Tragedy behind bars

2019-03-07 01:07:10

By Laura Spinney MANY deaths in custody that are blamed on the police using excessive force in restraining “difficult” prisoners may in fact be the result of the prisoners’ cocaine abuse. This provocative suggestion, from a leading forensic toxicologist, is sure to inflame controversy over one of the most contentious issues in policing. Steven Karch, assistant medical examiner of the City and County of San Francisco, is convinced that many people who die in custody are suffering from excited delirium (ED). This condition can be caused by the long-term use of stimulants such as cocaine. Sufferers experience a dangerous rise in body temperature, act strangely, appear terrified, yet can show surprising strength. Unless treated quickly, usually by packing them in ice to reduce their body temperature, patients often die from cardiac arrest. Many deaths from ED in custody are recognised as such. Last year, Canadian researchers found that 18 out of 21 people recorded as dying from ED in Ontario between 1988 and 1995 were under arrest. But at a meeting of the Royal Society of Medicine in London this week, Karch claimed that the documented cases are just the tip of the iceberg. He has devised a neurochemical test for ED that he argues should be done during autopsies whenever people die under restraint after arrest. Together with Deborah Mash, a neurologist and pharmacologist at the University of Miami School of Medicine, and Charles Wetli, medical examiner of Suffolk County, New York, Karch has compared brain tissue taken at autopsy from cocaine abusers who died of ED with tissue from people killed by cocaine overdoses. They found that the ED patients had a defect in the brain protein that mops up the neurotransmitter dopamine, which surges each time a dose of cocaine is taken. In the overdose victims, this protein had altered to become more efficient at mopping up dopamine—presumably an adaptive response to persistent use of the drug. But no such changes were seen in the ED patients, suggesting that their brains can’t adapt to remove excess dopamine. At this week’s meeting, Karch also revealed that ED patients show changes in opioid receptors in the amygdala—a brain region associated with fear. Taken together, these changes in brain chemistry represent a “signature” of ED, says Karch. But this can only be detected if samples of brain tissue are removed and frozen within 12 hours of death. The problem is that autopsies are frequently delayed for more than a day, and even then, brain tissue is not routinely analysed. Karch has waded deeper into controversy by contending that police often can’t be blamed for deaths from ED in custody. “These individuals are very sick and even with optimal medical care they don’t stand much chance,” he claims. Karch also argues that a recent rise in the number of deaths in British police cells (see Figure) could be linked to an upsurge in cocaine use in Britain. These conclusions are rejected by many campaigners on the issue of deaths in custody. “Over the years, excited delirium has been a kind of smoke screen for restraint-type deaths,” argues Deborah Coles of Inquest, a London-based group. Whether or not Karch is correct in identifying ED as an underdiagnosed problem, other experts believe the emphasis should be on changing police practices to avoid forms of restraint that make it more likely that ED patients will die. “The focus needs to be placed on the modes of constraint used, getting police to use alternatives to physical restraints and, when physical restraints are essential, to use the least dangerous approaches,