DRIVING, DVLA, AND ADVISING PATIENTS: TOP TIPS DR IÑIGO PEREZ MEDICAL ADVISER, DVLA GENERAL PRACTICE HOT TOPICS LIVERPOOL 4 FEBRUARY 2017
OUTLINE Case Scenarios Fit to fly X Fit to drive Drug driving Epilepsy & driving Employment issues?
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, he 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
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 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, she has only had asleep seizures and they occur every 3 or 4 months. Mr 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
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) A new offence of driving if the concentration of a specified drug in blood is above the limit prescribed for that drug - March 2015 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 Methadone 500 Diazepam 550 Clonazepam 50 Morphine 80 Oxazepam 300 Temazepam 1000 Amphetamine 250
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
ADVISING A PATIENT 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 they believe might be, impaired on any given occasion It is the responsibility of prescribers and suppliers of medicines to give clinical advice to patients about the likely risks of their medicines (including advice on serious and common sideeffects), which might include for example, for some drugs the advice that the drug may cause sleepiness and so might impair driving
EMPLOYMENT ISSUES Mr JP is a 57 y.o. lorry driver with a past medical history of myocardial infarction and coronary angioplasty (2010). He has been well since 2010 and his Group 2 entitlement has been renewed by DVLA every 3 years after successful Exercise Tolerance Tests. Mr JP has recently applied to renew Group 2 entitlement but the ETT has been positive and DVLA has refused to grant him a licence. Q. How can you help Mr JP?
TAKE-HOME MESSAGES 1. When assessing patients keep in mind their Fitness to Drive (Fitness to Drive = Eligibility, not just Ability) 2. Remember the permitted pattern of seizures (Epilepsy Regulations) 3. Drug Driving and the medical defence
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