Sedative-hypnotics are widely abused by drivers apprehended for driving under the influence of drugs

Driving under the influence of drugs: Correlation between blood psychoactive drug concentrations and cognitive impairment. A narrative review taking into account forensic issues

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.

Alcohol and drug consumption among motor vehicle drivers in the Brittany region of France: A 9-year cross-sectional population study

The primary objective of the present study was to evaluate the frequency of positive tests for alcohol and drugs during roadside testing or after road accidents among drivers in the Brittany region of France. The study’s secondary objective was to describe the blood concentrations of the substances found during these tests, in order to provide a scientific basis for the establishment or modification of legislative threshold values for road injuries prevention. We performed a cross-sectional study of a database compiled by Rennes University Hospital’s toxicology laboratory in the Brittany region of France between 2010 and 2018. Driver’s age, sex, and test status (positive or negative), and blood levels of ethanol, 9-tetrahydrocannabinol (THC), methylene dioxymethamphetamine (MDMA), amphetamine, benzoylecgonine and 6-monoacetylmorphine (6-MAM) were collected. Twelve thousand four hundred and ninety-seven drivers (males: 86.1%; median (range) age: 29 (15–94)) have provided roadside blood samples, giving a total of 25,998 test results. Among the 10,996 drivers with at least one positive test, the median blood concentrations of ethanol, THC, MDMA, amphetamine, benzoylecgonine, and 6-MAM were respectively 1.82 g/L, 2.41 ng/mL, 138.4 ng/mL, 67.7 ng/mL, 173.3 ng/mL, and 0.97 ng/mL. 1159 (10.54%) of the 10,996 drivers tested positive for two or more substances, and 151 (1.4%) tested positive for three or more substances. With the exception of heroin, the currently recommended threshold values appear to be appropriate for road injuries prevention with regard to the concentrations observed in offenders.

Driving performance assessments for benzodiazepine receptor agonist-related impairment: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify, map, and characterize the evidence for assessments that measure driving performance in people taking benzodiazepine receptor agonists.

INTRODUCTION

Benzodiazepines and Z-drugs are widely prescribed for the treatment of anxiety disorders and insomnia even though they are not recommended as an initial treatment for these indications. Benzodiazepine and Z-drug use is associated with an elevated risk of traffic accidents, and guidance documents instruct patients to consult with their health care providers for instructions on how to safely operate a motor vehicle while consuming these medications. However, little is known about the assessments that measure driving performance regarding the extent and length of impairment from the consumption of the individual benzodiazepines and Z-drugs.

INCLUSION CRITERIA

Eligible studies will include participants who are new, intermittent, or chronic users of benzodiazepines and Z-drugs. No exclusions will be applied regarding the health status of participants or whether their benzodiazepine and Z-drug use is for an approved indication as indicated by government agencies (eg, Health Canada) or practice guidelines. Studies that examine the consumption of a benzodiazepine and Z-drug in association with the operation of a motor vehicle (real or simulated) with direct or indirect objective or standard subjective measures or indicators of impairment while operating a motor vehicle will be considered.

METHODS

Embase (Elsevier), MEDLINE (Ovid), and PsycINFO (EBSCO) will be searched as sources of published studies. Only studies published in English will be included, and there will be no limit on dates of publication. After screening the titles and abstracts of identified citations, two independent reviewers will retrieve potentially relevant full-text studies and extract data. Data will be presented in diagrammatic or tabular form accompanied by a narrative summary.

Alcohol and illicit drugs in drivers involved in road traffic crashes in Italy. An 8-year retrospective study

This study aims to investigate the prevalence of alcohol and drugs of abuse in Italian drivers involved in road traffic crashes between 2011 and 2018. Toxicological analyses were performed on the whole blood of 7593 injured drivers. Alcohol and illicit drugs, namely tetrahydrocannabinol (THC; cut-off 2ng/ml), cocaine (cut-off 10ng/ml), illicit opiates (cut-off 10ng/ml) and amphetamines (amphetamine, methamphetamine, MDMA, MDA; cut-off 20ng/ml) were investigated. The age and gender of the driver, the time of the crash (weekend/weekday and day/night), the road crash year and Blood Alcohol Concentration (BAC) were also considered. The 16.2% of samples tested positive for alcohol, 2.5% for cocaine, followed by opiates (2.0%), cannabinoids (1.5%), and amphetamines (0.5%). The overall prevalence of alcohol and drugs was lower than those reported in previous epidemiological studies of the DRUID project. The year 2011 showed the highest prevalence of drug-positive cases (24.1%), while the lowest prevalence was found in 2016 (16.8%), after the update of the Road Traffic Law (RTL) that increased punishments for driving under the influence. A progressive increase in the number of alcohol-positive female drivers was observed from 2011 to 2018, and the highest prevalence was found in the 26-35-year-old age range. Illicit drugs showed the highest overall prevalence in drivers <26 years of age but, if considering single drugs, cocaine and opiates were mostly found in subjects older than 36 years of age. A higher percentage of drug-positive drivers was found on weekend nights for alcohol and on both weekend and weekday nights for drugs. The types of drugs used by drivers did not change during the studied period.

A review of drug abuse in recently reported cases of driving under the influence of drugs (DUID) in Asia, USA, and Europe

Driving Under the Influence of Drugs (DUID) is considered a serious issue related to the abuse of illegal drugs. DUID cases, including deaths, are being continuously reported in Asia, USA, and Europe. This literature review focuses on illegal drug abuse in recent DUID cases reported in Asia, USA, and Europe. To determine illegal drug abuse in DUID suspects, previous studies collected and analyzed biological samples, such as blood, urine, oral fluids, and hair. In addition, there were forensic autopsies and surveys for investigation of illegal drugs in DUID cases and drivers. In previous studies, ketamine, morphine, methamphetamine (MA), and khat were mainly reported in Asia, whereas amphetamine, benzodiazepines (BZDs), and cannabinoids were mainly reported in USA, and synthetic cannabinoids (SCs), opiates, and cocaine were mainly reported in Europe. Since DUID suspects related to illegal drugs have been frequently reported in Asia, USA, and Europe, there is a need to plan for national monitoring for drivers or motor vehicles to regulate and prevent drug abuse and relevant DUID cases.

Benzodiazepines and Z-Drugs: An Updated Review of Major Adverse Outcomes Reported on in Epidemiologic Research

Various adverse events resulting from, or associated with, benzodiazepine and/or Z-drug use have been extensively reported on and discussed in great detail within the biomedical literature. It is widely accepted that motor vehicle accidents and falls leading to fractures in older adults are major adverse events that have been shown to occur more frequently in users of sedative-hypnotic medication, especially of the benzodiazepine and related Z-drug variety. However, the last few years have seen increasing reports in the literature raising the issue of benzodiazepine and Z-drug exposure in the development of other serious medical issues including dementia, infections, respiratory disease exacerbation, pancreatitis, and cancer. This article provides an overview and interpretation on the current state of evidence regarding each of these associations and proposes what gaps in the evidence for drug-exposure–harm associations need to be addressed in the future for the purpose of evaluating causality of harm as it relates to these drugs.

LC-MS-MS with Post-Column Reagent Addition for the Determination of Zolpidem and its Metabolite Zolpidem Phenyl-4-carboxylic Acid in Oral Fluid after a Single Dose

A rapid, selective and sensitive LC-MS-MS method with a post-column addition of acetonitrile was developed and fully validated for the quantitative determination of zolpidem and its major metabolite, zolpidem phenyl-4-carboxylic acid (ZPCA), in oral fluid. Preliminary sample treatment was limited to a simple dilution of 1 mL oral fluid specimen aliquots with methanol. Chromatography was performed on a Capcell Pak C18 MGII column (250 × 2.0 mm, 5 μm i.d., Shiseido, Tokyo, Japan) with isocratic elution using a water-acetonitrile mobile phase with 0.1% formic acid, 5% acetonitrile and 20 mM ammonium acetate in an aqueous phase at a flow rate of 0.4 mL/min. Acetonitrile was added post-column at a flow rate of 0.4 mL/min to enhance ionization of the analytes in the MS source. Detection was carried out on a QTrapTM 6500 mass spectrometer in positive ionization mode. Good linearities were generated over the range of 0.05-200 ng/mL for zolpidem and 0.1-200 ng/mL for ZPCA. Limit of detection for zolpidem and ZPCA were 0.01 ng/mL and 0.05 ng/mL, respectively, whereas LLOQs were 0.05 ng/mL and 0.1 ng/mL, respectively. This method meets the required criteria for bioanalytical analyses to be used for clinical and forensic purposes. Application of this method was demonstrated by testing authentic samples collected after a single oral dose to obtain insights into the general detectability and detection windows of zolpidem and ZPCA in oral fluid.

Impact of Expanding ELISA Screening in DUID Investigations to Include Carisoprodol/Meprobamate and Zolpidem

In 2013, the National Safety Council's Alcohol Drugs and Impairment Division added zolpidem and carisoprodol and its metabolite meprobamate to the list of Tier 1 drugs that should be tested for in all suspected drug impaired driving and motor vehicle fatality investigations. We describe the validation of an enzyme linked immunosorbent assays (ELISA) for both drugs in whole blood, and the utilization of the ELISA to assess their positivity in a sample of 322 suspected impaired driving cases that was retrospectively screened using the validated assays. The occurrence of carisoprodol/meprobamate was found to be 1.2%, and for zolpidem, 1.6%. In addition, we analyzed a large dataset (n = 1,672) of Driving Under the Influence of Drugs (DUID) test results from a laboratory performing high volume DUID testing to assess the frequency of detection of both drugs after implementing the expanded NSC scope. Carisoprodol or meprobamate were found positive in 5.9% (n = 99) of these samples, while zolpidem was found positive in 5.3% (n = 89) in drivers who in many cases had been found to be negative for other drugs. Carisoprodol and zolpidem are both potent CNS depressants and are appropriate additions to the recommended NSC scope of testing.

Risk factors associated with benzodiazepine use among people who inject drugs in an urban Canadian setting

BACKGROUND

Though known to have abuse potential, benzodiazepine medications remain widely prescribed. Furthermore, issues related to benzodiazepine use by people who inject drugs (PWID) remain to be fully characterized. We therefore sought to examine the prevalence of and risk factors associated with benzodiazepine use in a street-involved urban population.

METHODS

Between May 1996 and November 2013, data were derived from two open prospective cohort studies in Vancouver, Canada, restricted to PWID. Multivariable logistic regression with generalized estimating equations (GEE) was used to determine factors independently associated with benzodiazepine use.

RESULTS

Over the study period, 2806 individuals were recruited, including 949 (34%) women. Of these, 1080 (38.5%) participants reported benzodiazepine use at least once during the study period. In the multivariable analysis, Caucasian ethnicity, ≥ daily heroin injection, ≥ daily cocaine injection, non-fatal overdose, incarceration, syringe sharing, and unsafe sex were all independently associated with benzodiazepine use. Conversely, older age, homelessness, and ≥ daily crack smoking were negatively associated with benzodiazepine use.

CONCLUSIONS

Use of benzodiazepines was common in this urban setting and was associated with several markers of addiction severity and significant health and social vulnerabilities including syringe sharing and unsafe sex. These findings underscore the need to promote treatment for benzodiazepine use, safer benzodiazepine prescribing, including greater recognition of the limited indications for evidence-based use of this medication class.

The use of psychoactive prescription drugs among DUI suspects

BACKGROUND

The study seeks to increase understanding of the use of psychoactive prescription drugs among persons suspected of driving under the influence (DUI). We studied whether the use of prescribed psychoactive medication was associated with DUI, and examined the difference in the use of prescription drugs between DUI recidivists and those arrested only once.

METHODS

In this register-based study, persons suspected of DUI (n=29470) were drawn from the Register of DUI suspects, and an age- and gender-matched reference population (n=30043) was drawn from the Finnish general population. Data on prescription drug use was obtained by linkage to the National Prescription Register. The associations of DUI arrest and use of psychoactive prescription drugs in different DUI groups (findings for alcohol only, prescription drugs, prescription drugs and alcohol, illicit drugs) were estimated by using mixed-effect logistic regression.

RESULTS

The use of psychoactive prescription drugs and DUI appeared to be strongly associated, with DUI suspects significantly more likely to use psychoactive prescription drugs compared to the reference population. Gender differences existed, with the use of benzodiazepines being more common among female DUI suspects. Moreover, DUI recidivists were more likely to use psychoactive prescription drugs compared to those arrested only once.

CONCLUSIONS

In addition to alcohol and/or illicit drug use, a significant proportion of DUI suspects were using psychoactive prescription drugs. When prescribing psychoactive medication, especially benzodiazepines, physicians are challenged to screen for possible substance use problems and also to monitor for patients' alcohol or illicit drug use while being medicated.