i0

t,

-lt

wmrw%ffiffi*$K
1fi(AilNS Il-Jf, |,40rHEl{ "
FROTECTIT9S

Lmril:

IHI

UNBORN

irrig:U$iU.A!1,ii'r-ua

\Vebsi tr-:,',.ivr'.mr:lltcrisk.org

llirt o or oJ :11 o thtriti

t.li'lc,rr Koren. \'1I1, IrACilII" ltrH.(.;11(
Tnr' J\ci { llxrr il Lh,llrrrbr l(r^rdol\)*}.
'f
hc l.;ni.:e*itl' ol'\\;rs:eru Onlrritr
Ivlarrl lllaren

January 1 1, 2013-01-1

Mr. Randy Schwartz

Crown Law Office
General
Ministry of the Attorney
+
720 Bay St
Toronto

.,!+ir..,..,,........ ......

.....fuh.*.,.,"',',

?hL)

a..

i)cp{rtmei1l oi }'rychrlogv

I)il

iC

ri.

l.lhii?)

l}:prriuleill

r)f

r"'li-). f l{t.'t'{:

Re: Hair Analysis in R.v. Broomfield,Toronto

(ieirtics

Lcc Drrtuis. l\'1Sc fhrrrn

irharniacy

Adli{nrre iiinari()x. I{li

Assi:ti:illi Di{r'cior, r\'loiht'ril;k

Tlvlr::as R.

}:li

Dear

rarrol. !hf)

Mr. Schwartz:

Filrslry 0i lthiil mac\'

I-lilon

i)Pr

L]

l'

This document constitutes my response to Dr Chatterton's document

f sY(:holl)1:}'

Dcn Farirc, \tD. FRfl){.

it4ount Sin:ri I)irspitnl

i:;ni*,

T.)i-p?ii1m{:1l

regarding the measurements of cocaine and benzoylegconine (BZE) in

{jllrtrdi, M1,}
lYloilnr Shai ]i,rsp;lrl
Shii.di

Maliq'shair.

f{ttul: I}irision ttl

l* rn u<n I o9.1'
{.' I i nittt!

These tests were conducted in my laboratory at the request

of

11

:iliinJr

1t{},

the physicians at Sickkids hospital who treated the toddler, as well at the

lv'lt). AllCP

i)huslrnn Krpur. l']hl)

.'{iuij.ir j!'il1'[ i)r j(ollri?,)'
lriorot ii, \iSc
Asrisnrrr l)irecr;r. \'lcfi *risii
N.1,vll

/*ri

d&/!! l)i n:*'tor,

ll tthsi

request of the Children's

Aid society of Toronto who was involved in his

care.

sli

rcla Nulriirr. F..1I)

Aletrhcl & L)rli:s in !)rt'3lnrnr:y
I

I
I

l
I

I
L

Joutl: Iliivrt, ['it[]

i)r'partrrcri

t)f Ps'",chdogY

llcier S'.!by- Ntlllls. {.(:FP

l, enifo tirr ,\ddir'ti.rn A Nlerrai Ilciildr

Ncii I{.

Shear. N1D. fRCPC

Sulrr.;bro'rk lierlrh $r;nticos {.'en1rt

l\ri

Srr,eI

i:li,ril \4D. irrr(

lVtrlcu s Orllegc ihs1:irrl

The Motherisk Drug Testing Laboratory (MDTL):

The MDTL was established in 1988 after I discovered that we could measure

i:

hair cocaine and its major by-product benzoylegconine (BZE) in newborns of

methers who admitted using cocaine in pregnancy. The hypothesis was that,

similar to adult hair, where circulating cocaine can be found in hair' cocaine

::

""'t ;,' :.
ilAWS

AFfl
A COtr;'"'llSJloll5Fl iiC41 T'rLi(illG

present in fetal blood

will find its way to fetal hair which

starts forming in the last trimester

pregnancy. This discovery (Reference 92) marked the beginning of a new field in the area

of

of

perinatal toxicology, enabling physicians to diagnose exposure to cocaine and other drugs of
abuse in pregnancy, in infancy and childhood.

and establish these tests and 25 years later

MDTL

has been the

first laboratory to investigate

it is still the preeminent laboratory to do so. We

have

pubiished over 90 peer review scientific papers which, in rnany cases, set the standard fcrr this
new field (references 1-93).

During these 25 years we established techniques to be able to measure drugs in small amounts of
hair, as is the case in young children. We were also one of the first laboratory to introduce the
segmental hair analysis, and the first to do so in children, which further revolutionized this test:
Because hair grows at art average pace

of l cm per month, sectioning of hair can tell not just

whether the individual was exposed to a drug of abuse, but also when.

Over the last 8 years, including the time relevant for this case, we have offered and performed a
large number of different tests in hair, from cocaine to heroin to alcohol.

Accrediatation, Proficiency and Quality Control of MDTL

1) MDTL is accredited by OLA (Ontario Laboratory Accreditation) . OLA is part of the

Standards Council of Canada, and OLA standards are based on the International

Organization for Standardization (ISO) criteria. We passed the accreditation with

outstanding marks, being the first drug hair testing laboratory to do so in Canada. The
tests we conducted as part of the accreditation further validated our

ELISA cocaine and

BZE tests as accurate, sensitive and specifi

2) In 1995, scientiits

from around the world specialized in measuring drugs in hair,

established the Society of Hair Testing (SoHT) and we joined

in 1996. The Society

recetve
established the first ever quality assurance program, whereby all participants

unknown hair samples and measure in them drugs. This has been the only international
process to assess the quality of resuits in laboratories acloss the world'

MDTL has

participated in this process since its inception, and our results have been consistently in
process in
agreement with the Round Robin consensus. Dr Chatterton acknowledges this
his report, but claims that we did not show specific results. Tab

presents our

performance in this test for the year of Maliq's case, ie 2005' It shows very clearly that
further
our measurements of cocaine and its metabolite BZE werc right on the spot. This
addresses

Dr Chatterton's criticism that we did not conduct GC-MS but rather

"radioimmunoassay" test . Dr Chatterton wrongly states that we conducted

results
radioimmunoassay; rather, we performed ELISA assays. The fact that our ELISA
are

similar to those achieved by GC-MS

addresses this question. Between 2005 qnd

now, we did nto have a case of false positive or false positive result of Cocaine or BZE.

3) It has always been critical

for us to check our hair test results against an external

the
reference laboratory. This is especially critical in low and borderline results, where

hair test is near the low quantification iimit of our assays. It is also critical in cases where
end we
there is dispute whether an individual had used the drug(s) in question. For that

have used the American- based "US Drug Testing Laboratory" in Des Plaines lllinois.
(similar to
There was not a single case in which high level of cocaine or BZE in our lab,
those measured in Maliq's hair), was negative or low in the US Drug Testing lab'

'

i
I
4)

I
I

During the accreditation of our laboratory by OLA, we compared the results of the
ELISA, used in 2005, to the definitive GC-MS. In All 55 samples where ELISA hair
cocaine was higher than2.}nglmg- the GC-MS results were also higher than 2.0ngim1.

Simiiar comparability was alsoestablished for BZE.

I
I
I

Dr Chatterton argues that the 2-5mg of hair used by us is "too small" a weight to be
tested, because the Society of Hair Testing recommends use of 25-5Omg of hair.

Dr

Chatterton is wrong, as the Society's statement relates to adult hair testing and not for

I
I

children. Over the last 25 years we have developed and validated the use of much smaller
amounts of hair, suitable for analysis of neonates and young children ( see for example

reference 74). Citically, too smail a sample of hair may not have sufficient cocaine to

I
I

measure, and therefore higher amounts of hair may be needed. However, this is not the
case

in Maliq's hair, because cocaine and BZE levels were extremely high. allowing

smaller amounts of hair to be accurately analyzed without any difficulty.

I
I
I

I
I
I

Put together, our hair tests conducted on Maliq's hair in August 2005 were highly

sensitive, specific, valid and aqcurate.

The results of

MDTL ELISA hair

tests

for cocaine andBZE,

as

well

as

for other drugs of

abuse and alcohol, have been accepted as evidence in numerous court cases

other provinceq of Canada and in the USA.

in Ontario, in

I
E

I
I
I
I
I
I

Distinguishing befween external contamination of cocaine in hair, and true systemic

exposure:

Both children and adults may have cocaine levels in their trat

db

to passive exposure

(e.g. from people smoking cocaine near them)) rather than from cocaine entering their

bodies. Separating between these two situations is critical and we have spent years of
research to solve this issue.

1)
T

The first way to separate external contamination from true exposure is by washing the
hair.

I
I
I

In

1992 we showed that in hair contaminated by crack cocaine smoke from the

outside- we could completely wash it (Reference 88). Critical to Maliq's case- in

2005 the analytical process included

try

washing of his hair. It included washing

with 3Tcentigrade water 3 times x 5 minutes with shaker, rinsing with warm water,
and dry ovemight at room temperature.

I
T

!
I
I
I
a.
.,'

2)

The second way is to compare cocaine levels toBZE leveis. BZE,the by-product of
cocaine, is produced mostly inside the body. So

if the hair contains only cocaine, or

very low isvels of BZE- the result is highly likely due to extemal contamination.
According to the Guidelines set in 2004 by the US Substance Abuse and Mental

3
3
Health Services Administration, acknowledging that some BZE can contaminate the

hair externally, if the level of BZE is rnore than 5% of that of cocaine- then it is
highlv unlikely to be an external contamination (Reference 94). These guidelines
were established in adults and it is possible that levels of environmental cocaine

;
;

I
t

exposure in children may result in somewhat higher levels of

Maliq's

BZE at 10%. In

case, the BZE levels were very high compared to cocaine levels, precluding

extemal contamination. In all segmental tests done, BZE levels were very high, at
25-200% of cocaine levels. This makes external contamination extremely unlikely.
Moreover, because toddlers breath on average much more rapidly that older children
and adults, what may seem to be 'external contamination" really means that much

more cocaine is taken by their lungs of the toddler and hence becomes a svstemic
exposure, resulting in intemal production of BZE.

In summary, Maliq's very high hair levels of BZE are highly unlikely to be due to

:
;

t
:

external comnamination.
3) Dr Chatterton argues that the levels measured in Maliq's hair levels are likely due to

extemal contamination_from cocaine either in sweat or vomiting. Vomiting is not

mentioned in Maliq's medical chart, except for one even!, when he was vomiting
pieces of banana he had eaten before his seizures. The fact that the medical team was
there to see the banana rules

out vomiting on his hair. Very soon after (within

than an hour), Maiiq was intubated for ventilation and could not have vomited. As

important, even if vomit did reach his hair, it cannot be expected to cgntaminate
evenly the-15 cm of length, and it would be washed by our extensive

t
T

less

washing

!
procedure described herein. Critically, we sampled Maliq's hair from the back of the

skull which is not an area that vomiting can typically reach'

I
4)

I
I

Dr Chatterton argues that Maliq's hair levels are "too excessive to be real"- This
ciaim is wrong and misleading, as we encounter numerous patients with hair levels in
this range. Maliq's highest levels were in our laboratory at the "High" fange'

However, above them there is the range of "very high". It all depends of course on the

extent of exposure.(TAB 2). As important, this range of ievels was reported by

numerous other cases in the medical literature. Hence, Dr Chatterton's claim that the
levels measured in Maliq's hair are unrealistically high, is not based on evidence and

are misleading.

I
5) Dr Chatterton

I
I

argues that,

if Maliq had been exposed to these high levels over

prolonged time (as he hair test suggests)- he should have had brain damage before

August 2005.I believe that this claim is redundant and frivolous and shows lack of
*,

clinical understanding of this case. First of ali, there are no tests to show that he had

I
I

I
I

I
I

had normal brain function before August 2005, and there are blatent signs of severe

physical abuse and negiect, old rib and extremity fractures. It is quite possible that

Maliq had sustained brain damage prior to the acute overdose of August 2005. The
mother admitted she had not taken him to see a physician despite deformed arm after
severe abuse. Hence one cannot know in this case how much brain damage the child
had sustairwd prior to August 2005 without the mother bringing him to a physician.

Moreover, in many cases chronic exposure to cocaine does not necessarily equate

with severe brain damage. Last, the phenornenon of "Acute on Chronic" organ
damage

is very well known: after sustaining chronic

exposure for long time, organs

such as the brain, liver and kidney can suffer a catastrophic acute exposure due to the

overall poor status of the chronically- weakened organ (Reference 95). In Maliq's
case- he suffered a catastrophic brain injury from an acute cocaine overdose in

August 2005, which attacked a brain that had seen cocaine chronically for many
months at a lower levels of exposure. Overall, I beiieve that this claim by Dr
Chatterton is unsupported by any ciinical evidence or experience'.

6) Dr Chatterton further

argues that the high leveis of hair cocaine andBZE all over the

25 cm of hair tested in Maliq were originated from a single overdose of cocaine. This
argument contradicts alarge body of scientific evidence. In fact, numerous
experiments

have_

shown that because hair grows only 1cm/mo, a single overdose

cannot be represented over more

that l-2

cm,because the elimination half

life in the

blood is measured in hours, and therefore there is no drug remaining in the blood after
several days to be the source for cocaine accumulation in hair.

The

Casepresented

in

the next paragruph(TAB 3) is an ultimate proof to show that Dr Chatterton is'

wrong and misleading:

In 1991, the FBI in the US reported

the case of a25 year

old American

man who

consumed by error a bottle of soft drink laced with very large dose of cocaine that
was intended to be smuggled across the border, The young man had very severe
cocaine toxicity and he eventually died after 21 days. However, during these 21 days,

I
his hair showed increased levels of cocaine andBZE which peaked early after the

overdose, and then fell off and subsided.(TAB 3).

If Maliq

was indeed exposed to

only one overdose, then his hair cocaine and BZE levels would have peaked and

then sutrsided within the next 2 cm of growth, and we would not have found high

levels over the whole length of 25 cm of hair, representing almost 2 years of life.

I
I

7)

In people who abused cocaine and then stopped- we have clearly shown that their
levels of cocaine subside over the next2-3 cm. (Reference 32). Within medical and

scientific certainty-and based on the available literature, the fact that Maliq had over
15 cm of high levels of cocaine andBZE can be explained only by chronic exposure

to high dose of this dangerous drug. As willbe fuither elucidated below, this is also

I
I
I
I
I

I
I

I
I

very consistent with the full pediatric clinical toxicology picture of this case.

8)

Furthermore, if Maliq's hair was contaminated by cocaine after a single overdose, as

claimed by Dr Chatterton, then the main potential source of extemal contamination

would be from sweat. But if sweat was

"source" of exterlal contamination, then the

rnost recent hair, near the scalp, should have had the highest levels of cocaine and

BZE. Close look on Maliq's results reveals the opposite; his hair levels near the skull
were in fact the lowest. As explained above, sweat cocaine would have been washed
by the aggressive washing procedure used in this case.

e)

Dr Chatterton concedes that it takes time for cocaine andBZE to appear in hair due to
its slow growth of hair. Indeed, this is exactly why the levels we encountered cannot
times'
represent the time of the acute overdose in early August 2005, but rather earlier

yet, Dr Chatterton claims that

a single overdose of cocaine can be reflected in 20 cm

of hair even after copious washing. His claim is unsupported by scientific evidence,
c__

and contradicts a iarge body ofscience presented here'

Dr Chatterton argues that"BZE

can be formed in situ by spontaneous hydrolysis

of

cocaine....It is possible therefore to detect both cocaine andBZE in the hair of an

individual who has not actively used cocaine". To support his claim Dr Chatterton
cites a study by Cordero and colieagues. However the quoted study by Cordero and
to
colleagues is about hair analysis in postmortem adult samples, which has nothing

irrelevant and does not support his claim'

Overall Clinical Toxicology Context of This Case:

Hair analysis for drugs of abuse is

powerful tool to uncovel long term exposure to

cocaine. However, this test does not intend to stand by itself, and it must be looked in

the overall clinical context of the case. The aim of this section is to put Maliq's hair
results in their clinical context, as I always do in my work as a pediatric toxicologist'

In his report, Dr Chatterton claims that in this case "forensic" test should have been
used. But this, at the time of our involvement, was a ciinical- toxicology test and not

a I
-)

:
:
forensic test, and we employed the best clinical toxicological test available to us,

which yields, as shown above, results comparable to the GC-MS test.

:
Here is the clinical context:

A woman brings her son to the emergency department after lam with severe and
intractable seizures, claiming she is not aware of any previous problems. The
emergency team notices that the toddler has a deformed hand, which reflects an

t
;

untreated fracture several months earlier. The mother admits she had not taken her
son to the doctor for

this. When the child is fighting for his life, it becomes apparent

that he has multiple broken ribs, numerous old fractures and many skin lesions
consistent with chronic trauma due to extreme abuse. Critically, a serious overdose of
cocaine is uncovered. The child was exposed to an overdose of cocaine in the middle

of the night.

A diagnosis of an extreme and horrendous child abuse

and neglect is confirmed by all

experts. The old fractures and different levels of wound healing prove beyond doubt
",

that this is chronic and repeated child abuse and not a single event.

;
;

I
I
I
I
I

The segmental hair analysis shows that the hair contains high levels of cocaine and its
metaboiize BZE over manv months. This is consistent with, and matches the chronic
nature of the proven abuse. These findings have been accepted by experts in the field
and accepted by a leading pediatric scientific journal (Reference 45). Acute, one time
exposure to cocaine, cannot explain the hair test results and was never shown to be

reflected in hair over 15 cm.

r
A11

evidence indicate at very high medical probability that the toddler was exposed to

cocaine chronically as part of an extreme case of chronic abuse and neglect.

;
ResPecttullY submitted

f,

fiiiHfff:r,*?-llffiFAcMr

it;T.'rt3lrtlli:'fi"?:r5ilu*u.ology,

pharmacy and Medical Genetics,

Univeristy of Toronto

;ff:fr:il1*H$'#':'elvsiotoevandPharmacologv'andPediatrics
Ivey Chair in Molecular Toxicology

References:

;
E
Cn.rril

I
t

|l

ethylens as a bjoqraiker to r]reciict heavy alcohol exposu.re among cocaine users.

Natekar A, Motok I, Waiasek P, Rao C, Clare-Fasullo G, Koren G.

J Popul

"'

Ther Clin Pharmacol .2012;19(3):e466-72

r:2

;
;

l
.

Pediatr Clin

North Arn.20l2Oct;59(5): 1059-70

r=3
Sair

as a

biornarker ol poiybrominated dietht4 ethers' expgsr-ire in iniants. children and adults.