IMMORTAL R4.1 Last printed 16/09/2002 10:55

Deliverable R4.1.

Review of impairment and accident risk for alcohol, drugs and medicines

Status:

IMMORTAL Contract No GMA1/2000/27043

Project Co-ordinator: Prof. Bob Hockey, Univ. Leeds, UK

Workpackage Leader: MS Inger Marie Bernhoft, DTF, DK

Authors: Dr. Eveline Braun, Dr. Rainer Christ, KUSS A

Date: 16 September 2002

Project Funded by the European Commission under the Transport RTD Programme of the 5th Framework Programme

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School of Psychology, UNIV LEEDS DOCUMENT CONTROL INFORMATION

Title Review of impairment and accident risk for alcohol, drugs and medicines

Author(s) Dr Eveline Braun, Dr. Rainer Christ

Editor(s)

Date 22.07.2002

Report Number D-R4.1.

Reference and version Public version number

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Availability Public

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Table of contents 1 SUMMARY...... 6 2 INTRODUCTION...... 7 3 EPIDEMIOLOGY OF IMPAIRED DRIVING – THE SIZE OF THE PROBLEM ...... 8 3.1 PREVALENCE OF ALCOHOL, DRUGS AND MEDICINES, COMBINATION OF SUBSTANCES...... 8 3.1.1 Descriptive Epidemiological Studies...... 8 3.1.1.1 Prevalence in Roadside stops ...... 9 3.1.1.2 Prevalence in Accidents – Drivers injured or killed ...... 9 3.1.1.3 Prevalence in Drivers suspected to drive under the influence ...... 11 3.1.1.4 Suspected Drivers: Overview of substances ...... 14 3.1.2 Responsibility Analysis Studies ...... 16 3.1.3 Studies with control groups...... 18 3.2 ACCIDENT RISK OF ALCOHOL, DRUGS AND MEDICINES AND COMBINATION OF SUBSTANCES...... 19 3.2.1 Relative risk of alcohol and illicit drugs ...... 19 3.2.1.1 Alcohol...... 19 3.2.1.2 Cannabis ...... 19 3.2.1.3 Opiates ...... 19 3.2.1.4 Cocaine ...... 20 3.2.1.5 Amphetamines and designer amphetamines...... 20 3.2.2 Relative risk and Medicines: Pharmaco-Epidemiological Data ...... 20 3.2.2.1 Benzodiazepines ...... 20 3.2.2.2 Antidepressants...... 21 3.2.2.3 Analgesics and Opioid Analgesics...... 21 3.2.2.4 Antihistamines ...... 21 3.3 ESTIMATED NUMBER OF UNKNOWN CASES...... 21 3.4 IMPLICATIONS FOR PRACTICAL IMPLEMENTATION ...... 22 4 RISK ASSESSMENT AND RISK CLASSIFICATION ...... 23 4.1 METHODS OF ESTIMATION ...... 23 4.2 CONCLUSIONS AND RECOMMENDATIONS...... 28 5 LEGISLATION IN THE EUROPEAN UNION CONCERNING LEGAL AND ILLEGAL DRUGS ...... 30 5.1 DEFINITION OF IMPAIRMENT – ALCOHOL, DRUGS, MEDICINES ...... 30 5.2 LEGISLATION IN GENERAL...... 31 5.3 POLICE CONTROLS...... 34 5.4 ROADSIDE TESTING...... 34 5.5 WITHDRAWAL OF DRIVING LICENCE AND FINES, RE- GRANTING ...... 34 5.6 PUBLIC INFORMATION AND SAFETY CAMPAIGNS...... 36 5.7 IMPLICATIONS FOR PRACTICAL IMPLEMENTATION ...... 36 6 PHARMACOKINETIC AND DRIVING PERFORMANCE...... 38

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6.1 APPEARANCE AND ACUTE EFFECTS OF DRUG CONSUMPTION ...... 38 6.1.1 Alcohol...... 38 6.1.2 Cannabis ...... 39 6.1.3 Opiates ...... 41 6.1.4 Cocaine ...... 42 6.1.5 Amphetamines...... 43 6.1.6 Hallucinogens ...... 45 6.1.7 Medicines ...... 46 6.1.7.1 Hypnotics, Sedatives, Anxiolytics: Benzodiazepines ...... 47 6.1.7.2 Antidepressants...... 48 6.1.7.3 Neuroleptics...... 49 6.1.7.4 Narcotic/Opioid Analgesics, Methadone ...... 49 6.1.7.5 Antihistamines ...... 50 6.2 COMBINATION OF SUBSTANCES ...... 50 7 IDENTIFICATION AND EVIDENCE OF DRUG CONSUMPTION AND DRIVER IMPAIRMENT: METHODS TO ASSESS IMPAIRMENT...... 52 7.1 ROADSIDE IDENTIFICATION OF DRIVER IMPAIRMENT...... 52 7.1.1 Police suspicion...... 54 7.1.1.1 Implications for practical implementation ...... 56 7.1.2 Psychometric tests - roadside...... 57 7.1.2.1 Device-free procedures ...... 58 7.1.2.2 Device procedures...... 58 7.1.2.3 Mixed Procedures...... 58 7.1.2.4 Remarks concerning the practical implementation ...... 58 7.1.3 The acute effects of various ADMs...... 58 7.1.4 Drug screening methods: For roadside and detailed investigation ...... 60 7.1.4.1 Analysis of body liquids ...... 62 7.1.4.2 Analysis of hair and skin ...... 66 7.1.4.3 Conclusions and recommendations...... 67 7.1.5 Medical screening - Physical and neurological examination...... 68 7.1.5.1 Crucial aspects ...... 68 7.1.5.2 Implications for practical implementation ...... 69 8 RE-GRANTING DRIVING LICENSE, RECIDIVISM ...... 70 8.1 GENERAL LEGISLATION ACROSS EU COUNTRIES ...... 70 8.2 INDIVIDUAL ASPECTS AND LEGISLATION ...... 70 8.2.1 Special Legislation in EU Countries...... 70 8.2.2 Driver performance and personality...... 71 8.2.2.1 Psychological assessment in context of an psychological expert opinion 71 8.2.2.2 Implications for practical implementation ...... 78 8.2.3 Medical reporting ...... 78 8.3 REHABILITATION...... 80 8.3.1 Evaluation studies...... 81 8.3.2 Implications for practical implementation ...... 81 9 RECOMMENDATIONS...... 82 10 INDEX OF ABBREVIATIONS ...... 86

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11 INDEX OF TABLES ...... 87 12 INDEX OF FIGURES...... 89 13 APPENDIX ...... 90 13.1 LEGISLATION...... 90 13.2 PSYCHOMETRIC TESTS...... 105 13.2.1 Non-instrumental procedures ...... 105 13.2.1.1 Romberg-Test...... 105 13.2.1.2 Walk and Turn Test ...... 105 13.2.1.3 One-Leg Stand Test ...... 106 13.2.1.4 Finger – Nose – Test ...... 106 13.2.1.5 Finger – Finger –Test ...... 106 13.2.1.6 Simple concentration tests...... 106 13.2.2 Device procedures...... 106 13.2.2.1 Schuhfried Vienna Test ...... 106 13.2.2.2 OMEDA...... 107 13.2.2.3 AGARD STRES Battery...... 107 13.2.2.4 CDR Test System ...... 107 13.2.2.5 CANTAB ...... 107 13.2.2.6 Electro-nystagmography (ENG)...... 107 13.2.2.7 Videographic procedures...... 108 13.2.2.8 The ART2020 test system ...... 108 13.2.3 Mixed Procedures...... 109 13.2.3.1 SFST –Standardised Field Sobriety Test...... 109 13.2.3.2 Drug Evaluation and Classification Programme...... 109 13.2.3.3 UK Roadside Field Impairment Testing Process ...... 109 13.2.3.4 Computer applications of SFST and DEC ...... 109 14 BIBLIOGRAPHY ...... 110

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1 SUMMARY

First, this report describes various ways which aim to estimate the number of impaired drives. It reports estimated figures and points out the problems in quantification of the size of the impaired driving problem. Risk classification then combines exposure data and impairment effects and results in a ranking – still to be seen as a preliminary attempt. A separate chapter describes different legal approaches to define impairment and outlines the variety of legal implications of impaired driving in European countries concerning alcohol and drugs and medicines. Especially concerning drugs the impairment definition is essential on how suspicion of impaired driving is dealt with – how police controls and roadside testing are conducted and what consequences for driving and driving license the convicted has to expect. To outline the basis for drug recognition and impairment assessment the pharmacokinetic and the acute effects of drugs and medicines are described in detail. If available studies focusing upon effects on driving are reported. Effects resulting from combinations of various substances are described and discussed. Based on this background the current ways of impairment identification are described - police suspicion, psychometric tests, drug screening methods and medical screening. Advantages and shortcomings of these methods are described; needs and ways to achieve improvement are discussed. Ways how European countries proceed in driving license issues once a driver is convicted for driving under the influence of alcohol or a drug are described in a separate chapter. The diversity concerning alcohol is listed. Concerning drugs the procedures established in some European countries are described in detail. This concerns especially the psychological and medical judgement of single cases with respect to recidivism risk and rehabilitation measures.

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2 INTRODUCTION

Each year in Europe more than 42.000 people die in road traffic accidents, 1.3 millions are injured. Here, impairment of the drivers by alcohol, drugs and medicines plays an important role. While the standard of knowledge of research concerning alcohol is extensive regarding the effects of the substance on performance tasks, there is still great need for research regarding the effects of drugs and medicines. The driving task is a complex demand, involving perception, decision, psychomotor skills, knowledge, but also attitudes and personality characteristics. Substance use and abuse has an impact on the brain functioning and mental processes and therefore on the performance of the driving task. In this paper, the current standard of knowledge will be outlined as well as legal and political measures. The essential basis for this literature report are the projects Rosita and Certified as well as the results of the Pompidou-group. Furthermore, current research work of the relevant specialised literature is added to some issues.

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3 EPIDEMIOLOGY OF IMPAIRED DRIVING – THE SIZE OF THE PROBLEM

Epidemiological studies are necessary to get information about the size of the problem: How many drivers are impaired while driving? There are three kinds of studies to provide information, as Maes et al. explain: • “Descriptive epidemiological studies: the prevalence of psychoactive drugs in the driving population is determined on representative samples selected according to various criteria: the whole driving population, injured or killed drivers, drivers suspected of driving under influence. • Responsibility analysis studies: in these studies, the authors try to determine the responsibility of drivers involved in road traffic accidents, to establish if drug use contributes to accidents or not. The responsibility is determined without knowledge of the results of the drug analysis.[...]. • Studies with control groups: the results of the test group are compared with the same drug analysis performed on a control population consisting of matched drivers or non- responsible subjects. Very few epidemiological studies have included a control group. Pharmaco-epidemiological studies are very useful as they compare the number of accidents in drivers for whom medicines are prescribed with the number of accidents in a matched control population. The results of the major reports are summarised in the present work. However, this kind is difficult to perform with illicit drugs, for easily understandable practical and ethical reasons” (Maes et al. 1999, Rosita, p.3).

3.1 PREVALENCE OF ALCOHOL, DRUGS AND MEDICINES, COMBINATION OF SUBSTANCES

3.1.1 Descriptive Epidemiological Studies Krüger et al. (1992-1994; in Rosita) give report of results of an analysis of 69 epidemiological studies about alcohol and drugs in road traffic:

Substance Roadside (% positive) Injured (% positive) Fatalities (% positive) Drugs 1 17 19 Medicines 4 13 10 Alcohol 6 35 52 Table 1: Median exposures from 69 epidemiological studies (Maes et al. 1999, Rosita, p. 9).

As shown in the table, the rate of drivers impaired by substances is considerably higher with the injured and fatalities than the rate in roadside tests. De Gier (1998, in Rosita) found similar data:

General driver population Collision-involved drivers Illicit drugs 1-5% 10-25% Licit drugs 5-15% 6-21% Table 2: Prevalence of drugs in different driver populations (Maes et al. 1999, Rosita, p. 9).

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Cannabis and opiates are most frequently observed in the general driver population. In some countries (e.g. Norway) the number of drivers impaired by the use of amphetamines is increasing. Within the group of licit drugs, benzodiazepines are most frequently found (Maes et al. 1999, Rosita). In the following, the most important European studies are reported, but there are also some interesting studies recently published.

3.1.1.1 Prevalence in Roadside stops In the Würzburg Roadside Survey (alcohol controls at drives without accidents), Krüger et. al. stated the following: 95% of the stopped drivers were en route without measurable alcohol concentration, 3% had an alcohol level up to 0.3‰. Thus, 98% of the drivers acted in compliance with the law. 2% of the drivers showed a higher or very high alcohol level. Few data exist on the prevalence of drug use in the general population. Maes et al. report a Dutch and a German study (Mathijssen 1998, Krüger et al. 1995 both in Rosita). The results are shown in the table below: DRIVERS STOPPED ON THE ROAD Netherlands Germany Period 1997-1998 1992-1993 (WE nights) Number of subjects 293 2234 Biological sample urine, sweat saliva Analytical methods Drugwipe®,Triage®,Accusig FPIA, RIA n® (benzodiaz.) HPLC, GC-MS RESULTS Alcohol 12.30% 5.50% Alcohol only 5.23% Drugs 8.20% 2.59% Drugs only 2.32% Drugs + alcohol 0.27%

Amphetamines 1.37% 0.08% Barbiturates 0.00% 0.53% Benzodiazepines 0.34% 2.60% Cannabinoids 5.12% 0.60% Cocaine 0.68% 0.01% Opiates 1.37% 0.70% Table 3: Drivers stopped on the road (Maes et al. 1999, Rosita, p. 11).

Maes et al. critically point out the different ways of data collection and applied analysis methods resp. the inter-individual preconditions in connection with the consuming behaviour.

3.1.1.2 Prevalence in Accidents – Drivers injured or killed Studies in Norway (Christophersen et al., 1995, as cited in Rosita), Spain (Alvarez et al., 1997, as cited in Rosita) and Belgium (Belgian Road Safety Institute 1996, as cited in Rosita)

Page 9 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 surveyed drivers who were injured or killed in an accident. Maes et al (1999, Rosita) summarise the results as follows: DRIVERS INJURED OR KILLED IN AN ACCIDENT Norway Spain Belgium Period 1993 1992-1995 1995-1996 Number of subjects 394 979 2053 (injured drivers) (killed drivers) (injured or killed drivers) Biological sample Blood Blood Blood, urine Analytical methods GC-MS,HPLC Immunoassay FPIA, HPLC GC-MS, HPLC GC, GC-MS RESULTS

Alcohol 62.9% 51.2% 27.0% Alcohol only 51.8% 44.3%

Drugs 24.1% 14.3% 19.0%

Drugs only 12.9% 5.9% (2 % illicit + 3.9 % medicines) Drugs + alcohol 11.2% 6.9%

Amphetamines 4.1% 0.9% 3.0% Barbiturates 1.3% Benzodiazepines 13.7% 8.5% Cannabinoids 7.6% 1.5% 6.0% Cocaine 5.0% 0.7% Methadone 0.4% Myorelaxants 0.5% Opiates 4.3% 3.1% 7.5% Propoxyphene 0.2% Table 4: Drivers injured or killed in an accident (Maes et al., 1999, Rosita, p. 11).

In the group of collision-involved drivers (injured or dead drivers), cannabis and opiates are found with a nearly equal frequency, amphetamines 2-3 times less. Cocaine has a low prevalence (except in Spain: 5-7%). Benzodiazepines can be found in 2 to 14%, it has the highest prevalence of the licit drugs. (Maes et al. 1999, Rosita). For the years 1995 to 1999, Wenning (2000) analysed the prevalence rates in Luxembourg. 268 collision-involved drivers were examined who were suspected of illicit drug use. In comparison to it, 3507 alcohol cases were registered in road traffic in the same period. Concerning the drivers with drug consumption, it showed that on the average 2.045 substances per case were detected, in detail, 43.7% had benzodiazepines, 42.9% heroin, 37% alcohol (co-consumption), 35.1% cannabis, 20.2% methadone, 17.5% cocaine and 7.8% amphetamines. The drivers mainly were between 26 and 30 years old, 80% were male. Wennig concludes that alcohol in road traffic is still the biggest problem. Concerning the high numbers of methadone cases, it remains unclear whether the collision-involved drivers were in a drug substitution programme or had consumed the substance illegally.

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Alvarez, Del Rio, Sancho, Rams and Gonzalez-Luque (2000) tried to assess the presence of alcohol and illicit drugs among Spanish drivers involved in fatal road accidents between 1991 and 1998. Blood samples were analysed for alcohol, and all samples were also screened for the presence of medicines and illicit drugs with immunological or chromatographic methods when appropriate. Positive samples were confirmed by GC/MS. 3191 drivers were involved in fatal accidents, in 53.6% of the cases psychoactive substances were found: 47.3% alcohol (35.1% above the legal limit of 0.8 g/l BAC at that time in Spain, 41.5% of the drivers had consumed only alcohol), 8.9% illicit drugs and 4.8% medicinal drugs.

The Transport Research Laboratory (UK) had carried out a study between 1985 and 1987 to measure the incidence of drugs in road accident fatalities. The results showed that the incidence of prescription drugs (5.5%) and drugs of abuse (3%) was relatively low in comparison to alcohol (35%). There was a recent suspicion that illicit drug taking has increased considerably since 1987. Thus, a new study was conducted between 1996 and 1999 to look at the current development of incidence of drugs in road fatalities (Tunbridge, Rowe, Keigan and Jackson, 2000). To this end, routine drug analyses of body fluid samples (blood and urine) were made from 259 persons killed in road accidents. The results show high consistence throughout the three years observed. The data also show that the incidence of medicinal drugs likely to affect driving has not changed significantly (6%) since the previous study. Incidence of the other major illicit drug group, amphetamines, still appears to be relatively small. There is, however, evidence that the incidence of cocaine use has increased. Also, a very significant increase in the incidence of cannabis in road fatalities (2.6%-12%) could be detected. The overall results show that illicit drug taking (mainly cannabis) has increased by a factor of five, whereas the incidence of medicinal drugs and alcohol has not. Mathijssen (2000) also gives account of a stabilisation of the rate of alcohol-conspicuous motorists in the Netherlands at 4.5%, but of a clear increase of driving under drug influence, especially with young men (75% cannabis, 12% co-consumption of alcohol). Möller, Hartung and Wilske (1999) detected in the course of their analyses that consumers of drugs and medicines show a significantly higher accident risk than “only alcoholised” persons. Among others, Rentsch, Weirich and Wegener (2000) arrive at the same conclusion. Behrensdorff (1999) also reports an increasing rate of legal and illicit drugs with collision- involved drivers (injured or killed) for Denmark. Lopianecki (2001) gives account of accident numbers in the district of North Baden (Germany). In 2001, with young drivers, 21% of the accidents with bodily injuries were caused by alcohol, but 58% under drug influence. Considering only the group of seriously injured persons, alcohol as accident cause accounts for 28%, drugs for 80%. These are, of course, very selective results, but they nevertheless make clear what can be determined with approriate controlling possibilities (legal, technical, and personal possibilities provided).

3.1.1.3 Prevalence in Drivers suspected to drive under the influence Another way to gain data is the analysis of drivers who are suspected to drive under the influence. There are studies in Norway (Skurtveit et al., 1996 as cited in Rosita), Switzerland (Augsburger and Rivier, 1997, as cited in Rosita), Denmark (Steenhoft et al., 1997, as cited in Rosita), Finland (Lillsunde et al, 1996, as cited in Rosita), Italy (Ferrara, 1999, as cited in Rosita), West Scotland (Seymour and Oliver, accepted for publication, as cited in Rosita) and

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Germany (Möller, 1994; Möller et al., 1999, in Rosita) that dealt with this problem. In Rosita, the results of these studies are assembled (see following table). Looking at the group of drivers suspected of driving under the influence, a higher prevalence of licit and illicit drugs can be found. Detection of this group depends on the perception of the police officers. Cannabis and opiates appear up to 57 and 42%, amphetamines up to 21%. There are remarkable differences between countries, probably because of different national road traffic acts and levels of attention to the problem (Christophersen and Morland, 1997, as cited in Maes et al., 1999, Rosita).

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DRIVERS SUSPECTED OF DRIVING UNDER THE INFLUENCE

Norway Switzerland Denmark Finland Italy West-Scotland Germany Period 1994 1982-1994 1995 1993 1994-1998 1995-1998 1989-90 1995 Number of subjects 2529 641 221 332 1123 752 660 632 (total of 2819 (40 % involved (46 % involved but 10.3 % BAC>>) in accident) in accident) Biological sample blood blood, urine blood blood, urine blood (B), urine (U) blood Analytical methods immunoassay Emit, RIA, Emit, GC immunoassay EIA RIA, FPIA, GC-MS TLC, GC, HPLC GC-MS GC, GC-MS, HPLC GC-ECD, GC-MS RESULTS B (640) U (112) Alcohol 89% 35.9% 95.5% 29.5% >0.8 g/l 25.8% 13.4% 96.2% Alcohol only 30% 7.8% 73.2% 16.3% 6.3% 86.4%

Drugs 59% 85.0% 86.0% 26.8% 14.0% 68.4% 90.2% 13.1% 30.4% (in 2529 cases (in 221 cases with BAC < 1.5 g/l) with BAC < 0.5 g/l)

Drugs only 56.9% 58.9% 83.0% 3.3% Drugs + alcohol 28.1% 24.1% 9.4% 9.5% 7.0% 9.8%

Amphetamines 21.1% 4.2% 10.0% 2.7% 1.3% 2.0% 25.0% 0.45% 6.2% Antidepressants < 5.0 % 0.0% Benzodiazepines 30.6% 14.8% 53.0% 22.9% 78% 71% 5.45% 12.3% Barbiturates 1.06% Cannabinoids 26.1% 57.3% 17.0% 2.4% 10.0% 26.6% 59.8% 8.2% 22.8% Cetobemidone 6.0% Cocaine 0.04% 10.5% 6.0% 1.2% 4.5% 0.93% 1.8% 0.0% 2.2% Methadone 10.3% 13.0% 5.5% 11.6% Opiates 7.6% M 36.3% 27.0% 0.0% 1.1% 15.2% M 58.0 % M 1.8% 4.3% 4.1% C 4.1% D 8.9% D M = morphine; C = codeine; D = dihydrocodeine Table 5: Drivers suspected of driving under the influence (Maes et al., 1999, Rosita, p. 12).

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Plaut and Staub (2000) report results of the analysis of 311 urine samples of drivers suspected to drive under the influence of drugs (1995-1998). In the Canton of Geneva (Switzerland), about 1000 to 1200 alcohol analyses vs. 50 to 80 drug analyses were made per year. The results show frequent co-consumption. 16% of the suspected drivers had not taken any psychoactive drug. 60% had consumed alcohol, 54% cannabis, 31% benzodiazepines, 27% opiates, 22% methadone, 20% cocaine, 8% amphetamines and 5% barbiturates. Seymour and Oliver (2000) analysed 312 biological samples of drug suspected drivers in the West of Scotland for the year 1999. The current results include blood (156) and urine (27) samples. In the 156 blood samples, drugs were found in 126 cases (81%), in 4 cases in combination with alcohol, and in 10 cases alcohol alone. The remaining 20 cases were found negative. The 27 urine samples showed 24 (89%) positive for drugs and 3 positive for alcohol alone. Multidrug use was found in 87 (69%) drug positive blood samples. Benzodiazepines (Diazepam with 82% and Temazepam with 58%) were the most frequent medicinal drugs. In case of illicit drugs, morphine was detected most frequently, followed by cannabis. Lillsunde (2000) also emphasises the frequent multiple drug use. The investigated numbers for Finland in 1998 point at an increase of drug influenced drivers (cases of suspicion). 1323 drivers were examined, 84% were drug positive (64% benzodiazepines, 57% illicit drugs, above all amphetamines, cannabis). Lopianecki (2001) gives account of results of the traffic surveillance of the motorway police in Karlsruhe (FRG) concerning blood samples commanded because of the suspicion of driving under drug influence:

Year No. of Cases Positive Hit Rate 1998 35 35 100% 1999 158 144 91% 2000 251 229 91% 1st half-year 207 178 86% 2001 Table 6: Increase of detected drug drivers with suspicion of drug influence while driving a motor vehicle in the period from 1998 to the first half-year of 2001 (numbers from Lopianecki 2001, p. 15)

Already in the first six months of 2001 the detected drugged drivers outnumbered the inebriated drivers. At full controls on sundays, Lopianecki reports a frequent ratio of 4:1 (drugged drivers : inebriated drivers). In the course of special controls subsequent to techno events – at which admittedly not all of the departing drivers could be controlled out of capacity reasons (extent of control: 5 to 10%) – a ratio resulted of 9:41 (inebriated drivers : drugged drivers), resp. 12:223 (inebriated drivers : drugged drivers). Furthermore, it could be determined that with 50% there was no mono-consumption, but that at least two substances had been taken.

3.1.1.4 Suspected Drivers: Overview of substances

3.1.1.4.1 Alcohol In case of alcohol data show a high prevalence. Especially remarkable is the fact that alcohol was frequently found combined with other substances.

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3.1.1.4.2 Cannabis According to the surveys, cannabis is the most frequently detected drug. Differences between European countries are observed, probably due to differences in selection criteria for studies and drug use patterns.

3.1.1.4.3 Opiates Opiates are less frequently observed. The NIFT annual report (1998, in Rosita) shows an increasing number of drivers in Norway having used monoacetylmorphin (± 10 in 1991 to ± 320 1998). It should be noted that drivers addicted to heroin tend to drive more and more rarely because of withdrawal from social life.

3.1.1.4.4 Cocaine Maes et al. (1999, Rosita) report a quite low prevalence of cocaine in Europe for the past. Though the incidence of illegal drugs (and combination of substance abuse) is increasing (see e.g. Mathijssen 2000), it can be expected that the prevalence of cocaine will increase too.

3.1.1.4.5 Hallucinogens There is no study presented in Rosita having explored or detected hallucinogens in drivers.

3.1.1.4.6 Amphetamines and Designer Amphetamines “The prevalence of amphetamines in different driver populations is, in general, lower compared to opiates [...]. A remarkable exception is the study by Skurtveit (1995): in Norway the largest increase in the number of drivers suspected of drugged driving was found for amphetamines (>145% from 1991 to 1994). Recent data show a further increase from 550 cases in 1994 to about 1300 drivers in 1998 (145% again) (Annual Report 1998, NIFT). Norway has the highest prevalence of amphetamines in non-fatal accidents. The detection of methamphetamine in drivers has recently dramatically increased in Finland: a tenfold increase was observed in 1998 compared to the preceding years, the “ice” cases constituting a 20% fraction of the amphetamines-group (unpublished statistics of KTL). The West-Scotland study (Seymour, accepted for publication) also revealed a high percentage of amphetamine (amphetamine + MDMA + MDEA) -positive urines (25%) in its tested population of suspected drugged drivers.” (Maes et al. 1999, Rosita p. 23)

3.1.1.4.7 Benzodiazepines “BZD are the most frequently detected licit drugs in all driver populations (De Gier 1998, EMCDDA/HRB report 1999). The prevalence of these drugs in the general driving population is rather low (Germany 3%). BZD are normally used in the older age category (> 40 y). In studies on drivers suspected of driving under the influence, BZD are found with very high prevalence (e.g. Denmark and West-Scotland: 53-78%). In accident-involved drivers the prevalence is lower (up to 13%)” (Maes et al. 1999, Rosita p. 26). This is reconfirmed in publications from 2000.

3.1.1.4.8 Antidepressants “The prevalence of (tricyclic) antidepressants in the general driving population is unknown due to lack of screening data in the reported surveys. Data are scarce in accident-involved or DUI-suspected drivers: prevalences are generally very low (≤ 1.5%) with an astonishing unexplained high prevalence of 21% in fatally injured drivers in a French study (De Gier 1998)” (Maes et al. 1999, Rosita, p.27)

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3.1.1.4.9 Neuroleptics: Maes et al. (1999, Rosita) report that data on the prevalence of neuroleptics in driving populations are completely lacking.

3.1.1.4.10 Narcotic/Opioid analgesics “In most epidemiological studies the prevalence of opiates is mentioned but identification of the molecules (illicit = heroin, 6MAM, morphine vs. licit = codeine) is seldom described. In the BTTS (1996): besides a 5.5% positives for licit opiates, very low prevalences for methadone (0.4%) and dextropropoxyphene (0.2%) were observed. Studies in Strathclyde (West of Scotland), Switzerland and Denmark revealed an important prevalence of methadone positives (10-13%) in drivers suspected of driving under the influence. Moreover the Strathclyde survey showed an important use of dihydrocodeine in suspected drugged drivers” (Maes et al., 1999, Rosita, p.29).

3.1.1.4.11 Antihistamines “Very few epidemiological studies mention this drug category in driving populations. The samples of the BTTS are being analysed for the presence of antihistamines (spin-off study)” (Maes et al, 1999, Rosita, p. 30). The low prevalence is also confirmed in other studies (e.g. see, Morland 2000).

3.1.1.4.12 Combination of substances In the studies summarised in Rosita the frequent co-consumption of alcohol is revealed. The further mentioned papers make clear that the mixed consumption of different drugs must not be neglected (e.g. Giorgetti et al., 2000, Seymour and Oliver, 2000).

3.1.2 Responsibility Analysis Studies Epidemiological studies show the frequency of specific substances in traffic. There is, however, no way to explore the real impact of drugs and medicines on accidents. Responsibility Analysis Studies can help to give an answer (Krüger, Kohnen, and Schöch, 1995). Maes et al. report in Rosita a study by Drummer (1994, in Rosita) who investigated data of 1045 killed drivers. Responsibility was defined with the help of 8 factors (responsibility index, without knowing the result of the drug analysis). The outcome of this were three groups of drivers: culpable drivers, contributory drivers and not culpable drivers. The culpability ratio was calculated.

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Drug group Prevalence Relative risk Relative risk Relative risk (all cases) (drug alone) (drug + alcohol) Drug free 51 % 1.0 Alcohol 27 % 6.0 Alcohol + drugs 9 % 9.0 Drugs 13 % 1.4 Cannabis 11 % 1.6 0.6 5.6 Stimulants 3.7 % 2.7 1.6 8.7 Opiates 2.7 % 5.0 2.3 2.9 Benzodiazepines 3.1 % 5.8 1.9 9.5 Misc. Drugs 5.6 % 4.0 8.7 Bold = statistically significant Table 7: Responsibility analysis results in fatal accidents (Maes et al., 1999, Rosita, p. 13).

Drivers positive for substances had a higher culpability ratio. Drivers with high drug concentrations were either culpable or contributory to an accident. Persons who drove while having used more than one substance were invariably found to be culpable of the accident. Terhune et al (1992, in Rosita) examined data of 1882 fatally injured drivers in the US. The authors found that the culpability ratio increased significantly for drivers with alcohol alone and with all alcohol-drug-combinations. “[Terhune et al. ] also found out that the responsibility rate for drivers with THC in their blood decreased compared to the drug-free control group. In contrast, the responsibility rate for amphetamine positive drivers was higher than the drug- free group. Crash responsibility rates increased significantly as the number of non-alcohol drugs in a driver increased. The responsibility analysis suggested little relation between drug use and crash risk, but the sample sizes were small. There appeared to be some potential for increased crash risk when certain drugs were combined with alcohol” (Maes et al., 1999, p. 13).

Drug groups Prevalence

Drug-free 42.1 % Alcohol-only 40.1 % Alcohol + drugs 11.4 % Drugs-only 6.4 % Cannabis 6.7 % Cocaine 5.3 % Benzodiazepines 2.9 % Amphetamines 1.2 % Table 8: Prevalence of drugs in fatally injured drivers (Terhune et al., 1992 in Maes et al., 1999, Rosita, p. 13).

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Drug groups % responsible % responsible (substance only) (drug + alcohol) Drug-free 67.7 ( = ref. group) Alcohol - < 1g/L 75.8 - ≥ 1 g/L 93.9 Cannabis - THC + THCCOOH 57.9 94.6 - THCCOOH 83.3 93.1 Cocaine 57.1 87.8 Benzodiazepines 66.7 100 Amphetamines 83.3 91.7 Bold = statistically significant Table 9: Responsibility analysis results for fatally injured drivers (Terhune et al., 1992 in Maes et al., 1999, Rosita, p.14)

“In his responsibility analysis study Drummer (1994) observed higher culpability ratios in drivers, positive for BZD, while Terhune et al. (1992) found no difference. However both studies show statistically significant higher culpability when BZD was combined with alcohol. Currie et al. (1995) compared blood sample results for BZD from people responsible (n=163) and non-responsible (n=63) for an accident: in the responsible group 18 people were positive for BZD and 4 had combined BZD and tricyclic antidepressants, while in the non-responsible group one person was positive for BZD” (Maes et al., 1999, Rosita, p. 26). Longo et al. (2000) investigated the relationship of prevalence and concentration of drugs, and culpability, too. They found that drivers tested positive for alcohol (only), benzodiazepines (only), the combination of alcohol and THC, and alcohol and benzodiazepines were significantly more likely to be responsible for the crash than persons of the drug-free group. For THC (only, increasing concentration) the authors report no increasing risk, in contrast to alcohol. In case of alcohol, the highly increasing risk is reconfirmed. This study again makes clear how much the risk increases with substance combination.

3.1.3 Studies with control groups Control-group studies compare results of, e.g., injured drivers or responsible drivers with results of, e.g., non culpable drivers. Honkanen et al (1980, in Rosita) found that accident-involved drivers were positive for psychotropics in 5% of the cases and for alcohol in 15%. The control group showed 2,5% and 1%. Currie et al (1995, in Rosita) compared accident-responsible and non-responsible drivers and found 18:1 (involved vs. control) drivers with bezodiazepines, 6:1 with tricyclic antidepressants, 4:0 with benzodiazepines and tricyclic antidepressants. In the BTTS (1996, in Rosita) no control group was used, but the authors compared the mortality of different groups. The results show a mortality of 3.3% with drivers negative for alcohol, of 4.6% with drivers above the 0.5 g/L alcohol-limit, of 5.6% with drivers positive for drugs and of 8.6% with drivers positive for drugs and alcohol. The risk when more than one substance is used is not merely additive (2.56, additive:1.60).

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In the case of alcohol, studies with control groups impressively showed a logarithmic risk increase with the increasing of the alcohol level (Borkenstein et al., 1964; Krüger et al., 1995).

3.2 ACCIDENT RISK OF ALCOHOL, DRUGS AND MEDICINES AND COMBINATION OF SUBSTANCES The accident risk can be assessed on the one hand by comparing accident-involved drivers with a control group, on the other hand – in the case of medicines – through pharmaco- epidemiological studies.

3.2.1 Relative risk of alcohol and illicit drugs As Maes et al explain, a comparison between accident-involved drivers and a control group is needed to assess the accident risk. For, “Knowledge of the prevalence of drug positive drivers in different populations is not a proof that the use of drugs is a serious safety problem“ (Maes et al., 1999, Rosita, p.9).

3.2.1.1 Alcohol Subject to the alcohol level the relative accident risk increases dramatically: with 0.6‰ the accident risk is doubled, with 0.8‰ quadrupled, with 1‰ the risk is increased eight-fold, etc. (e.g. Borkenstein et al, 1964; Krüger, Kazenwadel, and Vollrath, 1995).

3.2.1.2 Cannabis “In Belgium, the BTTS [1996] demonstrated that drivers with a positive THCCOOH-urine- test (6%) were 1.9 times more likely to be seriously injured (not significant) and 2.5 times more likely to be killed (significant). The responsibility analysis of Drummer [1994] demonstrates that drivers using cannabis showed a trend to a decrease in relative risk when THC and/or THCCOOH were detected in blood and/or urine. The relative risk compared to drug-free drivers was 0.6 but this was not statistically significant. In his report Drummer mentions other studies suggesting that cannabis users may not have a higher risk of an accident. In combination with alcohol however the higher risk is clearly significant, comparable with the risk of the alcohol-only group. Terhune (24, table 9) also found that the responsibility rate for drivers with THC in their blood decreased compared to the drug-free control group” (Maes et al., 1999, Rosita, p.19).

3.2.1.3 Opiates “In the BTTS [1996] the drivers who were positive for the illicit opiates (2%) had an increased risk of being seriously injured (x 3.4) and of a fatal outcome (x 2.3). These results were not significant, probably due to the small sample size. There is a lack of consensus regarding the responsibility of opiates in road accidents. Some studies show a greater incidence of accidents among abusers, while others fail to demonstrate such a link [Zancny 1995]” (Maes et al., 1999 Rosita, p. 20).

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3.2.1.4 Cocaine The BTTS (1996, in Rosita) found that drivers positive for cocaine (0,7%) had a higher risk of being injured or killed in an accident (not statistically significant).

3.2.1.5 Amphetamines and designer amphetamines “In the BTTS [1996] subjects with a positive test for amphetamines (3%) in urine were much more likely to be seriously injured (x 4). In collisions with an obstacle the prevalence of amphetamines was higher than in accidents between road users (5.6 vs. 2.2%, not significant). Drivers positive for stimulants (amphetamines and ephedrine) were more often responsible for the accidents than subjects with negative tests [Drummer 1994, Terhune et al. 1992]” (Maes et al., 1999, Rosita, p.23).

3.2.2 Relative risk and Medicines: Pharmaco-Epidemiological Data As explained above pharmaco-epidemiological studies cannot be performed with illicit drugs. In cases of medicines these studies give very useful information. The following summary is arranged by substances. There is a detailed description in Maes et al. (1999, Rosita).

3.2.2.1 Benzodiazepines “In most pharmaco-epidemiological studies [...] a significantly increased risk for accident involvement was revealed for drivers taking BZD. In a study of elderly drivers (>65 y) Ray et al. (1992) found that the relative risk of injurious crash involvement for BZD users was 1.5. The risk increased with dose and was substantial at high doses: 2.4 for ≥ 20 mg diazepam. Hemmelgarn et al. (1997) examined records of 5579 elderly people involved in crashes (1990-93) and 13256 controls: there was a significant increase in rate of crash involvement within the first week of long half-life BZD use (1.45); the rate ratio for continuous use up to one year was lower but still significant (1.26). There was no increased risk after initiation or continued use of short half-life BZD. Oster et al. (1990) compared 4554 persons who had been prescribed BZD tranquillisers with 13662 controls with prescriptions for other drugs. The probability of an accident-related medical encounter was higher during the months following the prescription of a BZD (1.15. vs control ; 1.28 vs the same person in period when he/she was not exposed to drugs). Leveille et al. (1994) performed a matched control study of older drivers involved in injurious crashes (234 cases/447 controls). Current use of BZD had little association with increased risk. This study is an exception to all other observations. A study by Neutel (1995) of 148000 people having received a BZD and 98000 controls revealed an odds ratio of hospitalisation of 3.9 within for 4 weeks and 6.5 within 2 weeks after the prescription of a BZD hypnotic, of 2.5 within 4 weeks and 5.6 within 2 weeks of the prescription of a BZD anxiolytic. The highest risk group were the younger males. In another study Neutel (1998) compared the risk of injurious traffic accidents in older (>60) and younger adults (225796 persons with a first BZD prescription and 9762 controls). The risk of accidents within the first 4 weeks was increased: 3.1 for all persons, 3.2 for persons under 60, 2.8 for older people. Flurazepam induced the highest risk (5.1), followed by triazolam (3.2), diazepam (3.1) and lorazepam.

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In the within-person case crossover study of Barbone et al. (1998) out of 19386 drivers involved in an accident 1731 used a psychoactive medicine. The odds ratio was increased only for BZD (1.62). Use of an intermediate half-life BZD was not significantly associated with a higher risk. The risk was significantly increased for long half-life anxiolytic BZD. The BZD-associated risk decreased with age. The authors calculated that in the UK 1577 accidents, of which 110 fatal, could be prevented if users of anxiolytic BZD did not drive” (Maes et al., 1999, Rosita, p.26).

3.2.2.2 Antidepressants Maes et al. (1999, Rosita, p. 27) report three studies: “According to the study of Ray et al. (1992) patients under cyclic antidepressants have a significantly increased risk for an injurious crash (2.2). The risk is dose-dependent. The intake of amitriptyline at doses ≥ 125 mg daily increases 6 times the risk for road accidents. Neutel (1995) and Barbone et al. (1998) found no increased risk of accident related to the intake of antidepressants.”

3.2.2.3 Analgesics and Opioid Analgesics Maes et al. (1999, Rosita, p. 30): “The study of Ray et al. (1992) showed no increased risk for injurious crash in elderly persons having been prescribed opioids. On the other hand Leveille et al (1994) observed a significantly higher risk of crash (1.8) with these analgesics in elderly persons.”

3.2.2.4 Antihistamines Antihistamines are not often investigated in pharmaco-epidemiological studies. “Skegg et al. (1979) found a relative risk of accident involvement of 1.8 (not significant) for antihistamine-users. However a significant increase (5.3) was observed in motorcycle accidents. Ray et al. (1992) and Leveille et al. (1994) found no increase in risk of crash involvement associated with the use of antihistamines” (Maes et al., 1999, Rosita, p. 30).

3.3 ESTIMATED NUMBER OF UNKNOWN CASES “Dark field” signifies all those drives under the influence of alcohol or drugs that remain undetected. That an impaired drive is not detected depends on several factors: • low frequency of surveillance by the police. • the driver is stopped in the course of a surveillance, but his impairment is not detected. • The accident is not recorded by the police (e.g. accident on one’s own). • The impairment is not detected at an accident that is recorded by the police. (Kazenwadel and Vollrath, 1995). In their analysis, Kazenwadel and Vollrath come to an estimated number of unknown cases of 1:589 for alcohol drives, that means out of approximately 600 drives with an alcohol level of at least 0.8‰, one drive is detected. Möller, Hartung, and Wilske (1999) estimated on the basis of an extrapolation that in the case of 16% of all traffic-conspicuous drivers drug and/or medicine consumption can be insinuated. Of all drivers that had consumed drugs or medicines, 12% were detected by the police (FRG, blood samples; sample n= 632 and random sample from 1995).

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Rentsch, Weirich, and Wegener (2000) report in the course of a survey of the drug consumption of accident-involved youths in West Mecklenburg 1998/99 of 18.4% of drug and benzodiazepine positive findings that were not detected at the routine alcohol diagnostics. Combined consumption was often found.

3.4 IMPLICATIONS FOR PRACTICAL IMPLEMENTATION Some critical considerations should be noted in context with epidemiological studies. The comparison of studies from different European countries is difficult (see e.g. Rosita), because: • samples are mostly not representative. • uniformity in reporting is lacking. • refusal rates of drivers are not indicated in percent tables (therefore the observed number of drug impaired drivers is probably misleading) • data collection in late night hours does not represent the general driving population, it includes more young people. • older people with medicinal drugs are underrepresented in late night hours. • samples with suspected drivers exclude persons who have combined drugs and a lot of alcohol (drug screenings are often used only at the time, when blood alcohol is below the limit). • the documentation of accidents varies between countries. • drug screening is no current use in many countries. • responsibility studies use highly pre-selected groups of drivers: injured and dead. It is difficult to make effects safe.

The Pompidou-group (2000) demands that intensive research in the field of prevalence is continued considering the ethical principles of the countries, specific legislation and the protection of privacy, to be able to close the gaps in knowledge. Data acquisition in this field should serve exclusively the scientific research. It should be possible to utilise roadside surveys regularly throughout Europe to be able to determine the prevalence of illicit drugs. Blood samples of injured drivers should be examined for illicit drugs, the analysing institutions (hospitals) should report annually. Above all, the prevalence of alcohol in combination with other drugs is of interest.

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4 RISK ASSESSMENT AND RISK CLASSIFICATION

4.1 METHODS OF ESTIMATION In case of risk assessment, the Pompidou–group (2000) reported the following conclusions and recommendations: • It is important to know which doses of drugs in blood or saliva are associated with acceptable and unacceptable driving quality. This is relevant, for example, for persons under therapy (e.g. heroin substitution). • Responsibility analyses or case control studies should be conducted for the most frequently used drugs. These risk studies should include combinations of drugs with alcohol.

Concerning the risk of alcohol in road traffic, Krüger, Kazenwadel, and Vollrath (1995) state that the accident risk - comparing the accident sample with the control sample (calculation of the relative risk) - increases logarithmically linear from an alcohol level of approx. 0.6‰: with an alcohol level of 0.6‰ the accident risk is doubled, with 0.8‰ quadrupled, with 1‰ the risk is increased eight-fold, etc. Krüger et al. give account of studies with responsibility analyses (injured, fatalities). Here, responsibility rates result between 54% and 80% for an alcohol level below 1‰, and between 74% and 98% for an alcohol level above 1‰. The authors remark critically that samples of injured and fatalities have problems of representation and that it is difficult to statistically ensure effects, because the responsibility rates of sober drivers at fatal accidents are already very high. “From the frequencies of driving under the influence of medicines it cannot and should not be deduced that through medicines a massive traffic hazard has already occurred” (Krüger, Kohnen, and Schöch, 1995, foreword). It is uncertain which medicines impair driving safety. Medicines also serve the restitution of the driving ability impaired by disease. Therefore, it is also a matter of therapeutically supervised medication that can reduce the acute risk caused by disease to a normal level. On the other side stands the abuse of medicine, the taking of medicines without medical prescription. Krüger names this a problem of the individual case where therapeutic use does not occur or the warning instructions are not observed. In case of high deficiencies, invasive procedures of verification are justifiable, so Krüger. The results of the pharmacological studies about the relative risk of the particular substances are to be found in chapter 2.2.2. Actually, there is no consensus on categorising or labelling medicinal drugs. Wolschrijn et al. (1991, in Maes et al., 1999, Rosita,) worked on a comprehensive attempt at categorisation. The following table shows their classification of medicinal drugs.

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Category Scale value Description I 1 No impairment I* 1 No impairment presumed II.1 2 Minor impairment II.2 3 Moderate impairment II* 3 No severe impairment presumed III 4 Severe impairment III* U Unknown effects, but suspected to cause impairment Table 10: Description of the Wolschrijn system (Maes et al., 1999, Rosita, p. 31).

Experts achieved consensus concerning an important number of drugs (570 drug doses/formulations) in about every pharmacological group. This ranking is important for prescribing physicians, it is relevant for choice of medicine and dosage. Tunbridge et al. (2000, Certified) deal with the risk assessment of drugs in road traffic. At the beginning, however, they record factors that can essentially affect the interpretation of the impairment: • “Most drugs have often both acute as well as residual effects that may persist for some time after consumption. • It is often difficult to distinguish between licit and illicit use (forms) of the drugs. • It is important when interpreting this report to note that the majority of the experimental evidence for the effects of various medicinal drugs has come from tests on young healthy volunteers. The effects on actual patients suffering from clinically treatable illness may differ from volunteers populations. • Indeed, some drugs consumed for medicinal purposes may improve by virtue of therapeutic action in patient populations. • Moreover, it is difficult to isolate the drug effect of the treated condition in clinical populations. • The interpretation of prevalence rates must be interpreted by reference to the different “window of detection” for each drug. For example, some drugs will persist longer, and therefore, be overrepresented in later testing while faster dissipating drugs have been eliminated from the system. • It is also necessary to distinguish between studies looking for the active ingredient and those looking for metabolites as this too will affect the detection window. This is particularly important for cannabis.” (Tunbridge et al., 2000, Certified, p. 10; for the effects of the particular substances see chapter 5).

Responsibility analysis studies provide more revealing data on accident risk. As Tunbrigde et al. (2000, Certified) report, Drummer et al. recently updated results of relative risk at different alcohol levels. It also shows an increasing – but not significant – risk for cannabis, THC.

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DRUG GROUP TOTAL ODDS RATIO Drug negative cases 1106 1.0 Alcohol only ≥0.01% 522 5.5** Alcohol only ≥0.05% 471 9.1** Alcohol only ≥0.15% 335 21** Drugs plus alcohol 205 11** All psychotropic drugs (no alcohol) 289 1.5** Cannabis only (all types) 110 0.94 Cannabis – THC only 10 1.3 Stimulants – only 29 1.4 Benzodiazepines – only 24 2.3 Opioids – only 33 0.9 Other psychotropic drugs – only 33 3.4* Psychotropic drug combinations – only 60 4.6 ** *p=0.05, **p<0.01 Table 11: Odds ratio responsibility analysis for fatally injured drivers tested positive for selected drug groups (Drummer et al., 1998, as cited in Tunbridge et al., 2000, Certified, p.21).

Tunbridge et al. (2000, Certified) undertake the following risk classification on the basis of available data on prevalence and impairment:

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Substance Risk-estimation Reasons Benzodiazepines high overall risk ↓a severe acute effect on driving performance, ↓most frequently detected licit drugs in all driver populations. Cannabis and High risk ↓ because alcohol alone has already a high risk. Alcohol Cocaine Moderate to high Out of ethical reasons no controlled experimental risk studies. ↑ Low incidence, except Spain, ↓ the effects of cocaine use, however, preclude safe driving Cannabis Moderate overall The authors state that despite extensive studies no risk reliable conclusions can be drawn concerning risk. ↓↑Some studies assume that drivers under the influence of cannabis are more cautious – but this does not necessarily ensue a lower accident risk. Amphetamines Moderate overall ↑ At the beginning improved reaction time and risk vigilance, ↓ but also increased self confidence and therefore increased risk taking. ↓ after high feeling, exhaustion. Narcotic / Opioid Low to moderate ↓ relatively low incidence in driver population. Analgesics and risk ↓ sedation and cognition impairment at the Opiates (e.g. heroin) beginning of treatment, ↑ impairment disappears after few days or weeks (Cancer patients in a long term study with morphine didn’t show increasing accident risk) ↓ Long term use of opiates: early stages of consumption and at higher doses. ↓ Methadone: in early stages of consumption or any methadone programme. Antihistamines Low to moderate ↑ Small incidence, risk ↑↓assumption that the more impairing older style compounds are less likely to be used by drivers. Antidepressants Low overall risk ↑The new generation medicines (having replaced the older generation tricyclics)and ↑ the low incidence of antidepressants in accident- involved or drug suspected drivers Table 12: Risk classification of substances by Tunbrigde et al. (2000, Certified). The arrows indicate the relevance for the risk assessment: ↓ means intensification, ↑ means relief.

Tunbridge et al. summarise: • High risk: alcohol, benzodiazepines, cannabis with alcohol • High-moderate risk: cocaine • Moderate risk: cannabis, amphetamines • Low-moderate risk: opiates, methadone, antihistamines • Low risk: antidepressants

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Tunbrigde et al. further tried to undertake an assessment of accident risk for particular drug groups on the basis of scientific consensus. With that, a ranking of the drug groups is to be made possible, for safety prioritisation. Tunbridge et al ranked the drug groups on a common risk metric. The “risk score” was determined by research evidence of impairment effects, estimation of exposure within the driving population, and evidence of association with accident causation. The following functions can be impaired and have been associated with accident causation (Tunbridge et al. S.31): • “Arousal (e.g. fatigue, mood) • Perception (e.g. visual performance, sensitivity to light) • Attention (e.g. vigilance, divided attention, distraction) • Cognition (e.g. RT, risk taking, decision-making) • Psychomotor performance (e.g. balance, stability, co-ordination)”.

The judgement of the particular drug groups occurred according to the following criteria:

A (hazard) x B (population exposure) x C (likelihood of outcome)1

The authors used a scoring system to estimate the components. The following table shows the results:

Impairment BZD AD Opiates Methad Antihis Cannabis Cocain Amphet . t. e . Perception 4 4 4 Arousal 42 4 4 4 4 Attention 4 4 4 4 Cognition: 4 4 4 4 4 Psychomotor 4 4 4 A. Hazard 2 2.5 3 2 1.5 2.5 3 2 B. Exposure 12 1 1.6 0.5 0.9 10 0.7 2 C. Outcome 2.3 1.2 1 1 1 1 1.4 1.4 Risk Score 55 3 5 1 1 25 3 6 RANKING = 1 6 4 7 8 2 5 3 Table 13: Rank order of drug groups and qualitative assignment of risk categories (Tunbrigde et al. 2000, Certified, p. 31; for details of estimation and critical comment, see Certified)

On the basis of this metric an assessment for road traffic is possible. With the exception of cannabis and anti-depressants, this assessment shows parallels to the assessment of absolute risk. The calculated risk of cannabis could have been increased on the one hand through the frequent co-consumption of alcohol, on the other hand because of the increased presence of cannabis in accident causes due to a longer traceability in body substances. Therefore, to the authors medium priority seems to be more appropriate.

1 Hazard means research evidence of impairment effects, likelihood of outcome means evidence of association with accident causation 2 See Table 10, severe impairment of this dimension is assumed.

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Concerning antidepressants, it has not been considered that the new generation compounds show less impairing effects and that persons drive better under medication than without. The authors therefore suggest low priority. Hence, the following prioritisation results: • High priority: alcohol, benzodiazepines • Medium priority: amphetamines, opiates, cocaine, cannabis • Low priority: methadone, antihistamines, antidepressants

The model described represents a possibility for orientation, for a first approach3, as to which substance group should be observed more severely because of its danger for road traffic. On this basis, problem solving attempts can be discussed at European level. The comparison of accident (fatal) cases and matched random sample of non-accident cases in the driving population could serve as an alternative assessment approach. According to Tunbridge et al. (2000), respective basic data for drugs do not exist. As epidemiological studies have shown, multiple consumption of different substances (not only co-consumption of alcohol) occurs more and more frequently. This fact has to be addressed more strongly in the risk assessments. Within the EU, efforts exist to collect accident data on a large basis. With that, directly comparable data exist for 13 countries within the Union. Currently, other variables are being collected. Causal factors, however, are currently being collected only in the UK. In a further step, Tunbridge et al deal with the assessment of the importance of drugs in comparison to other causal factors (fatigue, distraction, weather) with regard to the following question: Is this risk significant in comparison to other factors (e.g. speed, weather)? In 1996, a pilot study started in the UK at which both contributing and causal factors were collected. Concerning drugs, the problem was that driver impairment was not well identifiable because of lacking detection or screening methods. To the authors the result seemed therefore strongly underrated. If the problem of detection is taken into account, one can assume only a slightly lower risk for drugs as for alcohol – and for this reason drugs are originators of accidents on a significant scale (in comparison to other factors like driving mistakes, fatigue, inexperience, haste, slippery road).

4.2 CONCLUSIONS AND RECOMMENDATIONS Underlying the prioritisation of Tunbridge et al (2000) is a risk ranking based on impairment, exposure and likelihood of outcome. Hence, the following results: • High priority for alcohol, benzodiazepines • Medium priority for amphetamines, opiates, cocaine, cannabis • Low priority for methadone, antihistamines, antidepressants With that, it becomes clear that alcohol and benzodiazepines deserve great attention because of their dangerousness.

3 The authors set value on „first approach“, orientation. A definite assessment is not possible because, for example, different studies underlie the impairment assessment, exposure data stem from different countries with differing screening methods, etc.

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De Gier (2000) summarises important considerations concerning risk assessment of drugs in road traffic: • Determination of doses, and/or blood or saliva concentrations which can be associated with adequate driving ability and impairment caused by licit or illicit drugs. • Organisation and fund of experimental driving studies which support controlled heroin substitution therapy. • To minimise risks for the general driving population, it is necessary to control the driving of substitution patients by law. Risk assessment studies (e.g. responsibility studies) should be conducted for the mainly used substances. Risk studies should also take into account the combination with alcohol.

Because no “dark field”-free frequencies of occurrence of drugs and medicines at accidents exist, risk assessment is only possible through responsibility analyses (Berghaus and Krüger, 1998).

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5 LEGISLATION IN THE EUROPEAN UNION CONCERNING LEGAL AND ILLEGAL DRUGS

5.1 DEFINITION OF IMPAIRMENT – ALCOHOL, DRUGS, MEDICINES Concerning alcohol, defined limits exist in each country, from which on an impairment of the driver is assumed in any case. On the basis of long lasting and extensive research it was possible to establish limits for alcohol from which on it can be assumed in any case that a driver is impaired. Therefore, the proof of impairment on an individual basis does not have to be provided any longer (Huessy, 2000, Pompidou). The vast majority of countries has established a limit of 0.5‰, in Sweden even of 0.2‰. Italy lowers its limit with 1st of July 2002 to 0.5‰. With that, only the United Kingdom, Ireland and Luxembourg adhere to the old limit. Furthermore, two countries (Austria, Spain) have defined separate alcohol limits for specific driver groups to counteract the accident risk. Concerning alcohol, Mercier-Guyon (2000) illustrates that many countries have changed their laws in the last 20 years. In the past the impairment was assessed by a police officer or a physician. The assessment of the impairment and the blood analysis served the conviction of the offenders. Because of the technical development, many countries have now implemented test devices for breath alcohol and the conviction is based upon the detection and measurement of alcohol. DUI statutes concerning drugs and traffic in most of the European countries are complex and there are difficulties concerning enforcement. “There are three main types of DWI/drug statutes: 1. Statutes which derive from the Uniform Traffic code, which require drugs to render a driver “incapable of driving safely”. 2. Statutes requiring that the drug impairs the driver’s ability to operate safely or require a driver to be “under the influence or affected by an intoxicating liquor or drug”; and 3. “zero Tolerance” laws which make it a criminal offense to have a drug or metabolite in one’s body or bodily fluids at the time of driving” (Walsh et al., 2000, Icadts, p.10). And: “With regard to the prosecution of drugged driving most statutes require proof of impairment due to the use of illegal drug. This legislative approach is difficult to enforce because proving that the drug “caused” the impairment is problematical. Germany, Belgium and Sweden and 8 of the U.S. states have established “Per se” Laws that avoid having to prove impairment due to drug. This “per se” Law approach follows the prosecution to be based solely on the analytical detection of drugs in body fluids (primarily blood/urine)” (p. 5). Verstraete (2000, Icadts) records that “per se” laws convey a clear message to the motorists: It is prohibited to drive a motor vehicle if these substances may be found in the blood. In Germany the “per se” law for drugs applies since August 1998, in Sweden since July 1999, here, benzodiazepines are also included in supra-therapeutic doses or without proof of medical prescription. “Zero limit” law – so Moeller (2000, Icadts) – “is a powerful tool for the fight against DUID”, because the classification of the offence has become easier. In more than 95% of the charges

Page 30 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 the suspicion was confirmed by a measurable concentration of one of the banned drugs in blood. Concerning drugs, the situation is also therefore that complex, because numerous different substances with the most differing effects exist. Therefore, many countries adhere to the impairment approach, i.e., sanctions follow if impairment has been proven. Not the proof of the substance per se in the blood, but the impairment is vital. According to Huessy (2000), an approach like this makes public discussion about drugs redundant. In the case of (illicit) drugs and medicines (e.g. benzodiazepines), in most countries reasonable suspicion is needed to proceed drug detection. The impairment evaluation and/or the collection of samples can be led by police officers, specially trained police officers or medical doctors (required by the police) (Mercier-Guyon 2000). Implementing a limit approach for drugs is very difficult because of complex pharmaco- kinetic effects, unknown tolerance development, etc. Scientific justification is needed (Huessy 2000).

5.2 LEGISLATION IN GENERAL The Pompidou Group summarised legal regulations of 17 different European countries concerning drugs in general. There is a common consensus based on the United Nations Conventions concerning narcotic drugs and psychotropic substances on the necessity to use criminal law to fight illicit drugs: • The Single Convention on Narcotic Drugs of 1961, as amended by the 1972 protocol; • The Convention on Psychotropic Substances of 1971; • The United Nations Convention against Illicit Traffic in Narcotic Drugs and Psychotropic Substances of 1988.

Thus, criminal sanctions cover the most common and prevalent substances, as amphetamines (e.g. Ecstasy/ XTC), cannabis, cocaine, hallucinogens (e.g. LSD), heroin and psychoactive medications. Legal circumstances and prerequisites greatly influence the route and frequency of application of roadside test devices. “Legislative conditions not only empower the police forces of a country to use roadside testing equipment, they also determine the intensity of application and thus the general awareness of drugs and driving in the population. A lack of enforceable legal regulations and the absence of appropriate testing equipment have a detrimental effect on road safety” (Möller et al., 1999, Rosita, p. 10). Only Belgium and Germany (and Switzerland) permit the police to use testing devices for the examination of drug influence (8/99). In their extensive report for Rosita, Möller et al. (1999, Rosita, p. 4) state: “All countries of the European Union (EU) have legal provisons on driving under the influence of drugs (DUID). Generally, participation in street traffic is only allowed if one is capable of driving a motor vehicle in a safe and proper way. If driving ability is impaired by substance abuse, one can be sanctioned, but impairment has to be clearly proven in court. This legislative approach is difficult to enforce, because it is difficult to document the impairment objectively. Some states try to circumvent the difficulty of proving impairment by using legislation solely based on the analytical detection of drugs in the blood. Germany introduced such a law in August 1998 and in March 1999 Belgium put similar legislation into force. A few other states have comparable law proposals in their parliaments and will implement similar legislation in

Page 31 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 the near future. However, the biggest part of the European Union is still waiting and carefully following the activities of those states in the forefront. [Following] Table summarises the situation on drugs and driving in the countries included in this survey.” And further: “The enforcement of legislation of this type depends mainly on the ability of the police forces to obtain the appropriate specimens from the population participating in street traffic. At this point, the authority of the police forces to collect human specimens - either for roadside testing or for confirmatory analysis - is of importance. This authority is regulated by further legislation and differs from country to country. In some countries the police forces are allowed to control and test the driving population randomly. Suspicion of an offence is not necessary for testing. The majority of countries however treat any roadside testing procedure as an intrusion into personal rights which can only be done if an initial suspicion exists”(ibid., p. 4) Exceptions are Denmark, Greece, Iceland, Luxembourg for drugs. In the case of alcohol, random testing (without initial suspicion) can be practised in Austria, Belgium, Denmark, Finland, France, Netherlands and Spain. Legislation concerning driving under the influence of medicines can be found in Belgium (benzoylecgoine), Denmark (psychoactive substances), Germany (explicit exception for prescribed medicines).

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Country Does Impairment or Roadside Initial Roadside legislation analytical testing for suspicion drug test covering approach? DUID needed to devices in DUID allowed at apply a routine use? exist? this point of roadside time? drug test? Austria Yes Impairment Yes Yes No Belgium Yes Analytical/Impair Yes Yes Yes ment Czech Yes Impairment Yes Yes No Republic Denmark Yes Impairment No No No Finland Yes Impairment/Analyt Yes Yes No ical France Yes Impairment No - No Germany Yes Analytical/Impair Yes Yes Yes ment Greece Yes Analytical/Impair Yes No No ment Iceland Yes Impairment Yes No No Ireland Yes Impairment Yes Yes No Italy Yes Impairment Yes Yes No Luxembourg Yes Impairment/Analyt Yes No No ical Netherlands Yes Impairment/Analyt No - No ical Norway Yes Impairment Yes Yes No Poland Yes Impairment Yes Yes No Slovenia Yes Impairment Yes Yes No Spain Yes Impairment Yes Yes No Switzerland Yes Impairment Yes Yes No Unit. Yes Impairment No Yes No Kingdom Sweden Didn’t send back Portugal Didn’t send back Table 14: Overview of the legal situation in the field of DUID and the use of roadside drug tests (Möller et al., 1999, Rosita, p. 5; as of 8/1999)

To further clarify the individual legal basic conditions, two tables dealing with country-wise overviews can be found in appendix A (EU countries only, data from Möller et. al., 1999, Rosita).

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5.3 POLICE CONTROLS The tables in the appendix provide information on the possibilities of police controls and the legal frameworks of the individual countries for alcohol, drugs and medicines. Most of the countries allow police controls within the scope of general traffic controls or on specific roadblocks. Möller et al. (1999, Rosita) report that there are training programs for police forces in some European countries to enable officers to identify intoxicated drivers on the basis of physical and psychomotor signs (see chapter Identification and Evidence).

5.4 ROADSIDE TESTING The legal frameworks of the individual countries for roadside tests are to be found in tables in the appendix. There are great differences between the countries. Some countries permit random tests, i.e., even without signs of impairment any driver can be tested. This is not possible in other countries, i.e., no such general controls can be conducted. Measurement of breath alcohol, for example, may be conducted only with an initial suspicion. Concerning drugs, in most countries, however, further measures ensue only upon suspicion. Concerning alcohol, breath alcohol testing devices are already utilised as standard. Concerning drugs, sobriety tests are utilised in some countries, whereas in others test devices are already in use. „Roadside testing devices are used in Germany (sweat and urine) and in Belgium (urine), some other countries have used salvia or sweat devices experimentally with voluntary participation of drivers (Möller et al., 1999, Rosita). Möller et al further report that „interestingly the application of roadside drug test devices is prohibited by regulations in only very few European countries. In most countries drug test devices are not in use because of their low level of validations or their unavailability“ (1999, Rosita, p.5)

5.5 WITHDRAWAL OF DRIVING LICENCE AND FINES, RE- GRANTING As shown in the tables in the appendix, DUIA and DUID have partly very different administrative consequences, depending on the countries. In the case of impairment by alcohol, however, there are greater consistencies than in the case of impairment by drugs. A recurring point of discussion consists in the question of involuntary blood sampling for evidence supply. Some countries think of this procedure as invasive, therefore, no blood sample can be taken against the will of the concerned person. Some countries, however, have penalties for refusing to give a blood sample. Depending on the alcohol limits in force in each country, the following rules obtain (for detailed information see Krüger et al., 2000 Pompidou):

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Country Suspension Consequences of refusal Re-granting: Rehabilitation of driver Administrative/Judge licence decision Medical report Psychological report Austria Yes Refusal of breath test Yes/Yes/case Yes leads to assuming a BAC exceeding 1.6‰, appropriate sanctions are applied Belgium Yes Yes/Yes/ Yes Denmark Yes Refusal of breath test is Yes handled as suspicion Finland Yes Yes/ / Yes France Yes In case of refusal Yes/case/ Yes criminal sanctions are imposed Germany Yes Refusal of breath test Yes/case/case Yes will not be punished, because breath test is assumed to have a higher burden on the offender than passive blood sampling Greece No Ireland No Italy Yes Refusing the breath test Yes/Yes/case - will be punished with the same penalty as if exceeding the legal limit Luxem- Yes Yes/ / - bourg Nether- Yes Refusing is sanctioned Yes/case/ Yes lands as a criminal offence; refusing is sanctioned as having a BAC from 2.11 to 2.50‰, suspension of driver licence for 9 month. Portugal Yes Refusing is a crime of - qualified disobedience Spain Yes Refusing is a criminal Yes/case/case No offence Sweden Yes Yes/Yes/ Yes United Yes Refusing of an ordered Yes/case/ Yes Kingdom blood or urine test is a punishable offence

Table 15: Consequences of driving under the influence of alcohol (data from Krüger et al., 2000, Pompidou, as of 1999).

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The duration of the withdrawal of the driving licence varies depending on the alcohol level. In some countries there are also definitions of High Risk Offenders, for example by the alcohol level or by the number of pertinent offences, with the possibility of withdrawing the licence. Concerning the re-issue of the driving licence, some countries prescribe an anew acquisition of the driving licence, i.e., the driving licence test has to be passed anew. The penalty limits relating to specific BACs for drunk driving respectively for drugs are demonstrated in the tables in the appendix. Summing up, it may be said for alcohol that in most countries the penalty depends on the alcohol level, on whether there was an involvement in an accident or not, to what extent a traffic offence was committed, to what extent a repeated violation has taken place. The duration of the withdrawal of the driving licence shows a very large range, just as the extent of the fines. Involvement in respectively causation of an accident leads to more dramatic consequences, especially with high alcohol levels which in some countries is rated as a criminal offence. Concerning drugs, some countries also differentiate between involvement in/causation of an accident and no involvement/causation. Here, too, the penalty limits vary, but there is no such detailed formulation of the legal situation as in the case of alcohol.

5.6 PUBLIC INFORMATION AND SAFETY CAMPAIGNS For prevention purpose the Pompidou-group (2000) emphasises the need of information campaigns accompanying new legislation. Furthermore, public discussions should be pushed and campaigns evaluated. Regular campaigns should inform the public of the dangers of driving while being impaired, e.g., by medications. More information is needed concerning the intake of medications and there should be a warning pictogram. There is also a need to train pharmacists and medical doctors for information and impairment prevention. There should also be programmes to investigate the problem of drugs and driving, especially for young drivers. An extensive study on this subject was published by Vollrath, Löbmann, Krüger, Schöch, Widera, and Mettke (2001, see chapter 7.2.2.3.)

5.7 IMPLICATIONS FOR PRACTICAL IMPLEMENTATION Möller et al. (1999, Rosita) deduce as result of their extensive inquiry for Rosita: • Validation of existing devices (urine tests, but also saliva and sweat etc. devices). • Investigation of the correlation between impairment and pharmaco-kinetics in easily accessible body fluids. • Training of police forces in detection. • Development of optimal test devices that are able to identify even small amounts of specific substances (especially for drugs) • Traffic safety regulations for usage of test devices, industry will then be interested in investing in the generation of test devices (adequate market) • Harmonisation of national laws

The Pompidou-group (2000, p. 322) specifies conclusions and recommendations for the legislation:

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• “Police should receive sufficient powers to conduct roadside screening. For this purpose, the two principle options favoured by European countries are either to admit roadside screening only in the case of substantial suspicion of driving under substance influence, or to admit such screening on a random basis. As provided for in several countries, a possibility to reach drivers’ cooperation would be that those who refuse to test should face sanctions comparable to those in cases of an actual drug influence. • A zero tolerance limit of any illicit psychoactive agent should be a permitted option under the laws of any European country. The other option is adapting the impairment approach to the special problems of drug driving. • National bodies should consider the possibility of establishing lower per se blood alcohol limits for drivers depending upon the presence of illicit and licit drugs in the same samples. • There is a critical need for studies examining the consequences of changes in legislation”.

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6 PHARMACOKINETIC AND DRIVING PERFORMANCE

6.1 APPEARANCE AND ACUTE EFFECTS OF DRUG CONSUMPTION

6.1.1 Alcohol Resorption and Duration: The resorption of alcohol happens fast, the excretion is slow. After the maximum blood alcohol concentration is obtained, there is an apparent sharp drop, because the alcohol gets evenly spread throughout the body. At the end of this spreading phase the linear breakdown starts (0.1 to 0.2‰ per hour). The effect of the intoxication depends on the extent of the blood alcohol concentration and can possibly persist for hours. The residual alcohol, for example, in the morning after nightly over-consumption of alcohol and insufficient hours of sleep, is often underestimated. Even after complete excretion deficiency symptoms may still occur unless a sufficient recovery phase has taken place, because alcohol is a sedative. (Möller 1998). Acute effects: Alcohol has a centrally sedating effect. The main effect of alcohol is in the field of wellbeing and of socio-emotionality. Krüger, Kazenwadel, and Vollrath (1995) give account of an extensive meta-analysis of the relevant literature and of the following alcohol-induced changes dependent on the extent of the alcohol level: From 0.2‰: improvement of mood in social situations, reduction of anxiety and tension, increase of excitement and excitability. Up to 0.3‰: the positive effects for mood and excitement reach their maximum From 0.5‰: experience that capability is clearly reduced From 0.6‰: reversal of effects with increasing dosage

Observable effects of alcohol are unadapted mood, aggressiveness, increased risk willingness, increased willingness to spontaneous decisions, impairment of self-criticism, elongation of reaction time, impairment of concentration, impaired minute and coarse motor activity, impairment of articulation, impairment of visual perception. If there is no habituation, these changes appear already at minor alcohol levels (Möller, 1998). The “subjective limit of perception” means the mark when alcohol intake is first perceived. The alcohol level may be perceived already at 0.3‰ or less. Between 0.3 and 0.8‰ the subjective feeling of drunkenness does not increase essentially anymore (Krüger, Kazenwadel, and Vollrath, 1995). The impairing effect of alcohol increases exponentially: the higher the BAC, the more harmful is any further alcohol consumption. Krüger et al. state that the effects of alcohol are the stronger: • the higher the BAC, • the more control processes are required and

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• the sooner after the end of drinking the test took place. From 0.6‰ on, extreme performance losses are to be expected..

Experimental studies: Experimental studies and examinations of driving behaviour supplied the following results: Traffic-relevant effects in the acute phase already with low BAC are described by Möller (1998): • decreasing ability of criticism and increased risk willingness (e.g. speeding, aggressive driving style, pressing, dangerous overtaking); • impairment of concentration and attention, prolonged reaction time (e.g. biased orientation, inability to perceive multiple danger factors, belated recognition of dangerous situations).

With low to medium BAC furthermore the following shows: • impairment of the visual perception, of the bright and dark adaptation, of the twilight vision, increased sensitivity to blinding;

With higher BAC the following is central: • changing of the driving style (deficient estimation of distance, deficient assessment of roads and curves, anxious heeding of traffic regulations, very slow driving; failing at high traffic density, driving up to standing vehicles, and so on); • impairment of the minute and coarse motor activity (driving in serpentines, getting off the track, strongly delayed braking reaction, jerky driving, ...).

Numerous international studies have examined the acute performance impairments through alcohol. Three of them may be quoted here as examples: Louwerens et al. (1987) demonstrated the relationship between the amount of alcohol and the amount of weaving in an actual driving environment. A deviation in performance starts from “baseline” at around the legal limit (0,05%BAC). Krüger, Kazenwadel, and Vollrath (1995) give account of changes in the driving performance: from 0.4‰ already a more erratic driving style is to be observed. At routine driving tasks (oncoming traffic, traffic lights, curves,...), from 0.6, but at least from 0.8‰ on clear deterioration results that cannot be compensated even by experienced drivers. Inexperienced drivers are already clearly impaired at an earlier time. In a series of experiments on test performance under the influence of alcohol at the Austrian Road Safety Board (Bartl, Lager, and Domesle 1998) it could be detected that there is a statistically significant impairment of performance already from an average of 0.67‰ on (individual tests presented on the ART 90). The errors at the concentration test tripled, at the reaction test an doubling of errors occurred, twice as much errors also showed at the ability of visual structuring, and the reactive long-term resilience decreased. The risk willingness tested with an personality questionnaire increased significantly. At the intelligence test errors occurred more frequently, with simultaneously shorter working time.

6.1.2 Cannabis Resorption and Duration: After smoking, peak of effects is reached after 7-8 minutes. The changed state of consciousness (effect of intoxication) can last 2-4 hours.

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Appearance: marihuana (dried parts of the cannabis sativa plant) and hashish (resin of female flowering tops) and hashish oil (extract from resin). Mostly smoked. Acute effects: “Euphoria, relaxation, well-being, somnolence, increased social interaction, friendliness, laughing, changes in visual and auditory perception, altered perception of time and space, short-term memory loss, decreased psychomotor abilities, fear and panic, dysphoria, hallucinations, flash backs. Physiological effects: cardiovascular symptoms with tachycardia and blood pressure changes, bloodshot eyes with dilated pupils” (Maes et al, 1999, Rosita p. 17).

Experimental studies: Experimental studies and examination of driving behaviour showed the following results: Cannabis influences perception, psychomotor performance, cognitive functions, affective functions, it impairs co-ordination, tracking, perception, vigilance and alertness (Maes et al., 1999, Rosita). Berghaus et al. (1995, in Rosita) analysed data of 324 experiments, results were gained in laboratory tests, from tests in driving simulator and real driving tests. There is a relation between driving performance and THC concentrations. The performance after having consumed cannabis decreases more quickly than after consumption of alcohol. Even small concentrations can produce substantial adverse effects. Severe influences exist on attention, tracking and psychomotor skills. Robbe (1994, in Rosita) demonstrated in real driving experiments that tracking is impaired (“a THC dose of 100–300 µg tetrahydrocannabinol /kg body weight has an effect comparable to blood alcohol concentrations of 0.3-0.7 g/L”, p.18), drivers tend to overestimate the effect of cannabis and drive slowly, hold larger following distances and practice less overtaking. Reaction time increases when there are unexpected stressful and emergency situations. Impairing effects are more persistent when difficult tasks demand continuous attention. Robbe found that the effects depend on the dosage, and there is no correlation between the effects and the plasma concentration of THC or THCCOOH. The combination of cannabis and alcohol has a special negative effect. Ramaekers (1999) and Ramaekers et al. (2000) conducted a standardised driving test (highway-driving test, car-following test). It could be detected that with increasing doses of inhaled THC (100/200/300 mg/kg) there was - in comparison with a control group that got a placebo (randomised double blind test) - no significant result in the car-following test, but in the case of the highest dose (300mg/kg) a significant difference of 2.8 cm in tracking. With that, it showed that marijuana influenced the driving fitness of pleasure smokers to a small degree, dependent on the dose. In a second study the combination of cannabis and alcohol was investigated. An additive effect was observable. At a higher dose of 200mg a significant increase of the reaction time could be measured. Marijuana did not increase the negative characteristics of alcohol on driving ability, but the combination of a small amount of marijuana with the same small amount of alcohol impaired the driving fitness of the consumers in a way that can be compared to the impairments of the driving fitness by heavy sedating medicines (benzodiazepines, narcotics) demonstrated in studies!

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Krüger and Vollrath (2000) also examined the effects of cannabis (acute and previous consumption) as well as the effects of ecstasy respectively amphetamines (low < 0,05 mg/l and high concentration > 0,05 mg/l) with and without combination with alcohol and other drugs on certain driving behaviour parameters in the simulator (tracking and speed behaviour, peripheral and central attention, and risk behaviour). Disco-goers were examined in comparison to a drug-free control group. While the single substances produced no impairment of the driving behaviour, a considerable impairment of the response at secondary tasks could be found in case of a combination of these drugs respectively the combination with alcohol. Berghaus, Krüger, and Vollrath (1998) analysed studies about alcohol effects and studies about cannabis effects. They report in their meta-analysis of effects of alcohol (120 studies, 923 reports of performance) and effects of cannabis (66 studies, 761 reports) a fifty percent deterioration of performance with a BAC of 0.73‰, the same deterioration of performance could be determined with cannabis at a concentration of 11ng/mL THC. While with alcohol consumption, simulator performance and driving performance as complex performances consisting of automated and controlled actions are the most strongly affected in a negative way, losses at single automated performances showed relatively late. In case of cannabis consumption, many single performances are impaired quite early, while the complex driving task shows losses quite late. This is attributed to a compensation performance. With both of the substances, the impairment of reaction time is not to be found until at higher concentrations (cannabis 15ng/mL THC, alcohol 0.77‰). The authors point out that the danger potential of both substances takes effect in different traffic situations because of their different effects.

6.1.3 Opiates Resorption and Duration: Heroin is very rapidly metabolised. Duration of effects lasts 1-4 hours. Appearance: Opium is dried milk exudation from the unripe capsules of Papaver somniferum. Heroin is synthesised from morphine. Injected intravenously, smoked, or snorted. Acute effects: “The interaction of opiates with the opiate receptors of the CNS results in sedative, analgesic and antitussive effects. Respiratory depression is the cause of death in case of overdose. Heroin quickly induces a “high”, a relaxation, a feeling of wellbeing, euphoria and warmth. After 6-12 hours the very unpleasant sensations of withdrawal appear (cold turkey = sweating, runny nose, yawning, chills, abdominal cramps, muscle pain, nausea, diarrhoea…). The use of opiates leads to development of tolerance with physical and psychological dependence. Physiological effects of opiates are constricted pupils (miosis), constipation and hypotension.” (Maes et al., 1999, Rosita, p.19).

Experimental studies: Experimental studies and examination of driving behaviour showed the following results: “The sedation by opiates induces sleepiness, apathy and indifference to external stimuli, a decrease in concentration, a slowing down and an increase in reaction time. The combination with alcohol enhances the sedation.

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The miosis has a negative influence on the accommodation of the eyes to darkness (e.g. when entering a tunnel, driving at night). [see also Fous and Saurma 1999] Finally the withdrawal symptoms induce loss of concentration and will also impair driving performance” (Maes et al., 1999, Rosita, p.20). Recent controlled experimental studies do not exist because of ethical reasons. Zacny (1995, in Morland, 2000) made a review on relevant papers about the effects of opioids on psychomotor and cognitive performance in humans. After having analysed more than 200 studies he concluded that the impairment of the performance depends on the particular opioid and the dose. Effects on healthy volunteers were: impairment of psychomotor performance to a larger extent than impairment of cognitive performance, behaviour showed a slowing down effect, but did not tend to become more erratic. There is a dose-effect relationship across different studies, most studies have used doses at therapeutic range. “Repeated chronic use of morphine at a fixed dose to, e.g., cancer patients has in several studies been demonstrated to be accompanied by disappearance of the deleterious acute effects on motor performance, indicating the development of tolerance. Similar results have been reported for other opioids including methadone (Berghaus and Friedel, 1994). However, even in chronic opioid users some negative effects have been reported, also in methadone treated patients (Berghaus et al. 1993, Zacny 1995), especially after dose escalations” (Morland, 2000, p. 91). Lakemeyer and Friedel (1997) report a prolongation of reaction and working times with patients who must take opiates, that were measured by psychometric tests and in the driving simulator.

6.1.4 Cocaine Resorption and Duration: Effects appear immediately after injecting or smoking, effects last about a half hour. Appearance: Substance is extracted from leaves of the coca plant. Coca leaves: chewed, cocaine base smoked, hydrochloride snorted or injected. Acute effects: “During the cocaine “kick” the user experiences effects of euphoria, of increased alertness, activity, mental energy and self-confidence, sexual excitation, a loss of inhibitions, suppression of hunger and tiredness, sensory hallucinations. The euphoria is followed by a period of anxiety, paranoia and delusions. Finally a depressive phase with exhaustion, aggressiveness and nervousness incites the user to a new consumption. Physiological effects: dilated pupils, tachycardia and hypertension” (Maes et al., 1999, Rosita, p.20).

Experimental studies: Experimental studies and examination of driving behaviour showed the following results: “Cocaine (free base, crack,…) is also incompatible with safe driving. There are no experimental data on cocaine and driving. The subjectively experienced performance improvement during the phase of euphoria will lead to increased risk-taking in traffic. The

Page 42 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 objectively observed performance impairment is due to a loss of concentration and attentiveness, and an increased sensitivity for blinding by light (dilated pupils). Moreover the psychological symptoms such as paranoia, delusions, hallucinations will have an influence on driving behaviour” (Maes et al., 1999, Rosita, p.21). Crucial for traffic fitness are not only the acute drug effects, but the consequences resulting from the stimulation, like exhaustion, over-fatigue and the problems arising from the abuse. Withdrawal symptoms naturally constitute a further source of danger in road traffic. Schulz et al. (1997) conducted a literature study on driving inefficiency because of cocaine consumption. It could be determined that the application of drugs in experimental cocaine studies covers the broad range between 8 and 210 mg, whereby most often doses about 25 mg were given. Thus, these cocaine doses were mainly below the amounts typical for the scene. The drug doses taken by cocaine consumers are subject to great fluctuations and in case of chronic consumption often surmount 1 g per day. Despite the small amounts given, a drug- dependent change of the examined parameters occurred with 32%. Results that would suggest a negative influence on driving behaviour were found at 19% of all findings (respective measurement times under acute effects).

6.1.5 Amphetamines Resorption and Duration: Effects appear after about 1 hour and last at least for 4 hours. Appearance: Oral taking, sometimes snorted or injected. Acute effects: “Amphetamines are central stimulants. They suppress feelings of tiredness and hunger, and increase mental alertness and physical energy. In addition they stimulate the mood and increase self-confidence. [...] Because of the tolerance development, some abusers are known to swallow or inject up to 2000 mg daily. High doses lead to hallucinations, psychosis and dysphoria. MDMA and analogues have a dual effect: they are stimulants (dance-pills) and entactogens (emotional disinhibition and increased social communication abilities). When these effects decrease negative sensations of fatigue, anxiety, emptiness and depression appear. Later a hangover is experienced with headache, muscle aches, exhaustion, apathy, sweating, nausea, … Recent studies [CHDR report 1998, McCann et al. 1998] have revealed the toxic effect of chronic MDMA-use on brain serotonin neurones in humans, associated with mild impairment of memory and serotonergic neuroendocrine function. Physiological effects: dilated pupils, tachycardia and dry mouth” (Maes et al., 1999, Rosita, p. 22).

Experimental studies: Experimental studies and examination of driving behaviour showed the following results: “There are few studies on the influence of amphetamines and designer amphetamines (XTC, Eve, ….) on psychomotor function [EMCDDA/HRB report 1999]. These stimulating drugs will dangerously increase the self-confidence of the driver with increased risk-taking in

Page 43 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 traffic. The user becomes aggressive in the beginning and apathetic when the product disappears from the blood. Moreover, the wide pupils can cause blinding. Case reports show that amphetamines have a negative influence on the performance capabilities. However, in many cases of psycho-stimulation, it is not the acute effect of the drug but rather the exhaustion and overexertion resulting from the stimulation as well as other problems arising from misuse that are decisive for driving impairment” (Maes et al., 1999, Rosita, p. 4). In a literature review the authors of EMCDDA/HRB report (1999, in Rosita) report that some amphetamines enhance psychomotor skills (generally at low doses). They also found enhancing effects on measures of motor co-ordination and control, monitoring, vigilance and physical endurance, risk-taking also increased (doses of 10-15 mg). The authors found little experimental evidence for MDMA and its analogues. “Some studies indicate memory decrements in XTC users. Different test subjects experienced toxic psychosis, dysphoria, anxiety, flashbacks.” (Maes et al., 199 Rosita, p.22) “In the conclusions of their literature study, Schulz et al. [1997] stated that for amphetamines (as well as for cocaine) “the experimental material analysed is not suitable for indicating the hazard resulting from impairment of the driving ability on the basis of “dimensions and figures”. This should not induce the hasty conclusion that the drugs mentioned are of only minor significance for traffic safety. Publications of the non-experimental type and case reports show that amphetamines and cocaine have a negative influence on the performance capabilities in the reality of drug consumption. The fatal effects include euphoria, restlessness, anxiety, agitation and confusion. Moreover, of particular importance are the increase in the willingness to take risks, impairment of the ability to think critically and make judgements, exaggerated sense of self-esteem, misinterpretation of situations and loss of reality. However, in many cases, it is not the acute effect of the drug, but rather the exhaustion and overexertion resulting from the stimulation as well as other problems arising from misuse that are decisive for impairment of the driving ability resulting from psycho-stimulation”.” (Maes et al., 1999, Rosita, p. 22) It can be proceeded from the assumption that the impairment is similar to cocaine, possibly mitigated by the communication-stimulating effect of XTC. Seven cases of traffic- conspicuous or accident-involved drivers described by Bost 1988 where MDEA or MDMA consumption could be proved showed mainly lapses like massive speeding, ignoring of stop signs or endangering of other road users through uncontrolled lane changing. Krüger and Vollrath (2000) examined the effects of persons impaired by ecstasy respectively amphetamines (low < 0,05 mg/l and high concentration > 0,05 mg/l) or cannabis (acute and previous consumption), among other things in combination with alcohol. This study was conducted with a simulator, the results were compared with a control group. Ecstasy/amphetamines alone showed no adverse effects on parameters relevant for driving behaviour, while the combination of ecstasy/amphetamines with cannabis or alcohol produced clear impairment of reaction in secondary tasks. De Waard, Brookhuis, and Pernot (2000) on the other hand could nevertheless prove effects of ecstasy on the driving behaviour of regular consumers in a simulator study. Here, 20 persons attended a simulated drive through urban areas and on the motorway one hour after drug consumption (average dose of 56mg MDMA, range of 25-98mg) as well as a drug-free control drive. While tracking was not impaired, the speed choice was higher in the urban areas. Furthermore, a trend to shorten the following distance was discernible, either were interpreted as signs of a higher risk willingness. At braking manoeuvres of preceding vehicles 4 subjects caused an accident. In a self-assessment the drivers assessed their own driving qualities as clearly worse.

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As ecstasy consumers at techno-parties usually take clearly higher concentrations as the uniquely given average concentrations examined in experiments, or mix ecstasy with other substances, a very distinct impairment has to be assumed. The companion paper to De Waard et al. (2000) by Brookhuis, De Waard and Pernot (2000), also presented at ICADTS 2000, reports that their subjects in the second trial, after the techno- party, in the same simulator set-up, had used more MDMA, and also other drugs including alcohol, showing more impairment indeed. Five out of 20 subjects crashed the (simulator) car. In their literature study of experimental amphetamine studies, Schulz et al. (1997) arrive at the conclusion that in these studies mainly therapeutic doses were used and not the consumption amounts of the drug scene (up to 2 g per day). Drug-conditioned changes of the examined parameters were found at low doses in approximately 25%. Acute effects as well as after- effects were included in the analysis. Where an influence on the parameters could be determined, the effect was more often positive/performance enhancing („+1“-findings with 19%) than negative/performance decreasing („-1“-findings with 2.2%). However, it has to be considered that the low doses and the measurement times (in parts only after-effects could be measured) should not lead to the conclusion that these drugs are harmless in road traffic! Krüger and Vollrath (2000) point out the danger through combination effects of amphetamines with alcohol or other substances that must not be underestimated. Here, substantial impairment of the performance at secondary tasks at the driving simulator could be determined. Concerning the consumption of ketamines, the following has to be stated: In the first phase of intoxication, there is a complete driving incapacity. In the second phase, the dangers are similar to alcohol, i.e., the fatal combination of reduced psycho-physic performance capability, and enhanced ego and increased risk willingness. About the danger of psychotic derailments and echo-intoxication with ketamines, nothing is known (effect symptoms see Bolle, 1988).

6.1.6 Hallucinogens Resorption and Duration: GHB: peak after 20 to 45 minutes after oral absorption; LSD: effects appear 15 minutes to 1 hour after ingestion, can last 6 to 8 hours; Magic mushrooms: effects can last 5-6 hours. Appearance: GHB is naturally present in mammal species, oral taking. LSD is a synthetic substance version of ergotamine, oral taking. Magic mushrooms contain the substances psilocybin and psilocin, oral taking. Mescaline is an extract from the peyote-cactus, oral taking. Acute effects: GHB: has euphoric, sedative, and anabolic effects. ”Physical dependence can be noted; side effects are nausea, vomiting, vertigo, sleepiness, bradycardia and respiratory depression. Coma and seizures have been reported following GHB abuse. Patients regain consciousness spontaneously within a few hours after ingestion. Association with alcohol or other psychoactive drugs is very dangerous (reinforcement of side effects)” (Maes et al., 1999, Rosita, p.23). LSD: “Tolerance will develop after only a few days. Cardiac frequency, blood pressure and temperature are increased, spatio-temporal distortion and depersonalisation are frequently reported. Reaction time is significantly increased. Users can be so afraid that they will make suicide attempts. LSD induces a solid psychic dependence” (Maes et al., 1999, Rosita, p. 23)..

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Magic mushrooms: “First, the user will be affected by nausea, and then sensations affecting eyes, hearing and consciousness will occur. These products seem to induce less panic than LSD” (Maes et al., 1999, Rosita, p. 24). Mescaline: “The effects are very similar to LSD, with reinforcement of “colour” visions. Users call mescaline the “mellow LSD”, but real hallucinations are more frequent than with LSD. Tachycardia, hypertension, hyperthermia, hypersalivation and tremor are the most frequent side effects. Mescaline induces tolerance, psychic dependence and sometimes physical dependence.” (Maes et al., 1999, Rosita, p. 24).

Experimental studies: Experimental studies and examination of driving behaviour showed the following results: “Hallucinogens (GHB, LSD, magic mushrooms, mescaline,…) impair psychomotor performance, by producing hallucinations, sleepiness, psychotic reactions,… which are not compatible with safe driving. [...] However epidemiological (drugs not systematically screened) and experimental data on these compounds are lacking ” (Maes et al., 1999, Rosita, p. 24). The main danger of the acute effects lies in the „bad“ or „horror trip“ (Schmidbauer and Vom Scheidt, 1981). It is determined by massive fear, reality orientation collapses and the person concerned is helplessly exposed to his/her hallucinated imaginations. If this phase does not wear off, a prolonged psychotic phase with paranoid-hallucinatory symptomatology may follow that requires psychiatric treatment. According to Grof (1983), this occurs only with predisposed persons, though.

6.1.7 Medicines Under the condition of a therapeutic dosage, i.e., a medical prescription, a clear impairment may occur, mainly in the entrainment phase of the medication (several days to weeks – see results of the pharmacological studies). Furthermore, it has to be remarked as essential that therapeutically administered medicines often re-enable persons to participate as drivers in road traffic, e.g. antidepressants. Maes et al. (1999, Rosita, p. 25) show the impact of medicines on driving performance: “Psychotropic medicines act on psychic function, behaviour and experience; they alter the mental state by affecting the neurophysiological and biochemical activity of the functional units of the CNS (e.g. anxiolytic sedatives, antidepressants, neuroleptics, psychostimulants). The therapeutic action of these medicines may have an influence on driving. On the other hand non-psychotropic drugs can impair driving due to certain side effects, often linked to the penetration of the molecules through the blood-brain barrier (e.g. antihistamines, beta- blockers). Therapeutic or secondary effects of medicines which can have a detrimental effect on driving performance are: • somnolence: induced by many medicines (hypnotics, antidepressants, neuroleptics, antihistamines, narcotic analgesics,..) • loss of psychomotor co-ordination: medical treatment can influence the ability of the patient to integrate data correctly and react adequately (precision and rapidity) • behavioural changes: can lead to risk-taking and altered estimation of speed and distance • balance disturbance: e.g. vertigo

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• sensory disturbances: e.g. visual accommodation problems due to ophthalmic medication Factors that determine the possible influence on driving depend on: - the medication: dose, time after intake, tolerance development,… - the patient: age, individual sensibility, physical and psychological condition (e.g. stress, fatigue, visual acuity), pathologies (e.g. psychotic and neurological disorders, diabetes, epilepsy)”. Medicinal drugs need to be categorised according to their influence on driving performance. There should also be warnings (sticker or labels) on the packages. The use of such information is quite different in European countries (see e.g. Germany, the Netherlands, the Nordic countries, Italy, France) (Maes et al., 1999, Rosita).

6.1.7.1 Hypnotics, Sedatives, Anxiolytics: Benzodiazepines Resorption and Duration: Benzodiazepines: 3-4 hours Acute effects: These substances produce sedation at low doses and hypnosis at higher doses. “They have a central muscle relaxant activity. They may potentiate other CNS depressants. BZD have a high therapeutic index and the adverse effects are minor. Chronic abuse may induce tolerance; withdrawal symptoms are observed after stopping the BZD use (hypersensitivity to light and sound, tremor, sweating, insomnia, abdominal discomfort, and tachycardia). BZD are qualitatively comparable but differ in pharmacokinetic parameters and duration of the effects. Some BZD act quickly and have a short halflife; they are preferably used as hypnotics. Other BZD have an intermediate or long half life and are used as anxiolytics and sedatives. The duration of the effects depends on half life, the formation of active metabolites and the distribution of the drugs. BZD abuse, the non-therapeutic use of BZD - often in high doses - as a “drug” to induce euphoria, is extensive” (Maes et al., 1999, Rosita, p. 25).

Experimental studies: Experimental studies and examinations of driving behaviour showed the following results: Most of the studies concern benzodiazepines. “The most important (side) effects of benzodiazepines, susceptible of impairing driving performance, are somnolence and sedation, loss of motor co-ordination, memory impairment, behaviour disinhibition and paradoxical agitation. BZD are about the most solidly documented drug group with regard to the influence on driving behaviour. [...] Numerous studies describing the results of laboratory, simulator and real driving tests after intake of BZD have been published. A common finding is sedation and sleepiness related to impairment in psychomotor tests [EMCDDA/HRB report 1999, BLT report 1999]. Diazepam is a BZD with a severe influence on driving abilities and is used as a verum in many studies” (Maes et al., 1999, Rosita, p.25). Morland gives account of a study by O’Hanlon et al (1986) on the influence of benzodiazepines in “real” driving tests. It was shown that certain BZDs and zoplicone had

Page 47 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 effects on the standard deviation of lateral position during driving over a long distance on a four lane primary highway in normal traffic (continuous electro-optical recording). “It was found that some BZDs the morning after being used as hypnotics caused impairment comparable to that observed at BAC of 0,05-0,1%” (Morland, 2000, p. 85). Morland further records that several hundreds of studies show great similarities concerning the results: the overall picture in controlled experiments is that all BZDs have the potential to cause impairment. There are clear effects of dose/serum concentration (Berghaus and Grass, 1997, in Morland, 2000), but there are also significant inter-individual variations. Three more examples of impairment: “Chronic administration of diazepam (85 mg three times daily) for 9 days demonstrated extensive impairment in contrast to placebo or chronic buspirone treatment (20 mg daily, 9 days), when tested in a driving simulator” (Moskowitz and Smiley, 1982, as cited in Morland, 2000, p.86). Linnoila et al. (1983, as cited in Morland, 2000) report: “Diazepam, 10 mg three times daily for three weeks, gave rise to the same acute psychomotor effects with no tolerance development.” After a long-term drug intake, some degree of tolerance development can be shown in some studies (Morland, 2000), “but it appears that even after chronic use the acute dose might have at least some impairing effects.” As Morland reports, several studies have indicated pharmaco-dynamic interactions between BZDs and alcohol which lead to increasing psychomotor impairment. However, it was difficult to assess which proportion of observed effects were due to alcohol and to BZDs.

6.1.7.2 Antidepressants Antidepressants treat affective disorders, e.g. depression, panic disorders, phobias. Secondary effects of antidepressants are sedation, tremor, insomnia, blurred vision, mental confusion and dizziness. The occurrence of these effects depends on substance, dose, individual sensitivity and taking. (Maes et al., 1999, Rosita). Experimental studies and examinations of driving behaviour showed the following results: “Depressive patients may have an impaired driving behaviour for two reasons: the pathology itself involves cognitive troubles, concentration and attention disturbances, anxiety, irritability, tiredness secondary to insomnia. The adverse effects of the antidepressants (sedation) may be detrimental. On the other hand adequate treatment may improve the driving performance of depressive patients due to the drug relieving their depressive symptoms. The newer compounds with fewer side effects will be a better choice for drivers.” [...] “In a review of the literature published in 1985 Linnoila and Seppälä have found that studies with healthy volunteers on single doses show that the more sedative drugs induce more impairment. Many studies on psychomotor and driving performance since have analysed antidepressants, the first generation tricyclics (most sedative) often being used as a verum in the studies of the newer drugs (EMCDDA/HRB report 1999, BLT report 1999)”.(Maes et al., 1999, Rosita, p. 27).

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6.1.7.3 Neuroleptics “Psychoses are mental disorders characterised by disturbances of the thought process leading to distortions of affective responses and reality. Neuroleptics or antipsychotics are agents used for the treatment of psychosis and include the phenothiazines (e.g. chlorpromazine), the butyrophenones (e.g. haloperidol), the thioxanthenes (e.g. flupenthixol), and the substituted benzamides (e.g. sulpiride). [...] The numerous adverse effects derive from the pharmacological actions. Neuroleptics all are sedative; [...] akathesia (mental and motor restlessness), Parkinsonism-like syndrome, dystonic reactions (e.g. facial grimacing, torticollis) and tardive dyskinesia (e.g. protrusion of tongue and lipsmacking, choreiform movements of trunk and limbs)” (Maes et al., 1999, Rosita, p.28). Experimental studies and examinations of driving behaviour showed the following results: Neuroleptics have adverse effects on the driving performance: sedation, motor disturbances, decline of cognitive functions, reduction of visuo-motor abilities and vigilance, aggressiveness, temporary aggravation of psychotic troubles. On the other hand, the use of neuroleptics may enable the patient to perform social activities, e.g. driving a car. Maes et al. (1999, Rosita) report that there is an important lack of information relevant for these drugs and driving. Experimental studies often tested healthy volunteers and they found out various impairing effects. Studies on patients found similar effects, but there are contradictory results. It is difficult to draw conclusions yet because of the heterogenity of the pathologies and the attenuating effect of the neuroleptics on the psychosis.

6.1.7.4 Narcotic/Opioid Analgesics, Methadone “The opioid most extensively used in heroin detoxification maintenance programs is methadone, but in some countries (e.g. France) buprenorphine is also used. Narcotic analgesics [...] produce analgesia, mood changes, mental clouding and narcosis. Their primary use is the treatment of severe pain (burns, trauma, terminal illness). They have sedative and respiratory depressant effects, cause miosis and contraction of the smooth muscle, and block peristalsis” (Maes et al., 1999, Rosita p. 29). Experimental studies and examinations of driving behaviour showed the following results: “Effects relevant for driving safety are sedation, impairment of cognitive functions, mood changes (dysphoria and euphoria), impairment of psychomotor functions and pupil restriction. Sedation and cognition impairment are important in the beginning of treatment but seem to wear off in most patients after some days or weeks” (Maes et al., 1999, Rosita, p. 29). Lakemeyer (1998, in Maes et al., 1999, Rosita) investigated opioid analgesics and driving safety. It was a survey about pain physicians and their patients. Absolute driving unfitness could be noticed when there were important changes in drug dosage or when other CNS depressants like alcohol were co-ingested. In a long term stabilised opioid therapy with unchanged doses, no impairment was observed. In experimental studies on cancer patients it was observed that long-term treatment with morphine did not increase the risk of road accidents (Vaiinio et al., 1995, Bruera et al., 1989, both in Maes et al,. 1999, Rosita). “The review by Friedel and Berghaus [1995] and the EMCDDA [1999] report mention several experimental studies of the effect of methadone on naïve subjects, methadone maintenance patients and ex-heroin addicts. Some discrepancies in the study results notwithstanding, the following conclusions can be made: in naïve subjects acute methadone

Page 49 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 administration induces a dose-dependent reduction in reaction time, in visual acuity and in information processing, thus when starting up the methadone treatment the subject is unfit to drive. Once stabilised on the program there is little evidence of driving impairment: on different measures of psychomotor performance “optimal” methadone users did not differ from controls. However many methadone users frequently take other psychotropic medication” (Maes et al., 1999, Rosita).

6.1.7.5 Antihistamines “Antihistamines are used for treating allergies such as hay fever and urticaria, and travel sickness. They act by competitive inhibition and block the effects of histamine. Sedation is observed mostly with the first generation compounds (e. g. diphenhydramine, triprolidine) and is a consequence of their depressive activity on the CNS due to their ability to cross the blood-brain barrier. New agents (e. g. astemizole, terfenadine) do not cause significant sedation because of poor penetration of the CNS. Other side-effects include gastro-intestinal disturbances, headache, blurred vision, elation or depression, irritability” (Maes et al., 1999, Rosita, p.30). Experimental studies and examinations of driving behaviour showed the following results: “Adverse effects that can impair driving fitness are mostly sedation-related: drowsiness, dizziness, decreased alertness and concentration, inco-ordination, muscular weakness. As the new generation antihistamines cause very little sedation, they are likely to have little impairing influence on driving” (Maes et al., 1999, Rosita, p. 30). Maes et al (1999) report experimental data comparing the influence of both antihistamine generations on psychomotor skills and driving behaviour. Both enhancing and impairment could be found, depending on dose. At low doses no detrimental effects were observed. Sedation could occur at higher doses and in sensitive patients (EMCDDA/HRB, 1999; BLT- Report, 1999; O’Hanlon and Ramaekers, 1995, all in Maes et al., 1999, Rosita).

6.2 COMBINATION OF SUBSTANCES Besides the abuse of a single drug or a single medicine, simultaneous consumption of one or several further substances occurs frequently. This was impressively proven by numerous epidemiological studies. Especially with heavily drug- or medicine-addicted persons, multiple consumption (polytoxicomania) is frequently found. Möller (1998) states the following causes for multiple consumption: group pressure, curiosity, testing of combinations, enhanced effects, reduction of undesirable effects, it is cheaper because of prolonged or intensified effects, addiction to substance combinations. The basic consumption is constituted by the drug that is mainly taken, respectively to which the addiction primarily exists. As preferred combinations can be observed: Heroin co-consumption: cocaine, codeine, dihydrocodeine, benzodiazepines Methadone co-consumption: cannabis, heroin, cocaine, benzodiazepines Cocaine co-consumption: alcohol, benzodiazepines Cannabis co-consumption: alcohol Amphetamines co-consumption: cannabis, cocaine, LSD, designer drugs Designer drugs co-consumption: cannabis, cocaine, LSD, amphetamines, [and alcohol: Brookhuis, De Waard and Pernot (2000) report a high percentage of co- consumption of alcohol ]

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Benzodiazepines co-consumption: alcohol, other benzodiazepines.

Each drug develops its own characteristic effects, the totality of observable symptoms results from the combination of all single effects, thereby, miscellaneous interactions may also appear. Between dose, duration of effect, and concentration exists a reciprocal dependency. The way of consumption has also an essential influence on the effects. The location of the substance uptake (lungs, stomach, blood) has an essential influence on the quality of the intoxication effects. (Möller, 1998). The circulating active agents may have an additive, magnifying, weakening or cancelling effect in the organism.

Möller therefore discerns the following effects: • additive effect • over-additive effect • antagonistic effect (impediment to the recognition of the separate substances!)

For example: alcohol and benzodiazepines: potentiation alcohol and cannabis: addition alcohol and cocaine weakening or intensification (depending on the effect phase)

In the following table the combination effects are shown: ALK OPI COC CAN AM BE BA

OPIATES ↓↓

COCAINE ↑↓ ↑↓

CANNABIS ↑↓ ↑↓ ↑↓

AMPHETAMINES, ↑↓ ↑↓ ↑↑ ↑↓ DESIGNER DRUGS

BENZODIAZEPINES ↓↓↓ ↓↓ ↑↓ ↑↓ ↑↓

BARBITURATES ↓↓↓ ↓↓ ↑↓ ↑↓ ↑↓ ↓↓ ↓↓

Table 16: drug combination effects (from Möller, 1998, p. 88); key: ↓ ↓ = additive depressant, ↓↓↓ = over-additive depressant, ↑↑ = additive inciting, ↑↓ = various combination effects, = difficult to predict.

As far as there are studies about acute impairment by mixed consumption, they were already mentioned with the specific substances.

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7 IDENTIFICATION AND EVIDENCE OF DRUG CONSUMPTION AND DRIVER IMPAIRMENT: METHODS TO ASSESS IMPAIRMENT

This chapter deals with methods used to detect impaired driving, steps of argumentation, and proof of impairment. It was attempted to present best practise models that either are already successfully utilised or proposed by experts. Furthermore, problems occurring in practice are pointed out and recommendations and demands of experts are outlined. The first section deals with the possibilities of recognition and identification of drug impaired persons by police officers, the most important practical problems that result from it, and well- tried utilised methods. In the next section the existing psychomotor test procedures are shortly described (for details see appendix) and their possible fields of application are presented. Furthermore, an overview of driving-relevant acute impairment is given on the basis of findings from experimental psychology. The next section is about the present status of drug-screening analysis methods and about applicable devices and their requirements for practical roadside use. The last section comprises proposals on the best practice concerning the proof of an impairment by drug consumption in clinical and neurological examinations.

7.1 ROADSIDE IDENTIFICATION OF DRIVER IMPAIRMENT Most countries are willing to introduce legislation concerning impairment by drugs, but they are opposed to returning to any form of behavioural assessment either because of being afraid of additional subjectivity in assessment or overtaxing the police on road side. This is the reason for demanding useful detection devices and tests. A few countries have introduced clinical evaluation procedures, for which they use a variety of methods. The United States have been using a complex assessment system with the DRE- Program (Drugs Recognition Expertise) which is based on behavioural assessment, whereas the Southern European concept (e.g. French) is oriented towards biological methods. Other countries, especially Scandinavia, have adopted an approach between these two extremes. This concept is based on intervention by the police in the case of a reasonable suspicion. If drivers seem to be clearly impaired and the results of an alcohol test turn out to be negative, police officers are enabled to request a clinical assessment and a biological sample. The great variety of judicial systems and cultural circumstances induces numerous questions and problems about clinical assessment procedures in the field of drugs (Mercier- Guyon2000a). Mercier-Guyon, Malleret, and Lagier (2000) have summarised the following steps of procedures to identify drug impairment (depending on the qualification of the authorised agency): • the “glance”: Without specific tests, the police officer has to assess a potential drug impairment. The evaluation depends on his experience. It is used in countries where the determination of a reasonable suspicion does not require standardised batteries. • simple test batteries: are used in Switzerland and are based on a qualification of the global evaluation. The codification is based on simple clinical signs (standing up, walking,

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speaking). Observed impairment signs can allow a police officer to require a biological detection. • description of the police files: is used in France only as a description, in Germany as a part of the police evaluation. They are based on a description of general aspects and behaviour, but no tests. • standardised test batteries: The most known FST (Field Sobriety Test) is used in the USA and in Scandinavia. • DRE Test Battery

The diagnosis of a possible impairment by drugs or medicines is easier for the police when the substance consumed has effects similar to alcohol, i.e., mainly sedating substances. Otherwise, minimal knowledge has to exist about the possible effects of the various substances. Knowledge and decisions of the officers are mostly not sufficient to impose sanctions based on administrative or criminal law. This already becomes apparent from experiences in countries that have no legal regulations concerning the duty of co-operation, the giving of samples, etc. Because here, attention is paid to the exact observance and documentation of all perceptions, examinations, actions, and determinations to confirm the chain of evidence. Statements concerning traffic-relevant effects ought to be made only in a legitimate way on the level of single substances. (Springer, Kopf, and Uhl, 1999).

Suspicion gaining by the police: • traffic controls without suspicion, • initial suspicion: duty of investigation, suspicion-sustaining elements • indicators for consumption of intoxicants: driving behaviour, intoxicant-characteristic traffic accidents, suspicious behaviour, physical characteristics, pupillary changes, appearance, body reactions, conspicuities of behaviour, general behaviour, mood, psycho- motor performance, speech and expression, withdrawal symptoms, carrying of intoxicant utensils. • technical devices: Immunological intoxicant express test (TRIAGE, ONTRAK), Intoxicant detection wipe test (DRUGWIPE), pupillary reaction test (CIP Compact Integrated Pupillograph by AMTech), • characteristics of intoxicants • drug evaluation and classification programme

Possibilities for conservation of evidence: • Blood sample • Urine sample • Saliva sample • Clinical findings • Questioning of the accused • Securing of intoxicant utensils

Chemical and toxicological proof of intoxicants from body fluids: • examination substratum: blood, urine, saliva, sweat • immuno-chemical test procedures: EMIT Enzyme-Multiplied-Immunoassay-Technique, RIA Radio-Immuno-Assay, FPIA Fluorescence-Polarisation-Immuno-Assay, HI Haemagglutination-Inhibition-Procedure

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• Chromatographic and spectroscopic examinations: GC Gas-Chromatography, HPLC High-Pressure-Liquid-Chromatography, MS Mass-Spectrometry, GC/MS combination of GC and MS Assessment of the examination findings: consideration of the examination methods, pharmacologically relevant concentrations of active agents, counting back to the time of the offence, mixed intoxication

7.1.1 Police suspicion The execution of the steps of suspicion gaining and identification should be taken into consideration in the practice of the police (depending on the legal status). This leads to high requirements for police officers, especially when a general, easily detectable impairment of the driving fitness (symptoms similar to an impairment by alcohol) alone is not sufficient to set further investigation steps, or when they have to conclude specific substance groups from certain indicators. Principal fields of problems at the suspicion gaining • Irregular experience on the part of the police officers in recognising the symptomatology, in the knowledge about the legal regulations, in the knowledge about the appearance of drugs and medicines. • Overstrain of the police officers because of lacking training • Organisational problems • Problems concerning the differential diagnosis at certain symptoms, e.g., between impairment by drugs and medicines or psychic exceptions due to over-fatigue, increased excitation, etc.

In a first step, the impairment evaluation always rests on field police, in a second step, different approaches are used depending on legislation of the countries. The USA have developed a special training for the police in charge to perform a complete evaluation of the driver. The Scandinavian countries, Germany, and Belgium pursue different procedures. In a first step, the police officer has to identify if there is a suspicion of impairment, using simple behavioural tests (not always standardised). In the case of suspicion, a biological sample is collected. In countries like France, they have no obligation to perform a clinical evaluation of drivers and no obligation of reasonable suspicion. The detection is only focused on an alcohol test followed by a confirmation. Theoretically, they include behavioural evaluation by the police officer and a medical doctor who is requested to collect the blood sample (Mercier- Guyon, Mallaret, and Lagier, 2000). An example of a check-list is given by Möller et al.(1999) (also see Möller, 2000, Icadts; Möller, 2000, Pompidou, p.237; Maurer, 2000) with that, besides an illustration and comparative data on pupil sizes, also data on observation of the driving style and the behaviour during the stopping are collected.

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Findings by the police concerning impairment of the driving fitness Enclosure to the report against Name: First name: Date: Incident: No. of blood sample:

Observations about driving style, weather, and roadway

Driving style: Vehicle operation: Vehicle defects: O no observations O stalling of the engine O no O sure/unsure O unsure shifting of gears O yes, which O serpentines O roaring of the engine • deviation from the straight line O other: ...... up to m Roadway: Weather: • no. of jerks...... O good O rain O ice/snow • at an observed distance of O poor O strong wind / storm m O construction site O fog O unadapted speed. O well lit O day light O violation of right of way O poorly lit O twilight O otherwise conspicuous O dry O darkness ...... O wet Observation at stopping or meeting Reaction: Physical conspicuities: Appearance: O inconspicuous O none O cultivated O delayed O profuse perspiration O neglected O extreme slow O trembling O restlessness O seedy O vomiting Able to speak the [English] language: Pronounciation: Responsiveness/Orientation: O yes O articulate O drowsy O easy to wake O no O tripping over syllables O fast asleep/unconscious O limited O washy O oriented O disoriented O babbling Mood / Behaviour: Getting out of the vehicle: Walk: O calm, self-controlled O normal O sure O agitated O disturbance of equilibrium O shuffling O unreasonably cheerful O has to cling to the vehicle O unsteady O lethargic O staggering O without distance O provocative O aggressive O whining Alcoholic smell: Field sobriety test O yes O yes, at ...... o‘clock...... o/oo O no O no O refused O not feasible Eyes: Pupils: Light conditions at the place of O inconspicuous right left examination: O reddend conjunctivas O ca...... mm ca...... mm O daylight O twilight O watery / shiny O prompt reaction to light O night/streetlight O unsteady O slow reaction to light O night/room lightning Other observations (all secured powder, pills, etc., other conspicuities in the car, on the person; continue on the back, if required):

Behaviour during the official act: (Duration: from...... : ...... o’clock till ..... : ...... o‘clock) O constant O acts increasingly more conspicuous O acts increasingly more inconspicuous

Determined by: ______Name Signature

Table 17: Check-list for determining impairment of driving fitness by the police (Maurer, 2000, p. 72)

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An appropriate assignment of the signs of drug consumption to a certain drug requires a classification technique where these signs can be attributed systematically. Springer et al. (1999) compiled a classification pattern following Harbort (1995, in Springer et al., 1999). Supplementary to the pattern developed by Möller et al., this pattern sets value on e.g. conspicuities in terms of observed collusions by the vehicle passengers, arranging of clothes, drug utensils in the vehicle, etc. It is further attempted to attribute specific observable conspicuities to particular impairing substances. Drug recognition and identification methods are used in courses of instruction in Germany and USA, some procedures are still in a development stage (Springer et al., 1999). In some provinces in Germany police officers are instructed in drug recognition. The essential main focus is the schooling of observation for gaining suspicion, moreover the police officer should be able to formulate the suspicion of drug impairment orally and in writing as witness in court. (Aderjan et al., 1999, Joo, 1999). In the USA, there is also a nine-day training programme as DWI expert. After intensive training there is a final exam, the certification is valid for 2 years (for Germany, for USA see also: NHTSA, as cited in Springer et al., 1999; Perrine, 2000). An adoption of this system holds problems in the fields of legal regulations, ethics, assignment of medical and clinical competence to DWI-trained persons, medical secret (e.g. Mercier-Guyon et al., 2000). In Great Britain, several police officers have shared the US DEC-training and impairment testing at road side. They have developed the general principles and techniques of the DRE programme into a training package, suitable for use in the U.K. This Drug Recognition Training for police officers has been initiated. They received training in drug impairment recognition and also in the administration of a standardised Field Impairment Test (FIT). Then, they applied their training in a real world setting for a period of two months. As a comparison, specially trained TRL researches also used these techniques. Results show that the techniques used are very useful in identifying impairment and the drug group likely to be responsible (Jackson, Tunbridge, and Rowe, 2000; Tunbridge, Keigan, and James, 2000).

7.1.1.1 Implications for practical implementation The following aspects seem to be essential for an efficient practical implementation: • documentation of concrete driving conspicuities by the police (Springer et al., 1999). • a transfer of the DEC-programme to European cultural and social conditions requires adaptation and efficiency control (Springer et al., 1999). • standardised assessment of driving fitness by the police to guarantee the possibility of reconstructing all steps of the police and the clinical examination and to guarantee the transparency in view of the defensibility in court (Battista, Katzgraber, Steinlechner, Haidekker, Rössler, Ober, Kemmler, and Muigg, 1999). • standardised proceedings at the verification of the suspicion of drug impairment by means of a short written check-list (Chaloupka et al., 1999). • To achieve a better quality of police reports in general, it can be said that standardisation is needed to produce these reports; it is especially important to note if the person was a driver or a passenger, and whether the driver was responsible for the accident or not (De Gier, 2000). • Training and sensitisation of police officers concerning the detection and identification of motorists influenced by drugs respectively medicines (Battista et al., 1999). • Training of the police officers in personal contact with intoxicated motorists (Chaloupka et al., 1999).

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• Improved legal protection, clear possibilities of intervention on the part of the police (Chaloupka et al., 1999). • Exchange of methods and experiences in detection of police enforcement between countries should be encouraged (Pompidou, 2000).

7.1.2 Psychometric tests - roadside The existing tests for roadside assessment of drug-impaired driving ability is described in detail in Certified (Clark and Riedel, 2000). In this context the demands of psychometric road side tests - drawn up by Clark and Riedel - are summarised:

• Fulfilment of psychometric criteria like sensitivity, reliability and validity, objectivity. • In case of taxonomy, the following phenomena are considered to be part of driving: attention: vigilance, spatial processing and orientation, lateral tracking, longitudinal tracking, reaction time, eye-limb co-ordination, short term memory. • Data integrity • Unambiguous test outcomes • Covering of all aspects of driving like attention, vigilance, perception, spatial and temporal processing, reaction time and psychomotor co-ordination • Language free, language fair: The test should not include verbal material, so that it can be used without regard to language. Alternatively, it can be designed so that any verbal content is the same in all languages. • Acceptability for users: Users are drivers, test administrators, legislators and the general public. • Standardised administration: Explanations and instructions have to be standardised to ensure that the test is used in the same way every time by different personnel. • Easy to administer: For personnel with low knowledge and experience about tests • Characterised practice effect: All tests involve some practice effects, although it should not improve with practice. The alternative is to allow inevitable practice effects, but to characterise them. • Short duration: This is important to lessen disruption of the traffic flow and to avoid possible changing effects of the drugs. • No floor or ceiling effects • Valid population norms: Population norms must be of sufficient size and type to be truly representative of the population. • Available criterion data • Insensitivity to environmental effects: Especially at the road side environmental factors such as weather, light levels, noise levels and time of day exert an influence on the test results. Controlled testing environment is not possible in this case. It only can be noticed and included as a part of the population norms. • Insensitivity to personal factors: The influence of personal factors such as age, sex, traits such as personality and intelligence, states such as mood, anxiety and well-being should be used to stratify the population norms. • Insensitivity to road environment: driving on different sides on the road, different signs.

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• Training is needed to enable the personnel to handle the procedure well and safely. • Compatibility: Comparable to other testing (e.g. Breathalyser, drug detection) • Equipment easy to use, simple, small and robust • Economy: Set up time, running costs, purchase costs

The psychomotor tests described below that are also combined movement and concentration tests are utilised either at clinical examinations or directly at the police control, depending on the country. Some of the tests have to be performed with devices.

7.1.2.1 Device-free procedures The device-free tests work with the observation of ordered motion sequences. The instructor orders the person to perform certain actions. The tasks to be mastered test, e.g., the body clock, the sense of balance, the power of concentration, the minute motor activity. From the observable behaviour (or mistakes) conclusion can be drawn concerning the specific impairment. The device-free procedures are described in more detail in the appendix, along with specifications of the behaviour that give hints to impairment.

7.1.2.2 Device procedures With the device procedures, mainly computer test devices are utilised. By means of specific tests, perception, information uptake, power of concentration, reaction time, sensomotor performance, etc., are recorded (see appendix).

7.1.2.3 Mixed Procedures These procedures contain device-free procedures as well as device procedures. Here, too, descriptions are to be found in the appendix.

7.1.2.4 Remarks concerning the practical implementation Concerning the practical implementation, the following can be remarked comprehensively: • More or less promising chances are granted to different test procedures still in development. Video-graphic recordings for assessment of posture (Kennedy, Turnage, Dunlap & Drexler, 1995, in Springer et al., 1999), saliva examinations, pupillograph or contact-free measurements (Springer et al., 1999). • Further studies concerning a trend-setting method of electro-nystagmography are necessary. (Chaloupka et al., 1999). • An attribution of indicators to a specific drug (or at least drug group) for detection of drug consumption and thus an identification requires, however, a comprehensible systematic classification technique that is easily put across and taught to police officers.

7.1.3 The acute effects of various ADMs Following, the different substances are depicted in an overview in connection with the impairments determined in experimental studies. As shown in the overview, a specific impairment is to be found, for example, with diverse substances, therefore a specific impairment can be attributed exclusively to a single substance only in the rarest cases. Generally, the impairment affects the following fields (Tunbrigde et al., 2000, Certified):

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• Arousal • Perception • Attention • Cognition • Psychomotor performance

In the following, those impairments that can be observed4 will be mentioned. The list of performance functions was supplemented yet by behavioural aspects, e.g. attitudes, social behaviour.

Substance Observable changes: Impaired skill or performance, changed attitude and behaviour Alcohol prolonged reaction time late perception of dangerous situations impaired concentration impaired coarse and minute motor activity (e.g. abrupt braking, jerky driving, driving in serpentines, deviation from roadway) unadapted mood aggressiveness increased risk willingness (e.g. hazardous overtaking, speeding) increased disposition for spontaneous decisions reduced self-criticism articulation troubles Cannabis changed perception impaired attention prolonged reaction time slow driving poor tracking impairment of psychomotor performance Opiates deterioration of concentration considerable slowing down considerably prolonged reaction time apathy drowsiness Cocaine impairment of concentration and attention increased risk willingness (e.g. risky driving or/and speeding) exhaustion, over-fatigue Amphetamines, ecstasy at low doses: improved psychomotor performance, vigilance Designer increased risk willingness (e.g. risky driving or/and speeding, ignoring Amphetamines of stop signs, uncontrolled lane changing) restlessness anxiety dysphoria confusion aggressiveness apathy Hallucinogens impaired psychomotor performance sleepiness

4 This table lays no claim to completeness.

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massive anxiety, lacking reality orientation Benzodiazepines impaired memory performance poor sensomotor performance (inaccurate tracking) drowsiness Antidepressants older generation compounds: sedation Neuroleptics Narcotic/Opioid sedation Analgesics; prolonged reaction time Methadone impaired psychomotor performance changes of mood Antihistamines older generation compounds: reduced power of concentration poor co-ordination performance Combination of potentiation substances addition weakening or intensification (depending on the effect phase) (see below) Table 18: Overview of substances and their impairing effects (summary of the studies reported in Chapter 6).

With regard to the roadside detection, it is shortly referred again in this place to the frequent mixed consumption, respectively co-consumption. As preferred combinations can be observed (Möller, 1998; see also Brookhuis, De Waard and Pernot, 2000): Heroin co-consumption: cocaine, codeine, dihydrocodeine, benzodiazepines Methadone co-consumption: cannabis, heroin, cocaine, benzodiazepines Cocaine co-consumption: alcohol, benzodiazepines Cannabis co-consumption: alcohol Amphetamines co-consumption: cannabis, cocaine, LSD, designer drugs Designer drugs co-consumption: cannabis, cocaine, LSD, amphetamines, alcohol Benzodiazepines co-consumption: alcohol, other benzodiazepines.

With that, patterns of effects result that are different to the effects when a single substance is taken. Thus, the detection is clearly made more difficult for the police officers. Möller (1998) discerns the following effects: • additive effect • over-additive effect • antagonistic effect (impediment to the recognition of the separate substances!)

For example: alcohol and benzodiazepines: potentiation alcohol and cannabis: addition alcohol and cocaine weakening or intensification (depending on the effect phase) (See Chapter 5.1.8.)

7.1.4 Drug screening methods: For roadside and detailed investigation Samyn et al. (1999, Rosita) emphasise the following demands on a device:

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• Sensitivity: There are two kinds of devices. Aggressive tests are able to identify a higher percentage of positive results, but also reveal a higher number of false positives. In contrast to this, there exist conservative tests which give few false positives, but miss many true positives. The perfect device has neither false positives nor false negatives, and “positive predictive values” and “negative predictive values” of 100. • Reliability: Data must be storable at any temperature for road side testing. Present devices can only be used at room-temperature (15-25° C). • Validity: The appearance of a control-line and a second line indicates a negative result. • Objectivity: An electronic reader with easy data storage is necessary to maintain objective results independent of interpretation.

Practical requirements for roadside testing are: • One of the key elements in the enforcement process is the possibility to perform screening tests rapidly on the spot. These roadside tests must be performed on samples that are relatively easy to obtain, like urine, saliva, and sweat. The roadside test must have the following characteristics (Verstraete, 2000): • Easy to perform by non-laboratory personnel. • Getting results rapidly. • A check whether the test was performed correctly. • Sensitivity to detect all the drivers who have taken drugs. • The test should be able to detect related designer drugs. • Specificity to detect only drivers who have taken drugs that impair driving (drugs that are forbidden by the law). • Taking of samples without impairing or harming the motorist. • Good readability of the results even in the night. • Insensitivity to shocks and temperature

Battista (2000) sees the advantages of roadside devices in: • Immediate confirmation of an initial suspicion. • Acquiring of competence in the recognition of driving under drug influence. • Reduced costs. • Reduction of unjustified police actions.

Further demands and needs for samples collected in roadside testing are described in Rosita (1999, 2000): • Each test can be configured as single or multi-parameter device. Single tests are cheaper, multi-tests give more comprehensive information. Nearly all countries prefer multi-test devices – advantage of easy use, time saving, comprehensive information for not adequately trained police officers; • Multi/Single/Combination tests: Pre-selection of suspected drivers is only possible for well trained police officers to decide for a specific individual test. A combination of a double or triple test for the most prevalent narcotics and a single test for parameters with lower probability is more cost effective and can be used by well trained police officers. • Duration of test: Preference of very short measurement times (2-5 min) – more persons can be tested and there is a higher acceptance of controls. • Single use/reusable tests: There is no clear preference for single use or reusability. Arguments for preference of a single use system are avoidance of cross contamination and

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infections, ease of use, no maintenance and greater simplicity. Reusable device are more cost effective. • Application: Tests are to be performed at roadside (during darkness) – signal output should be independent of light conditions (readability), on-site application, clear results without any room for interpretation, in some countries it is necessary to store and document results. Preferred test specimen for road side testing is saliva according to its good availability, the low invasiveness of sampling and the good correlation with impairment. • Cost considerations: Average amount for single parameter device: 3.8 Euro and 13.6 Euro for a 4-parameter device. • Training: Combination of training with new devices and drug recognition training is not planned in most countries (Great Britain, Belgium, Finland, Norway, Switzerland use special training).

Roadside tests remain preliminary tests and the results must be confirmed in order to be admissible evidence in court. There is a large number of pretest possibilities that, however, operate mainly on the basis of urine samples. Those always serve for the initial examination of drug-conspicuous vehicle drivers. A positive test always has to be confirmed explicitly by reliable physical and chemical analysis methods. For the probability to detect drug consumption, the sensitivity of analysis, the frequency of consumption and the time period of traceability of the drug after consumption are of importance. The clinical screening analyses give even with exact performance only hints to drug consumption, the proof is supplied solely by chemical and toxicological analyses of blood and urine.

7.1.4.1 Analysis of body liquids

7.1.4.1.1 Urine screening In case of a positive testing by the on-site tests that are currently available, it always has to be proceeded from the fact that this test has to be confirmed explicitly by reliable physical and chemical analysis methods (Battista et al., 1999). Urine screenings have a long time period of traceability, so that substances can be proven in the urine even when their effects have worn off long ago and when no immediate impairment exists (Battista,2000). The time period of traceability of drugs depends on various factors (e.g. nature of the drug, amount of drug, elimination half-life period, metabolisation rate, intake of liquids, the pH value of the urine, sensitivity of the screening tests). It is not possible to draw conclusions concerning the amount of intake or the time of intake from the concentration of drugs in the urine (Battista et al., 1999). A disadvantage is the extension of the test duration in very cold weather. This was determined at a roadside test (Battista, 2000). Urine samples can also be manipulated, not only by drinking lots of water (Käferstein et al., 2000). Samyn et al. (1999, Rosita) report a market study of 19 devices for screening urine samples: There are three kinds of test design: “dip”-test, “pipette” test and “cup” test. Some tests are able to identify more than one substance. Most of the tests can detect: amphetamines, methamphetamines, cannabinoids, cocaine, opiates, phencylidine.

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The costs of an urine test vary between 2 and 6 Euro for a single parameter, and 10 and 20 Euro for a five panel multi-test. Most of the devices were tested in the laboratory; ease of use and interpretation of results were to be evaluated. 60 % were quoted “good” or “very good”, only one was not acceptable. To be able to discern between positive and negative results, some training is necessary. Only the most important findings will be reported in this context, more detailed information of the devices is given in Rosita (Samyn et al, 1999). Seven non-instrumental urine devices were evaluated in an experimental study in the laboratory for the screening of amphetamines/methamphetamines, cannabinoids, cocaine and opiates.

Cannabis Cocaine Opiates Amphetamines Very good ABM Cortez ABM Cortez Morwell Morwell Cortez Teststik Rapidtest Morwell Rapidtest Testcup Testcup Teststik Teststik Good Testcup ABM Rapidtest ABM Frontline Morwell Rapidtest Acceptable Frontline Not acceptable Cortez Frontline Testcup Frontline, Teststik Table 19: Evaluation of urine test devices by Samyn et al. (1999, Rosita).

The best results in accuracy in detection of cannabinoids in urine were found in Syva Rapidtest, Rapid Drug Screen (ABM), Rapitest (Morwell) and Teststik. With the exception of Frontline, all tests are suitable to detect cocaine metabolites. The Rapid drug screen is a very reliable test, but all tests are useable to detect opiates in urine. For detecting amphetamine and MDMA in urine Syva Rapidtest, Rapid drug screen, Rapitest and Instatest (Cortez) are applicable, only Testcup and Teststik failed to detect MDMA (Samyn et al., 1999, Rosita). „Most of the manufacturers of the on-site urine tests use the SAMHSA cut-offs for drugs of abuse. Some exceptions are observed. If the tests are too sensitive or if the experimental cut- off values are different from the theoretical cut-off values, the number of false positives increases. In the U.S., the screening cut-offs for the amphetamine class (1000 ng/ml) are only set for amphetamine(s) and methamphetamine(s). In a number of European countries, the increasing abuse of ecstasy requires the use of a screening test sufficiently sensitive for MDMA and its analogues (MDEA, MBDB). Generally, an AMP test also detects MDA (a metabolite of MDMA and MDEA), a mAMP test detects MDMA to a variable extent. Very few data on the other designer amphetamines are available. Moreover, some nasal decongestants and anorectic medication can interfere in an AMP type test. All opiate-type tests cross-react to a high extent with a number of cough suppressants, analgesics and morphine agonists and antagonists. Confirmation by GC/MS is absolutely necessary to establish the cause of the positive screening result. In conclusion, the main problem issues are the objective interpretation of the result (absence of a reader), the detection of ecstasy and other designer amphetamines, and the specificity of the tests for the illicit amphetamines and morphine“ (Samyn et al., Rosita, p. 3)

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7.1.4.1.2 Saliva screening Saliva is very well suited for the proof of body-extraneous substances, because here a higher concentration of drugs is traceable than in blood. The time period of traceability is also longer and the method is non-invasive (Kauert, 2000). Factors that adversely affect this method are dry mouth, small amounts of saliva and varying viscosity of the samples (Battista, 2000). Since only a limited amount of screening material is available with saliva, it may be that insufficient material remains for confirmation tests that are necessary for legal measures (Battista et al., 1999). Currently available procedures cannot be utilised for roadside tests, because pre-analytic preparation of the saliva sample is necessary. Another essential fact is that metabolites may be available in considerably smaller amounts, or lack entirely. Interfering saliva components like mucus and suspended matter have to be extracted. The procedure is not sensitive enough for cannabinoids and benzodiazepines. THC is not detected in saliva despite high serum concentration. Most of the immune procedures contain antibodies that are not aimed at secreted acidic metabolites that are to be found in the saliva only in small amounts or not at all (Kauert, 2000). Saliva normally contains the source substance, while urine contains the metabolites. Concentrations are lower in saliva than in urine (Kintz, 2000). In a study by Kintz, Cirimele, and Ludes (2000), in the case of 12 injured motorists out of 150, only THC was traceable in the saliva (range of concentration from 0.7 to 103ng/salivette), while in the case of 17 motorists THC, 11-OH-THC and THC-COOH were traceable in the blood. For the following substances the traceability in saliva is described (Kintz, 2000): • Cocaine can be detected for a period of 4-12 hours (intravenous, intranasal or by inhalation). • Heroin can be detected for less than an hour (intravenous), 6-acethylmorphine for one to four hours and morphine for twelve hours. • Codeine is detectable for a period of 9-12 hours (oral). • THC is detectable for several hours (inhalation). In the first half hour following the inhalation concentrations of THC >100ng/ml can be measured. The salivary concentrations are higher than the plasma concentrations in the first few hours. Saliva testing for THC seems to be more effective than urinary analyses in the case of recent cannabis exposure. • Amphetamines/Methamphetamines: The saliva concentrations are two to three times higher than the plasma concentrations (single oral, intravenous, or inhaled).

Samyn et al. (1999, Rosita) report in their market study costs of 6 to 18 Euro for a one to five parameter salvia test. They tested three devices that can be used for salvia or sweat.

7.1.4.1.3 Sweat Analysis A sweat test can be conducted only with a time delay, because the agents appear not until 4-6 hours after the intake. For confirmation, very sensitive and elaborate methods are necessary. Because of the difficulty of sweat production, this procedure is not practically applicable on the roadside (Rosita, 2000). For a doubtless proof with reliable physical and chemical measurement methods, a so-called “sweat pad” had to be worn additionally on the skin for several hours to accumulate sufficient substance for analysis. (Battista, Katzgraber, Steinlechner, Haidekker, Rössler, Ober, Kemmler & Muigg, 1999). Proof of benzodiazepine derivatives is problematic. In case of cannabinoids, cannabinol and cannabidiol are detected, but hardly THC (Battista, 2000).

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While cocaine and amphetamines, including ecstasy derivatives, as well as opiates and their metabolites are easy to detect in sweat, benzodiazepine or cannabis tracer concentrations are extremely low, probably because these drugs have a liposolubility which is not very conducive to passive diffusion from plasma to saliva. A quantity of 1 to 5 mg of ingested cocaine is detectable in sweat (Kintz, 2000).

7.1.4.1.4 Blood Analysis Blood analyses represent a very reliable method with which momentary drug consumption can be reliably determined. The method represents, however, a massive invasion of the integrity of the body, too. In the following figure, it can be seen that blood analysis and urine analysis provide different results over time.

Fig. 1: Concentration of intoxicants in blood and urine over the course of time (from: Möller, 1998, p.46). Translation of terms for Figure 1: Konzentrationszeitverläufe von Suchtstoffen in Blut und Urin: Concentration of intoxicants in blood and urine over the course of time intravenös/inhalativ: intravenous/inhalative oral: oral Blut: blood Urin: urine Konzentration: concentration Zeit: time Nachweisgrenze für Blut: limit of traceability for blood Drogenaufnahme: drug uptake Ende der Nachweisbarkeit ...: end of traceability of the agent in blood (approx. 6-8 hours); traceability of the breakdown substances in urine Nachweis Abbaustoffe nur noch im Urin: traceability of the breakdown substances solely in urine End of translation

Relative high concentrations of many substances can be determined in urine in comparison to blood. An acute consumption, e.g., of cannabis is to be recognised by determination of tetrahydrocannabinol in blood, but this is successful only some hours after the consumption (Käferstein and Sticht, 2000). Daldrup, Käferstein, Köhler, and Maier (1997) discern a one-time, infrequent consumption from habitual consumption, whereby not the THC-concentration is drawn upon in the blood analysis, but the concentration of the slowly degrading metabolite THC-COOH. This fact has

Page 65 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 been utilised for 5 years in North Rhine-Westfalia to be able to make a distinction between one-time, occasional, and regular cannabis consumption in the context of the assessment of driving fitness.

Result of the blood analysis Interpretation of the findings THC-COOH = 0ng/ml no evidence of consumption THC-COOH < 5.0ng/ml no evidence of persistent/regular cannabis consumption THC-COOH < 5.0ng/ml and no evidence of persistent/regular cannabis THC positive consumption, but temporal correlation between taking of the blood sample and cannabis consumption THC-COOH ≥ 5.0ng/ml and Persistent/regular cannabis consumption not precluded < 75 ng/ml THC-COOH ≥ 75ng/ml Persistent/regular consumption Table 20: Criteria for evaluation of cannabinoid concentration in the blood (according to Daldrup et al., 1997)

7.1.4.2 Analysis of hair and skin

7.1.4.2.1 Hair analysis Hair analyses for drug proof yielded that with different hair types different proof of drug concentration is possible. Studies have shown that this method is accordingly sensitive to the mainly abused illicit drugs with daily to weekly consumption, with the exception of LSD. Hair analysis does not provide information as to recent consumption, a hair about 4 cm long reflects the consumption during the last 3 months. With proper handling, false positive results are impossible. Attempts at cleaning the hair, bleaching or colouring have no influence on the procedure (Pragst, Sachs, and Sporkert, 1999). The reliability of proof of a hair analysis is higher in comparison to urine (because of the larger time window for all kinds of drugs). The advantage of hair analysis is that it can be ordered retrospectively for a period already gone by. Urine controls have to be arranged before the start of the examination period. A comparison of urine and hair analyses has shown that in case of cannabis positive urine findings, also negative hair analyses were possible. With cannabis negative urine findings, the hair analyses were negative, too. As a consequence for cannabis findings it resulted that only urine tests are to be utilised. In case of cocaine or opiates, a positive hair analysis is possible with up to 40%, when the urine findings are negative (Iwersen, Schmoldt, Lewrenz, and Püschel, 1998). In the literature, the following detectable concentrations are described (Pragst et al., 1999): • Cannabinoids In case of THC, the concentrations lie between 0.02 and 20 ng/mg. In case of daily consumption, the concentrations are above 1 ng/mg THC. One joint per week would result in values between 0.02 and 0.3 ng/mg (Cirimele, Sachs, Kintz, and Mangin, 1996, as cited in Pragst et al., 1999). • Heroin/Opiates A daily minimum uptake of 80mg heroin can be detected reliably (Kintz, Bundeli, Brenneisen, and Ludes 1998, as cited in Pragst et al., 1999). Concentrations of the metabolite 6-AM determined with heroin consumers lie between 0.3 and 20 ng/mg. A

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hair analysis allows to discern clearly between the abuse of heroin, morphine, codeine, and dihydrocodeine (Kauert and Röhrich, 1996, as cited in Pragst, et al., 1999). • Cocaine Positive findings were already found at 30 mg per month. In case of regular consumption, the concentrations lie between 0.3 and more than 100 ng/mg (clearly above the proof limit). • Amphetamines Amphetamines and metamphetamines are effectively accumulated in the hair. In cases of abuse, concentrations between 0.1 and 6.5 ng/mg could be found (Rothe, Pragst, Spiegel, Harrach, Fischer, and Kunkel, 1997; Röhrich and Kauert, 1997, as cited in Pragst et al., 1999). • Ecstasy Concentrations between 0.1 and 15 ng/mg of MDMA and MDE could be detected (Uhl. 1998, as cited in Pragst et al., 1999). • LSD LSD is not traceable in the hair.

In Italy, drug consumers have to undergo hair-analyses for the renewal of a driving license. The combination of this analytical tool with the adoption of restrictive measures (i.e. withdrawal of the driving license) acts as a strong deterrent and effective strategy, reducing the risk of relapse into drug use: two thirds of the persons positive for either opiates or cocaine and more than 90% of the negatives tested negative at a second control carried out one to two years later (Polettini and Montagna, 2000).

7.1.4.2.2 Analysis of skin Proof of the source substances and their primary metabolites; concentrations of opiates, cocaine, and their metabolites are clearly higher in comparison to cannabinoids; in case of all substances, a considerable range of the traceable concentrations resulted; no temporal relation between time of intake and proof; in case of one-time consumption, there is often a latency, so that despite a momentary influence the skin test is mostly negative. After the effects have worn off, a positive proof is possible for a long time (Skopp, Pötsch, Zimmer, and Mattern, 1997).

7.1.4.3 Conclusions and recommendations Since a summary of pharmacologically and toxicologically justified threshold values is currently not possible because of the varying breakdown of the various drugs and medicines, one has to rely in the near future always on exact statements of the police, an exact description of the subject’s behaviour, and medical examinations as well as confirming chemical and toxicological analyses for criminal prosecutions (Battista, Katzgraber, Steinlechner, Haidekker, Rössler, Ober, Kemmler, and Muigg, 1999). As emanating from the description of the particular analysis methods, currently developed devices are variably well able to detect substances. Further research is therefore much-needed. Battista et al. (1999) suggest to establish legal conditions that allow to secure 2 to 3 bodily fluids that are easily available (saliva, blood, or urine) to permit systematic pharmacological examinations and to gain the necessary experience (Battista et al. 1999).

Rosita (2000) concluded necessary future modifications in the development of drug screening devices:

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• Urine tests are validated devices. They are not applicable under the respective legal systems or operational conditions of police forces in most countries; • Saliva/sweat test devices fulfil most operational requirements, but are still in development and under validation; • Clear regulations will encourage the industry to invest more strongly in new products, intensification of developmental activities by harmonisation of national Traffic Safety Regulations or by public funds to co-finance the developments; • Close co-operation of police, national governments, medical and toxicological experts and industry in the future to solve legal, operational and technological problems; • Accreditation and homologisation on EU level: • Only 6 Countries (F, UK, NL, PL, SL, G) have accreditation of test devices, according to European level there exists a regulation for in-vitro diagnostic medical devices. A “CE” sign shows validity and a quality controlled system. • Future consolidation: manufacturers have to fulfil EU directive and police specific national approval criteria. Prerequisite-approval process must be well structured and can be passed in short time. • On national level, the countries of the EU have to adopt the in-vitro diagnostic medical device regulation until 7th of December 1999. From 7th of June 2000, medical devices have to comply with this new regulation. There is a 5-year transitional period, after 7th of December 2003, only products that fulfil the regulation-norms will be sold within the EU.

The Pompidou-group demands (2000): • European harmonised proficiency testing programme for drug analyses in blood should be implemented in each country. European proficiency testing survey should be elaborated (Pompidou 2000). • Procedures used by national forensic laboratories for assaying and reporting illicit and licit drugs should be standardised across the European countries.

7.1.5 Medical screening - Physical and neurological examination This section contains suggestions by experts on steps of a standardised clinical examination that is necessary for a proof of a potential impairment by drugs.

7.1.5.1 Crucial aspects Somatic examination Previous medical examination records concerning the detection of an influence of intoxicants register only physical deficiency symptoms – the intoxicating effects that constitute the real danger in road traffic are not verified (Schmoldt et.al 1998). Battista et al. (1999) are of the opinion that the assessment of the general physical condition is not very meaningful regarding a drug influenced state. Deficiencies due to malnutrition or signs of neglect are at the best unspecific hints toward drug addiction. In the outwardly visible state, evidence of recent drug consumption is hardly recognisable. Frequent organic damages are not relevant within the scope of these examinations. Typical characteristics of consumption like injection marks are concrete clues to drug consumption. Neurological examination Because of their complexity, neurological findings may generally be collected only by a specially trained physician or a neurologist. The interpretation of singular symptoms or of

Page 68 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 neurological findings without an extensive anamnesis is only moderately meaningful (Battista et al., 1999). Psychiatric examination (psychopathological findings) According to Battista et al. (1999), psychic conspicuities often are the only perceivable signs of drug influence. To recognise these changes, the person has to be engaged in a conversation and closely observed. A „diagnosis at a glance“ is able at best to show conspicuities in drive and mood. The psychic conspicuities are only to be described, not interpreted.

7.1.5.2 Implications for practical implementation There need for: • Training of physicians in neurological and psychopathological examination for the detection of influence of drugs and medicines (Battista, Katzgraber, Steinlechner, Haidekker, Rössler, Ober, Kemmler, and Muigg, 1999). • Standardised proceedings and documentation at the clinical and neurological examination (Flesch, 1994, as cited in Springer et al., 1999).

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8 RE-GRANTING DRIVING LICENSE, RECIDIVISM

8.1 GENERAL LEGISLATION ACROSS EU COUNTRIES As a rule with DUI-offence, a withdrawal of the driving licence takes place, a ban from driving for a certain period. In the tables of the section “Legislation”, the varying penalty limits were depicted. In some countries, the attendance at a rehabilitation measure is mandatory (e.g. from a certain alcohol level during the offence) to regain the driving licence. However, in some countries there additionally exists the possibility to dwell specially on the individual case, e.g. within the scope of a medical or traffic-psychological examination.

8.2 INDIVIDUAL ASPECTS AND LEGISLATION

8.2.1 Special Legislation in EU Countries Case-specific frameworks obtain, for example, in the case of the problem of addiction. In such cases, the drivers have to undergo, for example, a medical treatment and, e.g., in the case of alcohol, have to present inconspicuous laboratory data (e.g. Sweden). Case-specific application is also the case, if persons with a strongly increased recidivism risk are concerned. In some countries (e.g. Austria, Germany, Spain), a medical and frequently also a psychological examination takes place within the scope of the proceedings. The assignments to such an assessment are case-specific and can be justified, for example, by an extraordinarily high alcohol level, a problematic, serious abusing behaviour, or by the problem of addiction. Special groups are therefore subjected to an extended treatment, because an increased recidivism risk is assumed. The causes of the careless behaviour should be determined, and to what extent the driving fitness is restored, e.g., to what extent the driver has undertaken sustainable changes (Nickel 2000). Medical and psychological examinations in Germany as well as traffic-psychological opinions in Austria were able to lower the recidivism rate clearly. Specific rehabilitation measures represent a supplemental component with further positive influence (see also chapter „Rehabilitation“). The tradition of traffic-psychology has developed out of the performance survey. Today, an integrative approach is maintained: physical as well as mental abilities are of importance while driving a vehicle, personality variables and attitudes play an important role concerning risk potential and causes of accidents (Nickel 2000). The following chapter addresses traffic-psychological diagnostics where on the one hand the driving specific performance is assessed, on the other hand the willingness to adapt to the traffic (in Austria, defined terms in the driving licence law (FSG)).

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8.2.2 Driver performance and personality

8.2.2.1 Psychological assessment in context of an psychological expert opinion

8.2.2.1.1 Chronic effects of substance abuse on performance Assessments within the scope of roadside procedures deal with the acute impairment, e.g. driving under drug influence. In the context of a traffic-psychological examination, within the scope of the applied test procedures concerning visual perception, reactivity, attention and concentration, and sensomotor performance, not acute impairments, but mainly the driving specific capability in a „sober state“ is measured, whereby, however, chronic changes may be possibly determined. Which changes in performance show because of chronic substance consumption? Following, the changes concerning the particular substances are listed, if known. Alcohol: Krüger, Kazenwadel, and Vollrath (1995) discern moderate drinkers, consumption drinkers, heavy drinkers, and hard drinkers (highly pronounced habituation to alcohol due to a long drinking history). The development of an alcohol addiction happens frequently. Chronic alcoholics show changes in character as well as changes in performance. These changes concern the long term memory and the retentiveness; attention is reduced, further, increased fatigue, reduction of the ability for discrimination and criticism, and decreased power of concentration are observable. Uhl et al. (2001) state that many, if not most of the symptoms are reversible. They wear off when alcohol abuse is stopped. It is possible, on the other hand, - so Uhl et al. (2001) - that these deficits often arise because of an increasing organic damage of the brain due to alcohol. In those cases, the change in performance shows a progressive course and results in alcoholic dementia that can be countermanded by abstinence only within narrow limits. These aspects are constantly confirmed within the scope of traffic-psychology studies. Cannabis: While acute effects are relatively good traceable in case of cannabis consumption, chronic effects are discussed controversially. It is not explicitly provable, if chronic cannabis consumption is a cause of psychopathological syndromes or the result of them. Merely a correlation was determined, but not its trend (Shedler and Block, 1990, in Chaloupka, Risser, Grabmayer, Kisser, Ruby, Thorwartl, and Zehetner, 1999). Brenner-Hartmann (1998) cites the amotivational syndrome, impairment of concentration and memory, increased sensitivity to light, triggering of predisposed psychosis, various health troubles, and psychic addiction as possible permanent damages of chronic cannabis consumption. Finally, the phenomenon of „echo effect“ or „flash back“ should be mentioned, that sometimes, though rarely, occurs also with cannabis - according to Täschner (1991). According to Bresser (1972), this is the observation that after the intoxicating effect have apparently worn off, abruptly and without further administration of intoxicants, a state occurs with different time-lags up to several hours that is very similar to the previously abated intoxication. This controversial phenomenon was mainly observed after the intake of hallucinogens and complicated courses of intoxication.

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As explanation, the hypothesis was developed that a certain amount of the intoxicant is accumulated in body tissue and is washed out more or less suddenly by various causes (Fous, 1995). As undocumented and improbable the phenomenon is with cannabis, it was a sufficient reason for a court in Baden-Wuerttemberg to deny a regular cannabis consumer the driving aptitude. In the opinion they say (Haller, 1992): "Especially with so-called hallucinogens, to which cannabis has to be assigned, it has to be heeded that dangerous psychic changes or deficiencies appear not only during the acute intoxication, but also in the phase of after- effects, after the intoxication symptoms have worn off. Especially with hashish, a re-flash (flash back, echo intoxication) of the intoxication symptoms is possible after an interval of several days without symptoms even with a one-time administration. [...] This impossibility of controlling the consequences of intoxication over time justifies the assumption that hashish consumers - other than alcohol consumers - are generally not suited for driving motor vehicles." (p. 7). The discussion about whether flash backs are regular with cannabis consumption at all, is not to be accounted as completed despite the jurisdiction. According to a literature survey by Täschner (1991) concerning this problem, there are apparently flash backs in some cases of pure cannabis consumers, but not as a general rule. Opiates: Gerhard, Biedert, Hobi, Hug, and Ladewig (1997) examined the influence of long-time heroin addiction on driving fitness. The experimental group consisted of 25 healthier, most seriously addicted persons between 24 and 40 years of age who got medically prescribed opiates on the basis of the Swiss governmental programme existing since 1994. The drug addiction lasted on the average for 13 years. The daily consumption of pure heroin in the moment of the survey lay between 200 and 800 mg. This group was compared concerning their performance with a group of positively and a group of negatively rated persons failing at exams. Mental abilities like selective attention, reaction speed, stress resistance, vigilance, concentration in simple and complex situations, hand-eye co-ordination, and others were measured. The measurement of the crucial parameters took place at the time of maximum effect. The results showed that the opiate addicted persons had a comparatively large extent of information that even lay above the median of the positively rated persons failing at exams. At the same time, higher error values were apparent. The opiate addicted persons thus had an inconspicuous working pace, but at the expense of accurateness. With chronic abuse respectively addiction, a change of character can appear, the so-called amotivational syndrome with indifference and psychomotor slowdown. Methadone: “The aim of a methadone programme is the physical and social rehabilitation of heroin addicts, to allow them to lead a normal life (including driving). To evaluate driving abilities a case by case examination is needed that takes into account several circumstances: a substitution period of more than one year, a stable psychosocial integration, a sense of responsibility, therapy compliance, and no intake of other psychotropic substances or alcohol” (Maes et al. 1999, Rosita) According to Babst et al. (1973, as cited in Meyer-Gramcko, 1992), methadone patients show with 33% only inessentially more accidents after an examination period of 5 years than the - regarding age and sex - comparable control group with 29%.

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Gerhard-Choi (1990) reports that long-time heroin consumers that were changed over to methadone showed analogue group medians in traffic-relevant fields of performance to control persons that had never been drug-addicted. In a study by Presslich et al. (1990), 47 subjects were examined who were substituted with methadone with a stable dosage for at least three months. These persons had to undergo a clinic-psychiatric interview, a psychological and experimental-psychological examination and had to give a blood sample. The entire examination showed largely no gross conspicuities with methadone patients. Dimensions relevant for road traffic like motor reactivity to simple visual signals, sureness of motor reaction, resilience of the response behaviour at multiple reactions, and power of concentration in a permanent stress test supplied only one statistically significant difference. Thus, methadone-substituted persons showed a prolonged reaction time at simple visual signals. Concerning the driving licence anamnesis and driving history, no critical conspicuities could be found with methadone patients as well. None of the 25 owners of driving licences had had an accident since the time of his/her conversion to methadone (Presslich et al., 1990). Another empirical study on driving aptitude of methadone-substitution patients took place in Cologne. Berghaus et al. (1993) included 34 methadone-substituted persons in this study, whereby 21 patients had to be accounted as unfit for driving primarily because of co- consumption of other substances and alcohol as well as because of basic psychiatric disorders. The remaining 13 substitution patients were compared with a paralleled control group regarding psychophysical performance and personality traits. The substituted persons showed significantly worse performance at tracking, gaining of overview, and reactive permanent resilience. In the field of personality, the substitution patients were more anxious, had lower self-control and self-confidence, and higher aggressiveness, excitability and emotional responsiveness. Berghaus et al. (1993) point out, however, that the results must not be generalised because the sample was not representative and the practice of the methadone programmes varies strongly in the individual nations. Friedel and Berghaus (1998) conducted a meta-analysis of different morphine studies with pain patients and arrived at the conclusion that the assessment of driving fitness of the patients can be clarified only by an individual examination. Berghaus, Shibata, and Friedel (1998) could summarise the results of their first study on methadone to that effect that in a comparison of groups of methadone patients and a control group matched regarding age, sex, and educational background, the methadone patients showed significantly worse performance concerning keeping the track, the tachistoscopic perception test, peripheral perception at central tracking, and reactive resilience. Some patients, however, showed a performance comparable to that of the normal subjects. These results could also be confirmed in a second, extended study. Dittert, Naber, and Soyka (1999) could also determine a significant traffic-relevant deterioration of performance of methadone-substituted patients in comparison with a control group. There were, however, persons also with the methadone patients that had in parts a better performance than persons in the control group. This result confirms the demand for an individual assessment of the driving aptitude. In a study by Kubitzki (1997), the global aptitude of methadone patients for driving a motor vehicle was to be assessed. With a test battery, the reaction, attention, and perception standard was assessed, a standardised observation of driving behaviour and a psychological interview with hypothesis-directed personality diagnostics was conducted. The performance tests and the driving check betrayed no significant differences to healthy persons. The findings of the

Page 73 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 exploration, however, made clear that in the majority of cases a stable drug abstinence did not exist. At the same time, the increased appearance of simultaneous neurotic disorders with methadone patients was confirmed. The fact of methadone treatment alone does not justify the imperative assumption of inaptitude of driving a motor vehicle. However, stable drug abstinence is a scarce exception, diagnostics of the individual cases are therefore much- needed. Haag, Colmegna, and Thiele (1999) tested 196 methadone consumers admitted to road traffic for further administrative measures. It showed that 46% of the subjects judged fit for driving came on the records again. In a study from Australia not yet concluded (Lenné et. al. 2000), the effect of several substitution compounds on driving-relevant parameters (keeping the track, reaction speed) was examined in a simulator before and after their receipt and also in combination with alcohol. Respectively 10 persons with methadone as well as two alternative substitution compounds (LAAM, Buprenorphine) were examined in comparison with a control group. Currently, results for the methadone group as well as the LAAM group are available. Little fluctuation in lateral position seems to exist for methadone clients pre and post dosing, but alcohol seems to have no influence on keeping lateral position. Compared to methadone clients, LAAM clients were able to keep a more stable lateral position. No alcohol influence appeared for this group, but the time of dosing was effective. The authors interpreted the withdrawal symptoms as effective for the more variable lateral position when testing prior to a dose of LAAM. For both groups the mean reaction times are slightly higher with alcohol and in the pre-dosing conditions. The authors attribute the small increase of reaction time with alcohol to the possibly high tolerance of the patients for alcohol. Another explanation could be an interaction between the substitute and alcohol which reduces the effect of alcohol. At the university psychiatric hospital in Vienna (Austria), a research series was conducted between 1999 and 2001 concerning the effects of various substitution compounds and of the time of intake with opiate-addicted persons. The influence on driving-specific capability was also examined in this context in co-operation with the Austrian Road Safety Board (in preparation). The results will be available presumably in autumn 2002. Hallucinogens: Relevant for road traffic is the possibility of echo-intoxication. Amphetamines: Hurst (1976, 1987) concluded in his survey studies concerning amphetamine use and driving behaviour that road users with chronic abuse of amphetamines show about four times as much accidents in road traffic as was to be expected because of their age, sex, or driving aptitude.

8.2.2.1.2 Personality – characteristics of AMD drivers Further essential key aspects in the context of traffic-psychological studies are the exploration of personality, the assessment of the attitude toward drug consumption, possible abuse or addiction. In the context of the traffic-psychological examination of drug-conspicuous motorists, it has to be clarified in the field of personality (next to aspects of performance), first of all, if clues to repeated drug abuse can be found, possibly in conjunction with alcohol (polytoxicomania), if in case of previous massive abuse, a sufficiently long and stable abstinence exists, and if general adaptation problems linked to the drug abuse respectively clues to psychiatric co- morbidity (depressive disorders, anxiety disorders, etc.) exist, that preclude driving aptitude.

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Numerous studies have dealt in the meantime with the problem of characteristics of drugged drivers. Because of the highest detection rate in Europe, the Norwegian data can be accounted as especially reliable. The analyses of other countries confirm the picture: The typical drugged driver is predominantly male (85-90%), between 25 and 35 years old and multi-drug user, alcohol not included (Christophersen and Morland, 2000). Regarding the substance consumption, a trend away from sedating substances to stimulants can be observed (see e.g. Möller, Hartung, and Wilske 1999; Rentsch, Weirich, and Wegener 2000; Longo et al., 2000). Are there specific personality traits that characterise an AMD driver, respectively that are conspicuous for this group? Vollrath et al (2001) conducted an extensive study on characteristics of drugged drives and driver-relevant aspects of capability of drug consuming drivers. By means of interviews, 2555 car drivers were interrogated after selected events in Bavaria. An intensive examination of 503 persons ensued whose capability was assessed in the driving simulator and of whom blood, saliva and urine samples were collected within the scope of a medical examination. The authors could determine that drugged drives occurred as frequently as drives with an alcohol level of more than 0.5‰; alcohol is often co-consumed with drugs. Vollrath et. al. emphasise that in case of alcohol consumption, people decide rather not to drive, the consumption of illicit drugs, however, has no impact on the decision to drive. On the basis of the interviews, different groups of drug consumers with different patterns of consumption could be discerned. In detail: • Hard and heavy drug consumers drive even under drug influence. • Drugged drivers show increased risk willingness. • Drug consumers drive more often also with high alcohol levels. • Sanctions show impact only in case of little drug experience. • With consumption behaviour, the impairment of performance that is subjectively felt as small dominates the aspired effects of legislation. • Repressive governmental measures have an impact on the rating of drugged drives. Detected drugged drivers experience their offence as more condemnable than undetected drivers. Brenner-Hartmann (1998) cites the following aspects that have to be clarified in the context of traffic-psychological surveys: • Do disorders of attitude and adaptability exist because of psychic aberrations? • Do personality problems exist that possibly determine the drug consumption? Were they decisively corrected? Aside from these aspects that have to be clarified in the specific individual cases, there are general changes in the field of personality because of chronic consumption that are cited as follows. Alcohol and personality: With chronic alcoholics, also a change in character shows aside from the changes in capability: suggestibility is increased, interests are lost, the person is unreliable, affect labile, shows mood changes. Many of these symptoms are reversible when alcohol consumption is ended. Some deficits may have already an organic damage of the brain as a basis. In these cases the changes show a progressive course and lead to alcoholic dementia. A reduction because of abstinence is only possible within narrow limits (Uhl et al., 2001). Cannabis and personality:

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According to Buchholtz (1993), the cannabis consumer doubts his/her driving aptitude at the time when he/she consumes the drug regularly. The following clues point to that: • a substantial intensity and length of consumption that is not linked to certain and limited situations; • a psychic background conflict or a psychosis exists that the consumer attempts to treat by himself with cannabis; • a tendency to polytoxicomania; there often exists a combination of hashish with alcohol that intensifies the effects of cannabis; • psychic withdrawal symptoms like inner restlessness, anxieties, impairment of concentration, and depressions are ascertainable; • Drug selling and active frequenting of the drug scene. If psychic addiction is diagnosed, a positive assessment of driving aptitude is only possible, when a sufficiently proved abstinence from cannabis exists for one year. This period is considered necessary for a sufficient detachment from the drug scene. Abstinence statements appear to be credible, when an inner alienation to the drug, and familial and job-related re- integration have taken place. Brenner-Hartmann (1998) emphasises the amotivational syndrome as pattern of findings in case of chronic cannabis consumption. Even occasional consumption of the drug in small amounts can cause effects that massively impair the driving aptitude (Buchholtz, 1993). Occasional cannabis consumption has to be assessed as problematic mainly when the examined person has no problem awareness for the risks of driving impaired by drugs and therefore does not separate drug consumption from motorised road use. An inquiry of young cannabis consumers from Melbourne concerning their patterns of consumption and driving behaviour (Lenné, Dietze, and Rumbold, 2000a) had shown that they would rather drive a vehicle in case of exclusive cannabis consumption than in case of cannabis and alcohol consumption. They regard the second case as essentially more dangerous, but they attribute the increased impairment rather to the effects of alcohol than to a combination effect. Opiates and personality: In case of chronic abuse respectively addiction, a change in character can occur, the so-called amotivational syndrome. It is characterised by indifference and psychomotor slowdown.

8.2.2.1.3 From abuse to addiction The following statements do not refer exclusively to the consumption of illicit substances, but can be applied similarly to, e.g., alcohol consumption. Brenner-Hartmann (1998) describes the development of the behaviour from the first try to addiction or even polytoxicomania. The table below envisages the individual process within which the desirability and the bond to the drug increases permanently. The determination of the stage the person is in is important especially within the scope of the traffic-psychological examination. For here, it is to be clarified to which extent a consolidated pattern of consumption exists, a formation of habituation, a behaviour that cannot be controlled by the person concerned. The existence of exactly this factor, however, rules out driving aptitude: Kroj (1995, p. 98; in Brenner-Hartmann, 1998, p. 259) writes: „A person who is addicted to drugs or, without being addicted, abuses illicit drugs (in the sense of DSM-III-R) or uses them in a self-harming way (in the sense of ICD-10), so that the

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Form of consumption Description testing behaviour Motivation of behaviour: curiosity and group role models; gaining of first experience and forming of an expectation concerning the effect occasional consumption Linking of the consumption to sporadic, rather infrequent events (e.g. vacation, special occasions); elongated pauses of consumption and conscious decision for consumption with prevention of possible negative consequences; no serious effects on living yet habitual consumption Formation of habituation; the consumption gets a firm place within the recreational activities and living, more and more often unconscious decisions for consumption because of situation-related or emotional triggers; sometimes consumption in unfitting situations; still existing adaptability because of experienced downsides. harmful use Diagnosis category of ICD 10: Damage of psychic or physical health because of consumption (no statement about bond to the drug and psycho-social context) abuse Diagnosis category of DSM: Continuation of consumption despite known negative effects (e.g. in the field of health) or consumption in dangerous situations (e.g. alcohol in road traffic) polyvalent consumption At least habitual consumption of several intoxicants in the same biographic period; can be assessed as a sign of a far-reaching attempt to control emotions by external intoxicants, because of the mostly varying spectra of effects of the drugs; severe danger of developing a psychic addiction. Rather individualised problem; integration in a specific drug subculture and its control mechanisms is rather secondary. addiction Multidimensional diagnosis category of DSM and ICD-10 with, e.g., the following criteria (selection): Lacking possibility of controlling the consumption Failing attempts of control Increasing input of time and energy in consumption and recovery from consumption Neglect of other important duties Substantial tolerance development polytoxicomania Simultaneous addiction to several substances or addiction to a substance and abuse of another intoxicant

Table 21: Forms of consumption of intoxicants (Brenner-Hartmann, 1998, p. 258)

In the survey, the diagnostician should orient himself/herself by the driving aptitude guidelines of Kroj et al. (1995): • No clues to current drug consumption or medicine abuse can be found. • In the case of drug addiction, a withdrawal therapy or a professional counselling process has laid the personal foundations for a stable abstinence.

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• A permanent, sustainable inner alienation of drug consumption exists. • An adequate period of abstinence exists before the survey, 1 year as a rule. • An existing abstinence is supported by favourable factors in the person, in social behaviour and in the social environment. • Organic or psychic diseases relevant for driving aptitude that are associated with the drug consumption cannot be diagnosed anymore or are healed up sufficiently stable. • Disorders of attitude and adaptability because of psychic aberrations do not exist. • Personality problems that possibly determine drug consumption were detected and corrected decisively. • With the given intellectual and psychic-functional settings, a traffic-compatible behaviour is possible.

8.2.2.1.4 Risk sensation seeking Risk sensation seeking as an aspect of personality may play an interesting role just for risk assessment. Dolbeault, Girre, Hispard, Bozzi, Dugarin, and Dally (1997) looked for differences in driving behaviour according to the substance of abuse and established potential relations between these differences and a sensation seeking personality dimension. They compared alcohol addicted individuals with patients addicted to drugs. They found out that drug-addicted patients have more characteristics linked to the sensation seeking personality dimension than alcoholics. Their behaviour changes under drugs are thus maladapted to the addiction, leading to severe risk taking. Donohew, Hoyle, Clayton, Skinner, Colon, and Rice (1999) investigated the influence of the sensation seeking tendency of individual adolescents and the sensation seeking tendency of peers on the use of alcohol and marijuana. They were asked about family relations, sensation seeking, perception of their own and their friends’ use of alcohol and marijuana. They found direct effects of the peers’ sensation seeking on the adolescents’ own use of marijuana and alcohol two years later. The individuals’ own sensation seeking had indirect effects on drug use two years later. These findings indicate the potential importance of sensation seeking as a characteristic on which adolescent peers cluster. The results show that beyond the influence of a variety of other risk factors, peer sensation seeking contributes to substance use of adolescents.

8.2.2.2 Implications for practical implementation The experiences in Germany and Austria with regard to the validation of traffic-psychological examinations make clear that by this kind of case-specific assessment, the recidivism risk can be lowered by up to 50%. With that, this measure should surely be pushed in other countries, too.

8.2.3 Medical reporting For drink-driving the situation is as follows: Medical intervention is appropriate, if there is a health problem or a consumption pattern that has to be checked. In general, Member States do not include a medical test to assess the alcohol consumption of offenders on rehabilitation courses. Openshaw (2000) suggests, however, that a medical examination should be integrated in or accompany rehabilitation. The following table shows the practice of some countries.

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Country Condition Examination United 2 offences in 10 years or BAC of Medical examination and blood test Kingdom 2.0 g/l before regaining driving licence. Netherlands Over 2.1 g/l Medical examination demanded by the Minister of Transport; negative results -> licence is declared invalid Portugal Three serious offences connected Medical test after six months clinical with alcohol during a period of treatment before they get licence back five years Sweden BAC above 1.0 g/l Medical certificate (not dependent on alcohol; the driver has to see a specialist on at least three occasions during a period of six months; biological markers are used). -> provisional licence -> all driving tests -> new licence conditional for 18 months (clean liver enzyme tests on three occasions). Finland Course assessment identifies Blood and urine samples for alcohol dependency (and driver wants his markers license back) Denmark Institution running the course Treatment is set up decides if treatment is appropriate France Decision to refer the offender to further treatment rests with the judge Germany Court ordering, authorities Medico-psychological test. Positive ordering result -> the offender can attend the course. Attendance of course is precondition to get licence back Table 22: Conditions and Examinations in some EU-countries after drink-driving offences (data from Openshaw, 2000)

In connection with drug-driving, there is currently no overview of the handling of medical reporting within the EU. The information of several countries (Krüger et al., 2000, Pompidou), however, shows the following: In Austria, every driver has to pass a medical examination before licensing. In case of specific questions, e.g. addiction problems, he/she is assigned to a specialist. Germany uses medical-psychological examinations, too. This is defined on the basis of special aspects, e.g. addiction, drink-driving offence with BAC above 1.6‰. In France, a medical examination can be ordered, if there has been a serious accident or committing an offence against the Road Traffic Act. The person is examined by a medical commission consisting of two physicians. The medical doctors can consult other specialists. On the basis of the medical examination, the driving license can be withdrawn. The driving license is refused, if the person is addicted to euphoriants or other psychotropic drugs or alcohol.

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In Italy, re-granting is dependent on a medical examination (with urine screening). If this test is negative, the driving licence is re-granted for one year. Then, the medical examination is repeated; if the urine screening is again negative, the driving licence is extended. If the medical examination discovers addiction, the driving licence is refused. There is a special medical examination to investigate driving fitness. Psychological investigation can be conducted. In the Netherlands, the following is applied: If the licensing authorities are notified of a person’s drug use or addiction, a medical advisor investigates driver fitness, there can be a medical examination, too. In Spain, there are medical (and psychological) tests in special medical traffic centres to prove to be no longer drug-addicted. In Sweden, a doctor’s certificate has to ascertain that the person does not have a drug problem. In the UK, the driving licence is withdrawn if the person is addicted. The family doctor can be asked to give a declaration about the health state of a person. If the driving licence is limited, medical screening can be demanded on several intervals.

8.3 REHABILITATION Openshaw (2000) defines rehabilitation as “any course or treatment aimed at changing the behaviour of the offender so he/she does not persist in mixing drinking and driving. This may involve educational methods, psychological techniques, or medical examination and treatment or a mixture of these. We shall also briefly examine another method of influencing future driver behaviour, by the use of ignition interlock devices, though these have been little used within the EU or EEA” (p.31). The extent of psychological or educational courses varies between the European countries. Austria and Germany have a long tradition in providing such courses and a “highly professional approach to doing so” (Openshaw, 2000). Other countries have recently started (e.g. Netherlands, Norway). The following countries are known to run officially approved rehabilitation courses aimed at drink-drivers: Austria, Belgium, Denmark, Finland, France, Germany, the Netherlands, Norway, Sweden, and the UK. Portugal is planning to introduce them (Openshaw, 2000). At first, Austria and Germany had used “driver improvement” courses for the most serious cases of offenders, e.g., those drivers who had killed someone or were habitual offenders. After some time, these courses were also used for other offences, and recently for novice drivers and first offenders. This work is part of prevention, because there is the opinion that an early intervention is more likely to break a behavioural pattern that could lead to a serious drink-driving problem. In Austria, young drivers in the “probationary time” (a two year period after having received the driving licence) have to attend a course, if they had been detected while driving with a BAC of 0.1 g/l or higher. As Bartl, Esberger, and Brandstätter (1997) report, the results indicate that the treatment was more successful among those who were the youngest drivers and those who had the lowest blood alcohol level. In the UK, experimental courses were designed primarily for offenders having committed the first offence. It was observed that high risk offenders showed a greater relative improvement than offenders in general (Openshaw, 2000).

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Openshaw (2000) explains further: “[...] the only compulsory courses are those forming part of a conditional prison sentence (as in Sweden) or where failure to attend will lead to a prison sentence (as in Denmark and Norway) or a sentence of community service (as in Finland). In certain other countries (e.g. Austria, the Netherlands, Germany), attending a course (at least for certain categories of offenders) is obligatory for those who intend to keep or regain a driving licence. (In the Netherlands, first-time offenders with BAC below 2,5 g/l can normally keep their licences during the course, but will lose them if they fail to attend and complete it). Loss of the right to hold a licence is also the normal consequence of refusing to take a medical test where it is required. These regimes are virtually compulsory, though a proportion of offenders may opt not to continue driving (at least not legally)” (p.33). In Belgium, Denmark, France and the UK, rehabilitation is not compulsory, a positive inducement to participate may be necessary (Belgium: no further prosecution, Denmark: fine replaces imprisonment, France: restoration of points to the driving licence, UK: reduction of disqualification period up to 25%). In many countries there is more than one course model: severity of the offence, driving experience, age, and medical factors influence the decision which course is to be attended. As Bukasa and Christophersen (2000) report, psychological rehabilitation of drugged drivers is still at the beginning and there is limited experience with these group of drivers (e.g. Austria, Germany). There is, however, a great experience with drug addicts all over Europe. Drugged drivers have a high recidivism rate: e.g. in Norway, approximately 50% of the drivers are re-arrested during a period of three years. Therefore, psychological rehabilitation could be a promising approach to reduce the rate of recidivism. In Germany, addicts are sent to a classical addict treatment, offenders without addiction who are willing to stop drug consumption are treated in drug driving rehabilitation programmes.

8.3.1 Evaluation studies As numerous other validation studies confirm, rehabilitation courses can clearly reduce the probability of recidivism. The rates of recidivism could be reduced by such measures by up to 50 % (e.g. Christ, 2001; Davies, Broughton, Harland, and Tunbridge, 2000; Schützenhöfer and Krainz, 1999; Utzelmann and Jacobshagen, 1997; Michalke, Braglik-Chory, and Brandstätter, 1987; Utzelmann and Haas, 1985).

8.3.2 Implications for practical implementation As emanates from earlier experiences in Norway, penalties and high probabilities of detection alone are not sufficient to prevent recidivism or repeated offences. Especially persons with serious behaviour of abuse respectively addiction problems are not sufficiently deterred from endangering road use by penalties alone. Traffic-psychological examinations can determine the crucial deficits in the fields of performance, personality, and attitude and identify more appropriate rehabilitation programmes. Rehabilitation programmes give vital individual support in permanently lowering the risk of recidivism.

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9 RECOMMENDATIONS

Epidemiology The comparison of studies in epidemiology of impaired driving from different European countries is difficult because of a number of problems. This raises the demand that intensive research in the field of prevalence is continued, to be able to close the gaps in knowledge. Data acquisition in this field can be easier if it serves exclusively the scientific research. It should be possible to utilise roadside surveys regularly throughout Europe to be able to determine the prevalence of illicit drugs. Blood samples of injured drivers should be examined for illicit drugs, the analysing institutions (hospitals) should report annually. Above all, the prevalence of alcohol in combination with other drugs is of interest. Risk assessment With the risk assessment of drugs in road traffic several interpretation problems are vital - among others - the distinction of acute and residual effects, experimental evidence often comes only from young healthy volunteers, separation of drug effect and treatment effect, distinction active ingredient and metabolite. To improve risk assessment is important to know which doses of drugs in blood or saliva are associated with acceptable and unacceptable driving quality. This is relevant, for example, for persons under therapy (e.g. heroin substitution). Responsibility analyses or case control studies should be conducted for the most frequently used drugs. Comparisons of accident (fatal) cases and matched random sample of non-accident cases in the driving population are needed. Risk studies should include combinations of various drugs and combination of drugs with alcohol. Currently risk assessment can only be made as a first approach. As a possibility for orientation as to which substance group should be observed more severely because of its danger for road traffic the following ranking can be presented: • High risk: alcohol, benzodiazepines, cannabis with alcohol • High-moderate risk: cocaine • Moderate risk: cannabis, amphetamines • Low-moderate risk: opiates, methadone, antihistamines • Low risk: antidepressants

Legislation With regard to the prosecution of drugged driving most statutes require proof of impairment due to the use of illegal drug. This legislative approach is difficult to enforce because proving that the drug “caused” the impairment is problematical. Germany, Belgium and Sweden and 8 of the U.S. states have established “Per se” Laws that avoid having to prove impairment due to drug. These different approaches might offer a chance to compare the effectiveness of various ways in handling the drug driving problem. However, not only the legistic approach is different, differences between the countries concern for example the permission of random tests or measures only upon suspicion, use of breath alcohol testing devices, use of sobriety tests concerning drugs. If agreement can be achieved to collect data for scientific purpose comparisons between legal systems might become feasible. The effect of changes in legislation is a critical issue. Also for this purpose comparisons of legal systems and experience should be gathered.

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Harmonised national laws on the other hand might speed up the process of further development for screening methods, make them more valid and usable. Identification of impairment Closely connected with legal framework is the question whether drug enforcement in traffic needs to be based on the proof of impairment or can be based on an analysis which determines whether forbidden substances can be found in body liquids. For the impairment approach it is important to consider different complexity of drug effects. The kind of impairment of a single drug or a single medicine already varies dependent of the substance. But, simultaneous consumption of one or several further substances occurs frequently and results in a variety of interaction effects which makes impairment identification even more difficult. Preferred combinations as the following need consideration: Heroin co-consumption: cocaine, codeine, dihydrocodeine, benzodiazepines Methadone co-consumption: cannabis, heroin, cocaine, benzodiazepines Cocaine co-consumption: alcohol, benzodiazepines Cannabis co-consumption: alcohol Amphetamines co-consumption: cannabis, cocaine, LSD, designer drugs Designer drugs co-consumption: cannabis, cocaine, LSD, amphetamines, alcohol Benzodiazepines co-consumption: alcohol, other benzodiazepines. Most countries are willing to introduce legislation concerning impairment by drugs, but they are opposed to returning to any form of behavioural assessment either because of being afraid of additional subjectivity in assessment or overtaxing the police on road side. This is the reason for demanding useful detection devices and tests. A few countries have introduced clinical evaluation procedures, for which they use a variety of methods, whereas the Southern European concept (e.g. French) is oriented towards biological methods. Other countries, especially Scandinavia, have adopted an approach between these two extremes. This concept is based on intervention by the police in the case of a reasonable suspicion. If drivers seem to be clearly impaired and the results of an alcohol test turn out to be negative, police officers are enabled to request a clinical assessment and a biological sample. This approach needs the consideration of different demands within three steps: (1) Suspicion gaining by the police (2) Possibilities for conservation of evidence (3) Chemical and toxicological proof of intoxicants from body fluids For suspicion gaining it is important to establish training and sensitisation of police officers concerning the detection and identification of motorists influenced by drugs respectively medicines. Police officers need training in personal contact with intoxicated motorists. Exchange of methods and experiences in detection of police enforcement between countries should be encouraged. To conserve evidence a documentation of concrete driving conspicuities by the police is required. Assessment of driving fitness by the police has to be standardised to guarantee the possibility of reconstructing all steps of the police and the clinical examination and to guarantee the transparency in view of the defensibility in court. Proceedings at the verification of the suspicion of drug impairment should be standardised by means of a short written check-list

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Psychometric road side tests as a proof for impairment still need development, and have to be supported with defined procedures and training of the personal. More or less promising chances are granted to different test procedures still in development. Video-graphic recordings for assessment of posture, saliva examinations, pupillograph or contact-free measurements. Further studies concerning a trend-setting method of electro-nystagmography seem promising. Analytical roadside tests For analytical roadside tests some practical requirements are worth mentioning - the possibility to perform screening tests rapidly on the spot by non-laboratory personnel; roadside tests must be performed on samples that are relatively easy to obtain, like urine, saliva, and sweat; a check whether the test was performed correctly should be possible and good readability of the results even in the night and insensitivity to shocks and temperature should be given. Tests should be sensitive to detect all the drivers who have taken drugs and they should be specific to detect only drivers who have taken drugs that impair driving (drugs that are forbidden by the law). Roadside tests remain preliminary tests and the results must be confirmed in order to be admissible evidence in court. Since a summary of pharmacologically and toxicologically justified threshold values is currently not possible because of the varying breakdown of the various drugs and medicines, one has to rely in the near future always on exact statements of the police, an exact description of the subject’s behaviour, and medical examinations as well as confirming chemical and toxicological analyses for criminal prosecutions. For the improvement of methods it is suggested to establish legal conditions that allow to secure 2 to 3 bodily fluids that are easily available (saliva, blood, or urine) to permit systematic pharmacological examinations and to gain the necessary experience. Accreditation and homologisation on EU level is an important target. Medical examination The assessment of the general physical condition of a suspected driver is not a very meaningful method to judge a drug influenced state. Deficiencies due to malnutrition or signs of neglect are at the best unspecific hints toward drug addiction. Typical characteristics of consumption like injection marks are concrete clues to drug consumption. Because of their complexity, neurological findings may generally be collected only by a specially trained physician or a neurologist. Psychic conspicuities often are the only perceivable signs of drug influence. To recognise these changes, the person has to be engaged in a conversation and closely observed. A „diagnosis at a glance“ is able at best to show conspicuities in drive and mood. The psychic conspicuities are only to be described, not interpreted. Concerning medical examinations there is need for training of physicians in neurological and psychopathological examination for the detection of influence of drugs and medicines. Proceedings and documentation at the clinical and neurological examination need standardisation. Regranting of driving license, recidivism There is a lot of evidence that drug consumers are heterogenious groups. There is a range from testing behaviour to severe addiction. Also driving decisions differ between groups. Concerning young people it could be shown that in case of alcohol consumption, people decide rather not to drive, the consumption of illicit drugs, however, has no impact on the

Page 84 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55 decision to drive. Hard and heavy drug consumers drive even under drug influence. Drugged drivers show increased risk willingness. Drug consumers drive more often also with high alcohol levels. Sanctions show impact only in case of little drug experience. These facts underline the importance of specific driving aptitude judgement in case of drug driving offences in road traffic. In some countries psychological and medico-psychological judgement procedures have been developed and are used within a legal framework. Detailed criteria for the diagnostic process guarantee a fair and reasonable decision. These procedures are an instrument to assess recidivism risk and to reduce recidivism. The experiences in Germany and Austria with regard to the validation of traffic-psychological examinations make clear that by this kind of case-specific assessment, the recidivism risk can be lowered by up to 50%. With that, this measure should surely be pushed in other countries, too. But, this kind of professional expertise also helps to identify the most promising rehabilitation measure targeted to the specific problem of the individual. The success of rehabilitation programmes for alcohol offenders is documented in several studies and there are good arguments why specific programmes for drug offenders should be effective, too.

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10 INDEX OF ABBREVIATIONS

AD Antidepressant AGARD Advisory Group on Aerospace Research and Development BAC Blood alcohol concentration BAST Bundesanstalt für Strassenwesen BLT Toxicological Society of Belgium and Luxembourg BTTS Belgian Toxicology and Trauma Study BZD Benzodiazepine CAD cyclic antidepressant CDR Cognitive Drug Research CNS central nervous system DEC Drug Evaluation and Classification DECP Drug Evaluation and Classification Programme DEL Deliverable DRE Drug Recognition Expertise DUI Driving under Influence DUIA Driving under Influence of Alcohol DUID Driving under Influence of Drugs EIA enzyme immunoassay EMCDDA European Monitoring Centre for Drugs and Drug Addiction FPIA fluorescence polarisation immunoassay FIT Field Impairment Test FST Field sobriety Test GC gas chromatography GC-ECD gas chromatography – electron capture detection GC-MS gas chromatography - mass spectrometry GHB gamma hydroxybutyric acid HPLC high performance liquid chromatography KTL National Public Health Institute (Finland) LSD lysergic acid diethylamide 6MAM 6-monoacetylmorphine MAO monoamine oxidase MDA 3,4-methylenedioxyamphetamine MDEA 3,4-methylenedioxyethamphetamine MDMA 3,4-methylenedioxymethamphetamine NIFT National Institute for Forensic Toxicology (Norway) OMEDA Object Movement Estimation under Divided Attention RIA radio immunoassay SFST Standardised Field Sobriety Test SSRI selective serotonin reuptake inhibitor STRES Standardies Test for Research onto Environmental Stress TAD tricyclic antidepressant THC Tetrahydrocannabinol THCCOOH 11-nor-9-carboxy-tetrahydrocannabinol TLC thin layer chromatography TRL Transport Research Laboratory XTC ecstasy, MDMA

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11 INDEX OF TABLES

Table 1: Median exposures from 69 epidemiological studies (Maes et al. 1999, Rosita, p. 9). 8 Table 2: Prevalence of drugs in different driver populations (Maes et al. 1999, Rosita, p. 9). . 8 Table 3: Drivers stopped on the road (Maes et al. 1999, Rosita, p. 11)...... 9 Table 4: Drivers injured or killed in an accident (Maes et al., 1999, Rosita, p. 11)...... 10 Table 5: Drivers suspected of driving under the influence (Maes et al., 1999, Rosita, p. 12). 13 Table 6: Increase of detected drug drivers with suspicion of drug influence while driving a motor vehicle in the period from 1998 to the first half-year of 2001 (numbers from Lopianecki 2001, p. 15)...... 14 Table 7: Responsibility analysis results in fatal accidents (Maes et al., 1999, Rosita, p. 13).. 17 Table 8: Prevalence of drugs in fatally injured drivers (Terhune et al., 1992 in Maes et al., 1999, Rosita, p. 13)...... 17 Table 9: Responsibility analysis results for fatally injured drivers (Terhune et al., 1992 in Maes et al., 1999, Rosita, p.14)...... 18 Table 10: Description of the Wolschrijn system (Maes et al., 1999, Rosita, p. 31)...... 24 Table 11: Odds ratio responsibility analysis for fatally injured drivers tested positive for selected drug groups (Drummer et al., 1998, as cited in Tunbridge et al., 2000, Certified, p.21)...... 25 Table 12: Risk classification of substances by Tunbrigde et al. (2000, Certified). The arrows indicate the relevance for the risk assessment: ↓ means intensification, ↑ means relief. 26 Table 13: Rank order of drug groups and qualitative assignment of risk categories (Tunbrigde et al. 2000, Certified, p. 31; for details of estimation and critical comment, see Certified) ...... 27 Table 14: Overview of the legal situation in the field of DUID and the use of roadside drug tests (Möller et al., 1999, Rosita, p. 5; as of 8/1999) ...... 33 Table 15: Consequences of driving under the influence of alcohol (data from Krüger et al., 2000, Pompidou, as of 1999)...... 35 Table 16: drug combination effects (from Möller, 1998, p. 88); key: ↓ ↓ = additive depressant, ↓↓↓ = over-additive depressant, ↑↑ = additive inciting, ↑↓ = various combination effects, = difficult to predict...... 51 Table 17: Check-list for determining impairment of driving fitness by the police (Maurer, 2000, p. 72)...... 55 Table 18: Overview of substances and their impairing effects (summary of the studies reported in Chapter 6)...... 60 Table 19: Evaluation of urine test devices by Samyn et al. (1999, Rosita)...... 63 Table 20: Criteria for evaluation of cannabinoid concentration in the blood (according to Daldrup et al., 1997)...... 66 Table 21: Forms of consumption of intoxicants (Brenner-Hartmann, 1998, p. 258)...... 77 Table 22: Conditions and Examinations in some EU-countries after drink-driving offences (data from Openshaw, 2000)...... 79 Table 23: Alcohol limits in the EU-countries (data from Wilding 2000, Krüger et al. 2000 Pompidou; as of 1999; press information of 22/6/2002)...... 90 Table 24: Overview of the general legal conditions in EU countries concerning DUID (data from Moeller et al., 1999, for Sweden and Portugal: Mercier-Guyon, 2000, Icadts, resp. Nuncio, 2000, Pompidou). Empty cells indicate lacking information. Austria – new data for 2002 inserted by Christ...... 99 Table 25: Legal consequences of drunk driving in EU countries (data from Wilding, 2000)...... 101

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Table 26: Legal consequences of drugged driving (data from Möller (2000, for the FRG, Icadts), Wilding (2000); Krüger et al. (2000, Pompidou); Nuncio for Portugal, 2000 Pompidou; Frison et al., 2000 for Italy). Empty cells indicate lacking information...... 103

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12 INDEX OF FIGURES

Fig. 1: Concentration of intoxicants in blood and urine over the course of time (from: Möller, 1998, p.46)...... 65

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13 APPENDIX

13.1 LEGISLATION

Country alcohol limit established (mg/ml BAC) since Austria 0.5 1998 Belgium 0.5 1994 Denmark 0.5 1998 Finland 0.5 France 0.5 1995 Germany 0.5 1998 Greece 0.5 Ireland 0.8 1994 Italy 0.5 1/7/2002 Luxembourg 0.8 Netherlands 0.5 Portugal 0.5 1983 Spain 0.5 1999 Sweden 0.2 1990 United Kingdom 0,8 Table 23: Alcohol limits in the EU-countries (data from Wilding 2000, Krüger et al. 2000 Pompidou; as of 1999; press information of 22/6/2002)

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DUI Alcohol Country Roadside stop to control Specific annotations Conditions for Roadside Neg. for alcohol, Positive for alcohol DUI for alcohol and drug tests – Alcohol but signs of impairment Austria At general traffic controls No specific conditions Medical Directly usable for At specific roadblocks for examination, punishment law enforcement blood test for At random testing controls drugs will become At special checkpoints possible (new law In cases of accident in 2002) Belgium At general traffic controls Drugs: Analytical legal No specific conditions Further legal At specific roadblocks for limit for THC, morphine, actions law enforcement amphetamine, MDMA, At random controls MDEA, MBDB, cocaine, At specific checkpoints benzoylecgoine Any person involved in a traffic accident Czech At general traffic controls Initial suspicion, always Further police Directly usable for Republic At specific roadblocks for with accident measures punishment law enforcement In cases of general driving faults Denmark At general traffic controls Drugs: Law includes all No specific conditions Further legal At specific roadblocks psychoactive substances actions At random testing controls At special checkpoints (no controls for drugged drivers) Finland At general traffic controls No specific conditions Drug tests and/or At specific roadblocks for further legal law enforcement actions At random testing controls

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At special checkpoints If the driver is under suspicion In case of impaired driving France At general traffic controls Every driver who is No specific conditions At specific roadblocks for involved in a fatal accident law enforcement -> analysis for illicit drugs At random testing controls in blood. Explicitly At special checkpoints prohibited are opiates, In any circumstances like cocaine, cannabis, infractions, accidents amphetamines; (no drug controls for the benzodiazepines in moment) discussion Germany At general traffic controls Concrete prohibition of Initial suspicion Drug tests and/or At specific roadblocks for cannabis, cocaine, heroin, further legal law enforcement morphine, amphetamines, actions At special checkpoints designer drugs, ecstasy and In case of general driving MDE. Explicit exemption faults for medicines because of In case of accidents diseases Greece At special checkpoints No specific condition Further legal Directly useable for In case of accidents actions punishment Without any pre-condition Ireland At general traffic controls Initial suspicion Further legal Reference sample actions are acceptable to prove drug abuse Italy At general traffic controls Initial suspicion Drug testing Directly useable for At specific roadblocks for devices, further punishment law enforcement legal actions At special checkpoints In case of accidents

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Luxembourg In case of severe accidents Signs of impairment Further police Directly useable for (general or specific measures punishment roadblocks are normally not performed) Netherlands At specific traffic controls No specific conditions Further legal At specific roadblocks actions are At random testing controls acceptable to At special checkpoints prove drug use Poland At general traffic controls Initial suspicion Further legal Punishment, reference In case of accidents actions sample (personal/fatal injury) Slovenia At general traffic controls Initial suspicion, Further legal Directly useable for At specific roadblocks for accidents actions punishment law enforcement (alcohol) At random testing controls (alcohol) At special checkpoints (drugs) Spain At preventive random No specific conditions Can be directly used for testing controls punishment; the police In case of road accidents offers to perform a In case of driving offences blood test United At general traffic controls Initial suspicion, traffic Reference sample Reference sample Kingdom Without any pre-condition offence. Accidents, information Sweden At random check points Different conditions Further legal Positive screening test is At different kinds of traffic sanctions not considered controls Field policeman evidentiary; evidentiary requires a medical breath alcohol test is doctor -> clinical valid evaluation, blood and urine sampling

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for laboratory screening and confirmation Portugal Breath test is followed by evidential BT or blood sampling Table 24: Overview of the general legal conditions in EU countries concerning DUI, DUIA (data from Moeller et al.2000, Krüger et al. 2000 Pompidou). Empty cells indicate lacking information, Austria – new data for 2002 inserted by Christ.

Drugs EU-country Conditions Positive Negative Not possible Refusal Basis for Roadside Place of collection for Roadside conviction drug tests /collector/fixed tests – Drugs at present procedures Austria Initial In Further legal Blood test – No Police report None Health institution suspicion combination actions are change of consequences, Clinical evaluation /physicians only/- with roadside possible, legislation in roadside drug Presence of drugs observation: depending on 2002 testing is in blood, urine, obtaining the acting completely salvia blood samples police officer voluntary, - Statement of (analytical from 2002 expert witness result -> to will be treated obtain like positive evidence) test Belgium Initial Only reason In case of Driver can Driver can be Presence of drugs Are used Any place where suspicion for obtaining impairment -> be forced to forced to give in blood for the privacy of the blood sample further legal give a blood a blood research subject is (analytical actions to prove sample sample purposes guaranteed/police result -> basis drug abuse (validation officers/collection for of two punishment) urine tests, expert

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examinatio n of an salvia/swea t test) Czech ? Toxicological Toxicological Toxicologica Penalty or Clinical Are not Hospitals, medical Republic analysis and analysis and l analysis for sanctions evaluation, used ambulance/blood: medical medical drugs are not according to presence of drugs medical doctor; examination examination are often the in blood (urine) urine: nurse/yes are required to required to performed Misdeamour prove prove for Act impairment impairment economical which can be which can be reasons prosecuted prosecuted according to according to penal code penal code Denmark No specific - If other Police report None -/-/- conditions indications for Clinical evaluation drug abuse are Presence of drugs obvious, in blood/urine further police measures are justifiable Finland No specific Can be the In case of Driver can If other Presence of drugs Are not Roadside, police conditions only reason obvious be forced to indications for in blood; signs of used station, forensic for obtaining a impairment -> give blood drug abuse are impairment and outpatient blood sample further legal sample obvious, clinic, hospital, (analytical actions to prove further police emergency result is basis drug abuse measures are room/police for justifiable officers/- punishment) France - Only a - Blood Nothing will Statement of Are not -/-/- prosecutor can sampling for happen, expert witness used

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use the results alcohol roadside drug for a specific testing is prosecution- completely voluntary Germany Initial In Traffic law, no The driver No legal Police report Are used Any place where suspicion combination blood sampling, can be consequences, clinical evaluation routinely in the privacy of the with roadside but further legal forced to but the driver presence of drugs traffic subject is observations, measures are give a blood can be forced in blood (and controls guaranteed/police obtaining justifiable; sample to give a urine5) and on the officers/collection, blood samples penal law, blood sample checklist occasion conservation, (analytical mandatory statement of expert for storage, result is used blood test. witness research documentation to obtain purposes evidence) (Mahsan Urine tests, Drugwipe, Frontline) Greece Presence of drugs Roadside -/-/- in blood and urine drug testing law is in discussion Ireland Initial Basis for a - - Offence to Police report Are not Police station or suspicion conviction refuse Clinical evaluation used hospital/medical Presence of drugs doctors/collection, in blood/urine conservation, Statement of storage/documenta expert witness tion Italy Initial In In case of By an Is equated Police report Are used Roadside, health suspicion combination obvious evident state with a positive for institutions, in

5 Only evidence in court in case of offences according to the traffic law, no proof of impairment required.

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with roadside impairment, of result research conditions of observations; further legal impairment purposes clinical obtaining a actions are due to drugs: (Syva safety/physicians reference acceptable to obtaining Rapid test, only/- sample prove drug biological Merck (analytical abuse fluids Triage, result + Secureted clinical Drugwipe) documentatio n are the basis for punishment) Luxembourg Signs of In No more basis - Equated with Police report Are not Hospital/laborator impairment combination for further a positive Statement of used y personnel/- with roadside actions result expert witness observations: requesting of a blood sample voluntary Netherlands No - - - - Police report Are not Roadside regulations Presence of drugs routinely (screenings), in blood/urine used by the police station Statement of police, but (evid. tests)/police expert witness on the officers?/- (forensic lab.) occasion of research purposes by SWOV Poland Initial In In case of The driver The driver can Police report, Are not At the roadside, suspicion combination obvious can be be forced to clinical evaluation, used hospital/police with roadside impairment, forced to give a blood presence of drugs officers, laboratory

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observations, further legal give a blood sample in blood or urine personnel/yes obtaining actions are sample blood samples acceptable to (analytical prove drug result is used abuse to obtain evidence) Slovenia ? ? ? ? ? Suspicion of DUI, Are not Health presence of drugs used by the structure/?/? in blood/urine, in police; it is case of traffic not allowed accidents: also the to take the signs of specimen impairment in police (reported by stations police, medical doctor) Spain No specific Information to Nothing will - No Police report Are not Blood samples, in conditions the judge happen, no punishment Presence of drugs used health institutions/ legal in physicians or consequences blood/urine/body nurses/collection, fluids like saliva conservation, storage United - - - - - Police report Are used -/-/- Kingdom Clinical evaluation only for Presence of drugs research in blood purposes Statement of (Cozart, expert witness Drugwipe); Confession no possibility of using

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drug tests at roadside Sweden Reasonable No suspicion roadside devices Portugal Blood Person may Involved persons - No sampling in leave > public hospital; roadside case of fatal examination by devices accidents physician; suspicion -> blood and urine sample Table 24: Overview of the general legal conditions in EU countries concerning DUID (data from Moeller et al., 1999, for Sweden and Portugal: Mercier-Guyon, 2000, Icadts, resp. Nuncio, 2000, Pompidou). Empty cells indicate lacking information. Austria – new data for 2002 inserted by Christ.

Alcohol Country Penalties depending Administrative Administrati If BAC-limit If BAC-limit BAC- Judgement of on alcohol level, fines in Euro ve Driving (mg/ml) and no (mg/ml) and traffic range for blood sampling accident (no accident or Ban/disquali traffic offence or offence or accident criminal (invasive – non involvement, traffic injury) fication accident involvement offence invasive) offence, previous involvement (mg/ml) offence Austria Yes6 220-5800 4 weeks - ≥50 ≥50 Can be taken if lifetime suspicion, cannot be taken by force Belgium Yes 1000-10000 8 days – ≥50 ≥50 ≥50 lifetime

Denmark Yes 135 - 6 months – >50 >50 >50

6 Riders of motorcycles under 18 years:0.1mg/ml, novice drivers: 0.1mg/ml, drivers of buses and trucks over 7.5 tons: 0.1mg/ml.

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lifetime

Finland Yes - 5 years ? ? ? Blood test even ? without consent of the driver France Yes 0-4500 0 – 60 ≥50 ≥50 ≥80 months

Germany Yes 100-1500 0-60 months ≥50 ≥30 ≥110 Blood testing can be enforced Greece Yes 100-300 0 – 2 years >50 >50 >50

Ireland Yes -1270 3 – 48 >80 >80 >80 months

Italy - - >80 >80 >80 Invasive, not allowed

Luxem- - - bourg

Nether- Yes 175-1100 1 day – 9 ≥50 ≥50 ≥80 A blood test lands months cannot be taken with physical force; refusing the blood test is a criminal offence Portugal Yes 100-1000 1 – 24 ≥50 ≥50 ≥120 months

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Spain Yes7 301-451 2 –3 months >50 / >30 >50 / >30 >0

Sweden Yes 0-no max. 3–12 months ≥20 ≥20 ≥75 Compulsory blood test

United Yes -7500 12 months - >80 >80 >80 Kingdom lifetime

Table 25: Legal consequences of drunk driving in EU countries (data from Wilding, 2000).

Drugs and Medication Country Analytical limit Impairment Impairment Impairment Refusal Forced blood (no proof of (no accident or injury) (endangerment) (accident or sampling? impairment) injury) Austria Does not exist Administrative; criminal criminal; treated like an Can be taken, if Fine: 581-3633 Euro 6 months to 3 alcohol level of suspicion, but years (death 160mg/ml BAC cannot be taken by resulting) force Belgium Zero limit (with Criterion: Driving in a Influence of alcohol Fines: 40000 - refuse of urine analytical detection manner similar to that 400000 BEF; testing, a positive limits) of Prison: 15 result will be someone driving days to 6 assumed under influence months Denmark No fixed penalty. suspicion at refusal Prison up to 1 year

7 HGV drivers: 0.3mg/ml, Bus/coach, school bus, dangerous goods drivers: 0.30mg/ml, Learner drivers: 0.3mg/ml.

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Settled from case to case Finland Normal: Fine min. 20 Severe: min. 60 day Blood test even Fmk or imprisonment, fines max. 2 years without consent of max. 3 months the driver France Same as for alcohol No detailed information Germany Zero in blood Fine: max. 1534 Euro Criminal Blood testing can be Driving ban: 1-3 Same as for alcohol enforced months Greece Ireland Italy No limit Fine: 258 – 1033 Refusal to co- Driver must agree; Euro operate with police coercive blood Prison: max. 1 month is punished with the sampling is Suspension of driver same administrative considered invasive licence: 15 days to 3 and penal sanctions months deriving from positive ascertainments Luxembour Fine: 248 –4958 Euro g Prison 8 days to 3 years Netherlands None exist As with alcohol As with alcohol As with Refusing is a Blood test cannot be alcohol criminal offence taken with physical force, refusing is a criminal offence Portugal Legislation Fine: 200 –998 Euro, Refusing is a crime includes withdrawal of driving of qualified marijuana, cocaine, licence: 2 months to disobedience opioids and two years amphetamines;

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table of minimum permissible concentration Spain Does not exist for Refusing is a Blood sampling drugs criminal offence may not be taken by physical force Sweden Zero limit for Fine: 450-150000 Prison: max. 2 years; Compulsory blood drugs SEK; Prison: 14 days Serious intoxication: test to 6 months; regardless of any limit Serious intoxication: no limit for drugs United Refusing without Blood sampling Kingdom reasonable excuse is may not be taken by punishable physical force.

Table 26: Legal consequences of drugged driving (data from Möller (2000, for the FRG, Icadts), Wilding (2000); Krüger et al. (2000, Pompidou); Nuncio for Portugal, 2000 Pompidou; Frison et al., 2000 for Italy). Empty cells indicate lacking information.

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13.2 PSYCHOMETRIC TESTS The first part of the tests described deals with the device-free procedures, the tested person is supposed to follow the instructions of, e.g., the officer and to perform the tasks (e.g. UK Roadside Field Impairment Testing Process, described in Clark and Riedel, 2000, Certified). The second part deals with device procedures. In the third part, „test batteries“ are presented that either consist of device-free and device procedures or that instrumentally register different aspects.

13.2.1 Non-instrumental procedures

13.2.1.1 Romberg-Test The Romberg-Test serves the testing of the „body clock“ and the balance of the subject. The subject is instructed to put his/her feet together and to put his/her arms alongside the body. This position has to be maintained during the further instructions. After the starting signal he/she has to put back the head, eyes closed, and wait in this position for 30 seconds. After that, the subject has to raise the head again, open his/her eyes and say „stop“. Quiet counting for better estimation of time may not be recommended, but is also not prohibited. The actual time has to be clocked. After 90 seconds, the test may be cut short. The subject is questioned after the test about the actual length of the time span. The assessment takes place after signs of an impairment by alcohol, medicines or drugs in case of: discrepancy of the estimated time from the measured time (30 sec.) trembling of the body or the eyelids slack posture swaying of the head or the whole body to the side or backwards and forwards correcting steps to keep stand correct observation of the instructions

13.2.1.2 Walk and Turn Test This exercise serves the testing of concentration and balance. The subject stands at the starting line during the instructions of the test, the arms put alongside the body, and may not start until the explanation has ended, i.e. everything was demonstrated and understood. Clues to an impairment by alcohol, medicines or drugs show themselves by: • disturbance of equilibrium during the instruction • early start • stopping during the performance • additional steps • deviation from the line • using of arms • disturbances of equilibrium during the turn • wrong performance of the turn • wrong number of steps • wrong performance of the stepping motion • correct observation of the instructions

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13.2.1.3 One-Leg Stand Test This exercise serves the testing of balance, depth sensitivity and concentration. The subject puts his/her legs together, puts the arms alongside the body and gets the instruction to lift the right foot approx. 2 handbreadths above the floor and keep this position looking at the lifted foot for 30 seconds counted aloud, then to put the foot down and to lift the left foot after 10 seconds. Clues to an impairment by alcohol, medicines, or drugs may be: swaying, balancing with the arms, hopping, putting down the lifted foot, problems with counting, or trembling of the body.

13.2.1.4 Finger – Nose – Test With that, the minute motor activity can be checked. With legs put together, the arms have to be put alongside the body, the head slightly put back, the eyes closed. With the stretched index finger, the other fingers made into a fist, the tip of the nose has to be reached, then the starting position has to be resumed. Six tries are made, each with a pause of 2-3 seconds and change of hand. An impairment by alcohol, medicines, or drugs exists, when the tip of the nose is missed, the wrong arm or finger was used, the instructions could not be attended, and in case of excessive body sway.

13.2.1.5 Finger – Finger –Test With that, the minute motor activity can be checked. With eyes closed, the arms are extended horizontally to the side. The finger tips are to be brought together in the front with outstretched arms. An impairment by alcohol, medicines, or drugs exists, when the finger tips miss.

13.2.1.6 Simple concentration tests At the alphabet-test, the subject has to cite a predetermined section out of the middle of the alphabet. At the countdown-test, the subject has to count back from a certain number over approx. 15 numbers.

13.2.2 Device procedures Clark and Riedel (2000, Certified) report already used methods for roadside testing, here is a summary of impairment test methods.

13.2.2.1 Schuhfried Vienna Test The Vienna Test System is a suite of computerised intelligence, personality, and performance tests. It consists of software and hardware comprising several subsystems, five of which have been proposed for the assessment of drug-impaired driving performance: Tachistoscopic Traffic Test Mannheim for screen, Two-hand co-ordination, Visual pursuit, Determination test, Cognitrone. Test duration and probability do not make it an ideal roadside measurement device for performance.

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13.2.2.2 OMEDA The Leeds University (UK) OMEDA (Object Movement Estimation under Divided Attention) is a short computerised test that aims to differentiate between healthy and demented elderly people who are fit to drive and those who are not. OMEDA consists of two main movement estimation parts, each with a superimposed divided attention task. For roadside use it is necessary to adjust the parameters of the test.

13.2.2.3 AGARD STRES Battery The AGARD (Advisory Group on Aerospace Research and Development) STRES (Standardised Tests for Research into Environmental Stress) Battery was not designed specifically to assess driver performance, but it is an example of a set of tests with proven track records in stress (mainly drugs) measurement, standardised for use in different laboratories and different countries. The battery includes the following tests: Reaction times, Mathematical Processing, Verbal Processing, Spatial Processing, Memory Search, Tracking, Dual task.

13.2.2.4 CDR Test System Cognitive Drug Research (CDR) is a research company specialising in the assessment of pharmaceuticals that has developed a test system composed mainly of tests drawn from the literature that fulfil the company’s requirements, e.g. in terms of psychometric properties, short duration, language fairness, portability, standardised administration, known practice effects. The CDR tests are divided into four groups, with a fifth group of additional tests. These are described below, together with CDR’s own taxonomy. Attention: Simple Reaction Time, Choice Reaction Time, Digit Vigilance; Short Term or Working Memory: Digit Scanning, Spatial Working Memory; Long Term or Episodic Secondary Memory: Word Recall, Word Recognition, Picture Recognition, Face Recognition; Motor Control: Visual Tracking, Body sway; Other Tasks: Rapid Visual Information Processing, Logical Reasoning, Sentence Verification, Movement Times, Tapping Rates, Critical Flicker Fusion Frequency, Two-Flash Fusion, Digit Symbol Substitution, Pencil and Paper Procedures, Visual Analogue Scales.

13.2.2.5 CANTAB CANTAB is a portable touch-screen method of assessing learning, memory, attention, and problem solving. It is intended for use in clinical settings and neuropsychological research. The battery is language free. CANTAB comprises twelve tests described as follows: ID/ED Shift, Matching to Sample, Visual Search, Delayed Matching to Sample, Motor Screening, Paired Associate Learning, Big/Little Circle, Rapid Visual Information Processing, Pattern and Spatial Recognition Memory, Reaction Time, Spatial Working Memory, Stockings of Cambridge.

13.2.2.6 Electro-nystagmography (ENG) The electro-nystagmography is easy to implement and is suited as objective parameter from the medical side as well as from the side of the police on location. The test requires no great efforts of the person to be tested, and deliberate manipulation of the test is impossible and thus centrally determined dysfunctions of co-ordination can be pointed out.

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Nystagmus means vibrations of the eye, involuntary swift vibrating movements of the eyeball in the horizontal, vertical, or transversal direction or in the form of rotary motions. There is an optic, an opto-kinetic and a spontaneous nystagmus. This restlessness of the eyeballs at rest is intensified by movement, especially by looking sideways. Nystagmus is congenital or caused by diseases of ears or nerves. The motor nerves that trigger the muscle contractions for the adjustment of the eyeball are susceptible for the effects of alcohol. A horizontal backward jump of the eyeball like with a stroke of a pendulum can be observed. The check of the nystagmus comprises horizontal nystagmus, evenness of the eye movements, nystagmus at maximal deflection of the bulbus, critical angle of the nystagmus, vertical nystagmus, post-rotational nystagmus (for details see Chaloupka et al, 1999). Besides alcohol, also the intake of barbiturates and anti-histamines, especially of hypotensive and antispasmodic medicines, can lead to nystagmus. Specific nystagmus may, however, also be a sign of certain kinds of brain damage or neurological impairments, e.g., multiple sclerosis, myasthenia gravis and epilepsy. From noticeable nystagmus data, it is, however, also possible to conclude fatigue or problems with the balance (Chaloupka et al., 1999). From all of this, it is, however, also possible to conclude impairment of the momentary driving aptitude, and an individual clarification of the underlying impairment factors is necessary. Priemer, Gappmaier, Ruby, Sachs, Tutsch-Bauer, Peschel, and Eisenmenger (1999) examined the effects of an acute THC-influence on the pupils with 7 subjects. The width of the pupil and the pupillary reflex were recorded with the infrared video pupillography system CIP 8.00 (AMTech, Weinheim). The latency of the pupil constriction was not changed. In comparison to the sobriety data, a slight miosis could be measured. Also, the amplitude of contraction was a little bit smaller under THC-influence; this, in connection with vegetative accompaniments, is symptomatic for a atropin-similar resp. parasympatholytic effect of the THC. Primer and Sachs (2000) used the pupillograph CIP as a mobile measuring device that could also be used in the field. According to the authors, the device seems to be very effective for examining the effects of various psychoactive substances on brain function or vision control. Zancaner, Giorgetti, Dal Pozzo, Molinari, Snenghi, and Ferrara (1997) made the following considerations about eye parameters: Clinical eye parameters are far more sensitive than others in identifying subjects who have taken psychoactive substances. In particular, mydriasis is found in a very high percentage of DUI drivers and in two-third of those who have taken stimulants (amphetamines and cocaine). The absence of nystagmus was closely correlated with non-DUI drivers. A moderate frequency of mydriasis in subjects who have not taken psychoactive substances may be due to the particular circumstances in which they were stopped by the police (e.g. after the disco).

13.2.2.7 Videographic procedures These procedures are currently in a development stage. They are acknowledged good prospects for the future, for example, Videographic recordings on posture (Kennedy et al., 1995, as cited in Springer et al., 1999).

13.2.2.8 The ART2020 test system The “ART 2020-family” are test instruments which were initially designed for driver selection testing. A comprehensive number of psychometric tests can be administered on the standard test device. A mobile test device could be used in filed conditions also and allows

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13.2.3 Mixed Procedures These procedures are described in Certified, too (Clark and Friedel, 2000).

13.2.3.1 SFST –Standardised Field Sobriety Test In the United States, three tests were developed in the 70s as a Standardised Field Sobriety Test (SFST) battery, and have been used routinely ever since in all states as a standardised roadside method of assessing alcohol or drug-induced impairment. The tests in the SFST battery are as follows: Horizontal Gaze Nystagmus, Walk and Turn Test (WTT), One-Leg Stand Test

13.2.3.2 Drug Evaluation and Classification Programme In the United States, the standardised Drug Evaluation and Classification (DEC) programme is a post-arrest method to determine whether a driver is impaired by different categories of drugs. The DECP is based on the driver’s appearance, behaviour, performance in psychophysical tests, eyes and physiological vital signs. The assessment is carried out by specially trained Drug Recognition Experts and takes about 30 minutes. The DECP consists of the following 12 procedures: Breath or Blood Alcohol Concentration, Interview of Arresting Officer, Preliminary Examination, Eye Examination, Divided Attention Tests, Vital Sign Examination, Pupil Size and Nasal and Oral Examination, Muscle Tone, Injection Site Examination, Statements and Interrogation, Opinion, Urine and /or Blood sample.

13.2.3.3 UK Roadside Field Impairment Testing Process In the United Kingdom; it consists of two of the US SFST tests, together with three other tests derived from the US DECP. The five tests are as follows: Pupil Size, Romberg Test, Walk and Turn Test, One-Leg Stand Test, Finger to Nose.

13.2.3.4 Computer applications of SFST and DEC These devices are being developed and have to be assessed at roadside. Clark and Riedel (2000, Certified) describe a computer application of ocular measuring (nystagmus, smooth pursuit, pupil size in darkness and pupil response to dim and bright light).

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14 BIBLIOGRAPHY

Aderjan, R., Baum, C., Bregel, St., Daldrup, Th., Hartung, M., Ärztin, T.H., Iten, P.X., Jenewein, C., Joachim, H., Joó, S., Käferstein, H., Kauert, G., Megges, G., Möller, M., Reif, E., Rohde, O., Sachs, H., Schewe, G., Schmerling, K., Wagner, H.J., Wilske, J., Zimmer, M. (1999). In: Drogenerkennung im Straßenverkehr. Schulungsprogramm für Polizeibeamte. Bundesanstalt für Straßenwesen.

Alvarez, F.J.; Del Rio, M.C.; Sancho, M.; Rams,M.A. and Gonzalez-Luque, J.C. (2000): Alcohol and Illicit Drugs among Spanish Drivers. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 285- 290. www.art2020.com

Bartl, G.; Lager, F. und Domesle, L. (1998): Testleistungen bei Minderalkoholisierung. In: Bartl, G. und Kaba, A. (Hrsg.): Alkohol im Straßenverkehr. Forschungsergebnisse zur Grenzwertdiskussion. Kleine Fachbuchreihe des KfV, Band 34. Kuratorium für Verkehrssicherheit, Wien 1998, 97-142.

Bartl, G.; Esberger, R. und Brandstätter, Ch. (1997): Unfallbilanz nach fünf Jahren Führerschein auf Probe. Zeitschrift für Verkehrsrecht 1997, 42, 9, 317-321.

Battista, H.J., Katzgraber, F., Steinlechner, M., Haidekker, A., Rössler, H., Ober, A., Kemmler, G. & Muigg, A. (1999). Studie zur Erarbeitung von Grundlagen und Hilfsmitteln zur Erkennung von Kfz-Lenkern, die unter Einfluss von Suchtgiften, Medikamenten und gegebenenfalls in Kombination mit Genussalkohol am Straßenverkehr teilnehmen. In: Illegale Drogen und Medikamente – Absolute Fahruntauglichkeit und mögliche Beeinträchtigung der Fahrtauglichkeit (II). Forschungsarbeiten aus dem Verkehrswesen. Bundesministerium für Wissenschaft und Verkehr. Band 99/2.

Battista, H. J. (2000). 4th Projekt Meeting Montegrotto. 2-3. Juni 2000 – EU-Projekt Rosita Road Side Testing Assessment

Behrensdorff, I. (1999): Licit and illicit drugs in traffic – An international literature review with a link to Danish conditions. Journal of Traffic Medicine 1999, 27, 3-4, 81-90.

Berghaus, G.; Staak, M.; Glazinski, R. und Höher, K.(1993): Empirische Untersuchung zur Fahreignung von Methadon-Substitutions-Patienten. Interner Bericht des Institutes für Rechtsmedizin der Universität Köln und des Gesundheitsamtes Köln, Köln 1993.

Berghaus, G.; Shibata, J. und Friedel, B. (1998): Erweiterung der Kölner Studie zu Methadon- Substitution und Fahrtüchtigkeit. Bundesanstalt für Straßenwesen: Kongreßbericht 1997 der Deutschen Gesellschaft für Verkehrsmedizin e.V., 29.Jahrestagung Münster. Bundesanstalt für Straßenwesen 1998.

Berghaus, G. & Krüger H.P. (1998). Cannabis im Straßenverkehr. Gustav Fischer Verlag. Stuttgart 1998. Page 110 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Berghaus, G.; Krüger, H.-P. und Vollrath, M. (1998): Beeinträchtigung fahrrelevanter Leistungen nach Rauchen von Cannbis und nach Alkoholkonsum – eine vergleichende Metaanalyse experimenteller Studien. In: Berghaus, G. und Krüger, H.-P. (Hrsg.): Cannabis im Straßenverkehr. Gustav Fischer Verlag, Stuttgart 1998, 99-112.

Bolle, R.H. (1988): Am Ursprung der Sehnsucht. Tiefenpsychologische Aspekte veränderter Wachbewußtseinszustände am Beispiel des Anästhetikums Ketanest. Verlag für Wissenschaft und Bildung, Berlin 1988.

Borkenstein, R.F.; Crowther, R.F.; Shumate, R.P.; Ziel, W.B. and Zylman, R. (1964): The Role of Drinking Driver in Traffic Accidents (The Grand Rapids Study). Department of Police Administration, Indiana University. Second Edition prepared especially for Blutalkohol (Re-edited by R.F. Borkenstein). Blutalkohol 1974, 2.

Bost, R.O. (1988): 3,4 Methylenedioxymethamphetamine (MDMA) and other amphetamine derivates. Journal of Forensic Sciences, 1988, 33, 576-587.

Brenner-Hartmann, J. (1998): Fahreignungsbeurteilung bei Cannabis-Missbrauch. In: Berghaus, G. und Krüger, H.P. (Hrsg.): Cannabis im Straßenverkehr. Gustav Fischer Verlag, Stuttgart 1998, 251- 279.

Bresser, P.H. (1972): Die Beeinträchtigung der Fahrtüchtigkeit durch Rauschmittel. Alkohol, Arzneimittel, Rauschgifte und Verkehrssicherheit 1972, 10, 57-72.

Brookhuis, K.A., De Waard, D. and Pernot, L.M.C. (2000): A driving simulator study on driving performance and traffic safety after multiple drug use, consisting of MDMA (Ecstasy) and various other psychoactive compounds. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge.

K. Brookhuis, W. Riedel, R. Mathijssen, R. Tunbridge, A. Clarke, N. Ward, L. Dye, G. Berghaus (2000): Conception and Evaluation of Roadside testing Instruments to Formalise Impairment Evidence in Drivers; Summary Report. CERTIFIED-Delverable A3-1. School of Psychology, University of Leeds.

Buchholtz, U. (1993) Cannabiskonsum und Fahreignung. Unfall- und Sicherheitsforschung Straßenverkehr 1993, 89, 11-13.

Bukasa, B. and Christophersen, A. (2000): Rehabilitation of Drugged Drivers. In. Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000. www.Certified – Project Deliverables.htm

Chaloupka, C.; Risser, R.; Grabmayer, W.; Kisser, W.; Ruby, M.; Thorwartl, G.; Zehetner, E. und Antoniades, A. (1999): Literaturstudie, Versuchsdesign und ausführliche Ergebnisdarstellung der verkehrspsychologischen Leistungsuntersuchung sowie Beschreibung eines Nystagmustests. In: Hoffmann, O. et al.: Illegale Drogen und Medikamente – Absolute

Page 111 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Fahruntauglichkeit und mögliche Beeinträchtigung der Fahrtauglichkeit. Bundesministerium für Wissenschaft und Verkehr, Wien 1999, 149-297.

Christ, R. (2001): Das universelle Kursmodell? – Ergebnisse österreichscher Evaluationsstudien zu unterschiedlichen Kursmodellen. Referat anlässlich des 7. Internationalen Kongress „Driver Improvement“ in Salzburg, 8.-10. Oktober 2001.

Christophersen, A.S. and Morland, J. (2000): Drugged driving: The situation and Experience in Norway. In: Icadts: Illegal Drugs and Driving. 2000, 44-49.

Clark, A. and Riedel, W.(2000). Roadside impairment Testing methods. Certified, EU Research Project, Deliverable 2a, 2000.

Davis, , G.P.; Broughton, J.; Harland; D.G. and Tunbridge, R. (2000): Drink driver rehabilitation courses in England and Wales. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000.

Daldrup, T., Käferstein, H., Köhler, H. & Maier, R.D. (1997). Feststellung des dauernden bzw. gewohnheitsmäßigen Cannabis-konsums durch die Untersuchung einer Blutprobe. Kongreßbericht 1997 der Deutschen Gesellschaft für Verkehrsmedizin e.V. Berichte der Bundesanstalt für Straßenwesen. Heft M 92. Bergisch Gladbach.

De Gier, J.J. (2000). Working group B1: Prevalence, Epidemiology, Risk assessment. In Pompidou: Road Traffic and Drugs, Meeting Strasbourg, 1999. Council of Europe publishing 2000.

De Waard, Brookhuis und Pernot (2000): A driving simulator study on the effects of MDMA (Ectasy) on driving performance and traffic safety. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000,

Dilling, H., Mombour, W. und Schmidt, M.H. (Hrsg.): Internationale Klassifikation psychischer Störungen - ICD 10. Verlag Hans Huber, Bern 1991.

Dittert, S.; Naber, D. und Soyka, M. (1999): Methadon-Substitution und Fahrtauglichkeit. Nervenarzt 1999, 70, 457-462.

Dolbeault, S., Girre, C., Hispard, E., Bozzi, M.F., Dugarin, J. & Dally, S. (1997). Driving and alcohol or drug abuse: Differences in behaviour and their potential link to the sensation seeking personality dimension. In: Mercier-Guyon (Ed.) Alcohol, Drugs and Traffic Safety. 1997, 1, 477-480.

Donohew, R.L., Hoyle, R.H., Clayton, R.R., Skinner, W.F., Colon, S.E. & Rice, R.E. (1999). Sensation Seeking and Drug Use by Adolescents and their Friends: Models for Marijuana and Alcohol. Journal of Studies on Alcohol 1999,60, 5, 622-631.

Fous, R. (1995): Suchtgiftkonsum und Verkehrssicherheit – Ein Erfahrungsbericht der Bundespolizeidirektion Wien. Blutalkohol 1995, 32,3, 174-179.

Page 112 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Fous, R. und Saurma, W. (1999): Schulung der Exekutive. . In: Hoffmann, O. et al.: Illegale Drogen und Medikamente – Absolute Fahruntauglichkeit und mögliche Beeinträchtigung der Fahrtauglichkeit. Bundesministerium für Wissenschaft und Verkehr, Wien 1999, 395-425.

Friedel, B. und Berghaus, G. (1997): Morphine Treatment of Pain Patients and Driver Fitness. In: Mercier-Guyon, c. (Ed.): Alcohol, Drugs and Traffic Safety – T97. 1997.

Frison ,G. ; Brusini, G. ; Maietti, S, ; Zancaner, S. ; Tedeschi, L. and Ferrara, S.(2000): Alcohol, drugs and driving in Italy. Current status, future prospects, and the Veneto Region experience. Blutalkohol 2000, 37, 2 Supplement 1, 14-19.

Gerhard, U.; Biedert,E.; Hobi, V.; Hug, I. und Ladewig, D. (1997): Der Einfluß langjähriger Heroinabhängigkeit auf die Fahrtüchtigkeit. In: Schlag, B. (Hrsg.): Fortschritte der Verkehrspsychologie. 1996

Gerhard-Choi, U.(1990): Fahrtüchtigkeit psychiatrischer Patienten in Abhängigkeit von Störungen und Therapie. In: Zusammenfassung der Beiträge des 30. BDP-Kongresses für Verkehrspsychologie 1990

Giorgetti, R.; Zancaner, S.; Frison, G.; Maietti, S.; Montisci, M.; Tedeschi, L.; Molinari, G.; Nalin, S. and Ferrara, S. (2000): Epidemiological roadside survey on psychoactive substances and driving in the Veneto Region (North-East Italy). In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 352-357.

Grof, St. (1983): LSD-Psychotherapie. Klett Cotta, Stuttgart 1983.

Haag, M., Colmegna, S. & Thiele, I. (1999). Fahreignung von Methadon-Substitutierten. Kongreßbericht 1999 der Deutschen Gesellschaft für Verkehrsmedizin e.V. Mensch und Sicherheit Heft M 111. Berichte der Bundesanstalt für Straßenwesen, Bergisch Gladbach 1999..

Haller , F.(1992): Fahrtauglichkeit unter Cannabiseinfluß. Vortrag am Internationalen Tag der Vereinigten nationen im Kampf gegen Drogen. Zürich

Huessy, F. (2000): Police detection – Introductory report about legal provisions, difficulties faced by police, and analysis of prevention attempts in selected European countries. In: Pompidou-group (Eds.): Road traffic and drugs. Meeting Strasbourg 1999. Council of Europe publishing 2000.

Hurst, P.M. (1976): Amphetamines and driving behavior. Accident Analysis and Prevention 1976, 8, 9-13.

Hurst, P.M. (1987): Amphetamines and Driving. Alcohol, Drugs and Driving 1987, 3, 13-17.

Iwersen, S., Schmoldt, A., Lewrenz, H. und Püschel, K. (1998): Stellenwert der toxikologischen Urin- und Haaranalyse bei der Fahreignungsbegutachtung von Kraftfahrern. Blutalkohol 1998, 35, 1-9.

Page 113 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Jackson, P.G., Tunbridge, R.J. & Rowe, D.J. (2000). Drug recognition and field impairment testing: evaluation of trials. In: Swedisch National Road Administr,ation (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 269-275.

Joo, S. (1999). Drogenerkennung im Straßenverkehr – Bericht über ein Schulungsprogramm für Polizeibeamte. Allgemeiner Deutscher Automobilclub e.V. (ADAC): Alkohol, Drogen, Medikamente und Verkehrssicherheit. 20. Symposium Verkehrsmedizin des ADAC, 19. – 20. November 1999.

Kazenwadel, J. und Vollrath, M. (1995): Das Dunkelfeld der Trunkenheitsfahrten. In: Krüger, H.-P. (Hrsg.): Das Unfallrisiko unter Alkohol. Analyse, Konsequenzen, Maßnahmen. Fischer Verlag, Stuttgart 1995, 115-124.

Käferstein, H. & Sticht, G. (2000). Investigations of urine and blood before regranting driving licenses to consumers of cannabis. Proceedings of T2000 -15th Conference on Alcohol, Drugs and Traffic Safety, Held 22-26 May 2000, Stockholm, Sweden, Swedish National Road Administration, 2000.

Kauert, G. (2000). Drogennachweis in Speichel vs. Serum. Blutalkohol 2000, 37, 2, 76-83.

Kintz, P. (2000). The role of saliva and sweat in detecting cases of driving under influence. . In Pompidou: Road Traffic and Drugs, Meeting Strasbourg, 1999. Council of Europe publishing 2000.

Kintz, P., Cirimele, V. & Ludes, B. (2000). Testing for cannabis in saliva of impaired drivers. Blutalkohol 2000, 37, 89- 92.

Kroj, G.; Kaja, G.; Meyer-Gramcko; F.; Nickel, W.-R.; Preusser, W.; Richardt, G.; Schubert, W.; Spoerer, E.; Stephan, E.; Undeutsch, U.; Utzelmann, H.D. und Winckler, W. (1995): Psychologisches Gutachten Kraftfahreignung. Deutscher Psychologen Verlag, Bonn 1995.

Krüger, H.-P.; Kazenwadel, J. und Vollrath, M. (1995): Das Unfallrisiko unter Alkohol mit besonderer Berücksichtigung risikoerhöhender Faktoren. In: Krüger, H.-P. (Hrsg.): Das Unfallrisiko unter Alkohol. Analyse, Konsequenzen, Maßnahmen. Fischer Verlag, Stuttgart 1995, 1-114.

Krüger, H.-P. und Vollrath, M. (2000): Effects of Cannabis and Amphetamines on Driving Simulator. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 844-849.

Krüger, H.-P.; Perrine, B.; Mettke, M. and Huessy, F. (2000): Illicit drugs in road traffic. Overview of the legal provisions, difficulties faced by police, and analysis of prevention attempts in selected European countries. In: Pompidou: Road Traffic and Drugs, Meeting. Strasbourg 1999. Council of Europe publishung 2000

Krüger, H.P. (Hrsg.): Fahren unter Alkohol in Deutschland. Gustav Fischer Verlag, Stuttgart 1998

Page 114 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Krüger. H.-P., Kohnen, R. und Schöch, H. (Hrsg.): Medikamente im Straßenverkehr. Auftreten, Risiken, Konsequenzen. Gustav Fischer Verlag Stuttgart, 1995.

Krüger, H.P (1995).: Medikamente im Straßenverkehr. Epidemiologische Ergebnisse zu Auftreten und Risiken. In: Krüger. H.-P., Kohnen, R. und Schöch, H. (Hrsg.): Medikamente im Straßenverkehr. Auftreten, Risiken, Konsequenzen. Gustav Fischer Verlag, Stuttgart 1995.

Kubitzki, J. (1997): Charakteristische Merkmale der Kraftfahrtauglichkeit von Methadonpatienten. Berichte der Bundesanstalt für Straßenwesen, Mensch und Sicherheit Heft M96. Bergisch Gladbach 1997.

Lakemeyer, M. und Friedel, B. (1997): Expertengespräch zum Thema Fahreignung und – tüchtigkeit von Schmerzpatienten unter dem Einfluß von Opiaten. Zeitschrift für Verkehrssicherheit 1997, 43, 1.

Lenne, M.G. Dietze, C.L.M.; Rumbold, G.R.; Cvetkovski, S., Redman, J.R. and Triggs, J. (2000): Comparison of the effects of methadone, LAAM, and buprenorphine on simulated driving performance. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000.

Lenne, M.G.; Dietze, C.L.M. and Rumpold G.R.(2000a): Attitudes towards driving after using cannabis alone and in combination with alcohol among young people in Melbourne. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000.

Lillsunde, P. (2000): Drogen und Medikamente im Straßenverkerh in Finnland. Blutalkohol 2000, 37, 2, Supplement 1, 34-39.

Longo, M.C.; Hunter, C.E.; Lokan, R.J., White, J.M. and White M.A. (2000): The prevalence of alcohol, cannabinoids, benzodiazepines and stimulants amongst injured drivers and their role in driver culpability. Part II: The relationship between drug prevalence and drug concentration, and driver culpability. Accident Analysis and Prevention 2000, 32, 5, 623-632.

Lopianecki (2001): Rechtslage in Deutschland und polizeiliche Erfahrungen mit Drogenunfällen. In: Kuratorium für Verkehrssicherheit (Hrsg.): Drogen am Steuer. 31. Sitzung des Österreichischen Verkehrssicherheitsrates am 5.Oktober 2001. Kuratorium für Verkehrssicherheit, Wien 2001, 14-20.

Louwerens, J.W., Gloerich, A.B.M., De Vries, G., Brookhuis, K.A., & O'Hanlon, J.F. (1987): The relationship between drivers' blood alcohol concentration (BAC) and actual driving performance during high speed travel. In: Noordzij, P.C. & Roszbach, R. (Eds.): Alcohol, Drugs and Traffic Safety - T86, Amsterdam: Excerpta Medica, 183-187.

Maes, V., Charlier, C.; Grenez, O. and Verstraete, A. (1999): Drugs and Medicines that are suspected to have a detrimental impact on road user performance. Rosita EU research project, Deliverable 1, 1999.

Mathijssen, M.P.M. (2000): Lower level of drink-driving in The Netherlands coincides with increased drug-driving. In: Swedisch National Road Administration (ED.): 15th Conference on

Page 115 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 419-424.

Maurer, H.-J. (2000): Drogenerkennung im Straßenverkehr. Aus der polizeilichen Praxis. Blutalkohol 2000, 37, 2, Supplement 1, 70-75.

Meyer-Gramcko P.M. (1992): Medikamente und Drogen. Verkehrsunfall und Fahrzeugtechnik 1992, 30, 2, 32-37.

Mercier-Guyon; Ch. (2000): Current situation in France, the European approach, and the results of the seminar of the Pompidou Group of the European Council. In: Icadts: Illegal Drugs and Driving. 2000.

Mercier-Guyon, Ch. (2000). The clinical and behavioural assessment of person who drive while under the influence of psychotropic substances. In: Pompidou: Road Traffic and Drugs, Meeting Strasbourg, 1999. Council of Europe Publishung 2000.

Mercier-Guyon, C., Mallaret, M & Lagier, G. (2000). Clinical signs of drug use and drivers, comparison between the different test batteries, their interest their limits and their future evolution. Proceedings of T2000 -15th Conference on Alcohol, Drugs and Traffic Safety, Held 22-26 May 2000, Stockholm, Sweden, Swedish National Road Administration, 2000.

Michalke, H.; Barglik-Chory, Ch. und Brandstätter, Ch. (1987): Driver Improvement. Effizeinzkontrolle von Gruppentrainingsmaßnahmen für alkoholauffällige Kraftfahrer. Kuratorium für Verkehrssicherheit, Wien 1987.

Möller, M.R. (1998): Drogenerkennung im Straßenverkehr. Schulungsprogramm für Polizeibeamte. Berichte der Bundesanstalt für Straßenwesen, Mensch und Sicherheit, Heft 96. Bergisch Gladbach 1998.

Möller, M. Steinmeyer, St. and Aberl, F. (1999): Operational, User and legal Requirements across EU Member States for roadside Drug testing Equipment. Rosita EU research project, Deliverable 3; 1999.

Möller, M (2000): Practical aspects of zero-limit approach to drugs and driving. The situation and experience in Germany. In: Icadts: Illegal Drugs and Driving. 2000, 39-43.

Möller, M. (2000a). Standardisation of police reports and analytical procedures for drug testing in body fluids. In: Pompidou, Road Traffic and Drugs, Meeting Strasbourg 1999, Council of Europe publishing 2000.

Möller, M.R.; Hartung, M. und Wilske, J. (1999): Prävalenz von Drogen und Medikamenten bei verkehrsauffälligen Kraftfahrern. Blutalkohol 1999, 36, 1, 25-38.

Morland, J.M. (2000): Driving under the influence of non-alcohol drugs. Forensic Science Review 2000, 12, 1-2, 79-105.

Nickel, W.-R. (2000): Re-Granting of Driving Licenses and Medico-Psychological Assessment of Drivers in Germany and Selected European Countries. In: Pompidou-Group (Ed.): Road Traffic and Drugs. Meeting Strasbuorg 1999. Council of Europe publishing 2000, 293-300.

Page 116 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Nuncio, M. (2000): Driving under influence of psychotropic substances in the nex portugese legislation. In: Pompidou-Group (Ed.): Road traffic and drugs. Meeting Strasbourg 1999. Council of Europe publishing 2000.

Openshaw, P. (2000): Rehabilitation. In: EU-Working group on Alcohol, drugs and medicines: The Alcohol report and Recommendations. Annex 3.

Perrine M.W. B. (2000). The United States experience in developing and validating DER/DEC in the field. In: Pompidou: Road Traffic and Drugs, Meeting Strasbourg 1999. Council of Europe publishing 2000.

Plaut, O. and Staub, C. (2000): Driving under the Influence of Drugs in the Canton of Geneca, Switzerland. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 438-441.

Pragst, F., Sachs, H. & Sporkert, F. (1999). Zum gegenwärtigen Stand der Haaranalyse auf illegale Drogen im Rahmen der Fahreignungsprüfung. Kongreßbericht 1999 der Deutschen Gesellschaft für Verkehrsmedizin e.V. Berichte der Bundesanstalt für Straßenwesen. Heft M 111. Bergisch Gladbach.

Presslich, O. et al. (1990): Methadon und Fahrtauglichkeit. Studie im Auftrag des Gesundheitsministeriums. Wien 1990.

Priemer, F., Gappmaier, A., Ruby, M., Sachs, H., Tusch-Bauer, E., Peschel, O. & Eisenmenger, W. (1999). Pupillenverhalten unter akutem THC-Einfluss. Blutalkohol 1999, 36, 2, 84-98.

Priemer, F. & Sachs, H. (2000). The compact integrated pupillograph CIP (amtech) – ist value on detection of psychophysical disorder caused by drugs. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000.

Pompidou Group: Road Traffic and Drugs, Meeting Strasbourg 1999, Counicil of Europe publishing 2000

Polettini, A. & Montagna, M. (2000). Hair analysis for the assessment of exposure to drugs of abuse in applicants for driving license. Proceedings of T2000 -15th Conference on Alcohol, Drugs and Traffic Safety, Held 22-26 May 2000, Stockholm, Sweden, Swedish National Road Administration, 2000.

Ramaekers, J.G. (1999): Marijuana and Driving – risk assessment through experimental research. University of Maastricht 1999.

Ramaekers, J.G.; Robbe, H.W.J. and O’Hanlon, J.F. (2000): Marijuana, Alcohol and Actual drivin Performance. Human Psychopharmakology 2000, 15, 551-558. www.Rosita – Aims and Deliverables.htm

Page 117 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Rentsch, D.; Weirich, V. und Wegener, R. (2000): Zum Drogenkonsum von verunfallten Jugendlichen in Westmecklenburg 1998/1999. Blutalkohol 2000, 37, 5, 293-307.

Samyn, N.; Viane, B.; Vandevenne, L. and Verstraete, A. (1999): Inventory of state of the Art road side drug testing Equipment. Rosita EU research project, Deliverable 2, 1999.

Saß, H. und Houben, I.: Diagnostisches und statistisches Manual psychischer Störungen. DSM-IV (übersetzt nach der 4. Auflage des Diagnostic and Statistical Manual of Mental Disorders der American Psychiatric Assiciation). Hogrefe, Göttingen 1996.

Schmidbauer, W. und Vom Scheidt, J. (1981): Handbuch der Rauschdrogen. Nymphenburger, München 1981.

Schmoldt, A., Iwersen, S., Herms, A. (1998). Auswertung ärztlicher Untersuchungsprotokolle bei Opiatkonsumenten. In: Berichte der Bundesanstalt für Straßenwesen, Mensch und Sicherheit Heft M 92, Bergisch Gladbach, Mai 1998, S. 303-307.

Schulz, E.; Vollrath, M.; Klimesch, C. und Szegedi, A. (1997): Fahruntüchtigkeit durch Cannabis, Amphetamine und Kokain. Literaturanalyse. Berichte der Bundesanstalt für Straßenwesen, Mensch und Sicherheit, Heft M81. Bergisch Gladbach 1997.

Schützenhöfer, A., Krainz, D. (1999). Der Einfluß des Alkoholisierungsgrades beim ersten Alkoholdelikt auf die Rückfallwahrscheinlichkeit. Zeitschrift für Verkehrssicherheit 1999, 45, 2.

Seymour, A. and Oliver, J.S. (2000): Drugs and Driving on Strathclyde Roads – An Update. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000, 423-437.

Skopp, G., Pötsch, L., Zimmer, G. & Mattern, R. (1997). Zur Interpretation von Drogenbefunden auf der Haut. Blutalkohol 1997, 34, 427-434.

Springer, A., Kopf, N., & Uhl, A. (1999). Erkennung fahruntüchtiger Personen- Grundlagen für die Schulung der Exekutive und für einen Maßnahmenkatalog für Ärzte. In: Illegale Drogen und Medikamente – Absolute Fahruntauglichkeit und mögliche Beeinträchtigung der Fahrtauglichkeit (II). Forschungsarbeiten aus dem Verkehrswesen. Bundesministerium für Wissenschaft und Verkehr. Band 99/2.

Täschner, K.L. (1991): Fahrtüchtigkeit bei Drogenkonsumenten. Verkehrsmedizin 1991, 43, 6, 193-196.

Tunbridge, R.; Clark; A.; Ward, B.N.; Dye, L. and Berghaus, G.(2000): Priortising Drugs and Medicines for Development of Roadside Impairment Testing. Certified, EU Research Project, Deliverable 1, 2000.

Tunbridge,, R.J.; Rowe, D.J.; Keigan, M. and Jackson, P.G. (2000): The Incidence of Drugs in Road Accidents fatalities in Great Britain. In: Swedisch National Road Administration (ED.): 15th Conference on Alcohol, Drugs and Traffic Safety. Proceedings of T2000, Stockholm, May 22-26, 2000. Swedish National Road Administration, Borlänge 2000.

Page 118 of 119 IMMORTAL R4.1 Last printed 16/09/2002 10:55

Tunbridge, R.J.; Keigan, M. and James, F.J. (2000): Recognising drug use and drug related impairment in drivers at the roadside.TRL Report 464, Crowthorne, Berkshire 2000.

Uhl, A.; Kopf, N.; Springer, A.; Eisenbach-Stangl; I.; Kobrna, U.; Bachmayer, S.; Beiglböck, W.; Preinsperger, W. und Mader, R. (2001): Handbuch Alkohol - Österreich. Zahlen, Daten, Fakten, Trends. Zweite überarbeitete und ergänzte Auflage. Bundesministerium für soziale Sicherheit und Generationen, Wien 2001.

Utzelmann, H. und Jacobshagen, W. (1997): Validation of the german system of diagnosis and rehabilitation for traffic offenders. In: Rothengatter, T. and Carbonell Vaya, E. (Eds.): Traffic and Transport Psychology. Theory and Application. Pergamon, 1997, 435-444.

Utzelmann, H. und Haas, R. (1985): Evaluation der Kurse mehrfach auffälliger Kraftfahrer. Unfall- und Sicherheitsforschung, Bericht Nr. 52. Im Auftrag des Bundesminister für Verkehr. Bundesanstalt für Straßenwesen, Bergisch Gladbach 1985.

Vollrath, M.; Löbmann, R.; Krüger, H.-P.; Schöch, H.; Widera; T und Mettke, M. (2001): Fahrten unter Drogeneinfluß – Einflußfaktoren und Gefährdungspotential.Berichte der Bundesanstalt für Straßenwesen, Mensch und Sicherheit M132, Bergisch Gladbach 2001.

Verstraete, A.G. (2000). The EU project ROSITA (Roadside Testing assessment). Blutalkohol Vol. 37, No.2, S. 7-12.

Vertraete, A.G. (2000): Drugs and driving: the situation in Belgium.In: Icadts (Ed.): Illegal Drugs and Driving. 2000.

Verstraete, A. and Puddu, M (2000): Evaluation of different roadside drug tests. Rosita Eu research project, Deliverable 4, 2000.

Verstraete, A. and Puddu, M (2000): General Conclusions and Recommendations. Rosita EU research project, Deliverable 5, 2000.

Walsh, M. et al. (2000) (Eds.): Illegal Drugs and Driving. Icadts 2000.

Weirich, V.; Wegener, R. und Rentsch, D. (1999): Untersuchungen zur Problematik „Fahren unter Drogeneinfluß“ in Meckelnburg. Bundesanstalt für Straßenwesen (Hrsg.): Kongreßbericht 1999 der Deutschen Gesellschaft für Verkehrsmedizin e.V. 30. Jahrestagung, Berlin 10.-13. März 1999. Berichte der Bundesanstalt für Straßenwesen, Mensch und Sicherheit, Heft M 11, Bergisch Gladbach 1999, 54-57.

Wennig, R.(2000): Influence of Methadone Use on Traffic Safety in Luxembourg. Blutalkohol 2000, 37,2, Supplement 1, 84-88.

Wilding, P. (2000): Alcohol related injury Road Accident statistics in the EU. In: EU- Working group on Alcohol, drugs and medicines: The Alcohol report and Recommendations. Annex 5.

Zancaner, S. Giorgetti, R., Dal Pozzo, C., Molinari, G., Snenghi, R. & Ferrara, S.D. (1997). Proceedings of T2000 -14th Conference on Alcohol, Drugs and Traffic Safety, Mercier-Gyuon (Ed.) Vol. 1.

Page 119 of 119