Geographical mapping of road traffic injuries in Lilongwe, Malawi.

BACKGROUND: Road traffic injuries are a leading cause of death and disability, especially in low- and middle-income countries. Identifying injury hotspots are valuable for introducing preventive measures. This is usually accomplished by using police data, but these are often unreliable in low-income countries. This study aimed to identify hotspots for injuries by collecting geographical data in the emergency room. METHODS: This was a cross-sectional study of adult road traffic injury patients presenting to the Casualty Department in the central hospital in Lilongwe, the capital of Malawi. An electronic tablet with downloaded maps and satellite photos was used to establish the exact location of the injuries. The geographical data were analyzed with geographic information software. RESULTS: We included 1244 road traffic injured patients, of which 23.9% were car passengers or drivers, 18.6% were motorcyclists, 17.8% were pedestrians and 18.0% were cyclists or bicycle passengers. Heatmaps of the injuries identified 5 locations where the incidence of injuries was especially high, and 148 patients were injured in these hotspots during the 90 days of inclusion. Four of these hotspots were along the main road through the capital. Age over 55, rural setting, alcohol use before the injury, high speed limit at the site of injury and being a pedestrian or motorcyclist were significantly associated with a higher degree of injury severity. Around half of the patients that were injured in a four-wheeled vehicle did not use a seat belt, and these patients had a much higher risk of getting a more severe injury. CONCLUSION: We have identified specific locations with a high incidence of road traffic injuries in Lilongwe, Malawi, with a simple methodology and within a short time frame. The study demonstrates the feasibility of collecting geographical data at admission to hospital.

Prevalence of alcohol use among road traffic crash victims presenting to a Malawian Central Hospital: A cross-sectional study.

BACKGROUND: Alcohol consumption is a well-known risk factor for sustaining road traffic injuries worldwide. Malawi is a low-income country with a large and increasing burden of road traffic injuries. It has generally been viewed as a country with relatively little alcohol consumption. This study investigates the role of alcohol in road traffic injuries in and around the capital Lilongwe. METHODS: All patients presenting to the emergency department of Kamuzu Central Hospital after being injured in road traffic crashes were asked to participate in the study. Alcohol testing was done with a breathalyzer or a saliva test. Participants were asked about alcohol use before the injury as well as hazardous drinking using the AUDIT-C questionnaire. RESULTS: Of 1347 patients age 18 years or older who were asked to participate, 1259 gave informed consent, and data on alcohol use (alcohol test results and/or self-reported intake) were available for 1251 participants. Of those, 251 (20.1%) tested positive for alcohol, whereas 221 (17.7%) reported alcohol use before the crash; in total 311 (24.9%, 95% CI 22.5-27.3) either tested positive, reported use, or both. Females had a low prevalence of alcohol use (2.5%), while 30.6% of males had consumed alcohol before the injuries. Pedestrians had the highest prevalence at 41.8% (95% CI 35.5-48.4), while car drivers had 23.8% (95% CI 18.2-30.5). Among male pedestrians, 49.5% had used alcohol before the injury. Alcohol-associated injuries had a peak in the evening and at night, especially in the weekends. Of the patients, 63.1% reported that they had not consumed alcohol during the last year, while 21.4% had an AUDIT-C score suggesting hazardous drinking, and 66.2% of those had used alcohol before the injury. CONCLUSIONS: A large percentage of road traffic injured patients had been drinking alcohol before their injury, especially male pedestrians. A large proportion of the patients were abstaining from alcohol, but those not abstaining had a high prevalence both of alcohol use when injured and hazardous drinking identified by AUDIT-C. This has important implications for prevention.

The implementation of per-se limits for driving under the influence of benzodiazepines and related drugs: No increased risk for arrest during therapeutic use in Norway.

Objective: To investigate whether the use of recommended therapeutic doses of medicinal drugs has led to suspicion of driving under the influence of drugs (DUID) after implementation of legislative limits for illicit and medicinal drugs in 2012.Methods: Data from suspected drug-impaired drivers apprehended by the police from 2013 to 2015 were selected from the Norwegian Forensic Toxicology Database. The blood samples had been analyzed for benzodiazepines (BZDs), z-hypnotics, opioids, stimulants, certain hallucinogens, and alcohol. Drivers who tested positive for one BZD or a z-hypnotic only, were included in the study. Drug concentrations measured in their blood samples were compared to the maximal obtainable steady state concentrations if the drug had been used in accordance with the recommendations set by the Norwegian Directorate of Health.Results: BZDs or z-hypnotics were found in 10 248 samples, representing 59.6% of the total number of drivers arrested for suspected DUID (n = 17 201). Only one BZD or z-hypnotic with a blood drug concentration above the legislative limit was detected in 390 (2.3%) of the total number of samples. Clonazepam was the most frequently detected BZD (n = 4656), while as a single drug above the legislative limit, it was detected in only 3.6% (n = 168) of the clonazepam-positive blood samples. For drivers testing positive for only one z-hypnotic, drug concentrations above the legislative limit were found in 27% (n = 55) of the blood samples that tested positive for zolpidem and 12.4% (n = 53) of the samples that tested positive for zopiclone. In total, 155 subjects out of 10 248 testing positive for BZDs or z-hypnotics displayed concentrations above the legislative limit but within the concentration ranges that are expected when taking recommended therapeutic drug doses, and 77 below the legislativel limit.Conclusions: The results show that the implementation of legislative limits for BZDs and z-hypnotics may have contributed to DUID suspicion for a small group of patients using therapeutic drug doses; only 1.3% of the suspected DUID offenders had concentrations of only one of those drugs in-line with recommended therapeutic dosing.

Adult pedestrian and cyclist injuries in Lilongwe, Malawi: a cross-sectional study.

Background: Pedestrian and cyclist injuries are a major concern globally, but especially in low-income countries. Locally conducted research is needed to measure the size of the problem and advise policy on road safety interventions. We wanted to investigate the precise circumstances of these injuries in Lilongwe, Malawi and to identify risk factors for severe injuries. Methods: Cross-sectional study of all adult pedestrian and cyclist injuries presenting to a large central hospital. This was a sub-study of a larger study with all types of road users included. All patients provided detailed information about the incidents leading to injury and were tested for alcohol. Results: There were 222 pedestrians, 183 bicycle riders and 42 bicycle passengers among the 1259 adult road traffic injury victims that were treated at Kamuzu Central Hospital during a 90-day period in 2019. Of these injuries, 60.2% occurred while the victim was walking/cycling along the road and 22.3% when the victim was trying to cross the road. The majority of the victims were men (89.1%). Helmet use for bicyclists was almost non-existent. Only 1 patient had used reflective devices when injured in the dark, despite 44.7% of these injuries occurring in reduced light conditions. There was an increased risk for serious and fatal injuries for pedestrians compared with bicyclists, and also compared with all types of road users. Patients injured in rural areas and those hit by lorries were more severely injured. Consuming alcohol before being injured was associated with more severe injuries in bicyclists. Being injured while crossing the road at painted zebra crossings was associated with an increased risk of serious and potentially fatal injuries. Conclusion: This study identified important risk factors for severe injuries in pedestrians and cyclists. Implications for preventive measures are presented in a Haddon Matrix.

Extended Detection of Amphetamine and Methamphetamine in Oral Fluid.

BACKGROUND: Amphetamine and methamphetamine are popular drugs of abuse worldwide and are important components of drug monitoring programs. Windows of detection for amphetamine and methamphetamine in oral fluid after high doses have not been investigated. Repeated high-dose ingestions are likely to cause positive samples for extended periods. Common routes of administration of amphetamine/methamphetamine in Norway are oral intake or injection. The aim of this study was to investigate windows of detection for amphetamine and methamphetamine in oral fluid from drug addicts under sustained abstinence during detoxification. METHODS: Twenty-five patients admitted to a closed detoxification unit were included in this study. Oral fluid samples were collected daily in the morning and evening, and urine every morning for 10 days. A blood sample was drawn during the first 5 days after admission if the patient consented. Oral fluid results were compared with urine results to determine whether a new ingestion occurred. Oral fluid was collected with the Intercept oral fluid collection device. In-house cutoff concentrations for amphetamine and methamphetamine were 6.8 and 7.5 mcg/L, respectively, in oral fluid, and 135 and 149 mcg/L, respectively, in urine. RESULTS: Amphetamines were detected in 11 oral fluid, 5 urine, and 2 blood specimens from 25 patients. Patients self-reported amphetamines intake of up to 0.5-2 g daily. Windows of detection for amphetamine and methamphetamine in oral fluid were up to 8 days, longer than in urine at the applied cutoff values. CONCLUSIONS: These data confirm that oral fluid is a viable alternative to urine for monitoring amphetamine abuse, and that these substances might be detected in oral fluid for at least 1 week after ingestion of high doses. Such long detection times were, as far as we are aware, never reported previously for oral fluid amphetamines.

Use of alcohol and drugs by employees in selected business areas in Norway: a study using oral fluid testing and questionnaires.

BACKGROUND: Alcohol or drug use and associated hangover may reduce workplace safety and productivity and also cause sickness absence. The aims of this study were to examine (i) the use of alcohol and drugs, and (ii) reduced efficiency at work and absence due to such use among employees. METHODS: Forty-four companies were invited; half of them agreed to participate. Employees filled in a questionnaire and provided a sample of oral fluid, which was analysed for alcohol, 12 psychoactive medicinal drugs and 6 illicit drugs. Participation was voluntary and anonymous. RESULTS: Two thousand four hundred thirty-seven employees in eight business areas agreed to participate (92 % of those invited). By combining questionnaires and oral fluid testing, we found that 5.2 % had used psychoactive medication during the last couple of days, 1.4 % had used illicit drugs, 17.0 % had used alcohol during the last 24 h but only one person (0.04 %) was positive for alcohol in oral fluid. About 25 % reported reduced efficiency at work, and 5 % reported absence from work due to alcohol use during the past 12 months. The use of illicit drugs and binge drinking resulting in reduced efficiency and absence was most common among restaurant and bar workers and more common among men than women, whereas use of psychoactive medication was most common among healthcare, transportation and storage workers. CONCLUSION: Impairment at work due to alcohol or drugs was rare, whereas reduced efficiency due to drinking was reported by a fairly large proportion. There were marked differences between some business areas, and across gender.

Prevalence of alcohol and drugs among motorcycle riders killed in road crashes in Norway during 2001-2010.

The aim of the study was to examine the prevalence of alcohol and drugs in blood samples from motorcycle riders who died in road crashes in Norway from 2001 to 2010. An additional aim was to compare the prevalence of alcohol and drugs in blood samples from fatally injured motorcycle riders and car drivers who died during the same time period. Blood samples from motorcycle riders who died within 24h after the accident (n=207, 63% of all killed riders), were analysed for alcohol, psychoactive drugs (medicinal and illicit drugs). The cut-off concentrations for alcohol and drugs findings in blood samples (i.e., the drug concentrations above which a finding was regarded as positive) were set according to the legislative limits under the Norwegian Road Traffic Act. Results were assessed in relation to age, sex, time of the day and week, and single versus multiple-vehicle accidents. Alcohol or drugs were found in 27.1 percent of all investigated riders. For riders killed in single or multiple-vehicle accidents, alcohol or drugs were found in 44.6 and 15.3 percent, respectively. Alcohol was the most frequently found substance for all age groups and most prevalent in samples from riders below 25 years who died in single-vehicle accidents (45.8 percent). Drugs were most often found among riders between 25 and 34 years (19.6 percent in total and 25.9% for those killed in single-vehicle crashes). The prevalence of alcohol or drugs was highest among riders killed in single-vehicle accidents during weekend days and nights (60.9 and 65.2 percent). Alcohol and drugs were less often found in samples from killed motorcycles riders than in samples from car and van drivers (40.2 percent). For single-vehicle accidents, the total prevalence of alcohol or drugs among killed motorcycles riders and car drivers was 44.6 percent and 63.8 percent, respectively. The same pattern of alcohol and drugs was found among the two groups, except that the prevalence among motorcycle riders was lower compared to car drivers in all age groups and time periods, which may be related to the fact that they are more vulnerable for fatal injury compared to car drivers in similar accidents.

Determination of a selection of anti-epileptic drugs and two active metabolites in whole blood by reversed phase UPLC-MS/MS and some examples of application of the method in forensic toxicology cases.

Quantitative determination of anti-epileptic drug concentrations is of great importance in forensic toxicology cases. Although the drugs are not usually abused, they are important post-mortem cases where the question of both lack of compliance and accidental or deliberate poisoning might be raised. In addition these drugs can be relevant for driving under the influence cases. A reversed phase ultra-performance liquid chromatography-tandem mass spectrometry method has been developed for the quantitative analysis of the anti-epileptic compounds carbamazepine, carbamazepine-10,11-epoxide, gabapentin, lamotrigine, levetiracetam, oxcarbazepine, 10-OH-carbazepine, phenobarbital, phenytoin, pregabalin, and topiramate in whole blood, using 0.1 mL sample volume with methaqualone as internal standard. Sample preparation was a simple protein precipitation with acetonitrile and methanol. The diluted supernatant was directly injected into the chromatographic system. Separation was performed on an Acquity UPLC® BEH Phenyl column with gradient elution and a mildly alkaline mobile phase. The mass spectrometric detection was performed in positive ion mode, except for phenobarbital, and multiple reaction monitoring was used for drug quantification. The limits of quantification for the different anti-epileptic drugs varied from 0.064 to 1.26 mg/L in blood, within-day and day-to-day relative standard deviations from 2.2 to 14.7% except for phenobarbital. Between-day variation for phenobarbital was 20.4% at the concentration level of 3.5 mg/L. The biases for all compounds were within ±17.5%. The recoveries ranged between 85 and 120%. The corrected matrix effects were 88-106% and 84-110% in ante-mortem and post-mortem whole blood samples, respectively.

Detection Times of Diazepam, Clonazepam, and Alprazolam in Oral Fluid Collected From Patients Admitted to Detoxification, After High and Repeated Drug Intake.

BACKGROUND: Clonazepam, diazepam, and alprazolam are benzodiazepines with sedative, anticonvulsant, and anxiolytic effects, but their prevalence in drug abuse and drug overdoses has long been recognized. When detection times for psychoactive drugs in oral fluid are reported, they are most often based on therapeutic doses administered in clinical studies. Repeated ingestions of high doses, as seen after drug abuse, are however likely to cause positive samples for extended time periods. Findings of drugs of abuse in oral fluid collected from imprisoned persons might lead to negative sanctions, and the knowledge of detection times of these drugs is thus important to ensure correct interpretation. The aim of this study was to investigate the time window of detection for diazepam, clonazepam, and alprazolam in oral fluid from drug addicts admitted to detoxification. METHODS: Twenty-five patients with a history of heavy drug abuse admitted to a detoxification ward were included. Oral fluid was collected daily in the morning and the evening and urine samples every morning for 10 days, using the Intercept device. Whole blood samples were collected if the patient accepted. The cutoff levels in oral fluid were 1.3 ng/mL for diazepam, N-desmethyldiazepam, and 7-aminoclonazepam and 1 ng/mL for clonazepam and alprazolam. In urine, the cutoff levels for quantifications were 30 ng/mL for alprazolam, alpha-OH-alprazolam, and 7-aminoclonazepam, 135 ng/mL for N-desmethyldizepam, and 150 ng/mL for 3-OH-diazepam and for all the compounds, the cutoff for the screening analyses were 200 ng/mL. RESULTS: The maximum detection times for diazepam and N-desmethyldiazepam in oral fluid were 7 and 9 days, respectively. For clonazepam and 7-aminoclonazepam, the maximum detection times in oral fluid were 5 and 6 days, respectively. The maximum detection time for alprazolam in oral fluid was 2.5 days. New ingestions were not suspected in any of the cases, because the corresponding concentrations in urine were decreasing. Results from blood samples revealed that high doses of benzodiazepines had been ingested before admission, and explains the longer detection times in oral fluids than reported previously after intake of therapeutic doses of these drugs. CONCLUSIONS: This study has shown that oral fluid might be a viable alternative medium to urine when the abuse of benzodiazepines is suspected.

Prevalence of alcohol and drugs among car and van drivers killed in road accidents in Norway: an overview from 2001 to 2010.

OBJECTIVES: To examine the prevalence of alcohol and drugs in blood samples collected from car and van drivers killed in traffic accidents in Norway during the time period from 2001 to 2010. METHODS: Blood samples (n = 676, 63% of all killed drivers) were analyzed for alcohol, psychoactive medications, and illicit drugs. The cutoff limits for positive results were set according to the new legislative limits under the Norwegian Road Traffic Act. The results were assessed in relation to sex and age, time of day and day of week, and single- versus multiple-vehicle and all investigated vehicle accidents. RESULTS: Alcohol or one or more drugs was detected in samples from 40.2 percent of all investigated drivers, with 28.7 percent showing blood concentrations of at least 5 times the legislative limits. For the investigated female drivers, the total prevalence was 24.0 percent. Among the single-vehicle accidents, alcohol or drugs was found in 63.8 percent of the cases, with 49.1 percent showing blood concentrations of at least 5 times the legislative limits. Alcohol was detected in 25.3 and 49.1 percent of samples from all investigated drivers and among drivers killed in single-vehicle accidents, respectively. Psychoactive medications were found in 14.4 and 17.7 percent and illicit drugs in 14.1 and 19.2 percent, respectively. The most commonly detected group of medications was benzodiazepines, and amphetamines and tetrahydrocannabinol were the most commonly detected illicit drugs. The prevalence of alcohol alone was highest among drivers under the age of 25, and the combination of alcohol with other drugs was highest among drivers under the age of 35. Drivers between the ages of 25 and 54 showed the highest prevalence of medications and/or illicit drugs without the presence of alcohol. The highest prevalence of alcohol or drugs was found among drivers killed in single-vehicle accidents on weeknights (83.8%) and on weekend nights (89.3%). CONCLUSIONS: The findings confirm that a large number of fatally injured drivers, in particular among drivers involved in single-vehicle accidents, had concentrations of alcohol or drugs above the new legislative limits introduced in 2012. In many cases, concentrations of at least 5 times the limits were found. The proportion of drivers killed who tested positive for alcohol or other drugs did not change during the study period; however, the total number of drivers killed per year decreased by about 20 percent. Some changes were also observed with regard to the types of benzodiazepines and amphetamines detected during the 10-year period.

Detection time for THC in oral fluid after frequent cannabis smoking.

BACKGROUND: The use of oral fluid for detecting drugs of abuse has become increasingly more frequent. Few studies have, however, investigated the detection times for drugs of abuse in oral fluid, compared with that of in urine or in blood. Cannabis is the world's most widely used drug of abuse, and the detection times for cannabis, in different types of matrixes, are therefore important information to the laboratories or institutions performing and evaluating drugs of abuse analyses. It is well known that frequent use of high dosages of cannabis, for longer periods of time, might lead to prolonged detection times for THC-COOH in urine. Cannabis intake is detected in oral fluid as THC, and a positive finding is considered to be a result of recent smoking, although some studies have already reported longer detection times. The aim of this study was to investigate the detection time for THC in oral fluid, collected from drug addicts admitted for detoxification. Findings in oral fluid were compared with findings in urine, among 26 patients admitted to a closed detoxification unit. METHODS: The study, being the first in doing so, describes the concentration-time profiles for THC in oral fluid among chronic cannabis users, during monitored abstinence, using the Intercept collection kit. The study also includes the concentration-time profiles for creatinine-corrected THC-COOH ratios in urine samples, included to monitor for the possibility of new intakes. RESULTS: THC was detected in oral fluid collected from 11 of the 26 patients in the study. The elimination curves for THC in oral fluid revealed that negative samples could be interspersed among positive samples several days after cessation, whereas the THC-COOH concentrations in urine were decreasing. THC was, in this study, detected in oral fluid for up to 8 days after admission. CONCLUSIONS: The study shows that frequent use of high dosages of cannabis may lead to prolonged detection times, and that positive samples can be interspersed among negative samples. These results are of great importance when THC results from oral fluid analyses are to be interpreted.

A comparison of alcohol and drug use by random motor vehicle drivers in Brazil and Norway.

BACKGROUND: A large proportion of road traffic crashes are related to driving under the influence (DUI) of alcohol or drugs. The aim of this study was to compare the use of alcohol, illegal drugs and psychoactive medicinal drugs among random drivers in Brazil and Norway, two countries with the same legal limit for drunk driving, but with marked differences in legislation history, enforcement and penalties for DUI, and to discuss any differences found. METHODS: Roadside surveys were conducted on Fridays and Saturdays between noon and midnight. Samples of oral fluid were collected for analysis of drugs, whereas alcohol was determined by breath testing or by analysis of oral fluid. RESULTS: High participation rates of 94-97% were obtained in both countries. The weighted prevalence of driving with alcohol concentrations in breath or oral fluid equivalent to blood alcohol concentrations (BAC) above 0.2g/L was 2.7% (95% CI 2.2-3.3) in Brazil and 0.2% (95% CI 0.0-0.5) in Norway. Stimulants (amphetamines or cocaine) were found in samples from 1.0% (95% CI 0.7-1.4) of drivers in Brazil and 0.3% (95% CI 0.1-0.7) in Norway. The prevalence of amphetamines was highest among Brazilian truck drivers (3.6%; 95% CI 2.0-6.4). Tetrahydrocannabinol was found in samples from 0.5% (95% CI 0.3-0.8) of drivers in Brazil and 1.0% (95% CI 0.6-1.5) in Norway, whereas benzodiazepines or zopiclone were found in 1.0% (95% CI 0.7-1.4) and 1.7% (95% CI 1.2-2.4) of the samples from Brazil and Norway, respectively. CONCLUSIONS: The difference in the prevalence of alcohol may be related to the fact that Norway has implemented steps to reduce drunk driving since 1936, whereas Brazil has attempted to do the same for only a few years. Differences for drugs may be related to different patterns in the use of stimulants, cannabis and medicines.

Analyses of beverage remains in drug rape cases revealing drug residues--the possibility of contamination from drug concentrated oral fluid or oral cavity contained tablets.

In drug-facilitated sexual assault (DFSA) cases, drug residues may be detected in beverage remains found in cups or glasses known to have been used by the victims. In this small naturalistic study, the possibility of beverages being contaminated, either by drug concentrated oral fluid or by oral cavity contained tablets, was investigated. Analysis of residues from cups containing soft drinks was performed by immunoassay and ultra-performance liquid chromatography-mass spectrometry (UPLC-MS/MS). Beverage with both added tablets and spiked oral fluid was investigated, as well as simulation of swallowing tablets. Only the residues from added tablets were positive with immunoassay, while drugs were detectable in all cups using more sensitive UPLC-MS/MS. In conclusion, the possibility of detecting drug residues in beverages due to a contamination, from either drug concentrated oral fluid or oral cavity contained tablets at a time of consumption, should be kept in mind when performing sensitive analysis.

Screening of synthetic cannabinoids in preserved oral fluid by UPLC-MS/MS.

BACKGROUND: The abuse of a rapidly changing range of synthetic cannabinoids is increasing worldwide. Oral fluid, which contains the parent compounds and is easily collected, could be a good alternative medium for drug screening for synthetic cannabinoids. RESULTS: A method for screening of 18 synthetic cannabinoids in preserved oral fluid collected with the Intercept® collection device, using UPLC-MS/MS, was validated. Limits of quantification ranged from 0.2 to 2 ng/ml in oral fluid. In several real cases, AM-2201 and/or JWH-018 were found. CONCLUSION: The presented method allowed rapid and sensitive screening of synthetic cannabinoids in preserved oral fluid collected with the Intercept collection device.

Methyl tert-butyl ether (MTBE) detected in abnormally high concentrations in postmortem blood and urine from two persons found dead inside a car containing a gasoline spill.

Two deep frozen persons, a female and a male, were found dead in a car. There had been an explosive fire inside the car which had extinguished itself. On the floor inside the car were large pools of liquid which smelled of gasoline. The autopsy findings and routine toxicological analyses could not explain the cause of death. Carboxyhemoglobin levels in the blood samples were <10%. Analysis with a headspace gas chromatography revealed methyl tert-butyl ether (MTBE) concentrations of 185 mg/L (female victim) and 115 mg/L (male victim) in peripheral blood. The urine MTBE concentrations were 150 mg/L and 256 mg/L, respectively. MTBE is a synthetic chemical which is added to gasoline as a fuel oxygenate. Gasoline poisoning is likely to be the cause of the death in these two cases, and MTBE can be a suitable marker of gasoline exposure, when other volatile components have vaporized.

Norwegian roadside survey of alcohol and drug use by drivers (2008-2009).

OBJECTIVE: To examine alcohol and drug use among random drivers in different regions of Norway by analyzing oral fluid, compare drivers in urban and rural areas, compare with results from the roadside survey in southeastern Norway in 2005-2006, and roughly estimate the prevalence of driving with blood drug concentrations above the new Norwegian legislative limits among random drivers. This roadside survey was part of the European DRUID (Driving Under the Influence of Drugs, Alcohol and Medicines) Project. METHODS: Drivers were selected for a voluntary and anonymous study using a stratified multistage cluster sampling procedure in collaboration with the Mobile Police Service. Samples of oral fluid were taken using the Statsure Saliva Sample (Statsure Diagnostic Systems, Framingham, MA), and the drivers' gender, age, and nationality were recorded. Samples of oral fluid were analyzed for alcohol or drugs, for a total 28 psychoactive substances. RESULTS: One hundred eighty-four roadside survey sessions were conducted and 10,004 drivers were asked to participate. The refusal rate was 5.8 percent. Psychoactive substances were found in 4.8 percent of the 9410 oral fluid samples analyzed. Alcohol was detected in 0.3 percent, medicinal drugs in 3.2 percent, and illegal drugs in 1.5 percent of the samples. Illegal drugs were significantly more frequently detected in samples from southeastern Norway including the capital Oslo, whereas medicinal drugs were more frequently detected in samples from southeastern Norway excluding Oslo. Illegal drugs were significantly more frequently detected in samples from drivers in urban areas than in rural areas, though there were no significant differences for alcohol and medicinal drugs. Medicinal drugs were most commonly found in samples collected during the daytime on weekdays (3.8%), and illegal drugs were most commonly found in samples collected during late night on weekdays or weekends (2.8%-3.2%). The most commonly found substances were the sleeping agent zopiclone (1.4%), the main active substance in cannabis tetrahydrocannabinol (1.1%), and the sedative drug diazepam (0.7%). The prevalence of driving with drug concentrations above the Norwegian legislative limits for blood was estimated to be about 0.2 percent for alcohol, 0.6 percent for illegal drugs, and about 1.3 percent for medicinal drugs. CONCLUSIONS: The incidence of drink driving was very low, though driving after using psychoactive illegal or medicinal drugs was more frequent.

Analysis of alcohol and drugs in oral fluid from truck drivers in Norway.

OBJECTIVE: To examine alcohol and drug use among truck drivers compared to car or van drivers in Norway by analyzing samples of oral fluid. METHODS: Drivers were selected for a voluntary and anonymous study using a stratified multistage cluster sampling procedure. Drivers of trucks were recruited at two control stations for heavy vehicles in southeastern Norway in collaboration with the Norwegian Roads Administration, and drivers of cars and vans were recruited in a roadside survey in collaboration with the mobile police service. Samples of oral fluid were taken by using the Statsure Saliva Sampler (Statsure Diagnostic Systems, Framingham, MA), and the drivers' gender, age, and nationality were recorded. Samples of oral fluid were analyzed for alcohol or drugs, in total 28 psychoactive substances. RESULTS: About 97 percent of the truck drivers and 94 percent of the car or van drivers agreed to participate in the study. Of the 882 studied truck drivers studied, 1.4 percent were female and 29.1 percent were Norwegian; of the 5305 car or van drivers, 27.6 percent were female and 90.9 percent were Norwegian. Alcohol or drugs were found in 1.9 and 6.6 percent of the samples from truck drivers and car/van drivers, respectively. The adjusted odds ratio (OR) for the detection of a psychoactive substance in a sample from a truck driver compared to car or van driver was 0.29; the 95 percent confidence interval (95% CI) was 0.17 to 0.53. The adjusted OR for the detection of an illegal drug was 0.42 (95% CI: 0.18-0.82), the adjusted OR for the detection of a psychoactive medicinal drug was 0.29 (95% CI: 0.13-0.68), and the adjusted OR for the detection of alcohol was 0.13 (95% CI: 0.02-1.10). CONCLUSIONS: The proportion of oral fluid samples containing psychoactive substances was lower for truck drivers than for car or van drivers.

[Effect and occurrence of synthetic cannabinoids]. / Syntetiske cannabinoider--effekt og forekomst.

BACKGROUND: ''Spice'' is the term used for various products that contain synthetic cannabinoids. In recent years a growing number of products have been reported on the illegal market, also in Norway. The substances are sold over the internet as 'legal' cannabis. A number of the substances have gradually been classified as narcotics, also in Norway, but new variants continue to be developed. An overview is provided here of current knowledge of the efficacy and occurrence of synthetic cannabinoids. METHOD: The article is based on a discretionary selection of relevant articles found by means of a literature search in PubMed and on reports from Norwegian and European authorities and research institutions. RESULTS: Synthetic cannabinoids are a large group of drugs of abuse that have an effect similar to cannabis, but may be considerably more potent. The contents of the various Spice products vary with respect to potency, purity and the number and types of additives, and this implies a risk of unintentional overdose. There are reports from abroad of cardiac infarction in teenagers, severe psychoses, anxiety, unconsciousness and deaths following use. INTERPRETATION: Synthetic cannabinoids are marketed over the internet as legal and harmless cannabis, but can cause severe intoxication and death. There is a considerable need for more knowledge about the action and harmful effects of these substances.

Morphine to codeine concentration ratio in blood and urine as a marker of illicit heroin use in forensic autopsy samples.

A morphine to codeine ratio greater than unity (M/C>1) has been suggested as an indicator of heroin use in living individuals. The aim of this study was to examine the morphine to codeine ratio in a large population (N=2438) of forensically examined autopsy cases positive for 6-monoacetylmorphine (6-MAM) and/or morphine in blood and/or urine. Blood and urine concentrations of 6-MAM, morphine and codeine were examined using GC-MS and LC-MS/MS methods. In 6-MAM positive samples, the M/C ratio was greater than unity in 98% (N=917) of the blood samples and 96% (N=665) of the urine samples. Stratification of 6-MAM negative cases by M/C above or below unity revealed similarities in morphine and codeine concentrations in cases where M/C>1 and 6-MAM positive cases. Median blood and urine morphine concentrations were 8-10 times greater than codeine for both groups. Similarly to 6-MAM positive cases, 25-44 year-old men prevailed in the M/C>1 group. In comparison to cases where M/C ≤ 1, the M/C ratio was a hundred times higher in both 6-MAM positive and M/C>1 cases. The range of morphine concentration between the lowest and the highest quintile of codeine in M/C>1 cases was similar to that in 6-MAM positive cases. This range was much higher than for M/C ≤ 1 cases. Moreover, linear regression analyses, adjusted for age and gender, revealed a strong positive association between morphine and codeine in 6-MAM positive and M/C>1 cases. The M/C ratio appeared to be a good marker of heroin use in post-mortem cases. Both blood and urine M/C>1 can be used to separate heroin users from other cases positive for morphine and codeine.