Alcohol use among fatally injured drivers in Spain

Forensic Science International 104 (1999) 117–125 www.elsevier.com/locate/forsciint Alcohol use among fatally injured drivers in Spain * ´ M. Carmen del Rıo, F. Javier Alvarez Drugs and Alcohol Research Group , Department of Pharmacology and Therapeutics , Faculty of Medicine , University of Valladolid , Valladolid , Spain Received 10 March 1999; received in revised form 13 July 1999; accepted 13 July 1999 Abstract Blood from 285 fatally injured drivers in Northern Spain was collected and tested for the presence of alcohol and drugs. Alcohol was detected in 50.5% of all fatalities. Alcohol alone was detected in 44.2% of all samples and in the remaining 6.3% another substance was found together with alcohol. Blood alcohol concentration was classified in different levels. It has been observed that in 35.4% of the cases the blood alcohol level was$0.8 g/l, the legal limit in Spain for car drivers. Alcohol together with other substances was encountered in 18 cases, with medication in 22.2% (4 out of 18), alcohol with illegal drugs in 66.6% of the cases (12 out of 18), and alcohol with medicines and illegal drugs in 11.1% (2 out of 18). Cocaine was the most commonly detected drug. The study shows how widespread the incidence of a high level of alcohol concentration among drivers involved in fatal accidents in Spain. 1999 Elsevier Science Ireland Ltd. All rights reserved. Keywords : Alcohol; Drugs; Fatal injuries; Traffic accidents; Spain 1. Introduction It has been estimated that more than 2 million people are killed each year in road traffic accident worldwide. Within the European Union, traffic accidents result yearly in 50 000 fatalities and 1.5 million injuries. Alcohol plays an increasing role in accidents, as accident severity increases [1]. It has been estimated that alcohol is involved in 19% of accidents involving injuries and 22% of serious fatal accidents in the European Union [2]. *Corresponding author. Tel.: 134-983-423-077; fax: 134-983-423-022. E-mail address : [email protected] (F.J. Alvarez) 0379-0738/99/$ – see front matter 1999 Elsevier Science Ireland Ltd. All rights reserved. PII: S0379-0738(99)00101-2 ´ 118 M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 The problem of drinking and driving is of special relevance in Spain. This is due, not only to the fact that alcohol consumption is frequent in our country (and, therefore, driving under the influence of alcohol), but also because of an alcohol-related culture: society is very permissive towards its consumption and tolerant towards alcohol-related problems. Furthermore, Spain is one of the European Union countries showing highest figures for road accidents. Consequently, psychoactive drugs and driving are a matter of great interest for developing health policies. In this regard, a study carried out by our group for the National Traffic Agency ´´ (Direccion General de Trafico), showed how frequent drinking alcohol was among Spanish drivers: 62.9% of drivers are regular drinkers (drinking at least once a week), drink an average of 46.9 gr/day, with a total of 16.8% heavy drinkers, consuming more than 80 gr/day. Furthermore, those who drove more frequently are those who drank alcohol more frequently and in a higher quantity [3]. With a population of 39 million, 19.5 million vehicles and 17.2 million drivers (34.5% women), Spain, as mentioned earlier, is one of the European Union countries which has a high incidence of road traffic accidents. 85 588 road accidents occurred in 1996, with a toll of 5483 deaths and 124 157 injuries, thereby constituting the main cause of death among young people under 30 [4]. However, the magnitude of alcohol and/or drug-related road accidents in our country is not well known. The National Institute of Toxicology produces annual reports including samples sent by forensic doctors or as instructed by a judge for legal purposes, and the indication is that, between 1992 (52%) and 1996 (49%) alcohol was detected in just over half the number of road accident victims. One of the priorities in this context has been to detect alcohol and other substances in road accident victims. The objective of this study has been: (i) to analyse alcohol presence in drivers killed in road accidents; (ii) to determine whether alcohol alone was consumed or mixed with other substances; and (iii) to quantify the amount of alcohol and other substances detected according to various levels. 2. Material and methods This study has been carried out by the University of Valladolid for the National Traffic Agency. It was stated in the said study that all information obtained would be anonymous and used for scientific and not legal purposes. The target population consisted of drivers killed in road accidents (passengers were not included). The data available in each case was: sex, age, day and time of the accident. Samples of venous blood were taken within eight hours of the victim’s death and were later sent to our centre. Samples concerning 285 road accident victims from January 1994 to October 1996 in the north of Spain were obtained. Two hundred and fifty-five (89.5%) out of the 285 samples analysed were men, and 30 (10.5%) were women. Ninety-six subjects (33.7%) were people belonging to the 16–25 age group, 129 (45.3%) were between 26 and 45 years old and 60 (21.0%) were over 45. one hundred and thirteen samples (39.6%) represented fatally injured drivers on working days (Monday to Friday) and 172 (60.4%) ´ M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 119 on non-working days (Saturday and Sunday). The average age (6SD) was 34.1613.2 (33.9613.1 for men and 36.0%614.7 for women). 46% of the samples obtained on non-working days represented people under the age of 26, whilst on working days the figure was 29%. Blood samples were analysed for alcohol (ethanol) by Head-Space Gas chromatography. All samples were also screened for the presence of drugs other than alcohol (medicines and illicit drugs) by immunological or chromatographic methods when appropriate. The cut-off levels of the first screening were: opiates 300 ng/ml; cocaine metabolite 150 ng/ml; cannabinoids 20 ng/ml; amphetamines 300 ng/ml and benzodiazepines 200 ng/ml. Positive results after screening were confirmed by means of gas chromatography/ mass spectrometry (GC–MS) and concentrations of the psychoactive drugs or metabolites were determined [2,5,6]. In the case of opiates, amphetamines and cocaine, the cut-off levels for GC–MS confirmation test were in selected ion monitoring mode (SIM) 50 ng/ml, and 10ng/ml in the case of cannabis. Positive results were confirmed by GC–NPFID (nitrogen-phosforus flame-ionization detection) for benzodiazepines (cut-off 0.1 mg/ml) and for the analgesic drug dipyrone (cut-off 1mg/ml). Substances other than alcohol were classified in two groups: illicit drugs and medicines. Within the first group, categorization into the following groups was established: opiates, cocaine, cannabis, amphetamines, synthetic drugs (ecstasy) and hallucinogenic drugs. Within the second group, different sub-groups were established, in accordance with the Anatomical Therapeutic Chemical classification system. Once a substance had been detected, samples were classified for this study in the following groups: (i) only with alcohol, (ii) alcohol plus medicines, (iii) alcohol plus illicit drugs, (iv) alcohol plus medicines plus illicit drugs, (v) no alcohol–no drugs. The concentration of alcohol in the samples was determined, and two scales were established accordingly. The first categorization was adopted, because determination was also made in the study of concentrations of illicit drugs and medicines, the aim being to consider the possible significance of blood concentration. The rating used was based on three levels: low, medium and high concentration (low therapeutic, therapeutic, and high non-therapeutic concentration for medicines), such as has previously been used in other studies for substances other than alcohol [7]. In relation to alcohol, these categories have been established arbitrarily in: level I or low (0.01– 0.49 g/l), level II or medium (0.5–0.99 g/l) and level III or high-toxic ($1 g/l). In the second categorization, a double ranking system was used: level I, 0.01–0.79 g/l; and level II,$0.8 g/l, corresponding to the maximum permitted level in car drivers in Spain. Analysis of the data was conducted in the Data Processing Center at Valladolid University. Statistics analysis was by means of SAS software version 6.07 (SAS Institute SAS). P-Values ,0.05 were considered to be significant differences. 3. Results Of the 285 samples analyzed, some type of substances were detected in 60% (n5171) of them. Alcohol was found in 50.5% (n5144), Illicit drugs in 10.2% (n529) and ´ 120 M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 Table 1 Incidence of alcohol and/or drugs in fatally injured drivers in Spain n% No substance 114 40.0 Some substance 171 60.0 Alcohol 144 50.5 Alone 126 44.2 1illegal drugs 12 4.2 1medicines 4 1.4 1illegal drugs 1medicines 2 0.7 Illegal drugs 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 drugs 8 2.8 1alcohol 1illegal drugs 2 0.7 medicines in 9.1% (n526). Regarding alcohol, alcohol alone was detected in 44.2% (n5126), alcohol plus medicines in 1.4% (n54), alcohol plus illegal drugs in 4.2% (n512), and alcohol together with illegal drugs and medicines in 0.7% (n52) (Table 1). The percentage of cases in which alcohol was found was greater for men (54.1%) than for women (20.0%), and also when only alcohol was detected (47.5% and 16.7%, respectively); no significant differences were observed between sexes when alcohol, together with other substances, was presented. Significant differences were not observed with regard to the different established age groups (Table 2). The average age of those in whom alcohol was detected was 37.8 years (30.2 for those persons in whom alcohol was accompanied by other substances) (Table 2). Figures relating to alcohol detection were higher on non-working days (62.8%) than on working days (42.4%, p,0.001). In 9.5% of samples analyzed, alcohol concentration was at level I-low-(blood alcohol between 0.01 and 0.49 g/l), 9.1% at level II -medium- (blood alcohol between 0.5 and 0.99 g/l) and 31.9% was at level III -high- (blood alcohol concentration $1g/l) (Table 3). Within grade III, positive cases were more frequent among men (34.5%) than among women (10%), and on non-working days (38.9%) rather than on working days (27.3%). The number of samples in which the level of alcohol was above the legal limit in Spain ($0.8 g/l) represented 35.4%. Finally, in Table 4, the presence of other substances together with alcohol is observed and their distribution according to the three levels considered. Of the 18 cases in which alcohol was detected with other substances, cocaine was found in two out of every three ´ M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 121 Table 2 Sociodemographic characteristics of fatally injured drivers testing positive or negative for alcohol and/or drugs Total Alcohol Alcohol Alcohol and Negative nn(%) only Drugs (no alcohol–no drugs) n(%) n(%) n(%) Total 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 Working 172 73 (42.4) 63 (36.6) 10 (5.8) 77 (44.8) Non-working 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, not significant. (66.7%); in eight cases (44.4%) the substance detected was only cocaine, and in another four (22.2%) cocaine plus a further substance were found to be present. Opiates were found in two cases, amphetamines in four cases, cannabis in two cases and ecstasy was found in three cases. Benzodiazepines (three cases of diazepam, one bromacepam, one midazolam) were the most commonly detected medicines (27.8%) together with alcohol, only benzodiazepines with alcohol (16.7%) or with other substances (11.1%). 4. Discussion Our study shows how often alcohol is detected (50.5%), either on its own or together with other substances, in the blood samples taken from fatally injured drivers in Spain. Secondly, in a high percentage of cases, the blood alcohol concentration detected was considerable: levels of more than 1 g/l were found in 31.9% of cases and 35.4% had blood alcohol levels above those permitted in car drivers by law ($0.8 g/l), and. Finally, it should be pointed out that, although in most cases (87.5%) only alcohol was found, it was not uncommon (12.5%) to detect alcohol along with other substances. In our study, cocaine was the most commonly detected drug. During a recent ICADTS Conference in 1997 [8], we presented a comparison of the data included in this paper (a determination of blood alcohol concentration for non-legal purposes) with that obtained between 1992 and 1995 in the National Institute of ´ 122 M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 Table 3 Percentage of fatally injured drivers with BACs above specific limits Blood Alcohol Level Level I Level II Level III (0.01–0.49 g/l) (0.5–0.99 g/l) ($1g/l) n%n%n% Total (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 Working (172) 14 8.1 12 7.0 47 27.3 Non-working (113) 13 11.5 14 12.4 44 38.9 n.s n.s P,0.05 a n.s, not significant. Toxicology concerning 979 people killed in road accidents (analysis carried out with legal aims). Data from both sources proved very similar; 50.5% of positive cases in our study compared with 51.3% in the samples provided by the National Institute of Toxicology. In both cases it was mainly alcohol on its own that was detected, and the number of cases with blood alcohol levels $0.8 g/l in our study represent 35.4%, as against 37.4% in the National Institute of Toxicology data. Figures from both sources clearly reveal how common it is to find alcohol in victims of road accidents in Spain. These data have been one of the aspects that have encouraged the authorities to reduce the current legal blood alcohol limits. Spanish legislation establishes legal blood alcohol concentration limits of 0.8 g/l in motor-vehicle drivers; 0.5 g/l in those driving vehicles over 3.500 kg and 0.3 g/l in those driving vehicles used for transporting passengers and for carrying dangerous goods [4]. Since May 7, 1999 the legal blood alcohol concentration limits have been changed to 0.5 g/l in motor-vehicle drivers and 0.3 g/l in the other cases. In any case, figures derived from the National Institute of Toxicology have always been viewed with caution. Firs of all, because samples are only taken to determine alcohol (or other drugs) in very few cases (generally in fewer than 3–5% of road deaths). How to explain this? Because of what we colloquially refer to as the ‘‘widow syndrome’’: that is to say, no interest is shown as to whether the victim was under the influence of alcohol or not; they would rather the insurance companies paid the families ´ M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 123 Table 4 Level of blood alcohol and substances detected along with alcohol Blood alcohol Alcohol Drugs and Drugs level alone alcohol found n%n%nType Level Level I 24 88.9 3 11.1 2 benzodiazepine I (0.01–0.49 g/l) 1 Cocaine 1I Opiates 1I Benzodiazepine1II Analgesic drug I Level II 22 84.6 4 15.4 1 cocaine III (0.5–0.99 g/l) 1 opiate 1III cocaine 1I benzodiazepine III 2 amphetamine 1I ecstasy I Level III 80 87.9 11 12.1 5 cocaine I ($1g/l) 1 cocaine II 1 cocaine III 1 amphetamine II 1 benzodiazepine I 1 cocaine 1I amphetamine 1II cannabis I 1 ecstasy 1I cocaine 1I cannabis I of the victims and the incident was forgotten. Thus, there has always been the fear that blood alcohol (and other drugs) concentration test are carried out only in cases in which the victim has shown clear signs of being either under the effect of alcohol or not. The fact that testing for alcohol in people killed or injured in road accidents has become a formal requirement in Spain since December 1996, might be a means to put an end to that situation. Although comparison with data from other countries should be carefully made, the figures observed in our study are among the highest [9,10]. Within the European Union, perhaps one of the countries with the most complete information is the United Kingdom, through the Coroner’s data [11]: data accumulated from 1990 to 1994 revealed that in 45.5% of deaths alcohol was detected, and that this exceeded 0.8 g/l in 20.25% of victims. Alcohol has been frequently detected in Italy (49.0%) [10] and in Belgium (28% over 0.49 g/l) [12], whilst figures for the Nordic countries (Sweden: 27% [13] and 20.3% [14], Norway: 28.3% [15]) are considerably lower, perhaps as a result of the fact that in these countries there exists a very strict policy with regard to alcohol and driving. Data from the Fatality Analysis Reporting System (FARS) show that alcohol involvement in fatal road accidents has been decreasing in the United States in the last ´ 124 M . C . del Rıo , F . J . Alvarez /Forensic Science International 104 (1999) 117 – 125 years [16–18], although in certain studies alcohol has been often found (46%) [19]. High figures have also been recorded for Canada (48%) [20], whereas in Australia figures are lower (36%) [7]. In addition, as regards the association between alcohol and drugs, the frequency with which this is detected varies greatly 4.0% [14], 11.45% [20], 13% [19], as do the types of substances found. In 1995 two reports examined drink-driving in the European Union [21,22] considering the role of different countermeasures and making recommendations. Drink-Driving does have to be tackled in an integrated and multidisciplinary way. A reduction in the legal blood alcohol limit, has been widely thought to be the next step. Many drivers look to these legal limits as a guide to safe drink-driver’s levels, and one suggestion is the harmonisation of maximum blood alcohol concentrations at 0.5 g/l throughout the European Union [23]. At present most of the European Union countries have changed this limit. But besides this measure, other preventive programs also need to be undertaken. Different research [9] shows that only reducing the legal limit would be effective. Experience shows that a much more significant, sustained and long-term impact could be achieved by a four-point program. These vital four measures are: stricter enforcement; tougher punishment; rehabilitation schemes; continuous public education and publicity. In our country drinking alcohol forms part of many people’s daily and social life, and great tolerance and permissiveness exist with regard to alcohol, thereby making intervention in this area rather difficult. However, a great effort is being made with regard to preventive policies, including the reduction of the legal limit, as mentioned earlier. The present study shows how widespread alcohol is and its high concentration level in the blood of fatally injured drivers, and suggest that drugs other than alcohol (fundamentally illegal drugs) are present in and causally related to impairment resulting in fatal traffic accidents. Cocaine together with alcohol, is the most frequent drug detected. Alcohol is the main problem in traffic fatalities in Spain, thereby making it necessary to intensify efforts and to set up specific programs to reduce drinking and driving, while also clarifying the role of drugs other than alcohol in traffic accidents. Acknowledgements ´´ Support for this study was provided by the Direccion General de Trafico (Traffic National Agency), Ministerio del Interior (Home Office), Madrid, Spain. References [1] European Comission white paper on transport policy (COM 92/494). 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