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January 18,2013

:rred to in the

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.

ffi

v. BroomJield, Tamara

Dear Mr. Schwartz,

I
I

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.
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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)

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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.
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

All methods used in our laboratory undergo extensive validation. Unlike routine

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.

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:

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).

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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.

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
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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

of some mysterious unknown

benzoylecgonine effectively rules out any reasonable possibiiity

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)

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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"

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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 lowweight hair samples; due to the very high nature of the results; this would have no impact on the
n.
interpretation of the findings.

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).
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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).

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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?

this affect the validity of your test results?

If the washings

were not tested, does

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?
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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.
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.

My interpretation of these findings, were the hair

Coutd contamination by vomit, sweat, or contact with cocaine or smoke account

results?

for

the test

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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..."; found no

It should be noted

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 cocainecontaminated 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
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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 cocainecontaining 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,.

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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.

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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
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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.

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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 15month 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.

If

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.

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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
I 0].
external contamination of hair [3'4'5'6' 8'e'
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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

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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 .
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