Psychoactive Substances and Driving Disability: Epidemiological Roadside Survey in North-East Italy

S Zancaner, R Giorgetti, F Fenato, A Rossi, L Tedeschi, R Snenghi, G Frison, M Montisci, F Tagliaro, M Meroni, G Giron, M Marigo and SD Ferrara

Centre of Behavioural and Forensic Toxicology, Institute of Legal Medicine, University of Padova, Via Falloppio 50, 35121 Padova, Italy

ABSTRACT

Deaths due to road accidents during weekends have become a worrying phenomenon in Italy. With the aim of highlighting the role of psychotropic substances (alcohol, drugs of abuse, psychoactive drugs) in causing road accidents, a survey based on clinical and chemico-toxicological analyses was carried out on car drivers in the Veneto region during the weekends of the three-month period June-August 1994.

Rapid clinical screening was carried out on 1237 drivers. 265 of these, suspected to be under the influence of psychotropic substances, were subjected to complete clinical and toxicological ascertainment involving the following procedures: a) anamnesis, aiming at evidence of possible current or past use of psychotropic substances; b) objective clinical examination, aiming at finding evidence of recent (signs of acute or chronic intoxication) or past use (signs of withdrawal or associated organic pathologies) of psychotropic substances; c) double sampling of blood and urine and chemico-toxicological analysis using immunochemical and GC/MS-SIM techniques.

As well as many data of social and behavioural interest, processing of results demonstrated that: a) 58% of the drivers examined had consumed alcohol beverages; b) 34.8% had BACs higher than the threshold permitted in Italy (80mg% mL); c) 10.56% of drivers were found to be under the influence of drugs of abuse or psychoactive drugs; d) 42.8% of the BACs in the range 50-100mg% mL as ascertained by breathalyser, showed significant discrepancies with respect to direct blood dosage; e) the most frequently found substances were (in order): cannabinoids, cocaine, amphetamines, opiates, benzodiazepines, barbiturates.

INTRODUCTION

The frequency and prevalence of alcohol and psychoactive substances in the driving population not involved in road accidents have never been investigated in Italy. Widespread concern at the high numbers of young people killed in road accidents over weekends in Italy (the so-called "Saturday night massacre") led the Centre of Behavioural and Forensic Toxicology of the University of Padova, in collaboration with the highway police of north-east Italy, to set up a service for clinical and toxicological checks on the roadside. This study has the following aims:

• survey of the frequency of "driving under the influence of alcohol and psychoactive substances" in north-east Italy;
• acquisition of data for preparing prevention programs for the at-risk population and rehabilitation programs for drivers stopped by the police in a state of intoxication due to alcohol and/or psychoactive substances.

MATERIALS AND METHODS

"Saturday night" ascertainments were carried out between 1.00 a.m. and 7.00 a.m. on Sunday mornings during the months of July, August and December 1994 and January 1995. Each survey involved 7 medical teams (one for each province of the Veneto Region: population about 4 million), working in collaboration with police patrols.

Equipment and Personnel

Surveys were carried out in collaboration with highway police personnel equipped with radio-controlled speed checking equipment and breathalysers.

Each of the 7 medical teams was composed of: 1 forensic doctor, specializing in ascertaining driving ability from the toxicological standpoint; 1 doctor specializing in emergency intensive care; 2 Italian Red Cross volunteers. All personnel worked inside a Red Cross ambulance equipped with instrumentation for emergency intensive care, ordinary health care and a chemical WC.

Materials

• Forms for clinical and forensic ascertainments;
• Kits for double sampling of blood and urine (analysis and counter-analysis);
• Portable refrigerators for preserving samples;

Procedures

A) By highway police

1. Analysis of expired air, by breathalyser.
2. Request for consent to medical ascertainment (verbal or in writing).

B) By toxicologico-forensic service

1. Request for informed consent to clinical ascertainment and sampling of biological fluids.
2. Certification of possible refusal of clinical ascertainment and report to highway police.
3. Rapid clinical assessment by optical and neurological tests.
4. Complete specialized clinical ascertainment on selected subjects by application of standardized procedure.
5. Sampling of blood and urine for analysis and counter-analysis.
6. Guarantee of a proper chain of custody.
7. Search for drugs and psychoactive substances by means of a standardized analytical procedure on blood and urine samples identified by the label "Analyses".
8. Freezing and preservation for a minimum period of 6 months of blood and urine samples (identified by the label "Counter-analyses"), available to examined subjects for possible counter-analysis.
9. Compilation and sending of response forms to highway police offices.

Toxicological Investigation

The analytical procedure described in Tedeschi et al. (1992) was used, with minor changes.

REGULATIONS

Articles 186 and 187 of law no. 295/92 (new Highway Code) define driving in a state of drunkenness due to alcohol (Art. 186) and under the influence of psychoactive substances (Art. 187), and fix the maximum permitted BAC at 80 mg%ml. They also define how the BAC is to be sampled, general procedures for ascertainment of driving under the influence of drugs, and penal sanctions for those in a state of drunkenness and for those who refuse to cooperate with the authorities.

RESULTS AND DISCUSSION

Rapid clinical screening was carried out on 1537 drivers. 309 were subjected to complete clinical and toxicological ascertainment. 14 refused to supply any kind of biological sample, and were prosecuted for driving under the influence of psychoactive substances. 17 refused to use the breathalyser or to submit to clinical screening and were prosecuted for driving under the influence of alcohol and of psychoactive substances (Arts. 186 and 187).

The final study population was thus represented by 295 car drivers. 249 drivers supplied a blood sample and 221 a urine sample.

Table 1 lists the main characteristics of the final study population. 51.4% of subjects undergoing toxicological ascertainment had a measurable BAC, and 30.9% of the entire population were legally drunk (BAC > 80 mg%ml) (Figure 1). 10.2% (n =30) of tested subjects were driving under the influence of drugs psychoactive substances (Figure 2).

Table 1
Characteristics of Population Examined

Figure 1
Blood Alcohol Concentrations (n = 249)

Figure 2
Psychoactive Substances in Biological Fluids

Figure 3 shows the phenomenon of multiple intake of psychoactive substances.

Figure 3
Multiple Intake of Psychoactive Substances

Table 2 shows the frequency of intake of psychoactive substances according to where the driver came from. There were no particular differences in intake patterns according to place of provenance, although if this assessment is made separating where subjects came from according to class of psychoactive substances taken (Table 3), amphetamines (and stimulants in general) are found to be exclusively taken by drivers coming from discos, while cannabis is found in all environmental settings.

Table 2
Driving Under the Influence of Alcohol or Psychoactive Substances According to Place of Provenance

Table 3
Use of Psychoactive Substances According to Place of Provenance

The results of this epidemiological study lead to the following considerations.

1. In the driving population examined, driving under the influence of alcohol and of psychoactive substances is an important problem. Comparisons with epidemiological studies in the literature place Italy high on the list of countries with a high frequency of DUID (Christophersen AS et al., 1990, 1993; Christensen LQ et al., 1990; Geywitz C et al. 1991; Worm et al., 1985).
2. Most drivers examined had taken cannabinoids or psychostimulants.
3. The pharmacological effect of disinhibition/altered perception of risk, confirmed in studies on amphetamines and cocaine (Burns M, 1993; Ferrara SD et al., 1994; Schmedtje JF et al, 1988) probably explains the dangerous behaviour on the roads which leads to the high number of accidents among young people over the weekend.
4. The lack in Italy of proper prevention/education programs for young people and the lack of any deterrent effect, due to the non-application of laws in force, produce the twofold result of maintaining at-risk behaviour at high levels.
5. Italy needs prevention programs targeted at the young at-risk population. It also needs to create an appropriate deterrent effect by setting up a permanent service of clinical and toxicological checks, to be applied throughout the country.

REFERENCES

Burns M (1993). Cocaine effects on performance. In HD Utzelmann, G Berghaus, G Kroj. (Eds.), Alcohol, Drugs and Traffic Safety -T92.Köln, Verlag TÜV Rheinland, pp.612-619.

Christensen LQ, Nielsen LM, Nielsen SL (1990). Traffic accidents and drivers suspected for drug influence. Forensic Science International 45, 273-280.

Christophersen AD, Gjerde H, Bjorneboe A, Sakshaug J, Morland J (1990). Screening for drug use among Norwegian drivers suspected of driving under influence of alcohol or drugs. Forensic Science International 45, 5-14.

Christophersen AS, Gjerde H, Mørland J (1993). Benzodiazepines, tetrahydrocannabinol and drugged driving. In HD Utzelmann, G Berghaus, G Kroj (Eds.), Alchol, Drugs and Traffic Safety-T'92 (pp.1082-1087), Köln, Verlag TÜV Rheinland.

Ferrara SD, Giorgetti R, Zancaner S (1994). Psychoactive substances and driving: state of the art and methodology, Alcohol Drugs Driving 10, 1-55.

Geywitz C, Graws M, Mallach HJ (1991). Epidemiological investigations on the combined effect of alcohol and drugs related to psychophysical performance capability. Blutalkohol 28, 206-209.

Schmedtje JF, Oman CM, Baker EL (1988). Effects of scopolamine and dextroamphetamine on human performance. Aviation Space and Environmental Medicine 59, 407-410.

Tedeschi L, Frison G, Castagna F, Ferrara SD (1992). Comprehensive EIA/GC screening and GC/MS confirmation of psychoactive substances in blood and urine. In: SD Ferrara, R Giorgetti (Eds). Methodology in Man-Machine Interaction and Epidemiology on Drugs and Traffic Safety, Addiction Research Foundation of Italy, Padova, pp. 147-166.

Worm K, Christensen H, Steentoft A. (1985). Diazepam in blood of Danish drivers: Occurrence as shown by gas-liquid chromatographic assay following radioreceptor screening. Forensic Science Society 25, 407-413.