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Cannabis and Driving: A Scientific and Rational Review

By Paul Armentano

Policy debates regarding marijuana law reform invariably raise the question: “How does society address concerns regarding pot use and driving?”  The subject is worthy of serious discussion.  NORML’s Board of Directors addressed this issue by ratifying a “no driving” clause to the organization’s “Principles of Responsible Cannabis Use”1 stating, “Although cannabis is said by most experts to be safer with motorists than alcohol and many prescription drugs, responsible cannabis consumers never operate motor vehicles in an impaired condition.”

Nevertheless, questions remain regarding the degree to which smoking cannabis impairs actual driving performance.  Unlike alcohol, which is known to increase drivers’ risk-taking behavior and is a primary contributor in on-road accidents, marijuana’s impact on psychomotor skills is subtle and its real-world impact in automobile crashes is conflicting.

Drugged Driving: True Threat Or False Panic?

Survey data indicates that approximately 112 million Americans (46 percent of the US population) have experimented with the use of illicit substances.2 Of these, more than 20 million (8.3 percent of the population) self-identify as “current” or “monthly” users of illicit drugs,3 and more than 10 million Americans say that they’ve operated a motor vehicle while under the influence of an illicit substance in the past year.4 These totals, while far from negligible, suggest that the prevalence of illicit drug use among US drivers is far less than the prevalence of alcohol among this same population.5

To date, “[The] role of drugs as a causal factor in traffic crashes involving drug-positive drivers is still not well understood.”6 While some studies have indicated that illicit drug use is associated with an increased risk of accident, a relationship has not been established regarding the use of psychoactive substances and crash severity.7 Drivers under the influence of illicit drugs do experience an enhanced fatality risk compared to sober drivers.  However, this risk is approximately three times lower than the fatality risk associated with drivers who operate a vehicle above or near the legal limit for alcohol intoxication.8 According to one recent review: “The risk of all drug-positive drivers compared to drug-free drivers is similar to drivers with a blood alcohol concentration of 0.05%. The risk is also similar to drivers above age 60 compared to younger drivers [around age 35].”9

Marijuana is the most common illicit substance consumed by motorists who report driving after drug use.10 Epidemiological research also indicates that cannabis is the most prevalent illicit drug detected in fatally injured drivers and motor vehicle crash victims.11 Reasons for this are twofold.  One, pot is by far the most widely used illicit drug among the US population, with nearly one out of two Americans admitting having tried it.12 Two, marijuana is the most readily detectable illicit drug in toxicological tests.  Marijuana’s primary psychoactive compound, THC, may be detected in blood for several hours, and in some extreme cases days after past use,13 long after any impairing effects have worn off.  In addition, non-psychoactive byproducts of cannabis, known as metabolites, may be detected in the urine of regular users for days or weeks after past use.14 (Other common drugs of abuse, such as cocaine or methamphetamine, do not possess such long half-lives.)  Therefore, pot’s prevalence in toxicological evaluations of US drivers does not necessarily indicate that it is a frequent or significant causal factor in auto accidents.  Rather, its prevalence affirms that cannabis remains far more popular and is far more easily detectable on drug screening tests than other controlled substances.

Cruising On Cannabis: Clarifying The Debate

While it is well established that alcohol consumption increases accident risk, evidence of marijuana’s culpability in on-road driving accidents and injury is far less clear. Although acute cannabis intoxication following smoking has been shown to mildly impair psychomotor skills, this impairment is seldom severe or long lasting.15 In closed course and driving simulator studies, marijuana’s acute effects on psychomotor performance include minor impairments in tracking (eye movement control) and reaction time, as well as variation in lateral positioning, headway (drivers under the influence of cannabis tend to follow less closely to the vehicle in front of them), and speed (drivers tend to decrease speed following cannabis inhalation).16 In general, these variations in driving behavior are noticeably less consistent or pronounced than the impairments exhibited by subjects under the influence of alcohol.17 Also, unlike subjects impaired by alcohol, individuals under the influence of cannabis tend to be aware of their impairment and try to compensate for it accordingly, either by driving more cautiously18 or by expressing an unwillingness to drive altogether.19

As a result, cannabis-induced variations in performance do not appear to play a significant role in on-road traffic accidents when THC levels in a driver’s blood are low and/or cannabis is not consumed in combination with alcohol.20-21 For example, a 1992 National Highway Traffic Safety Administration review of the role of drug use in fatal accidents reported, “There was no indication that cannabis itself was a cause of fatal crashes” among drivers who tested positive for the presence of the drug.22 A more recent assessment by Blows and colleagues noted that self-reported recent use of cannabis (within three hours of driving) was not significantly associated with car crash injury after investigators controlled for specific cofounders (e.g., seat-belt use, sleepiness, etc.)23 A 2004 observational case control study published in the journal Accident, Analysis and Prevention reported that only drivers under the influence of alcohol or benzodiazepines experience an increased crash risk compared to drug-free controls.  Investigators did observe increased risks – though they were not statistically significant – among drivers using amphetamines, cocaine and opiates, but found, “No increased risk for road trauma was found for drivers exposed to cannabis.”24

A handful of more recent studies have noted a positive association between very recent cannabis exposure and a gradually increased risk of vehicle accident.  Typically, these studies reveal that drivers who possess THC/blood concentrations above 5ng/ml – implying cannabis inhalation within the past 1-3 hours25-26 – experience an elevated risk of accident compared to drug-free controls.27-28 (Motorists who test positive for the presence of THC in the blood at concentrations below this threshold typically do not have an increased risk compared to controls.29)  However, this elevated risk is below the risk presented by drivers who have consumed even small quantities of alcohol.

Two recent case-controlled studies have assessed this risk in detail.  A 2007 case-control study published in the Canadian Journal of Public Health reviewed 10-years of US auto-fatality data.  Investigators found that US drivers with blood alcohol levels of 0.05% – a level well below the legal limit for intoxication – were three times as likely to have engaged in unsafe driving activities prior to a fatal crash as compared to individuals who tested positive for marijuana.30 A 2005 review of auto accident fatality data from France showed similar results, finding that drivers who tested positive for any amount of alcohol had a four times greater risk of having a fatal accident than did drivers who tested positive for marijuana in their blood.31 In the latter study, even drivers with low levels of alcohol present in their blood (below 0.05%) experienced a greater elevated risk as compared to drivers who tested positive for high concentrations of cannabis (above 5ng/ml).  Both studies noted that overall few traffic accidents appeared to be attributed to driver’s operating a vehicle while impaired by cannabis.

Defining A Rational ‘Drugged Driving’ Policy

The above review illustrates the need for further education and understanding regarding the effects of cannabis upon driving behavior.  While pot’s adverse impact on psychomotor skills is less severe than the effects of alcohol, driving under the acute influence of cannabis still may pose an elevated risk of accident in certain situations.  However, because marijuana’s psychomotor impairment is subtle and short-lived, consumers can greatly reduce this risk by refraining from driving for a period of several hours following their cannabis use.

By contrast, motorists should never be encouraged to operate a vehicle while smoking cannabis.  Drivers should also be advised that engaging in the simultaneous use of both cannabis and alcohol can significantly increase their risk of accident compared to the consumption of either substance alone.32-33 Past use of cannabis, as defined by the detection of inactive cannabis metabolites in the urine of drivers, is not associated with an increased accident risk.34

Educational or public service campaigns targeting drugged driving behavior should particularly be aimed toward the younger driving population age 16 to 25 – as this group is most likely use cannabis35 and report having operated a motor vehicle shortly after consuming pot.36 In addition, this population may have less driving experience, may be more prone to engage in risk-taking behavior, and may be more naïve to pot’s psychoactive effects than older, more experienced populations.  This population also reports a greater likelihood for having driven after using cannabis in combinations with other illicit drugs or alcohol.37 Such an educational campaign38 was recently launched nationwide in Canada by the Canadian Public Health Association and could readily be replicated in the United States.  Arguably, such a campaign would enjoy enhanced credibility if coordinated by a private public health association or traffic safety organization, such as the American Public Health Association or the AAA Automobile Club, as opposed to the federal Office of National Drug Control Policy – whose previous public service campaigns have demonstrated limited influence among younger audiences.39

Finally, increased efforts should be made within the law enforcement community to train officers and DREs (drug recognition experts) to better identify drivers who may be operating a vehicle while impaired by marijuana.  In Australia, efforts have been made to adapt elements of the roadside Standardized Field Sobriety Test to make it sensitive to drivers who may be under the influence of cannabis.  Scientific evaluations of these tests have shown that subjects’ performance on the modified SFSTs may be positively associated with dose-related levels of marijuana impairment.40 Similarly, clinical testing for cannabis impairment among suspected drugged drivers in Norway has been positively associated with identifying drivers with THC/blood concentrations above 3ng/ml.41

Though the development of such cannabis-specific impairment testing is still in its infancy, an argument may be made for the provisional use of such tests by specially trained members of law enforcement.  In addition, the development of cannabis-sensitive technology to rapidly identify the presence of THC in drivers, such as a roadside saliva test, would provide utility to law enforcement in their efforts to better identify intoxicated drivers.  The development of such technology would also increase public support for the taxation and regulation of cannabis by helping to assuage concerns that liberalizing marijuana policies could potentially lead to an increase in incidences of drugged driving.42 Such concerns are a significant impediment to the enactment of marijuana law reform, and must be sufficiently addressed before a majority of the public will embrace any public policy that proposes regulating adult cannabis use like alcohol.

Paul Armentano is the Deputy Director of NORML and the NORML Foundation.  Mr. Armentano is an expert in the field of marijuana policy, health, and pharmacology.  He has spoken at numerous national conferences and legal seminars, testified before several state legislatures and federal bodies, and assisted dozens of criminal defense attorneys in cases pertaining to the use of medicinal cannabis and drugged driving. He has attended various international conferences on the subject of cannabis and psychomotor impairment, including those sponsored by the Society of Forensic Toxicologists (SOFT) and the The International Council on Alcohol, Drugs & Traffic Safety (ICADTS), and coordinated lobbying efforts to successfully liberalize so-called ‘zero tolerant’ drugged driving laws in Virginia and Ohio.  He is the author of the 2006 cover story, “Cannabis and Zero Tolerance Per Se DUID Legislation: A Special (and Problematic) Case,” for Florida Defender, the journal of the Florida Association of Criminal Defense Lawyers. (FACDL).  He may be contacted via e-mail at: paul@norml.org.

Footnotes

Medical marijuana debate is politics more than science | greatfallstribune.com | Great Falls Tribune.

Dr. Phillip Leveque Salem-News.com

CONFIRMED SAFE & EFFECTIVE: SURPRISE!

Salem-News.com

(MOLALLA, Ore.) – I had heard rumors about studies conducted in the past ten years that the California Legislature had spent several million dollars on, to confirm that marijuana/cannabis was really a safe, effective drug –but it smelled fishy to me.

As it has been used for at least 4,000 years by at least 400 million people who weren’t stoned “staring at the spots on the wall” but getting good relief, one would wonder if those studies were real.

California has about 300,000 legal users and probably a million or more who smoke it when they can get it, regardless of the legal standing.

There are so many people in California and elsewhere who are infected with the Reefer Madness Virus that such Government-paid boondoggling as this doesn’t really surprise me.

Learning about who the 22 members of the Scientific Review Board are was really a shock. Only 6 were M.D.’s who might have had some inkling of marijuana benefits, but where do the 16 Ph.D’s fit here? If they are Pharmacologists who teach that marijuana is “dangerous and addicting”, where and how did they get their scientific background on this subject?

For the 8 M.D.’s of the 23 that serve on the National Advisory Council, where did they acquire medical marijuana expertise? I see some of this group are bought and paid for Government employees who rarely have anything good to say about this DEVIL DRUG used medically by millions of people.

Don’t get me wrong, their collective approval that cannabis/marijuana is truly a safe medication has finally caught up with the U.S. Government figures which verifiably state that 70,000,000 Americans use it once in a while with little to mild detriment.

Getting to the studies and their results one-by-one:

Dr. Donald Abrams’ on HIV Peripheral Neuropathy. He has been working with these patients for about 20 years and it must have been amusing to him to participate. Smoking as in a cigarette is totally archaic but I do see he used vaporizers, the modern method. The concurrent use of Neurontin (gabapentin), Amitryptyline (Elavil), narcotics (Oxycontin?) and NSAIDS (aspirin like) are ungentle throwbacks, but yes, cannabis works better than any of the latter. The adverse effects of the latter don’t compare with the beneficial cannabis.

Dr. Ronald Ellis’ double blind study with placebos should have given him pause. Marijuana users can tell with the first puff that the placebos are NOT marijuana. He also used marijuana cigarettes. Cannabis was superior to the FAKE DRUG and even the patients use of concurrent analgesics.

Dr. Barth Wilsey’s study on neuropathic pain indicated that even low doses of marijuana were beneficial with minimal adverse effects.

Dr. Mark Wallace’s experimental pain production with dermal injection of capsaicin (from chili peppers) was really scary and cannabis didn’t work well here. After about 45 minutes it helped but higher doses (8% THC) caused worse pain? I would guess that the higher dose of cannabis elicited the “panic reaction” response. My suggestion is – don’t inject capsaicin!

Dr. Jody Corey-Bloom studied cannabis on spasticity of Multiple Sclerosis with pain. Cannabis reduced both spasms and pain which M.S. patients discovered years ago. They have found it better than “standard” M.S. drugs.

Dr. Donald Abrams’ other investigation with vaporizers in which 14 of 18 patients preferred the vaporizers. This is a standard observation.

Dr. Sean Drummond (Ph.D.) discovered that cannabis enabled sleep which is the main reason why severe chronic pain patients have been using it for years.

Dr. Thomas Marcotte (Ph.D.) studied if cannabis affected driving ability. He indicated the results are in preparation but here is a warning, we know cannabis acts like a sedative and the patients know this also. Studies in Australia found cannabis users to be more careful drivers, they didn’t want to get caught. Alcohol users didn’t care and they got caught.

Dr. Mark Wallace studied smoked cannabis on the pain of Diabetic Neuropathy. He should know that cannabis works on almost all types of pain and by the way isn’t all pain cause by sensory neuropathy.

Dr. Barth Wilsey has another study on vaporized cannabis against neuropathic pain. He shouldn’t be surprised of the beneficial results.

Dr. Howard Fields performed studies on cannabis and migraines. Other researchers have found cannabis to be very effective in migraines, Trigeminal Neuralgia and Tempo Mandibular Joint (TMJ) pain.

Dr. Mark Barad studied the effects of cannabis on Fear Extinction such as Post Traumatic Stress Disorder in mice. Battle Veterans have found that cannabis is better than any other medication for suppressing immediate Battle Stress but also for Post Traumatic Stress. His studies were with mice. I would guess that mice might think differently than humans. In Iraq, soldiers have found that their “sniffer dogs” DO get canine PTSD.

Dr. Danielle Piomelli studied if the effects of acute use of THC, the botanic cannabinoid, had any effect on Anandamide, the natural endocannabinoid. He found that THC had no effect on levels of the natural endocannabinoid. Chronic use DID cause an increase in Anandamide. It is not surprising that chronic THC use might cause a different response. Acute doses rapidly go into body fats and last only for a few hours.

Again, I congratulate these marijuana scientists. If only those with Reefer Madness Virus would read and understand them. Marijuana/cannabis is more than a miracle drug of the past. It is also efficacious for about 200 medical conditions of the present and future.

Sic Semper Cannabis

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After California became the first state to allow medical use of marijuana, legislators decided in 1999 to fund research that was supposed figure out what the drug was good for therapeutically. Now we have an answer: a report issued today says it seems to ease some types of pain, and maybe muscle spasticity from multiple sclerosis.

Of course, lots of state residents have found their own, much more varied, answers, since California’s law is one of the most open-ended about who’s eligible for medical marijuana. Anyone who can get a doctor to write a recommendation, based on just about any medical condition, can buy marijuana in California. But this is the official report from the Center for Medicinal Cannabis Research, based at the University of California, San Diego.

Since its 2000 founding, the center has funded 15 clinical studies, including seven trials. The results include some fodder for medical-marijuana supporters who argue for the drug’s unique importance, particularly the finding that it worked as an add-on to more standard treatments for pain stemming from nerve damage.

The report argues marijuana may have a “novel mechanism of action not fully exploited by current therapies.” The drug may also have an effect on multiple-sclerosis patients’ spastic motions “beyond the benefit available from usual medical care,” the report says. Other research hasn’t shown this effect consistently.

The report also flags some mild side effects, including dizziness and, ahem, “changes in cognition.” Marijuana opponents will probably say that the studies weren’t long-term enough to show the potential downsides of chronic use.

The center has made these findings public before — they can be found on the center’s Web site. Still, the report is important because it pulls together the results in a document that is supposed to reach the general public.

And now that 13 other states have followed California in adopting medical marijuana laws, the research is likely to play a role as the Golden State once again tries to take the lead in marijuana policy: a California ballot measure that would attempt to legalize the drug’s use by adults 21 and older is likely to come to a vote later this year.

The WSJ took a recent look at marijuana research here.

http://blogs.wsj.com/health/2010/02/17/medical-marijuana-putting-together-californias-research/

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Politicians and decision makers seem to be worried that if we make cannabis legal for medicinal use, then it will become in higher demand and people would abuse the drug more than is happening now. The Institute of Medicine (someone I’d be highly included to trust based on name alone) released a report in 1999 on medical marijuana examining whether the medical use of marijuana would lead to an increase of marijuana use in the general population and concluded that, “At this point there is no convincing data to support this concern. The existing data is consistent with the idea that this would not be a problem if the medical use of marijuana were as closely regulated as other medications with abuse potential.” The report also noted that, “this question is beyond the issues normally considered for medical uses of drugs, and should not be a factor in evaluating the therapeutic potential of marijuana or cannabinoids.”

This reminds me of the drinking age here in the United States versus other countries around the world, and rates of death and accidents caused by minors abusing drinking. If you look at statistics, young people under the legal drinking age of 21 here in the US tend to drink more excessively than youth in other countries, and I believe that is because alcohol consumption is considered to be so much more taboo here. In European countries, for example, wine will be served at family dinners, and it doesn’t seem that teenagers having a glass is a big to-do at all. This may be true for some American families, but I don’t feel it’s the norm across the board. I digress, but this example is meant to show that I think that legalizing cannabis can actually help take the taboo and stigma off of using the drug, and hopefully make people less likely to try and get their hands on it illegally.

The Health Insurance Angle

Although we’re certainly not there yet, seeing as there are still 35 states which have yet to legalize medical marijuana, it does make you wonder if cannabis can and will ever be covered by health insurance plans. This is an interesting pickle, and doesn’t seem like it could be feasible unless cannabis was legalized at the federal level. This is because health insurance plans usually cover a specific service area within the country (for example, Health Net offers coverage in California, New York, New Jersey, Oregon, Arizona, and Connecticut), so if even one of the states an insurance company offered plans in didn’t have legal cannabis at the state level, then the plan couldn’t cover the drug at all.

A more radical way to get cannabis covered by health insurance plans would be for insurers to change the way their plan worked. Assuming that cannabis legalization stays at the state level and a health insurance company feels very strongly about giving medical marijuana coverage to its patients, they could choose to alter the states in which they offer coverage to coincide with states where it is legal.

There are always so many things to consider when thinking about health insurance. Some things are covered, others aren’t, and navigating the mess can seem like a hopeless pursuit. Special insurance is also something to learn about the particular types of special coverage and the conditions you may find yourself in. Arming yourself with knowledge around your health is crucial, so treat your body and mind well.