Fatal Crashes from Drivers Testing Positive for Drugs in the U.S.,

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1 Reserch Articles Ftl Crshes from Drivers Testing Positive for Drugs in the U.S., Fernndo A. Wilson, PhD Jim P. Stimpson, PhD José A. Pgán, PhD b ABSTRACT Objective. Illegl drug use is persistent problem, prescription drug buse is on the rise, nd there is clinicl evidence tht drug use reduces driving performnce. This study describes trends in chrcteristics of drivers involved in ftl motor vehicle crshes who test positive for drugs. Methods. We used the Ftlity Anlysis Reporting System census of motor vehicle crshes resulting in t lest one ftlity on U.S. public rods to investigte suspected drug use for the period Results. Drugged drivers who were tested for drug use ccounted for 11.4% of ll drivers involved in ftl motor vehicle crshes in Drugged drivers re incresingly likely to be older drivers, nd the percentge using multiple drugs incresed from 32.6% in 1993 to 45.8% in About hlf (52.4%) of ll drugged drivers used lcohol, but nerly three-qurters of drivers testing positive for cocine lso used lcohol. Prescription drugs ccounted for the highest frction of drugs used by drugged drivers in ftl crshes in 2010 (46.5%), with much of the increse in prevlence occurring since the mid-2000s. Conclusions. The profile of drugged driver hs chnged substntilly over time. An incresing shre of these drivers is now testing positive for prescription drugs, cnnbis, nd multiple drugs. These findings hve implictions for developing interventions to ddress the chnging nture of drug use mong drivers in the U.S. University of Nebrsk Medicl Center, Deprtment of Helth Services Reserch nd Administrtion, Omh, NE b New York Acdemy of Medicine, Center for Helth Innovtion, New York, NY Address correspondence to: Fernndo A. Wilson, PhD, University of Nebrsk Medicl Center, Deprtment of Helth Services Reserch nd Administrtion, Nebrsk Medicl Center, Omh, NE ; tel ; fx ; e-mil <[email protected]> Assocition of Schools nd Progrms of Public Helth 342

2 Ftl Crshes nd Drugs 343 Overll ftlity rtes from motor vehicle crshes in the United Sttes, including those from drunk driving, hve declined in recent yers, 1,2 but less is known bout the trend in legl nd illegl drug use nd trffic ftlities involving drugged drivers in the U.S. 3 Empiricl evidence from observtionl nd clinicl studies shows the negtive influence of illegl drug use on driving behvior nd crsh risk For exmple, cnnbis hs been shown to increse driving rection times, impir time nd distnce estimtion, nd decrese motor coordintion for up to three hours fter dosge. 14 One study found tht cnnbis doubles the risk of being ftlly injured in trffic nd found lrge increses in the odds of injury when cnnbis is combined with cocine, lcohol, or benzodizepines. 15 Another study showed tht cnnbis is the most frequently found drug mong ftlly injured drivers who were speeding t the time of the crsh. 16 High doses of cocine nd methmphetmines re ssocited with ggressive nd reckless driving behviors. 14,16 19 A recent nd growing body of epidemiologicl nd clinicl reserch lso demonstrtes the complex influence tht prescription medictions hve on crsh risk Results from these studies my be cuse for concern in light of recent report tht prescription drug buse is on the rise nd is growing public helth problem. 29 We used popultion dt to report on trends involving certin legl nd illegl drugs in ftl motor vehicle crshes nd describe the chrcteristics of people in crshes who tested positive for drugs. METHODS Dt sources We used the Ntionl Highwy Trffic Sfety Administrtion s (NHTSA s) Ftlity Anlysis Reporting System (FARS) to exmine trends in the chrcteristics of drugged drivers nd their involvement in ftl motor vehicle crshes. FARS is census of ll crshes on public rods tht result in t lest one ftlity within 30 dys of the crsh. It provides detiled records for every crsh compiled from severl uthorittive sources, including police, medicl exminers, emergency medicl technicins, nd hospitl providers, nd contins detiled informtion on ll occupnts involved in the crsh. If investigtors suspect drug use by people involved in ftl crshes, blood nd/or urine smples re collected from the driver or other vehicle occupnts nd sent to lbortory for toxicology testing. Nicotine, spirin, or ny drug dministered by emergency medicl or hospitl personnel fter crsh re excluded from test results. Results from toxicology reports for ech tested vehicle occupnt re provided. More informtion on FARS is vilble elsewhere. 30 The study period ws Toxicology findings prior to 1993 re not vilble, nd 2010 is the most recent yer of dt vilble from FARS. A totl of 986,173 drivers ged 16 yers or older were involved in ftl crshes during this period; 287,907 (29.2%) of these drivers were tested for drugs. Of the drivers who were tested for drugs, 184,554 (64.1%) tested negtive, 60,560 (21.0%) tested positive nd the drugs used were identified (excluding inhlnts), 42,696 (14.8%) tested positive but the drugs were not identified by nme, nd 97 (,1%) tested positive for inhlnts. A totl of 128,602 (13.0%) drivers involved in ftl crshes were unknown to hve been tested. This study exmines the 60,560 drivers who tested positive for t lest one identifible drug from 1993 to The distribution of tests given to drivers testing positive for drugs in 2010 ws 87.0% blood testing only, 4.8% urine testing only, 7.2% both blood nd urine testing, nd 1.0% other testing. These findings compre with 66.2% blood testing only, 17.7% urine testing only, 14.5% both blood nd urine testing, nd 1.6% other testing in Mesures FARS provides the drug nmes from positive drug testing, spnning 373 possible drugs in eight drug ctegories, including nrcotics, depressnts, stimulnts, hllucinogens, cnnbinoids, phencyclidine (PCP), nbolic steroids, nd inhlnts. Indeterminte drug results were coded s other, tested; results unknown, tested; drugs found; type unknown, or unknown if tested for drugs. We exmined drugs clssified by the U.S. Drug Enforcement Agency (DEA) into Schedules I-V. 31 Schedule I drugs include those determined by the DEA to hve high potentil for buse, hve no currently ccepted medicl use in tretment in the United Sttes, nd there is lck of ccepted sfety for use of the drug or other substnce under medicl supervision. Schedule II-V drugs my be prescribed by physicins for medicl tretment but vry in their potentil for drug buse nd psychologicl/physicl dependence. 31 Schedule definitions nd selected exmples of these drugs re provided in Figure 1. Schedule II-V drugs re defined s prescription drugs in the nlysis. Inhlnts such s voltile solvents, plstic cement, pint, nd erosols were excluded. The most commonly bused illicit drugs identified in FARS cnnbis, cocine (including crck), nd methmphetmine were exmined seprtely nd compred with prescription drugs. The cnnbis vrible includes ll cnnbinoid vrints (e.g., delt 9, hshish, nd tetrhydrocnnbinol [better known s THC]). The cocine vrible includes cocine nd

3 344 Reserch Articles Figure 1. Schedule definitions nd exmples of controlled substnces clssified by the U.S. Drug Enforcement Administrtion: U.S., 2013 Schedule Definition Exmples I II III Substnce hs no currently ccepted medicl use, lck of ccepted sfety for use under medicl supervision, nd high potentil for buse. Substnce hs high potentil for buse, which my led to severe psychologicl or physicl dependence. Substnce hs potentil for buse less thn substnces in Schedule I or II, nd buse my led to moderte or low physicl dependence or high psychologicl dependence. Heroin, LSD, mrijun Morphine, methdone, oxycodone, methmphetmine, mphetmine Vicodin, nbolic steroids IV Substnce hs low potentil for buse reltive to substnces in Schedule III. Alprzolm, dizepm, clonzepm V Substnce hs low potentil for buse reltive to substnces listed in Schedule IV nd consists primrily of preprtions contining limited quntities of certin nrcotics. Cough medicine (e.g., Robitussin ) Source: Drug Enforcement Administrtion (US), Office of Diversion Control. Controlled substnce schedules [cited 2013 Jun 21]. Avilble from: URL: benzoylecgonine, metbolite for cocine. Prescription drugs re defined s other Schedule II-V drugs. Note tht cocine nd methmphetmine re Schedule II drugs nd, thus, my be prescribed for medicl resons; however, they re excluded from the definition of other Schedule II-V drugs. Demogrphic vribles included gender nd ge. We ctegorized driver s ge s 16 29, 30 49, or $50 yers of ge. Other chrcteristics included whether the driver ws drinking nd U.S. Census region. We exmined blood lcohol concentrtion (BAC) level using multiple imputtion vlues for BAC provided by NHTSA. 32 We ctegorized the use of multiple drugs s testing positive for one, two, or $3 drugs. We lso exmined injury severity (none, nonftl injury, or ftl injury) of drugged drivers. Anlyticl pln We exmined ll drivers testing positive for drugs nd their motor vehicle crshes from We lso compred drugged drivers by cnnbis, cocine, methmphetmine, nd prescription drug use in Trends in multidrug use re shown, nd the most prevlent illicit nd prescription drugs detected in drugged drivers re identified. We used Stt version 12 for ll nlyses. 33 RESULTS From 1993 to 2010, the number of drivers tested for drugs mong ll drivers involved in ftl motor vehicle crshes incresed from 1,631 to 2,363. Drugged drivers involved in ftl motor vehicle crshes in 2010 tended to be mle (75.4%) nd younger thn 50 yers of ge (72.8%). However, the ge distribution of drivers vried by drug type. For exmple, in 2010, 59.9% of cnnbisonly users vs. 24.9% of prescription drug nd 24.8% of cocine-only users were younger thn 30 yers of ge; 39.2% of prescription drug users were $50 yers of ge (Tble). In fct, the percentge of ll drugged drivers ged $50 yers incresed from 14.4% in 1993 to 26.2% in 2010 (dt not shown but vilble from the uthors upon request). The likelihood of hving positive BAC lso vried by drug type. In 2010, 54.9% of drivers testing positive for cnnbis only nd 70.3% of drivers testing positive for cocine only were lso using lcohol t the time of the motor vehicle crsh vs. 31.1% of drivers testing positive for prescription drugs (excluding cocine nd methmphetmines). For methmphetmine-only users, 31.5% were using lcohol. Cnnbis-only motor vehicle crshes were more likely to occur in the Midwest (32.4%) nd South (30.7%), but nerly hlf of cocine (44.1%) nd prescription drug (49.3%) crshes occurred in the South; together, 85.3% of crshes involving methmphetmine-only drivers occurred in the South nd West. We did find rising trend in the number of drugs detected mong drugged drivers (Tble). The percentge of drivers detected with $3 drugs nerly doubled from 1993 to 2010, from 11.5% to 21.5% (p,0.001) (Figure 2). Figure 3 shows the percentge of drugged drivers in ftl crshes using cnnbis, cocine, methmphetmine, other Schedule I drugs, nd other Schedule II-V (prescription) drugs. The percentge of drugged drivers testing positive for cocine decresed during the study period. For exmple, the percentge of drugged drivers detected using cocine fell from 20.6% in 1993

4 Ftl Crshes nd Drugs 345 to 9.8% in 2010 (p,0.001). By contrst, detection of cnnbis in drugged drivers incresed from 28.8% in 1993 to 36.9% in 2010 (p,0.001), lthough the trend ws flt for much of the 2000s. Compred with the use of ll other ctegories of drugs by drivers in ftl crshes, prescription drug use ws more prevlent. After declining in use by drugged drivers from 42.2% in 1993 to 36.6% in 2004 (p50.001), prescription drugs (Schedule II-V) were used by 46.5% of ll drugged drivers in 2010 (p,0.001 since 2004). Figure 4 presents trends in drugged drivers use of the most commonly prescribed medictions s percentge of ll prescribed drugs, excluding cocine nd methmphetmine, for (p,0.001 for ech mediction). The presence of dizepm (e.g., Vlium ) stedily declined during the study period, from 18.5% of ll prescribed medictions used in 1993 to 8.4% of ll prescribed medictions used in The nlgesic oxycodone (e.g., Oxycontin ) quickly incresed in use fter 1999, ccounting for 10.2% of prescribed medictions used by drugged drivers in The use of lprzolm (e.g., Xnx ) nd hydrocodone by drugged drivers in ftl motor vehicle crshes lso incresed. In 2010, lprzolm, which is lso benzodizepine, becme the most commonly detected prescription drug used by drugged drivers. In 2010, 12.1% of detected prescription drugs were lprzolm followed by hydrocodone (11.1%), oxycodone (10.2%), nd dizepm (8.4%). Tble. Chrcteristics of drugged drivers involved in ftl motor vehicle crshes: U.S., 2010 Chrcteristic Any drug (n54,969) Cnnbis only b (n5998) Cocine only b (n5145) Methmphetmine only b (n595) Prescription drugs b,c (n52,363) Gender Mle d 82.8 e d Femle d 17.2 e d Men ge (in yers) d e 44.5 d Age (in yers) d 24.8 d d d 63.4 d 51.6 d 35.9 $ d 11.7 d 12.6 d 39.2 d Injury outcome Not injured e d 7.0 Nonftl injury d e 14.7 Ftl injury d d 78.4 Positive BAC f Yes d 70.3 d d No d 29.7 d d Number of drugs detected NA NA NA 59.4 d NA NA NA 18.6 d $ NA NA NA 22.0 Census region of crsh Northest d 20.7 d 0.0 d 11.0 d Midwest d e 21.3 d South d d 49.3 d West d 18.3 d Dt source: Ntionl Highwy Trffic Sfety Administrtion (US). FARS nlytic reference guide DOT HS Wshington: Deprtment of Trnsporttion (US); b Person s Chi-squre test ws used to test sttisticl significnce by chrcteristic nd drug type (cnnbis only, cocine only, methmphetmine only, nd prescription drugs). c Defined s Schedule II-V drugs other thn cocine or methmphetmines d Significnt t p,0.001 e Significnt t p,0.05 f Bsed on hving positive BAC using multiple imputtion vlues provided by the Ntionl Highwy Trffic Sfety Administrtion BAC 5 blood lcohol concentrtion NA 5 not vilble

5 346 Reserch Articles Figure 2. Trend in number of drugs detected mong drugged drivers involved in ftl motor vehicle crshes, by yer: U.S., b Yer Excluding lcohol b Dt source: Ntionl Highwy Trffic Sfety Administrtion (US). FARS nlytic reference guide DOT HS Wshington: Deprtment of Trnsporttion (US); DISCUSSION The findings in our study show tht the shre of drugged drivers in ftl motor vehicle crshes who tested positive for cnnbis reched 36.9% in 2010 (Figure 3). Our results indicte tht drivers ged $50 yers ccount for n incresing shre of drugged drivers nd for the highest proportion of prescription drug users. In fct, study by the Substnce Abuse nd Mentl Helth Services Administrtion (SAMHSA) shows tht the percentge of dults ged yers reporting illicit drug use more thn doubled from 2002 to 2010, incresing from 3.4% to 7.2%. Also, consistent with our findings on gender differences, self-reported users of illicit drugs in the SAMHSA study were more likely to be mle, with 11.2% of men vs. 6.8% of women reporting drug use. 34 Our results suggest tht the shre of drugged drivers testing positive for prescription drugs in motor vehicle crshes incresed during the lst decde; more drivers involved in ftl crshes tested positive for prescription medictions thn for ny other drug type. This trend is consistent with n increse in the number of drugs being prescribed per cpit since the 1990s. The number of nnul prescriptions dispensed in the U.S. nerly doubled from 1993 to 2009, reching 3.9 billion. The verge number of prescriptions dispensed nnully per person incresed 62% during the study period, from 7.8 per person in 1993 to 12.6 per person in ,36 Unfortuntely, comprehensive study hs not been performed exmining trends in dispensed prescriptions hving side effects tht would compromise driving bility. Given the increse in prescription drug use, more reserch on trends in specific cognitiveimpiring prescription drugs is needed. Furthermore, mny of these prescription drugs re bused; in fct, n estimted seven million people $12 yers of ge buse prescription drugs in the U.S. 37 Much of the totl volume of prescriptions dispensed is concentrted in older ge groups. For exmple, 90% of people $65 yers of ge vs. 58% of people younger thn 65 yers of ge hve prescription drug expenses. 35 These percentges re consistent with our findings tht n incresing portion of drugged drivers re older drivers, mny of whom would be expected to tke prescription medictions. The New Englnd

6 Ftl Crshes nd Drugs 347 Figure 3. Trends in drugs used s percentge of ll drugged drivers involved in ftl motor vehicle crshes, by drug type nd yer: U.S., b Yer Cocine nd methmphetmine re excluded from the other Schedule II-V ctegory. b Dt source: Ntionl Highwy Trffic Sfety Administrtion (US). FARS nlytic reference guide DOT HS Wshington: Deprtment of Trnsporttion (US); Helthcre Institute estimtes tht poor mediction dherence nd suboptiml prescribing, drug dministrtion, nd dignosis cost the U.S. economy nerly $300 billion nnully. 38 Crshes involving drugged drivers using prescription medictions re expected to further increse these economic losses. Benzodizepines such s lprzolm ccount for the highest percentge of prescription drugs used by drugged drivers in ftl motor vehicle crshes, followed by hydrocodone nd oxycodone. Severl studies hve linked the use of benzodizepines to incresed crsh risk resulting from their side effects of dizziness nd drowsiness. 13,21 28,39 For exmple, one study showed tht errors in mintining lne position while driving incresed 50% for drivers who were prescribed lprzolm vs. plcebo. 24 Hydrocodone nd oxycodone lso impir criticl thinking skills nd increse drowsiness, nd driving is not recommended for users of these medictions. 40 Our findings suggest tht the profile of the verge drugged driver hs chnged over time, nd there re resons to believe this trend will continue for severl more yers. First, much of this trend is driven by prescription mediction use. As the U.S. popultion ges, both the number nd potency of prescription medictions will likely rise s the popultion s helthcre needs increse. Phrmceuticl mngement will lso increse in complexity, with higher prevlence of comorbidities in the ging popultion, which will further increse problems with drug side effects nd hrmful interctions. In fct, our study results show possible reltionship between certin drugs nd using multiple drugs nd mixing lcohol with drugs. This finding is consistent with findings from Gjerde et l. showing substntilly higher odds of ftl injury for drivers using two or more drugs nd mixing drugs with lcohol. 5 Results from nother study on ftlly injured drivers suggest tht multidrug use nd mixing drugs with lcohol re more likely to be ssocited with risky behviors such s speeding nd non-use of setbelts. 16 Although prescription medictions re expected to hve substntil positive benefits in incresing qulity of life nd longevity, ptients my not fully pprecite tht some side effects cn seriously compromise driving bility. Furthermore, opportunities for prescription drug buse will continue to increse s the number of prescriptions per cpit increses with n ging popultion. Second, lrge frction of drugged drivers involved in ftl crshes tested positive for cnnbis. Unless policy mkers ddress this issue, perhps by incresing penlties for drugged driving in loclities with greter

7 348 Reserch Articles ccessibility to cnnbis, the high incidence in drugged driver use of cnnbis will likely continue. Currently, 18 sttes plus Wshington, D.C., hve leglized medicl mrijun, nd more stte legisltures re considering similr policies. 41 At the sme time, current stte drug policies my not be effective in ddressing the thret of drugged driving on trffic sfety. For exmple, recent study by Anderson nd Rees concluded tht per se drugged driving lws hve not been effective in decresing trffic ftlity rtes in sttes implementing these lws. 42 Policy mkers should consider dditionl mesures to increse primry prevention of drug use by drivers. For exmple, our study findings suggest tht older drivers using drugs, including prescription medictions, my be responsible for growing shre of rod ftlities. Novel policies tht exmine the licensing of people who tke multiple cognitive-impiring medictions my be wrrnted in light of these findings. However, it my not be fesible nd/or cost-effective to screen for mediction use longside test for eyesight in driver s licensing office. At minimum, physicins should be encourged to counsel their ptients bout the potentil dngers of driving while tking cognitive-impiring medictions. In ddition, primry prevention of drugged driving my be enhnced with policies tht increse ffordble ccess to mss trnsit nd other lterntives to driving, especilly during the dy, when our results suggest tht lrge frction of ftl drugged-driving crshes occur. Limittions These results should be interpreted with the following limittions. First, these dt relied on blood nd/or urine testing of drivers suspected of drug use; s such, if lw enforcement does not suspect drug use, cses of drugged driving will go unreported. In fct, Romno nd Vos showed tht only 12 sttes in tested t lest 80% of ftlly injured drivers for drug use. 16 For this reson, our nlyses were restricted to drivers who tested positive for drugs. However, the likelihood of being tested by lw enforcement my Figure 4. Trends in prescription drugs used by drugged drivers in motor vehicle crshes, s percentge of ll prescribed drugs tested, by drug nd yer: U.S., Yer Dt source: Ntionl Highwy Trffic Sfety Administrtion (US). FARS nlytic reference guide DOT HS Wshington: Deprtment of Trnsporttion (US); 2010.

8 Ftl Crshes nd Drugs 349 hve systemticlly chnged for specific drugs (e.g., mrijun vs. cocine) over time. In ddition, there my hve been vrition in lbortory testing procedures over time nd cross jurisdictions nd in the sensitivity nd relibility of these procedures. Our results indicte tht blood tests hve become more prevlent nd urine tests hve become less prevlent in testing drugged drivers. Second, FARS provides no informtion on the time elpsed between the motor vehicle crsh nd drug testing. For exmple, the U.S. Deprtment of Trnsporttion currently requires commercil drivers involved in ftl motor vehicle crsh to be tested within 32 hours for drugs. 43 If the verge dely between crsh nd testing ws significnt nd systemticlly vried over time in the U.S., it my influence trends in the detection of certin drugs. Finlly, we cnnot estblish cuslity between tking certin drugs nd involvement in ftl motor vehicle crsh. The phrmcologicl effects of certin medictions (e.g., benzodizepines) on driving hve been studied, but there re no dt in FARS concerning the degree of impirment drugged driver my hve experienced t the time of crsh. Thus, while our nlysis documents the profile of drugged drivers in the U.S., we cnnot mke inferences s to the effect specific drugs hve hd on rodwy sfety. CONCLUSIONS Concurrent with trends in prescribing drugs, more drugged drivers involved in ftl crshes re testing positive for prescription medictions in recent yers. Prescription medictions hve provided nd will continue to provide mny positive benefits in both improving qulity of life nd extending the lives of ptients. However, people driving under the influence of prescription drugs seem to represent n incresing shre of drugged drivers involved in ftl collisions. This trend is expected to continue with the ging U.S. popultion nd s relince on phrmceuticl tretment increses. 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