Combined effect of alcohol and cannabis on simulated driving

Effects of different methods of cannabis use on cognition and blood THC: A systematic review

Novel methods of cannabis use are becoming popular, but the differential impact of these new methods on cognition have not been widely studied. Further, the impact of cannabis on cognition is mediated by delta-9-tetrahydrocannabinol (THC), but few studies have directly compared the pharmacokinetics of different methods. This systematic review (PROSPERO, CRD42023442731) was conducted to determine whether the different forms of cannabis and routes of administration have differential acute effects on cognition or blood THC. In total, six studies were found that directly compared the effects of at least two different methods of cannabis administration on cognition and eight studies compared the impact of different methods on blood THC. In general, few differences between methods were found on cognitive performance but two studies found some evidence for worse performance on attention tasks after vaping cannabis versus edibles or smoked cannabis. One study found worse performance on a memory task in participants who smoked high potency flower with cannabidiol compared to a group of concentrates users. Despite this, the clear consensus is that inhaled routes of administration result in higher peak levels of THC, while edible cannabis has a longer duration of action. Additionally, one study found an inverse correlation between blood THC and cognition. Given that THC levels are used to detect impairment, this suggests that the ability to detect impairment may vary by method, with edibles presenting more of a challenge. More studies are needed to understand the effects of these newer methods of cannabis administration on performance and blood THC.

Association of driving with blood delta-9-tetrahydrocannabinol: a systematic review

IMPORTANCE

Driving under the influence of cannabis increases the risk of motor vehicle collisions. In some jurisdictions, deterrence rests on the ability to detect delta-9-tetrahydrocannabinol (THC) in blood. Recent evidence suggests that there may be a nuanced relationship of blood THC to driving.

OBJECTIVE

The purpose of this systematic review was to summarize all published papers investigating the presence of a linear relationship between blood THC and driving, primarily measured by simulated driving in the lab.

OUTCOMES

The main outcomes assessed included "weaving"/lateral control (eg, standard deviation of lateral position), speed, car following (following distance; coherence), reaction time, and overall driving performance.

RESULTS

Of the 4845 records from the literature search, only 12 met the inclusion criteria. Ten of these reported no significant linear correlations between blood THC and measures of driving (8 out of 9 for "weaving"/lateral control, 4 out of 5 for speed, 2 of 3 for car following tasks (coherence/headway maintenance task), 1/1 for reaction time, 3/3 for overall driving performance). The studies that did find an association between driving and blood THC employed complex driving situations.

CONCLUSIONS

This synthesis has important implications for road safety given driving situations can be complex due to challenging road situations and increases in potency of cannabis over the past years. Current methods of detection of impairment may be suited to some types of situations but more large-scale studies on the relationship of blood THC and driving are needed that systematically vary driving complexity and cannabis potency.

A randomized, placebo-controlled, double-blind, pilot study of cannabis-related driving impairment assessed by driving simulator and self-report

AIMS

In the context of increasing cannabis use, understanding how cannabis affects specific driving behaviors is crucial in mitigating risks and ensuring road safety.

DESIGN AND SETTING

The current study included 38 adults aged 18-40 years, administered a single 0.5 g acute dose of vaporized cannabis (5.9% Tetrahydrocannabinol (THC), 13% THC or placebo) in a randomized, within-subject, double-blind, counterbalanced design. Throughout each of the three, 8-h assessment days, at 4 time points, participants underwent simulated driving tests, including lane-keeping, car following, and overtaking tasks, capturing 19 behavioral metrics. An SPSS linear mixed model assessed the main effects of dose, time, and dose × time.

FINDINGS

During lane-keeping, participants exhibited reduced steering reversal rates up to 5.5 h following 13% THC and 3.5 h for 5.9%. For car following, participants showed reduced pedal peak-to-peak deviation and reversal rates, persisting for 1-3 h post-dose (only at 13% THC). During overtaking, following 13% THC, subjects demonstrated a shorter median gap to passed cars, lower time-to-potential collision, and more time in the oncoming lane. Drug effects on driving metrics improved gradually, to varying degrees over time. Approximately 66% of participants reported willingness to drive, despite subjective awareness of being impaired and objectively worse driving performance.

CONCLUSIONS

Our study reveals for the first time long-lasting cannabis-induced impairments across multiple driving behaviors, that extend beyond the typical 3-h window explored in most previous research. The observed discrepancy between participants' willingness to drive and their actual impairment highlights an important public safety concern. In addition, the lack of correlation between cannabinoid metabolite concentrations and driving performance challenges the reliability of blood THC levels as impairment indicators, emphasizing the need for a multifaceted approach to assessing cannabis-impaired driving risk.

The association between cannabis and alcohol co-use and momentary subjective effects: Risks for increasingly hazardous cannabis use

BACKGROUND

Co-use of cannabis and alcohol is associated with a higher prevalence of health-related, psychiatric, and psychosocial impairments. The aims of this study were to 1) examine the association between cannabis and alcohol co-use and subjective effects, 2) determine whether the time between cannabis and alcohol use is associated with subjective effects, and 3) examine whether subjective responses to co-use are associated with hazardous cannabis use over time.

METHODS

Young adults who co-used cannabis and alcohol (N = 155, 55.5 % women, Mean age=21 yo) completed baseline, six-month, and twelve-month assessments of hazardous cannabis use. Co-use and subjective effects were assessed across 21 days of EMA at baseline.

FINDINGS

Co-use was associated with greater momentary subjective intoxication, compared to cannabis- and alcohol-only, and stimulation and bad effects, compared to cannabis-only. Subjective intoxication was significantly higher for co-use within 0-90minutes compared to cannabis-only. Subjective intoxication was significantly higher for co-use within 0-120minutes compared to alcohol-only. Co-use within 0-30minutes was associated with significantly greater stimulation and bad effects, compared to cannabis-only use moments. The extent to which an individual becomes more intoxicated when co-using the greater the risk the individual had for increasing hazardous cannabis use six and twelve months later.

CONCLUSION

Findings indicate that co-use is associated with increased intoxication, compared to cannabis or alcohol use alone, and increased stimulation and bad effects, compared to cannabis use alone. Subjective responses to co-use in a naturalistic setting are important to consider when evaluating long-term risk of cannabis use among young adults.

The driving-related attitudes, beliefs and behaviours of cannabis users in the Australian Capital Territory following decriminalisation

INTRODUCTION

In January 2020, the government of the Australian Capital Territory (ACT) decriminalised the possession and cultivation of cannabis for personal use. This study explored the driving-related attitudes, beliefs and behaviours of ACT residents who are legally cultivating and consuming cannabis.

METHODS

A two-part cross-sectional study was conducted. Part-1: Cannabis users residing in the ACT were invited to complete an online survey. Part-2: Survey respondents who reported 'currently growing' cannabis were invited to submit a sample of their home-grown cannabis for phytocannabinoid analysis. Data from Parts 1 and 2 were used to estimate participants' usual Δ9-tetrahydrocannabinol (THC) intakes.

RESULTS

N = 385 cannabis users completed all or part of the online survey and N = 52 submitted cannabis samples for phytocannabinoid analysis. Most participants (N = 224/330; 67.9%) reported waiting ≥7 h following cannabis use before driving. However, 21.5% (N = 71/330) reported waiting ≤3 h. These individuals had the highest cannabis and THC intakes of the sample (where known). Further analyses revealed that individuals who expressed less concern about roadside drug testing and the effects of non-medicinal and medicinal cannabis on driving, and who used cannabis more frequently, in larger amounts, and exclusively for non-medicinal purposes were more likely to report shorter 'wait times'.

DISCUSSION AND CONCLUSION

A small proportion of cannabis users in the ACT appear to be driving shortly (i.e., ≤3 h) after consuming considerable quantities of cannabis and THC. This behaviour puts them at risk of driving while impaired and incurring legal sanctions. Interventions alerting these individuals to these possible risks are, therefore, warranted.

Proximal antecedents and acute outcomes of simultaneous alcohol and cannabis use: Systematic review of daily- and event-level studies

Many studies have revealed that individuals who engage in simultaneous use of alcohol and cannabis report elevated substance-related consequences relative to those who use only alcohol or cannabis; however, evidence from emerging studies examining within-person differences across simultaneous use and single substance use occasions is less consistent. This systematic review aimed to synthesize findings from existing day- and event-level studies of within-person differences in the proximal antecedents and acute outcomes associated with simultaneous use versus single substance use episodes. Our search strategy revealed 30 eligible articles. Two categories of antecedents (i.e., internal [e.g., motives] and external [e.g., social context]) and three categories of outcomes (i.e., consumption behavior, general positive and negative consequences, and specific consequences) were identified. The current literature consistently suggests that greater day- or event-level social and enhancement motives, as well as being in a social context, predict greater likelihood of engaging in simultaneous use compared with alcohol- or cannabis-only use. However, there was heterogeneity in findings regarding the role of other person-level antecedents. Further, while most evidence pointed to heavier alcohol consumption on simultaneous use occasions versus alcohol-only occasions, findings for elevations in acute negative and positive substance-related consequences on simultaneous use versus single substance use occasions were mixed. Additionally, four studies found that increased consequences on simultaneous use occasions depended on the level of alcohol consumed. This review identifies several antecedents for simultaneous use events but suggests that simultaneous use occasions are not always associated with more acute harms than single substance use occasions. Given the extent to which the current literature is mixed, this review emphasizes the importance of methodological improvements and future research examining the mechanisms linking simultaneous use with substance-related consequences to help reconcile findings across within-person and between-person studies.

Assessing the impact of cannabis use on freeway driving performance and practices: A comparative analysis with placebo and alcohol-influenced driving

OBJECTIVE

The objectives of this study were 1) to identify the effects cannabis has on driving performance and individual motor practices when on the freeway compared to placebo and 2) to bring context to the effects of cannabis on driving by comparing effect sizes to those of alcohol.

METHODS

Data for analysis was collected from a study of fifty-three participants with a history of tetrahydrocannabinol (THC) cannabis use who completed three visits in randomized order (placebo (0% THC), 6.18% THC, and 10.5% THC). Data for the alcohol analysis was from a subset of eighteen of these participants with a history of recent alcohol use that completed a fourth alcohol visit that targeted a .05 g/210L breath alcohol content (BrAC) during the drive. Comparisons were made using an analysis of variance approach with the SAS General Linear Models Procedure. Cohen's d effect sizes were calculated for the cannabis and alcohol conditions relative to placebo for both the full sample and alcohol subset.

RESULTS

Standard deviation of lane position (SDLP) for cannabis significantly increased compared to placebo and the effect size was comparable to that of alcohol at .05 BrAC. Lane departures for cannabis significantly increased relative to placebo as did the time out of the lane. Cannabis use resulted in an increased amount of time at 10% or more below the speed limit for the 6.18% THC condition. Relative to alcohol, cannabis produced more time at slower speeds and less time at speeds more than 10% above the speed limit.

CONCLUSIONS

Multiple factors of lateral and longitudinal vehicle control on the freeway showed statistical significance. Drivers under the influence of cannabis exhibited higher rates of driving errors but also showed more cautious behaviors such as generally lower speeds on the freeway. Compared with alcohol, effect sizes varied. For longitudinal control, there were larger effect sizes for alcohol with speed effects in opposite directions, but relatively equivalent effect sizes for lateral control and driving errors associated with lane keeping.

The effects of simultaneous alcohol and cannabis use on subjective drug effects: A narrative review across methodologies

Over 75% of young adults who use cannabis also report drinking alcohol, leading to increased risks that include impaired cognition, substance use disorders, and more heavy and frequent substance use. Studies suggest that subjective responses to either alcohol or cannabis can serve as a valuable indicator for identifying individuals at risk of prolonged substance use and use disorder. While laboratory studies show additive effects when alcohol and cannabis are used together, the impact of co-using these substances, specifically with respect to cannabidiol, on an individual's subjective experience remains unclear. This narrative review explores the effects of simultaneous alcohol and cannabis (SAM) use on subjective drug effects, drawing from qualitative research, laboratory experiments, and naturalistic studies. Experimental findings are inconsistent regarding the combined effects of alcohol and cannabis, likely influenced by factors such as dosage, method of administration, and individual substance use histories. Similarly, findings from qualitative and naturalistic studies are mixed regarding subjective drug effects following SAM use. These discrepancies may be due to recall biases, variations in assessment methods, and the measurement in real-world contexts of patterns of SAM use and related experiences. Overall, this narrative review highlights the need for more comprehensive research to understand more fully subjective drug effects of SAM use in diverse populations and settings, emphasizing the importance of frequent and nuanced assessment of SAM use and subjective responses in naturalistic settings.

The effect of cannabis edibles on driving and blood THC

BACKGROUND

Cannabis has been shown to impact driving due to changes produced by delta-9-tetrahydrocannabinol (THC), the psychoactive component of cannabis. Current legal thresholds for blood THC while driving are based predominantly on evidence utilizing smoked cannabis. It is known that levels of THC in blood are lower after eating cannabis as compared to smoking yet the impact of edibles on driving and associated blood THC has never been studied.

METHODS

Participants drove a driving simulator before and after ingesting their preferred legally purchased cannabis edible. In a counterbalanced control session, participants did not consume any THC or cannabidiol (CBD). Blood was collected for measurement of THC and metabolites as well as CBD. Subjective experience was also assessed.

RESULTS

Participants consumed edibles with, on average, 7.3 mg of THC, which is less than the maximum amount available in a single retail package in Ontario, providing an ecologically valid test of cannabis edibles. Compared to control, cannabis edibles produced a decrease in mean speed 2 h after consumption but not at 4 and 6 h. Under dual task conditions in which participants completed a secondary task while driving, changes in speed were not significant after the correction for multiple comparison. No changes in standard deviation of lateral position (SDLP; 'weaving'), maximum speed, standard deviation of speed or reaction time were found at any time point or under either standard or dual task conditions. Mean THC levels were significantly increased, relative to control, after consuming the edible but remained relatively low at approximately 2.8 ng/mL 2 h after consumption. Driving impairment was not correlated with blood THC. Subjective experience was altered for 7 h and participants were less willing/able to drive for up to 6 h, suggesting that the edible was intoxicating.

INTERPRETATION

This is the first study of the impact of cannabis edibles on simulated driving. Edibles were intoxicating as revealed by the results of subjective assessments (VAS), and there was some impact on driving. Detection of driving impairment after the use of cannabis edibles may be difficult.

Cannabis and Driving in Older Adults

Importance

Epidemiological studies have found that cannabis increases the risk of a motor vehicle collision. Cannabis use is increasing in older adults, but laboratory studies of the association between cannabis and driving in people aged older than 65 years are lacking.

Objective

To investigate the association between cannabis, simulated driving, and concurrent blood tetrahydrocannabinol (THC) levels in older adults.

Design, Setting, and Participants

Using an ecologically valid counterbalanced design, in this cohort study, regular cannabis users operated a driving simulator before, 30 minutes after, and 180 minutes after smoking their preferred legal cannabis or after resting. This study was conducted in Toronto, Canada, between March and November 2022 with no follow-up period. Data were analyzed from December 2022 to February 2023.

Exposures

Most participants chose THC-dominant cannabis with a mean (SD) content of 18.74% (6.12%) THC and 1.46% (3.37%) cannabidiol (CBD).

Main outcomes and measures

The primary end point was SD of lateral position (SDLP, or weaving). Secondary outcomes were mean speed (MS), maximum speed, SD of speed, and reaction time. Driving was assessed under both single-task and dual-task (distracted) conditions. Blood THC and metabolites of THC and CBD were also measured at the time of the drives.

Results

A total of 31 participants (21 male [68%]; 29 White [94%], 1 Latin American [3%], and 1 mixed race [3%]; mean [SD] age, 68.7 [3.5] years), completed all study procedures. SDLP was increased and MS was decreased at 30 but not 180 minutes after smoking cannabis compared with the control condition in both the single-task (SDLP effect size [ES], 0.30; b = 1.65; 95% CI, 0.37 to 2.93; MS ES, -0.58; b = -2.46; 95% CI, -3.56 to -1.36) and dual-task (SDLP ES, 0.27; b = 1.75; 95% CI, 0.21 to 3.28; MS ES, -0.47; b = -3.15; 95% CI, -5.05 to -1.24) conditions. Blood THC levels were significantly increased at 30 minutes but not 180 minutes. Blood THC was not correlated with SDLP or MS at 30 minutes, and SDLP was not correlated with MS. Subjective ratings remained elevated for 5 hours and participants reported that they were less willing to drive at 3 hours after smoking.

Conclusions and relevance

In this cohort study, the findings suggested that older drivers should exercise caution after smoking cannabis.

Preliminary study of the interactive effects of THC and ethanol on self-reported ability and simulated driving, subjective effects, and cardiovascular responses

RATIONALE

Drug- and alcohol-related motor vehicle accidents are a leading cause of morbidity and mortality worldwide. Compared to alcohol, less is known about the effects of cannabis on driving and even less about their combined effects.

OBJECTIVE

To characterize the combined and separate effects of ethanol and tetrahydrocannabinol (THC) on perceived ability to drive, subjective effects, and simulated driving.

METHODS

In a within-subject (crossover), randomized, placebo-controlled, double-blind, 2 × 2 design, the effects of oral THC (10 mg [dronabinol] or placebo) and low-dose intravenous ethanol (clamped at BAC 0.04% or placebo) on perceived ability to drive, simulated driving (standard deviation of lateral position [SDLP]), subjective effects (e.g., "high"), and physiological effects (e.g., heart rate) were studied in healthy humans (n = 18).

RESULTS

Subjects reported reductions in perceived ability to drive (THC < ethanol < combination) which persisted for ~ 6 h (placebo = ethanol, THC < combination). Ethanol and THC produced synergistic effects on heart rate, significant differences compared to either drug alone on perceived ability to drive and feeling states of intoxication (e.g., high), as well increases in SDLP compared to placebo.

CONCLUSIONS

Perceived ability to drive is reduced under the influence of THC against the backdrop of blood alcohol levels that are below the legal limit. People should be aware that the effects of oral THC on driving may persist for up to six hours from administration. Findings are relevant to the increasingly common practice of combining alcohol and cannabinoids and the effects on driving.

Crash-involved THC-positive drivers in Norway have a high frequency of polysubstance use

BACKGROUND

Tetrahydrocannabinol (THC) is the most frequently detected drug in blood samples from apprehended drug driving suspects in Norway. This investigation aimed to study the extent of polysubstance use among apprehended crash-involved drivers with THC concentrations above the legal limit and explore the importance of THC in polysubstance cases.

METHODS

We selected all drug driving cases where blood samples had been submitted for forensic toxicology testing after involvement in road traffic crashes during 2013-2020, except drivers who were fatally injured.

RESULTS

Twenty percent (n = 2133) of the 10,520 apprehended crash-involved drivers had concentrations of THC in their blood above the legal limit of 1.3 ng/mL, and 84 % of those also had concentrations of alcohol or other drugs above the legal limits; 61 % for sedatives, 38 % for stimulants, 33 % for alcohol, and 10 % for opioids. The most frequent substance combination was cannabis together with sedatives and stimulants (22.9 %; n = 488). Polysubstance use was least common among drivers under 24 years. The proportion of drivers with THC > 5 ng/mL was highest if the blood sample was collected within 90 min after the crash, and when only THC was detected. There was a statistically significant inverse association between THC > 5 ng/mL and concentrations of alcohol or amphetamines at the highest sanction level.

CONCLUSIONS

Most apprehended crash-involved THC-positive drivers also tested positive for other psychoactive substances. Drivers with high blood THC concentrations had less often high concentrations of other substances; cannabis might then have been a more important contributor to impairment.

The Utility of THC Cutoff Levels in Blood and Saliva for Detection of Impaired Driving

Background: Δ9-Tetrahydrocannabinol (THC) is the psychoactive component in cannabis and a relationship of THC to driving impairment is expected. Despite this, there are discrepant findings with respect to the relationship of blood THC to driving. This study investigated the relationship of blood, urine, and saliva THC/THC-COOH levels to "weaving," as measured by a driving simulator. Methods: Participants smoked cannabis alone or with alcohol. THC/THC-COOH levels in blood, urine, and saliva were correlated with standard deviation of lateral position (SDLP), measuring "weaving." In addition, SDLP after cannabis and/or alcohol were compared with SDLP after placebo when THC/THC-COOH levels were above or below specified thresholds in blood (5 ng/mL), urine (50 ng/mL), or saliva (25 ng/mL). Results: A clear linear relationship between blood THC concentration and SDLP was not observed based on calculation of Spearman coefficients. When compared with placebo, SDLP was significantly increased after cannabis and cannabis combined with alcohol when THC in the blood was above the legal limit. SDLP was increased in drug conditions when saliva cutoffs were above the legal limit. Conclusions: The findings of this study suggest that specified thresholds for THC in blood and saliva may be able to detect driving impairment, but future studies are needed. ClinicalTrials.gov ID: NCT03106363.

Cannabis and Driving: Developing Guidelines for Safety Policies

INTRODUCTION

The dynamism in the regulatory frameworks concerning the consumption of cannabinoids has placed their effects on cognitive and psychomotor skills at the center of the scientific debate. In consideration of the potential repercussions on public safety, particular attention has been focused on the impairment of driving skills, opening up the need to specifically regulate driving under the effects of cannabinoids.

PHARMACOKINETICS

Both native cannabinoids and metabolites show a long positivity at low concentrations in the biological fluids, especially in the case of chronic consumption. Qualitative positivity to cannabinoids does not itself prove the presence of detrimental effects, which require the presence of active substances at relevant concentrations. Driving Skill Impairment: Multiple studies highlight a tetrahydrocannabinol (THC) concentration- based alteration of driving skills mainly affecting automatisms, whereas skills subjected to cognitive control are preserved up to higher dosages. The evidence relating to associations with other substances, chronic consumption and other cannabinoids, on the other hand, is still burdened by a high degree of uncertainty. Regulation Policies: Different models can be adopted in the regulation of driving under the effects of cannabinoids: sanctions can be applied in case of qualitative positivity, cannabinoids concentration above a defined threshold, or in presence of a demonstrated state of cognitive alteration.

CONCLUSION

"Per se limit" with a quantitative THC cut-off between 3.5 and 5 ng/ml can currently be considered the most balanced choice. Finally, the analysis carried out allowed to identify pitfalls in both scientific and legislative fields for the improvement of safety policies.

The Impact of Physical Motion Cues on Driver Braking Performance: A Clinical Study Using Driving Simulator and Eye Tracker

Driving simulators are increasingly being incorporated by driving schools into a training process for a variety of vehicles. The motion platform is a major component integrated into simulators to enhance the sense of presence and fidelity of the driving simulator. However, less effort has been devoted to assessing the motion cues feedback on trainee performance in simulators. To address this gap, we thoroughly study the impact of motion cues on braking at a target point as an elementary behavior that reflects the overall driver's performance. In this paper, we use an eye-tracking device to evaluate driver behavior in addition to evaluating data from a driving simulator and considering participants' feedback. Furthermore, we compare the effect of different motion levels ("No motion", "Mild motion", and "Full motion") in two road scenarios: with and without the pre-braking warning signs with the speed feedback given by the speedometer. The results showed that a full level of motion cues had a positive effect on braking smoothness and gaze fixation on the track. In particular, the presence of full motion cues helped the participants to gradually decelerate from 5 to 0 ms^-1 in the last 240 m before the stop line in both scenarios, without and with warning signs, compared to the hardest braking from 25 to 0 ms^-1 produced under the no motion cues conditions. Moreover, the results showed that a combination of the mild motion conditions and warning signs led to an underestimation of the actual speed and a greater fixation of the gaze on the speedometer. Questionnaire data revealed that 95% of the participants did not suffer from motion sickness symptoms, yet participants' preferences did not indicate that they were aware of the impact of simulator conditions on their driving behavior.

Separate and combined effects of alcohol and cannabis on mood, subjective experience, cognition and psychomotor performance: A randomized trial

Co-use of alcohol and cannabis is associated with increased frequency and intensity of use and related problems. This study examined acute effects of alcohol and cannabis on mood, subjective experience, cognition, and psychomotor performance. Twenty-eight healthy cannabis users aged 19-29 years with recent history of binge drinking completed this within-subjects, double-blind, double-dummy, placebo-controlled, randomized clinical trial. Participants received: placebo alcohol and placebo cannabis (<0.1% THC); alcohol (target breath alcohol content [BrAC] 80 mg/dL) and placebo cannabis; placebo alcohol and active cannabis (12.5% THC); and active alcohol and cannabis over four sessions. Profile of Mood States (POMS), Addiction Research Centre Inventory (ARCI), verbal free recall (VFR), Digit Symbol Substitution Test (DSST), Continuous Performance Test (CPT), and grooved pegboard (GPB) task were administered before and approximately 75 min after drinking alcohol (1 h after smoking cannabis ad libitum). Significant effects of condition were found for the POMS (Tension-Anxiety, Confusion) and ARCI (MBG, LSD, PCAG, Euphoria, Sedation), predominantly with greater increases emerging after cannabis or alcohol-cannabis combined relative to placebo. Significant effects were found for VFR (immediate total and delayed recall, percent retained), DSST (trials attempted, trials correct, reaction time), and GPB (non-dominant hand) predominantly with greater declines in performance after alcohol and alcohol-cannabis combined relative to placebo and/or cannabis. Cannabis appeared to affect mood and subjective experience, with minimal impact on cognitive performance. Alcohol appeared to impair cognitive and psychomotor performance, with minimal impact on mood and subjective experience. Acute effects of alcohol and cannabis combined were additive at most.

Lower-Risk Cannabis Use Guidelines (LRCUG) for reducing health harms from non-medical cannabis use: A comprehensive evidence and recommendations update

BACKGROUND

Cannabis use is common, especially among young people, and is associated with risks for various health harms. Some jurisdictions have recently moved to legalization/regulation pursuing public health goals. Evidence-based 'Lower Risk Cannabis Use Guidelines' (LRCUG) and recommendations were previously developed to reduce modifiable risk factors of cannabis-related adverse health outcomes; related evidence has evolved substantially since. We aimed to review new scientific evidence and to develop comprehensively up-to-date LRCUG, including their recommendations, on this evidence basis.

METHODS

Targeted searches for literature (since 2016) on main risk factors for cannabis-related adverse health outcomes modifiable by the user-individual were conducted. Topical areas were informed by previous LRCUG content and expanded upon current evidence. Searches preferentially focused on systematic reviews, supplemented by key individual studies. The review results were evidence-graded, topically organized and narratively summarized; recommendations were developed through an iterative scientific expert consensus development process.

RESULTS

A substantial body of modifiable risk factors for cannabis use-related health harms were identified with varying evidence quality. Twelve substantive recommendation clusters and three precautionary statements were developed. In general, current evidence suggests that individuals can substantially reduce their risk for adverse health outcomes if they delay the onset of cannabis use until after adolescence, avoid the use of high-potency (THC) cannabis products and high-frequency/-intensity of use, and refrain from smoking-routes for administration. While young people are particularly vulnerable to cannabis-related harms, other sub-groups (e.g., pregnant women, drivers, older adults, those with co-morbidities) are advised to exercise particular caution with use-related risks. Legal/regulated cannabis products should be used where possible.

CONCLUSIONS

Cannabis use can result in adverse health outcomes, mostly among sub-groups with higher-risk use. Reducing the risk factors identified can help to reduce health harms from use. The LRCUG offer one targeted intervention component within a comprehensive public health approach for cannabis use. They require effective audience-tailoring and dissemination, regular updating as new evidence become available, and should be evaluated for their impact.

Are blood and oral fluid Δ9-tetrahydrocannabinol (THC) and metabolite concentrations related to impairment? A meta-regression analysis

Blood and oral fluid Δ⁹-tetrahydrocannabinol (THC) concentrations are often used to identify cannabis-impaired drivers. We used meta-analytic techniques to characterise the relationships between biomarkers of cannabis use, subjective intoxication, and impairment of driving and driving-related cognitive skills. Twenty-eight publications and 822 driving-related outcomes were reviewed. Each outcome was measured in concert with one or more biomarkers of cannabis/THC use and/or subjective intoxication. Higher blood THC and 11-OH-THC concentrations, oral fluid THC concentrations and subjective ratings of intoxication were associated with greater impairment in 'other' (mostly occasional) cannabis users (p's<0.05). Blood 11-COOH-THC concentrations were associated with impairment after inhaling, but not orally ingesting, cannabis/THC. However t these 'biomarker-performance' relationships (R) were only very weak (blood THC_{post-ingestion}: -0.08; blood THC_{post-inhalation}: -0.10; blood 11-OH-THC_{post-ingestion}: -0.13), weak (blood 11-OH-THC_{post-inhalation}: -0.24; oral fluid THC_{post-inhalation}: -0.36; subjective intoxication: -0.29) or moderate (blood 11-COOH-THC_{post-inhalation}: -0.43) in strength. No significant biomarker-performance relationships were observed in 'regular' (weekly or more often) cannabis users (p's>0.10), although the analyses were less robust. Blood and oral fluid THC concentrations are relatively poor indicators of cannabis/THC-induced impairment.

Preliminary Eye-Tracking Data as a Nonintrusive Marker for Blood Δ-9-Tetrahydrocannabinol Concentration and Drugged Driving

Background: Cannabis is one of the drugs most often found in drivers involved in serious motor vehicle collisions. Validity and reliability of roadside cannabis detection strategies are questioned. This pilot study aimed to investigate the relationship between eye characteristics and cannabis effects in simulated driving to inform potential development of an alternative detection strategy. Materials and Methods: Multimodal data, including blood samples, eye-tracking recordings, and driving performance data, were acquired from 10 participants during a prolonged single-session driving simulator experiment. The study session included a baseline driving trial before cannabis exposure and seven trials at various times over ∼5 h after exposure. The multidimensional eye-tracking recording from each driving trial for each participant was segmented into nonoverlapping epochs (time windows); 34 features were extracted from each epoch. Blood Δ-9-tetrahydrocannabinol (THC) concentration, standard deviation of lateral position (SDLP), and mean vehicle speed were target variables. The cross-correlation between the temporal profile of each eye-tracking feature and target variable was assessed and a nonlinear regression analysis evaluated temporal trend of features following cannabis exposure. Results: Mean pupil diameter (r=0.81-0.86) and gaze pitch angle standard deviation (r=0.79-0.87) were significantly correlated with blood THC concentration (p<0.01) for all epoch lengths. For driving performance variables, saccade-related features were among those showing the most significant correlation (r=0.61-0.83, p<0.05). Epoch length significantly affected correlations between eye-tracking features and speed (p<0.05), but not SDLP or blood THC concentration (p>0.1). Temporal trend analysis of eye-tracking features after cannabis also showed a significant increasing trend (p<0.01) in saccade-related features, including velocity, scanpath, and duration, as the influence of cannabis decreased by time. A decreasing trend was observed for fixation percentage and mean pupil diameter. Due to the lack of placebo control in this study, these results are considered preliminary. Conclusion: Specific eye characteristics could potentially be used as nonintrusive markers of THC presence and driving-related effects of cannabis. clinicaltrials.gov (NCT03813602).