ALCOHOL, ROAD INJURIES AND COUNTERMEASURES
McDERMOTT
ALCOHOL, ROAD CRASH CASUALTIES, AND COUNTERMEASUHES FRANCIS T. MCDERMOTT Road Trauma Committee, Royal Australasian College of Surgeons, and Monash University Department of Surgery, Alfred Hospital, Melbourne Alcohol is a m a j o r contributing factor i n over one-third o f a l l road fatalities i n this community. Almbst half t h e fatalities occur i n people aged less than 25 years of age. Results of recent compulsory blood test legislation i n Australia and N e w Zealand are presented and provide incontrovertible evidence of t h e vast extent of the problem o f alcohol on the road. T h e social and drinking profiles o f road crash casualties w i t h blood alcohol concentrations greater t h a n .05 g/100 m l differ f r o m those o f other casualties. Countermeasures used in t h e control of this epidemic include legislation, improved community education, and greater awareness of the need t o rehabilitate rather than to penalize.
ALCOHOL impairs driving ability and is the most impoitant single cause of road traffic accidents. In 1975, 3,694 persons were killed on Australian roads and 89,499 were injured. Of those killed, 56% were under 30 years of age; 35% were under 21. Of the injured, 64% were under 30 years and 40% under 21 (AUStralian Bureau of Statistics, 1976). Extrapolation of these data to a decade predicts approximately 40,000 road deaths and 1.25 million injuries. The cost to the community is three million dollars per day. The commonplaceness of the road trauma epidemic deceptively insinuates the notion that this disaster is a normal expectation. Alcohol is a major contributing factor in over one-third of all road fatalities and in over one-quarter of non-fatal in juries. The privileged position of alcohol as a freely available hard drug of addiction is securely established. Per capita alcohol intake has more than doubled in the last 25 years, and purchases of alcoholic liquor now make up 13% of all Australian retail sales. Persons of all social classes conform to their group norm of alcohol expectation and intake. The alcohol cult, expanded well beyond the civilized rituals of wine cellar devotees, includes
a large teenage population, many of whom, more experimental than their parents, mix the mainstream of alcohol with marihuana, Mandrax, heroin, cocaine, Vegemite and other drugs. Both the liquor industry and the Government maintain vested interests in alcohol consumption. Excise revenue exceeds 760 million dollars per year. The social need to drink is commonly followed by the need to drive. The dominant measures against the problem of alcohol on the road during the last ten years have been legislative. Progressive legislation has attempted to eliminate the drinking driver from the road by the introduction of breathalyzer tests, by compulsory blood alcohol concentration tests on road crash casualties in South Australia and Victoria during 1973 and 1974 respectively, and by random breath testing in Victoria in 1976. New Zealand introduced legislation in 1971 for compulsory blood alcohol testing of drivers involved in road traffic accidents. These measures have additionally provided incontrovertible data on the magnitude of the alcohol problem on the road in Australia and New Zealand.
Address for reprints : Monash University Department of Surgery, Alfred Hospital, Commercial Road, Prahran, Victoria 3181.
ALCOHOLA N D DEATHO N THE ROAD Results of estimations of blood alcohol concentrations in fatal road crash casualties are summarized in Table I . The incidence of
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ALCOHOL, ROAD I N JURIES AN11 COUNTERMEASURES TABLEI Alcohol and Death O R the R o a d Percentage with Elevated Blood Alcohol Concentration Category of Road User
state
Morc t h a n 'oj g/Ioo rnl
.. .. .. Drivers . . Drivers . . _. .. .. Drivers . . ., .. Drivers under z;.years of as? Single vehicle accident drivers Male drivers ,, ., .. .. ._ Motor-cyclists . _ Male motor-cyclists .. .. Passengers .. ., .. hlale paswngers .. ,, Pedestrians ,, .. .. Pedestrians .. . , ..
..
.. ,,
.. .. .. ,. ., .. .. ., ,,
._ .. .. ., .. .. .. ., ,
.
.. .. ..
Vic. Qld Vic. Vic. &Id Vic. Qld. Vic. Vic. Vic. Qld. Vic.
60%
-
47% 781% 39%
-
33% 25% 33% -
-
excessive alcohol intake in the population of killed drivers is of the order of 1000%. Approximately 50% of killed drivers have illegal blood alcohol levels, compared with less than 2+70 of the total driver population (Duncan, 1973). Blood alcohol concentrations R cre obtained in 158 of 171 drivers killed in Victoria during I970 and 1971 (Hossack, 1972). Fifty per cent had levels of -10g/Ioo ml or more, and 40% had levels of '15 g/Ioo ml or more. Of killed drivers under 25 years of age, 68% had levels in excess of -10g/Ioo ml and in 58% the levels were in excess of '15 g/Ioo inl. Analysis of 567 Victorian road fatalities during 1972 and 1973 showed that 47% of 251 drivers had hlood alcohol concentrations of inore than -05 g/100 nil, 37% of more than -10g / ~ o oml, and 27% of more than -15g/Ioo ml (Hossack and Brown, 1974). Blood alcohol conceiitrations greater than '05 g/Ioo ml were presxt in 18% of motor cyclists, 22% of pedestrians and 25% of passengers. Similar results were reported in Queensland (Tonge, 1972). Blood alcohol concentrations greater than '10S/IOOml were detected in 45% of 447 killed drivers. Twenty-five per cent of motor cyclists had concentrations gr eater than -10g/ IOO ml. Notahly, in 152 fatal single vehicle accidents, 64% of drivers had blood alcohol coricentrations in excess of '10g / ~ o oml and 31% in excess of '20 g/Ioo ml. A high incidence of elevated blood alcohol levels has also been found in killed pedestrians and passengers. Surveys in Brisbane and Victoria have shown blood alcohol concentrations greater than '10 g/100 ml in 23% and 37% respectively of killed pedestrians (Whitlock et a%, 1971 ; Hossack, 1975). AUST N.Z. J. SURG,VOL. 47-"o
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More t h a n nil
'10 g/Ioo
50% 45% 37% 68% 64% 32 % 25%
-
23%
37%
More t h a n 15
Aiithor a n d Year
g/ioo 1111 40%
-
27% 58%
-
-
-
Hos5xtk (1972) T o n s ('972) Hossack a n d Brown (1974) Hossacli (1972) T011ge (1972) Jacoby ( I 9 7 i ) Tonge (1972) Jacoby (19751 Hossack a n d Brown (1974) W o b y (10%) Whitlock et aiii (1971) Hossack (19;s)
Road deaths in Victoria during 1974 have recently been analysed (Jacoby, 1975). Drivers and motor cyclists comprised 47% of the 806 fatalities. Forty-seven per cent of those killed were less than 25 years of age, and 75% were male. Blood alcohol concentrations were ohtainecl in 84% of the adult fatalities. Of the male population 36% of pedestrians, 33% of passengers and 33% of motor cyclists had blood alcohol concentrations in excess of -05 g/Ioo ml. Alcohol concentrations were greatest in drivers: 39% of male drivers killed had readings which exceeded -05 g / ~ o onil, and in 32% they exceeded '10g/roo ml. These data are final witness to the effectiveness of alcohol in impairing motor skills and the processing of sensory information. Even at hlood levels less than -05 g/Ioo nil, driving ability is decreased : controlled drinking studies have demonstrated a greater than 30% decrease in driving skills at blood alcohol concentrations of -04 g/Ioo ml (Laurel], 197s). The state of altered consciousness produced by this drug is especially dangerous in that the driver loses the ability to evaluate his driving performance, takes increased risks, and feels in confident command of his vehicle until the impact of accident. ALCOHOLA N D NON-FATALROADCRASH
CASUALTIES Blood alcohol concentrations of road crash casualties became available in Australia after introduction of the compulsory blood test laws of South Australia and Victoria during 1973 and 1974 respectively. Results are communicated to the Road Trauma Committee of the Royal Australasian College of Surgeons by the State Governments. I n Victoria these estima-
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tions have been obtained from all road crash casualties aged 15 years or more presenting at hospital casualty departments between October I, 1974 and September 30, 1975, and from drivers, including motor cyclists, between October I , 1975 and September 30, 1976. Data from South Australia are less comprehensive because the legislation is only applicable to ten designated hospitals. New Zealand introduced a compulsory blood alcohol test law in 1971, but because of incomplete analysis, information is more restricted. The legal maximum blood alcohol concentrations for drivers are '05 g/Ioo ml in Victoria, .08 g/Iw ml in South Australia, and -10 g/ 100 ml in New Zealand. Results of estimations of blood alcohol concentrations of non-fatal road crash casualties in Victoria and New Zealand are summarized in Table 2. The total number of blood samples tested in Victoria between October I , 1974, and September 30, 1975, was 15,178. Twentyseven per cent were collected from country hospitals. Sixty-five per cent of samples were from males and 35% from females. Seventythree per cent of samples were from drivers, including motor cyclists. The high proportion of drivers to non-drivers was unexpected, even allowing for several intervals totalling eight weeks in which only driver samples were estimated. Surveys made during April and May, 1974, at the Alfred Hospital, Prince Henry's Hospital and Preston and Northcote Community Hospital, and during the period June to September, 1974, at the Alfred Hospital on 466 and 474 consecutive road crash casualties respectively, demonstrated that drivers, including motor cyclists, comprised 41% of the total road casualty population (Ryan et alii, 1976). Thirty-five per cent were drivers and 7% were motor cycIists. Documentary error in identification of the category of the road user may explain the discrepancy
in the Victorian State figures. Of the 15,178 Victorian samples tested, 24.7% were positive for alcohol, i.e., alcohol was detected in the blood. Out of all samples 2 2 2 % had levels above '05 g/Ioo ml; 23'3% of city casualties had positive readings, compared with 28.5% of country hospital casualties. Thirty-three per cent of samples from males, but only 10% from females, were positive. Positive levels were present in 25'5% of drivers and 22.6% of non-drivers ( x 2 test, P < .0005). Levels in drivers were more frequently above -10 g:/100 ml than in non-drivers (x" test, P < 0.01).I n drivers, 87% of positive readings were above '05 g/100 mI, 67% above '10g / ~ wml, and an alarming 46% greater than -15 g/Im ml. The Melbourne hospital surveys of 1974 had shown considerably larger differences between the results in drivers and in non-drivers: 29% of drivers, compared with 19% of non-drivers, had positive levels. Because of logistic difficulties only driver (including motor cyclist) samples were estimated between October I , 1975, and September 30, 1976.Of 10,753 samples 26.4% were positive for alcohol: 23.4% of injured drivers had alcohol concentrations greater than '05 g/ 100 mI, 19.1% greater than '10g / ~ o omi, and 13.8% greater than '15 g/Ioo ml. These results closely resemble thoke found in the previons 12 months. In South Australia, during 1475, positive levels were detected in 24% of drivers, 23% of passengers. and 33% of pedestrians. Of the 7,570samples tested, 15'5% had alcohol concentrations in excess of *08g/100 ml. During 1976, 22.5% of drivers, 23% of passengers, and 31% of pedestrians had positive levels. The number of samples tested (7,600) was comparahle with that in 1975, as were the results. Alcohol concentrations in excess of -08g/roo nil were present in 14.6% of drivers, of whom 63% had concentrations in excess of
TABLE 2 Alcohol and Non-Fatal Road Crash Caszcnlties Category of Road User
Drivers and motor cyclists Non-drivers Drivers and motor cyclisis' Drivers .. Motor cycIiSis ..
::
158
Nurnbrr Injured
Locality
Vic. Vic. Vic. N.Z. N.Z.
..
..
11,040
:. :.
:. .
4,088 10,753 178 198
..
,
.
Year
Percentage with Elevated Blood Alcohol Concmiration
More than '05 p/mo ml 1974-5 1974-5 1975-6 I975 1975
22.0%
18.r0/,
___
More than c/roo rnl
More than ml
'10qlrno
16.2~4 rz.94/,
II.ZO/,
19.10/,
1?.8%
28.7X
I8
23.4% 30.904
14.6%
ro.oyo
AUST.N.Z. J. SURG., VOL. 4 7 - " o .
8.4% 4%
5.7%
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ALCOHOL, ROAD I N JURIES AND COUNTERMEASURES -1.5 g/Ioo ml. Of passengers and pedestrians with levels in excess of so8 g/Im ml, 53% and 77% respectively had blood alcohol concentrations greater than -15 g/Ioo ml. Less comprehensive information is available on blood alcohol concentration results of New Zealand road crash casualties because only seIected samples from drivers suspected of having illegal levels are estimated. However, analysis of a fully representative sample of road crash casualties from the urban and rural area of Christchurch has shown a pattern of alcohol involvement similar to that found in South Australia and Victoria. Of 178 driver samples collected, 30.9% exceeded '05 g/100 nil, 28.7% exceeded '10g/Ioo ml, and 18.5% exceeded '15 g / ~ o oml. Of samples from motor cyclists, 14'6% exceeded '05 g/Ioo ml, 10.0% exceeded '10 g / r m ml, and 5.7% exceeded '15 g/Ioo ml (Hart et a%, 1975a, 19756). A survey of 474 consecutive road crash casualties treated at the Alfred Hospital casualty department from June to September, 1974, was characterized by differences between those with positive and negative blood alcohol results (Ryan et alii, 1976). Forty-eight per cent of all casualties were motor cyclists ( 7 % ) , and drivers ($3%), pedal cyclists ( 3 % ) . Thirty-four per cent were passengers and 15% pedestrians, while the classification of 3% was unknown. Alcohol was detected in 29% of drivers and 24% of m o t h cyclists. Eighteen per cent of passengers and of pedestrians had positive IeveIs. Seventy per cent of all positive samples had alcohol concentrations of '05 g / I m nil or more, while 33% of samples from males hut only 12% from females were positive. Fifty-seven per cent of all road crash casualties with positive levels were under the age of 30 years. Of casualties with positive alcohol levels, 52% presented on Saturday or Sunday, in contrast to only 32% of alcohol neqative casualties. Of those with positive levels, 59% were admitted to the cactlalty department hetween Q p.m. and 3 a.m., while casualties with neqative alcohol results did not show this peak distribution. Only 20% of this latter category were admitted during these hours. Unpublished investigations made during rq75 at the Alfred Hospital hv W. E.Salter. G. A. Rvan 2nd the writer showed that road crash casualties with hlood alcohol concen-
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trations in excess of '05 g/Ioo ml differed in their drinking profile from other casualties. The group with concentrations exceeding '05 g/Ioo ml had a significantly increased incidence of drinking alcohol regularly on two or more days per week, consuming on the average more than 80 g of alcohol (equivalent to two bottles of beer) in each drinking session, and drinking and driving once or more than once a week. The data obtained since enactment of the compulsory blood alcohol laws have clearly demonstrated a massively increased probability of accidental injury in road users with elevated alcohol levels. Involvement of alcohol in onequarter of non-fatal road crash casualties in Australia and New Zealand reveals the present vast extent of the problem. Already some differences have been delineated between social and drinking profiles of alcohol positive and alcohol negative road crash casualties. COUNTERMEASURES Methods are similar to those used in the control of any epidemic. Progr ess ive improvement in prophylaxis and treatment is dependent upon research. Countermeasures include improved community education concerning the effect of alcohol in greatlv increasing the road user's risk of accident with death or injury ; legislation facilitating the detection and elimination of excessively drinking drivers from the road : and, associated with increasing awareness of the need to rehabilitate rather than merely penalize, the development of programmes directed towards reeducation of convicted drinking drivers. Recent research ha.; focused on identification of the characteristics of different groups of high-risk road users, evaluation of the implementation and results of legislation. and analvsis of the effectiveness of convicted drinking driver reeducation programmes. Ejfective I ~ ~ Z e ? ~ z e n f a of t ~ oBlood n Akohol
Legislation Legislation enacted in South Australia, Victoria, and New Zealand, requiring compulsorv blood alcohol tests on adult road crash casualties, has extended the scope of detection of tho excessively drinkiny driver and eliniinated the anomaly wherehv admission to a hospital casualty department frequently
I59
ALCOHOL, ROAD INJURIES AND COUNTERMEASURES
permitted escape. Differences exist between these legislative acts. The South Australian legislation at present applies to a limited number of hospitals. Extension of the legislation to include all road crash casualties is planned for 1977. Victorian legislation applies to all road crash casualties aged 15 years or more admitted to any hospital casualty department. I n New Zealand, usually only identified or suspected drinking drivers are tested. Kot unexpectedly, problems have arisen during the implementation of these Acts. South Australian legislation necessitates the attendance in court of the casualty doctor responsible for taking the driver’s blood sample if the case is defended. In Victoria, unsatisfactory documentation and logistic support, failure to perform alcohol estimations on all collected blood samples. and inadequate hospital feedback, bedevilled the first 18 months of enforcement. After repeated criticism from the medical profession and the media, the Government agreed to make essential changes to the reyulations and logistics. These entail testing of all collected samples in a single laboratory, immediate feedback of results to the hospital medical staff, elimination of some timeconsuming responsibilities for casualty doctors, and revised documentation. At the time of writing, it is believed that these improvements will he operational from January 1977. Another problem remains. The legislation is applicahle only to drivers whose blood sample is taken within two hours of the accident. Because onlv 43% of samples are obtained within two hours (Ryan et alii, 1976), $he majority of drivers remain immune fioin prosecution. Anienclnient of the legislation is being sought. I n New Zealand, nianv doctors refusc to take the blood samples, and their opposition has been strengthened by the failure of law enforcement authorities to collect more than one-third of samples with illegal alcohol concentrations. Recommendations of a review committee are awaited. Technical advances in the miniaturization and accuracy of breath testing instruments make their use for an initial screening test probable in the near future.
McDEKMOTT
excessively drinking driver from the road. Review of the legislation will be made after a twelve months’ trial period. The success of this type of legislation is directly dependent upon effective enforcement and publicity. Between J d y and December 1976, illegal levels were detected in 2.2% of 6,000 drivers. These results differ slightly from those of a research breath test investigation of drivers in the Australian Capital Territory during 1971 and 1972, in which it was found that 6 7 % of 7,000 drivers had alcohol concentrations in excess of 0.3 ~ / I W ml and 1.2% in excess of -08 g/roo nil. Predictably, at certain times increased percentages were found. On Fridays 9.3% of drivers had concentrations greater than 0.3 g/100 ml and 2.4% greater than 0.8 g/roo nil. The hours between 10 p m. and 2 a m . found z;.o% of drivers with concentrations exceeding -03 q/100 ml and 4.5% exceedinq -08 g/roo tnl. Obviously, for maximum effectiveness, random testing should be selectively directed to high-risk areas at highrisk times. The method used in the Netherlands, whereby individual drivers are tested by niolrile units, is preferred to the Victorian use of well-illuminated road blocks.
Random Breath Testing Random breath testing legislation in Victoria during 1976 has further extended the community’s capability to eliminate and deter the
Medical Revim There is increasinq appreciation that conviction for a drink-drivinq offence frequet7tlv represents merely one crisis situation for a person with a serious alcohol problem, and that the thrust of countermeasures should be towards reeducation and rehahilitation rather than mere application of penalties. In 1 ~ 7 the 0 Victorian Parliamentary Select Committee on Road Casualtiei; sug-gested that convicted drinkinq drivers with blood alcohol concentrations of ’15 g/100 ml or more should undergo compulsory medical examination and review. Return of the driver’s licence would he dependent upon medical evidence that his alcohol prohlein was now controlled. RPcatiCe most of these persons are under 30 vears of ace, the opportunity exists for overcoming a drinkino- prohlem before proqress to later staces. Earlier treatment is far more successful (Deakin r t alG, 1977). Preliniinarv resultc; of rehabilitation courses for convicted drinking drivers at St Vincent’s Hospital, Melbourne. stiqeeqt that the likelihood of a further drinkdrivinq; conviction is significantly decreased. The courses consist of four two-hour sessions
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concerning the effects of alcohol on the body and on driving ability, discussion with the driver regarding his attitudes to alcohol, driving, and social life, and the experiences which led to conviction. Programmes utilizing educational self-image confrontation by videotape and group discussion after controlled drinking and driving simulator performance evaluation have been initiated by the Alcoholics and Drug Dependent Persons Services Branch, Department of Health, Victoria. More prevalent court referral of drinking drivers to rehabilitation courses is envisaged after successful results are conclusively demonstrated.
of coin-operated breath alcohol test devices in hotels and, more gimmicky, the development and installation of warning systems in the vehicles of convicted drinking drivers. Unless the driver first succeeds in critical tracking tasks his automobile becomes automatically unoperational for a predetermined interval. It is believed that ultimately, improved countermeasures will assist in progressive evolution of cultural mores so that excessive drinking and driving become the exception, rather than the destructive custom they have been, and still are, in this community.
Reeducation and Treatment An urgent need for establishment of facilities in hospitals and community health centres, where reeducation, counselling and treatment may be given, is evident from the magnitude of the alcohol problem on the road. Victorian breathalyzer experience alone in 1975 detected 13,600 drivers with alcohol Concentrations in excess of .08 g/Ioo ml. The mean blood alcohol concentration of 16,000 tested drivers was -14 g/Ioo ml, and 55% of levels were in excess of -15 g/Im ml. I n addition, more than 2,000 road crash casualties with blood alcohol concentrations greater than '15 g / I m ml are identified per year by compulsory blood alcohol tests. Similar proportions of road crash casualties with extremely high blood alcohol concentrations are found in South Australia and New Zealand.
DEAKIN, C. M. L., SANTAMARIA,J. N. and WILKINSON,P. (I973), Med. J . Aust., I : 1305. DUNCAN,J. A. (1976), Drinking Driving by Canberra Motorists, Australian Government Publishing Service, Canberra. HART,D. N. J., COTTER,P. W. and MACBETH,W. A. A. G. (rg75a), N . Z . med. J., 81: 503. HART, D. N. J., COTTER, P. W. and MACBETH,W. A. A. G. (1975b), N.Z. med. J., 8 1 : 543. HOSSACK, D. W. (1972), Med. J . Aust., 2 : 255. HOSSACK, D. W. (1975), Med. J . Aust., I : 678. HOSSACK,D. and BROWN,G. (I974), Med. I . Aust., 2 : 473. JACOBY, J. (1975), Alcohol Involvement in 1974 Victorian Road Fatalities, published by Gibb and Associates, Melbourne. LAURELL,H. (1975), Effects of Alcohol on the Performance of Drivers, National Road and Traffic Research Institute Publication, Stockholm, Sweden. RYAN, G. A., SALTER,W. E., Cox, C. J. and MCDERMOTT, F. T. (1976), Med. J . Aust., 2 : 129. TONGE,J. I. (1972), Post-Mortem Blood Alcohol Levels in Road Accident Victims, presented at the National Road Safety Symposium, March 1972, Australian Government Publishing Service, Canberra : ZOI. WHITLOCK,F. A., ARMSTRONG, J. L., TONGE, J. I., O'REILLY,M. J. J., DAVISON, A , JOHNSTON, N. G. and BILTOFT,R. F. (1g71), Med. J. Aust., 2 : 5.
0 t her Couqtermeasures These entail the deveiopment and evaluation of education courses for special target groups such as learner drivers and school leavers. Controversial measures include the installation
REFERENCES
Who alone suffers suffers most i' the mind, Leaving free things and happy shows behind : But then the mind much sufferance doth o'er skip When grief hath mates and bearing fellowship. William Shakespeare, King Lear, 111, VI. AUST. N.Z. J. SURG., VOL. 47-NO. 0
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ALCOHOL, ROAD CRASH CASUALTIES, AND COUNTERMEASUHES FRANCIS T. MCDERMOTT Road Trauma Committee, Royal Australasian College of Surgeons, and Monash University Department of Surgery, Alfred Hospital, Melbourne Alcohol is a m a j o r contributing factor i n over one-third o f a l l road fatalities i n this community. Almbst half t h e fatalities occur i n people aged less than 25 years of age. Results of recent compulsory blood test legislation i n Australia and N e w Zealand are presented and provide incontrovertible evidence of t h e vast extent of the problem o f alcohol on the road. T h e social and drinking profiles o f road crash casualties w i t h blood alcohol concentrations greater t h a n .05 g/100 m l differ f r o m those o f other casualties. Countermeasures used in t h e control of this epidemic include legislation, improved community education, and greater awareness of the need t o rehabilitate rather than to penalize.
ALCOHOL impairs driving ability and is the most impoitant single cause of road traffic accidents. In 1975, 3,694 persons were killed on Australian roads and 89,499 were injured. Of those killed, 56% were under 30 years of age; 35% were under 21. Of the injured, 64% were under 30 years and 40% under 21 (AUStralian Bureau of Statistics, 1976). Extrapolation of these data to a decade predicts approximately 40,000 road deaths and 1.25 million injuries. The cost to the community is three million dollars per day. The commonplaceness of the road trauma epidemic deceptively insinuates the notion that this disaster is a normal expectation. Alcohol is a major contributing factor in over one-third of all road fatalities and in over one-quarter of non-fatal in juries. The privileged position of alcohol as a freely available hard drug of addiction is securely established. Per capita alcohol intake has more than doubled in the last 25 years, and purchases of alcoholic liquor now make up 13% of all Australian retail sales. Persons of all social classes conform to their group norm of alcohol expectation and intake. The alcohol cult, expanded well beyond the civilized rituals of wine cellar devotees, includes
a large teenage population, many of whom, more experimental than their parents, mix the mainstream of alcohol with marihuana, Mandrax, heroin, cocaine, Vegemite and other drugs. Both the liquor industry and the Government maintain vested interests in alcohol consumption. Excise revenue exceeds 760 million dollars per year. The social need to drink is commonly followed by the need to drive. The dominant measures against the problem of alcohol on the road during the last ten years have been legislative. Progressive legislation has attempted to eliminate the drinking driver from the road by the introduction of breathalyzer tests, by compulsory blood alcohol concentration tests on road crash casualties in South Australia and Victoria during 1973 and 1974 respectively, and by random breath testing in Victoria in 1976. New Zealand introduced legislation in 1971 for compulsory blood alcohol testing of drivers involved in road traffic accidents. These measures have additionally provided incontrovertible data on the magnitude of the alcohol problem on the road in Australia and New Zealand.
Address for reprints : Monash University Department of Surgery, Alfred Hospital, Commercial Road, Prahran, Victoria 3181.
ALCOHOLA N D DEATHO N THE ROAD Results of estimations of blood alcohol concentrations in fatal road crash casualties are summarized in Table I . The incidence of
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ALCOHOL, ROAD I N JURIES AN11 COUNTERMEASURES TABLEI Alcohol and Death O R the R o a d Percentage with Elevated Blood Alcohol Concentration Category of Road User
state
Morc t h a n 'oj g/Ioo rnl
.. .. .. Drivers . . Drivers . . _. .. .. Drivers . . ., .. Drivers under z;.years of as? Single vehicle accident drivers Male drivers ,, ., .. .. ._ Motor-cyclists . _ Male motor-cyclists .. .. Passengers .. ., .. hlale paswngers .. ,, Pedestrians ,, .. .. Pedestrians .. . , ..
..
.. ,,
.. .. .. ,. ., .. .. ., ,,
._ .. .. ., .. .. .. ., ,
.
.. .. ..
Vic. Qld Vic. Vic. &Id Vic. Qld. Vic. Vic. Vic. Qld. Vic.
60%
-
47% 781% 39%
-
33% 25% 33% -
-
excessive alcohol intake in the population of killed drivers is of the order of 1000%. Approximately 50% of killed drivers have illegal blood alcohol levels, compared with less than 2+70 of the total driver population (Duncan, 1973). Blood alcohol concentrations R cre obtained in 158 of 171 drivers killed in Victoria during I970 and 1971 (Hossack, 1972). Fifty per cent had levels of -10g/Ioo ml or more, and 40% had levels of '15 g/Ioo ml or more. Of killed drivers under 25 years of age, 68% had levels in excess of -10g/Ioo ml and in 58% the levels were in excess of '15 g/Ioo inl. Analysis of 567 Victorian road fatalities during 1972 and 1973 showed that 47% of 251 drivers had hlood alcohol concentrations of inore than -05 g/100 nil, 37% of more than -10g / ~ o oml, and 27% of more than -15g/Ioo ml (Hossack and Brown, 1974). Blood alcohol conceiitrations greater than '05 g/Ioo ml were presxt in 18% of motor cyclists, 22% of pedestrians and 25% of passengers. Similar results were reported in Queensland (Tonge, 1972). Blood alcohol concentrations greater than '10S/IOOml were detected in 45% of 447 killed drivers. Twenty-five per cent of motor cyclists had concentrations gr eater than -10g/ IOO ml. Notahly, in 152 fatal single vehicle accidents, 64% of drivers had blood alcohol coricentrations in excess of '10g / ~ o oml and 31% in excess of '20 g/Ioo ml. A high incidence of elevated blood alcohol levels has also been found in killed pedestrians and passengers. Surveys in Brisbane and Victoria have shown blood alcohol concentrations greater than '10 g/100 ml in 23% and 37% respectively of killed pedestrians (Whitlock et a%, 1971 ; Hossack, 1975). AUST N.Z. J. SURG,VOL. 47-"o
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More t h a n nil
'10 g/Ioo
50% 45% 37% 68% 64% 32 % 25%
-
23%
37%
More t h a n 15
Aiithor a n d Year
g/ioo 1111 40%
-
27% 58%
-
-
-
Hos5xtk (1972) T o n s ('972) Hossack a n d Brown (1974) Hossacli (1972) T011ge (1972) Jacoby ( I 9 7 i ) Tonge (1972) Jacoby (19751 Hossack a n d Brown (1974) W o b y (10%) Whitlock et aiii (1971) Hossack (19;s)
Road deaths in Victoria during 1974 have recently been analysed (Jacoby, 1975). Drivers and motor cyclists comprised 47% of the 806 fatalities. Forty-seven per cent of those killed were less than 25 years of age, and 75% were male. Blood alcohol concentrations were ohtainecl in 84% of the adult fatalities. Of the male population 36% of pedestrians, 33% of passengers and 33% of motor cyclists had blood alcohol concentrations in excess of -05 g/Ioo ml. Alcohol concentrations were greatest in drivers: 39% of male drivers killed had readings which exceeded -05 g / ~ o onil, and in 32% they exceeded '10g/roo ml. These data are final witness to the effectiveness of alcohol in impairing motor skills and the processing of sensory information. Even at hlood levels less than -05 g/Ioo nil, driving ability is decreased : controlled drinking studies have demonstrated a greater than 30% decrease in driving skills at blood alcohol concentrations of -04 g/Ioo ml (Laurel], 197s). The state of altered consciousness produced by this drug is especially dangerous in that the driver loses the ability to evaluate his driving performance, takes increased risks, and feels in confident command of his vehicle until the impact of accident. ALCOHOLA N D NON-FATALROADCRASH
CASUALTIES Blood alcohol concentrations of road crash casualties became available in Australia after introduction of the compulsory blood test laws of South Australia and Victoria during 1973 and 1974 respectively. Results are communicated to the Road Trauma Committee of the Royal Australasian College of Surgeons by the State Governments. I n Victoria these estima-
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tions have been obtained from all road crash casualties aged 15 years or more presenting at hospital casualty departments between October I, 1974 and September 30, 1975, and from drivers, including motor cyclists, between October I , 1975 and September 30, 1976. Data from South Australia are less comprehensive because the legislation is only applicable to ten designated hospitals. New Zealand introduced a compulsory blood alcohol test law in 1971, but because of incomplete analysis, information is more restricted. The legal maximum blood alcohol concentrations for drivers are '05 g/Ioo ml in Victoria, .08 g/Iw ml in South Australia, and -10 g/ 100 ml in New Zealand. Results of estimations of blood alcohol concentrations of non-fatal road crash casualties in Victoria and New Zealand are summarized in Table 2. The total number of blood samples tested in Victoria between October I , 1974, and September 30, 1975, was 15,178. Twentyseven per cent were collected from country hospitals. Sixty-five per cent of samples were from males and 35% from females. Seventythree per cent of samples were from drivers, including motor cyclists. The high proportion of drivers to non-drivers was unexpected, even allowing for several intervals totalling eight weeks in which only driver samples were estimated. Surveys made during April and May, 1974, at the Alfred Hospital, Prince Henry's Hospital and Preston and Northcote Community Hospital, and during the period June to September, 1974, at the Alfred Hospital on 466 and 474 consecutive road crash casualties respectively, demonstrated that drivers, including motor cyclists, comprised 41% of the total road casualty population (Ryan et alii, 1976). Thirty-five per cent were drivers and 7% were motor cycIists. Documentary error in identification of the category of the road user may explain the discrepancy
in the Victorian State figures. Of the 15,178 Victorian samples tested, 24.7% were positive for alcohol, i.e., alcohol was detected in the blood. Out of all samples 2 2 2 % had levels above '05 g/Ioo ml; 23'3% of city casualties had positive readings, compared with 28.5% of country hospital casualties. Thirty-three per cent of samples from males, but only 10% from females, were positive. Positive levels were present in 25'5% of drivers and 22.6% of non-drivers ( x 2 test, P < .0005). Levels in drivers were more frequently above -10 g:/100 ml than in non-drivers (x" test, P < 0.01).I n drivers, 87% of positive readings were above '05 g/100 mI, 67% above '10g / ~ wml, and an alarming 46% greater than -15 g/Im ml. The Melbourne hospital surveys of 1974 had shown considerably larger differences between the results in drivers and in non-drivers: 29% of drivers, compared with 19% of non-drivers, had positive levels. Because of logistic difficulties only driver (including motor cyclist) samples were estimated between October I , 1975, and September 30, 1976.Of 10,753 samples 26.4% were positive for alcohol: 23.4% of injured drivers had alcohol concentrations greater than '05 g/ 100 mI, 19.1% greater than '10g / ~ o omi, and 13.8% greater than '15 g/Ioo ml. These results closely resemble thoke found in the previons 12 months. In South Australia, during 1475, positive levels were detected in 24% of drivers, 23% of passengers. and 33% of pedestrians. Of the 7,570samples tested, 15'5% had alcohol concentrations in excess of *08g/100 ml. During 1976, 22.5% of drivers, 23% of passengers, and 31% of pedestrians had positive levels. The number of samples tested (7,600) was comparahle with that in 1975, as were the results. Alcohol concentrations in excess of -08g/roo nil were present in 14.6% of drivers, of whom 63% had concentrations in excess of
TABLE 2 Alcohol and Non-Fatal Road Crash Caszcnlties Category of Road User
Drivers and motor cyclists Non-drivers Drivers and motor cyclisis' Drivers .. Motor cycIiSis ..
::
158
Nurnbrr Injured
Locality
Vic. Vic. Vic. N.Z. N.Z.
..
..
11,040
:. :.
:. .
4,088 10,753 178 198
..
,
.
Year
Percentage with Elevated Blood Alcohol Concmiration
More than '05 p/mo ml 1974-5 1974-5 1975-6 I975 1975
22.0%
18.r0/,
___
More than c/roo rnl
More than ml
'10qlrno
16.2~4 rz.94/,
II.ZO/,
19.10/,
1?.8%
28.7X
I8
23.4% 30.904
14.6%
ro.oyo
AUST.N.Z. J. SURG., VOL. 4 7 - " o .
8.4% 4%
5.7%
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ALCOHOL, ROAD I N JURIES AND COUNTERMEASURES -1.5 g/Ioo ml. Of passengers and pedestrians with levels in excess of so8 g/Im ml, 53% and 77% respectively had blood alcohol concentrations greater than -15 g/Ioo ml. Less comprehensive information is available on blood alcohol concentration results of New Zealand road crash casualties because only seIected samples from drivers suspected of having illegal levels are estimated. However, analysis of a fully representative sample of road crash casualties from the urban and rural area of Christchurch has shown a pattern of alcohol involvement similar to that found in South Australia and Victoria. Of 178 driver samples collected, 30.9% exceeded '05 g/100 nil, 28.7% exceeded '10g/Ioo ml, and 18.5% exceeded '15 g / ~ o oml. Of samples from motor cyclists, 14'6% exceeded '05 g/Ioo ml, 10.0% exceeded '10 g / r m ml, and 5.7% exceeded '15 g/Ioo ml (Hart et a%, 1975a, 19756). A survey of 474 consecutive road crash casualties treated at the Alfred Hospital casualty department from June to September, 1974, was characterized by differences between those with positive and negative blood alcohol results (Ryan et alii, 1976). Forty-eight per cent of all casualties were motor cyclists ( 7 % ) , and drivers ($3%), pedal cyclists ( 3 % ) . Thirty-four per cent were passengers and 15% pedestrians, while the classification of 3% was unknown. Alcohol was detected in 29% of drivers and 24% of m o t h cyclists. Eighteen per cent of passengers and of pedestrians had positive IeveIs. Seventy per cent of all positive samples had alcohol concentrations of '05 g / I m nil or more, while 33% of samples from males hut only 12% from females were positive. Fifty-seven per cent of all road crash casualties with positive levels were under the age of 30 years. Of casualties with positive alcohol levels, 52% presented on Saturday or Sunday, in contrast to only 32% of alcohol neqative casualties. Of those with positive levels, 59% were admitted to the cactlalty department hetween Q p.m. and 3 a.m., while casualties with neqative alcohol results did not show this peak distribution. Only 20% of this latter category were admitted during these hours. Unpublished investigations made during rq75 at the Alfred Hospital hv W. E.Salter. G. A. Rvan 2nd the writer showed that road crash casualties with hlood alcohol concen-
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trations in excess of '05 g/Ioo ml differed in their drinking profile from other casualties. The group with concentrations exceeding '05 g/Ioo ml had a significantly increased incidence of drinking alcohol regularly on two or more days per week, consuming on the average more than 80 g of alcohol (equivalent to two bottles of beer) in each drinking session, and drinking and driving once or more than once a week. The data obtained since enactment of the compulsory blood alcohol laws have clearly demonstrated a massively increased probability of accidental injury in road users with elevated alcohol levels. Involvement of alcohol in onequarter of non-fatal road crash casualties in Australia and New Zealand reveals the present vast extent of the problem. Already some differences have been delineated between social and drinking profiles of alcohol positive and alcohol negative road crash casualties. COUNTERMEASURES Methods are similar to those used in the control of any epidemic. Progr ess ive improvement in prophylaxis and treatment is dependent upon research. Countermeasures include improved community education concerning the effect of alcohol in greatlv increasing the road user's risk of accident with death or injury ; legislation facilitating the detection and elimination of excessively drinking drivers from the road : and, associated with increasing awareness of the need to rehabilitate rather than merely penalize, the development of programmes directed towards reeducation of convicted drinking drivers. Recent research ha.; focused on identification of the characteristics of different groups of high-risk road users, evaluation of the implementation and results of legislation. and analvsis of the effectiveness of convicted drinking driver reeducation programmes. Ejfective I ~ ~ Z e ? ~ z e n f a of t ~ oBlood n Akohol
Legislation Legislation enacted in South Australia, Victoria, and New Zealand, requiring compulsorv blood alcohol tests on adult road crash casualties, has extended the scope of detection of tho excessively drinkiny driver and eliniinated the anomaly wherehv admission to a hospital casualty department frequently
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ALCOHOL, ROAD INJURIES AND COUNTERMEASURES
permitted escape. Differences exist between these legislative acts. The South Australian legislation at present applies to a limited number of hospitals. Extension of the legislation to include all road crash casualties is planned for 1977. Victorian legislation applies to all road crash casualties aged 15 years or more admitted to any hospital casualty department. I n New Zealand, usually only identified or suspected drinking drivers are tested. Kot unexpectedly, problems have arisen during the implementation of these Acts. South Australian legislation necessitates the attendance in court of the casualty doctor responsible for taking the driver’s blood sample if the case is defended. In Victoria, unsatisfactory documentation and logistic support, failure to perform alcohol estimations on all collected blood samples. and inadequate hospital feedback, bedevilled the first 18 months of enforcement. After repeated criticism from the medical profession and the media, the Government agreed to make essential changes to the reyulations and logistics. These entail testing of all collected samples in a single laboratory, immediate feedback of results to the hospital medical staff, elimination of some timeconsuming responsibilities for casualty doctors, and revised documentation. At the time of writing, it is believed that these improvements will he operational from January 1977. Another problem remains. The legislation is applicahle only to drivers whose blood sample is taken within two hours of the accident. Because onlv 43% of samples are obtained within two hours (Ryan et alii, 1976), $he majority of drivers remain immune fioin prosecution. Anienclnient of the legislation is being sought. I n New Zealand, nianv doctors refusc to take the blood samples, and their opposition has been strengthened by the failure of law enforcement authorities to collect more than one-third of samples with illegal alcohol concentrations. Recommendations of a review committee are awaited. Technical advances in the miniaturization and accuracy of breath testing instruments make their use for an initial screening test probable in the near future.
McDEKMOTT
excessively drinking driver from the road. Review of the legislation will be made after a twelve months’ trial period. The success of this type of legislation is directly dependent upon effective enforcement and publicity. Between J d y and December 1976, illegal levels were detected in 2.2% of 6,000 drivers. These results differ slightly from those of a research breath test investigation of drivers in the Australian Capital Territory during 1971 and 1972, in which it was found that 6 7 % of 7,000 drivers had alcohol concentrations in excess of 0.3 ~ / I W ml and 1.2% in excess of -08 g/roo nil. Predictably, at certain times increased percentages were found. On Fridays 9.3% of drivers had concentrations greater than 0.3 g/100 ml and 2.4% greater than 0.8 g/roo nil. The hours between 10 p m. and 2 a m . found z;.o% of drivers with concentrations exceeding -03 q/100 ml and 4.5% exceedinq -08 g/roo tnl. Obviously, for maximum effectiveness, random testing should be selectively directed to high-risk areas at highrisk times. The method used in the Netherlands, whereby individual drivers are tested by niolrile units, is preferred to the Victorian use of well-illuminated road blocks.
Random Breath Testing Random breath testing legislation in Victoria during 1976 has further extended the community’s capability to eliminate and deter the
Medical Revim There is increasinq appreciation that conviction for a drink-drivinq offence frequet7tlv represents merely one crisis situation for a person with a serious alcohol problem, and that the thrust of countermeasures should be towards reeducation and rehahilitation rather than mere application of penalties. In 1 ~ 7 the 0 Victorian Parliamentary Select Committee on Road Casualtiei; sug-gested that convicted drinkinq drivers with blood alcohol concentrations of ’15 g/100 ml or more should undergo compulsory medical examination and review. Return of the driver’s licence would he dependent upon medical evidence that his alcohol prohlein was now controlled. RPcatiCe most of these persons are under 30 vears of ace, the opportunity exists for overcoming a drinkino- prohlem before proqress to later staces. Earlier treatment is far more successful (Deakin r t alG, 1977). Preliniinarv resultc; of rehabilitation courses for convicted drinking drivers at St Vincent’s Hospital, Melbourne. stiqeeqt that the likelihood of a further drinkdrivinq; conviction is significantly decreased. The courses consist of four two-hour sessions
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concerning the effects of alcohol on the body and on driving ability, discussion with the driver regarding his attitudes to alcohol, driving, and social life, and the experiences which led to conviction. Programmes utilizing educational self-image confrontation by videotape and group discussion after controlled drinking and driving simulator performance evaluation have been initiated by the Alcoholics and Drug Dependent Persons Services Branch, Department of Health, Victoria. More prevalent court referral of drinking drivers to rehabilitation courses is envisaged after successful results are conclusively demonstrated.
of coin-operated breath alcohol test devices in hotels and, more gimmicky, the development and installation of warning systems in the vehicles of convicted drinking drivers. Unless the driver first succeeds in critical tracking tasks his automobile becomes automatically unoperational for a predetermined interval. It is believed that ultimately, improved countermeasures will assist in progressive evolution of cultural mores so that excessive drinking and driving become the exception, rather than the destructive custom they have been, and still are, in this community.
Reeducation and Treatment An urgent need for establishment of facilities in hospitals and community health centres, where reeducation, counselling and treatment may be given, is evident from the magnitude of the alcohol problem on the road. Victorian breathalyzer experience alone in 1975 detected 13,600 drivers with alcohol Concentrations in excess of .08 g/Ioo ml. The mean blood alcohol concentration of 16,000 tested drivers was -14 g/Ioo ml, and 55% of levels were in excess of -15 g/Im ml. I n addition, more than 2,000 road crash casualties with blood alcohol concentrations greater than '15 g / I m ml are identified per year by compulsory blood alcohol tests. Similar proportions of road crash casualties with extremely high blood alcohol concentrations are found in South Australia and New Zealand.
DEAKIN, C. M. L., SANTAMARIA,J. N. and WILKINSON,P. (I973), Med. J . Aust., I : 1305. DUNCAN,J. A. (1976), Drinking Driving by Canberra Motorists, Australian Government Publishing Service, Canberra. HART,D. N. J., COTTER,P. W. and MACBETH,W. A. A. G. (rg75a), N . Z . med. J., 81: 503. HART, D. N. J., COTTER, P. W. and MACBETH,W. A. A. G. (1975b), N.Z. med. J., 8 1 : 543. HOSSACK, D. W. (1972), Med. J . Aust., 2 : 255. HOSSACK, D. W. (1975), Med. J . Aust., I : 678. HOSSACK,D. and BROWN,G. (I974), Med. I . Aust., 2 : 473. JACOBY, J. (1975), Alcohol Involvement in 1974 Victorian Road Fatalities, published by Gibb and Associates, Melbourne. LAURELL,H. (1975), Effects of Alcohol on the Performance of Drivers, National Road and Traffic Research Institute Publication, Stockholm, Sweden. RYAN, G. A., SALTER,W. E., Cox, C. J. and MCDERMOTT, F. T. (1976), Med. J . Aust., 2 : 129. TONGE,J. I. (1972), Post-Mortem Blood Alcohol Levels in Road Accident Victims, presented at the National Road Safety Symposium, March 1972, Australian Government Publishing Service, Canberra : ZOI. WHITLOCK,F. A., ARMSTRONG, J. L., TONGE, J. I., O'REILLY,M. J. J., DAVISON, A , JOHNSTON, N. G. and BILTOFT,R. F. (1g71), Med. J. Aust., 2 : 5.
0 t her Couqtermeasures These entail the deveiopment and evaluation of education courses for special target groups such as learner drivers and school leavers. Controversial measures include the installation
REFERENCES
Who alone suffers suffers most i' the mind, Leaving free things and happy shows behind : But then the mind much sufferance doth o'er skip When grief hath mates and bearing fellowship. William Shakespeare, King Lear, 111, VI. AUST. N.Z. J. SURG., VOL. 47-NO. 0
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