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Dr. D. Love
Dr. D. Love, Doctor
Category: Drug Testing
Satisfied Customers: 17541
Experience:  Family Physician for 10 years; Hospital Medical Director for 10 years.
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I am need of assistance of interpreting a toxicologist

Customer Question

I am need of assistance of interpreting a toxicologist report for medications I have been taking for 10 and 12 years, same dosages, one since 2005 and one over a year and a half. My doctors have all stated that since I have been taking for so long that it obviously would be in my system but I have built up such a tolerance to it that it wouldn't affect me after all these years of taking and it wouldn't even impair me, even to the slightest degree and I would actually be "normal." They all have stated that it looking at my reports and the length of time of taking, it obviously affect people differently and again, the length of time, I have built up such a tolerance to it, the affect wears off, though it still helps my symptoms. But all the toxicologist sees if the medications, not knowing my history, the length of time taking and I've passed every drug test every given and they wouldn't have kept prescribing if there was any indication of misuse, etc. I only use one pharmacy and cannot refill early as I have medicaid. I didn't even take my medications on the day of the incident, nor was I driving. I was sitting parked, texting and I have 2 types of tremors, orthostatic and essential, one affects me standing requiring the need to hold on, the other my voice which causes stuttering, repeating, issues getting words out and sometimes slurring and the later it got that morning, plus under duress, it gets worse. My disability was mistaken for being impaired and all of my doctors disagree completely with the toxicologist but most have moved to other states, on to other positions and my new doctors have attempted to help but weren't the original prescribers of the meds and state I need another toxicologist to go up against a toxicologist but it's my doctors who know my medical history and have made these statements. But my public defender has failed to go over any of my evidence, the police report, tox report or even attempted to talk to an independent toxicologist to provide this information about the length of time taking my meds and what my doctors are saying to get this answer. I need someone to look at my report, to get another input.
Submitted: 2 months ago.
Category: Drug Testing
Expert:  Dr. D. Love replied 2 months ago.

Which medicines were you taking?

What levels were found?

Customer: replied 2 months ago.
clonazepam 2mg 3x/day since '04, can miss middle dose if doing well but not very often at all.
topirimate 200mg 2x/day since '05
hydrodocode since '97, switched to elixir 7.5/325 3x/day as needed max dose of 3x/day PRN chronic pain. changed to elixir due to gastric bypass surgery in '08, didn't tolerate pill form. Taken mostly at night
Quetinapine 300mg 1x day since 2009 take at night
Butalbital chronic migraines since jan 15, take 1 to 2 pills every 4hrs PRN, prescribed 40 per month. Started botox April '15. migraines very severe. would get very frequently, would last 3 to 4 days n left with a "hangover headache affect" never drove when taking that medication as would vomit pain so severe. though it really had no affect on me n wear off after bout 3 hrs if taking 1 pill after starting Botox Used entire RX each month. Referred to migraine specialist in Feb 2016 right before incident, explained what happened. He looked over tox report, asked why taking Butalbital? Said had tried several others n they didn't work he said that is bad drug, needed to be taken off, switched to Maxalt. Said was a bartibituate. Asked what barbiturate was, said it was bad n shouldn't take it. Said u shouldn't take a barbiturate. I know nothing about drugs, n when researching it, I was given an actual "DRUG." Was floored n told no information from my neurologist about this or pharmacist n doesn't say any of this even in pamphlet!! Doesn't say not to drive, just wait to see how it affects u until operating heavy machinery. This is what it states on all of my bottles n pamphlets. Thought I'm if starting anything new, always wait at least a week or so before doing any driving n always start on weekend. This is the only new medication I had been on since all of the others I have been on for years. Plus each dr. had list of meds so all knew what I take, n pharmacy, I only use one, I also have to take random drug tests, never not passed one EVER in all these years. Meds are also run through Federal Drug monitoring program, can't pick up meds early, on Medicare, doses haven't changed, Drs. even said I have built up such a tolerance by now that I am considered "normal" in their eyes n they even wanted to increase but I saw no need as I am functioning fine with disorders n don't want more meds. Had severe thyroid issues last year that caused severe issues cuz was left on a thyroid med 2 years too long (methimazole) which left me with irreversible symptoms that cant be cured now:almost removed my thyroid for no reason, insomnia, memory loss, found incompetent for a period, pituitary damage, peripheral & polyneuropathy, chronic dry eye, vision issues & need new glasses I cannot afford (on disability) dental issues (7 cavities/ 4 crowns *no insurance on payment plans for indigent but over $1500), urinary incontinence & now need pacemaker device inserted as 7 mediations failed to control my bladder at 46 which getting now so in trial process),IBS exacerbated, tinnitus worse n lost more hearing, essential tremors in voice worsened causing stuttering, repeating, getting words out, slurring, n have to possibly have botox into my voicebox. That is what police I believe mistook disability for is being impaired as had not taken my meds that morning as never do before taking daughter to school n was well past taking, didn't take since 2am n was 10:12 when they arrived n I was talking to principal, my 11yr old was sexually assaulted by 5th grader in same class n I reported principal to school board day before believe she retaliated against me by calling cuz she failed to mandatory report it, when police arrived got me more upset n caused tremors to worsen, especially in voice n was shaking n principal knows I have medical issues but doesn't understand them n never heard voice tremors n more I spoke worse they got. Teachers I work see them alot. Also had 2 letters in car from Drs. explaining my disabilities but refused to get. Stated what they were n if any roadside tests were needed which ones I could/couldn't do. I have a speech issue or cannot stand without holding on doesn't make me impaired. Drs. looked at report n did conversion, plus tolerance level of years taking meds am well below therapeutic levels if they suggest adding a med because I've been on same doses for so long I refuse cuz they know how long I've been on n think I need to up doses or change so that's why they think they aren't doing what they should be They've stated I would be considered "normal" n not impaired to slightest degree to years of taking meds.Toxicologist states would be significantly impaired on meds calling it conconcontion.Doesn't know how long been taking, will say I've been impaired since 2004 then. Did take butalbutial at 5am n drove at 10am, 5hrs after 1 pill that wears off after 3hrs n taking for 1 1/2yrs. Roadside done 10:30, blood 11am. Parked,keys not in ignition,texting.Sending tox report. Codeine is showing for unknown reason. Not even a metabolite??
Customer: replied 2 months ago.
I don't have a phone....
Expert:  Dr. D. Love replied 2 months ago.

Thank you for the additional information.

All of these drug levels are within the respective therapeutic ranges for the various drugs.

As for the key question of whether impairment can be deduced from therapeutic drug levels, you are correct that someone that has been on each drug for a while can develop tolerance to the effect of the drug. However, it would be just as ridiculous for a Toxicologist to say that you are not impaired, simply because of the amount of time that you have been taking each drug.

From a medical perspective, the best argument would be the provision of evidence that interpretation of blood levels is difficult. For example, if you look at http://www.nhtsa.gov/people/injury/research/job185drugs/morphine.htm, the National Highway Traffic Safety Administration discusses morphine, and about a third of the way down the page discusses Interpretation of Blood Levels, and notes that "Tolerance makes interpretation of blood or plasma morphine concentrations extremely difficult." The you can present an assessment by the doctor that is prescribing the medicines attesting to the physiologic effect in you, and that the assessment shows no impairment that would affect driving.

I realize that any argument must also must take the local law into account, as some states have more stringent drugged driving laws. But from a medical perspective, the argument against this report is a physiologic argument, not a toxicologic argument.

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