Which illicit drugs are injected in Oslo? A study based on analysis of drug residues in used injection equipment and self-reported information.

BACKGROUND: People who inject drugs (PWID) have a high risk of premature death due to fatal overdoses. Newly emerged fentanyls, much more potent than heroin and other opioids, may increase this risk further. Therefore, precise information on injected drugs is critical to improving prevention strategies. AIMS: This study aimed to analyse drug residues in used injection equipment in order to determine drug and drug combinations and compare and complement findings with self-reported information. METHODS: Used syringes and needles (n=766) were collected at the supervised drug consumption facilities, the needle exchange service and two low-threshold health services for problem drug users in Oslo, Norway. The material was collected every third month from June 2019 to June 2020 and analysed for 64 substances using highly specific analytical methods (ultra-high performance liquid chromatography tandem mass spectrometry). Additionally, a street-recruited sample of PWID was interviewed from 2017 to 2019 regarding their drug injection habits (n=572). RESULTS: Heroin (65.5%) or amphetamines (59.8%), often in combination (30.5%), were commonly detected in drug residues. Other opioids, stimulants or benzodiazepines were rarely detected (6.1%). Fentanyl was detected in only one syringe. Heroin was the most reported drug (77.6% during the past four weeks, 48.3% daily/almost daily), followed by amphetamines (57.5% during the past four weeks, 23.1% daily or almost daily). Injection of methadone, buprenorphine and dissolved tablets was self-reported more frequently than determined in drug residue findings. CONCLUSIONS: Analysis of the injection equipment proved useful as a non-invasive, rapid and accurate means to obtain detailed information on injected drugs in Oslo and supplement traditional PWID survey information.

Prevalence and Correlates of Illicit Drug Use among Norwegian Nightlife Patrons.

BACKGROUND: Nightclubs and bars are recreational settings with extensive availability and consumption of alcohol and recreational drugs. OBJECTIVES: This study aims to determine the proportion of nightclub patrons in Norway that tested positive for illicit drugs, moreover, we examined the correlation between positive test results and demographic and substance use characteristics. METHODS: Patrons were recruited outside nightclubs on Friday and Saturday nights between 10:00 pm and 04:00 am. Substance use was determined by breath testing and oral fluid testing for alcohol and drugs, respectively, using accurate and specific analytical methods. Questionnaires recorded demographic and substance use characteristics. RESULTS: Of the 1988 included nightclub patrons, 90% tested positive for alcohol, 14% for illicit drug use, and 3% for two or more illicit drugs. The proportion of patrons who tested positive for illicit drugs was highest in the early hours of the morning. Nine out of ten who tested positive for illicit drugs also consumed alcohol. Testing positive for one or more illicit drugs was most strongly correlated with being male and unemployed, using tobacco or other nicotine products, and early on-set illicit drug use; further the correlations were strongest among those who tested positive for two or more illicit drugs.Conclusions/Importance: Patrons who used illicit drugs before or during nightclub visits most often combined drug use with alcohol consumption. Substituting alcohol with cannabis or other drugs was not common in this cohort. The study results provide evidence to introduce harm-reduction prevention programs to address illicit drug and excessive alcohol consumption.

Oral Fluid to Blood Concentration Ratios of Different Psychoactive Drugs in Samples from Suspected Drugged Drivers.

BACKGROUND: The ratio between the concentrations of drugs in the oral fluid and blood (OF/B ratio) reflects the transfer of drugs from blood to oral fluid, which is influenced by several factors such as oral fluid contamination. OF/B drug concentration ratios for psychoactive drugs, including interindividual variation, were investigated in this study. For a portion of the material, oral fluid concentrations in both sides of the mouth were compared. METHODS: Samples of whole blood and oral fluid collected using the Intercept device were obtained from 489 suspected drugged drivers. Concentrations of amphetamine, methamphetamine, THC, diazepam, N-desmethyldiazepam, clonazepam, alprazolam, oxazepam, nitrazepam, morphine, buprenorphine, and methadone were determined in blood and oral fluid samples using liquid chromatography-tandem mass spectrometry. RESULTS: Median OF/B ratios were 18.6 for amphetamine, 13.8 for methamphetamine, 3.8 for morphine, 24.8 for buprenorphine, 3.7 for methadone, 0.026 for diazepam, 0.031 for N-desmethyldiazepam, 0.28 for alprazolam, 0.16 for clonazepam, 0.12 for oxazepam, 0.099 for nitrazepam, and 4.3 for THC. Large interindividual variations in OF/B ratios were observed. The median difference in concentrations in oral fluid from both sides of the mouth was less than 20% for all drugs, except THC and buprenorphine, which had median differences of 32%-34%. CONCLUSIONS: High OF/B ratios were found for amphetamines and opioids, reflecting a high degree of drug transfer from blood to oral fluid and a longer detection window in oral fluid than in blood. For benzodiazepines, low OF/B ratios were found. Results of the concentration measurements in oral fluid from both sides of the mouth could indicate that some remnants of THC and buprenorphine were present in the oral cavity. The large variations among individuals and between the 2 sides of the mouth suggest that drug concentrations in oral fluid do not accurately reflect drug concentrations in the blood.

Associations between psychoactive substance use and sensation seeking behavior among drivers in Norway.

BACKGROUND/AIM: Drug use and risky driving is associated with sensation seeking. The aim of this study was to investigate the association between use of psychoactive substances and levels of the sensation seeking personality trait as measured with the Brief Sensation Seeking Scale 4 among drivers in Norway. METHOD: A cross-sectional design was applied to estimate the association between psychoactive substance use and sensation seeking behavior. Drivers in normal traffic were included in two roadside surveys: one in the north (September 2014 - October 2015) and the other in the south-east of Norway (April 2016 - April 2017). Oral fluid was analyzed for alcohol and psychoactive drugs, and data on sex, age and time of participation were recorded. Participants filled in the Brief Sensation Seeking Scale 4 questionnaire. RESULTS: A total of 8053 drivers were included, of which 32% were women and 62% were under 40 years. The prevalence of alcohol was 0.3%, stimulants 0.6%, tetrahydrocannabinol 1.4%, benzodiazepines and/or z-hypnotics 2.0% and polydrug use 0.6%. Associations were found between the use of tetrahydrocannabinol or benzodiazepines and/or z-hypnotics and a low score on the "thrill and adventure seeking" domain of the Brief Sensation Seeking Scale 4 (OR = 1.723, 95% C.I. = 1.001-2.966). Associations were also found between the use of stimulants and the highest scores on the "experience seeking" (OR = 2.085, 95% C.I. = 1.084-4.009) and "disinhibition" (OR = 4.791, 95% C.I. =1.748-13.135) domains of the Brief Sensation Seeking Scale 4. No associations were found between sensation seeking behavior and alcohol or polydrug use. CONCLUSION: A high degree of sensation seeking was found among drivers who had used stimulating drugs, in contrast to drives who had used tetrahydrocannabinol and benzodiazepines and/or z-hypnotics who showed a low degree of sensation seeking. The combination of sensation seeking behavior and the use of stimulants might lead to increased risky behavior and thus traffic crashes.

Pharmacokinetics of Single Doses of Methadone and Buprenorphine in Blood and Oral Fluid in Healthy Volunteers and Correlation With Effects on Psychomotor and Cognitive Functions.

PURPOSE: We aimed to study the pharmacokinetics of methadone and buprenorphine in blood and oral fluid after single-dose administration and investigate correlations between concentrations in blood and neurocognitive functions. METHODS: A 5-way, double-blind, randomized, placebo-controlled, double-dummy, crossover study was performed to study the pharmacokinetics and neurocognitive effects of methadone (5 and 10 mg per oral) and buprenorphine (0.2 and 0.4 mg sublingual) in 22 healthy volunteers. Blood and oral fluid were collected throughout the test days, and drug concentrations in both matrices were analyzed using ultrahigh-performance liquid chromatography-tandem mass spectrometry. On-road driving testing, neurocognitive computerized tests, and subjective questionnaires were performed. RESULTS: Large individual variations in concentrations of methadone and buprenorphine in blood and oral fluid, and accordingly oral fluid/blood drug concentration ratios, were observed. The mean ratio 6.5 hours after drug administration was 2.0 (range, 0.49-7.39) for methadone after both doses. Buprenorphine was not detected above the limit of quantification in blood after 6.5 hours. No significant correlation between methadone concentration in blood and effect was found. Significant correlations were found between buprenorphine concentration in blood and standard deviation of lateral position in the driving test and some measures of reaction time, divided attention, balance, alertness, contentedness. and sleepiness. CONCLUSIONS: Concentrations of methadone and buprenorphine in blood and oral fluid showed large interindividual variations. No concentration-effect correlations were found for methadone, whereas low to moderate correlations were observed between buprenorphine concentration and driving, psychomotor function, and subjective rating of sleep and alertness.

A clinical trial on the acute effects of methadone and buprenorphine on actual driving and cognitive function of healthy volunteers.

AIMS: The present study assessed the acute effects of methadone and buprenorphine on actual on-road driving performance and neurocognitive function. METHODS: Methadone (5 and 10 mg per os) and buprenorphine (0.2 and 0.4 mg sublingual) were administered to 22 healthy volunteers in a five-way, double-blind, randomized, placebo-controlled, double-dummy, cross-over study. Driving performance was assessed with an on-road driving test. The primary outcome measure was standard deviation of lateral position (SDLP), a measure of road tracking control. Laboratory tests were used to measure cognitive function (e.g. reaction time and attention) and questionnaires were used to assess subjective measures of mood and sedation. RESULTS: There was no significant main effect of treatment on SDLP. Yet, analysis of individual drug-placebo contrast data revealed that buprenorphine 0.4 mg significantly increased SDLP. Driving impairment was mild and below the impairment threshold of a blood alcohol concentration of 0.5 mg ml-1 . Four participants stopped their driving test while under the influence of either opioid due to sleepiness. Both opioids produced impairments of cognitive task performance and increased sleepiness particularly at the highest dose. CONCLUSIONS: Analgesic doses of buprenorphine produced mild impairing effects on driving and related cognitive skills, while methadone impaired cognitive task performance but not driving performance. Large individual variations were observed for both drugs. Patients should be informed about the possibility of driving impairment when initiating opioid treatment.

Illegal substance use among 1,309 music festival attendees: An investigation using oral fluid sample drug tests, breathalysers and questionnaires.

AIMS: Illegal substance use at music festivals is less documented than it is in nightlife and electronic dance music settings. This study investigated such use through questionnaires, breathalysers and oral fluid drug testing. We also examined the associations between testing positive for illegal substances and demographics, self-reported substance use and measured blood alcohol concentration levels. METHODS: A cross-sectional study of 1,309 festival attendees from six Norwegian music festivals taking place between July and August 2016. Logistic regression models estimated the likelihood of a positive oral fluid drug test. Covariates were male, age, education, employment, smoking status, early age for alcohol intoxication, alcohol intoxication ⩾2 times a week, past-month and past-year illegal substance use, blood alcohol concentration levels and festivals. RESULTS: Overall, 12% reported illegal substance use in the past 30 days and 11% tested positive for illegal substances. Cannabis (6%), cocaine (3%) and MDMA/ecstasy (2%) were most commonly detected. One-third had a blood alcohol concentration ⩾0.10%. Of those with a positive test result ( n=146), 95% had detectable alcohol levels and 41% had a blood alcohol concentration above 0.10%. Those studying or working part-time were less likely to test positive compared to those who were not employed. Furthermore, those reporting daily smoking and past-year cannabis or MDMA/ecstasy use were more likely to test positive, compared to those not reporting such use. CONCLUSIONS: Illegal substance use was less prevalent than in previous nightlife and electronic dance music studies. Almost all those testing positive for illegal substances had detectable alcohol levels and 41% had a blood alcohol concentration greater than 0.10%, possibly indicating combined use.

Identification and Assessment of Drug-User Groups Among Nightlife Attendees: Self-Reports, Breathalyzer-Tests and Oral Fluid Drug Tests.

BACKGROUND AND OBJECTIVES: Even though nightlife studies with potentially intoxicated participants provide the much needed information on drug use, they face additional methodological challenges. This study aimed to explore the utility of such studies by (i) classifying nightlife attendees based on their self-reported drug use and by (ii) examining whether these classifications were meaningful when assessed against other sources of data, including oral fluid drug tests. METHODS: Self-reported questionnaires, oral fluid samples and blood alcohol concentration readings were collected in a sample of 1,085 nightlife patrons recruited outside 12 popular nightclubs in Oslo, Norway, in 2014. Patrons were classified using multiple approaches, including latent class analysis. Group differences were examined by logistic regression models. RESULTS: Participants were classified into 5 mutually exclusive groups: 2 among current non-users ("Never-users"; "Previous users"), 2 among current users ("Multiple drugs"; "Cannabis mainly") and one "Incomplete information" group. Meaningful differences across these groups were observed. For instance, positive tests for any illicit drug were more common in "Multiple drugs" group than in "Cannabis mainly" (62.7 vs. 29.1%, adjusted OR [aOR] 3.77 [2.42-5.84]) or "Incomplete information" groups (62.7 vs. 34.4%, aOR 2.46 [1.26-4.79]). Despite their self-declared non-use, illicit substances were detected in oral fluids of "Never-users" (13.1%; 95% CI 9.9-17.2) and "Previous users" (7.9%; 95% CI 5.1-12.1). CONCLUSIONS: Despite some discrepancies between self-reports and biological tests, self-reports proved both suitable and useful in identification of substantively different drug-user typologies, potentially informing targeted policy responses. Still, methodological challenges associated with onsite studies of illicit drug use should be further explored.

Correspondence between Oral Fluid Drug Test Results and Self-Reported Illicit Drug Use among Music Festival Attendees.

BACKGROUND: Use of illicit substances is often under-reported. Testing positive in oral fluid provides an objective confirmation of recent intake. OBJECTIVES: To examine the agreement between oral fluid test results and self-reported substance use among music festival attendees, and factors associated with reporting past 48 h drug use among users identified by drug testing. METHODS: One thousand three hundred nine participants were recruited from six music festivals in Norway (June-August 2016). They completed a questionnaire and provided oral fluid samples analyzed for amphetamines, MDMA, tetrahydrocannabinol (cannabis), and cocaine. Additionally, their blood alcohol levels were measured. RESULTS: Overall, 5.5% reported use of amphetamines, cannabis, cocaine, and/or MDMA during past 48 h in the questionnaire, whereas 10.8% tested positive in oral fluid. Only 16.7% of identified cocaine users and 31.1% of identified MDMA users reported past 48 h cocaine or MDMA use, respectively. Higher proportions of identified cannabis and amphetamine users reported past 48 h use (53.8% and 55.6%, respectively). Multivariable logistic regression analysis showed that among participants who tested positive, those reporting weekly illicit substance use (Adjusted Odds Ratio [AOR] 30.6; 95% Confidence Interval [CI] 6.3-147.9), and using such substances when younger than 18 years (AOR 5.0; 95% CI 1.9-13.4) were more likely to report past 48 h use. Conclusions/Importance: Oral fluid testing appears to be an important tool when studying illicit substance use among music festival attendees, as significant under-reporting was observed. Among those testing positive, regular, and experienced users were more likely to report recent use, compared to less regular and experienced users.

Drug Use by Music Festival Attendees: A Novel Triangulation Approach Using Self-Reported Data and Test Results of Oral Fluid and Pooled Urine Samples.

Background: Self-reported data are commonly used when investigating illicit substance use. However, self-reports have well-known limitations such as limited recall and socially desirable responding. Mislabeling or adulteration of drugs on the illicit market may also cause incorrect reporting. Objectives: We aimed to examine what could be gained in terms of illicit drug use findings among music festival attendees when including biological sample test results in the assessment. Methods: We included 651 attendees at three music festivals in Norway from June to August 2016. Self-reported drug use was recorded using questionnaires, and samples of oral fluid were analyzed to detect use of illicit drugs. In addition, we analyzed samples of pooled urine from portable toilets at each festival. Results: All methods identified cannabis, MDMA, and cocaine as the most commonly used drugs. Overall, 6.6% of respondents reported use of illicit substances during the previous 48 hours. Oral fluid testing identified a larger number of drug users as 12.6% tested positive for illicit drugs. In oral fluid testing, we identified ketamine and three new psychoactive substances (NPS) that had not been reported on the questionnaire. In pooled urine testing, we identified amphetamine and three additional NPS that were neither reported used nor found in oral fluid samples. Conclusions/Importance: Drug testing of biological samples proved to be an important supplement to self-reports as a larger number of illicit substances could be detected.

The significance of preexisting medical conditions, alcohol/drug use and suicidal behavior for drivers in fatal motor vehicle crashes: a retrospective autopsy study.

Driver fatalities in motor vehicle collisions (MVCs) encompass accidents, suicides, and natural deaths when driving. The objective of this study was to determine the significance of pathology and other autopsy findings for drivers in fatal MVCs. Forensic autopsy records of driver fatalities in southeast Norway between 2000 and 2014 were studied retrospectively. Data from individual police and collision investigation reports were also collected and analyzed. In 406 driver fatalities, the male/female ratio was 340/66; 9% died from natural causes, 9% were suicides, 65% were culpable accidental deaths, 14% were nonculpable deaths, and 3% were undetermined deaths. Head injuries and thoracic injuries were the most common causes of death. A seatbelt had been worn in 50% of the fatalities, and its prevalence did not differ between accidental deaths and suicides. Blood levels of alcohol and/or drugs that indicated impairment at the time of the collision were found in 40% (105/262) of all culpable accidental deaths but in 50% (64/127) of drivers aged up to 35 years. Pathology (most often cardiovascular disease) suggestive of sudden incapacitation before the collision was present in 24% (62/264) of drivers who were culpable in the accident and in 70% (46/66) of culpable drivers older than 55 years. A substantial proportion of drivers are killed in accidental collisions that may have occurred as a result of either alcohol/drug impairment or preexisting disease. Suicides and natural deaths both constitute significant proportions of MVC fatalities and may be misclassified unless a full inquest including an autopsy is performed.

Has Previous Abuse of Flunitrazepam Been Replaced by Clonazepam?

BACKGROUND AND AIMS: For many years, flunitrazepam was the benzodiazepine of choice among users of illegal drugs. The aim of this study was to investigate to which extent clonazepam use has increased in this population, and whether this was related to increased prescription or because of illegal availability. METHODS: We used data from three sources to study the changes in the use of clonazepam: (1) Presence and concentrations of clonazepam and flunitrazepam in blood samples collected from Norwegian drugged drivers; (2) Sales numbers (legal market) for clonazepam, extracted from the Norwegian prescription database (NorPD), and (3) Specific seizures (illegal market) for clonazepam in Norway. RESULTS: In 2004, 13.0% of the analysed blood samples from drugged drivers contained clonazepam, whereas this proportion had increased to 27.7% in 2013. In the same period, the frequency of flunitrazepam in drugged drivers decreased from 16.6% in 2004 to 3.2% in 2013. The number of clonazepam prescriptions decreased, while the number of seized tablets containing clonazepam increased considerably from 2004 to 2013. CONCLUSIONS: For the last 10 years, a significant increase in the illegal use of clonazepam has been seen, now replacing flunitrazepam as the most used illegal benzodiazepine in Norway.

Detection of 4 benzodiazepines in oral fluid as biomarker for presence in blood.

BACKGROUND: Analysis of samples of oral fluid (mixed saliva) is increasingly being used to detect recent drug use. The aim of this investigation was to assess the suitability of testing oral fluid as a biomarker for the presence of 4 benzodiazepines in blood and its possible application in clinical settings and in research on drug use. METHODS: Paired samples of oral fluid and blood from 4080 individuals in 4 European countries were collected and analyzed for benzodiazepines using gas or liquid chromatography with mass spectroscopic detection. RESULTS: Concentration data for the 4 most commonly detected benzodiazepines were studied: alprazolam, clonazepam, diazepam, and nordiazepam. Large variations in oral fluid to blood concentration ratios were observed for the studied benzodiazepines. The interquartile ranges for the oral fluid to blood concentrations ratios corresponded to 88%-197% of the median values. Selecting cutoff concentrations in oral fluid that gave the best accuracy in identifying individuals with benzodiazepine concentrations in blood above chosen thresholds produced accuracies of 74%-85% and the fraction of false negatives was 9%-23%. CONCLUSIONS: The concentration of the 4 studied benzodiazepines in oral fluid can neither be used to accurately estimate the concentrations in blood nor to correctly identify patients with blood drug concentrations below or above recommended therapeutic levels. When using analytical methods with limits of quantitation corresponding to concentrations less than 0.5 ng/mL in undiluted oral fluid, it may be used to confirm a recent intake of benzodiazepines. However, it is likely that some false negatives may occur.

Recommendations for effective collaboration and capacity building in epidemiological studies on the effect of alcohol and drug use on traffic safety in low- and middle-income countries.

OBJECTIVE: Alcohol or drug impairment is a major risk factor for road traffic crashes, and studies on this issue are essential to provide evidence-based data for policymakers. In low- and middle-income countries (LMICs), such studies are often conducted in partnership with one or more organizations in high-income countries (HICs). The aim of this article is to provide recommendations for improving project planning and decision-making processes in epidemiological studies on alcohol, drug and traffic safety in LMICs involving HICs. METHODS: We searched Pubmed, Google Scholar, and Google Search for articles and reports in English about lessons learned when conducting collaborative research in LMIC as well as papers presenting recommendations for effective research collaboration with partners in LMICs. RESULTS: Based on the search results, we selected 200 papers for full text examination. Few were related to studies on the effect of alcohol or drug use on road traffic safety. However, several conclusions and recommendations from other studies were found to be relevant. We combined the findings with our own experience in a narrative review. We also present a checklist for risk and quality assessment. CONCLUSIONS: Many papers presented similar recommendations, which included the importance of addressing local needs, ensuring adequate resources, local project ownership and leadership, establishing strong partnerships among all involved stakeholders, promoting shared decision-making and planning, and implementing strategies to translate research findings into policy, practice, and publications. It is also important to avoid HIC bias, which prioritizes the interests or perspectives of HICs over those of LMICs.

Prevalence of alcohol and drugs among drivers killed in road traffic crashes in Norway during 2011-2020.

OBJECTIVE: Driving under the influence of alcohol or drugs is one of the main contributing causes of serious road traffic crashes (RTCs). This study aimed to investigate the involvement of alcohol and drugs in driver fatalities in Norway during 2011-2020 and compare the findings with data from the previous decade. METHODS: We linked the results of forensic toxicology testing for alcohol and the 17 most commonly used drugs assigned with legal limits with data on fatal road traffic crashes obtained from Statistics Norway and the Norwegian Public Roads Administration. RESULTS: The number of fatalities had decreased significantly since the previous decade, while the proportion of drivers and riders tested for alcohol and drug use increased. Blood alcohol concentrations at the legal limit or higher were found in 14.4% and psychoactive drugs were detected in 15.8% of the cases; 10.7% tested positive for illicit drugs, and 10.1% for medicinal drugs. The most prevalent illicit drugs were tetrahydrocannabinol (7.9%) and amphetamine/methamphetamine (4.7%), whereas the most prevalent medicinal drugs were clonazepam (3.7%) and diazepam (2.2%). CONCLUSIONS: There was a marked reduction in the number of motor vehicle drivers killed in RTCs compared with the previous decade, and also a reduction in the prevalence of alcohol. For other substances, there were no marked changes in the prevalence.

Nystagmus among suspected amphetamine impaired drivers.

Clinical signs of drug use can be helpful to identify which drug has been consumed. Amphetamine intake has traditionally not been considered to cause nystagmus. The aim of this study was to explore whether there is a relationship between amphetamine use and nystagmus in a population of apprehended drivers in a naturalistic setting. We evaluated drivers suspected of drug-impaired driving where blood samples were collected and a clinical test of impairment (CTI) was performed. Evaluation of nystagmus is one of the CTI subtests. The samples were analysed for alcohol and psychoactive drugs. Cases with a nystagmus test were recorded and amphetamine-only cases were compared with alcohol-only cases and with cases where alcohol or drugs were not detected, respectively. Samples from 507 amphetamine-only cases were compared to 485 alcohol-only cases and 205 drug-negative cases. The median blood amphetamine concentration was 0.37 mg/L and the median alcohol concentration was 1.57 g/kg. The proportion of cases with nystagmus was similar in amphetamine-only cases (21%) and drug-negative controls (25%), p = 0.273, but higher in alcohol-only cases (53%), p < 0.001. No association was found between the blood amphetamine concentration and degree of nystagmus (Spearman's ρ = 0.008, p = 0.860), whereas an association between blood alcohol concentration and degree of nystagmus was demonstrated (ρ = 0.249, p < 0.001). In conclusion, our study did not find that apprehended drivers using amphetamine had more frequently nystagmus than a control group that tested negative for alcohol and drugs, even at high amphetamine concentrations in blood. Hence, nystagmus should not be considered a tool for identifying amphetamine-induced impairment in drivers.

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.

Prevalence of use and impairment from drugs and alcohol among trauma patients: A national prospective observational study.

BACKGROUND: Being under the influence of psychoactive substances increases the risk of involvement in and dying from a traumatic event. The study is a prospective population-based observational study that aims to determine the prevalence of use and likely impairment from psychoactive substances among patients with suspected severe traumatic injury. METHOD: This study was conducted at 35 of 38 Norwegian trauma hospitals from 1 March 2019 to 29 February 2020. All trauma admissions for patients aged ≥ 16 years admitted via trauma team activation during the study period were eligible for inclusion. Blood samples collected on admission were analysed for alcohol, benzodiazepines, benzodiazepine-like hypnotics (Z-drugs), opioids, stimulants, and cannabis (tetrahydrocannabinol). RESULTS: Of the 4878 trauma admissions included, psychoactive substances were detected in 1714 (35 %) and in 771 (45 %) of these, a combination of two or more psychoactive substances was detected. Regarding the level of impairment, 1373 (28 %) admissions revealed a concentration of one or more psychoactive substances indicating likely impairment, and 1052 (22 %) highly impairment. Alcohol was found in 1009 (21 %) admissions, benzodiazepines and Z-drugs in 613 (13 %), opioids in 467 (10 %), cannabis in 352 (7 %), and stimulants in 371 (8 %). Men aged 27-43 years and patients with violence-related trauma had the highest prevalence of psychoactive substance use with respectively 424 (50 %) and 275 (80 %) testing positive for one or more compounds. CONCLUSION: The results revealed psychoactive substances in 35 % of trauma admissions, 80 % of which were likely impaired at the time of traumatic injury. A combination of several psychoactive substances was common, and younger males and patients with violence-related injuries were most often impaired. Injury prevention strategies should focus on high-risk groups and involve the prescription of controlled substances. We should consider toxicological screening in trauma admissions and incorporation of toxicological data into trauma registries.

Alcohol, psychoactive substances and non-fatal road traffic accidents--a case-control study.

BACKGROUND: The prevalence of alcohol and other psychoactive substances is high in biological specimens from injured drivers, while the prevalence of these psychoactive substances in samples from drivers in normal traffic is low. The aim of this study was to compare the prevalence of alcohol and psychoactive substances in drivers admitted to hospital for treatment of injuries after road traffic accidents with that in drivers in normal traffic, and calculate risk estimates for the substances, and combinations of substances found in both groups. METHODS: Injured drivers were recruited in the hospital emergency department and drivers in normal conditions were taken from the hospital catchment area in roadside tests of moving traffic. Substances found in blood samples from injured drivers and oral fluid samples from drivers in moving traffic were compared using equivalent cut off concentrations, and risk estimates were calculated using logistic regression analyses. RESULTS: In 21.9% of the injured drivers, substances were found: most commonly alcohol (11.5%) and stimulants eg. cocaine or amphetamines (9.4%). This compares to 3.2% of drivers in normal traffic where the most commonly found substances were z-hypnotics (0.9%) and benzodiazepines (0.8%). The greatest increase in risk of being injured was for alcohol combined with any other substance (OR: 231.9, 95% CI: 33.3- 1615.4, p < 0.001), for more than three psychoactive substances (OR: 38.9, 95% CI: 8.2- 185.0, p < 0.001) and for alcohol alone (OR: 36.1, 95% CI: 13.2- 98.6, p < 0.001). Single use of non-alcohol substances was not associated with increased accident risk. CONCLUSION: The prevalence of psychoactive substances was higher among injured drivers than drivers in normal moving traffic. The risk of accident is greatly increased among drivers who tested positive for alcohol, in particular, those who had also ingested one or more psychoactive substances. Various preventive measures should be considered to curb the prevalence of driving under the influence of psychoactive substances as these drivers constitute a significant risk for other road users as well as themselves.

Poor correlation between alcohol concentration in oral fluid and breath in subjects consuming beverages immediately before testing.

INTRODUCTION: In previous research projects and clinical settings, alcohol analysis in oral fluid (saliva) has been used as an alternative to breath or blood alcohol testing. In this study we examined whether it is possible to obtain clinically relevant data regarding alcohol consumption in individuals who recently consumed alcohol by analysing oral fluid samples when the recommended rinsing of the mouth is impossible before sample collection. MATERIALS AND METHODS: We conducted a study of 89 nightclub patrons in Norway. Before collecting oral fluid samples and performing breath alcohol testing, participants were required to drink a glass of water to remove residual alcohol from the mouth. Oral fluid samples were collected with the Quantisal oral fluid collection device and analysed using an enzymatic method for alcohol. The alcohol concentration in the neat (undiluted) oral fluid was then calculated. Breath alcohol testing was performed using Lion Alcolmeter 500 instruments. RESULTS: No false-negative or false-positive results for alcohol were detected in the oral fluid when compared with those in the breath. The Intraclass Correlation Coefficient of 0.40 indicated a poor correlation between alcohol concentrations in the two sample types. CONCLUSIONS: The procedure for collecting oral fluid was suitable for the qualitative determination of alcohol intake but not for quantitative assessment. We recommend that oral fluid samples should not be used for estimating blood or breath alcohol concentrations in people who have recently consumed alcohol or non-alcoholic beverages, as recommended in the instructions for use.