Preventing Drug-Impaired Driving and Overdoses: Lessons from Alcohol-Impaired Driving

Ralph Hingson, Sc.D., M.P.H.

Director, Division of Epidemiology and Prevention Research National Institute on Alcohol Abuse and Alcoholism RADD-ONDCP Columbus, OH July 11, 2014

Alcohol- vs. Non-Alcohol-Related Traffic Fatalities, Rate Per 100,000, All Ages, United States, 1982-2010 12,00 11.3 (n=26,173) 10,00 Non-Alcohol-Related ↓ 16 % 8,00 6,00 7.67 (n= 17,772) 6.42 (n= 19,521) 4,00 Alcohol-Related ↓ 62% 4.32 (n= 13,364) 2,00 0,00 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Sources: National Highway Traffic Safety Administration, 2012; U.S. Census Bureau, 2012

 Reductions in driving after drinking have prevented over 300,000 deaths, more than the combined effects of increases in use of: – Seat belts – Airbags – Motor cycle helmets – Bicycle helmets Source: Cummings & Rivara,

Injury Prevention

, 2006; Fell & Voas, Traffic Injury Prev, 2006

Alcohol- vs. Non-Alcohol-Related Traffic Fatalities, Rate Per 100,000, Ages 16-20, United States,1982-2010 U.S. MLDA Age 21 law 30 25.58 (n=5,244) 25 MLDA 21 in all 50 states Non-Alcohol-Related ↓ 25% 20 10 (n=2,179) 15 10 13.36 (n=2,738) Alcohol-Related ↓ 77% 5 5.80 (n=1,262) 0 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 Sources: U.S. Fatality Analysis Reporting System, 2012; U.S. Census Bureau, 2012

 One reason for this dramatic progress is that most fatally injured drivers are tested for alcohol, and alcohol involvement is reported by community and state on an annual basis.

 In states where not all drivers are tested for alcohol, the National Highway Traffic Safety Administration (NHTSA) uses an “imputation formula” and multiple imputation methods to estimate which fatal crashes involved alcohol.

Source: NHTSA, Transforming to Multiple Imputation: A New Method to Estimate Missing Blood Alcohol Concentration (BAC) Values in FARS, NHTSA Technical Report, DOT 809403, 2002.

5

  This permits evaluation of laws aimed at reducing drinking and driving, by comparing fatal crash trends in states that pass such laws with states that do not (e.g. per se laws, ALR, minimum legal drinking ages, & illegal blood alcohol limits).

Community programs to reduce drunken driving, e.g.: – Saving Lives Program – Communities Mobilizing for Change – Community Trials – Fighting Back 7

Key Strengths MADD

      Support victims – channel victim energy Personalizes the problem – anyone can be affected Family – Mothers Against Drunk Driving Clear measurable goals Attention to research findings Grassroots – inclusive (everyone can be part of the solution)

Key Facts: Alcohol-Impaired Driving

***NEED SIMILAR INFO FOR DRUG DRIVING*** 1) • 40% of people who die in crashes involving drinking drivers are people other than the drinking driver (50% with drinking drivers under age 25)

Need to protect other people from drinking drivers

2) • The more severe the traffic crash, the greater the • • • likelihood alcohol was involved: 40% of traffic deaths are in alcohol-related crashes 9% of people injured were in alcohol-related crashes 5% of vehicle damage only

Important to focus attention on traffic deaths

Key Facts: Alcohol-Impaired Driving (cont.)

3) • Only a small minority of drivers in alcohol-related fatal crashes have prior DUI convictions

Underscores the importance of general deterrence in addition to specific deterrence

4) a. 32% of drivers recently in crashes under the influence of alcohol met DSM-IV alcohol dependence criteria, and 58% met alcohol abuse b. 35% of those dependents and 18% of those abusers received alcohol treatment during that period •

Need screening to identify more drinking drivers with alcohol dependence Source: NESARC, Waves 1 and 2

BAC and Impairment

.10

.09

.08

.07

.06

.05

.04

.03

.02

.01

BAC Concentrated Attention, Speed Control, Braking, Steering, Gear Changing, Lane Tracking, Judgement Tracking, Divided Attention, Coordination, Comprehension, Eye Movement Simple Reaction Time, Emergency Response Choice Reaction Time 

Key driving functions are impaired at levels as low as .02-.04%.

Source: National Highway Traffic Safety Administration

Increased Risk of Driver Single Vehicle Crash Death at Various BACs Relative to Sober Drivers

Driver Age 16-20 21-34 35+ 0.02 0.049%

3.8

3.4

3.3

Blood Alcohol Concentration (BAC) 0.05 0.079% 0.08% 0.099% 0.100 0.149%

12.2

9.7

31.9

23.2

122.4

78.7

9.0

20.9

68.1

0.150+

4728.0

2171.5

1684.9

Source: Voas et al., JSAD, 2012 • Risk of death increases with higher BAC • Risk is highest for drivers ages 16-20

Growing Concern about Driving after Drug Use

 National Roadside Surveys (NHTSA, 2009) indicate that at night on weekends, a higher percentage of drivers test positive for drugs than alcohol (14% vs. 12%)  Among drivers under age 21 at night, a higher percent tested positive for drugs than alcohol (16% vs. 7%)  Only 17 states have per se laws making it illegal to drive with positive drug blood levels

Research Priority #1: Alcohol, Drugs, and Driving

1.



Need research to assess crash/fatal crash risk

Driving after various drugs    Alone/In combination Relative to alcohol Drugs and alcohol combined at various BACs   Risk to others Risks for different age groups

Possible Types of Studies

 Experimental laboratory – Effect on cognitive tasks needed to safely operate a vehicle (e.g., simple reaction time, divided attention, tracking, recovery from glare, etc.)  Road Course strudies  Epidemiologic studies – Culpability studies – Case/control studies – Cohort studies

Drugs found to increase traffic crash risk:

    Marijuana Illicit opiates  Benzodiazepines Cocaine    Medicinal opioids Amphetamines Multiple drugs Alcohol and drugs combined  

Sources:

   Driving Under the Influence of Drugs, Alcohol, and Medicines (DRUID): Risk of Injury by Driving with Alcohol and Other Drugs (2011) Ashbridge et al., Acute cannabis consumption and motor vehicle collision risk, British Medical Journal, 2012.

Elvik. Risk of raod accident and associated with use of drugs,

Accident Analysis and Prevention

, 2012 Li et al., Marijuana use and motor vehicle crashes, Epidemiologic Reviews, 2012 National Highway Traffic Safety Administration is supporting a case/control study

 ◦ ◦ ◦ ◦ Method: Case-control study based on:  Data from seriously injured/killed drivers (cases)  Data from road side surveys (controls) Assessment of the risk for drivers of passenger cars and vans:    Alcohol Illicit and medicinal drugs Alcohol combined with drugs  Multiple drug use Risk of serious injury:   BE, DK, FI, IT, LT and NL Risk of fatality: FI, NO, PT and SE

Overall Risk Levels Hatching - results must be handled with care

Research Prioity #2

Increase drug testing of drivers in fatal crashes  In 2012: – 18 states tested 70% or more of fatally injured drivers for both alcohol and drugs (36 for alcohol)  Ohio tested 64% of fatally-injured drivers for alcohol and drugs after testing over 80% for several consecutive years

States that Test 70% or More of Fatally Injured Drivers for Alcohol and Drugs: Test Results

Age 16-20 21+ Total Any Alcohol

30% 40 38

Drugs

38% 36 36

Only Alcohol

18% 23 22

Drugs

26% 19 16

Alcohol & Drugs

12% 17 16 • • Drivers 16-20 are more likely to test positive for drugs (38%) than alcohol (30%) Drivers 21+ are more likely to test positive for alcohol (40%) than drugs (36%)

Ohio Fatally-Injured Drivers: Test Results

Age 16-20 21+ Total Any Alcohol

20% 40 38

Drugs

42% 36 36

Only Alcohol

10% 24 23

Drugs

32% 20 21

Alcohol & Drugs

12% 17 16 • • Drivers 16-20 are more likely to test positive for drugs (42%) than alcohol (20%) Drivers 21+ are more likely to test positive for alcohol (40%) than drugs (36%)

Age 16-20 21+

Drugs Used Among Fatally-Injured Drivers Tested for Drugs

Drug

Cannabis

Narcotic Depressant Stimulant Other Drugs Cannabis Narcotic Depressant Stimulant Other Drugs Ohio

53% 12 23 0 47 36% 22 22 12 39

Good Testing States

64% 7 8 14 29 64% 19 19 25 32

Research Priority #3

 Develop Imputation for various drugs

Research Priority #4

Study effects of policy changes in drugs and driving (control for alcohol policies) – Adoption of drug per se or zero tolerance laws – Administrative license revocation for driving after drug use – Heightened penalties for driving while impaired by alcohol and drugs combined – 24/7 drug and alcohol monitoring (felony arrestees) – Random drug monitoring periods before license reinstatement – Mandatory assessment and treatment of convicted offenders for both alcohol and drugs

Alcohol Policy Information System

(http://www.alcoholpolicy.niaaa.nih.gov/)    

35 Policy Topics, 1998-present:

Alcohol control systems Alcohol beverage taxes  Underage drinking policies DWI laws  Keg registration BAC limits (adults, youths)   Beverage server training Hours/Days sale  Alcohol and pregnancy   Health insurance parity Insurers’ liability for losses due to intoxication (UPPL)  Vehicular insurance exclusions  Open container laws

Will add:

 Medical marijuana  Legalized/Recreational marijuana  Drug driving laws 25

Can alcohol policies influence use of -Tobacco -Other drugs (Norberg et al.,

ACER

, 2009) Can policies regarding other substances influence alcohol use/harms E.g.: -Tobacco price, Synar Amendment -Drugs: Medical marijuana, legalized marijuana, drug-driving laws -Clean indoor air/ bars, restaurants (Bernat et al.,

Am J Public Health

, 2012) 26

Research Needs

5. Studies of various enforcement strategies – Sobriety check points combining alcohol and drug driving detectors (effects of being highly publicized) – Saturation patrols – Combined • Speed- alcohol/drug impaired driving • Safety belt- alcohol/drug impaired driving 6.

Multi-Component community interventions to reduce alcohol and drug impaired driving – What combinations of strategies are most effective at the least cost?

Research Priority #5

 Need studies of screening and brief interventions for alcohol, drugs, and tobacco in combination

 

Next Generation Health Study, Wave 1, National Survey (N=2,519 10 th graders average age 16)

82% saw a doctor in the past year At their last MD visit:

All Respondents

Doctor asked about Advised about related health risks

Drinking alcohol

54% 40

Smoking Other Drug use

57% 42 55% 40 Advised to reduce or stop

Frequent Substance Users

17

Drunk

17

Smoking

Doctor asked about Advised about related health risks 60% 52 58% 46 Advised to reduce or stop  24 36 Drunk, smoking 6+ times past month: 7%, 9%  Drugs 6+ times past year: 5% Source: Hingson et al., Pediatrics, 2013 17

Other Drug use

56% 54 42 29

High certainty of substantial net benefit for screening and counseling: – Alcohol misuse by adults and pregnant women in primary care – Adult tobacco use counseling Insufficient evidence: Screening/Counseling for: – Alcohol: Adolescents – Illicit drug use: Adolescents, adults, and pregnant women – Tobacco Use: Children and adolescents

Screening and Brief Intervention Studies for Drugs that Show Some Benefit

        Bernstein et al,

Drug Alcohol Depend

, 2005 Madras et al,

Drug Alcohol Depend

Humeniuk et al, McCambidge et al, Stephens et al,

Addiction

Grossbard et al, Lee et al,

Addiction

, 2012

Addiction

, 2004 , 2007 , 2009

J Subst Abuse Treat J Consult Clin Psychol

Kim-Harris et al,

Pediatrics

, 2012 , 2010 , 2013