Transcript Drug Impaired Driving - Stop Drugged Driving

STOP DRUGGED DRIVING
Bruce A. Goldberger, Ph.D., DABFT
Professor and Director of Toxicology
College of Medicine - Pathology & Psychiatry
President, American Academy of Forensic Sciences
Alcohol / Drugs and Driving
Which Drugs Can Affect Driving?
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Any drug that affects the brain’s
perception, collection, processing,
storage or critical evaluation
processes.
Any drug that affects
communication of the brain’s
commands to muscles or organ
systems.
For the most part, drugs that affect
the central nervous system.
Alcohol and Drugs
Drug Impaired Driving Results in
Injuries and Deaths –
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No database to track injuries and deaths
Problem is under-reported, underrecognized
Drugs are a constant factor in traffic
crashes
Societal impact unknown
Alcohol and Drugs
National Center for Injury Prevention
and Control –
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“During 2005, 16,885 people in the U.S. died in alcohol-related
motor vehicle crashes, representing 39% of all traffic-related
deaths (NHTSA 2006).”
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“In 2005, nearly 1.4 million drivers were arrested for driving
under the influence of alcohol or narcotics (Department of
Justice 2005).”
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“Drugs other than alcohol (e.g., marijuana and cocaine) are
involved in about 18% of motor vehicle driver deaths. These
other drugs are generally used in combination with alcohol
(Jones et al. 2003).”
www.cdc.gov/ncipc/factsheets/drving.htm
Drug Impaired Driving
Drugs detected in 10 to 22% of drivers
involved in crashes, often in combination
with alcohol
 Drugs detected in up to 40% of injured
drivers requiring medical treatment
 Drug use among drivers arrested for motor
vehicle offenses is 15-50%
 Highest rates reported among those
arrested for impaired or reckless driving
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Source: NHTSA, National Highway and Traffic Safety Administration
Young People
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Incidence of non-alcohol related driving impairment
higher among young people
22% of young people report using drugs prior to
driving
23.5% of drivers under 21 tested positive for drugs
(DHHS)
16-20 year olds more than twice as likely to drive
after non-alcohol drug use compared with those over
21y (SAMHSA)
20% of twelfth grade students report smoking
marijuana in cars (PRIDE)
The Grand Rapids Study
Relative Probability
of Causing an Accident
Traffic Fatalities in Florida
4000
3000
Total Fatalities
No Alcohol
Low Alcohol
High Alcohol
Very High Alcohol
2000
1000
0
Traffic Fatalities
www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/AlcoholTSF05.pdf
Drugged Driving In a Campus Community
Excessive drinking threatens the academic
mission of colleges, and the health and
safety of their communities.
Research Team
Binge Drinking
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Heavy episodic or “binge” drinking has been
associated with numerous problems in the
college student population:
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sexual assault
violent behavior
physical injury
property damage
high-risk sexual
behavior
poor academic
performance
death
Methods
This study was conducted during six nights of
December, 2006 and May, 2007.
 Sidewalk interviews and breath alcohol tests
were conducted with 291 patrons exiting 15
drinking establishments in Gainesville, FL.
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University of Florida (49,000 students)
Santa Fe Community College (16,000 students)
Establishment Visits
Each establishment visit consisted of:
(1) Observational
assessment inside
establishment
(2) Sidewalk
interviews outside
establishment
Sidewalk Interviews
Each sidewalk interview consisted of a 3-5
minute interview and breath alcohol test.
Sidewalk Interviews
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Examples of questions asked during
interview:
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When did you start drinking today?
How many drinks have you had today?
Did you take advantage of a drink special today?
After the interview and breath test,
participants were given a “walk-away” card:
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phone numbers for safe ride services
local sources of help for an alcohol problem
contact information of principal investigator and
institutional review board
Sample
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Of approximately 600 exiting patrons,
291 agreed to participate.
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61% were men
86% were college students
84% were 21 years of age or older
Average BrAC =0.091 (range 0.0-0.281)
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58% above the legal limit to drive (BAC ≥ .08)
No sex differences in regards to BAC.
The Interview
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After being recruited and giving verbal
informed consent, participants completed a
10-15 minute interview and anonymous survey
about their behaviors that night.
Participants also provided 3 specimens –
breath and oral fluid (2x)
Oral Fluid Specimen
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Participants provided a saliva sample to be
examined for genetic markers linked to
excessive drinking and alcohol
dependence.
Oral Fluid Specimen
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Participants provided an oral fluid sample
to detect recent use (i.e., tobacco,
marijuana, other illicit and prescription
drugs).
Breath Sample
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Participants provided a breath sample to
estimate blood alcohol concentration.
Sample
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Demographics (N=477)
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65% were men
77% were white
91% were college students
76% were 21 years of age or older
Average BAC =0.091 (range: 0 - 0.262)
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58% above the 0.08
25% were under 21 years of age
21% planned to drive home in less than an hour
15% used drugs besides alcohol to get high that night
Results of Drug Testing
Of those participants who provided an oral
fluid sample to detect recent drug use,
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95% reported drinking alcohol that night
12% reported using drugs other than alcohol
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11% tested positive for drugs
8% tested positive for marijuana
2% tested positive for cocaine
2% tested positive for multiple drugs
Effects of Drugs on Driving
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Coordination
Effects on nerves/muscles steering, braking,
accelerating, manipulation of
vehicle
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Reaction Time
Insufficient response reaction
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Judgment
Cognitive effects, risk
reduction, avoidance of
potential hazards,
anticipation, risk-taking
behavior, inattention,
decreased fear, exhilaration,
loss of control
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Tracking
Staying in lane,
maintaining distance
Attention
Divided, not focussed.
Time-shared task with
high demand for info
processing
Perception
90% of info processed
while driving is visual.
Glare resistance,
recovery, dark and light
adaptation, dynamic
visual acuity
Alcohol and Drugs
Drugs commonly associated with
impaired driving –
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Cannabinoids (marijuana)
Depressants: sedative/hypnotics, muscle
relaxants, antihistamines
Stimulants: cocaine, methamphetamine
Narcotic analgesics: morphine, codeine,
hydrocodone, hydromorphone, oxycodone,
methadone
Alcohol and Drugs
Depressants commonly associated
with impaired driving –
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Sedative/hypnotics including diazepam
and alprazolam (Valium and Xanax)
Muscle relaxants including carisoprodol
(Soma)
Antihistamines including diphenhydramine
(Benadryl)
Basis for the Opinion of Impairment?
Impairment is based on knowledge of the
drug(s), intended effects, side effects and
toxic effects
 The toxicologist can rarely give an opinion
based upon the toxicology report alone
 The opinion may depend on the context of
the case and information gathered by the
investigator (situation, environment,
observations, driving pattern etc.)
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Determining “Under the Influence”
A. Driving pattern
B. Impairment
 Visual
 Physiological
 Performance
C. Positive toxicology
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Ethanol
Drugs
- blood vs. urine
- parent vs. metabolite
- quantitation
What the Toxicologist cannot do….
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Determine impairment in a specific
individual from a blood concentration alone
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Determine exactly how much drug was
taken
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Determine exactly when a drug was taken
Drug Interpretation Issues
Multiple drug use
 Tolerance
 History of drug use (chronic vs. naïve)
 Health
 Metabolism
 Genetic/ethnic differences
 Individual sensitivity/response
 Withdrawal
 Put in context of case e.g. environmental
factors
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Toxicology Issues
Quantitative or Qualitative Analysis?
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Therapeutic, toxic, lethal concentration
in blood?
High or low dose?
Recent use or residual drug?
Effect of tolerance, history of drug use
Individual sensitivity/response
Effect of other drugs?
Drugs in Urine
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Good specimen to screen for large
number of drugs and drug classes
Typically see metabolites
Usually indicates drug use within the
past 2-3 days or more
Cannot definitively establish
impairment
“Consistent with” or “Explanation for”
the impairment
Drugs in Blood
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If drug is present in the blood, it is
assumed to be affecting central
nervous system and other target
organs
Typically see parent compounds (or
both)
Quantitation is vital to prosecution
Urine vs Blood
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Since urine is an end-product of
absorption, distribution and
metabolism, a drug in the urine
does not show it is still circulating in
the body and producing an effect
Cannot say one is “under the
influence”
Urine vs Blood
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Blood however is circulating
throughout the body and one is
experiencing the drug’s effects –
“under the influence”
But, is one “impaired”?
Must know pharmacology
Drugs and Driving literature evolving
Parent vs Drug Metabolite
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Parent drug is the compound ingested
Metabolites are formed by enzymatic or
chemical processes in the body
Metabolites can be pharmacologically
active or inactive, more or less toxic than
the parent
Metabolites usually have longer half-lives
so will be detected longer and exert its
effects longer than the parent drug and
may help determine time frame of use
Quantitation
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Numbers help, but certainly aren’t
the end all answer
Therapeutic vs. abuse vs. toxic
Research is still evolving
Drug Impairment Issues
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More complex than alcohol
Often in combination with other drugs and/or
alcohol (additive or synergistic effects)
Scientific literature is complex
May require a toxicologist to interpret the
results and provide an opinion
These complex issues must be explained to
the court using every day language
It Gets Very Complicated…
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Unusual or incomplete signs
Individual responses vary
Phase of the drug use (up or down?)
Chronic or naïve drug user
Tolerance
Are there “normal ranges”?
Poly-drug Challenges
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Inconsistent symptoms
Determine dominant drug
Show consistencies with that drug
Explain how other drugs present
may contribute to effects
How it’s done now
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Work with the triad of driving pattern,
impairment and positive toxicology
whenever possible
Research the drugs and driving literature
before forming an opinion
Is the number meaningful?
Missing information needs to be carefully
considered
Be prepared to discuss general issues in
cases where impairment cannot be
definitively determined
Approaches to Prosecution
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May require the driver
to be “affected by”
May require the drug to
impair a driver’s ability
to operate a vehicle
safely, incapable of
driving safely or require
a driver to be under the
influence, impaired or
affected by an
intoxicating drug
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Per-se or zero
tolerance drug laws
Make it a criminal
offense to have a
specified drug or
metabolite in the body
while operating a motor
vehicle
Any amount (zero
tolerance) or a
specified level (per se)
How is the testing done…
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Specimens - blood, urine and oral fluid
Immunoassay screen for drug or drug panel
• Homogeneous immunoassay
• ELISA
Gas Chromatography Screen
• GC or GC-MS
Confirmation/Quantitation by mass spectrometry
• GC-MS or GC-MS-MS
• LC-MS or LC-MS-MS
Analytical Recommendations
Survey Data
Ten Drugs Most Often Identified
Recommended Scope of Cutoffs
Medical/Clinical/Forensic Diagnostics
BREATH
Specific Molecular Entities in Breath
Endogenous Biomarkers of Disease
 Glutamate – Brain injury (trauma or stroke)
 Stress markers – Inflammatory mediators
 Histamine – Asthma
Exogenous Drugs – particularly those with a narrow TI
 Chemotherapeutic agents
 Antimicrobials
 THC, cocaine, GHB, ecstasy, etc. – Drugs of Abuse
 Biomarker Drugs – Assess enzyme competence
Target Molecules in Breath
HO
O
OH
HO
OH
OH
Ethanol
CH3
OH
a-D-glucose
CH3
H3C
CH3
O
H 3C
N
N
Propofol
Fentanyl
Human Lung and Breath
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Ideal Media for Diagnostics (Breath =
Gas + Liquid)
 Blood  Lungs  Breath
 Blood transports all chemicals
 Breath - volatiles and non-volatiles
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100% Cardiac Output  Lungs
 Excellent transport given lungs surface
area for diffusion
Breath a free drug blood concentration
Rapid kinetics
Non-invasive
Not “dirty” versus other sampling sites
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Unprecedented opportunities for portable, accurate, sensitive/specific,
non-invasive, real time (breath-to-breath) POC diagnostics for many
medical applications
Why do we need nano for breath detectors?
Answer: Nano provides the “horsepower” to sensitively and
specifically detect low concentrations of analytes.
2 critical factors in breath: 1) physiologically relevant free drug
concentrations, and 2) relationship between blood and breath drug
concentrations.
Potent Drugs
±
Type D Behavior =
NANO
Molecular Recognition Entities (MREs)
3 general types:
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Antibodies – proteins (amino acids)
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Many commercially available; vast array available including
those directed against multiple epitopes on a specific molecule
Functional well in vivo and ex vivo
Excellent for nano-based breath diagnostics
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Aptamers – DNA/RNA (oligonucleotides)
 Few available for small molecules; most proteins
 Functional poorly in vivo; better ex vivo
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Enzymes – catalyze degradation of substrates
 Can have extraordinary selectivity for specific substrates
 e.g., glucose oxidase for glucose
Breath Propofol - Measurements
PROPOFOL RELATIVE BREATH CONCENTRATION PROFILE
TOTAL SIGNAL (COUNTS)
6000
50 μg/Kg/min
5000
4000
infusion
off
40mg bolus,100μg/Kg/min
3000
TOT. SIG.
2000
60 mg bolus
120μg/Kg/min
1000
40 mg bolus
0
-
1000
0
200 mg bolus
5
10
15
20
25
TIME (MIN.)
30
35
40
In the future…
Will we develop per se laws
for drugs and driving?
And will you really be driving
under the influence?
Recent Trends in Florida
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Marijuana
Xanax
Methamphetamine
Inhalants - Difluoroethane
(Dust-off)
Thank You!