Prevalence of alcohol, illicit drugs and psychoactive medicines in killed drivers in four European countries.

Our objective was to determine the presence of psychoactive substances in blood of drivers killed in road crashes in four European countries. Data from 1118 drivers of car and vans, killed between 2006 and 2009, were collected in Finland, Norway, Portugal and Sweden. The prevalence of any psychoactive substance ranged between 31 and 48%. Alcohol (≥ 0.1 g/L) was the most common finding, 87% had a blood alcohol concentration (BAC) ≥ .5 g/L. Benzodiazepines (1.8-13.3%) and amphetamines (0-7.4%) were the most prevalent psychoactive medicines and illicit drugs, respectively. Alcohol-drug and drug-drug combinations were rather prevalent. Differences in alcohol/drug findings seemed to reflect differences in use in the countries. More research should be done to develop preventive strategies to reduce the number of alcohol- and drug-related traffic accidents targeting at-risk groups, such as drivers with very high BACs and novice drivers.

Presence of psychoactive substances in injured Belgian drivers.

OBJECTIVE: To estimate the percentage of drivers involved in a traffic crash in Belgium who have alcohol and drugs in their blood. METHODS: Blood samples of the drivers injured in a traffic crash and admitted to the emergency departments of 5 hospitals in Belgium between January 2008 and May 2010 were analyzed for ethanol (with an enzymatic method) and 22 other psychoactive substances (with ultra-performance liquid chromatography with tandem mass spectrometry or gas chromatography-mass spectrometry). RESULTS: One thousand seventy-eight drivers were included in the study. Alcohol (≥0.1 g/L) was the most common substance (26.2%). A large majority of the drivers (64%) who were positive for alcohol had a blood alcohol concentration (BAC) ≥1.3 g/L (legal limit in Belgium: 0.5 g/L). These high BACs were most frequent among male injured drivers. Cannabis was the most prevalent illicit drug (5.3%) and benzodiazepines (5.3%) were the most prevalent medicinal drugs. Approximately 1 percent of the drivers were positive for cocaine and amphetamines. No drivers tested positive for illicit opioids. Medicinal drugs were more likely to be found among female drivers and drivers older than 35 years, and alcohol and illicit drugs were more likely to be found among male drivers and drivers younger than 35 years. CONCLUSION: A high percentage of the injured drivers were positive for a psychoactive substance at the time of injury. Alcohol was the most common substance, with 80 percent of the positive drivers having a BAC ≥0.5 g/L. Compared to a roadside survey in the same area, drivers/riders with high BACs and combinations of drugs were overrepresented. Efforts should be made to increase alcohol and drug enforcement. The introduction of a categorization and labeling system might reduce driving under the influence of medicinal drugs by informing health care professionals and patients.

Random and systematic errors in case-control studies calculating the injury risk of driving under the influence of psychoactive substances.

Between 2006 and 2010, six population based case-control studies were conducted as part of the European research-project DRUID (DRiving Under the Influence of Drugs, alcohol and medicines). The aim of these case-control studies was to calculate odds ratios indicating the relative risk of serious injury in car crashes. The calculated odds ratios in these studies showed large variations, despite the use of uniform guidelines for the study designs. The main objective of the present article is to provide insight into the presence of random and systematic errors in the six DRUID case-control studies. Relevant information was gathered from the DRUID-reports for eleven indicators for errors. The results showed that differences between the odds ratios in the DRUID case-control studies may indeed be (partially) explained by random and systematic errors. Selection bias and errors due to small sample sizes and cell counts were the most frequently observed errors in the six DRUID case-control studies. Therefore, it is recommended that epidemiological studies that assess the risk of psychoactive substances in traffic pay specific attention to avoid these potential sources of random and systematic errors. The list of indicators that was identified in this study is useful both as guidance for systematic reviews and meta-analyses and for future epidemiological studies in the field of driving under the influence to minimize sources of errors already at the start of the study.

Comparison of drug concentrations measured in roadside surveys and in seriously injured drivers in Belgium.

The objective of this paper is to compare concentrations of alcohol, illicit, and medicinal drugs in seriously injured drivers and drivers selected randomly at the roadside. Blood samples were analyzed for alcohol, 17 medicinal drugs and 8 illicit psychoactive substances and/or their metabolites by ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) and gas chromatography mass spectrometry (GC-MS) in injured drivers admitted to the emergency departments of five hospitals in Belgium between January 2008 and May 2010 and in drivers randomly selected between January 2008 and September 2009. Three hundred and seventy-seven seriously injured drivers and 2750 roadside respondents were selected. In the roadside survey, out of the 203 concentrations above DRUID (Driving Under the Influence of Drugs, Alcohol and Medicines) cut-offs for medicinal drugs, 51% were in the therapeutic range, 46% infratherapeutic, and 2.5% supratherapeutic. In the seriously injured drivers, out of the 78 concentrations above DRUID cut-offs for medicinal drugs, these percentages were respectively 63%, 33%, and 4%. Significant differences were found in the distribution of concentrations for opioids, benzodiazepines, and Z-drugs. For the latter, while in the seriously injured drivers study most concentrations were therapeutic, in the roadside survey most were infratherapeutic. The opposite was observed for the opioids. Eight and 41% of the roadside respondents and injured drivers, respectively, had an alcohol concentration above 0.1 g/L, with higher concentrations found in the injured drivers. For illicit drugs, significant differences were found for amphetamine and cocaine, for which respectively lower and higher concentrations were observed in the blood samples taken in the roadside survey.

Alcohol and drugs in seriously injured drivers in six European countries.

The objective of this study was to determine the presence of alcohol and drugs in drivers severely injured in traffic crashes in six European countries. Data were collected from 2492 seriously injured drivers of cars and vans in Belgium, Denmark, Finland, Italy, Lithuania, and the Netherlands, between 2007 and 2010. Toxicological analysis was performed with chromatographic techniques on whole blood for 23 substances. The percentage of drivers positive for at least one psychoactive substance ranged between 28% (Lithuania) and 53% (Belgium). Alcohol (≥0.1 g/L) was the most common finding with the highest percentage in Belgium (42.5%). Among the alcohol-positive drivers, 90.5% had a blood alcohol count (BAC) ≥0.5 g/L and 65.7% had a BAC ≥1.3 g/L. Benzodiazepines (0.0-10.2%) and medicinal opioids (0.5-7.8%) were the most prevailing medicinal drugs, but half of the concentrations were lower than therapeutic. Cannabis (0.5-7.6%) was the most prevailing illicit drug. Alcohol was found in combination with drugs in 2.3-13.2% of the drivers. Drug combinations were found in 0.5-4.3% of the drivers. This study confirms the high prevalence of psychoactive substances in injured drivers, but we observed large differences between the participating countries. Alcohol was the most common finding, followed by cannabis and benzodiazepines. Notable are the many drivers having a BAC ≥ 1.3 g/L. The majority of the substances were found in combination with another psychoactive substance, mostly alcohol. The high prevalence of high BACs and combinations (compared to roadside surveys) suggest that those drivers are most at risk and that preventive actions should target them preferentially.

Repeatability of oral fluid collection methods for THC measurement.

STUDY OBJECTIVES: To determine the influence of sample collection for two different collection methods on THC concentrations and to compare THC concentrations collected by both methods. METHODS: A total of 136 pairs of oral fluid samples from subjects who had recently smoked Cannabis were obtained by the non-acidic Statsure oral fluid collection device and by ordinary spit tubes. Oral fluid was analyzed for THC by LC-MS/MS. Bland-Altman plots were used for the quantitative analysis of repeatability, whereas Cohen's kappa was used for qualitative analysis to determine the consistency of the results with regard to the Belgian legal limit. RESULTS: Repeatability of both sampling methods was very low. The Statsure device had a better rate of agreement when compared with the Belgian legal limit than the spitting method. THC concentrations of samples collected by spit tubes were on average a factor 5.9 higher than the corresponding concentrations in samples collected by the Statsure device. CONCLUSIONS: The repeatability of both the Statsure collection method and the ordinary spit tubes was low when applied to subjects who had consumed Cannabis very recently. Furthermore, THC concentrations were higher in samples obtained by spitting than samples collected with Statsure. These results may have implications for confirmation analysis in oral fluid, when applied for legal purposes.

Prevalence of psychoactive substances in dutch and belgian traffic.

OBJECTIVE: The purpose of this study was to compare the prevalence of psychoactive substances in general traffic in The Netherlands and Belgium. METHOD: Randomly selected car drivers and drivers of small vans in six police regions in The Netherlands and five police regions in Belgium were included between January 2007 and August 2009. Blood and oral fluid samples were analyzed for 23 substances, including ethanol (alcohol), by means of ultra performance liquid chromatography-tandem mass spectrometry or gas chromatography-mass spectrometry analysis. Samples were weighted according to the distribution of traffic over eight 6-hour periods. Substance groups were categorized in five mutually exclusive classes: single alcohol use, single illicit drug use, single medicinal drugs use, multiple drug use (including drugs from two or more separate substance groups but excluding alcohol), and drug use (either single or multiple) in combination with alcohol. RESULTS: In total, 7,771 drivers (4,822 in The Netherlands and 2,949 in Belgium) were included in the study. In Belgium, the prevalence of single alcohol (6.4%) and single medicinal drugs (3.0%) was much higher than in The Netherlands (2.2% and 0.6%, respectively), whereas the single illicit drugs were more common in Dutch traffic (2.2%) than in Belgian traffic (0.6%). Compared with the estimated prevalence of psychoactive substances in the general driving public in Europe, the prevalence in Belgium (10.7%) was greater than the European average (7.4%), and the prevalence in The Netherlands was below the European average (5.5%). CONCLUSIONS: The observed prevalence of psychoactive substances varies largely between The Netherlands and Belgium. Probable reasons for the differences are the higher level of alcohol enforcement in The Netherlands and nonresponse bias in the Belgian study (for illicit drugs in particular). Furthermore, cultural differences and variances in prescription policy could also be influential.

A case-control study estimating accident risk for alcohol, medicines and illegal drugs.

BACKGROUND: The aim of the present study was to assess the risk of having a traffic accident after using alcohol, single drugs, or a combination, and to determine the concentrations at which this risk is significantly increased. METHODS: A population-based case-control study was carried out, collecting whole blood samples of both cases and controls, in which a number of drugs were detected. The risk of having an accident when under the influence of drugs was estimated using logistic regression adjusting for gender, age and time period of accident (cases)/sampling (controls). The main outcome measures were odds ratio (OR) for accident risk associated with single and multiple drug use. In total, 337 cases (negative: 176; positive: 161) and 2726 controls (negative: 2425; positive: 301) were included in the study. RESULTS: Main findings were that 1) alcohol in general (all the concentrations together) caused an elevated crash risk; 2) cannabis in general also caused an increase in accident risk; at a cut-off of 2 ng/mL THC the risk of having an accident was four times the risk associated with the lowest THC concentrations; 3) when ranking the adjusted OR from lowest to highest risk, alcohol alone or in combination with other drugs was related to a very elevated crash risk, with the highest risk for stimulants combined with sedatives. CONCLUSION: The study demonstrated a concentration-dependent crash risk for THC positive drivers. Alcohol and alcohol-drug combinations are by far the most prevalent substances in drivers and subsequently pose the largest risk in traffic, both in terms of risk and scope.

Medicines and driving: evaluation of training and software support for patient counselling by pharmacists.

BACKGROUND: The consumption of some psychotropic medicines has a negative effect on the fitness to drive. Pharmacists are expected to give useful advice to patients on their participation in traffic. However, almost no information is available on this topic. OBJECTIVE: To assess the effect of training and implementation of new dispensing guidelines with regard to driving-impairing medicines, in two types of dispensing support tools. User acceptance was measured as well as the effect on pharmacists' attitudes & awareness, self-reported behaviour and knowledge. SETTING: Pharmacists from East Flanders in Belgium. METHODS: Two intervention groups and a control group participated. The intervention groups followed a training and were provided with a dispensing support tool containing information on the effect of medicines on driving ability, which was either stand-alone (USB stick) or integrated into the daily used software (ViaNova). The three groups filled out a questionnaire prior to and after the intervention period. MAIN OUTCOME MEASURE: Answers to a pre/post-questionnaire on attitudes and awareness, self-reported behaviour, knowledge and user acceptance. RESULTS: Many pharmacists were already strongly interested in the topic at the beginning of the study. Positive changes in attitude, self-reported behaviour and knowledge were measured mostly in the group of pharmacists for which the information was integrated in their daily used software. These pharmacists asked significantly more about the patients' driving experience, informed them more about driving-related risk and gave more detailed information on impairing effects of medicines. The knowledge of the participating pharmacists on the topic 'medicines and driving' remained generally low. The participants acknowledge the importance of being aware of the topic medicines and driving but they report a lack of information or education. They strongly prefer a tool that integrates the information in their daily used software. CONCLUSION: Dispensing support tools with information on the potential impairing effect of a medicine on the fitness to drive increases awareness, reported risk communication behaviour as well as knowledge of pharmacists on this topic. Computerised dispensing support tools are most effective when the information is integrated into the daily used dispensing software.

DUID: oral fluid and blood confirmation compared in Belgium.

The objective of this study was to compare the number of drivers with drug concentrations above the legal cutoffs for driving under the influence of illicit substances in paired samples of blood and oral fluid. Between January 2008 and September 2009, 2,949 randomly selected drivers participated in a roadside survey. Each was asked to provide blood and oral fluid. Samples were analyzed for 11 illicit substances or metabolites by ultra-performance liquid chromatography-tandem mass spectrometry and gas chromatography-tandem mass spectrometry. Out of the 2,750 drivers who gave both blood and oral fluid, 28 (1.0%) had drug concentrations above the legal cutoff in blood and 71 (2.6%) were above the legal cutoff in oral fluid. Fifteen (7.5%) of the 199 drivers who gave an oral fluid sample but refused to provide blood tested positive, significantly more than drivers who provided both samples. Based on oral fluid analysis, 2.6 times more subjects tested positive for drugs compared to blood analysis. Those that refused to give a blood sample were 3 times more likely to test positive for drugs. Even in a survey that guaranteed total anonymity, people fearing a positive test result might have been more likely to refuse to give a blood sample.

Prevalence of alcohol and other psychoactive substances in injured drivers: comparison between Belgium and The Netherlands.

STUDY OBJECTIVE: To compare the prevalence of alcohol and (il)licit drugs in seriously injured drivers in Belgium (BE) and the Netherlands (NL). METHODS: Injured car and van drivers admitted to the emergency departments of five hospitals in Belgium and three in the Netherlands from January 2008 to May 2010 were included. Blood samples were taken and analysed for ethanol (with an enzymatic method) and 22 other psychoactive substances (UPLC-MS/MS or GC-MS). RESULTS: In total 535 injured drivers were included in the study (BE: 348; NL: 187). More drivers were found positive for alcohol and drugs in Belgium (52.6%) than in the Netherlands (33.9%). Alcohol (≥0.1 g/L) was the most prevalent substance in both countries (BE: 42.5%; NL: 29.6%). A similar prevalence was found for amphetamine (BE: 2.6%; NL: 2.2%) and cocaine (BE: 2.3%; NL: 2.1%). In the Netherlands almost no positive findings for cannabis were recorded (0.5%). No driver tested positive for benzodiazepines in the Netherlands compared to 7.3% in Belgium. More injured drivers tested positive for Z-drugs (BE: 1.8%; NL: 0.5%) and medicinal opioids (BE: 3.3%; NL: 0.5%) in Belgium. CONCLUSIONS: The prevalence of alcohol in seriously injured drivers was 12% higher found in Belgium than in the Netherlands. The prevalence of drugs was similar in both countries except for THC and medicinal drugs, particularly benzodiazepines, with a much higher prevalence in Belgium. In comparison to previous survey there were differences in the prevalence of THC, benzodiazepines and combinations of drugs. Possible explanations are the different matrix used, a bias in study population, or in case of illicit opiates and benzodiazepines a different consumption pattern in the two countries. Alcohol is still the most prevalent substance among the injured driver population and this increased the last 15 years.

Analytical evaluation of four on-site oral fluid drug testing devices.

The use of oral fluid (OF) as an alternative matrix for the detection of drugs of abuse has increased over the last decade, leading to the need for a rapid, simple, and reliable on-site OF testing device. Four on-site OF drug testing devices (Dräger DrugTest 5000, Cozart DDS, Mavand Rapid STAT, and Innovacon OrAlert) were evaluated on 408 volunteers at drug treatment centers. UPLC-MS-MS results were used as reference to determine sensitivity, specificity and accuracy for each device, applying Belgian legal confirmation cutoffs for benzoylecgonine, cocaine, and THC (10 ng/mL); morphine and 6-acetylmorphine (5 ng/mL); and amphetamine and 3,4-methylenedioxymethylamphetamine (25 ng/mL). Sensitivity for cocaine was 50%, 50%, 27%, and 11% for DrugTest, OrAlert, Rapid STAT, and DDS 806, respectively. For opiates, sensitivities were 84%, 73%, 77%, and 65%, respectively. For THC, the sensitivities were 81%, 23%, 43%, and 28%, respectively. For amphetamines, the sensitivities were 75%, 33%, 17%, and 67%, respectively. Specificity was >88% for opiates and THC, > 90% for amphetamines, and > 97% for cocaine. All tests showed good specificity. DrugTest had the highest sensitivity, although it was still low for some analytes.

An analytical evaluation of eight on-site oral fluid drug screening devices using laboratory confirmation results from oral fluid.

The performance of eight on-site oral fluid drug screening devices was studied in Belgium, Finland and the Netherlands as a part of the EU-project DRUID. The main objective of the study was to evaluate the reliability of the devices for testing drivers suspected of driving under the influence of drugs (DUID). The performance of the devices was assessed by their ability to detect substances using cut-offs which were set at sufficiently low levels to allow optimal detection of positive DUID cases. The devices were evaluated for the detection of amphetamine(s), cannabis, cocaine, opiates and benzodiazepines when the relevant test was incorporated. Methamphetamine, MDMA and PCP tests that were included in some devices were not evaluated since there were too few positive samples. The device results were compared with confirmation analysis results in oral fluid. The opiates tests appeared to perform relatively well with sensitivity results between 69 and 90%. Amphetamines and benzodiazepines tests had lower sensitivity, although the DrugWipe test evaluated was promising for amphetamine. In particular, it is evident that the cannabis and cocaine tests of the devices still lack sensitivity, although further testing of the cocaine tests is desirable due to the low prevalence and low concentrations encountered in this study.