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Karch's Pathology of Drug Abuse, Fourth Edition

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REFERENCE: Karch SB. Karch's pathology of drug abuse,
4th ed. Boca Raton, FL: CRC Press, 2009, 709 pp.
Dr. Karch brings us the fourth edition of his indispensable text
on drug abuse, 7 years after the publication of the third edition.
Many of the photographs are now printed in color, but the real
prize is an additional 168 pages of information. The fourth edition
contains a new chapter on marijuana. Other topics are presented
with new or augmented information; the chapter on solvents, for
example, includes a useful section with information on proper procedures
for collecting and storing specimens in cases of solvent
abuse. With the fourth edition each section on an individual drug
begins with a helpful display of that drug's pharmacological data,
its molecular formula, molecular weight, method of metabolism,
volume of distribution, elimination half-life, known drug interactions,
and so on.
Much of the increase in the fourth edition is due to the addition
of discoveries in molecular biology and genetics that have
altered our scientific understanding of the mechanisms by which
drugs of abuse cause damage and death. In his Preface to the
Fourth Edition, Dr. Karch summarizes the changes in forensic
toxicology that have occurred in the past 20 years, specifically
citing the role of genetic polymorphism in contributing to deaths
related to methadone. The fourth edition includes information on
deaths related to cocaine and other drugs as well, all succinctly
summarized by Dr. Karch, with references for additional study
by the reader.
Reading the fourth edition of Karch's Pathology of Drug Abuse
is an occasion for both despair and hope. The despair comes as
Karch repeatedly shows that determining the cause of death in a
given case is never as simple as looking at a blood concentration
of a drug to see whether it is within some published reference
range for lethality. Indeed, Karch shows that the overlap between
lethal and nonlethal concentrations of drugs of abuse is often so
broad as to be useless, taken purely by itself. This means that those
who certify causes of death must always consider a given case in
its entirety to determine the cause of death for that case, an appropriate
way to practice medicine, but one with no hope for easy
determinations of death caused by drugs of abuse. The hope comes
from the promise of a better understanding of how drugs of abuse
cause deaths. Sections 1.10 on the Electrophysiology of Sudden
Death in Cocaine Abusers and 5.9.7 on Methadone provide a better
understanding of how these drugs cause death and why death
occurs in some individuals but not others. Clearly the day is coming
when testing for genetic polymorphism will occur as part of
the evaluation for a death related to drugs of abuse. Karch ends his
Preface by stating that the role of DNA technology and molecular
biology will become ever more important in understanding the
pathology of drugs of abuse. We are fortunate to have Karch's
Pathology of Drug Abuse to help in that understanding.