Elucidating the Potential Role of Microorganisms in Postmortem Biotransformation: A Comparison of Clonazolam and its Metabolite in Postmortem and DUID Cases.

Clonazolam is a designer triazolobenzodiazepine first synthesized in 1971 and primarily used for its anxiolytic and sedative effects. It became a drug of misuse in 2012 and is known for its high potency and long duration of effects. Previous studies of nitrobenzodiazepines such as nitrazepam, clonazepam, flunitrazepam, and their metabolites have demonstrated that bacterial species native to the gastrointestinal tract and active during postmortem (PM) decomposition are capable of affecting positivity and compound-to-metabolite ratios. Further studies have not been performed with clonazolam; however, it possesses the nitro functional group necessary for this biotransformation. To understand whether clonazolam may be similarly affected, PM (n = 288) and driving under the influence of drugs (DUID, n = 54) cases positive for 8-aminoclonazolam reported by NMS Labs from 2020 to 2023 were selected for inclusion in this study. Concentrations of clonazolam and 8-aminoclonazolam were evaluated, and concurrent identification of parent drug and metabolite occurred less frequently in PM cases (n = 1, 0.30% of cases) than in DUID cases (n = 21, 38% of cases). The clonazolam concentration in one PM case was 13 ng/mL. In DUID cases the median clonazolam concentration was 4.0 ng/mL and ranged from 2.0-10 ng/mL. 8-Aminoclonazolam had median concentrations of 13 and 19 ng/mL and ranges of 2.0-580 and 2.8-59 ng/mL for PM and DUID cases, respectively. Due to the everchanging landscape of the DBZD market, in vitro studies of PM microbial biotransformation of clonazolam are unavailable. The data reported herein provide valuable information in the absence of such studies and represent an alternative method of investigating this phenomenon as a potential cause of parent nitrobenzodiazepine to metabolite conversion.

Does the Quantification of Δ9-Tetrahydrocannabinolic Acid A in Serum/Plasma Provide Any Additional Information About Consumption Pattern from Drivers Under the Influence of Cannabis?

Introduction: Δ9-tetrahydrocannabinolic acid A (THCA-A) is one of the main ingredients of cannabis plants and is converted to the psychoactive substance Δ9-tetrahydrocannabinol (THC) by decarboxylation during heating above ∼90°C. During the consumption of cannabis, a varying proportion of THCA-A is absorbed into the body. Therefore, the quantification of THCA-A in serum/plasma might provide additional information on consumption behavior in driving under the influence of cannabis cases. Materials and Methods: In this study, an already established gas-chromatography mass-spectrometry (GC-MS) method for the quantification of THC, 11-OH-THC, and THC-COOH in serum and plasma samples was extended to include THCA-A. This validated method was then applied to 1228 routinely achieved serum/plasma samples from drivers suspected of cannabis consumption in Western Saxony. Two different grouping systems for chronic/occasional consumption, one system for acute/subacute consumption, Huestis formulas, and the cannabis influence factor (CIF) were used for evaluation. Results: Method validation showed appropriate results for forensic toxicological routine analysis. Limit of detection and lower limit of quantification (LLOQ) for THCA-A were 0.3 and 1.0 ng/mL, respectively. Reproducibility was <11% and accuracy ranged between 104% and 107%. THCA-A was stable in native samples at least for 2 weeks at room temperature or 4°C as well as 1 month at -20°C. Freeze-thaw stability for three cycles and processed sample stability over 3 days was proven. A total of 865 cases with a THC concentration above the German analytical cutoff of 1 ng/mL as well as the analytical LLOQs of 0.9 and 2.5 ng/mL for 11-OH-THC and THC-COOH, respectively, were included in further statistical analysis. In 407 (47.1%) of these samples, THCA-A was quantifiable. Different statistical analyses indicated a correlation between THCA-A and THC concentrations in cases of chronic and acute consumption. In addition, an increase of chronic and acute cases with increasing THCA-A concentrations was observed. However, no correlation between THCA-A and CIF was found. Discussion: These data show that THCA-A might be an additional indicative marker to provide information about consumption frequency and acuteness. Additional studies with known consumption frequencies and times are required to verify these findings.

Determination of cannabinoids in 50 µL whole blood samples by online extraction using turbulent flow chromatography and LC-HRAM-Orbitrap-MS: Application on driving under the influence of drugs cases.

The analysis of cannabinoids in whole blood is usually done by traditional mass spectrometry (MS) techniques, after offline cleanup or derivatization steps which can be lengthy, laborious, and expensive. We present a simple, fast, highly specific, and sensitive method for the determination of Δ9 -tetrahydrocannabinol (THC), cannabidiol (CBD), cannabinol (CBN), 11-hydroxy-Δ9 -tetrahydrocannabinol (11-OH-THC), and 11-nor-9-carboxy-Δ9 -tetrahydrocannabinol (THC-COOH) in 50 µL whole blood samples. After the addition of deuterated internal standards (IS) and a simple protein precipitation step, an online extraction of sample supernatants using turbulent flow chromatography (TurboFlow-Thermo Scientific) was carried out. Analytes were separated on a C18 analytical column and detected by LC-HRAM-Orbitrap-MS using a Thermo Scientific Q Exactive Focus MS system. MS detection was performed in polarity switching and selected ion monitoring (SIM) modes using five specific acquisition windows, at a resolution of 70,000 (FWHM). Total run time was about 10 min including preanalytical steps. Method validation was carried out by determining limit of detection (LOD), lower limit of quantitation (LLOQ), linearity range, analytical accuracy, intra-assay and interassay precision, carry-over, matrix effect, extraction recovery, and selectivity, for all analytes. Measurement uncertainties were also evaluated, and a decision rule was set with confidence for forensic purposes. The method may become suitable for clinical and forensic toxicology applications, taking advantage of the small matrix volume required, the simple and cost-effective sample preparation procedure, and the fast analytical run time. Performances were monitored over a long-term period and tested on 7620 driving under the influence of drugs (DUID) samples, including 641 positive samples.

Do crashed drivers need more drug testing? A retrospective analysis of blood samples from hospitalised post-crash drivers in New Zealand.

Driving under the influence of alcohol and other drugs is a prominent safety concern in New Zealand and across the world. While alcohol testing is routinely performed for drivers involved in hospitalisation crashes, testing for other drugs is often not undertaken. The present study refers to 530 traffic crashes that occurred from October 2019 to January 2020 on New Zealand roads. The blood samples from 550 drivers who were injured in a crash and were admitted to a hospital (66% of all drivers involved in these crashes), previously tested for drugs and/or alcohol, were retested for a wider range of drugs. Alcohol above the applicable limit was found to be present in 38% of hospitalised drivers, while other drugs of interest were found in 47% of hospitalised drivers. Binary logistic regression was used to predict the presence of drugs of interest for a crashed driver using previous offence data. A driver having at least one prior drink and drug driving offence is 61% more likely to be positive for a drug of interest when involved in a crash. Similarly, a driver having at least one prior non-traffic drug offence is 4.7 times more likely to be positive for at least a drug of interest when involved in a crash. While the presence of a drug or drugs cannot be presumed to have played a role in the occurrence of the crash, this study has provided a unique and comprehensive picture of the presence of various drugs present in New Zealand drivers' blood. It is recommended to consider standardising drug testing on all blood specimens taken in relation to a serious injury or fatal crash. This procedure is not only of interest for information purposes but may importantly inform appropriate charging decisions.

Driving under the influence of nitrous oxide - A retrospective study of HS-GC-MS analysis in whole blood.

Since 2020, our lab has received blood samples from traffic cases involving suspicion of driving under the influence of nitrous oxide (N2O). While N2O analysis by gas chromatography (GC) has been around for decades, quantitative results in blood from drivers have been only scarcely reported. We present a three-year (2020-2022) retrospective study of N2O from traffic cases in Eastern Denmark with suspected involvement of N2O intake. Whole blood samples from traffic cases were analysed for N2O using headspace-GC-MS. Freshly made calibration curves and additions of xenon gas as an internal standard were used for calculation of N2O concentrations. Positive samples have been defined as having concentrations greater than 0.1 mL N2O/L blood. Over a three-year period, we have tested 62 traffic case blood samples for the presence of N2O. Despite the technical challenges associated with the analysis of N2O, we have found N2O in 52 of the samples. Calculated concentrations were in the range 0.1-48 mL N2O/L blood, which are similar to the few cases previously found in the literature.

The impact of fentanyl on DUIDs and traffic fatalities: Blood and oral fluid data.

Fentanyl has emerged as the most prolific drug in the ongoing opioid epidemic and has greatly impacted traffic safety in recent years. This study aimed to evaluate fentanyl prevalence and concentrations in blood and oral fluid in driving under the influence of drugs (DUID) cases in three different regions (i.e., Alabama, Orange County, CA, and Houston, TX) from 2017 to 2022. Furthermore, traffic fatalities were evaluated for Alabama and Orange County, CA. Fentanyl positivity in DUID and traffic fatalities increased for most years in this study. In Alabama, the prevalence of fentanyl DUID cases increased 4-fold in 2022 compared to 2017. Orange County's increase from 2017 to 2022 was 14-fold. In Houston, the increase was approximately 2-fold from 2019 to 2022. The greatest increase for all laboratories coincided with the start of the COVID-19 pandemic. In 2022, the median fentanyl DUID blood concentrations were 4.7, 11, and 4.7 ng/mL in Alabama, Orange County, and Houston, respectively. Most fentanyl cases were polydrug cases (≥90%). Methamphetamine, THC, and alprazolam were the most frequently detected drugs in combination with fentanyl. Alabama has collected oral fluid and blood in DUID cases since 2018. The detection of fentanyl in oral fluid was comparable to blood. However, 59% and 8.7% of fentanyl-positive cases had concentrations of >20 ng/mL in oral fluid and blood, respectively. Therefore, oral fluid as an alternative or supplemental specimen to blood is an attractive approach for fentanyl in DUID cases. This study contributes to understanding recent fentanyl trends and their impact on traffic safety.

Ethanol enhances JWH-018-induced impairment of sensorimotor and memory functions in mice: From preclinical evidence to forensic implication in Driving Under the Influence of Drugs.

BACKGROUND: Several new Synthetic Cannabinoids have appeared each year since their introduction into the illicit drug market as recreational drugs. Among these, naphtalen-1-yl-(1-pentylindol-3-yl) methanone (JWH-018) is one of the most detected compounds in biological samples from patients involved in intoxication or death cases. Furthermore, consumption of JWH-018 has been linked to several cases of Driving Under the Influence of Drugs (DUID) suggesting that effects induced by this compound can affect individuals' ability to drive. METHODS: Given the high spread of polydrug consumption and the wide number of alcohol-related traffic accidents, this study aims to investigate the acute effects induced by co-administration of JWH-018 with ethanol on sensorimotor and motor responses, grip strength and memory functions in CD-1 male mice. Acute impairments induced by JWH-018 and ethanol alone have also been investigated, in order to compare their effects with that induced by their concurrent administration. RESULTS: In vivo behavioral experiments revealed a worsening of the cognitive and sensorimotor disruption after the co-administration of JWH-018 with ethanol compared to single compounds. CONCLUSIONS: These animal-based findings suggest a potential increased impairment on psychomotor performances which could be related to driving abilities posed by poly-drug consumption involving SCs and ethanol.

Sensorimotor Alterations Induced by Novel Fentanyl Analogs in Mice: Possible Impact on Human Driving Performances.

Operating a vehicle is a complex task that requires multiple cognitive functions and psychomotor skills to cooperate. Driving might be impaired by licit or illicit drugs, including novel psychoactive substances (NPS) and novel synthetic opioids (NSO), the effects of which are still yet to be elucidated in humans. In the present work, a revision of the literature regarding the psychomotor impairing effects of Fentanyl (FENT) and three analogues (Acrylfentanyl, Ocfentanyl and Furanylfentanyl) is presented, as emerged by experimental studies on humans, driving under the influence of a drug (DUID) and intoxication cases. An experimental study on a mouse model evaluated the sensorimotor alterations induced by FENT and the three fentalogs. Acute systemic administration of the four opioids (0.01-15 mg/kg i.p.) dose-dependently decreased the visual object and placing tests, the acoustic and the tactile responses of mice. The preclinical data are in accordance with the data that emerged from the revision of the literature regarding experimental data on humans, driving under the influence of drugs and intoxication cases, suggesting that novel synthetic opioids might affect the psychomotor performances on daily human tasks with a particular focus on driving.

How Nordic Countries Enforce Impaired Driving Legislation.

This article reviews how the Nordic countries of Denmark, Finland, Norway, and Sweden enforce their legislation pertaining to driving under the influence of alcohol and/or other impairing drugs. The evidence necessary for a successful prosecution of traffic offenders has undergone radical changes over the past 50 years. The once widely used clinical tests of impairment are no longer a major element of the prosecution case and a physician is more seldom required to examine apprehended drivers and document any clinical signs and symptoms of alcohol and/or drug influence. These clinical tests have been superseded by results derived from a comprehensive toxicological analysis of psychoactive substances in samples of the driver's blood. The current statutory limits of blood-alcohol concentration (BAC) are among the lowest in the world: Norway and Sweden (0.20 g/kg) and Denmark and Finland (0.50 g/kg). Results from using evidential quality breath-alcohol instruments are accepted as evidence in drunk-driving cases and this has necessitated setting statutory breath-alcohol concentration (BrAC) limits. Laws dealing with driving under the influence of drugs (DUID) other than alcohol have also been updated and made more pragmatic for prosecution of traffic offenders. In Finland and Sweden zero-tolerance laws exist, making it illegal to drive with any quantifiable amount of a scheduled drug in the driver's blood. Prescription drugs are exempt from this zero-tolerance mandate provided the medication was used in accordance with a physician's ordination. Lacking a valid prescription or if there is a supratherapeutic concentration of the drug in blood, this will lead to a prosecution for DUID. In Denmark and Norway threshold concentration limits have been established for many psychoactive drugs, both licit and illicit. After these stricter laws for DUID were introduced, the number of suspects apprehended by the police per year increased by as much as tenfold in some Nordic countries. There is increasing evidence that many traffic delinquents in the Nordic countries suffer from a substance-use disorder, because repeat-offending is a common occurrence. This suggests that some type of treatment and rehabilitation program might be more beneficial compared with conventional penalties for people arrested for DUI and/or DUID.

Common opioids and stimulants in autopsy and DUID cases: A comparison of measured concentrations.

Quantitative results from toxicological analyses of autopsy material are widely compared to ranges in reference works to determine if drug concentrations are in relevant levels for establishing intoxication. This study compares concentrations of commonly used opioids and stimulants from drug addict autopsies and driving under the influence of drugs (DUID) cases to supplement current knowledge of the possible span and overlaps of measured concentrations. The study included whole-blood results from forensic autopsies of drug addicts performed from 2015 to 2020 (n = 220) and DUID cases from 2015 to 2019 (n = 7088). The focus was on heroin/morphine, methadone, cocaine, amphetamine and MDMA concentrations because these drugs are commonly encountered in both fatal intoxications and DUID cases and the potential for abuse is well known. In the DUID group, the opioids heroin/morphine and methadone and the stimulants amphetamine and MDMA were often seen in concentrations above the reported lower comatose-fatal level whereas cocaine was almost always below. Thus, based on our data, the potential for false assessment of intoxication cases when comparing to reported comatose-fatal limits appears greatest on lower end concentrations of heroin/morphine, methadone, amphetamine and MDMA, whereas false assessment of cocaine appears less likely because most control cases are below reported comatose-fatal levels.

Effect of -NBOMe Compounds on Sensorimotor, Motor, and Prepulse Inhibition Responses in Mice in Comparison With the 2C Analogs and Lysergic Acid Diethylamide: From Preclinical Evidence to Forensic Implication in Driving Under the Influence of Drugs.

In the last decade, the market for new psychoactive substances has been enriched by numerous psychedelic phenethylamines, which mimic the psychoactive effect of lysergic acid diethylamide (LSD). In particular, the -NBOMe series, which are more potent than their 2C compounds analogs, are considered worthy substitutes for LSD by users. The purpose of this study was to assess the effects of 25H-NBOMe and its halogenated derivatives (25I-NBOMe and 25B-NBOMe) in comparison to their 2C compounds analogs and LSD on the sensorimotor (visual, acoustic, and overall tactile), reaction time, spontaneous (total distance traveled) and stimulated (drag, accelerod test) motor activity, grip strength test, and prepulse inhibition (PPI) responses in mice. Systemic administration of -NBOMe, 2C compounds analogs, and LSD (0.001-10 mg/kg) differently impaired the sensorimotor, reaction time, motor, and PPI responses in mice. In particular, halogenated (25I and 25B)-NBOMe derivatives appear to be more effective than the entire class of 2C compounds analogs in altering visual and acoustic responses, affecting reaction time, and motor and sensory gating in PPI test. In fact, the specific rank order of compounds potency for nearly all of the experiments showed that (25I and 25B)-NBOMe were more potent than 2C compounds analogs and LSD. -NBOMe and 2C compounds analogs impaired not only the reception of incoming sensory stimuli (visual and acoustic), but their correct brain processing (PPI) in an equal and sometimes stronger way than LSD. This sensory impairment directly affected the spontaneous motor response and reaction time of mice, with no change in performance in stimulated motor activity tests. These aspects should be carefully considered to better understand the potential danger that psychedelic phenethylamines, in particular -NBOMe, may pose to public health, with particular reference to decreased performance in driving and hazardous works that require special sensorimotor skills.

Drug consumption of suspected drug-influenced drivers in Hungary (2016-2018).

The hazard caused by driving under the influence of drugs (DUID) is determined by the time of consumption, dose and biological effects of a substance, as well as by synergistic drug interactions after multi-drug use. The aim of this work was to investigate the prevalence and pattern of psychoactive substance use of suspected DUID drivers and to present the advantages and disadvantages of the system currently used for determination of impairment in Hungary. Blood and urine samples, collected between 2016 and 2018, were taken from 2369 drivers with a positivity rate of 95% for at least one substance. Classical illicit drugs were detected in 76-87%, prescription medications in 9-15%, stimulant New Psychoactive Substances (sNPS) in 3-8%, and synthetic cannabinoids (SCs) in 20-22% of the positive samples. The most frequent substances according to substance groups were: classical illicit drugs: cannabis (n = 1240), amphetamine and methamphetamine (AM/MA) (n = 753), MDMA (n = 196), and cocaine (n = 180), medicines: alprazolam (n = 188) and clonazepam (n = 83), sNPS: N-ethyl-hexedrone (n = 115), SCs: 5 F-MDMB-PINACA (n = 267), AMB-FUBINACA (n = 92) and ADB-FUBINACA (n = 90). The median age of classical illicit drugs users was 29 years, prescription medicine users were 33 years old, sNPS users were 28 years, and SC users were 26 years old. Compared to the previous two years, we found pronounced changes in the ratio of sNPS (14% decrease) and SC users (10% increase), and in the pattern of NPS consumption. The ratio of multi-drug use varied between 38% and 50%. 69% of drivers tested positive were deemed impaired. Impairment was determined according to impairment limits (80-82%), multi-drug use (12-13%), and the result of medical investigation when a single active substance with no set impairment limit was detected in the blood (6-8%). The results of medical investigations may be uncertain due to the long time delay between arrest and clinical examination and to the structure of medical investigations created for determination of alcoholic impairment. In conclusion, a revision of the current medical investigation protocol is warranted to standardize clinical symptom scores that better correlate with driving impairment.

A Retrospective Metabolomics Analysis of Gamma-Hydroxybutyrate in Humans: New Potential Markers and Changes in Metabolism Related to GHB Consumption.

GHB is an endogenous short-chain organic acid presumably also widely applied as a rape and knock out drug in cases of drug-facilitated crimes or sexual assaults (DFSA). Due to the endogenous nature of GHB and its fast metabolism in vivo, the detection window of exogenous GHB is however narrow, making it challenging to prove use of GHB in DFSA cases. Alternative markers of GHB intake have recently appeared though none has hitherto been validated for forensic use. UHPLC-HRMS based screening of blood samples for drugs of abuse is routinely performed in several forensic laboratories which leaves an enormous amount of unexploited data. Recently we devised a novel metabolomics approach to use archived data from such routine screenings for elucidating both direct metabolites from exogenous compounds, but potentially also regulation of endogenous metabolism and metabolites. In this paper we used UHPLC-HRMS data acquired over a 6-year period from whole blood analysis of 51 drivers driving under the influence of GHB as well as a matched control group. The data were analyzed using a metabolomics approach applying a range of advanced analytical methods such as OPLS-DA, LASSO, random forest, and Pearson correlation to examine the data in depth and demonstrate the feasibility and potential power of the approach. This was done by initially detecting a range of potential biomarkers of GHB consumption, some that previously have been found in controlled GHB studies, as well as several new potential markers not hitherto known. Furthermore, we investigate the impact of GHB intake on human metabolism. In aggregate, we demonstrate the feasibility to extract meaningful information from archived data here exemplified using GHB cases. Hereby we hope to pave the way for more general use of the principle to elucidate human metabolites of e.g. new legal or illegal drugs as well as for applications in more global and large scale metabolomics studies in the future.

Evaluation of RapidSTAT®, DrugWipe® 6S, DrugScreen® 5TK and DrugScreen® 7TR for on-site drug testing in German police roadside traffic patrol.

Driving under the influence of drugs (DUID) remains a subject of concern worldwide, and its increasing trend is likely to continue. Therefore, there is a constant need for reliable on-site drug tests to identify drugged drivers during roadside patrols. Performance and reliability of four on-site drug tests were evaluated among a high number of DUID cases in Germany. Results of oral fluid (OF) (RapidSTAT® and DrugWipe® 6S) and urine (DrugScreen® 5TK and 7TR) test devices were compared with corresponding serum/plasma results obtained by confirmation analyses in consideration of recommended analytical limits for substances pertaining the annex of the German Road Traffic Code ('Straßenverkehrsgesetz', StVG) s. 24a (2). Overall, the screening devices performed well for individual drugs; however, none of the test devices assessed in this study fulfilled the ROSITA-1 criteria (sensitivity, specificity ≥ 90% and accuracy ≥ 95%) for all substances. Our data demonstrated that both urine tests showed high sensitivities for most compounds. DrugWipe® 6S (94%) and RapidSTAT® (93%) revealed high sensitivities, especially for amphetamine screening. Poor specificities (<90%) and accuracies (<95%) were observed for all tests except for low-prevalent substances (e.g., opiates). For drug testing in OF, Δ9 -tetrahydrocannabinol (THC) still seems to be a compound of concern due to poor sensitivity (RapidSTAT®, 77%; DrugWipe® 6S, 85%), although the results indicate improvements compared with previously reported data. Although the obtained data indicate reliable detection for some substances, deployment of trained police officers is inevitable to identify DUID suspects by signs of recent use and recognising impairment.

A systematic review of factors associated with illegal drug driving.

Drug driving is a serious problem worldwide that can increase the risk of road crashes. This systematic review seeks to identify factors associated with drug driving (i.e., driving after consuming drugs other than alcohol) to highlight gaps in existing knowledge and inform the design of more effective countermeasures. A search of the literature was conducted for the period January 1, 2005 to July 31, 2021 using six different databases. The search protocol followed PRISMA guidelines and was registered in PROSPERO (#CRD42021234616). Studies that met inclusion criteria compared drug drivers with either non-drug drivers, alcohol-only drivers or drug drivers from an earlier time period, to identify factors specifically associated with drug driving, rather than common to all drivers. Two hundred and nineteen publications met the inclusion criteria and were included within the review. Based on the findings, a logic model was developed that presents the factors associated with drug driving. Various sociodemographic, psychosocial and legal factors emerged as the main factors associated with illegal drug driving. At the sociodemographic and psychological levels, drug drivers were more likely to be single, young males who often drive after using cannabis and who score high on sensation-seeking and impulsivity scales. The key social factor found to be associated with drug driving was peer acceptance/disapproval of the behaviour. At the legal level, the review suggested that the effectiveness of current enforcement approaches to drug driving vary among jurisdictions around the world due to differences in the level of perceived certainty of apprehension and the chances of punishment avoidance. Future research into the anticipated and actual rewards for drug driving is needed to inform the development of more effective countermeasures.

The incidence of psychoactive substances and alcohol among impaired drivers in Denmark in 2015-2019.

This study examines the presence of psychoactive drugs and alcohol in blood from apprehended drivers driving under the influence of drugs (DUID) and alcohol in Denmark in a five-year period from 2015 to 2019. Data were analysed with respect to gender, age, substances with concentrations above the Danish legal limit, arresting time of day and repeat arrest. By request of the police, the blood samples were subjected to analysis for alcohol and/or tetrahydrocannabinol (THC) alone, for "other drugs" (covering all drugs including new psychoactive substances (NPS), except THC, listed in the Danish list of narcotic drugs) or for both THC and other drugs. About the same number of alcohol traffic cases (37,960) and drug traffic cases (37,818) were submitted for analysis for the five-year period. The number of drug traffic cases per year increased from 5660 cases in 2015 to 9505 cases in 2019, while the number of alcohol traffic cases per year (average, 7600) was unchanged. Ethanol (89.2%) was the overall most frequent single substance, followed by THC (68.2%). CNS stimulants (46.8%) were the second most prevalent group of non-alcoholic drugs. Cocaine (23.8%) and amphetamine (22.9%) were the most frequent CNS stimulants. The proportion of CNS-stimulant positive drivers more than doubled in ten years. Benzodiazepines/z-hypnotics (12.7%) were the third most prevalent drug group detected, with clonazepam (8%) as the most frequent drug. Opioids were above the legal limit in 9.8% of the cases. NPS was above the legal limit in 128 cases (0.6%). Poly-drug use occurred in 40% of the DUID cases in the requested groups: other drug or other drug/THC. Young males dominated the DUID cases (median age 26). Drink-drivers (median age 39) were also mainly men, but the age distribution was equally spread over the age groups. Re-arrest occurred more often in DUID drivers (18-29%) than in drinking drivers (6-12%). DUID was evenly spread over the week, while drink-driving was most frequent on weekends. This study is an important supplement to the knowledge of drug use in Denmark. It was the well-known psychoactive substances that were detected. Only a few NPS occurred. However, the abuse pattern has changed, and CNS stimulants now account for a much higher proportion than earlier. Our results indicate a drug use problem among DUID drivers. This gives rise to concern because of a risk of traffic accidents. Treating the underlying abuse problem is therefore recommended, rather than focusing solely on prosecuting.

Prevalence and concentrations of sedative-hypnotic drugs in blood of drivers involved in road traffic crashes in the Padova region of Italy - not so easy to interpret.

BACKGROUND & OBJECTIVES: This study reports the prevalence and concentrations of sedative-hypnotic drugs as exemplified by benzodiazepines (BZD) and zolpidem (Z-hypnotic) in blood samples from drivers involved in road traffic accidents (RTA) in the Padova region of Italy. Another aim of the study was to estimate the prevalence of these drugs with concentrations in blood above the therapeutic intervals and above specific per se limits. METHODS: A total of 4066 blood samples collected from drivers involved in RTA were analysed for the presence of alcohol, drugs of abuse and medicinal drugs with sedative-hypnotic properties. Prevalence of drivers positive for BZDs and zolpidem were reported according to the reporting limit of our laboratory (1 ng/mL) in a sort of zero tolerance approach and compared with the prevalence according to analytical cut-offs used in the "European Union's research project on Driving Under the Influence of Drugs, Alcohol and Medicines" (DRUID). The impairment-based, per se limits adopted in Norway and in England and Wales and the values used to define "therapeutic ranges" in blood and in plasma/serum were also applied to the case study. RESULTS: 175 blood samples were positive for sedative-hypnotics above 1 ng/mL, with the following prevalence: diazepam 44%, nordazepam 41.8%, lorazepam 32.6%, zolpidem 28%, oxazepam 25.6%, alprazolam 16%, delorazepam 11,6%, lormetazepam 11,6%, temazepam 11.6%, clonazepam 11.6%, triazolam 6.9%, N-desalkylflurazepam 4.6%, bromazepam 2.3%. When applying DRUID analytical cut-offs, the prevalence of BZDs and zolpidem sharply decreases. Applying the impairing cut-offs used in Norway, 56% of positive samples were above the limits equivalent to a BAC of 0.2 g/L, 39% above the limits corresponding to 0.5 g/L, and 23% above the cut-off corresponding to 1.2 g/L. Only 1% of the drivers had drug concentrations above the per se concentration limits adopted in England and Wales [26]. When comparing blood levels with therapeutic ranges in plasma, bromazepam, lormetazepam and delorazepam were often found above the highest limits. The adjustment of the concentrations with the plasma-to-blood ratios causes a significant increase of cases above the therapeutic ranges in plasma. CONCLUSIONS: Sedative-hypnotic drugs are medicinal substances frequently identified in drivers involved in RTA, commonly in concentrations associated with driving impairment. Besides the concentrations of drugs in blood, several factors have to be considered to conclude that a driver was impaired. The frequent association with alcohol, cocaine and other BZDs, confirms the abuse potential of these medications.

Road traffic deaths: A retrospective analysis (2009-2019) in the north of the Italian region Emilia Romagna.

OBJECTIVE: International literature and several national studies demonstrate that alcohol and illicit drugs impair driving abilities, diminishing the level of attention, and cause traffic accidents. In Italy, driving under the influence of alcohol or drugs is regulated by Articles 186 and 187 of the National Street Code, which defines penalties and fines for the convicted. The aim of this study was the collection of all available data from 2009 to 2019 focusing on deaths related to road accidents in the Unit of Legal Medicine of Department of Medicine and Surgery at the University of Parma, in order to assess any consumption of alcohol, illicit drugs, and medicinal drugs among drivers. METHODS: Data were retrieved from autopsy reports found at the Unit of Legal Medicine of Parma University related to 327 subjects who died following road accidents in the Italian areas of Parma, Reggio-Emilia, and Piacenza. The population was divided into subgroups according to age, gender, crash time, and drug positivity. RESULTS: Those in the age group 46 to 65 years old were involved in the most accidents, whereas the category with fewest members included subjects under 26 years old. The majority of road accidents occurred during the daytime and on weekends. Among the toxicological investigations carried out (only for drivers), the highest prevalence was found for alcohol (43.1%), followed by illicit drugs (14.4%) and medicinal drugs (7.8%). The prevalence of alcohol and illicit drugs in combination was 11.8%. Regarding subjects positive for alcohol and illicit drugs in combination, 44.4% had a blood alcohol concentration (BAC) > 1.5 g/L and overall, in 61.1% of the total cases a BAC > 0.81 g/L was detected. CONCLUSIONS: Our results are in line with national and international studies highlighting the prevalence of high BAC levels in most of the cases. Confirmation analyses on blood collected from people who died following road accidents showed levels of BAC above 0.8 g/L (threshold for penal sanctions) in the majority of the subjects who tested positive for alcohol. They also revealed cocaine, cannabis, and benzodiazepines as the most common illicit drugs and medicinal drugs used, respectively, as demonstrated in several international studies.

Suspicion of driving under the influence of alcohol or drugs: Cross sectional analysis of drug prevalence in the context of the Swiss legislation.

Driving under the influence of alcohol and drugs (DUID) is a major field of study to improve road safety. In Switzerland, during controls whether or not they follow an accident, the police can request toxicological analysis targeted either on alcohol only (ALC cases), or on drugs and alcohol (DUID cases). To evaluate both the drugs consumption on the road and whether or not these requests are well correlated with toxicological results, we built a database recording 4003 offenders (3443 males, 550 females) over a two-year period (2018-2019) in Western Switzerland. ALC case samples were then analyzed to target other substances than ethanol. We found one or more psychoactive drugs in 89% of DUID cases and alcohol alone was found in 56% of ALC cases. In ALC cases, alcohol alone was found in 72% of non-accident cases and in 52% of accident cases. This highlights an influence of accident context, inducing a too high suspicion of alcohol after accidents, and therefore an underestimation of the prevalence of other drugs. The most frequently detected drugs in DUID cases were cannabinoids (58%), ethanol (30%), cocaine (21%), benzodiazepines (11%), amphetamines (7%), opiates (6%), and antidepressants (5%). For the ALC cases, the drugs found were ethanol (84%), cannabinoids (13%), benzodiazepines (9%), antidepressants (6%), opiates (5%), cocaine (4%), methadone (3%), and amphetamines (1%). Prescription drugs, such as benzodiazepines, were common in accidents (22%) but rare in non-accidents DUID cases (5%). Thus, these drugs highly impact driving skills while being hard to suspect. This is of first concern as prescription drugs are largely found in poly-drug consumption, especially in combination with alcohol in accident cases. This emphasizes the emerging issue of prescription drugs and should motivate a strategy of prevention focused on the noxious effect of combining alcohol and prescription drugs on driving skills.