Fo ensic Science In e na ional
104 (1999) 117–125 www.else ie .com/loca e/ o sciin
Alcohol use among a ally inju ed d i e s in Spain
*
´
M. Ca men del Rıo, F. Ja ie Al a ez
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
,
Valladolid
,
Spain
Recei ed 10 Ma ch 1999; ecei ed in e ised o m 13 July 1999; accep ed 13 July 1999
Abs ac
Blood om 285 a ally inju ed d i e s in No he n Spain was collec ed and es ed o he
p esence o alcohol and d ugs. Alcohol was de ec ed in 50.5% o all a ali ies. Alcohol alone was
de ec ed in 44.2% o all samples and in he emaining 6.3% ano he subs ance was ound oge he
wi h alcohol. Blood alcohol concen a ion was classi ied in di e en le els. I has been obse ed
ha in 35.4% o he cases he blood alcohol le el was$0.8 g/l, he legal limi in Spain o ca
d i e s. Alcohol oge he wi h o he subs ances was encoun e ed in 18 cases, wi h medica ion in
22.2% (4 ou o 18), alcohol wi h illegal d ugs in 66.6% o he cases (12 ou o 18), and alcohol
wi h medicines and illegal d ugs in 11.1% (2 ou o 18). Cocaine was he mos commonly de ec ed
d ug. The s udy shows how widesp ead he incidence o a high le el o alcohol concen a ion
among d i e s in ol ed in a al acciden s in Spain. 1999 Else ie Science I eland L d. All
igh s ese ed.
Keywo ds
:
Alcohol; D ugs; Fa al inju ies; T a ic acciden s; Spain
1. In oduc ion
I has been es ima ed ha mo e han 2 million people a e killed each yea in oad
a ic acciden wo ldwide. Wi hin he Eu opean Union, a ic acciden s esul yea ly in
50 000 a ali ies and 1.5 million inju ies. Alcohol plays an inc easing ole in acciden s,
as acciden se e i y inc eases [1]. I has been es ima ed ha alcohol is in ol ed in 19%
o acciden s in ol ing inju ies and 22% o se ious a al acciden s in he Eu opean Union
[2].
*Co esponding au ho . Tel.: 134-983-423-077; ax: 134-983-423-022.
E-mail add ess
:
[email p o ec ed] (F.J. Al a ez)
0379-0738/99/$ – see on ma e 1999 Else ie Science I eland L d. All igh s ese ed.
PII: S0379-0738(99)00101-2
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The p oblem o d inking and d i ing is o special ele ance in Spain. This is due, no
only o he ac ha alcohol consump ion is equen in ou coun y (and, he e o e,
d i ing unde he in luence o alcohol), bu also because o an alcohol- ela ed cul u e:
socie y is e y pe missi e owa ds i s consump ion and ole an owa ds alcohol- ela ed
p oblems. Fu he mo e, Spain is one o he Eu opean Union coun ies showing highes
igu es o oad acciden s. Consequen ly, psychoac i e d ugs and d i ing a e a ma e o
g ea in e es o de eloping heal h policies.
In his ega d, a s udy ca ied ou by ou g oup o he Na ional T a ic Agency
´´
(Di eccion Gene al de T a ico), showed how equen d inking alcohol was among
Spanish d i e s: 62.9% o d i e s a e egula d inke s (d inking a leas once a week),
d ink an a e age o 46.9 g /day, wi h a o al o 16.8% hea y d inke s, consuming mo e
han 80 g /day. Fu he mo e, hose who d o e mo e equen ly a e hose who d ank
alcohol mo e equen ly and in a highe quan i y [3].
Wi h a popula ion o 39 million, 19.5 million ehicles and 17.2 million d i e s
(34.5% women), Spain, as men ioned ea lie , is one o he Eu opean Union coun ies
which has a high incidence o oad a ic acciden s. 85 588 oad acciden s occu ed in
1996, wi h a oll o 5483 dea hs and 124 157 inju ies, he eby cons i u ing he main
cause o dea h among young people unde 30 [4].
Howe e , he magni ude o alcohol and/o d ug- ela ed oad acciden s in ou coun y
is no well known. The Na ional Ins i u e o Toxicology p oduces annual epo s
including samples sen by o ensic doc o s o as ins uc ed by a judge o legal pu poses,
and he indica ion is ha , be ween 1992 (52%) and 1996 (49%) alcohol was de ec ed in
jus o e hal he numbe o oad acciden ic ims.
One o he p io i ies in his con ex has been o de ec alcohol and o he subs ances in
oad acciden ic ims. The objec i e o his s udy has been: (i) o analyse alcohol
p esence in d i e s killed in oad acciden s; (ii) o de e mine whe he alcohol alone was
consumed o mixed wi h o he subs ances; and (iii) o quan i y he amoun o alcohol
and o he subs ances de ec ed acco ding o a ious le els.
2. Ma e ial and me hods
This s udy has been ca ied ou by he Uni e si y o Valladolid o he Na ional
T a ic Agency. I was s a ed in he said s udy ha all in o ma ion ob ained would be
anonymous and used o scien i ic and no legal pu poses. The a ge popula ion
consis ed o d i e s killed in oad acciden s (passenge s we e no included). The da a
a ailable in each case was: sex, age, day and ime o he acciden . Samples o enous
blood we e aken wi hin eigh hou s o he ic im’s dea h and we e la e sen o ou
cen e.
Samples conce ning 285 oad acciden ic ims om Janua y 1994 o Oc obe 1996 in
he no h o Spain we e ob ained. Two hund ed and i y- i e (89.5%) ou o he 285
samples analysed we e men, and 30 (10.5%) we e women. Nine y-six subjec s (33.7%)
we e people belonging o he 16–25 age g oup, 129 (45.3%) we e be ween 26 and 45
yea s old and 60 (21.0%) we e o e 45. one hund ed and hi een samples (39.6%)
ep esen ed a ally inju ed d i e s on wo king days (Monday o F iday) and 172 (60.4%)
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on non-wo king days (Sa u day and Sunday). The a e age age (6SD) was 34.1613.2
(33.9613.1 o men and 36.0%614.7 o women). 46% o he samples ob ained on
non-wo king days ep esen ed people unde he age o 26, whils on wo king days he
igu e was 29%.
Blood samples we e analysed o alcohol (e hanol) by Head-Space Gas ch oma og-
aphy. 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 amines 300 ng/ml and benzo-
diazepines 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 concen a ions o he psychoac i e d ugs o me abo-
li es we e de e mined [2,5,6]. In he case o opia es, amphe amines and cocaine, he
cu -o le els o GC–MS con i ma ion es we e in selec ed ion moni o ing mode (SIM)
50 ng/ml, and 10ng/ml in he case o cannabis. Posi i e esul s we e con i med by
GC–NPFID (ni ogen-phos o us lame-ioniza ion de ec ion) o benzodiazepines (cu -o
0.1 mg/ml) and o he analgesic d ug dipy one (cu -o 1mg/ml).
Subs ances o he han alcohol we e classi ied in wo g oups: illici d ugs and
medicines. Wi hin he i s g oup, ca ego iza 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. Wi hin 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.
Once a subs ance had been de ec ed, samples we e classi ied o his s udy in he
ollowing g oups: (i) only wi h alcohol, (ii) alcohol plus medicines, (iii) alcohol plus
illici d ugs, (i ) alcohol plus medicines plus illici d ugs, ( ) no alcohol–no d ugs.
The concen a ion o alcohol in he samples was de e mined, and wo scales we e
es ablished acco dingly. The i s ca ego iza ion was adop ed, because de e mina ion was
also made in he s udy o concen a ions o illici d ugs and medicines, he aim being o
conside he possible signi icance o blood concen a ion. The a ing used was based on
h ee le els: low, medium and high concen a ion (low he apeu ic, he apeu ic, and high
non- he apeu ic concen a ion o medicines), such as has p e iously been used in o he
s udies o subs ances o he han alcohol [7]. In ela ion o alcohol, hese ca ego ies ha e
been es ablished a bi a ily in: le el I o low (0.01– 0.49 g/l), le el II o medium
(0.5–0.99 g/l) and le el III o high- oxic ($1 g/l). In he second ca ego iza ion, a
double anking sys em was used: le el I, 0.01–0.79 g/l; and le el II,$0.8 g/l,
co esponding o he maximum pe mi ed le el in ca d i e s in Spain.
Analysis o he da a was conduc ed in he Da a P ocessing Cen e a Valladolid
Uni e si y. S a is ics analysis was by means o SAS so wa e e sion 6.07 (SAS
Ins i u e SAS). P-Values ,0.05 we e conside ed o be signi ican di e ences.
3. Resul s
O he 285 samples analyzed, some ype o subs ances we e de ec ed in 60% (n5171)
o hem. Alcohol was ound in 50.5% (n5144), Illici d ugs in 10.2% (n529) and
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Table 1
Incidence o alcohol and/o d ugs in a ally inju ed d i e s in Spain
n%
No subs ance 114 40.0
Some subs ance 171 60.0
Alcohol 144 50.5
Alone 126 44.2
1illegal d ugs 12 4.2
1medicines 4 1.4
1illegal d ugs 1medicines 2 0.7
Illegal d ugs 29 10.2
Alone 7 2.5
1alcohol 12 4.2
1medicines 8 2.8
1medicines 1alcohol 2 0.7
Medicines 26 9.1
Alone 12 4.2
1alcohol 4 1.4
1illegal d ugs 8 2.8
1alcohol 1illegal d ugs 2 0.7
medicines in 9.1% (n526). Rega ding alcohol, alcohol alone was de ec ed in 44.2%
(n5126), alcohol plus medicines in 1.4% (n54), alcohol plus illegal d ugs in 4.2%
(n512), and alcohol oge he wi h illegal d ugs and medicines in 0.7% (n52) (Table 1).
The pe cen age o cases in which alcohol was ound was g ea e o men (54.1%) han
o women (20.0%), and also when only alcohol was de ec ed (47.5% and 16.7%,
espec i ely); no signi ican di e ences we e obse ed be ween sexes when alcohol,
oge he wi h o he subs ances, was p esen ed. Signi ican di e ences we e no obse ed
wi h ega d o he di e en es ablished age g oups (Table 2). The a e age age o hose in
whom alcohol was de ec ed was 37.8 yea s (30.2 o hose pe sons in whom alcohol was
accompanied by o he subs ances) (Table 2). Figu es ela ing o alcohol de ec ion we e
highe on non-wo king days (62.8%) han on wo king days (42.4%, p,0.001).
In 9.5% o samples analyzed, alcohol concen a ion was a le el I-low-(blood alcohol
be ween 0.01 and 0.49 g/l), 9.1% a le el II -medium- (blood alcohol be ween 0.5 and
0.99 g/l) and 31.9% was a le el III -high- (blood alcohol concen a ion $1g/l) (Table
3). Wi hin g ade III, posi i e cases we e mo e equen among men (34.5%) han among
women (10%), and on non-wo king days (38.9%) a he han on wo king days (27.3%).
The numbe o samples in which he le el o alcohol was abo e he legal limi in Spain
($0.8 g/l) ep esen ed 35.4%.
Finally, in Table 4, he p esence o o he subs ances oge he wi h alcohol is obse ed
and hei dis ibu ion acco ding o he h ee le els conside ed. O he 18 cases in which
alcohol was de ec ed wi h o he subs ances, cocaine was ound in wo ou o e e y h ee
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Table 2
Sociodemog aphic cha ac e is ics o a ally inju ed d i e s es ing posi i e o nega i e o alcohol and/o d ugs
To al Alcohol Alcohol Alcohol and Nega i e
nn(%) only D ugs (no alcohol–no d ugs)
n(%) n(%) n(%)
To al 285 144 (50.5) 126 (44.2) 18 (6.3) 114 (40)
Sex
Male 255 138 (54.1) 121(47.5) 17 (6.7) 92 (36.1)
Female 30 6 (20.0) 5 (16.7) 1 (3.3) 22 (73.3)
a
P,0.001 P,0.001 n.s P,0.001
Age
16–25 96 51 (53.1) 44 (45.8) 7 (7.29) 35 (36.5)
26–45 129 67 (51.9) 57 (44.2) 10 (7.8) 50 (38.8)
.45 60 26 (43.3) 25 (41.7) 1 (1.7) 29 (48.3)
n.s n.s n.s n.s
Age Mean 37.8 33.2 30.2 35.9
SD 12.0 12.4 8.6 14.3
Day
Wo king 172 73 (42.4) 63 (36.6) 10 (5.8) 77 (44.8)
Non-wo king 113 71 (62.8) 63 (55.8) 8 (7.1) 37 (32.7)
P,0.001 P,0.001 n.s P,0.05
a
n.s, no signi ican .
(66.7%); in eigh cases (44.4%) he subs ance de ec ed was only cocaine, and in ano he
ou (22.2%) cocaine plus a u he subs ance we e ound o be p esen . Opia es we e
ound in wo cases, amphe amines in ou cases, cannabis in wo cases and ecs asy was
ound in h ee cases. Benzodiazepines ( h ee cases o diazepam, one b omacepam, one
midazolam) we e he mos commonly de ec ed medicines (27.8%) oge he wi h alcohol,
only benzodiazepines wi h alcohol (16.7%) o wi h o he subs ances (11.1%).
4. Discussion
Ou s udy shows how o en alcohol is de ec ed (50.5%), ei he on i s own o oge he
wi h o he subs ances, in he blood samples aken om a ally inju ed d i e s in Spain.
Secondly, in a high pe cen age o cases, he blood alcohol concen a ion de ec ed was
conside able: le els o mo e han 1 g/l we e ound in 31.9% o cases and 35.4% had
blood alcohol le els abo e hose pe mi ed in ca d i e s by law ($0.8 g/l), and.
Finally, i should be poin ed ou ha , al hough in mos cases (87.5%) only alcohol was
ound, i was no uncommon (12.5%) o de ec alcohol along wi h o he subs ances. In
ou s udy, cocaine was he mos commonly de ec ed d ug.
Du ing a ecen ICADTS Con e ence in 1997 [8], we p esen ed a compa ison o he
da a included in his pape (a de e mina ion o blood alcohol concen a ion o non-legal
pu poses) wi h ha ob ained be ween 1992 and 1995 in he Na ional Ins i u e o

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Table 3
Pe cen age o a ally inju ed d i e s wi h BACs abo e speci ic limi s
Blood Alcohol Le el
Le el I Le el II Le el III
(0.01–0.49 g/l) (0.5–0.99 g/l) ($1g/l)
n%n%n%
To al (285) 27 9.5 26 9.1 91 31.9
Sex
Male (255) 25 9.8 25 9.8 88 34.5
Female (30) 2 6.7 1 3.3 3 10.0
a
n.s n.s P,0.01
Age
16–25 (96) 20 20.8 11 11.5 30 31.2
26–45 (129) 12 9.3 10 7.7 45 34.9
.45 (60) 5 8.3 5 8.3 16 26.7
P,0.05 n.s n.s
Day
Wo king (172) 14 8.1 12 7.0 47 27.3
Non-wo king (113) 13 11.5 14 12.4 44 38.9
n.s n.s P,0.05
a
n.s, no signi ican .
Toxicology conce ning 979 people killed in oad acciden s (analysis ca ied ou wi h
legal aims). Da a om bo h sou ces p o ed e y simila ; 50.5% o posi i e cases in ou
s udy compa ed wi h 51.3% in he samples p o ided by he Na ional Ins i u e o
Toxicology. In bo h cases i was mainly alcohol on i s own ha was de ec ed, and he
numbe o cases wi h blood alcohol le els $0.8 g/l in ou s udy ep esen 35.4%, as
agains 37.4% in he Na ional Ins i u e o Toxicology da a.
Figu es om bo h sou ces clea ly e eal how common i is o ind alcohol in ic ims
o oad acciden s in Spain. These da a ha e been one o he aspec s ha ha e encou aged
he au ho i ies o educe he cu en legal blood alcohol limi s. Spanish legisla ion
es ablishes legal blood alcohol concen a ion limi s o 0.8 g/l in mo o - ehicle d i e s;
0.5 g/l in hose d i ing ehicles o e 3.500 kg and 0.3 g/l in hose d i ing ehicles used
o anspo ing passenge s and o ca ying dange ous goods [4]. Since May 7, 1999 he
legal blood alcohol concen a ion limi s ha e been changed o 0.5 g/l in mo o - ehicle
d i e s and 0.3 g/l in he o he cases.
In any case, igu es de i ed om he Na ional Ins i u e o Toxicology ha e always
been iewed wi h cau ion. Fi s o all, because samples a e only aken o de e mine
alcohol (o o he d ugs) in e y ew cases (gene ally in ewe han 3–5% o oad dea hs).
How o explain his? Because o wha we colloquially e e o as he ‘‘widow
synd ome’’: ha is o say, no in e es is shown as o whe he he ic im was unde he
in luence o alcohol o no ; hey would a he he insu ance companies paid he amilies
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Table 4
Le el o blood alcohol and subs ances de ec ed along wi h alcohol
Blood alcohol Alcohol D ugs and D ugs
le el alone alcohol ound
n%n%nType Le el
Le el I 24 88.9 3 11.1 2 benzodiazepine I
(0.01–0.49 g/l) 1 Cocaine 1I
Opia es 1I
Benzodiazepine1II
Analgesic d ug I
Le el II 22 84.6 4 15.4 1 cocaine III
(0.5–0.99 g/l) 1 opia e 1III
cocaine 1I
benzodiazepine III
2 amphe amine 1I
ecs asy I
Le el III 80 87.9 11 12.1 5 cocaine I
($1g/l) 1 cocaine II
1 cocaine III
1 amphe amine II
1 benzodiazepine I
1 cocaine 1I
amphe amine 1II
cannabis I
1 ecs asy 1I
cocaine 1I
cannabis I
o he ic ims and he inciden was o go en. Thus, he e has always been he ea ha
blood alcohol (and o he d ugs) concen a ion es a e ca ied ou only in cases in which
he ic im has shown clea signs o being ei he unde he e ec o alcohol o no . The
ac ha es ing o alcohol in people killed o inju ed in oad acciden s has become a
o mal equi emen in Spain since Decembe 1996, migh be a means o pu an end o
ha si ua ion.
Al hough compa ison wi h da a om o he coun ies should be ca e ully made, he
igu es obse ed in ou s udy a e among he highes [9,10]. Wi hin he Eu opean Union,
pe haps one o he coun ies wi h he mos comple e in o ma ion is he Uni ed Kingdom,
h ough he Co one ’s da a [11]: 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
ic ims. Alcohol has been equen ly de ec ed in I aly (49.0%) [10] and in Belgium
(28% o e 0.49 g/l) [12], whils igu es o he No dic coun ies (Sweden: 27% [13] and
20.3% [14], No way: 28.3% [15]) 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 alcohol and d i ing.
Da a om he Fa ali y Analysis Repo ing Sys em (FARS) show ha alcohol
in ol emen in a al oad acciden s has been dec easing in he Uni ed S a es in he las
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yea s [16–18], al hough in ce ain s udies alcohol has been o en ound (46%) [19].
High igu es ha e also been eco ded o Canada (48%) [20], whe eas in Aus alia
igu es a e lowe (36%) [7].
In addi ion, as ega ds he associa ion be ween alcohol and d ugs, he equency wi h
which his is de ec ed a ies g ea ly 4.0% [14], 11.45% [20], 13% [19], as do he ypes
o subs ances ound.
In 1995 wo epo s examined d ink-d i ing in he Eu opean Union [21,22] conside -
ing he ole o di e en coun e measu es and making ecommenda ions. D ink-D i ing
does ha e o be ackled in an in eg a ed and mul idisciplina y way. A educ ion in he
legal blood alcohol limi , has been widely hough o be he nex s ep. Many d i e s look
o hese legal limi s as a guide o sa e d ink-d i e ’s le els, and one sugges ion is he
ha monisa ion o maximum blood alcohol concen a ions a 0.5 g/l h oughou he
Eu opean Union [23]. A p esen mos o he Eu opean Union coun ies ha e changed
his limi .
Bu besides his measu e, o he p e en i e p og ams also need o be unde aken.
Di e en esea ch [9] shows ha only educing he legal limi would be e ec i e.
Expe ience shows ha a much mo e signi ican , sus ained and long- e m impac could be
achie ed by a ou -poin p og am. These i al ou measu es a e: s ic e en o cemen ;
oughe punishmen ; ehabili a ion schemes; 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 he educ ion o he legal limi , as men ioned
ea lie .
The p esen s udy shows how widesp ead alcohol is and i s high concen a ion le el in
he blood o a ally inju ed d i e s, and sugges ha d ugs o he han alcohol
( undamen ally illegal d ugs) a e p esen in and causally ela ed o impai men esul ing
in a al a ic acciden s. Cocaine oge he wi h alcohol, is he mos equen d ug
de ec ed. 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 Di eccion Gene al de T a ico (T a ic
Na ional Agency), Minis e io del In e io (Home O ice), Mad id, Spain.
Re e ences
[1] Eu opean Comission whi e pape on anspo policy (COM 92/494). Eu opean Commision,
B ussels,1992. ´
[2] P. Lillsunde, D ugs and D i ing. Analı ical and Epidemiological Aspec s, The Na ional Public Heal h
Ins i u e, Helsinki, 1996.
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[3] F.J. Al a ez, M.C. Del Rıo, R. P ada, D inking and D i ing in Spain, J. S ud. Alcohol 56 (1995)
403–407.
´´ ´´
[4] Di eccion Gene al de T a ico, Road Sa e y in Spain. 1996 Repo . Di eccion Gene al de T a ico, Mad id,
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