Forensic Medical Procedure for Illegal Drug Users in Turkey

Psychotropic medications, also known as psychoactive compounds, primarily function by acting on the central nervous system. They are used to treat mental illnesses and include mood stabilizers, anxiolytics, antidepressants, antipsychotics, sedative-hypnotics, and other similar medication classes [1]. The inappropriate use of a substance in a way that does not fit the criteria for addiction but results in clinically substantial impairment or distress is known as substance abuse [2]. Addiction criteria are determined according to ICD 10 and DSM V. In ICD-10, these criteria are; a very strong desire or compulsion to take the substance, difficulty in controlling the behavior of taking the substance, physiological withdrawal syndrome when substance use is reduced or stopped, tolerance symptoms, an increase in the time spent to obtain, use and get rid of the effects of the substance to the extent that there is no room for other interests and pursuits, and continuing substance use despite clear evidence of harm such as physical and mental illnesses. The presence of three of these is sufficient to diagnose addiction [3,4].

ICD-10 criteria for substance use dependency

At least three of the following must be encountered or demonstrated in the preceding year:
1. A strong need or feeling of obligation to consume the drug.
2. Challenges in managing substance-related behavior concerning its commencement, progression, or extent of usage.
3. A physiological withdrawal state following cessation or reduction of substance usage, as demonstrated by the substance’s typical withdrawal syndrome; or the use of the substance in question (or one that is closely related) to prevent or treat withdrawal symptoms.
4. Proof of tolerance, whereby higher dosages of the psychoactive ingredient are needed to produce the same effects that were initially induced by smaller amounts.
5. The gradual abandonment of other interests or pleasures due to the use of psychoactive substances, the lengthier time required to purchase or take the substance, or the recovery period following its effects.
6. Continuing to use drugs or alcohol despite obvious proof of their obvious detrimental effects, such as liver damage from binge drinking, depressed moods brought on by heavy drug use, or cognitive impairment from drug usage. It is important to try to ascertain if the user knew the nature and scope of the arm or could reasonably be expected to [3].

The DSM-III was the first to make the distinction between substance misuse and dependence. Early and milder stages of addiction were included in the DSM-IV definition of substance misuse. Drug abuse and drug dependence diagnoses were integrated under the heading of substance use disorders with DSM-V, nevertheless, the substance abuse criteria observed in practice can be severe [5,6].

The European Drug Report 2022 states that drug use and access are still widespread throughout the European Union, albeit with significant national variations. In the European Union, 83.4 million persons (or 29%) between the ages of 15 and 64 are estimated to have used illicit substances at some point. Men are more likely than women to report using illicit drugs (50.5 million versus 33 million). Cannabis remains the most widely consumed drug in Europe, with over 22 million people reporting using it in the previous year. In the category with the most reports, stimulants come in second. It is estimated that 3.5 million adults consumed cocaine, 2.6 million consumed MDMA, and 2 million consumed amphetamines last year. Around 1 million Europeans used heroin or another illicit opioid last year. Opioids still cause the greatest portion of harm associated with illegal drug use, despite their use being less common than other substances. This is demonstrated by the fact that over 75% of fatal overdoses reported in the European Union in 2020 involved opioids, frequently in combination with other substances. It should be remembered that the majority of drug addicts use a range of substances. Drug problems have been linked to medicinal products, new, unregulated psychoactive substances, and substances like ketamine and GBL/GBH (gamma-butyrolactone) (gammahydroxybutyrate). As a result, we are witnessing a marked increase in the complexity of drug consumption patterns in certain countries or among certain groups [7].

The prevalence of substance use and related diseases both in the world and in Turkey is increasing [8]. In our nation, the prevalence of drug misuse is 2.7%. There aren’t many sociodemographic details available regarding the patients. The incidence of drug addiction in our country is approximately 2.7%. Socio-demographic data on treated individuals are limited [9]. In studies on illicit substance use in Turkey, it is reported that the male/female ratio in inpatient treatment is higher than in European Union countries. While the age range was mainly between 20-29 years (31.95 ± 11.42,) (26.09±7.87), the rate for men was recorded in several research as 92.1%, 94.07%, 94.5%, 95.67%, and 95.7% [5,8-12]. It is reported that treatment applications are low due to patients’ belief that cannabis is not addictive and therefore does not need to be treated. In 2005, it was claimed that cannabis abuse applications increased due to probation practices. However, research indicates that cannabis is the drug most commonly used by treatment applicants (n=133, 51.6%). Other research indicates that 80% of applicants suffer from an opiate use disorder or heroin addiction, 74% are addicted to multiple drugs (such as synthetic cannabis and methamphetamine), and 18.2% are alcohol dependent. Since 2005, it is thought that the diagnosis of cannabis abuse has increased due to the probation measures that started in 2005, which enabled people with cannabis abuse to apply to hospitals. In the study in which 76 cases treated in Ankara AMATEM were analyzed, the majority of the cases were young, single, male adults addicted to heroin. The average age of drug addicts was lower than that of alcohol addicts, and they thought that the number of treatment clinics was low, the duration of treatment was short and the treatment methods were inadequate [5,8-12]. Anxiety disorders were the most common axis I diagnosis (n = 58, 22.5%) and antisocial personality disorder (n=30, 11.6%) among patients hospitalized in the Alcohol and Substance Use Disorders Treatment Center (AMATEM) of a regional hospital, according to a study assessing the sociodemographic and clinical characteristics of those patients [8].

There were 246 direct drug-related deaths in 2022. 89% (219) of the deceased were men, while 11% (27) were women. In 2022, 62.2% of drug-related deaths were due to polysubstance use. In 2022, the oldest direct drug-related death was 74 years old and this death was due to heroin use. Thirty-four was the average age of death. Methamphetamine usage was the cause of 52.3% of 153 polysubstance-related deaths in 2022. However, methamphetamine accounted for 64.5% of the 93 fatalities brought on by a single substance usage. There were 135 drug addiction treatment facilities at the end of 2022. While 76 centers exclusively offer outpatient treatment services, 59 centers offer both inpatient and outpatient treatment services. By the end of 2022, the total bed capacity of treatment centers is 1,388. In 2022, the total number of outpatient treatment applications to treatment centers alone was 302,911. Of these, 113,981 were referred under probation. In 2022, the number of applications to inpatient treatment centers was 18,187. When duplicate cases are subtracted from this number, the total number of unique persons is 14,042. In 2022; outpatient admissions due to F11 (Opioid Addiction) 113,191, inpatients 7,042, 121,154 and 8,851 for F19 (Multi-drug et al. psychoactive substance addiction), 53,054 and 818 for F12 (Cannabinoid addiction), 1,852 and 275 for F14 (Cocaine addiction), 1,725 and 232 for F16 (Hallucinogens addiction), 1,074 and 313 for F13 (Sedative and hypnotic substance addiction), 1,084 and 1,084 for F18 (Inhalant-volatile and solventaddiction). 725 and 232 for F13 (Addiction to sedative and hypnotic substances), 1,074 and 313 for F18 (Addiction to inhalants, volatile and solvents), 1,084 and 111 for F18 (Addiction to inhalants, volatile and solvents); in total, it was reported that the number of outpatient applications in 2022 was 302,911 and the number of inpatients was 18,187 [13]. These drugs listed in the Turkey Drug Report are all prohibited. By 2022, there will be 400 facilities for capital punishment. There are 340,793 inmates and convicts housed in these facilities altogether. There are 114,924 prisoners serving life sentences in prisons for drug-related offenses as of 2022. 2022 saw 109,021 decisions under Article 191 of the Turkish Penal Code sent to probation directorates [13].

If we review the regulations on illegal substances in the Turkish penal code

Article 57- (7): Concerning an offender who is addicted to alcohol, narcotics, or psychotropic substances it shall be determined whether he requires treatment at a health institution that has expertise on alcohol narcotic and psychotropic substance addicts. The treatment shall continue until such persons are cured of using alcohol, narcotics, and psychotropic substance addicts. The treatment shall continue until such persons are cured of using alcohol, narcotics or psychotropic substances. They may be released from the health institution by a decision of a court or a judge based on a report to be prepared by the commission of the health institution in which the person was placed.

Article 188- (1): Any person who produces, imports or exports narcotics or psychotropic substances without a license, shall be sentenced to a penalty of imprisonment for a term of twenty to thirty years and a judicial fine of two thousand to twenty thousand days.

Article 190- (1): Any person facilitating the use of narcotics or psychotropic substances by:
a. Providing a particular environment, equipment, or material,
b. Taking precautions to ensure the avoidance of the arrest of any users, or
c. Providing information to others about the method of usage shall be sentenced to a penalty of imprisonment for a term of five to ten years and a judicial fine of one thousand to ten thousand days.
d. Any person who publicity or through broadcast media, encourages another to use narcotics or psychotropic substances, shall be sentenced to a penalty of imprisonment for a term of five to ten years and a judicial fine of one thousand to ten thousand days.
e. Where an offense under this Article is committed by a physician, dentist, pharmacist, chemist, veterinarian, health personnel, laboratory technician, midwife, nurse, dentistry technician, patient care nurse, the person providing health services or a person engaged in the chemical or pharmaceutical industry, the penalty to be imposed shall be increased by one half.

Article 191- (1): Any person who purchases, receives or possesses narcotics or psychotropic substances for personal use or uses shall be sentenced to a penalty of imprisonment for a term of two to five years.

Article 192- (1): If a person, who participated in an offense concerning the production or sale of narcotics or psychotropic substances, provides authorities with the names of any other parties to the offense, or the place where the narcotics or psychotropic substances are hidden or produced before the authorities themselves receive such information, and the information given by him leads to either the seizure of the narcotics or psychotropic substances, no penalty shall be imposed [14].

Legally, substance-related offenses are sanctioned in different ways, such as manufacturing, importing or exporting, possessing for use, or being addicted to a substance. Expert witnesses are asked for their opinion on whether people caught in possession or use of a substance are addicted to the substance. A person is entirely criminally accountable if they commit a crime while under the influence of a substance they willingly took, as stated in Article 34 of the Turkish Penal Code. Here, the individual’s circumstances before substance use are taken into account. In the case of substance addiction and crimes committed during the abstinence phase, it is concluded that there is no criminal ability. As a security precaution, persons who are officially diagnosed as addicted by a medical professional are admitted to alcohol and drug treatment facilities for treatment. Those who are believed to be non-addicts face varied sanctions from courts, based on allegations that they are either drug users or traffickers. Those discovered to have manufactured, imported, or exported the chemical face lengthy prison terms under our Penal Code [15,16]

July 20, 2005, dated 5402 numbered Law on Probation and Assistance Centers and Protection Boards, which entered into force with the Law on Probation and Assistance Centers and Protection Boards; the court has given a conviction about the convicted child, suspect, defendant or convicted person; It is a community-based practice that covers program and resource provision, information, guidance, rehabilitation and assistance services in the fields of monitoring, improvement, solving psycho-social problems, supervision, integration with society and all kinds of similar needs within the framework of the supervision plan, within the framework of the conditions and duration determined by the court for children, suspects, defendants or convicts who have been convicted by the court, whose sentences have been postponed, released and for whom any measure other than imprisonment has been decided. To stop an offender from committing the same crime twice, the psychological and social issues that underlie their conduct are found during probation. This forms the foundation for rehabilitation and, with the required interventions, execution in the community. By rehabilitating and improving convicted individuals, probation is intended to prevent recidivism, maintain public safety, assist victims in repairing harm, prevent substance abuse-related harm, reintegrate convicted individuals into society by ensuring that their cautionary decisions are followed in the community, and ultimately lower the number of prisons [17-19].

One of the reasons for limitation is “... alcohol or drug addiction...” according to Article 406 of the Civil Code. Article 432 of the Civil Code - Any adult person who poses a danger to society due to mental illness, mental weakness, alcohol or narcotic addiction, gravely dangerous infectious disease, or vagrancy may be placed in a suitable institution for his treatment, education, or rehabilitation or may be detained if his protection cannot be provided in any other way... According to Article 475 of the Civil Code, an individual who has been placed under guardianship because of their extravagance, drug or alcohol addiction, poor lifestyle, or mishandling of their assets may ask for the guardianship to be removed, if they have not received any complaints about the reason they were placed under guardianship for a minimum of a year. If the Civil Code’s alcohol and drug regulations are scrutinized, dependent individuals may lose their legal capacity, be placed in a suitable rehabilitation facility, or have their guardianship revoked with a report stating their legal rights if they haven’t filed any complaints regarding the matter for a minimum of a year [20]. In cases of alcohol and substance use disorders and addictions, the relevant experts are asked for their opinions on criminal liability in criminal cases and the capacity to exercise civil rights [16].

Legal practices should carefully consider whether individuals caught using or in possession of prohibited substances meet DSM and ICD criteria for addiction. Experts should assess the patient and the medical file based on the significance of the topic while writing a report.

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