The prevalence of drugs in injured drivers

Personality, perceptions and behavior: A study of speeding amongst drivers in Victoria, Australia

INTRODUCTION

Road crashes present a serious public health issue. Many people are seriously or fatally injured every year in avoidable crashes. While these crashes can have multiple contributing factors, including road design and condition, vehicle design and condition, the environment and human error, the performance of illegal driving behavior, including speeding, may also play a role. The current study aimed to examine the mediating influence that four potential deterrents (perceptions towards enforcement, crash risk, social norms and disapproval, and negative personal/emotional affect) have between the Big Five personality traits (conscientiousness; extraversion; agreeableness; neuroticism; openness) and expectations to speed.

METHODS

A total of 5,108 drivers in Victoria, Australia completed an online survey in 2019. A mediated regression analysis was used to examine pathways in a conceptual model developed for the study.

RESULTS

The results showed that perceptions towards the four potential deterrents examined did mediate the relationship (either completely or partially) between personality and expectations to speed.

CONCLUSIONS

The results of this study suggest that if interventions to deter illegal driving behavior are to be successful, one factor that could be taken into account is the personality traits of drivers who may be at greatest risk of the performance of illegal driving behaviors.

Road traffic deaths: A retrospective analysis (2009-2019) in the north of the Italian region Emilia Romagna

OBJECTIVE

International literature and several national studies demonstrate that alcohol and illicit drugs impair driving abilities, diminishing the level of attention, and cause traffic accidents. In Italy, driving under the influence of alcohol or drugs is regulated by Articles 186 and 187 of the National Street Code, which defines penalties and fines for the convicted. The aim of this study was the collection of all available data from 2009 to 2019 focusing on deaths related to road accidents in the Unit of Legal Medicine of Department of Medicine and Surgery at the University of Parma, in order to assess any consumption of alcohol, illicit drugs, and medicinal drugs among drivers.

METHODS

Data were retrieved from autopsy reports found at the Unit of Legal Medicine of Parma University related to 327 subjects who died following road accidents in the Italian areas of Parma, Reggio-Emilia, and Piacenza. The population was divided into subgroups according to age, gender, crash time, and drug positivity.

RESULTS

Those in the age group 46 to 65 years old were involved in the most accidents, whereas the category with fewest members included subjects under 26 years old. The majority of road accidents occurred during the daytime and on weekends. Among the toxicological investigations carried out (only for drivers), the highest prevalence was found for alcohol (43.1%), followed by illicit drugs (14.4%) and medicinal drugs (7.8%). The prevalence of alcohol and illicit drugs in combination was 11.8%. Regarding subjects positive for alcohol and illicit drugs in combination, 44.4% had a blood alcohol concentration (BAC) > 1.5 g/L and overall, in 61.1% of the total cases a BAC > 0.81 g/L was detected.

CONCLUSIONS

Our results are in line with national and international studies highlighting the prevalence of high BAC levels in most of the cases. Confirmation analyses on blood collected from people who died following road accidents showed levels of BAC above 0.8 g/L (threshold for penal sanctions) in the majority of the subjects who tested positive for alcohol. They also revealed cocaine, cannabis, and benzodiazepines as the most common illicit drugs and medicinal drugs used, respectively, as demonstrated in several international studies.

Suspicion of driving under the influence of alcohol or drugs: Cross sectional analysis of drug prevalence in the context of the Swiss legislation

Driving under the influence of alcohol and drugs (DUID) is a major field of study to improve road safety. In Switzerland, during controls whether or not they follow an accident, the police can request toxicological analysis targeted either on alcohol only (ALC cases), or on drugs and alcohol (DUID cases). To evaluate both the drugs consumption on the road and whether or not these requests are well correlated with toxicological results, we built a database recording 4003 offenders (3443 males, 550 females) over a two-year period (2018-2019) in Western Switzerland. ALC case samples were then analyzed to target other substances than ethanol. We found one or more psychoactive drugs in 89% of DUID cases and alcohol alone was found in 56% of ALC cases. In ALC cases, alcohol alone was found in 72% of non-accident cases and in 52% of accident cases. This highlights an influence of accident context, inducing a too high suspicion of alcohol after accidents, and therefore an underestimation of the prevalence of other drugs. The most frequently detected drugs in DUID cases were cannabinoids (58%), ethanol (30%), cocaine (21%), benzodiazepines (11%), amphetamines (7%), opiates (6%), and antidepressants (5%). For the ALC cases, the drugs found were ethanol (84%), cannabinoids (13%), benzodiazepines (9%), antidepressants (6%), opiates (5%), cocaine (4%), methadone (3%), and amphetamines (1%). Prescription drugs, such as benzodiazepines, were common in accidents (22%) but rare in non-accidents DUID cases (5%). Thus, these drugs highly impact driving skills while being hard to suspect. This is of first concern as prescription drugs are largely found in poly-drug consumption, especially in combination with alcohol in accident cases. This emphasizes the emerging issue of prescription drugs and should motivate a strategy of prevention focused on the noxious effect of combining alcohol and prescription drugs on driving skills.

From phone use to speeding and driving under influence: Identifying clusters of driving risk behaviors as an opportunity for targeted interventions

Identifying the profile of risky behaviors among drivers is central to propose effective interventions. Due to the multidimensional and overlapping aspects of risky driving behaviors, cluster analysis can provide additional insights in order to identify specific subgroups of risk. This study aimed to identify clusters of driving risk behavior (DRB) among car drivers, and to verify intra-cluster differences concerning clinical and sociodemographic variables. We approached a total of 12,231 drivers and we included 6392 car drivers. A cluster algorithm was used to identify groups of car drivers in relation to the DRB: driving without a seat belt (SB), exceeding the speed limit (SPD), using a cell phone while driving (CELL), and driving after drinking alcohol (DUI). The algorithm classified drivers within five different DRB profiles. In cluster 1 (20.1%), subjects with a history of CELL. In cluster 2 (41.4%), drivers presented no DRB. In cluster 3 (9.3%), all drivers presented SPD. In cluster 4 (12.5%), drivers presented all DRB. In cluster 5 (16.6%), all drivers presented DUI. Clusters with DUI-related offenses (4 and 5) comprised more men (81.9 and 78.8%, respectively) than the overall sample (63.4%), with more binge drinking (50.9 and 45.7%) and drug use in the previous year (13.5 and 8.6%). Cluster 1 had a high years of education (14.4 ± 3.4) and the highest personal income (Md = 3000 IQR [2000-5000]). Cluster 2 had older drivers (46.6 ± 15), and fewer bingers (10.9%). Cluster 4 had the youngest drivers (34.4 ± 11.4) of all groups. Besides reinforcing previous literature data, our study identified five unprecedented clusters with different profiles of drivers regarding DRB. We identified an original and heterogeneous group of drivers with only CELL misuse, as well as other significant differences among clusters. Hence, our findings show that targeted interventions must be developed for each subgroup in order to effectively produce safe behavior in traffic.

Screening major trauma patients for prevalence of illicit drugs

INTRODUCTION

Australasian emergency departments (ED) routinely test patient alcohol levels following major trauma, but assessment for illicit drugs is uncommon.

METHODS

A prospective cross-sectional study of major motor-vehicle-related trauma patients attending both adult major trauma centres in Victoria, Australia. All eligible patients had point-of-care saliva testing to determine the prevalence of common illicit drugs.

RESULTS

Over 12 months, 1411 patients were screened, 36 refused (2.6%) and 63 were excluded. Of the final 1312 cases included, 173 (13.2%; 95% confidence interval 11.5, 15.1) tested positive to at least one illicit substance, with 133 (76.9%; 69.7, 82.8) positive for meth/amphetamines. One in five had more than one illicit substance detected. Patients testing positive were most frequently in motor vehicles (91.9% vs. 85.6%) and least frequently cyclists (2.3% vs. 4.2%) or pedestrians (5.2% vs. 10.3%), compared to those testing negative. They were younger (mean age 35.4 vs. 43.1 years), more likely to arrive overnight (27.2% vs. 12.1%) or after single vehicle crashes (54.3% vs. 42.3%). Although the initial disposition from ED did not differ, those testing positive were more likely to re-present within 28 days (13.9% vs. 5.4%).

DISCUSSION AND CONCLUSIONS

A high prevalence of potentially illicit substances among patients presenting with suspected major trauma supports the need for urgent preventive strategies. The low rate of patient refusal and large numbers screened by ED staff suggests that point-of care testing for illicit substances in major trauma is acceptable and feasible. This study and ongoing surveillance may be used to inform driver education strategies.

The prevalence of alcohol and other drugs in fatal road crashes in Victoria, Australia

BACKGROUND

Driving under the influence of drugs, including alcohol, is a globally recognised risk factor for road traffic crashes. While the prevalence of alcohol and other drugs in fatal road crashes has been examined in other countries, recent data investigating drug driving in fatal Australian crashes are limited. This study aimed to examine how the presence of alcohol and other drugs in fatal road trauma in Victoria has changed over time in different road users.

METHODS

A population-based review of road trauma deaths was performed over the period of 01 July 2006 to 30 June 2016 in Victoria, Australia, using data from the National Coronial Information System (NCIS) and the Victorian State Trauma Registry (VSTR). Drugs were grouped according to type and analysed accordingly. Poisson regression models were used to determine change in incidence rates over the study period.

RESULTS

There were 2287 road traffic fatalities with complete toxicology data (97% of all road traffic fatalities). Alcohol (blood alcohol concentration, BAC) was the most commonly detected drug (>0.001 g/100 mL: 21.1%; >0.05 g/100 mL: 18.4%), followed by opioids (17.3%), THC (13.1%), antidepressants (9.7%), benzodiazepines (8.8%), amphetamine-type stimulants (7.1%), ketamine (3.4%), antipsychotics (0.9%) and cocaine (0.2%). Trends demonstrated changing use over time with specific drugs. Alcohol positive road fatalities declined 9% per year in passenger car/4WD drivers (IRR = 0.91, 95% CI: 0.88-0.95). The incidence of strong opioids (oxycodone, fentanyl, morphine, and methadone) increased 6% per year (IRR = 1.06; 95% CI: 1.02-1.10). Methylamphetamine was detected in 6.6% of cases and showed a yearly increase of 7% (IRR = 1.07; 95% CI: 1.01-1.13). The incidence of THC remained unchanged over the period, observed in 13.1% of cases. Stronger opioids were more commonly detected among pedal cyclists (19.0%) and pedestrians (20.9%) while THC was more commonly detected among motorcyclists (19.8%) and other light vehicle drivers (17.6%).

CONCLUSIONS

A decline in the prevalence of alcohol in fatalities suggests that law enforcement and public health strategies in Australia to address road fatalities and drink-driving may have had a positive effect. However, increases were observed in the incidence of other potentially impairing drugs including opioids and amphetamines, specifically methylamphetamine, indicating a concerning trend in road safety in Victoria that warrants further monitoring.

Epidemiology of drug driving: protocol from a national Canadian study measuring levels of cannabis, alcohol and other substances in injured drivers

Background

Drug driving is an emerging global road safety problem. As the prevalence of alcohol-impaired driving decreases, and as more jurisdictions decriminalize or legalize cannabis, it is increasingly important for policy makers to have accurate information on the prevalence and pattern of drug driving. Unfortunately, this data is not widely available and the World Health Organization identifies lack of accurate data on the prevalence of drug driving as an important knowledge gap.

Methods

In this paper, we discuss the limitations of current methods of monitoring drug use in drivers. We then present a novel methodology from a multi-centre study that monitors the prevalence and pattern of drug use in injured drivers across Canada. This study uses “left-over” blood taken as part of routine medical care to quantify cannabis and other drugs in non-fatally injured drivers who present to participating emergency departments after a collision. Toxicology testing is done with waiver of consent as we have procedures that prevent results from being linked to any individual. These methods minimize non-response bias and have the advantages of measuring drug concentrations in blood obtained shortly after a collision.

Discussion

Our methods can be applied in other jurisdictions and provide a consistent approach to collect data on drug driving. Consistent methods allow comparison of drug driving prevalence from different regions. Data from this research can be used to inform policies designed to prevent driving under the influence of cannabis and other impairing drugs.

Odds of culpability associated with use of impairing drugs in injured drivers in Victoria, Australia

Culpability analysis was conducted on 5000 drivers injured as a result of a vehicular collision and in whom comprehensive toxicology testing in blood was conducted. The sample included 1000 drivers for each of 5 years from approximately 5000-6000 drivers injured and taken to hospital in the State of Victoria. Logistic regression was used to investigate differences in the odds of culpability associated with alcohol and drug use and other selected crash attributes using the drug-free driver as the reference group. Adjusted odds ratios were obtained from multivariable logistic regression models in which other potentially explanatory driver and crash attributes were included. Drivers with alcohol present showed large increases in the odds of culpability similar to that seen in other studies investigating associations between blood alcohol concentration and crash risk. Methylamphetamine also showed a large increase in the odds of culpability (OR 19) compared to the reference group at both below and above 0.1 mg/L, whereas those drivers with Δ⁹-tetrahydrocannabinol (THC) present showed only modest increase in odds when all concentrations were assessed (OR 1.9, 95 %CI 1.2-3.1). Benzodiazepines in drivers also gave an increase in odds (3.2, 95 %CI 1.6-6.1), but not other medicinal drugs such as antidepressants, antipsychotics and opioids. Drivers that had combinations of impairing drugs generally gave a large increase in odds, particularly combinations of alcohol with THC or benzodiazepines, and those drivers using both THC and methamphetamine.

Association of benzodiazepines, opioids and tricyclic antidepressants use and falls in trauma patients: Conditional effect of age

INTRODUCTION

The relationship between benzodiazepines, opioids and tricyclic antidepressants and trauma is of great importance because of increased consumption and the growing evidence of a positive association among older adults. The objective of this study was to determine the effect size of the association between the consumption of psychotropic medications /opioids and falls in patients who have suffered trauma by studying the role of other variables in this relationship.

METHOD

From 2011 to 2016, the presence of benzodiazepines, opioids and tricyclic antidepressants and other drugs in 1060 patients admitted for trauma at a level I trauma hospital was analysed. Multivariate models were used to measure the adjusted effect size of the association between consumption of benzodiazepines, opioids and tricyclic antidepressants and falls, and the effect of age on this association was studied.

RESULTS

A total of 192 patients tested positive for benzodiazepines, opioids and tricyclic antidepressants, with same-level falls being the most frequent mechanism of injury in this group (40.1%), with an odds ratio of 1.96 (1.40-2.75), p < 0.001. Once other covariates were introduced, this association was not observed, leaving only age, gender (woman) and, to a lesser extent, sensory conditions as variables associated with falls. Age acted as an effect modifier between benzodiazepines, opioids and tricyclic antidepressants and falls, with significant effect sizes starting at 51.9 years of age.

CONCLUSIONS

The association between the consumption of benzodiazepines, opioids and tricyclic antidepressants and falls in patients admitted for trauma is conditioned by other confounding variables, with age being the most influential confounding variable.

Positive drug test trends in fatally-injured drivers in the United States from 2007 to 2017

Background

The last two decades have seen tremendous changes in the U.S. environment surrounding drugs. Driving under the influence of drugs is a growing public health hazard. The present study examined trends in drug involvement in fatally-injured drivers in the U.S.

Methods

Data were drawn from the 2007–2017 Fatality Analysis Reporting System. Cochran–Armitage tests were performed to assess the statistical significance of changes in the yearly prevalence of positive drug tests in fatally-injured drivers over time. In addition, analyses were stratified by sex, race, and age.

Results

The yearly prevalence of positive drug tests in fatally-injured drivers increased significantly from 20.7% in 2007 to 30.7% in 2017, with results showing a higher prevalence among males, those aged 21–44, and Whites. The gap between Blacks and Whites narrowed in 2017. There was a decline in the yearly prevalence in all age groups between 2016 and 2017, although the decrease in the 21–44 age group was much smaller than other age groups. Among drivers who tested positive for drugs, 34.6% had a blood alcohol concentration (BAC) above the threshold of per se evidence for impaired driving, and 63% had a BAC below the threshold.

Conclusions

Our results indicate that the overall yearly prevalence of fatally-injured drivers who tested positive for drugs increased significantly from 2007 to 2017, with similar results found for subgroups. Findings further highlight that drugged driving remains a public health priority, and more action is needed to stem this disturbing trend.

First evaluation of the possibility of testing for drugged driving using exhaled breath sampling

Objective: Driving under the influence of psychoactive drugs causes an increased risk for accidents. In combating this, sobriety tests at the roadside are common practice in most countries. Sampling of blood and urine for forensic investigation cannot be done at the roadside and poses practical problems associated with costs and time. An alternative specimen for roadside testing is therefore warranted and the aerosol particles in exhaled breath are one such alternative. Methods: The present study investigated how the exhaled breath sample compared with the routine legal investigations of blood and urine collected from suspects of drugged driving at 2 locations in Sweden. Exhaled breath was collected using a simple filter collection device and analyzed with state-of-the-art mass spectrometry technique. Results: The total number of cases used for this investigation was 67. In 54 of these cases (81%) the results regarding a positive or negative drug test result agreed and in 13 they disagreed. Out of these, the report from the forensic investigation of blood/urine was negative in 21 cases. In 6 of these, analytical findings were made in exhaled breath and these cases were dominated by the detection of amphetamine. In 7 cases a positive drug test from the forensic investigation was not observed in the breath sample and these cases were dominated by detection of tetrahydrocannabinol in blood. In total, 45 samples were positive with breath testing and the number of positives with established forensic methods was 46. Conclusion: The promising results from this study provide support to exhaled breath as a viable specimen for testing of drugged driving. The rapid, easy, and convenient sampling procedure offers the possibility to collect a drug test specimen at the roadside. The analytical investigation must be done in a laboratory at present because of the need for a highly sensitive instrument, which is already in use in forensic laboratories. The analytical work is not more challenging than for blood or oral fluid and should not cause an increase in cost. However, more studies need to be done before exhaled breath drug testing can be applied routinely for drugged driving investigation.

Driving under the influence of alcohol and drugs in the eastern part of Denmark in 2015 and 2016: Abuse patterns and trends

OBJECTIVES

The objective of this study was to examine the frequency of psychoactive drugs and alcohol in drivers under suspicion of driving under the influence of drugs and alcohol in 2015 and 2016 in the eastern part of Denmark. The trends in the number of traffic cases sent for drug analysis since 2000 and alcohol analysis since 2011 are also discussed.

METHODS

Blood samples from drivers suspected of being under the influence of alcohol and/or medication and/or illicit drugs in 2015 and 2016 were investigated as requested by the police. The blood samples were screened for alcohol and/or tetrahydrocannabinol (THC) alone, for other drugs (covering all drugs, except THC, listed in the Danish list of narcotic drugs), or for THC and other drugs. Age and gender were also recorded. The number of drug traffic cases since 2000 and the number of alcohol cases since 2011 were extracted from our Laboratory Information Management System (LIMS).

RESULTS

In total, 11,493 traffic cases were investigated. Alcohol and/or drugs exceeded the legal limit in 9,657 (84%) cases. Men constituted 95% of the drivers investigated for drugs and 88% of the alcohol cases. The drivers investigated for drugs consisted primarily of young men, whereas drivers investigated for alcohol were older. The frequency was higher for positive alcohol cases above the legal limit (87%) than for drug cases (76%) above the fixed concentration limit. THC (67-69%) was the most frequently detected drug above the legal limit, followed by cocaine (27-28.5%), amphetamine (17%), and clonazepam (6-7%) in both years. Morphine (5.4%), included among the 5 most frequent drugs in 2015, was replaced by methadone (4.6%) in 2016. Few new psychoactive drugs (NPS) were detected. The number of traffic cases sent for drug analysis has increased more than 30-fold since 2000-2006, and the number of traffic cases submitted in 2016 for drug analysis was higher than the number for alcohol analysis; the latter has decreased since 2011.

CONCLUSION

Overall, alcohol was the most frequent compound detected above the legal limit in both years, followed by the well-known illicit drugs THC, cocaine, and amphetamine. NPS were seldom seen. One consequence of the increased focus on drugs in traffic has been an immense increase in drug traffic cases sent for analysis since 2006 in the eastern part of Denmark. Although this survey revealed only minimal changes compared to earlier investigations, surveys like this are invaluable for monitoring abuse patterns and trends in drugged and drunken driving.

Determination of 12 commonly found compounds in DUID cases in whole blood using fully automated supported liquid extraction and UHPLC-MS/MS

A high-throughput UHPLC-MS/MS method for the most frequently found compounds; tetrahydrocannabinol (THC), amphetamine, methamphetamine, MDMA, clonazepam, diazepam, nordiazepam, oxazepam, alprazolam, nitrazepam, morphine, and codeine, in driving under the influence of drugs (DUID) cases in whole blood, is presented. Automated sample preparation by 96-well supported liquid extraction (SLE) plates with ethyl acetate + heptane (80 + 20, v/v) as organic solvent was carried out on a Freedom Evo 200 platform from Tecan. An aliquot of 100 μL whole blood was used. Sample preparation time for 96 samples was 1.5 h. Compounds were separated with gradient elution on a C₁₈ column (50 × 2.1 mm, 1.7 μm) with a mobile phase consisting of 5 mM pH 10.2 ammonium formate and methanol. The run time was 4.5 min and 1 μL was injected on an Acquity UPLC I-Class system with a Xevo TQS tandem-quadrupole mass spectrometer in multiple-reaction monitoring mode (MRM) from Waters. Isotope labelled, ¹³C, internal standards (ISs) were used for all compounds except for alprazolam and morphine, which had deuterated analogs. Quantification was carried out with calibrators without whole blood matrix. Full validation was carried out according to international guidelines, and a new approach for evaluation of process efficiency (PE) has been presented. Linear or quadratic weighted (1/x) calibration curves were used with R² ≥ 0.999. The method showed satisfactory deviations ±16% when compared to the existing methods, and satisfactory agreement with proficiency testing control samples (z-score -1.6 to 1.8, n = 16 samples). The precision, estimated as the relative standard deviation (RSD) of the concentration difference between results from two independent analyses of authentic whole blood samples, was ≤7.2% in antemortem and ≤9.3% in postmortem samples. Recovery was ≥85% for all the compounds, except morphine ≥62% and THC ≥ 50%. PE was satisfactory for all the compounds with low variation in IS response, RSD ≤ 16% (THC 27%) in antemortem samples and ≤34% (THC 66%) in postmortem samples. To the best of our knowledge, this is the first automated 96-well SLE UHPLC-MS/MS method developed for the simultaneous determination of these 12 compounds in whole blood covering the concentration ranges found in forensic samples. The method has been used in routine work during the last ten months, analysing about 9900 antemortem and 1000 postmortem whole blood samples, and has proven to be robust and reliable.

Prevalence of alcohol among nonfatally injured road accident casualties in two level III trauma centers in northern Ghana

BACKGROUND

Alcohol use is pervasive among motorists on the road in Ghana; however, we do not know the extent to which this behavior is implicated in road accidents in this country.

OBJECTIVES

The main objective of this research was to establish the prevalence of alcohol in the blood of nonfatally injured casualties in the emergency departments (EDs) in northern Ghana.

METHOD

Participants were injured road traffic crash victims, namely, pedestrians, cyclists, motorcyclists, and drivers seeking treatment at an ED. The study sites were 2 level III trauma centers located in Wa and Bolgatanga. Participants were screened for alcohol followed by breath tests for positive participants using breathalyzers.

RESULTS

Two hundred and sixty-two accident victims visited EDs, 58% of whom were in Wa. Among the victims, 41% were hospitalized and 57% experienced slight injuries. The vast majority (76%) of the casualties were motorcyclists, 13% were pedestrians, 8% were cyclists, and 2% were drivers. Casualties who had detectable alcohol in their blood were predominantly vulnerable road users. In all, 34% of participants had detectable blood alcohol concentrations (BACs) and the mean BAC for all casualties who tested positive and could give definitive BACs was 0.2265 (226 mg/dl). The prevalence of alcohol use was 53% among cyclists, 34% among motorcyclists, 21% among pedestrians, and 17% among drivers. Male casualties were more likely to test positive for alcohol than females. In addition, the prevalence of alcohol was significantly higher among injured casualties in Bolgatanga compared to Wa.

CONCLUSION

There was a high prevalence of alcohol use among nonfatally injured casualties in northern Ghana and injury severity increased with BAC. AUDIT screening in the hospital, alcohol consumption guideline, road safety education with an emphasis on minimizing or eliminating alcohol consumption, and enhanced enforcement of the BAC limit among motorists are recommended.

Driving under the influence of drugs: Perceptions and attitudes of New Zealand drivers

This study explored the patterns of drug driving in New Zealand by investigating 1) drivers' perceptions about impairment caused by legal and illegal drugs 2) countermeasures employed by drivers when under the influence of drugs (e.g., decisions not to drive) 3) drivers' attitudes about police enforcement of drug driving and 4) the factors that predict the likelihood of engaging in drug driving. Participants (n=434) were licensed drivers who completed an online questionnaire. Results of the questionnaire indicated that drivers rated hallucinogens and opiates as being the illegal drugs producing the highest level of driving impairment and cannabis the lowest. For legal drugs, sedatives were rated as having the highest driving impairment and anti-nausea and anti-depressants the lowest. Respondents' drug use history had an effect on their ratings of impairment for anti-anxiety drugs, anti-depressants, kava, sedatives, cannabis and hallucinogens such that drug users reported higher impairment ratings than Non-user. Making a decision not to drive after taking drugs was reported by users of alcohol (73.6%), cannabis (57.0%), strong painkillers (42.5%), and anti-depressants (10.0%). Respondents who reported drink driving were 3.26 times more likely to report drug driving than those reporting no drink driving. Respondents also showed greater acceptance towards driving under the influence of legal drugs (43.5%) compared to illegal drugs (10.3%). Those who did not have favourable attitudes about drug driving were less likely to report having driven under the influence of drugs. Drivers in this sample were less aware of the potential negative effects of legal drugs on driving compared to illegal drugs. More than half the respondents from this study acknowledged drug driving as a road safety issue which needs more resources dedicated to it.

Trends in reports of driving following illicit drug consumption among regular drug users in Australia, 2007-2013: Has random roadside drug testing had a deterrent effect?

INTRODUCTION

Driving following illicit drug consumption ('drug-driving') is a potential road safety risk. Roadside drug testing (RDT) is conducted across Australia with the dual aims of prosecuting drivers with drugs in their system and deterring drug-driving. We examined trends over time in self-reported past six-month drug-driving among sentinel samples of regular drug users and assessed the impact of experiences of RDT on drug-driving among these participants.

METHODS

Data from 1913 people who inject drugs (PWID) and 3140 regular psychostimulant users (RPU) who were first-time participants in a series of repeat cross-sectional sentinel studies conducted in Australian capital cities from 2007 to 2013 and reported driving in the past six months were analysed. Trends over time were assessed using the χ² test for trend. Multivariable logistic regressions assessed the relationship between experiences of RDT and recent drug-driving, adjusting for survey year, jurisdiction of residence and socio-demographic and drug use characteristics.

RESULTS

The percentage of participants reporting recent (past six months) drug-driving decreased significantly over time among both samples (PWID: 83% [2007] vs. 74% [2013], p<0.001; RPU: 72% vs. 56%, p<0.001), but drug-driving remained prevalent. Lifetime experience of RDT increased significantly over time (PWID: 6% [2007] vs. 32% [2013], p<0.001; RPU: 2% vs. 11%, p<0.001). There were no significant associations between experiencing RDT and drug-driving among either PWID or RPU.

CONCLUSION

Although there is some evidence that drug-driving among key risk groups of regular drug users is declining in Australia, possibly reflecting a general deterrent effect of RDT, experiencing RDT appears to have no specific deterrent effect on drug-driving. Further intervention, with a particular focus on changing attitudes towards drug-driving, may be needed to further reduce this practice among these groups.

Predominance of alcohol and illicit drugs among traffic accidents fatalities in an urban area of Brazil

OBJECTIVE

The objective of this study was to determine the prevalence of alcohol and illicit drug use among victims of fatal traffic accidents in the Metropolitan Region of Vitória, Brazil, during the period 2011-2012.

METHODS

Blood samples were collected and analyzed for the presence of drugs from 391 deceased victims of traffic crashes that occurred in the Metropolitan Region of Vitória, Brazil. The victims included drivers, passengers, and pedestrians. Sociodemographic variables such as age, gender, day of the week, and period of the year in which the accidents occurred were recorded. The analyses were performed by a gas chromatography-flame ionization method for alcohol and by a gas chromatography-mass spectrometry for amphetamines, cocaine, and cannabis.

RESULTS

The results showed that 44.8% (n = 175) of all cases were positive for alcohol and/or illicit drugs. The detection of alcohol and/or drugs was more frequent in young males, aged 17 to 34, whose samples were positive in 46.8% of cases. Small differences among drivers, passengers, and pedestrians were observed (drivers = 45.9%, passengers = 46.4%, and pedestrians = 45.6%). In general, the most prevalent drug was alcohol, with 141 positive cases (36.1%), followed by cocaine, with 47 positive cases (12%). Amphetamines and cannabis had positivity rates of 4.1 and 4.3%, with 16 and 17 positive cases, respectively. The combined use of alcohol and other drugs was found in 36 cases (9.2%). Crack cocaine use was observed in 27.7% of the positive cases for cocaine.

CONCLUSIONS

For the effective reduction of traffic accidents related to driving under influence of drugs (DUID), we suggest the intensification of enforcement actions against the use of alcohol by drivers, the definition of which illicit drugs should be surveyed, as well the cutoff values, the promotion of changing legislation to oblige drivers to provide samples for toxicological testing, and the establishment of public information programs and specific actions aimed at young drivers to promote behavioral changes.

Blood alcohol analysis alone versus comprehensive toxicological analysis - Systematic investigation of missed co-ingested other drugs in suspected alcohol-impaired drivers

Driving under the influence of alcohol and/or drugs (DUID) is a safety issue of increasing public concern. When a police officer has reasonable grounds to classify a driver as impaired, he may arrange for a blood sample to be taken. In many countries, alcohol analysis only is ordered if impairment is suspected to be exclusively due to alcohol while comprehensive toxicological screening will be performed if additional suspicion for other illegal drugs of abuse (DoA) or medicinal drugs is on hand. The aim of the present study was firstly to evaluate whether signs of impairment can be differentiated to be caused by alcohol alone or a combination of alcohol and other driving-impairing drugs and secondly to which extent additional drugs are missed in suspected alcohol-impaired drivers. A total of 293 DUID cases (negative n=41; alcohol positive only, n=131; alcohol+active drug positive, n=121) analyzed in 2015 in the Canton of Zurich were evaluated for their documented impairment symptoms by translating these into a severity score and comparing them applying principle component analysis (PCA). Additional 500 cases suspected for alcohol-impaired driving only were reanalyzed using comprehensive LC-MS/MS screening methods covering about 1500 compounds. Drugs detected were classified for severity of driving impairment using the classification system established in the DRUID study of the European Commission. As partly expected from the pharmacological and toxicological point of view, PCA analysis revealed no differences between signs of impairment caused by alcohol alone and those caused by alcohol plus at least one active drug. Breaking it down to different blood alcohol concentration ranges, only between 0.3 and 0.5g/kg trends could be observed in terms of more severe impairment for combined alcohol and drug intake. In the 500 blood samples retrospectively analyzed in this study, a total of 330 additional drugs could be detected; in some cases up to 9 co-ingested ones. In total, 37% of all cases were positive for additional drugs, thereby 15% of classic DoAs and further 9% of prescription drugs with a severe risk to cause driving impairment based on the DRUID classification system. A decision whether signs of impairment are related to alcohol alone or to the combination of alcohol and other drugs is impossible. Taking into consideration the high rate of missed drugs in DUI cases, police should think about increasing the number of DUID cases in countries were sanctioning differs between alcohol and alcohol plus drug impaired driving.

Techniques and technologies for the bioanalysis of Sativex®, metabolites and related compounds

Sativex® is an oromucosal spray indicated for the treatment of moderate-to-severe spasticity in multiple sclerosis and is also an effective analgesic for advanced cancer patients. Sativex contains Δ9-tetrahydrocannabinol (THC) and cannabidiol in an approximately 1:1 ratio. The increasing prevalence of medicinal cannabis products highlights the importance of reliable bioanalysis and re-evaluation of the interpretation of positive test results for THC, as legal implications may arise in workplace, roadside and sports drug testing situations. This article summarizes published research on the bioanalysis of THC and cannabidiol, with particular focus on Sativex. Common screening and confirmatory testing of blood, urine, oral fluid and hair samples are outlined. Correlations between matrices and current analytical pitfalls are also addressed.

Prevalence of alcohol and drug use in injured British Columbia drivers

OBJECTIVES

Determine the prevalence of drug use in injured drivers and identify associated demographic factors and crash characteristics.

DESIGN

Prospective cross-sectional study.

SETTING

Seven trauma centres in British Columbia, Canada (2010-2012).

PARTICIPANTS

Automobile drivers who had blood obtained within 6 h of a crash.

MAIN OUTCOME MEASURES

We analysed blood for cannabis, alcohol and other impairing drugs using liquid chromatography/mass spectrometry (LCMS).

RESULTS

1097 drivers met inclusion criteria. 60% were aged 20-50 years, 63.2% were male and 29.0% were admitted to hospital. We found alcohol in 17.8% (15.6% to 20.1%) of drivers. Cannabis was the second most common recreational drug: cannabis metabolites were present in 12.6% (10.7% to 14.7%) of drivers and we detected Δ-9-tetrahydrocannabinol (Δ-9-THC) in 7.3% (5.9% to 9.0%), indicating recent use. Males and drivers aged under 30 years were most likely to use cannabis. We detected cocaine in 2.8% (2.0% to 4.0%) of drivers and amphetamines in 1.2% (0.7% to 2.0%). We also found medications including benzodiazepines (4.0% (2.9% to 5.3%)), antidepressants (6.5% (5.2% to 8.1%)) and diphenhydramine (4.7% (3.5% to 6.2%)). Drivers aged over 50 years and those requiring hospital admission were most likely to have used medications. Overall, 40.1% (37.2% to 43.0%) of drivers tested positive for alcohol or at least one impairing drug and 12.7% (10.7% to 14.7%) tested positive for more than one substance.

CONCLUSIONS

Alcohol, cannabis and a broad range of other impairing drugs are commonly detected in injured drivers. Alcohol is well known to cause crashes, but further research is needed to determine the impact of other drug use, including drug-alcohol and drug-drug combinations, on crash risk. In particular, more work is needed to understand the role of medications in causing crashes to guide driver education programmes and improve public safety.

Cannabinoid Concentrations Detected in Fatal Road Traffic Collision Victims Compared with a Population of Other Postmortem Cases

BACKGROUND

Acute cannabis consumption nearly doubles the risk of motor vehicle collision resulting in injury or death. Limited data have been published regarding the concentrations of cannabinoids associated with fatal road traffic collisions (RTCs), and these have not previously been compared to a population of other postmortem cases.

METHODS

We conducted analysis for cannabinoids [Δ9-tetrahydrocannabinol (THC), 11-hydroxy-THC, 11-nor-THC-9-carboxylic acid, cannabidiol, and cannabinol], drugs, and alcohol on consecutive fatal RTC cases (100) and non-RTC cases (114) from coroners' jurisdictions in London and southeast England and compared the data.

RESULTS

The incidence of cannabinoids detected in non-RTC and RTC cases was similar (25% vs 21%, P = 0.44), but THC was detected more frequently (90% vs 59%, P = 0.01) and at significantly higher concentrations in the cannabinoid-positive RTC cases than the non-RTC cases (P = 0.01). The distribution of non-RTC and RTC cases over 4 categories of THC concentration was significantly different (P = 0.004). There was no significant difference in the concentrations of other cannabinoids detected between the 2 groups. Cannabinoids were detected in more fatal RTC cases (21) than alcohol &gt;80 mg/dL (17). Detection of other drugs was low compared to cannabis and alcohol.

CONCLUSIONS

These first data on the concentrations of cannabinoids in the postmortem blood of fatal RTC victims compared with a population of other routine coroners' cases highlight the importance of specifically measuring THC concentrations in the blood to aid interpretation of postmortem cases where cannabis may be implicated.

Alcohol and Drug Use in Injured Drivers - An Emergency Room Study in a Regional Tertiary Care Centre of North West India

BACKGROUND

Statistics show an increasing proportion of alcohol and drug use in drivers in more recent times throughout the world. It has been found that among the various human factors, alcohol consumption, using drugs and subsequent driving on the roads are major risk factors. Traffic regulations in India penalises drivers who drive beyond permissible alcohol limit of 30 mg%. Consumption of psychoactive drugs such as opioid, cannabis and benzodiazepines has been reported mainly among youngsters. Hardly any data is available in Indian context particularly from North-West Zone of India.

STUDY OBJECTIVE

To study the pattern of alcohol, opioid, cannabis and benzodiazepines use in injured drivers presenting to a designated trauma centre in Chandigarh zone of North-West India.

MATERIALS AND METHODS

Consenting injured drivers who presented to the trauma centre in Chandigarh from September 2013 to January 2014 were included. Urine samples collected from the subjects were screened for abusive drug exposure (opioid, cannabis and benzodiazepines) and alcohol using commercial bedside urine immunoassay kits. In urine alcohol positive cases blood samples were collected and analysed for alcohol concentration using standard gas chromatography. Retrograde extrapolation method was used to assess BAC at the time of accident.

RESULTS

A total of 200 injured drivers were included in this study. We found substance consumption in 54.5% of drivers and alcohol (40.5%) was the most prevalent substance consumed followed by opiates (13%), cannabis (7%) and benzodiazepines (7%). More than one substance was shown in urine of 11.5% of drivers. Among 81 alcohol positive screening cases, the quantitative analysis was successfully done for 76 cases. Except one, all cases showed BAC value more than 30 mg% which is the legal limit for driving any vehicle in India. The values of alcohol concentration in blood at the time of accident were in the range of 20 to 391 mg%.

CONCLUSION

This study has shown that drivers are consuming not only alcohol but other psychoactive drugs also. Indian traffic regulatory authorities are penalising drunk drivers by doing road side breath alcohol testing with no protocols for drug screening. Appropriate measures should be adopted to screen traffic offenders for psychoactive drugs also.

Driving under the influence of alcohol. A 5-year overview in Piedmont, Italy

Alcohol consumption represents a major health issue worldwide and a crucial factor in road accidences. This study provides information on the prevalence of alcohol in blood testing performed on 2752 subjects involved in vehicle accidents, which occurred in Piedmont (northern Italy) between 2008 and 2013. Blood alcohol concentration (BAC) was determined by an ISO 17025 accredited GC/MS procedure. Fifty-one % of positive samples showed BAC concentrations above 1.5 g/L, with a legal cut-off fixed at 0.5 g/L (and 0 g/L for specified categories such as novice and professional drivers). BAC values proved statistically different regarding the day of sampling (week or weekend days), age and gender, with a prevalence of positive results that reflects different drinking habits of a multifaceted population of alcohol consumers.

Smoked cannabis' psychomotor and neurocognitive effects in occasional and frequent smokers

Δ9-Tetrahydrocannabinol (THC), the primary psychoactive constituent in cannabis, impairs psychomotor performance, cognition and driving ability; thus, driving under the influence of cannabis is a public safety concern. We documented cannabis' psychomotor, neurocognitive, subjective and physiological effects in occasional and frequent smokers to investigate potential differences between these smokers. Fourteen frequent (≥4x/week) and 11 occasional (<2x/week) cannabis smokers entered a secure research unit ∼19 h prior to smoking one 6.8% THC cigarette. Cognitive and psychomotor performance was evaluated with the critical tracking (CTT), divided attention (DAT), n-back (working memory) and Balloon Analog Risk (BART) (risk-taking) tasks at -1.75, 1.5, 3.5, 5.5 and 22.5 h after starting smoking. GLM (General Linear Model) repeated measures ANOVA was utilized to compare scores. Occasional smokers had significantly more difficulty compensating for CTT tracking error compared with frequent smokers 1.5 h after smoking. Divided attention performance declined significantly especially in occasional smokers, with session × group effects for tracking error, hits, false alarms and reaction time. Cannabis smoking did not elicit session × group effects on the n-back or BART. Controlled cannabis smoking impaired psychomotor function, more so in occasional smokers, suggesting some tolerance to psychomotor impairment in frequent users. These data have implications for cannabis-associated impairment in driving under the influence of cannabis cases.

Alcohol: Pharmacology and Disposition

Alcohol is the most common drug detected in forensic cases, is often associated with increased aggression and other disinhibitory behaviors in criminal matters, and frequently contributes to the cause of death in medical examiner cases. Significant adverse effects of alcohol generally manifest at blood alcohol concentrations above 100 mg/dL. In postmortem cases, a number of factors can affect the accuracy of the blood measurement, including site of sampling and putrefactive formation. This paper provides an overview of the pharmacology, pharmacokinetics, and interpretation of alcohol and its concentrations in key specimens, with application to forensic medical cases.

Cannabinoids in oral fluid by on-site immunoassay and by GC-MS using two different oral fluid collection devices

Oral fluid (OF) enables non-invasive sample collection for on-site drug testing, but performance of on-site tests with occasional and frequent smokers' OF to identify cannabinoid intake requires further evaluation. Furthermore, as far as we are aware, no studies have evaluated differences between cannabinoid disposition among OF collection devices with authentic OF samples after controlled cannabis administration. Fourteen frequent (≥4 times per week) and 10 occasional (less than twice a week) adult cannabis smokers smoked one 6.8% ∆(9)-tetrahydrocannabinol (THC) cigarette ad libitum over 10 min. OF was collected with the StatSure Saliva Sampler, Oral-Eze, and Draeger DrugTest 5000 test cassette before and up to 30 h after cannabis smoking. Test cassettes were analyzed within 15 min and gas chromatography-mass spectrometry cannabinoid results were obtained within 24 h. Cannabinoid concentrations with the StatSure and Oral-Eze devices were compared and times of last cannabinoid detection (t(last)) and DrugTest 5000 test performance were assessed for different cannabinoid cutoffs. 11-nor-9-Carboxy-THC (THCCOOH) and cannabinol concentrations were significantly higher in Oral-Eze samples than in Stat-Sure samples. DrugTest 5000 t(last) for a positive cannabinoid test were median (range) 12 h (4-24 h) and 21 h (1- ≥ 30 h) for occasional and frequent smokers, respectively. Detection windows in screening and confirmatory tests were usually shorter for occasional than for frequent smokers, especially when including THCCOOH ≥20 ng L(-1) in confirmation criteria. No differences in t(last) were observed between collection devices, except for THC ≥2 μg L(-1). We thus report significantly different THCCOOH and cannabinol, but not THC, concentrations between OF collection devices, which may affect OF data interpretation. The DrugTest 5000 on-site device had high diagnostic sensitivity, specificity, and efficiency for cannabinoids.

Phase I and II Cannabinoid Disposition in Blood and Plasma of Occasional and Frequent Smokers Following Controlled Smoked Cannabis

BACKGROUND

Δ9-Tetrahydrocannabinol (THC), 11-hydroxy-THC (11-OH-THC), and 11-nor-9-carboxy-THC (THCCOOH) have been reported in blood from frequent cannabis smokers for an extended time during abstinence. We compared THC, 11-OH-THC, THCCOOH, cannabidiol, cannabinol, THC-glucuronide, and 11-nor-9-carboxy-THC-glucuronide (THCCOO-glucuronide) blood and plasma disposition in frequent and occasional cannabis smokers.

METHODS

Frequent and occasional smokers resided on a closed research unit and smoked one 6.8% THC cannabis cigarette ad libitum. Blood and plasma cannabinoids were quantified on admission (approximately 19 h before), 1 h before, and up to 15 times (0.5–30 h) after smoking.

RESULTS

Cannabinoid blood and plasma concentrations were significantly higher in frequent smokers compared with occasional smokers at most time points for THC and 11-OH-THC and at all time points for THCCOOH and THCCOO-glucuronide. Cannabidiol, cannabinol, and THC-glucuronide were not significantly different at any time point. Overall blood and plasma cannabinoid concentrations were significantly higher in frequent smokers for THC, 11-OH-THC, THCCOOH, and THCCOO-glucuronide, with and without accounting for baseline concentrations. For blood THC &gt;5 μg/L, median (range) time of last detection was 3.5 h (1.1–&gt;30 h) in frequent smokers and 1.0 h (0–2.1 h) in 11 occasional smokers; 2 individuals had no samples with THC &gt;5 μg/L.

CONCLUSIONS

Cannabis smoking history plays a major role in cannabinoid detection. These differences may impact clinical and impaired driving drug detection. The presence of cannabidiol, cannabinol, or THC-glucuronide indicates recent use, but their absence does not exclude it.

Drug use among drivers who drank on alcohol outlets from Porto Alegre, Brazil

BACKGROUND

Driving under the influence of multiple substances is a public health concern, but there is little epidemiological data about their combined use and putative impact on driving in low and middle-income countries where traffic crashes have been clustering in recent years. The aim of this study is to estimate the prevalence of alcohol and drug use - as well as their associated factors - among drivers in the context of alcohol outlets (AOs).

METHODS

A probability three-stage sample survey was conducted in Porto Alegre, Brazil. Individuals who were leaving AO were screened, with the selection of 683 drivers who met the inclusion criteria. Drivers answered a structured interview, were breathalyzed, and had their saliva collected for drug screening. Prevalences were assessed using domain estimation and logistic regression models assessed covariates associated with substance use.

FINDINGS

Benzodiazepines 3.9% (SE 2.13) and cocaine 3.8% (SE 1.3) were the most frequently detected drugs in saliva. Among drivers who were going to drive, 11% had at least one drug identified by the saliva drug screening, 0.4% two, and 0.1% three drugs in addition to alcohol. In multivariable analyses, having a blood alcohol concentration (BAC)>0.06% was found to be associated with a 3.64 times (CI 95% 1.79-7.39) higher chance of drug detection, compared with interviewees with lower BACs.

CONCLUSIONS

To drive under the influence of multiple substances is likely to be found in this setting, highlighting an association between harmful patterns of consume of alcohol and the misuse of other substances.

Current knowledge on cannabinoids in oral fluid

Oral fluid (OF) is a new biological matrix for clinical and forensic drug testing, offering non-invasive and directly observable sample collection reducing adulteration potential, ease of multiple sample collections, lower biohazard risk during collection, recent exposure identification, and stronger correlation with blood than urine concentrations. Because cannabinoids are usually the most prevalent analytes in illicit drug testing, application of OF drug testing requires sufficient scientific data to support sensitive and specific OF cannabinoid detection. This review presents current knowledge of OF cannabinoids, evaluating pharmacokinetic properties, detection windows, and correlation with other biological matrices and impairment from field applications and controlled drug administration studies. In addition, onsite screening technologies, confirmatory analytical methods, drug stability, and effects of sample collection procedure, adulterants, and passive environmental exposure are reviewed. Delta-9-tetrahydrocannabinol OF concentrations could be >1000 µg/L shortly after smoking, whereas minor cannabinoids are detected at 10-fold and metabolites at 1000-fold lower concentrations. OF research over the past decade demonstrated that appropriate interpretation of test results requires a comprehensive understanding of distinct elimination profiles and detection windows for different cannabinoids, which are influenced by administration route, dose, and drug use history. Thus, each drug testing program should establish cut-off criteria, collection/analysis procedures, and storage conditions tailored to its purposes. Building a scientific basis for OF testing is ongoing, with continuing OF cannabinoids research on passive environmental exposure, drug use history, donor physiological conditions, and oral cavity metabolism needed to better understand mechanisms of cannabinoid OF disposition and expand OF drug testing applicability. Published 2013. This article is a U.S. Government work and is in the public domain in the USA.

In vitro stability of free and glucuronidated cannabinoids in urine following controlled smoked cannabis

Analyte stability is an important factor in urine test interpretation, yet cannabinoid stability data are limited. A comprehensive study of Δ(9)-tetrahydrocannabinol (THC), 11-hydroxy-THC (11-OH-THC), 11-nor-9-carboxy-THC (THCCOOH), cannabidiol, cannabinol, THC-glucuronide, and THCCOOH-glucuronide stabilities in authentic urine was completed. Urine samples after ad libitum cannabis smoking were pooled to prepare low and high pools for each study participant; baseline concentrations were measured within 24 h at room temperature (RT), 4 °C and -20 °C. Stability at RT, 4 °C and -20 °C was evaluated by Friedman tests for up to 1 year. THCCOOH, THC-glucuronide, and THCCOOH-glucuronide were quantified in baseline pools. RT THCCOOH baseline concentrations were significantly higher than -20 °C, but not 4 °C baseline concentrations. After 1 week at RT, THCCOOH increased, THCCOOH-glucuronide decreased, but THC-glucuronide was unchanged. In RT low pool, total THCCOOH (THCCOOH + THCCOOH-glucuronide) was significantly lower after 1 week. At 4 °C, THCCOOH was stable 2 weeks, THCCOOH-glucuronide 1 month and THC-glucuronide for at least 6 months. THCCOOH was stable frozen for 1 year, but 6 months high pool results were significantly higher than baseline; THC-glucuronide and THCCOOH-glucuronide were stable for 6 months. Total THCCOOH was stable 6 months at 4 °C, and frozen 6 months (low) and 1 year (high). THC, cannabidiol and cannabinol were never detected in urine; although not detected initially, 11-OH-THC was detected in 2 low and 3 high pools after 1 week at RT. Substantial THCCOOH-glucuronide deconjugation was observed at RT and 4 °C. Analysis should be conducted within 3 months if non-hydrolyzed THCCOOH or THCCOOH-glucuronide quantification is required.

Oral fluid and plasma 3,4-methylenedioxymethamphetamine (MDMA) and metabolite correlation after controlled oral MDMA administration

Oral fluid (OF) offers a noninvasive sample collection for drug testing. However, 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) in OF has not been adequately characterized in comparison to plasma. We administered oral low-dose (1.0 mg/kg) and high-dose (1.6 mg/kg) MDMA to 26 participants and collected simultaneous OF and plasma specimens for up to 143 h after dosing. We compared OF/plasma (OF/P) ratios, time of initial detection (t first), maximal concentrations (C max), time of peak concentrations (t max), time of last detection (t last), clearance, and 3,4-methylenedioxyamphetamine (MDA)-to-MDMA ratios over time. For OF MDMA and MDA, C max was higher, t last was later, and clearance was slower compared to plasma. For OF MDA only, t first was later compared to plasma. Median (range) OF/P ratios were 5.6 (0.1-52.3) for MDMA and 3.7 (0.7-24.3) for MDA. OF and plasma concentrations were weakly but significantly correlated (MDMA: R(2) = 0.438, MDA: R(2) = 0.197, p < 0.0001). Median OF/P ratios were significantly higher following high dose administration: MDMA low = 5.2 (0.1-40.4), high = 6.0 (0.4-52.3, p < 0.05); MDA low = 3.3 (0.7-17.1), high = 4.1 (0.9-24.3, p < 0.001). There was a large inter-subject variation in OF/P ratios. The MDA/MDMA ratios in plasma were higher than those in OF (p < 0.001), and the MDA/MDMA ratios significantly increased over time in OF and plasma. The MDMA and MDA concentrations were higher in OF than in plasma. OF and plasma concentrations were correlated, but large inter-subject variability precludes the estimation of plasma concentrations from OF.

Comparison of drug concentrations measured in roadside surveys and in seriously injured drivers in Belgium

The objective of this paper is to compare concentrations of alcohol, illicit, and medicinal drugs in seriously injured drivers and drivers selected randomly at the roadside. Blood samples were analyzed for alcohol, 17 medicinal drugs and 8 illicit psychoactive substances and/or their metabolites by ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and gas chromatography mass spectrometry (GC-MS) in injured drivers admitted to the emergency departments of five hospitals in Belgium between January 2008 and May 2010 and in drivers randomly selected between January 2008 and September 2009. Three hundred and seventy-seven seriously injured drivers and 2750 roadside respondents were selected. In the roadside survey, out of the 203 concentrations above DRUID (Driving Under the Influence of Drugs, Alcohol and Medicines) cut-offs for medicinal drugs, 51% were in the therapeutic range, 46% infratherapeutic, and 2.5% supratherapeutic. In the seriously injured drivers, out of the 78 concentrations above DRUID cut-offs for medicinal drugs, these percentages were respectively 63%, 33%, and 4%. Significant differences were found in the distribution of concentrations for opioids, benzodiazepines, and Z-drugs. For the latter, while in the seriously injured drivers study most concentrations were therapeutic, in the roadside survey most were infratherapeutic. The opposite was observed for the opioids. Eight and 41% of the roadside respondents and injured drivers, respectively, had an alcohol concentration above 0.1 g/L, with higher concentrations found in the injured drivers. For illicit drugs, significant differences were found for amphetamine and cocaine, for which respectively lower and higher concentrations were observed in the blood samples taken in the roadside survey.

On-site test for cannabinoids in oral fluid

BACKGROUND

Oral fluid (OF) testing offers noninvasive sample collection for on-site drug testing; however, to date, test performance for Δ(9)-tetrahydrocannabinol (THC) detection has had unacceptable diagnostic sensitivity. On-site tests must accurately identify cannabis exposure because this drug accounts for the highest prevalence in workplace drug testing and driving under the influence of drugs (DUID) programs.

METHODS

Ten cannabis smokers (9 males, 1 female) provided written informed consent to participate in this institutional review board-approved study and smoked 1 6.8%-THC cigarette ad libitum. OF was collected with the Draeger DrugTest(®) 5000 test cassette and Quantisal™ device 0.5 h before and up to 22 h after smoking. Test cassettes were analyzed within 15 min (n = 66), and Quantisal GC-MS THC results obtained within 24 h. Final THC detection times and test performances were assessed at different cannabinoid cutoffs.

RESULTS

Diagnostic sensitivity, diagnostic specificity, and efficiency at DrugTest 5000's 5 μg/L screening cutoff and various THC confirmation cutoffs were 86.2-90.7, 75.0-77.8, and 84.8-87.9%, respectively. Last detection times were >22 h, longer than previously suggested. Confirmation of 11-nor-9-carboxy-THC, absent in THC smoke, minimized the potential for passive OF contamination and still provided 22-h windows of detection, appropriate for workplace drug testing, whereas confirmation of cannabidiol, and/or cannabinol yielded shorter 6-h windows of detection, appropriate for DUID OF testing.

CONCLUSIONS

The DrugTest 5000 on-site device provided high diagnostic sensitivity for detection of cannabinoid exposure, and the selection of OF confirmation analytes and cutoffs provided appropriate windows of detection to meet the goals of different drug testing programs.