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Background  While driving impaired is a well-recognized risk factor for motor vehicle (MV) crash, recent trends in recreational drug use and abuse may pose increased threats to occupant safety. This study examines mechanisms through which drug and/or alcohol combinations contribute to fatal MV crash.    Methods  The Fatality Analysis Reporting System (FARS) for 2008–2013 was used to examine drugs, alcohol, driver restraint use, driver violations/errors and other behaviors of drivers of passenger vehicles who were tested for both alcohol and drugs ( n  = 79,932). Statistical analysis was based on Chi-square tests and multivariable logistic regression. Associations of restraint use and other outcomes with alcohol and drug use were measured by estimated odds ratios (ORs) and 95 % confidence intervals (95 % CIs).    Results  More than half (54.8 %) of the study population were positive for drugs or alcohol at the time of crash. Approximately half of drivers were belted, but this varied from 67.1 % (unimpaired) to 33.0 % (drugs plus alcohol). Compared to the unimpaired, the odds of a driver being unbelted varied: alcohol and cannabis (OR 3.70, 95 % CI 3.44–3.97), alcohol only (3.50,3.36–3.65), stimulants (2.13,1.91–2.38), depressants (2.09,1.89–2.31), narcotics (1.84,1.67–2.02) and cannabis only (1.55,1.43–1.67). Compared to belted drivers, unbelted drivers were over 4 times more likely to die. Driving violations varied across drug/drug alcohol combinations. Speed-related violations were higher for drivers positive for stimulants, alcohol, cannabis, and cannabis plus alcohol, with a more than two fold increase for alcohol and cannabis (2.36, 2.05, 2.71).    Conclusions  Mechanisms through which drugs, alcohol and substance combinations produce increased risks to occupant safety include lowered restraint use and increases in risky driving behaviors, including speeding, lane, passing, turning and signal/sign violations.

injury epidemiology.

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