methods

to

be

within

one

standard

deviation

of

the

mean

of

participating

and

reference laboratories

and

that

our

benzoylecgonine

analyses

demonstrate

that

our

laboratory

was

showing a bias towards

underestimating

benzoylecgonine

ievels

in

hair. In

our

entire

proficiency

testing

history during

my

tenure

managing

this

iaboratory

(2005

to

present),

we

have

no

instances

of false-positive

or false-negative

iindings for

cocaine or benzoylecgonine.

HAIR TEST

RESULTS

(p.

7

of

22)

I

would

like

to note that

Dr. Chatterton

has erroneously

reproduced

our results

on this

page

of his Witness

Statement.

The

segments

listed for

Reference

9223 are "0-1cm"

and

"1-2cm",

when

in fact

the segments

tested

from

Refereice"9223

were "0-1cm"

and

"1-15cm".

CHOICE

OF

ANALYSIS

(p.

10-12 of

22)

:rred

to

in

the

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To clarifu,

this

child's

hair

test results

were

obtained

via

enzyme-linked immunoso.rbent

assay

(ELISA)

from

Immunalysis

Corporation

as

stated

in

Ms.

Karaskov's

testimony

in-chief

(p.

1093),

and

not

radioimmunoassay.

As Dr.

Chatterton

presented

for

Immunalysis'

Cocaine/Cocaine

Metaboiite Direct

zuA

Kit,

the

ELISA kit

contains

a

similar

manufacturer's

instruction:

The

Immunalysis

COCAINE

Direct

ELISA Kit

provides only

a

preliminary

analytical

test

result.

A

more

specift.c

slternate

chemical method

must

be

used in

order to

obtain

a confirmed

analytical result.

Gss

chromstography/

mass

spectrometry

(GC-MS)

is

the

preferred conJirmatory

method

Professional

jadgement

should

be

applied

to

any

drug of abuse

test

result,

particularly

when

preliminary

positive

results are

used.

Dr.

Chatterton

is correct

about immunoassay

tests

generaliy

serving

as a

preiiminary

screening

method

for

analyticai results

in

many

iaboratories. The

caveat

to

this is

that whether

an immunoassay

is

simply

a

preliminary test

or

whether

the results

can

be considered

robust is

dependent

upon

the

performance

characteristics

of

the specific

imrmrnoassay

test

invoived.

Immunoassay

test

performance varies from

analyte

to

analyte

and

for

the same analyte

between

different

manufacturers.

Because

most

immunoassay

tests

are designed

for

and used

as

preliminary screening

methods,

Dr'

Chatterton

is

correct

to

raise the

question

of

unreliability

of

immunoassay-based

results,

however he is

incorrect

in

concluding

that

our

immunoassay

test results

were

unreiiable.

His

assertion

is based

on an

incomplete

understanding

of

the capability

of

some immunoassays

to

perform in a

much more

robust

manner

than others.

All

methods

used

in

our

laboratory

undergo

extensive

validation.

Unlike

routine

tests

for

urine

and blood,

there were

no commercially

available immunoassay

kits specifically

designed

for

analysis

of

hair

extracts

in 2005

or eariier.

To my

knowledge,

we

are

the only laboratory

that does

routine

child

and neonatal hair

analysis

in

Canada;

no

manufacturer

is

going

to

produce

a

product

labeled

specifically

for our use

right

out

of

the box.

The

manufacturer'

s

instructions,

while

useful,

are not

gg43r

and as stated,

are

subj

ect

to

professional

judgement.

In

developing

our

testing methods

we took

eGTffi'analyticai

tools

and adapted

them

for

analysis

of

neonatal

and child

hair,

adjusting the

test

conditions

in

order

to optimize

performance.

The

following

paragaphs will specifically

address

the aspects

of

forensic

sampie

anaiysis

raised

by Mr.

Chatterton

in

page

12

of

his

Witness Statement:

As

part

of our

routine

protocol;

and

specifically

in

testing

Malique's

samples;

we used

a

6-point external

matrix-matched caiibration

curve

using certified

standard

reference materials

and

quality control

samples

including

a

biank

hair

sample and

a

positive-control known

to contain

cocaine

and

benzoylecgonine.

It

should

be noted that

Ms. Karaskov

briefly

described

our

laboratory's

use

of

standards

and

quality

controi

samples

in

her

testimony

in-chief

(p.

109a).

It is apparent on

this

page,

by his

reference

to

"carry-over

between

analyses"

that

Dr.

Chatterton

is

speaking in

general

terms

and

not specificaliy

in relation

to the

testing

we

conducted

on

Maiique's

hair.

He is

aware

that our

testing was done

by

immunoassay;

with

immunoassay,

sample

carry

over

is not

an

issue

as each sample

is tested

in

an

independent

well.

Carry-over

must be

assessed

in

GC,MS

and

LC,MS

based

testing

where

all

samples

are injected

into

one analyical

system

and

the detection

of

very high

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concentrations

of analye

on one

sample may leave residual

analyte

that

shows up

when

the

next

sampie

is

injected.

I disagree with

Dr.

Chatterton's

opinion

that

"cocaine

and

benzoylecgonine

cannot be

unequivocally

identified

using

immunoassay

techniques

".

Over the

years,

in

order

to continually

assess

the accuracy

of

our

immunoassay

methods, we have

extensively

cross-tested our

ELISA

results against

gas

chromatography

/ mass

spectrometry (GC/\4S)

methods

and

liquid-chromatography

tandem-mass

spectrometry

GC/MS-MS

methods

from

an

extemal reference laboratory

(United

States Drug

Testing

Laboratories;

Des

Plaines, Illinois).

in

addition to

oul annual

proficiency

testing,

we

have independently

cross-tested

over

one-hundred

cocaine-positive and

benzoylecgonine-positive

(by

ELISA) hair

samples against

GC-MS

and LC-MSAvIS.

OUTELISA method

shows a

confirmationrate

of

960/o

for cocaine

and

100%

forbenzoylecgonine,

The

few samples

demonstrating

non-concordance

are

those

with

low

concentrations

near

the

recommended

SOHT cut-off for

cocaine

of

0.5

ngimg.

In

cocaine- and benzoylecgonine-positive

samples demonstrating

concentrations

above

1.0

nglmg

(two-fold

lower than Malique's lowest result);

the

rate

of

agreement

between our

BLISA

and

mass

snectrometrv-based

testins is

10070.

I

disagree with

Dr.

Chatterton's opinion that

"accurate

quantitative

data

concerning these

drugs

cannot

be obtained by immunoassay

because

of

the potentialfor

compounds,

wltich

are

unrelqted to cocaine

and

benzoylecgonine,

contributing

to

the magnitude

of

a

positive

result,

based

on their

cross-reactivity".

Based on the

information I

have

provided

above,

it

is

evident

that

our manner

of

determining cocaine

and

benzoylecgonine results by

ELISA were very

robust and

accurate. We

have

no

history of

false-positive

cocaine

or

benzoyiecgonine

results

using this

highly specific

immunoassay

method as measured

against

chromatographic

mass spectrometry-based

methods and

through

our

annual

proficiency

testing

program.

It is

my

opinion

that there is no

reasonable

possibility

of

false-positive

cocaine

and/or benzoylecgonine

results

in

our assessment of

Malique's

hair. This opinion is supportedby

the

performance

record

of

our

ELISA

test

as

well

as the

following

facts related to

this

specific case:

n,

i)

Two hair

tests

were

conducted

on Malique;

Reference No.

9223 and

10175;

the

samples were

tested

months

apart

using two

different

manufactured lot numbers and

showed consistent results

with

one

another.

This

effectively ru1es

out any

reasonable

possibility

of

random

error

in the

results

(random

errors cannot

be

controlled for

through

analytical

methodology).

ii)

The

two

hair

tests conducted

were

both

segmented:

two

segments

for

9223 and

fifteen

segments

for

10175.

Each

segment

is of hair

is extracted

and tested individually, so

practically

speaking

we

conducted

seventeen

separate tests

on

Malique's hair,

all

of

which

were

positive

for

cocaine and

benzoylecgonine.

This

again,

effectively

rules out

any

reasonable

possibiiity

of

random

error in

the results

we

obtained.

iii)

Our laboratory

was not

the

only laboratory

to

clearly

determine

systemic

(i.e.

internal

to the

body)

exposure

to

pocaine

in

Malique. Testing conducted

by

the

Hospital for

Sick

Chiidren's

Department

of

Paediatric

Laboratory

Medicine confirmed the

presence

of cocaine

in

Maiique's

urine

and

gastric

content

and the

presence

of

benzoylecgonine

in Malique's

urine.

These

results

were

determined

by both

immunoassay

and

liquid

chromatography.

Furthermore,

the

Centre

for

Page

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Forensic

Sciences

also confirmed

the

presence

of cocaine and

benzoylecgonine

in Malique's

blood

and

urine

samples.

Both

of these

reports are available

in tab

10

of

the document brief.

The

independent

analysis

of

all these

samples confirming the

presence

of cocaine

and

benzoylecgonine

effectively

rules

out any

reasonable

possibiiity

of

some mysterious unknown

compound

impacting

the results

obtained

in

our laboratory.

INTERPRETING

MOTHERISK LABORATORY

RESULTS

(p.

13

of

22)

"The analytical

results presented

by

Motherisk

Laboratory

raise

immediate

concerns

because

the

reported concentrqtions

of cocaine

and

benzoylecgonine

are extraordinarily

high.

They

are

so

high

that

they

call into

question

their

validity.

Th"y are higher

than

the

results that

would

be expected

for

an adult

cocaine

(or

crack)

addict."

The

results

are extraordinarily

high,

but

the

magnitude of the

cocaine

and

benzoylecgonine

levels

in

Malique's hair in

and

of itself

does not

constitute evidence of

invalidity

of

the

results.

If

this were

a sinele

result

of

unusually

high-magnitude, validity

would rightfully

be

questioned;

however

Malique's

results

do

not

constitute

a single

piece

of data.

Seventeen separate

hair

extracts

were tested

with

consistent

findings.

Extraordinarily

high hair

concentrations

are

not actually

out of

place

in this clinical

situation.

The

entire

clinical

presentation

was

extraordinary.

This is

a

highly unique

case; the

physiological

consequences

to

the

chiid were

extraordinary

as

well.

Unusually high

ingestions and

chronic

exposures are a

hallmark

of

clinical

toxicoiogy

cases.

One

of

the

primary

challenges in

clinical

toxicology

is

the

ability

to

assess

the

effectiveness

of

interventions

because

overdoses are

so highiy

variable

between

patients.

n,

"For

guidance,

research

has suggested...

concentrations

in

the range

4 to

21ng/mg

are

suggestive

of

moderate

drug

abuse

for

users

who typically

use

in

excess

of

1

gram

of the drug

per

day"

While

research

on

adult users is

important

in

supplementing

child-only research in

advancing

our

understanding

of

child

hair

test

result

interpretation; adult

research

is

based

on adult

paradigms

of

drug

exposure

and

adult

physiology

with

regards

to

pharmacokinetics

(e.g.

drug absorption,

metabolism,

distribution,

elimination

in

the body).

Adult

research data

does not

provide

us

with

a

clear

picture

of

how

children

respond

to drug

exposures and

therefore

adult

data cannot be used

to

state that my interpretation

of these

findings

or

the findings

themselves

are invalid.

Children,

with

respect

to

pharmacokinetics,

do

not

physiologically

behave as

"small

adults".

This

is weli

established

in

paediatric

medicine

and

toxicology

ttl.

Th"

fact

that

Malique's hair

test

results are

similar

to

those

.rp.it"d for

an

adult

cocaine

addict,

in

my

opinion,

support mine and

Dr.

Koren's conclusions

of

chronic

(i.e.

long-term),

repeated

systemic

cocaine

exposure

in

this

child.

THE

OUANTITY/WEIGHT

OF

HAIR

TESTED

(p.

15-16 of 22)

Page

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"In

my

opinion

2-4mg

af

hair

sample

is too

small

a

quantie

to

be

usedfor

analysis."

The

SOHT

guidelines

recommending

l0-50mg

of hair

for

analysis are

intended

primarily

for use in

adult

subjects.

The very

basis

of our laboratory's

advancements

and contributions

in this

field

are

with

the

use

of

smaller quantities

of hair

in

order

to

enable neonatal

hair

to

be

tested.

The

primary

advantage

of

using

more

hair

is

increasing

the

absolute

amount

of

drug

extracted with

the

goal

of avoiding

false

negative

findings.

The

fact that

we

use less

hair

means

that we

carry a

risk of

zrol

detecting

low

amounts

of

drug

that

might

be

found

if we

used

ten times

as rnuch

hair;

you

do not accidentally

find higher

amounts

of

drug

from

using

less

hair.

In this

case,

because

high

concentrations ofcocaine

and

benzoylecgonine

were

found, there

is no

basis

upon which

our use

of low

quantities

of

hair

impacts

the

interpretation

of

the

results

"Firstly

it is

vety

dfficult

to

accurately

weight

out such

o small

qmount

of hair"

Our technician,

Ms. Karaskov,

who handled the

analysis

of this

sample,

is

highly

skilled

and extensively

experienced

in working

with small

sample

amounts.

I

have

no

concerns

with relation to

the

accuracy

of

sample

weighing

in this

case.

"Secondly,

the

likelihood

of inaccuracy

resulting

in

poor

precision

of test results

is

greatly

increqsed...the

margin

for

error

becomes

very

significant.

"

What

I

believe

Dr.

Chatterton is

referring

to

here, is

the

analytical

consideration

that at the

low

end

of

any

testing range

(be

it

testing

for drugs

or testing the

weight

of

a sample

with

a scale), there

is

a

higher

degree

of variability

in

the

result.

.Firstiy,

our

scales are appropriateiy

calibrated

in

order

to

weigh

out

hair

in

the

24mg range

used.

Secondly,

even if

we

apply

the

uncertainty

measurements

involved

in

using

low-

weight

hair

samples;

due

to the

very high nature

of

the

results;

this

would

have

no

impact

on

the

interpretation

of

the

findings.

n.

Here is

an

illustrative

example

using a

hair

drug

concentration

typicai

of

Malique's

segmental

concentrations

from

Reference

No.

10175

(Refer

to

Tab 4):

A

cocaine

concentration

of 25,43

ng/mg was

determined

in the

3-4cm segment.

If

2

milligrams

of

hair

were

used

for

this

segment, we would

have

detected 50.86 nanograms

of

cocaine

in

the

hair

extract

(50.86

ng

+

2

mg

:

25.43 nglmg).

The

error

of measurement

on our

scales

is

+/-

0.05 mg;

this

means that

when

measuring

out

2.0 mg,

we could

in

fact

have a weight

as

low

as

1.95mg or

as

high

as

2.05 mg,

and

when

weighing

our 10.0

mg

of

hair the actual

weight

would

be between

9.95

and

10.05

mg.

Using

2mg

oThair,

if

we

extracted

50 ng

of

cocaine, the

potential

'range'

of final

results

with

a

+l-

of

0.05

mg

on our

scale

would

be between 24.39

ngims

(50ne

+

2.05mg)

and

25.64

neimg

(50ng

+

1.95mg).

Page

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Using

1Omg

of

hair, if we

extracted five

times more drug

(250

ng

of

cocaine)

because

we

used

five

times more hair, the

potential'range'of

final results with

a

+/-

of

0.05 mg on

our

scale would

be befween 24.88

ng/me

(250ne

+

l0.05mg)

and

25.12 ngime

(250n9

+

9.95me).

You

can

see

from

this

example

how

a

lower

sample

weight

can decrease

the

analytical

precision

of

findings,

but

the

margin for

error

remains

quite

insisnificant.

Even

if

we

applied a factor

of

variability

of

I0%

(which

is far above the measurement

variability I

have shown here) to every

one

of Malique's

segmental

results; the

results

would

remain

high

and the interpretation

of

the

findings would

remain the same. it is

my opinion

that

Dr.

Chatterton's

stated

concems

regarding

the impact

of

low

hair

sample

weight

on

precision

are

over-stated

and

out of context

for

this

case.

POTENTIAL

SOURCES OF

CONTAMINATION

(p.

16

of

22)

Was

the

hair

sample washed before

it

was

tested?

The

sample

(Reference

No.

10175) was

washed prior

to

testing.

Our

technician,

Ms.

Karaskov,

is

certain

that the

sample was washed

prior

to

analysis

even though

pre-washing

of

the

sample

was not

explicitly

stated on our records.

If

the

hair

sample was washed, were the washings

tested?

If

the washings were

not

tested,

does

this affect the

validity of

your

test

results?

s

The

washings were

not analyzed.

The fact that the washings were

not

analyzed does not impact

the

validity

of

the

findings.

The substantial

levels

of

cocaine

and

benzoylecgonine determined

in

Malique's

sample

provide

a clear basis

to

establish

chronic

systemic

exposure,

even

if

additional

drug were found to be

present

in a

wash solution.

Numerous

studies have been conducted

using

external

contamination

of

hair samples to evaluate

washing

proceduresl3'4's'61.

These studies have

externally

contaminated hair samples

by

exposing

them

to

a

much more

extensive

"environmental"

cocaine

treatment

than

expected

in

a

real-life

passive

exposure

scenario:

namely

directly rubbing

cocaine on

locks

of

hair

[''o]

or

soaking hair

in

cocaine-containing

solutions

for up

to one hour

I5l.

In

several

hundred

of

these

samples

assessed,

none

of

them

retained

the levels

of cocaine

or

benzoylecgonine

evident

in

Malique's

hair

sample after comparable

washing.

If

the

hair

sample

was

not washed,

does

this affect the validity of

ltour

test

results?

Page

6 of

11


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If

the

sample

were

not

washed,

the

validity

of

the results

would

remain

intact.

The

identification

of

cocaine

and

benzoylecgonine

would

remain

sound;

the

question

would

emerge

as

to

what

proportion

of cocaine

was

deposited

on the

hair through

the

environment

and

what

proportion

was deposited

via blood

supply

to the

follicle.

Our

laboratory

has

hair-tested

hundreds

of

children in

the context

of

social

service

investigations

using

unwashed samples:

the

primary

goal

in

these

cases

is

to establish

passive

(i.e.

external)

exposure

to

cocaine in their

environment.

If suspicion

of

systemic

exposure

arises in these

cases

(such

as in Malique's

case), samples

are

re-analyzed

after

washing.

I have

reviewed

hundreds

of

cases of

chiidren

with

cocaine and

benzoylecgonine-positive

hair;

Maiique's

results

remain

uniquelv

hish

amongst

children

exposed

to

cocaine

in

other high-risk

environments

be

it due

to

parental

cocaine

use

or

trafficking

of

the drug in

the home.

My

interpretation

of

these findings,

were

the

hair

unwashed,

would

differ

oniy

by

adding

environmental

exposure

as

an

additional

concern.

The

extensive

levels

of

both

cocaine

and

benzoylecgonine

in

the sample

wouid

still

dictate

that chronic

systemic

exposure

is

the

best

interpretation

of

the findings.

Coutd

contamination

by vomit,

sweat,

or

contact

with

cocaine

or smoke

account

for

the

test

results?

VOMIT:

It should

be

noted

that at

the

time

of hair

sampling

(August

9'h

20051,

Malique

had been

washed

by

hospital staff

and

his

hair

was

clean; any

theoretical

contamination

with

vomit

would

have

occurred

prior

to his admission

to Sickkids.

Dr.

Chatterton's

report

(p.

16 of

22)

states,

'7

understand

(from

the

medical

records)

that Malique

was

vomiting

frequently...";

I

found

no

references

in the

document brief

to

frequent

vomiting.

In reviewing

the

testimony

of

Dr.

Cox

(refertotab

11,p.671),thereisapparentlynoreferencetoactivevomitingatSickkidshospital,

vomiting is

only

referred

to

as

part

of

the

patient's

clinical

history,

verbatim:

"the

history

included a

history

of

lethargy,

poor

feeding

and vomiting

and then

a seizure

".

The hair

collected

from Malique

was

from

the

vertex

posterior

of

his

head

(crown),

I

consider

it

highly

implausible

that cocaine-contaminated

vomit

could,

a)

physically reach

the section

of

the scalp

that was

tested

and

b)

coat

the

entire length

of hair from

this section

of the

scalp in

such a

way as

to

produce the

results

we

found.

ln

the

potential

scenario

that this

child

vomited

and

then

placed

his

head

in a

pool

of

cocaine-

contaminated

vomit,

there

could

be

external

contamination

of

the hair sample.

This

external

contamination

would

have

then

been impacted

by

washing

of

the child

in

the

hospital

and

the

Page

7

of

11


8/11

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subsequent

pre-analytical

washin-g

of

the

hair

that

took

place

before

analysis.

Hair

soaking

studies

that

I

referred

to

earlier

L+':'b],

show

that

samples soaked

for,up

to

t

hour

in

cocaine-

containing solutions do

not

demonstrate the

levels

of

cocaine and benzoylecgonine

or

the ratios

of

benzoylecgonine

to

cocaine found

in Malique's

hair. I do

not consider

is

reasonably

plausible

that

the

cocaine and benzoylecgonine determined in Malique's

hair

was

primarily

present

due to

vomit-contamination.

SWEAT,.

Sweat

contamination

is

a

very

important

consideration

in this case,

particulariy

because

of

the

repeated

seizures

and

fever that were

occurring

in

this

child.

If

sweat contamination

were the

primary

route of drug

entry

into

Malique's

hair,

I

would

expect

a

pattern

of

results showing the

highest

drug

concentrations

occurring closest

to the source

of

sweat

(i.e.

immediately

adjacent

to

the

scalp). This

is

supported

by

a documented

case

report showing an acute cocaine overdose

in

an adult

with

hair

analysis

results

t7l;

in this

case,

the

peak

cocaine

level

occurs

within

the

first

1.5

centimetres of hair

adjacent

to the scaip.

Contrary

to this, Malique's

hair

sample

demonskated

the highest

concentrations

of

cocaine and

benzoylecgonine

approximately

ten

centimetres

from

the scalp.

In

addition,

similar

to

my

response regarding vomit-contamination,

hair

soaking studies

(which

include

synthetic

sweat contamination)

do not demonstrate

the

levels

of

cocaine and benzoylecgonine

or

the

ratios

of

benzoylecgonine

to

cocaine

found

in

Malique's

hairta'5'61. It

is

my opinion

that

the

pattern

and

magnitude

of

the drug

concentrations found

in

this

case

do

not

support sweat

contamination

as a

reasonable

primary

cause

for

these

results.

CONTACT WITH COCAINE

OR

SMOKE,.

The

results

of

Malique's

hair

analysis

provide evidence

of chronic

systemic

cocaine

exposure

based

on

the

length

of hair

tested and

the magnitude

of

cocaine and benzoylecgonine leveis

found. These

results

(and

toxicology

results

in

general)

provide

evidence

of

the

presence

of

a

drug

in

the body,

but

cannot determine the

route

of

drug

administration. Potential

routes of

administration

include

oral

ingestion, inhalation, and

injection.

I

cannot determine

if

the

cocaine

that was

chronically

present

inside

Malique's

body was

placed

there

via

oral ingestion,

injection,

or intensive

inhalational

exposure.

I

can state

with certainfy;

based

on

my

extensive experience

in evaluating

hundreds of

passive

cocaine

exposures

in children

involved

with

social

services;

that Maiique's

hair

test results

far exceed

levels

expected

in

high-nsk

children

exposed to

parental

crack

cocaine

use.

There

are

several

published

case

reports

of

acute

cocaine ingestions

in

children, however

in these

cases

it

is

difficult

to clearly

determine

whether

the

cocaine

got

into

the

child's

body

via

passive

smoke

inhalation

or direct

ingestion.

There

is only one

paediatric

case

published

containing

hair

test

evidence

that

is

clearly

related

to

second-hand

smoke inhalation

due to

respiratory

systems

in

Page

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addition

to

evident

cocaine

toxicity

t8l.

This child's

hair

benzoyiecgonine

level

from

chronic

second-hand smoke

exposure,

was

lowerthan

eleven

of

the

fifteen

segments

tested

inMalique's

sample

(Reference

No.

i0175). Several

of Malique's

benzoylecgonine

concentrations

were three

to

six

times higher

than this child's.

If

passive

smoke

inhalation

were the route

of

exposure

in

Malique's

case, I

would

expect the

exposure of this child

to cocaine

smoke

to

be

relatively

constant

and

highly

intensive

(i.e.

in a

very

small

enclosed

area), keeping

him

at constant

risk of

overdose.

I

would consider

this

scenario

to be a form

of

drug

administration

to this

child based on

the intensity

of smoke

exposure

required

consider

it consistent

with Malique's

hair

test results.

If

environmental

exposure

to cocaine in

his

home

(hand-to-mouth

ingestion)

were the route

of

cocaine exposure

in

Malique's

case,

I

would

expect

that he

had

constant

access

to

large,

potentially

lethal,

quantities

of

cocaine within

arm's

reach

on a

constant basis

through

the

15-

month

time

period

tested.

I consider

this

scenario

highly

unlikely, as

I

have

reviewed

a number

of

cases

of

children

residing

in

homes

with

confirmed

cocaine-trafficking

occurring and

Malique's

hair

test results

distinguish

him

to be

outside

of

this

group.

In

addition

to exhibiting

results

far

exceeding

those

found

in our own

laboratory's

social

services

population,

published

accounts

of

hair testing

in drug-exposed

(via drugs

in

the

home)

children,

and narcotics offices

and

evidence

clerks

frequently

handling

cocaine, show

substantially

lower

levels of

cocaine

and

benzoylecgonine

detected

te'lol.

To

summarize this

section;

Dr.

Chatterton's

report

(p.

17

of

22)

suggests that,

"the

presence

of

cocaine

and

benzoylecgonine in Malique's

hair

sample

could

be as

a result of

the hair

coming

into direct

contact

with

a

cocaine substance,

perhaps

as

a result of

poor

housekeeping

and/or

as

a

result

of

direct

contact

with the

smoke

produced during

drufi

use".

I disagree

with this

statement, as

poor

housekeeping

and

incidental

second-hand

smoke

exposure

is

quite

typical in

the

social

services

population our laboratory

services

and in

other

populations examined

in

the

the

published

literature.

Malique

's

test results

distinguish

clearly

that

his

degree

of

exposure to

cocaine is far beyond

what

would

be

expected

from

a

typical

drug-related neglect

scenario.

Could

the

presence

of

benzoylecgonine

in

the

quantities reported

in this

case be

caused by

something other than active

drug use?

Benzoylecgonine

can be

produce

in situ

as

described

by

Dr.

Chatterton in

his

report;

this is an

important

consideration

as

small

amounts

of

benzoylecgonine

may not

provide

sufficient

evidence

of

systemic cocaine

exposure

in hair

samples.

The

quantities

of

both

cocaine

and

benzoylecgonine

as"well

as

the

ratio

of

benzoylecgonine

to

cocaine

found

in

Malique's

sample,

are

much

higher than any

clinical

case

I have

reviewed

or

any

published

reports

examining

external

contamination

of

hair

[3'4'5'6'

8'e'

I 0].

Page 9 of11


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AND

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In

my

opinion,

the

benzoylecgonine

levels

determined

in

Malique's

hair

segments

are

too

high

to

reasonabiy

be considered

as

caused

by external

contamination

alone.

Is it

necessary

to testfor norcocaine

and/or cocaethylene

in order to

confirm

active

drug

use?

Norcocaine

and

cocaethylene,

when

present,

provide

additional

certainty

of

systemic

cocaine

exposure.

These

two metabolites,

however,

are

highly

insensitive

and

are

absent

in

the

majority

of

hair

test

results

from

established

users.

These

are

useful markers

when

present,

but

cannot

serve

to

exclude

systemic

exposure

when

they

are

absent.

According

to

the

SOHT

consensus

guidelines, the

presence

of

a

sufficient relative

amount

of

benzoylecgonine

in

a

hair

sample

is

considered

adequate

to

establish

active cocaine

use

[tt].

It is

not ,r.r.riury

for

norcocaine

and./or

cocaethylene

to

be

present

to

establish

strong evidence

of

systemic

exposure.

LIMTTATIONS

ASSocIATED wITH

SAMPLE

coLLECTIoN

(n.

20-21

of

22)

Dr.

Chatterton's states

in

this

section

of his

report

that the

limited

elapsed

time

of

sample

collection

(occurring

only

9 days after

hospitalization)

is

problematic

because

it does

not

reflect

the

hospitalization

event and

that

"

...a

further

hair

sample

should

have

been

taken

from

tr[alique

three

or

more weeks

after his admission

to

hospital."

My

response

is that, this.hair

sample

was

not

intended

to

reflect

the

hospitalization

event.

The

acute

cocaine

overdose

was

clearly

evident

in this

child

based

on the

urine,

gastric,

and

cerebrospinal

fluid

results.

The

hair

sample was

intended

to

exaqrine

for

evidence

of

long-term

historical

drug

exposure

prior

to

the

hospitalization

episode,

and

this

is

exactly

what

was

found.

There

was

no

clinical

basis to

take

a

new sample

from

Malique three

weeks

afler the

event.

Regards,

Joey

Gareri,

M.Sc.

Laboratory

Manager

Motherisk

Program

Division of

Ciinical

Pharmacology

&

Toxicology

Hospital

for

Sick

Children

REFERENCES

tll

Quality

Management

Program

-

Laboratory

Services,

Ontario

Medical

Association.

Ontario

Laboratory

Accreditation

Program

Information.

August

Z0I2,v.

15.

[2]

Kearns,

GL

et al.

Developmental

Pharmacology

-

Drug

Disposition,

Action,

and

Therapy

in

lnfants

and

Children.

New

England

Journal of

Medicine 2003;349:1157-67

.

Page

10

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11/11

Documents

Joey Gareri, M.Sc. response to Dr. Chatterton witness statement