S TOP D RUGGED D RIVING Bruce A. Goldberger, Ph.D., DABFT Professor and Director of Toxicology...
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Transcript of S TOP D RUGGED D RIVING Bruce A. Goldberger, Ph.D., DABFT Professor and Director of Toxicology...
STOP DRUGGED DRIVING
Bruce A. Goldberger, Ph.D., DABFT
Professor and Director of ToxicologyCollege of Medicine - Pathology & Psychiatry
President, American Academy of Forensic Sciences
Alcohol / Drugs and Driving
Which Drugs Can Affect Driving? Any drug that affects the brain’s
perception, collection, processing, storage or critical evaluation processes.
Any drug that affects communication of the brain’s commands to muscles or organ systems.
For the most part, drugs that affect the central nervous system.
Alcohol and Drugs
Drug Impaired Driving Results in Injuries and Deaths –
No database to track injuries and deaths Problem is under-reported, under-
recognized Drugs are a constant factor in traffic
crashes Societal impact unknown
Alcohol and Drugs
National Center for Injury Prevention and Control –
“During 2005, 16,885 people in the U.S. died in alcohol-related motor vehicle crashes, representing 39% of all traffic-related deaths (NHTSA 2006).”
“In 2005, nearly 1.4 million drivers were arrested for driving under the influence of alcohol or narcotics (Department of Justice 2005).”
“Drugs other than alcohol (e.g., marijuana and cocaine) are involved in about 18% of motor vehicle driver deaths. These other drugs are generally used in combination with alcohol (Jones et al. 2003).”
www.cdc.gov/ncipc/factsheets/drving.htm
Drug Impaired Driving
Drugs detected in 10 to 22% of drivers involved in crashes, often in combination with alcohol
Drugs detected in up to 40% of injured drivers requiring medical treatment
Drug use among drivers arrested for motor vehicle offenses is 15-50%
Highest rates reported among those arrested for impaired or reckless driving
Source: NHTSA, National Highway and Traffic Safety Administration
Young People
Incidence of non-alcohol related driving impairment higher among young people
22% of young people report using drugs prior to driving
23.5% of drivers under 21 tested positive for drugs (DHHS)
16-20 year olds more than twice as likely to drive after non-alcohol drug use compared with those over 21y (SAMHSA)
20% of twelfth grade students report smoking marijuana in cars (PRIDE)
The Grand Rapids Study
Relative Probability of Causing an Accident
www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2005/AlcoholTSF05.pdf
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Traffic Fatalities
Total FatalitiesNo AlcoholLow AlcoholHigh AlcoholVery High Alcohol
Traffic Fatalities in Florida
Drugged Driving In a Campus Community
Excessive drinking threatens the academic mission of colleges, and the health and
safety of their communities.
Research Team
Binge Drinking
Heavy episodic or “binge” drinking has been associated with numerous problems in the college student population:
sexual assault violent behavior physical injury property damage high-risk sexual
behavior poor academic
performance death
Methods
This study was conducted during six nights of December, 2006 and May, 2007.
Sidewalk interviews and breath alcohol tests were conducted with 291 patrons exiting 15 drinking establishments in Gainesville, FL. University of Florida (49,000 students) Santa Fe Community College (16,000 students)
Establishment Visits
Each establishment visit consisted of:(1) Observational
assessment inside establishment
(2) Sidewalk interviews outside establishment
Sidewalk Interviews
Each sidewalk interview consisted of a 3-5 minute interview and breath alcohol test.
Sidewalk Interviews Examples of questions asked during
interview: When did you start drinking today? How many drinks have you had today? Did you take advantage of a drink special today?
After the interview and breath test, participants were given a “walk-away” card: phone numbers for safe ride services local sources of help for an alcohol problem contact information of principal investigator and
institutional review board
Sample
Of approximately 600 exiting patrons, 291 agreed to participate. 61% were men 86% were college students 84% were 21 years of age or older
Average BrAC =0.091 (range 0.0-0.281) 58% above the legal limit to drive (BAC ≥ .08) No sex differences in regards to BAC.
The Interview
After being recruited and giving verbal informed consent, participants completed a 10-15 minute interview and anonymous survey about their behaviors that night.
Participants also provided 3 specimens – breath and oral fluid (2x)
Oral Fluid Specimen
Participants provided a saliva sample to be examined for genetic markers linked to excessive drinking and alcohol dependence.
Oral Fluid Specimen
Participants provided an oral fluid sample to detect recent use (i.e., tobacco, marijuana, other illicit and prescription drugs).
Breath Sample
Participants provided a breath sample to estimate blood alcohol concentration.
Sample
Demographics (N=477) 65% were men 77% were white 91% were college students 76% were 21 years of age or older
Average BAC =0.091 (range: 0 - 0.262) 58% above the 0.08 25% were under 21 years of age 21% planned to drive home in less than an hour 15% used drugs besides alcohol to get high that night
Results of Drug Testing
Of those participants who provided an oral fluid sample to detect recent drug use, 95% reported drinking alcohol that night 12% reported using drugs other than alcohol
• 11% tested positive for drugs• 8% tested positive for marijuana• 2% tested positive for cocaine• 2% tested positive for multiple drugs
Effects of Drugs on Driving
• CoordinationEffects on nerves/muscles - steering, braking, accelerating, manipulation of vehicle
• Reaction TimeInsufficient response - reaction
• JudgmentCognitive effects, risk reduction, avoidance of potential hazards, anticipation, risk-taking behavior, inattention, decreased fear, exhilaration, loss of control
• TrackingStaying in lane, maintaining distance
• AttentionDivided, not focussed. Time-shared task with high demand for info processing
• Perception90% of info processed while driving is visual. Glare resistance, recovery, dark and light adaptation, dynamic visual acuity
Alcohol and Drugs
Drugs commonly associated with impaired driving –
Cannabinoids (marijuana) Depressants: sedative/hypnotics, muscle
relaxants, antihistamines Stimulants: cocaine, methamphetamine Narcotic analgesics: morphine, codeine,
hydrocodone, hydromorphone, oxycodone, methadone
Alcohol and Drugs
Depressants commonly associated with impaired driving – Sedative/hypnotics including diazepam and
alprazolam (Valium and Xanax) Muscle relaxants including carisoprodol
(Soma) Antihistamines including diphenhydramine
(Benadryl)
Basis for the Opinion of Impairment?
Impairment is based on knowledge of the drug(s), intended effects, side effects and toxic effects
The toxicologist can rarely give an opinion based upon the toxicology report alone
The opinion may depend on the context of the case and information gathered by the investigator (situation, environment, observations, driving pattern etc.)
Determining “Under the Influence”
A. Driving pattern
B. Impairment Visual Physiological Performance
C. Positive toxicology Ethanol Drugs
- blood vs. urine
- parent vs. metabolite
- quantitation
What the Toxicologist cannot do….
Determine impairment in a specific individual from a blood concentration alone
Determine exactly how much drug was taken
Determine exactly when a drug was taken
Drug Interpretation Issues Multiple drug use Tolerance History of drug use (chronic vs. naïve) Health Metabolism Genetic/ethnic differences Individual sensitivity/response Withdrawal Put in context of case e.g. environmental
factors
Toxicology IssuesQuantitative or Qualitative Analysis?
Therapeutic, toxic, lethal concentration in blood?
High or low dose? Recent use or residual drug? Effect of tolerance, history of drug use Individual sensitivity/response Effect of other drugs?
Drugs in Urine
Good specimen to screen for large number of drugs and drug classes
Typically see metabolites Usually indicates drug use within the
past 2-3 days or more Cannot definitively establish
impairment “Consistent with” or “Explanation for”
the impairment
Drugs in Blood
If drug is present in the blood, it is assumed to be affecting central nervous system and other target organs
Typically see parent compounds (or both)
Quantitation is vital to prosecution
Urine vs Blood
Since urine is an end-product of absorption, distribution and metabolism, a drug in the urine does not show it is still circulating in the body and producing an effect
Cannot say one is “under the influence”
Urine vs Blood
Blood however is circulating throughout the body and one is experiencing the drug’s effects – “under the influence”
But, is one “impaired”? Must know pharmacology Drugs and Driving literature evolving
Parent vs Drug Metabolite
Parent drug is the compound ingested Metabolites are formed by enzymatic or
chemical processes in the body Metabolites can be pharmacologically
active or inactive, more or less toxic than the parent
Metabolites usually have longer half-lives so will be detected longer and exert its effects longer than the parent drug and may help determine time frame of use
Quantitation
Numbers help, but certainly aren’t the end all answer
Therapeutic vs. abuse vs. toxic Research is still evolving
Drug Impairment Issues
More complex than alcohol Often in combination with other drugs and/or
alcohol (additive or synergistic effects) Scientific literature is complex May require a toxicologist to interpret the
results and provide an opinion These complex issues must be explained to
the court using every day language
It Gets Very Complicated…
Unusual or incomplete signs Individual responses vary Phase of the drug use (up or down?) Chronic or naïve drug user Tolerance Are there “normal ranges”?
Poly-drug Challenges
Inconsistent symptoms Determine dominant drug Show consistencies with that drug Explain how other drugs present
may contribute to effects
How it’s done now
Work with the triad of driving pattern, impairment and positive toxicology whenever possible
Research the drugs and driving literature before forming an opinion
Is the number meaningful? Missing information needs to be carefully
considered Be prepared to discuss general issues in
cases where impairment cannot be definitively determined
Approaches to Prosecution
May require the driver to be “affected by”
May require the drug to impair a driver’s ability to operate a vehicle safely, incapable of driving safely or require a driver to be under the influence, impaired or affected by an intoxicating drug
Per-se or zero tolerance drug laws
Make it a criminal offense to have a specified drug or metabolite in the body while operating a motor vehicle
Any amount (zero tolerance) or a specified level (per se)
How is the testing done…
Specimens - blood, urine and oral fluid Immunoassay screen for drug or drug panel
• Homogeneous immunoassay• ELISA
Gas Chromatography Screen• GC or GC-MS
Confirmation/Quantitation by mass spectrometry• GC-MS or GC-MS-MS• LC-MS or LC-MS-MS
Analytical Recommendations
Survey Data
Ten Drugs Most Often Identified
Recommended Scope of Cutoffs
Medical/Clinical/Forensic Diagnostics
BREATH
Specific Molecular Entities in Breath
Endogenous Biomarkers of Disease Glutamate – Brain injury (trauma or stroke) Stress markers – Inflammatory mediators Histamine – Asthma
Exogenous Drugs – particularly those with a narrow TI Chemotherapeutic agents Antimicrobials THC, cocaine, GHB, ecstasy, etc. – Drugs of Abuse Biomarker Drugs – Assess enzyme competence
Target Molecules in Breath
O
HO
OH
OH
OHHO
-D-glucose
OH
H3C CH3
CH3CH3
Propofol
H3C
O
N
N
Fentanyl
Ethanol
Human Lung and Breath Ideal Media for Diagnostics (Breath =
Gas + Liquid) Blood Lungs Breath Blood transports all chemicals Breath - volatiles and non-volatiles
100% Cardiac Output Lungs Excellent transport given lungs surface
area for diffusion Breath free drug blood concentration Rapid kinetics Non-invasive Not “dirty” versus other sampling sites
Unprecedented opportunities for portable, accurate, sensitive/specific, non-invasive, real time (breath-to-breath) POC diagnostics for many medical applications
Why do we need nano for breath detectors?
NANO
Answer: Nano provides the “horsepower” to sensitively and specifically detect low concentrations of analytes.
2 critical factors in breath: 1) physiologically relevant free drug concentrations, and 2) relationship between blood and breath drug concentrations.
Potent Drugs ±
Type D Behavior =
3 general types: Antibodies – proteins (amino acids)
Many commercially available; vast array available including those directed against multiple epitopes on a specific molecule
Functional well in vivo and ex vivo Excellent for nano-based breath diagnostics
Aptamers – DNA/RNA (oligonucleotides) Few available for small molecules; most proteins Functional poorly in vivo; better ex vivo
Enzymes – catalyze degradation of substrates Can have extraordinary selectivity for specific substrates e.g., glucose oxidase for glucose
Molecular Recognition Entities (MREs)
Breath Propofol - Measurements
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TOT. SIG.
PROPOFOL RELATIVE BREATH CONCENTRATION PROFILE
TIME (MIN.)
TO
TA
L S
IGN
AL
(C
OU
NT
S)
120 μg/Kg/min
50 μg/Kg/min
200 mg bolus
40mg bolus, 100 μg/Kg/min
40 mg bolus
60 mg bolus
infusion off
4035302520151050-1000
0
1000
2000
3000
4000
5000
6000
TOT. SIG.
PROPOFOL RELATIVE BREATH CONCENTRATION PROFILE
TIME (MIN.)
TO
TA
L S
IGN
AL
(C
OU
NT
S)
120 μg/Kg/min
50 μg/Kg/min
200 mg bolus
40mg bolus, 100 μg/Kg/min
40 mg bolus
60 mg bolus
infusion off
Will we develop per se laws for drugs and driving?
And will you really be driving under the influence?
In the future…
Recent Trends in Florida
Marijuana Xanax Methamphetamine Inhalants - Difluoroethane
(Dust-off)
Thank You!