Ambien Drives Like a Dream Case Studies of

Ambien : Drives Like a Dream? - Case Studies of Zolpidem-Impaired Drivers in Wisconsin Laura J. Liddicoat Patrick Harding Wisconsin State Laboratory of Hygiene AAFS 58 th Annual Meeting Feb 23, 2006

2005 Wisconsin DUID Data 45, 539 Impaired Driving Arrests n 23, 074 Blood Alcohol Tests (WSLH ) n 2, 347 Blood Drug Panels (WSLH ) Toxicology Session: other than alcohol n 1, 902 Positive for ≥ 1 Special drugs n Driving Under the Influence of Drugs

Wisconsin DUID Data Drug Name THC (Cannabinoids) Cocaine Diazepam/Nordiaz. Alprazolam Amphetamine Morphine Methamphetamine Oxycodone Hydrocodone Clonazepam 2004 # Cases Rank 1005 250 141 134 94 83 79 76 73 72 1 2 3 4 5 6 7 8 9 10 Toxicology Special Session: Driving Under the Influence of Drugs 2005 # Cases Rank 1300 333 182 162 131 113 105 85 78 136 1 2 3 4 6 8 9 11 12 5

Wisconsin DUID Data Drug Name Citalopram/Norcital Diphenhydramine Lorazepam Methadone Venlafaxine/Norven Meprobamate Carisoprodol Fluoxetine/Norfluox Zolpidem Trazodone Dextromethorphan 2004 # Cases Rank 72 62 141 55 54 51 46 49 46 45 (27 11 12 13 14 15 16 17 18 19 20 -) Toxicology Special Session: Driving Under the Influence of Drugs 2005 # Cases Rank 86 75 66 118 49 57 49 55 53 (33 41 10 13 14 7 18 -Tie 15 18 -Tie 16 17 -) 20

Wisconsin DUID Laws n “Impaired by…” Any intoxicant or drug n Illicit, prescription & OTC included n “…rendered incapable of safely operating a motor vehicle” n n “Per Se” / Zero Tolerance n Illicit Drugs - Any Detectable Amount n Schedule I Drugs n Cocaine & metabolites n Methamphetamine Toxicology Special Session: Driving Under the Influence of Drugs

Zolpidem (Ambien ) Facts Non-benzodiazepine sedative hypnotic Available since 1993 in US Time release formula now available 5 mg or 10 mg tablet Use only with 8 hours uninterrupted sleep Peak concentrations 1. 5 – 2. 5 hours T½ = 1. 4 - 4. 5 hours Therapeutic serum levels: 29 - 272 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs

Zolpidem Case Studies Selection Criteria: n RANDOM: 6 Recent cases set for trial Toxicology Results: n n n Ethanol - Negative for all cases Other Drugs n 3 Cases – No other drugs n 3 Cases – SSRI Antidepressants (1 or 2 present) Zolpidem Concentrations Range: 190 to 4400 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs

Zolpidem Impaired Drivers in Wisconsin: Toxicology Special Session: Driving Under the Influence of Drugs A Six Year Retrospective; William R. Johnson et al - SOFT 2005

Case #1: Funeral Home Parking Lot n Driving Multiple citizens called dispatch to report n Subject drove into funeral home parking n Almost hit another vehicle n Toxicology Special Session: Driving Under the Influence of Drugs

Case #1: Funeral Home Parking Lot n Behavior/Physical Abilities Slow to respond n Swaying, unsteady gait n Subject seemed “very out of it” n n Drugs Detected: n Zolpidem - 670 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs

Case #2: Bridge Over Troubled Waters n Driving Crashed into parked car (Officer observed) n Bizarre driving with near-collision n Inattentive – Unsafe stop by a bridge n Didn’t follow simple driving directions n Drove over curb (all 4 wheels) & struck a chain between two posts n Toxicology Special Session: Driving Under the Influence of Drugs

Case #2: Bridge Over Troubled Waters n Behavior/Physical Abilities Delayed response; Speech slow, slurred n Very unsteady – almost fell over n Did not recall any of the recent incidents n Inappropriate clothing & eyewear n Blurred & double vision n n Drugs Detected: Zolpidem - 500 ng/m. L, Citalopram <50 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs

Case #3: Blue-Light Special n Driving Two citizens reported erratic driver n Drove westbound in eastbound lane n Nearly struck two vehicles head-on n Stopped car ~2 ft from curb n Toxicology Special Session: Driving Under the Influence of Drugs

Case #3: Blue-Light Special n Behavior/Physical Abilities Slow to react n Slow to respond n Poor balance, nearly fell over n Poor comprehension, confused w/ colors n Questions needed to be repeated n n Drugs Detected: n Zolpidem - 820 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs

Case #4: Little Red Corvette n Driving Citizen reported red corvette driving erratically n Weaving, crossing lane, near head-on collisions n Driving southbound in northbound lane n Toxicology Special Session: Driving Under the Influence of Drugs

Case #4: Little Red Corvette n Behavior/Physical Abilities Very slow speech, 3 -4 seconds to respond n Disoriented; confused n Unable to focus on officer n Body was shaking n n Drugs Detected: Zolpidem - 190 ng/m. L Venlafaxine – 510 ng/m. L Fluoxetine – 340 ng/m. L Norvenlafaxine – Present Norfluoxetine – 350 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs

Case #5 a: Repeat Customer n Driving Witness: Incorrect stop position at 1 st stop light n Didn’t proceed when light turned green n Weaving n Crashed into truck stopped at next red light n Driver said brakes needed fixing. n Officer tested brakes, found no problems n Toxicology Special Session: Driving Under the Influence of Drugs

Case #5 a: Repeat Customer n Behavior/Physical Abilities Confused n Disoriented n Eyes barely open – drowsy n Extremely slow slurred speech n Poor balance Drugs Detected: Zolpidem – 1, 000 ng/m. L Sertraline/Norsertraline - Present n n Toxicology Special Session: Driving Under the Influence of Drugs

Case #5 a: Repeat Customer n Further Investigation (Per Daughter) Prescribed Ambien in 1997 n Subject increased doses after 6 years n Subject no longer has prescription n Obtains zolpidem on-line n n Medbizsupply. com n Previous arrest 1. 5 months before in neighboring jurisdiction Toxicology Special Session: Driving Under the Influence of Drugs

Case #5 b: Repeat Customer n Driving to mall n Attempted to turn around - struck several mailboxes n Drove on rim after getting flat tire n Citizen called Police Dept. n Toxicology Special Session: Driving Under the Influence of Drugs

Case #5 b: Repeat Customer n Behavior/Physical Abilities Very confused n Speech extremely slurred n Could not maintain eye contact w/officer n Poor balance while standing Drugs Detected: Zolpidem – 4, 400 ng/m. L n n Toxicology Special Session: Driving Under the Influence of Drugs

SFST - HGN Clues 1 2 3 4 5 a 5 b Lack smooth pursuit Yes Yes Yes - HGN at max. dev. Onset prior to 45 o No No - Yes - No No - Instructed many times No No Yes Didn’t Finish/Perform Pupil description No No Yes No Dilated Yes - Dilated Normal Toxicology Special Session: Driving Under the Influence of Drugs

SFST – Walk and Turn WAT Issues 1 2 3 4 5 a 5 b No Yes Did not hold instruct. pos. Yes Yes Balance Probs/Body Sway Yes Yes Yes Did not Count Out Loud Yes - Yes Did not walk heel to toe Yes Yes - Yes Stepped off the line Yes Yes - Yes Did not take 9 steps Yes - Yes Incorrect or no turn Yes - Was reminded to continue Yes - No - Unable to Complete/Perform No - Yes Yes Toxicology Special Session: Driving Under the Influence of Drugs -

SFST – One Leg Stand OLS Issues 1 2 3 4 5 a 5 b Body Sway noted Yes - Yes Yes Almost Fell Over Yes - Yes Yes No Many attempts Yes - Yes Yes Yes Didn’t Try Yes Yes Unable to Complete/Perform Toxicology Special Session: Driving Under the Influence of Drugs

Zolpidem Cases: A Common Theme n Extreme driving impairment Wide lane deviations n Many near head-on collisions n Bizarre driving maneuvers n Mode of driver detection – citizen cell phone n Collision with stationary objects n Toxicology Special Session: Driving Under the Influence of Drugs

Zolpidem Cases: A Common Theme n Profound loss of balance - Incomplete SFST’s – stopped for safety n Confused & Disoriented – No recognition of poor driving n Greatly reduced comprehension Untypical, exaggerated delay in responding n Unable to follow directions - Instructions repeated multiple times n Do not remember recent events Toxicology Special Session: n Driving Under the Influence of Drugs

Zolpidem Summary n Therapeutic concentration while driving = 0 ng/m. L Toxicology Special Session: Driving Under the Influence of Drugs