National Highway Traffic Safety Administration
By Robbe HWJ, O'Hanlon JF
Conducted by Institute for Human Psychopharmacology University of Limburg Abstract 2A-6211 LS Maastricht -- Netherlands
Sponsoring Agency: U.S. Department of Transportation National Highway Traffic Safety Administration 400 Seventh Street, S.W. Washington, DC 20590
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Abstract: This report concerns the effects of marijuana smoking on actual driving performance. It presents the results of one pilot and three actual driving studies. The pilot study's major purpose was to establish the THC dose current marijuana users smoke to achieve their desired "high". From these results it was decided that the maximum THC dose for subsequent driving studies would be 300 mcg / kg (0.3 mg / kg). The first driving study was conducted on a closed section of a primary highway. After smoking marijuana delivering THC doses of 0, 100, 200, and 300 mcg / kg, subjects drove a car while maintaining a constant speed and lateral position. This study was replicated with a new group of subjects, but now in the presence of other traffic. In addition, a car following test was executed. The third driving study compared the effects of a modest dose of THC (100 mcg / kg) and alcohol )BAC of 0.04 g %) on city driving performance. This program of research has shown that marijuana, when taken alone, produces a moderate degree of driving impairment which is related to the consumed THC dose. The impairment manifests itself mainly in the ability to maintain a steady lateral position on the road, but its magnitude is not exceptional in comparison with changes produced by many medicinal drugs and alcohol. Drivers under the influence of marijuana retain insight in their performance and will compensate where they can, for example, by slowing down or increasing effort. As a consequence, THC's adverse effects on driving performance appear relatively small.
This report concerns the effects of marijuana smoking on actual driving performance. It presents the results of one pilot and three actual driving studies which were conducted between April 1990 and March 1992. The program was funded by the U.S. National Highway Traffic Safety Administration (NHTSA), with the exception of the alcohol part of the city driving study which was sponsored by the Dutch Ministry of Transport and Public Works. The project was conducted by the Institute for Drugs, Safety and Behavior of the University of Limburg, Maastricht, The Netherlands. The major objectives of the program were to determine the dose-response relationship between delta-9-tetrahydrocannabinol (THC), marijuana's main constituent, and objectively and subjectively measured aspects of real-world driving; and, to determine whether it is possible to correlate driving performance impairment with plasma concentrations of the drug or a metabolite. A variety of driving tests were employed, including: maintenance of a constant speed and lateral position during uninterrupted highway travel, following a leading car with varying speed on a highway, and city driving. The purpose of applying different tests was to determine whether similar changes in performance under the influence of THC occur in all, thereby indicating a general drug effect on driving ability.
Chapter One provides background information about the drug, its pharmacological properties, the prevalence of its use, and a review of marijuana smoking and traffic safety. THC's effects on the ability of drivers to operate safely in traffic situations have traditionally been determined in two ways: from epidemiological surveys of users' involvement in traffic accidents and from empirical studies to measure the drug's influence on skills related to driving, or driving itself. Epidemiology shows that people drive after marijuana use and that drivers involved in accidents often show the drug's presence. The results are, however, inconclusive because of the high proportion of cases which also involve alcohol use and the lack of proper control groups. There, the extent marijuana contributes to traffic accident causality remains obscure. Results from driving simulator and closed-course tests show that THC in single inhaled doses up to about 250 mcg / kg has relatively minor effects on driving performance, certainly less than blood alcohol concentrations (BAC's) in the range of 0.08-0.10 g-%.
Chapter Two describes the studies of the program and certain procedures that were common to all. These were subject recruiting, compliance with ethical and legal standards, screening for the presence of other illicit drugs and alcohol, blood sampling procedures and quantitative analyses. Subjects in all studies were recreational users of cannabis, i.e. smoking marijuana or hashish more than once a month but not daily. They were all healthy, between 21 and 40 years of age, had normal weight and binocular acuity, and were licensed to drive an automobile. Subjects were accompanied in every driving test by a licensed driving instructor, experienced in supervising subjects who operated under the influence of medicinal drugs in previous studies. Redundant control system in the test vehicle was available for controlling the car if emergency situations should arise. Marijuana and placebo marijuana cigarettes were supplied by the U.S. National Institute on Drug Abuse (NIDA). [Isn't it curious that a study done in the Netherlands used NIDA supplied marijuana? It is nearly IMPOSSIBLE to get NIDA supplied marijuana in the U.S. for these kind of studies or medical studies.]
Chapter Three presents the results of the pilot study. It was conducted in a hospital under strict medical supervision to identify THC doses that recreational marijuana users were likely to consume before driving. Twenty-four subjects, twelve males and twelve females, participated. They were allowed to smoke part or all of the THC content in three cigarettes until achieving the desired psychological effect. Cigarettes were smoked through a plastic holder in a manner determined by the subjects. The only requirement was to smoke continuously for a perod not exceeding 15 minutes. When subjects voluntarily stopped smoking, cigarettes were carefully extinguished and retained for subsequent gravimetric estimation of THC consumed. Six subjects consumed one cigarette, thirteen smoked two and four smoked three. The average amount of THC consumed was 20.8 mg, after adjustment for body weight, 308 mcg / kg [of body weight]. There was no significant difference between males and females with respect to the weight adjusted preferred dose. It was decided that the maximum dose for subsequent driving studies would be 300 mcg / kg. This is considerably higher than doses that have usually been administered to subjects in experimental studies (typically, 100-200 mcg / kg THC).
The study provided the opportunity for obtaining valuable information about THC's pharmacokinetics and its pharmacodynamic effects after marijuana smoking. Blood samples were repeatedly taken for measuring plasma concentrations of THC and its major inactive metabolite, THC-COOH. The subjects repeatedly performed certain simple laboratory tests, estimated their levels of intoxication and indicated their willingnes to drive under several specified conditions of urgency. Heart rate was measured at these times. The secondary purpose of the pilot study was that of specifying relationships between (THC) and (THC-COOH) with changes in the other physiological, performance or subjective variables. Other results from the pilot study showed that perceived "high" and heart rate are very sensitive measures of marijuana intoxication which confirms prior findings. Impairments in laboratory tests performance were found at the time of peak subjective feelings but generally, objective impairment dissipated more rapidly than lthe feelings themselves.
The first driving study, described in Chapter Four, was conducted on a highway closed to other traffic. One objective of the study was to determine whether it would be safe to repeat the study on a normal highway in the presence of other traffic. The second objective was to define the dose-effect relationship between inhaled THC dose and driving performance. The same twelve men and twelve women who participated in the pilot study served again as the subjects. They were treated on separate occasions with THC doses of 0, 100, 200, 300 mcg / kg. Treatments were administered double-blind and in a counterbalanced order. On each occasion, subjects performed a road tracking test beginning 40 minutes after initiation of smoking and repeated one hour later. The test, developed and standardized by O'Hanlon et al. (1982, 1986), involved maintaining a constant speed at 90 km / h (56 mph) and a steady lateral position between the delineated boundaries of the traffic lane. Subjects drove 22 km (13.6 mi) on a primary highway and were accompanied by a licensed driving instructor. The latter was charged with responsibility for ensuring safety at all times and was able to intervene, if necessary, using redundant vehicular controls. The primary dependent variable was the standard deviation of lateral position (SDLP), which has been shown to be both highly reliable and very sensitive to the influence of sedative drugs and alcohol. Other dependent variables were mean speed, and standard deviation of speed and steering wheel angle. Blood samples were taken prior to each driving test; and, performance in critical tracking and hand steadiness tests, heart rate, and blood pressure were measured after its termination. Questionnaires were repeatedly administered to estimate the "high" and other subjective feelings.
All subjects were willing and able to finish the driving tests without great difficulty. The study demonstrated that marijuana impairs driving performance as measured by an increase in SDLP; all three THC doses significantly affected SDLP relative to placebo. The driving performance decrement after smoking marijuana persisted almost undiminished for two hours after smoking while drug plasma concentrations, perceived "high" and heart rate elevation had decreased. Marijuana's effects on SDLP were compared to those of alcohol obtained in a very similar study by Louwerens et al. (1985, 1987). It appeared that THC's effects on SDLP were equivalent to those associated with BAC's in the range of 0.03-0.07 g %. Other driving performance measures were not significantly affected by THC. Intersubject correlations between plasma concentrations of the drug and driving performance after every dose were essentially nil. Thus, driving impairment cannot be predicted by prevailing plasma concentrations of THC or THC-COOH. Driving impairment was also not related to performance in the laboratory tests. Both the observed degree of driving impairment, and what subjects said and did, indicated that normal safeguards would be sufficient for ensuring safety in further testing. Hence, the final conclusion was to repeat this study on a normal highway in the presence of other traffic.
The second driving study, described in Chapter Five, was conducted to come a step closer to driving reality than its predecessor. Driving tests were now conducted on a highway in the presence of other traffic. The major objective of this study was to confirm the relationship between inhaled THC dose and lateral position variability in the context of a standard road tracking test. A secondary objective was to measure performance in another actual driving test, i.e. car following. The third objective was to continue efforts to correlate plasma concentrations of THC and THC-COOH with driving performance impairment as measured in both tests.
A new group of sixteen subjects, equally comprised of men and women, participated in this study. A conservative approach was chosen in designing the present study in order to satisfy the series design where both active drug and placebo conditions were administered, double-blind, at each of three THC dose levels. THC doses were the same as those used in the previous study, namely 100, 200, and 300 mcg / kg. Cigarettes appeared identical at each level of treatment conditions and were smoked through a plastic holder in a fashion determined by the subject within a time limit of 10 minutes. If any subject would have reacted in an unacceptable manner to a lower dose, he / she would not have been permitted to receive a higher dose.
Two subjects at a time commenced smoking. Thirty minutes after onset of smoking the subjects performed a battery of laboratory tests (tracking, hand steadiness and body sway), yielded a blood sample, and rated their "high" and other subjective feelings. They were then transported to a primary highway where the driving tests were performed. Two instrumented vehicles were employed. The subjects performed the car following test on a 16 km (9.9 mi) segment of the highway for about twelve minutes. After conclusion of the car following test, both subjects then commenced the road tracking test in separate instrumented vehicles. The highway was the same as for the car following test. Subjects drove 64 km (40 mi) without stopping in about 50 minutes. At the conclusion of this test, both subjects participated again in the car following test. Subjects were then transported back to the laboratory where they rated subjective feelings, yielded a blood sample, and repeated the test battery. The subjects' heart rate was registered continuously during both driving tests.
The road tracking test was the same as in the previous study except for its duration and the presence of other traffic. Subjects were instructed to maintain a constant speed of 95 km / h (59 mph) and a steady lateral position between lane boundaries in the right traffic lane. They were allowed to deviate from this only if it would become necessary to pass a slower vehicle in the same lane. Data from the standart test were analyzed to yield the same performance measures as in the previous study; i.e. SDLP, mean and standard deviation of speed, and standard deviation of steering wheel angle. The car following test measures drivers' ability to perceive changes in a preceding vehicle's speed and to react in a manner maintaining a constant headway. It began as the preceding and the following vehicle, respectively driven by one of the driving instructors and the subject, operated in tandem on the slower traffic lane while travelling at a speed of 100 km / h (62 mph). The subject was instructed to maintain a 50 m (164 ft) headway however the preceding vehicle's speed might vary. After driving in this manner for about one minute, the operator of the preceding vehicle released the accelerator pedal allowing its speed to fall to 80 km / h (50 mph). Immediately thereafter, the operator of the preceding vehicle accelerated to 100 km / (62 mph). The duration of one deceleration and acceleration maneuver was approximately 50 seconds and six to eight, depending upon traffic density, were executed during one test. The subject's average reaction time to the movements of the leading vehicle, mean headway and coefficient of variation of headway during maneuvers were taken as the dependent variables from this.
All subjects were able to complete the series without suffering any untoward reaction while driving. Road tracking performance in the standard test was impaired in a dose-related manner by THC and confirmed the results obtained in the previous closed highway study. The 100 mcg / kg dose produced a slight elevation in mean SDLP, albeit nearly significant. The 200 mcg / kg dose produced a significant elevation, of dubious practical relevance. The 300 mcg / kg dose produced a highly significant elevation which may be viewed as practically relevant but unexceptional in comparison with similarly measured effects of many medicinal drugs. Following marijuana smoking subjects drove with an average speed that was only slightly lower than after placebo and very close to the prescribed level.
In the car following test, subjects maintained a headway of 45-50 m (148-164 ft) while driving in the successive placebo conditions. They lengthened mean headway by 8, 6 and 2 m (26.2, 19.7 and 6.6 ft) in the corresponding THC conditions after 100, 200 and 300 mcg / kg, respectively. The initially large drug-placebo difference and its subsequent decline is a surprising result. Our explanation for this observation is that the subjects' caution was greatest the first time they undertook the test under the influence of THC and progressively less thereafter. Reaction time to changes in the preceding vehicle's speed increased following THC treatment, relative to placebo. The administered THC dose was inversely related to the change in reaction time, as it was to headway. However, increased reaction times were partly due to longer headway. Statistical adjustment for this confounding resulted in smaller and non-significant increases in reaction time following marijuana treatment, the greatest impairment (0.32 s) being observed in the first test following the lowest THC dose. Headway variability followed a similar pattern as mean headway and reaction time; the greatest impairment was found following the lowest dose.
An important practical objective of this study was to determine whether degrees of driving impairment can be accurately predicted from either measured concentrations of THC in plasma or performance measured in potential roadside "sobriety" tests of tracking ability or hand and posture stability. The results, like many reported before, indicate that none of these measures accurately predicts changes in actual driving performance under the influence of THC.
The program then proceeded into the third driving study, presented in Chapter Six, which involved tests conducted in high-density urban traffic. There were logical and safety reasons for restricting the THC dose to 100 mcg / kg. It was given to a group of regular cannabis users, along with placebo. For comparative purposes another group of regular alcohol users were treated with a modest dose of their preferred recreational drug, and again placebo, before undertaking the same city driving test. Two groups of sixteen new subjects apiece, equally comprised of men and women, participated. Subjects in the alcohol group were regular users of alcohol but not marijuana. Both groups were treated on separate occasions with active drug and placebo. Active marijuana was administered to deliver 100 mcg / kg THC. The driving test commenced 30 minutes after smoking. The alcohol dose was chosen to yield a BAC approaching 0.05 g % when the driving test commenced 45 minutes after onset of drinking. Active drug and placebo conditions were administered double-blind and in a counterbalanced order in each group.
Driving tests were conducted in daylight over a constant 17.5 km (10.9 mi) route within the city limits of Maastricht. Subjects drove their placebo and active drug rides through heavy, medium and low density traffic on the same day of the week, and at the same time of day. Two scoring methods were employed in the present study. The first, "molar" approach, required the driving instructor acting as the safety controller during the tests to retrospectively rate the driver's performance using a standard scale. The second, a more "molecular" approach, involved the employment of a specially trained observer who applied simple and strict criteria for recording when the driver made or failed to make each in a series of observable responses at predetermined points along a chosen route. Immediately prior to and following the driving tests subjects performed hand steadiness and time perception tests, yielded a blood sample, and were administered the same subjective questionnaires used in the previous studies.
The study showed that a modest dose of alcohol (BAC = 0.04 g %) produced a significant impairment in city driving as measured by the molar approach, relative to placebo. More specifically, alcohol impaired vehicle handling and traffic maneuvers. Marijuana, administered in a dose of 100 mcg / kg THC, on the other hand, did not signifcantly change mean driving performance as measured by this approach. Neither alcohol nor marijuana significantly affected driving performance measures obtained by the molecular approach indicating that it may be relatively insensitive to drug-induced changes.
Driving quality as rated by the subjects contrasted with observer ratings. Alcohol impaired driving performance according to the driving instructor but subjects did not perceive it; marijuana did not impair driving performance but the subjects themselves perceived their driving performance as such. Both groups reported about the same amount of effort in accomplishing the driving test following placebo Yet only subjects in the ;marijuana group reported significantly higher levels of invested effort following the active drug. Thus, there was evidence that subjects in the marijuana group were not only aware of their intoxicated condition but were also attempting to compensate for it. These seem to be important findings. They support both the common belief that drivers become overconfident after drinking alcohol and investigators' suspicions that they become more cautious and self-critical after consuming low THC doses by smoking marijuana.
The laboratory performance tests also discriminated between the drugs' effects. Hand steadiness was impaired following THC and improved following alcohol, relative to placebo. The difference between the drugs' effects was significant, both before and after the driving test. Impairment after THC was about as much as that produced by the same dose in the previous study, indicating equivalent sensitivities of the present and previous groups. Production of time intervals was not affected by alcohol, but THC significantly shortened interval production, relative to placebo.
Drug plasma concentrations were neither related to absolute driving performance scores nor to the changes that occurred from placebo to drug conditions. With respect to THC, these results confirm the findings in previous studies. They are somewhat surprising for alcohol but may be due to the restricted range of ethanol concentrations in the plasma of different subjects.
Chapter Seven concludes the report with a general discussion of the results of the program and ends with list of conclusions and recommendations. It starts with a discussion of the THC dose which marijuana users actually prefer for achieving their desired "high." Several questions are raised and discussed, such as: how do people regulate their THC consumption, what role plays familiarization with the drug, and what would the preferred dose have been if marijuana of much higher potency were smoked. The discussion then continues with a description of the differences between the driving tests in terms of the type of information processing each requires, automatic vs controlled, and the relevance of each to traffic safety.
Attention is further focussed on the effects of THC on driving performance. The results of the studies corroborate those of previous driving simulator and closed-course tests by indicating that THC in single inhaled doses up to 300 mcg /kg has significant, yet not dramatic, dose-related impairing effects on driving performance. Standard deviation of lateral position in the road tracking test was the most sensitive measure for revealing THC's adverse effects. This is because road tracking is primarily controlled by an automatic information processing system which operates outside of conscious control The process is relatively impervious to environmental changes but highly vulnerable to internal factors that retard the flow of information through the system. THC and many other drugs are among these factors. When they interfere with the process that restricts SDLP, there is little the afflicted individual can do by way of compensation to restore the situation. Car following and, to a greater extent, city driving performance depend more on controlled information processing and are therefore more accesible for compensatory mechanisms that reduce the decrements or abolish them entirely.
It appears that performance is more affected by THC in laboratory than actual driving tests. Several reasons that may account for the apparent discrepancy are discussed. First, laboratory tests are experimentally controlled by drastic simplification which may affect a subjects motivation to perform the test by making it appear "unreal." Secondly, the restriction of response options in laboratory performance tests leave fewer possibilities for compensation. In real life, drivers always apply numerous skills in parallel and series. Should one become deficient, they are often able to compensate in a number of ways to achieve a satisfactory level of proficiency. Finally, after learning to drive, subjects possess such skills in abundance and one can only demonstrate how they vary with drug effects in the real task or a very close approximation thereof. Profound drug impairment constituting an obvious traffic safety hazard could as easily be demonstrated in a laboratory performance test as anywhere else. But THC is not a profoundly impairing drug. It does affect automatic information processing, even after low doses, but not to any great extent after high doses. It apparently affects controlled information processing in a variety of laboratory tests, but not to the extent which is beyond the individual's ability to control when he is motivated and permitted to do so in real driving.
Marijuana's effects on driving performance were compared to those of many other drugs. It was concluded that THC's effects after doses up to 300 mcg / kg never exceed alcohol's at BAC's of 0.08 g %; and were in no way unusual compared to many medicinal drugs'. Yet THC's effects differ qualitatively from many other drugs, especially alcohol. Evidence from the present and previous studies stronly suggests that alcohol encourages risky driving whereas THC encourages greater caution, at least in experiments. Another way THC seems to differ qualitatively from many other drugs is that the former's users seem better able to compensate for its adverse effects while driving under the influence. Still one can easily imagine situations where the influence of marijuana smoking might have an exceedingly dangerous effect; i.e., emergency situations which put high demands on the driver's information processing capacity, prolonged monotonous driving, and after THC has been taken with other drugs, especially alcohol
Finally, the relation between driving impairment following marijuana smoking and plasma concentrations of THC and THC-COOH is discussed. It appears not possible to conclude anything about a driver's impairment on the basis of his / her plasma concentrations of THC and THC-COOH determined in a single sample.