Driving under the influence of cocaine and MDMA: Relationship between blood concentrations and results from clinical test of impairment.

The general use of cocaine is increasing in recent years, while the trend for 3,4-methylenedioxymethamphetamine (MDMA) is less clear. The relationship between blood concentrations and impairment is poorly understood, which complicates interpretation. The aims of this study were to report prevalence and blood concentrations of cocaine and MDMA in drugged drivers, and to investigate the relationship between blood concentrations and impairment. Samples of whole blood were collected from apprehended drivers in the period 2000-2022, and a clinical test of impairment (CTI) was simultaneously performed. The samples were initially analyzed for cocaine and MDMA using gas chromatography-mass spectrometry (until 2009 and 2012, respectively), and later using ultra-high-performance liquid chromatography-tandem mass spectrometry. Overall, cocaine was detected in 2,331 cases and MDMA in 2,569 cases. There were 377 and 85 mono cases of cocaine and MDMA, respectively. In the mono cases, the median cocaine concentration was 0.09 mg/L (range: 0.02-1.15 mg/L), and 54% of the drivers were clinically impaired. The median MDMA concentration was 0.19 mg/L (range: 0.04-1.36 mg/L), and 38% were clinically impaired. There was a statistically significant difference in the median cocaine concentration between drivers assessed as not impaired (0.07 mg/L) and drivers assessed as impaired (0.10 mg/L) (P = 0.009). There was also a significant effect of the blood concentration of cocaine (adjusted odds ratio [aOR] = 6.42, 95% confidence interval [CI] = 1.13-36.53, P = 0.036) and driving during the evening/night-time (aOR = 2.17, 95% CI = 1.34-3.51, P = 0.002) on the probability of being assessed as impaired on the CTI. No significant differences were found for MDMA. Many drivers are not assessed as impaired on a CTI following cocaine or especially MDMA use. For cocaine, a relationship between blood concentrations and impairment was demonstrated, but this could not be shown for MDMA.

All-cause and cause-specific mortality among individuals imprisoned for driving under the influence of alcohol and drugs in Norway (2000-2016): a retrospective cohort study.

AIMS: To describe all-cause and cause-specific mortality and to investigate factors associated with mortality among individuals imprisoned for driving under the influence (DUI) of alcohol and psychoactive drugs in the Norwegian prison population. DESIGN: Retrospective cohort study. The Norwegian prison registry was linked to the Norwegian Cause of Death Registry (2000-2016). SETTING: Norway. PARTICIPANTS/CASES: The cohort consisted of 96 856 individuals imprisoned in Norway over a 17-year period obtained from the Norwegian prison registry. PRIMARY AND SECONDARY OUTCOME MEASURES: Adjusted ORs (aOR) with 95% CI were calculated for death due to any, natural and unnatural causes of death. Analyses were stratified according to DUI convictions: no DUI convictions, only DUI convictions (DUI only), DUI and at least one other drug and alcohol conviction (DUI drug), and DUI and at least one conviction other than drug and alcohol conviction (DUI other). RESULTS: In total, 29.3% individuals had one or more imprisonments for DUI. The risk of all-cause mortality was elevated for those convicted for DUI, but only in combination with other types of crimes (DUI drug: aOR=1.5, 95% CI 1.4 to 1.6, DUI other: aOR=1.2, 95% CI 1.1 to 1.4). The risk of death from natural causes was significantly elevated for DUI drug (aOR: 1.8, 95% CI 1.6 to 2.0) and for DUI other (aOR=1.3, 95% CI 1.1 to 1.6). The risk of death from unnatural causes was lower for DUI only (aOR=0.8, 95% CI 0.7 to 0.9) and elevated for DUI drug (aOR=1.5, 95% CI 1.3 to 1.6). CONCLUSIONS: The risk of all-cause mortality was significantly elevated for those convicted of DUI, but only in combination with other types of crimes.

Psychoactive substances and previous hospital admissions, triage and length of stay in rural injuries: a prospective observational study.

BACKGROUND: Patients admitted to hospital after an injury are often found to have used psychoactive substances prior to the injury. The aim of this study was to investigate the associations between psychoactive substances (alcohol, psychoactive medicinal drugs and illicit drugs) and previous hospital admissions, triage and length of stay in the arctic Norwegian county of Finnmark. METHODS: Patients ≥ 18 years admitted due to injury to trauma hospitals in Finnmark from January 2015 to August 2016 were approached. Parameters regarding admittance and hospital stay were collected from 684 patients and blood was analysed for psychoactive substances. Using a prospective, observational design, time, triage, length of stay in hospital, use of intensive care unit (ICU), injury severity, Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) and number of previous admittances were investigated by bivariable testing and logistical regression analysis. RESULTS: Of 943 patients approached, 81% consented and 684 were included in the study. During the weekend, 51.5% tested positive for any substance versus 27.1% Monday-Friday. No associations were identified between testing positive and either triage or injury severity for any substance group although triage level was lower in patients with AUDIT-C ≥ 5. Short length of stay was associated with alcohol use prior to injury [odds ratio (OR) 0.48 for staying > 12 h, confidence interval (CI) 0.25-0.90]. The OR for staying > 24 h in the ICU when positive for an illicit substance was 6.33 (CI 1.79-22.32) while negatively associated with an AUDIT-C ≥ 5 (OR 0.30, CI 0.10-0.92). Patients testing positive for a substance had more often previously been admitted with the strongest association for illicit drugs (OR 6.43 (CI 1.47-28.08), compared to patients in whom no substances were detected. CONCLUSIONS: Triage level and injury severity were not associated with psychoactive substance use. Patients using alcohol are more often discharged early, but illicit substances were associated with longer ICU stays. All psychoactive substance groups were associated with having been previously admitted.

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.

Use of alcohol and illicit drugs by trauma patients in Sao Paulo, Brazil.

INTRODUCTION: Alcohol and illicit drugs impair cognitive and psychomotor skills and may thereby increase the risk of involvement in a road traffic crash and other types of injuries. However, the knowledge on the use of psychoactive substances among injured patients presenting to emergency departments in low and middle-income countries remains limited. AIMS: To estimate the prevalence of alcohol and illicit drug use among patients with traumatic injuries admitted to an emergency department in Sao Paulo, Brazil. METHODS: Blood samples from injured patients requiring hospitalization for more than 24 h due to road traffic crashes, falls, or violence, were collected from July 2018 to June 2019. The samples were analyzed for alcohol and illicit drugs. RESULTS: A total of 376 patients were included in this study; the median age was 36 years and 80% of patients were male. The majority (56%) of injuries resulted from road traffic crashes, with approximately half of them being motorcyclists. Alcohol, drugs, or both were detected in 32% of samples. The proportion that tested positive was highest for males (35%), for the age group 18-39 years (41%), for singles (43%), and for patients injured at nighttime (44%). Patients injured due to violence had the highest prevalence of alcohol or drugs in their blood samples (44%). Alcohol was most prevalent (23%), followed by cocaine (12%) and cannabis (5%). CONCLUSION: The use of alcohol and illicit drugs was common among injured patients in Sao Paulo; it was likely a contributing factor in a third of the injurious accidents. Alcohol was the most prevalent substance followed by cocaine and cannabis.

Association between alcohol and drug use and arrest for driving under the influence after crash involvement in a rural area of Norway: a case-control study.

OBJECTIVES: The rate of deaths caused by road traffic crashes is particularly high in rural areas. It has been hypothesised that one factor that may contribute is differences in patterns of alcohol use. The aim was to compare the prevalence of psychoactive substances among crash-involved drivers arrested for suspicion of driving under the influence (DUI) who are tested for alcohol and drugs and recent random drivers in a rural area. Furthermore, we investigated the association between traffic crashes and driving after using alcohol, illicit or medicinal drugs either alone or in combination. METHODS: A case-control study was carried out in which the case group consisted of crash-involved drivers arrested for suspicion of DUI from 2000 to 2015. This group was compared with a control group of randomly selected drivers recruited to a roadside survey in normal traffic from 2014 to 2015. The case group consisted of 612 individuals (542 men and 70 women) and the control group of 3027 individuals (2099 men and 927 women). Drug and alcohol screening was performed on blood samples from the cases and samples of oral fluid from the controls. RESULTS: The proportion of psychoactive substances was 81.7% among cases and 1.6% among the controls. The prevalence of combinations of psychoactive substances was 18% among the cases and 0.3% among the controls. The multivariate regression model analysis identified significant drug interactions. CONCLUSION: The prevalence of alcohol and drugs was high among the crash-involved drivers arrested for suspicion of DUI by the police. In contrast to earlier published research combinations of different psychoactive substances did not increase the OR for traffic crash involvement more than the single drug with highest OR. The statistical methodology presented in this study should be allied in future studies with greater statistical power to confirm these findings.

Prevalence of drugs in oral fluid from truck drivers in Brazilian highways.

Traffic accidents are responsible for 1.25 million deaths worldwide and are the most common cause of death among those aged 15-29 years. In Brazil, traffic accidents caused more than 44,000 deaths in 2014. The use of psychoactive drugs is an important risk factor for being involved in traffic accidents. Previous studies have found that psychoactive substances are commonly used by truck drivers in Brazil to maintain their extensive work schedule and stay awake while driving during nighttime hours. The state of Sao Paulo is one of the most important states regarding goods transportation. Important highways cross through Sao Paulo to other regions from Brazil and to other countries in Latin America. This study aims to determine the prevalence of illicit drug use by truck drivers in the state of Sao Paulo through toxicological analyses of oral fluid. Truck drivers were randomly stopped by police officers on federal roads during morning hours. Oral fluid samples were collected using the Quantisal™ device. In addition, a questionnaire concerning sociodemographic characteristics and health information was administered. Oral fluid samples were screened for amphetamine, cocaine, and tetrahydrocannabinol (Δ9-THC) by ELISA and the confirmation was performed using ultra performance liquid chromatography with tandem mass spectrometry detection (UPLC-MS/MS). Of the 764 drivers stopped, 762 agreed to participate. The participants were driving an average of 614km and 9.4h a day. Of the total samples, 5.2% (n=40) tested positive for drugs. Cocaine was the most frequently found drug (n=21), followed by amphetamine (n=16) and Δ9-THC (n=8). All drivers were men with an average age of 42.5 years. With these results we were able to verify that many truck drivers were still consuming psychoactive drugs while driving, and cocaine was the most prevalent one. This reinforces the need for preventive measures aimed at controlling the use of illicit drugs by truck drivers in Brazil.

Electromembrane extraction of stimulating drugs from undiluted whole blood.

For the first time, electromembrane extraction (EME) of six basic drugs of abuse from undiluted whole blood and post mortem blood in a totally stagnant system is reported. Cathinone, methamphetamine, 3,4-methylenedioxy-amphetamine (MDA), 3,4-methylenedioxy-methamphet-amine (MDMA), ketamine and 2,5-dimethoxy-4-iodoamphetamine (DOI) were extracted from the whole blood sample, through a supported liquid membrane (SLM) consisting of 1-ethyl-2-nitrobenzene (ENB) immobilized in the pores of a hollow fiber, and into an aqueous acceptor solution inside the lumen of the hollow fiber. The SLM acts as a barrier with efficient exclusion of all macromolecules and acidic substances in the sample. Due to the application of the electrical field, only the cationic compounds of interest are extracted efficiently across the membrane, thus providing extremely clean extracts for analysis with liquid chromatography-mass spectrometry, LC-MS. Recoveries in the range 10-30% were obtained from 80 µl whole blood within 5 min extraction time and an applied voltage of 15V across the SLM. The optimized technique was tested on real forensic whole blood samples taken from three forensic autopsy cases and on five forensic whole blood samples from living persons. The results were in agreement with the analysis using standard sample preparation methods (liquid-liquid extraction) performed on the same samples by Norwegian Institute of Public Health (NIPH), Division of Forensic Toxicology and Drug Abuse Research. Evaluation data were acceptable, with limit of detections (LODs) in the range 40-2610 pg/mL, well below concentrations associated with drug abuse; linearites in the range between 10 and 250 ng/mL with r(2) values above 0.9939, and with repeatability (RSD) of 7-32%.