D R W I L L A N D E R S O N

F R C S , D F M S , F F F L M , L L M , F B I P P

L E A D F O R E N S I C M E D I C A L E X A M I N E R

H A M P S H I R E A N D B T P ( L O N D O N )

Recreational and Prescribed Drugs and Fitness to Drive

Why am I here???

2014/ 2018: FFLM/ DfT/ NHS England:

Competencies for doctors, nurses and paramedics, to ensure awareness of drink and drug drive procedures.

https://fflm.ac.uk/wp-content/uploads/2018/02/Drug-Driving-Competencies-Dr-Will-Anderson-Feb-2018.pdf

Times have changed…

1885: Karl Benz, Benz-Motorwagen

March 2018:

37.9 million vehicles (31.3 million cars) registered in the UK.

Some Key Events…

1861: Locomotive Act Limited to 12 tons.

Speed limit of 10 mph in towns.

1865: The Locomotive Act (“Red Flag Act”)

Reduced speed limits: 4 mph rural area, 2 mph in towns.

Flag man warned horse riders/ carriages of approaching self-propelled machine.

Repealed 1896.

Some Key Events…

1869: Mary Ward:

World’s first fatality of a motor vehicle accident (experimental steam car)

Some Key Events…

1896: Bridget Driscoll

First pedestrian victim of a car accident in the UK.

Driver (Arthur Edsall) was giving demonstration rides at Crystal Palace.

A witness reported the driving as being:

“… in a reckless manner, in fact, like a fire engine.”

The engine had a limiter: 4mph.

Some Key Events…

1897: George Smith, a London taxi driver.

First person to be convicted of drink driving, on 10 September 1897.

“… the divisional surgeon was sent for, who certified that he was drunk.”

Admitted that he’d had ‘two or three glasses of beer.’

Crashed into a wall: fined 20 shillings. (Approx £80 today.)

Some Key Events…

1936: “Drunkometer”

Dr Rolla Harger, Indiana.

Some Key Events…

•1953-54: “Breathalyzer”

• Dr Robert Borkenstein,

Indiana.

Some Key Events…

•1964: “The Role of the Drinking Driver in Traffic

Accidents.”

• Borkenstein RF, Crowther RF, Shumante RP, et

al.

•245 pages.

• “The Grand Rapids Study.”

• Approx 6000 drivers from collisions vs approx

7500 drivers not involved in collisions.

• Age/ gender/ drinking habits can affect degree

of impairment at similar levels.

• Suggested limits of 35mcg/100ml breath and

80mg/100 ml blood.

Some Key Events…

Road Safety Act 1967: alcohol limit set at max 80mg/ 100ml of blood. Use of breathalysers was

approved.

Can conduct breathalyser if: Collision

Moving motor offence

Suspect alcohol in body.

1968: Alcotest 80 breathalyser introduced in UK. With alcohol, potassium

dichromate crystals turned from orange to green.

Oct 2017

50 years since Road Safety Act introduced (7th Oct 1967)

80mg/ 100ml of blood

1979: 1640 drink drive deaths

2015: 200 drink drive deaths

Overall, 22 deaths/ day in the 1960s down to 5 deaths/ day.

Alcohol Limits

England, Wales and NI:

35mcg/ 100ml of breath

80mg/ 100ml of blood

107mg/ 100ml of urine

NB: THESE ARE THE HIGHEST LIMITS IN THE WORLD.

Scotland (Dec 2014)

22mcg/ 100ml of breath

50mg/ 100ml of blood

67mg/ 100ml of urine

Some Key Events…

1981: Transport Act Allowed for evidential breath readings.

Section 25 and Schedule 8

However, not rolled-out until 1983.

Lion Intoximeter 3000

(Admissible under PACE 1984 S69, “Evidence from Computer Records”)

Some Key Events…

Road Traffic Act 1988

Section 4: Driving, or being in charge, when under influence of drink or drugs.

Section 5: Driving or being in charge of a motor vehicle with alcohol concentration above prescribed limit.

Section 5a: Driving, or being in charge of a motor vehicle with concentration of specified controlled drug above specified limit.

Some Key Events…

Section 4 Field Impairment Tests

Eye examination

Romberg Test/ 30 second count

Walk-and-turn test

One-legged stand test

Finger-to-nose test

DO NOT need to demonstrate impairment

Only need to determine if there “may be a condition due to drink or drugs”

Some Key Events…

Police Reform Act 2002

Sections 56/57: Specimens taken from persons incapable of consenting/ Use of specimens taken from persons incapable of consenting.

Inserted after Section 7 RTA 1988

Must not impede on-going medical care

NI: Criminal Justice (Northern Ireland) Order 2005

Role extended to nurses and paramedics 10th April 2015

Some Key Events…

“Taking blood specimens from incapacitated drivers: Guidance for doctors from the BMA/ FFLM.”

July 2010

First published October 2002. (Revised 2004, 2007, 2009 and 2010.)

Further revised Sept 2017

https://fflm.ac.uk/wp-content/uploads/2017/10/Taking-Blood-Specimens-from-Incapacitated-Drivers-September-2017.pdf

Some Key Events…

2009-10: The North Report

2011: Government Response to North Report

2012-13: Expert working group (Wolff Report)

2015: New legislation.

June 2010

Published June 2010 “Report of the Review of

Drink and Drug Driving Law.” Sir Peter North CBE, QC.

Oxford academic/ lawyer.

51 recommendations 28 for drink-drive 23 for drug-drive

41% of drug driving cases dismissed/ failed at Court. 3% for drink driving.

http://webarchive.nationalarchives.gov.uk/20100921035247/http://northreview.independent.gov.uk/docs/NorthReview-Report.pdf

North Report: (Drink-drive)

Recommendation (3): blood alcohol limit should be reduced to 50 mg of alcohol in 100 ml of blood.

(And the equivalent amounts in breath and urine.)

North Report: (Drink-drive)

Recommendation (7): Best practice should be rolled out to transport industry, e.g. interlocks, and employer guidelines.

Recommendation (12): The Government should determine the levels of the active and impairing metabolites of:

• opiates;

• amphetamines;

• methamphetamine;

• cocaine;

• benzodiazepines;

• cannabinoids;

• methadone;

• ecstasy (MDMA).

Expert Working Group

March 2013: “Report from the Expert Panel on

Drug Driving”, Dr Kim Wolff et al.

Produced a list of acceptable limits for medical and illicit drugs.

Limits with/ without alcohol.

https://www.bl.uk/britishlibrary/~/media/bl/global/social-welfare/pdfs/non-secure/d/r/i/driving-under-the-influence-of-drugs-report-from-the-expert-panel-on-drug-driving.pdf

List of Drugs

Illicit Drugs Wolff Recommendation(March 2013)

Govt Proposal(March 2014)

Benzoylecgonine 500 μg/L 50 µg/L

Cocaine 80 μg/L 10 µg/L

Delta–9–Tetrahydrocannabinol (Cannabis and Cannabinol),

5 μg/L 2 µg/L

Ketamine 200 μg/L 20 µg/L

Amphetamine 600 μg/L Further consultation required

Lysergic Acid Diethylamide (LSD), No recommendation 1 µg/L

Methylamphetamine 200 μg/L 10 µg/L

Methylenedioxymethaphetamine (MDMA – Ecstasy),

300 μg/L 10 µg/L

6-Monoacetylmorphine (6-MAM –Heroin and Diamorphine),

80 μg/L 5 µg/L

April 2014:

Amphetamine 250µg/L

List of Drugs

Generally prescription drugs

Wolff Recommendation(March 2013)

Govt Proposal(March 2014)

Clonazepam 50 μg/L 50 µg/L

Diazepam 550 μg/L 550 µg/L

Flunitrazepam, 300 µg/L 300 µg/L

Lorazepam 100 μg/L 100 µg/L

Methadone 500 μg/L 500 µg/L

Morphine 80 µg/L 80 µg/L

Oxazepam 300 μg/L 300 µg/L

Temazepam 1000 µg/L 1000 µg/L

New Laws 2015

2nd March 2015:• Section 5A of RTA 1988.

• New offence of driving with certain controlled drugs, including some prescription drugs, above specified limits.

• Allows for roadside testing of drugs: “Drugalyser”• Cocaine/ Cannabis

• Medical defence is incorporated into law.

• In Court, no need for CPS to prove impairment.

Remember

If someone takes medication that causes side effects that may affect driving, e.g. visual disturbance, drowsiness, tremors etc., they still have a responsibility to society and the DVLA/DVA

This has NOT changed since the new legislation in 2015.

Manual of Guidance Drink and Drug Driving (MGDD) Forms

A: (Nov 2017) Drink/ Drugs Station procedure

B: (Nov 2017) Drink/ Drugs Station procedure

C: (Sept 2017) Drink/ Drugs Hospital procedure

D: (Jan 2018) Technical Defences and Back Calculation

E: (Feb 2015) Drug Drive Laboratory Submissions

F: (March 2016) Roadside Impairment Test

GMC Guidelines

GMC: April 2017

“Confidentiality: patients’ fitness to drive and reporting concerns to the DVLA or DVA”

https://www.gmc-uk.org/-/media/documents/confidentiality---patients-fitness-to-drive-and-reporting-concerns-to-dvla-or-

dva_pdf-70063275.pdf

Only 3 pages

Based on GMC Confidentiality guidance.

Drivers still have duty to notify DVLA/ DVA about any medical conditions or treatment that may make driving unsafe.

Can notify DVLA/DVA without driver’s consent if they continue to drive, and it would be in public interest to notify DVLA/DVA.

Refers to DVLA guidance: “Assessing fitness to drive: a guide for medical professionals”

“Assessing fitness to drive: a guide for medical professionals” https://assets.publishing.service.gov.uk/government/uploads/

system/uploads/attachment_data/file/736938/assessing-fitness-to-drive-a-guide-for-medical-professionals.pdf

2016 (Updated Aug 2018), 142 pages, updated every 6 months.

Several references to the GMC 2017 guidelines.

Expectations apply to doctors, optometrists and other healthcare professionals

DVLA/ DVA Guidance for Doctors

GMC/ DVLA

i.e. there is now written expectation from GMC and DVLA that doctors and other HCPs will act in the best interests of the patient and/or the public interest.

Both the GMC and the DVLA state that the clinician has a responsibility for medical concerns with drivers.

DVLA/ DVA Guidance to Drivers

Penalties for drug driving

If you’re convicted of drug driving you’ll get:

a minimum 1 year driving ban

an unlimited fine

up to 6 months in prison

a criminal record

Your driving licence will also show you’ve been convicted for drug driving. This will last for 11 years.

DVLA/ DVA Guidance to Drivers

The penalty for causing death by dangerous driving under the influence of drugs is a prison sentence of up to 14 years.

Other problems you could face:

A conviction for drug driving also means:

Your car insurance costs will increase significantly

If you drive for work, your employer will see your conviction on your licence

You may have trouble travelling to countries like the USA

DVLA/ DVA Guidance to Drivers

You must tell DVLA if you have a driving licence and:

you develop a ‘notifiable’ medical condition or disability

a condition or disability has got worse since you got your licence

Notifiable conditions are anything that could affect your ability to drive safely. They can include:

diabetes or taking insulin

syncope (fainting)

heart conditions (including atrial fibrillation and pacemakers)

sleep apnoea

epilepsy

strokes

Glaucoma

Drug use and driving

You must tell DVLA if you’ve used illegal drugs or misused prescription drugs.

You can be fined up to £1,000 if you don’t tell DVLA about a medical condition that affects your driving. You can be prosecuted if you’re involved in an accident as a result.

DVLA/ DVA Guidance to Drivers

You must surrender your licence to DVLA if your doctor tells you that you need to stop driving for 3 months or more because of your medical condition.

You can apply to get your licence back when you meet the medical standards for driving again.

Some Key Events…

April 2017: Scottish Government announced that legislation will be introduced in 2019 relating to drug-drive limits.

Date not confirmed.

Drugs/ their limits not yet confirmed.

Some Key Events…

April 2017:

“Expert Panel Review of alternative biological matrices for use as an evidential sample for drug driving”

Wolff, Agombar, Clatworthy et al.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/624915/expert-panel-report.pdf

Some Key Events…

They considered:

Blood

Oral Fluid (OF)

Sweat

Hair

Dried Blood Spots (DBS) and small liquid samples

Latent Fingerprints

Exhaled Breath Condensate (EBC)

Some Key Events…

Recommendations:

1: Add amphetamine-type drugs and ketamine to oral screening.

2: Blood remains the gold standard for establishing levels.

3: Oral testing is satisfactory for lower limits of quantification

4: Hair testing is appropriate for re-licensing decisions.

5: Need new approach for polysubstance detection.

6: DfT needs to monitor changing drug use and amend procedures/ legislation to reflect this.

7: DfT should monitor developments in other countries.

Some Key Events…

April 2017 (published Aug 2017):

“Evaluation of the new drug driving legislation, one year after its introduction”

Dept. for Transport

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/609852/drug-driving-evaluation-report.pdf

Some Key Events…

Implementation successful.

Too early to say whether it has improved road safety.

Public awareness of drug driving has increased.

“As well as removing drug drivers from the roads, police forces believe the new offence has helped disruption of criminality more widely”.

Some Key Events…

32% of (saliva) positive for cannabis produced blood levels below limits.

1 in 8 that proceeded to blood could not provide a blood test: failure for medical reasons (approx50%) or refusal to provide.

Emphasises need to gather evidence of impairment or a condition that could be due to drink or drugs , i.e. arrest for S4 as well as S5a.

Some Key Events…

Oct 2017: Dominic Raab, Minister for Courts and Justice: Tougher sentences for drivers who cause death by drug driving, driving while using mobile phones, and speeding.

Public consultation from Dec 2016-Feb 2017

9115 responses

Currently maximum 14 years in prison for death by drug driving.

Would become a life sentence under new legislation.

Nov 2017

Randox Testing Services (Manchester):

10,000 forensic cases being reviewed

50 cases involving drug driving dropped

2 drivers appealing convictions for death by drug driving

Feb 2017

2 members of staff suspended

Allegations of manipulation of samples and results

Suspected 500 samples affected.

Some Key Events…

May 2018:

“Changing driving laws to support automated vehicles. Policy paper.”

National Transport Commission, Australia

S 7.2: Alcohol and drug offences should not apply to passengers in a dedicated automated vehicle

-“…exemptions should be provided for occupants of dedicated automated vehicles because they will always be passengers.”

Some Key Events…

Nov 2017 (Budget)

Chancellor Philip Hammond:

£1Bn for development/ car charging points/ testing of autonomous cars on UK roads

Self-driving cars on UK roads by 2021

Post-Brexit (March 2019), this would be ahead of other European countries due to their tighter legislation on testing driverless cars.

Some Key Events…

First fatality from Autonomous Car

Joshua Brown, 7th May 2016, Florida:

Tesla Model S

Crashed into tractor lorry.

Worldwide: 1 death per 60 million miles driven

Tesla cars tested over 130 million miles at time of this fatality

GB Figures

First compiled 1926 (RoSPA)

Between 1951 and 2006: 309,144 people were killed/ 17.6 million were injured on British roads.

March 2018

Roads Minister, Jesse Norman:

Review of road traffic legislation over the next 3 years.

Allocation of civil and criminal responsibility by law where there is shared control between humans and computers.

The role of automated vehicles in public transport, car sharing and on-demand passenger services.

March 2018

Roads Minister, Jesse Norman:

Review of road traffic legislation over the next 3 years.

Any need for new criminal offences.

The impact on other road users and how they can be protected from risk.

Determining who the responsible person is in a self-driving vehicle.

June 2018

UK Government announced plans for evidential roadside breathalysers by summer of 2020

Had been suggested in North Report (2010)

Overseen by PACTS (Parliamentary Advisory Council for Transport Safety)

Companies invited to submit evidential breathalysers

Some final thoughts…

Drivers frequently lie!

Amount they have drunk. Weekly consumption. When they last ate. Whether using illicit drugs. What medication they take. Whether they were driving.

Any Questions?????