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