Traffic Injury Prevention
ISSN: 1538-9588 (Print) 1538-957X (Online) Journal homepage: http://www.tandfonline.com/loi/gcpi20
Underlying Substance Abuse Problems in Drunk Drivers Rossella Snenghi, Giovanni Forza, Donata Favretto, Daniela Sartore, Silvia Rodinis, Claudio Terranova, Alessandro Nalesso, Massimo Montisci & Santo Davide Ferrara To cite this article: Rossella Snenghi, Giovanni Forza, Donata Favretto, Daniela Sartore, Silvia Rodinis, Claudio Terranova, Alessandro Nalesso, Massimo Montisci & Santo Davide Ferrara (2015) Underlying Substance Abuse Problems in Drunk Drivers, Traffic Injury Prevention, 16:5, 435-439, DOI: 10.1080/15389588.2014.968656 To link to this article: http://dx.doi.org/10.1080/15389588.2014.968656
Accepted author version posted online: 01 Dec 2014. Published online: 28 Jan 2015. Submit your article to this journal
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Date: 06 November 2015, At: 03:53
Traffic Injury Prevention (2015) 16, 435–439 C Taylor & Francis Group, LLC Copyright ISSN: 1538-9588 print / 1538-957X online DOI: 10.1080/15389588.2014.968656
Underlying Substance Abuse Problems in Drunk Drivers ROSSELLA SNENGHI1, GIOVANNI FORZA1, DONATA FAVRETTO2, DANIELA SARTORE1, SILVIA RODINIS2, CLAUDIO TERRANOVA1, ALESSANDRO NALESSO2, MASSIMO MONTISCI2, and SANTO DAVIDE FERRARA2 1
Forensic Toxicology and Antidoping, University Hospital of Padova, Padova, Italy Department of Cardiologic Thoracic and Vascular Sciences and Public Health, School of Medicine, University Hospital of Padova, Padova, Italy 2
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Received 19 February 2014, Accepted 18 September 2014
Objectives: The aim of this study was to investigate polydrug use in drunk drivers. Methods: The experimental study was conducted on 2,072 drunk drivers undergoing a driving license reissue protocol at the Department of Legal Medicine of Padova University Hospital in the period between January 2011 and December 2012. The study protocol involved anamnesis, clinical examination, toxicological history, and toxicological analyses on multiple biological samples. Results: One thousand eight hundred seventy-seven subjects (90.6%) were assessed as fit to drive, and 195 (9.5%) were declared unfit. Among those unfit, 32 subjects (1.6%) were declared unfit due to recent use of an illicit drug (time span < 6 months), 23 (1.1%) spontaneously interrupted the protocol before its end, and 140 (6.8%) completed the assessment. Ineligibility to drive after completeness of the protocol was established in 1.2% of cases for alcohol disorders and in 5.7% of cases for illicit drug abuse; only one subject was included in both subgroups. Cocaine was the most widely used substance, followed by cannabis, opiates, and psychotropic pharmaceutical drugs. Conclusions: The application of the protocol presented in this study allowed the identification of underlying polydrug use in drunk drivers. The study led to the identification of 6.8% unfit subjects on the basis of alcohol disorders and/or drug abuse, compared to 1.2% of identifiable unfitness if the protocol were limited to the mere assessment of alcohol consumption. The frequent association of alcohol and cocaine is different from other patterns of use in North Europe countries. Keywords: drunk drivers, polydrug use, driving license reissuing, road safety
Introduction Polydrug use, the dominant European pattern of consumption, poses a medico-social challenge to institutions working to provide tools for prevention, control, and treatment (Ahlm et al. 2009; Del Rio et al. 2002; European Monitoring Centre for Drugs and Drug Addiction 2011). In the sector of European road safety, an important contribution was provided by the integrated Driving Under the Influence of Drugs, Alcohol and Medicines (DRUID) Project, a multicenter project financed by the European Union and implemented in 2006–2011 through diversified macroactivities or “work packages” (DRUID 2006–2011). In line with numerous epidemiological studies (Brady and Li 2013; Steentoft et al. 2010), DRUID confirmed the primary role of alcohol in causing road accidents, showing a prevalence ranging from 17 to 42%. Use of alcohol combined with other psychoactive substances was found to be in the range of 2–13% with
Associate Editor Kathy Stewart oversaw the review of this article. Address correspondence to Donata Favretto, Department Cardiologic Thoracic and Vascular Sciences and Public Health, School of Medicine, University Hospital of Padova, Via Falloppio 50. 35121 Padova, Italy. E-mail: [email protected]
an incidence of 4.6% in Italy, where the association of alcohol with cocaine was the most frequent (1:8) among drinking drivers. Despite the considerable increase in polydrug use, Jones has stated that “reliable statistics about the types of drugs used by drivers who also drink alcohol to exceed the legal limit are lacking, because most forensic laboratories don’t analyze other drugs if the driver has a punishable Blood Alcohol Concentration” (Jones and Holmgren 2012). The issue is clearly connected to a multiplicity of conditions, such as local–national judicial structures, limited resources, and the greater difficulties associated with the chemical–toxicological analysis of psychoactive substances compared to the dosage of ethyl alcohol in breath tests (Gjerde et al. 2011; Jones et al. 2009). There is unanimous agreement on the need to address these issues through the harmonization of legislation among European countries involving effective enforcement measures combined with prevention programs. Less attention has been given to the implementation of rigorous medicolegal procedures in the context of administrative procedures for the reissuing of driving licenses, a process that begins following formal notice of the offense. A valuable initiative was carried out in 1993 by the International Council on Alcohol, Drugs and Traffic Safety through the establishment of a working group that outlined for drinking drivers 2 levels
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436 of assessment (medical screening and medical–psychological assessment) in relation to individual risk parameters, such as blood alcohol concentration (BAC), category of license, and recidivism (Nickel et al. 1996). For individuals having committed violations to the Italian Highway code for driving under the influence (DUI) of alcohol (and/or drugs), Italian law requires a mandatory examination prior to driving license regranting that should produce a medicolegal evaluation of fitness to drive. That same Italian law does not provide/suggest any methodological standards and the whole regranting procedure is entrusted to local health authorities (local medical commissions). The need to tackle the social danger related to emerging polydrug use is stimulating the development and standardization of methodologies of assessment and evaluation to be adopted in the field of legal medicine. To protect the safety of the community and the rights of individual drivers, in 2006 the Italian Society of Legal Medicine and Insurance published methodological and evaluation guidelines aimed at the verification of fitness to drive in subjects committing the offense of driving under the influence of psychoactive substances (Ferrara et al. 2006). On the basis of these guidelines, we have set up a comprehensive clinical and toxicological assessment protocol that includes the screening of the most common illicit drugs of abuse on multiple biological matrices (multiple urine samples coupled with hair analysis). We investigated polydrug use through the application of this comprehensive protocol in drivers sanctioned for DUI of alcohol. The effectiveness of a such integrated clinical–toxicological approach in the evaluation of the overall fitness to drive is also emphasized.
Materials and Methods Clinical and Toxicological Protocol The experimental study was conducted on 2,072 drunk drivers undergoing driving license reissue at the Forensic Toxicology and Antidoping Unit at Padova University Hospital in the period between January 2011 and December 2012. The study protocol involved the following steps: 1. Anamnestic and clinical history, including the collection of data regarding family, school, and work conditions; the time and circumstances of the violation of the Italian Highway Code;; the type and quantity of the psychoactive substances taken; their manner and timing of consumption; the possible existence of viral liver disease; possible contacts with the Services for Addiction and use of detoxifying pharmacological treatments; and collection of previous medical reports concerning markers of chronic alcohol consumption, such as mean corpuscular volume of red blood cells, gamma-glutamyltransferase, transaminases (AST, ALT), and carbohydrate-deficient transferrin (CDT; Martello et al. 2004; Montalto and Bean 2003; Tagliaro et al. 2003).
Snenghi et al. 2. Toxicological history based on the overall score obtained by the evaluation of the 10 items on the Alcohol Use Disorders Identification Test and the number of criteria fulfilled relative to the substance use disorder (American Psychiatric Association 2000; Demartini and Carey 2012). 3. Clinically objective examination distinct in internal medicine, neurology, orthopedics, and toxicology, dedicating greater attention to the signs of acute and chronic intoxication from ethyl alcohol, pathologies related to the abuse of ethyl alcohol, outcomes of trauma related to road accident, and possible signs of acute and chronic intake of narcotic substances. 4. Toxicological analysis of a blood sample taken during the medical assessment for the evaluation of seric CDT performed by capillary zone electrophoresis (Lanz et al. 2008); toxicological analysis of 2–3 urine samples collected in a period of 30 days, with a preannouncement of 24 h, with verification of the physicochemical characteristics of the sample (color, temperature, specific weight, pH, urinary creatinine) and analysis of ethyl alcohol, amphetamines, ecstasy, benzodiazepines, cannabinoids, cocaine, methadone, opiates, and buprenorphine by enzyme multiplied immunoassay technique, enzyme linked immunosorbent assay screening, followed by liquid chromatography mass spectrometry (LC/MS) or gas chromatography–mass spectrometry (GC/MS) confirmation (Italian Forensic Toxicologists Association 2012); hair analysis collected from subjects with suspected drug abuse (head hair, proximal segment of 3–5 cm, or pubic hair) on the basis of both the toxicological history searching for cannabinoids, cocaine, opiates, and amphetamines through screening and confirmation by LC/MS and GC/MS analytical methods (Cooper et al. 2012). 5. Integrated evaluation of clinical and toxicological data with a final judgment of fitness/unfitness to drive. A subject is declared “unfit” at the end of the protocol when one or more of the following occurs:
Table 1. Description of the recruited subjects (gender, age, driving license category) in the fit and unfit groups. The statistical analysis does not show significant differences and/or trends when the 2 groups are compared
Total Gender Male Female Age 18–25 26–45 46–65 Italian license category A–Ba C–D–Eb aDriver’s
Fit n (%)
Unfit n (%)
1,877 (100)
140 (100)
1,693 (90.2) 184 (9.8)
130 (92.8) 10 (7.2)
n.s.
389 (20.7) 1,256 (66.9) 233 (12.4)
27 (19.3) 101 (72.1) 12 (8.6)
n.s.
1,627 (86.7) 250 (13.3)
125 (89.3) 15 (10.7)
n.s.
license for motorcycle or car. license for truck, carrier, or bus. n.s. = not significant.
bDriver’s
Chi-square
Substance Abuse Problems in Drunk Drivers
437
Table 2. Prevalence of psychoactive substances in biological samples (hair and/or urine) of drivers declared unfit for drug use (n = 115) Class of substance
n (%)
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Cocaine Cannabis Opiates Benzodiazepines without prescription Association of 2 or more classes of substances Total
68 (59) 44 (38) 9 (7.8) 3 (2.6) 10 (8.7) 115 (100)
Self-reported lifetime nonuser 47 23 6 3
1. His or her clinical–objective examination evidences signs of excessive alcohol and/or drug use, and those signs are corroborated by the integration of biochemical markers or toxicological analysis. 2. The integrated evaluation of all biomarkers for excessive chronic drinking (serum CDT, GGT, ALT, AST, blood mean corpuscular volume) evidences alcohol use disorders. 3. Urine analysis and/or hair analysis are positive for one or more drug of abuse. Suspended group. Subjects who reported during the anamnesis a recent use of psychoactive substances other than alcohol (time span < 6 months) were immediately declared unfit and they were excluded from the study. Noncompliant group. Subjects who, after having begun the assessment, were unjustifiably absent at the summons for drug testing on urine. They were judged unfit to drive and excluded from the study. Statistical Analysis The collected data were entered into a database and analyzed using the Statistical Package for the Social Sciences, version 14.0. The chi-square test (or Fischer’s exact test, where appropriate) was used for the analysis of the difference of proportions and Student’s t test was used for independent samples to analyze the differences in means in the different groups.
Results Our assessment protocol was applied to an initial sample of 2,072 subjects. Of these, 32 subjects spontaneously reported using drugs in the previous 6 months (suspended group) and 23 did not complete the assessment for unknown reasons Table 3. Alcohol–drug combined use deduced from anamnesis Class of substance
Unfit n = 140 (%)
Fit n = 1,877 (%)
P value, Fisher’s exact test
At least one Cannabis Cocaine Opiates Other At least one
64(45.7) 53(37.9) 28(20.0) 4(2.9) 4(2.9) 64(45.7)
197(10.5) 188(10.0) 32(1.7) 8(0.4) 9(0.5) 197(10.5)
.001 .001 .001 .001 .004 .001
Table 4. Classification of BAC measured at the time of DUI offense according to the Italian Highway Code and comparison with the final judgment of fitness/unfitness Fit Unfit n = 1,877 (%) n = 140 (%) Chi-square
BAC 0.51–0.8 g/L (administrative offense) 0.81–1.50 g/L (minor criminal offense) >1.50 g/L (major criminal offense)
381 (20.3) 827 (44.1) 668 (35.6)
18 (13) 66 (47) 56 (40)
n.s.
(noncompliant group); 2017 subjects completed the protocol: 1877 drivers were declared fit and 140 were unfit. The assessment of unfitness was due to alcohol use disorders in 1.2% and to illicit drug use in 5.6% of cases; only one subject was included in both subgroups. The statistical analysis does not show significant differences and/or trends when gender, age, and driving license category between fit/unfit subjects are compared (see Table 1). Table 2 shows the prevalence of psychoactive substances established by the analysis of biological samples (head hair, pubic hair, urine) compared to the declared anamnestic data. Cocaine is the most widely used drug among drivers sanctioned for DUI of alcohol, followed by cannabis, opiates, and benzodiazepines. In self-reported toxicological history, summarized in Table 3, cannabis emerges as the primary substance of declared past use (time span > 6 months), followed by cocaine, opiates, and others (ecstasy, amphetamines, hallucinogenic drugs) in both fit and unfit groups. The subjects belonging to the unfit group have a higher tendency to declare a past use (time span > 6 months of illicit drugs as evidenced by Fisher’s test. We investigated whether a correlation exists between BAC at the time of the offense and the judgment of fitness to drive as reported in Table 4. Three ranges of BAC, corresponding to Italian legislation, were evaluated but the chi-square test evidenced no significant differences between the fit and unfit groups. In Table 5, the two groups are compared with regard to the circumstances of the charge of DUI of alcohol. Subjects were controlled after being involved in a traffic accident or at a road side control. Quite unexpectedly, a higher prevalence of traffic accidents is observed among fit drivers (P = .002). Refusal of a breath test and exhibiting signs of impairment were described for a small percentage of cases, without significant differences in the fit or unfit groups.
Table 5. Circumstances of the charge of DUI of alcohol in 2,017 subjects Unfit, n (%)
Fit, n (%)
Traffic accident 16 (11.4) 419 (22.3) Roadside random check 124 (88.6) 1,458 (77.7) Refusal of breath test 11 (7.9) 135 (7.2) Presence of impairment symptoms 5 (3.5) 39 (2.1)
P value according to chi-square test .002 n.s. n.s.
438
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Discussion At an international level, the assessment procedures for medicolegal driving license reissuing to drunk drivers, though heterogeneous, are generally based on 2 kinds of assessments: assessment of biomarkers of chronic ethanol abuse and/or a medical–psychological evaluation, in relation to individual risk parameters, such as BAC, category of driving license, and recidivism (Nickel et al. 1996; Walsh et al. 2004). The emerging phenomenon of the associated intake of alcohol and illicit drugs, confirmed by multiple epidemiological studies, has not been currently considered in the medical–legal procedures for license reissuing to drunk drivers. According to Italian legislation, we were authorized to apply this extended toxicological protocol, which includes illicit drugs, on subjects sanctioned for DUI of alcohol. Indeed, the role of the local medical commission is to evaluate the comprehensive psychophysical requirements of drivers, which include the absence of illicit drug use. The application of the protocol presented in the present study allowed the identification of underlying polydrug abuse disorders. In particular, the study led to the identification of 172 (140 unfit + 32 suspended; 8.3%) subjects who were not fit to drive due to use of substances, compared to only 25 (1.2%) identifiable with a protocol limited to alcohol biomarkers, with a 7-fold increase in the number of unfit subjects. Noncompliant subjects were declared unfit to drive, but they gave no explanation for their noncompliance, which could be due to reasons other than alcohol or drug use. In agreement with a recent Swedish study (Jones and Holmgren 2012), BAC ranging from 0.81 to 1.50 g/L was the most prevalent at the time of DUI offense. In our study, however, statistical analysis is not able to detect a significant trend among the 3 different ranges of BACs considered and the final fitness judgment (Table 4, chi-square test not significant). Moreover, the polydrug use phenomenon must be adequately investigated at low BACs. Indeed, as shown in Table 4, in the range 0.51–0.8 g/L there is a prevalence of unfit subjects of about 13.2%. Interestingly, drivers who lost their driving license because they were alcohol-positive at the time of an accident were more likely to have a judgment of fit to drive (see Table 5). A traffic accident can be a major stressful experience that might induce one to rethinking one’s dangerous driving habits such as DUI of alcohol and drugs. In the present study, the prevalent association of alcohol and cocaine, already detected in Italy through the study of circulating drivers, as in the DRUID project, was confirmed; it clearly differs from other patterns of combined use (alcohol and cannabinoids or alcohol and amphetamines) described in different North European countries (Blencowe et al. 2012; Jones and Holmgren 2012; Morland et al. 2011; Peinzleve et al. 2004; Senna et al. 2010). The association of alcohol with a stimulant such as cocaine activates the dopaminergic reward mechanisms (Millan and McNally 2012), the expression of craving and relapse, and determines the formation of the metabolite cocaethylene, pharmacologically active, capable of reinforcing the abuse of cocaine.
Snenghi et al. The recurrence of drug use in drinking drivers, detected in our forensic setting, can be considered clinical evidence of disturbance from psychoactive substance use (American Psychiatric Association 2000). The lack of public health awareness regarding this issue and the consequent absence of specific treatment programs entails a higher risk of recidivism (Jones and Holmgren 2012). The underestimation of polydrug use in drivers who committed the offense of drunk driving, as highlighted in this study, prompts the development of further research for accurate and homogenous protocols of assessment and the intensification of educational and preventative campaigns for road safety (World Health Organization 2012).
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ISSN: 1538-9588 (Print) 1538-957X (Online) Journal homepage: http://www.tandfonline.com/loi/gcpi20
Underlying Substance Abuse Problems in Drunk Drivers Rossella Snenghi, Giovanni Forza, Donata Favretto, Daniela Sartore, Silvia Rodinis, Claudio Terranova, Alessandro Nalesso, Massimo Montisci & Santo Davide Ferrara To cite this article: Rossella Snenghi, Giovanni Forza, Donata Favretto, Daniela Sartore, Silvia Rodinis, Claudio Terranova, Alessandro Nalesso, Massimo Montisci & Santo Davide Ferrara (2015) Underlying Substance Abuse Problems in Drunk Drivers, Traffic Injury Prevention, 16:5, 435-439, DOI: 10.1080/15389588.2014.968656 To link to this article: http://dx.doi.org/10.1080/15389588.2014.968656
Accepted author version posted online: 01 Dec 2014. Published online: 28 Jan 2015. Submit your article to this journal
Article views: 101
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=gcpi20 Download by: [Florida State University]
Date: 06 November 2015, At: 03:53
Traffic Injury Prevention (2015) 16, 435–439 C Taylor & Francis Group, LLC Copyright ISSN: 1538-9588 print / 1538-957X online DOI: 10.1080/15389588.2014.968656
Underlying Substance Abuse Problems in Drunk Drivers ROSSELLA SNENGHI1, GIOVANNI FORZA1, DONATA FAVRETTO2, DANIELA SARTORE1, SILVIA RODINIS2, CLAUDIO TERRANOVA1, ALESSANDRO NALESSO2, MASSIMO MONTISCI2, and SANTO DAVIDE FERRARA2 1
Forensic Toxicology and Antidoping, University Hospital of Padova, Padova, Italy Department of Cardiologic Thoracic and Vascular Sciences and Public Health, School of Medicine, University Hospital of Padova, Padova, Italy 2
Downloaded by [Florida State University] at 03:53 06 November 2015
Received 19 February 2014, Accepted 18 September 2014
Objectives: The aim of this study was to investigate polydrug use in drunk drivers. Methods: The experimental study was conducted on 2,072 drunk drivers undergoing a driving license reissue protocol at the Department of Legal Medicine of Padova University Hospital in the period between January 2011 and December 2012. The study protocol involved anamnesis, clinical examination, toxicological history, and toxicological analyses on multiple biological samples. Results: One thousand eight hundred seventy-seven subjects (90.6%) were assessed as fit to drive, and 195 (9.5%) were declared unfit. Among those unfit, 32 subjects (1.6%) were declared unfit due to recent use of an illicit drug (time span < 6 months), 23 (1.1%) spontaneously interrupted the protocol before its end, and 140 (6.8%) completed the assessment. Ineligibility to drive after completeness of the protocol was established in 1.2% of cases for alcohol disorders and in 5.7% of cases for illicit drug abuse; only one subject was included in both subgroups. Cocaine was the most widely used substance, followed by cannabis, opiates, and psychotropic pharmaceutical drugs. Conclusions: The application of the protocol presented in this study allowed the identification of underlying polydrug use in drunk drivers. The study led to the identification of 6.8% unfit subjects on the basis of alcohol disorders and/or drug abuse, compared to 1.2% of identifiable unfitness if the protocol were limited to the mere assessment of alcohol consumption. The frequent association of alcohol and cocaine is different from other patterns of use in North Europe countries. Keywords: drunk drivers, polydrug use, driving license reissuing, road safety
Introduction Polydrug use, the dominant European pattern of consumption, poses a medico-social challenge to institutions working to provide tools for prevention, control, and treatment (Ahlm et al. 2009; Del Rio et al. 2002; European Monitoring Centre for Drugs and Drug Addiction 2011). In the sector of European road safety, an important contribution was provided by the integrated Driving Under the Influence of Drugs, Alcohol and Medicines (DRUID) Project, a multicenter project financed by the European Union and implemented in 2006–2011 through diversified macroactivities or “work packages” (DRUID 2006–2011). In line with numerous epidemiological studies (Brady and Li 2013; Steentoft et al. 2010), DRUID confirmed the primary role of alcohol in causing road accidents, showing a prevalence ranging from 17 to 42%. Use of alcohol combined with other psychoactive substances was found to be in the range of 2–13% with
Associate Editor Kathy Stewart oversaw the review of this article. Address correspondence to Donata Favretto, Department Cardiologic Thoracic and Vascular Sciences and Public Health, School of Medicine, University Hospital of Padova, Via Falloppio 50. 35121 Padova, Italy. E-mail: [email protected]
an incidence of 4.6% in Italy, where the association of alcohol with cocaine was the most frequent (1:8) among drinking drivers. Despite the considerable increase in polydrug use, Jones has stated that “reliable statistics about the types of drugs used by drivers who also drink alcohol to exceed the legal limit are lacking, because most forensic laboratories don’t analyze other drugs if the driver has a punishable Blood Alcohol Concentration” (Jones and Holmgren 2012). The issue is clearly connected to a multiplicity of conditions, such as local–national judicial structures, limited resources, and the greater difficulties associated with the chemical–toxicological analysis of psychoactive substances compared to the dosage of ethyl alcohol in breath tests (Gjerde et al. 2011; Jones et al. 2009). There is unanimous agreement on the need to address these issues through the harmonization of legislation among European countries involving effective enforcement measures combined with prevention programs. Less attention has been given to the implementation of rigorous medicolegal procedures in the context of administrative procedures for the reissuing of driving licenses, a process that begins following formal notice of the offense. A valuable initiative was carried out in 1993 by the International Council on Alcohol, Drugs and Traffic Safety through the establishment of a working group that outlined for drinking drivers 2 levels
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436 of assessment (medical screening and medical–psychological assessment) in relation to individual risk parameters, such as blood alcohol concentration (BAC), category of license, and recidivism (Nickel et al. 1996). For individuals having committed violations to the Italian Highway code for driving under the influence (DUI) of alcohol (and/or drugs), Italian law requires a mandatory examination prior to driving license regranting that should produce a medicolegal evaluation of fitness to drive. That same Italian law does not provide/suggest any methodological standards and the whole regranting procedure is entrusted to local health authorities (local medical commissions). The need to tackle the social danger related to emerging polydrug use is stimulating the development and standardization of methodologies of assessment and evaluation to be adopted in the field of legal medicine. To protect the safety of the community and the rights of individual drivers, in 2006 the Italian Society of Legal Medicine and Insurance published methodological and evaluation guidelines aimed at the verification of fitness to drive in subjects committing the offense of driving under the influence of psychoactive substances (Ferrara et al. 2006). On the basis of these guidelines, we have set up a comprehensive clinical and toxicological assessment protocol that includes the screening of the most common illicit drugs of abuse on multiple biological matrices (multiple urine samples coupled with hair analysis). We investigated polydrug use through the application of this comprehensive protocol in drivers sanctioned for DUI of alcohol. The effectiveness of a such integrated clinical–toxicological approach in the evaluation of the overall fitness to drive is also emphasized.
Materials and Methods Clinical and Toxicological Protocol The experimental study was conducted on 2,072 drunk drivers undergoing driving license reissue at the Forensic Toxicology and Antidoping Unit at Padova University Hospital in the period between January 2011 and December 2012. The study protocol involved the following steps: 1. Anamnestic and clinical history, including the collection of data regarding family, school, and work conditions; the time and circumstances of the violation of the Italian Highway Code;; the type and quantity of the psychoactive substances taken; their manner and timing of consumption; the possible existence of viral liver disease; possible contacts with the Services for Addiction and use of detoxifying pharmacological treatments; and collection of previous medical reports concerning markers of chronic alcohol consumption, such as mean corpuscular volume of red blood cells, gamma-glutamyltransferase, transaminases (AST, ALT), and carbohydrate-deficient transferrin (CDT; Martello et al. 2004; Montalto and Bean 2003; Tagliaro et al. 2003).
Snenghi et al. 2. Toxicological history based on the overall score obtained by the evaluation of the 10 items on the Alcohol Use Disorders Identification Test and the number of criteria fulfilled relative to the substance use disorder (American Psychiatric Association 2000; Demartini and Carey 2012). 3. Clinically objective examination distinct in internal medicine, neurology, orthopedics, and toxicology, dedicating greater attention to the signs of acute and chronic intoxication from ethyl alcohol, pathologies related to the abuse of ethyl alcohol, outcomes of trauma related to road accident, and possible signs of acute and chronic intake of narcotic substances. 4. Toxicological analysis of a blood sample taken during the medical assessment for the evaluation of seric CDT performed by capillary zone electrophoresis (Lanz et al. 2008); toxicological analysis of 2–3 urine samples collected in a period of 30 days, with a preannouncement of 24 h, with verification of the physicochemical characteristics of the sample (color, temperature, specific weight, pH, urinary creatinine) and analysis of ethyl alcohol, amphetamines, ecstasy, benzodiazepines, cannabinoids, cocaine, methadone, opiates, and buprenorphine by enzyme multiplied immunoassay technique, enzyme linked immunosorbent assay screening, followed by liquid chromatography mass spectrometry (LC/MS) or gas chromatography–mass spectrometry (GC/MS) confirmation (Italian Forensic Toxicologists Association 2012); hair analysis collected from subjects with suspected drug abuse (head hair, proximal segment of 3–5 cm, or pubic hair) on the basis of both the toxicological history searching for cannabinoids, cocaine, opiates, and amphetamines through screening and confirmation by LC/MS and GC/MS analytical methods (Cooper et al. 2012). 5. Integrated evaluation of clinical and toxicological data with a final judgment of fitness/unfitness to drive. A subject is declared “unfit” at the end of the protocol when one or more of the following occurs:
Table 1. Description of the recruited subjects (gender, age, driving license category) in the fit and unfit groups. The statistical analysis does not show significant differences and/or trends when the 2 groups are compared
Total Gender Male Female Age 18–25 26–45 46–65 Italian license category A–Ba C–D–Eb aDriver’s
Fit n (%)
Unfit n (%)
1,877 (100)
140 (100)
1,693 (90.2) 184 (9.8)
130 (92.8) 10 (7.2)
n.s.
389 (20.7) 1,256 (66.9) 233 (12.4)
27 (19.3) 101 (72.1) 12 (8.6)
n.s.
1,627 (86.7) 250 (13.3)
125 (89.3) 15 (10.7)
n.s.
license for motorcycle or car. license for truck, carrier, or bus. n.s. = not significant.
bDriver’s
Chi-square
Substance Abuse Problems in Drunk Drivers
437
Table 2. Prevalence of psychoactive substances in biological samples (hair and/or urine) of drivers declared unfit for drug use (n = 115) Class of substance
n (%)
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Cocaine Cannabis Opiates Benzodiazepines without prescription Association of 2 or more classes of substances Total
68 (59) 44 (38) 9 (7.8) 3 (2.6) 10 (8.7) 115 (100)
Self-reported lifetime nonuser 47 23 6 3
1. His or her clinical–objective examination evidences signs of excessive alcohol and/or drug use, and those signs are corroborated by the integration of biochemical markers or toxicological analysis. 2. The integrated evaluation of all biomarkers for excessive chronic drinking (serum CDT, GGT, ALT, AST, blood mean corpuscular volume) evidences alcohol use disorders. 3. Urine analysis and/or hair analysis are positive for one or more drug of abuse. Suspended group. Subjects who reported during the anamnesis a recent use of psychoactive substances other than alcohol (time span < 6 months) were immediately declared unfit and they were excluded from the study. Noncompliant group. Subjects who, after having begun the assessment, were unjustifiably absent at the summons for drug testing on urine. They were judged unfit to drive and excluded from the study. Statistical Analysis The collected data were entered into a database and analyzed using the Statistical Package for the Social Sciences, version 14.0. The chi-square test (or Fischer’s exact test, where appropriate) was used for the analysis of the difference of proportions and Student’s t test was used for independent samples to analyze the differences in means in the different groups.
Results Our assessment protocol was applied to an initial sample of 2,072 subjects. Of these, 32 subjects spontaneously reported using drugs in the previous 6 months (suspended group) and 23 did not complete the assessment for unknown reasons Table 3. Alcohol–drug combined use deduced from anamnesis Class of substance
Unfit n = 140 (%)
Fit n = 1,877 (%)
P value, Fisher’s exact test
At least one Cannabis Cocaine Opiates Other At least one
64(45.7) 53(37.9) 28(20.0) 4(2.9) 4(2.9) 64(45.7)
197(10.5) 188(10.0) 32(1.7) 8(0.4) 9(0.5) 197(10.5)
.001 .001 .001 .001 .004 .001
Table 4. Classification of BAC measured at the time of DUI offense according to the Italian Highway Code and comparison with the final judgment of fitness/unfitness Fit Unfit n = 1,877 (%) n = 140 (%) Chi-square
BAC 0.51–0.8 g/L (administrative offense) 0.81–1.50 g/L (minor criminal offense) >1.50 g/L (major criminal offense)
381 (20.3) 827 (44.1) 668 (35.6)
18 (13) 66 (47) 56 (40)
n.s.
(noncompliant group); 2017 subjects completed the protocol: 1877 drivers were declared fit and 140 were unfit. The assessment of unfitness was due to alcohol use disorders in 1.2% and to illicit drug use in 5.6% of cases; only one subject was included in both subgroups. The statistical analysis does not show significant differences and/or trends when gender, age, and driving license category between fit/unfit subjects are compared (see Table 1). Table 2 shows the prevalence of psychoactive substances established by the analysis of biological samples (head hair, pubic hair, urine) compared to the declared anamnestic data. Cocaine is the most widely used drug among drivers sanctioned for DUI of alcohol, followed by cannabis, opiates, and benzodiazepines. In self-reported toxicological history, summarized in Table 3, cannabis emerges as the primary substance of declared past use (time span > 6 months), followed by cocaine, opiates, and others (ecstasy, amphetamines, hallucinogenic drugs) in both fit and unfit groups. The subjects belonging to the unfit group have a higher tendency to declare a past use (time span > 6 months of illicit drugs as evidenced by Fisher’s test. We investigated whether a correlation exists between BAC at the time of the offense and the judgment of fitness to drive as reported in Table 4. Three ranges of BAC, corresponding to Italian legislation, were evaluated but the chi-square test evidenced no significant differences between the fit and unfit groups. In Table 5, the two groups are compared with regard to the circumstances of the charge of DUI of alcohol. Subjects were controlled after being involved in a traffic accident or at a road side control. Quite unexpectedly, a higher prevalence of traffic accidents is observed among fit drivers (P = .002). Refusal of a breath test and exhibiting signs of impairment were described for a small percentage of cases, without significant differences in the fit or unfit groups.
Table 5. Circumstances of the charge of DUI of alcohol in 2,017 subjects Unfit, n (%)
Fit, n (%)
Traffic accident 16 (11.4) 419 (22.3) Roadside random check 124 (88.6) 1,458 (77.7) Refusal of breath test 11 (7.9) 135 (7.2) Presence of impairment symptoms 5 (3.5) 39 (2.1)
P value according to chi-square test .002 n.s. n.s.
438
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Discussion At an international level, the assessment procedures for medicolegal driving license reissuing to drunk drivers, though heterogeneous, are generally based on 2 kinds of assessments: assessment of biomarkers of chronic ethanol abuse and/or a medical–psychological evaluation, in relation to individual risk parameters, such as BAC, category of driving license, and recidivism (Nickel et al. 1996; Walsh et al. 2004). The emerging phenomenon of the associated intake of alcohol and illicit drugs, confirmed by multiple epidemiological studies, has not been currently considered in the medical–legal procedures for license reissuing to drunk drivers. According to Italian legislation, we were authorized to apply this extended toxicological protocol, which includes illicit drugs, on subjects sanctioned for DUI of alcohol. Indeed, the role of the local medical commission is to evaluate the comprehensive psychophysical requirements of drivers, which include the absence of illicit drug use. The application of the protocol presented in the present study allowed the identification of underlying polydrug abuse disorders. In particular, the study led to the identification of 172 (140 unfit + 32 suspended; 8.3%) subjects who were not fit to drive due to use of substances, compared to only 25 (1.2%) identifiable with a protocol limited to alcohol biomarkers, with a 7-fold increase in the number of unfit subjects. Noncompliant subjects were declared unfit to drive, but they gave no explanation for their noncompliance, which could be due to reasons other than alcohol or drug use. In agreement with a recent Swedish study (Jones and Holmgren 2012), BAC ranging from 0.81 to 1.50 g/L was the most prevalent at the time of DUI offense. In our study, however, statistical analysis is not able to detect a significant trend among the 3 different ranges of BACs considered and the final fitness judgment (Table 4, chi-square test not significant). Moreover, the polydrug use phenomenon must be adequately investigated at low BACs. Indeed, as shown in Table 4, in the range 0.51–0.8 g/L there is a prevalence of unfit subjects of about 13.2%. Interestingly, drivers who lost their driving license because they were alcohol-positive at the time of an accident were more likely to have a judgment of fit to drive (see Table 5). A traffic accident can be a major stressful experience that might induce one to rethinking one’s dangerous driving habits such as DUI of alcohol and drugs. In the present study, the prevalent association of alcohol and cocaine, already detected in Italy through the study of circulating drivers, as in the DRUID project, was confirmed; it clearly differs from other patterns of combined use (alcohol and cannabinoids or alcohol and amphetamines) described in different North European countries (Blencowe et al. 2012; Jones and Holmgren 2012; Morland et al. 2011; Peinzleve et al. 2004; Senna et al. 2010). The association of alcohol with a stimulant such as cocaine activates the dopaminergic reward mechanisms (Millan and McNally 2012), the expression of craving and relapse, and determines the formation of the metabolite cocaethylene, pharmacologically active, capable of reinforcing the abuse of cocaine.
Snenghi et al. The recurrence of drug use in drinking drivers, detected in our forensic setting, can be considered clinical evidence of disturbance from psychoactive substance use (American Psychiatric Association 2000). The lack of public health awareness regarding this issue and the consequent absence of specific treatment programs entails a higher risk of recidivism (Jones and Holmgren 2012). The underestimation of polydrug use in drivers who committed the offense of drunk driving, as highlighted in this study, prompts the development of further research for accurate and homogenous protocols of assessment and the intensification of educational and preventative campaigns for road safety (World Health Organization 2012).
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