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

Patterns of substance use among non-offender drivers: Associations with demographics, aberrant driving behaviors, and near-collisions

OBJECTIVES

A substantial body of literature documents the association between alcohol and drug use with impaired driving, increased risky driving behavior, and traffic crashes. However, most research has focused on offender drivers, with limited attention given to non-offenders. Thus, the applicability of these findings to non-offender drivers remains unclear. This study aimed to: (a) examine alcohol consumption patterns, drug problems, and non-prescription medication use among non-offender drivers; (b) investigate the relationship between driver characteristics (age, sex, education, and driving experience) and substance use; and (c) explore the associations between substance use, near-collisions, and aberrant driving behaviors.

METHODS

A total of 360 non-offender drivers (52.5% male) aged 18-75 years (M = 33.52) from Spain participated in the study. Participants provided data on their sociodemographic characteristics, substance use (alcohol, drugs, and non-prescription medications), and self-reported driving behavior, including near-collisions and aberrant behaviors, as measured by the Driver Behavior Questionnaire (DBQ).

RESULTS

Over 85% of participants reported consuming alcohol, with approximately 60% drinking regularly or occasionally (2-4 times a month). The majority (80.1%) had low-risk alcohol consumption as indicated by AUDIT scores. A small proportion (5%) reported drug problems, and most participants (84.4%) did not use non-prescription medications. Alcohol consumption patterns varied significantly by sex, age, and driving experience. Men, younger drivers, and less experienced drivers were more likely to engage in high-risk alcohol consumption. Notably, a high proportion of women reported moderate risk levels of alcohol consumption. No significant differences were found in drugs or non-prescription medication use. Multiple regression analysis revealed that alcohol use, but not drug or non-prescription medication use, predicted violations, aggressive violations, errors, and lapses.

CONCLUSIONS

Findings indicate a high prevalence of alcohol consumption among non-offender drivers and a significant association between alcohol use and aberrant driving behaviors, confirming alcohol as a significant risk factor among non-offenders. While young and male drivers represent the primary risk group, attention should also be given to non-offender women due to their increased alcohol consumption and the associated risks for road safety. Gender-specific research and targeted strategies to reduce alcohol consumption and drink driving among women are discussed.

Driving under the influence of drugs - The failed quest of finding medical signs indicative to driving impairment

Motor vehicle accidents (MVA) are the leading cause of death in childhood and young adult age. One of the most important factors behind MVA is driving under the influence of alcohol (DUIA) and drugs (DUID). The importance of DUID is rising together with the increasing drug abuse. The legal approaches to DUID are based on impairment, impairment per se or zero tolerance. In case of impairment, the negative effect of the substance on the driving abilities has to be proven by a forensic expert, which can be challenging. This study compares the medical signs registered during blood sampling with the concentrations of substances detected by toxicological examination to find medical signs indicative of impairment. Statistical analysis did not find a correlation between substance concentration and measured parameters (pupil diameter, blood pressure and pulse rate). No connection was found between substance concentrations and the appearance of medical signs. The results indicate that pupil dilation, heart rate, and blood pressure could not be used as indicators of possible driving impairment by drugs, and no medical sign could reliably indicate the driving impairment by substances other than ethanol.

Four-year evaluation of drug-impaired driving drug concentrations

Drug-impaired driving is a significant public health and safety concern in the USA. To help assess current patterns of drug use in drivers, we evaluated 4 years of drug positivity in a large cohort of suspected impaired drivers. Samples collected between January 2017 and December 2020 were tested via a method compliant with the National Safety Council's Alcohol, Drugs, and Impairment Division's Tier I scope of recommended drugs. In 2017, NMS Labs received 17 346 driving under the influence of drugs cases, 17 471 in 2018, 19 050 in 2019, and 16 539 in 2020. The most common drug class detected was cannabinoids in ∼50% of the cases each year. The most common drugs detected over the 4 years were delta-9 tetrahydrocannabinol (delta-9 THC), ethanol, amphetamine/methamphetamine, fentanyl, and alprazolam. Delta-9 THC increased in positivity over the study, having been identified in 45% of cases in 2017, 46% in 2018, 46% in 2019, and 49% in 2020. Ethanol was found in 59% of cases in 2017, 59% in 2018, 61% in 2019, and 53% in 2020. Delta-9 THC and ethanol were the most common drug combination, found together in ∼19% of the cases every year of the study. Statistically significant increases in the average concentration of the following drugs were observed: fentanyl (5.7 ng/mL in 2017 to 9.6 ng/mL in 2020), methamphetamine (301 ng/mL in 2017 to 381 ng/mL in 2020), and delta-9-THC (6.4 ng/mL in 2017 to 7.3 ng/mL in 2020). Other findings included increases in the maximum reported concentrations between 2017 and 2020 for amphetamine (1400 to 2700 ng/mL), methamphetamine (5550 to 13 000 ng/mL), and fentanyl (56 to 310 ng/mL). Statistically significant concentration decreases were noted for several central nervous system depressants, notably prescription benzodiazepines, and several prescription narcotic analgesics.

Detection of cocaine 24 h after administration before nasotracheal intubation

BACKGROUND

Cocaine may be applied to decongest the nasal mucosa before nasotracheal intubation, but patients risk a criminal offence if cocaine is detected when patients drive a car shortly after surgery. We aimed to evaluate whether benzoylecgonine levels in saliva exceeded the cut-off point 24 h after administration in patients undergoing nasotracheal intubation and whether cocaine would be detectable above the Danish legal fixed limit in blood samples 1 and 24 h after surgery.

METHODS

We conducted a prospective study following approval from the local research ethics committee and the national medicine agency. Written informed consent was obtained from all patients. We included patients scheduled for surgery under general anaesthesia with nasotracheal intubation. They received 80 mg cocaine as a nasal spray 5 min before induction and nasotracheal intubation. The primary outcome was a dichotomous assessment of benzoylecgonine levels in saliva samples measured 24 h after administration of nasal cocaine with a cut-off limit of 200 ng/mL. Secondary outcomes were dichotomous assessments of cocaine in whole blood samples measured 1 and 24 h after administration of nasal cocaine with a cut-off limit of 0.01 mg/kg.

RESULTS

Overall, 70 patients had valid saliva samples and 75 had valid blood samples 24 h after cocaine administration. Benzoylecgonine in saliva was traceable above the cut-off in 9/70 patients (13%; CI95%: 6% to 23%), and cocaine in blood was detected above the cut-off in 2/75 patients (3%; CI95%: 0.3% to 9%).

CONCLUSION

We found benzoylecgonine traceable in saliva in 13% of patients and cocaine traceable in blood in 3% of patients 24 h after administration of 80 mg nasal cocaine. Patients should be informed when receiving cocaine and advised not to drive for at least 24 h.

Carbon fiber-sampling combined flame ionization mass spectrometry for direct analysis of drugs in oral fluid

Drug-impaired driving poses a significant risk of collisions and other hazardous accidents, emphasizing the urgent need for simple and rapid roadside detection methods. Oral fluid, as an easily collectible and non-invasive test material, has gained widespread use in detecting drug-impaired driving. In this study, we have devised a method for direct sampling using a carbon fiber bundle combined with flame ionization mass spectrometry. The essence of this method lies in the synergy between the adsorption properties of carbon fiber and the plasma characteristics of the flame. Leveraging the strong adsorption capabilities of the carbon fiber bundle allows for the use of a minimal sample size (<100 μL) during sampling, presenting a distinct advantage in the roadside inspection and sampling process. Throughout the flame ionization process, proteins and salts within the oral fluid matrix adhere well to the carbon fiber bundle, while small molecule targets can be efficiently desorbed and react with charged species in the flame, leading to ionization. The results demonstrate the successful development of carbon fiber-sampling combined flame ionization mass spectrometry, capable of qualitative and quantitative analysis of drugs in oral fluid without the need for sample pre-treatment. Its quantitative capabilities are sufficient for real sample detection, providing an effective analytical method for the roadside detection of drugs in oral fluids.

Alcohol and drug presence in traffic crash fatalities before and after the COVID-19 pandemic: Evaluation of the fatality analysis reporting system (FARS) and linked medical examiner-vital records data in Clackamas, Multnomah, and Washington County, Oregon, 2019-2021

Traffic fatalities, with and from increased risky behaviors (reduced seat belt use, increased impairment from licit and illicit substances), have been increasing, especially during the COVID-19 pandemic. Death certificates are a major source of epidemiologic data in the United States, but have known underreporting of drug and alcohol presence. The Fatality Analysis Reporting System (FARS) is one major source of data on fatal crashes with intoxication. This study links FARS data for three counties in Oregon (2019-2021) with local medical examiner and death certificate data (FARS source data) and compares their concordance with blood alcohol concentration and toxicology for three major drug classes by year. For drivers only, our study finds good concordance between FARS and its source data in 2019 but poor concordance in 2020. This discordance may impact future analysis of impaired crash deaths, and we list some suggestions for amelioration.

Blood alcohol concentration and road accidents: Underestimation due to time of the arrival to the emergency department (ED) or delay in blood sampling. A 4-Year Retrospective Study in Rome

Alcohol is a significant public health issue, according to the World Health Organization. Our study aims to analyze the correlation between blood alcohol concentrations (BACs) of drivers, their demographic features, and the possible underestimation of BACs due to the time elapsed between hospital admission and blood sampling. Methods: This study includes patients evaluated for BAC levels in the emergency department (ED) of Fondazione Policlinico Universitario A. Gemelli IRCCS from January 2013 to December 2016. BAC levels were compared in patients involved in road crashes according to age group, sex, and time of the accident. The delays in blood sampling and BAC measurement in the ED were recorded for each patient. The time between the accident and access to the hospital in most cases was unknown. Results: A total of 398 patients were included in the analysis, 107 of them had BACs more than 0.05 g/L., and 86 of these individuals had BAC levels more than 0.5 g/L. Road accident patients had higher rates of positive BAC readings at night and on weekends. A significant delay in blood sampling for BAC determination was observed. Discussion: This study demonstrates a critical bias due to the arrival time at the ED and the delay in blood sampling that inevitably influences and underestimates the BAC, resulting in possible false negative results (BAC values below the cutoff). Zero tolerance or a retrospective BAC calculation could mitigate this bias. It is necessary to implement preventive strategies to reduce instances of driving under the influence (DUI) of alcohol.