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U.S. DEPARTMENT OF TRANSPORTATION
NATIONAL HIGHWAY TRAFFIC SAFETY ADMINISTRATION
DOT HS 808 078 NOVEMBER 1993
MARIJUANA AND ACTUAL DRIVING PERFORMANCE
EFFECTS OF THC ON DRIVING PERFORMANCE
One of the issues addressed by the first driving study was whether it would be safe to continue using the same approach for subsequent on-road studies in traffic. The first group complied with all instructions, even after high doses of THC. Changes in mood were often reported but changes in personality were never observed. Most importantly, the subjects were always able to complete every ride without major interventions by the driving instructors and their safety was never compromised. The same occurred in the subsequent studies showing that it is possible to safely study marijuana's effects on actual driving performance in the presence of other traffic. In this respect, the drug is no different from many others studied by the same investigators and their colleagues.
The standard test measured the subjects' ability to maintain a constant speed and a steady lateral position between the lane boundaries. Standard deviation of lateral position, SDLP, increased after marijuana smoking in a dose-related manner. The lowest dose, i.e. 100 ug/kg THC, produced a slight elevation in mean SDLP, albeit significant in the first driving study. The intermediate dose, i.e. 200 ug/kg THC, increased SDLP moderately; and, the highest, i.e. 300 ug/kg THC, substantially. It is remarkable how well the changes in SDLP following THC in the first driving study were replicated in the second, in spite of the many differences in the ways they were designed. The replication of THC's effects on SDLP substantiates the generality of these results. Other objective measures obtained by this test were much less affected by THC. Mean speed was somewhat reduced following the higher THC doses, but the effects were relatively small (max. 1.1 km/hr or 0.7 mph). Standard deviations of speed and steering wheel movements were unaffected by the drug. Subjective ratings of perceived driving quality followed a similar pattern as SDLP indicating that the subjects were well aware of their diminished ability to control the vehicle after marijuana smoking.
The car following test measured the subjects' ability to follow a leading car with varying speed at a constant distance. All THC doses increased mean headway, but according to an inverse dose-response relationship. This type of relationship was unexpected and probably due to the particular design of the second driving study, i.e. the ascending dose series. It means that subjects were very cautious the first time they undertook the test under the influence of THC (i.e. after the lowest dose) and progressively less thereafter. As a consequence of this phenomenon, mean reaction time to changes in the preceding car's speed also followed an inverse dose-response relationship. Statistical adjustment for this confounding by analysis of covariance indicated that reaction times would not have increased significantly if the mean headway were constant. Coefficient of headway variation increased slightly following THC. Together, these data indicate that there is no more than a slight tendency towards impairment in car following performance after marijuana smoking. They also show that subjects try to compensate for anticipated adverse effects of the drug buy increasing headway, especially when they are uncertain of what these might be. As in the standard test, subjects' ratings of driving quality corresponded to the objective changes in their performance.
The city driving study measured the subjects' ability to operate a vehicle in urban traffic. for reasons mentioned in the respective chapter the THC dose in that study was restricted to 100 ug/kg. For comparative purposes another group of subjects was treated with a modest dose of alcohol, producing a mean BAC of about 0.04g%. Results of the study showed that the modest dose of alcohol, but not THC, produced a significant impairment in driving performance, relative to placebo. Alcohol impaired driving performance but subjects did not perceive it. THC did not impair driving performance yet the subjects thought it had. After alcohol, there was a tendency towards faster driving and after THC, slower.
The results of these studies corroborate those of previous driving simulator and closed-course tests by indicating that THC in single inhaled doses up to 300 ug/kg has significant, yet not dramatic, dose-related impairing effects on driving performance. They contrast with results from many laboratory tests, reviewed by Moskowitz (1985), which show that even low doses of THC impair skills deemed important for driving, such as perception, coordination, tracking and vigilance. The present studies also demonstrated that marijuana can have greater effects in laboratory than driving tests. The last study, for example, showed a highly significant effect of THC on hand unsteadiness but not on driving in urban traffic.
It is a natural question why the effects of marijuana on actual driving performance appear to be so small. As in many previous investigations, subjects attempted to compensate for anticipated adverse effects of marijuana smoking. Our subjects were aware of the impairing effects of THC as shown by lower ratings of perceived driving quality. Consequently, they invested more effort to accomplish the driving tests following THC than placebo. Furthermore, in the car following test, they drove at a greater headway after marijuana smoking; and, in both road tracking and city driving tests, they slightly reduced their driving speed. yet despite their effort, subjects were unable to fully compensate for THC's adverse effects on lateral position variability. This is because SDLP is primarily controlled by an automatic information processing system which operates outside of conscious control. The process is relatively impervious to environmental changes, as shown by the high reliability of SDLP under repeated placebo conditions, 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 accessible for compensatory mechanisms that reduce the decrements or abolish them entirely.
That still leaves the question open why performance appears to be more affected by THC in laboratory than actual driving tests. many researchers defend the primacy of laboratory performance tests for measuring drug effects on skills related to driving on the basis of superior experimental control. Certainly some control is always necessary to reduce the confounding influence of extraneous factors that would otherwise so increase measurement error as to totally obscure the drug's effects. however, only some extraneous factors are truly sources of measurement error and others either attenuate or amplify drug effects in real driving and must be considered as relevant to a test's predictive validity. Simply eliminating all of them, first, removes their normal mediating influence on the drug effect, and secondly, affects the subject's motivation to perform the test by making it appear "unreal". Controlling the test usually involves drastic simplification and restriction of response options. The desire in doing this is to isolate a particular driving skill and determine how it changes under the influence of drugs. However, 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. Thus the demonstration of some particular skill decrement in the laboratory in no way indicates that this would ultimately reduce driving safety in reality. Finally there are some skills that simply can not be measured in laboratory tests, at least not easily enough to make it a routine matter. The acquisition of any skill which depends upon automatic information processing requires practice over weeks or months. 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. In short, it would appear as if over-control in laboratory performance tests has resulted in a misimpression of THC's effect, incomplete in some respects and exaggerated in others. The actual driving tests may provide a more realistic impression of the drug's effects, albeit still incomplete and perhaps tending to minimize them with respect to more complex driving situations that come closer to "worst case".
The degree of experimental control also varied between driving tests in this series in ways affecting the subjects' motivation. This is illustrated by a comparison between the first and second driving study. The standard road tracking test was applied in both, first in the absence and then in the presence of other traffic. It was only during the former that disturbing observations of two individual's attentional deficits caused the driving instructor to intervene. Driving in the presence of other traffic, subjects were always able to complete the rides without intervention. Lateral position control, an automatic process, did not change as a consequence of the absence or presence of other traffic. What did change was the subjects' motivation to focus attention, a controlled process. Motivation in the second study was very probably affected by recognition of the increased risk of the untoward consequences of wandering attention. This means that the intrinsic motivation produced by the reality of the test situation is an important mediator of THC's effects on performance. Compensatory mechanisms help the driver under the influence of marijuana to maintain an effective level of performance but with an associated cost. If drivers compensate for THC's adverse effects by diminishing driving demands (e.g. by reducing speed and/or increasing headway), this will occur without a reduction in spare capacity. But if they increase effort as well (e.g. by focusing attention), it will occur at the expense of spare capacity. Less capacity would be left for simultaneously performing another task, such as conversing with passengers, using a car telephone, or handling emergency situations. The information processing capacity these situations demand may well go beyond the driver's spare capacity with the result of impaired and perhaps dangerous driving. Results of the present program show that THC increases the mental load of driving, as shown by increased effort ratings and reduced heart rate variability, and consequently reduces spare capacity. This corroborates results from previous simulator and closed-course studies that with reasonable consistency show an adverse THC effect on subsidiary task performance (Smiley, 1986). Further research is required to determine marijuana's effects on actual driving performance when the driver is simultaneously performing another task or suddenly confronted with a situation that requires a rapid adaptive response. The latter was occasionally encountered during the city driving test, but only after a low THC dose. The city driving test should therefore be repeated with subjects consuming higher THC doses.
Hazardous driving can also occur in situations that demand very little of the driver's information processing capacity. If the driving task is very monotonous and the demand is low, wandering attention may result in negligent monitoring with disastrous results. This is in fact what happened twice during the driving study on the closed road. After the highest THC dose, one subject failed to shift attention from the prescribed task to an unexpected event (screwdriver on the road); another failed to anticipate a normal event (end of circuit). Though even sober experienced drivers may experience similar deficits, the fact that it happened twice after the highest THC dose, and never after a lower dose or placebo, strongly suggests that drivers under the influence of THC would be unusually susceptible to attentional deficits during prolonged and monotonous driving.
How do marijuana's effects on driving performance compare to those of alcohol? There are two sources from which one can draw to answer the question. Information can be directly obtained from studies comparing THC and alcohol effects in the same experiment; and, indirectly, from studies wherein alcohol's effects were assessed using the same methods as applied in the present THC studies. As mentioned in Chapter 1, most closed-course studies on THC also measured alcohol's effects (BACs between 0.04 and 0.10g%). It was generally concluded that THC's effects were less than alcohol's especially at BACs above 0.08g%. The city driving study in the present program also compared the effects of modest doses of alcohol and THC. For doses administered in that study, alcohol produced the greater effects. Indirect evidence concerning the relative effects of THC and alcohol can be obtained from three studies. First, the alcohol calibration study by Louwerens et al. (1985, 1987) which resembled our first driving study in many respects. According to their empirical equation, THC's effects on SDLP were equal to or less than that of BAC = 0.07g%. More recently, studies by Riedel et al. (1989) and Ramaekers et al. (1992a) measured the effects of low doses of alcohol (BACs of 0.05 and 0.03g% respectively) on SDLP. Both groups applied the standard test in the presence of other traffic, as in our second driving study, but on another highway. Mean SDLPs were respectively about 5.0 and 2.5 cm higher while driving after alcohol than placebo. The former elevation is greater than that produced by the highest THC dose in our study. The latter lies between the effects of 200 and 300 ug/kg doses, which were 1.8 and 2.9 cm respectively. There was some discrepancy between alcohol's effects on SDLP in the more recent studies and those predicted by the empirical equation: the former where higher than predicted. The discrepancy appears to be related to the difference between alcohol's effects on the ascending and descending phases of its pharmacokinetic profile. Louwerens measured alcohol's effects at the time when BAC was at the ascending but Riedel and Ramaekers measured them during the descending phase. Notwithstanding methodological differences among studies, both direct and indirect evidence coverage on the conclusion that THC's effects after doses up to 300 ug/kg never exceed alcohol's at BACs of 0.08g%.
How do marijuana's effects on driving performance compare to those of drugs other than alcohol? No direct comparisons have ever been made, but many studies employing the standard road tracking test were conducted for measuring other drugs' effects on SDLP during the last decade. The results from a few will be mentioned. Diazepam (Valium) given for one week in a low therapeutic dose (5 mg, thrice daily) caused anxious patients to drive with a mean SDLP about 7 cm higher than their premedication baseline (Van Laar et al., 1992). The same drug and dose given over the same period caused healthy volunteers to drive with a mean SDLP about 6 cm higher than placebo (Van Veggel and O'Hanlon, 1993). Lorazepam (ativan), another anxiolytic, given twice daily for one week in a 1.5 mg dose to healthy volunteers (Volkerts et al., 1988) and a 2 mg dose to patients (Vermeeren et al. 1993), produced an elevation of SDLP of about 10 cm in both cases. Amitriptyline (Elavil), a widely prescribed antidepressant, given in a dose of 50 mg at night and 25 mg in the morning caused healthy volunteers to drive with a mean SDLP about 6 cm higher than placebo (Robbe et al., 1989. Fluraxepam (Dalmane), a hypnotic, was administered to insomniacs and its "hang-over" effects on SDLP were measured 10-11 hours after ingestion. A 15 mg dose of flurazepam elevated mean SDLP by about 4 cm; a 30 mg does, 7 cm. Antihistamines also cause sedation and, consequently, impair road tracking performance. Triprolidine (actifed) increased SDLP by 3.5 cm after a single 5 mg dose (Riedel et al., 1990); and, diphenhydramine 50 mg (Benadryl kapseals) increased SDLP by 4.5 cm (Ramaekers et al., 1992b). This is not to say that all psychotropic drugs produce greater elevations of SDLP than THC. Many in the same and other experiments had less effect than THC did in our studies. These examples are merely cited to indicate that THC's effects as measured in the standard test were in no way unusual. In so far as its effects on SDLP are concerned, THC was just another moderately impairing drug.
The foregoing comparisons might be misleading. THC's effects differ qualitatively from many other drugs, especially alcohol. For example, subjects drive faster after drinking alcohol and slower after smoking marijuana (Hansteen et al., 1976/ Casswell, 1979; Peck et al., 1986; Smiley et al., 1987).. Moreover, the simulator study by Ellingstad et al. (1973) showed that subjects under the influence of marijuana were less likely to engage in overtaking maneuvers, whereas those under the influence of alcohol showed the opposite tendency. Very importantly, our city driving study showed that drivers who drank alcohol over-estimated their performance quality whereas those who smoked marijuana under-estimated it. Perhaps as a consequence, the former invested no special effort for accomplishing the task whereas the latter did, and successfully. This evidence strongly 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 users seem better able to compensate for its adverse effects while driving under the influence. Weil et al. (1968) were among the earliest authors who mentioned the possibility that marijuana users can actively suppress the drug's adverse effects. They presumed that THC's effects were confined to higher cortical functions without any general stimulatory or depressive effect on lower brain centers. According to them, the relative absence of neurological, as opposed to psychiatric, symptoms in marijuana intoxication suggests this possibility. More recently, Moskowitz (1985) concluded that the variety of impairments found after marijuana smoking could not be explained by decrements in sensory or motor functions which led him to hypothesize that some important central cognitive process is impaired by THC, without saying what it is. Identification of THC's site of action would greatly enhance our understanding of the drug's psychopharmacological effects.
Epidemiological research has shown that THC is infrequently detected in the blood of fatally injured drivers as the only drug present. In most cases alcohol is also detected. The effects of the combination of THC and alcohol on actual driving performance have never been studied in the presence of other traffic. Closed-course studies have shown that the effects of both drugs, when taken in combination, are generally additive (Atwood et al., 1981; Peck et al., 1986). This may only be so for those behaviors that are similarly affected by both rugs given separately. Closer examination of the combined use is warranted in those driving situations where both drugs produce qualitatively different effects. It may well be so that alcohol reduces drivers' insight or motivation to the point where they would no longer attempt to compensate for the THC effect. As a result, the combined effects on drivers' performance could well be greater than the sum of either drug acting separately. There is therefore a great need for further research on marijuana and actual driving research, but now extended to the combination of marijuana and alcohol.
In summary, 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. Still we 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. We therefore agree with Moskowitz' conclusion that "any situation in which safety both for self and others depends upon alertness and capability of control of man-machine interaction precludes the use of marijuana". However, the magnitude of marijuana's, relative to many other drugs', effects also justify Gieringer's (1988) conclusion that "marijuana impairment presents a real, but secondary, safety risk; and that alcohol is the leading drug-related accident risk factor". Of the many psychotropic drugs, licit and illicit, that are available and used by people who subsequently drive, marijuana may well be among the least harmful. Campaigns to discourage the use of marijuana by drivers are certainly warranted. But concentrating a campaign on marijuana alone may not be in proportion to the safety problem it causes.
DRUG PLASMA CONCENTRATIONS AND DRIVING PERFORMANCE
One of the program's objectives was to determine whether it is possible to predict driving impairment by plasma concentrations of THC and/or its metabolite, THC-COOH, in single samples. The answer is very clear: it is not. Plasma of drivers showing substantial impairment in these studies contained both high and low THC concentrations; and, drivers with high plasma concentrations showed substantial, but also no impairment, or even some improvement. The first driving study showed that impairment in the road tracking test was nearly the same in the first and second test, executed between 40-60 and 100-120 minutes after initiation of smoking, respectively. Plasma concentrations of THC and THC-COOH, however, were not the same during the tests: both were lower during the second than the first. The same pattern was found for ratings of perceived "high". It has been said that behavioral signs of intoxication, though small, outlast physiological and subjective reactions to THC (Reeve et al. 1983; Yesavage et al., 1985). to examine this hypothesis, future research should extend actual driving performance measurements to 4, 8, 16 and 24 hours after smoking. If driving impairment still occurs after THC disappears from plasma, it could mean that previous epidemiological research has underestimated the proportion of drivers who were driving under the influence of marijuana at the times their accidents occurred.
Mean speed was the only measure of driving performance that was even moderately related to plasma concentrations of the drug. Subjects with higher THC concentrations in plasma drove slower in the standard road tracking test (correlations varying from r = -.18 to r = -.72 between conditions). This effect might have been even more pronounced if the subjects had not been instructed to drive at a particular speed, and if they had had no feedback from the speedometer.
The major conclusions from the present program are summarized as follows:
* Current users of marijuana prefer THC doses of about 300 ug/kg to achieve their desired "high".
* It is possible to safely study the effects of marijuana on driving on highways or city streets in the presence of other traffic.
* Marijuana smoking impairs fundamental road tracking ability with the degree if impairment increasing as a function of the consumed THC dose.
* Marijuana smoking which delivers THC up to a 300 ug/kg dose slightly impairs the ability to maintain a constant headway while following another car.
* A low THC dose (100 ug/kg) does not impair driving ability in urban traffic to the same extent as a blood alcohol concentration (BAC) of 0.04g%.
* Drivers under the influence of marijuana tend to over-estimate the adverse effects of the drug on their driving quality and compensate when they can; e.g. by increasing effort to accomplish the task, increasing headway or slowing down, or a combination of these.
* Drivers under the influence of alcohol tend to under-estimate the adverse effects of the drug on their driving quality and do not invest compensatory effort.
* The maximum road tracking impairment after the highest THC dose (300 ug/kg) was within a range of effects produced by many commonly used medicinal drugs and less than that associated with a blood alcohol concentration (BAC) of 0.08g% in previous studies employing the same test.
* It is 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.