Alcohol, illicit drugs and medicinal drugs in fatally injured drivers in Spain between 1991and 2000

Alcohol, illici d ugs and medicinal d ugs in a ally inju ed d i e s in Spain be ween 1991and 2000 M. Ca men del Rı ´o a , Jose ina Go ´mez b , Manuel Sancho b , F. Ja ie Al a ez a,* a D ugs and Alcohol Resea ch G oup, Depa men o Pha macology and The apeu ics, Facul y o Medicine, Uni e si y o Valladolid, 47005 Valladolid, Spain b Na ional Toxicological Cen e, Ins i u o Nacional de Toxicologı ´a, Mad id, Spain Recei ed 9 Oc obe 2001; ecei ed in e ised o m 24 Ma ch 2002; accep ed 12 Ap il 2002 Abs ac The aim o his s udy was o assess he p esence o alcohol, illici d ugs and medicinal d ugs among Spanish d i e s in ol ed in a al oad acciden s be ween 1991 and 2000. Samples we e ob ained o 5745 d i e s killed in oad acciden s om Janua y 1991 o Decembe 2000. O he samples, 91.7% ep esen ed males and 8.3% emales; 40.7% we e unde 30 yea s o age, 31.9% we e unde 31–50 yea s o age, 19.5% we e o e 51 yea s o age, and o 7.9% he age was unknown. Be ween 1991 and 2000, some ype o psychoac i e subs ance was de ec ed among 50.1% o hose d i e s killed in oad acciden s, his being mainly alcohol (43.8%) and, less equen ly, illici d ugs (8.8%) and medicinal d ugs (4.7%). In all he cases, in which alcohol was de ec ed, combined use wi h o he subs ances accoun ed o only 12.5%, whils in he case o illici and medicinal d ugs, igu es ep esen ing combined use wi h o he subs ances we e 75.6% o he o me and 65.8% o he la e . Fo one in e e y h ee cases (32.0%), a blood alcohol le el o e 0.8 g/l was eco ded; cocaine (5.2%), opia es (3.2%) and cannabis (2.2%) we e he h ee illici d ugs mos equen ly de ec ed. Among medicinal d ugs, we e benzodiazepines (3.4%), an i-dep essan d ugs (0.6%) and analgesics (0.4%). The esul s show he equen p esence o psychoac i e subs ances, pa icula ly alcohol, among Spanish mo o ehicle use s in ol ed in a al oad acciden s. I should be poin ed ou ha illici and medicinal d ugs in combina ion wi h o he subs ances we e a common ea u e. #2002 Else ie Science I eland L d. All igh s ese ed. Keywo ds: Alcohol; D ugs; Fa al inju ies; Medicinal d ugs; Road a ic acciden s; Spain 1. In oduc ion Resea ch has shown ha alcohol impai s d i ing skills and inc eases c ash isk [1]. Wi hin he Eu opean Union, a e age yea ly oad a ic acciden s be ween 1991 and 1998 in ol ed 10,000 (21.3%), ou o he 47,000 a al acciden s, ela ed o alcohol [2]. In he las yea s, esea ch has shown ha illici d ugs and ce ain medicinal d ugs also impai d i ing skills and can inc ease c ash isk [3,4]. The e o e, as d ink-d i ing is dec easing in some coun ies, he ole played by illici and medicinal d ugs has become he objec o inc easing in e es [5,6]. In a ecen e iew [7,8], i was shown ha he p esence o alcohol and d ugs among inju ed d i e s (36 and 19%, espec i ely) and d i e s killed on he oads (31.7 and 16.3%, espec i ely) was a common ea u e. In he s udy conduc ed by Gie [9] o he Pompidou G oup, Council o Eu ope, and based on 13 Eu opean coun ies, ce ain in e - es ing indings we e ob ained. Among he gene al d i e popula ion, he p e alence o illici d ug use was in he ange o 1–5%, while ha o medicinal d ugs ep esen ed 5–15%. Among hose d i e s suspec ed o d i ing unde he in lu- ence o d ugs, a high p e alence o medicinal d ugs was epo ed (14–74%), while he p e alence o illici d ugs was lowe (9–57% o cannabis, 8–42% o opia es and 1–20% o amphe amines). Rega ding collision-in ol ed d i e s, he p e alence o illici d ugs anged om 10 o 25% (in a al oad acciden s) and, in he case o medicinal d ugs, Fo ensic Science In e na ional 127 (2002) 63–70 * Co esponding au ho . Tel.: þ34-983-423077; ax: þ34-983-423022. E-mail add ess: [email p o ec ed] a.es (F.J. Al a ez). 0379-0738/02/$ – see on ma e #2002 Else ie Science I eland L d. All igh s ese ed. PII: S 0379-0738(02)00116-0 om 6 o 21%. The au ho [9] also poin ed ou he di i- cul ies encoun e ed when compa ing he di e en s udies. The e idence a ailable in Spain indica es ha alcohol consump ion and use o o he psychoac i e subs ances a e equen among mo o ehicle use s, and ha d i ing unde he in luence o hese subs ances is equally cus oma y [10,11]. Only in he las ew yea s has in o ma ion begun o be a ailable abou he in ol emen o psychoac i e sub- s ances in he incidence o a ic acciden s [12–14]. Cu en legisla ion in Spain s a es ha one may no d i e unde he in luence o psychoac i e subs ances (illici d ugs and medicinal d ugs) ha may al e he physical o men al s a e in which one is i o d i e wi hou dange (Royal Dec ee 13/1992). Likewise, maximum pe missible blood alcohol le els among mo o ehicle use s ha e been es ab- lished o se e al decades. On 7 May 1999, Royal Dec ee 2282/1998 became e ec i e, es ablishing blood alcohol concen a ions and o malising es s on mo o ehicle use s, as well as modi ying he legisla ion which had been in e ec un il ha ime unde he Gene al D i ing Regula ions (Royal Dec ee 13/1992). In acco dance wi h he new legisla ion, mo o ehicle use s a e no allowed o d i e i hei blood alcohol concen a ion is g ea e han 0.5 g/l (o 0.25 mg/l in exhaled ai ). These limi s a e 0.3 g/l (0.15 mg/l in exhaled ai ) o use s o ehicles in ended o anspo ing goods, passenge s/school child en, haza dous goods, special ans- po a ion, e c. as well as o any ope a o in he i s 2 yea s a e ob aining a d i e ’s licence o pe mi [12,13]. In his s udy, we analyse he da a om he Na ional Toxicological Cen e ega ding he p esence o subs ances in mo o ehicle d i e s killed in oad acciden s. The aim is o de e mine he ole ha alcohol, illici d ugs and medicinal d ugs play in he incidence o a ic acciden s, as well as o analyse hei e olu ion o e he las 10 yea s (1991–2000). A p elimina y e sion was p esen ed a he ICADTS Con e - ence in S ockholm [14]. 2. Ma e ial and me hods Samples om 5745 d i e s killed in oad acciden , om Janua y 1991 o Decembe 2000, we e ob ained. Sample dis ibu ion acco ding o yea was as ollows: 1991, 259; 1992, 250; 1993, 199; 1994, 244; 1995, 279; 1996, 383; 1997, 487; 1998, 1090; 1999, 1191; 2000, 1363. A o al o 91.7% (n¼5266) o he samples we e om males and 8.3% (n¼479) om emales. As ega ds age ange, 10.0% (n¼ 575) we e unde 20 yea s o age; 30.7% (n¼1763) we e aged 21–30 yea s; 19.3% (n¼1107) we e aged 31–40 yea s; 12.6% (n¼726) we e aged 41–50 yea s; 8.9% (n¼511) we e aged 51–60 yea s; 10.6% (n¼611) we e o e 60 yea s o age; in he es o he cases 7.9% (n¼452), he age was unknown. The cases co espond o samples e e ed o he Na ional Toxicological Cen e (Ins i u o Nacional de Toxicologı ´a) by o ensic doc o s o as ins uc ed by he judge. Blood samples we e analysed o alcohol (e hanol) by Head-Space Gas ch oma og aphy) [12–14]. All samples we e also sc eened o he p esence o d ugs o he han alcohol (medicines and illici d ugs) by immunological o ch oma og aphic me hods when app op ia e. The cu -o le els o he i s sc eening we e: opia es 300 ng/ml; cocaine me aboli e 150 ng/ml; cannabinoids 20 ng/ml; amphe a- mines 300 ng/ml; benzodiazepines 200 ng/ml. Posi i e esul s a e sc eening we e con i med by means o gas ch oma og aphy–mass spec ome y (GC–MS), and con- cen a ions o psychoac i e d ugs o me aboli es we e de e - mined [12–14]. In he case o opia es, amphe amines and cocaine, he cu -o le els o he GC–MS con i ma ion es we e in he selec ed ion moni o ing mode (SIM) 50 ng/ml, and 10 ng/ml in he case o cannabis. Posi i e esul s we e con i med by GC–ni ogen–phospho us lame-ionisa ion de ec ion (GC–NPFID) o benzodiazepines (cu -o 0.1 mg/ ml) and o he analgesic d ug dipy one (cu -o 1 mg/ml). Subs ances o he han alcohol we e classi ied in wo g oups: illici d ugs and medicines. In he i s g oup, ca ego isa ion in o he ollowing g oups was es ablished: opia es, cocaine, cannabis, amphe amines, syn he ic d ugs (ecs asy) and hallucinogenic d ugs. In he second g oup, di e en sub-g oups we e es ablished, in acco dance wi h he Ana omical The apeu ic Chemical classi ica ion sys em. The analy ical esul s we e exp essed as ollows: (i) no subs ance de ec ed, o (ii) some ype o subs ance de ec ed. Once a subs ance had been de ec ed, samples we e classi ied in he ollowing g oups: (i) alcohol alone, (ii) alcohol plus medicinal d ugs, (iii) alcohol plus illici d ugs, (i ) alcohol plus medicinal d ugs plus illici d ugs, ( i) illici d ugs alone, ( ii) medicinal d ugs alone, ( iii) illici d ugs plus medicinal d ugs. Calcula ion was made o he pe cen age e e ing o he cases in which alcohol, medicinal d ugs and illici d ugs, as well as hei possible combina ions, we e ound. Fo alcohol, cases in which blood alcohol concen a ion was equal o, o o e 0.8 g/l, and equal o, o o e 0.5 g/l o 1999 and 2000, we e shown. Be ween 1991 and 2000, 59,071 people we e killed in oad acciden s in Spain (Fig. 1). The smalles numbe o dea hs occu ed in 1996 (5483) and he la ges numbe in 1991 (6797). Wi hin ha pe iod o ime, he Spanish popula- ion changed om 38.9 million inhabi an s in 1991 o 39.5 million inhabi an s in 2000. As shown in Fig. 1, he numbe o d i e s in hose yea s inc eased g adually om 16.9 million in 1991 o 21.4 million in 2000. This was due o he g adual inc ease in he numbe o women ob aining a d i ing licence. Consequen ly, in 1991, 31 ou o e e y 100 d i e s we e women, whe eas, in 2000, he numbe was 35 ou o e e y 100. Da a analysis was conduc ed in he Da a P ocessing Cen e a Valladolid Uni e si y. S a is ic analysis was by means o SAS so wa e e sion 6.12 (SAS Ins i u e SAS). An analysis o a iance es (ANOVA) was employed. P- alues <0.05 we e conside ed o be signi ican di e ences. 64 M. Ca men del Rı ´o e al. / Fo ensic Science In e na ional 127 (2002) 63–70 3. Resul s A o al o 5745 blood samples we e aken om he 59,071 d i e s killed in oad acciden s be ween 1991 and 2000. Tha is o say ha he p esence o subs ances was analysed in only 9.7% o a al oad acciden cases. Howe e , his pe cen age inc eased g adually om 3.8% in 1991 o 23.8% in 2000 (Fig. 1). As demons a ed in Fig. 2, in 50.1% o cases some psy- choac i e subs ance, mainly alcohol (43.8%), was de ec ed and, o a lesse ex en , illegal d ugs (8.8%) and medicines (4.7%). These h ee pe cen ages exceeded 100%, since se e al o hese subs ances could be ound in jus one case. The mean o subs ances de ec ed in posi i e cases is 1:19  0:52 (mean S:D:), a ying acco ding o he p esence o alcohol, illici d ugs o medicinal d ugs (F¼720:62, P<0:0001). 3.1. Alcohol In alcohol-de ec ed cases (n¼2517, 43.8%, Fig. 2), alcohol alone was p esen in he majo i y (n¼2195, 38.2%, Fig. 2; 87.5% o all alcohol-de ec ed cases). Alcohol combined wi h d ugs was much less common (n¼230, Fig. 1. E olu ion o he numbe o d i e s, o oad acciden ic ims, and analyses o a ali ies in Spain be ween 1991 and 2000. Fig. 2. P esence o subs ances among d i e s in ol ed in a al oad acciden s, Spain, 1991–2000. M. Ca men del Rı ´o e al. / Fo ensic Science In e na ional 127 (2002) 63–70 65 4.0%), ollowed by alcohol and medicinal d ugs (n¼68, 1.2%), and alcohol, d ugs and medicinal d ugs (n¼24, 0.4%). The mean o subs ances de ec ed in hose cases in which alcohol was p esen was 1:13 0:37 (mean S:D:). Be ween 1991 and 2000, in 32.0% (n¼1836) o all cases, blood concen a ion was highe han 0.8 g/l ( he legal limi un il 6 May 1999); in o he wo ds, in nea ly one in e e y h ee cases he concen a ion le el was highe han ha pe mi ed by law. In 1999 and 2000, in 29.8% (n¼355) and 32.6% (n¼444) o he cases, espec i ely, blood concen- a ion was ound o be o e 0.5 g/l ( he legal limi es ab- lished om 7 May 1999). 3.2. Illegal d ugs Be ween 1991 and 2000, a leas one illegal d ug was de ec ed in 8.8% (n¼504) o he people killed in oad acciden s. In mos cases, illegal d ugs and subs ances o he han alcohol we e de ec ed: in 4.0% (n¼230) oge he wi h alcohol, in 1.2% (n¼67) wi h medicinal d ugs, and in 0.4% (n¼24) wi h alcohol and medicinal d ugs (Fig. 2). Tha is o say, ha in 63.7% (321 ou o 504) o all he cases in which an illegal d ug was de ec ed, alcohol and/o medicinal d ugs we e also p esen . Mo eo e , wi h ega d o he cases in which only illegal d ugs we e ound (n¼183; 3.2%), a leas wo illici d ugs we e de ec ed in combined use in 60 o he 183 cases. In o he wo ds, wo o mo e subs ances we e ac ually p esen in 75.6% (381 ou o 504) o he cases in which illici d ugs we e ound. The mean o subs ances de ec ed in cases in which one illegal d ug appea ed was 1:86 0:62, and his was highe han when alcohol was de ec ed (F¼1236:15, P<0:001) o medicinal d ugs (F¼6:21, P<0:01). An analysis o he d ugs de ec ed shows ha cocaine was he mos common (n¼300, 5.2%) ollowed by opia es (n¼186, 3.2%), cannabis (n¼127, 2.2%), amphe amines (n¼67, 1.2%) and designe d ugs (n¼33, 0.6%). We analysed in g ea e de ail he cases in which cocaine was de ec ed (n¼300), as i happened o be he mos common d ug ound. As shown in Fig. 3, in 82% o he cases, cocaine was p esen wi h some o he subs ance. In mo e han hal o he cases cocaine was de ec ed oge he wi h alcohol (54.3%). Besides, cocaine was commonly ound wi h o he illici d ugs (39.7%). The p esence o cocaine wi h medicinal d ugs was less equen (17.3%). Thei possible combina ions appea in Fig. 3. 3.3. Medicines Be ween 1991 and 2000, medicines we e de ec ed in 4.7% (n¼269) o he cases. As o he p esence o o he subs ances in combina ion wi h medicines, in 59.1% (159 ou o 269) o he cases in which medicines we e ound, alcohol and/o illegal d ugs we e p esen (Fig. 2). In 18 ou o he 110 cases in which only medicines we e de ec ed, wo o mo e medicines we e p esen . Tha is o say, ha in eali y Fig. 3. P esence o cocaine among Spanish d i e s in ol ed in a al oad acciden s, Spain, 1991–2000. 66 M. Ca men del Rı ´o e al. / Fo ensic Science In e na ional 127 (2002) 63–70 wo o mo e subs ances we e de ec ed in 65.8% (177 om 269) o he cases in which some medicine was ound. The mean o subs ances de ec ed in cases in ol ing some med- icinal d ug was 1:74 0:60, g ea e han when alcohol was de ec ed (F¼564:96, P<0:001) and lowe when illici d ugs we e ound (F¼6:21, P<0:01), as was men ioned abo e. Benzodiazepines ep esen ed he mos commonly de ec ed g oup o medicines (n¼196, 3.4%), ollowed in dec easing o de by an i-dep essan s (n¼33, 0.6%), analge- sics (n¼26, 0.4%), an i-epilep ic d ugs (n¼18, 0.3%), ba bi u a es (n¼15, 0.3%), H-1 an i-his amines (n¼15, 0.3%), asodila o s (n¼9, 0.15%), calcium an agonis s (n¼8, 0.14%), an i-heme ic d ugs (n¼1, 0.01%) and an i-psycho ic d ugs (n¼1, 0.01%). As in he case o illegal d ugs, we ha e analysed mo e ca e ully he cases in which benzodiazepines we e de ec ed (n¼196), as his d ug was he one mos commonly aced. As may be obse ed in Fig. 4, in 72.4% o cases, benzo- diazepines we e de ec ed oge he wi h some o he sub- s ance, mainly illegal d ugs (41.3%) and alcohol (33.7%), and less equen ly, wi h o he medicines (14.8%). 4. Discussion This s udy shows ha he p esence o subs ances (50.1%) in Spanish d i e s killed in a ic acciden s and om whom blood samples we e aken and analysed o alcohol and o he d ugs is by no means negligible. Al hough alcohol is he mos commonly de ec ed subs ance, he p esence o illici and medicinal d ugs canno be igno ed ei he . Rega ding alcohol, i should be poin ed ou ha i was equen ly de ec ed (43.8%), and ha i was o en o e 0.8 g/l (32.0%). In cases in which illegal d ugs (8.8%) and med- icinal d ugs (4.7%) we e de ec ed, i is no ewo hy ha in mos cases hese we e ound alongside o he subs ances (75.6 and 65.8%, espec i ely), wi h cocaine (5.2%) and benzodiazepines (3.4%) being he subs ances mos com- monly aced in ela ion o illici and medicinal d ugs. In a p e ious s udy [12,13], conduc ed on 259 Spanish d i e s killed in a ic acciden s be ween 1994 and 1996 ( andomly selec ed and o no legal pu pose), a leas one ype o subs ance was de ec ed in 60.0% o he cases, alcohol in 50.5% (0.8 g/l in 35.4%), illici d ugs in 10.2% and medicinal d ugs in 9.1%. These igu es a e highe han hose obse ed in he p esen s udy be ween 1991 and 2000. Ou indings show a high le el o psychoac i e sub- s ances in oad acciden ic ims. Ne e heless, we belie e ha hese igu es mus be iewed wi h cau ion, since he numbe o d i e s killed in whom subs ances we e de ec ed is e y low (9.7% o oad dea hs). How can his be explained? Up o 1996 (B.O.E. 23/XII/1996, pp. 38203– 38221) es ing o alcohol (o o he d ugs) was no a o mal equi emen in Spain. As a esul , he numbe o oad Fig. 4. P esence o benzodiazepines among Spanish d i e s in ol ed in a al oad acciden s, Spain, 1991–2000. M. Ca men del Rı ´o e al. / Fo ensic Science In e na ional 127 (2002) 63–70 67 acciden ic ims analysed o alcohol (o o he d ugs) was e y low. In ac , his si ua ion was e e ed o colloquially as he ‘widow synd ome’: ha is o say, no in e es was shown as o whe he he ic im was unde he in luence o alcoholo no ;i wasp e e ed ha heinsu ancecompa- nies paid he amilies o he ic ims and he inciden s we e o go en. Consequen ly, he e was always he suspicion ha ha es s o blood alcohol (and o he d ugs) concen- a ion we e ca ied ou only in cases in which he ic im showed clea signs o being unde he e ec o alcohol. Since 1996, he yea in which he law came ou , es ing o alcohol has inc eased signi ican ly(3.8%in1991asagains 23.8% in 2000), which enhances he us wo hiness o hese indings. Conce ning alcohol, al hough compa ison wi h da a om o he coun ies should be ca e ully conduc ed, he igu es obse ed in ou s udy we e among he highes . In he UK [15], da a accumula ed om 1990 o 1994 e ealed ha in 45.5% o dea hs alcohol was de ec ed, and ha his exceeded 0.8 g/l in 20.25% o he ic ims. Recen da a om 1997 [16] e eals ha alcohol o e 0.8 g/l was de ec ed in 23% o all ic ims. Alcohol has been equen ly de ec ed in I aly (49.0%) [17], in F ance (45:7%>0:7 g/l) [18] and in Bel- gium (28% o e 0.49 g/l) [19], whils igu es o he No dic coun ies (Sweden: 27% [20] and 20.3% [21], No way: 28.3% [22]) a e conside ably lowe , pe haps as a esul o he ac ha in hese coun ies he e exis s a e y s ic policy wi h ega d o d inking and d i ing. High igu es ha e also been eco ded o Canada (48%) [23] and some a eas o he USA (46%) [24–27], whe eas in Aus alia igu es a e lowe (36%) [28]. Dec easing ends o d inking and d i ing ha e been obse ed in some indus ialised coun ies like he USA [27]. The p esence o illici d ugs (8.8%) and medicinal d ugs (4.7%; 11.9% i we conside he p esence o bo h illici and medicinal d ugs), is lowe han ha men ioned in p e ious e iews [7–9] analysing published s udies on oad acciden ic ims. He e igu es o 16.3% [7,8] ha e been quo ed when conside ing a combina ion o illici and medicinal d ugs, 10– 25% o illici d ugs, and 6–21% in he case o medicinal d ugs [9]. Al hough he p esence o illici and medicinal d ugs is much less common han ha o alcohol, hei impo ance should no be unde es ima ed [5,6]. As ega ds he di e en kinds o illegal d ugs encoun- e ed, in s udies ca ied ou in a ious coun ies [7,8], he mos commonly ound d ugs ha e been cannabis (7.6%), ollowed by opia es (3.1%), amphe amines (1.8%) and cocaine (0.5%). The si ua ion among Spanish d i e s killed in oad acciden s is comple ely di e en : cocaine is he mos equen ly de ec ed d ug (5.2%), 10.5 imes mo e common han he mean de ec ed in o he s udies [7,8], whils cannabis was ound 3.45 imes less equen ly (2.2%). As ega ds opia es (3.2%) and amphe amines (1.2%; 1.8% i hey a e conside ed alongside designe d ugs), equencies a e simi- la . We can ind no explana ion o his g ea e equency o cocaine wi h espec o cannabis. Al hough consump ion equency o he di e en d ugs may a y be ween coun ies, d ug- aking pa e ns a e no so di e en among Spania ds han among o he Eu opean Union ci izens o hese changes o be accoun ed o . Cannabis is he mos equen ly used subs ance in he Eu opean Union [29]. Benzodiazepines we e he mos commonly de ec ed med- icinal d ugs (3.4%), albei wi h no ably less equency, and his—despi e he ac ha he use o benzodiazepines is pa icula ly common in ou coun y in ela ion o o he indus ialised coun ies [30]—co esponds wi h p e ious s udies (8.5%) [7,8]. An impo an poin is ha in mos cases in ol ing de ec ion o illici d ugs (75.6%) and medicinal d ugs (65.8%), a leas one o he subs ance was ound alongside hem; howe e , alcohol was de ec ed oge he wi h ano he subs ance in only 12.5% o cases. This accoun s o he high a e age o subs ances de ec ed in cases in which some ype o illegal d ug (1.86) and medicinal d ug (1.74) was ound in ela ion o alcohol (1.13). The p e alence o mul iple subs ances (alcohol, illici d ugs, medicinal d ugs) used in combina ion is equen ly epo ed in mos o he s udies [7–9,21,23,24]. The combina ion o a ious sub- s ances may b ing abou an inc eased isk o in ol emen in oad acciden s [5,6]. D i e, c ash and inju y cha ac e is ics among alcohol and/o d ug posi i e cases in oad a ic ic ims has been analysed in p e ious s udies [21,22]. D i e s who es ed posi i e o alcohol and/o d ugs we e mo e likely o be in ol ed in single ehicle c ash han hose who es ed nega i e. In he p esen s udy, in o ma ion ega ding c ash cha ac e is ics was no a ailable. We assume ha he p esen esul s ep esen an unspeci ied combina ion o single and mul iple ehicle acciden s. The igu es obse ed in his s udy be ween 1991 and 2000 e eal ha subs ances a e egula ly ound in ic ims o oad acciden s in Spain. Se e al ecen epo s ha e made a de ailed analysis o possible in e en ion and ecommenda- ions bo h in he a ea o d inking and d i ing [6,31–33] and in ha o d ugs (illici and/o medicinal) and d i ing [5,6,34,35]. D ink-d i ing and d ugs-d i ing ha e o be ackled in an in eg a ed and mul idisciplina y way, wi h he inclusion o a leas s ic e en o cemen , oughe punish- men , ehabili a ion schemes, and con inuous public educa- ion and publici y. In ou coun y, d inking alcohol o ms pa o many people’s daily and social li e, and g ea ole ance and pe missi eness exis wi h ega d o alcohol, he eby making in e en ion in his a ea a he di icul . Howe e , a g ea e o is being made wi h ega d o p e en i e policies, including, as men ioned ea lie , he educ ion o he legal limi . The p esen s udy shows how widesp ead alcohol con- sump ion is and e eals he high concen a ion le el o his subs ance in he blood o a ally inju ed d i e s. Al hough he p esence o illici and medicinal d ugs is less equen , hey should, none heless, no be dismissed as unimpo an . 68 M. Ca men del Rı ´o e al. / Fo ensic Science In e na ional 127 (2002) 63–70 Cocaine and benzodiazepines a e, espec i ely, he mos equen illici and medicinal d ugs de ec ed. As epo ed p e iously [12], alcohol is he main p oblem in a ic a ali ies in Spain, he eby making i necessa y o in ensi y e o s and o se up speci ic p og ams o educe d inking and d i ing, while also cla i ying he ole o d ugs o he han alcohol in a ic acciden s. Acknowledgemen s Suppo o his s udy was p o ided by he Na ional Plan on D ugs (Delegacio ´n del Gobie no pa a el Plan Nacional sob e D ogas) and he Na ional T a ic Agency (Di eccio ´n Gene al de T a ´ ico), Home O ice (Minis e io del In e io ), Mad id, Spain, as well as he Conseje ı ´adeSanidady Bienes a Social, Jun a de Cas illa y Leo ´n, Valladolid, Spain. We also hank Inmaculada Fie o o he echnical suppo . Re e ences [1] H. Moskowi z, D. 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