Forensic
Pharmacy & Forensic Pharmacist
Forensic: Application
of science for detection of crime.
Forensic Pharmacy: Forensic Pharmacy is the application of drug sciences to legal
issues.
Forensics should not be confused with
thanatology (study of death)
Pharmacists have
been involved in a variety of leadership roles in the field of forensics.
Pharmacists have been doing medicolegal work and law enforcement work for
years. The only aspect of forensic pharmacy that is new is the terminology.
Forensic
Pharmacists engage in professional work relating to litigation (the conduct of
a lawsuit), regulatory affairs and process, and the criminal justice system.
Domain of forensic pharmacy includes clinical, distributive, administrative
aspects of pharmacy and basic pharmaceutical sciences.
Forensic
Pharmacy is a vast field. It overlaps with many other forensic fields e.g.,
forensic medicine, forensic psychology, forensic toxicology, forensic
accounting, fraud examination, forensic chemistry, forensic document
examination, polygraph examination (the lie detector), death investigation,
forensic nursing, forensic optometry, and accident reconstruction (forensic
pharmacist helps in determining the role of drugs or medications as a
contributing factor to the accident). In fact, almost every profession has a
forensic application. It can also be said that almost every specialty of a
profession has a forensic role.
Almost every
pharmacist does some type of forensic work whether he or she realizes it or
not.
ü
A
community pharmacist needs to scrutinize a prescription for possible forgery.
ü
A
pediatric pharmacist may watch for signs of child abuse.
ü
A hospital
pharmacist develops systems to detect and prevent drug diversion.
ü
A nuclear
pharmacist may serve as radiation safety officer.
ü
A
psychiatric pharmacist may monitor patients for signs of substance abuse.
Specific issues
involving forensic pharmacists include professional malpractice, patient
confidentiality, drug diversion, drank and drugged driving, impaired capacity,
drug-induced violence, appropriate use of chemical restraints, adverse drug
reactions, drug interactions, product tampering, medication errors, quackery
and health care fraud, and poisoning.
The most common
consulting forensic role for a pharmacist is that of forensic litigation
consultant. Pharmacist can review and educate the lawyer about
medication-related issues.
Pharmacist
Malpractice:
Pharmacist have
been sued for many reasons including dispensing the wrong medication,
compounding errors, failure to detect interactions, failure to contact
prescribers about excessive dosages, and failure to warn patients about side
effects. Clinical pharmacists can be liable for improperly monitoring drug
therapy.
Malpractice
cases against pharmacists generally require testimony from another pharmacist;
the exception being an error that is so obvious that even a layperson can understand
it without expert testimony.
Most lawyers
will not file lawsuits against pharmacists unless an affidavit is obtained from
another pharmacist expressing an opinion of negligence. This pharmacist expert
witness would express an opinion supporting the allegations of malpractice. The
defence may have pharmacists as expert witnesses for rebuttals.
Malpractice
against other health professionals:
The forensic
pharmacists can assist lawyers regarding malpractice cases of other health
professionals, for example physicians and nurses.
Generally,
pharmacists cannot testify as to the professional standards of other
professionals. However, if the case involves an adverse drug reaction, the
pharmacist can testify about causation. He can also testify about alternative
therapies with less risk. He can also provide opinions about medications that
can prevent disease complications.
For example, if
a patient develops renal failure from diabetes or hypertension, the pharmacist
can discuss medications that would have prevented or reduced the risk of kidney
damage.
Blood levels:
Certain drugs
have a narrow therapeutic range and need to be closely monitored (e.g.,
digoxin, theophylline, lithium, etc.).
Clinical reasons
for which to draw blood samples include high doses and borderline doses, signs
of toxicity occurring, lack of a therapeutic effect, or suspected poor
adherence.
Toxicology
analysis is a common part of the forensic autopsy and often forensic
pharmacists are consulted to interpret drug levels.
Numerous changes
occur postmortem that may increase or decrease blood levels detected at
autopsy. The postmortem blood level may not reflect an antemortem blood level.
Drugs,
Alcohol, and Driving:
Pharmacists have
numerous skills that are useful in driving under influence (DUI) cases.
The forensic
pharmacist can interpret the levels of blood alcohol and discuss the typical
effects from different alcohol levels.
Pharmacists can
apply pharmacokinetics to estimate the level of alcohol at the time of the
alleged event. Pharmacokinetics calculations can especially be helpful if an
extended time period exists between the incident and time of collection.
Drug Interaction
can be relevant to DUI cases. Certain medications can have additive effects
with ethanol, that is lower levels of ethanol will produce greater effects.
Other medications can alter the absorption or metabolism of ethanol. Certain
disease states may make a person susceptible to the effects of ethanol.
Pharmacists can
provide input regarding these other factors relating to alcohol consumption
such as personal injury cases.
Criminal
Cases:
The work of
forensic pharmacist may be needed in various types of criminal cases. This
includes cases where drug or poison was used as a weapon, or where medications
impair the mental capacity of the dependent or victim.
Drugs as a
causative factor for aggression have been used as a criminal defence. This
defence is more likely to be successful if the drug is a prescribed medication
rather than a substance of abuse. This defence is more likely to be accepted
with involuntary ingestion rather than voluntary intoxication. Medication
effects can be an issue in determining whether a defendant is competent to
stand trial.
The effects of
drugs on victims are often related to criminal cases.
ü
Medications
are often used as agents for suicide and in suicide attempts.
ü
Drugs and
poisons have been used as tools for homicide.
ü
Drugs have
been used to facilitate sexual assault, especially in dating situations. The
most well-known date rape drugs are flunitrazepam, gamma-hydroxybutyrate (GHB),
ketamine and alcohol.
In
theory, any drug that has sedating, mind altering effects or impairs memory
could be used to facilitate sexual assault.
Off-Label/Unlabeled
Drug Use:
Can review
insurance claims relating to medication therapy, especially where new and
unusual uses of medications are prescribed.
Patients,
medical professionals, and health care organizations often submit claims to
insurance companies, seeking payment for unlabeled uses. This may raise “red
flags” with the insurance company.
A forensic
pharmacist can review such claims and offer an opinion whether the use is
reasonable and common practice.
Off-label use
may be brought up in malpractice lawsuits as a standard of care issue.
Prescribing off-label medications is in itself not malpractice. Many off label
uses of medications are appropriate and medically necessary.
The forensic
pharmacist may offer testimony about the need for unlabeled indications and
provide insight into appropriate use of that medication.
Fraud and
White-Collar Crime:
“Any intentional
or deliberate act to deprive another’s money or property by means of deception”
Types of fraud
related to forensic pharmacy include:
1.
Scientific
Fraud: Submitting intentional false data for publication in a book or journal.
2.
Quackery:
The promotion of remedies that lack scientific support to consumers or health
professionals.
3.
Drug
Diversion: Obtaining controlled substances for misuse or abuse.
4.
Health
care fraud: Submitting intentionally false data to insurance companies.
5.
Occupational
Fraud and Abuse: This is no way limited to pharmacy and or even the health care
industry.
6.
Record
Tampering: Improper changes in the writing in the medical records after a
lawsuit has been initiated or fear lawsuit after an unexpected occurrence.
7.
Counterfeit
drugs
Overlap exists
in the above areas. Case reports suggest that some cases of financial fraud may
be due to the need to purchase illegal drugs.
Lecture notes by Syed M. Ashad Halimi
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