Introduction and Aim(s) Rates of illicit drug use, especially opioids, and road traffic crashes (RTC; i.e., 25.7 per 100,000 inhabitants) are high in Iran, and they pose striking challenges to the health system. Drug driving (DD) is one of the important risk factors for RTC. The current review focuses on the following risk factors for DD in Iran: individual factors, other risky driving behaviors, and factors associated with specific drivers’ subgroups. • Methods A narrative review of published papers focusing on DD in Iran was conducted using three databases: PubMed and two national databases. Keywords included a combination of “drug/substance/alcohol/illicit drug use/abuse”, “driving behavior/performance/skills, “risky driving behavior”, “attitude/cognition/awareness” and “Iran”. Thematic analysis was used to summarize and characterize the identified risk factors. • Results Ten studies (i.e., population, hospital, subgroups, forensic) have investigated risk factors for DD in Iran. They highlighted the following individual risk factors: male (70%-100%), age 18-45 years (mean=35), single (36.5%-65%), illiterate or less than 12 years of education (50%-85.8%), unemployment (7.8%-19.4%), previous imprisonment (49%), involvement in extramarital relationship (45%), and past experience of non-fatal intoxication (39.3%). Individuals involved in DD were also involved in other risky driving behaviors, as measured by questionnaires or driving simulation: mobile phone during driving; sudden lane changes or poorer maneuvers during lane change; speed over the limit; and lack of safety belt use. DD was also associated with poorer hazard perception and visual search skills in traffic. Studies on drivers’ subgroups focused on commercial drivers. They have shown that about 14% of these drivers tested positive for drugs: 46.6%-76.0% for opioids (10% in the general driver population) and 11% stimulant drugs (1.5% in the general driver population). Amongst the substance-dependent professional drivers, over 45% reported regular use of opioids, 2.5% stimulant drugs and 17% illicit multiple drug use. Driving-related risk factors were long hours of driving (26.8%) and driving at nights (44.3%). • Discussion Results of studies conducted in Iran about individual factors and other risky driving behaviors showed similar results as studies conducted in other countries. Use of drugs in commercial drivers is important, especially opioids that have a long history in Iran for both recreational and medical purposes (e.g., treating pain and, cough). There are also strong beliefs that opioids enhance skills, boost self-confidence, and reduce fatigue and sleepiness. Educational and enforcement interventions are required to change beliefs and to raise knowledge about the effects of DD on traffic injuries.

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