Recommendations for Toxicological Investigation of Drug-Impaired Driving and Motor Vehicle Fatalities—2017 Update

Abstract

This report describes the outcomes of a process undertaken to review and update the National Safety Council's Alcohol, Drugs and Impairment Division's recommendations for the toxicological investigation of suspected alcohol and drug-impaired driving cases and motor vehicle fatalities. The updates to the recommendations are made based on a survey of practices in laboratories in the USA and Canada performing testing in these cases, consideration of existing epidemiological crash and arrest data, current drug use patterns, and practical considerations of widely available technology platforms in laboratories performing this work. The final recommendations updates are derived from a consensus meeting of experts recruited from survey respondents and the membership of the National Safety Council's Alcohol, Drug and Impairment Division. The principal changes in this round of recommendations include removal of butalbital, phenobarbital, and phencyclidine from Tier I (mandatory) to Tier II (optional) due to changes in prevalence. In addition, buprenorphine, fentanyl, tramadol, and their metabolites were moved from Tier II to Tier I due to increased prevalence and concerns about their potential for causing impairment. In addition, screening and confirmatory cutoffs for the oral fluid scope were further refined. Other additions were made to the list of Tier II compounds including fentanyl analogs (e.g., acetylfentanyl, butyrylfentanyl, furanylfentanyl, etc), mitragynine, novel opioids (e.g., MT-45, U-47700), atypical antipsychotics, and novel benzodiazepines (e.g., clonazolam, flubromazolam, etc).

Tramadol use and public health consequences in Iran: a systematic review and meta‐analysis

“…Several studies have shown a correlation between seizure and long‐term tramadol use or abuse [121,123]; however, the reported seizure rate among tramadol poisoning varied in different studies [120,123,124]. There are also concerns regarding driving under the influence of tramadol from other countries [125,126]. Moreover, fatal cases due to tramadol consumption have been reported in the United States and European countries [127–131].…”

Benzodiazepines in the oral fluid of Spanish drivers

“…We speculate that in these circumstances, it is debatable and not cost effective to include these benzodiazepines in the panel of substances to be confirmed and quantified in the laboratory; there would be room for the assessment of other substances or resources to carry out more roadside drug tests, for example. In addition, benzodiazepines are medicines/drugs well known to impair driving, and recommendations for their assessment in drivers are provided [1,[28][29][30].…”

“…Roadside drug tests detect cannabis, cocaine, amphetamine, methamphetamine and opioids but not benzodiazepines. While recommendations and guidelines for toxicological investigations of drug-impaired driving have been published [1,[28][29][30] and Spain follows DRUID recommendations [1], one issue that arises is whether it is rational to include benzodiazepines in the confirmation analysis at the laboratory if the devices used in the roadside drug test do not include the kit to detect benzodiazepines.…”

Interpreting γ-hydroxybutyrate concentrations for clinical and forensic purposes

“…The available evidence verifies that saliva is a viable matrix for analysis of GHB but does not seem to offer any advantage over blood in terms of extending the window of detection [81,82]. However, obtaining samples of saliva is less invasive than drawing blood, which makes this fluid more convenient for off-site testing, such as drug screening in various populations, such as motorists [83,84]. Despite more water in saliva (99%) compared with whole blood (80%) the endogenous GHB concentrations were mostly lower in saliva [46].…”