The impact of medicinal drugs on traffic safety: a systematic review of epidemiological studies

A scoping review of motor vehicle operator performance assessments for benzodiazepine receptor agonists

Background

Benzodiazepines and Z-drugs (e.g., zopiclone, zolpidem) (benzodiazepine receptor agonists or BZRAs), are prescribed for anxiety and insomnia disorders. However, they are not indicated as first line therapies for long-term management due to harms and efficacy limitations. BZRAs have also been associated with traffic accident risks. Patients taking BZRAs are told to consult with health care providers regarding motor vehicle operation safety. However, advice on driving is variable. The objective of this scoping review is to identify, map, and characterize the evidence for assessments that measure driving performance in people taking BZRAs.

Methods

Embase (Elsevier), MEDLINE (Ovid), and PsycINFO (EBSCO) were searched. Covidence was used for screening. Each stage of screening included two independent reviewers. A REDCap database was used for data extraction by two independent reviewers. Results were tabulated and summarised as a narrative.

Results

Driving performance was assessed with 20 unique BZRAs across 183 studies (n = 92 experimental; n = 91 observational) in 178 publications. Zopiclone was the most studied. In experimental studies, the Standard Deviation of Lateral Position (SDLP) was used most often (n = 54, 62 %) and many studies (n = 35, 38 %) were conducted in the Netherlands. For observational studies, biological detection (e.g., urine, blood) (n = 73, 80 %) followed by prescription drug/dispensing records (n = 17, 19 %) were the most common impairment measures and Norway (n = 20) is where most studies took place. In experimental studies, most (n = 89, 97 %) were conducted using only one driving setting. Simulated driving in a car (n = 36) and road driving in traffic (n = 36) were common as compared to nontraffic driving course (n = 8) and simulated driving (n = 9). In experimental studies, seventy-eight of the 92 studies (85 %) had at least one measure that identified impairment.

Conclusions

BZRA effects on motor vehicle driving performance have been studied using heterogenous protocols with multiple measures and settings, ranging from simulation to authentic traffic situations in experimental studies to biological detection and dispensing records in observational studies. Many BZRAs have been studied but study representation does not match prescribing pattern prevalence. The interpretation and contextualization of results for clinical practice is challenging due to the complexity (i.e., protocols, measures, settings). Future work in this area should work to improve knowledge translation of results so information is more readily accessible and applicable to health care providers and patients.

Trends in the Use of Driving-Impairing Medicines According to the DRUID Category: A Population-Based Registry Study with Reference to Driving in a Region of Spain between 2015 and 2019

The European DRUID (Drive Under the Influence of drugs, alcohol, and medicines) program classifies medications into three categories according to their effect on one’s fitness to drive. The trend in the use of driving-impairing medicines (DIMs) in a region of Spain between 2015 and 2019 was analyzed through a population-based registry study. Pharmacy dispensing records for DIMs are provided. The use of DIMs on drivers was weighted according to the national driver’s license census. The analysis was performed considering the population distribution by age and sex, treatment length, and the three DRUID categories. DIMs were used by 36.46% of the population and 27.91% of drivers, mainly chronically, with considerable daily use (8.04% and 5.34%, respectively). Use was more common in females than in males (42.28% vs. 30.44%) and increased with age. Among drivers, consumption decreases after 60 years of age for females and after 75 years of age for males. There was a 34% increase in the use of DIMs between 2015 and 2019, with a focus on daily use (>60%). The general population took 2.27 ± 1.76 DIMs, fundamentally category II (moderate influence on fitness to drive) (20.3%) and category III (severe influence on fitness to drive) (19.08%). The use of DIMs by the general population and drivers is significant and has increased in recent years. The integration of the DRUID classification into electronic prescription tools would assist physicians and pharmacists in providing adequate information to the patient about the effects of prescribed medications on their fitness to drive.

Association between road traffic accidents and drugs belonging to the antiseizure medications class: A pharmacovigilance analysis in VigiBase

AIMS

Due to their central mechanism of action, antiseizure medications (ASMs) could lead to adverse effects likely to impair driving skills. Their extended use to neuropsychiatric disorders makes it a class of drugs to monitor for their road traffic accidental (RTA) potential. We aimed to assess the reporting association between ASMs and RTAs using the World Health Organization pharmacovigilance database (VigiBase).

METHODS

We performed a disproportionality analysis to compute adjusted reporting odds ratios to evaluate the strength of reporting association between ASMs and RTAs. A univariate analysis using the reporting odds-ratio was used to assess drug-drug interactions between ASMs and RTAs.

RESULTS

There were 1 341 509 reports associated with at least 1 ASM in VigiBase of whom 2.91‰ were RTAs reports. Eight ASMs were associated with higher reporting of RTAs compared to others (ranging from 1.35 [95% confidence interval 1.11-1.64] for lamotrigine to 4.36 [95% confidence interval 3.56-5.32] for cannabis). Eight significant drug-drug interactions were found between ASMs and the onset of RTA, mainly involving CYP450 induction.

CONCLUSION

A significant safety signal between RTAs and some ASMs was identified. Association of several ASMs might further increase the occurrence of RTA. ASMs prescription in patients with identified risk factors of RTA should be considered with caution. Study number: ClinicalTrials.gov, NCT04480996.

Are individual risky behaviours relevant to healthcare allocation decisions? An exploratory study

Purpose

The problematic surrounding patients' prioritization decisions are currently at the centre of political leaders' concerns. How to define whom to treat when there are not enough resources to treat everybody is the key question. This exploratory study aims to investigate the views of Bulgarian citizens regarding the relevance of the information concerning eight individual health-related behaviours in priority setting decisions: smoking, excess of alcohol, illegal drug use, overweight/obesity, speed driving, extreme sports practice, unsafe sex and overuse of internet and/or mobile devices.

Design/methodology/approach

Data were collected through a questionnaire where 322 respondents faced hypothetical rationing dilemmas comprising option pairs of the eight risky behaviours. Descriptive statistics and non-parametric tests were performed to define the penalization of each of the risky behaviours and to test for the association between this penalization and the respondent's health habits and sociodemographic characteristics.

Findings

Most respondents would refuse to grant access to healthcare based on patients' personal responsibility for the disease. Nevertheless, respondents were more willing to consider illegal drug use, excessive alcohol consumption, engagement in unsafe sex behaviours and smoking. Respondent's own interest or advantage seems to be somehow relevant in explaining the penalization of risk behaviours in priority setting.

Practical implications

This study shows that most respondents support the lottery criterion and thus do not want to see lifestyle prioritization in action.

Originality/value

This study is the first attempt to awaken attention to the impact that personal responsibility for health may have on intergenerational access to healthcare in Bulgaria.

Association of benzodiazepines, Z-drugs, pregabalin, and melatonin with traffic accidents: A nationwide cohort and case-crossover study in Danish adults

BACKGROUND

Benzodiazepines, Z-drugs, pregabalin, and melatonin (BZPMs) have been associated with a higher risk of traffic accidents, but the evidence is inconsistent, and lacking for newer drugs.

AIM

To examine the association of BZPMs with risk of traffic accidents.

METHODS

All Danish adults (n = 3,823,588) were followed for redeemed prescriptions of BZPM and for incident traffic accidents registered in Danish registers from 2002 through 2018. Associations were examined in cohort and case-crossover designs using Cox proportional hazard and conditional logistic regression with adjustment for co-variables.

RESULTS

A total of 19.3% (n = 738,019) of all participants initiated treatment with BZPMs. During the mean follow-up of 10.3 years, 595,173(15.5%) of participants were involved in a traffic accident. In the cohort analysis, all BZPMs besides pregabalin were associated with a higher risk of traffic accidents in adults below 70 years, with chlordiazepoxide showing the strongest association (hazard ratio (HR)_{age 18-49} = 1.76, 95% confidence interval (CI): 1.67-1.86 and HR_{age 50-69} = 1.84, 95% CI: 1.70-2.00). In the older age groups, the specific BZPM medications were associated with lower or no risk of traffic accidents. However, in case-time-crossover analysis with inherited control for confounders, no BZPM medication was positively associated with traffic accidents, except for chlordiazepoxide, which had a higher odds ratio in middle-aged group (1.62, 95% CI: 1.15-2.29).

CONCLUSIONS

This study does not fully support that BZPM use is a risk factor for traffic accidents. However, a positive association was found for chlordiazepoxide, which is approved for treatment of acute alcohol withdrawal.

Development and validation of questionnaires on professional drivers’ knowledge and attitudes about various medications’ influence on driving ability

Introduction

Professional drivers’ knowledge about driving-impairing medications is not satisfactory. The aim of this study was to develop and test the reliability and validity of the questionnaires designed to measure the knowledge and attitude of professional drivers about the influence of various medications on driving ability.

Methods

The questionnaires for assessing professional driver’s knowledge (performance-based) and attitudes about influence of various medications on driving abilities were developed by creating the item pool, testing reliability and validity, and factor analysis. The study was conducted as a multicenter, cross-sectional study in Serbia and Bosnia and Herzegovina. The study population consisted of professional drivers, who filled out both questionnaires in three time intervals.

Results

Both questionnaires showed great internal consistency and temporal stability. Cronbach’s Alpha for the first questionnaire was 0.984 and for the second it was 0.944. The Kaiser–Meyer–Olkin test for the first questionnaire confirmed sampling adequacy with its value of 0.964 and for the second questionnaire it was 0.933. Exploratory factor analysis of the questionnaire showed that three factors were revealed after rotation for the first questionnaire and they explained 78.0% of variance. Both questionnaires showed high degree of correlation between scores after the first and repeated administration, Spearman’s rho coefficient of correlation for was 0.962 and 0.980.

Conclusion

Based on the results of this study, we believe that both questionnaires are useful tools for testing professional drivers’ knowledge and attitudes about the influence of medications on driving ability.

Changes in benzodiazepine use in the French general population after November 2015 terrorist attacks in Paris: an interrupted time series analysis of the national CONSTANCES cohort

OBJECTIVES

To determine whether the terrorist attacks occurring in Paris on November 2015 have changed benzodiazepine use in the French population.

DESIGN

Interrupted time series analysis.

SETTING

National population-based cohort.

PARTICIPANTS

90 258 individuals included in the population-based CONSTANCES cohort from 2012 to 2017.

OUTCOME MEASURES

Benzodiazepine use was evaluated according to two different indicators using objective data from administrative registries: weekly number of individuals with a benzodiazepine delivered prescriptions (BDP) and weekly number of defined daily dose (DDD). Two sets of analyses were performed according to sex and age (≤50 vs >50). Education, income and area of residence were additional stratification variables to search for at-risk subgroups.

RESULTS

Among women, those with younger age (incidence rate ratios (IRR)=1.18; 95% CI=1.05 to 1.32 for BDP; IRR=1.14; 95% CI=1.03 to 1.27 for DDD), higher education (IRR=1.23; 95% CI=1.03 to 1.46 for BDP; IRR=1.23; 95% CI=1.01 to 1.51 for DDD) and living in Paris (IRR=1.27; 95% CI=1.05 to 1.54 for BDP) presented increased risks for benzodiazepine use. Among participants under 50, an overall increase in benzodiazepine use was identified (IRR=1.14; 95% CI=1.02 to 1.28 for BDP and IRR=1.12; 95% CI=1.01 to 1.25 for DDD) and in several strata. In addition to women, those with higher education (IRR=1.22; 95% CI=1.02 to 1.47 for BDP), lower income (IRR=1.17; 95% CI=1.02 to 1.35 for BDP) and not Paris residents (IRR=1.13; 95% CI=1.02 to 1.26 for BDP and IRR=1.13; 95% CI=1.03 to 1.26 for DDD) presented increased risks for benzodiazepine use.

CONCLUSION

Terrorist attacks might increase benzodiazepine use at a population level, with at-risk subgroups being particularly concerned. Information and prevention strategies are needed to provide appropriate care after such events.

Trends in the use of antihistamines with reference to drivers between 2015 and 2019: A population-based registry analysis

BACKGROUND

First-generation antihistamines are considered driving-impairing medicines (DIM), while second- and third-generation antihistamines are relatively safe for driving.

OBJECTIVES

The aim of this study was to know the trend of consumption of antihistamines and other DIMs in Spain between 2015 and 2019.

METHODS

This is a population-based registry study. The population distribution by age and gender has been taken into account, as well the treatment duration with these medicines and the concomitant use of other DIMs. Adjusted consumption for licensed drivers is also presented.

RESULTS

Between 2015 and 2019, antihistamines were dispensed to 12.1% of the population and 9.25% of drivers. Oral antihistamines are the most consumed with 85.83%, and generally more used by women than men. Regardless of systemic antihistamines, the second-generation were the most consumed (8.9%) followed by the third-generation (2.07%) and the first-generation (0.61%). Subacute use was predominant in second -generation antihistamines (4.96%) and third-generation (1.26%), while acute use was predominant in third-generation antihistamines. On the other hand, only 0.36% of the population consumed antihistamines daily. The concomitant use of antihistamines with other DIMS was considerable, especially anxiolytics, opioids, other analgesics and antipyretics and antidepressants. The results in drivers were similar than in the general population.

CONCLUSIONS

The use of antihistamines has increased in recent years, however, in Spain, the use of less sedatives predominates, which is safe for driving. Finally, it is important to consider that concomitant use with other DIMs was frequent, which may affect the fitness to drive.

Medication use and driving patterns in older drivers: preliminary findings from the LongROAD study

Background

The potential for impaired driving due to medication use can occur at any age, though older adults are more likely to take multiple prescribed medications and experience side effects that may affect driving ability. The purpose of this study was to characterize the relationship between medications and driving safety behaviors.

Methods

Data for this study came from the five-site Longitudinal Research on Aging Drivers (LongROAD) project. Participants were active drivers, age 65–79 years at enrollment, and patients at one of the 5 participating sites. Medication names and doses were obtained at baseline based on the “brown-bag review” method. Medications were coded using the American Hospital Formulary Service system. Driving data were collected by a GPS accelerometer installed in the study participants’ main vehicles.

Results

Medication data were available for 2949 (98.6%) of the 2990 participants, and 2898 (96.9% of all participants) had both medication data and at least 30 recorded days of driving. The median number of medications taken per study participant was seven, with a range of 0–51. Total number of medications was significantly associated with a higher rapid deceleration rate. Certain medication classes were significantly associated with other driving outcomes, including central nervous system agents (more speeding events), hormones and gastrointestinal medications (more rapid decelerations), electrolytes (fewer rapid decelerations), and antihistamines (greater right to left turn ratio).

Conclusions

Older adult drivers are taking large quantities of prescription and non-prescription medications that may affect their driving safety. Certain medication classes are associated with potentially adverse driving patterns, such as speeding and rapid decelerations, while others are associated with potentially protective maneuvers, such as right hand turning. Further research is warranted to identify and mitigate potential adverse effects of such medications on driving safety in older adults.

Prescription medication use as a risk factor for motor vehicle collisions: a responsibility study

INTRODUCTION

Previous studies on the effect of prescription medications on MVCs are sparse, not readily applicable to real-world driving and/or subject to strong selection bias. This study examines whether the presence of prescription medication in drivers' blood is associated with being responsible for MVC.

METHODS

This modified case-control study with responsibility analysis compares MVC responsibility rates among drivers with detectable levels of six classes of prescription medications (anticonvulsants, antidepressants, antihistamines, antipsychotics, benzodiazepines, opioids) versus those without. Data were collected between January 2010 and July 2016 from emergency departments in British Columbia, Canada. Collision responsibility was assessed using a validated and automated scoring of police collision reports. Multivariable logistic regression was used to determine OR of responsibility (analysed in 2018-2019).

RESULTS

Unadjusted regression models show a significant association between anticonvulsants (OR 1.92; 95% CI 1.20 to 3.09; p=0.007), antipsychotics (OR 5.00; 95% CI 1.16 to 21.63; p=0.03) and benzodiazepines (OR 2.99; 95% CI 1.56 to 5.75; p=0.001) with collision responsibility. Fully adjusted models show a significant association between benzodiazepines with collision responsibility (aOR 2.29; 95% CI 1.16 to 4.53; p=0.02) after controlling for driver characteristics, blood alcohol and Δ-9-tetrahydrocannabinol concentrations, and the presence of other prescription medications. Antidepressants, antihistamines and opioids exhibited no significant associations.

CONCLUSION

There is a moderate increase in the risk of a responsible collision among drivers with detectable levels of benzodiazepines in blood. Physicians and pharmacists should consider collision risk when prescribing or dispensing benzodiazepines. Public education about benzodiazepine use and driving and change to traffic policy and enforcement measures are warranted.

Benzodiazepines in the oral fluid of Spanish drivers

Background

Driving under the influence of alcohol, illicit drugs and certain medicines is not allowed worldwide. Roadside drug testing is considered an important tool for determining such behavior. In Spain, mandatory roadside oral fluid drug testing is carried out regularly. The aim of this study was to determine the prevalence of benzodiazepines and benzodiazepines in combination with other drugs in drivers, examine benzodiazepine concentrations in drivers, and analyze the association of these factors with age and sex.

Methods

This study assessed data on Spanish drivers with confirmed drug-positive results recorded by the Spanish National Traffic Agency (Dirección General de Tráfico) between 2011 and 2016, accounting for 179,645 tests and 65,244 confirmed drug-positive tests.

Results

Benzodiazepines were confirmed in 4.3% of all positive roadside drug tests. In most of those cases (97.1%), other substances were also detected, particularly cocaine (75.3%) and cannabis (64.0%). The frequency of benzodiazepine-positive drivers (OR, 1.094; 95% CI, 1.088–1.100) increased with age, while the frequency of drivers who tested positive for benzodiazepines in conjunction with other substances, compared with drivers who tested positive for benzodiazepines alone, decreased with age (OR, 0.903; 95% CI, 0.825–0.988). Nordiazepam (54.8%) and alprazolam (46.9%) were the most common benzodiazepines detected.

Conclusion

Concomitant use of benzodiazepines and other psychoactive substances was found to be a common behavior among drivers who tested positive on the road. It is important to raise awareness of all those involved in the consumption of driving-impairing substances (authorities, healthcare providers, patients and their families, etc.): roadside detection of driving-impairing substances is suggested, in addition to promoting the use of fewer driving-impairing medications and the provision of clear information to patients.

The relationship between illnesses and medical drug consumption with the occurrence of traffic accidents among truck and bus drivers in Tehran, Iran

PURPOSE

To determine the relationship of illnesses and medical drug consumption with the occurrence of traffic accidents among truck and bus drivers.

METHODS

This is a cross-sectional study on truck and bus drivers in Tehran, Iran. The criteria for participating in this study were: married males over 30 years old, driving license in grade one, five years of job experience, mental health and non-addiction license. The criterion for not participating in this study was the lack of cooperation in responding to the questions. Six months was spent to collect the latest five years data of driving accidents from 2011 to 2016. A total of 323 truck and bus drivers in Tehran city and the suburbs, Iran were chosen. Among them, 112 were responsible for accidents (accident group) while 211 were not responsible for any accidents or involved in an accident in the last five years (non-accident group). A specially designed questionnaire was used to investigate the demographic information, medical drug consumption, medical backgrounds and history of accidents.

RESULTS

The results revealed that compared with healthy subjects, the occurrence of accidents among people with diabetes (OR = 2.3, p = 0.001) and vision weakness (OR = 1.7, p = 0.020) was significantly higher, while that among people with cardiac (OR = 0.5, p = 0.002) and hypertension (OR = 0.9, p = 0.048) problems was remarkably lower. Moreover, consumption of Gemfibrozil (OR = 1.8, p = 0.010) and Glibenclamide (OR = 2.2, p = 0.002) drugs resulted in significantly higher incidence of accidents than those without.

CONCLUSION

Frequencies of illnesses like cardiovascular and hypertension were not higher in accident drivers than in non-accident drivers; but diabetes, vision weakness and consumption of Gemfibrozil and Glibenclamide lead to more traffic accidents.

Prevalence of prescribed benzodiazepine long-term use in the French general population according to sociodemographic and clinical factors: findings from the CONSTANCES cohort

Background

Data are lacking regarding the prevalence of benzodiazepine long-term use in the general population. Our aim was to examine the prevalence of prescribed benzodiazepine long-term use (BLTU) according to sociodemographic and clinical factors in the French general population.

Methods

Data came from 4686 men and 4849 women included in 2015 in the French population-based CONSTANCES cohort. BLTU was examined using drug reimbursement administrative registries from 2009 to 2015. Analyses were weighted to provide results representative of the French general population covered by the general health insurance scheme. Weighted prevalence of BTLU and weighted Odds Ratios (OR) of having BTLU were computed with their 95% Confidence Interval (95% CI) according to age, education level, occupational status, occupational grade, household income, marital status, alcohol use disorder risk and depressive symptoms. All the analyses were stratified for gender.

Results

Weighted prevalence of BLTU were 2.8%(95% CI:2.3–3.4) and 3.8%(95% CI: 3.3–4.5) in men and women, respectively. Compared to men, women had an increased risk of having benzodiazepine long-term use with OR = 1.34(95% CI = 1.02–1.76). Aging, low education, not being at-work, low occupational grade, low income, being alone and depressive state were associated with increased risks of having BTLU.

Conclusions

BLTU is widespread in the French general population, however this issue may particularly concern vulnerable subgroups. These findings may help in raising attention on this public health burden as well as targeting specific at-risk subgroups in preventive intervention.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6933-8) contains supplementary material, which is available to authorized users.

Prescription opioids, alcohol and fatal motor vehicle crashes: a population-based case-control study

BACKGROUND

The prevalence of prescription opioid use among drivers has increased markedly in the past two decades. The purpose of this study is to assess the associations of prescription opioid use and alcohol use with the risk of fatal crash involvement in US drivers.

METHODS

We performed a population-based case-control study using toxicological testing data from two national data systems. Cases (n = 3606) were drivers involved in fatal motor vehicle crashes selected from the Fatality Analysis Reporting System and controls (n = 15,600) were drivers participating in the 2007 and 2013 National Roadside Surveys of Alcohol and Drug Use by Drivers. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (95% CIs) of fatal crash involvement associated with prescription opioid use with and without the presence of alcohol.

RESULTS

Overall, cases were significantly more likely than controls to test positive for prescription opioids (5.0% vs. 3.7%, p < 0.001), alcohol (56.2% vs. 7.1%, p < 0.0001), and both substances (2.2% vs. 0.2%, p < 0.001). Relative to drivers testing negative for prescription opioids and alcohol, the adjusted ORs of fatal crash involvement were 1.72 (95% CI: 1.37, 2.17) for those testing positive for prescription opioids and negative for alcohol, 17.92 (95% CI: 16.19, 19.84) for those testing positive for alcohol and negative for prescription opioids, and 21.89 (95% CI: 14.38, 33.32) for those testing positive for both substances. The interaction effect on fatal crash risk of prescription opioid use and alcohol use was not statistically significant on either additive or multiplicative scale.

CONCLUSIONS

Prescription opioid use is associated with a significantly increased risk of fatal crash involvement independently of alcohol use. Concurrent use of prescription opioids and alcohol is associated with a 21-fold increased risk of fatal crash involvement.

Association between speeding and use of alcohol and medicinal and illegal drugs and involvement in road traffic crashes among motor vehicle drivers

OBJECTIVE

The objective of this study was to study the association between self-reported road traffic crashes (RTCs) and recent use of alcohol and medicinal and illicit drug use and self-reported speeding in the previous 2 years.

METHODS

During the period from April 2016 to April 2017, drivers of cars, vans, motorcycles, and mopeds were stopped in a Norwegian roadside survey performed in collaboration with the police. Participation was voluntary and anonymous. The drivers were asked to deliver an oral fluid sample (mixed saliva), which was analyzed for alcohol and 39 illicit and medicinal drugs and metabolites. In addition, data on age, sex, and self-reported speeding tickets and RTCs during the previous 2 years were collected.

RESULTS

A total of 5,031 participants were included in the study, and 4.9% tested positive for the use of one or more illicit or medicinal drugs or alcohol. We found a significant, positive association between the use of cannabis and RTC involvement (odds ratio [OR] = 1.93; 95% confidence interval [CI], 1.05-3.57; P = 0.035) and also between previous speeding tickets and RTC involvement (OR = 1.39; 95% CI, 1.08-1.80; P = 0.012). In addition, older age groups were found to have a significant, negative association with RTC involvement, with ORs equal to or less than 0.49, when using the age group 16-24 as reference.

CONCLUSION

Speeding, as an indicator of risk behavior, and the use of cannabis were associated with previous RTC involvement, whereas increasing age was significantly associated with lower risk. This is consistent with previous studies on RTCs.

Work stress and health problems of professional drivers: a hazardous formula for their safety outcomes

Background

Several empirical studies have shown that professional drivers are a vulnerable occupational group, usually exposed to environmental stressors and adverse work conditions. Furthermore, recent studies have associated work-related stress with negative job performances and adverse health outcomes within this occupational group, including cardiovascular diseases and unsafe vehicle operation.

Objective

The aim of this study was to describe the working conditions and the health status of this occupational group, and to evaluate the association between the Demand-Control model of job stress and their self-reported health and safety outcomes.

Methods

A pooled sample of 3,665 Colombian professional drivers was drawn from five different studies. The Job Content Questionnaire and the General Health Questionnaire were used to measure work stress and self-reported mental health, respectively. Additionally, professional drivers self-reported health problems (hypertension, dyslipidemia, diabetes and overweight) and health-related risky behaviors (smoking and sedentary behavior).

Results

Regarding the Job Demands-Control (JDC) model, it was found that approximately a third part of Colombian professional drivers suffer from high job strain (29.1%). Correlational and multivariate analyses suggest that de JDC model of stress is associated with the professional drivers' mental health, traffic accidents and fines, but not with other physical and behavioral health-related outcomes, which are highly prevalent among this occupational group, such as hypertension, dyslipidemia, diabetes, overweight, smoking and sedentary behavior.

Conclusion

The results of this study suggest that (a) stressful working conditions are associated with health and lifestyle-related outcomes among professional drivers, and (b) that evidence-based interventions are needed in order to reduce hazardous working conditions, job stress rates and their negative impact on the health of this occupational group.

Prevalence of consumption of psychoactive substances amongst Moroccan taxi drivers

Background:

The prevalence of psychoactive substances is constantly increasing in developing countries, and all professional sectors are concerned. Taxi drivers are a particular target because of the dangerousness and complexity of their work. However, few studies have investigated toxic habits in this population.

Objectives:

The aim of the study was to determine the prevalence of the use and misuse of addictive substances in taxi drivers and to appreciate poly-consumptions according to socio-demographic and occupational characteristics.

Methods:

This cross-sectional study took place in five big cities during the second quarter of 2014, and was conducted amongst 2,927 taxi drivers who went through official, obligatory control areas on a daily basis. The questionnaire covered socio-demographic and occupational characteristics, toxic habits (tobacco, alcohol, cannabis and others psychotropic substances). The misuse was assessed by specific tests: Fagerström test for tobacco smoking, Cannabis Abuse Screening Test (CAST) and DETA (Diminuer, Entourage, Trop, Alcool) test for alcohol.

Results:

The prevalence of consumption was 36.6% for smoking tobacco, 18.4% for cannabis, and 10.5% for alcohol. Amongst consumers, the prevalence of dependence or misuse was 36.6% for smoking tobacco, 37.2% for cannabis and 56.5% for alcohol. Fifty point three percent had no toxic habit, 35 % had one toxic habit, 11.5% had two toxic habits, 2.7% had three toxic habits and 0.6% had four toxic habits. The most frequent associations were tobacco-alcohol (6.8%) and tobacco-cannabis (4.1%).

Conclusions:

The elaboration of the prevention approach needs a cooperative spirit. It will be more accepted and applied if all taxi drivers, their representatives and road safety officers are involved in its preparation.

Impact of Medical Conditions and Medications on Road Traffic Safety

Objectives

Many medical conditions and medicines with therapeutic importance have been shown to impair driving skills, causing road traffic accidents, which leads to great human and economic suffering in Oman. The primary purpose of this study was to assess retrospectively the extent of medical conditions and medications influencing road traffic safety among drivers involved in road accidents.

Methods

We conducted a retrospective study among 951 injured or non-injured drivers who reported to Khoula and Nizwa hospitals. We used the Al-Shifa database to find the drivers and contacted randomly selected patients over phone.

Results

The majority of victims were male (72.0%), involving personal cars, and reported at Khoula Hospital. The results show that 7.6% of the victimized drivers had a history of medical conditions with diabetes and hypertension (36.1% each) the most common. About 4.0% of victims were on medications of which insulin was the most common (9.4%). Loss of control was contributed to 38.5% of cases followed by dizziness (25.6%), sleep amnesia (10.3%), and blurred vision (7.7%). Other effects blamed by victimized drivers include vertigo, phonophobia, photophobia, back pain, loss of sensation, and headache accounting for 17.9% of cases.

Conclusion

Medical conditions and medications influence road traffic safety to some extent in Oman.

Cognitive Expectancies for Hypnotic Use among Older Adult Veterans with Chronic Insomnia

OBJECTIVES

To examine relationships between cognitive expectancies about sleep and hypnotics and use of medications commonly used for insomnia (hypnotics).

METHODS

We analyzed baseline data from older veterans who met diagnostic criteria for insomnia and were enrolled in a trial comparing CBTI delivered by a supervised, sleep educator to an attention control condition (N = 159; 97% male, mean age 72 years). We classified individuals as hypnotic users (N = 23) vs. non-users (N = 135) based upon medication diaries. Associations between hypnotic status and Dysfunctional Beliefs and Attitudes about Sleep-16 (DBAS) total score (0-10, higher = worse) and two DBAS medication item scores (Item 1: "…better off taking a sleeping pill rather than having a poor night's sleep;" Item 2: "Medication… probably the only solution to sleeplessness"; 0-10, higher = worse) were examined in logistic regression models.

RESULTS

Higher scores on the DBAS medication items (both odds ratios = 1.3; p-values < .001) were significantly associated with hypnotic use. DBAS-16 total score was not associated with hypnotic use.

CONCLUSION

Cognitive expectancy (dysfunctional beliefs) about hypnotics was associated with hypnotic use in older adults with chronic insomnia disorder.

CLINICAL IMPLICATIONS

Strategies that specifically target dysfunctional beliefs about hypnotics are needed and may impact hypnotic use in older adults.

The anxiolytic effect of Juniperus virginiana L. essential oil and determination of its active constituents

Essential oil from Juniperus virginiana L. (eastern red cedarwood essential oil, CWO) has been used to relax mind and enhance comfort for medical purposes. Few reports showed its effect on anxiety behaviors in animal models. The present study investigated the anxiolytic effect of CWO using two anxiety tests in mice, then determined the major active constituents, examined the change of neurotransmitters after intraperitoneal (i.p.) administration. Analysis using GC/MS revealed that the CWO contained (-)-α-cedrene (28.11%), (+)-β-cedrene (7.81%), (-)-thujopsene (17.71%) and (+)-cedrol (24.58%). CWO at 400-800mg/kg increased the percentage of open arm entries and the percentage of the time spent in open arms in the elevated plus maze (EPM), suggesting that the oil has anxiolytic effect. However, it didn't show anxiolytic effect in the light-dark box (LDB) test. Tests of the cedrene did not show anxiolytic effect in either test, but rather induced anxiety-related behaviors and inhibited the locomotor activity in EPM and LDB. Cedrol produced significant anxiolytic effect in both EPM and LDB tests at 400-1600mg/kg and 800-1600mg/kg, respectively. A more significant increase in locomotor activity was observed in cedrol at 200-1600mg/kg administration than CWO. CWO increased the 5-hydroxytryptamine (5-HT) concentration at 800mg/kg, whereas it didn't affect the dopamine (DA) concentration. Cedrol significantly reduced the DA level at 100-200mg/kg and elevated the 5-HT level at 1200-1600mg/kg. Moreover, it changed the ratio of 5-hydroxyindoleacetic acid/5-HT and 3, 4-dihydroxyphenyl acetic acid/DA at 1200-1600mg/kg. CWO and cedrol, in particular might act in an anxiolytic effect through the 5-HTnergic and DAnergic pathways.

Use of prescription opioids and motor vehicle crashes: A meta analysis

OBJECTIVES

Opioid analgesics are a major driver of the ongoing opioid epidemic in the United Sates, accounting for about two thirds of drug overdose fatalities. There are conflicting reports regarding the effects of prescription opioids on driving safety. A meta-analysis was performed to assess the epidemiologic evidence for the association between use of prescription opioids and the risk of motor vehicle crashes.

METHODS

Studies examining the association between driver prescription opioid use and motor vehicle crash involvement or crash culpability and published in English were identified through a comprehensive search of 15 bibliographic databases. Eligible articles were fully reviewed and summarized. Study quality was assessed using the Newcastle-Ottawa Scale. Overall summary odds ratios (ORs) and 95% confidence intervals (CIs) were estimated through random effects models.

RESULTS

Overall, 15 studies were included in the meta-analysis; of them, 10 assessed the association of prescription opioid use with the risk of crash involvement and 5 assessed the association of prescription opioid use with the risk of crash culpability. Reported crude ORs associated with prescription opioid use ranged from 1.15 to 8.19 for the risk of crash involvement and from 0.75 to 2.78 for the risk of crash culpability. Summary ORs based on pooled data were 2.29 (95% CI: 1.51, 3.48) for crash risk and 1.47 (95% CI: 1.01, 2.13) for crash culpability.

CONCLUSIONS

The existent epidemiologic evidence indicates that use of prescription opioids by drivers is associated with significantly increased risks of crash involvement and crash culpability. Further research is needed to understand the epidemiologic patterns of prescription opioid use in the driver population and the interaction effects between opioids and alcohol on driving safety.

Number of medications and adverse drug events by unintentional poisoning among older adults in consideration of inappropriate drug use: a Swedish population-based matched case-control study

PURPOSE

This national, population-based study aims to determine the association between the number of prescribed medications and adverse drug events (ADE) by unintentional poisoning and examine this risk when known indicators of inappropriate drug use (IDU) are accounted for.

METHODS

We employed a matched case-control design among people living in Sweden who were 50 years and older. Cases experiencing an ADE by unintentional poisoning resulting in hospitalization or death (n = 5336) were extracted from the National Health and Death Registers from January 2006 to December 2009. Four controls per case matched by age, sex and residential area were randomly selected among those without an ADE (n = 21,344). Prescribed medications dispensed during the 4-month period prior to the ADE were identified via the Swedish Prescribed Drug Register and coded according to the number of different dispensed medications (NDDM) (0 to 10 medications) and IDU indicators (one single-drug, and three drug-combinations). Conditional logistic regression was used.

RESULTS

Each of the IDU indicators was significantly associated with very high risks of ADE. For NDDM, we found a lower but graded positive association from two to ten or more medications (adjusted OR, 1.5; 95% CI, 1.2-1.8). Exclusion of IDU from the NDDM decreased the risk of ADE, but the effects remained significant for three or more medications (adjusted OR excl. IDU, 1.5; 95% CI, 1.2-2.0).

CONCLUSION

At population level, the number of different dispensed medications starting from three or more remains associated with ADE even after adjusting for known IDUs. Clinicians and patients need to be made aware of the increased likelihood of serious ADE, not only in case of documented inappropriate medications but also in the case of an increasing number of medications.

New, Occasional, and Frequent Use of Zolpidem or Zopiclone (Alone and in Combination) and the Risk of Injurious Road Traffic Crashes in Older Adult Drivers: A Population-Based Case-Control and Case-Crossover Study

BACKGROUND

Previous studies on the effect of zolpidem or zopiclone use on the risk of road traffic crashes (RTCs) have shown mixed results.

OBJECTIVE

Our objective was to determine the association between zolpidem or zopiclone use (as separate drugs or combined) and the occurrence of injurious RTCs among older adult drivers.

METHODS

This was a population-based matched case-control and case-crossover study based on secondary data linked together from Swedish national registers. Cases were drivers aged 50-80 years involved in a vehicle crash resulting in injuries between January 2006 and December 2009 for the case-control study (n = 27,096) and from February 2006 to December 2009 for the case-crossover study (n = 26,586). For the first design, four controls were matched to each case by sex, age, and residential area, and exposure was categorized into new, occasional, and frequent use of zolpidem only, zopiclone only, and combined zolpidem and zopiclone. For the case-crossover study, newly dispensed zolpidem or zopiclone users were assessed during the 28 days prior to the crash and compared with an equally long control period using a 12-week washout period. Matched adjusted odds ratios (OR) were computed using conditional logistic regression.

RESULTS

Increased ORs for all users were observed. In the case-control study, the highest odds were seen among newly initiated zolpidem-only users involved in single-vehicle crashes (adjusted OR 2.27; 95% confidence interval [CI] 1.21-4.24), followed by frequent combined zolpidem and zopiclone users [adjusted OR 2.20; CI 1.21-4.00]. In the case-crossover, newly initiated treatment with zolpidem or zopiclone showed an increased risk that was highest in the 2 weeks after the start of the treatment (OR 2.66; 95% CI 1.04-6.81).

CONCLUSIONS

These results provide more compelling evidence for the role of zolpidem or zopiclone in the occurrence of RTCs among older adults, not only in frequent users, but also at the beginning of treatment.

Drivers' psychiatric disorders and fatal motor vehicle accidents in Finland

Relatively little is known about fatal motor vehicle accidents (FMVA) involving drivers with psychiatric disorders. In this study of all drivers killed in FMVAs in Finland between 1990 and 2011, we aimed to study drivers' death rate trends in FMVAs, with special focus on drivers with a history of psychiatric disorders. Prevalence of drivers' hospital treated psychiatric disorders, and characteristics of drivers with psychiatric disorders were also studied. For the purpose of this study, three national registers were accessed. Drivers' hospital treated psychiatric disorders were screened in a five-year period prior to death. Drivers with (n = 425) and without (n = 3856) psychiatric disorders were compared, female and male drivers separately. The main outcome measure was any psychiatric disorder in drivers within the five-year timescale. Socio-demographic factors, use of intoxicants and medication at the time of death, recent adverse life events, and drivers' physical and emotional states were used as covariates in the statistical analyses. During the study period, death rates increased for females with psychiatric disorders, and decreased for females without psychiatric disorders. Death rates for males with psychiatric disorders decreased between the years 1990-2000 and 2007-2011, and increased between the years 2000-2007. Death rates decreased over the whole study period in males without psychiatric disorders. Alcohol related disorders and affective disorders were the most prevalent hospital treated psychiatric disorders among drivers involved in FMVAs. Use of medications at the time of death, and committing suicide in traffic both associated with being a driver with psychiatric disorders involved in FMVAs for both genders. As FMVAs involving drivers with psychiatric disorders have increased, a more focused and detailed evaluation of the driving performance of drivers with psychiatric disorders is recommended. These evaluations should also be extended to drivers with non-psychotic disorders.

The anxiolytic effect of essential oil of Cananga odorata exposure on mice and determination of its major active constituents

BACKGROUND

Essential oil from Cananga odorata (ylang-ylang essential oil, YYO) is usually used in reducing blood pressure, improving cognitive functioning in aromatherapy in human. Few reports showed its effect on anxiety behaviors.

HYPOTHESIS/PURPOSE

To investigate the anxiolytic effects of YYO exposure on anxiety animal models, determine the major active constituents and investigate the change of neurotransmitters after odor exposure.

STUDY DESIGN AND METHODS

ICR mice were subjected to three anxiety models including open field, elevated plus maze and light-dark box tests after acute and chronic YYO exposure. Main constituents of YYO were defined using GC/MS. These compounds were then tested on the male mice separately on three anxiety models. The monoamines neurotransmitters and their metabolites were analyzed after acute odor exposure and elevated plus maze test.

RESULTS

YYO exposure only showed significant anxiolytic effect on the male mice. It increased the time that mice visited open arms and light box area in elevated plus maze and light-dark box tests after acute and chronic YYO exposures. Three main constituents of YYO, benzyl benzoate, linalool and benzyl alcohol showed anxiolytic effect on the male mice individually. YYO exposure brought changes of neurotransmitters on the male mice more significantly than the female mice. It decreased the dopamine (DA) concentration in the striatum and increased the 5-hydroxytryptamine (5-HT) concentration in the hippocampus of the male mice. The major constituent benzyl benzoate changed neurotransmitters concentration in accordance with the YYO. Moreover, it decreased the ratio of 5-HIAA/5-HT in the hippocampus.

CONCLUSION

Both acute and chronic YYO exposure showed anxiolytic effect on the male mice. YYO and its major constituent benzyl benzoate might act on the 5-HTnergic and DAnergic pathways.

Medication use and the risk of motor vehicle collisions among licensed drivers: A systematic review

OBJECTIVES

Driving under the influence of prescription and over-the-counter medication is a growing public health concern. A systematic review of the literature was performed to investigate which specific medications were associated with increased risk of motor vehicle collision (MVC).

METHODS

The a priori inclusion criteria were: (1) studies published from English-language sources on or after January 1, 1960, (2) licensed drivers 15 years of age and older, (3) peer-reviewed publications, master's theses, doctoral dissertations, and conference papers, (4) studies limited to randomized control trials, cohort studies, case-control studies, or case-control type studies (5) outcome measure reported for at least one specific medication, (6) outcome measure reported as the odds or risk of a motor vehicle collision. Fourteen databases were examined along with hand-searching. Independent, dual selection of studies and data abstraction was performed.

RESULTS

Fifty-three medications were investigated by 27 studies included in the review. Fifteen (28.3%) were associated with an increased risk of MVC. These included Buprenorphine, Codeine, Dihydrocodeine, Methadone, Tramadol, Levocitirizine, Diazepam, Flunitrazepam, Flurazepam, Lorazepam, Temazepam, Triazolam, Carisoprodol, Zolpidem, and Zopiclone.

CONCLUSIONS

Several medications were associated with an increased risk of MVC and decreased driving ability. The associations between specific medication use and the increased risk of MVC and/or affected driving ability are complex. Future research opportunities are plentiful and worthy of such investigation.

New opioid analgesic use and the risk of injurious single-vehicle crashes in drivers aged 50-80 years: A population-based matched case-control study

BACKGROUND

the increasing trend in opioid analgesic use among older drivers has raised concerns about their risk of being involved in car crashes.

AIM

to investigate if older drivers who started using opioid analgesics have a higher probability of being involved in injurious crashes.

METHODS

population-based matched case-control study. Data from population registers were merged using a personal identity number. Cases were drivers aged 50-80 years responsible for a single vehicle crash between 01.07.05 and 31.12.09 that led to at least one injured passenger (n = 4,445). Four controls were randomly matched to each case by sex, birth month/year, and residence area from persons holding a valid driving license who did not crash during the study period. New use was defined as at least one dispensation within 1-30 days prior to the crash, but none within the previous 31-180 days; frequent use when ≥3 dispensations were given within 0-180 days, with at least one within 31-180 days. Individuals using 1-2 non-opioid analgesic medications were used as reference category. Conditional logistic regression was used to estimate odds ratios (OR; 95% CI) adjusting for benzodiazepine use, co-morbidity, civil status and occupation.

RESULTS

adjusted odds for new use were two-fold that of drivers using 1-2 non-opioid analgesics medications (2.0; 1.6-2.5). For frequent use, adjusted odds were also increased regardless of number of dispensations (3-4 = 1.7; 1.3-2.1, 5-6 = 1.6; 1.2-2.3, and ≥7 = 1.7; 1.3-2.1).

CONCLUSION

new, but also frequent opioid analgesic use, resulted in an increased probability of single vehicle crashes. While more epidemiologic evidence is needed, patients could be advised to refrain from driving when using opioid analgesics.

The Approach Taken to Substance Abuse by Occupational Physicians: A Qualitative Study on Influencing Factors

OBJECTIVE

Aiming to enhance occupational physicians' (OPs) practice when dealing with employee substance abuse, this study analyzes the experiences of OPs to gain insight into the factors influencing their behavior.

METHODS

Semi-structured interviews were conducted and analyzed using Interpretative Phenomenological Analysis.

RESULTS

OPs act differently depending on the type of drug. Their approach was mainly determined by contextual factors and by their attitudes and skills. Many OPs want to invest in health promotion. Barriers such as lack of time and focus on periodic examinations often hamper both adequate prevention and the management of workers with substance abuse.

CONCLUSIONS

The approach to substance abuse by OPs could be supported by initiatives both at the individual and the collective level. A facilitating work context seems to be particularly important in their commitment to alcohol- and drug-related issues at work.

Blood alcohol analysis alone versus comprehensive toxicological analysis - Systematic investigation of missed co-ingested other drugs in suspected alcohol-impaired drivers

Driving under the influence of alcohol and/or drugs (DUID) is a safety issue of increasing public concern. When a police officer has reasonable grounds to classify a driver as impaired, he may arrange for a blood sample to be taken. In many countries, alcohol analysis only is ordered if impairment is suspected to be exclusively due to alcohol while comprehensive toxicological screening will be performed if additional suspicion for other illegal drugs of abuse (DoA) or medicinal drugs is on hand. The aim of the present study was firstly to evaluate whether signs of impairment can be differentiated to be caused by alcohol alone or a combination of alcohol and other driving-impairing drugs and secondly to which extent additional drugs are missed in suspected alcohol-impaired drivers. A total of 293 DUID cases (negative n=41; alcohol positive only, n=131; alcohol+active drug positive, n=121) analyzed in 2015 in the Canton of Zurich were evaluated for their documented impairment symptoms by translating these into a severity score and comparing them applying principle component analysis (PCA). Additional 500 cases suspected for alcohol-impaired driving only were reanalyzed using comprehensive LC-MS/MS screening methods covering about 1500 compounds. Drugs detected were classified for severity of driving impairment using the classification system established in the DRUID study of the European Commission. As partly expected from the pharmacological and toxicological point of view, PCA analysis revealed no differences between signs of impairment caused by alcohol alone and those caused by alcohol plus at least one active drug. Breaking it down to different blood alcohol concentration ranges, only between 0.3 and 0.5g/kg trends could be observed in terms of more severe impairment for combined alcohol and drug intake. In the 500 blood samples retrospectively analyzed in this study, a total of 330 additional drugs could be detected; in some cases up to 9 co-ingested ones. In total, 37% of all cases were positive for additional drugs, thereby 15% of classic DoAs and further 9% of prescription drugs with a severe risk to cause driving impairment based on the DRUID classification system. A decision whether signs of impairment are related to alcohol alone or to the combination of alcohol and other drugs is impossible. Taking into consideration the high rate of missed drugs in DUI cases, police should think about increasing the number of DUID cases in countries were sanctioning differs between alcohol and alcohol plus drug impaired driving.

Prevalence of alcohol and drug use in injured British Columbia drivers

OBJECTIVES

Determine the prevalence of drug use in injured drivers and identify associated demographic factors and crash characteristics.

DESIGN

Prospective cross-sectional study.

SETTING

Seven trauma centres in British Columbia, Canada (2010-2012).

PARTICIPANTS

Automobile drivers who had blood obtained within 6 h of a crash.

MAIN OUTCOME MEASURES

We analysed blood for cannabis, alcohol and other impairing drugs using liquid chromatography/mass spectrometry (LCMS).

RESULTS

1097 drivers met inclusion criteria. 60% were aged 20-50 years, 63.2% were male and 29.0% were admitted to hospital. We found alcohol in 17.8% (15.6% to 20.1%) of drivers. Cannabis was the second most common recreational drug: cannabis metabolites were present in 12.6% (10.7% to 14.7%) of drivers and we detected Δ-9-tetrahydrocannabinol (Δ-9-THC) in 7.3% (5.9% to 9.0%), indicating recent use. Males and drivers aged under 30 years were most likely to use cannabis. We detected cocaine in 2.8% (2.0% to 4.0%) of drivers and amphetamines in 1.2% (0.7% to 2.0%). We also found medications including benzodiazepines (4.0% (2.9% to 5.3%)), antidepressants (6.5% (5.2% to 8.1%)) and diphenhydramine (4.7% (3.5% to 6.2%)). Drivers aged over 50 years and those requiring hospital admission were most likely to have used medications. Overall, 40.1% (37.2% to 43.0%) of drivers tested positive for alcohol or at least one impairing drug and 12.7% (10.7% to 14.7%) tested positive for more than one substance.

CONCLUSIONS

Alcohol, cannabis and a broad range of other impairing drugs are commonly detected in injured drivers. Alcohol is well known to cause crashes, but further research is needed to determine the impact of other drug use, including drug-alcohol and drug-drug combinations, on crash risk. In particular, more work is needed to understand the role of medications in causing crashes to guide driver education programmes and improve public safety.

Mobility and safety issues in drivers with dementia

Although automobiles remain the mobility method of choice for older adults, late-life cognitive impairment and progressive dementia will eventually impair the ability to meet transport needs of many. There is, however, no commonly utilized method of assessing dementia severity in relation to driving, no consensus on the specific types of assessments that should be applied to older drivers with cognitive impairment, and no gold standard for determining driving fitness or approaching loss of mobility and subsequent counseling. Yet, clinicians are often called upon by patients, their families, health professionals, and driver licensing authorities to assess their patients' fitness-to-drive and to make recommendations about driving privileges. We summarize the literature on dementia and driving, discuss evidenced-based assessments of fitness-to-drive, and outline the important ethical and legal concerns. We address the role of physician assessment, referral to neuropsychology, functional screens, dementia severity tools, driving evaluation clinics, and driver licensing authority referrals that may assist clinicians with an evaluation. Finally, we discuss mobility counseling (e.g. exploration of transportation alternatives) since health professionals need to address this important issue for older adults who lose the ability to drive. The application of a comprehensive, interdisciplinary approach to the older driver with cognitive impairment will have the best opportunity to enhance our patients' social connectedness and quality of life, while meeting their psychological and medical needs and maintaining personal and public safety.

The use and safety of medications known to affect driving in Jordan: A cross-sectional study

OBJECTIVES

The aim of this study was to estimate the main driving-impairing medications used by drivers in Jordan, the reported frequency of medication side effects, the frequency of motor vehicle crashes (MVCs) while using driving-impairing medicines, as well as factors associated with MVCs.

METHODS

A cross-sectional study involving 1,049 individuals (age 18-75 years) who are actively driving vehicles and taking at least one medication known to affect driving (anxiolytics, antidepressants, hypnotics, antiepileptics, opioids, sedating antihistamines, hypoglycemic agents, antihypertensives, central nervous system [CNS] stimulants, and herbals with CNS-related effects) was conducted in Amman, Jordan, over a period of 8 months (September 2013-May 2014) using a structured validated questionnaire.

RESULTS

Sixty-three percent of participants noticed a link between a medicine taken and feeling sleepy and 57% stated that they experience at least one adverse effect other than sleepiness from their medication. About 22% of the participants reported having a MVC while on medication. Multiple logistic regression analysis showed that among the participants who reported having a crash while taking a driving-impairing medication, the odds ratios were significantly higher for the use of inhalant substance (odds ratio [OR] = 2.787, P = .014), having chronic conditions (OR = 1.869, P = .001), and use of antiepileptic medications (OR = 2.348, P = .008) and significantly lower for the use of antihypertensives (OR = 0.533, P = .008).

CONCLUSION

The study results show high prevalence of adverse effects of medications with potential for driving impairment, including involvement in MVCs. Our findings highlight the types of patient-related and medication-related factors associated with MVCs in Jordan, such as inhalant use, presence of chronic conditions, and use of antiepileptics.

Young Drivers and Their Passengers: A Systematic Review of Epidemiological Studies on Crash Risk

PURPOSE

A systematic review of the literature was conducted to appraise the evidence from epidemiological studies of crash risk in young drivers accompanied by passengers, compared with solo driving.

METHODS

Databases searched were the Cochrane Library, Embase, Scopus, Transportation Research Information Services, and Web of Science for studies published between January 1, 1989 and August 1, 2013. Epidemiological studies were selected for review if they focused on crashes of young drivers (≤24 years old) and included both a no-passenger comparison group and some measure of exposure to enable calculation of estimates.

RESULTS

Fifteen articles (17 studies) were selected; seven studies reported on fatal crashes and 10 on nonfatal or combined fatal/nonfatal crashes. Studies on fatal crashes showed increased risk, compared with solo driving, for young drivers with at least one passenger (significant estimates ranging from 1.24 to 1.89) and two or more passengers versus solo driving (1.70-2.92). Increased risk was also found for fatal crashes and for combined or nonfatal crashes with male versus female passengers (1.53-2.66) and for younger versus older drivers (1.42-3.14).

CONCLUSIONS

Results more clearly indicated an increased risk for passenger presence in fatal crashes than that in nonfatal or combined fatal/nonfatal crashes. Findings of this review, based on correlational studies, support licensing policies that limit the presence and number of young passengers for young drivers.

Sedative Hypnotic Medication Use and the Risk of Motor Vehicle Crash

OBJECTIVES

We sought to estimate the association between sedative hypnotic use and motor vehicle crash risk.

METHODS

We conducted a new user cohort study of 409 171 adults in an integrated health care system. Health plan data were linked to driver license and collision records. Participants were aged 21 years or older, licensed to drive in Washington State, had at least 1 year of continuous enrollment between 2003 and 2008, and were followed until death, disenrollment, or study end. We used proportional hazards regression to estimate the risk of crash associated with 3 sedatives.

RESULTS

We found 5.8% of patients received new sedative prescriptions, with 11 197 person-years of exposure. New users of sedatives were associated with an increased risk of crash relative to nonuse: temazepam hazard ratio (HR) = 1.27 (95% confidence interval [CI] = 0.85, 1.91), trazodone HR = 1.91 (95% CI = 1.62, 2.25), and zolpidem HR = 2.20 (95% CI = 1.64, 2.95). These risk estimates are equivalent to blood alcohol concentration levels between 0.06% and 0.11%.

CONCLUSIONS

New use of sedative hypnotics is associated with increased motor vehicle crash risk. Clinicians initiating sedative hypnotic treatment should consider length of treatment and counseling on driving risk.

Driving under the influence, public policy, and pharmacy practice

Motor vehicle accidents due to prescription drug impairment have increased in the past decade. Typically, impairment is associated with medications causing excessive drowsiness, such as opioids or benzodiazepines, but the scope of driving under the influence (DUI)-drug charges is reaching into medications that are not typically considered impairing, such as antipsychotics, antiepileptics, and mood stabilizers. Data associating medication use with driving impairment are growing, especially with agents not typically thought of as impairing. Forty-three states currently train drug recognition experts who employ a 12-step evaluation to detect the presence of drug impairment. Seventeen states have instituted "per se" laws, which make it illegal to drive with the presence of drugs or metabolites in the body. Pharmacists should recognize an ethical, professional, and perhaps legal responsibility to inform patients of the risk of impaired driving with prescription agents. Pharmacists should reconsider how they are counseling patients on medication impairment and lower their threshold for warning a patient of potential impairment, expanding to agents typically not thought of as impairing. Pharmacists are in a position to ensure that patients fully understand the risk of impaired driving and the potential for DUI prosecution.

Trends in drug use among drivers killed in U.S. traffic crashes, 1999-2010

OBJECTIVE

Driving under the influence of drugs is a global traffic safety and public health concern. This trend analysis examines the changes in general drug usage other than alcohol, broad categories, and typical prescription and illegal drugs among drivers fatally injured in motor vehicle crashes from 1999 to 2010 in the U.S.

METHODS

Data from the Fatality Analysis Reporting System were analyzed from 1999 to 2010. Drug prevalence rates and prevalence ratios (PR) were determined comparing rates in 2009-2010 to 1999-2000 using a random effects model. Changes in general drug usage, broad categories, and representative prescription and illegal drugs including, methadone, oxycodone, hydrocodone, barbiturates, benzodiazepines, and cocaine, were explored.

RESULTS

Comparing 2009-2010 to 1999-2000, prevalence of drug usage increased 49% (PR=1.49; 95% confidence interval [CI] 1.42, 1.55). The largest increases in broad drug categories were narcotics (PR=2.73; 95% CI 2.41, 3.08), depressants (PR=2.01; 95% CI 1.80, 2.25), and cannabinoids (PR=1.99; 95% CI 1.84, 2.16). The PR were 6.37 (95% CI 5.07, 8.02) for hydrocodone/oxycodone, 4.29 (95% CI 2.88, 6.37) for methadone, and 2.27 (95% CI 2.00, 2.58) for benzodiazepines. Barbiturates declined in rate over the 12-year period (PR=0.53; 95% CI 0.37, 0.75). Cocaine use increased until 2005 then progressively declined, though the rate remained relatively unchanged (PR=0.94; 95% CI 0.84, 1.06).

CONCLUSIONS

While more drivers are being tested and found drug-positive, there is evidence that a shift from illegal to prescription drugs may be occurring among fatally injured drivers in the U.S. Driving under the influence of prescription drugs is a growing traffic concern.

Naturalistic conversation improves daytime motorway driving performance under a benzodiazepine: a randomised, crossover, double-blind, placebo-controlled study

The adverse effects of benzodiazepines on driving are widely recognised. The aims of this study were both to determine the impact of naturalistic conversation on the driving ability of drivers under a benzodiazepine, and to measure the accuracy of drivers' assessments of the joint effects of the benzodiazepine and conversation. Sixteen healthy male participants (29.69 ± 3.30 years) underwent a randomised, crossover, double-blind, placebo-controlled study with the benzodiazepine lorazepam (2mg). They drove 200 km (125 miles) on a motorway in the morning. We measured two driving ability-related variables (i.e., lane-keeping performance), and collected a set of self-assessed variables (i.e., self-assessment of driving performance) during two 10-min sequences of interest (no conversation vs. conversation). An analysis of variance revealed an interaction whereby lane-keeping performance under lorazepam was worse in the no-conversation condition than in the conversation condition. No such difference was detected under placebo. Pearson's correlation coefficients revealed that self-assessments were (i) not at all predictive of lane-keeping when performed before the drive, but (ii) moderately predictive of lane-keeping performance when performed during or after the drive. We conclude that conversation with a passenger may contribute to safer lane-keeping when driving under a benzodiazepine. Moreover, a degree of awareness may be attained after some experience of driving under the influence of this type of medication.

The Epidemiology of Injuries in Mixed Martial Arts: A Systematic Review and Meta-analysis

BACKGROUND

Mixed martial arts (MMA) has experienced a surge in popularity since emerging in the 1990s, but the sport has also faced concomitant criticism from public, political, and medical holds. Notwithstanding the polarized discourse concerning the sport, no systematic review of the injury problems in MMA has been published to date.

PURPOSE

To systematically review the epidemiologic data on injuries in MMA and to quantitatively estimate injury incidence and risk factor effect sizes.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

Electronic searching of PubMed, Scopus, CINAHL, EMBASE, AMED, and SPORTDiscus databases to identify studies reporting on the epidemiology of injuries in MMA. Random-effects models were used to obtain pooled summary estimates of the injury incidence rate per 1000 athlete-exposures (IIRAE) and rate ratios with 95% confidence intervals (CIs). Heterogeneity was evaluated with the I (2) statistic.

RESULTS

A total of 6 studies were eligible for inclusion in this review. The IIRAE summary estimate was found to be 228.7 (95% CI, 110.4-473.5). No studies reported injury severity. The most commonly injured anatomic region was the head (range, 66.8%-78.0%) followed by the wrist/hand (range, 6.0%-12.0%), while the most frequent injury types were laceration (range, 36.7%-59.4%), fracture (range, 7.4%-43.3%), and concussion (range, 3.8%-20.4%). The most notable risk factors pertained to the outcome of bouts. Losers incurred 3 times as many injuries as winners, and fighters in bouts ending with knockout or technical knockout incurred more than 2 times as many injuries as fighters in bouts ending with submission.

CONCLUSION

Notwithstanding the paucity of data, the injury incidence in MMA appears to be greater than in most, if not all, other popular and commonly practiced combat sports. In general, the injury pattern in MMA is very similar to that in professional boxing but unlike that found in other combat sports such as judo and taekwondo. More epidemiologic research is urgently needed to improve the accuracy of the injury incidence estimate, to determine the injury severity, and to identify more risk factors for injury in MMA.

Prevalence of alcohol and drugs among car and van drivers killed in road accidents in Norway: an overview from 2001 to 2010

OBJECTIVES

To examine the prevalence of alcohol and drugs in blood samples collected from car and van drivers killed in traffic accidents in Norway during the time period from 2001 to 2010.

METHODS

Blood samples (n = 676, 63% of all killed drivers) were analyzed for alcohol, psychoactive medications, and illicit drugs. The cutoff limits for positive results were set according to the new legislative limits under the Norwegian Road Traffic Act. The results were assessed in relation to sex and age, time of day and day of week, and single- versus multiple-vehicle and all investigated vehicle accidents.

RESULTS

Alcohol or one or more drugs was detected in samples from 40.2 percent of all investigated drivers, with 28.7 percent showing blood concentrations of at least 5 times the legislative limits. For the investigated female drivers, the total prevalence was 24.0 percent. Among the single-vehicle accidents, alcohol or drugs was found in 63.8 percent of the cases, with 49.1 percent showing blood concentrations of at least 5 times the legislative limits. Alcohol was detected in 25.3 and 49.1 percent of samples from all investigated drivers and among drivers killed in single-vehicle accidents, respectively. Psychoactive medications were found in 14.4 and 17.7 percent and illicit drugs in 14.1 and 19.2 percent, respectively. The most commonly detected group of medications was benzodiazepines, and amphetamines and tetrahydrocannabinol were the most commonly detected illicit drugs. The prevalence of alcohol alone was highest among drivers under the age of 25, and the combination of alcohol with other drugs was highest among drivers under the age of 35. Drivers between the ages of 25 and 54 showed the highest prevalence of medications and/or illicit drugs without the presence of alcohol. The highest prevalence of alcohol or drugs was found among drivers killed in single-vehicle accidents on weeknights (83.8%) and on weekend nights (89.3%).

CONCLUSIONS

The findings confirm that a large number of fatally injured drivers, in particular among drivers involved in single-vehicle accidents, had concentrations of alcohol or drugs above the new legislative limits introduced in 2012. In many cases, concentrations of at least 5 times the limits were found. The proportion of drivers killed who tested positive for alcohol or other drugs did not change during the study period; however, the total number of drivers killed per year decreased by about 20 percent. Some changes were also observed with regard to the types of benzodiazepines and amphetamines detected during the 10-year period.

Psychotropic drugs and driving: prevalence and types

BACKGROUND

Some psychotropic medications (e.g., benzodiazepines, sedative antidepressants, etc.) may impair cognitive and psychomotor functions and, therefore, endanger traffic safety (Ravera, Br J Clin Pharmacol, 72(3):505-513, 2011). They affect detection, registration, and information processing, problem solving, and decision-making processes, and they also affect emotional and social aspects. The objective of this research was to clarify three closely related issues that are significant for traffic safety: the prevalence of psychotropic drugs on driving, the most frequently used psychotropic drugs to treat depression, anxiety, insomnia, or any tranquilizers (whether it is a medical prescription or self-medication), and finally, provide a further understanding of the socio-demographic and psycho-social characteristics of drivers related to the psychotropic drugs consumption in Spain.

METHODS

A sample of 1,200 Spanish drivers ranging from 18 to 64 years was used, 666 men and 534 women were asked to answer a questionnaire composed by a set of questions structured in different sections. The only selection criteria were to be in possession of any type of driving license for vehicles other than motorcycles and drive frequently.

RESULTS

The results showed that 15% of the participants were consuming psychotropic drugs to treat depressive disorders, anxiety disorders, insomnia, or tranquilizers; 13.5% were using drugs to treat one of these disorders; while 1.5% used them for several of these disorders. A 2.5% of drivers were using medicines to treat depression, 2.6% to treat anxiety, and 3.7% to treat insomnia. The 8.3% of those drivers who were not using any drugs to treat these three disorders were occasionally using some type of tranquilizers. Benzodiazepines and selective serotonin reuptake inhibitors (SSRIs) were the most used type of medicines among drivers. Benzodiazepines were the most used medicines to treat anxiety, while SSRIs were the most used to treat depression, 56.5% and 43.5%, respectively.

CONCLUSIONS

Measures can be developed to reduce traffic accidents caused by the effects of these drugs; however, this will only be possible once the drivers and the use of these drugs are understood. Health care professionals and patients should be properly informed about the potential effects of some psychotropic medications on driving abilities considering individual and group differences.

Second-generation antihistamines exhibit a protective effect on drivers in traffic-a preliminary population-based case-control study

INTRODUCTION

Although there have been experimental studies concerning driving and drugs, studies on the risk of antihistamines are not numerous. This is the first population-based epidemiological study concerning the association of sedating/nonsedating antihistamines and fatal traffic accidents.

METHODS

Car drivers (n = 428) who died in accidents before reaching the hospital and controls (n = 688) matched for accident area and driving season were studied for antihistamines in blood. At the time of the fatal road traffic accident, 6 drivers had a detectable amount of sedating antihistamines in blood, and the corresponding number for controls was 4; nonsedating antihistamines in blood were detected in 12 accident cases and 28 controls. The fatal accidents occurred between 1998 and 2002 and the information on the controls was collected between 2000 and 2002 in Finland.

RESULTS

Regarding fatal traffic accident causality, the nonsedating antihistamines proved to have a protective effect after adjusting for age and gender (relative risk = 0.40, 95% confidence interval [CI], 0.20 to 0.82; P =.01). The risk of fatal traffic accident of those driving under the influence of sedating antihistamines was 1.61 (0.38 to 6.77, P =.51) times the risk of those without medication.

DISCUSSION

This preliminary study supports the protective effect of second-generation antihistamines with respect to fatal traffic accidents. Due to the small sample size the results are not conclusive.

Drug use and fatal motor vehicle crashes: a case-control study

Drugged driving is a serious safety concern, but its role in motor vehicle crashes has not been adequately studied. Using a case-control design, the authors assessed the association between drug use and fatal crash risk. Cases (n=737) were drivers who were involved in fatal motor vehicle crashes in the continental United States during specific time periods in 2007, and controls (n=7719) were participants of the 2007 National Roadside Survey of Alcohol and Drug Use by Drivers. Overall, 31.9% of the cases and 13.7% of the controls tested positive for at least one non-alcohol drug. The estimated odds ratios of fatal crash involvement associated with specific drug categories were 1.83 [95% confidence interval (CI): 1.39, 2.39] for marijuana, 3.03 (95% CI: 2.00, 4.48) for narcotics, 3.57 (95% CI: 2.63, 4.76) for stimulants, and 4.83 (95% CI: 3.18, 7.21) for depressants. Drivers who tested positive for both alcohol and drugs were at substantially heightened risk relative to those using neither alcohol nor drugs (Odds Ratio=23.24; 95% CI: 17.79, 30.28). These results indicate that drug use is associated with a significantly increased risk of fatal crash involvement, particularly when used in combination with alcohol.

Risk of road accident associated with the use of drugs: a systematic review and meta-analysis of evidence from epidemiological studies

This paper is a corrigendum to a previously published paper where errors were detected. The errors have been corrected in this paper. The paper is otherwise identical to the previously published paper. A systematic review and meta-analysis of studies that have assessed the risk of accident associated with the use of drugs when driving is presented. The meta-analysis included 66 studies containing a total of 264 estimates of the effects on accident risk of using illicit or prescribed drugs when driving. Summary estimates of the odds ratio of accident involvement are presented for amphetamines, analgesics, anti-asthmatics, anti-depressives, anti-histamines, benzodiazepines, cannabis, cocaine, opiates, penicillin and zopiclone (a sleeping pill). For most of the drugs, small or moderate increases in accident risk associated with the use of the drugs were found. Information about whether the drugs were actually used while driving and about the doses used was often imprecise. Most studies that have evaluated the presence of a dose-response relationship between the dose of drugs taken and the effects on accident risk confirm the existence of a dose-response relationship. Use of drugs while driving tends to have a larger effect on the risk of fatal and serious injury accidents than on the risk of less serious accidents (usually property-damage-only accidents). The quality of the studies that have assessed risk varied greatly. There was a tendency for the estimated effects of drug use on accident risk to be smaller in well-controlled studies than in poorly controlled studies. Evidence of publication bias was found for some drugs. The associations found cannot be interpreted as causal relationships, principally because most studies do not control very well for potentially confounding factors.

Driving under the influence (DUI) among patients in opioid maintenance treatment (OMT): a registry-based national cohort study

AIMS

To investigate convictions for driving under the influence (DUI) before, during and after opioid maintenance treatment (OMT) and to examine factors associated with convictions for DUI during treatment.

DESIGN, SETTING AND PARTICIPANTS

Treatment data on all patients who started OMT in Norway between 1997 and 2003 (n = 3221) were cross-linked with national criminal records using unique person identifiers. Patients were followed over a 9-year period, before, during and in periods out of opioid maintenance treatment.

MEASUREMENTS

Data were formal charges leading to convictions recorded during four different time-periods: 3 years prior to application, waiting-list, in-treatment and in periods out of treatment.

FINDINGS

During OMT, convictions for DUI were reduced by almost 40% compared with pre-application levels. The conviction rate for DUI for males in the pre-application period was 9.59 per 100 person-years (PY) and for females, 3.44 per 100 PY. During OMT, rates of DUI convictions were reduced to 5.97 per 100 PY among men and to 1.09 per 100 PY among women. However, when estimating the effect of OMT on convictions for DUI, the interaction between gender and exposure to OMT was not statistically significant. Patients who remained in continuous treatment had fewer convictions for DUI during treatment compared with patients in discontinuous treatment. Compared with patients having no road traffic convictions during the pre-application period, patients with two or more pre-application convictions for DUI had higher odds [odds ratio (OR) = 3.69 (2.30-5.93)] for further convictions for DUI during OMT.

CONCLUSION

In Norway, patients receiving opioid maintenance treatment (OMT) have reduced convictions for driving under the influence (DUI) compared with their pre-treatment levels. Being male and having a previous history of several convictions for DUI were found to be important risk factors for convictions for DUI during OMT.