Drugged Driving Annotated Bibliography

Introduction .................................................................................................................................................. 1

Enforcement ................................................................................................................................................. 3

Epidemiology................................................................................................................................................. 7

Prevention ................................................................................................................................................... 13

Transportation ............................................................................................................................................ 15

Treatment ................................................................................................................................................... 18

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Introduction

DEVELOPMENT OF THE NATIONAL DRUGGED DRIVING REPORTING SYSTEM:

Using Data to Understand the Relationship Between Drugs and Driving

Identifying the problem

The Office of National Drug Control Policy’s (ONDCP) 2010 National Drug Control Strategy identified

drugged driving as a significant problem and established a goal of reducing U.S. drugged driving by

10 percent by 2015.i This was the first time that ONDCP’s strategy identified drugged driving as a

priority, and one that it continued in its 2011 strategy.ii The strategy aims to make the prevention of

drugged driving on par with that employed to prevent drunk driving.

However, a precise estimate of drugged driving prevalence is difficult to capture with the current

disparate national and state-level data definitions, data capture tools, and data management

systems. What is needed is a comprehensive understanding of the relationship between drugs and

driving, along with the resulting arrests, accidents and fatalities that may be caused by driving under

the influence of drugs.

Data tell a story, and we believe that the effective use of quantitative and qualitative data can result

in a compelling story for multiple target audiences, including legislators, law enforcement,

prosecutors, scientists, researchers, and others in the private sector with interest in knowing more

about risks associated with drugged driving.

Project purpose

The team, Advocates for Human Potential, Inc. (AHP) and Carnevale Associates, LLC (CALLC)

received a Phase I Small Business Innovation Research (SBIR) contract to develop the National

Drugged Driving Reporting System (DDRS). This system will include the creation of a national

minimum data set (NMDS) for drugged driving. The Drugged Driving Reporting System will be used to

consolidate, centralize, and analyze data to inform policies and programs, support research and

policy analysis and assess risks associated with drugged driving. This data can be used to support

multi-component prevention strategies and innovative approaches to reducing drugged driving, help

law enforcement personnel with better detection and allocation of resources and support for

changing laws and policies.

The research question for Phase I is focused on both programs and public policy: To what extent is

the Drugged Driving Reporting System, including a national minimum data set, an effective strategy

to mitigate the social, economic, and public health and safety consequences of drugged driving?

Phase I of the project will be completed by February 2013.

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If awarded a Phase II contract, the team will design, develop and implement the National Drugged

Driving Information Clearinghouse (DDIC)--a Web portal focused on drugged driving designed to

provide access to data, best practice information, policy development materials and resources

needed to support a national effort to mitigate the problems of drugged driving. This comprehensive

electronic clearinghouse will address the need for a centralized source of data and communication

and will house the Drugged Driving Reporting System.

Additional information

Augusto Diana, Ph.D., is the Contract Officer’s Technical Representative (COTR) for this project, and

works within the Prevention Research Branch, Division of Epidemiology, Services & Prevention

Research, National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH). AHP Senior

Director Richard Landis, M.S.W. is the Principal Investigator; Fran Basche, M.A., Senior Program

Associate at AHP is the Project Manager. John Carnevale, Ph.D., President of Carnevale Associates,

LLC is the Senior Subject Matter Expert. Raanan Kagan, Senior Policy Analyst from Carnevale

Associates researched and developed this annotated bibliography.

Contact

For more information, please contact Fran Basche at Advocates for Human Potential at (978) 261-

1438 or fbasche@ahpnet.com.

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Enforcement Adler, E.V., & Burns, M. (1994, June 4). Drug Recognition Expert (DRE) validation study. Final report to Governor’s Office of Highway Safety. Retrieved September 2012 from http://www.borkensteincourse.org/faculty%20documents/DREValidationStudy.pdf

This study used survey data from the Drug Influence Evaluation records of 500 suspects over 53 months to determine the scientific validity of a Drug Recognition Expert (DRE) program in Arizona. The study found that the DRE’s appraisals of drug impairment status and identification of drug categories were highly accurate and that the DRE program, with the support of a toxicology laboratory, is a valid method for detecting and classifying drug-impaired individuals. Advanced roadside impaired driving enforcement. (n.d.) Sam Houston State University, College of Criminal Justice. http://dev.cjcenter.org/clients/shsu/idi/ARIDE.html http://www.cjcenter.org/idi/ARIDE/

Advanced Roadside Impaired Driving Enforcement (ARIDE) is a program designed to address the gap in training between the Standardized Field Sobriety Testing (SFST) and the Drug Evaluation and Classification (DEC/DRE) Program by providing officers with general knowledge related to drug impairment and by promoting the use of DREs. Beck, O., Leine, K., Palmskog, G., & Franck, J. (2010). Amphetamines detected in exhaled breath from drug addicts: A new possible method for drugs-of-abuse testing. Journal of Analytical Toxicology, 34 (5), 223-237. http://jat.oxfordjournals.org/content/34/5/233.abstract This paper assessed the feasibility of detecting amphetamine use by examining suspects’ exhaled breath. The authors filtered subjects’ breath through a modified silica surface and analyzed it with a combined liquid chromatography-tandem mass spectrometry method. The study used 12 drug addicted patients whose use of amphetamines was confirmed via urine and plasma tests and 8 healthy adults as a control group. The method detected amphetamine use in all 12 of the users and in none of the control group. Blencowe, T. et al (2010) Analytical evaluation of oral fluid screening devices and preceding selection procedures. DRUID 6th Framework Programme D 3.2.2. Retrieved September 2012 from http://www.rosita.org/ This is the 2.0 revised version of the DRUID study which evaluated 13 different oral fluid (OF) tests used among EU countries’ police agencies. Bosker, W.M. & Huestis, M.A. (2009). Oral fluid testing for drugs of abuse. Clinical Chemistry, 55(11), 1910-1931. This meta-analysis of the research on using oral fluid (OF) testing to detect drug usage finds that OF testing presents multiple advantages over other testing options; however, further research is needed to identify new biomarkers, determine drug detection windows, characterize OF adulteration

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techniques, and evaluate analyte stability. Additionally, SAMHSA delayed approval of OF testing due to questions about drug OF disposition, and collection device performance and testing assays requiring improvement. Cone, E. J. & Huestis, M. A. (2007). Interpretation of oral fluid tests for drugs of abuse. Annals of the New York Academy of Sciences, 1098:51-103. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700061/pdf/nihms118888.pdf This paper argues for the use OF testing for drugs over urine testing due the ability to directly observe its collection and the possibility of drug particles remaining directly within the oral cavity as well diffusing from the bloodstream to OF. Crouch, D.J., Hersch, R.K., Cook, R.F., Frank, J.F., & Walsh, J.M. (2002). A field evaluation of five on-site drug-testing devices. Journal of Analytical Toxicology, 26(7), 493-499. http://jat.oxfordjournals.org/content/26/7/493.full.pdf+html This is a field study of five on-site urinalysis drug tests at two police departments. Using 400 arrestees at each department, the study tested for the false-positive and false-negative rates of marijuana, cocaine and metabolites, amphetamine(s), opiates, and PCP and found that the false-negative rate was <1% for all drug classes and that false-positives varied from 0.25% to 4%. The study concludes that urinalysis is an effective drug testing measure. Disney, L. et al. Drug Testing and Drug-Involved Driving of Fatally Injured Drivers in the United States: 2005-2009. ONDCP. October 2011. http://www.whitehouse.gov/sites/default/files/ondcp/issues-content/fars_report_october_2011.pdf Among the many statistics provided by this report are: 18% of fatally injured drivers tested positive for drugs; drug testing of fatally injured drivers in the US varies by state from 0% to 100%; testing has increased 5% from 2005 to 2009; gender proportions were similar; cannabis was found in 43% of fatally injured drivers under age 24 who tested positive for a drug; alcohol was found in 34% of all fatal crashes, but 48% of drivers who tested positive for drugs also had illegal BAC levels. DuPont RL, Voas RB, Walsh JM, Shea C, Talpins SK, Neil MM (2012). The need for drugged driving per se laws: a commentary. Traffic Inj Prev. 13(1), 31-42. http://www.ncbi.nlm.nih.gov/pubmed/22239141 This paper argues that enforcement statistics regarding the prevalence of drugged driving are incomplete because of a lack of drugged driving per se laws. Farrell, L.J., Kerrigan, S., & Logan, B.K. (2007). Recommendations for toxicological investigation of drug impaired driving. Journal of Forensic Science, 52(5), 1214-1218. http://onlinelibrary.wiley.com/doi/10.1111/j.1556-4029.2007.00516.x/abstract This paper proposes a set of minimum standards for U.S. toxicology labs regarding which drug classes to uniformly test for and what the analytical cutoffs should be for confirming drug use. As of 2007, no such standard exists, which presents a barrier to obtaining accurate data regarding the extent of drug use among drivers and hampers evaluations.

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International Association of Chiefs of Police. (2009). The 2009 Annual Report: The Drug Recognition Expert section of the International Association of Chiefs of Police. Alexandria, VA. http://www.decp.org/oversight/2009AnnualReport.pdf This report presents the status of Drug Recognition Expert (DRE) programs in each of the U.S. states and Canadian provinces that have them. Kuijten, C. (2009). Evaluation of oral fluid Screening devices by TISPOL to Harmonise European policy requirements (ESTHER). DRUID 6th Framework Programme D 3.1.1. Retrieved September 2012 from http://www.druid-project.eu/nn_107548/Druid/EN/deliverales-list/downloads/Deliverable__3__1__1,templateId=raw,property=publicationFile.pdf/Deliverable_3_1_1.pdf This paper is an element of the DRUID study listed above (although based on the 3.1.1 version instead of the 3.2.2), focusing specifically on how to standardize EU countries’ requirements for OF testing devices. Lacey, J., Brainard, K. & Snitlow, S. (2010). Drug per se laws: A review of their use in states (DOT HS 811 317). Washington, DC: National Highway Traffic Safety Administration, Office of Behavioral Safety Research. www.nhtsa.gov/staticfiles/nti/impaired_driving/pdf/811317.pdf This paper studied the effects implementing drugged driving per se laws in U.S. states. Using document reviews, telephone conversations, and site visits to assess whether there were differences in arrest and disposition patterns, the researchers found significant data limitations. However, based on the limited existing data, they found that per se laws had a positive effect on the enforcement and prosecution of drug-impaired driving offenders. Martin, D.M. (2010). An overview of present and future drug testing. Journal of Global Drug Policy and Practice, 3(4). http://globaldrugpolicy.org/Issues/Vol%203%20Issue%204/An%20overview%20of%20present%20and%20future%20drug%20testing.pdf This paper provides a broad overview of a variety of drug testing technologies, their successes, and where the author thinks the field is headed. National Highway Traffic Safety Administration. (2004). Priorities and strategies for improving the investigation, use of toxicology results, and prosecution of drug-impaired driving cases: Findings and recommendations. Committee on Alcohol and Other Drugs of the National Safety Council. Seattle, WA, May 23-25, 2004 http://www.decp.org/pdfs/ImprovingDUICasesNHTSAReport.pdf These proceedings from a panel of toxicologists, DREs, and prosecutors on the topic of driving under the influence of drugs (DUID) determined that there should be a greater number of better trained police officers dedicated to stopping DUIDs. Additionally, the proceedings conclude that more work must be done to prepare police, toxicologists, and prosecutors for DUID trials.

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Smith, J.A., Hayes, C.E., Yolton, R.L., Rutledge, D.A., & Citek, K. (2002). Drug recognition expert evaluations made using limited data. Forensic Science International, 130(2), 167-173. http://www.ncbi.nlm.nih.gov/pubmed/12477639 This investigates the relative importance of DREs’ face-to-face interactions with suspects, physical evidence (drugs or paraphernalia found), and confessions/statements made by the suspect (or others) in making drug usage/classification determinations. The overall accuracy rate using these methods was found to be 95%; however, the authors say that the majority of drug category decisions can be made solely on the basis of recorded suspect observations and DRE evaluation results, finding that additional elements are only needed as adjuncts. U.S. Department of Transportation Federal Motor Carrier Safety Administration (2012). Alcohol and drug rules. http://www.fmcsa.dot.gov/safety-security/safety-initiatives/drugs/engtesting.htm This U.S. Government website presents a general overview of the Federal Motor Carrier Safety Administration's (FMCSA) alcohol and drug testing rules for persons required to obtain a commercial driver's license (CDL). Verstraete A.G., Puddu, M. (2000). Evaluation of different roadside drug tests. In A.G. Verstraete (Ed.). Rosita: Roadside Testing Assessment (pp.167-232). Ghent, Belgium: Ghent University. Retrieved March 29, 2011 from http://www.transport-research.info/Upload/Documents/200310/rositarep.pdf & Verstraete, A.G. & Puddu, M. (2000). General conclusions and recommendations. In A.G. Verstraete (Ed.). Rosita: Roadside Testing Assessment (pp. 393-397). Ghent, Belgium: Ghent University. Retrieved March 29, 2011 from http://www.transport-research.info/Upload/Documents/200310/rositarep.pdf These are two citations from the same study of roadside urine and OF testing for DUID in the EU. The study found that such tests are a useful tool (and have a deterrent effect) to detect DUIDs; although noted that many police officers lack experience in conducting such tests which may hamper their effectiveness. However, the paper recommended against using the devices to test for marijuana due to their current (as of publication) technical limitations, and also stated that the devices for other drugs could still use improvements as well despite being found effective already. Walsh, J.M. (2009). A state-by-state analysis of laws dealing with driving under the influence of drugs (DOT HS 811 236). Washington, DC: National Highway Traffic Safety Administration. http://druggeddriving.org/pdfs/WalshStatebyStateDrugLawsAnalysis811236.pdf This paper analyzes U.S. states’ DUID statutes. The paper finds that there is a lack of uniformity or consistency in the way the states approach drugged drivers and that having no separate offense for driving under the influence of drugs makes it difficult to distinguish between DUID and DWI-alcohol arrests and dispositions. Additionally, the author concludes that there is a need for national leadership to develop model statutes and to strongly encourage the States to modify their laws to provide separate and distinct sanctions for alcohol- and drug-impaired driving.

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Woolley, J.E., & Baldock, M.R.J. (2009). Review of Western Australian drug driving laws. South Australia: Centre for Automotive Safety Research, University of Adelaide. http://digital.library.adelaide.edu.au/dspace/handle/2440/50002 This paper reviews a 2007 update to Australian traffic laws as well as roadside OF testing and DUID enforcement. The abstract does not provide details on the authors’ conclusions.

Epidemiology

Ashbridge, M., Hayden, J. A., & Cartwright, J. L. (2012). Acute cannabis consumption and

motor vehicle collision risk: Systematic review of observational studies and meta-

analysis. British Medical Journal, 344:e536 doi: 10.1136/bmj.e536

This paper used a meta-analysis of 9 studies and found that acute marijuana use is associated with an increased risk of traffic accidents (odds ratio 1.92). Assum, T., Mathijssen, M.P.M., Houwing, S., Buttress, S.C., Sexton, B., Tunbridge, R.J., & Oliver, J. (2005). Prevalence of drug driving and relative risk estimations: A study conducted in The Netherlands, Norway and United Kingdom. IMMORTAL 5th Framework Programme. European Commission, Transport RTD Programme. http://trid.trb.org/view/1156315 This paper examined whether drivers in the Netherlands, Norway, and the UK using one or more of eight defined drug groups have a higher risk of accident than drivers not using those drugs. The paper also attempts to quantify this risk. The authors were unable to calculate exact figures due to the small number of test and control cases; however, with the exception of cannabis, the authors found that use of drugs considerably increased the odds of an accident. Biecheler, M.B., Peytavin, J.F., Sam Group, Facy, F., & Martineau, H. (2008). SAM survey on “drugs and fatal accidents”: search of substances consumed and comparison between drivers involved under the influence of alcohol or cannabis. Traffic Injury Prevention, 9(1), 11-21. http://www.tandfonline.com/doi/full/10.1080/15389580701737561 This paper found that 21% of all drivers involved in traffic accidents in France were above the legal alcohol limit. Drivers in accidents were also tested for drugs, with 6.8% testing for cannabis (40% of whom also were above the legal limit for alcohol) and other illegal drugs being relatively rare. Bierness, D. & Beasley, E. Alcohol and Drug Use Among Drivers. 2008 British Columbia Roadside Survey http://www.stopdruggeddriving.org/pdfs/BritishColumbiaSurveyExaminesHighRatesofImpairedDrivinginCanada.pdf This Canadian Centre on Substance Abuse study found that 8% of drivers in British Columbia tested positive for alcohol while 10% tested positive for drugs. Additionally, drug use was more evenly distributed across time, day, and demographics than alcohol use.

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Blows S, Ivers RQ, Connor J, Ameratunga S, Woodward M, Norton R (2005). Marijuana Use and Car Crash Injury. Addiction. 100(5), 605-11. Retrieved September 2012: http://ukcia.org/research/CarCrashInjury.pdf This study of traffic accidents in New Zealand found a significant relationship (OR 9.5, 95% CI 2.8-32.3) between habitual marijuana use and likelihood of being in an accident. However acute marijuana use in the 3 hours before driving, when controlling for BAC, sleepiness score, habitual use status, time of day, and other demographical data, was not found to increase the likelihood of an accident. However, acute use was associated with habitual use and the paper suggests that intervention strategies may be better served targeting high use groups. Centers for Disease Control. (2006). Alcohol and other drug use among victims of motor-vehicle crashes – West Virginia, 2004-2005. Morbidity and Mortality Weekly Report, 55(48), 1293-1296. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5548a2.htm This paper determined that the prevalence of drug use (25.8%) was similar to the prevalence of being above the legal alcohol limit (27.7%) among persons killed in motor-vehicle crashes in West Virginia. Center for Substance Abuse Research. (2010). One-third of fatally injured drivers with known test results tested positive for at least one drug in 2009. CESAR FAX, 19(49). December 20, 2010. http://www.cesar.umd.edu/cesar/cesarfax/vol19/19-49.pdf In 2009, 33% of the 12,055 of drivers fatally injured in motor vehicle crashes with known test results tested positive for at least one drug (with Marijuana being the most common at 28%), compared to 28% in 2005. The drugs tested for included both illegal substances as well as over-the-counter and prescription medications. Compton, R., & Berning, A. (2009). Results of the 2007 National Roadside Survey of Alcohol and Drug Use by Drivers. Traffic Safety Facts Research Note (DOT HS 811 175). Washington, DC: National Highway Traffic Safety Administration http://www.nmslabs-blog.com/post/Results-of-the-2007-National-Roadside-Survey-of-Alcohol-and-Drug-Use-by-Drivers.aspx NHSTA conducted a roadside testing survey to determine the prevalence of drug use among nighttime drivers. The survey found 16.3% of the nighttime drivers were drug-positive with the most commonly detected drugs being marijuana at 8.6%, cocaine at 3.9%, and methamphetamine at 1.3%. Drummer, O.H., Gerostamoulos, J., Batziris, H., Chu, M., Caplehorn, J.R., Robertson, M.D., Swann, P. (2003). The incidence of drugs in drivers killed in Australian road traffic crashes. Forensic Science International, 134(2-3), 154-162. http://www.sciencedirect.com/science/article/pii/S0379073803001348 This paper investigated the use of alcohol and drugs among individuals in fatal traffic accidents and found that illegal levels of alcohol were found in 29.1% of cases. The highest prevalence was in car drivers (30.3%) and the lowest in truckers (8.6%). Drugs were present in 26.7% of cases, and almost 10% of cases involved both drugs and illegal alcohol levels.

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Hingson, R., Winter, M., & Heeren, T. (2010). “Alcohol and drug use in fatally injured drivers in states that test over 80% for both alcohol and drugs.” International Conference on Alcohol, Drugs and Traffic Safety. Oslo, Norway. 22 Aug. 2010. http://tsforum.event123.no/FHI/ICADTS2010/pop.cfm?FuseAction=Doc&pAction=View&pDocumentId=27313 These slides from a 2010 conference in Norway provide 45 pages covering a variety of statistics on DWIs and DUIDs in the United States. Reductions in the number of DWIs are estimated to have saved 150,000 lives since 1982; a larger impact than the combined result of increases in the use of seatbelts, airbags, and motorcycle and bicycle helmets. Holmgren, A., Holmgren, P., Kugelberg, F.C., Jones, A.W., & Ahlner, J. (2007). Predominance of illicit drugs and poly-drug use among drug-impaired drivers in Sweden. Traffic Injury Prevention, 8(4), 361-367. http://www.tandfonline.com/doi/full/10.1080/15389580701329344 This study examines use type and frequency of drugs used by DUID suspects in Sweden after the 1999 zero-tolerance law went into effect. Drug use was found in 85% of suspects’ blood samples (15% were negative for drugs, although in nearly half of these cases, the blood level of ethanol was found to be above the legal limit), with amphetamines the most common seen drug at 60%. The paper concludes that the number of DUID arrests has dramatically increased since the zero-tolerance law began and that Sweden should consider moving more resources to substance abuse treatment instead of traffic enforcement. Jones, A.W., Holmgren, A. & Kugelberg, F.C. (2007). Concentrations of scheduled prescription drugs in blood of impaired drivers: Considerations for interpreting the results. Therapeutic Drug Monitoring, 29(2), 248-260. http://journals.lww.com/drug-monitoring/Abstract/2007/04000/Concentrations_of_Scheduled_Prescription_Drugs_in.15.aspx This study examines the concentration of prescription drugs found in people arrested for DUID in Sweden. “Diazepam and were the therapeutic agents most frequently identified in these forensic blood samples along with other benzodiazepines such as alprazolam, flunitrazepam, and nitrazepam. The newer hypnotics, exemplified by zolpidem and zopiclone were also found.” Prescription drugs being used in accordance with a doctor’s prescription are exempt from Sweden’s zero-tolerance law. Jones, A.W., Holmgren, A., & Kugelberg, F.C. (2008). Driving under the influence of cannabis: A 10-year study of age and gender differences in the concentrations of tetrahydrocannabinol in blood. Addiction, 103(3), 452-461. http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2007.02091.x/abstract This study found that, over a 10-year period in Sweden, 18% to 30% of DUID suspects had cannabis in their blood samples. The authors also examined proposals to set a legal limit on THC blood levels similar to alcohol levels, finding that it would ineffective and difficult to enforce as THC concentrations can decrease below that limit in the 30 to 90 minutes between apprehension and drug testing.

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Jones, A.W., Kugelberg, F.C., Holmgren, A., & Ahlner, J. (2009). Five-year update on the occurrence of alcohol and other drugs in blood samples from drivers killed in road-traffic crashes in Sweden. Forensic Science International, 186(1), 56-62. http://www.sciencedirect.com/science/article/pii/S0379073809000413 This study on the frequency of alcohol or drugs found in traffic fatalities in Sweden found that 40% of the deceased had drugs or a BAC above the legal limit in their blood samples. 93% of the cases with an illegal BAC were men, as were 83% of the cases with drugs. Jones, R.K., Shinar, D., & Walsh, J.M. (2003, September). State of Knowledge of Drug-Impaired Driving. (DOT HS 809 642). Washington, DC: National Highway Traffic Safety Administration. http://www.nhtsa.gov/people/injury/research/stateofknwlegedrugs/stateofknwlegedrugs/pages/TOC.html This is the final report of a project entitled "State of Knowledge of Drug-Impaired Driving" conducted by NHTSA . Among other conclusions, the study finds “no evaluations of the impact of any drugged driving countermeasure on crashes, either in the United States or Europe. This might be expected, given the lack of any databases containing objective measures of the presence of drugs in crash-involved drivers.”

Laumon, B., Gadegbeku, B., Martin, JL., Biecheler, MB. (2006). Cannabis intoxication and

fatal crashes in France: Population based case-control study BMJ, 332, 1298.

http://www.bmj.com/content/332/7553/1298.1

This French study of drivers considered at fault in fatal car crashes found that 681 drivers (8.8%) were positive for THC, with 285 of them also at an illegal BAC. A person with a positive THC level was found to have a 3.32 odds ratio of being an accident; however, the study found no statistical interaction between marijuana use and alcohol use. After controlling for other factors as well as crashes where the driver was not at fault, the study found marijuana use to be responsible for 2.5% of fatal crashes, compared to 28.6% for alcohol.

Li M, Brady JE, DiMaggio CJ, Lusardi AR, Tzong KY, Li G (2012). Marijuana use and motor

vehicle crashes. Epidemiological Reviews, 34(1), 65-72.

http://epirev.oxfordjournals.org/content/34/1/65

This paper found that non-alcohol-related use of marijuana was associated with an increased risk of accident (a summary odds ratio of 2.66). MacLennan, P., Owsley, C., Rue, L., & McGwin, G. (2009). 2009 older adults’ knowledge about medications that can impact driving. Washington, DC: AAA Foundation. Retrieved September 2012 http://www.aaafoundation.org/pdf/KnowledgeAboutMedicationsAndDrivingReport.pdf. This study of drivers aged 55 and older found that only 27.6% were aware of which medications they were currently prescribed were potentially driver impairing.

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McCarthy, D.M, Lynch, A.M., & Pederson, S.L. (2007). Driving after use of alcohol and marijuana in college students. Psychology of Addictive Behaviors, 21(3), 425-430. http://psycnet.apa.org/journals/adb/21/3/ This is a study of college students’ normative beliefs regarding the dangerous of driving after consuming alcohol or marijuana. Results showed a greater acceptance of driving after consumption of either alcohol or drugs and a greater belief than the population as a whole that they would avoid the negative consequences. National Highway Traffic Safety Administration. (2010). Drug involvement of fatally injured drivers. Traffic Safety Facts Crash Stats (DOT HS 811 415). Washington, DC: National Center for Statistics and Analysis. http://www-nrd.nhtsa.dot.gov/Pubs/811415.pdf This study examined the level of drug testing in the US after fatal car crashes, as well as the results of those tests. The percentage of deceased drivers tested for drugs grew from 56% in 2005 to 63% in 2009 while the percentage of tested drivers who tested positive for drugs grew from 13% to 18%. O’Malley, P.M., & Johnston, L.D. (2007). Drugs and driving by American high school seniors, 2001-2006. Journal of Studies on Alcohol and Drugs, 68(6), 834-42. http://www.jsad.com/jsad/article/Drugs_and_Driving_by_American_High_School_Seniors_20012006/2185.html This study found that the percentage of high school students who reported exposure to a driver who had consumed alcohol or drugs declined from 35% in 2001 to 30% in 2006. Penning, R., Veldstra, J.L., Daamen, A.P., Olivier, B., Verster, J.C. (2010). Drugs of abuse, driving and traffic safety. Current Drug Abuse Review, 3(1), 23-32. http://www.ncbi.nlm.nih.gov/pubmed/20088818 This article shows that studies indicate that 1% to 15% of all drivers drive while impaired by drugs or alcohol. Furthermore most illegal drugs have been proven to impair driving ability; however, most of those drivers are unaware that their driving abilities have been affected. Reisfield GM, Goldberger BA, Gold MS, DuPont RL (2012). The mirage of impairing drug concentration thresholds: a rationale for zero tolerance per se driving under the influence of drugs laws. J Anal Toxicol. 36(5), 353-6. http://jat.oxfordjournals.org/content/36/5/353.abstract This paper argues that “due to variable drug tolerance, lack of consistent relationships between drug blood concentrations and impairment, innumerable drug combinations and multiple other factors” it is impossible to find a drug equivalent to the BAC .08 limit and that there should simply be zero tolerance laws (per se) drugged driving laws. Reisfield, G.M. (2010). Medical cannabis and chronic opioid therapy. Journal of Pain & Palliative Care Pharmacotherapy, 24, 356-361. http://informahealthcare.com/doi/abs/10.3109/15360288.2010.519431

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This study of the effect separate and combined effect of marijuana and opioids on driving ability concluded that patients who are prescribed medical marijuana should not be prescribed opioids, as the two in combination severely decrease driving ability. Schwilke, E.W., dos Santos, M.I.S., & Logan, B.K. (2006). Changing patterns of drug and alcohol use in fatally injured drivers in Washington State. Journal of Forensic Sciences, 51(5), 1191-1198. http://onlinelibrary.wiley.com/doi/10.1111/j.1556-4029.2006.00239.x/abstract Using data from 2001, this study of fatally injured drivers in Washington State found alcohol in 41% of drivers and CNS-affecting drugs in 39%. When compared to data from 1992, alcohol use has declined; however, drug use has increased significantly—particularly for methamphetamines. Substance Abuse and Mental Health Services Administration. (2012). Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings (NSDUH Series H-44, HHS Publication No. (SMA) 12-4713.). Rockville, MD. http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.pdf

This is the 2012 NSDUH. In 2011, 9.4 million persons aged 12 or older (3.7%) reported driving under the influence of illicit drugs during the past year, a lower rate than in 2010 (4.2%) or 2002 (4.7%). The overall rate of current illicit drug use among persons aged 12 or older in 2011 (8.7 percent) was the same as the rate in 2010 and higher than the rates in 2004 (7.9 percent), 2005 (8.1 percent), 2007 (8.0 percent), and 2008 (8.0 percent) Walsh, J.M., de Gier, J., Christopherson, A. & Verstraete, A. (2004). Drugs and Driving. Traffic Injury Prevention, 5(3)241-253. http://www.tandfonline.com/doi/full/10.1080/15389580490465292 This is a global survey of the state of knowledge on topics relating to drugged driving. Walsh, J.M., Verstraete, A.G., Morland, J., & Huestis, M. (2008). Guidelines for research on drugged driving. Addiction, 103(8), 1258-1268. http://onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2008.02277.x/abstract This paper provides a set of guidelines derived from a 2006 expert panel designed to standardize research on drugged driving. The authors note that the lack of standardization prevents comparisons between various tests and surveys. Walsh, J., Flegel, R., Atkins, R., Cangianelli, L.A., Cooper, C., Welsh, C., & Kerns, T.J. (2005, September). Drug and alcohol use among drivers admitted to a level-1 trauma center. Accident Analysis and Prevention, 37(5), 894-901. http://www.sciencedirect.com/science/article/pii/S0001457505000692 This was a 90-day study to determine the prevalence of alcohol and/or drug use in drivers admitted to level-1 trauma centers after automobile accidents. 65.7% tested positive for alcohol or drugs, 50.9% for drugs, 25% for Marijuana. Of those who tested positive, 42% were referred to substance abuse evaluation.

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Prevention Brady, J.E., Baker, S.P., DiMaggio, C., McCarthy, M.L., Rebok, G.W., & Li, G. (2009). Effectiveness of mandatory alcohol testing programs in reducing alcohol involvement in fatal motor carrier crashes. American Journal of Epidemiology, 170(6), 775-782. http://aje.oxfordjournals.org/content/170/6/775.short This paper found that implementing mandatory alcohol testing programs was associated with a 23% reduced risk of alcohol involvement in fatal crashes by motor carrier drivers. The study used data from the Fatality Analysis Reporting System during 1982–2006. The paper did not discuss drug testing, however similar risk reductions may be achievable. European Monitoring Centre for Drugs and Drug Addiction. (2007). Drugs and driving. Lisbon, Portugal: Office for Official Publications of the European Communities. Retrieved September 2012. http://www.emcdda.europa.eu/html.cfm/index44716EN.html This paper studies the prevalence of driving under the influence of cannabis and benzodiazepines in select EU countries using a variety of testing methods. A variety of methods and countries are compared, using OF and blood/urine road tests for all drivers, tests for drivers stopped on suspicion of DUID, tests after accidents, and tests of roadside fatalities. The authors also analyze EU countries’ drug prevention programs and public awareness of the dangers of DUID. One of the main conclusions is that there is not always a strong correlation between the number of DUIDs and the number of people who took drugs in the previous week. European Monitoring Centre for Drugs and Drug Addiction. (2009). Responding to drug driving in Europe. Drugs in Focus. Lisbon, Portugal: Office for Official Publications of the European Communities. http://www.emcdda.europa.eu/publications/drugs-in-focus/driving Alcohol is responsible for 10,000 annual road deaths in the EU, or one quarter of all road deaths. No comparable figure is available for illegal drugs and the extent of drugged driving is not currently being studied in a majority of EU countries. Fell, J.C., Langston, E.A., Lacey, J.H., Tippetts, A.S., & Cotton, R. (2008). Evaluation of seven publicized enforcement demonstration programs to reduce impaired driving: Georgia, Louisiana, Pennsylvania, Tennessee, Texas, Indiana, and Michigan. Washington, DC: National Highway Traffic Safety Administration. http://www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/810941.pdf Between 2000 and 2003 NHSTA funded demonstration projects in 7 states to reduce DUIs, with projects focusing on increased enforcement and greater public awareness. As compared to surrounding States, fatal crash reductions in Georgia, Tennessee, Indiana, and Michigan ranged from 11 to 20 percent. The other three States showed only marginal, non-significant changes relative to their comparison jurisdictions or States. Impaired driving initiatives. (n.d.) Sam Houston State University, College of Criminal Justice. Retrieved September 2012. http://www.cjcenter.org/training/decp/

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The four biggest training courses for law enforcement officers to detect and prevent drugged driving are DRE, ARIDE, DITEP, and DITTE. The linked site provides background information and links to each of these courses. Mørland J. (2000) Driving under the influence of non-alcoholic drugs, Forensic Science Review, 12, 80-105. http://www.forensicsciencereview.com/Abstract/12-5A%20(Morland).pdf This article is a summary of the knowledge within the field of drugged driving. Key concepts identified are: studies on overall drug use are not sufficient to inform local drugged driving rates; of the new drugged driving tests, OF testing is the most promising; Benzodiazepines (BZDs) and related drugs appear to be a larger problem (in the US) then opioids or antidepressants; and Norway’s system may prove to be an example for other countries to follow—demonstrating the highest rate of detection despite not particularly high overall use. Office of National Drug Control Policy. (2010). National drug control strategy, 2010. Washington, DC: Author. Retrieved March 29, 2011 from http://www.whitehousedrugpolicy.gov/publications/policy/ndcs10/ndcs2010.pdf

President Obama’s 2010 National Drug Control Strategy calls for a 10 percent reduction in the prevalence of drugged driving as one of its goals. This will be accomplished through encouraging states to adopt per se laws, enhancing prevention through education, providing additional training to police officers, develop standard screening methodologies for drug labs, and collecting further data on drugged driving. Shults, R.A., Elder, R.W., Sleet, D.A., Nichols, J.L., Alao, M.O., Carande-Kulis, V.G., et al. (2001). Reviews of evidence regarding interventions to reduce alcohol-impaired driving. American Journal of Preventive Medicine, 21(4 Suppl), 66-88. http://www.ajpmonline.org/article/S0749-3797(01)00381-6/abstract This study of the effectiveness of interventions to reduce DUIs found that strong evidence for the effectiveness of .08 blood alcohol concentration laws, minimum legal drinking age laws, and sobriety checkpoints. Sufficient evidence was found for the effectiveness of lower blood alcohol concentration laws for young and inexperienced drivers and of intervention training programs for servers of alcoholic beverages. Williams, A. F. (2007). Public information and education in the promotion of highway safety. National Cooperative Highway Research Program, NCHRP Project 17-33, Research Results Digest 322. Washington, DC: Transportation Research Board of the National Academies. http://onlinepubs.trb.org/onlinepubs/nchrp/nchrp_rrd_322.pdf This study of the effectiveness of public information and education programs in improving highway safety through reducing behaviors such as alcohol, drug, and tobacco use while driving found that such programs often do not cause measurable reductions in traffic accidents or injuries. In fact, a small number of programs have been linked to increases in accidents or injuries. More importantly, these programs are often implemented without evidence of their efficacy. The author advocates for discontinuing that practice.

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Transportation Anderson, B.M., Rizzo, M., Block, R.I., Pearlson, G.D. & O’Leary, D.S. (2010). Sex differences in the effects of marijuana on simulated driving performance. Journal of Psychoactive Drugs, 42(1), 19-30. http://www.ncbi.nlm.nih.gov/pubmed/20464803 This study found no gender difference in marijuana’s impact on driving ability. When driving on marijuana, participants’ driving speeds decreased and they failed to make the expected adjustments when forced to perform a distracted drive; however, no impact was found in regular driving ability or in collision avoidance skills. Bédard, Michel; Dubois, Sacha; Weaver, Bruce. (2007). The Impact of Cannabis on Driving. Canadian Journal of Public Health. 1, 6-11. http://www.ncbi.nlm.nih.gov/pubmed/17278669 This test of traffic fatalities found that 5% of those who tested negative for alcohol consumption tested positive for marijuana. After controlling for age, sex, and prior driving record, the study found that the presence of marijuana was associated with a higher risk of a potentially unsafe driving action (1.29 adjusted odds ratio, 99% CI = 1.11-1.50). Bramness, J.G., Khiabani, H.Z., & Mørland, J. (2010). Impairment due to cannabis and ethanol: Clinical signs and additive effects. Addiction, 105(6), 1080-1087. http://web.monroecc.edu/manila/webfiles/cfinch/MarijuanaStudy.pdf This paper studied the driving impairment caused by cannabis and ethanol to determine if their impairment effects are related to the blood concentration of THC and ethanol. The study found no relationship between blood concentration of THC and clinical tests for impairment; however, THC blood concentration was found to be related to conjunctival injection, pupil dilation and reaction to light, and to the overall risk of being judged impaired. When cannabis and ethanol are taken together, the risk of impairment increased, as did the risk of addiction. Brookhuis, K.A., de Waard, D., & Samyn, N. (2004). Effects of MDMA (ecstasy), and multiple drugs use on (simulated) driving performance and traffic safety. Psychopharmacology, 173(3-4), 440-445. http://altmetis.eldoc.ub.rug.nl/FILES/root/2004/k.a.brookhuis/psychopharmacology2004.pdf This before-and-after test of the effect of MDMA on driving abilities using driving simulators and volunteers who indicated MDMA use, found that driving while using MDMA was associated with a 150% increase in the chances of being involved in an accident. C W Ch'ng, M Fitzgerald, J Gerostamoulos, P Cameron, D Bui, P McCaffrey, O Drummer, J Potter, M Odell. Drug Use in Motor Vehicle Drivers Presenting to an Australian, Adult Major Trauma Centre, C Emerg Med Australas. 2007 Aug;19 (4):359-65). Abstract retrieved from http://druggeddriving.org/research.html This study of blood samples of drivers taken to major trauma centers in Victoria, Australia found a “high rate” of drug use. “Metabolites of cannabis were the most commonly found drug (46.7%), the active form of cannabis (Delta9-tetrahydrocannabinol) was found in 33 specimens (7.6%). The next most

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prevalent drugs were benzodiazepines (15.6%), opiates (11%), amphetamines (4.1%) and methadone (3%). Cocaine was detected in 1.4% of cases”.

C'de Baca, J., McMillan, G.P., & Lapham, S.C. (2009). Repeat DUI Offenders Who Have Had a

Drug Diagnosis: Are They More Prone to Traffic Crashes and Violations? Traffic Injury

Prevention,10 (2),134-140. http://www.ncbi.nlm.nih.gov/pubmed/19333825

This study of DUI and DUID offenders found that those diagnosed with lifetime drug use disorders had a greater risk of being in a traffic accident then those who did not have such diagnoses (47% for CNS depressant use disorder and 28% for stimulant use disorder). Crancer, Jr., A., Dille, J.M., Delay, J.C., Wallace, J.E., & Haykin, M.D., (1969). Comparison of the effects of marijuana and alcohol on simulated driving performance. Science, 164(881), 851-854. http://www.onlinepot.org/medical/Dr_Tods_PDFs/s4_4.pdf This simulated test of the effects of marijuana and alcohol on driving ability found marijuana to be associated only with an increase in speedometer errors; whereas, the same subjects under the influence of alcohol committed a significant number of accelerator, brake, signal, speedometer, and total errors. Fishbain, D.A., cutler, R.B., Rosomoff, H.L., & Rosomoff, R.S. (2002). Can patients taking opioids drive safely? A structured evidence-based review. Journal of Pain & Palliative Care Pharmacotherapy, 16(1), 9-28. http://informahealthcare.com/doi/abs/10.1080/J354v16n01_03 This literature review of clinical studies testing for a relationship between prescription opioid use and traffic accidents found no studies indicating an association. Lacey, J.H., Kelley-Baker, T., Furr-Holden, D. Voas, R.B., Romano, E., Ramirez, A. et al. (2009). 2007 National Roadside Survey of Alcohol and Drug Use by Drivers: Drug results (DOT HS 811 249). National Highway Traffic Safety Administration. http://www.nhtsa.gov/Driving+Safety/Research+&+Evaluation/ci.2007+National+Roadside+Survey+of+Alcohol+and+Drug+Use+by+Drivers.print The 2007 National Roadside Survey (NRS) found that 11% of daytime drivers and 14% of nighttime drivers tested positive for drugs. Lenné , M.G., Dietze, P.M., Triggs, T.J., Walmsley, S., Murphy, B., & Redman, J.R. (2010). The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand. Accident Analysis and Prevention, 42(3), 859-866. http://www.ncbi.nlm.nih.gov/pubmed/20380913 This report tested the effects of cannabis and alcohol on simulated driving ability at 3 dosing levels (placebo, “low”, and “high”). Alcohol, at the levels given (no specific number was provided, but it appears that even the “high” level was well below the legal limit), had a limited impact on driving ability and had no synergistic effect with cannabis. As for cannabis, at the “high” level, it was found to have a greater impact on driving ability than at the “low” level, particularly in the areas of speed and lateral position variability.

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Kay, G.G., & Logan, B.K. (2011). Drugged Driving Expert Panel report: A consensus protocol for assessing the potential of drugs to impair driving (DOT HS 811 438). Washington, DC: National Highway Traffic Safety Administration. http://www.nhtsa.gov/staticfiles/nti/pdf/811438.pdf This report summarizes the findings of a NHTSA expert panel assembled to determine whether a list could be developed to indicate which medications or classes of medications may pose a hazard to driving. The paper presents a proposed protocol to act as a structured, standardized method to assess the driving impairment of prescription drugs. MacDonald, S., Mann, R., Chipman, M., Pakula, B., Erickson, P., Hathaway, A. et al. (2008). Driving behavior under the influence of cannabis or cocaine. Traffic Injury Prevention, 9(3), 190-194. http://www.ncbi.nlm.nih.gov/pubmed/18570139 This report details the results of a self-report survey on the perceptions and frequency of driving under the influence of cannabis or cocaine. Drivers reported heightened nervousness, greater alertness, and poorer concentration in all cases, but reported driving extra cautiously when using cannabis and more recklessly when using cocaine. The survey also found that the negative effects of using cannabis decreased the likelihood of individuals driving while under its influence. Mallick, Jennifer Johnston, Netzach Goren and Vanessa Kennedy. Drugs and Driving in Australia. Australian Drug Foundation. Jane 2007. http://www.stopdruggeddriving.org/pdfs/FullReportAustraliaReportonImpairedDrivingShowsDruggedDrivingGreatConernforCountry.pdf http://www.stopdruggeddriving.org/pdfs/SummaryAustraliaReportonImpairedDrivingShowsDruggedDrivingGreatConernforCountry.pdf Among the findings of this report on the status of drugged driving in Australia, are that it has a similar prevalence to drunk driving and that a harm-reduction approach would be the most effective way to curb it. Mura, P., Brunet, B., Favreau, F., Hauet, T. (2006). Cannabis and road crashes: A survey of recent French studies. Annales pharmaceutiques françaises, 64(3), 192-196. http://www.ncbi.nlm.nih.gov/pubmed/16710117 This survey of French studies on the frequency of driving under the influence of marijuana found that the studies are probably underestimating frequency due to long time-delays between apprehension and testing as well as excessively high thresholds for THC positivity. Papafotiou, K., Carter, J.D., & Stough, C. (2005). The relationship between performance on the standardised field sobriety tests, driving performance and the level of Delta9-tetrahydrocannabinol (THC) in blood. Forensic Science International, 155(2-3). http://www.ncbi.nlm.nih.gov/pubmed/16226154 This study of standardized field sobriety tests in individuals with positive THC blood levels found that they accurately determine impairment in 65.8 to 76.3% of cases. The study also found that such tests are a moderate predicator of actual driving ability after consuming marijuana.

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Rafaelsen, O.J., Bech, P., Christiansen, J., Christrup, H., Nyboe, J., & Rafaelsen, L. (1973). Cannabis and alcohol: Effects on simulated car driving. Science, 179(76), 920-923. This study of the impact of cannabis and alcohol on driving found that both cannabis and alcohol increased the time required to brake and start, whereas alcohol increased while cannabis decreased the number of gear changes. Ramaekers, J.G., Robbe, H.W., O'Hanlon, J.F. (2000). Marijuana, alcohol and actual driving performance. Human Psychopharmacology, 15(7), 551-558. http://onlinelibrary.wiley.com/doi/10.1002/1099-1077(200010)15:7%3C551::AID-HUP236%3E3.0.CO;2-P/abstract This study of the impact of marijuana and alcohol on driving performance found that low doses of marijuana have a limited impact on performance; however, this dramatically increases when combined with even low amounts of alcohol. Romano, E., Kelley-Baker, & Voas, R.B. (2008). Female involvement in fatal crashes: Increasingly riskier or increasingly exposed? Accident Analysis & Prevention, 40(5), 1781-1788. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2720618/pdf/nihms70260.pdf This study aimed to determine why female involvement in fatal traffic accidents has been increasing (limited data in US, but NHSTA found a 12% relative increase from 1993 to 2003). The authors attributed the increase to a combination of more women driving and more woman, particularly underage women, engaging in behaviors that increase the risk of accidents, including DUIs and DUIDs. Sewell, R.A., Poling, J., & Sofuoglu, M. (2009). The effect of cannabis compared with alcohol on driving. American Journal of Addiction, 18(3), 185-193. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722956/pdf/nihms115730.pdf This study of the impact that cannabis and alcohol use have on driving found that marijuana users’ awareness of their impairment often allows them to effectively compensate when performing complex driving functions but will impair highly automatic functions. The opposite effect is found in alcohol users, and combining alcohol and marijuana eliminates the compensation ability.

Treatment Babor, T. F., & Higgins-Biddle, J. C. (2000). Alcohol screening and brief intervention: Dissemination strategies for medical practice and public health. Addiction, 95, 677–686. http://www.ncbi.nlm.nih.gov/pubmed/10885042 This review finds that alcohol screening and brief intervention (SBI) is an effective tool to reduce alcohol-related problems; however, it should be better promoted in the more general context of preventive health.

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Babor, T. F., Higgins-Biddle J., Dauser, D., Higgins P, & Burleson, J. (2005). Alcohol screening and brief intervention in primary care settings: Implementation models and predictors. Journal on Studies of Alcohol and Drugs, 66(3), 361–369. http://www.ncbi.nlm.nih.gov/pubmed/16047525 This study of SBIs found that, in many cases, they are more effective in models where nurses act as clinical specialists as opposed to models where primary medical providers conducted the interventions. However, the authors concluded that a variety of organizational characteristics determine the most effective model in any given setting. Bernstein, J., Bernstein, E., Tassiopoulos, K., Heeren, T., Levenson, S. & Hingson, R. (2005). Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77(1), 49-59. http://www.bu.edu/bniart/files/2011/02/SBIRT-drugs.pdf This study found that applying SBI techniques to drugs found that it may be effective in reducing use of cocaine and heroin. In testing, the intervention group was more likely to be abstinent than the control group for cocaine alone (22.3% versus 16.9%), heroin alone (40.2% versus 30.6%), and both drugs (17.4% versus 12.8%), with adjusted OR of 1.51-1.57. DuPont, R.L., McLellan, A.T., White, W.L., Merlo, L.J., & Gold, M.S. (2009). Setting the standard for recovery: Physicians’ Health Programs evaluation review. Journal for Substance Abuse Treatment, 36(2), 159-171. http://www.ncbi.nlm.nih.gov/pubmed/19161896 This study of the effectiveness of Physicians’ Health Programs in reducing substance abuse found that, of the 904 patients admitted to programs in 16 states, 72% were still abstinent 5 years later. Maxwell, J.C., Freeman, J., & Davey, J. (2009). Too young to drink but old enough to drive under the influence: A study of underage offenders as seen in substance abuse treatment in Texas. Drug and Alcohol Dependence, 104(1-2), 107-112. http://www.ncbi.nlm.nih.gov/pubmed/19473785 This study examined underage drivers in Texas who were admitted to substance abuse treatment following a DUI. The authors found that, from 1997 to 2007, there was a shift in the primary cause of the DUI from alcohol to marijuana. The study also found that the factors that increase chances of a failure to remain abstinent following treatment include: being admitted for marijuana instead of alcohol, living in a household with exposure to alcohol or drugs, having been in residential treatment, and having less family support. i ONDCP Website http://www.whitehouse.gov/ondcp/drugged-driving

ii DuPont, R. (2011). Drugged Driving Research: A White Paper. Rockville, MD: Institute of Behavior and Health,

Inc. Retrieved from http://www.whitehouse.gov/sites/default/files/ondcp/issues-content/drugged-

driving/nida_dd_paper.pdf