Commentary: Drugs and Driving
2015; Elsevier BV; Volume: 66; Issue: 6 Linguagem: Inglês
10.1016/j.annemergmed.2015.10.002
ISSN1097-6760
Autores Tópico(s)Substance Abuse Treatment and Outcomes
Resumo[Kahn CA. Commentary: drugs and driving. Ann Emerg Med. 2015;66:670-672.] It’s no secret that in the United States, we’ve made great strides in reducing the burden of road traffic injuries and deaths. In 2013, the last year for which we have reliable final data, there were 32,719 motor vehicle crash fatalities.1National Highway Traffic Safety AdministrationOverview: 2013 Data (Traffic Safety Facts). National Highway Traffic Safety Administration, Washington, DC2015http://www-nrd.nhtsa.dot.gov/Pubs/812169.pdfGoogle Scholar For comparison, this represents an age-adjusted death rate of 10.9 persons per 100,000 population compared with 27.6 per 100,000 in 1970.2Centers for Disease Control and PreventionHealth, United States, 2014 (Table 18). Centers for Disease Control and Prevention, 2015ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus14tables/table018.xlsGoogle Scholar In the road traffic injury prevention world, it’s understandable that we often get focused just on motor vehicle fatalities. However, it’s a good idea from time to time to step back a bit and look at broader trends in injury-related fatalities, and see whether there are areas of overlap that might be worth some extra effort. The current report from NHTSA on alcohol and drug use by drivers gives us that opportunity.3Berning A. Compton R. Wochinger K. Results of the 2013-2014 National Roadside Survey of Alcohol and Drug Use by Drivers. National Highway Traffic Safety Administration, Washington, DC2015http://www.nhtsa.gov/staticfiles/nti/pdf/812118-Roadside_Survey_2014.pdfGoogle Scholar The 2013-2014 NRS was the fifth direct survey of drivers on the road—the first was in 1973—to analyze alcohol use among drivers. There’s good news here: the percentage of weekend nighttime drivers found to have any alcohol in their system has decreased from 35.9% to 8.3%, with the percentage of drivers having a BrAC of 0.08 (the legal limit in all US states since 2004) or higher decreasing from 7.5% to 1.5%. Weekend nights (Friday and Saturday) are the peak time for alcohol use by drivers. During weekday daytime hours, only 1.1% of drivers were alcohol positive, with 0.4% having illegal BrACs. Alcohol-impaired crashes make up a disproportionately high number of all fatal crashes: 10,076 of the 32,719 fatalities, or 31%, involved a driver with a blood alcohol concentration of 0.08 or higher.1National Highway Traffic Safety AdministrationOverview: 2013 Data (Traffic Safety Facts). National Highway Traffic Safety Administration, Washington, DC2015http://www-nrd.nhtsa.dot.gov/Pubs/812169.pdfGoogle Scholar Compare that with the 1.5% peak prevalence of alcohol-impaired drivers on the road and that’s one pretty hefty risk factor. How about drugs, though? How often are drivers in fatal motor vehicle crashes potentially impaired by drugs? Which drugs seem to be the most problematic, if there’s a problem at all? With the 2007 survey and the present survey being the first 2 to examine this, we now have 2 points we can compare to start to evaluate trends.4Compton R. Berning A. Results of the 2007 National Roadside Survey of Alcohol and Drug Use by Drivers. National Highway Traffic Safety Administration, Washington, DC2009http://www.nhtsa.gov/DOT/NHTSA/Traffic%20Injury%20Control/Articles/Associated%20Files/811175.pdfCrossref Google Scholar Some interesting distinctions appear between alcohol use and drug use. Unlike the changes in alcohol use by time of day or week, drug use is fairly consistent, with 22.4% of weekday daytime and 22.5% of weekend nighttime drivers testing positive for either an illegal drug or a potentially impairing medication (eg, sedative, narcotic analgesic). Those numbers are quite a bit higher than the number of drivers using alcohol. There’s a major caveat here, though, which is that we don’t have a great evidence base to draw from to declare a certain drug level to represent impairment (unlike the 0.08% alcohol limit).5Karschner E.L. Swortwood M.J. Hirvonen J. et al.Extended plasma cannabinoid excretion in chronic frequent cannabis smokers during sustained abstinence and correlation with psychomotor performance.Drug Test Anal. 2015; http://dx.doi.org/10.1002/dta.1825PubMed Google Scholar When comparing the presence of illegal drugs to the presence of medications, we might not be surprised to discover that the pattern is more consistent with alcohol use, in that the recreational (illegal) substances are more often found at night. Another key distinction is that unlike the alcohol numbers, drug use by drivers is increasing. The number of people driving with potentially impairing medications in their system increased a little, from 3.9% to 4.9%; these data aren’t quite the same as those discussed just above because the cutoff levels for determining “present” or “absent” was changed for this part of the analysis to make them comparable to those of the 2007 data. With that same caveat, drivers using illegal drugs increased in prevalence from 12.4% to 15.1% during that same time. For the curious among us, the drug with the biggest increase in prevalence (for weekend nighttimes) wasn’t hydrocodone or oxycodone, but marijuana; Δ-9-tetrahydrocannabinol was found in 12.6% of weekend nighttime drivers in this survey. Next time you find yourself driving home from work at midnight on a Saturday, just know that about 1 of every 8 cars around you is being operated by somebody with detectable (although not necessarily impairing) Δ-9-tetrahydrocannabinol in their system. So how does this relate to other foci of injury prevention efforts? It’s still true that unintentional injury is the leading cause of death in US residents aged 1 to 44 years; that’s been the case for at least a decade. However, in 2011, unintentional poisoning overtook motor vehicle crashes as the leading single cause of unintentional injury deaths.2Centers for Disease Control and PreventionHealth, United States, 2014 (Table 18). Centers for Disease Control and Prevention, 2015ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus14tables/table018.xlsGoogle Scholar The unintentional poisoning category includes deaths related to drug overdose, and the increase in deaths in this category unsurprisingly parallels the epidemic of opiate-related deaths. From 2000 through 2013, the age-adjusted rate for heroin deaths quadrupled from 0.7 deaths per 100,000 people to 2.7 deaths, with most of the increase occurring after 2010.6Hedegaard H. Chen L.H. Warner M. National Center for Health Statistics Data Brief #190: Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. Centers for Disease Control and Prevention, Hyattsville, MD2015http://www.cdc.gov/nchs/data/databriefs/db190.htmGoogle Scholar Perhaps coincidentally, the increase in deaths from opioid analgesics, although also much higher in 2013 than 2000 (5.1 per 100,000 people compared with 1.5), began to level off in approximately 2010 and has actually decreased slightly from the 2010 peak of 5.4 deaths per 100,000 people. Total drug poisoning deaths in 2013 numbered 43,982, including 16,235 deaths related to opioid analgesics and 8,257 deaths related to heroin. In light of the results from the NHTSA survey, it’s intuitive that the number of drivers with drugs in their system increases when the number of people dying from drug use (and therefore presumably the number of people using drugs) is increasing as well. As always, life doesn’t occur in a vacuum. Overall trends in public health are likely to be reflected in individual categories of public health concerns. What does this mean to us? We already know we’re supposed to be advocates for injury prevention measures in our emergency departments. We tell people about the benefits of wearing seat belts, bicycle helmets, and motorcycle helmets. We remind parents not to leave their kids in hot cars, to look behind them and know where the children are before backing up, and never to leave a kid alone with access to a swimming pool. Our hospitals require slip-resistant socks on at-risk patients and won’t let a baby go home without being in a car seat. Some of us even remind our injection drug users that a cheap box of alcohol wipes will go a long way toward reducing the incidence of cutaneous abscesses. Does it matter? Are we making a difference? The age-adjusted rates of unintentional injury deaths over time suggest that we are, in fact, part of an effective force for improved public health. Unintentional injury rates have decreased by approximately 50% since 1950 (Figure).2Centers for Disease Control and PreventionHealth, United States, 2014 (Table 18). Centers for Disease Control and Prevention, 2015ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/Health_US/hus14tables/table018.xlsGoogle Scholar Naturally, that’s not just from emergency physicians advocating road traffic safety. Injury prevention is the responsibility of parents, manufacturers, legislators, regulators, primary care physicians, trauma surgeons, emergency medical services physicians, and a whole host of other stakeholders. In other words, we don’t need to do this alone. However, despite the gains we’ve seen in unintentional injury death rates, we need to make sure we keep up our efforts. We already know what happens when we think a problem is solved and we turn our back on it; infectious disease rates increase when vaccination rates decrease, and there’s no reason to think that injury prevention efforts are any different.7Atkinson P. Cullinan C. Jones J. et al.Large outbreak of measles in London: reversal of health inequalities.Arch Dis Child. 2005; 90: 424-425Crossref PubMed Scopus (17) Google Scholar Thanks for all of your efforts to keep our patients and communities safe, and thanks for keeping up the good fight. Results of the 2013-2014 National Roadside Survey of Alcohol and Drug Use by DriversAnnals of Emergency MedicineVol. 66Issue 6Preview[Results of the 2013-2014 national roadside survey of alcohol and drug use by drivers. Ann Emerg Med. 2015;66:669.] Full-Text PDF
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