M. Carmen Del Rio

Alcohol, illicit drugs and medicinal drugs in fatally injured drivers in Spain between 1991and 2000

The aim of this study was to assess the presence of alcohol, illicit drugs and medicinal drugs among Spanish drivers involved in fatal road accidents between 1991 and 2000. Samples were obtained for 5745 drivers killed in road accidents from January 1991 to December 2000. Of the samples, 91.7% represented males and 8.3% females; 40.7% were under 30 years of age, 31.9% were under 31-50 years of age, 19.5% were over 51 years of age, and for 7.9% the age was unknown. Between 1991 and 2000, some type of psychoactive substance was detected among 50.1% of those drivers killed in road accidents, this being mainly alcohol (43.8%) and, less frequently, illicit drugs (8.8%) and medicinal drugs (4.7%). In all the cases, in which alcohol was detected, combined use with other substances accounted for only 12.5%, whilst in the case of illicit and medicinal drugs, figures representing combined use with other substances were 75.6% for the former and 65.8% for the latter. For one in every three cases (32.0%), a blood alcohol level over 0.8 g/l was recorded; cocaine (5.2%), opiates (3.2%) and cannabis (2.2%) were the three illicit drugs most frequently detected. Among medicinal drugs, were benzodiazepines (3.4%), anti-depressant drugs (0.6%) and analgesics (0.4%). The results show the frequent presence of psychoactive substances, particularly alcohol, among Spanish motor vehicle users involved in fatal road accidents. It should be pointed out that illicit and medicinal drugs in combination with other substances were a common feature.

Presence of illegal drugs in drivers involved in fatal road traffic accidents in Spain

This study investigated the presence of illegal drugs in the blood of 285 fatally injured drivers in Spain. Illegal drugs were detected in 10.2% of all samples. Illicit drugs alone were detected in 2.5% and together with other substances in 7.7%. Cocaine was the most common drug detected. The mean number (+/- S.D.) of substances detected was 2.6 +/- 1.2: consisting of 46 illegal drugs, 14 alcohol cases and 16 medicines. Three concentration levels of the different substances have been established: low, medium and high-toxic. In 68.9% of the samples in which an illegal drug was detected, a substance was also found at the high-toxic level. The results show that illegal drugs are commonly detected in road accident victims.

Illegal drug taking and driving: patterns of drug taking among Spanish drivers

This study investigated patterns of illegal drug taking among Spanish drivers. The study was conducted in the fall of 1993 on 1500 drivers aged over 16, who properly completed and returned the questionnaires. The statistical SAS package was used. Among those surveyed, 23.5% had taken illegal drugs within their lifetime, 6.1% in the past year, 4.2% in the past month and 3.1% in the past week. Cannabis was the drug most frequently taking drug within lifetime (17.3%), the past year (3.4%), the past month (2.7%) or the past week (2.1%). Of those surveyed, 3% had driven after taking illegal drugs in the last year before the survey, and had been stopped during road checks (P < 0.001) and involved in road accidents (P < 0.0001) more often than those who had not driven under the influence of drugs. The study shows that driving under the influence of illegal drugs is somewhat frequent in Spain.

ALCOHOL USE AMONG FATALLY INJURED DRIVERS IN SPAIN

Blood from 285 fatally injured drivers in Northern Spain was collected and tested for the presence of alcohol and drugs. Alcohol was detected in 50.5% of all fatalities. Alcohol alone was detected in 44.2% of all samples and in the remaining 6.3% another substance was found together with alcohol. Blood alcohol concentration was classified in different levels. It has been observed that in 35.4% of the cases the blood alcohol level was > or = 0.8 g/l, the legal limit in Spain for car drivers. Alcohol together with other substances was encountered in 18 cases, with medication in 22.2% (4 out of 18), alcohol with illegal drugs in 66.6% of the cases (12 out of 18), and alcohol with medicines and illegal drugs in 11.1% (2 out of 18). Cocaine was the most commonly detected drug. The study shows how widespread the incidence of a high level of alcohol concentration among drivers involved in fatal accidents in Spain.

Medicinal drugs and driving: from research to clinical practice.

From the point of view of traffic authorities, the relationship between medicinal drugs and driving can be seen from a dual perspective. First, countries have regulations against driving under the influence of certain substances (alcohol, illegal drugs, and medicaments) that impair ability to drive. Most countries take one of two positions: ‘zero-tolerance’ – if the substance is detected, the law has been broken; or ‘impairment’, which requires evidence of impairment in the driver who is under the effect of the substance in question [20xOverview of legal provisions, difficulties faced by police, and analysis of prevention attemps in selected european countries. Kruger, H.P. et al. : 63–85See all References[20]. Second, Directive 91/439 EEC on driving licences, in Annex III, establishes the minimum standards of physical and mental fitness of an individual to drive a motor vehicle. It indicates that ‘driving licences shall not be issued to, or renewed for, applicants or drivers who regularly use psychotropic substances, in whatever form, which can hamper the ability to drive safely where the quantities absorbed are such as to have an adverse effect on driving. This shall apply to all other medicinal products or combinations of medicinal products which affect the ability to drive’.All EU member countries have legislation concerning this Directive, although there are differences between them. This would mean that many drivers being treated with medication for a particular illness would not be allowed to receive or renew their driving licence, either because of the illness itself or because of the medication. Once again, this would require information as precise as possible about the medication and its effect on driving ability to facilitate the selection, prescription and information of medicaments.Those of us working in the pharmacological field (experimental pharmacology, clinical pharmacology, pharmacy, pharmaco-epidemiology, and so on), with our very different views, need to join forces to deal with the subject of drugs and driving in a more scientific manner. It is clear that more effort must be made to avoid or reduce as much as possible the occurrence of traffic accidents caused by the effects of medication.

The Use of Medication by the Spanish Population

The aim of the study was to assess patterns of the use of medicines by the general population older than 0 years. The study was based on the information contained in the computerized database from the 1993 Spanish Household Health Survey. A representative sample of the population older than 0 was identified, and a survey of 26,334 persons was carried out. Of the population 45.3% had taken some medicine in the last 2 weeks prior to the carrying out of the survey. The proportion was greater for women (50.6%) than for men (39.6%). With increasing age, the frequency and amount of medication use increased. A little over 20% of the medicines used were not prescribed by a doctor (self‐medication). Data show the frequency of the use of medicines by the Spanish population.

Illicit drugs and fitness to drive: assessment in Spanish Medical Driving Test Centres

This study investigated the incidence of problems related to illicit drugs and fitness to drive among 8043 Spanish drivers assessed in 25 Medical Driving Test Centres at national level. In accordance with Spanish and European Union legislation, driving licences cannot be issued or renewed to people suffering from illicit drug-related problems. A small percentage (0.3%; n=24) of drivers interviewed had problems relating to drug use (abuse, dependence and induced disorders) and half of them (n=12) were also diagnosed as having problems with alcohol. Drivers with illicit drug-related problems were more often involved in road accidents and committed more traffic infractions during the last year (33.3%, n=8, and 79.2%, n=19, respectively) than those without problems related to illegal drug taking (12.3%, n=986, and 9.3%, n=748, respectively). Of drivers with drug problems 70.8% (n=17) were considered fit to drive. The results show that the incidence of drug-related problems is rare among Spanish drivers, and that in three out of four cases drivers with drug-related problems were considered fit to drive.

Do Spanish patients drink alcohol while undergoing treatment with benzodiazepines

In this study, we analyzed patterns of combined benzodiazepines and alcohol use among the Spanish general population over the age of 16 years. The study was based on information from the 1997 Spanish National Household Health Survey. A total of 6,396 persons over 16 years of age, a representative sample of noninstitutionalized Spaniards, were surveyed. One percent of the population are consumers of benzodiazepines and daily drinkers of alcohol; fundamentally, these consumers are men, of whom 15.4% drink alcohol at a high level (>50 units/week). Findings show the frequency of concurrent use of benzodiazepines and alcohol by the Spanish population.

Medication Use by the Driving Population

This study investigated patterns of medicine use among Spanish drivers. The study was conducted in the fall of 1993 on 1500 drivers aged over 16, all of whom completed accordingly and then returned the questionnaires. Among those surveyed, 45.1% had used drugs at least once in the previous year, while 17.3% of drivers surveyed were using medicines chronically. Chronic users, the majority of whom were female and belonging to the older age group, were using an average of two drugs. Central nervous system drugs (21.7%), respiratory system drugs (19.2%), cardiovascular system drugs (14.9%) and alimentary tract drugs (14.3%) were the most frequent groups of medication used. Of those surveyed 76.5% who took drugs regularly had never been warned by health professionals about the effects of the medication use on driving skills. The study shows both how often drivers use medication as well as the need to inform patients and drivers about the effect of medication on driving performance.

Response to Ramaekers: Pitfalls in estimating drug-related crash risk

There are several approaches to quantifying the contribution of medicinal drug use to road accidents. These include, among others, case-control studies, correlational studies (where the relationship between variables describing medicinal drug use and accident involvement is estimated) and responsibility analysis (where drivers are classified as culpable, contributory or not culpable on the basis of several factors, and then related to the presence or not of the substance in their biological fluids). As Ramaekers has pointed out in his letter to TiPS [1xSee all References][1] in response to our recent TiPS article [2xMedicinal drugs and driving: from research to clinical practice. Alvarez, F.J. and de Rio, M.C. Trends Pharmacol. Sci. 2002; 23: 441–443Abstract | Full Text | Full Text PDF | PubMed | Scopus (11)See all References][2] case-control studies are the most powerful tools to determine the causal relationship between medicinal drug use and road accidents.However, the available data show inconsistent trends regarding the relationship between medicinal drug use and road accidents, except in the case of benzodiazepines (nearly all studies identify benzodiazepines as a risk factor for road accident involvement). The mismatch between experimental studies that show driving impairment related to some groups of medicinal drugs and the lack of increased risk in road accidents is a very relevant key question [2xMedicinal drugs and driving: from research to clinical practice. Alvarez, F.J. and de Rio, M.C. Trends Pharmacol. Sci. 2002; 23: 441–443Abstract | Full Text | Full Text PDF | PubMed | Scopus (11)See all References][2]. This controversy has caused policy makers to question whether or not medicinal drugs represent real risks.The factors suggested by Ramaekers to contribute to this mismatch, such as misclassification of drug exposure, dose and duration of treatment, sample size and statistical powers [2xMedicinal drugs and driving: from research to clinical practice. Alvarez, F.J. and de Rio, M.C. Trends Pharmacol. Sci. 2002; 23: 441–443Abstract | Full Text | Full Text PDF | PubMed | Scopus (11)See all References][2], together with other factors such as exposure (i.e. the number of kilometres driven per year), which are not well controlled in most studies, accounts, at least partly, for the discrepancies between experimental and epidemiological studies. We agree with Ramaekers [2xMedicinal drugs and driving: from research to clinical practice. Alvarez, F.J. and de Rio, M.C. Trends Pharmacol. Sci. 2002; 23: 441–443Abstract | Full Text | Full Text PDF | PubMed | Scopus (11)See all References][2] that only large multi-centre studies that cover these confounding factors will provide a real picture of the matter.A recent funded project by the 5th Framework Programme of the European Union, IMMORTAL (http://www.immortal.or.at) has tried to address the role of health status and medication in driving in the context of European legislation. Deliverable R1.1∗∗∗Deliverable R1.1. (Vaa, T. Literature review of impairment and accident risk associated with ageing, illness and disease) is pending approval by the European Commission. Following approval, it will be freely available at http://www.immortal.or.at. presents data of meta-analyses of health-related risk factors and road accidents, according to the categories of Directive 91/439 [2xMedicinal drugs and driving: from research to clinical practice. Alvarez, F.J. and de Rio, M.C. Trends Pharmacol. Sci. 2002; 23: 441–443Abstract | Full Text | Full Text PDF | PubMed | Scopus (11)See all References][2]. Medicinal products assumed to be used as prescribed are associated with an increased relative risk of involvement in a traffic accident (1.22, 1.18–1.25 95% CI).