National Association of Drug Court Professionals

Robert L. DuPont, M.D., PresidentInstitute for Behavior and Health, Inc.

www.ibhinc.org www.StopDruggedDriving.org

Qualifications and Disclosures 1968: Started career in District of Columbia

Department of Corrections1970: Founded Narcotics Treatment Administration 1973 to 1977: Second White House Drug Chief1973 to 1978: Founding Director, National Institute

on Drug Abuse 1978 to Present: President, Institute for Behavior

and Health, Inc. 1980 to Present: Clinical Professor of Psychiatry,

Georgetown Medical School1982 to Present: Co-founder and Executive Vice

President, Bensinger, DuPont & Associates; Chairman, Prescription Drug Research Center (subsidiary of BDA)

Presentation TodayIntroduction to drugged driving Prevalence of the drugged driving problemNational policy efforts to reduce drugged

drivingDefining a drugged driving violationDrug testing needsLinking drugged drivers to treatmentNext steps for drugged driving

The ProblemDrugged Driving refers to operating a vehicle after

the use of impairing substances which may include:Illegal drugsMisused prescription drugs (with and without

prescriptions)Over-the-counter medicationsOther chemicals (e.g. inhaling aerosol spray)

Drug Court participants, as well as returning veterans, many of whom face co-occurring diagnoses and addiction issues, are prime candidates for arrests for drugged driving

A Growing National FocusDrugged driving is an under-recognized

highway safety problem, particularly among the public

Dedicated leadership has elevated drugged driving to the national stage in the United States, including the Office of National Drug Control Policy and National Highway Traffic Safety Administration

Turning PointsDecember 2009 release of data from the 2007

National Roadside Survey 2010 National Drug Control Strategy identified

reducing drugged driving by 10% by 2015 as a national priority; reaffirmed in 2011 and 2012 in the National Strategy

The National Institute on Drug Abuse has led by promoting a new generation of policy-relevant drugged driving researchNIDA’s 2011 Drugged Driving Research: A White Paper

Leadership from National Association of Drug Court Professionals (NADCP), National Transportation Safety Board (NTSB), and Mothers Against Drunk Driving (MADD)

(ONDCP 2010; 2011a; 2011b; 2012)

Drugs Impair DrivingExamples of the dangerous effects of drugs on

driving include: Disorientation, poor judgment/decision-making,

changes in reaction time, distance estimation, concentration, impulse control

Many factors influence the effects of a drug on a driver and can be enhanced by drug-drug interactions, including alcohol

Drug use triples the risk of fatal crash; a combination of drugs and alcohol produces 23 times the risk of fatal crash

(Couper & Logan, 2004; Li, Brady & Chen, 2013)

Drugged Driving ResearchDecades of research on alcohol and driving,

now with other drugsSignificant prevalence of drugs among driver

populations: National surveys (self-report and random stops)Impaired driving (DUI) suspectsSeriously injured driversFatally injured drivers

There is much more research than the studies reviewed in this presentation

(DuPont, et al., 2011)

Driving Under the Influence29.1 million (11.2%) drivers aged 12 and older

report that they drove under the influence of alcohol in the previous year

10.3 million (3.9%) report driving under the influence of illicit drugs

But among randomly stopped drivers, impaired driving suspects, and seriously and fatally injured drivers, we see that drugged driving is roughly equal to the problem of drunk driving

(SAMHSA, 2013)

National Roadside Survey: Drug Use Among Weekend Nighttime Drivers

16.3% of drivers were positive for potentially impairing drugs

Most common illegal drugs:Cannabis, 8.6%Cocaine, 3.9%Methamphetamine,

1.3%(Lacey, et al., 2009)

NRS: Alcohol Use Among Weekend Nighttime Drivers

12.4% of drivers were alcohol-positive

Illegal Blood Alcohol Concentrations (BAC) of 0.08 g/dL or higher steadily decreased during this time

(Compton & Berning, 2009)

Crash-Involved Drivers Taken to Shock-Trauma

(Walsh, et al., 2005)

Half were positive for illegal drugs

One third positive for alcohol

One quarter positive for both illegal drug(s) and alcohol

One quarter positive for marijuana; 39% of marijuana-positive drivers were also positive for another drug

Impaired Driving SuspectsA US study of impaired driving suspects showed

that 31% positive for drugs86% positive for alcohol25% positive for both

51% of drivers with BACs below 0.08 were drug-positive

22% of drivers with illegal BACs were drug-positive

(Buchan, et al., 1998; Fix, et al., 1997)

Fatally Injured DriversResearch shows that the while the prevalence

of alcohol among fatally injured drivers decreased from 2005 to 2009, the prevalence of drugs among dead drivers increased 18%

In 2009, one third (33%) of all fatally injured drivers in the U.S. who had confirmed drug test results (n=12,055) were drug-positive 28% of drug-positive drivers tested positive

for marijuana

(NHTSA, 2010)

Drug Prevalence Among Fatally Injured Drivers Has Increased, 2005-2009

(Center for Substance Abuse Research, 2010)

Fatally Injured DriversWith national fatally injured driver data we

are only seeing a part of the picture Only 20 states test at least 80% of fatally

injured drivers for drugsTesting procedures and panels are not

standardized Some states do not test for marijuanaResearch has shown that drug-involved

crashes occur throughout the day while alcohol crashes are more common at night

(Romano & Pollini, 2013)

Fatally Injured DriversIn a study of fatally injured drivers in

Washington State (n=370), 39% were positive for drugs12.7% were positive for marijuana

41% of all drivers were positive for alcohol

Of all alcohol-positive cases, 42% were also positive for one or more drug showing the overlap in drug and alcohol use among drivers

(Schwilke, Sampaio dos Santos, & Logan, 2006)

Drugged Driving Policy and Demand ReductionStrong, effective drugged driving laws and

comprehensive enforcement are crucial elements of improved demand reduction

Reducing drugged driving is part of the solution to:1) Prevent illegal drug use2) Promote highway safety3) Deliver substance abusers to treatment with

the leverage to help them become and stay drug-free

Drugged Driving Laws

1) Per se drug laws2) Impairment laws3) Administrative license revocation (ALR)

Drugged driving laws cannot follow same path as alcohol-impaired driving laws

Alcohol Impairment StandardReducing drugged driving is wrongly based

on the model of 0.08 g/dL BAC Obscures the fact that many drivers are

significantly impaired at levels well below 0.08 BACTolerance and consumption effects vary among

alcohol users displaying widely varying degrees of impairment at 0.08 BAC or higher

Though cases are much more difficult to try, impaired drivers under 0.08 BAC can be prosecuted

Most Western European countries use 0.05 g/dL limit; Sweden and Norway use 0.02 g/dL limit

(DuPont, et al., 2013)

Mirage of BAC Equivalent for DrugsAlcohol is a poor model for studying impairing

effects of drugs; metabolized in simpler ways than drugs

No close link between blood or other levels of a drug (or drug metabolites) and measured impairments

Vast number of potentially impairing drugs Drug-drug, drug-alcohol combinationsEmergence of synthetic “designer” drugs

(Reisfield, et al., 2012; DuPont, et al., 2013)

Mirage of BAC Equivalent for DrugsRole of tolerance in impairment: e.g.

methadoneConsumption of 50 mg of methadone can be

lethal to person who has not used opioids in prior few weeks or months

Chronic administration of methadone at stable doses typically produces no measurable impairment at higher doses

Others factors on impairment include time of day, driver age and driver experience

(Reisfield, et al., 2012; DuPont, et al., 2013)

The Bottom LineSetting impairment thresholds based on

tissue levels of drugs or metabolites for illegal drugs is not a viable enforcement option

0.08 BAC equivalent is not needed

We have abundant successful precedents for using the per se standard for drugs of abuse

(Reisfield, et al., 2012; DuPont, et al., 2013)

Per Se Drug LawsUnder a per se drug law, any identified illegal

drug level found in a driver is defined as a drugged driving violation

Modeled on the successful per se drug program used for the 10 million American commercial drivers and others in safety-sensitive positions

In the United States, drivers under age 21 are held to a zero tolerance per se standard for alcohol

(Walsh, 2009; DuPont, et al., 2012)

The Bright Line of IllegalityFor drivers arrested for impaired driving:

When the drug use is illegal, the zero tolerance per se standard is used

When the drug use is legal (e.g. prescription drug for which the driver has a valid prescription), the “impairment” standard is used

(Voas, et al., 2013; DuPont, et al., 2012)

Impairment LawsImpairment is a hard case to make without

per se law but it can be done

Drivers can be prosecuted for impaired driving when they are under 0.08 BAC alcohol

Remember that it is illegal to drive impaired with no alcohol and no drugs

(DuPont, et al., 2012)

Complexity of MarijuanaThis is a political complexity; not a scientific complexityA solution:

When marijuana use is “legal”, use the impairment standard

When marijuana use is illegal, use the zero tolerance per se standard

Caveat: Marijuana is illegal throughout the U.S. under federal law

The two wild cards are state-based “medical marijuana” and legal marijuana in Colorado and Washington which will have to be settled by the U.S. Supreme Court

Policy Focus on MarijuanaState-based marijuana policy changes have ignited

a renewed focus on finding a BAC equivalent for marijuana with recommendations between 2 ng/mL and 10 ng/mL THC in whole blood

Large study of drivers arrested for impairment in Sweden over 10 years tested between 30-90 minutes after arrest:90% had THC concentrations below 5 ng/mL in blood61% had THC concentrations below 2 ng/mL in blood43% had THC concentrations below 1 ng/mL in blood

(Jones, Holmgren, & Kugelberg, 2008)

Frequency Distribution of Blood THC Concentrations Among DUI Suspects

Under a 5 ng/mL THC limit for blood, only 10% of drivers in this study would have been prosecuted

(Jones, Holmgren, & Kugelberg, 2008)

Washington and ColoradoWashington has a 5 ng/ml THC per se limit for blood

Any driver at or over 5 ng/ml is in violation

Colorado has a 5 ng/ml permissible inference limit for blood – weakest drugged driving law for marijuanaInference that any driver at or over 5 ng/ml was under the

influence at time of arrest but impairment must be proved70% of Colorado drivers arrested for suspicion of driving

under the influence who test positive for active THC test at less than 5 ng/ml

Both 5 ng/ml limits – per se and permissible inference – give free passes for most stoned drivers

(Wood, 2013)

Latest Marijuana ResearchRecent smoking and/or blood THC concentrations

of 2-5 ng/mL are associated with substantial driving impairment

Epidemiological research suggests that marijuana use doubles risk of motor vehicle crash

Whole blood THC concentrations persist multiple days after drug discontinuation in heavy chronic marijuana users

After 3 weeks of abstinence, chronic daily marijuana users showed observable impairment compared to occasional marijuana users

(Li, et al 2012; Asbridge, et al. 2012; Hartman & Huestis 2013; Karschner et al. 2009; Bosker et al. 2013)

Role of the Pro-Drug LobbyAdvocates for permissive drug policies aim to

legalize the use, production and sale of drugs, beginning with marijuana

“Medical marijuana” movement has been successful in shifting the lobby’s goal to full marijuana legalization

“Psychedelic medicine” is the next candidate for drug legalization

Pro-drug lobby opposes driving restrictions on drug users – particularly against laws related to marijuana

Administrative License RevocationNon-criminal penalty system used today to get

drunk drivers off the road quicklyALR process begins after arrest for impairment

is madeLoss of license for drivers who test at or above

0.08 BAC alcoholALR for drugs is the next step in drugged

driving enforcementPresumption of innocence is preserved for

later adjudication of criminal charge of DUI or DUID by a judge

(National Transportation Board, 2013)

Importance of ALR ALR is a potential game-changer because it

would bring drug testing to the police station in a way parallel to alcohol testing

Use of on-site oral fluid or urine testing

Loss of license for positive screening drug test results

Laboratory confirmation of positive tests prior to adjudication

Typical Testing ProceduresIn the U.S. impairment is determined prior to

arrest Use of Standardized Field Sobriety Tests (SFSTs)Some states use Drug Recognition Experts (DREs)

Specimen testing typically occurs after arrestWhen illegal BAC is found, testing usually ends

and driver is charged with drunk drivingIf an impaired driver has a low BAC then drug

testing should but does not always occur

Improve Drug Testing ProceduresUse on-site screening tests for ALL impaired

driving suspects, including those who have illegal BACsTesting technology has improved; oral fluid testing

permits easy specimen collection and initial screening results but today few states permit its use

Laboratory confirmation Address laboratory staff/funding issues

Drivers who have illegal BACs and test positive for drugs should be charged with an aggravated offense, like drivers with high BACs (≥ 0.15 g/dL)

Other Drug Testing OpportunitiesDrivers in crashes causing serious injuries

or death, either at the scene or at the hospital/trauma center

When drugs have been found in vehicles or on drivers

When drivers admit to recent drug useHighway security checkpoints

Education, Training & TreatmentIncorporate drugged driving into drivers’ education

and substance abuse prevention programs

Educate groups at higher risk about drugged driving, e.g. Drug Court participants

Increased training to law enforcement on identifying drugged drivers

Screen and refer drugged drivers to treatment and appropriate monitoring programs to reduce recidivism

DUI Offender ManagementAssess DUI offenders for both alcohol and

drug use problems and other disorders

Ensure all DUI offenders are tested for alcohol and drugs

Close monitoring after conviction using model programs that stop alcohol and drug use rather than focusing exclusively on driving behaviors

DWI/Drug CourtsManage hardcore repeat impaired driving

offenders

Leverage criminal justice system to improve long-term outcomes including reduced recidivism

Focus on accountability and long-term treatment

Address other issues including mental health problems

(Fell, et al., 2011; Hiller, et al, 2009; Michigan SCAO, 2008)

DWI/Drug CourtsFrequent random drug and alcohol testing

with immediate consequences

Great potential resource to address drugged drivers

Consider prominent overlap of drug problems among alcohol-impaired drivers

(Fell, et al., 2011; Hiller, et al, 2009; Michigan SCAO, 2008)

Education Within DWI/Drug CourtsParticipants in both DWI Courts and Drug

Courts need to be educated about the risks of drugged driving

Remind them that it is unsafe – and illegal – to drive under the influence of alcohol and after using drugs

Place special emphasis on marijuana which many people do not recognize as a highway safety threat

24/7 Sobriety Program• Focuses on keeping DUI offenders abstinent from

alcohol and drugs• Treatment and 12-Step involvement is optional• Frequent alcohol and drug testing:

• Twice daily alcohol breath tests (7 AM & 7 PM) or• SCRAM alcohol monitoring ankle bracelets; and• Random drug urinalysis or• Drug patch

• Any positive test results in an immediate short-term stay in jail

(South Dakota Office of the Attorney General, 2013)

24/7 Sobriety Results55% never fail a test16.7% fail only one test12.5% fail only twice16.9% fail three or more timesDUI recidivism substantially lower among

24/7 participants at 1, 2, and 3 years from program completion

(South Dakota Office of the Attorney General, 2012)

Community Impact24/7 Sobriety has helped reduce:

Repeat drunk driving offenses by 12% at the county level

Domestic violence by 9%Traffic crashes for males between ages 18-40

by 4%

Frequent random monitoring linked to swift, certain and meaningful consequences – mostly brief incarceration – produces fewer failures

(Kilmer, et al., 2013; DuPont, et al., 2010 )

Next Steps for Drugged DrivingUse of administrative license revocation to

get drugged drivers immediately off the roads and to increase drug testing of DUI suspects

Use of the per se standard to effectively identify and prosecute drugged drivers

Ongoing research and evaluation of drugged driving laws and enforcement strategies

Focus on the management of the 1.2 million people arrested for DUI each year

ConclusionsFocusing on drugged driving builds upon

and enhances efforts to reduce drunk driving; they are synergetic – NOT COMPETITIVE

The never-ending search for impairment thresholds derails actions to prevent drugged driving and enforce laws

ConclusionsEffective action on drugged driving will

achieve 3 important goals: 1) Reduce illegal drug use and reinforce

prevention2) Improve highway safety3) Provide an important new pathway to

treatment and recovery for drug users as drunk driving enforcement now does for individuals with alcohol use problems

Thank you!

www.StopDruggedDriving.orgFor more information

on drugged driving visit IBH’s website devoted to this public health and public safety problem

www.IBHinc.orgFor more information

on other new and important ideas to reduce illegal drug use visit IBH’s home website

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