The role of exposure on differences in driver death rates by gender and age: Results of a quasi-induced method on crash data in Spain.

AIM: Part of the differences by age and gender in driver death rates from traffic injuries depends on the amount of exposure (km/year travelled). Unfortunately, direct indicators of exposure are not available in many countries. Our aim was to compare the age and gender differences in death rates with and without adjustment by exposure using a quasi-induced exposure approach in Spain, during 2004-2012. METHODS: Crude and adjusted death rate ratios (CDRR and ADRR, respectively) were calculated for each age and gender group. To obtain the latter estimates, in accordance with quasi-exposure reasoning, the number of registered drivers was replaced by the number of non-infractor drivers, passively involved in collisions with another vehicle whose driver committed an infraction. 18-29 years and female drivers were chosen as the reference categories for age and gender. RESULTS: Striking differences were found between CDRR and ADRR estimates. When CDRR were estimated, we found the highest traffic mortality among the youngest drivers, except for females in non-urban roads. ADRR however showed the highest mortality among the oldest groups, especially in females, peaking among drivers >74 years in all types of roads. Regarding differences by gender, both estimates revealed higher traffic mortality in males, although the differences were much smaller when using ADRR. CDRR and ADRR for males tended to converge as age increased. CONCLUSIONS: Death risk from traffic injuries among drivers is clearly influenced by the amount of exposure. These findings further emphasize the need to obtain direct traffic exposure estimates by subgroups of drivers.

Nothing good ever happens after midnight: observed exposure and alcohol use during weekend nights among young male drivers carrying passengers in a late licensing country.

Similar to other countries, also in the Netherlands young male drivers (ages between 18 and 24 years) are overrepresented in crashes during weekend nights, thereby fatally injuring one or more of their passengers. This overrepresentation may be due to two contributing factors: (a) a higher exposure-to-risk because of dangerous trip condition, and (b) a higher tendency to take risks. Studies on these factors, mostly carried out in jurisdictions where youngsters are licensed at an earlier age than in Europe, suggest a strong -often negative- influence from peer-aged passengers. Given that in adolescence susceptibility to peer pressure reduces with age, these findings may not be applicable to late licensing countries, such as in Europe. In the Netherlands -a late licensing country- youngsters are licensed after the age of 18 years, followed by a 5 year probation period with a legal alcohol limit of 0.2g/L. Further, designated driver schemes are in place since 2001, alcohol limits are enforced by random breath testing schemes, and no passenger and night time restrictions are in force. Against this background, we examined the incidence of dangerous trip conditions and risk taking among young male drivers and compared those with a reference group with a low passenger fatality rate. To that end, data on trip conditions and risk behavior were obtained from a data base on 18,608 randomly selected drivers during weekend nights in 2010, between 22:00 and 06:00. This data base held information for each randomly selected on breath alcohol concentration (BAC), license status, driver characteristics (age and gender), number of passengers, time of night, and level of urbanization. Binary logistic regression analysis confirmed the overrepresentation of young male drivers in traffic, carrying more frequently passengers than the reference group, especially after midnight. Urbanization level was not a modifying factor, but 'time of night' was, with riskier conditions after midnight in terms of: (a) a higher young male driver presence, (b) young male drivers carrying more frequently multiple passengers and (c) a higher prevalence of illegal BACs. After midnight, no evidence was found for a protective effect of the presence of one passenger on alcohol use. Of the young male drivers, 5% were over the legal limit and 3 in 5 young males who were over the limit carried passengers. However, the indicative result that young male drivers with multiple passengers were less likely to have been drinking than solo drivers or drivers with just one passenger, is suggestive of a protective effect of multiple passengers. These results may guide preventive strategies, including police enforcement and designated driver programmes.

Driving under the influence of alcohol in the Netherlands by time of day and day of the week.

The purpose of this study is to provide an overview of the variation in the prevalence of alcohol in everyday traffic in the Netherlands during all days of the week and all times of day. Breath tests were taken from randomly selected car drivers and drivers of small vans in six police regions in the Netherlands between January 2007 and August 2009. A total of 28,057 drivers were included in the study. The prevalence of driving under the influence of alcohol was highest during night-time hours of weekend days. Large proportions of sampled drivers under the influence of alcohol were also found during day-time hours on weekend days, especially early in the morning and early in the evening. Furthermore, a small proportion of sampled drivers under the influence of alcohol was found during morning traffic on Monday and Friday mornings. The results of this study indicate that drink driving is not only limited to night-time hours and that prevalence of drink driving is also high during evening hours from Wednesday to Sunday. In addition to these time periods, breath testing activities may also be effective from a police enforcement perspective on Monday, Friday, and Saturday mornings between 06.00h and 08.00h and on Sunday mornings until 10.00h.

Random and systematic errors in case-control studies calculating the injury risk of driving under the influence of psychoactive substances.

Between 2006 and 2010, six population based case-control studies were conducted as part of the European research-project DRUID (DRiving Under the Influence of Drugs, alcohol and medicines). The aim of these case-control studies was to calculate odds ratios indicating the relative risk of serious injury in car crashes. The calculated odds ratios in these studies showed large variations, despite the use of uniform guidelines for the study designs. The main objective of the present article is to provide insight into the presence of random and systematic errors in the six DRUID case-control studies. Relevant information was gathered from the DRUID-reports for eleven indicators for errors. The results showed that differences between the odds ratios in the DRUID case-control studies may indeed be (partially) explained by random and systematic errors. Selection bias and errors due to small sample sizes and cell counts were the most frequently observed errors in the six DRUID case-control studies. Therefore, it is recommended that epidemiological studies that assess the risk of psychoactive substances in traffic pay specific attention to avoid these potential sources of random and systematic errors. The list of indicators that was identified in this study is useful both as guidance for systematic reviews and meta-analyses and for future epidemiological studies in the field of driving under the influence to minimize sources of errors already at the start of the study.

Alcohol and drugs in seriously injured drivers in six European countries.

The objective of this study was to determine the presence of alcohol and drugs in drivers severely injured in traffic crashes in six European countries. Data were collected from 2492 seriously injured drivers of cars and vans in Belgium, Denmark, Finland, Italy, Lithuania, and the Netherlands, between 2007 and 2010. Toxicological analysis was performed with chromatographic techniques on whole blood for 23 substances. The percentage of drivers positive for at least one psychoactive substance ranged between 28% (Lithuania) and 53% (Belgium). Alcohol (≥0.1 g/L) was the most common finding with the highest percentage in Belgium (42.5%). Among the alcohol-positive drivers, 90.5% had a blood alcohol count (BAC) ≥0.5 g/L and 65.7% had a BAC ≥1.3 g/L. Benzodiazepines (0.0-10.2%) and medicinal opioids (0.5-7.8%) were the most prevailing medicinal drugs, but half of the concentrations were lower than therapeutic. Cannabis (0.5-7.6%) was the most prevailing illicit drug. Alcohol was found in combination with drugs in 2.3-13.2% of the drivers. Drug combinations were found in 0.5-4.3% of the drivers. This study confirms the high prevalence of psychoactive substances in injured drivers, but we observed large differences between the participating countries. Alcohol was the most common finding, followed by cannabis and benzodiazepines. Notable are the many drivers having a BAC ≥ 1.3 g/L. The majority of the substances were found in combination with another psychoactive substance, mostly alcohol. The high prevalence of high BACs and combinations (compared to roadside surveys) suggest that those drivers are most at risk and that preventive actions should target them preferentially.

Is law enforcement of drug-impaired driving cost-efficient? An explorative study of a methodology for cost-benefit analysis.

BACKGROUND: Road users driving under the influence of psychoactive substances may be at much higher relative risk (RR) in road traffic than the average driver. Legislation banning blood alcohol concentrations above certain threshold levels combined with roadside breath-testing of alcohol have been in lieu for decades in many countries, but new legislation and testing of drivers for drug use have recently been implemented in some countries. METHODS: In this article we present a methodology for cost-benefit analysis (CBA) of increased law enforcement of roadside drug screening. This is an analysis of the profitability for society, where costs of control are weighed against the reduction in injuries expected from fewer drugged drivers on the roads. We specify assumptions regarding costs and the effect of the specificity of the drug screening device, and quantify a deterrence effect related to sensitivity of the device yielding the benefit estimates. RESULTS: Three European countries with different current enforcement levels were studied, yielding benefit-cost ratios in the approximate range of 0.5-5 for a tripling of current levels of enforcement, with costs of about 4000 EUR per convicted and in the range of 1.5 and 13 million EUR per prevented fatality. CONCLUSIONS: The applied methodology for CBA has involved a simplistic behavioural response to enforcement increase and control efficiency. Although this methodology should be developed further, it is clearly indicated that the cost-efficiency of increased law enforcement of drug driving offences is dependent on the baseline situation of drug-use in traffic and on the current level of enforcement, as well as the RR and prevalence of drugs in road traffic.

In search of a standard for assessing the crash risk of driving under the influence of drugs other than alcohol; results of a questionnaire survey among researchers.

OBJECTIVE: To find a gold standard for crash risk assessment studies in the field of driving under the influence of psychoactive substances. METHODS: A questionnaire survey on methodological aspects concerning study designs was sent to researchers in the field of driving under the influence of psychoactive substances. The questionnaire was aimed at the 4 main study designs to assess the crash risk of driving under the influence: case-control studies, culpability studies, pharmaco-epidemiological studies, and experimental studies. RESULTS: The response rate for the questionnaire was 68 percent (N = 57). Forty-six percent of the respondents had a preference for assessing the crash risk by means of case-control studies, 35 percent by means of experimental studies, 14 percent by means of culpability studies, and 5 percent by means of pharmaco-epidemiological studies. In practice, however, only 51 percent of the researchers actually used the study type they preferred in theory. For the 4 most commonly used study designs, similarity rates varied from 66 to 81 percent for the theoretically preferred design and from 52 to 77 percent for the design that was actually applied. CONCLUSIONS: Based on the results of the questionnaire survey, it can be concluded that despite several attempts in the past to standardize study design, there is still no common standard for assessing the crash risk of driving under the influence. The differences are not only caused by practical, legal, financial, or ethical issues but also by differences between researchers concerning their theoretically preferred study design.

Repeatability of oral fluid collection methods for THC measurement.

STUDY OBJECTIVES: To determine the influence of sample collection for two different collection methods on THC concentrations and to compare THC concentrations collected by both methods. METHODS: A total of 136 pairs of oral fluid samples from subjects who had recently smoked Cannabis were obtained by the non-acidic Statsure oral fluid collection device and by ordinary spit tubes. Oral fluid was analyzed for THC by LC-MS/MS. Bland-Altman plots were used for the quantitative analysis of repeatability, whereas Cohen's kappa was used for qualitative analysis to determine the consistency of the results with regard to the Belgian legal limit. RESULTS: Repeatability of both sampling methods was very low. The Statsure device had a better rate of agreement when compared with the Belgian legal limit than the spitting method. THC concentrations of samples collected by spit tubes were on average a factor 5.9 higher than the corresponding concentrations in samples collected by the Statsure device. CONCLUSIONS: The repeatability of both the Statsure collection method and the ordinary spit tubes was low when applied to subjects who had consumed Cannabis very recently. Furthermore, THC concentrations were higher in samples obtained by spitting than samples collected with Statsure. These results may have implications for confirmation analysis in oral fluid, when applied for legal purposes.

Prevalence of psychoactive substances in dutch and belgian traffic.

OBJECTIVE: The purpose of this study was to compare the prevalence of psychoactive substances in general traffic in The Netherlands and Belgium. METHOD: Randomly selected car drivers and drivers of small vans in six police regions in The Netherlands and five police regions in Belgium were included between January 2007 and August 2009. Blood and oral fluid samples were analyzed for 23 substances, including ethanol (alcohol), by means of ultra performance liquid chromatography-tandem mass spectrometry or gas chromatography-mass spectrometry analysis. Samples were weighted according to the distribution of traffic over eight 6-hour periods. Substance groups were categorized in five mutually exclusive classes: single alcohol use, single illicit drug use, single medicinal drugs use, multiple drug use (including drugs from two or more separate substance groups but excluding alcohol), and drug use (either single or multiple) in combination with alcohol. RESULTS: In total, 7,771 drivers (4,822 in The Netherlands and 2,949 in Belgium) were included in the study. In Belgium, the prevalence of single alcohol (6.4%) and single medicinal drugs (3.0%) was much higher than in The Netherlands (2.2% and 0.6%, respectively), whereas the single illicit drugs were more common in Dutch traffic (2.2%) than in Belgian traffic (0.6%). Compared with the estimated prevalence of psychoactive substances in the general driving public in Europe, the prevalence in Belgium (10.7%) was greater than the European average (7.4%), and the prevalence in The Netherlands was below the European average (5.5%). CONCLUSIONS: The observed prevalence of psychoactive substances varies largely between The Netherlands and Belgium. Probable reasons for the differences are the higher level of alcohol enforcement in The Netherlands and nonresponse bias in the Belgian study (for illicit drugs in particular). Furthermore, cultural differences and variances in prescription policy could also be influential.

Prevalence of alcohol and other psychoactive substances in injured drivers: comparison between Belgium and The Netherlands.

STUDY OBJECTIVE: To compare the prevalence of alcohol and (il)licit drugs in seriously injured drivers in Belgium (BE) and the Netherlands (NL). METHODS: Injured car and van drivers admitted to the emergency departments of five hospitals in Belgium and three in the Netherlands from January 2008 to May 2010 were included. Blood samples were taken and analysed for ethanol (with an enzymatic method) and 22 other psychoactive substances (UPLC-MS/MS or GC-MS). RESULTS: In total 535 injured drivers were included in the study (BE: 348; NL: 187). More drivers were found positive for alcohol and drugs in Belgium (52.6%) than in the Netherlands (33.9%). Alcohol (≥0.1 g/L) was the most prevalent substance in both countries (BE: 42.5%; NL: 29.6%). A similar prevalence was found for amphetamine (BE: 2.6%; NL: 2.2%) and cocaine (BE: 2.3%; NL: 2.1%). In the Netherlands almost no positive findings for cannabis were recorded (0.5%). No driver tested positive for benzodiazepines in the Netherlands compared to 7.3% in Belgium. More injured drivers tested positive for Z-drugs (BE: 1.8%; NL: 0.5%) and medicinal opioids (BE: 3.3%; NL: 0.5%) in Belgium. CONCLUSIONS: The prevalence of alcohol in seriously injured drivers was 12% higher found in Belgium than in the Netherlands. The prevalence of drugs was similar in both countries except for THC and medicinal drugs, particularly benzodiazepines, with a much higher prevalence in Belgium. In comparison to previous survey there were differences in the prevalence of THC, benzodiazepines and combinations of drugs. Possible explanations are the different matrix used, a bias in study population, or in case of illicit opiates and benzodiazepines a different consumption pattern in the two countries. Alcohol is still the most prevalent substance among the injured driver population and this increased the last 15 years.

An analytical evaluation of eight on-site oral fluid drug screening devices using laboratory confirmation results from oral fluid.

The performance of eight on-site oral fluid drug screening devices was studied in Belgium, Finland and the Netherlands as a part of the EU-project DRUID. The main objective of the study was to evaluate the reliability of the devices for testing drivers suspected of driving under the influence of drugs (DUID). The performance of the devices was assessed by their ability to detect substances using cut-offs which were set at sufficiently low levels to allow optimal detection of positive DUID cases. The devices were evaluated for the detection of amphetamine(s), cannabis, cocaine, opiates and benzodiazepines when the relevant test was incorporated. Methamphetamine, MDMA and PCP tests that were included in some devices were not evaluated since there were too few positive samples. The device results were compared with confirmation analysis results in oral fluid. The opiates tests appeared to perform relatively well with sensitivity results between 69 and 90%. Amphetamines and benzodiazepines tests had lower sensitivity, although the DrugWipe test evaluated was promising for amphetamine. In particular, it is evident that the cannabis and cocaine tests of the devices still lack sensitivity, although further testing of the cocaine tests is desirable due to the low prevalence and low concentrations encountered in this study.