Prevalence of alcohol and illicit drugs in blood specimens from drivers involved in traffic law offenses. Systematic review of cross-sectional studies

Prevalence of alcohol and other drug use in patients presenting to hospital for fall-related injuries: a systematic review

BACKGROUND

Alcohol and other drug (AOD) use is a key preventable risk factor for serious injuries. Prevention strategies to date have largely focused on transport injuries, despite AOD use being a significant risk factor for other injury causes, including falls. This systematic review aimed to report the prevalence of AOD use in patients presenting to hospital for fall-related injuries.

METHODS

This systematic review includes studies published in English after the year 2010 that objectively measured the prevalence of AOD use in patients presenting to hospital for a fall-related injury. Screening, data extraction and risk of bias assessments were completed by two independent reviewers. Data were presented using narrative synthesis and, where appropriate, meta-analyses.

RESULTS

A total of 12 707 records were screened. Full texts were retrieved for 2042 records, of which 29 were included. Four studies reported the combined prevalence of any alcohol and/or drug use, generating a pooled prevalence estimate of 37% (95% CI 25% to 49%). Twenty-two records reported on the prevalence of acute alcohol use alone and nine reported specifically on the prevalence of drugs other than alcohol, with prevalence ranging from 2% to 57% and 7% to 46%, respectively. The variation in prevalence estimates likely resulted from differences in toxicology testing methods across studies.

CONCLUSIONS

AOD exposure was common in hospitalised fall-related injuries. However, research addressing prevalence across different types of falls and the use of drugs other than alcohol was limited. Future research should address these areas to improve our understanding of which populations should be targeted in AOD and injury prevention strategies .

PROSPERO REGISTRATION NUMBER

CRD42020188746.

Minor Injury Crashes: Prevalence of Driver-Related Risk Factors and Outcome

BACKGROUND

The majority of crashes cause "minor" injuries (i.e., treated and released from the emergency department [ED]). Minor injury crashes are poorly studied.

OBJECTIVES

This study aims to determine the prevalence of driver-related risk factors and subsequent outcome in drivers involved in minor crashes.

METHODS

We interviewed a convenience sample of injured drivers, aged over 17 years, who were treated and released from the ED. Follow-up interviews were conducted 6 months after the crash.

RESULTS

We approached 123 injured drivers; baseline interviews were completed in 69 and follow-up interviews in 45. Prior to the index crash, 1.4% of drivers drank alcohol, 1.4% used illicit drugs, and 7.2% used sedating prescription medications. Nine drivers (13%) were distracted. In this sample, 5.8% met criteria for being aggressive drivers, 7.2% were risky drivers, and 11.6% drove while experiencing negative emotions. At 6-month follow-up, many drivers were still having health problems, 53.3% were not fully recovered, 46.7% had not returned to usual activities, and 28.9% were off work. Of the 42 participants who resumed driving, 16.7% had a near miss and 4.8% had another crash. Nine (21.4%) reported drinking and driving, and 9.5% reported driving after cannabis use. Cell phone use (16.7%) and use of other electronics while driving (23.8%) were also common.

CONCLUSIONS

Driver-related risk factors are common in drivers involved in minor injury crashes, and drivers persist in taking risks after being involved in a crash. Despite their name, minor injury crashes are often associated with slow recovery and prolonged absenteeism from work.

The efficacy of electroencephalogram neurofeedback training in cognition, anxiety, and depression in alcohol dependence syndrome: A case study

Electroencephalogram (EEG) neurofeedback's efficacy in reducing the symptoms of patients with alcohol dependence syndrome is well-documented in previous literature. Here, a case is being described who presented with alcohol dependence syndrome was given EEG neurofeedback training. After 10 sessions of EEG neurofeedback training program, a significant reduction was found in the cognitive deficits, anxiety, and depression of the patient. Furthermore, noticeable improvement was found in his memory and neurological functioning. He also showed a significant reduction in his alcohol intake on follow-up.

Alcohol calibration of tests measuring skills related to car driving

RATIONALE

Medication and illicit drugs can have detrimental side effects which impair driving performance. A drug's impairing potential should be determined by well-validated, reliable, and sensitive tests and ideally be calibrated by benchmark drugs and doses. To date, no consensus has been reached on the issue of which psychometric tests are best suited for initial screening of a drug's driving impairment potential.

OBJECTIVE

The aim of this alcohol calibration study is to determine which performance tests are useful to measure drug-induced impairment. The effects of alcohol are used to compare the psychometric quality between tests and as benchmark to quantify performance changes in each test associated with potentially impairing drug effects.

METHODS

Twenty-four healthy volunteers participated in a double-blind, four-way crossover study. Treatments were placebo and three different doses of alcohol leading to blood alcohol concentrations (BACs) of 0.2, 0.5, and 0.8 g/L.

RESULTS

Main effects of alcohol were found in most tests. Compared with placebo, performance in the Divided Attention Test (DAT) was significantly impaired after all alcohol doses and performance in the Psychomotor Vigilance Test (PVT) and the Balance Test was impaired with a BAC of 0.5 and 0.8 g/L. The largest effect sizes were found on postural balance with eyes open and mean reaction time in the divided attention and the psychomotor vigilance test.

CONCLUSIONS

The preferable tests for initial screening are the DAT and the PVT, as these tests were most sensitive to the impairing effects of alcohol and being considerably valid in assessing potential driving impairment.

Population drinking and drink driving in Norway and Sweden: an analysis of historical data 1957-89

AIM

Research suggests an association between population drinking and a large number of outcomes. However, driving while under the influence of alcohol (DWI) is conspicuously absent from this list of outcomes. The aim of this study was to estimate the relation between DWI and total consumption of alcohol on annual time-series data for Norway and Sweden. DESIGN, SETTING, AND MEASUREMENTS: For Norway, we used data on convictions for DWI per 100 000 inhabitants (aged 15-69 years). The DWI proxy for Sweden comprised the proportion (%) of all police-reported traffic accidents with personal injuries where the driver was under the influence of alcohol. Data on total alcohol sales in litres of pure alcohol per inhabitant (aged 15 years and older) were used as proxy for total alcohol consumption. We focused on the period 1957-89, during which the legislation concerning DWI remained unchanged in Norway as well as in Sweden. The statistical analyses were based on co-integrated models.

FINDINGS

The estimates of the association between DWI and per capita alcohol consumption were strongly significant in Norway as well as in Sweden. For Norway, the estimated elasticity equalled 2 (P < 0.001) and for Sweden 1.5 (P < 0.001).

CONCLUSIONS

In Norway and Sweden, as total population level of alcohol consumption increases or decreases so does the incidence of driving while intoxicated.

Drugs related to motor vehicle crashes in northern European countries: a study of fatally injured drivers

The aim of this study was to find which drugs and drug combinations were most common in drivers who died, in particular, in single vehicle crashes where the responsibility for the crash would be referred to the driver killed. The study included all available blood samples from drivers, who died within 24h of the accident, in the years 2001 and 2002 in the five Nordic countries (total population about 24 million inhabitants). The samples were analysed for more than 200 different drugs in addition to alcohol, using a similar analytical programme and cut-off limits in all countries. In three countries (Finland, Norway and Sweden) blood samples were available for more than 70% of the drivers, allowing representative prevalence data to be collected. 60% of the drivers in single vehicle crashes had alcohol and/or drug in their blood samples, compared with 30% of drivers killed in collisions with other vehicles. In single vehicle accidents, 66% of the drivers under 30 years of age had alcohol and/or drugs in their blood (alcohol only - 40%; drugs only - 12%; alcohol and drugs - 14%). The drugs found were mostly illicit drugs and psychoactive medicinal drugs with warning labels (in 57% and 58% respectively of the drivers under 30 with drugs present). Similar findings were obtained for drivers 30-49 years of age (63% with alcohol and/or drugs). In drivers aged 50 years and above, killed in single vehicle crashes (48% with alcohol and/or drugs) illicit drugs were found in only one case, and psychoactive medicinal drugs were detected less frequently than in younger age groups. In 75% of single vehicle crashes, the driver was under 50 years. Thus, the majority of accidents where the drivers must be considered responsible, occurred with drivers who had recently used alcohol, or drugs, alone or in combination. The drugs involved were often illicit and/or psychoactive drugs with warning labels. Therefore a large proportion of single vehicle accidents appear to be preventable, if more effective measures against driving after intake of alcohol and drugs can be implemented.

Postmortem redistribution of Δ9-tetrahydrocannabinol (THC), 11-hydroxy-THC (11-OH-THC), and 11-nor-9-carboxy-THC (THCCOOH)

INTRODUCTION

Postmortem redistribution (PMR), a well-described phenomenon in forensic toxicology for certain drugs, can result in increased central blood concentrations relative to peripheral blood concentrations. Δ(9)-tetrahydrocannabinol (THC), the primary psychoactive component in cannabis or marijuana, is the illicit substance most commonly implicated in driving under the influence of drugs (DUID) cases and fatally-injured drivers. No investigation of PMR of THC in human blood has been reported to date.

METHODS

Matched heart and iliac postmortem blood specimens were collected from 19 medical examiner cases (16 Males, 3 Females) with positive cannabinoid urine immunoassay screens. THC, its equipotent metabolite 11-hydroxy-THC (11-OH-THC) and non-psychoactive metabolite 11-nor-9-carboxy-THC (THCCOOH) were quantified by two-dimensional gas chromatography-mass spectrometry with cryofocusing, with 0.5 ng/mL limits of quantification (LOQ) for all analytes.

RESULTS

10 cases had quantifiable THC and 11-OH-THC; THCCOOH was present in all 19. Median (range) heart:iliac blood ratios were 1.5 for THC (range: 0.3-3.1); 1.6 for 11-OH-THC (range: 0.3-2.7); and 1.8 for THCCOOH (range: 0.5-3.0).

DISCUSSION

Cannabinoids, in general, exhibited a mean and median central:peripheral (C:P) concentration ratio of less than 2 following death. A trend was observed for greater PMR with increasing postmortem interval between death and sampling. To our knowledge, these are the first data on THC PMR in humans, providing important scientific data to aid in the interpretation of postmortem cannabinoid concentrations in medico-legal investigations.

Toxicological investigations of drivers killed in road traffic accidents in Norway during 2006-2008

AIM

To study the results from the toxicological investigations of drivers of cars and vans who were fatally injured in road traffic accidents in 2006-2008 and discuss the findings in relation to the proposed legal limits and impairment thresholds for drugs.

METHODS

Analyses for alcohol, illegal drugs and psychoactive medicinal drugs were performed by the Norwegian Institute of Public Health. Information on type of accident (single or multiple vehicles) and type of road (urban or rural) was obtained from Statistics Norway.

RESULTS

Toxicological analyses were requested for 59% of the fatally injured drivers. Drivers involved in single vehicle accidents were more often subject to toxicological investigations, so were also young male drivers and drivers killed on urban roads. Alcohol or drugs were found in concentrations above the current (for alcohol) or proposed (for drugs) legal limits in samples from 37.8% of the drivers; from 64.3% those killed in single-vehicle accidents and 17.9% of those killed in multiple-vehicle accidents. In total, alcohol was found in 25.0%, illicit drugs in 10.2%, and psychoactive medicinal drugs in 13.8% of the samples. Combinations of alcohol and drugs were found in 5.1% and multiple drugs without alcohol in 6.1% of the samples. The prevalence of alcohol or drugs was higher in samples from males than females, higher in samples from young drivers, and higher in samples from drivers killed during weekends. Two thirds of the drivers with alcohol or drug concentrations above the current or proposed legal limits had concentrations above the proposed high impairment threshold. About 60% of the latter ones were impaired by alcohol only, 20% by drugs in combination with alcohol, and 20% by drugs only, mainly due to multi-drug use.

CONCLUSION

The use of alcohol or drugs before driving was a significant contributing factor in fatal road traffic accidents, particularly in single vehicle accidents, and particularly among young male drivers. Alcohol was the most significant intoxicant, but multi-substance use was also significantly prevalent. The majority of the drivers with alcohol or drug findings were strongly impaired.

Alcohol, psychoactive drugs and fatal road traffic accidents in Norway: a case-control study

A case-control study was conducted on 204 drivers fatally injured in road traffic accidents in south-eastern Norway during the period 2003-2008. Cases from single vehicle accidents (N = 68) were assessed separately. As controls, 10540 drivers selected in a roadside survey in the same geographical area during 2005-2006 were used. Blood samples were collected from the cases and oral fluid (saliva) samples from the controls. Samples were analysed for alcohol, amphetamines, cannabis, cocaine, opioid analgesics, hypnotics, sedatives and a muscle relaxant; altogether 22 psychoactive substances. Equivalent cutoff concentrations for blood and oral fluid were used. The risk for fatal injury in a road traffic accident was estimated using logistic regression adjusting for gender, age, season of the year, and time of the week. The odds for involvement in fatal road traffic accidents for different substances or combination of substances were in increasing order: single drug < multiple drugs < alcohol only < alcohol+drugs. For single substance use: medicinal drug or THC < amphetamine/methamphetamine < alcohol. For most substances, higher ORs were found when studying drivers involved in single vehicle accidents than for those involved in multiple vehicle accidents, but confidence intervals were wider.

First nationwide study on driving under the influence of drugs in Switzerland

In Switzerland, a two-tier system based on impairment by any psychoactive substances which affect the capacity to drive safely and zero tolerance for certain illicit drugs came into force on 1 January 2005. According to the new legislation, the offender is sanctioned if Delta(9)-tetrahydrocannabinol THC is >or=1.5ng/ml or amphetamine, methamphetamine, 3,4-methylenedioxymethamphetamine (MDMA), 3,4-methylenedioxyethylamphetamine (MDEA), cocaine, free morphine are >or=15ng/ml in whole blood (confidence interval+/-30%). For all other psychoactive substances, impairment must be proven in applying the so-called "three pillars expertise". At the same time the legal blood alcohol concentration (BAC) limit for driving was lowered from 0.80 to 0.50g/kg. The purpose of this study was to analyze the prevalence of drugs in the first year after the introduction of the revision of the Swiss Traffic Law in the population of drivers suspected of driving under the influence of drugs (DUID). A database was developed to collect the data from all DUID cases submitted by the police or the Justice to the eight Swiss authorized laboratories between January and December 2005. Data collected were anonymous and included the age, gender, date and time of the event, the type of vehicle, the circumstances, the sampling time and the results of all the performed toxicological analyses. The focus was explicitly on DUID; cases of drivers who were suspected to be under the influence of ethanol only were not considered. The final study population included 4794 DUID offenders (4243 males, 543 females). The mean age of all drivers was 31+/-12 years (range 14-92 years). One or more psychoactive drugs were detected in 89% of all analyzed blood samples. In 11% (N=530) of the samples, neither alcohol nor drugs were present. The most frequently encountered drugs in whole blood were cannabinoids (48% of total number of cases), ethanol (35%), cocaine (25%), opiates (10%), amphetamines (7%), benzodiazepines (6%) and methadone (5%). Other medicinal drugs such as antidepressants and benzodiazepine-like were detected less frequently. Poly-drug use was prevalent but it may be underestimated because the laboratories do not always analyze all drugs in a blood sample. This first Swiss study points out that DUID is a serious problem on the roads in Switzerland. Further investigations will show if this situation has changed in the following years.

Alcohol and drugs in fatally and non-fatally injured motor vehicle drivers in northern Sweden

Alcohol and drugs are important risk factors for traffic injuries, a major health problem worldwide. This prospective study investigated the epidemiology and the presence of alcohol and drugs in fatally and hospitalized non-fatally injured drivers of motor vehicles in northern Sweden. During a 2-year study period, blood from fatally and hospitalized non-fatally injured drivers was tested for alcohol and drugs. The study subjects were recruited from well-defined geographical areas with known demographics. Autopsy reports, medical journals, police reports, and toxicological analyses were evaluated. Of the fatally injured, 38% tested positive for alcohol and of the non-fatally 21% tested positive; 7% and 13%, respectively, tested positive for pharmaceuticals with a warning for impaired driving; 9% and 4%, respectively, tested positive for illicit drugs. The most frequently detected pharmaceuticals were benzodiazepines, opiates, and antidepressants. Tetrahydrocannabinol was the most frequently detected illicit substance. No fatally injured women had illegal blood alcohol concentration. The relative proportion of positively tested drivers has increased and was higher than in a similar study 14 years earlier. This finding indicates that alcohol and drugs merit more attention in future traffic safety work.

Trends in driving under the influence of drugs: a register-based study of DUID suspects during 1977-2007

Our aim was to describe the incidence and trends of driving under the influence of drugs (DUID) and to examine the main drug findings and their trends in suspected DUID cases in Finland. A register-based study was conducted of all suspected DUID cases during 1977-2007. The data included 31,963 DUID offenders apprehended by the police with a positive finding for illicit/licit drug impairing driving performance. Toxicological results were analyzed in blood and/or urine specimens in one central laboratory. The incidence of suspected DUID cases increased 18-fold during 1977-2007. Most of the suspects were men (89.7%). However, the male-female ratio decreased from 13.9 to 7.3. The mean age decreased from 36.2 years in 1977 to 29.9 years in 2001 but has since reincreased. Most often found substances were benzodiazepines (75.7%), amphetamines (46.0%), cannabinoids (27.7%) and opioids (13.8%). Most common illicit drugs, amphetamines and cannabinoids, started to appear at the end of the 1980s. Poly-drug findings were common (77.1%). Suspected DUID cases have increased sharply after the introduction of a zero tolerance law, especially in regard to amphetamines. DUID is an increasing problem in Finland, and needs serious attention.

Driving under the influence of cannabis: a 10-year study of age and gender differences in the concentrations of tetrahydrocannabinol in blood

BACKGROUND

Delta(9)-Tetrahydrocannabinol (THC) is the major psychoactive constituent of cannabis and its various preparations. Increasing use of cannabis for recreational purposes has created a problem for road-traffic safety. This paper compares age, gender and the concentrations of THC in blood of individuals apprehended for driving under the influence of drugs (DUID) in Sweden, where a zero-tolerance law operates.

MEASUREMENTS

Specimens of blood or urine were subjected to a broad screening analysis by enzyme immunoassay methods. THC positives were verified by analysis of blood by gas chromatography-mass spectrometry (GC-MS) with a deuterium-labelled internal standard (d(3)-THC). All toxicology results were entered into a database (TOXBASE) along with the age and gender of apprehended drivers.

FINDINGS

Over a 10-year period (1995-2004), between 18% and 30% of all DUID suspects had measurable amounts of THC in their blood (> 0.3 ng/ml) either alone or together with other drugs. The mean age [+/- standard deviation (SD)] of cannabis users was 33 +/- 9.4 years (range 15-66 years), with a strong predominance of men (94%, P < 0.001). The frequency distribution of THC concentrations (n = 8794) was skewed markedly to the right with mean, median and highest values of 2.1 ng/ml, 1.0 ng/ml and 67 ng/ml, respectively. The THC concentration was less than 1.0 ng/ml in 43% of cases and below 2.0 ng/ml in 61% of cases. The age of offenders was not correlated with the concentration of THC in blood (r = -0.027, P > 0.05). THC concentrations in blood were higher when this was the only psychoactive substance present (n = 1276); mean 3.6 ng/ml, median 2.0 ng/ml compared with multi-drug users; mean 1.8 ng/ml, median 1.0 ng/ml (P < 0.001). In cases with THC as the only drug present the concentration was less than 1.0 ng/ml in 26% and below 2.0 ng/ml in 41% of cases. The high prevalence of men, the average age and the concentrations of THC in blood were similar in users of illicit drugs (non-traffic cases).

CONCLUSIONS

The concentration of THC in blood at the time of driving is probably a great deal higher than at the time of sampling (30-90 minutes later). The notion of enacting science-based concentration limits of THC in blood (e.g. 3-5 ng/ml), as discussed in some quarters, would result in many individuals evading prosecution. Zero-tolerance or limit of quantitation laws are a much more pragmatic way to enforce DUID legislation.

Concentrations of cocaine and its major metabolite benzoylecgonine in blood samples from apprehended drivers in Sweden

Cocaine and its major metabolite benzoylecgonine (BZE) were determined in blood samples from people arrested in Sweden for driving under the influence of drugs (DUID) over a 5-year period (2000-2004). Venous blood or urine if available, was subjected to a broad toxicological screening analysis for cannabis, cocaine metabolite, amphetamines, opiates and the major benzodiazepines. Verification and quantitative analysis of cocaine and BZE in blood was done by gas chromatography-mass spectrometry (GC-MS) at limits of quantitation (LOQ) of 0.02mg/L for both substances. Over the study period 26,567 blood samples were analyzed and cocaine and/or BZE were verified in 795 cases (3%). The motorists using cocaine were predominantly men (>96%) with an average age of 28.3+/-7.1 years (+/-standard deviation, S.D.). The concentration of cocaine was below LOQ in 574 cases although BZE was determined at mean, median and highest concentrations of 0.19mg/L, 0.12mg/L and 1.3mg/L, respectively. In 221 cases, cocaine and BZE were together in the blood samples at mean and (median) concentrations of 0.076mg/L (0.05mg/L) and 0.859mg/L (0.70mg/L), respectively. The concentrations of BZE were always higher than the parent drug; mean BZE/cocaine ratio 14.2 (median 10.9) range 1-55. Cocaine and BZE were the only psychoactive substances reported in N=61 cases at mean (median) and highest concentrations of 0.095 (0.07) and 0.5mg/L for cocaine and 1.01 (0.70) and 3.1mg/L for BZE. Typical signs of drug influence noted by the arresting police officers included bloodshot and glossy eyes, agitation, difficulty in sitting still and incoherent speech.