Can drugged driving on benzodiazepines or opioids be safe? Benzodiazepines and opioids are two classes of drugs heavily used recreationally and prescribed. The effects of both substances are varied but both are extremely addictive, leading to many people having physical dependencies on them. Benzodiazepines are too varied and understudied to have a conclusive law regarding their use driving, but it is apparent that many dangers exist. This has led to tens of thousands of deaths through lack of knowledge and their abuse. Opioids also carry danger, but these dangers typically are not seen in stable users who are opioid dependent and do not abuse prescriptions. Rather, opioid-dependent patients are in more harm by driving without the necessary amount of their prescription to be titrated. Driving laws differ between nations and states. The DVLA, or Driver and Vehicle Licensing Association of the UK, has a policy which leads to many driving deaths of patients using benzodiazepines and abuses of opioid user’s rights. The US has no national restrictions on driving under the influence of drugs and most states have very ambiguous policies. Australia has a much more guided and sensible policy, likely due to much further research into the effects of drugged driving. Ultimately, it is the author’s opinion that most rules regarding prescription drugs should be altered due to lack of correspondence with scientific data. Many drugs are under treated and there is a great threat of people driving under the influence of dangerous pharmaceuticals due to lack of knowledge. Restrictions on driving under the influence of a prescribed opioid should be made less strict as they put unnecessary restrictions on people, wrongfully removing the right for thousands of people to drive for a very excessive amount of time. This is especially the case for methadone users, both under rehabilitation for previous drug use or for general pain relief. Changes in regulations might also help remove the taboos of prescription opioids, especially methadone, as used only by ex-drug abusers. A more sensible policy regarding drugged driving could help addicts choose to get treated, aid in recovery, inform the public of dangers, and drastically increase safety on the road.

Introduction:

A lack of clear cut laws and regulations regarding Class A drugs, used legally, has made many recovering addicts go through unnecessary troubles in their attempt to be drug free. Typically methadone and buprenorphine users are required to tell their licensing agency of their use. Limitations and bans on driving under the influence of narcotics have led to many recovering addicts becoming immobile, even when completely functional. Reacquiring a license may be equally problematic, with waits of 3 years in the UK and completely forbidding license renewal in opioid users in certain states in the US. These restrictions are excessive and need to be changed. While driving under the influence of an illegal substance is nearly always dangerous, there is a concern that recovering addicts who are dependent on a substance, often fully functioning members of society with complete mental clarity, are being alienated and unfairly treated. Even more concerning is the lack of knowledge about the effects of prescribed drugs and user’s knowledge about current guidelines.

Public Information:

It should be the responsibility of doctors, dentists, pharmacists, and other medical professionals to counsel patients about effects of different medicines. Unfortunately there is a common belief that there is less impairment caused by pharmaceutical drugs then alcohol and illicit drugs. This is not the case. Drugged driving (DUI) is a top cause of driving accidents though it is hardly mentioned compared to other accident causes. In Florida, deaths caused by prescription drugs were three times as many as deaths caused by illegally taken drugs (Cave). The vast majority of these deaths are from benzodiazepines, mainly Valium and Xanax, sometimes mixed with alcohol and other drugs.

Most medicines have warning labels with verbal information that should be read by consumers. These typically mention reduction of motor skills and explicit warnings to not drive or operate heavy machinery (if applicable). Of course patients often think they are or not receiving side effects of their medication and may choose to drive regardless of warnings. One in four Australian drivers admits to ignoring medical advice about not driving under the influence of prescription medication. Campaigns to increase knowledge about adverse effects of driving under the influence of prescribed medication have drastically improved people’s attitudes (Queensland Transport). Generally medication is unpredictable for the first two weeks, when mixed with other substances, or dosage is not kept stable. The largest threat to patients is that they are often not able to predict affects on driving under medication until a situation requires quick response.

The most crucial information to patients is that they should not mix their medication or change dosages without consulting their health care provider. If a patient receives sedation, unsteadiness, or cognitive decline, they should also immediately tell a physician and proper adjustments to their medication should be made.

Prescription Drugs Overview:

Class A drugs are controversial in that they are substances with extremely high chance of abuse and dependency, but may be dispensed directly through a pharmacist. Drugs inherently change the bodily functions of a person for a period of time. This period of time differs between drugs and most drugs will have some sort of effect even after the drug has worn off. Benzodiazepines and opioids are the two drug classes discussed because of their effects on perception, consciousness, and behavior. Their effects are often used to treat addiction and habituation, creating taboos about the drugs regardless of their other uses. They also may be used by naïve and dependent patients for short periods or the entirety of a person’s life.

Benzodiazepines are the most commonly prescribed psychotropic drugs. Benzodiazepines are typically used to treat anxiety, insomnia, agitation, seizures, muscle spasms, alcohol and drug withdrawal, panic, and as a premedication for medical and dental procedures. There effects may be short, intermediate, or long acting. There are currently more than 25 benzodiazepines marketed, but the most common include Xanax, Valium, Halcion, Klonopin, and Ativan.

Benzodiazepines all have some degree of sedative, hypnotic, and anxiolytic effects. They typically also carry anticonvulsant, muscle relaxant, and amnesic action. Because of the large variety of Benzodiazepines, it is difficult to describe how functional the taker is. They are often abused by drug takers to self-medicate for adverse effects, such as withdrawal and crashing from amphetamine use. They are also abused to receive their general properties, making them a giant cause of death in developed nations. Benzodiazepines have occasionally created paradoxical effects, such as increased aggression in place of relief or depression instead of elation. There are many studies reporting the dangers of long term use, and many known psychological and physical effects caused by increased tolerance, physical dependence, and withdrawal.

Methadone and buprenorphine are synthetic opiate derivatives used typically in treatment of heroin and opiate addiction. Methadone maintenance treatment is by far the most evaluated form of treatment in the field of drug abuse treatment, though it remains controversial. Methadone is seen as advantageous in its ability to reduce criminal activity amongst addicts, and give chance for addicts to contribute to society without being worried about arrest. One study by Gearing (1971) claims that 80-90% of heroin addicts using methadone treatment stay free from other drug use, are self-supporting, and refrain from committing criminal acts. The same study reports only 1% of patients reverting back to heroin use. It is uncertain if the program’s benefits derive from the use of weaning off opiates in a controlled manner or the general counseling and structure of the program involved.

Methadone and buprenorphine at most stable doses will not make addicts high, but rather just rids cravings. Drug cravings often lead to drug-seeking behavior and subsequent crime, especially when cravings are not fed. Methadone is often prescribed just because of its lack of high in patients who are taking it to the point of titration. Furthermore, it is often used as primary treatment for chronic pain because of its analgesic and antitussive properties, as well as having a lesser chance of addiction than many other pharmaceutical drugs. Some patients are prescribed methadone because of allergic reactions to other pain killers.

Prescription Medication Effects on Driving

There is no conclusive research on the effects of benzodiazepines on driving skills in patients on stable doses. Instead, it seems apparent that the effects on individuals differs greatly and it is possible that there will be adverse, beneficial, or no effects on driving skills. Each benzodiazepine should be treated and studied differently. The dosage of benzodiazepines can differ 20 fold in mg to mg basis, so it is important to know the details of what is being taken before making assumptions about driving. For example, 0.5 mg of alprazolam (Xanax) is the same dosage as 10 mg of diazepam (Valium). A switch to a new medication should not only be gauged based on dosage. The amount of time the medication is left in the system also differs greatly between medications. Triazolam (Halcion) has a half-life of 2-5 hours, while diazepam has a half life of 36-200 hours. Metabolism and half-life are also dependent on the duration of taking a medication since concentrations of the medication can store in the body for extended periods of time.

People dependent on benzodiazepines often suffer from benzodiazepine withdrawal syndrome upon leaving their medication. This often produces anxiety, irritability, insomnia, and sensory disturbances. There have been reported cases of schizophrenia and seizure disorders developing in some individuals, and studies of increased suicide rates from withdrawal. Having a sudden sensation of fitting can occur up to 15 days from withdrawal, which can be particularly dangerous if occurring while driving. Weaning off of the medication may be pivotal to safety, and drivers should strongly consider not driving for several weeks after leaving their medication in case of random fits.

The effects of opioids are highly dependent on dose and whether the user is opioid-naïve or opioid-dependent. Opioid-naïve patients are more likely to have impairment of some psychomotor skills (Zacny (2.5-10 mg doses of morphine)). Most studies point out that opioid-dependent patients typically see no significant difference in comparison to drug-free patients, changes only when increasing dosages and not left at a stable amount (Bruera; Chesher), and sometimes even improved reaction time (O’Neill; Brooke – both using 10-15 mg of morphine every 4 hours). If you speak to anyone who’s being treated by methadone or buprenorphine they will likely tell you that they are much safer driving with their dosage then without. This derives from increased opioid tolerance and more stability with their necessary “fix” to be titrated (stable but not over-sedated).

Nearly all records of driving accidents where methadone was found in the person’s system, the person was not tolerant to the dose or there were additional drugs or alcohol found in the patient. Reviews of driving records have shown that narcotic users do not have driving records significantly different from aged-matched individuals in the general population, nor do methadone-dependent patients (Gordon). Findings typically suggest that standards around methadone patients driving should be the same as for other people when stabilized on methadone, LAAM, or buprenorphine treatment (Lenne, Dietze, Rumbold, Redman, Triggs; Schindler, Ortner, Peternell, Eder, Opgenoorth, Fischer; Baewert, Gombas, Schindler, Peternell-Moelzer, Eder, Jagsch). A study in Australia points out that impairment by alcohol consumption is similar in effects in drug-free drivers and opioid-dependent drivers (Dietze). Studies have even gone as far as to point out, “The formal assertion that addiction equals driving-inability, which is largely practiced at present, is inadmissible and therefore harmful to the therapeutic efforts for rehabilitation.” (Rössler, Battista, Deisenhammer, Günther, Pohl, Prokop, Riemer)

Buprenorphine, a low-efficacy, partial mu-opioid agonist sold as Suboxone and Subutex, is an alternative to methadone used in Germany and several other countries. It’s considerably safer then other opiate treatments and may be administered every other day. It has also been reported to effect cognitive and psychomotor abilities less than other opioids, meaning it would be an even better solution to opioid-dependent drivers (Soyka, Horak, Dittert, Kagerer). A test on buprenorphine patients matched with healthy control subjects and methadone patients, using tests which the Austrian road safety board validated, concluded that patients involved given buprenorphine did better than patients given methadone. The biggest difference was in performance under stress conditions and monotony, possibly the biggest role in possible accidents while driving.

Current Treatment in the UK

The majority of the UK has licenses distributed by the DVLA, or Driver and Vehicle Licensing Agency. Northern Ireland has licenses distributed by the Driver & Vehicle Agency. If the DVLA suspects you are using illegal drugs they may require you to attend a medical examination and produce a urine sample, or require a doctor’s medical report. A positive urine sample can lead to a license being removed for a specified period. For most controlled substances, the ban is at least a year with a right to appeal against the ban in a Magistrates court.

The DVLA goes by the latest DVLA Medical Rules book (February 2011) which says that persistent use of heroin, morphine, methadone, cocaine, and methamphetamines, “will lead to license refusal or revocation until a minimum one year period free of such use has been attained. Independent medical assessment and urine screen arranged by DVLA may be required. In addition favorable Consultant or Specialist report may be required on reapplication.” A user who proves to be complying with a supervised oral methadone or buprenorphine program can be licensed only after annual medical reviews proving no substance abuse (including cannabis and minor drugs). Drivers of HGV/LGVs (large goods vehicles) have even stricter laws. “Persistent use of, or dependence on these substances, will require revocation or refusal of a vocational license until a minimum three year period free of such use has been attained. Independent medical assessment and urine screen arranged by DVLA will normally be required. In addition favorable Consultant or Specialist report will be required before relicensing…. Expert Panel advice will be required in each case.”

In the case of benzodiazepines, it is clearly stated that “prescribed use of these drugs at therapeutic doses (BNF), without evidence of impairment, does not amount to misuse/dependence for licensing purposes (although clinically dependence may exist).

Persistent misuse of, or dependence on these substances, confirmed by medical enquiry, will lead to license refusal or revocation until a minimum one year period free of such use has been attained. Independent medical assessment and urine screen arranged by DVLA may be required. In addition favorable Consultant or Specialist report may be required on reapplication.” There is also a three-year period for HGV relicensing if found abusing the substance repeatedly, that requires urine screening and specialist reports.

Catch-22 for Opioid Patients in UK

The treatment for opioids lacks a clause, like benzodiazepines, that makes it legal for people on prescriptions to stay licensed. This current treatment of opioids by the DVLA creates a Catch-22 situation in which patients must choose to lose their right to drive for an excessive period of time or go against the law. Both situations cause physical danger for the public.

Imagine that the user tells the DVLA of their previous use and treatment. Most opioid-dependent patients wind up falling under the harms of being considered dependent on the drug, rendering them unlicensed for 1 or 3 years. This is especially true of newly recovering patients, who are most at the harms of relapse. Being unlicensed adds to the stress and problems of trying to break an addiction and resume a normal life. It forces the patient to rethink many daily tasks, such as going to work and getting groceries.

The other possible situation is a methadone user not telling the DLVA of their drug use. This situation is rare because the choice to be drug free through opioid treatment usually shows a choice to comply with governmental regulation. There is also no enforcement of confidentiality of drug use, meaning a physician can tell the DVLA that a patient is being treated without their consent. Remaining silent about drug use may stem from a person’s want to keep their license, job, family etc. as much as it may stem from general ignorance of the need to inform the DVLA. There is chance the user will get away with driving illegally for an extended period of time, as certainly tons of people in the UK currently do. However, there is the physical danger of an accident caused by being on the substance, especially if newly put on the drug and not considered stable, or mixed with alcohol or other substances. There is also risk of uninsured driving accidents.

It can not be certain why there is a discrepancy between the treatment of opioid-dependent and benzodiazepine-dependent drivers. It may be associated with class, the taboo behind opioid addiction, or just lack of research by the DVLA regarding proper treatment of drug-dependent patients. It should also be noted that many restrictions on licenses are forgotten by average citizens. Over 40,000 people in the UK unwittingly drive illegally by not renewing there photocard license every 10 years, risking fines and even insurance refusing to make payments for claims on accidents.

Current Treatment in Australia

Australia had approximately 30,000 people undertaking methadone treatment in 2009 (National Opioid Pharmacotherapy Statistics Annual Data Collection). Australia has done a great deal of research on the influence of drugs and driving finding things such as that in a sample of 436 injured drivers that cannabis metabolites were found in 46.7%, delta-9-tetrahydrocannabinol (THC) in 7.6%, benzodiazepines in 15.6%, opiates in 11%, amphetamines in 4.1%, methadone in 3%, and cocaine in 1.4%.

Australian drug laws have more scientific basis, and as such patients on an opioid regimen are typically advised to not drive for up to 4 weeks, until their opioid regimen is stabilized. There is no national legal obligation to inform the driving agency of opioid use, but a doctor may recommend it. This relatively short period of waiting is much more reasonable then 1-3 years and allows for patients to resume normal life at a quick rate. Licensing varies by state or territory under their Ministry of Transports. Licensing agencies include The Road Transport Authority, Roads and Traffic Authority, Motor Vehicle Registry, Queensland Transport, Transport SA, Department of Infrastructure, Vicroads, and the Department for Planning Infrastructure. Each one may carry a different underlying policy, so it’s best to check with the correct agency before driving.

Current Treatment in US

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In a country where marijuana is now legal in 16 states and illegal use of prescription pills is constantly rising, the treatment of drugs is highly dependent on the state. In the US, a Department of Motor Vehicles at a state-level is responsible for administering licenses and for enforcing state and federal laws regarding motor vehicles. The DMV has more power then standard law enforcement officers by being able to refuse and cancel registration and tags based upon investigations. While there are no federal laws regarding opioid and benzodiazepine-dependent patients, there has been a push by President Obama to create stronger federal laws pushing against drugged driving. This started in 2010 and is continuing, especially cracking down on the Massachusetts area. Massachusetts reports 6.4% of drivers admitting to driving under the influence of illegal drugs, compared to the national average of 4.7%.

Driving with any amount of impairing drug, including prescription opioids and benzodiazepines, is illegal in 15 states including: Arizona, Georgia, Indiana, Illinois, Iowa, Michigan, Minnesota, Nevada, North Carolina, Ohio, Pennsylvania, Rhode Island, Utah, Virginia, and Wisconsin. California’s drug laws do not distinguish between illegal drugs, prescribed opioid drugs, alcohol, and even over-the-counter medications that may cause drowsiness. Getting pulled over and being found to be under the influence of any pharmaceutical drug may result in a DUI charge in any of these states. These strict restrictions stem from the misconception that opioids mimic narcotics in all users.

In Laconia, New Hampshire an approved methadone clinic was dropped a year later based upon a requirement to have uniformed off-duty police officer checking if patients were impaired driving. The price of hiring the officers would cost the clinic more than $100,000 a year and greatly reduce its use. Nationally, few methadone clinics have off-duty officers. Clinics serving over 1,000 patients a day use off-duty officers to make sure things stay in order, not to check impairment of driving. Bars do not even require off-duty officers to check upon driver’s impairment, though the dangers created by drinking are clearly greater then opioid-dependency.

It is uncertain what will become of state and federal drugged driving laws and if methadone patients will receive more or less rights in the future. Hopefully more informed policy makers will lift unnecessary restrictions on driving and help patients resume normal lives. Lifting restrictions might allow for more clinics and less expenses when commute to clinics is covered by the state.

Further Reading

Baewert, Andjela, Wolfgang Gombas, Shird-Dieter Schindler, Alexandra Peternell-Moelzer, Harald Eder, Reinhold Jagsch, and Gabriele Fischer. "Influence of Peak and Trough Levels of Opioid Maintenance Therapy on Driving Aptitude." European Addiction Research 13.3 (2007): 127-35. Print.

Brooke, C., A. Ebnhage, B. Fransson, F. Haggi, B. Jonzon, I. Kraft, and K. Wesnes. "The Effects of Intravenous Morphine on Cognitive Function in Healthy Volunteers." Journal of Psychopharmacology 12 (1998): 45. Print.

Cave, Damien. "Legal Drugs Kill Far More Than Illegal, Florida Says - NYTimes.com." The New York Times. 14 June 2008. Web. 11 July 2011. <http://www.nytimes.com/2008/06/14/us/14florida.html>.

Chesher, G., J. Lemon, M. Gomel, and G. Murphy. "The Effects of Methadone, as Used in a Methadone Maintenance Program, on Driving Related Skills." National Drug and Alcohol Research Centre (1989). Print.

Chesher, G. "Understanding the Opioid Analgesics and Their Effects on Skills Performance." Alcohol Drugs Driving 5 (1989): 111-38. Print.

Darke, Shane, Jamie Sims, Skye McDonald, and Wendy Wickes. "Cognitive Impairment among Methadone Maintenance Patients." Addiction 95.5 (2000): 687-95. Print.

For Medical Practitioners; At a Glance Guide to the Current Medical Standards of Fitness to Drive. Rep. Swansea: Drivers Medical Group, DVLA, 2011. Print.

Gordon, N. "Influence of Narcotic Drugs on Highway Safety." Influence of Narcotic Drugs on Highway Safety. Accident Analysis & Prevention 8.1 (1976): 3-7. Print.

Hanks, G., W. O'Neill, P. Simpson, and K. Wesnes. "The Cognitive and Psychomotor Effects of Opioid Analgesics. II. A Randomised Controlled Trial of Single Doses of Morphine, Lorazepam and Placebo in Healthy Subjects. "European Journal of Clinical Pharmacology 48 (1995): 455-60. Print.

Jauregui, I., J. Mullol, J. Barta, A. Cuvillo, I. Davila, J. Montoro, J. Sastre, and A. Valero. "H1 Antihistamines: Psychomotor Performance and Driving." Journal of Investigational Allergology and Clinical Immunology16.1 (2006): 37-44. Print.

Lenne, M., P. Dietze, G. Rumbold, J. Redman, and T. Triggs. "The Effects of the Opioid Pharmacotherapies Methadone, LAAM and Buprenorphine, Alone and in Combination with Alcohol, on Simulated Driving." Drug and Alcohol Dependence 72.3 (2003): 271-78. Print.

Lenne, M., P. Dietze, G. Rumbold, J. Redman, and T. Triggs. "The Effects of the Opioid Pharmacotherapies Methadone, LAAM and Buprenorphine, Alone and in Combination with Alcohol, on Simulated Driving." Drug and Alcohol Dependence 72.3 (2003): 271-78. Print.

O'Neill, W., G. Hanks, P. Simpson, M. Fallon, E. Jenkins, and K. Wesnes. "The Cognitive and Psychomotor Effects of Morphine in Healthy Subjects: a Randomized Controlled Trial of Repeated (four) Oral Doses of Dextropropoxyphene, Morphine, Lorazepam and Placebo." Pain 85.1-2 (2000): 209-15. Print.

Ramaekers, J., M. Uiterwijk, and J. O'Hanlon. "Effects of Loratadine and Cetirizine on Actual Driving and Psychometric Test Performance and EEG during Driving." European Journal of Clinical Pharmacology 42 (1992): 363-69. Print.

Rössler, H., H.J. Battista, F. Deisenhammer, V. Günther, P. Pohl, L. Prokop, and Y. Riemer. "Methadone-substitution and Driving Ability." Forensic Science International 62.1-2 (1993): 63-66. Print.

Schindler, Shird-Dieter, Romana Ortner, Alexandra Peternell, Harald Eder, Elfriede Opgenoorth, and Gabriele Fischer. "Maintenance Therapy with Synthetic Opioids and Driving Aptitude." European Addiction Research 10.2 (2004): 80-87. Print.

Schindler, Shird-Dieter, Romana Ortner, Alexandra Peternell, Harald Eder, Elfriede Opgenoorth, and Gabriele Fischer. "Maintenance Therapy with Synthetic Opioids and Driving Aptitude." European Addiction Research 10.2 (2004): 80-87. Print.

Soyka, M., M. Horak, S. Dittert, and S. Kagerer. "Less Driving Impairment on Buprenorphine than Methadone in Drug-Dependent Patients?" J Neuropsychiatry Clinical Neuroscience 13 (2001): 527-28. Print.

Specka, M., Th. Finkbeiner, E. Lodemann, K. Leifert, J. Kluwig, and M. Gastpar. "Cognitive-Motor Performance of Methadone-Maintained Patients." European Addiction Research 6.1 (2000): 8-19. Print.

Stough, Con, and Rebecca King. "Drugs and Driving." Prevention Research Quarterly (2010). DrugInfo Clearinghouse, Mar. 2010. Web. <www.druginfo.adf.org.au>.

"Study Suggests Driving Restrictions Are Not Necessary for Users of Methadone, Buprenorphine and LAAM." Web log post. Science Blog. Elsevier Science, Dec. 2003. Web. <http://scienceblog.com/community/older/2003/E/20032737.html>.