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

OBJECTIVE: To determine which is the reported prevalence of alcohol and illicit drugs in blood specimens from drivers involved in traffic law offenses worldwide. METHODS: The search was performed by using several international biomedical databases. In order to reduce publication bias, additional publications were identified using further sources of information. The present review includes cross-sectional studies published between 1990 and 2005 in English, Spanish, German, Portuguese, and Italian. Only studies based on the analysis of blood specimens and chromatographic quantification of drugs were included. RESULTS: Forty-nine studies fulfilled the inclusion criteria. Eighteen were excluded considering practical reasons regarding limitations for a reliable interpretation of their results. Alcohol appears to be still the predominant substance, with the consideration that among drivers primarily suspected of DUID, cannabinoids are more prevalent. Among the illicit drugs, cannabinoids are the most commonly found substance. Certain trends could be identified, e.g., very low prevalence of cocaine in reports from Nordic countries, a high prevalence of amphetamines between Norwegian and Swedish studies, and low rates of THC among Australian studies. CONCLUSION: The results of this study should be regarded as an attempt to obtain more reliable data concerning the prevalence of alcohol and illicit drugs among drivers. To obtain a better assessment of the real current role of alcohol and drugs (illicit and medications), it seems strongly necessary to update the case-control study conducted by Borkenstein et al. in 1964, including now blood analyses of the whole spectrum of substances that can impair drivers.     

DUID prevalence in Colorado's DUI citations

IntroductionThere are limited studies that measure the prevalence of driving under the influence of drugs (DUID) based upon impairment measures because most prevalence studies are based on drug tests. The aim of this study was to provide the first estimate of DUID prevalence in Colorado using data collected by Colorado law enforcement officers in vehicular homicide (VH) and vehicular assault (VA) cases, and reported in court records.MethodsThe four research questions of this study were answered by completing independent t-tests or Mann–Whitney U tests, Pearson chi-square analyses or Fisher's exact tests, and Kruskal–Wallis tests.ResultsSeventy percent (119 out of 170) of the cases involved alcohol only and 30% (51 out of 170) involved drugs. Of the latter cases, 32 cases involved a combination of alcohol and drugs and 19 cases identified drugs only, with no alcohol. Marijuana was the most commonly cited drug (23 cases); however, it was the sole impairing substance identified in only three cases.ConclusionPolydrug use was very common among DUID cases, which makes it difficult to identify which drug or drugs caused the impairment responsible for the Driving Under the Influence citation. This study revealed tha (a) drugged driving is a frequent cause of DUI citations in cases charged with VH or VA; (b) that polydrug use, rather than marijuana, is the most common cause of drugged driving in Colorado; and (c) that current warrant procedures render blood test results meaningless in cases of marijuana-impairment.Practical applicationStates should collect and analyze DUID data to ensure legislators focus on the right DUID problems to improve biological testing for drugs, adopt more appropriate roadside testing, and enact stronger DUID laws to protect the public.     

Methiopropamine in blood samples from drivers suspected of being under the influence of drugs

Objectives: Methiopropamine (MPA; 1-(thiophen-2-yl)-2-methylaminopropane) belongs to the new psychoactive substances (NPS) that have emerged on the drug market in recent years. MPA appeared in 2011 and is an analogue of methamphetamine, sold as, for example, "Slush Eric"and "Blow." It is reported to have effects similar to those of methamphetamine, but the toxicity in humans is not known. Three fatal cases involving MPA have been reported. One analytical confirmed intoxication case has been published, and this supports the symptoms described by the users. The prevalence of recreational use of MPA is unknown, and no studies have reported the prevalence in driving under the influence of drug (DUID) cases.

Methods: We investigated the frequency of MPA in DUID cases received at our institute during a 12-week period and report the analytical method using an ultraperformance liquid chromatography.tandem mass spectrometry for quantification of MPA in whole blood. The analytical findings were compared to the results from a clinical test of impairment performed by a physician shortly after the driving episode. The samples were analyzed for 42 different psychoactive substances.

Results: MPA was detected in 10 DUID cases (0.8% of the cases), only from male drivers. Other drugs were detected concomitantly in all the cases. Two of the cases were traffic accidents.

Conclusions: Our study shows that MPA is found in DUID cases and reveals that NPS are used among drivers and also proven in blood from drivers involved in traffic accidents. More studies are requested regarding the pharmacological and toxicological effects of MPA and other NPS. This is the first article that describes a method for analyzing and quantifying MPA in whole blood samples.     

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.     

Roadside survey on alcohol and drug use among drivers in the Arctic county of Finnmark (Norway)

Objective: The objective of this study was to determine the prevalence of alcohol and potentially impairing drugs among the general driving population in Finnmark and to compare the prevalence among Norwegian, Russian, and other foreign drivers by analyzing samples of oral fluid.

Methods: In collaboration with local police, drivers were selected for a voluntary and anonymous study using a multistage cluster sampling procedure (selection of roads, time intervals, and drivers within each interval) from September 2014 to October 2015. Age, gender, citizenship, time, and geographical site were recorded. Samples of oral fluid were collected using the Quantisal device. The samples were analyzed for alcohol with an enzymatic method and for 12 illicit drugs and 16 medicinal drugs and some metabolites using ultra-high-performance liquid chromatography with tandem mass spectrometry detection.

Results: A total of 3,228 drivers were asked to participate in the study. The refusal rate was 6.2%. Of the 3,027 participants in the study, 111 (3.7%) were Russian and 204 (6.7%) had citizenship other than Norwegian or Russian. The total prevalence of psychoactive substances was 4.3%. Alcohol was detected in 0.3%, psychoactive medicinal drugs in 2.5%, and illicit drugs in 1.6% of the samples. The most commonly found substances were the sleeping agent zopiclone (1.1%), tetrahydrocannabinol (THC; 1.1%), and the analgesic agent codeine (0.6%). Illicit drugs were detected significantly more often in samples from drivers of citizenship other than Norwegian or Russian. The prevalence of alcohol was somewhat higher among Russian drivers but not statistically significant. There were large differences between age groups and genders concerning illicit drugs and psychoactive medicinal drugs; illicit drugs were more frequently in samples from young male drivers, whereas psychoactive medicinal drugs were more frequently in samples from elderly female drivers.

Conclusion: The total prevalence of alcohol and drugs among the general driving population in Finnmark was low and similar to previous Norwegian roadside surveys. Illicit drugs were detected significantly more often in samples from drivers with citizenship other than Russian and Norwegian and among young male drivers.     

Driver's alcohol and passenger's death in motor vehicle crashes

OBJECTIVE: Previous studies on alcohol involvement associated with fatal injury in traffic crashes have focused on the drivers, but the passenger's view is not well known. This study (1) analyzes the relationship between passenger's death and alcohol inebriation of the driver and (2) estimates the role of alcohol as the cause of a crash by examining who was at fault, sober, or inebriated. METHOD: The study includes all motor vehicle passengers (n = 420) who died in crashes in Sweden 1993 through 1996 and were medicolegally autopsied. Autopsy reports from the Departments of Forensic Medicine, including toxicological analyses, and police reports were studied. Presence of alcohol among drivers was based on blood and breath tests. RESULTS: One-fifth of the fatally injured passengers and one-fifth of the tested drivers were under the influence of alcohol. The youngest drivers had the highest prevalence of drunken driving. Drivers at fault were alcohol positive in 21% of these crashes and drivers were not at fault in 2% of these crashes. In 53% of the crashes where both the passenger and driver were alcohol positive, the passenger had a lower alcohol concentration than the driver. Children (<16 years) comprised 15% of the killed passengers. Notably, the children were riding with a driver who was under influence of alcohol in 13% of these crashes. Alcohol involvement was not tested in half of the surviving drivers. CONCLUSIONS: The data show that 20% of both passengers and drivers were under the influence of alcohol. Increased testing of surviving drivers regarding alcohol and other drugs is recommended.     

Drugs and driving

The authors present a global overview on the issue of drugs and driving covering four major areas: (1) Epidemiology and Prevalence--which reviews epidemiological research, summarizes available information, discusses the methodological shortcomings of extant studies, and makes recommendations for future research to better define prevalence and epidemiology; (2) Effects of Medicinal and Illegal Drugs on Driving Performance--focuses on the six classes of drugs most often found in impaired and injured drivers, draws conclusions regarding the risk of these drugs to traffic safety and discusses the need for additional research; (3) Toxicological Issues--discusses ways to identify drug users via behavioral testing and analytical techniques, reviews the approaches used by different countries, screening and confirmation techniques, alternative specimens (e.g., urine, oral fluid, sweat), and how rapid roadside testing could be coupled with behavioral and laboratory testing in an effective approach to identifying and prosecuting drugged drivers; (4) Driving Under the Influence of Drugs [DUID] Laws--provides an overview of DUID laws in the United States and Europe, discusses the basic tenets of these laws, the various types of DUID statutes, the reasons why many existing laws hinder the prosecution of drugged drivers and the rationale for developing per se legislation as a strategy to more effectively manage the drugged driver problem.     

Relationship between THC concentration in blood and impairment in apprehended drivers

OBJECTIVE: The most important psychoactive ingredient in cannabis, Delta (9)-tetrahydrocannabinol (THC) is one of the most frequently detected substances in blood samples from suspected impaired drivers in Norway. There is growing concern over possible links between the use of cannabis and increased risk of motor-vehicle crashes. Experimental studies have provided useful information on the role of THC and dose-effect relations with respect to psychomotor performance. The main purpose of the present study was to investigate whether a physician's judgment on impairment in a real-life setting among suspected drugged drivers, was related to blood THC concentration. METHODS: In Norway a police physician performs a clinical test for impairment (CTI) shortly after apprehension. The Norwegian Institute of Public Health analyze blood samples from all drivers suspected of driving under the influence of non-alcoholic drugs. In the present study 589 samples from approximately 30,000 cases of suspected drug impaired driving from the period 1997-99, contained THC as the only drug. In 456 of these cases a conclusion of the CTI was available. RESULTS: 230 (54%) drivers were considered not impaired and 226 (46%) impaired. Impaired drivers had higher blood THC concentration than the drivers who were judged as not impaired (median; 2.5 ng/mL (range; 0.3-45.3 ng/mL) vs 1.9 ng/mL (range; 0.32-24.8 ng/mL), (p < 0.05). Furthermore, drivers with blood THC concentrations above 3 ng/mL had an increased risk for being judged impaired compared to drivers with lower concentration ranges. CONCLUSION: The relationship between the concentration of THC in blood and risk of being assessed impaired found in this cross-sectional study of suspected drugged drivers, supports findings from previous experimental studies of concentration related effects of THC on psychomotor performance and driving skills.     

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.     

Characteristics of drivers testing positive for heroin or ecstasy in Norway

An increasing number of heroin and ecstasy seizures were recorded by the Norwegian police and customs authorities in the 1990s. The number of apprehended drivers in whom heroin and ecstasy were detected also rose in the same period (Heroin, 1991: n = 17, 1999: n = 320. Ecstasy, 1995: n = 6, 1999: n = 123). Drivers who tested positive for heroin (detected in urine as the metabolite 6-monoacetyl-morphine, 6-MAM) or ecstasy (3,4-methylenedioxy-metamphetamine, MDMA, detected in blood) were characterized with regard to age distribution, drug use pattern, and earlier arrests. In 1998-1999, the police apprehended 9013 drivers on suspicion of being under the influence of drugs other than alcohol. Blood and urine samples from the drivers were sent to the Norwegian Institute of Public Health, Division of Forensic Toxicology and Drug Abuse and analyzed for the most commonly abused drugs. 6-MAM was detected in urine in 7% of the cases (n = 637), representing 542 different drivers (male: 85%, n = 463, female: 15%, n = 79) as some drivers were rearrested several times during the selection period. MDMA was detected in 2% of the cases (n = 190), representing 177 drivers (male: 90%, n = 160, female: 10%, n = 17). The median ages of drivers who tested positive for 6-MAM or MDMA were 32 and 24 years, respectively. Multi-drug use was very common in both groups (83% and 98% for the heroin and ecstasy group, respectively). Drivers in both groups were followed back to 1985 to detect earlier arrests for the same offence. Of the heroin group, 78% (n = 417) had earlier been arrested for drunken or drugged driving. Alcohol was the drug most frequently detected on first arrest. Of the ecstasy group, 47% (n = 83) had earlier been arrested, and amphetamine was most frequently found on first arrest.     

Fatigue and beyond: patterns of and motivations for illicit drug use among long-haul truck drivers

OBJECTIVES: The present study aimed to investigate the illicit drug use patterns of long-distance truck drivers. This population is considered to be a special interest group in terms of drug-driving research and policy due to high rates of use, involvement of drugs in truck accidents, and the link between drug use and work-related fatigue. METHODS: Qualitative interview data were collected from 35 long-haul truck drivers in Southeast Queensland and analyzed through grounded theory techniques. Interviews were conducted at truck stops and loading facilities in both metropolitan and regional cites throughout Queensland. RESULTS: High rates of licit and illicit drug use (particularly amphetamines) were reported by the majority of the sample. However, unlike previous studies that focus on fatigue, this research found overlapping and changing motivations for drug use during individual lifetimes. Becker's model of a drug use "career" was utilized to reveal that some drivers begin illicit drug use before they commence truck driving. As well as fatigue, powerful motives such as peer pressure, wanting to fit the trucking "image," socialization, relaxation, and addiction were also reported as contributing factors to self-reported drug driving. CONCLUSIONS: The results indicate that these additional social factors may need to be considered and incorporated with fatigue factors when developing effective drug prevention or cessation policies for truck drivers.     

Marijuana-, alcohol-, and drug-impaired driving among emerging adults: Changes from high school to one-year post-high school

IntroductionDriving while impaired (DWI) increases the risk of a motor vehicle crash by impairing performance. Few studies have examined the prevalence and predictors of marijuana, alcohol, and drug-specific DWI among emerging adults.MethodsThe data from wave 3 (W3, high school seniors, 2012, N = 2407) and wave 4 (W4, one year after high school, N = 2178) of the NEXT Generation Health Study with a nationally representative cohort. W4 DWI (≥ 1 day of past 30 days) was specified for alcohol-specific, marijuana-specific, alcohol/marijuana-combined, illicit drug-related DWI. Multinomial logistic regression models estimated the association of W4 DWI with W3 covariates (perceived peer/parent influence, drinking/binge drinking, marijuana/illicit drug use), and W4 environmental status variables (work/school/residence) adjusting for W3 overall DWI, demographic, and complex survey variables.ResultsOverall DWI prevalence from W3 to W4 changed slightly (14% to 15%). W4 DWI consisted of 4.34% drinking-specific, 5.02% marijuana-specific, 2.41% drinking/marijuana combined, and 3.37% illicit drug-related DWI. W3 DWI was significantly associated with W4 alcohol-related and alcohol/marijuana-combined DWI, but not other DWI. W3 marijuana use, binge drinking, and illicit drug use were positively associated with W4 marijuana-specific, alcohol/marijuana-combined, and illicit drug-related DWI, respectively. W3 friend drunkenness and marijuana use were positively associated with W4 alcohol-specific and marijuana-related DWI, respectively. W3 peer marijuana use was negatively associated with W4 alcohol-specific DWI.ConclusionsDriving under the influence of alcohol, marijuana, and illicit drugs is a persistent, threatening public health concern among emerging U.S. adults. High school seniors' binge drinking as well as regular alcohol drinking and marijuana/illicit drug use were independently associated with respective DWI one year after high school. Peer drunkenness and marijuana use in high school may be related to subsequent DWI of emerging adults.Practical applicationsThe results support the use of injunctive peer norms about getting drunk and smoking marijuana in guiding the development of prevention programs to reduce youth DWI.     

The Victorian legislative framework for testing drivers for impairment caused by drugs other than alcohol: an evaluation of the characteristics of drivers detected from 2000 to 2005

On December 1, 2000, new legislation came into force in Victoria, Australia, that involved a framework for the procedure to be followed by the police for the detection of drivers impaired by drugs other than alcohol. An integral part of the procedure is the use of performance tests known as the standardized field sobriety tests (SFSTs) and the analysis of blood samples for the presence of drugs other than alcohol. This paper outlines the new legislative framework and the drug impairment detection procedures currently in place in Victoria. This paper also evaluates the data collected using the framework for the first five years since implementation in Victoria.     

Trends in the use of psychoactive substances by truck drivers in São Paulo State,Brazil: A time-series cross sectional roadside survey (2009–2016)

Objective: Truck drivers represent a group that is susceptible to the use of stimulant substances to reduce the symptoms of fatigue, which may be caused by a stressful and exhausting work environment. The use of psychoactive substances may increase the risk for involvement in road traffic crashes. Previous studies have demonstrated that amphetamine, cocaine, and cannabis are the 3 main drugs used by Brazilian truck drivers. We studied the prevalence of amphetamine, benzoylecgonine (indicating use of cocaine), and Δ-9-tetrahydrocannabinol-9-carboxylic acid (THC-COOH; indicating use of cannabis) in urine samples from truck drivers in the state of São Paulo, Brazil, using the same methodology during 8 years (2009–2016).

Methods: Samples were collected during a health program supported by the Federal Highway Police. Toxicological analyses were performed using immunoassays and gas chromatography–mass spectrometry.

Results: The total prevalence of illicit drugs was 7.8%. Benzoylecgonine was the most prevalent substance (3.6%), followed by amphetamine (3.4%) and THC-COOH (1.6%). We found the highest drug prevalence in 2010 (11.3%) and the lowest in 2011 (6.1%). We could detect a slight change in the pattern of stimulant use: until 2010, amphetamine was the most prevalent substance; however, in 2011 benzoylecgonine became the most frequently detected substance. This lasted until 2015, probably due to changes in Brazilian legislation regarding appetite suppressants; the most common one is metabolized to amphetamine.

Conclusion: These data show that the use of psychoactive substances by truck drivers in Brazil did not decrease during the study period. This reinforces the need for further preventive measures to reduce drug use among drivers, which could lead to a decrease in traffic crashes in Brazil.     

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.