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UNITED STATES DISTRICT COURT FOR THE DISTRICT OF COLUMBIA UNITED STATES OF AMERICA CRIMINAL NO. 07-MJ-258-AK VIOLATIONS: 18 U.S.C. § 1038 (False Information and Hoaxes) CHRISTOPHER ORLOSKI Defendant. GOVERNMENT’S BRIEF IN SUPPORT OF ITS REQUEST FOR AN ORDER TO INVOLUNTARY MEDICATE THE DEFENDANT TO RESTORE HIS COMPETENCY FOR TRIAL
The United States, by and through its attorney, the United States Attorney for the District
of Columbia, hereby requests that the Court order the defendant to submit to the involuntary
administration of antipsychotic medications, consistent with Supreme Court’s decision in Sell v.
United States, 539 U.S. 166 (2003). In support of this request, the government states as follows:
Background Nature Of Charge And Arrest1
On May 27, 2007, at approximately 1:30 p.m., officers of the United States Capitol Police
(USCP) were conducting a security sweep of the United States Capitol grounds in preparation for
a Memorial Day concert later that evening. A USCP officer discovered a Deer Park-brand
water bottle, one half-liter in size and containing a clear liquid, on the concrete in the Grotto area
of the United States Capitol grounds. The Grotto is located on the west front of the United States
Capitol near the Senate air shaft. The words “for U.S. defense” were handwritten on the label of
the water bottle. The same words were handwritten on the clear part of the bottle.
1 The description of Mr. Orloski’s actions giving rise to his arrest and the charge before
the Court is taken from the Amended Complaint, dated June 1, 2007.
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The USCP officer found approximately 17 loose sheets of paper in a pile next to the
water bottle. The top sheet of paper consisted of a black-and-white photocopy of three keys with
handwriting above the keys. Two of the keys appeared to be Architect of the Capitol (AOC)
Medico keys. The serial number for one of the AOC Medico keys was legible in the photocopy
and corresponded with the master key for all telecommunication closets in the Senate Hart office
building. The handwriting above the depiction of the keys appeared to refer to the travel
schedule of two CSX trains and various items transported on the trains, with a reference to
A second sheet of paper consisted of the printout of an email containing a threat to release
chlorine gas in Washington, D.C. The subject heading in the email stated: “Cloreen [sic] to visit
U.S. Capitol.” The body of the email stated: “I am going to release Cloreen [sic] in DC. What u
tink about dat, asswhips?” The email was addressed to an employee at the United States Defense
Intelligence Agency (DIA). The remaining papers contained numerous references to “chlorine”
or “Cloreen” and to Christopher Orloski.
Also, on May 27, at approximately 1:30 p.m., a citizen found two United States Postal
Service Priority Mail envelopes on the concrete near Grant’s statue on the United States Capitol
grounds, and provided the envelopes to a uniformed USCP officer. One of the envelopes had
handwriting on the outside. That handwriting stated: “Go to the grotto fountain for the complete
details on the U.S. Senate Thanks.” The envelope without handwriting on the outside contained
numerous papers. One of the papers appeared to be the resume of a Christopher Orloski.
Another papered appeared to be a letter from “Chris.” The letter, dated May 20, 2007, was
addressed as follows: “To all in the family.” The letter contained the statement: “There is also a
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reason why I captured the U.S. Senate’s keys and gave them to the Islamic Republic of ********
in 2007.” The letter also contained a reference to “making the Seung-Hui Cho Virginia Tech
event look like a cribling using a plaything.”
In response to this threat, the USCP established a perimeter around the scene and called
for its Hazardous Devices Unit to arrive. The Hazardous Devices Unit tested the water bottle
and its contents for explosives and chemicals on the scene. The water bottle and its contents
On May 31, 2007, at approximately 2:30 a.m., USCP officers found Christopher Orloski
sleeping outside on the United States Capitol grounds. A USCP detective interviewed Mr.
Orloski soon afterward, and Mr. Orloski admitted that he had left the papers at the Grotto as a
Mr. Orloski was subsequently arrested and charged with a violation of 18 U.S.C. § 1038. Post-Arrest Procedural History
Following the defendant’s arrangement and, by order dated June 11, 2007, this Court
ordered competency restoration and treatment, pursuant to 18 U.S.C. § 4241. On July 2, 2007,
Mr. Orloski was admitted to the Mental Health Department of the Federal Medical Center (FMC)
Since Mr. Orloski arrived at FMC-Butner, Mr. Orloski was seen individually by Jason
Cohen, M.A., Psychological Intern, and supervised by Carlton Pyant, Ph.D, Staff Psychologist.
Psychiatric consultation was provided by Mark Cheltenham, M.D., Staff Psychiatrist. Report at
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2.2 Other members of the FMC-Butner forensic team, correctional, and mental health staff also
had the opportunity to observe Mr. Orloski since his arrival. Id. Assessment procedures were
conducted for Mr. Orloski’s evaluation, including clinical interviews, behavioral observations,
and a July 2, 2007 physical examination.
The staff at FMC-Butner believed that, through the evaluative process, Mr. Orloski was
uncooperative, guarded, and self righteous. Report at 5. During interpersonal encounters, Mr.
Orloski was also argumentative and antagonistic. Id. The most prominent and striking feature of
his presentation stemmed from his delusional belief system. Id. The staff felt that the delusions
to which he subscribes are the defining characteristic of Mr. Orloski and drive much of his
In particular, Mr. Orloski believes that he is some type of covert operative, currently held
as an enemy combatant and the subject of a multi-national and multi-agency conspiracy. Id.; TR
at 17, 26, 37. Mr. Orloski strongly believed that there was a political conspiracy against him that
involved the utilization of a host of United States governmental officials and departments. He
reported the existence of a “political agenda operating” for charging him with “communicating
threats to use chemical weapons against the United States Senate.” Report at 7.
Over the course of his hospitalization, Mr. Orloski became increasingly angry with Dr.
Pyant. Report at 8. His discontentment commenced shortly after Dr. Pyant and other evaluators
communicated that they believed he was mentally ill and recommended his treatment with
2 “Report at ___” refers to the page number of the November 19, 2007 report prepared by
the medical staff of FMC-Butner in response to the Court’s request for a competency restorationstudy of Mr. Orloski. This Report was admitted as evidence during the hearing held by theCourt on January 29, 2007, to address the Government’s request to involuntary medicated thedefendant. Hearing Transcript at page 4 (subsequently cited, herein, as “TR at ___”).
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psychotropic medication. Report at 8-9, TR at 38. Mr. Orloski initially began refusing
communication with team members, especially if Dr. Pyant was present. Report at 9. He
modified this strategy and began conveying intense hostility towards Dr. Pyant via sarcasm,
questioning his professionalism and credentials, speaking with his superiors and communicating
vague threats of harm. Id. Mr. Orloski avoided making direct threats. Id. He usually insinuated
plans to utilize his purported connections with powerful people and organizations to influence or
command acts of aggression against specific individuals. Id.
With the passage of time, Mr. Orloski’s psychological symptoms worsened.
Behaviorally, he began following his peers around the unit and initiating contact with them, only
to verbally insult or disparage them. Id. The unit officer reported an increasing number of his
peers expressing an intent to assault Mr. Orloski if he continued this aggressive behavior. Id. In
addition, on October 27, 2007, Mr. Orloski directly confronted Dr. Pyant. Id. Upon making eye
contact with Dr. Pyant, Mr. Orloski stated, “we are going to do things my way.” Id. Mr. Orloski
continued to prevent Dr. Pyant from continuing and failed to comply with Dr. Pyant’s instruction
for him to return to his unit. Id. Dr. Pyant ultimately was required to contact a unit officer to
ensure his safety. Id. Following this incident on October 27, Mr. Orloski was removed from
open population at FMC-Butner, and placed in a single cell, restricted movement housing unit,
where he is required to be inside of his cell for 23 hours a day. Id.; TR at 13.
On November 19, 2007, a report was issued by FMC-Butner – which was signed by Mr.
Cohen, Dr. Pyant, and Dr. Cheltenham – opining that Mr. Orloski was not competent to proceed
to trial and that he should be involuntary medicated with psychotropic medications to restore his
competency to proceed to trial, consistent with the Supreme Court’s decision in Sell v. United
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States. Report at 20-21. The conclusions in this Report were based on the totality of the
observations and evaluations by the FMC-Butner personnel of Mr. Orloski and documents
On January 29, 2008, a hearing was held before this Court on the Government’s request
for the Court to issue an order for the defendant to submit to the involuntary administration of
antipsychotic medications to restore his competency. At this hearing, Drs. Pyant and Cheltenham
testified for the Government and were qualified as experts in their respective fields of forensic
psychology and psychiatry. TR at 6, 43. Mr. Orloski testified on his own behalf, without cross-
examination. TR at 65. Following this hearing, this Court requested briefing from both parties
to address the involuntary medication of Mr. Orloski. TR at 76.
The Defendant Has Been Diagnosed As Having Delusional Disorder And This Disorder Has Rendered The Defendant Currently Incompetent To Stand Trial The Defendant Has Been Diagnosed As Having Delusional Disorder
The Report states that Mr. Orloski meets diagnostic criteria for Delusional Disorder.
Report at 10. The Report explains that, according to the Diagnostic and Statistical Manuel of
Mental Disorders, Fourth Edition, Tex Revision (DSM-IV-TR), a delusion is “a false belief
based on incorrect inference about external reality that is firmly sustained despite what almost
everyone else believes and despite what constitutes incontrovertible and obvious proof or
evidence to the contrary. The belief is not one ordinarily accepted by other members of the
person’s culture or subculture (e.g., it is not an article of religious faith).” Id.
The Report further explains that Mr. Orloski falsely believes he is a covert operative
employed by the DIA. Report at 10. Although he has been presented with insurmountable
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evidence that is contrary to his belief, including being informed by several mental health
professionals that he is mentally ill, and has been arrested, charged, and incarcerated by the very
government he claims sanctions his actions, he has not altered his beliefs. Id. Rather, he has
adapted his delusion to incorporate this incongruent information, and currently believes that his
incarceration is simply a new mission. Id.
The Report states that the reviewed evidence indicates that Mr. Orloski has been
delusional since January 2007 and, based on the typical onset of this disorder, was likely
The Defendant’s Severe Mental Illness Has Rendered Him Currently Incompetent To Stand Trial
Given the defendant’s severe mental illness, the Report concludes that Mr. Orloski’s
rational understanding of the proceedings against him is seriously flawed and he is currently
incompetent to stand trial. Report at 12-13, TR at 25, 27, 39. The Report explains that Mr.
Orloski’s Delusional Disorder has rendered him unable to appreciate the nature and
consequences of the proceedings filed against him and unable to work with an attorney in his
The Report clarifies that Mr. Orloski believes that the charges against him are the result
of a grand scale governmental conspiracy, and he is a covert operative, acting in a government
sanctioned, occupational capacity, and therefore, exempt from legal proceedings. Id. He also
believes the proceedings are a retaliation from the United States Department of Justice for filing
3 The Report indicates, however, that Mr. Orloski has a sufficient factual knowledge of
the proceedings against him. Report at 12. In general, he understands plea options and personnelinvolved in the judicial process, including the judge, jury, defense attorney, prosecutor andwitness. Id. He also expressed an understanding of various pleas and verdicts. Id.
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a lawsuit, and believes his current situation serves only to confirm the allegations he raised in the
lawsuit. Id. Although Mr. Orloski understands the adversarial nature of the courtroom, he
believes the United States Attorney General is unethical and will contrive allegations. Id.
Accordingly, the Report opines that Mr. Orloski has paranoid delusions which preclude him from
rationally applying factual knowledge to his case. Id.
The Report further states that Mr. Orloski has made it abundantly clear he does not feel
his attorney can defend him or even wants to try. Report at 13. Paranoid delusions cause Mr.
Orloski to believe his attorney is part of the conspiracy against him, and Mr. Orloski is not
willing to discuss any details relevant to his case due to the secretive nature of “covert
operations.”4 Report at 13, TR at 18, 26. Mr. Orloski also will not discuss alternative defense
strategies with his attorney, and does not plan on having his attorney represent him and intends to
represent himself. Report at 13. On more than one occasion, he explained that his lawyer would
not be able to defend him and had “malice” intentions. Id. On October 11, 2007, Mr. Orloski
stated his lawyer was aware of the “political agenda” operating against him and sent him to be
evaluated rather than lose the case. He stated that his lawyer’s motivation is not to help him but
strictly financial compensation and maintenance of his “win versus loss record in court.”
According to Mr. Orloski, his case is “undefendable” because orders have come down from the
top and everyone involved in his case takes orders from someone.
Consistent With The Supreme Court’s Decision In Sell, Mr. Orloski Should Be Involuntary Medicated To Restore His Competency For Trial
4 Although Mr. Orloski asserted at the January 29 hearing that he believes he would be
able to assist his attorney in preparing a defense (TR at 67), there was no discussion of how orwhy Mr. Orloski was able to change his prior, strongly-held beliefs regarding his attorney,especially in the absence of any medical treatment.
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The Forensic Report Indicates, Given Mr. Orloski’s Current State Of Restriction, He Does Not Pose A Danger To Himself, Others, Or Property Sufficient To Meet The Dangerousness Criteria Of Harper And The Government Does Not Contest That Determination For Purposes Of This Hearing
In Sell, the Supreme Court instructs that the first step in ascertaining the appropriateness
of involuntary medication is an assessment of whether or not the defendant is a danger to himself
There are often strong reasons for a court to determine whetherforced administration of drugs can be justified on these alternativegrounds before turning to the trial competence question. For onething, the inquiry into whether medication is permissible, say, torender an individual nondangerous is usually more “objective andmanageable” than the inquiry into whether medication ispermissible to render a defendant competent.
Sell, 539 U.S. at 182 (emphasis in the original) (citing Riggins v. Nevada, 504 U.S. 127, 140
(1992) (Kennedy, J., concurring in judgment)). The Supreme Court further explained that in
those cases involving dangerous defendants, – that is, those defendants whose “failure to accept
treatment threatens injury to the patient or others” (id., citing 18 U.S.C. § 4246), “the need to
consider authorization on trial competence grounds will likely disappear.” Id. at 183.
The government recognizes that the Report indicates Mr. Orloski does not pose a danger
to himself, others or property – given his current state of restriction – sufficient to meet the
criteria of Washington v. Harper, 494 U.S. 210 (1990), which would allow the Government to
use medically appropriate antipsychotic drugs to reduce that danger. Report at 14, 20. The
Report explains that Mr. Orloski has been housed on the open population for the majority of his
hospitalization. Report at 14. In addition, although his recent threats against staff have resulted
in his placement in restricted housing, Mr. Orloski has continued to manage his personal hygiene
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without assistance, and maintains adequate nutritional practices. Id. His delusional beliefs have
not impacted his physical health, nor is he considered to be gravely disabled secondary to
medical or psychiatric pathology.” Id.
For purposes of this hearing, the United States does not contest the Report’s conclusion
that Mr. Orloski does not meet the criteria set forth in Harper necessary to justify involuntary
Consistent With The Supreme Court’s Decision In Sell, Mr. Orloski Should Be Involuntary Medicated To Restore His Competency For Trial
The United States Court of Appeals for the District of Columbia Circuit has held that a
criminal defendant’s due process liberty interest in avoiding unwanted antipsychotic medication
is not absolute. See United States v. Weston, 255 F.3d 873, 876 (citing Kansas v. Hendricks,
521 U.S. 346, 356 (1997)). The defendant’s interest can be substantially outweighed by
compelling governmental interests, including the “essential government policies” of preventing
and punishing criminality. Id. at 880 (citing Schall v. Martin, 467 U.S. 253, 264 (1984)). As the
[t]o allow the government forcibly to medicate a defendant prior totrial with antipsychotic drugs, the district court must find that: (1)an “essential state policy” is at issue, (2) “treatment withantipsychotic medication [is] medically appropriate and,considering less intrusive alternatives, essential for the sake of [thedefendant’s] own safety or the safety of others,” or essential toenable an adjudication of the defendant’s guilt or innocence; and(3) the defendant’s due process rights are protected.”
Id. at 888 (Rogers, J., concurring) (citing Riggins, 504 U.S. at 135-38 ). Generally, the
government must show that in the opinion of medical experts, the proposed treatment and
medications are “medically appropriate,” and that the “potential side effects [are] manageable.”
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Subsequent to the D.C. Circuit’s analysis in Weston, the Supreme Court examined the
issue of involuntary medication in the context of non-dangerous defendants in Sell, 539 U.S.
166. Looking to the more narrow issue of whether trial competence alone justifies involuntary
medication, the Supreme Court found that here, too, under appropriate circumstances, a
defendant’s right to resist medication can be outweighed by the government’s interest in
prosecuting the perpetrators of crime. Id. at 180 (quoting Illinois v. Allen, 397 U.S. 337, 347
(1970) (Brennan, J., concurring) (“[P]ower to bring an accused to trial is fundamental to a
scheme of ‘ordered liberty’ and prerequisite to social justice and peace”).
To render a defendant just competent for trial, as opposed to “nondangerous”, the
Supreme Court in Sell set forth the following standards. As an initial matter, the court must find
that important governmental interests are at stake. Sell, 539 U.S. at 180. This element is
satisfied where the defendant is charged with a serious crime against a person or against property,
because “[i]n both instances the Government seeks to protect through the application of the
criminal law the basic human need for security.” Id. Where a trial court first finds this important
governmental interest, the Supreme Court directed that it then examine how that interest is
furthered by the involuntary administration of medication:
Second, the court must conclude that involuntary medication willsignificantly further [the] state interests. It must find that theadministration of the drugs is substantially likely to render thedefendant competent to stand trial [and] is substantially unlikely tohave side effects that will interfere significantly with thedefendant’s ability to assist counsel in conducting a trial defense,thereby rendering the trial unfair.
Third, the court must conclude that involuntary medication is
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necessary to further [the state interest]. The court must find thatalternative, less intrusive treatments are unlikely to achievesubstantially the same results. . . .
Fourth, . . . the court must conclude that administration of thedrugs is medically appropriate, i.e., in the patient’s best medicalinterest in light of his medical condition.
Sell, 539 U.S. 180-183 (emphasis in original) (citations omitted).
As discussed below, the Government has met this requisite 4-prong standard to justify the
involuntary medication of Mr. Orloski to restore his competency for trial.
Important Governmental Interests Are At Stake In Bringing To Trial Mr. Orloski Who Is Accused Of A Serious Crime
Mr. Orloski is charged with committing a dangerous felony offense — providing false
information and perpetrating a hoax in violation of 18 U.S.C. § 1038. As discussed above in
section I.A., Mr. Orloski knowingly and wilfully disseminated false and/or misleading
information on the United States Capitol grounds where such information could reasonably be
believed and where such information indicated that an activity has taken, is taking or will take
place relating to the release of harmful chlorine gas. Indeed, the significant nature of this
incident – the possible release of chlorine gas on the United States Capitol grounds close to the
United States Senate air shaft – caused the USCP to establish a perimeter around the scene and to
call for its Hazardous Device Unit. As a result, the defendant is currently charged with a serious
crime – a violation of 18 U.S.C. § 1038, consistent with the Government’s efforts to “protect
through the application of the criminal law the basic human need for security.” Sell, 539 U.S. at
180; see also Weston, 255 F.3d at 880 (“Preventing and punishing criminality are essential
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In addition, because a violation of 18 U.S.C. § 1038 is punishable by up to five years in
prison, Mr. Orloski faces a significant potential maximum sentence, which further demonstrates
that the crime is “serious” for involuntary medication purposes. See United States v. Evans, 404
F.3d 227, 237 (4th Cir. 2005) (focusing on the maximum penalty authorized by statute in
determining if a crime is “serious” in the context of an involuntary medication determination);
see also Duncan v. Louisiana, 391 U.S. 145, 158 (1968) (observing that the Sixth Amendment’s
right to trial by jury exists only in “serious” criminal cases).
Treatment Is Substantially Likely To Restore The Defendant To Competency And Is Substantially Unlikely To Have Side Effects That Will Interfere Significantly With the Defendant’s Ability To Assist His Counsel a. Treatment Is Substantially Likely To Restore The Defendant To Competency
Treatment with antipsychotic medication is the accepted and appropriate treatment for an
individual with the diagnosis of Delusion Disorder, Mixed Type. Report at 14, TR at 46. The
Report explains that providing Mr. Orloski with intramuscular, long acting Haldol decanoate
medication will have a substantially probability of restoring him to competency. Report at 13,
14; see Weston, 255 F.3d at 883 (crediting the district court’s finding and the evidence in the
record showing “a strong-likelihood exists that medication will enhance some of Weston’s trial
rights, particularly his right to consult and to assist in his defense”) (citing United States v.
Weston, 134 F.Supp.2d 115, 133 (D.D.C. 2001).
Expected efficacy in the case of Mr. Orloski should approach 80%. Report at 19, TR at
50, see Weston, 255 F.3d at 882 (finding a sufficient likelihood that antipsychotic medication
would restore competency where the government presented evidence that such medication
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mitigated symptoms for a least 70 percent of patients and the defendant’s response might be
higher). The Government does not need to demonstrate “100% probability” that the medication
will restore competency. Id. at 882. Good outcome predictors for Mr. Orloski include primarily
delusions with a paucity of deficit symptoms, lack of substance abuse, and no evidence of
The Report specifically explains that antipsychotic medication can produce beneficial
clinical effects such as decreasing delusional beliefs, and these are the psychotic symptoms
which render Mr. Orloski incompetent to stand trial. Report at 14. By decreasing delusional
beliefs, the influence they have on decisions, judgments, and perceptions are decreased and, with
time, eliminated. Report at 14. As a result, Mr. Orloski is anticipated to make reasonable,
rational, and reality based decisions regarding the processing of his legal charges. Report at 14.
In addition, antipsychotic medication can decrease agitation and increase one’s ability to become
appropriately focused on one’s case and, consequently, improve the level of communication
between Mr. Orloski and his attorney. Report at 14; see Weston, 225 F.3d at 882 (crediting the
the district court’s finding that “antipsychotic medication is the only therapeutic intervention
available that could possibly improve Weston’s symptom picture, lessen his delusions, and make
him competent to stand trial”) (citing Weston, 134 F.Supp.2d at 132).
The Treatment Is Not Substantially Likely To Have Serious Side Effects Which Would Interfere With Mr. Orloski’s Ability To Assist His Attorney In Conducting His Defense
The side-effects of the antipsychotic medication, with appropriate clinical management,
would be unlikely to interfere with Mr. Orloski’s ability to assist counsel in his defense. Report
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As with all medications, antipsychotic medication has side effects. Report at 16. A few
of the side effects of the antipsychotic medications are serious and others are relatively benign
and have no long term effects. Id. As a matter of course, these side effects are monitored and
routinely managed by psychiatrists throughout the country in daily clinical practice. Id. The
risks and benefits of the particular medication are considered prior to initiating treatment. Id. If
serious side effects emerge, they are managed in a clinically appropriate manner. Id., see
Weston, 255 F.3d at 885 (crediting the district court’s finding and the evidence in the record
showing “Weston’s doctors can manage side effects in a number of ways” and concluding that
“the possibility of side effects from anti-psychotic medication is undeniable, but the ability of
Weston’s treating physicians and the district court to respond to them substantially reduces the
In particular, antipsychotic medication would be unlikely: to impair Mr. Orloski’s ability
to communicate, impair his ability to effectively react to and participate in courtroom
proceedings, impair his ability to express emotions, or sedate him. TR at 50-51, see Sell, 539
U.S. at 185 (“Whether a particular drug will tend to sedate a defendant, interfere with
communication with counsel, prevent rapid reaction to trial developments, or diminish the ability
to express emotions are matters important in determining the permissibility of medication to
restore competence . . .”) (citing Riggins, 504 U.S. at 142-145 (Kennedy, J., concurring in
Less Intrusive Alternatives To Medication Will Not Achieve The Same Results
Any alternative, less intrusive treatments are unlikely to achieve substantially the same
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results of restoring Mr. Orloski to competency. As explained in the Report, Mr. Orloski is
unlikely to improve in the foreseeable future without treatment with antipsychotic medication,
which he is now refusing on a voluntary basis. Report at 16. In particular, without the benefit of
medication, Mr. Orloski is substantially unlikely to attain the ability to fully appreciate the nature
and consequences of the proceedings against him or to assist properly in his defense. Report at
There is no evidence that psychotherapeutic techniques alone are effective alternatives for
antipsychotic agents. Report at 16, TR at 8, 9, 39. First, Mr. Orloski does not have any insight
or understanding that he has a mental illness. Id. He therefore does not believe that he is in need
of treatment of any type and, consequently, he is unlikely to engage in any form of
psychothereapy. Report at 16. Second, while there is evidence in the psychiatric literature that
some forms of psychotherapy are beneficial to an individual with psychotic symptoms, such
psychotherapy is as an adjunctive treatment to the antipsychotic agents to improve such issues as
insight, compliance, or coping skills. Id. Treatment With Antipsychotic Medications Is Medically Appropriate
As discussed above, the Report indicates that the standard and accepted treatment for
anyone with the diagnosis of Delusional Disorder, Mixed Type would involve the prescription of
antipsychotic medication. Report at 14. The Report further indicates that Mr. Orloski does not
have any chronic medical conditions which would be adversely affected by the proposed
treatment of antipsychotic medication and, consequently, administering the proposed treatment is
medically and clinically appropriate. Report at 17.
The Report details that Mr. Orloski’s individual treatment plan would be tailored to
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appropriately address his refusal to comply with any oral psychotropic medication. Id. Because
it would not be practical to administer a short-acting injectable medication on a daily basis, the
Butner medical staff would rely on a long acting injectable antipsychotic. Id. These
antipsychotics would include Haldol decanoate and Prolixin decanoate. Id. Prior to the
administration of any of these long-acting medications, a test dose of the short acting formulation
would be required for safety purposes to rule out unexpected allergic reactions. Id., TR at 57.
Dr. Cheltenham would choose to administer Haldol decanoate as the first line medication
for a number of reasons. Report at 17. These reasons include that Haldol decanoate provides a
more even absorption into the blood from the depot site in the muscle. Id. Dr. Cheltenham
proposes that Mr. Orloski would initially be administered 100 mg of Haldol decanoate
intramuscularly every two weeks over the first two months of treatment in order to hasten steady
blood levels required for optimal therapeutic effects. Id. Thereafter, the dose would be
Side effects of Haldol and Proxilin decanoate are most notable for movement disorder,
including Parkinsonian effects, dystonic reactions, akathisia, and tardive dyskensia. Id. As set
forth in the Report and discussed below, with the exception of tardive dyskinesia, these effects
are reversible with discontinuation of the medication and are otherwise manageable. Report at
5 Notably, the Report explains that, if at any time Mr. Orloski voluntarily agreed to take
an oral antipsychotic, he would be transitioned to one of the newer atypical antipsychotics,defined for the lower risk of movement disorders, such as Parkinsonism, dystonic reactions, andmost importantly tardive dyskinesia. Report at 19, TR at 51.
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Parkinsonian effects are most common, occurring in approximately 15% of patients,
usually 5 to 90 days after the initiation of the medication. Report at 18. Symptoms include
muscle stiffness, cogwheel rigidity, shuffling gait, stooped posture and a coarse tremor. Id. If
Mr. Orloski were to develop this side effect, he would be administered 2 mg of Cogentin up to
every eight hours, as needed, which usually provides immediate relief of these symptoms. Id.
Side effects of Cogentin are dry mouth, blurred vision, dizziness, and constipation, and chronic
administration of Cogentin may increase the risk of tardive dyskinesia. Id. Along with the
administration of Cogentin, a dosage reduction of Haldol decanoate would be considered.
Dystonic reactions occur in approximately 10% of patients treated with either Haldol or
Prolixin decanoate, and these reactions occur within the first few hours or days of treatment
initiation. Id. Dystonic reactions consist of a slow, sustained muscular contraction or spasm that
can result in an involuntary movement involving the neck, jaw, tongue, or the entire body. Id.
This side effect is avoided by giving a dose of 2 mg of Cogentin intramuscularly during the first
two weeks of the long acting Haldol or Prolixin administration. Id.
Akathisia is a subjective feeling of muscular discomfort that can cause the patient to be
agitated, pace, stand and sit, and feel dysphoric. Id. This side effect can occur any time during
treatment and is less frequent than Parkinsonism or dystonic reaction, but may be under
diagnosed as psychosis, agitation or poor cooperation. Id. If Mr. Orloski were to develop
akathisia, the dose of either Haldol or Prolixin decanoate would be reduced, with the possible
temporary addition of Indera or Ativan. Inderal may cause dizziness, bradycardia, and dysphoria,
Case 1:07-mj-00258-AK-RCL Document 21 Filed 02/12/2008 Page 19 of 20
and Ativan may result in sedation and unsteadiness.
Tardive dyskensia is considered the most serious side effect due to possible irreversibility
and incapacitation. Report at 18. This is a delayed effect of the typical antipsychotics such as
Haldol and Prolixin which rarely occurs until after six months of treatment, but then occurs at an
incidence of 4% per year, with a lifetime prevalence of approximately 30%. Report at 18. The
likelihood that a patient will develop this side effect, which may not be dose related, increases
over time. Id. This syndrome consists of involuntary, irregular combinations of writhing and
jerking movements of the voluntary muscles of the head, limbs and/or trunk. Id. The severity of
these movements range from minimal to grossly incapacitating. Id.
To address tardive dyskinesia, the medical approach would be prevention, diagnosis and
management. Id. Following the initiation of treatment, tardive dyskinesia is monitored at each
clinical contact and documented monthly with the use of the Abnormal Involuntary Movement
Scale (AIMS). Id. Because there is no effective treatment for tardive dyskinesia, early
intervention is imperative at the first signs of tardive dyskinesia, where discontinuation of the
antipsychotic results in the reversal of tardive dyskinesia in 50% of the cases. Id.
The only established treatment for intractable tardive dyskinesia is discontinuation of the
offending antipsychotic and switching to the atypical antipsychotic Clozaril. Id.
For the foregoing reasons, the United States Attorney for the District of Columbia,
respectfully requests that the Court order the defendant to submit to the administration of
antipsychotic medications consistent with the Supreme Court’s decision in Sell v. United States.
Case 1:07-mj-00258-AK-RCL Document 21 Filed 02/12/2008 Page 20 of 20
OPHER SHWEIKIAssistant United States AttorneyBar No. 458776Federal Major Crimes Section555 4th Street, N.W. Washington, D.C. 20530(202) 353-8822
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