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What is Drugged Driving?

"Have one [drink] for the road" was, until recently, a commonly used phrase in American culture. It has only been within the past 20 years that as a Nation, we have begun to recognize the dangers associated with drunk driving. Through a multipronged and concerted effort involving many stakeholders, including educators, media, legislators, law enforcement, and community organizations such as Mothers Against Drunk Driving, the Nation has seen a decline in the numbers of people killed or injured as a result of drunk driving. It is now time that we recognize and address the similar dangers that can occur with drugged driving.

In 15 states (Arizona, Georgia, Indiana, Illinois, Iowa, Michigan, Minnesota, Nevada, North Carolina, Ohio, Pennsylvania, Rhode Island, Utah, Virginia, and Wisconsin), it is illegal to operate a motor vehicle if there is any detectable level of a prohibited drug, or its metabolites, in the driver's blood. Other state laws define "drugged driving" as driving when a drug "renders the driver incapable of driving safely" or "causes the driver to be impaired."

The principal concern regarding drugged driving is that driving under the influence of any drug that acts on the brain could impair one's motor skills, reaction time, and judgment. Drugged driving is a public health concern because it puts not only the driver at risk, but also passengers and others who share the road.

How Many People Take Drugs and Drive?

The National Highway Traffic Safety Administration (NHTSA) reports that more than 17,000 people were killed in alcohol-related crashes in 2006.¹ Studies also have found that drugs are used by 10 to 22 percent of drivers involved in crashes, often in combination with alcohol.

According to the 2006 National Survey on Drug Use and Health, an estimated 10.2 million people age 12 and older reported driving under the influence of illicit drugs during the year prior to being surveyed.² This corresponds to 4.2 percent of the population age 12 and older, similar to the rate in 2005 (4.3 percent), but lower than the rate in 2002 (4.7 percent). In 2006, the rate was highest among young adults age 18 to 25 (13.0 percent).² In addition:

• In 2006, an estimated 13.3 percent of persons age 12 and older drove under the influence of an illicit drug or alcohol at least once in the past year. This percentage has dropped since 2005, when it was 14.1 percent. The 2006 estimate corresponds to 32.8 million persons.²
• Driving under the influence of an illicit drug or alcohol was associated with age. In 2006, an estimated 7.3 percent of youth age 16 drove under the influence. This percentage steadily increased with age to reach a peak of 31.8 percent among young adults age 22. Beyond the age of 22, these rates showed a general decline with increasing age.²
• Also in 2006, among persons age 12 and older, males were nearly twice as likely as females (17.6 percent versus 9.3 percent) to drive under the influence of an illicit drug or alcohol in the past year.²

In recent years, drugs other than alcohol that act on the brain have increasingly been recognized as hazards to road traffic safety. Some of this research has been done in other countries or in specific regions within the United States, and the prevalence rates for different drugs vary accordingly. Overall, the research indicates that marijuana is the most prevalent illegal drug detected in impaired drivers, fatally injured drivers, and motor vehicle crash victims. Other drugs also implicated include benzodiazepines, cocaine, opiates, and amphetamines.³

A number of studies have examined illicit drug use in drivers involved in motor vehicle crashes, reckless driving, or fatal accidents. For example:

• One study found that about 34 percent of motor vehicle crash victims admitted to a Maryland trauma center tested positive for “drugs only”; about 16 percent tested positive for “alcohol only.” Approximately 9.9 percent (or 1 in 10) tested positive for alcohol and drugs, and within this group, 50 percent were younger than age 18.⁴  Although it is interesting that more people in this study tested positive for “drugs only” compared with “alcohol only,” it should be noted that this represents one geographic location, so findings cannot be generalized. In fact, many studies among similar populations have found higher prevalence rates of alcohol compared with drug use.⁵
• Studies conducted in several localities have found that approximately 4 to 14 percent of drivers who sustained injury or died in traffic accidents tested positive for delta-9-tetrahydrocannabinol (THC), the active ingredient in marijuana.⁶
• In a large study of almost 3,400 fatally injured drivers from three Australian states (Victoria, New South Wales, and Western Australia) between 1990 and 1999, drugs other than alcohol were present in 26.7 percent of the cases.⁷ These included cannabis (13.5 percent), opioids (4.9 percent), stimulants (4.1 percent), benzodiazepines (4.1 percent), and other psychotropic drugs (2.7 percent). Almost 10 percent of the cases involved both alcohol and drugs.
  
  

Teens and Drugged Driving

• According to the NHTSA, vehicle accidents are the leading cause of death among young people age 16 to 20.¹ It is generally accepted that because teens are the least experienced drivers as a group, they have a higher risk of being involved in an accident compared with more experienced drivers. When this lack of experience is combined with the use of marijuana or other substances that impact cognitive and motor abilities, the results can be tragic.
• Results from NIDA's Monitoring the Future survey indicate that, in 2006, more than 13 percent of high school seniors admitted to driving under the influence of marijuana in the 2 weeks prior to the survey.⁸
• The 2004 State of Maryland Adolescent Survey indicates that 13.5 percent of the State’s licensed adolescent drivers reported driving under the influence of marijuana on three or more occasions.⁹
  
  

Why is Drugged Driving Hazardous?

Drugs act on the brain and can alter perception, cognition, attention, balance, coordination, reaction time, and other faculties required for safe driving. The effects of specific drugs of abuse differ depending on their mechanisms of action, the amount consumed, the history of the user, and other factors.

Marijuana

THC affects areas of the brain that control the body’s movements, balance, coordination, memory, and judgment, as well as sensations. Because these effects are multifaceted, more research is required to understand marijuana's impact on the ability of drivers to react to complex and unpredictable situations. However, we do know that:

• A meta-analysis of approximately 60 experimental studies, including laboratory, driving simulator, and on-road experiments, found that behavioral and cognitive skills related to driving performance were impaired in a dose-dependent fashion with increasing THC blood levels.¹⁰
• Evidence from both real and simulated driving studies indicates that marijuana can negatively affect a driver's attentiveness, perception of time and speed, and the ability to draw on information obtained from past experiences.
• Research shows that impairment increases significantly when marijuana use is combined with alcohol.¹¹
• Studies have found that many drivers who test positive for alcohol also test positive for THC, making it clear that drinking and drugged driving are often linked behaviors.¹
  

Other Drugs

• Prescription drugs: Many medications (e.g., benzodiazepines and opiate analgesics) act on systems in the brain that could impair driving ability. In fact, many prescription drugs come with warnings against the operation of machinery—including motor vehicles—for a specified period of time after use. When prescription drugs are taken without medical supervision (i.e., when abused), impaired driving and other harmful reactions can also result.
  
  

In short, drugged driving is a dangerous activity that puts us all at risk.

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1.  National Highway Traffic Safety Administration. Traffic Safety Facts Research Note. Washington, DC, 2007. U.S. Department of Transportation Report No. DOT HS 810 821.

2.  Substance Abuse and Mental Health Services Administration. 2006 National Survey on Drug Use and Health. Rockville, MD, 2007.

3.  Soderstrom CA, Dischinger PC, Kerns TJ, Kufera JA, Scalea TM. Epidemic increases in cocaine and opiate use by trauma center patients: Documentation with a large clinical toxicology database. J Trauma 51:557–564, 2001.

4. Walsh JM, Flegel R, Cangianelli LA, Atkins R, Soderstrom CA, Kerns TJ. Epidemiology of alcohol and other drug use among motor vehicle crash victims admitted to a trauma center. Traffic Inj Prev 5(3):254–260, 2004.

5.  Kelly E, Darke S, Ross J. A review of drug use and driving: Epidemiology, impairment, risk factors, and risk perceptions. Drug Alcohol Rev 23(3):319–344, 2004.

6.  Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis use. Drug Alcohol Depend 73(2):109–119, 2004.

7.  Drummer OH, Gerostamoulos J, Batziris H, et al. The incidence of drugs in drivers killed in Australian road traffic crashes. Forensic Sci Int 134:154–162, 2003.

8.  O’Malley PM, Johnston LD. Drugs and driving by American high school seniors, 2001–2006. J Studies Alcohol Drugs 68(6):834–842, 2007.

9.  Maryland State Department of Education. 2004 Maryland Adolescent Survey. Available at: http://www.marylandpublicschools.org/NR/rdonlyres/852505C8-7FDB-4E4E-B34E-
448A5E2BE8BC/10500/2004_MAS.pdf.

10.  Berghaus G, Sheer N, Schmidt P. Effects of Cannabis on Psychomotor Skills and Driving Performance–A Meta-Analysis of Experimental Studies. In: Kloeden CN and McLean AJ, eds. Proceedings of the 13th International Conference on Alcohol, Drugs and Traffic Safety. Adelaide, Australia: The University of Adelaide, NHMRC Road Accident Research Unit, pp. 403–409, 1995.

Four Great Books on Overcoming Addiction:

1. Overcoming Addictions: The Spiritual Solution (Chopra, Deepak. Perfect Health Library.) by Deepak Chopra
2. Welcome Home: A Book About Overcoming Addictions
3. Freedom from Addiction: The Chopra Center Method for Overcoming Destructive Habits by Deepak Chopra
4. Sex, Drugs, Gambling and Chocolate: A Workbook for Overcoming Addictions by A. Thomas Horvath

Support Groups for Addictions:

1. Smart Recovery
2. Transformations
3. Yahoo Substance Abuse Support Group  

Additional Resources:

• For related articles on Addiction the Web, click on: “Sphere: Related Content” located at the bottom of this blog post.
• For related books or blog posts with related content in Dr. Jeff’s and Dr. Tanya’s Blog, click on the “Addictions: General” category at the bottom of the post or type in keywords “Addiction” into “Google Search” located in the sidebar.
• For related articles from Psychology Today, click on the “Psychology Today” banner in the side bar and type in Key words, “Addiction” into the Psychology Today “Search”.
• For more books with related content, click any hyperlinked key word in the blog or type in key words, “Addiction“ into “Amazon Search” on the Amazon banner located in the side bar.

Sources: National Institute of Drug Abuse, See blogposts in: Addictions: Drug Abuse, and Psychiatry: Addictions: General

Dr. Jeffrey Speller

Dr. Tanya Korkosz

Psychopharmacology Associates of New England

www.psychopharmassociates.com

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Factsheet on Abuse of Club Drugs (GHB, Ketamine, and Rohypnol)

Club drugs* are a pharmacologically heterogeneous group of psychoactive compounds that tend to be abused by teens and young adults at a nightclub, bar, rave, or trance scene. Gamma hydroxybutyrate (GHB), Rohypnol, and ketamine are some of the drugs in this group; so are MDMA (ecstasy) and methamphetamine, which are featured in a separate InfoFacts.

• GHB (Xyrem) is a central nervous system (CNS) depressant that was approved by the Food and Drug Administration (FDA) in 2002 for use in the treatment of narcolepsy (a sleep disorder). This approval came with severe restrictions, including its use only for the treatment of narcolepsy, and the requirement for a patient registry monitored by the FDA. GHB is also a metabolite of the inhibitory neurotransmitter gamma-aminobutyric acid (GABA); thus, it is found naturally in the brain, but at concentrations much lower than doses that are abused.
• Rohypnol (flunitrazepam) started appearing in the United States in the early 1990s. It is a benzodiazepine (chemically similar to Valium or Xanax), but it is not approved for medical use in this country, and its importation is banned.
• Ketamine is a dissociative anesthetic, mostly used in veterinary practice.

How are Club Drugs Abused?

Raves and trance events are generally night-long dances, often held in warehouses. Many who attend raves and trances do not use club drugs, but those who do may be attracted to their generally low cost and the intoxicating highs that are said to deepen the rave or trance experience.

• Rohypnol is usually taken orally, although there are reports that it can be ground up and snorted.
• GHB and Rohypnol have both been used to facilitate date rape (also known as “drug rape,” “acquaintance rape,” or “drug-assisted” assault). They can be colorless, tasteless, and odorless, and can be added to beverages and ingested unbeknownst to the victim. When mixed with alcohol, Rohypnol can incapacitate victims and prevent them from resisting sexual assault.
• GHB also has anabolic effects (it stimulates protein synthesis) and has been sought by bodybuilders to aid in fat reduction and muscle building.
• Ketamine is usually snorted or injected intramuscularly.

How do Club Drugs Affect the Brain?

• GHB acts on at least two sites in the brain: the GABAB receptor and a specific GHB binding site. At high doses, GHB's sedative effects may result in sleep, coma, or death. Rohypnol, like other benzodiazepines, acts at the GABAA receptor. It can produce anterograde amnesia, in which individuals may not remember events they experienced while under the influence of the drug.
• Ketamine is a dissociative anesthetic, so called because it distorts perceptions of sight and sound and produces feelings of detachment from the environment and self. Ketamine acts on a type of glutamate receptor (NMDA receptor) to produce its effects, similar to those of the drug PCP.¹ Low-dose intoxication results in impaired attention, learning ability, and memory. At higher doses, ketamine can cause dreamlike states and hallucinations; and at higher doses still, ketamine can cause delirium and amnesia.

Addictive Potential

• Repeated use of GHB may lead to withdrawal effects, including insomnia, anxiety, tremors, and sweating. Severe withdrawal reactions have been reported among patients presenting from an overdose of GHB or related compounds, especially if other drugs or alcohol are involved.²
• Like other benzodiazepines, chronic use of Rohypnol can produce tolerance and dependence.
• There have been reports of people binging on ketamine, a behavior that is similar to that seen in some cocaine- or amphetamine-dependent individuals. Ketamine users can develop signs of tolerance and cravings for the drug.³

What Other Adverse Effects do Club Drugs Have on Health?

Uncertainties about the sources, chemicals, and possible contaminants used to manufacture many club drugs make it extremely difficult to determine toxicity and associated medical consequences.

• Coma and seizures can occur following use of GHB. Combined use with other drugs such as alcohol can result in nausea and breathing difficulties. GHB and two of its precursors, gamma butyrolactone (GBL) and^1,4 butanediol (BD), have been involved in poisonings, overdoses, date rapes, and deaths.
• Rohypnol may be lethal when mixed with alcohol and/or other CNS depressants.
• Ketamine, in high doses, can cause impaired motor function, high blood pressure, and potentially fatal respiratory problems.

What Treatment Options Exist?

There is very little information in scientific literature about treatment for persons who abuse or are dependent upon club drugs.

• There are no GHB detection tests for use in emergency rooms, and as many clinicians are unfamiliar with the drug, many GHB incidents likely go undetected. According to case reports, however, patients who abuse GHB appear to present both a mixed picture of severe problems upon admission and good response to treatment, which often involves residential services.²
• Treatment for Rohypnol follows accepted protocols for any benzodiazepine, which may consist of a 3- to 5-day inpatient detoxification program with 24-hour intensive medical monitoring and management of withdrawal symptoms, since withdrawal from benzodiazepines can be life-threatening.²
• Patients with a ketamine overdose are managed through supportive care for acute symptoms, with special attention to cardiac and respiratory functions.⁴

How Widespread is Club Drug Abuse?

Monitoring the Future (MTF) Survey**

According to results of the 2007 MTF survey, 0.7 percent of students in the 8th grade reported past-year*** use of GHB, as did 0.6 percent and 0.9 percent of students in grades 10 and 12, respectively. This is consistent with use reported in 2006.

Past-year use of ketamine did not change significantly from 2006 to 2007—use was reported by 1.0 percent of 8th-graders, 0.8 percent of 10th-graders, and 1.3 percent of 12th-graders in 2007.

There was no significant change in the illicit use of Rohypnol from 2006 to 2007, according to 2007 MTF results, which report consistently low levels of Rohypnol use since the drug was added to the survey in 1996. Annual prevalence of use stands now at around 0.5 percent in all three grades surveyed.

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* For more information about club drugs, visit www.clubdrugs.gov, www.teens.drugabuse.gov, and www.backtoschool.drugabuse.gov; or call NIDA at 877-643-2644. For street terms searchable by drug name, street term, cost and quantities, drug trade, and drug use, visit http://www.whitehousedrugpolicy.gov/streetterms/default.asp.

** These data are from the 2007 Monitoring the Future survey, funded by the National Institute on Drug Abuse, National Institutes of Health, Department of Health and Human Services, and conducted annually by the University of Michigan’s Institute for Social Research. The survey has tracked 12th-graders’ illicit drug use and related attitudes since 1975; in 1991, 8th- and 10th-graders were added to the study. The latest data are online at www.drugabuse.gov.

*** “Past year” refers to use at least once during the year preceding an individual’s response to the survey. “Past month” refers to use at least once during the 30 days preceding an individual’s response to the survey. “Lifetime” refers to use at least once during a respondent’s lifetime.

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1 Maeng S, Zarate CA Jr. The role of glutamate in mood disorders: Results from the ketamine in major depression study and the presumed cellular mechanism underlying its antidepressant effects. Curr Psychiatry Rep 9(6):467–474, 2007.

2 Maxwell JC, Spence RT. Profiles of club drug users in treatment. Subst Use Misuse 40(9–10):1409–1426, 2005.

3 Jansen KL, Darracot-Cankovic R. The nonmedical use of ketamine, part two: A review of problem use and dependence. J Psychoactive Drugs 33(2):151–158, 2001.

4 Smith KM, Larive LL, Romanelli F. Club Drugs: Methylenedioxymethamphetamine, flunitrazepam, ketamine hydrochloride, and γ–hydroxybutyrate. Am J Health-Syst Pharm 59(11):1067–1076, 2002.

Source: National Institute of Drug Abuse

Dr. Jeffrey Speller
Dr. Tanya Korkosz
Psychopharmacology Associates of New England
www.psychopharmassociates.com