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~ A REPORT OF CANNIBIS USE AND AUTO ACCIDENTS ~

INTRODUCTION

Twenty-one states have legalized medicinal use of cannabis and two for recreational use; if there was ever a major accident one would think that it would be a major media story. After all, it would be proof that legalizing marijuana by any measure a victory for the opponents of legalization. So, where is the information that reports these cannabis-induced car accidents? There just arent any, - the data is simply not there. The information that does emerge in fact: reflects that there are often other factors that overrule many of these ongoing presumptions. Imagine a world where cats are illegal but, dogs are not. Few have even seen a cat. Imagine explaining a cat to a person who has only known dogs. Well, a cat is furry, stands on four legs, follows you around, and can become your best friend. Imagine the response from the person whom you are trying to convince responds: But, they sound like dogs, - and dogs bite, look how many people have been bitten by dogs! How can we allow more pets that can bite people? After all, cats have been illegal for a long time and they could bite worse than dogs! Although this seems crazy, to describe a cat in terms to dog owners in a world where cats are illegal this scenario makes for plausible similarities and concerns. However, we all know, although the description of both animals sounds the same that there are vast differences between cats and dogs. Cannabis, alcohol, cigarettes, candy, heroin, caffeine, and aspirin are also all very different things, all have very different outcomes, and all are considered drugs but whoever saw them would have to consider them to be vastly different things. It would be unfair to equate aspirin with alcohol as much as alcohol with cannabis - neither can be sufficiently equated with one another. Both ingestion and intoxication are as uniquely different as comparing a cup of coffee with heroin. Comparing a marijuana cigarette with two beers is as vastly unequal as both are exclusive to their own unique properties and identities. It is grossly insufficient to relate cannabis to what it is we know about alcohol, as many peoples only experience with any intoxicant: - is alcohol alone. It seems in a world where alcohol IS the
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only thing known, that those similar scenarios are applied to those things that are yet to be understood. This is analogous to being concerned about cats over dogs despite in word they seem very similar but, they are in fact - very different, and the truth will always continue to evade us until we see a cat for ourselves. With considering cannabis legalization many would not understand that it is a substance of its own unique contribution. After all, who would? It has been banned for many years. When learning about this - it is understandable that many would substitute what it is that we do know for the concerns of we would know in the observable in the world with what we do understand. As equally as cats are not dogs, cannabis simply does not contain the properties that alcohol has, and as those who would not know this it would appear reasonable for them to trust the data that scientists and researchers that have cumulated from careful tests and unbiased analysis. I can understand the concern that accidents are the fifth leading cause of death in the US; and nearly half are motor vehicle accidents. According to the Fatality Analysis Reporting System (FARS) motor vehicle accidents have killed 38,588 people in 2006 alone. There are many causes that account for this number, - alcohol is the primary culprit. Although no one can argue that cannabis did not exist in 2006. Many would say that legalization would lead to more people smoking, - this is patently untrue. After all, whoever reads this - must be asked: if cannabis was legalized, would that change your personal lifestyle? If marijuana was legal would you go and smoke it? If you already use marijuana, - would you stop it because it is illegal? Prevention is always a concern, but the many concerns of marijuana liberation, traffic accidents are vaguely a notable one. Medical cannabis is a drug, but so is aspirin, and as per many drugs (over the counter and prescribed) do act adversely when combined with alcohol.

I have compiled a menu of abstracts, results, summaries from many scientific studies, and journals to provide quick reference to address all of these concerns of traffic accidents and the use of medical marijuana...

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Studies suggest cannabis may actually reduce the responsibility rate and lower crash risk. Put another way, cannabis consumption either increases driving ability or, more likely, drivers who use cannabis make adjustments in driving style to compensate for any loss of skill (Drummer, 1995). This is consistent with simulator and road studies that show drivers who consumed cannabis slowed down and drove more cautiously (see Ward & Dye, 1999; Smiley, 1999. This compensation could help reduce the probability of being at fault in a motor vehicle accident since drivers have more time to respond and avoid a collision.
Source: Laberge, Jason C., Nicholas J. Ward, Research Note: Cannabis and Driving Research Needs and Issues for Transportation Policy, Journal of Drug Issues, Dec. 2004, pp. 980.

The decriminalization of cannabis and the subsequent reduction, more cannabis use, which substituted for alcohol consumption, leading to less frequent and less heavy drinking and the reduction in the amount of alcohol consumed resulted in fewer nonfatal accidents.
Source: Laberge, Jason C., Nicholas J. Ward, Research Note: Cannabis and Driving Research Needs and Issues for Transportation Policy, Journal of Drug Issues, Dec. 2004, pp. 980-1.

Several reviews of driving and simulator studies have concluded that marijuana use by drivers is likely to result in decreased speed and fewer attempts to overtake, as well as increased following distance. The opposite is true of alcohol.
Smiley A. Marijuana: On-road and driving simulator studies. Alcohol, Drugs and Driving. 1986;2(34):121134.

One review of eight driving simulator studies and seven on-road studies found that cannabis use was associated with slower driving that successfully maintained lane control.
. Peck R, Biasotti A, Boland P, Mallory C, Reeve V. The effects of marijuana and alcohol on actual driving performance. Alcohol, Drugs and Driving: Abstracts and Reviews 1986. 1986;2:135154. Casswell S. Cannabis and alcohol: Effects on closed-course driving behavior. Paper presented at: 7th International Conference on Alcohol, Drugs, and Traffic Safety; 1979; Melbourne, Australia.

One study found no significant associationbetween marijuana use and crash risk. More recent studies found no increase in the past-year accident rate between cannabis smokers and controls.
Movig KL, Mathijssen MP, Nagel PH, et al. Psychoactive substance use and the risk of motor vehicle accidents. Accid Anal Prev. 2004 Jul;36(4):631636.

Lowenstein and Koziol-McLains study of 414 injured drivers admitted to a Colorado E/R found that marijuana use was not associated with increased crash responsibility.
Lowenstein SR, Koziol-McLain J. Drugs and traffic crash responsibility: a study of injured motorists in Colorado. J Trauma. 2001 Feb;50(2):313320

This same information has been recently correlated by American studies now that medical marijuana has been decriminalized (in a Time.com article written by: Maia Szalavitz) named
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Why Medical Marijuana Laws Reduce Traffic Deaths is as follows: States that legalize medical marijuana see fewer fatal car accidents, according to a new studies economists looked at 1990-2009 government data on marijuana use and traffic deaths in the 13 states that had passed legalization laws during that time period. The data were from the National Household Survey on Drug Use and Health and the National Highway Traffic Safety Administration. Comparing traffic deaths over time in states with and without medical marijuana law changes, the researchers found that fatal car wrecks dropped by 9% in states that legalized medical use. The rate of fatal crashes in which a driver had consumed any alcohol dropped 12% after medical marijuana was legalized, and crashes involving high levels of alcohol consumption fell 14%. The overall reduction in traffic deaths was comparable to that seen after the national minimum drinking age was raised to 21.
http://healthland.time.com/2011/12/02/why-medical-marijuana-laws-reduce-traffic-deaths/

Many investigators have suggested that the reason why marijuana does not result in an increased crash rate in laboratory tests despite demonstrable neurophysiologic impairments is that, unlike drivers under the influence of alcohol, who tend to underestimate their degree of impairment, marijuana users tend to overestimate their impairment, and consequently employ compensatory strategies. Cannabis users perceive their driving under the influence as impaired and more cautious.
MacDonald S, Mann R, Chipman M, et al. Driving behavior under the influence of cannabis or cocaine. Traffic Inj Prev. 2008;9(3):1901994

The effect of marijuana on driving is not uniform for all subjects, however, but is in fact bidirectional; whether or not significant decline occurs in driving ability is dependent both on the subject's capacity to compensate and on the dose of marijuana. For those subjects who improved their performance, the explanation may lie in overcompensation and possibly the sedative effect of the drug.
Marijuana and driving in real-life situations. (PMID:4414573) Klonoff H Science (New York, N.Y.) [1974, 186(4161):317-324] DOI: 10.1126/science.186.4161.317

Drivers were more aware of being intoxicated after using cannabis and thus invoked greater compensatory effort to offset impairment in the driving task.
Cannabis and Driving Research Needs and Issues for Transportation Policy Jason C. Laberge, M.Sc., Visiting Scientist Nicholas J. Ward, Ph.D., Director

Under the influence of marijuana, participants decreased their speed and no differences were found during the baseline driving segment or collision avoidance scenarios. No differences
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attributable to sex were observed. This study enhances the current literature by identifying distracted driving and the integration of prior experience as particularly problematic under the influence of marijuana.
Sex Differences in the Effects of Marijuana on Simulated Driving Performance DOI: 10.1080/02791072.2010.10399782 Beth M. Anderson a, Matthew Rizzo b, Robert I. Block b, Godfrey D. Pearlson ca & Daniel S. O'Leary b

We conclude that, as currently implemented, making it illegal to operate a motor vehicle with marijuana in the system, has no discernible impact on traffic fatalities. Simulator and drivingcourse studies provide little evidence that marijuana use leads to an increased risk of collision (Kelly et al. 2004; Sewell et al. 2009), perhaps because drivers under the influence of marijuana tend to overestimate the degree to which they are impaired (Kelly et al. 2004; Sewell et al. 2009)
Per Se Drugged Driving Laws and Traffic Fatalities D. Mark Anderson Montana State University Daniel I. Rees University of Colorado Denver and IZA Discussion Paper No. 7048 November 2012

120 studies have found that in general, those more frequent users of marijuana show less impairment than infrequent users at the same dose, either because of physiological tolerance or learned compensatory behavior. Maximal impairment is found 20 to 40 minutes after smoking, but the impairment has vanished 2.5 hours later.
Kruger H. Low alcohol concentrations and driving. Bergisch Gladbach: Bundesanstalt fur Strassenwesen; 1990. Berghaus G. Comparison of the effecvts of cannabis and alcohol from experimental studies. In: Grotenhermen F, Karus M, editors. Cannabis, Driving and Workplace. Heidelberg/New York: Springer Verlag; 2002. pp. 225235.

Drummers review of blood samples of traffic fatalities in Australia found that drivers testing positive for marijuana were actually less likely to have been judged responsible for the accident.
Drummer O. Inquiry into the effects o drugs (other than alcohol) on road safety in Victoria, Incorporating Selected Papers. Melbourne, Australia: LV North, Government Printer; 1995. A review of the contributions of drugs in drivers to road accident;

Several other studies have found no increase in crash risk with cannabis.
Terhune K, Ippolito C, Hendricks D, et al. The incidence and role of drugs in fatally injured drivers. Washington, DC: National Highway Traffic Safety Administration, U.S. Department of Transportation; 1992. Drummer O. Drugs and accident risk in fatally injured drivers. Paper presented at: T95: 13th International Conference on Alcohol, Drugs and Traffic Safety; 1995; Adelaide, Australia. Terhune K. An evaluation of crash culpability to assess alcohol and drug impairment effects. Paper presented at: 26th Annual Meeting, American Association for Automotive Medicine; 1982;

The Colorado study that found that marijuana use was not associated with increased crash responsibility.
Lowenstein SR, Koziol-McLain J. Drugs and traffic crash responsibility: a study of injured motorists in Colorado. J Trauma. 2001 Feb;50(2):313320.

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There was no difference in rates of failure to stay within lane between cannabis users and nonusers, contradicting the findings of several laboratory studies.
Robbe H, OHanlon J. Marijuana and Actual Driving Performance. National Highway Traffic Safety Administration, U.S. Department of Transportation; 1993.

In seven of ten studies cited, cannabis use was associated with a decrease in driving speed despite explicit instructions to maintain a particular speed, whereas under the influence of alcohol, subjects consistently drove faster. Two simulator studies showed that the tendency to overtake was decreased with cannabis use but increased with alcohol.
Dott A. Effect of marijuana on risk acceptance in a simulated passing task. Washington, DC: US Government Printing Office; Ellingstad V, McFarling L, Struckman D. Alcohol, Marijuana and Risk Taking. Vermillion, DS: Vermillion Human Factors Laboratory, South Dakota University; 1973.

One simulator study and two on-road studies examining car-following behavior concluded that cannabis smokers tend to increase the distance between themselves and the car in front of them.
Marczinski CA, Harrison EL, Fillmore MT. Effects of alcohol on simulated driving and perceived driving impairment in binge drinkers. Alcohol Clin Exp Res. 2008 Jul;32(7):13291337. Smiley A. Marijuana: On-road and driving simulator studies. Alcohol, Drugs and Driving. 1986;2(34):121134. Smiley A. Marijuana: On-Road and Driving Simulator Studies. In: Kalant H, Corrigal W, Hall W, Smart R, editors. The Health

Williams California study of 440 male traffic accident deaths found that while alcohol use was related to crash culpability, cannabis use was not.
Williams AF, Peat MA, Crouch DJ, Wells JK, Finkle BS. Drugs in fatally injured young male drivers. Public Health Rep. 1985

A subsequent study showed that regular cannabis smokers demonstrate less of a decrement in peripheral signal detection under the influence of alcohol.
Marks DF, MacAvoy MG. Divided attention performance in cannabis users and non-users following alcohol and cannabis separately and in combination. Psychopharmacology (Berl) 1989;99(3):397401.

Laumons study of 10,748 motor vehicle fatalities found that although rates of alcohol and cannabis intoxication were similar (nearly 3%), ten times as many crashes were associated with alcohol as with cannabis.
Laumon B, Gadegbeku B, Martin JL, Biecheler MB. Cannabis intoxication and fatal road crashes in France: population based case-control study. Bmj. 2005 Dec 10;331(7529):1371.

Some reviewers have concluded that there is no evidence that cannabis alone increases the risk of culpability for crashes, and may actually reduce risk.
Bates MN, Blakely TA. Role of cannabis in motor vehicle crashes. Epidemiol Rev. 1999;21(2):222232. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722956/

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THE EFFECT OF CANNABIS COMPARED WITH ALCOHOL ON DRIVING

R. Andrew Sewell, MD, James Poling, PhD, and Mehmet Sofuoglu, MD, PhD Am J Addict. 2009; 18(3): 185193. doi: 10.1080/10550490902786934

Cannabis and alcohol acutely impair several driving-related skills in a dose-related fashion, but the effects of cannabis vary more between individuals than they do with alcohol because of tolerance. Surprisingly, given the alarming results of cognitive studies, most marijuana-intoxicated drivers show only modest impairments on actual road tests. Experienced smokers who drive on a set course show almost no functional impairment under the influence of marijuana, except when it is combined with alcohol. Some reviewers have concluded that there is no evidence that cannabis alone increases the risk of culpability for crashes, and may actually reduce risk. Several other studies have found no increase in crash risk with cannabis. Williams California study of 440 male traffic accident deaths found that while alcohol use was related to crash culpability, cannabis use was not. Lowenstein and Koziol-McLains study of 414 injured drivers admitted to a Colorado E/R found an OR of indicating that marijuana use was not associated with increased crash responsibility. Laumons study of 10,748 French motor vehicle fatalities found that although rates of alcohol and cannabis intoxication were similar (nearly 3%), ten times as many crashes were associated with alcohol as with cannabis. Longos large, well-known study of hospitalized injured drivers in South Australia showed few adverse effects of cannabis on crash risk.

Although the results of culpability studies have therefore been somewhat contradictory, all find that the combination of alcohol and cannabis has worse consequences than use of cannabis alone. Although cognitive studies suggest that cannabis use may lead to unsafe driving, experimental studies have suggested that it can have the opposite effect. Epidemiological studies have themselves been inconsistent, and thus have not resolved the question. One possibility is that people who smoke marijuana share qualitiesbeing young, male, and risk-takingthat would increase their risk of road traffic accidents even in the absence of marijuana use. It has been suggested that there is a single factor that underlies adolescent problem behaviors such as illicit drug use, precocious sexual intercourse, and problem drinking.

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Literature Review on the Relation between Drug Use, Impaired Driving and Traffic Accidents
Research Team: Colin Gemmell - Trinity College. Dublin Rosalyn Moran Drugs Misuse Research Division - Health Research Board. James Crowley Professor - Transport Policy Research Institute, University College Dublin. Richeal Courtney Medical Expert.
European Monitoring Centre for Drugs and Drug Addiction. Literature Review on the Relation between Drug Use, Impaired Driving and Traffic Accidents. (CT.97.EP.14) Lisbon: EMCDDA, February 1999.

Epidemiological studies It often remains unclear whether accidents occur as a direct result of medicinal drug consumption per se or as a result of the underlying reasons why the drugs were being taken. Drug traces found in crash victims are often mixed with alcohol and/or other drugs, hence making it difficult to isolate the effects of a single drug. The fact that drug traces may be discovered in the body does not necessarily imply that they were producing impairing effects in the user. Field studies have shown that, where involvement in traffic accidents is concerned, no drug or drug group has ever been found with a frequency that compares to that of alcohol. Where experimental studies are concerned, although there is some conflicting evidence, cannabis does not seem to significantly impair very basic perceptual mechanisms. One possible method of drug testing is to give police forces expert training in roadside\ behavioral evaluation of suspects. Such a scheme has been established in the United States and is relatively inexpensive to set up. Drug wipe devices using sweat or saliva samples (Securetec, Ottobrun, Germany) have been developed which can test for cannabis, amphetamines, MDMA, methadone, benzodiazepines, cocaine, barbiturates and opiates. Several other tests are now available including Triage, Ezscreen, Accupinch, Mach IV, Verdict, Biosign and I.D. Block. Newer methods using sweat or saliva samples are potentially preferable because they are virtually non-invasive, fast, and easy to execute by non-scientists (e.g. police officers). Saliva-testing or "lollipop" technologies (Cozart Bioscience LTD, Oxfordshire) can detect cannabis, amphetamines, MDMA, cocaine, benzodiazepines and opiates. THC had no effect on gear changing (unlike alcohol). Drug-wipe devices have been developed which take a sweat specimen from the forehead, or armpit, and can be used with saliva also (drug traces are revealed by color changes on the strip). The chemical test box uses antibodies to detect substances, and results are presented within
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approximately five minutes. If positive, drivers can be taken to a police station to give a blood or urine sample for confirmatory purposes. At present, a different device is required for different drugs, but the wipe can test for cannabis, amphetamines, MDMA, methadone, benzodiazepines, cocaine, barbiturates and opiates. There are also saliva-testing or "lollipop" technologies which give digital readouts from color changes and these also can detect cannabis, amphetamines, MDMA, cocaine benzodiazepines and opiates. A possible alternative to blood sampling for a case control study would be saliva sampling. Sensitive methods for analyzing cannabinoids in saliva now exist (12), and sampling of saliva would be more likely to be acceptable to randomly selected control drivers than would blood sampling. Despite this, saliva sampling has its problems. 1) Control drivers would have to give consent to provide a saliva sample, and this would be likely to reduce participation rate. 2) It appears that THC is sequestered into the salivary glands during eating or smoking cannabis, and there is no significant exchange of THC between saliva and blood. Thus, there is not necessarily any relation between THC levels in saliva and the degree of cannabis intoxication. 3) Little is known about the relation of salivary THC levels and frequency or timing of cannabis use in relation to saliva sampling. It may be that THC accumulates in saliva after regular use.

http://www.craigmedical.com/salivascreen5_drug_tests.htm http://www.youtube.com/watch?v=D822MSTrag4 http://www.expomed.com/product/saliva-drug-testing/oralert-saliva-drug-test.html

OraLert Multi-Drug Saliva Test

NewMed Diagnostics u201cIntelligent Test

QED A150 Saliva Screen

There are a variety of low cost saliva screens that can be utilized.

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Saliva tests are simple to use and easy to administer.

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STUDYOFTRAFFICSAFTEYANDCANNIBISUSE 1) Unadjusted odds ratios for non-fatally injured drivers*

No. of drivers Substance(s) Culpable Not Culpable Odds ralro T'

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95% Confidence interval

Drug free Alcohol only f Cannabis only Total

94 45 9 148

179 16 8 203

1.0 5.4 2.1 2.8, 10.5 0.7, 6.6

* Based on data reported by Terhune and Fell (16). t Relative to drug free. * Blood alcoholc oncentration> 100 mq/100 ml.

2) Unadjusted odds ratios for fatally injured drivers*

No. of drivers Substance(s) Culpable Not Culpable Odds ralro T' 95% Confidence interval

Drug free Alcohol only f Cannabis only Alcohol & Cannabis Total

55 120 10 123 308

23 10 9 6 48

1.0 10 0.5 8.6 2.1, 12.2 0.2, 1.5 3.1, 26.9

* Based on data reported by Williams et al. (17). t Relative to drug free. (unless otherwise indicated). f Alcohol and cannabis together relative to alcohol only. Results in table 2 confirm the well-established association between alcohol and crash culpability, and suggest that cannabis alone is associated with a decreased risk.

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Unadjusted odds ratios for fatally injured drivers*

No. of drivers Substance(s) Culpable Contributory

Analysis I Not culpable 140 17 Odds ratio 1.0 6.0 3.5, 10 95% confidence interval

Analysis I Odds ratio 1.0 5.5 3.2, 9.6 95% confidence interval

Drug free Alcohol only Cannabis only Alcohol and cannabis Total

339 245

53 16

21 54 659

8 5 82

14 4 175

0.6 536

0.3, 1.2 2.0, 1.6

0.7 5.3

0.4, 1.5 1.9, 20.3

Using data from Drummer (2 0). Culpable versus not culpable (results from report) Culpable plus contributory versus not Culpable (calculated from data in report) Relative to drug free (unless otherwise indicated) Alcohol and cannabis together versus alcohol alone (calculated from data in report) Michael Bates and Tony Blakely Role of Cannabis in Motor Vehicle Crashes Epidemiologic Reviews Vol. 21, No. 2 Copyright @ 1999 byThe Johns Hopkins University School of Hygiene and Public Health

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Unadjusted odds ratios for hospitalized injured drivers*

Substance(s) Drug free Alcohol only Cannabis only THC (any) <1 .0 ng / ml 1.1-2.0 ng / ml >2.1 ng / ml cooH-THC 1-10 ng / ml 1'l-20 ng / ml 21-30 ng / ml >31 ng / ml Alcohol and cannabis Total

Culpable 944 173 83 21 5 12 6 62 24 15 12 7 66 1,266

No. of drivers Not Culpable 821 22 81 23 2 7 12 58 19 18 12 13 5 929

Odds ratio 1.00 6.84 0.89 0.79 0.35 0.51 1.74 0.93 0.69 1.04 0.87 1.62 11.48

95% confidence interval

4.27, 11.06 0.64,1.24 0.421, 1.50 0.03, 2.13 0.17, 1.41 0.60, 5.67 0.63, 1.37 0.36, 1.32 0.50, 2.19 0.36, 2.08 0.60, 4.80 4.64, 36.66

Based on data reported by Hunter et al. (22). Relative to drug free (unless otherwise indicated). Includes both ^-9-tetrahydrocannabinol (THC) and/or 11-nor--9-carboxytetrahydrocannabinol (COOH-THC). Alcohol and cannabis together relative to alcohol only.

A possible interpretation for these results, consistent with the experimental evidence, is that cannabis intoxicated drivers modify their driving behavior to compensate for their perceived impairment. This means that they seldom take risks and tend not to drive at speeds likely to result in fatalities or serious injuries, - leading to minor injuries and vehicle damage, rather than deaths and serious injuries

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Different Procedures / Techniques for Drug Detection

These techniques vary from specimen analysis, such as immunoassays and chromatography, to performance testing, such as sobriety tests. The main focus of this chapter is the validation of performance tests, specifically the Standardized Field Sobriety Tests (SFSTs), to detect drug intoxication in drivers. There are several ways in which drug consumption/intoxication can be detected. These methods include the analysis of drug levels in body tissues; blood; urine; sweat; and hair samples, as well as the administration of performance tests. The most common means of testing for the presence of drugs in the body is blood and urine sample analysis. Immunoassay is most commonly used for testing for drugs in urine samples. Immunoassays use an antigen-antibody procedure to detect illegal substances. Antibodies are developed that bind selectively to certain drugs or drug metabolites. The sample to be tested is mixed with antibodies and the presence and extent of antigen/antibody reaction is used to estimate the amount of drug present. Performance testing involves the assessment of performance on a given task to test for the presence of drugs. The most popular performance tests known to the drugs and driving research community are sobriety tests. The tests assess abilities such as balance, divided attention and some physiological process such as involuntary eye jerks. The most popular sobriety test battery is the Standardized Field Sobriety Test (SFSTs), and was developed by the Southern California Research Institute (contracted by National Highway Traffic Safety Administration, NHTSA, US Department of Transport) to facilitate the accurate recognition of alcohol intoxicated drivers in the United States of America. NHTSA adopted the SFSTs, developed training curricula and sponsored training. The tests were initially most commonly used by the Los Angeles Police Department (LAPD), but today are used in all 50 states of the U.S.A. Even though the use of this test has had some recorded success in the detection of alcohol intoxicated drivers, the reliability of these tests to successfully detect drug impaired drivers is constantly under review. The study was conducted by Stuster and Burns (1998) and was a field study that involved the interception of drivers suspected of being impaired by alcohol. Overall, the roadside decisions to arrest on the basis of performance on SFSTs where highly accurate. More than 91% of arrests based on .08% BAC estimates were correct, and 94% of estimates that BAC was between .04% BAC and .08% BAC were correct. The researchers concluded that the SFSTs were a valid test battery for the detection of drivers with BAC levels as low as .08%. The LAPD developed the DRE program to detect drug impairment in drivers, after the development of the SFSTs, because of the steady incline of drug abuse and drug impaired drivers contributing to traffic accidents and deaths. LAPD officers consulted with doctors, psychologists and drug abusers about the effects of drugs. The result was the 12-step procedure that enables police officers to determine drug influence and the type of drug causing observable impairment. The Johns Hopkins Study was a controlled clinical study conducted to test the validity and reliability of the procedure (DRE/DECP) used by Drug Recognition Experts (DREs). The study involved the analysis of data gathered from 80 participants who were administered amphetamine,
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marijuana, diazepam, secobarbital or placebo. The researchers claimed that the DREs were over 90% accurate in determining intoxication. The results revealed that in 75.6% of cases a drug was predicted and found (hit), in 8.4% of cases a drug was predicted but not found (false positive), in 7.6% of cases a drug was not predicted but found (miss) and finally, in 5.2% of cases a drug was not predicted and not found (correct rejection). Specifically, misses occurred most often in cases where marijuana was detected in the specimen. Ideally a study such as this, requires an equal number of non-impaired drivers correctly classified as not impaired (correct rejection) in order to establish that the DECP is successful in predicting drug intoxication. Adler and Burns (1994) acknowledge this limitation when they concluded that the DRE program requires scientifically sound support from the laboratory. In 1996 Heishman et al (1996) tested eighteen participants who had been administered ethanol, cocaine, and marijuana, where in each session there was one active dose as well as a placebo. The study was double blind and randomized. It was found that the DECP was extremely sensitive (probability of dosed subject identified as dosed) and specific (non-dosed subject identified as non-dosed) in predicting drug intake. Specifically, in the marijuana condition, the DECP, when utilizing 28 variables, was efficient in accurately identifying whether a subject was dosed or not in 98.8% of cases. Results from the driving task indicated that between 20 and 50 minutes after the consumption of cannabis, driving ability was not significantly impaired by increasing levels of THC. At this point the level of THC in blood varied between 6 and 13 ng/ml. Between 75 and 100 minutes however, driving ability was significantly impaired by increasing levels of THC. At this point the level of THC in blood had dropped to between 3 and 5 ng/ml. It may be assumed that with higher levels of THC in blood, there would be an increased probability that driving ability will be impaired, but this was not observed in the present study. Regular users appear to have a higher tolerance level to the psychological and physiological effects of THC and this is reflected in their performance on the sobriety tests. The perception that the high THC dose induced minimal psychological and physical changes may be due to an increased tolerance to the drug by regular users. This hypothesis is consistent with the comments made by Ramaekers et al. (2000), who reported that regular users may have a higher tolerance to the effects of THC, in which the impairing effects of THC are more effectively compensated for by regular cannabis users than by non-regular cannabis users. A difference in performance between regular and nonregular users was observed for driving ability and sobriety test performance. Generally most non-regular users reported that the low THC cigarette produced a similar level of intoxication as the cannabis usually smoked, whereas regular cannabis users reported that the high THC cigarette produced a similar intoxication as the cannabis usually smoked. Again, it was expected that differences in performance would be observed for regular and non-regular users and this was reported for driving ability and sobriety test performance.

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Large statistically significant differences were observed in the impairment of driving performance caused by THC for regular cannabis users compared to non-regular cannabis users. These differences revealed that the driving ability of non-regular users was impaired by cannabis relative to that of regular users. Non-regular users had slower RTs to emergency situations in which this impairment was observed at 30 minutes after the smoking of cannabis. This result is consistent with those of Rafaelson, et al. (1973) who reported an increased latency when stopping and starting. Caswell (1979), Smiley et al. (1981) and Barnett et al. (1985) also found that high doses of THC slowed RT to subsidiary tasks. Robbe (1995) indicated that even though reported effects of THC do not seem to be severe, in emergency situations this impairment may be detrimental. In contrast, Stein et al. (1983) who used a task that ran for the same duration as the present study, observed no impairment on the subsidiary task. The results of the present study also indicated that differences in performance between regular cannabis users and non-regular cannabis users exist. Non-regular users performed worse on most sobriety tests in the low and high THC conditions, compared to regular users. This was revealed by the large number of significant relationships between signs and level of THC for non-regular users. In conclusion, the SFSTs as a test battery is a moderately good predictor of driving impairment and the recent consumption of cannabis. In the absence of reliable and accurate physical tests of THC blood levels and driving ability, the SFSTs can provide relevant information concerning drug intoxication and driver fitness. In addition driver characteristics such as frequency of cannabis use may hinder the ability to successfully detect cannabis intoxication or recent cannabis use with the SFSTs. However if the individual is also impaired on driving, the SFSTs will demonstrate this, irrespective of THC blood levels.

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An Evaluation of the Efficiency of Sobriety Testing to Detect Blood Levels of Cannabis and Impaired Driving Ability
Katherine Papafotiou BAppSc. (Hons). October 2001 Which drug do you think is the most serious concern for the general community?. In 1985, most people agreed that heroin was the most serious (65.3%), and then alcohol (46.9%) followed by marijuana (33.7%). The relationship in frequency of responses between these drugs remained the same through 1988 to 1991, but in 1993 and 1995, the percentages changed significantly, where alcohol became the drug thought of as most serious (1993; 33.4%, 1995; 30.5%), followed by heroin (1993; 8.7%, 1995; 9.9%) and then marijuana (1993; 3.8%, 1995; 3.9%). Finally in 1998, the most obvious change was the increase in the number of individuals that felt heroin was again becoming a serious concern; alcohol 27%, heroin 20.1% and marijuana 4.1% (National Campaign Against Drug Abuse survey; 1985, 1988, 1991, 1993; National Drug Household Survey; 1995, 1998). Over the years the number of deaths on the roads has decreased by almost half from 776 in 1989 to 391 in 1998 and to 407 in 2000 (TAC, 2000). The patterns of alcohol related deaths from 1990 to 1998 have been previously reported by Drummer and Gerostamoulos (Drummer, 1994; Drummer, 1998; Drummer & Gerostamoulos, 1999). From 1990 to 1993, the percentage of drivers killed on the roads with alcohol in their blood was 32%. This figure dropped to 26.6% from 1995 to 1996, and, to 25.8% from 1997 to 1998. Ellingstad et al. (1973) reported similar effects of cannabis, where intoxicated drivers allowed more time for passing a vehicle when compared to drivers in the placebo condition. The findings of both these studies can be interpreted as either marijuana consumption resulting in more conservative driving. It appears that marijuana, although reported by these studies as reducing risk-taking behavior. (Conservative driving) A review by Moskowitz (1985) summarized that research conducted in the 1960s and early 1970s showed no effects of low doses of cannabis on car control (maintaining steady and consistent position of the vehicle when driving straight and turning). a reduction in risk-taking behavior in tasks requiring a decision to overtake a vehicle in the presence of an oncoming car. Results indicated that THC-COOH decreased speed and improved the maintenance of lateral position of the vehicle. For THC the same results were observed for lateral position of the vehicle but speed and performance on secondary tasks was unaffected. The investigators conclude that marijuana has no impairing effects on driving ability it is difficult to conclude that the changes or patterns observed are a result of the drug consumed. In addition, it would be inappropriate to compare these findings to the studies reviewed in this section as most previous research included placebo sessions and retested the same participants. There have been several on-road driving studies examining the effects of cannabis on driving performance. The research in this area is important because results from these studies
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provide the most accurate assessment of driving (in a research environment), in which the environment is real (not computer graphics) and a drivers peripheral vision is not limited (computer projection/monitor). Relative to real life driving, on-road driving studies allow the investigation of driving and drug consumption without placing participants (drivers) and pedestrians in as much danger, since researchers to some extent can manipulate potentially dangerous situations. One of the earliest studies examining real driving was conducted by Klonoff (1974). Klonoff (1974) examined the effects of three doses of THC (placebo, 4.0 mg THC & 8.4 mg THC) on driving using both a closed course test and a city streets test. The closed course driving test consisted of a driving course that was marked out using cones and tunnels. Errors were calculated by the number of cones hit. This performance was then compared to performance on three initial drives where no drug was administered. The report revealed that low doses of THC impaired performance on two tests (tunnel and corner) and that the high dose impaired performance on five tests (slalom, two tunnel, funnel and risk judgment). High doses of THC impaired judgment and concentration in the city streets test, compared to placebo, but this was not the case for the low THC dose. However, a small percentage of subjects performed better in both the low and high dose condition, compared to the placebo condition. This indicates that there are qualitatively different effects of THC across different individuals. The city streets test involved driving a specific route in city traffic, and performance was rated by a qualified driver-license examiner. Results i n each m a r i j u a n a c o n d i t i o n w e r e a n a l y z e d b y comparing performance to the placebo condition. Any difference in score was considered a representation of impairment. Results indicated that marijuana impaired judgment and concentration in the high THC condition, but not in the low THC condition, however, the means in which these results were obtained have been regarded by other experimenters as problematic, because the definition of each variable measured differs between raters. In addition, the requirement that examiners must assess many measures at once may result in the loss of some driving related errors. Cannabis alone (6.25 mg THC) resulted in drivers driving significantly slower on straight sections of the driving course as well as when performing hairpin turns. Unlike the results reported in previous research, marijuana consumption was not associated with any changes in the lateral position of the vehicle. The author concluded that subjects under the influence of cannabis compensated for the effect of the drug on performance and therefore drives slower. A reported increase in RT to the subsidiary task under the THC condition was interpreted as the direct impairing effects of the drug on attention. These results are consistent with those reported in earlier studies. The report revealed that marijuana had no impairing effects on a single variable. Peck et al. (1986) in a similar conclusion to Caswell (1979), reported that marijuana (1.9% THC) reduced speed of driving and impaired stopping behavior. However unlike the results of previous research, marijuana significantly reduced the number of cones knocked over in a chicane driving task. The impairment was described as more rapid compared to alcohol, but less severe. Interestingly, when the speedometer was covered, marijuana resulted in increased speed of the vehicle. This finding may be indicative of the effect of marijuana on time and distance estimation. In the same year Smiley (1986) examined the effects of placebo, 100 g/kg THC and 200 g/kg THC on driving performance. The results showed that the high THC dose increased headway and headway variability. The author stated that although cannabis appeared to impair driving performance, this decrement, if perceived, might be compensated for by the subject.

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In city traffic no significant differences were observed between performance under the low THC condition and placebo condition. The authors concluded that drivers under the THC conditions tended to over-estimate the effects of the drug and hence compensated by increasing headway distance and by reducing speed, however, it was reported that subjects caution was greatest in the first session involving THC, and progressively less thereafter. The authors nevertheless concluded that a THC dose up to 300 g/kg has a significant but not a dramatically impairing effect on driving behavior. The effects of THC on driving were described as similar to those produced by many common medicinal drugs and less than that produced by a BAC (Blood Alcohol Content) of .08%, suggesting that the impairing effects of marijuana should be considered slight, relative to other drugs including alcohol. Finally, one of most recent reports on marijuana and driving examined visual search frequency and overall driving proficiency after the administration of 100 g/kg THC (Lamers & Ramaekers, 2000). The study showed that marijuana alone did not affect the mean frequency of visual search at an intersection, compared to placebo. In addition, there were no significant differences between mean scores on the driving proficiency test between the THC condition and the placebo condition. The researchers explained the results in terms of the subjects being aware of the impairing properties of THC, and therefore compensating for them by driving more carefully. It was also highlighted that the s a m p l e c o n s i s t e d o f regular cannabis s m o k e r s , a n d p o s s i b l y , t h e i r p r e v i o u s experience with the drug under driving conditions had resulted in a developed tolerance to the effects of THC and a better strategy to compensate for the impairing effects of THC. In conclusion, past research indicates that although the effects of THC on driving behavior are at times minimal.

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Medical Marijuana Laws, Traffic Fatalities, and Alcohol Consumption

D. Mark Anderson Montana State University Daniel I. Rees University of Colorado Denver and IZA

IZA Discussion Paper No. 6112 November 2011

Medical marijuana laws (hereafter MMLs) remove state-level penalties for using, possessing and cultivating medical marijuana. Patients are required to obtain approval or certification from a doctor, and doctors who recommend marijuana to their patients are immune from prosecution. MMLs allow patients to designate caregivers, who can buy or grow marijuana on their behalf. On July 1, 2011 Delaware became the 16th state, along with the District of Columbia, to enact a MML. Six more state legislatures, including those of New York and Illinois, have recently considered medical marijuana bills. If these bills are eventually signed into law, approximately 40 percent of the United States population will live in states that permit the use of medical marijuana. Opponents of medical marijuana tend to focus on the social issues surrounding substance use. They argue that marijuana is addictive, serves as a gateway drug, has little medicinal value, and leads to criminal activity (Adams 2008; Blankstein 2010). Another often raised argument against legalization is that it encourages the recreational use of marijuana, especially by teenagers (Brady et al. 2011; OKeefe and Earleywine 2011). Proponents contend that marijuana is both efficacious and safe, and can be used to treat the side effects of chemotherapy as well as the symptoms of AIDS, multiple sclerosis, epilepsy, glaucoma and other serious illnesses. They cite clinical research showing that marijuana relieves chronic pain, nausea, muscle spasms and appetite loss (Eddy 2010; Marmor 1998; Watson et al. 2000), and note that neither the link between medical marijuana and youth consumption, nor the link between medical marijuana and criminal activity, has been substantiated (Belville 2011; Corry et al. 2009; Hoeffel 2011; Lamoureux 2011). This study begins by examining marijuana use in three states that passed a MML in the mid2000s. Drawing on data collected by the National Survey on Drug Use and Health (NSDUH), we find that the passage of a MML was associated with increased marijuana use by adults in Montana and Rhode Island, but not by adults in Vermont where, as of June 2011, only 349 patients were registered. We find no evidence to support the hypothesis that MMLs are related to the use of marijuana by minors. Next, we turn our attention to MMLs and traffic fatalities, the primary relationship of interest. In the United States, traffic fatalities are the leading cause of death among Americans ages 5 through 34 (Centers for Disease Control and Prevention 2010). To our knowledge, there has been no previous examination of this relationship. Data on traffic fatalities at the state level are obtained from the Fatality Analysis Reporting System (FARS) for the years 1990-2009. Thirteen
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states enacted a MML during this period. FARS includes the time of day the traffic fatality occurred, the day of the week it occurred, and whether alcohol was involved. Using this information, we contribute to the long-standing debate on whether marijuana and alcohol are substitutes or complements. Specifically, we find that traffic fatalities fall by nearly 9 percent after the legalization of medical marijuana. However, the effect of MMLs on traffic fatalities involving alcohol appears to be larger, and is estimated with more precision, than the effect of MMLs on traffic fatalities that did not involve alcohol. Likewise, we find that the estimated effects of MMLs on fatalities at night and on weekends (when alcohol consumption rises) are larger, and are more precise, than the estimated effects of MMLs on fatalities during the day and on weekdays. Finally, the relationship between MMLs and more direct measures of alcohol consumption is examined. Using data from the Behavioral Risk Factor Surveillance System (BRFSS), we find that MMLs are associated with decreases in the number of drinks consumed, especially among 20- through 29-year-olds, providing additional evidence that alcohol is the mechanism by which traffic fatalities are reduced. Using data from the Beer Institute, we find that beer sales fall after a MML comes into effect, suggesting that marijuana substitutes for beer, the most popular alcoholic beverage among young adults.

All studies find that alcohol has worse consequences than use of cannabis alone.

Terhune K, Ippolito C, Hendricks D, et al. The incidence and role of drugs in fatally injured drivers. Washington, DC: National Highway Traffic Safety Administration, U.S. Department of Transportation; 1992. Williams AF, Peat MA, Crouch DJ, Wells JK, Finkle BS. Drugs in fatally injured young male drivers. Public Health Rep. 1985 Jan-Feb;100(1):1925. Drummer O, Gerostamoulos J, Batziris H, Chu M, Caplehorn J, Robertson M. The involvement of drugs in drivers of motor vehicles killed in Australian road traffic crashes. Accid Anal Prev. 2004;36:239248. Hunter CE, Lokan RJ, Longo M, White J, White M. The prevalence and role of alcohol, cannabinoids, benzodiazepines and stimulants in non-fatal crashes. Adelaide, Australia: Forensic Science, Department for Administrative and Information Services; 1998. Mathijssen MP, Movig KL, De Gier JJ, Nagel PH, van Egmond T, Egberts AC. Use of psychoactive medicines and drugs as a cause of road trauma. Paper presented at: 16th International Conference on Alcohol, Drugs and Traffic Safety T2002; 2002; Montreal, Canada. Jones C, Donnelly N, Swift W, Weatherburn D. Driving under the influence of cannabis: The problem and potential countermeasures. Crime and Justice Bulletin. 2005;87:115.

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