1
|
Gjerde H, Jamt REG, Stenehjem JS, Bogstrand ST. Substance use and driver fatality in Norway: An expanded case-control study. TRAFFIC INJURY PREVENTION 2024:1-9. [PMID: 39190537 DOI: 10.1080/15389588.2024.2392274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/13/2024] [Accepted: 08/10/2024] [Indexed: 08/29/2024]
Abstract
OBJECTIVE Using alcohol or psychoactive drugs before driving a motor vehicle may increase the risk of crash involvement, injury, and death. This is better documented for alcohol than for drugs. The aim of this study was to expand a previous case-control study on substance use and driver fatality by doubling the number of cases and controls, and hence improve the statistical power and enable the analysis of combined substance use. METHODS We collected data on alcohol and drug use from all 1197 drivers of cars and vans who were fatally injured in road traffic crashes in Norway between 2005 and 2020 ('cases') by analyzing blood samples or reviewing other information on substance use. We also collected data on alcohol and drug use among 17,219 drivers in random road traffic ('controls') by analyzing oral fluid samples. Substance use was converted to dichotomous variables (no use/use). We used unconditional logistic regression to estimate adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of driver fatality for mutually exclusive substance groups, adjusted for sex, age, geographic region, urban centrality class, and time interval of the week. RESULTS Compared to no substance use, the aOR (95% CI) for driver fatality was for alcohol 91 (61-137), stimulants (primarily amphetamines) aOR 22 (9-56), benzodiazepines and z-hypnotics (BZDs) aOR 4.0 (2.7-5.9), tetrahydrocannabinol (THC) aOR 3.4 (1.7-6.7), and opioids aOR 1.4 (0.4-4.9). The aOR for any polysubstance use was 168 (96-297). The combinations of BZDs with stimulants or THC were associated with markedly higher aORs for driver fatality than the use of single substance groups. CONCLUSIONS Alcohol and polysubstance use are the most important predictors of fatal injury, followed by stimulants.
Collapse
Affiliation(s)
- Hallvard Gjerde
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
| | | | - Jo Steinson Stenehjem
- Department of Research, Cancer Registry of Norway, National Institute of Public Health, Oslo, Norway
- Oslo Centre of Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Stig Tore Bogstrand
- Department of Forensic Sciences, Oslo University Hospital, Oslo, Norway
- Department of Public Health Science, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| |
Collapse
|
2
|
Lo LA, Christiansen AL, Strickland JC, Pistawka CA, Eadie L, Vandrey R, MacCallum CA. Does acute cannabidiol (CBD) use impair performance? A meta-analysis and comparison with placebo and delta-9-tetrahydrocannabinol (THC). Neuropsychopharmacology 2024; 49:1425-1436. [PMID: 38528133 PMCID: PMC11251190 DOI: 10.1038/s41386-024-01847-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/23/2024] [Accepted: 03/08/2024] [Indexed: 03/27/2024]
Abstract
Cannabidiol (CBD) is widely used and believed to be non-intoxicating, lacking acute performance effects (e.g., non-impairing). However, a synthesis of data has not evaluated this. This meta-analysis synthesized data from controlled human laboratory studies that evaluated if acute CBD use impairs performance. Performance on objective and subjective measures of cognitive and psychomotor function were used as markers for potential performance changes and impairment. Studies were identified through systematic database searches. Adult clinical trials measuring acute CBD effects (within 0-8 h of administration) were included. The primary outcome was the peak mean difference in performance measures between CBD and placebo. A secondary analysis utilizing delta-9-tetrahydrocannabinol (Δ9-THC) as a positive control for comparison to CBD was completed. Pooled Hedges' g estimates were calculated using robust variance estimation (RVE) meta-regression. The omnibus RVE meta-analysis indicated a statistically significant, but small effect size (Hedge's g < 0.2) for impaired performance following acute CBD consumption compared to placebo (N = 16 trials, Hedges' g = 0.122, 95% CI: 0.023-0.221, p = 0.019). Measure type was a significant moderator with larger mean differences between CBD and placebo when subjective measures, specifically self-reported sedation, were used versus objective performance tasks (Hedges' gSubjective = 0.288 versus Hedges' gObjective = 0.048). Δ9-THC had a significantly greater magnitude of impairment compared to CBD (N = 8, Hedges' g = 0.416, 95% CI: 0.017-0.816, p = 0.043). In summary, acute CBD consumption was associated with a small increase in subjective ratings of sedation, but no difference from placebo was observed across multiple domains of objectively assessed cognitive or psychomotor performance. These findings suggest that acute CBD alone is unlikely to significantly impair daily functioning or workplace performance.
Collapse
Affiliation(s)
- Lindsay A Lo
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- School of Medicine, Queen's University, Kingston, ON, Canada
| | | | | | - Carly A Pistawka
- Faculty of Science, University of British Columbia, Vancouver, BC, Canada
| | - Lauren Eadie
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ryan Vandrey
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | |
Collapse
|
3
|
Trif C, Harpaz D, Eltzov E, Parcharoen Y, Pechyen C, Marks RS. Detection of Cannabinoids in Oral Fluid Specimens as the Preferred Biological Matrix for a Point-of-Care Biosensor Diagnostic Device. BIOSENSORS 2024; 14:126. [PMID: 38534233 DOI: 10.3390/bios14030126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/28/2024]
Abstract
An increasing number of countries have started to decriminalize or legalize the consumption of cannabis for recreational and medical purposes. The active ingredients in cannabis, termed cannabinoids, affect multiple functions in the human body, including coordination, motor skills, memory, response time to external stimuli, and even judgment. Cannabinoids are a unique class of terpeno-phenolic compounds, with 120 molecules discovered so far. There are certain situations when people under the influence of cannabis may be a risk to themselves or the public safety. Over the past two decades, there has been a growing research interest in detecting cannabinoids from various biological matrices. There is a need to develop a rapid, accurate, and reliable method of detecting cannabinoids in oral fluid as it can reveal the recent intake in comparison with urine specimens, which only show a history of consumption. Significant improvements are continuously made in the analytical formats of various technologies, mainly concerning improving their sensitivity, miniaturization, and making them more user-friendly. Additionally, sample collection and pretreatment have been extensively studied, and specific devices for collecting oral fluid specimens have been perfected to allow rapid and effective sample collection. This review presents the recent findings regarding the use of oral fluid specimens as the preferred biological matrix for cannabinoid detection in a point-of-care biosensor diagnostic device. A critical review is presented, discussing the findings from a collection of review and research articles, as well as publicly available data from companies that manufacture oral fluid screening devices. Firstly, the various conventional methods used to detect cannabinoids in biological matrices are presented. Secondly, the detection of cannabinoids using point-of-care biosensors is discussed, emphasizing oral fluid specimens. This review presents the current pressing technological challenges and highlights the gaps where new technological solutions can be implemented.
Collapse
Affiliation(s)
- Călin Trif
- Avram and Stella Goldstein-Goren Department of Biotechnology Engineering, Faculty of Engineering Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Dorin Harpaz
- Institute of Biochemistry, Food Science and Nutrition, Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot 76100, Israel
- Department of Postharvest Science of Fresh Fruit, Volcani Center, Agricultural Research Organization, Rishon LeZion 7505101, Israel
| | - Evgeni Eltzov
- Department of Postharvest Science of Fresh Fruit, Volcani Center, Agricultural Research Organization, Rishon LeZion 7505101, Israel
| | - Yardnapar Parcharoen
- Chulabhorn International College of Medicine, Thammasat University, Klong Luang 12120, Pathum Thani, Thailand
| | - Chiravoot Pechyen
- Center of Excellence in Modern Technology and Advanced Manufacturing for Medical Innovation, Thammasat University, Klong Luang 12120, Pathum Thani, Thailand
- Department of Materials and Textile Technology, Faculty of Science and Technology, Thammasat University, Klong Luang 12120, Pathum Thani, Thailand
| | - Robert S Marks
- Avram and Stella Goldstein-Goren Department of Biotechnology Engineering, Faculty of Engineering Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
- The Ilse Katz Center for Meso and Nanoscale Science and Technology, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| |
Collapse
|
4
|
Kassim FM, Tod S, Rodger J, Hood SD, Lee JWY, Albrecht MA, Martin-Iverson MT. Nabilone Impairs Spatial and Verbal Working Memory in Healthy Volunteers. Cannabis Cannabinoid Res 2024; 9:199-211. [PMID: 36201240 DOI: 10.1089/can.2022.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Memory impairments and psychosis-like experiences can be adverse effects of cannabis use. However, reports on the cognitive impact of cannabis use are not consistent. There are also limited studies on the psychotomimetic effects of cannabinoid compounds to reveal the association between cannabis and psychosis. Therefore, we investigated the effect of acute cannabinoid intoxication on verbal working memory (VWM) and spatial working memory (SWM) following oral doses of the synthetic cannabinoid agonist, nabilone (1-2 mg, oral). We further investigated the effect of nabilone on psychosis-like experiences (schizotypy scores) and associations of schizotypy with VWM and SWM. Methods: Healthy participants (n=28) completed spatial and digit span tasks across different delay conditions (0, 6, 12, and 18 sec) after receiving nabilone (1-2 mg, PO) or placebo in a randomized, double-blind, counterbalanced, crossover manner. A subset of participants completed a short battery of schizotypy measures (n=25). Results: Nabilone impaired VWM (p=0.03, weak effect size η2=0.02) and SWM (p=0.00016, η2=0.08). Nabilone did not significantly change overall schizotypy scores. Schizotypy scores were negatively correlated with working memory (WM) averaged across all delays and both modalities, under placebo (ρ=-0.41, p=0.04). In addition, there were significant negative correlations between occasions of cannabis use and overall WM averaged scores across drug treatments (ρ=-0.49, p=0.007) and under placebo (ρ=-0.45, p=0.004). The results showed that the drug effect in the less frequent cannabis users was more pronounced on the SWM (p<0.01) and VWM (p<0.01), whereas there appeared to be little drug effect in the frequent cannabis users. Conclusion: Low doses of synthetic cannabinoid impaired SWM and VWM, indicating that exogenous activation of the cannabinoid system influences cognitive performance. Further, the results replicated previous findings that schizotypy is correlated with deficits in WM. Clinical Trial Registry Name: Nabilone and caffeine effects on the perceptions of visually, auditory, tactile and multimodal illusions in healthy volunteers. Clinical Trial Registration Number: CT-2018-CTN-02561 (Therapeutic Goods Administration Clinical Trial Registry) and ACTRN12618001292268 (The Australian New Zealand Clinical Trials Registry).
Collapse
Affiliation(s)
- Faiz M Kassim
- Psychopharmacology Research Unit, Discipline of Pharmacology, School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Sophie Tod
- Psychopharmacology Research Unit, Discipline of Pharmacology, School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Jennifer Rodger
- Experimental and Regenerative Neurosciences, School of Biological Sciences, University of Western Australia, Crawley, Western Australia, Australia
- Brain Plasticity Group, Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Sean D Hood
- Division of Psychiatry, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Joseph W Y Lee
- Division of Psychiatry, Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Matthew A Albrecht
- Western Australian Centre for Road Safety Research, School of Psychological Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Mathew T Martin-Iverson
- Psychopharmacology Research Unit, Discipline of Pharmacology, School of Biomedical Sciences, University of Western Australia, Perth, Western Australia, Australia
| |
Collapse
|
5
|
Lalwani K, Martin J, Barton E, Frazier G, Abel W. Drug driving: a secondary analysis of factors associated with driving under the influence of cannabis in Jamaica. BMJ Open 2024; 14:e078437. [PMID: 38262644 PMCID: PMC11148678 DOI: 10.1136/bmjopen-2023-078437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES To determine cannabis use patterns, the predictive sociodemographic correlates of driving under the influence of cannabis (DUIC) and the association between risk perception and cannabis dependence among vehicle drivers in Jamaica. DESIGN Secondary data analysis. SETTING Used the Jamaica National Drug Prevalence Survey 2016 dataset. PARTICIPANTS 1060 vehicle drivers extracted from the population sample of 4623. PRIMARY AND SECONDARY OUTCOME MEASURES Analysis used Pearson's χ2 test and logistic regression. ORs and 95% CIs were recorded. A p<0.05 was considered statistically significant. RESULTS More than 10% of Jamaican drivers admitted to DUIC in the past year. Approximately 43.3% of drivers who currently use cannabis reported DUIC only. Evidently, 86.8% of drivers who DUIC were heavy cannabis users. Approximately 30% of drivers with moderate to high-risk perception of smoking cannabis sometimes or often were dependent on cannabis. Notwithstanding, drivers with no to low-risk perception of smoking cannabis sometimes or often were significantly likelier to be dependent (p<0.001 and p<0.001, respectively). Logistic regression highlighted male drivers (OR 4.14, 95% CI 1.59 to 14.20, p=0.009) that were 34 years and under (OR 2.97, 95% CI 1.71 to 5.29, p<0.001) and were the head of the household (OR 2.22, 95% CI 1.10 to 4.75, p=0.031) and operated a machine as part of their job (OR 1.87, 95% CI 1.09 to 3.24, p=0.023) were more likely to DUIC, while those who were married (OR 0.42, 95% CI 0.22 to 0.74, p=0.004) and had achieved a tertiary-level education (OR 0.26, 95% CI 0.06 to 0.76, p=0.031) were less likely. CONCLUSIONS Two in five Jamaican drivers, who currently smoke cannabis, drive under its influence, with over 85% engaging in heavy use. Public health implications necessitate policy-makers consider mobile roadside drug testing and amending drug-driving laws to meet international standards.
Collapse
Affiliation(s)
- Kunal Lalwani
- Department of Community Health and Psychiatry, The University of the West Indies, Mona, Jamaica
| | - Jacqueline Martin
- Department of Community Health and Psychiatry, The University of the West Indies, Mona, Jamaica
| | - Everard Barton
- Department of Medicine, The University of the West Indies, Mona, Jamaica
| | - Gralyn Frazier
- Department of Economics, Western Michigan University, Kalamazoo, Michigan, USA
| | - Wendel Abel
- Department of Community Health and Psychiatry, The University of the West Indies, Mona, Jamaica
| |
Collapse
|
6
|
Hartley S, Simon N, Cardozo B, Larabi IA, Alvarez JC. Can inhaled cannabis users accurately evaluate impaired driving ability? A randomized controlled trial. Front Public Health 2023; 11:1234765. [PMID: 38074719 PMCID: PMC10703156 DOI: 10.3389/fpubh.2023.1234765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/26/2023] [Indexed: 12/18/2023] Open
Abstract
Aims To study the effect of inhaled cannabis on self-assessed predicted driving ability and its relation to reaction times and driving ability on a driving simulator. Participants and methods 30 healthy male volunteers aged 18-34: 15 chronic (1-2 joints /day) and 15 occasional (1-2 joints/week) consumers. Self-assessed driving confidence (visual analog scale), vigilance (Karolinska), reaction time (mean reciprocal reaction time mRRT, psychomotor vigilance test), driving ability (standard deviation of lane position SDLP on a York driving simulator) and blood concentrations of delta-9-tétrahydrocannabinol (THC) were measured before and repeatedly after controlled inhalation of placebo, 10 mg or 30 mg of THC mixed with tobacco in a cigarette. Results Cannabis consumption (at 10 and 30 mg) led to a marked decrease in driving confidence over the first 2 h which remained below baseline at 8 h. Driving confidence was related to THC dose and to THC concentrations in the effective compartment with a low concentration of 0.11 ng/ml for the EC50 and a rapid onset of action (T1/2 37 min). Driving ability and reaction times were reduced by cannabis consumption. Driving confidence was shown to be related to driving ability and reaction times in both chronic and occasional consumers. Conclusions Cannabis consumption leads to a rapid reduction in driving confidence which is related to reduced ability on a driving simulator. Clinical trial registration ClinicalTrials.gov, identifier: NCT02061020.
Collapse
Affiliation(s)
- Sarah Hartley
- Sleep Unit, Physiology Department, AP-HP GHU Paris-Saclay, Raymond Poincaré Hospital, Garches, France
| | - Nicolas Simon
- Department of Clinical Pharmacology, Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, CAP-TV, Marseille, France
| | - Bibiana Cardozo
- Department of Clinical Pharmacology, Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM, Hop Sainte Marguerite, CAP-TV, Marseille, France
| | - Islam Amine Larabi
- Plateform MasSpecLab, Department of Pharmacology and Toxicology, Raymond Poincaré Hospital, GHU AP-HP.Paris-Saclay, Paris-Saclay University, UVSQ, Inserm U-1018, CESP, Team MOODS, Garches, France
| | - Jean Claude Alvarez
- Plateform MasSpecLab, Department of Pharmacology and Toxicology, Raymond Poincaré Hospital, GHU AP-HP.Paris-Saclay, Paris-Saclay University, UVSQ, Inserm U-1018, CESP, Team MOODS, Garches, France
| |
Collapse
|
7
|
Egloff L, Frei P, Gerlach K, Mercer-Chalmers-Bender K, Scheurer E. Effect of vaporizing cannabis rich in cannabidiol on cannabinoid levels in blood and on driving ability - a randomized clinical trial. Int J Legal Med 2023; 137:1713-1723. [PMID: 37626214 PMCID: PMC10567805 DOI: 10.1007/s00414-023-03076-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023]
Abstract
The aim of this prospective, placebo-controlled, double-blind, randomized, cross-over study was to determine cannabinoid levels in blood and driving-related ability after single (S1) and repetitive (S2) vaporization of cannabis rich in cannabidiol (CBD) containing < 1% Δ9-etrahydrocannabinol (THC). Healthy adult volunteers (Nsingle = 27, Nrepetitive = 20) with experience in smoking vapor-inhaled two low-THC/CBD-rich cannabis products both with < 1% THC (product 1: 38 mg CBD, 1.8 mg THC; product 2: 39 mg CBD, 0.6 mg THC) and placebo. Main outcomes were THC- and CBD-levels in whole blood and overall assessment of driving-related ability by computerized tests. Among 74 participants included, 27 (mean age ± SD, 28.9 ± 12.5 years) completed S1, and 20 (25.2 ± 4.0) completed S2. Peak concentrations and duration of detectability depended on the THC-content of the product. After single consumption THC dropped below 1.5 µg/L after 1.5 h, but was detected in some participants up to 5 h. Pairwise comparison of driving-related ability revealed no significant differences between low-THC/CBD-rich products (P1, P2) and placebo. Detection of THC after consumption of low-THC/CBD-rich cannabis might have legal consequences for drivers. Regarding overall driving-related ability, no significant differences were observed between the interventional products. This trial was registered with the German Clinical Trials Register (DRKS00018836) on 25.10.2019 and with the Coordination Office for Human Research (kofam) which is operated by the Federal Office of Public Health (FOPH) (SNCTP000003294).
Collapse
Affiliation(s)
- Laura Egloff
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Priska Frei
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Kathrin Gerlach
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Katja Mercer-Chalmers-Bender
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| | - Eva Scheurer
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Pestalozzistrasse 22, 4056 Basel, Switzerland
| |
Collapse
|
8
|
Ganesh S, Cortes-Briones J, Schnakenberg Martin AM, Skosnik PD, D'Souza DC, Ranganathan M. Delta-9-Tetrahydrocannabinol, Cannabidiol, and Acute Psychotomimetic States: A Balancing Act of the Principal Phyto-Cannabinoids on Human Brain and Behavior. Cannabis Cannabinoid Res 2023; 8:846-856. [PMID: 35319274 PMCID: PMC10589482 DOI: 10.1089/can.2021.0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: THC and CBD are the principal phyto-cannabinoids in the cannabis plant. The differential and possibly antagonistic effects of these compounds on specific brain and behavioral responses, and the mechanisms underlying their effects have generated extensive interest in pre-clinical and clinical neuroscience investigations. Methods: In this double-blind randomized placebo-controlled counterbalanced Human Laboratory Study, we examined the effects of three different dose ratios of CBD:THC (1:1, 2:1, and 3:1) on "neural noise," an electrophysiological biomarker of psychosis known to be sensitive to cannabinoids as well as subjective and psychotomimetic effects. Healthy volunteers (n=28, 12 women) with at least one prior exposure to cannabis participated in the study. Outcomes: The lowest CBD (2.5 mg):THC (0.035 mg/kg) ratio (1:1) resulted in maximal attenuation of both THC-induced psychotomimetic effects (Positive and Negative Syndrome Scale [PANSS] positive: Anova Type Statistic [ATS]=7.83, pcorrected=0.015) and neural noise (ATS=8.83, pcorrected=0.009). Further addition of CBD did not reduce the subjective experience of THC-induced "high" (p>0.05 for all CBD doses). Interpretation: These novel results demonstrate that CBD attenuates specific THC-induced subjective and objective effects relevant to psychosis in a dose/ratio-dependent manner. Given the increasing global trend of cannabis liberalization and application for medical indications, these results assume considerable significance given the potential dose-related interactions of these key phyto-cannabinoids. Trial registration: The trial was registered in clinicaltrials.gov ID: NCT01180374.
Collapse
Affiliation(s)
- Suhas Ganesh
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Jose Cortes-Briones
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Ashley M. Schnakenberg Martin
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Patrick D. Skosnik
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Deepak C. D'Souza
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Mohini Ranganathan
- Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
| |
Collapse
|
9
|
Fitzgerald RL, Umlauf A, Hubbard JA, Hoffman MA, Sobolesky PM, Ellis SE, Grelotti DJ, Suhandynata RT, Huestis MA, Grant I, Marcotte TD. Driving Under the Influence of Cannabis: Impact of Combining Toxicology Testing with Field Sobriety Tests. Clin Chem 2023; 69:724-733. [PMID: 37228223 PMCID: PMC10320013 DOI: 10.1093/clinchem/hvad054] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/13/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Cannabis is increasingly used both medically and recreationally. With widespread use, there is growing concern about how to identify cannabis-impaired drivers. METHODS A placebo-controlled randomized double-blinded protocol was conducted to study the effects of cannabis on driving performance. One hundred ninety-one participants were randomized to smoke ad libitum a cannabis cigarette containing placebo or delta-9-tetrahydrocannabinol (THC) (5.9% or 13.4%). Blood, oral fluid (OF), and breath samples were collected along with longitudinal driving performance on a simulator (standard deviation of lateral position [SDLP] and car following [coherence]) over a 5-hour period. Law enforcement officers performed field sobriety tests (FSTs) to determine if participants were impaired. RESULTS There was no relationship between THC concentrations measured in blood, OF, or breath and SDLP or coherence at any of the timepoints studied (P > 0.05). FSTs were significant (P < 0.05) for classifying participants into the THC group vs the placebo group up to 188 minutes after smoking. Seventy-one minutes after smoking, FSTs classified 81% of the participants who received active drug as being impaired. However, 49% of participants who smoked placebo (controls) were also deemed impaired at this same timepoint. Combining a 2 ng/mL THC cutoff in OF with positive findings on FSTs reduced the number of controls classified as impaired to zero, 86 minutes after smoking the placebo. CONCLUSIONS Requiring a positive toxicology result in addition to the FST observations substantially improved the classification accuracy regarding possible driving under the influence of THC by decreasing the percentage of controls classified as impaired.
Collapse
Affiliation(s)
| | - Anya Umlauf
- Department of Psychiatry, University of California San Diego, Center for Medicinal Cannabis Research, San Diego, CA, United States
| | | | | | | | - Shannon E Ellis
- Department of Cognitive Sciences, University of California San Diego, La Jolla, CA, United States
| | - David J Grelotti
- Department of Psychiatry, University of California San Diego, Center for Medicinal Cannabis Research, San Diego, CA, United States
| | | | - Marilyn A Huestis
- Institute for Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA, United States
| | - Igor Grant
- Department of Psychiatry, University of California San Diego, Center for Medicinal Cannabis Research, San Diego, CA, United States
| | - Thomas D Marcotte
- Department of Psychiatry, University of California San Diego, Center for Medicinal Cannabis Research, San Diego, CA, United States
| |
Collapse
|
10
|
Kroon E, Kuhns L, Colyer-Patel K, Filbey F, Cousijn J. Working memory-related brain activity in cannabis use disorder: The role of cross-cultural differences in cannabis attitudes. Addict Biol 2023; 28:e13283. [PMID: 37252877 DOI: 10.1111/adb.13283] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 03/20/2023] [Accepted: 04/14/2023] [Indexed: 06/01/2023]
Abstract
Cannabis legislation and attitudes towards use are changing. Given that evidence from cultural neuroscience research suggests that culture influences the neurobiological mechanisms underlying behaviour, it is of great importance to understand how cannabis legislation and attitudes might affect the brain processes underlying cannabis use disorder. Brain activity of 100 dependent cannabis users and 84 controls was recorded during an N-back working memory (WM) task in participants from the Netherlands (NL; users = 60, controls = 52) and Texas, USA (TX; users = 40, controls = 32). Participants completed a cannabis culture questionnaire as a measure of perceived benefits (positive) and perceived harms (negative) of cannabis from their personal, friends-family's and country-state's perspectives. Amount of cannabis use (grams/week), DSM-5 CUD symptoms and cannabis use-related problems were assessed. Cannabis users self-reported more positive and less negative (personal and friends-family) cannabis attitudes than controls, with this effect being significantly larger in the TX cannabis users. No site difference in country-state attitudes was observed. TX cannabis users, compared with NL cannabis users, and those cannabis users perceiving more positive country-state attitudes showed a more positive association between grams/week and WM-related activity in the superior parietal lobe. NL cannabis users, compared with TX cannabis users, and those cannabis users with less positive personal attitudes showed a more positive association between grams/week and WM-load-related activity in the temporal pole. Both site and cultural attitudes moderated the association of quantity of cannabis use with WM- and WM-load-related activity. Importantly, differences in legislation did not align with perceived cannabis attitudes and appear to be differentially associated with cannabis use-related brain activity.
Collapse
Affiliation(s)
- Emese Kroon
- ADAPT-Laboratory, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
- Neuroscience of Addiction (NofA) Lab, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Lauren Kuhns
- ADAPT-Laboratory, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
- Neuroscience of Addiction (NofA) Lab, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
| | - Karis Colyer-Patel
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Francesca Filbey
- School of Behavioral and Brain Sciences, University of Texas at Dallas, Dallas, Texas, USA
| | - Janna Cousijn
- Neuroscience of Addiction (NofA) Lab, Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands
- Department of Psychology, Education and Child Studies, Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
11
|
Manning B, Hayley AC, Catchlove S, Shiferaw B, Stough C, Downey LA. Effect of CannEpil ® on simulated driving performance and co-monitoring of ocular activity: A randomised controlled trial. J Psychopharmacol 2023; 37:472-483. [PMID: 37129083 PMCID: PMC10184186 DOI: 10.1177/02698811231170360] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Medicinal cannabis products containing Δ9-tetrahydrocannabinol (THC) are increasingly accessible. Yet, policy guidelines regarding fitness to drive are lacking, and cannabinoid-specific indexations of impairment are underdeveloped. AIMS To determine the impact of a standardised 1 mL sublingual dose of CannEpil®, a medicinal cannabis oil containing 100 mg cannabidiol (CBD) and 5 mg THC on simulated driving performance, relative to placebo and whether variations in vehicle control can be indexed by ocular activity. METHODS A double-blind, within-subjects, randomised, placebo-controlled, crossover trial assessed 31 healthy fully licensed drivers (15 male, 16 female) aged between 21 and 58 years (M = 38.0, SD = 10.78). Standard deviation of lateral position (SDLP), standard deviation of speed (SDS) and steering variability were assessed over time and as a function of treatment during a 40 min simulated drive, with oculomotor parameters assessed simultaneously. Oral fluid and plasma were collected at 30 min and 2.5 h. RESULTS CannEpil did not significantly alter SDLP across the full drive, although increased SDLP was observed between 20 and 30 min (p < 0.05). CannEpil increased SDS across the full drive (p < 0.05), with variance greatest at 20-30 min (p < 0.001). CannEpil increased fixation duration (p < 0.05), blink rate (trend p = 0.051) and decreased blink duration (p < 0.001) during driving. No significant correlations were observed between biological matrices and performance outcomes. CONCLUSIONS CannEpil impairs select aspects of vehicle control (speed and weaving) over time. Alterations to ocular behaviour suggest that eye tracking may assist in determining cannabis-related driver impairment or intoxication. Australian and New Zealand Clinician Trials Registry, https://anzctr.org.au(ACTRN12619000932167).
Collapse
Affiliation(s)
- Brooke Manning
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Amie C Hayley
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- International Council for Alcohol, Drugs, and Traffic Safety
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| | - Sarah Catchlove
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Brook Shiferaw
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- Seeing Machines, Melbourne, VIC, Australia
| | - Con Stough
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
| | - Luke A Downey
- Centre for Human Psychopharmacology, Swinburne University of Technology, Hawthorn, VIC, Australia
- Institute for Breathing and Sleep, Austin Health, Melbourne, VIC, Australia
| |
Collapse
|
12
|
Wennberg E, Windle SB, Filion KB, Thombs BD, Gore G, Benedetti A, Grad R, Ells C, Eisenberg MJ. Roadside screening tests for cannabis use: A systematic review. Heliyon 2023; 9:e14630. [PMID: 37064483 PMCID: PMC10102219 DOI: 10.1016/j.heliyon.2023.e14630] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/20/2022] [Accepted: 03/13/2023] [Indexed: 04/04/2023] Open
Abstract
As more countries legalize recreational cannabis, roadside screening programs are imperative to detect and deter driving under the influence of cannabis. This systematic review evaluated roadside screening tests for cannabis use. We searched six databases (inception-March 2020) and grey literature sources for primary studies evaluating test characteristics of roadside screening tests for cannabis use compared to laboratory tests for cannabinoids in blood or oral fluid. The synthesis was focused on sensitivity and specificity of delta-9-tetrahydrocannabinol (THC) detection. 101 studies were included. Oral fluid tests were higher in specificity and lower in sensitivity compared to urine tests when evaluated against blood laboratory tests. Oral fluid tests were higher in sensitivity and similar in specificity compared to observational tests when evaluated against blood and oral fluid laboratory tests. Sensitivity was variable among oral fluid tests; two instrumented immunoassays (Draeger DrugTest 5000 [5 ng/mL THC cut-off] and Alere DDS 2 Mobile Test System) appeared to perform best, but definitive conclusions could not be drawn due to imprecise estimates. Specificities were similar. Overall, oral fluid tests showed the most promise for use in roadside screening for blood THC levels over legal limits; their continued development and testing are warranted. Urine tests are generally inadvisable, and observational tests require sensitivity improvements.
Collapse
|
13
|
Di Ciano P, Brands B, Fares A, Wright M, Stoduto G, Byrne P, McGrath M, Hasan OSM, Le Foll B, Wickens CM. The Utility of THC Cutoff Levels in Blood and Saliva for Detection of Impaired Driving. Cannabis Cannabinoid Res 2023. [PMID: 36730769 DOI: 10.1089/can.2022.0187] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Background: Δ9-Tetrahydrocannabinol (THC) is the psychoactive component in cannabis and a relationship of THC to driving impairment is expected. Despite this, there are discrepant findings with respect to the relationship of blood THC to driving. This study investigated the relationship of blood, urine, and saliva THC/THC-COOH levels to "weaving," as measured by a driving simulator. Methods: Participants smoked cannabis alone or with alcohol. THC/THC-COOH levels in blood, urine, and saliva were correlated with standard deviation of lateral position (SDLP), measuring "weaving." In addition, SDLP after cannabis and/or alcohol were compared with SDLP after placebo when THC/THC-COOH levels were above or below specified thresholds in blood (5 ng/mL), urine (50 ng/mL), or saliva (25 ng/mL). Results: A clear linear relationship between blood THC concentration and SDLP was not observed based on calculation of Spearman coefficients. When compared with placebo, SDLP was significantly increased after cannabis and cannabis combined with alcohol when THC in the blood was above the legal limit. SDLP was increased in drug conditions when saliva cutoffs were above the legal limit. Conclusions: The findings of this study suggest that specified thresholds for THC in blood and saliva may be able to detect driving impairment, but future studies are needed. ClinicalTrials.gov ID: NCT03106363.
Collapse
Affiliation(s)
- Patricia Di Ciano
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Bruna Brands
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Controlled Substances Directorate, Health Canada, Ottawa, Ontario, Canada
| | - Andrew Fares
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Madison Wright
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - Gina Stoduto
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Patrick Byrne
- Research and Evaluation Office, Ontario Ministry of Transportation, Toronto, Ontario, Canada
| | - Michael McGrath
- Research and Evaluation Office, Ontario Ministry of Transportation, Toronto, Ontario, Canada
| | - Omer S M Hasan
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Institute of Medical Science, University of Toronto, Medical Sciences Building, Toronto, Ontario, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.,Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - Christine M Wickens
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
14
|
Rius C, Saint-Marcoux F. Expérimentation du cannabis médical : une impasse pour la réglementation sur la conduite automobile ? TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2022. [DOI: 10.1016/j.toxac.2022.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
15
|
Rock KL, Englund A, Morley S, Rice K, Copeland CS. Can cannabis kill? Characteristics of deaths following cannabis use in England (1998-2020). J Psychopharmacol 2022; 36:1362-1370. [PMID: 35946604 PMCID: PMC9716494 DOI: 10.1177/02698811221115760] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Cannabis is the most widely used illegal drug but is rarely considered a causal factor in death. AIMS This study aimed to understand trends in deaths in England where cannabinoids were detected at post-mortem, and to evaluate the clinical utility of post-mortem cannabinoid concentrations in coronial investigations. METHODS Deaths with cannabinoid detections reported to the National Programme on Substance Abuse Deaths (NPSAD) were extracted and analysed. RESULTS From 1998 to 2011, on average 7% of all cases reported to NPSAD had a cannabinoid detected (n = 110 deaths per year), rising to 18% in 2020 (n = 350). Death following cannabis use alone was rare (4% of cases, n = 136/3455). Traumatic injury was the prevalent underlying cause in these cases (62%, n = 84/136), with cannabis toxicity cited in a single case. Polydrug use was evident in most cases (96%, n = 3319/3455), with acute drug toxicity the prevalent underlying cause (74%, n = 2458/3319). Cardiac complications were the most cited physiological underlying cause of death (4%, n = 144/3455). The median average Δ9-tetrahydrocannabinol post-mortem blood concentrations were several magnitudes lower than previously reported median blood concentrations in living users (cannabis alone: 4.3 µg/L; cannabis in combination with other drugs: 3.5 µg/L). CONCLUSIONS Risk of death due to cannabis toxicity is negligible. However, cannabis can prove fatal in circumstances with risk of traumatic physical injury, or in individuals with cardiac pathophysiologies. These indirect harms need careful consideration and further study to better elucidate the role cannabis plays in drug-related mortality. Furthermore, the relevance of cannabinoid quantifications in determining cause of death in coronial investigations is limited.
Collapse
Affiliation(s)
- Kirsten L Rock
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Sciences, King’s College London, London, UK
| | - Amir Englund
- Department of Addictions, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, South London and Maudsley NHS Foundation Trust, London, UK
| | - Stephen Morley
- Toxicology Unit, Leicester Royal Infirmary, Leicester, UK
| | - Kathleen Rice
- Toxicology Unit, Leicester Royal Infirmary, Leicester, UK
| | - Caroline S Copeland
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Sciences, King’s College London, London, UK,National Programme on Substance Abuse Deaths, London, UK,Caroline Copeland, Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Sciences, King’s College London, London, UK.
| |
Collapse
|
16
|
Lorenzetti V, Hindocha C, Petrilli K, Griffiths P, Brown J, Castillo‐Carniglia Á, Caulkins JP, Englund A, ElSohly MA, Gage SH, Groshkova T, Gual A, Hammond D, Lawn W, López‐Pelayo H, Manthey J, Mokrysz C, Pacula RL, van Laar M, Vandrey R, Wadsworth E, Winstock A, Hall W, Curran HV, Freeman TP. The International Cannabis Toolkit (iCannToolkit): a multidisciplinary expert consensus on minimum standards for measuring cannabis use. Addiction 2022; 117:1510-1517. [PMID: 34590359 PMCID: PMC9298052 DOI: 10.1111/add.15702] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 09/03/2021] [Accepted: 09/07/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The lack of an agreed international minimum approach to measuring cannabis use hinders the integration of multidisciplinary evidence on the psychosocial, neurocognitive, clinical and public health consequences of cannabis use. METHODS A group of 25 international expert cannabis researchers convened to discuss a multidisciplinary framework for minimum standards to measure cannabis use globally in diverse settings. RESULTS The expert-based consensus agreed upon a three-layered hierarchical framework. Each layer-universal measures, detailed self-report and biological measures-reflected different research priorities and minimum standards, costs and ease of implementation. Additional work is needed to develop valid and precise assessments. CONCLUSIONS Consistent use of the proposed framework across research, public health, clinical practice and medical settings would facilitate harmonisation of international evidence on cannabis consumption, related harms and approaches to their mitigation.
Collapse
Affiliation(s)
- Valentina Lorenzetti
- Neuroscience of Addiction and Mental Health Program, the Healthy Brain and Mind Research Centre, School of Behavioural and Health Sciences, Faculty of Health SciencesAustralian Catholic UniversityMelbourneAustralia
| | - Chandni Hindocha
- Clinical Psychopharmacology Unit (CPU)University College LondonLondonUK
| | - Kat Petrilli
- Addiction and Mental Health Group (AIM), Department of PsychologyUniversity of BathBathUK
| | - Paul Griffiths
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)LisbonPortugal
| | - Jamie Brown
- Behavioural Science and Health Institute of Epidemiology and HealthUniversity College LondonLondonUK
| | - Álvaro Castillo‐Carniglia
- Society and Health Research Center and School of Public HealthUniversidad MayorSantiagoChile
- Department of Population HealthNYU Grossman School of MedicineNew YorkNYUSA
| | | | - Amir Englund
- Addictions Department, Institute of Psychiatry, Psychology & NeuroscienceKings College LondonLondonUK
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & NeuroscienceKing's College LondonLondonUK
| | - Mahmoud A. ElSohly
- National Center for Natural Products Research, School of PharmacyUniversity of MississippiUniversityMSUSA
- Department Pharmaceutics and Drug Delivery, School of PharmacyUniversity of Mississippi, UniversityMSUSA
| | - Suzanne H. Gage
- Department of Psychology, Institute of Population HealthUniversity of LiverpoolLiverpoolUK
| | - Teodora Groshkova
- European Monitoring Centre for Drugs and Drug Addiction (EMCDDA)LisbonPortugal
| | - Antoni Gual
- Psychiatry DepartmentNeurosciences Institute, Hospital Clínic, IDIBAPS, RTABarcelonaSpain
| | - David Hammond
- School of Public Health and Health SystemsUniversity of WaterlooWaterlooCanada
| | - Will Lawn
- Clinical Psychopharmacology Unit (CPU)University College LondonLondonUK
- Addictions Department, Institute of Psychiatry, Psychology & NeuroscienceKings College LondonLondonUK
| | - Hugo López‐Pelayo
- Psychiatry DepartmentNeurosciences Institute, Hospital Clínic, IDIBAPS, RTABarcelonaSpain
| | - Jakob Manthey
- Center for Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and PsychotherapyUniversity Medical Center Hamburg‐Eppendorf (UKE)HamburgGermany
- Institute of Clinical Psychology and PsychotherapyTechnische Universität DresdenDresdenGermany
| | - Claire Mokrysz
- Clinical Psychopharmacology Unit (CPU)University College LondonLondonUK
| | - Rosalie Liccardo Pacula
- USC Sol Price School of Public PolicyUSC Leonard D. Schaeffer Center for Health Policy & EconomicsLos AngelesCAUSA
| | | | - Ryan Vandrey
- Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreMDUSA
| | - Elle Wadsworth
- School of Public Health and Health SystemsUniversity of WaterlooWaterlooCanada
| | - Adam Winstock
- Behavioural Science and Health Institute of Epidemiology and HealthUniversity College LondonLondonUK
- Global Drug SurveyLondonUK
| | - Wayne Hall
- National Addiction Centre, King's College LondonLondonUK
- National Centre for Youth Substance Use ResearchThe University of QueenslandBrisbaneAustralia
| | - H. Valerie Curran
- Clinical Psychopharmacology Unit (CPU)University College LondonLondonUK
| | - Tom P. Freeman
- Addiction and Mental Health Group (AIM), Department of PsychologyUniversity of BathBathUK
| |
Collapse
|
17
|
Liut J, Bott U, Madea B, Krämer M, Maas A. Evaluation of RapidSTAT®, DrugWipe® 6S, DrugScreen® 5TK and DrugScreen® 7TR for on-site drug testing in German police roadside traffic patrol. Drug Test Anal 2022; 14:1407-1416. [PMID: 35343088 DOI: 10.1002/dta.3262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 11/07/2022]
Abstract
Driving under the influence of drugs (DUID) remains a subject of concern worldwide, and its increasing trend is likely to continue. Therefore, there is a constant need for reliable on-site drug tests to identify drugged drivers during roadside patrols. Performance and reliability of four on-site drug tests were evaluated among a high number of DUID cases in Germany. Results of oral fluid (OF) (RapidSTAT®, DrugWipe® 6S) and urine (DrugScreen® 5TK and 7TR) test devices were compared with corresponding serum/plasma results obtained by confirmation analyses in consideration of recommended analytical limits for substances pertaining the annex of the German Road Traffic Code ('Straßenverkehrsgesetz', StVG) s. 24a (2). Overall, the screening devices performed well for individual drugs; however, none of the test devices assessed in this study fulfilled the ROSITA-1 criteria (sensitivity, specificity ≥ 90%, and accuracy ≥ 95%) for all substances. Our data demonstrated that both urine tests showed high sensitivities for most compounds. DrugWipe® 6S (94%) and RapidSTAT® (93%) revealed high sensitivities, especially for amphetamine screening. Poor specificities (< 90%) and accuracies (< 95%) were observed for all tests except for low-prevalent substances (e.g. opiates). For drug testing in OF, Δ9 -tetrahydrocannabinol (THC) still seems to be a compound of concern due to poor sensitivity (RapidSTAT®, 77%; DrugWipe® 6S, 85%), although the results indicate improvements compared to previously reported data. Although the obtained data indicate reliable detection for some substances, deployment of trained police officers is inevitable to identify DUID suspects by signs of recent use and recognizing impairment.
Collapse
Affiliation(s)
- Jennifer Liut
- Institute of Forensic Medicine, Forensic Toxicology, University Hospital Bonn, Bonn, Germany
| | - Ulrich Bott
- North-Rhine Westphalia Police Force Central Support Services Bureau, Duisburg, Germany
| | - Burkhard Madea
- Institute of Forensic Medicine, Forensic Toxicology, University Hospital Bonn, Bonn, Germany
| | - Michael Krämer
- Institute of Forensic Medicine, Forensic Toxicology, University Hospital Bonn, Bonn, Germany
| | - Alexandra Maas
- Institute of Forensic Medicine, Forensic Toxicology, University Hospital Bonn, Bonn, Germany
| |
Collapse
|
18
|
Blandino A, Cotroneo R, Tambuzzi S, Di Candia D, Genovese U, Zoja R. Driving under the influence of drugs: Correlation between blood psychoactive drug concentrations and cognitive impairment. A narrative review taking into account forensic issues. Forensic Sci Int Synerg 2022; 4:100224. [PMID: 35330981 PMCID: PMC8938866 DOI: 10.1016/j.fsisyn.2022.100224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 03/11/2022] [Accepted: 03/14/2022] [Indexed: 12/05/2022]
Abstract
Driving under the influence of alcohol has been shown to increase the risk of involvement in road traffic collisions (RTCs) however, less is known about the effects of illicit drugs, and a clear correlation between drug concentrations and RTC risk is still debated. The goal of this narrative review is to assess the current literature regarding the most detected psychoactive drugs in RTC (ethanol, amphetamines, cannabis, opioids and cocaine), in relation to driving performance. Evidence on impaired driving due to psychoactive substances, forensic issues relating to the assessment of the impact of drugs, blood cut-off values proposed to date as well as scientific basis for proposed legislative limits are discussed. At present there is no unequivocal evidence demonstrating a clear dose/concentration dependent impairment in many substances. Per se and zero tolerance approaches seem to have negative effect on drugged driving fatalities. However, the weight of these approaches needs further investigation.
Collapse
Affiliation(s)
- Alberto Blandino
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 31, Milan, Italy
| | - Rosy Cotroneo
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 31, Milan, Italy
| | - Stefano Tambuzzi
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 31, Milan, Italy
| | - Domenico Di Candia
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 31, Milan, Italy
| | - Umberto Genovese
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 31, Milan, Italy
| | - Riccardo Zoja
- Department of Biomedical Sciences for Health, University of Milan, Via Luigi Mangiagalli 31, Milan, Italy
| |
Collapse
|
19
|
Bosnyak D, McDonald AC, Gasperin Haaz I, Qi W, Crowley DC, Guthrie N, Evans M. Use of a Novel EEG-Based Objective Test, the Cognalyzer ®, in Quantifying the Strength and Determining the Action Time of Cannabis Psychoactive Effects and Factors that May Influence Them Within an Observational Study Framework. Neurol Ther 2022; 11:51-72. [PMID: 34727345 PMCID: PMC8857346 DOI: 10.1007/s40120-021-00293-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/13/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Current methods to detect recent delta-9-tetrahydrocannabinol (THC) use cannot objectively quantify its psychoactive effects (PE). The Cognalyzer®, an electroencephalography (EEG)-based method, detects and quantifies the strength of THC-induced PE on a scale from 0 to 100%. This study assesses the relationship between the magnitude of Cognalyzer® PE predictions and reported subjective drug effects for 4-h post-cannabis inhalation. METHODS Seventy-five participants were enrolled in the study. Prior to ad libitum cannabis inhalation, an EEG recording episode was completed. Immediately after inhalation, the Drug Effects Questionnaire (DEQ) was administered and another EEG recording performed. For 25 participants, the study ended. For 50 participants, assessments were repeated at 30-min intervals for 4 h. EEG files were blinded and analyzed using two versions of the Cognalyzer® algorithm. The relationship between the Cognalyzer® PE level results and the DEQ was assessed using generalized linear models and multiple regression. RESULTS There were significant PE increases from pre-cannabis for up to 3.5 h. Mean reports of feeling drug effects were > 0 at all post-inhalation time points (p ≤ 0.024). Furthermore, there were significant relationships between the Cognalyzer® PE and self-reported perception of drug effects (p ≤ 0.001). Subgroup analysis showed that Cognalyzer® PE levels were impacted by cannabis use history, subjective ratings of drug effects, oral fluid THC concentration and the cannabis product inhaled. CONCLUSION The findings show that the Cognalyzer® can be used to objectively determine the strength of cannabis psychoactive effects that cannabis products create on consumers and how it changes depending on their experience with cannabis. The Cognalyzer® can be used to conduct scientific consumer research to generate trustworthy informational material about the psychoactive experience of cannabis products. For clinical research, the Cognalyzer® can be used to study the pharmacodynamics of cannabinoids or delivery systems, such as nano-emulsifications.
Collapse
Affiliation(s)
- Dan Bosnyak
- Zentrela Inc. Suite B21, 175 Longwood Rd S, Hamilton, ON, L8P 0A1, Canada.
| | | | | | - Weikai Qi
- Zentrela Inc. Suite B21, 175 Longwood Rd S, Hamilton, ON, L8P 0A1, Canada
| | - David C Crowley
- KGK Science Inc., 255 Queens Ave, London, ON, N6A 5R8, Canada
| | - Najla Guthrie
- KGK Science Inc., 255 Queens Ave, London, ON, N6A 5R8, Canada
| | - Malkanthi Evans
- KGK Science Inc., 255 Queens Ave, London, ON, N6A 5R8, Canada
| |
Collapse
|
20
|
Grotsch K, Fokin VV. Between Science and Big Business: Tapping Mary Jane's Uncharted Potential. ACS CENTRAL SCIENCE 2022; 8:156-168. [PMID: 35233448 PMCID: PMC8875429 DOI: 10.1021/acscentsci.1c01100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Indexed: 06/14/2023]
Abstract
At the intersection of science and medicine, government policy, and pop culture, cannabis has prompted society since the beginning of recorded history. And yet, there is comparatively little replicable data on the plant, its constituents, and their capacity to modify human physiology. Over the past decades, several findings have pointed toward the importance of the endogenous cannabinoid system in maintaining homeostasis, making it an important target for various diseases. Here, we summarize the current state of knowledge on endogenous- and plant-based cannabinoids, address the issues related to cannabinoid-based drug discovery, and incite efforts to utilize their polypharmacological profile toward tackling diseases with a complex underlying pathophysiology. By fusing modern science and technology with the empirical data that has been gathered over centuries, we propose an outlook that could help us overcome the dearth of innovation for new drugs and synchronously redefine the future of drug discovery. Simultaneously, we call attention to the startling disconnect between the scientific, regulatory, and corporate entities that is becoming increasingly evident in this booming industry.
Collapse
Affiliation(s)
- Katharina Grotsch
- Bridge Institute and Loker
Hydrocarbon Research Institute, University
of Southern California, 1002 Childs Way, Los Angeles, California 90089-3502, United States
| | - Valery V. Fokin
- Bridge Institute and Loker
Hydrocarbon Research Institute, University
of Southern California, 1002 Childs Way, Los Angeles, California 90089-3502, United States
| |
Collapse
|
21
|
Beitzke B, Pate DW. A broader view on deriving a reference dose for THC the in foods. Crit Rev Toxicol 2022; 51:695-722. [PMID: 35174773 DOI: 10.1080/10408444.2021.2008867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
An Acute Reference Dose (ARfD) of 1 µg of delta-9-tetrahydrocannabinol (THC) per kilogram (kg) of body weight (bw) per day was recommended by the European Food Safety Authority (EFSA) for its assessment of possible acute health risks from the intake of industrial hemp food products. The scientific basis for this opinion, such as their choice of a Point of Departure for identification of the Lowest Observed Adverse Effect Level (LOAEL) for THC on the central nervous system, and the seeming absence of an experimental No Observed Adverse Effect Level (NOAEL), is critically reviewed. Moreover, the risk assessment for an ARfD derivation for THC is then reconsidered. In contrast to the EFSA Scientific Opinion of 2015, a higher LOAEL is presently identified from pharmacokinetic and pharmacodynamic studies, and forensic data, in representative cohorts of healthy humans after oral administrations of low THC doses. A NOAEL for THC is derived through this combination of results, demonstrating a threshold for impairment of psychomotor function only after intake of an oral THC bolus beyond 2.5 mg for the average healthy adult. This 2.5 mg dose produces mean THC blood serum levels of <2 ng/mL, as well as do two doses when taken daily within a time interval of ≥6 h. The forensic threshold of THC that is correlated with the impairment of psychomotor function is known to be between 2 and 5 ng/mL in blood serum for adults. For an appropriately spaced intake of 2 × 2.5 mg THC per day, an adult can therefore be regarded as being at the NOAEL. Applying a default uncertainty factor of 10 for intraspecies variability to a NOAEL of 2 × 2.5 mg (over ≥6 hours) for THC, yields a "daily dose of no concern" or a "tolerable upper intake level" of 0.50 mg, corresponding to 7 µg/kg bw. Starting with a NOAEL of only 2.5 mg, consumed as a single bolus, the lowest possible daily THC Acute Reference Dose would therefore be 0.25 mg, or 3.5 µg/kg bw for healthy adults, as the absolutely most conservative estimate. Other justifiable estimates have ranged up to 14 µg/kg bw per day.
Collapse
Affiliation(s)
- Bernhard Beitzke
- EIHA Advisory Committee, European Industrial Hemp Association, Brussels, Belgium
| | - David W Pate
- NICM Health Research Institute, Western Sydney University, Westmead, Australia
| |
Collapse
|
22
|
Borden SA, Saatchi A, Palaty J, Gill CG. A direct mass spectrometry method for cannabinoid quantitation in urine and oral fluid utilizing reactive paper spray ionization. Analyst 2022; 147:3109-3117. [DOI: 10.1039/d2an00743f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Reactive paper spray mass spectrometry mitigates many of the challenges associated with direct cannabinoid measurements, allowing for rapid, reliable and quantitative measurements in oral fluid and in urine at clinically relevant levels.
Collapse
Affiliation(s)
- Scott A. Borden
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - Armin Saatchi
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
| | - Jan Palaty
- LifeLabs Medical Laboratories, Burnaby, BC, Canada
| | - Chris G. Gill
- Applied Environmental Research Laboratories, Department of Chemistry, Vancouver Island University, Nanaimo, BC, Canada
- Department of Chemistry, University of Victoria, Victoria, BC, Canada
- Department of Chemistry, Simon Fraser University, Burnaby, BC, Canada
- Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA
| |
Collapse
|
23
|
Workman CD, Sosnoff JJ, Rudroff T. Disparity between Perceptual Fall Risk and Physiological Fall Risk in Older Cannabis Users: A Pilot Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:ijerph19010109. [PMID: 35010369 PMCID: PMC8750873 DOI: 10.3390/ijerph19010109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 01/22/2023]
Abstract
Aging is associated with cognitive decline and increased fall risk. Cognitive impairment is associated with cannabis use, which is increasing among older adults. Perceptual and physiological fall risk are discordant in some older adults, but whether cannabis use influences this association is unknown. The purpose of this study was to investigate possible disparities between perceptual and physiological fall risk in older cannabis users. Eight older medical cannabis users and eight sex- and age-matched non-users provided data on perceptual and physiological fall risk. Group differences were assessed, and perceptual fall risk was correlated with physiological fall risk. Perceptual risk and most of the physiological fall risk variables were equivalent between the groups. However, cannabis users performed significantly worse on unipedal stance than non-users. In addition, perceptual fall risk had weak correlations with physiological fall risk in the users (Spearman’s rho = 0.17–0.41) and moderate-strong correlations in non-users (rho = −0.18–0.67). Cannabis users might have a discrepancy between perceptual and physiological fall risk. Because both concepts play a role in quality of life, identifying strategies to improve them may have significant benefits. Future studies investigating additional perceptual (e.g., cognition, fear of falling, depression, anxiety), physiological (e.g., more challenging static and dynamic balance conditions), and general fall risk are warranted.
Collapse
Affiliation(s)
- Craig D. Workman
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA 52242, USA;
| | - Jacob J. Sosnoff
- Department of Physical Therapy and Rehabilitation Sciences, University of Kansas Medical Center, Kansas City, KS 66160, USA;
| | - Thorsten Rudroff
- Department of Health and Human Physiology, University of Iowa, Iowa City, IA 52242, USA;
- Department of Neurology, University of Iowa Health Clinics, Iowa City, IA 52242, USA
- Correspondence: ; Tel.: +1-319-467-0363
| |
Collapse
|
24
|
Gelmi TJ, Weinmann W, Pfäffli M. Impact of smoking cannabidiol (CBD)-rich marijuana on driving ability. Forensic Sci Res 2021; 6:195-207. [PMID: 34868711 PMCID: PMC8635612 DOI: 10.1080/20961790.2021.1946924] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
To investigate effects of smoking cannabidiol (CBD)-rich marijuana on driving ability and determine free CBD and Δ9-tetrahydrocannabinol (THC) concentrations in capillary blood samples, a randomised, double-blind, placebo-controlled, two-way crossover pilot study was conducted with 33 participants. Participants smoked a joint containing 500 mg of tobacco and either 500 mg of CBD-rich marijuana (16.6% total CBD; 0.9% total THC) or 500 mg of a placebo substance, then performed three different dimensions of the Vienna Test System TRAFFIC examining reaction time, behaviour under stress, and concentration performance. For further assessment of participants' fitness to drive, three tests of balance and coordination were evaluated and vital signs (blood pressure and pulse) were measured. Dried blood spot samples of capillary blood were taken after smoking and after completion of the tests to determine the cannabinoid concentrations (CBD, THC and THC-metabolites). The results revealed no significant differences between the effects of smoking CBD-rich marijuana and placebo on reaction time, motor time, behaviour under stress, or concentration performance. Maximum free CBD and THC concentrations in capillary blood were detected shortly after smoking, ranging between 2.6-440.0 ng/mL and 6.7-102.0 ng/mL, respectively. After 45 min, capillary blood concentrations had already declined and were in the range of 1.9-135.0 ng/mL (free CBD) and 0.9-38.0 ng/mL (free THC). Although the observed levels of free THC concentrations have been reported to cause symptoms of impairment in previous studies in which THC-rich marijuana was smoked, no signs of impairment were found in the current study. This finding suggests that higher CBD concentrations cause a negative allosteric effect in the endocannabinoid system, preventing the formation of such symptoms. Nevertheless, it is recommended that consumers refrain from driving for several hours after smoking CBD-rich marijuana, as legal THC concentration limits may be exceeded. Supplemental data for this article is available online at https://doi.org/10.1080/20961790.2021.1946924 .
Collapse
Affiliation(s)
- Tim J Gelmi
- Department of Forensic Toxicology and Chemistry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.,Graduate School for Cellular and Biomedical Sciences (GCB), University of Bern, Bern, Switzerland
| | - Wolfgang Weinmann
- Department of Forensic Toxicology and Chemistry, Institute of Forensic Medicine, University of Bern, Bern, Switzerland
| | - Matthias Pfäffli
- Department of Traffic Sciences, Institute of Forensic Medicine, University of Bern, Bern, Switzerland
| |
Collapse
|
25
|
McCartney D, Arkell TR, Irwin C, Kevin RC, McGregor IS. Are blood and oral fluid Δ 9-tetrahydrocannabinol (THC) and metabolite concentrations related to impairment? A meta-regression analysis. Neurosci Biobehav Rev 2021; 134:104433. [PMID: 34767878 DOI: 10.1016/j.neubiorev.2021.11.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 10/29/2021] [Accepted: 11/05/2021] [Indexed: 12/17/2022]
Abstract
Blood and oral fluid Δ9-tetrahydrocannabinol (THC) concentrations are often used to identify cannabis-impaired drivers. We used meta-analytic techniques to characterise the relationships between biomarkers of cannabis use, subjective intoxication, and impairment of driving and driving-related cognitive skills. Twenty-eight publications and 822 driving-related outcomes were reviewed. Each outcome was measured in concert with one or more biomarkers of cannabis/THC use and/or subjective intoxication. Higher blood THC and 11-OH-THC concentrations, oral fluid THC concentrations and subjective ratings of intoxication were associated with greater impairment in 'other' (mostly occasional) cannabis users (p's<0.05). Blood 11-COOH-THC concentrations were associated with impairment after inhaling, but not orally ingesting, cannabis/THC. However t these 'biomarker-performance' relationships (R) were only very weak (blood THCpost-ingestion: -0.08; blood THCpost-inhalation: -0.10; blood 11-OH-THCpost-ingestion: -0.13), weak (blood 11-OH-THCpost-inhalation: -0.24; oral fluid THCpost-inhalation: -0.36; subjective intoxication: -0.29) or moderate (blood 11-COOH-THCpost-inhalation: -0.43) in strength. No significant biomarker-performance relationships were observed in 'regular' (weekly or more often) cannabis users (p's>0.10), although the analyses were less robust. Blood and oral fluid THC concentrations are relatively poor indicators of cannabis/THC-induced impairment.
Collapse
Affiliation(s)
- Danielle McCartney
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, New South Wales, Australia; The University of Sydney, Brain and Mind Centre, Sydney, New South Wales, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, New South Wales, Australia.
| | - Thomas R Arkell
- Centre for Human Psychopharmacology, Swinburne University of Technology, Melbourne, Victoria, Australia
| | - Christopher Irwin
- Menzies Health Institute Queensland and School of Health Sciences and Social Work, Griffith University, Gold Coast, Queensland, Australia
| | - Richard C Kevin
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, New South Wales, Australia; The University of Sydney, Brain and Mind Centre, Sydney, New South Wales, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, New South Wales, Australia
| | - Iain S McGregor
- The University of Sydney, Lambert Initiative for Cannabinoid Therapeutics, Sydney, New South Wales, Australia; The University of Sydney, Brain and Mind Centre, Sydney, New South Wales, Australia; The University of Sydney, Faculty of Science, School of Psychology, Sydney, New South Wales, Australia
| |
Collapse
|
26
|
Burt TS, Brown TL, Milavetz G, McGehee DV. Mechanisms of cannabis impairment: Implications for modeling driving performance. Forensic Sci Int 2021; 328:110902. [PMID: 34634690 DOI: 10.1016/j.forsciint.2021.110902] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 06/30/2021] [Accepted: 07/02/2021] [Indexed: 10/20/2022]
Abstract
Past research on cannabis has been limited in scope to THC potencies lower than legally available and efforts to integrate the effects into models of driving performance have not been attempted to date. The purpose of this systematic review is to understand the implications for modeling driving performance and describe future research needs. The risk of motor vehicle crashes increases 2-fold after smoking marijuana. Driving during acute cannabis intoxication impairs concentration, reaction time, along with a variety of other necessary driving-related skills. Changes to legislation in North America and abroad have led to an increase in cannabis' popularity. This has given rise to more potent strains, with higher THC concentrations than ever before. There is also rising usage of novel ingestion methods other than smoking, such as oral cannabis products (e.g., brownies, infused drinks, candies), vaping, and topicals. The PRISMA guidelines were followed to perform a systematic search of the PubMed database for peer-reviewed literature. Search terms were combined with keywords for driving performance: driving, performance, impairment. Grey literature was also reviewed, including congressional reports, committee reports, and roadside surveys. There is a large discrepancy between the types of cannabis products sold and what is researched. Almost all studies that used inhalation as the mode of ingestion with cannabis that is around 6% THC. This pales in comparison to the more potent strains being sold today which can exceed 20%. Which is to say nothing of extracts, which can contain 60% or more THC. Experimental protocol is another gap in research that needs to be filled. Methodologies that involve naturalistic (real world) driving environments, smoked rather than vaporized cannabis, and non-lab certified products introduce uncontrollable variables. When considering the available literature and the implications of modeling the impacts of cannabis on driving performance, two critical areas emerge that require additional research: The first is the role of cannabis potency. Second is the route of administration. Does the lower peak THC level result in smaller impacts on performance? How long does potential impairment last along the longer time-course associated with different pharmacokinetic profiles. It is critical for modeling efforts to understand the answers to these questions, accurately model the effects on driver performance, and by extension understand the risk to the public.
Collapse
Affiliation(s)
- Thomas S Burt
- National Advanced Driving Simulator, University of Iowa, Iowa City, IA, USA; Department of Industrial and Systems Engineering, University of Iowa, Iowa City, IA, USA.
| | - Timothy L Brown
- National Advanced Driving Simulator, University of Iowa, Iowa City, IA, USA; Department of Industrial and Systems Engineering, University of Iowa, Iowa City, IA, USA
| | - Gary Milavetz
- National Advanced Driving Simulator, University of Iowa, Iowa City, IA, USA; College of Pharmacy, University of Iowa, Iowa City, IA, USA
| | - Daniel V McGehee
- National Advanced Driving Simulator, University of Iowa, Iowa City, IA, USA; Department of Industrial and Systems Engineering, University of Iowa, Iowa City, IA, USA; Carver College of Medicine, University of Iowa, Iowa City, IA, USA; Public Policy Center, University of Iowa, Iowa City, IA, USA
| |
Collapse
|
27
|
Abstract
As more states in the U.S legalize recreational and medicinal cannabis, rates of driving under the influence of this drug are increasing significantly. Aspects of this emerging public health issue potentially pit science against public policy. The authors believe that the legal cart is currently significantly ahead of the scientific horse. Issues such as detection procedures for cannabis-impaired drivers, and use of blood THC levels to gauge impairment, should rely heavily on current scientific knowledge. However, there are many, often unacknowledged research gaps in these and related areas, that need to be addressed in order provide a more coherent basis for public policies. This review focuses especially on those areas. In this article we review in a focused manner, current information linking cannabis to motor vehicle accidents and examine patterns of cannabis-impairment of driving related behaviors, their time courses, relationship to cannabis dose and THC blood levels, and compare cannabis and alcohol-impaired driving patterns directly. This review also delves into questions of alcohol-cannabis combinations and addresses the basis for of per-se limits in cannabis driving convictions. Finally, we distinguish between areas where research has provided clear answers to the above questions, areas that remain unclear, and make recommendations to fill gaps in current knowledge.
Collapse
Affiliation(s)
- Godfrey D. Pearlson
- Department of Psychiatry, Olin Neuropsychiatry Research Center, Institute of Living, Hartford Healthcare Corporation, Hartford, CT, United States
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
- Department of Neuroscience, Yale University School of Medicine, New Haven, CT, United States
| | - Michael C. Stevens
- Department of Psychiatry, Olin Neuropsychiatry Research Center, Institute of Living, Hartford Healthcare Corporation, Hartford, CT, United States
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| | - Deepak Cyril D'Souza
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
| |
Collapse
|
28
|
Shahidi Zandi A, Comeau FJE, Mann RE, Di Ciano P, Arslan EP, Murphy T, Le Foll B, Wickens CM. Preliminary Eye-Tracking Data as a Nonintrusive Marker for Blood Δ-9-Tetrahydrocannabinol Concentration and Drugged Driving. Cannabis Cannabinoid Res 2021; 6:537-547. [PMID: 34432541 DOI: 10.1089/can.2020.0141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: Cannabis is one of the drugs most often found in drivers involved in serious motor vehicle collisions. Validity and reliability of roadside cannabis detection strategies are questioned. This pilot study aimed to investigate the relationship between eye characteristics and cannabis effects in simulated driving to inform potential development of an alternative detection strategy. Materials and Methods: Multimodal data, including blood samples, eye-tracking recordings, and driving performance data, were acquired from 10 participants during a prolonged single-session driving simulator experiment. The study session included a baseline driving trial before cannabis exposure and seven trials at various times over ∼5 h after exposure. The multidimensional eye-tracking recording from each driving trial for each participant was segmented into nonoverlapping epochs (time windows); 34 features were extracted from each epoch. Blood Δ-9-tetrahydrocannabinol (THC) concentration, standard deviation of lateral position (SDLP), and mean vehicle speed were target variables. The cross-correlation between the temporal profile of each eye-tracking feature and target variable was assessed and a nonlinear regression analysis evaluated temporal trend of features following cannabis exposure. Results: Mean pupil diameter (r=0.81-0.86) and gaze pitch angle standard deviation (r=0.79-0.87) were significantly correlated with blood THC concentration (p<0.01) for all epoch lengths. For driving performance variables, saccade-related features were among those showing the most significant correlation (r=0.61-0.83, p<0.05). Epoch length significantly affected correlations between eye-tracking features and speed (p<0.05), but not SDLP or blood THC concentration (p>0.1). Temporal trend analysis of eye-tracking features after cannabis also showed a significant increasing trend (p<0.01) in saccade-related features, including velocity, scanpath, and duration, as the influence of cannabis decreased by time. A decreasing trend was observed for fixation percentage and mean pupil diameter. Due to the lack of placebo control in this study, these results are considered preliminary. Conclusion: Specific eye characteristics could potentially be used as nonintrusive markers of THC presence and driving-related effects of cannabis. clinicaltrials.gov (NCT03813602).
Collapse
Affiliation(s)
- Ali Shahidi Zandi
- Research & Development Department, Alcohol Countermeasure Systems (ACS), Toronto, Canada
| | - Felix J E Comeau
- Research & Development Department, Alcohol Countermeasure Systems (ACS), Toronto, Canada
| | - Robert E Mann
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
| | - Patricia Di Ciano
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Eliyas P Arslan
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Thomas Murphy
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada
| | - Bernard Le Foll
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.,Translational Addiction Research Laboratory, Centre for Addiction and Mental Health, and Centre for Addiction and Mental Health, Toronto, Canada.,Acute Care Program, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Family and Community Medicine, Management and Evaluation, University of Toronto, Toronto, Canada.,Division of Brain and Therapeutics, Department of Psychiatry, Management and Evaluation, University of Toronto, Toronto, Canada.,Institute of Medical Sciences, and Management and Evaluation, University of Toronto, Toronto, Canada
| | - Christine M Wickens
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| |
Collapse
|
29
|
Martin AMS, Kim DJ, Newman SD, Cheng H, Hetrick WP, Mackie K, O’Donnell BF. Altered cerebellar-cortical resting-state functional connectivity in cannabis users. J Psychopharmacol 2021; 35:823-832. [PMID: 34034553 PMCID: PMC8813046 DOI: 10.1177/02698811211019291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Cannabis use has been associated with abnormalities in cerebellar mediated motor and non-motor (i.e. cognition and personality) phenomena. Since the cerebellum is a region with high cannabinoid type 1 receptor density, these impairments may reflect alterations of signaling between the cerebellum and other brain regions. AIMS We hypothesized that cerebellar-cortical resting-state functional connectivity (rsFC) would be altered in cannabis users, relative to their non-using peers. It was also hypothesized that differences in rsFC would be associated with cannabis use features, such as age of initiation and lifetime use. METHODS Cerebellar-cortical and subcortical rsFCs were computed between 28 cerebellar lobules, defined by a spatially unbiased atlas template of the cerebellum, and individual voxels in the cerebral regions, in 41 regular cannabis users (20 female) and healthy non-using peers (N = 31; 18 female). We also investigated associations between rsFC and cannabis use features (e.g. lifetime cannabis use and age of initiation). RESULTS Cannabis users demonstrated hyperconnectivity between the anterior cerebellar regions (i.e. lobule I-IV) with the posterior cingulate cortex, and hypoconnectivity between the rest of the cerebellum (i.e. Crus I and II, lobule VIIb, VIIIa, VIIIb, IX, and X) and the cortex. No associations were observed between features of cannabis use and rsFC. CONCLUSIONS Cannabis use was associated with altered patterns of rsFC from the cerebellum to the cerebral cortex which may have a downstream impact on behavior and cognition.
Collapse
Affiliation(s)
- Ashley M Schnakenberg Martin
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA,Psychology Service, VA Connecticut Healthcare System, West Haven, CT, USA,Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dae-Jin Kim
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA
| | - Sharlene D Newman
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA
| | - Hu Cheng
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA
| | - William P Hetrick
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ken Mackie
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Brian F O’Donnell
- Department of Psychological and Brain Sciences and Program in Neuroscience, Indiana University, Bloomington, IN, USA,Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| |
Collapse
|
30
|
Hubbard JA, Hoffman MA, Ellis SE, Sobolesky PM, Smith BE, Suhandynata RT, Sones EG, Sanford SK, Umlauf A, Huestis MA, Grelotti DJ, Grant I, Marcotte TD, Fitzgerald RL. Biomarkers of Recent Cannabis Use in Blood, Oral Fluid and Breath. J Anal Toxicol 2021; 45:820-828. [PMID: 34185831 DOI: 10.1093/jat/bkab080] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/15/2021] [Accepted: 07/07/2021] [Indexed: 12/25/2022] Open
Abstract
Proving driving under the influence of cannabis (DUIC) is difficult. Establishing a biomarker of recent use to supplement behavioral observations may be a useful alternative strategy. We determined whether cannabinoid concentrations in blood, oral fluid (OF), or breath could identify use within 3h, likely the period of greatest impairment. In a randomized trial, 191 frequent (≥4/week) and occasional (<4/week) cannabis users smoked one cannabis (placebo [0.02%], 5.9% or 13.4% THC) cigarette ad libitum. Blood, OF and breath samples were collected prior to and up to 6h after smoking. Samples were analyzed for 10 cannabinoids in OF, 8 in blood, and THC in breath. Frequent users had more residual THC in blood and were categorized as "recently used" prior to smoking; this did not occur in OF. Per se limits ranging from undetectable to 5 ng/mL THC in blood offered limited usefulness as biomarkers of recent use. Cannabinol (CBN, cutoff=1 ng/mL) in blood offered 100% specificity but only 31.4% sensitivity, resulting in 100% PPV and 94.0% NPV at 4.3% prevalence; but CBN may vary by cannabis chemovar. A 10 ng/mL THC cutoff in OF exhibited the overall highest performance to detect use within 3h (99.7% specificity, 82.4% sensitivity, 92.5% PPV, 99.2% NPV) but was still detectable in 23.2% of participants ~4.4h post smoking limiting specificity at later time points. OF THC may be a helpful indicator of recent cannabis intake, but this does not equate to impairment. Behavioral assessment of impairment is still required to determine DUIC. This study only involved cannabis inhalation and additional research evaluating alternative routes of ingestion (i.e., oral) is needed.
Collapse
Affiliation(s)
- J A Hubbard
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - M A Hoffman
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - S E Ellis
- Department of Cognitive Science, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92092 USA.,Halıcıoğlu Data Science Institute, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92092 USA
| | - P M Sobolesky
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - B E Smith
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - R T Suhandynata
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - E G Sones
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - S K Sanford
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - A Umlauf
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - M A Huestis
- Institute for Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - D J Grelotti
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - I Grant
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - T D Marcotte
- Department of Psychiatry, University of California, San Diego, 220 Dickinson, MC #8231, San Diego, CA 92103 USA
| | - R L Fitzgerald
- Department of Pathology, University of California, San Diego, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| |
Collapse
|
31
|
Hoffman MA, Hubbard JA, Sobolesky PM, Smith BE, Suhandynata RT, Sanford S, Sones E, Ellis S, Umlauf A, Huestis MA, Grelotti DJ, Grant I, Marcotte TD, Fitzgerald RL. Blood and Oral Fluid Cannabinoid Profiles of Frequent and Occasional Cannabis Smokers. J Anal Toxicol 2021; 45:851-862. [PMID: 34173005 DOI: 10.1093/jat/bkab078] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/14/2021] [Accepted: 06/25/2021] [Indexed: 01/14/2023] Open
Abstract
Increased prevalence of cannabis consumption and impaired driving are a growing public safety concern. Some states adopted per se driving laws, making it illegal to drive with more than a specified ∆9-tetrahydrocannabinol (THC) blood concentration of THC in a biological fluid (typically blood). Blood THC concentrations decrease significantly (~90%) with delays in specimen collection, suggesting use of alternative matrices, such as oral fluid (OF). We characterized 10 cannabinoids' concentrations, including THC metabolites, in blood and OF from 191 frequent and occasional users by LC-MS-MS for up to 6 h after ad libitum smoking. Subjects self-titrated when smoking placebo, 5.9 or 13.4% THC cannabis. Higher maximum blood THC concentrations (Cmax) were observed in individuals who received the 5.9% THC versus the 13.4% THC plant material. In blood, the Cmax of multiple analytes, including THC and its metabolites, were increased in frequent compared to occasional users, whereas there were no significant differences in OF Cmax. Blood THC remained detectable (≥5 ng/mL) at the final sample collection for 14% of individuals who smoked either the 5.9% or 13.4% THC cigarette, whereas 54% had detectable THC in OF when applying the same cutoff. Occasional and frequent cannabis users' profiles were compared, THC was detectable for significantly longer in blood and OF from frequent users. Detection rates between frequent and occasional users at multiple per se cutoffs showed larger differences in blood versus OF. Understanding cannabinoid profiles of frequent and occasional users and the subsequent impact on detectability with current drug per se driving limits is important to support forensic interpretations and the development of scientifically supported driving under the influence of cannabis laws.
Collapse
Affiliation(s)
- Melissa A Hoffman
- Department of Pathology, University of California, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - Jacqueline A Hubbard
- Department of Pathology, University of California, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - Philip M Sobolesky
- Department of Pathology, University of California, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - Breland E Smith
- Department of Pathology, University of California, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - Raymond T Suhandynata
- Department of Pathology, University of California, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| | - Sandra Sanford
- Department of Psychiatry Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Emily Sones
- Department of Psychiatry Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Shannon Ellis
- Department of Cognitive Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA.,Halıcıoğlu Data Science Institute, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Anya Umlauf
- Department of Psychiatry Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Marilyn A Huestis
- Institute for Emerging Health Professions, Thomas Jefferson University, Philadelphia, PA 19107 USA
| | - David J Grelotti
- Department of Psychiatry Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Igor Grant
- Department of Psychiatry Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Thomas D Marcotte
- Department of Psychiatry Science, University of California, 9500 Gilman Drive, San Diego, La Jolla, CA 92092 USA
| | - Robert L Fitzgerald
- Department of Pathology, University of California, 10300 Campus Point Drive, Suite 150, San Diego, CA 92121 USA
| |
Collapse
|
32
|
The why behind the high: determinants of neurocognition during acute cannabis exposure. Nat Rev Neurosci 2021; 22:439-454. [PMID: 34045693 DOI: 10.1038/s41583-021-00466-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 11/08/2022]
Abstract
Acute cannabis intoxication may induce neurocognitive impairment and is a possible cause of human error, injury and psychological distress. One of the major concerns raised about increasing cannabis legalization and the therapeutic use of cannabis is that it will increase cannabis-related harm. However, the impairing effect of cannabis during intoxication varies among individuals and may not occur in all users. There is evidence that the neurocognitive response to acute cannabis exposure is driven by changes in the activity of the mesocorticolimbic and salience networks, can be exacerbated or mitigated by biological and pharmacological factors, varies with product formulations and frequency of use and can differ between recreational and therapeutic use. It is argued that these determinants of the cannabis-induced neurocognitive state should be taken into account when defining and evaluating levels of cannabis impairment in the legal arena, when prescribing cannabis in therapeutic settings and when informing society about the safe and responsible use of cannabis.
Collapse
|
33
|
Pelletti G, Barone R, Giorgetti A, Garagnani M, Rossi F, Fais P, Pelotti S. "Light cannabis" consumption in a sample of young adults: Preliminary pharmacokinetic data and psychomotor impairment evaluation. Forensic Sci Int 2021; 323:110822. [PMID: 33971503 DOI: 10.1016/j.forsciint.2021.110822] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 04/27/2021] [Accepted: 04/28/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION In 2019, the Italian Supreme Court established that hemp cannot be commercialized for human use, when the "psychotropic effect" of the product or its "offensiveness" can be demonstrated. The aim of the present study is to assess Δ9-tetrahydrocannabinol (Δ9-THC) and cannabidiol (CBD) blood concentrations after smoking cannabis with a low percentage of Δ9-THC, also referred as "light cannabis", and its effects on young adults' vigilance, cognitive and motor skills. MATERIALS AND METHODS Eighteen young adults consumed three light cannabis cigarettes containing 400 mg of inflorescences each, with a percentage of 0.41% of Δ9-THC and of 12.41% of CBD. Blood samples were collected before the experiment (t0), after each light cannabis cigarette (t1→t3), 60 (t4) and 120 (t5) minutes after the beginning of the experiment. Five performance tasks and a subjective scale were employed for measuring cognitive and psychomotor performances the day before the experiment (TT0) and after the third cigarette (TT1). RESULTS Mean (SD) concentrations (ng/ml) were 1.0 (0.8) in t1, 1.2 (0.9) in t2, 1.0 (0.8) in t3, 0.6 (0.4) in t4 and 0.3 (0.3) in t5 for Δ9-THC; 10.5 (10.3) in t1, 10.3 (13.2) in t2, 15.1 (14.8) in t3, 9.9 (9.2) in t4 and 5.7 (5.7) in t5 for CBD. No significant differences were observed between TT0 and TT1 for all performed psychomotor performance task. None of the subjects declared to feel "high" after the experiment. DISCUSSION All study participants reported that a higher number of cigarettes, corresponding in this study to 1200 mg of herbal product, could hardly be consumed by smoking in a recreational setting. Δ9-THC and CBD concentrations showed a high inter-subject variability, and the average concentrations were lower than those previously reported. Toxicological results showed a decrease of Δ9-THC and CBD after the third light cannabis cigarette, and a Δ9-THC /CBD ratio always<1 was observed. The lack of impairment observed in our participants can be interpreted as a consequence of the very low concentrations detectable in the blood.
Collapse
Affiliation(s)
- Guido Pelletti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy.
| | - Rossella Barone
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Arianna Giorgetti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Marco Garagnani
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Francesca Rossi
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Paolo Fais
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| | - Susi Pelotti
- Department of Medical and Surgical Sciences, Unit of Legal Medicine, University of Bologna, Via Irnerio 49, 40126 Bologna, Italy
| |
Collapse
|
34
|
McDonald AC, Gasperin Haaz I, Qi W, Crowley DC, Guthrie N, Evans M, Bosnyak D. Sensitivity, Specificity and Accuracy of a Novel EEG-Based Objective Test, the Cognalyzer ®, in Detecting Cannabis Psychoactive Effects. Adv Ther 2021; 38:2513-2531. [PMID: 33826089 PMCID: PMC8024442 DOI: 10.1007/s12325-021-01718-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 03/18/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Current standards for identifying recent cannabis use are based on body fluid testing. The Cognalyzer® is a novel electroencephalography (EEG) measurement device and algorithm designed to objectively characterize brainwave alterations associated with cannabis. The objective of this study was to assess the accuracy, sensitivity and specificity levels of the Cognalyzer® to characterize brainwave alterations following cannabis inhalation. METHODS Seventy-five participants, aged 19-55 years, were enrolled, and oral fluid samples were collected pre-cannabis inhalation. EEG and subjective drug effects questionnaire (DEQ) were administered pre- and post-ad libitum cannabis inhalation. Fifty participants remained in the clinic for 4 h post-inhalation. Blinded analyses of the EEG files were conducted by Zentrela Inc. using two versions (V1 and V2) of the Cognalyzer® algorithm. Pre- vs. post-inhalation comparison status was characterized by the Cognalyzer® and summarized for: sensitivity, specificity, accuracy, percent false positive, percent false negative and positive and negative predictive value. The null hypothesis was tested using McNemar's test. Cognalyzer® results pre- and post-inhalation were combined with the oral fluid tetrahydrocannabinol (THC) concentration to evaluate potential to improve current drug testing. RESULTS The two versions of the Cognalyzer® algorithm had similar diagnostic results. Diagnostic outcomes were improved when participants with missing EEG recordings or electrode placement errors were removed. The Cognalyzer® accuracy was 85.5% and 83.9%, sensitivity was 87.1% and 88.7%, and specificity was 83.9% and 79.0% for algorithm V1 and V2, respectively. Combining Cognalyzer® results with oral fluid concentrations reduced false-positive oral fluid test results by up to 49%. CONCLUSION The Cognalyzer® characterized brainwave alterations associated with cannabis inhalation with high levels of accuracy in a population of participants with varied cannabis inhalation histories, relative to the comparison standard of pre- vs. post-inhalation status. The Cognalyzer® allows the results to be generalized to the larger population addressing a limitation in currently accepted standards.
Collapse
Affiliation(s)
| | | | - Weikai Qi
- Zentrela Inc., Suite B21, 175 Longwood Rd S, Hamilton, ON, L8P 0A1, Canada
| | - David C Crowley
- KGK Science Inc., 255 Queens Ave, London, ON, N6A 5R8, Canada
| | - Najla Guthrie
- KGK Science Inc., 255 Queens Ave, London, ON, N6A 5R8, Canada
| | - Malkanthi Evans
- KGK Science Inc., 255 Queens Ave, London, ON, N6A 5R8, Canada
| | - Dan Bosnyak
- Zentrela Inc., Suite B21, 175 Longwood Rd S, Hamilton, ON, L8P 0A1, Canada.
| |
Collapse
|
35
|
Are the Acute Effects of THC Different in Aging Adults? Brain Sci 2021; 11:brainsci11050590. [PMID: 34062795 PMCID: PMC8147270 DOI: 10.3390/brainsci11050590] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 01/05/2023] Open
Abstract
In recent years of expanding legalization, older adults have reported the largest increase in cannabis use of any age group. While its use has been studied extensively in young adults, little is known about the effects of THC in older adults and whether the risks of cannabis might be different, particularly concerning intoxication and cognition. The current study investigated whether age is associated with the deleterious effects of THC on cognitive performance and other behavioral measures before and after ad libitum self-administration of three different types of cannabis flower (THC dominant, THC + CBD, and CBD dominant). Age groups consisted of young adults (ages 21–25) and older adults (ages 55–70). Controlling for pre-use scores on all measures, the THC dominant chemovar produced a greater deleterious effect in younger adults compared with older adults in tests of learning and processing speed, whereas there were no differences between old and young in the effects of the other chemovars. In addition, the young group reported greater cannabis craving than the older group after using the THC chemovar. Consistent with some reports in the preclinical literature, the findings suggest that older adults may be less sensitive to the effects of THC on cognitive and affective measures.
Collapse
|
36
|
Rangel-Pacheco A, Lew BJ, Schantell MD, Frenzel MR, Eastman JA, Wiesman AI, Wilson TW. Altered fronto-occipital connectivity during visual selective attention in regular cannabis users. Psychopharmacology (Berl) 2021; 238:1351-1361. [PMID: 33241479 PMCID: PMC8068572 DOI: 10.1007/s00213-020-05717-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 11/10/2020] [Indexed: 01/09/2023]
Abstract
RATIONALE AND OBJECTIVES Cognitive processing impairments have been associated with acute cannabis use, but there is mixed evidence regarding the cognitive effects of chronic cannabis use. Several neuroimaging studies have noted selective-attention processing differences in those who chronically use cannabis, but the neural dynamics governing the altered processing is unclear. METHODS Twenty-four adults reporting at least weekly cannabis use in the past 6 months on the Cannabis Use Disorder Identification Test - Revised were compared to 24 demographically matched controls who reported no prior cannabis use. All participants completed a visual selective attention processing task while undergoing magnetoencephalography. Time-frequency windows of interest were identified using a data-driven method, and spectrally specific neural activity was imaged using a beamforming approach. RESULTS All participants performed within normal range on the cognitive task. Regular cannabis users displayed an aberrant cognitive interference effect in the theta (4-8 Hz) frequency range shortly after stimulus onset (i.e., 0-250 ms) in the right occipital cortex. Cannabis users also exhibited altered functional connectivity between the right prefrontal cortex and right occipital cortices in comparison to controls. CONCLUSIONS Individuals with a history of regular cannabis use exhibited abnormal theta interference activity in the occipital cortices, as well as altered prefrontal-occipital functional connectivity in the theta range during a visual selective attention task. Such differences may reflect compensatory processing, as these participants performed within normal range on the task. Understanding the neural dynamics in chronic, regular cannabis users may provide insight on how long-term and/or frequent use may affect neural networks underlying cognitive processes.
Collapse
Affiliation(s)
- Abril Rangel-Pacheco
- Institute for Human Neuroscience, Boys Town National Research Hospital, Boys Town, NE, USA,College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Brandon J. Lew
- Institute for Human Neuroscience, Boys Town National Research Hospital, Boys Town, NE, USA,College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mikki D. Schantell
- Institute for Human Neuroscience, Boys Town National Research Hospital, Boys Town, NE, USA,College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Michaela R. Frenzel
- Institute for Human Neuroscience, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Jacob A. Eastman
- Institute for Human Neuroscience, Boys Town National Research Hospital, Boys Town, NE, USA
| | - Alex I. Wiesman
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA,Montreal Neurological Institute, McGill University, Montreal, QC, Canada
| | - Tony W. Wilson
- Institute for Human Neuroscience, Boys Town National Research Hospital, Boys Town, NE, USA,College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| |
Collapse
|
37
|
Scheunemann A, Elsner K, Germerott T, Hess C, Röhrich J. Simultaneous quantification of 18 different phytocannabinoids in serum using a highly sensitive liquid chromatography-tandem mass spectrometry (LC-MS/MS) method. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1173:122685. [PMID: 33882447 DOI: 10.1016/j.jchromb.2021.122685] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/22/2021] [Accepted: 03/29/2021] [Indexed: 11/18/2022]
Abstract
The potential therapeutic effects of various phytocannabinoids and the availability of multiple cannabis-based medicines make it desirable to have an analytical method that simultaneously quantifies a wide range of cannabinoids in blood, beyond delta-9-tetrahydrocannabinol and its metabolites. A liquid chromatography tandem mass spectrometry (LC-MS/MS) method for quantification of 18 phytocannabinoids and cannabinoid metabolites in serum was developed and validated. The method enables simultaneous detection of delta-9-tetrahydrocannabinol, cannabidiol, cannabinol, cannabigerol, cannabichromene, cannabicyclol, tetrahydrocannabivarin and cannabidivarin and their acidic precursors tetrahydocannabinolic acid A, cannabidiolic acid, cannabinolic acid, cannabigerolic acid, cannabichromenic acid, cannabicyclolic acid, tetrahydrocannabivarinic acid and cannabidivarinic acid as well as the delta-9-tetrahydrocannabinol metabolites 11-hydroxy-tetrahydrocannabinol and 11-nor-9-carboxy-tetrahydrocannabinol. Limits of detection ranged from 0.0004 to 1 ng/mL and limits of quantification ranged from 0.004 to 2 ng/mL. Calibration curves of all analytes were linear over the whole calibration range. Recovery rates of 52 to 86% were obtained for all analytes except for cannabicyclol (49%), 11-nor-9-carboxy-tetrahydrocannabinol (46%), cannabichromenic acid (44%) and cannabidivarinic acid (36%). Acceptable bias and precision data were demonstrated for all analytes. The method was successfully applied to 55 forensic serum samples, obtained from the Institute of Legal Medicine Mainz.
Collapse
Affiliation(s)
- A Scheunemann
- Institute of Legal Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Am Pulverturm 3, 55131 Mainz, Germany.
| | - K Elsner
- Institute of Legal Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Am Pulverturm 3, 55131 Mainz, Germany
| | - T Germerott
- Institute of Legal Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Am Pulverturm 3, 55131 Mainz, Germany
| | - C Hess
- Institute of Legal Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Am Pulverturm 3, 55131 Mainz, Germany
| | - J Röhrich
- Institute of Legal Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Am Pulverturm 3, 55131 Mainz, Germany
| |
Collapse
|
38
|
Kuhn J, Bonnet U. Medizinisches Cannabis und Fahrtauglichkeit. FORTSCHRITTE DER NEUROLOGIE-PSYCHIATRIE 2021; 89:81-83. [PMID: 33684945 DOI: 10.1055/a-1344-7900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
39
|
Rinehart L, Spencer S. Which came first: Cannabis use or deficits in impulse control? Prog Neuropsychopharmacol Biol Psychiatry 2021; 106:110066. [PMID: 32795592 PMCID: PMC7750254 DOI: 10.1016/j.pnpbp.2020.110066] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/12/2020] [Accepted: 08/05/2020] [Indexed: 12/16/2022]
Abstract
Impulse control deficits are often found to co-occur with substance use disorders (SUDs). On the one hand, it is well known that chronic intake of drugs of abuse remodels the brain with significant consequences for a range of cognitive behaviors. On the other hand, individual variation in impulse control may contribute to differences in susceptibility to SUDs. Both of these relationships have been described, thus leading to a "chicken or the egg" debate which remains to be fully resolved. Does impulsivity precede drug use or does it manifest as a function of problematic drug usage? The link between impulsivity and SUDs has been most strongly established for cocaine and alcohol use disorders using both preclinical models and clinical data. Much less is known about the potential link between impulsivity and cannabis use disorder (CUD) or the directionality of this relationship. The initiation of cannabis use occurs most often during adolescence prior to the brain's maturation, which is recognized as a critical period of development. The long-term effects of chronic cannabis use on the brain and behavior have started to be explored. In this review we will summarize these observations, especially as they pertain to the relationship between impulsivity and CUD, from both a psychological and biological perspective. We will discuss impulsivity as a multi-dimensional construct and attempt to reconcile the results obtained across modalities. Finally, we will discuss possible avenues for future research with emerging longitudinal data.
Collapse
Affiliation(s)
- Linda Rinehart
- University of Minnesota, Department of Psychiatry and Behavioral Sciences
| | - Sade Spencer
- University of Minnesota, Department of Pharmacology, Minneapolis, MN, USA.
| |
Collapse
|
40
|
Arkell TR, Spindle TR, Kevin RC, Vandrey R, McGregor IS. The failings of per se limits to detect cannabis-induced driving impairment: Results from a simulated driving study. TRAFFIC INJURY PREVENTION 2021; 22:102-107. [PMID: 33544004 DOI: 10.1080/15389588.2020.1851685] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE Many jurisdictions use per se limits to define cannabis-impaired driving. Previous studies, however, suggest that THC concentrations in biological matrices do not reliably reflect cannabis dose and are poorly correlated with magnitude of driving impairment. Here, we first review a range of concerns associated with per se limits for THC. We then use data from a recent clinical trial to test the validity of a range of extant blood and oral fluid THC per se limits in predicting driving impairment during a simulated driving task. METHODS Simulated driving performance was assessed in 14 infrequent cannabis users at two timepoints (30 min and 3.5 h) under three different conditions, namely controlled vaporization of 125 mg (i) THC-dominant (11% THC; <1% CBD), (ii) THC/CBD equivalent (11% THC; 11% CBD), and (iii) placebo (<1% THC & CBD) cannabis. Plasma and oral fluid samples were collected before each driving assessment. We examined whether per se limits of 1.4 and 7 ng/mL THC in plasma (meant to approximate 1 and 5 ng/mL whole blood) and 2 and 5 ng/mL THC in oral fluid reliably predicted impairment (defined as an increase in standard deviation of lateral position (SDLP) of >2 cm relative to placebo). RESULTS For all participants, plasma and oral fluid THC concentrations were over the per se limits used 30 min after vaporizing THC-dominant or THC/CBD equivalent cannabis. However, 46% of participants failed to meet SDLP criteria for driving impairment. At 3.5 h post-vaporization, 57% of participants showed impairment, despite having low concentrations of THC in both blood (median = 1.0 ng/mL) and oral fluid (median = 1.0 ng/mL). We highlight two individual cases illustrating how (i) impairment can be minimal in the presence of a positive THC result, and (ii) impairment can be profound in the presence of a negative THC result. CONCLUSIONS There appears to be a poor and inconsistent relationship between magnitude of impairment and THC concentrations in biological samples, meaning that per se limits cannot reliably discriminate between impaired from unimpaired drivers. There is a pressing need to develop improved methods of detecting cannabis intoxication and impairment.
Collapse
Affiliation(s)
- Thomas R Arkell
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Tory R Spindle
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard C Kevin
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| | - Ryan Vandrey
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Iain S McGregor
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Science, School of Psychology, The University of Sydney, Sydney, New South Wales, Australia
| |
Collapse
|
41
|
Theunissen EL, Reckweg JT, Hutten NRPW, Kuypers KPC, Toennes SW, Neukamm MA, Halter S, Ramaekers JG. Intoxication by a synthetic cannabinoid (JWH-018) causes cognitive and psychomotor impairment in recreational cannabis users. Pharmacol Biochem Behav 2021; 202:173118. [PMID: 33497715 DOI: 10.1016/j.pbb.2021.173118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 01/14/2021] [Accepted: 01/15/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Smoking mixtures containing synthetic cannabinoids (SCs) have become very popular over the last years but pose a serious risk for public health. Limited knowledge is, however, available regarding the acute effects of SCs on cognition and psychomotor performance. Earlier we demonstrated signs of impairment in healthy volunteers after administering one of the first SCs, JWH-018, even though subjective intoxication was low. In the current study, we aimed to investigate the acute effects of JWH-018 on several cognitive and psychomotor tasks in participants who are demonstrating representative levels of acute intoxication. METHODS 24 healthy cannabis-experienced participants took part in this placebo-controlled, cross-over study. Participants inhaled the vapor of 75 μg JWH-018/kg body weight and were given a booster dose if needed to induce a minimum level of subjective high. They were subsequently monitored for 4 h, during which psychomotor and cognitive performance, vital signs, and subjective experience were measured, and serum concentrations were determined. RESULTS Maximum subjective high (average 64%) was reached 30 min after administration of JWH-018, while the maximum blood concentration was shown after 5 min (8 ng/mL). JWH-018 impaired motor coordination (CTT), attention (DAT and SST), memory (SMT), it lowered speed-accuracy efficiency (MFFT) and slowed down response speed (DAT). CONCLUSION In accordance with our previous studies, we demonstrated acute psychomotor and cognitive effects of a relatively low dose of JWH-018.
Collapse
Affiliation(s)
- Eef L Theunissen
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands.
| | - Johannes T Reckweg
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Nadia R P W Hutten
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Kim P C Kuypers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Stefan W Toennes
- Department of Forensic Toxicology, Institute of Legal Medicine, Goethe University of Frankfurt, Frankfurt, Germany
| | - Merja A Neukamm
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany
| | - Sebastian Halter
- Institute of Forensic Medicine, Forensic Toxicology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Germany; Hermann Staudinger Graduate School, University of Freiburg, Hebelstr. 27, 79104 Freiburg, Germany
| | - Johannes G Ramaekers
- Department of Neuropsychology and Psychopharmacology, Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
42
|
Bourque J, Potvin S. Cannabis and Cognitive Functioning: From Acute to Residual Effects, From Randomized Controlled Trials to Prospective Designs. Front Psychiatry 2021; 12:596601. [PMID: 34177633 PMCID: PMC8222623 DOI: 10.3389/fpsyt.2021.596601] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 05/17/2021] [Indexed: 12/30/2022] Open
Abstract
In recent years, several jurisdictions have revised their regulation policy toward both medical and recreational use of cannabis. These changes have elicited concerns regarding how legalization impacts academic achievement and work performance. This review evaluates the acute and long-term (residual) association between cannabis use and cognitive functioning that underlies poor academic and work performance. Relative to other reviews, this article focuses on cross-over randomized controlled trials and prospective designs given that they allow to test the impairing effects of cannabis exposure at the within-subject level. Acute cannabis cognitive effects are discussed separately for known confounding factors such as levels of delta-9-tetrahydrocannabinol (Δ9-THC), Δ9-THC:cannabidiol ratio, previous cannabis use and, comorbidity with psychosis-spectrum disorders. The cognitive residual effects of cannabis are detailed in relation to duration of abstinence, frequency of use, comorbidity with psychosis-spectrum disorders, types of cognitive domains assessed, and age of cannabis use initiation. Moreover, considering the fact that adequate longitudinal studies can make inferences about causality between cannabis use and impaired cognitive functioning when disentangling between-subject from within-subject variation, proofs for the three main non-mutually exclusive hypotheses about this relationship will be presented: i) the cognitive vulnerability hypothesis as part of the more general common antecedent hypothesis, ii) the concurrent cannabis impairing hypothesis, and iii) the neurotoxic hypothesis of cannabis. Current research provides evidence for mild to moderate acute cannabis effects on episodic and working memory, processing speed, and executive functions. Mild residual impairing effects were also observed in these exact same cognitive domains, suggesting that adverse effects following cannabis intoxication persist at least days or weeks following cannabis abstinence. Relative to adult-onset, adolescent-onset cannabis use seems to explain the dose-response relationship and is associated with longer lasting residual effects even in mild users (<weekly). The association between cannabis and cognition is likely explained by common antecedents, such that genetic and shared environment factors predispose individuals to both cannabis use and cognitive deficits, and to a lesser degree, neurotoxic effects.
Collapse
Affiliation(s)
- Josiane Bourque
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Stéphane Potvin
- Department of Psychiatry and Addiction, Faculty of Medicine, University of Montreal, Montreal, QC, Canada.,Centre de Recherche de l'Institut Universitaire en Santé Mentale de Montréal, Montréal, QC, Canada
| |
Collapse
|
43
|
Eadie L, Lo LA, Christiansen A, Brubacher JR, Barr AM, Panenka WJ, MacCallum CA. Duration of Neurocognitive Impairment With Medical Cannabis Use: A Scoping Review. Front Psychiatry 2021; 12:638962. [PMID: 33790818 PMCID: PMC8006301 DOI: 10.3389/fpsyt.2021.638962] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
While the recreational use of cannabis has well-established dose-dependent effects on neurocognitive and psychomotor functioning, there is little consensus on the degree and duration of impairment typically seen with medical marijuana use. Compared to recreational cannabis users, medical cannabis patients have distinct characteristics that may modify the presence and extent of impairment. The goal of this review was to determine the duration of acute neurocognitive impairment associated with medical cannabis use, and to identify differences between medical cannabis patients and recreational users. These findings are used to gain insight on how medical professionals can best advise medical cannabis patients with regards to automobile driving or safety-sensitive tasks at work. A systematic electronic search for English language randomized controlled trials (RCTs), clinical trials and systematic reviews (in order to capture any potentially missed RCTs) between 2000 and 2019 was conducted through Ovid MEDLINE and EMBASE electronic databases using MeSH terms. Articles were limited to medical cannabis patients using cannabis for chronic non-cancer pain or spasticity. After screening titles and abstracts, 37 relevant studies were subjected to full-text review. Overall, seven controlled trials met the inclusion/exclusion criteria and were included in the qualitative synthesis: six RCTs and one observational clinical trial. Neurocognitive testing varied significantly between all studies, including the specific tests administered and the timing of assessments post-cannabis consumption. In general, cognitive performance declined mostly in a THC dose-dependent manner, with steady resolution of impairment in the hours following THC administration. Doses of THC were lower than those typically reported in recreational cannabis studies. In all the studies, there was no difference between any of the THC groups and placebo on any neurocognitive measure after 4 h of recovery. Variability in the dose-dependent relationship raises the consideration that there are other important factors contributing to the duration of neurocognitive impairment besides the dose of THC ingested. These modifiable and non-modifiable factors are individually discussed.
Collapse
Affiliation(s)
- Lauren Eadie
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Lindsay A Lo
- Department of Psychology, Queens University, Kingston, ON, Canada
| | - April Christiansen
- Centre for Neuroscience Studies, Queens University, Kingston, ON, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Alasdair M Barr
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada
| | - William J Panenka
- British Columbia Mental Health and Substance Use Services Research Institute, Vancouver, BC, Canada.,Department of Psychiatry, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada.,British Columbia Provincial Neuropsychiatry Program, Vancouver, BC, Canada
| | - Caroline A MacCallum
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
44
|
Arkell TR, Vinckenbosch F, Kevin RC, Theunissen EL, McGregor IS, Ramaekers JG. Effect of Cannabidiol and Δ9-Tetrahydrocannabinol on Driving Performance: A Randomized Clinical Trial. JAMA 2020; 324:2177-2186. [PMID: 33258890 PMCID: PMC7709000 DOI: 10.1001/jama.2020.21218] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Cannabis use has been associated with increased crash risk, but the effect of cannabidiol (CBD) on driving is unclear. OBJECTIVE To determine the driving impairment caused by vaporized cannabis containing Δ9-tetrahydrocannabinol (THC) and CBD. DESIGN, SETTING, AND PARTICIPANTS A double-blind, within-participants, randomized clinical trial was conducted at the Faculty of Psychology and Neuroscience at Maastricht University in the Netherlands between May 20, 2019, and March 27, 2020. Participants (N = 26) were healthy occasional users of cannabis. INTERVENTIONS Participants vaporized THC-dominant, CBD-dominant, THC/CBD-equivalent, and placebo cannabis. THC and CBD doses were 13.75 mg. Order of conditions was randomized and balanced. MAIN OUTCOMES AND MEASURES The primary end point was standard deviation of lateral position (SDLP; a measure of lane weaving) during 100 km, on-road driving tests that commenced at 40 minutes and 240 minutes after cannabis consumption. At a calibrated blood alcohol concentration (BAC) of 0.02%, SDLP was increased relative to placebo by 1.12 cm, and at a calibrated BAC of 0.05%, SDLP was increased relative to placebo by 2.4 cm. RESULTS Among 26 randomized participants (mean [SD] age, 23.2 [2.6] years; 16 women), 22 (85%) completed all 8 driving tests. At 40 to 100 minutes following consumption, the SDLP was 18.21 cm with CBD-dominant cannabis, 20.59 cm with THC-dominant cannabis, 21.09 cm with THC/CBD-equivalent cannabis, and 18.28 cm with placebo cannabis. SDLP was significantly increased by THC-dominant cannabis (+2.33 cm [95% CI, 0.80 to 3.86]; P < .001) and THC/CBD-equivalent cannabis (+2.83 cm [95% CI, 1.28 to 4.39]; P < .001) but not CBD-dominant cannabis (-0.05 cm [95% CI, -1.49 to 1.39]; P > .99), relative to placebo. At 240 to 300 minutes following consumption, the SDLP was 19.03 cm with CBD-dominant cannabis, 19.88 cm with THC-dominant cannabis, 20.59 cm with THC/CBD-equivalent cannabis, and 19.37 cm with placebo cannabis. The SDLP did not differ significantly in the CBD (-0.34 cm [95% CI, -1.77 to 1.10]; P > .99), THC (0.51 cm [95% CI, -1.01 to 2.02]; P > .99) or THC/CBD (1.22 cm [95% CI, -0.29 to 2.72]; P = .20) conditions, relative to placebo. Out of 188 test drives, 16 (8.5%) were terminated due to safety concerns. CONCLUSIONS AND RELEVANCE In a crossover clinical trial that assessed driving performance during on-road driving tests, the SDLP following vaporized THC-dominant and THC/CBD-equivalent cannabis compared with placebo was significantly greater at 40 to 100 minutes but not 240 to 300 minutes after vaporization; there were no significant differences between CBD-dominant cannabis and placebo. However, the effect size for CBD-dominant cannabis may not have excluded clinically important impairment, and the doses tested may not represent common usage. TRIAL REGISTRATION EU Clinical Trials Register: 2018-003945-40.
Collapse
Affiliation(s)
- Thomas R Arkell
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Central Clinical School, Faculty of Medicine, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Frederick Vinckenbosch
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Richard C Kevin
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Science, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Eef L Theunissen
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| | - Iain S McGregor
- Lambert Initiative for Cannabinoid Therapeutics, The University of Sydney, Sydney, New South Wales, Australia
- Brain and Mind Centre, The University of Sydney, Sydney, New South Wales, Australia
- Faculty of Science, The University of Sydney School of Psychology, Sydney, New South Wales, Australia
| | - Johannes G Ramaekers
- Faculty of Psychology and Neuroscience, Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
45
|
Howard J, Osborne J. Cannabis and work: Need for more research. Am J Ind Med 2020; 63:963-972. [PMID: 32797692 DOI: 10.1002/ajim.23170] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 12/12/2022]
Abstract
Cannabis sativa is one of the oldest and most widely used plants in the world with a variety of industrial, medical, and nonmedical applications. Despite its long history, cannabis-derived products remain a source of controversy across the fields of medicine, law, and occupational safety and health. More favorable public attitudes about cannabis in the US have resulted in greater access to cannabis through legalization by states, leading to more consumption by workers. As more states adopt cannabis access laws, and as more workers choose to consume cannabis products, the implications for existing workplace policies, programs, and practices become more salient. Past workplace practices were grounded in a time when cannabis consumption was always viewed as problematic, considered a moral failing, and was universally illegal. Shifting cultural views and the changing legal status of cannabis indicate a need for research into the implications and challenges relating to cannabis and work. This commentary suggests research needs in the following areas: (a) data about industries and occupations where cannabis consumption among workers is most prevalent; (b) adverse health consequences of cannabis consumption among workers; (c) workplace supported recovery programs; (d) hazards to workers in the emerging cannabis industry; (e) relationship between cannabis consumption and occupational injuries; (f) ways to assess performance deficits and impairment from cannabis consumption; (g) consumption of synthetic cannabinoids to evade detection by drug testing; (h) cannabis consumption and its effect on occupational driving; and (i) ways to craft workplace policies and practices that take into consideration conflicting state and federal laws pertaining to cannabis.
Collapse
Affiliation(s)
- John Howard
- Office of the Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention US Department of Health and Human Services Washington DC
| | - Jamie Osborne
- Office of the Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention US Department of Health and Human Services Atlanta Georgia
| |
Collapse
|
46
|
Lloyd SL, Lopez-Quintero C, Striley CW. Sex differences in driving under the influence of cannabis: The role of medical and recreational cannabis use. Addict Behav 2020; 110:106525. [PMID: 32711286 DOI: 10.1016/j.addbeh.2020.106525] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Existing evidence suggest that cannabis may impair driving and is the most prevalent drug identified in drivers. Males exhibit an excess risk for driving under the influence of drugs or alcohol compared to females. We assessed sex differences in the association between the reason for cannabis use (medical, recreational, or both) and driving under the influence of cannabis (DUIC). METHODS A sample of 17,405 past 12-month cannabis users (18 + years old) were analyzed from the 2016-17 National Survey on Drug Use and Health. Multivariable logistic regression was used to assess the interaction of sex and reason for cannabis use on DUIC using predicted probabilities. RESULTS Among cannabis users in the sample, 88.1% used for recreational reasons, 7.8% used for medical reasons, and 4.1% used for medical and recreational reasons. The probability of DUIC was as low as 20% among female medical only users, and as high as 40% among male combined medical and recreational users. Females showed more similar probabilities of DUIC across reasons of use (range 20% to 25%s) than males (range 28% to 40%). The difference in the probability of DUIC between combined medical and recreational users and recreational only users was significantly greater among males than among females (Δ 0.1, p < 0.05). CONCLUSIONS The observed effects of sex and reasons for cannabis use on DUIC suggests a need for targeted educational interventions, particularly among males reporting combined medical and recreational marijuana use.
Collapse
|
47
|
Wallace MS, Marcotte TD, Atkinson J, Padovano HT, Bonn-Miller M. A Secondary Analysis from a Randomized Trial on the Effect of Plasma Tetrahydrocannabinol Levels on Pain Reduction in Painful Diabetic Peripheral Neuropathy. THE JOURNAL OF PAIN 2020; 21:1175-1186. [DOI: 10.1016/j.jpain.2020.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/06/2020] [Accepted: 03/07/2020] [Indexed: 10/24/2022]
|
48
|
Pennypacker SD, Romero-Sandoval EA. CBD and THC: Do They Complement Each Other Like Yin and Yang? Pharmacotherapy 2020; 40:1152-1165. [PMID: 33080058 DOI: 10.1002/phar.2469] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 01/12/2023]
Abstract
Increased public access to cannabis calls for a deeper understanding of cannabis's constituents and how they interact to induce clinical effects. Whereas trans-Δ9 -tetrahydrocannabinol (THC) is considered the main psychoactive component in cannabis, producing the associated "high" or "euphoria," various findings demonstrate medical potential for cannabidiol (CBD), from anxiolytic to antiepileptic implications. This has translated into a public optimism and given way to the popular opinion that CBD can provide countless other therapeutic benefits, including the potential to mitigate some of the adverse side effects of THC, such as intoxication, psychomotor impairment, anxiety, and psychotic symptoms. This is particularly relevant for patients seeking to garner therapeutic benefits from cannabis without experiencing the burden of a significant subjective high. Thus, this article analyzes the scientific evidence available to support or disprove the idea that presence of CBD is beneficial and can exude a protective effect against THC. A thorough review of relevant literature, a basis from which to interpret such evidence through a critical mechanistic discussion, and the implications for patients are presented in this article.
Collapse
Affiliation(s)
- Sarah D Pennypacker
- Department of Anesthesiology, Pain Mechanisms Laboratory, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - E Alfonso Romero-Sandoval
- Department of Anesthesiology, Pain Mechanisms Laboratory, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| |
Collapse
|
49
|
Malik A, Fatehi KS, Menon NN, Chaturvedi P. Review of Medicinal Use of Cannabis Derivatives and the Societal Impact of Legalization. Indian J Palliat Care 2020; 26:369-380. [PMID: 33311882 PMCID: PMC7725166 DOI: 10.4103/ijpc.ijpc_19_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 03/06/2020] [Indexed: 12/13/2022] Open
Abstract
Background: In recent past, there has been a rush to legalize marijuana along with a lot of support for its medicinal uses. This review intends to discuss the medicinal uses of marijuana and its adverse effects based on the current available evidence. Furthermore, it discusses the impact of legalization of marijuana. Methodology: This was a narrative review for which a thorough literature search was conducted on the Medline and PubMed databases. A detailed search of the Internet to find relevant information on webpages was also performed. Results: High-quality evidence for the majority of medical indications of marijuana remains investigational. Most of the available literature compares it against placebos. Postlegalization usage of marijuana has increased. Conclusion: It would be prudent to wait for studies which prove beyond doubt the advantages of marijuana over the existing drugs and also outweigh its side effects and addiction potential. Moreover, further legalization of marijuana should only be considered after evaluating its effects at places where it is already legally available.
Collapse
Affiliation(s)
- Akshat Malik
- Department of Head and Neck Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | | | - Nandini N Menon
- Department of Head and Neck Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Pankaj Chaturvedi
- Department of Head and Neck Oncology, Tata Memorial Centre, Mumbai, Maharashtra, India
| |
Collapse
|
50
|
Ramaekers JG, Mason NL, Theunissen EL. Blunted highs: Pharmacodynamic and behavioral models of cannabis tolerance. Eur Neuropsychopharmacol 2020; 36:191-205. [PMID: 32014378 DOI: 10.1016/j.euroneuro.2020.01.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/22/2019] [Accepted: 01/12/2020] [Indexed: 02/07/2023]
Abstract
Acute exposure to cannabis comes with neurocognitive impairment, leading to increased risk of human error and injury. Evidence however indicates that such acute effects are less prominent in chronic users, suggesting cannabis tolerance. Models of cannabis tolerance stress the importance of neurobiological or behavioral adaptations following repeated cannabis exposure. The pharmacodynamic model relates neuroadaptive changes in the brain to a blunted response to cannabis. Downregulation of CB1 receptors in chronic cannabis users has been associated with a normalization of dopaminergic output from the ventral tegmental area to the mesolimbic circuit, and a reduction of impairment during acute cannabis exposure. Such neuroadaptions are absent in occasional users, who show strong increments of dopamine and glutamate levels in the striatum, a loss of functional connectivity within the mesolimbic circuit and neurocognitive impairments when exposed to cannabis. Evidence for a behavioral model of cannabis tolerance that poses that users can have volitional control to overcome functional impairment during cannabis intoxication is relatively weak, and at best shows limited control over a limited number of behavioral functions. Cannabis tolerance is most likely to occur in users that consume high doses of cannabis continuously, at a high pace, for a prolonged period of time. Knowledge on frequency, dose and duration of cannabis use that is needed to achieve, maintain or lessen tolerance however is very limited, but will be of importance in the context of cannabis therapeutics and in legal settings when evaluating the impact of cannabis exposure on human function.
Collapse
Affiliation(s)
- J G Ramaekers
- Faculty of Psychology and Neuroscience, Department of Neuropsychology and Psychopharmacology, Maastricht University, the Netherlands.
| | - N L Mason
- Faculty of Psychology and Neuroscience, Department of Neuropsychology and Psychopharmacology, Maastricht University, the Netherlands
| | - E L Theunissen
- Faculty of Psychology and Neuroscience, Department of Neuropsychology and Psychopharmacology, Maastricht University, the Netherlands
| |
Collapse
|