Recommendations for Toxicological Investigation of Drug-Impaired Driving and Motor Vehicle Fatalities-2021 Update.

This report describes updates to the National Safety Council's Alcohol, Drugs and Impairment Division's recommendations for drug testing in driving under the influence of drug (DUID) cases and motor vehicle fatalities. The updates are based on a survey of drug testing practices in laboratories in the USA and Canada, a comprehensive review of the prior recommendations and data and research on drugs most frequently detected in DUID cases. A consensus meeting was held with representative forensic science practitioners and the authors of this report to update recommendations. No changes were made to the Tier I scope; however, there were changes to cutoffs of some analytes for blood, urine and oral fluid. Due to increased prevalence in DUID cases, trazodone and difluoroethane were added to the Tier II scope. For clarification, Tier I cutoffs reflect free concentrations, and hydrolysis is recommended but not required. The consensus panel concluded that urine is an inferior matrix to blood and oral fluid as it may represent historical use or exposure unrelated to observed impairment; therefore, future iterations of these recommendations will not include urine as a recommended matrix. Laboratories currently testing urine should work with traffic safety partners to encourage the use of blood and oral fluid as more appropriate specimens and adjust their capabilities to provide that testing.

Recommendations for Toxicological Investigation of Drug-Impaired Driving and Motor Vehicle Fatalities-2017 Update.

This report describes the outcomes of a process undertaken to review and update the National Safety Council's Alcohol, Drugs and Impairment Division's recommendations for the toxicological investigation of suspected alcohol and drug-impaired driving cases and motor vehicle fatalities. The updates to the recommendations are made based on a survey of practices in laboratories in the USA and Canada performing testing in these cases, consideration of existing epidemiological crash and arrest data, current drug use patterns, and practical considerations of widely available technology platforms in laboratories performing this work. The final recommendations updates are derived from a consensus meeting of experts recruited from survey respondents and the membership of the National Safety Council's Alcohol, Drug and Impairment Division. The principal changes in this round of recommendations include removal of butalbital, phenobarbital, and phencyclidine from Tier I (mandatory) to Tier II (optional) due to changes in prevalence. In addition, buprenorphine, fentanyl, tramadol, and their metabolites were moved from Tier II to Tier I due to increased prevalence and concerns about their potential for causing impairment. In addition, screening and confirmatory cutoffs for the oral fluid scope were further refined. Other additions were made to the list of Tier II compounds including fentanyl analogs (e.g., acetylfentanyl, butyrylfentanyl, furanylfentanyl, etc), mitragynine, novel opioids (e.g., MT-45, U-47700), atypical antipsychotics, and novel benzodiazepines (e.g., clonazolam, flubromazolam, etc).

Dextromethorphan in Wisconsin drivers.

Dextromethorphan is a synthetic analogue of codeine used in hundreds of over-the-counter medications for its antitussive effects. There have been numerous reports of dextromethorphan abuse by young adults. Dextromethorphan can produce psychoactive effects similar to that of marijuana, and higher doses will produce dissociative effects, including sensory enhancement and hallucinations. The Wisconsin State Laboratory of Hygiene examined data from blood samples submitted from January 1999 through December 2004 to determine the incidence of dextromethorphan in suspected impaired drivers. A total of 108 samples were found to be positive for dextromethorphan during this time. Dextromethorphan concentrations in these cases ranged from less than 5 to 1800 ng/mL (mean 207 ng/mL), compared to an expected therapeutic concentration range of 0.5-5.9 ng/mL. Overall, the highest dextromethorphan concentrations observed were in males aged 16-20 years. Ninety-six percent of the specimens included in this study were also found to be positive for drugs other than dextromethorphan. A review of police and drug recognition expert reports from several of these cases showed that dextromethorphan-impaired drivers exhibited poor psychomotor performance on standardized field sobriety tests, horizontal gaze nystagmus, vertical gaze nystagmus, and overall signs of central nervous system depression.

Evaluation of ten oral fluid point-of-collection drug-testing devices.

Previously, the laboratory evaluations of six point-of-collection oral fluid (POC-OF) drug testing devices were reported. Four additional devices, Oralstat (American Bio Medica); SmartClip (Envitec); Impact (LifePoint); and OraLine IV s.a.t (Sun Biomedical Laboratories), were recently evaluated for their ability to meet the claimed (and proposed) cutoff concentrations set by the manufacturers for the detection of amphetamine(s), cocaine/metabolite, opiates, and cannabinoids (Oralstat also benzodiazepines). With the exception of the Sun Biomedical device, actual false-positive results were not encountered. Most devices performed well for the detection of opiates and amphetamine(s), but approximately half had amphetamine(s) cutoff concentrations greater than that proposed by the Substance Abuse and Mental Health Services Administration (SAMHSA). Only three devices had cocaine cutoffs less than or equal to 20 ng/mL (SAMHSA), and a number of false-negative results were obtained. The devices still were not capable of detecting Delta(9)-tetrahydrocannabinol at 4 ng/mL (SAMHSA). However, sensitivities improved since the initial studies, and approximately half of the devices met the THC-COOH cutoff proposed by SAMHSA. Results from the current and previous evaluations are presented in the paper and indicate that the sensitivity and performance of commercial OF drug testing devices is improving, but remains problematic for the reliable detection of cannabinoid use.

Zolpidem and traffic safety - the importance of treatment compliance.

Zolpidem is among the most frequently prescribed hypnotic drugs for those who suffer from insomnia. Recent media reports drew attention to driving impairment after zolpidem misuse. This review summarizes the available data on the effects of recommended use and misuse of zolpidem on driving ability and traffic safety. Both experimental studies and roadside evidence were taken into account. From these studies it must be concluded that patients should fully comply with the prescription instructions of zolpidem, i.e. to take the medication just prior to a full 8 hours of uninterrupted sleep. If this strategy is adopted, zolpidem is a safe alternative to benzodiazpine hypnotics and zopiclone who do show significant driving impairment the morning following bedtime administration. However, to ensure traffic safety higher dosages than recommended (10 mg) or allowing less than 8 hours between zolpidem intake and actual operation of a motor vehicle should be avoided.

Forensic Toxicology Program: alcohol and drug testing in Wisconsin drivers.

The Forensic Toxicology Program of the Wisconsin State Laboratory of Hygiene (WSLH) provides analytical and support services to assist in the identification of alcohol- and/or drug-impaired drivers and to assist in determining cause of death. These services are provided to law enforcement agencies, the Wisconsin Department of Natural Resources, the Wisconsin Department of Transportation, and county medical examiners and coroners. Program staff is active in alcohol and drug training, policy-making, and research on a national and international level.