assessment of driving impairment from cannabis docs/2018conf/schmitz cannabis... · 2018. 6....
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Assessment of Driving Impairment from Cannabis
Stephen Schmitz, PhD, MAForensic NeuropsychologistDirector, The Brain and Behavior Clinic - Denver and BoulderClinical and Scientific Advisor, [email protected]
303.938.9244
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National Marijuana Laws
46 states have medical MJ lawsMedical MJ laws vary
30 states and DC have laws in some form broadly legalizing MJ
8 states and DC have laws legalizing recreational MJ
Federal law classifies MJ as a Schedule 1 drug (CSA)MJ dangerous, highly addictive, and having no
medical value Inherent conflict between state and federal law
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Colorado Legalization of Marijuana
1975 – Marijuana decriminalized in Colorado November 2000 – Amendment 20: First medical
marijuana law November 2012 – Amendment 64: Ended
marijuana prohibition May 2013 – DWDI 5ng/ml permissible inference
standard – but defense can argue not impaired January 2014 – Full legalization statewide October 2017 – Colorado ranked #1 in the nation
for adult MJ use
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Impact of Decriminalization of Marijuana on Driving Fatalities in Colorado
MVA Fatality – Driver positive for marijuana# of deaths
2013
55
2016
125
MVA Fatality –Marijuana related# of deaths
2009 – 2012(Pre-Legalization Era)
53
2013 – 2016 (Legalization Era)
88(66% increase)
MVA Fatality – Driver positive for marijuana –Percent of all traffic deaths
2009 and prior
9%
2016 and since
21%
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Prevalence of MJ Availability
McDonald’s 208
Starbucks 392
Marijuana Retail Stores 491
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Marijuana and Driving Ability
MJ most frequently detected drug (except ETOH) in crash-involved drivers
Effect on CNS functions necessary for safe drivingMemory Sustained and divided attentionReaction time TrackingMotor functioning
Association not causation
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Marijuana and Increased Crash Risk
YES Systematic reviews and meta-analyses of epidemiological
studies2x increased risk of a motor vehicle collision
Asbridge, 2012; Li, 2012; Hartman and Huestis, 2013NO No increase in crash risk after adjusting for alcohol and
demographicsRomano, 2013; Elvik, 2013DRUID study
9 European countries – seriously injured and fatality crashes
1.33 – 1.39x increased risk – NOT statistically significant
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Drug and Alcohol Crash Risk: A Case-Control StudyUS Department of Transportation 2015
National Highway Traffic Safety AdministrationCase-control methodology3000 crash-involved drivers – 6000 control subjects selected
for each crash driver66% property damage only 33% injury crash 1% fatality crashOral fluid or Blood draw
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Unadjusted and Adjusted Odds Ratios for Age, Gender, and Race
Unadjusted odds ratio significantly associated with THC (1.25x)
Adjusted odds ratio not significantly associated with THC (1.05x)
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Current Colorado Marijuana Driving Law
5ng/ml permissible inferenceDriver can argue not impaired while driving
Too low or too high? Too low
Heavy users develop tolerance for impairing effects
No scientific basis for a 5ng/ml THC legal limit impairing driving ability
Too highAny MJ impairs cognitive functioningEssentially establishes a license to drive stonedNo scientific basis for a 5ng/ml THC legal limit
impairing driving ability
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Meta-analysis of cognitive effects of smoked cannabis,comparing dose, plasma THC levels, and test performance
Following a single THC exposure to occasional users, a whole blood THC of 1.9 ng/ml corresponded to a blood alcohol concentration of 0.05%*
* Based on 888 neuropsychological effects reported in 78 studies employing THC doses of 1 - 52 mg in occasional users.The range of blood THC associated with ± 10% variation in this level of impairment was 1.7 to 2.3 ng/ml.
After 4.75 hours <15% of the tests results were impaired, a performance found at BAC < 0.03%
[Berghaus, G, Sticht G, Grellner W et al. Meta-analysis of empirical studies concerning the effects of medicines and illegal drugs including pharmacokinetics on safe driving." Bergisch Gladbach: BASt2010. Report No.: D 1 (2011)]
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Neurocognitive performance during acute THC intoxication in heavy and occasional cannabis users[Ramaekers J et al. J Psychopharm 23:266-277; 2009]
•12 occasional cannabis users and 12 heavy users participated in double-blind, placebo-controlled, 2-way balanced trial.
• Endpoints included critical tracking task, and divided attention tasks• Paced smoking of placebo or joint (13% THC) delivering 500 μg/kg dose in 10 minutes (≈25 hits)• Whole blood THC 15 min after smoking:
23.7 ± 14.1 ng/ml (heavy users); 10.4 ± 4.6 ng/ml (occ users)
critical tracking test (standardized score)
Heavy users were tolerant to impaired performance after THC
Occ. users + THC
divided attention task
Occ. users + THCOcc. users + THC
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Psychomotor and neurocognitive effects in occasional and frequent smokers
Both groups feel “high”Frequent users tolerant to slowed reaction time [Desrosiers N et al. J Anal Toxicol 39:251-261; 2015]
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[Hart C et al. Pharmacol Biochem Behav 96:333-341; 2010]
Neurophysiological and cognitive effects of smoked marijuana in frequent users
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Hart et al, 2011
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In an on-the-road driving test, oral dronabinol (THC 20 mg) significantly impaired road tracking (SDLP) and car following performance in occasional but not heavy cannabis users
Blood THC at 1.5 hr post 20 mg5.1 ± 1.1 ng/ml (heavy users)3.1 ± 0.7 ng/ml (occ. users)
dotted line equates to BAC 0.05%
Bosker W et al. Addiction 107:1837-1844; 2012
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Blood THC Levels Decline Rapidly
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Tolerance in Chronic Users
Days of supervised abstinence (subject L)
Karschner et al. Jour Annal Toxicol. 33: 469 – 477, 2009
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Observational Study of Driving Impairment in Occasional Versus Heavy Marijuana Users
Co-PI’s: Michael Kosnett & Ashley Brooks-Russell - CU Anschutz
Co-investigators: Tim Brown & Gary Milavetz - U of Iowa Chris Halsor, Dave Carbonetti - Understanding Legal
Marijuana Greg Dooley – CSU Stephen Schmitz - DriveABLE and Private Practice Sam Wang, CU Anschutz Becki Bartelson,Victoria Anderson, AR Olson, Kyle
Friedman - Denver Health
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Primary Aim
Compare driving impairment in occasional vs. heavy marijuana users, before and after smoked marijuanaDriving simulator Standardized Field Sobriety Test iPad-based neurocognitive test battery
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Secondary Aims
Calculate the sensitivity, specificity and predictive value of the iPad CARE test battery for validated benchmarks of driving impairment measured in the MiniSim.
Determine if blood cannabinoid profiles predict driving impairment differentially in occasional and heavy (i.e. daily) marijuana users as measured on the three driving assessment tools.
Evaluate the predictive value of a blood THC concentration of ≥ 5 ng/ml (and other blood THC cut-points, including various metabolite ratios) for driving impairment in occasional marijuana users and in heavy marijuana users.
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Pre-Post Change Analysis
3 groups – 30 ss each Occasional users
MJ use ≥ 1 day/week and ≤ 2 days/week (last 30 days)
Heavy users≥ daily (last 30 days)
Non-usersNo MJ use (last 30 days) ≤ 2 times/month (last 90 days)
Baseline assessments
(after overnight abstinence)
Smoking session
Post assessments
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Methods
Pre-screening Inclusion/exclusion criteria
Screening visitUrineBreathalyzerDriving simulator
7 minutesSimulator adaptation syndrome
Visual acuity Study diary
MJ use, medications, alcohol, sleep duration2 days before first study visit
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National Advanced Driving Simulator – MiniSim
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Simulated Scenarios
Highway and city driving environmentsCollision situation Following Lane positionDistractor
Each subject will undergo 2 sessions Duration – 30 minutes
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Braking Lead Vehicle Braking While the driver is distracted, the lead vehicle which is 3.5seconds ahead brakes to 20 mph at a high level of deceleration (0.85g) (~2.25s), and then maintains 20 mph for 5 seconds. Oncoming traffic prevents passing.
Braking Lead Vehicle Stopped While the driver is distracted, the lead vehicle which is 4 seconds ahead brakes to a stop at very high level of deceleration (2g)
Steering Curve Departure Driver going around a tightening radius curve at too great a speed (missing reduced speed sign) requiring a steering response
Steering Slick Road Departure Similar to Curve Departure but simulates loss of control due to weather conditions as opposed to aggressive driving.
Steering Avoidance Departure - right incursion Driver traveling on a two-lane roadway. Vehicle enters roadway from hidden driveway requiring steering response
Steering Wind Gust Driver traveling on two-lane roadway. Wind gust from the left pushes the driver requiring a steering response for recovery.
Steering Obstacle Avoidance Driver traveling on a multilane roadway. Desk falls out of the back of truck requiring driver to make steering response
Steering Left Incursion Driver traveling on a two-lane roadway. Oncoming vehicle crosses into driver's lane requiring a steering resposne.
Braking Lead Vehicle Braking Traveling on a two-lane roadway, while driver is distracted, vehicle slows to turn onto interstate causing lead vehicle to brake
Varied Red Light Runner Driver approaches signalized intersection with the green light. Hidden vehicle from the left runs the red light
Varied Left Turn Across Path Driver approaches intersection to turn left. Oncoming traffic is hidden. As driver accelerates oncoming traffic enters the intersection
Braking Lead Vehicle Revealed Following a vehicle at 40 mph with a time headway of 2.25 seconds, the lead vehicle changes lanes while the driver is engaged in a distraction task revealing a stopped lead vehicle.
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MiniSim - Limitations
Not highly correlated with actual driving More relaxed and less “controlled” in a simulator Sd larger
Simulator adaptation syndrome
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Standardized Field Sobriety Test -SFST
Horizontal Gaze NystagmusVisually focus on object moved horizontally and
vertically Walk and Turn
9 heel-to-toe steps forward and back along straight line
One Leg Stand Stand on one leg with other leg stretched out in
front of themCount out loud for 30 seconds
Sensitive test related to BAC Sensitive-ish to marijuana
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Sensitivity of SFST to Detect Impairment Due to Marijuana Intoxication
40 Ss Occasional users Placebo or marijuana Low dose - 1.74% THC High dose – 2.93% THC One cigarette fully consumed Blood sample
Prior, immediately after smoking, and every 20 min for 2 hrs
SFST5 min after smoking, 55 min, 105 min
Papafotiou et al. PsyPharm, 2005, 180, 107 - 114
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SFST and Marijuana
5 minutes 55 minutes 105 minutes
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Impairment on SFST in Low (1.8%) vs High (3.0%) THC Content Levels
Stough, et al. 2006, NDLERF
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DriveABLE Ipad - Cognitive Ability Real-Time Evaluation (CARE)
Originally developed driving assessment tools for dementia/TBIOn-Road evaluationPC based evaluationOver 100,000 evaluationsPredictive values > .88
Roadside assessment tool in development - CARE Ipad based Measure of real-time cognitive abilities correlated
with driving 5-10 minute administration
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Cognitive Ability Real-Time Evaluation (CARE)
Evidence based Correlates to actual behind the wheel driving riskPurposely focused on ease of useQuick to administer Legally defensible in court
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Task 1: Motor Speed & Control
Task 2: Span of Attentional Field
Task 3: Spatial Judgement & Decision
Task 4: Attentional Shifting
Task 6: Identification of Driving Situations
Task 5: Memory & Exective Function
Task 1: Reactions
Task 2: Judgement
Task 4: Memory Function
Task 4: Control
DriveABLE Cognitive Assessment Tool Cognitive Ability Real-Time Evaluation
Cognitive Ability Real-Time Evaluation (CARE)
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Challenges
Observational study (IRB) University legal concerns Finding off-campus space Timeline
Begin recruitment: early 2018 Initiate study: early 2018 – mid 2019 Share findings: late 2019 – early 2020
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Summary of Key Points
Use of THC can result in acute CNS effects that may impact cognitive performance and driving in some users for several hours
Tolerance to CNS effects that mitigates impairment may develop in chronic frequent users
Blood tests that measure THC and other cannabinoids in blood may correlate with impairment in some users (moreso occasional users than chronic users)
Additional research is needed regarding the temporal pattern of pharmacokinetic and pharmacodynamic effects, including the utility and predictive value of “roadside measurements”