DRIVING, DVLA, AND ADVISING PATIENTS: TOP TIPS DR IÑIGO PEREZ MEDICAL ADVISER, DVLA GENERAL PRACTICE HOT TOPICS NOTTINGHAM 22 APRIL 2017
OUTLINE Drug driving Epilepsy concessions Fit to drive
DRUG DRIVING Mrs D has a diagnosis of fibromyalgia, which is controlled with strong analgesia and benzodiazepines (Morphine 360 mg/day and Diazepam 40 mg/day). Last week, after having had lunch with two friends (she had 1 glass of wine), Mrs D was stopped by the Police for erratic driving and failed a Field Impairment Test. A blood test revealed: - Morphine 100 μg/l - Diazepam 575 μg/l Mrs D comes to see you. The Police are going to prosecute her. She wants a letter explaining that Morphine and Diazepam had been prescribed and that she takes them in accordance with the advice given by you. She is planning to use your letter as medical defence. Q. Do you know what Mrs D is talking about?
DRUG DRIVING It is an offence to drive whilst impaired through drugs (legal or illegal) - Section 4 of Road Traffic Act 1988 Securing a conviction is not straightforward Police had to prove: - driver was impaired and unfit to drive - impairment was caused by drugs 2.600 proceedings under Section 4 53% guilty 52.000 for drink-driving 96% guilty
DRUG DRIVING A new offence of driving if the concentration of a specified drug in blood is above the limit prescribed for that drug - March 2015 Police do not have to prove impairment Legislation provides statutory medical defence for patients taking their medicines in accordance with instructions If the police had evidence that the patient's driving was impaired due to drugs (prescribed or not) they can prosecute under Section 4 of Road Traffic Act (no statutory medical defence )
Controlled Drug Limit (µg/l of blood) Cocaine 10 Benzoylecgonine (cocaine metabolite) 50 MDM A (ecstasy) 10 6-MAM (heroin metabolite) 5 Delta-9-Tetrahydrocannabinol 2 Ketamine 20 LSD 1 Methylamphetamine 10 Lorazepam 100 Flunitrazepam 300 Temazepam 1000 Diazepam 550 Clonazepam 50 Oxazepam 300 Morphine 80 Methadone 500 Amphetamine 250
DRUG DRIVING: FIRST GROUP OF DRUGS Commonly abused drugs Low limits have been set Group contains medicines taken by small proportion of drivers As low limits, patient could test above specified limit medical defence Cocaine (and metabolite, BZE) Ecstasy Heroin metabolite Cannabis (THC) Ketamine LSD Methylamphetamine
DRUG DRIVING: SECOND GROUP OF DRUGS Licensed medicines Significant liability to be abused Limits have been set at a higher level As higher limits, patients unlikely to test above specified limit If they do medical defence Lorazepam Diazepam Morphine Flunitrazepam Clonazepam Methadone Temazepam Oxazepam Amphetamine
DRUG DRIVING: MEDICAL DEFENCE A patient would generally be entitled to raise the statutory medical defence if: a. The drug was lawfully prescribed, supplied, or purchased over-the-counter, for medical or dental purposes; and b. The drug was taken in accordance with advice given by the person who prescribed or supplied the drug, and in accordance with any accompanying written instructions Advice from a prescriber can be patient-specific and differ from the general instructions in information leaflet
ADVICE TO GIVE TO PATIENTS it is against the law to drive if your driving ability is impaired by any medicine if you are taking your medicine as directed and your driving is not impaired, then you are not breaking the law check the leaflet that comes with your medicine for information on how your medicine may affect your driving ability do not drive while taking this medicine until you know how it affects you do not drive if you feel sleepy, dizzy, unable to concentrate or make decisions, or if you have blurred or double vision
ADVISING PATIENTS AS TO WHETHER THEIR DRIVING IS LIKELY TO BE IMPAIRED It is a driver s responsibility to decide whether they consider their driving is, or might be, impaired on any given occasion It is the responsibility of prescribers and suppliers of medicines: - to advice patients about the likely risks of their medicines - including advice on serious and common side-effects - some drugs may cause sleepiness and impair driving
DRUG DRIVING: METHADONE Full compliance with oral Methadone or Buprenorphine programme Supervised by Consultant, Specialist or Healthcare Practitioner Subject to favourable assessment No evidence of continued use of other substances, including cannabis Usually medical review driving licence valid for 1 year
EPILEPSY & DRIVING Mr E's epilepsy (awake seizures) had been controlled for 4 years. Three months ago, his Consultant Neurologist suggested a slow withdrawal of his antiepileptic medication. Unfortunately, Mr E had a seizure yesterday. He comes to see you today. You advise him to go back to the dose of antiepileptic medication he was taking 3 months ago. Mr E raises the issue of driving. Q. What would you advise Mr E?
EPILEPSY & DRIVING The Law defines Epilepsy as: Group 1 - two or more epileptic seizures during a 5 year period Group 2 - two or more epileptic seizures during a 10 year period Group 1 can be regained if seizure-free for 12 months Group 2 can be regained if seizure and medication-free for 10 years
EPILEPSY REGULATIONS: CONCESSIONS Medication Adjustment Seizure - i.e. seizure occurring during and because of physician substitution, reduction or withdrawal of anti epilepsy medication Period off driving could be 6 months Seizures not affecting Consciousness or Ability to Act seizures for at least 12 months never other type of unprovoked seizure
EPILEPSY REGULATIONS: ASLEEP CONCESSIONS Mrs R has a diagnosis of epilepsy. She presented with an awake seizure 3 years ago. Her second seizure was 6 months later while she was sleeping. Since, Mrs R has only had asleep seizures and they occur every 3 or 4 months. Mrs R comes to see you and tells you that, apparently, a friend of a friend was granted a driving licence by DVLA after she had just attained a 12 month period of asleep seizures. Mr R wants you to support her fitness to drive. Q. Would you support Mrs R's fitness to drive?
EPILEPSY REGULATIONS: ASLEEP CONCESSIONS Asleep Seizures Only 12 months of asleep seizures Never an awake attack Asleep Seizures (and h/o Awake Seizure) At least one awake seizure in past 3 years of asleep seizures only
FITNESS TO DRIVE Mr A had surgery for a solitary brain metastasis 6 months ago. Treatment was completed with adjuvant radiotherapy. Although he initially had cognitive problems, Mr A has recovered very well. Mr A self-referred himself for a driving assessment and passed with flying colours. A recent brain scan has confirmed no evidence of residual tumour or recurrence. Mr A has had no seizures. Q. Is Mr A fit to drive?
FITNESS TO DRIVE Miss HI fell off her horse 4 weeks ago. She lost consciousness for few minutes and was taken to hospital. Brain scan revealed a frontal contusion and a small acute subdural haematoma. Miss HI was discharged next day with no significant symptoms. Miss HI had an outpatient appointment yesterday. As she has fully recovered, she was discharged back to your care. Miss HI has had no seizures. Q. Does Miss HI satisfy the standards of fitness to drive?
FITNESS TO DRIVE Mrs O (88 y.o.) complains of exhaustion and weight loss. She walks slowly with a stick. Examination reveals generalised weakness and mild cognitive impairment. Corrected Visual Acuities are 6/12 in both eyes. Mrs O lives in 'the middle of nowhere' and needs her car for shopping, to go to the post office, etc. Q. Is Mrs O fit to drive?
FITNESS TO DRIVE Fitness to Drive = Eligibility ability to drive risk of sudden & disabling event (20% for car - 2% for Lorry/Bus) - medical standards (advised by Panels of Experts) - legal standards ('the Law is harsh but it is the Law')
FITNESS TO DRIVE Establish driving status during the consultation No upper age limit to hold a driving licence If unsure of standards, check Assessing Fitness to Drive If in doubt, consider: - phoning DVLA 01792 782337 - emailing DVLA - medadviser@dvla.gsi.gov.uk It is the driver's responsibility to inform DVLA but they will seek your advice Always document any advice given in the notes Confidentiality remember GMC guidelines and DVLA
TAKE-HOME MESSAGES 1. Drug Driving: - if impaired, do not drive - if not impaired, the medical defence 2. Permitted pattern of seizures (Epilepsy Regulations) - seizure during withdrawal of medication - seizures not affecting consciousness + ability to act - asleep seizures (1 or 3 years) 3. When assessing patients keep in mind their Fitness to Drive (Fitness to Drive = Eligibility, not just Ability)
THANK YOU To contact the DVLA Medical Advisers: - Telephone - 01792 782337 (10:30 am 1 pm) - Email: medadviser@dvla.gsi.gov.uk Inigo.Perez-Celorrio@dvla.gsi.gov.uk