Impaired driving Generally the complex interface of vehicular and pedestrian traffic is uneventful. Occasionally, but far too often, the system is disrupted and the outcome disastrous. One source of disruption is the alcohol-impaired driver. To correct this problem we must acquire at least two basic elements of information, obtainable from answers to two questions. The first question is, How large a problem does this disruption constitute? The second is, How effective have the efforts been to reduce the size of the problem? The answer to the first question requires precise epidemiologic data, especially from the perspective of the allocation of scant resources to this problem rather than to others; the answer to the second bears directly on the efficiency of resource allocation as well as the prospects for elimination or attenuation of impaired driving. Concerning the magnitude of the impaired-driver problem, definition has been inadequate, largely because the data base has been inadequate. In the absence of epidemiologic evidence the "problem" has been defined on the basis of a "feel" for its magnitude. Such impressionistic approaches, however, are dangerous and fast becoming unnecessary as research delineates the dimensions of the impaired-driving issue. One such study is that of Bako, Mackenzie and Smith in this issue of the Journal (page 149). Even so, uninformed "statistics" persist, though persons outside the research community are beginning to appreciate the need for a precise definition of problems, realizing that without clear evidence of the prevalence of a phenomenon and its clear definition, its amelioration will, at best, be protracted. But this evidence never accumulates through a simple process of enumeration and, though
this often frustrates those who want only the "bottom line", all must recognize the complexities inherent in describing and understanding the impaired-driving problem. In this country the Traffic Injury Research Foundation (TIRF) of Canada has for several years been a prime source of information on the importance of alcohol in serious motor vehicle collisions - those with a fatality. Surveys conducted by the TIRF1'2 have established the value as well as the limitations of the data base. A recent publication,3 based on an analysis of 1725 driver fatalities, has provided a comprehensive statement on the magnitude of the problem in Canada. Of the 1725 drivers killed, at least 38% were legally impaired. A projection to national fatality statistics means that in 1 year about 950 of the drivers who died were legally impaired at the time of the accident. The magnitude of the problem is apparently substantial; for example, many other persons not driving died or were injured because they were involved in some way in the fatal accidents. Impairment varies with sex and age of the individual; of persons who died in accidents only 19% of women but 40% of men were impaired, as were 29% of the 16- to 17-year-old drivers, 52% of the 30- to 34-year-old drivers and 27% of the 55- to 60-year-old drivers. Striking as such statistics may seem, they are only a first step in ascertaining the true magnitude of the problem. Also needed are data relative to the population at risk, in order to determine the extent to which the number impaired in each age category of fatalities is over-representative of impairment in the normal driving population. Such estimates of the population at
risk are now to some extent available.4 These data have been compared with the fatality data already cited to determine relative amounts of overrepresentation of alcohol in the various age groups.5 The combination of alcohol and age-related factors produces revealing information. The 30- to 34year-old impaired driver was found to be 17 times more likely to be killed than the average unimpaired driver. With older persons the risk increased: the impaired driver over 50 years of age was 39 times more likely to be killed than the average unimpaired driver. Similarly, with younger persons who were impaired, the risk of death also increased: those aged 18 or 19 were 70 times, and those 16 or 17 years old 165 times, more likely to be killed than the average unimpaired driver. Definition of the problem in this manner begins to place the impaired-driver issue in perspective. For example, fewer young drivers than middle-aged drivers are impaired, but among the young drivers who are impaired there is an extremely high risk of fatal collision. Such work on the magnitude of the problem and its parameters is essential because informed development of programs can proceed only when highrisk, potential target groups are delineated. The second question to be answered is whether the magnitude of the problem has changed. It is now 7 years since the amendments to the Criminal Code, proclaimed on Dec. 1, 1969, made it illegal for a person to operate a motor vehicle with a blood alcohol concentration exceeding 80 mg/dl. In those 7 years, education and information on drinking and driving have been expanded; treatment-oriented approaches to the problem have emerged
CMA JOURNAL/JANUARY 22, 1977/VOL. 116 121
(e.g., Driving While Impaired [DWI] - a rehabilitative program for persons convicted of impaired driving); the drinking age, after being lowered in all jurisdictions, has subsequently been raised in Saskatchewan; and most recently, further amendments to the legislation dealing with impaired driving have been proclaimed in Alberta and Ontario, where the potential detection powers of the police have also been extended. Have such programs been successful in reducing the impaired-driver problem? This question is difficult to answer, mainly because, historically, information that would reveal such changes has not been collated. However, economic strictures have resulted in beneficial changes in attitude. The old notion that the cost does not matter as long as a life is saved has come to face the realistic proposition that only limited resources can be deployed at any one time - and mobilization of these resources for one effort may, in fact, cost lives through their being withdrawn from other efforts. Such evaluation is healthy in many ways because it forces countermeasure efforts to overcome, for example, the use of slogans and it raises questions about the continual reliance on legislation to solve our difficulties. Alcohol is inextricably implicated in society and will not silently fade away because of legislation. For example, what was the effect of Canadian legislation introducing the limit to a blood alcohol concentration of 80 mg/dl? After the legislation was introduced there was an immediate and substantial decline in the number of traffic fatalities.6 The legislation apparently had the desired effect. But this effect was short-lived: by 1973 the number of fatalities had exceeded the estimated number if there had been no legislation. What is more surprising are the findings of a report in which impaireddriver fatalities were separated from unimpaired-driver fatalities (previously only gross mortality rates had been considered): the reported decrease in number of deaths and the subsequent increase occurred only for the unimpaired drivers,7 so that the legislation apparently had no effect on the incidence of impaired-driver fatalities. Undoubtedly some effect was produced, but it was transient and did not affect one important segment of the population. The usual response to such commentary is that the legislation is only as good as its enforcement; but enforcement requires detection and it is well known that the frequency of detection of impaired driving is incredibly low. To augment the detection rate to meaningful levels is no easy task.
It seems unfortunate that the majority of countermeasures have been punitive and aimed at either secondary or tertiary prevention. Secondary prevention, which assumes that the drinking driver is on the road, focuses on systems of prevention before an accident can occur. One element of this system is detection but, as I have suggested, this is exceedingly problematic. Tertiary prevention focuses on events following detection or a survivable accident. Such measures are, of course, to some extent contingent on the success of secondary prevention and include punitive systems (e.g., fines and jail terms), rehabilitative methods (e.g., DWI) and combinations of these. The general effectiveness will necessarily be limited, and there is widespread concern about the value of the specific systems.8 Only marginal effort has been expended on primary prevention measures (directed at the time before drinking and driving occur) except through the use of slogans urging people not to drink and drive. More work needs to be directed at the development of primary preventive measures. Such developments can occur only when definition of a problem is adequate. What is needed is a fresh, realistic appraisal of impaired driving in general and of the development of countermeasures in particular. Concerning impaired driving, impassioned zeal has far too long been the prime guiding force and, in an effort to solve the problem, more attention has been devoted to mounting countermeasures and intervention programs than to identifying the precise elements of the problem. If researchers and practitioners combine their talents, progress can be expected. H.M. SIMPsoN, PH D Research director Traffic Injury Research Foundation of Canada Ottawa. Ont.
References 1. SiMi'sor.i HM, HEAYN B: Alcohol and drug determinations in traffic fatalities: a survey of coroners and testing laboratories, in Proceedings of the XIIth Conference of the Traffic Injury Research Foundation of Canada, Ottawa, 1975, pp 1-23 2. Idem: Alcohol and other drug testing in traffic deaths: a report on current practices in Canada. Can J Forensic Sci 9: 27, 1976 3. Traffic Injury Research Foundation of Canada: Analysis of fatal crashes in Canada, 1973, focus: the impaired driver. TIRF Rep, Dec 1975 4. SMITH G, WOLYNErL M, DAvIDsON M. Ct al: Estimated blood/alcohol concentrations of nighttime Canadian drivers, in Proceedings of the XIIth Conference of the Traffic Injury Research Foundation of Canada, op cit, pp 24-49 5. WARREN RA: Total impairment risk factors. TIRF Rep, July 1976 6. CHAMBERS LW, RoBERTs RS, VOELKER CA: The epidemiology of traffic accidents and the effect of the 1969 breathalyzer amendment in Canada. Accident Anal Prey 8: 201, 1976 7. WARREN RA: Empirical evaluation of impaired driver legislation, in Proceedings oj the XIIIth Conference of the Traffic Injury Research Foundation of Canada, Ottawa. 1976, pp 60-80 8. WHITEHEAD PC: D.W.I. programmes: doing what's in or dodging what's indicated. I Sal Res 7: 127, 1975
122 CMA JOURNAL/JANUARY 22, 1977/VOL. 116
.Serax. OXAZEPAM
The non-accumulafing am. INDICATIONS: For management of anxiety, tension, tear, agitation, irritability, insomnia and anxiety associated with depression, e.g. as in transient situational disorder, psychoneurotic reaction, psychophysiological reaction, geriatric behavioral disturbances or personality disorder. Also in anxiety syndrome secondary to organic disease and in residual anxiety syndrome in alcoholics and in alcohol withdrawal. CONTRAINDICATIONS: Not indicated in children under 6 years of age. No definite established dose for children 6 to 12 years of age. Contraindicated in patients who have exhibited previous hypersensitivity to oxazepam. Not indicated in psychoses. PRECAUTIONS: Ambulatory patients may become drowsy or dizzy or experience reduced tolerance to alcohol, so should be warned against driving automobiles or operating dangerous machinery. Some cases of attempted suicide have been reported in which highest dosage ingested was in excess of 600 mg. When treatment is protracted periodic blood counts and liver function tests may be advisable. If rash or other symptoms of hypersensitivity occur, administration of oxazepam should be discontinued and appropriate symptomatic treatment initiated. Hypotensive reactions are rare, but use with caution where complications could ensue from a fall in blood pressure, especially in the elderly. Withdrawal symptoms upon discontinuation have been noted in some patients exhibiting drug dependence through chronic overdose. Carefully supervise dose and amounts prescribed, especially for patients prone to overdose; excessive, prolonged use in susceptible patients (alcoholics, addicts) may result in dependence or habituation. Reduce dosage gradually after prolonged excessive dosage to avoid possible epileptiform seizures. Withdrawal symptoms following abrupt discontinuances are similar to those seen with barbiturates. Safety for use in pregnant women has not been established, therefore oxazepam should not be used during the first trimester of pregnancy unless the benefit to the patient outweighs the possible hazards to the fetus. ADVERSE EFFECTS: Rarely require discontinuance of therapy. Transient mild drowsiness occurs during initial days - if it persists, reduce dosage. In a few cases, dizziness, vertigo, headache and rarely syncope have also occurred. Mild paradoxical reactions, e.g. excitement, stimulation of affect have occurred in psychiatric patients, usually in first 2 weeks of therapy. Minor diffuse skin rashes, leukopenia, hepatic dysfunction including jaundice and nausea, edema, slurred speech, tremor, altered libido and lethargy have occurred infrequently. Ataxia has been reported in rare instances. DOSAGE: Mild to moderate anxiety syndromes, 10 to 15 mg 3 or 4 times daily. Severe anxiety syndromes, 15 to 30 mg 3 or 4 times daily. Geriatric behavior problems, 10mg initially 3 times a day, if necessary increase cautiously to 15 mg 3 or 4 times daily. Residual anxiety syndrome in alcoholics and in alcohol withdrawal, 15 to 30 mg 3 or 4 times daily. SUPPLIED: Each scored tablet contains: oxazepam 10 mg (light yellow), 15 mg (yellow) or 30 mg (white). Tablet weight: 190 mg. Caloric contents: 0.5 caltablet. Bottles of 100 and 500 tablets. REFERENCES: 1. Greenblaft, D. J., Shader, R. I., KochWeser, J.: Pharmacokinetics In Clinical Medicine: Oxazepam versus Other Benzodiazepines. Diseases of the Nervous System. 36:5:2:6-1 3, May, 1975. 2. ibid. 3. Greenblaft, D. J., Shader, R. I.: Drug Therapy: Benzodiazepines, N. Eng. J. Med.: 291: 1011-1015, 1239-1243, 1974. 4. Merlis, S., Koepke, H. H.: The Use of Oxazepam In Elderly Patients. Diseases of the Nervous System, 36:52:27-29, May, 1975. 5. ibid. 6. Halpern, M. M.: The Antianxiety Activity of Oxazepam in Patients with Multiple Organic Disorders. Clinical Practice, July, 1968.
Wyeth L4Ah. lWyeth Ltd., Toronto .R TM tTrademark
EJ
this often frustrates those who want only the "bottom line", all must recognize the complexities inherent in describing and understanding the impaired-driving problem. In this country the Traffic Injury Research Foundation (TIRF) of Canada has for several years been a prime source of information on the importance of alcohol in serious motor vehicle collisions - those with a fatality. Surveys conducted by the TIRF1'2 have established the value as well as the limitations of the data base. A recent publication,3 based on an analysis of 1725 driver fatalities, has provided a comprehensive statement on the magnitude of the problem in Canada. Of the 1725 drivers killed, at least 38% were legally impaired. A projection to national fatality statistics means that in 1 year about 950 of the drivers who died were legally impaired at the time of the accident. The magnitude of the problem is apparently substantial; for example, many other persons not driving died or were injured because they were involved in some way in the fatal accidents. Impairment varies with sex and age of the individual; of persons who died in accidents only 19% of women but 40% of men were impaired, as were 29% of the 16- to 17-year-old drivers, 52% of the 30- to 34-year-old drivers and 27% of the 55- to 60-year-old drivers. Striking as such statistics may seem, they are only a first step in ascertaining the true magnitude of the problem. Also needed are data relative to the population at risk, in order to determine the extent to which the number impaired in each age category of fatalities is over-representative of impairment in the normal driving population. Such estimates of the population at
risk are now to some extent available.4 These data have been compared with the fatality data already cited to determine relative amounts of overrepresentation of alcohol in the various age groups.5 The combination of alcohol and age-related factors produces revealing information. The 30- to 34year-old impaired driver was found to be 17 times more likely to be killed than the average unimpaired driver. With older persons the risk increased: the impaired driver over 50 years of age was 39 times more likely to be killed than the average unimpaired driver. Similarly, with younger persons who were impaired, the risk of death also increased: those aged 18 or 19 were 70 times, and those 16 or 17 years old 165 times, more likely to be killed than the average unimpaired driver. Definition of the problem in this manner begins to place the impaired-driver issue in perspective. For example, fewer young drivers than middle-aged drivers are impaired, but among the young drivers who are impaired there is an extremely high risk of fatal collision. Such work on the magnitude of the problem and its parameters is essential because informed development of programs can proceed only when highrisk, potential target groups are delineated. The second question to be answered is whether the magnitude of the problem has changed. It is now 7 years since the amendments to the Criminal Code, proclaimed on Dec. 1, 1969, made it illegal for a person to operate a motor vehicle with a blood alcohol concentration exceeding 80 mg/dl. In those 7 years, education and information on drinking and driving have been expanded; treatment-oriented approaches to the problem have emerged
CMA JOURNAL/JANUARY 22, 1977/VOL. 116 121
(e.g., Driving While Impaired [DWI] - a rehabilitative program for persons convicted of impaired driving); the drinking age, after being lowered in all jurisdictions, has subsequently been raised in Saskatchewan; and most recently, further amendments to the legislation dealing with impaired driving have been proclaimed in Alberta and Ontario, where the potential detection powers of the police have also been extended. Have such programs been successful in reducing the impaired-driver problem? This question is difficult to answer, mainly because, historically, information that would reveal such changes has not been collated. However, economic strictures have resulted in beneficial changes in attitude. The old notion that the cost does not matter as long as a life is saved has come to face the realistic proposition that only limited resources can be deployed at any one time - and mobilization of these resources for one effort may, in fact, cost lives through their being withdrawn from other efforts. Such evaluation is healthy in many ways because it forces countermeasure efforts to overcome, for example, the use of slogans and it raises questions about the continual reliance on legislation to solve our difficulties. Alcohol is inextricably implicated in society and will not silently fade away because of legislation. For example, what was the effect of Canadian legislation introducing the limit to a blood alcohol concentration of 80 mg/dl? After the legislation was introduced there was an immediate and substantial decline in the number of traffic fatalities.6 The legislation apparently had the desired effect. But this effect was short-lived: by 1973 the number of fatalities had exceeded the estimated number if there had been no legislation. What is more surprising are the findings of a report in which impaireddriver fatalities were separated from unimpaired-driver fatalities (previously only gross mortality rates had been considered): the reported decrease in number of deaths and the subsequent increase occurred only for the unimpaired drivers,7 so that the legislation apparently had no effect on the incidence of impaired-driver fatalities. Undoubtedly some effect was produced, but it was transient and did not affect one important segment of the population. The usual response to such commentary is that the legislation is only as good as its enforcement; but enforcement requires detection and it is well known that the frequency of detection of impaired driving is incredibly low. To augment the detection rate to meaningful levels is no easy task.
It seems unfortunate that the majority of countermeasures have been punitive and aimed at either secondary or tertiary prevention. Secondary prevention, which assumes that the drinking driver is on the road, focuses on systems of prevention before an accident can occur. One element of this system is detection but, as I have suggested, this is exceedingly problematic. Tertiary prevention focuses on events following detection or a survivable accident. Such measures are, of course, to some extent contingent on the success of secondary prevention and include punitive systems (e.g., fines and jail terms), rehabilitative methods (e.g., DWI) and combinations of these. The general effectiveness will necessarily be limited, and there is widespread concern about the value of the specific systems.8 Only marginal effort has been expended on primary prevention measures (directed at the time before drinking and driving occur) except through the use of slogans urging people not to drink and drive. More work needs to be directed at the development of primary preventive measures. Such developments can occur only when definition of a problem is adequate. What is needed is a fresh, realistic appraisal of impaired driving in general and of the development of countermeasures in particular. Concerning impaired driving, impassioned zeal has far too long been the prime guiding force and, in an effort to solve the problem, more attention has been devoted to mounting countermeasures and intervention programs than to identifying the precise elements of the problem. If researchers and practitioners combine their talents, progress can be expected. H.M. SIMPsoN, PH D Research director Traffic Injury Research Foundation of Canada Ottawa. Ont.
References 1. SiMi'sor.i HM, HEAYN B: Alcohol and drug determinations in traffic fatalities: a survey of coroners and testing laboratories, in Proceedings of the XIIth Conference of the Traffic Injury Research Foundation of Canada, Ottawa, 1975, pp 1-23 2. Idem: Alcohol and other drug testing in traffic deaths: a report on current practices in Canada. Can J Forensic Sci 9: 27, 1976 3. Traffic Injury Research Foundation of Canada: Analysis of fatal crashes in Canada, 1973, focus: the impaired driver. TIRF Rep, Dec 1975 4. SMITH G, WOLYNErL M, DAvIDsON M. Ct al: Estimated blood/alcohol concentrations of nighttime Canadian drivers, in Proceedings of the XIIth Conference of the Traffic Injury Research Foundation of Canada, op cit, pp 24-49 5. WARREN RA: Total impairment risk factors. TIRF Rep, July 1976 6. CHAMBERS LW, RoBERTs RS, VOELKER CA: The epidemiology of traffic accidents and the effect of the 1969 breathalyzer amendment in Canada. Accident Anal Prey 8: 201, 1976 7. WARREN RA: Empirical evaluation of impaired driver legislation, in Proceedings oj the XIIIth Conference of the Traffic Injury Research Foundation of Canada, Ottawa. 1976, pp 60-80 8. WHITEHEAD PC: D.W.I. programmes: doing what's in or dodging what's indicated. I Sal Res 7: 127, 1975
122 CMA JOURNAL/JANUARY 22, 1977/VOL. 116
.Serax. OXAZEPAM
The non-accumulafing am. INDICATIONS: For management of anxiety, tension, tear, agitation, irritability, insomnia and anxiety associated with depression, e.g. as in transient situational disorder, psychoneurotic reaction, psychophysiological reaction, geriatric behavioral disturbances or personality disorder. Also in anxiety syndrome secondary to organic disease and in residual anxiety syndrome in alcoholics and in alcohol withdrawal. CONTRAINDICATIONS: Not indicated in children under 6 years of age. No definite established dose for children 6 to 12 years of age. Contraindicated in patients who have exhibited previous hypersensitivity to oxazepam. Not indicated in psychoses. PRECAUTIONS: Ambulatory patients may become drowsy or dizzy or experience reduced tolerance to alcohol, so should be warned against driving automobiles or operating dangerous machinery. Some cases of attempted suicide have been reported in which highest dosage ingested was in excess of 600 mg. When treatment is protracted periodic blood counts and liver function tests may be advisable. If rash or other symptoms of hypersensitivity occur, administration of oxazepam should be discontinued and appropriate symptomatic treatment initiated. Hypotensive reactions are rare, but use with caution where complications could ensue from a fall in blood pressure, especially in the elderly. Withdrawal symptoms upon discontinuation have been noted in some patients exhibiting drug dependence through chronic overdose. Carefully supervise dose and amounts prescribed, especially for patients prone to overdose; excessive, prolonged use in susceptible patients (alcoholics, addicts) may result in dependence or habituation. Reduce dosage gradually after prolonged excessive dosage to avoid possible epileptiform seizures. Withdrawal symptoms following abrupt discontinuances are similar to those seen with barbiturates. Safety for use in pregnant women has not been established, therefore oxazepam should not be used during the first trimester of pregnancy unless the benefit to the patient outweighs the possible hazards to the fetus. ADVERSE EFFECTS: Rarely require discontinuance of therapy. Transient mild drowsiness occurs during initial days - if it persists, reduce dosage. In a few cases, dizziness, vertigo, headache and rarely syncope have also occurred. Mild paradoxical reactions, e.g. excitement, stimulation of affect have occurred in psychiatric patients, usually in first 2 weeks of therapy. Minor diffuse skin rashes, leukopenia, hepatic dysfunction including jaundice and nausea, edema, slurred speech, tremor, altered libido and lethargy have occurred infrequently. Ataxia has been reported in rare instances. DOSAGE: Mild to moderate anxiety syndromes, 10 to 15 mg 3 or 4 times daily. Severe anxiety syndromes, 15 to 30 mg 3 or 4 times daily. Geriatric behavior problems, 10mg initially 3 times a day, if necessary increase cautiously to 15 mg 3 or 4 times daily. Residual anxiety syndrome in alcoholics and in alcohol withdrawal, 15 to 30 mg 3 or 4 times daily. SUPPLIED: Each scored tablet contains: oxazepam 10 mg (light yellow), 15 mg (yellow) or 30 mg (white). Tablet weight: 190 mg. Caloric contents: 0.5 caltablet. Bottles of 100 and 500 tablets. REFERENCES: 1. Greenblaft, D. J., Shader, R. I., KochWeser, J.: Pharmacokinetics In Clinical Medicine: Oxazepam versus Other Benzodiazepines. Diseases of the Nervous System. 36:5:2:6-1 3, May, 1975. 2. ibid. 3. Greenblaft, D. J., Shader, R. I.: Drug Therapy: Benzodiazepines, N. Eng. J. Med.: 291: 1011-1015, 1239-1243, 1974. 4. Merlis, S., Koepke, H. H.: The Use of Oxazepam In Elderly Patients. Diseases of the Nervous System, 36:52:27-29, May, 1975. 5. ibid. 6. Halpern, M. M.: The Antianxiety Activity of Oxazepam in Patients with Multiple Organic Disorders. Clinical Practice, July, 1968.
Wyeth L4Ah. lWyeth Ltd., Toronto .R TM tTrademark
EJ
