Driving under the influence of opioids: What prescribers should know


  • Joseph V. Pergolizzi, Jr, MD
  • Robert Taylor, Jr, PhD
  • John Bisney, MA
  • Jo Ann LeQuang, BA
  • Robert B. Raffa, PhD
  • Fabianna Pergolizzi, JD
  • Daniel Colucci
  • Lisa Batastini, JD, BS Pharm




driving under the influence, drugged driving, driving under the influence of drugs, opioids and driving


Opioids affect the central nervous system and are known to produce dizziness, sleepiness, mood changes, and other actions that in some people have a negative impact on psychomotor or mental performance. The negative effects can be exacerbated in persons who are taking other prescription medications or illegal substances. Opioid-abusing drivers clearly represent an unnecessary danger to the public; although the vast majority of patients taking prescription opioids for pain safely drive to work and other activities, a subset may be impaired, but not be aware of or recognize the problem. The majority of pain patients would likely be surprised to learn that the legal systems in most parts of the world, including most states in the United States, do not differentiate between a pain patient taking a prescribed opioid at the right dose and frequency, and an abuser taking an illegal drug. For example, in some parts of the United States, a driver may be initially stopped for a relatively minor offense and, if the officer notices that the driver is wearing a fentanyl patch, charged with driving under the influence of drugs (DUID). The present narrative review attempts to highlight the existing problem, the different legal thresholds for arrest and prosecution for DUID, and the challenge of trying to have zero-tolerance for driving under the influence of a drug used illegally, while at the same time not arresting legitimate patients who are taking pain medication as prescribed. There is a clear and present need for an integrated assessment and addressing of the current confounding situation.

Author Biographies

Joseph V. Pergolizzi, Jr, MD

NEMA Research Inc., Naples, Florida

Robert Taylor, Jr, PhD

NEMA Research Inc., Naples, Florida

John Bisney, MA

NEMA Research Inc., Naples, Florida

Jo Ann LeQuang, BA

NEMA Research Inc., Naples, Florida

Robert B. Raffa, PhD

Adjunct Professor, University of Arizona College of Pharmacy, Tucson, Arizona; Professor Emeritus, Temple University School of Pharmacy, Philadelphia, Pennsylvania.

Fabianna Pergolizzi, JD

Associate Attorney, Spear, Greenfield, Richman & Weitz, P.C., Philadelphia, Pennsylvania

Daniel Colucci

Student, NEMA Research Inc., Naples, Florida

Lisa Batastini, JD, BS Pharm

Attorney Pharmacist Consultant, Mid Atlantic PharmaTech Consultants, LLC, Ventnor, New Jersey; Attorney Pharmacists Consultant, Opioid Consulting Educational Solutions, LLC, Ventnor, New Jersey


Sise R, Calvo R, Spain D, et al.: The epidemiology of trauma-related mortality in the United States from 2002 to 2010.

J Trauma Acute Care Surg. 2014; 76: 913-920.

Oster C, Strong J: Analyzing road safety in the United States. Res Transp Econ. 2013; 43: 98-111.

National Highway Traffic Safety Administration: Drug Involvement of Fatally Injured Drivers. Washington, DC: U.S. Department of Transportation, 2010.

Brady J, Li G: Trends in alcohol and other drugs detected in fatally injured drivers in the United States, 1999-2010. Am J Epidemiol. 2014; 179(6): 692-699.

Karjalainen K, Lintonen T, Impinen A, et al.: Mortality and causes of death among drugged drivers. J Epidemiol Community Health. 2010; 64(6): 506-512.

Walsh J, Flegel R, Atkins R, et al.: Drug and alcohol abuse among drivers admitted to a level-1 trauma center. Accid Anal Prev. 2005; 37: 894-901.

Senna MC, Augsburger M, Aebi B, et al.: First nationwide study on driving under the influence of drugs in Switzerland. Forensic Sci Int. 2010; 198(1-3): 11-16.

Zacny JP: Profiling the subjective, psychomotor, and physiological effects of tramadol in recreational drug users. Drug Alcohol Depend. 2005; 80(2): 273-278.

Fishbain D, Cutler R, Rosomoff H, et al.: Are opioid-dependent/tolerant patients impaired in driving-related skills? A structured evidence-based review. J Pain Symptom Manage. 2003; 25: 559-577.

Rudisill TM, Zhu M, Kelley GA, et al.: Medication use and the risk of motor vehicle collisions among licensed drivers: A systematic review. Accid Anal Prev. 2016; 96: 255-270.

Sigona N, Williams KG: Driving under the influence, public policy, and pharmacy practice. J Pharm Pract. 2015; 28(1): 119-123.

Fierro I, Colas M, Gonzalez-Luque JC, et al.: Roadside opioid testing of drivers using oral fluid: The case of a country with a zero tolerance law, Spain. Subst Abuse Treat Prev Policy. 2017; 12(1): 22.

Walsh J: A state-by-state analysis of laws dealing with driving under the influence of drugs. 2009. Available at http://www.juliericelaw.com/files/811236.pdf. Accessed June 3, 2017.

Department of Transport: Guidance for healthcare professionals on drug driving. 2014. Available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/325275/healthcare-profs-drug-driving.pdf. Accessed June 2, 2017.

Christophersen A, Morland J: Frequent detection of benzodiazepines in drugged drivers in Norway. Drug Alcohol Depend. 2008; 47: 125-135.

Wilhelmi BG, Cohen SP: A framework for “driving under the influence of drugs” policy for the opioid using driver. Pain Phys. 2012; 15(3 suppl): ES215-ES230.

Xtampza ER Prescribing Information [Package insert]. Canton, MA: Collegium Pharmaceutical, Inc., 2016.

International Association of Chiefs of Police, Drug Recognition Experts (DRE): The International Drug Evaluation and Classification Program. 2017. Available at http://www.decp.org/drug-recognition-experts-dre/. Accessed June 3, 2017.

DuPont RL, Voas RB, Walsh JM, et al.: The need for drugged driving per se laws: A commentary. Traffic Inj Prev. 2012; 13(1): 31-42.

Findlay J, Jones E, Butz R, et al.: Plasma codeine and morphine concentrations after therapeutic oral doses of codeine-containing analgesics. Clin Pharmacol Ther. 1978; 24: 60-68.

Quiding H, Anderson P, Bondesson U, et al.: Plasma concentrations of codeine and its metabolite morphine after single and repeated oral administration. Eur J Clin Pharmacol. 1986; 30: 673-677.

Goldberger B, Darwin W, Grant T, et al.: Measurement of heroin and its metabolites by isotope dilution electron-impact mass spectrometry. Clin Chem Lab Med. 1993; 39: 670-675.

Inturrisi C, Max M, Foley K, et al.: The pharmacokinetics of heroin in patients with chronic pain. N Engl J Med. 1984; 310: 1213-1217.

Cone E, Welch P, Mithcell J, et al.: Detection of 6-acetylmorphine in urine as an indicator of recent heroin exposure: Drug and assay considerations and detection times. J Analytical Toxicol. 1991; 15: 1-7.

Paul B, Shimomura E, Smith M: A practical approach to determine cutoff concentrations for opiate testing with simultaneous detection of codeine, morphine, and 6-acetylmorphine in urine. Clin Chem. 1999; 45: 510-519.

Ceder G, Jones AW: Concentration ratios of morphine to codeine in blood of impaired drivers as evidence of heroin use and not medication with codeine. Clin Chem. 2001; 47(11): 1980-1984.

Jones AW, Holmgren A, Kugelberg FC: Driving under the influence of opiates: Concentration relationships between morphine, codeine, 6-acetyl morphine, and ethyl morphine in blood. J Anal Toxicol. 2008; 32(4): 265-272.

Gjerde H, Langel K, Favretto D, et al.: Detection of illicit drugs in oral fluid from drivers as biomarker for drugs in blood. Forensic Sci Int. 2015; 256: 42-45.

Tiscione NB, Shan X, Yeatman DT: Case management in a DUI lab: Effect on drugs reported. J Anal Toxicol. 2014; 38(8): 555-558.

Borriello R, Carfora A, Cassandro P, et al.: Clinical and forensic diagnosis of very recent heroin intake by 6-acetylmorphine immunoassay test and LC-MS/MS analysis in urine and blood. Ann Clin Lab Sci. 2015; 45(4): 414-418.

Kelley-Baker T, Waehrer G, Pollini R: Prevalence of self-reported prescription drug use in a national sample of U.S. drivers. J Stud Alcohol Drugs. 2017; 78(1): 30-38.

Valen A, Bogstrand ST, Vindenes V, et al.: Toxicological findings in suspected drug-impaired drivers in Norway – Trends during 1990-2015. Forensic Sci Int. 2017; 280: 15-24.

Compton R, Berning A: Results of the 2007 National Roadside Survey of Alcohol and Drug Use by Drivers. Traffic Safety Facts: Research Note. 2009. Available at https://www.google.com/search?q=nhtsa+traffic+safety+facts+2007+drug+and+alcohol&oq=nhtsa+traffic+safety+facts+2007+drug+and+alcohol&aqs=chrome..69i57.8871j0j4&sourceid=chrome&ie=UTF-8. Accessed June 2, 2017.

Rooney B, Gouveia GJ, Isles N, et al.: Drugged drivers blood concentrations in England and Wales prior to the introduction of per se limits. J Anal Toxicol. 2017; 41(2): 140-145.

Lacey J, Kelley-Baker T, Furr-Holden D, et al.: 2007 National Roadside Survey of Alcohol and Drug Use by Drivers. 2009. Available at https://www.nhtsa.gov/sites/nhtsa.dot.gov/files/811249.pdf. Accessed June 5, 2017.

Benotsch EG, Martin AM, Koester S, et al.: Driving under the influence of prescription drugs used nonmedically: Associations in a young adult sample. Subst Abus. 2015; 36(1): 99-105.

Gjerde H, Strand MC, Morland J: Driving under the influence of non-alcohol drugs—An update. Part I: Epidemiological studies. Forensic Sci Rev. 2015; 27(2): 89-113.

Chihuri S, Li G: Use of prescription opioids and motor vehicle crashes: A meta analysis. Accid Anal Prev. 2017; 109: 123-131.

Wiese Simonsen K, Steentoft A, Bernhoft IM, et al.: Psychoactive substances in seriously injured drivers in Denmark. Forensic Sci Int. 2013; 224(1-3): 44-50.

Liu C, Huang Y, Pressley JC: Restraint use and risky driving behaviors across drug types and drug and alcohol combinations for drivers involved in a fatal motor vehicle collision on U.S. roadways. Injury Epidemiol. 2016; 3(1): 9.

Li G, Brady JE, Chen Q: Drug use and fatal motor vehicle crashes: A case-control study. Accid Anal Prev. 2013; 60: 205-210.

Pilkinton MW, Robertson A, McCluskey DL: Drugged driving: Increased traffic risks involving licit and illicit substances. J Drug Educ. 2013; 43(2): 183-201.

Chihuri S, Li G: Trends in prescription opioids detected in fatally injured drivers in 6 US States: 1995-2015. Am J Public Health. 2017; 107(9): 1487-1492.

Smyth T, Sheehan M, Siskind V: Hospital outpatients' responses to taking medications with driving warnings. Traffic Injury Prev. 2013; 14(1): 18-25.

MacKinnon D, Nohre L, Pentz M, et al. The alcohol warning and adolescents: 5-year effects. Am J Public Health. 2000; 90: 1589-1594.

Veldhuijzen DS, van Wijck AJ, Verster JC, et al.: The impact of chronic pain patients’ psychotropic drug knowledge and warning labels on the decision whether to drive a car or not. Traffic Injury Prev. 2006; 7(4): 360-364.

Mailis-Gagnon A, Lakha SF, Furlan A, et al.: Systematic review of the quality and generalizability of studies on the effects of opioids on driving and cognitive/psychomotor performance. Clin J Pain. 2012; 28(6): 542-555.

Amato JN, Marie S, Lelong-Boulouard V, et al.: Effects of three therapeutic doses of codeine/paracetamol on driving performance, a psychomotor vigilance test, and subjective feelings. Psychopharmacology. 2013; 228(2): 309-320.

Bachs L, Skurtveit S, Morland J: Codeine and clinical impairment in samples in which morphine is not detected. Eur J Clin Pharmacol. 2003; 58(12): 785-789.

Bachs L, Hoiseth G, Skurtveit S, et al.: Heroin-using drivers: Importance of morphine and morphine-6-glucuronide on late clinical impairment. Eur J Clin Pharmacol. 2006; 62(11): 905-912.

Bernard JP, Morland J, Krogh M, et al.: Methadone and impairment in apprehended drivers. Addiction. 2009; 104(3): 457-464.

Byas-Smith MG, Chapman SL, Reed B, et al.: The effect of opioids on driving and psychomotor performance in patients with chronic pain. Clin J Pain. 2005; 21(4): 345-352.

Corsenac P, Lagarde E, Gadegbeku B, et al.: Road traffic crashes and prescribed methadone and buprenorphine: A French registry-based case-control study. Drug Alcohol Depend. 2012; 123(1-3): 91-97.

Lenne MG, Dietze P, Rumbold GR, et al.: The effects of the opioid pharmacotherapies methadone, LAAM and buprenorphine, alone and in combination with alcohol, on simulated driving. Drug Alcohol Depend. 2003; 72(3): 271-278.

Pickering G, Estrade M, Dubray C: Comparative trial of tramadol/paracetamol and codeine/paracetamol combination tablets on the vigilance of healthy volunteers. Fundam Clin Pharmacol. 2005; 19(6): 707-711.

Schindler SD, Ortner R, Peternell A, et al.: Maintenance therapy with synthetic opioids and driving aptitude. Eur Addict Res. 2004; 10(2): 80-87.

Schneider U, Bevilacqua C, Jacobs R, et al.: Effects of fentanyl and low doses of alcohol on neuropsychological performance in healthy subjects. Neuropsychobiology. 1999; 39(1): 38-43.

Stout PR, Farrell LJ: Opioids - Effects on human performance and behavior. Forensic Sci Rev. 2003; 15(1): 29-59.

Strand MC, Fjeld B, Arnestad M, et al.: Can patients receiving opioid maintenance therapy safely drive? A systematic review of epidemiological and experimental studies on driving ability with a focus on concomitant methadone or buprenorphine administration. Traffic Injury Prev. 2013; 14(1): 26-38.

Verster JC, Veldhuijzen DS, Volkerts ER: Effects of an opioid (oxycodone/paracetamol) and an NSAID (bromfenac) on driving ability, memory functioning, psychomotor performance, pupil size, and mood. Clin J Pain. 2006; 22(5): 499-504.

Strand MC, Gjerde H, Morland J. Driving under the influence of non-alcohol drugs—An update. Part II: Experimental studies. Forensic Sci Rev. 2016; 28(2): 79-101.

Moeller FG, Barratt ES, Dougherty DM, et al.: Psychiatric aspects of impulsivity. Am J Psychiatry. 2001; 158(11): 1783-1793.

Mitchell M, Potenza M: Addictions and personality traits: Impulsivity and related constructs. Curr Behav Neurosci Rep. 2014; 1(1): 1-12.

Reynolds B, Schiffbauer R: Measuring state changes in human delay discounting: An experiential discounting task. Behav Process. 2004; 67(3): 343-356.

Meda SA, Stevens MC, Potenza MN, et al.: Investigating the behavioral and self-report constructs of impulsivity domains using principal component analysis. Behav Pharmacol. 2009; 20(5-6): 390-399.

Madden GJ, Petry NM, Badger GJ, et al.: Impulsive and self-control choices in opioid-dependent patients and non-drug-using control participants: Drug and monetary rewards. Exp Clin Psychopharmacol. 1997; 5(3): 256-262.

Garavan H, Hester R: The role of cognitive control in cocaine dependence. Neuropsychol Rev. 2007; 17(3): 337-345.

Petry NM: Delay discounting of money and alcohol in actively using alcoholics, currently abstinent alcoholics, and controls. Psychopharmacology. 2001; 154(3): 243-250.

Hopwood CJ, Morey LC, Skodol AE, et al.: Pathological personality traits among patients with absent, current, and remitted substance use disorders. Addict Behav. 2011; 36(11): 1087-1090.

Veldhuijzen DS, van Wijck A, Wille F, et al.: Effect of chronic nonmalignant pain on highway performance. Pain. 2006; 122: 28-35.

Epilepsy Foundation: Driver information by state. State Driving Laws Database. 2017. Available at http://www.epilepsy.com/driving-laws/2008886. Accessed June 9, 2017.

Jamison R, Schein J, Vallow S, et al. Neuropsychological effects of long-term opioid use in chronic pain patients. J Pain Symptom Manage. 2003; 26: 913-921.

Centers for Disease Control and Prevention: CDC grand rounds: Prescription drug overdoses - A U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012; 61(1): 10-13.

Ryan H: Senator calls for investigation of Purdue Pharma following Times story on OxyContin. Los Angeles Times. May 27, 2016.

Ryan H, Girion L, Glover S: More than 1 million OxyContin pills ended up in the hands of criminals and addicts. What the drugmaker knew. Los Angeles Times. July 10, 2016.

Hedlund J: Drug-impaired driving: A guide for states. 2015. Available at http://www.ghsa.org/sites/default/files/2017-04/GHSA_DruggedDriving2017_FINAL.pdf. Accessed June 10, 2017.

MADD: Our mission. 2017. Available at http://www.madd.org/. Accessed June 10, 2017.

Lipari R, Hughes A, Bose J: Driving under the influence of alcohol and illicit drugs. CBHSQ Report. 2016. Available at https://www.samhsa.gov/data/sites/default/files/report_2688/ShortReport-2688.html. Accessed June 9, 2017.



How to Cite

Pergolizzi, Jr, MD, J. V., Taylor, Jr, PhD, R., Bisney, MA, J., LeQuang, BA, J. A., Raffa, PhD, R. B., Pergolizzi, JD, F., Colucci, D., & Batastini, JD, BS Pharm, L. (2018). Driving under the influence of opioids: What prescribers should know. Journal of Opioid Management, 14(6), 415–427. https://doi.org/10.5055/jom.2018.0474