Professor Denis A. Cusack, Director, Medical Bureau of Road Safety

& Forensic & Legal Medicine, UCD School of Medicine

Road Safety Authority Annual International Road Safety

Conference Alcohol – Tackling the crisis on our roads.

Dublin Castle 1st June 2017.

Drink Driving –

It Has Not Gone Away You Know

Medical Bureau of Road Safety Functions

•  Test blood and urine for alcohol and/or drugs

MBRS Functions

•  Provide Preliminary Breath testing Devices

•  Provide Evidential Breath Testing Instruments

MBRS Functions Update •  2017- supply preliminary drug testing

devices (Draeger DrugTest 5000) •  86 installed in the Garda Stations with EBT

instruments and first tranche of 50 for Roadside Testing supplied with further devices to be supplied as requested

•  72 Gardaí trained (MBRS/GTC) to trainer level in March 2017: training of Garda members

•  New in 2018 – “next generation” PBT devices with enhanced features for operational uses

Intoxicant

•  “intoxicant” includes alcohol and drugs and any combination of drugs or of drugs and alcohol

•  substance which when taken into a body by one mean or another produces a condition of diminished mental and physical ability, hyperexcitability, or stupefaction.

Alcohol

Physiology

•  Alcohol concentrations •  absorption •  metabolism •  excretion •  gender differences

Physiology

•  Alcohol concentrations – beer 4-6% v/v – wine 6-12% v/v – spirits 20-40% v/v –  liqueurs > 40% v/v

Physiology

•  absorption – stomach and upper small bowel – optimally at 20% – peak blood levels at 60 - 120 minutes – absorption, plateau and elimination phases

Physiology

•  Metabolism – 95% detoxified in liver

•  excretion – 90% excreted by kidney – 10 - 20 mgs% per hour –  tubular absorption of water, 1:1.3 ratio

•  gender differences

Clinical Pathology

•  history •  examination •  chronic gastritis •  fatty liver •  cirrhosis •  gammaglutamyl transpeptidase •  carbohydrate-deficient transferrin

Clinical Effects of Alcohol •  Levels (100mg/100ml = 1.0 g/l) and examples

–  0-50mg%: relaxed and more sociable –  50-100mgs%: mild euphoria, reduced co-ordination

and reaction [crash risk increases] –  100-150mgs%: impaired balance, clumsiness,

reduced alertness –  150-200mgs%: drunkenness, slurred speech,

staggered gait, impaired co-ordination –  200-250mgs%: heavy drunkenness, grossly impaired

co-ordination –  250-300mgs%: extreme drunkenness, stupor,

impaired consciousness –  >300mgs%: unconsciousness, coma, possible death

Autopsy Findings

•  Cardiac •  Hepatic •  Pancreatic •  Muscular •  Neural •  Testicular •  Vascular

Alcohol and Driving

Effects of Intoxicant on Driving

•  Sensory input •  Concentration •  Reaction time •  Action response •  Risk taking behaviour

Crash Risk

Sláinte agus Tiomáint [DUI and the link with Fitness to Drive]

Chapter 6.1 and 6.2: Alcohol and Drugs Misuse and Dependence Information Leaflets: Alcohol and Driving; Medicines and Driving; & Driving Under the Influence of Illicit Drugs and/or the Abuse of Prescription Drugs

Medical Fitness to Drive

•  Road Traffic (Licensing of Drivers) (Amendment) (No. 2) Regulations 2010

•  Form D501 (medical report) •  Form D502 (eyesight report) •  Patient Advisory Form •  If applicant is a regular user of drugs or

medication that would be likely to make driving unsafe

MFtD Guidelines – Chapter 6

•  Drug and alcohol misuse and dependence •  Group 1 and Group 2 Licences •  National Driving Licence Service •  Driver must notify NDLS •  Cannabis, cocaine, amphetamines,

metamphetamine, heroin, methadone and other opiates, benzodiazepines

Alcohol Misuse and Dependence – Group 1 Driver

•  Persistent misuse – driving cessation until minimum 3 months controlled drinking or abstinence (biomarkers if relevant)

•  Dependence – 6 months cessation and return to driving requires satisfactory medical assessment

•  Alcohol related seizures •  Alcohol related disorders •  Driver must notify NDLS

Alcohol Consumption in Ireland 2013 (Long and Mongan)

•  A third (33%) of drivers / motorcycle riders who died in fatal crashes in 2014 had a positive toxicology for alcohol

•  35% of car drivers killed had a positive toxicology for alcohol

•  2 out of 5 (40%) motorcyclists killed had a positive toxicology for alcohol

•  28% of pedestrians killed had a positive toxicology for alcohol

•  96% of the drivers / motorcycle riders who had a positive toxicology were male

Source: The Health Research Board National Drug-Related Death Index (NDRDI) on behalf of the RSA

RSA Review of 2014 RTC Fatalities and Alcohol Toxicology

•  The median age for male drivers / motorcycle riders with a positive Blood Alcohol Concentration (BAC) was 38 years

•  The median Blood Alcohol Concentration (BAC) for deceased car drivers was 192mg and the median for deceased motorcycle riders was 104mg (legal limit for non-specified drivers is 50mg).

Source: The Health Research Board National Drug-Related Death Index (NDRDI) on behalf of the RSA

RSA Review of 2014 RTC Fatalities and Alcohol

Toxicology

Fatal Collisions 2008-2012 (RSA Report)

Fatal Collisions 2008-2012 (RSA Report)

Fatal Collisions 2008-2012 (RSA Report)

Causation

•  Causing •  Contributing •  Factor •  Found •  Multiple factors

Drink (Intoxicant) Driving Legislative History

•  Road Traffic Act 1994 – 80mg% BAC •  Road Traffic Act 1995 – graded penalties •  Road Traffic Act 2006 – mandatory alcohol testing

•  Road Traffic Act 2010 – 50mg%& 20mg% BAC –  Specified driver (learner, newly qualified,

professional driver [goods, bus, public service]) –  cf. Aviation statutory provisions (Order 1999)

•  Road Traffic Act 2011 – mandatory accident testing & intoxicant impairment testing

•  Road Traffic Act 2016

Alcohol Facts - MBRS

Table 1 Total Number of Specimens Received within Programmes

Programme 2016 2015 2014 2013

Alcohol Blood & Urine 3,020 3,077 2,934 3,310

Table 2 Mean Alcohol Level in Blood and Urine

mg Alcohol/100ml 2015 2014 2013 2010 2005 Blood 119.6 104 120 127 171 Urine 147.0 123 137 135 202

Table 3 Gender Profile of Specimens – Blood and Urine

Gender 2015 2014 2013

No. (%) No. (%) No. (%) Male 2,497 81% 2,377 81% 2,665 80.5%

Female 561 18% 521 18% 606 18.3% Not Stated 19 1% 36 1% 39 1.2%

Table 4 Age Profile of Specimens – Blood and Urine

Age Profile 2015 2014 2013

No. (%) No. (%) No. (%) ≤ 24 675 22.0% 710 24.2% 844 25.5%

25 – 34 825 26.8% 826 28.2% 25 - 44 1,557 47.0% 35 – 45 654 21.2% 598 20.4% 45 – 54 449 14.6% 361 12.3% 454 13.7% ≥55 457 14.9% 412 14.0% 428 13.0%

Not Stated 17 0.6% 27 0.9% 27 0.8%

Table 5 Certified Blood Alcohol Level – Comparison with previous year

mg Alcohol/100ml Blood 2015 2014 2013

No. (%) No. (%) No. (%) 0 – 20 471 26.9% 499 29.6% 465 25.3%

21 – 50 66 3.8% 90 5.3% 83 4.5% 51 – 80 104 5.9% 99 5.9% 124 6.7% 0 – 80 641 36.6% 688 40.8% 672

81 – 100 81 4.6% 105 6.2% 96 5.2% 101 – 150 285 16.3% 300 17.8% 315 17.2% 151 – 200 370 20.9% 362 21.4% 342 18.6%

201 & Over 379 21.6% 231 13.7% 414 22.5%

TABLE 6 Certified Urine Alcohol Level – Comparison with previous year

mg Alcohol/100ml Urine 2015 2014 2013 No. (%) No. (%) No. (%)

0 – 27 319 25.6% 380 30.5% 378 27.9% 28 – 67 60 4.8% 80 6.4% 87 6.4%

68 – 107 106 8.5% 99 7.9% 107 7.9% 0 – 107 485 39.0% 559 44.9% 572

108 – 135 76 6.1% 89 7.1% 93 6.9% 136 – 200 235 18.9% 249 20.0% 233 17.2% 201 – 267 248 19.9% 256 20.5% 281 20.7%

268 & Over 200 16.1% 93 7.5% 177 13.0%

CDT Update •  Carbohydrate-deficient transferrin (CDT) •  Used to detect heavy alcohol consumption

over time •  Green - %CDT < or equal to 2.2%

–  Indicates not harmful or dependent •  Amber - %CDT 2.3 – 2.9%

– Can be indication of problem drinking •  Red - %CDT equal to or > 3.0%

– Can indicate dependency on drinking

CDT •  Amber: daily consumption of >60g alcohol

for minimum of 1-2 weeks or ”binge” drinking

•  Red: typical daily intake of >100-150g alcohol per day

•  Used in UK in the context of assessing Medical Fitness to Drive and Driver Licensing and for “High Risk Offenders”

Enforcement / Technology •  Evidential breath testing introduced

1999 - new generation instruments 2011 (measure down to 9mcg% BrAC level)

•  Currently 86 instruments in Garda Stations

•  MAT introduced 21st July 2006 •  1,100+ roadside alcohol screening

devices supplied to Gardaí by MBRS •  40-50 (estd. – under review) checks per

1000 population (c. 2% above limit)

Drugs and Medications

DUID Results (2016)

Classes of Drugs - MBRS

•  Alcohol •  Cannabis •  Benzodiazepines •  Amphetamine / Metamphetamine •  Cocaine •  Methadone •  Opiates

Most Prevalent Drugs (in order)

1.  Alcohol 2.  Cannabis 3.  Benzodiazepines 4.  Cocaine 5.  Opiates

Impairment •  Impairment evidence is frequently challenged in

Court •  Standardised impairment testing introduced in

November 2014: at roadside or in Garda Station •  5 Tests: Romberg balance (and time

awareness); one leg stand; finger to nose; walk the line; and pupil diameter measurement – 78 Garda Trainers trained to train Gardaí

•  New law requires increased impairment testing use

Clinical Assessment •  Acute signs and symptoms •  Chronic signs and symptoms •  Psychological effects •  Psychomotor effects •  Physical effects •  Not whether licit or illicit drugs

Roadside Intoxicant Impairment Testing: Overall Assessment

SUBJECT: IMPAIRED / NOT IMPAIRED

Integrated Intoxicant Testing

•  Preliminary Alcohol Test •  Preliminary Drug Test – roadside or Garda

station •  Standardised Impairment Test •  Evidential Alcohol Test •  Forensic Laboratory Testing

Summary of DUI Ireland 2017

•  Evidence based road safety measures •  Alcohol still the “top DUI drug” •  Also now have PDT and per se levels for 3 illicit

drugs introduced 13th April, 2017 •  New PBT devices in 2018 •  Impairment evidence remains a critical part of

enforcement •  Enforcement is the key – RESOURCE IT

These notes are intended for use in conjunction with this

educational presentation only.

The notes do not constitute medical, legal or medico-legal advice. No part to be reproduced without permission

of the author. © 2017.

Scoil an Leighis agus Eolaíocht an Leighis

School of Medicine and Medical Science

Medical Bureau of Road Safety