Expert Commentary

Driving under the influence of marijuana: An explainer and research roundup

As marijuana legalization sweeps the U.S., researchers and policymakers are grappling with a growing public safety concern: marijuana-impaired driving. We explain the challenges of setting legal limits for THC in bodily fluids and what the research shows about how marijuana use affects driving.

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Image by Franz P. Sauerteig from Pixabay

As marijuana use continues to rise and state-level marijuana legalization sweeps the U.S., researchers and policymakers are grappling with a growing public safety concern: marijuana-impaired driving.

The issue has not been an easy one to tackle because, unlike alcohol, which has well-established thresholds of impairment, the metrics for marijuana’s effects on driving remain rather elusive.

“We don’t have that kind of deep knowledge right now and it’s not because of lack of trying,” says Dr. Guohua Li, professor of epidemiology and the founding director of the Center for Injury Science and Prevention at Columbia University.

“Marijuana is very different from alcohol in important ways,” says Li, who has published several studies on marijuana and driving. “And one of them is that the effect of marijuana on cognitive functions and behaviors is much more unpredictable than alcohol. In general, alcohol is a depressant drug. But marijuana could act on the central nervous system as a depressant, a stimulant, and a hallucinogenic substance.”

Efforts to create a breathalyzer to measure the level of THC, the main psychoactive compound found in the marijuana plant, have largely failed, because “the THC molecule is much bigger than ethanol and its behavior after ingestion is very different from alcohol,” Li says.

Currently, the two most common methods used to measure THC concentration to identify impaired drivers are blood and saliva tests, although there’s ongoing debate about their reliability.

Marijuana, a term interchangeably used with cannabis, is the most commonly used federally illegal drug in the U.S.: 48.2 million people, or about 18% of Americans reported using it at least once in 2019, according to the latest available data from the Centers for Disease Control and Prevention. Worldwide, 2.5% of the population consumes marijuana, according to the World Health Organization.

As of April 2023, 38 U.S. states had legalized medical marijuana and 23 had legalized its recreational use, according to the National Conference of State Legislatures. Legalizing recreational marijuana is on the ballot in Ohio in November this year, and recreational or medical marijuana measures are on the ballot in six states in 2024.

Marijuana is legal in several countries, including Canada, where it was legalized in 2018. Despite state laws legalizing cannabis, it remains illegal at the federal level in the U.S.

As states grapple with the contentious issue of marijuana legalization, the debate is not just about public health, potential tax revenues and economic interests. At the heart of the discussion is also the U.S. criminal justice system.

Marijuana is shown to have medicinal qualities and, compared with substances like alcohol, tobacco, and opioids, it has relatively milder health risks. However, it’s not risk-free, a large body of research has shown.

Marijuana consumption can lead to immediate effects such as impaired muscle coordination and paranoia, as well as longer-term effects on mental health and cognitive functions — and addiction. As its use becomes more widespread, researchers are trying to better understand the potential hazards of marijuana, particularly for younger users whose brains are in critical stages of development.

Marijuana and driving

The use of marijuana among drivers, passengers and pedestrians has increased steadily over the past two decades, Li says.

Compared with the year 2000, the proportion of U.S. drivers on the road who are under the influence of marijuana has increased by several folds, between five to 10 times, based on toxicology testing of people who died in car crashes, Li says.

A 2022 report from the National Transportation Safety Board finds alcohol and cannabis are the two most commonly detected drugs among drivers arrested for impaired driving and fatally injured drivers. Most drivers who tested positive for cannabis also tested positive for another potentially impairing drug.

“Although cannabis and many other drugs have been shown to impair driving performance and are associated with increased crash risk, there is evidence that, relative to alcohol, awareness about the potential dangers of driving after using other drugs is lower,” according to the report.

Indeed, many U.S. adults perceive daily marijuana use or exposure to its smoke safer than tobacco, even though research finds otherwise.

Several studies have demonstrated marijuana’s impact on driving.

Marijuana use can reduce the drivers’ ability to pay attention, particularly when they are performing multiple tasks, research finds. It also slows reaction time and can impair coordination.

“The combination is that you potentially have people who are noticing hazards later, braking slower and potentially not even noticing hazards because of their inability to focus on competing things on the road,” says Dr. Daniel Myran, an assistant professor at the Department of Family Medicine and health services researcher at the University of Ottawa.

In a study published in September in JAMA Network Open, Myran and colleagues find that from 2010 to 2021 the rate of cannabis-involved traffic injuries that led to emergency department visits in Ontario, Canada, increased by 475%, from 0.18 per 1,000 traffic injury emergency department visits in 2010 to 1.01 visits in 2021.

To be sure, cannabis-involved traffic injuries made up a small fraction of all traffic injury-related visits to hospital emergency departments. Out of 947,604 traffic injury emergency department visits, 426 had documented cannabis involvement.

Myran cautions the increase shouldn’t be solely attributed to marijuana legalization. It captures changing societal attitudes toward marijuana and acceptance of cannabis use over time in the lead-up to legalization. In addition, it may reflect an increasing awareness among health care providers about cannabis-impaired driving, and they may be more likely to ask about cannabis use and document it in medical charts, he says.

“When you look at the 475% increase in cannabis involvement in traffic injuries, rather than saying legalizing cannabis has caused the roads to be unsafe and is a public health disaster, it’s that cannabis use appears to be growing as a risk for road traffic injuries and that there seem to be more cannabis impaired drivers on the road,” Myran says. “Legalization may have accelerated this trend. Faced with this increase, we need to think about what are public health measures and different policy interventions to reduce harms from cannabis-impaired driving.”

Setting a legal limit for marijuana-impaired driving

Setting a legal limit for marijuana-impaired driving has not been easy. Countries like Canada and some U.S. states have agreed upon a certain level of THC in blood, usually between 1 to 5 nanograms per milliliter. Still, some studies have found those limits to be weak indicators of cannabis-impaired driving.

When Canada legalized recreational marijuana in 2018, it also passed a law that made it illegal to drive with blood THC levels of more than 2 nanograms. The penalties are more severe for blood THC levels above 5 nanograms. The blood test is done at the police station for people who are pulled over and are deemed to be drug impaired.

In the U.S., five states — Ohio, Illinois, Montana, Washington and Nevada — have “per se laws,” which set a specific amount of THC in the driver’s blood as evidence of impaired driving, according to the National Conference of State Legislatures. That limit ranges between 2 and 5 nanograms of THC per milliliter of blood.

Colorado, meanwhile, has a “permissible inference law,” which states that it’s permissible to assume the driver was under the influence if their blood THC level is 5 nanograms per milliliter or higher, according to NCSL.

Twelve states, most which have legalized some form of marijuana of use, have zero tolerance laws for any amount of certain drugs, including THC, in the body.

The remaining states have “driving under the influence of drugs” laws. Among those states, Alabama and Michigan, have oral fluid roadside testing program to screen drivers for marijuana and other drugs, according to NCSL.

In May this year, the U.S. Department of Transportation published a final rule that allows employers to use saliva testing for commercially licensed drivers, including truck drivers. The rule, which went into effect in June, sets the THC limit in saliva at 4 nanograms.

Saliva tests can detect THC for 8 to 24 hours after use, but the tests are not perfect and can results in false positives, leading some scientists to argue against using them in randomly-selected drivers.

In a 2021 report, the U.S. National Institute of Justice, the research and development arm of the Department of Justice, concluded that THC levels in bodily fluids, including blood and saliva “were not reliable indicators of marijuana intoxication.”

Studies on marijuana and driving

Over the past two decades, many studies have shown marijuana use can impair driving. However, discussions about what’s the best way to measure the level of THC in blood or saliva are ongoing. Below, we highlight and summarize several recent studies that address the issue. The studies are listed in order of publication date. We also include a list of related studies and resources to inform your audiences.

Are Blood and Oral Fluid Δ9-tetrahydrocannabinol (THC) and Metabolite Concentrations Related to Impairment? A Meta-Regression Analysis
Danielle McCartney, et al. Neuroscience & Biobehavioral Reviews, March 2022.

Summary: Commonly used THC measurements may not be strong indicators of driving impairment. While there is a relationship between certain biomarkers like blood THC concentrations and impaired driving, this correlation is often weak. The study underscores the need for more nuanced and comprehensive research on this topic, especially as cannabis usage becomes more widespread and legally accepted.

The Effects of Cannabis and Alcohol on Driving Performance and Driver Behaviour: A Systematic Review and Meta-Analysis
Sarah M. Simmons, Jeff K. Caird, Frances Sterzer and Mark Asbridge. Addiction, January 2022.

Summary: This meta-analysis of experimental driving studies, including driving simulations, confirms that cannabis impairs driving performance, contrary to some beliefs that it might enhance driving abilities. Cannabis affects lateral control and speed — typically increasing lane excursions while reducing speed. The combination of alcohol and marijuana appears worse than either alone, challenging the idea that they cancel each other out.

Cannabis Legalization and Detection of Tetrahydrocannabinol in Injured Drivers
Jeffrey R. Brubacher, et al. The New England Journal of Medicine, January 2022.

Summary: Following the legalization of recreational marijuana in Canada, there was a notable increase in injured drivers testing positive for THC, especially among those 50 years of age or older. This rise in cannabis-related driving incidents occurred even with new traffic laws aiming to deter cannabis-impaired driving. This uptick began before legalization became official, possibly due to perceptions that cannabis use was soon-to-be legal or illegal but not enforced. The data suggests that while legalization has broad societal impacts, more comprehensive strategies are needed to deter driving under the influence of cannabis and raise public awareness about its risks.

Cannabis and Driving
Godfrey D. Pearlson, Michael C. Stevens and Deepak Cyril D’Souza. Frontiers in Psychiatry, September 2021.

Summary: Cannabis-impaired driving is a growing public health concern, and studies show that such drivers are more likely to be involved in car crashes, according to this review paper. Drivers are less affected by cannabis than they are by alcohol or cocaine, but the problem is expected to escalate with increasing cannabis legalization and use. Unlike alcohol, THC’s properties make it challenging to determine direct impairment levels from testing results. Current roadside tests lack precision in detecting genuine cannabis-impaired drivers, leading to potential wrongful convictions. Moreover, there is a pressing need for research on the combined effects of alcohol and cannabis on driving, as well as the impact of emerging popular forms of cannabis, like concentrates and edibles. The authors recommend public awareness campaigns about the dangers of driving under the influence of cannabis, similar to those against drunk driving, to address misconceptions. Policymakers should prioritize science-based decisions and encourage further research in this domain.

Demographic And Policy-Based Differences in Behaviors And Attitudes Towards Driving After Marijuana Use: An Analysis of the 2013–2017 Traffic Safety Culture Index
Marco H. Benedetti, et al. BMC Research Notes, June 2021.

Summary: The study, based on a U.S. survey, finds younger, low-income, low-education and male participants were more tolerant of driving after marijuana consumption. Notably, those in states that legalized medical marijuana reported driving after use more frequently, aligning with studies indicating a higher prevalence of THC detection in drivers from these states. Overall, while the majority perceive driving after marijuana use as dangerous, not all research agrees on its impairment effects. Existing studies highlight that marijuana impacts motor skills and executive functions, yet its direct correlation with crash risk remains debated, given the variations in individual tolerance and how long THC remains in the system.

Driving Under the Influence of Cannabis: A Framework for Future Policy
Robert M. Chow, et al.Anesthesia & Analgesia, June 2019.

Summary: The study presents a conceptual framework focusing on four main domains: legalization, driving under the influence of cannabis, driver impairment, and motor vehicle accidents. With the growing legalization of cannabis, there’s an anticipated rise in cannabis-impaired driving cases. The authors group marijuana users into infrequent users who show significant impairment with increased THC blood levels, chronic users with minimal impairment despite high THC levels, and those with consistent psychomotor deficits. Current challenges lie in the lack of standardized regulation for drivers influenced by cannabis, primarily because of state-to-state variability and the absence of a federal statutory limit for blood THC levels. European nations, however, have established thresholds for blood THC levels, ranging from 0.5 to 50.0 micrograms per liter depending on whether blood or blood serum are tested. The authors suggest the combined use of alcohol and THC blood tests with a psychomotor evaluation by a trained professional to determine impairment levels. The paper stresses the importance of creating a structured policy framework, given the rising acceptance and use of marijuana in society.

Additional research

Cannabis-Involved Traffic Injury Emergency Department Visits After Cannabis Legalization and Commercialization
Daniel T. Myran, et al. JAMA Network Open, September 2023.

Driving Performance and Cannabis Users’ Perception of Safety: A Randomized Clinical Trial
Thomas D. Marcotte, et al. JAMA Psychiatry, January 2022.

Medicinal Cannabis and Driving: The Intersection of Health and Road Safety Policy
Daniel Perkins, et al. International Journal of Drug Policy, November 2021.

Prevalence of Marijuana Use Among Trauma Patients Before and After Legalization of Medical Marijuana: The Arizona Experience
Michael Levine, et al. Substance Abuse, July 2021.

Self-Reported Driving After Marijuana Use in Association With Medical And Recreational Marijuana Policies
Marco H. Benedetti, et al. International Journal of Drug Policy, June 2021.

Cannabis and Driving Ability
Eric L. Sevigny. Current Opinion in Psychology, April 2021.

The Failings of per se Limits to Detect Cannabis-Induced Driving Impairment: Results from a Simulated Driving Study
Thomas R. Arkell, et al. Traffic Injury Prevention, February 2021.

Risky Driving Behaviors of Drivers Who Use Alcohol and Cannabis
Tara Kelley-Baker, et al. Transportation Research Record, January 2021.

Direct and Indirect Effects of Marijuana Use on the Risk of Fatal 2-Vehicle Crash Initiation
Stanford Chihuri and Guohua Li. Injury Epidemiology, September 2020

Cannabis-Impaired Driving: Evidence and the Role of Toxicology Testing
Edward C. Wood and Robert L. Dupont. Cannabis in Medicine, July 2020.

Association of Recreational Cannabis Laws in Colorado and Washington State With Changes in Traffic Fatalities, 2005-2017
Julian Santaella-Tenorio, et al. JAMA Internal Medicine, June 2020.

Marijuana Decriminalization, Medical Marijuana Laws, and Fatal Traffic Crashes in US Cities, 2010–2017
Amanda Cook, Gregory Leung and Rhet A. Smith. American Journal of Public Health, February 2020.

Cannabis Use in Older Drivers in Colorado: The LongROAD Study
Carolyn G. DiGuiseppi, et al. Accident Analysis & Prevention, November 2019.

Crash Fatality Rates After Recreational Marijuana Legalization in Washington and Colorado
Jayson D. Aydelotte, et al. American Journal of Public Health, August 2017.

Marijuana-Impaired Driving: A Report to Congress
National Highway Traffic Safety Administration, July 2017

Interaction of Marijuana And Alcohol on Fatal Motor Vehicle Crash Risk: A Case–Control Study
Stanford Chihuri, Guohua Li and Qixuan Chen. Injury Epidemiology, March 2017.

US Traffic Fatalities, 1985–2014, and Their Relationship to Medical Marijuana Laws
Julian Santaella-Tenorio, et al. American Journal of Public Health, February 2017.

Delays in DUI Blood Testing: Impact on Cannabis DUI Assessments
Ed Wood, Ashley Brooks-Russell and Phillip Drum. Traffic Injury Prevention, June 2015.

Establishing Legal Limits for Driving Under the Influence of Marijuana
Kristin Wong, Joanne E. Brady and Guohua Li. Injury Epidemiology, October 2014.

Cannabis Effects on Driving Skills
Rebecca L. Hartman and Marilyn A. Huestis. Clinical Chemistry, March 2014.

Acute Cannabis Consumption And Motor Vehicle Collision Risk: Systematic Review of Observational Studies and Meta-Analysis
Mark Asbridge, Jill A. Hayden and Jennifer L. Cartwright. The BMJ, February 2012.

Resources for your audiences

The following resources include explainers from federal agencies and national organizations. You’re free to use images and graphics from federal agencies.

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