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Open Access

Impaired driving and legalization of recreational cannabis

Sarah B. Windle, Crystal Sequeira, Kristian B. Filion, Brett D. Thombs, Pauline Reynier, Roland Grad, Carolyn Ells and Mark J. Eisenberg
CMAJ April 06, 2021 193 (14) E481-E485; DOI: https://doi.org/10.1503/cmaj.191032
Sarah B. Windle
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Crystal Sequeira
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Kristian B. Filion
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Brett D. Thombs
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Pauline Reynier
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Roland Grad
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Carolyn Ells
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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Mark J. Eisenberg
Lady Davis Institute (Windle, Sequeira, Filion, Thombs, Reynier, Grad, Ells, Eisenberg), Jewish General Hospital; Department of Epidemiology, Biostatistics and Occupational Health (Windle, Filion, Thombs, Eisenberg), McGill University; Department of Medicine (Filion, Thombs, Eisenberg), McGill University; Departments of Psychiatry, of Psychology, and of Educational and Counselling Psychology (Thombs), McGill University; Department of Family Medicine (Grad, Ells), McGill University; Biomedical Ethics Unit, Division of Experimental Medicine, and Department of Social Sciences of Medicine (Ells), McGill University; Division of Cardiology (Eisenberg), Jewish General Hospital, Montréal, Que.
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  • RE: Youth tetrahydrocannabinol (THC) vaping and driving
    Ediriweera Desapriya [PhD], Sarah Yassami [MD] and Kamal Gunatunge [MD]
    Posted on: 22 May 2021
  • RE: Residual blood THC levels
    Ediriweera Desapriya [PhD], Kamal Gunatunge [MD] and Sarah Yassami [MD]
    Posted on: 19 May 2021
  • RE: Impaired driving and legalization of recreational Cannabis
    Tom Bell [BSc MD CCFP FCFP]
    Posted on: 06 April 2021
  • Posted on: (22 May 2021)
    Page navigation anchor for RE: Youth tetrahydrocannabinol (THC) vaping and driving
    RE: Youth tetrahydrocannabinol (THC) vaping and driving
    • Ediriweera Desapriya [PhD], Educator special need, Burnaby School District
    • Other Contributors:
      • Sarah Yassami, -
      • Kamal Gunatunge, GP

    This review is an excellent contribution to cannabis and traffic accident prevention research. However, reviews ‘lack of focus and information on youth tetrahydrocannabinol (THC) vaping and driving'. Recently, Canada has approved cannabis for medicinal and non-medicinal use. These changes have also spawned novel cannabis products and formulations including THC vape products (2). Vaporization is an increasingly popular method for cannabis administration, among youths. According to recent research youth cannabis use is increasing in Canada. Vaporization is an increasingly popular method for cannabis administration, among youths (3, 4).
    It should be noted that during 2019-2020, both CMAJ and BC Medical Journal reported serious cases of e-cigarette-related lung injury. These cases were predominantly related to THC vaping. Evidence from the recent US/Canada outbreak of e-cigarette, or vaping, associated lung injury (EVALI)-cases of life-threatening pulmonary illnesses caused by THC-containing vaping products. The Government advise that the Canadians should not use vaping products that contain cannabis (According to a recent Canadian Pediatric Society position statement-usually with higher concentrations of THC than traditional dried cannabis)- https://www.cps.ca/en/documents/position/protecting-children-and-adolesc...)-...

    Show More

    This review is an excellent contribution to cannabis and traffic accident prevention research. However, reviews ‘lack of focus and information on youth tetrahydrocannabinol (THC) vaping and driving'. Recently, Canada has approved cannabis for medicinal and non-medicinal use. These changes have also spawned novel cannabis products and formulations including THC vape products (2). Vaporization is an increasingly popular method for cannabis administration, among youths. According to recent research youth cannabis use is increasing in Canada. Vaporization is an increasingly popular method for cannabis administration, among youths (3, 4).
    It should be noted that during 2019-2020, both CMAJ and BC Medical Journal reported serious cases of e-cigarette-related lung injury. These cases were predominantly related to THC vaping. Evidence from the recent US/Canada outbreak of e-cigarette, or vaping, associated lung injury (EVALI)-cases of life-threatening pulmonary illnesses caused by THC-containing vaping products. The Government advise that the Canadians should not use vaping products that contain cannabis (According to a recent Canadian Pediatric Society position statement-usually with higher concentrations of THC than traditional dried cannabis)- https://www.cps.ca/en/documents/position/protecting-children-and-adolesc...)- https://www.canada.ca/en/public-health/services/diseases/vaping-pulmonar...
    Vaping has changed the youth’s tobacco smoking landscape and now the same with cannabis. A recent JAMA study shows that vaping in fact, intensifies the drug effects of cannabis (2). Will the Health Canada and Government of Canada which have become more aggressive in limiting vaping of tobacco also do so for cannabis? Will they step up and disseminate current evidence of extreme danger of THC vaping and driving? This is necessary as it is well known that young drivers are at particularly high risk of crash involvement, in part as a result of their relative inexperience with the complex demands of driving. Moreover, cannabis is the most common illicit drug found among young drivers who die in crashes in Canada (3, 4, 5). These data must inform future road traffic safety legislation and tailor youth targeted appropriate prevention efforts. In addition, this evidence must guide public health policy and clinical interventions surrounding the use of cannabis among youths.
    According to a recent position statement of Canadian Pediatric Society (2021), Pediatric health care providers and primary care physicians should address the risks of vaping with all the adolescents they see and further routinely assess youth for vaping, with evidence-based screening tools when needed. Every pediatric patient encounter is an opportunity for a “teachable moment” and clinicians can educate, empower and increase awareness among pediatric patients, parents and caregivers on the extreme danger of mixing THC vaping and driving.

    Show Less
    Competing Interests: None declared.

    References

    • Sarah B. Windle, Crystal Sequeira, Kristian B. Filion, et al. Impaired driving and legalization of recreational cannabis. CMAJ 2021;193:E481-E485.
    • (2). Spindle TR, Cone EJ, Schlienz NJ, et al. Acute Effects of Smoked and Vaporized Cannabis in Healthy Adults Who Infrequently Use Cannabis: A Crossover Trial. JAMA Netw Open. 2018;1(7):e184841. doi:10.1001/jamanetworkopen.2018.4841.
    • (3). Fataar F, Hammond D. The Prevalence of Vaping and Smoking as Modes of Delivery for Nicotine and Cannabis among Youth in Canada, England and the United States. Int J Environ Res Public Health. 2019 Oct 25;16(21):4111. doi: 10.3390/ijerph16214111. PMID
    • (4). Stanwick R. E-cigarettes: Are we renormalizing public smoking? Reversing five decades of tobacco control and revitalizing nicotine dependency in children and youth in Canada. Paediatr Child Heal, 2015;20(2):101-05.
    • (5). Chadi N, Minato C, Stanwick R. Cannabis vaping: Understanding the health risks of a rapidly emerging trend. Paediatr Child Health. 2020 Jun;25(Suppl 1):S16-S20. doi: 10.1093/pch/pxaa016. Epub 2020 Jun 15. PMID: 33390752; PMCID: PMC7757764.
  • Posted on: (19 May 2021)
    Page navigation anchor for RE: Residual blood THC levels
    RE: Residual blood THC levels
    • Ediriweera Desapriya [PhD], Special need educator, Burnaby School District
    • Other Contributors:
      • Kamal Gunatunge, GP
      • Sarah Yassami, -

    We read your recent review article with interest. However, the article lacks information to guide appropriate legislative revisions and current legislative enhancement strategies to prevent THC and driving in Canada. This is mainly due to lack of accurate information regarding chronic cannabis users and their residual blood THC levels.

    Our recent systematic review examined studies on blood THC levels in heavy cannabis users following monitored abstinence of at least 4 hours. The findings of our review suggest that chronic cannabis users may have blood THC levels that persist above the per se limits of 2 ug/L and 5 ug/L despite prolonged abstinence (2). A number of studies reported blood THC levels above 2 ug/L that could persist up to 6 days despite abstinence, with the longest reported duration being 30 days (2, 3). In addition, high THC levels of above 5 ug/L over several days is also a significant finding that informs our knowledge of blood cannabinoid concentrations in heavy users during sustained abstinence.

    The current interpretation of THC levels in long-term cannabis users may need to be reconsidered based on the evidence that THC levels may be higher and persist for longer than previously described. Some studies have reported a rapid fall in blood THC levels within an hour or two within smoking and a prolonged terminal elimination phase. During the latter, the blood THC concentrations fall to a residual level of up to 2 to 3 ug/L and decline slowly...

    Show More

    We read your recent review article with interest. However, the article lacks information to guide appropriate legislative revisions and current legislative enhancement strategies to prevent THC and driving in Canada. This is mainly due to lack of accurate information regarding chronic cannabis users and their residual blood THC levels.

    Our recent systematic review examined studies on blood THC levels in heavy cannabis users following monitored abstinence of at least 4 hours. The findings of our review suggest that chronic cannabis users may have blood THC levels that persist above the per se limits of 2 ug/L and 5 ug/L despite prolonged abstinence (2). A number of studies reported blood THC levels above 2 ug/L that could persist up to 6 days despite abstinence, with the longest reported duration being 30 days (2, 3). In addition, high THC levels of above 5 ug/L over several days is also a significant finding that informs our knowledge of blood cannabinoid concentrations in heavy users during sustained abstinence.

    The current interpretation of THC levels in long-term cannabis users may need to be reconsidered based on the evidence that THC levels may be higher and persist for longer than previously described. Some studies have reported a rapid fall in blood THC levels within an hour or two within smoking and a prolonged terminal elimination phase. During the latter, the blood THC concentrations fall to a residual level of up to 2 to 3 ug/L and decline slowly over a week or more (3, 4).

    However, the studies included in our review showed that although the plasma THC levels in chronic users generally declines gradually over the course of abstinence, a number of chronic users’ blood THC profile did not follow this classical and predictable pattern. Some subjects had high detectable blood THC levels above 5 ug/L that persist for several days or even weeks, and some users displayed alternating positive and negative samples throughout the course of abstinence.

    Furthermore, our review demonstrated that blood THC level may not indicate recent cannabis use in chronic cannabis users, and that users with elevated THC levels above the per se limits of 2 or 5 ug/L may be criminalized despite no recent exposure. These findings also make the interpretation of THC toxicology more challenging for forensic practitioners. In light of new knowledge gained from this body of research needs to be incorporated into strategies to enhance road safety and to implement effective THC related traffic laws.

    Show Less
    Competing Interests: None declared.

    References

    • (1). Sarah B. Windle, Crystal Sequeira, Kristian B. Filion, et al. Impaired driving and legalization of recreational cannabis. CMAJ 2021;193:E481-E485.
    • (2). Peng YW, Desapriya E, Chan H, R Brubacher J. "Residual blood THC levels in frequent cannabis users after over four hours of abstinence: A systematic review.". Drug Alcohol Depend. 2020 Nov 1;216:108177. doi: 10.1016/j.drugalcdep.2020.108177. Epub 202
    • (3)Karschner EL, Swortwood MJ, Hirvonen J, Goodwin RS, Bosker WM, Ramaekers JG, et al. Extended plasma cannabinoid excretion in chronic frequent cannabis smokers during sustained abstinence and correlation with psychomotor performance. Drug Testing & Anal
    • (4). Bergamaschi MM, Karschner EL, Goodwin RS, Scheidweiler KB, Hirvonen J, Queiroz RH, Huestis MA. Impact of prolonged cannabinoid excretion in chronic daily cannabis smokers' blood on per se drugged driving laws. Clin Chem. 2013 Mar;59(3):519-26. doi: 1
  • Posted on: (6 April 2021)
    Page navigation anchor for RE: Impaired driving and legalization of recreational Cannabis
    RE: Impaired driving and legalization of recreational Cannabis
    • Tom Bell [BSc MD CCFP FCFP], Family Physician, Retired, Past Adjunct Prof. Queens U. Dept. Family Medicine, Author, "Cannabis and Kids - A Primer on Pot for Parents and Caregivers", Member, "Cannabis and Youth Clinical Information Team,

    During my research for my book "Cannabis and Kids" I came across a worrisome study, albeit with only 9 subjects, but the article was in Aviation Space Environmental Medicine Mar 1991 62(3) 221-227 - pilots subjected to a single joint were largely incapable of properly passing flight simulation challenges (7/9 inadequate) 24 HOURS after smoking (and this was with lower potency weed back then) and of the 7, only 1 reported feeling any high. We have a lot of work to do!
    Dr. Tom Bell MD CCFP FCFP

    Competing Interests: None declared.

    References

    • Sarah B. Windle, Crystal Sequeira, Kristian B. Filion, et al. Impaired driving and legalization of recreational cannabis. CMAJ 2021;193:E481-E485.
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Impaired driving and legalization of recreational cannabis
Sarah B. Windle, Crystal Sequeira, Kristian B. Filion, Brett D. Thombs, Pauline Reynier, Roland Grad, Carolyn Ells, Mark J. Eisenberg
CMAJ Apr 2021, 193 (14) E481-E485; DOI: 10.1503/cmaj.191032

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Impaired driving and legalization of recreational cannabis
Sarah B. Windle, Crystal Sequeira, Kristian B. Filion, Brett D. Thombs, Pauline Reynier, Roland Grad, Carolyn Ells, Mark J. Eisenberg
CMAJ Apr 2021, 193 (14) E481-E485; DOI: 10.1503/cmaj.191032
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    • What is known about the use of cannabis and driving in Canada?
    • How has legalization of recreational cannabis affected the incidence of motor vehicle collisions in other jurisdictions?
    • Are steps to detect and deter cannabis-impaired driving in Canada likely to be effective?
    • Can health care professionals help to prevent cannabis-impaired driving?
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