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This is a book about Forensic Toxicology, focusing on the issues surrounding drug use and misuse. Everyone seems to think they know about forensic toxicology, but the depth of knowledge possessed is often very superficial. In my experience, students wishing to enter the field have garnered most of their opinions on the topic from popular TV programmes. So, it's good to have the latest authoritative insights from a set of experts on a range of problems that consume significant parts of our medical and social budgets.

Alas, the terms drug use and misuse do tend to go together. Almost every drug for pharmaceutical use that I've ever worked on has ended up being misused in some way and, of course, a high proportion of the drugs we work on in forensic toxicology have been manufactured for or diverted into the illicit drug market.

In forensic toxicology we set out to detect and measure these drugs and then to use the measurements as a guide to medical intervention, to interpret findings after death, to support legal investigations or to give substance to epidemiological surveys on drug use and changing patterns of drug use.

There have indeed been some significant changes in the pattern of illicit drug use of late. Just which drugs are being sold on the illicit market has become an increasingly difficult question to answer, with the burgeoning of a large number of compounds with psychoactive properties. From just a few new compounds emerging onto the market each year about a decade ago, by 2014 the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) Early Warning System reported 101 new psychoactive compounds in that year alone. A high proportion of these compounds were the synthetic cannabinoids, more accurately described as synthetic cannabinoid receptor agonists; by the end of 2014, 134 had been notified to the Early Warning System.

For the laboratory these rapid changes pose substantial methodological problems in terms of sourcing reliable calibrators and in developing methods for the detection and quantification of these new compounds, in drug seizures and in biological samples. Happily, improvements in the availability of mass spectrometric equipment suitable for clinical laboratories has greatly facilitated the development of methodology to address these issues, but these techniques require high levels of investment in personnel with analytical skills for their optimal use.

For law enforcement a major problem is the ease with which these compounds can be made available to users via the internet and poorly regulated courier systems. This, in turn, has been a driving force for some focused entrepreneurs to make small changes to the molecular structures of some starting materials with known psychoactive properties. These compounds have appeared at a faster rate than they can be controlled by legislation, and they have been sold on the so-called “legal highs” market. Of course, by the nature of their production and marketing, these compounds have not been subject to any pharmaceutical regulatory procedure, so that their clinical toxicology remains largely unknown until patients arrive in hospital, or individual users post their own, unreliable, reports on social media sites.

Forensic toxicology plays an important role in defining which drugs are being consumed and matching these data with clinical harm. For some time, we have known that finding out what people are taking is not as simple as asking them, or relying on drug seizures. Too often, packaging is designed to obfuscate the contents and purchasers on the illicit market may not receive what they were under the impression they had bought. Nor should it be overlooked that there is a similar problem in the purchase of pharmaceutical preparations. Patients, both within and outside socialised medical settings, do resort to purchasing drugs online, or in open market places in poorly regulated countries. Many of these drugs, for diseases such as HIV, malaria and tuberculosis, are falsified or substandard, posing a global health risk. In this book some of the approaches that help to define the changing patterns of drug use, in areas such as driving, drug use in the workplace and in sport, are explored.

If we are going to bring any order to the problems outlined in this book, either by defining them or introducing regulatory controls, then the careful and thoughtful approaches encapsulated in these chapters, backed by apposite case examples, are a prerequisite. Those working in laboratories must keep abreast of developments in a constantly changing environment by maintaining an active dialogue with those using their services. In the clinical field, drug measurements must be integrated with both pharmacokinetic and pharmacodynamic measurements if they are to be of value in supporting treatment regimens or to interpret toxicological findings. For forensic legal applications, innovative approaches to sampling may be needed, backed by analyses and interpretation that pass the ever increasing demands of international regulatory strictures.

These chapters will be of interest and value to a wide range of readers, not only those with a day-to-day involvement in the topics covered, but also those who have a peripheral involvement in the issues dealt with and wish to extend their own knowledge of the highly topical issues covered.

David W. Holt

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