Formulary and Clinical Guideline Document Pharmacy Department Medicines Management Services DRIVING AND MENTAL HEALTH CONDITIONS AND TREATMENTS General information Driving while impaired by a physical or mental health condition or the influence of drugs can seriously impact on safe control of a vehicle and increase the risk of accidents. Mental disorders can affect judgement, concentration and reaction times. Pharmacological treatments can reduce the driving-related risks associated with mental disorders; however, they can also impair driving skills due to the side-effect profile. Drugs can impair driving performance as a consequence of adverse effects such as drowsiness, poor coordination, impaired or slowed thinking, dizziness, or visual problems Alcohol, even in small amounts, will significantly potentiate the effects of medication on the central nervous system impairing safe driving It is an offence to drive or attempt to drive whilst unfit to do so due to alcohol and/or drugs, whether illegal drugs or legally prescribed medicines. All drugs that act on the central nervous system can impair alertness, concentration and driving performance. This is particularly so at initiation of treatment and when the dose is increased or if another drug is added that could also impair driving ability. Driving must be avoided if adversely affected From March 2015, it is now an offence to drive with certain specified controlled drugs above specified limits in the blood. These include illegal drugs and medicines. Some medical conditions can affect a person s fitness to drive and in some cases need to be notified to the Driver and Vehicle Licensing Agency DVLA. Drivers with psychiatric illnesses are usually safer when well and on regular psychotropic medication than when they are ill. However, inadequate treatment or lack of compliance may render the driver impaired by both illness and medication. Notification to the DVLA Doctors and other healthcare professionals should: advise individual drivers of the impact of their condition on fitness to drive; advise the individual on their legal requirement to notify the DVLA; treat, manage and monitor the individual s condition with on-going consideration of the impact on driving. Health professionals prescribing or dispensing medication should consider the risk associated with that medicine or combination of medicines, and driving and take the opportunity to appropriately advise their patients. It is the duty of the license holder or license applicant to notify DVLA of any illness, injury or medication, which may affect safe driving and comply with any requirements indicated by the DVLA including any periodic medical reviews. They should also adhere, with ongoing consideration of fitness to drive, to prescribed medical treatment, and to monitor and manage the condition and any adaptations. On occasions however, there are circumstances in which the license holder cannot, or will not notify the DVLA. In such cases, it may be necessary for the healthcare professional to contact the DVLA if there is concern for road safety for the benefit of the individual and the wider public. Medico-legal implications make it necessary for doctors and psychiatrists to be aware of the GMC guidance and also advice of the Royal College of Psychiatrists. http://www.gmc-uk.org/guidance/ethical_guidance/30117.asp http://www.rcpsych.ac.uk/ Driving and Mental Health Conditions and Treatments Next Review June 2017 1
Medical conditions, medication and driving Driving is a complex information processing task which can be divided in 3 steps: perception (detection and identification), decision and reaction which may be affected by mental health disorders due to : o Poor cognition reduced attention, memory problems o Impaired motor function slower reaction times, loss of coordination o Altered thoughts and behaviours, impaired judgement including ability to predict and anticipate o Emotional states eg agitation, irritation, depression have a detrimental influence on perception and information processing Anyone with a medical condition likely to cause a sudden disabling event at the wheel, or who is unable to control their vehicle safely for any other reason, must not drive. Medical conditions such as diabetes mellitus, cardiac disorders, epilepsy, visual impairments and renal and respiratory conditions are subject to DVLA rules for fitness to drive. The rules relating to mental health conditions and alcohol or substance misuse and dependence are summarised in the tables below. If psychiatric illness has been associated with substance misuse, continued misuse contraindicates driving and licensing. The latest guidance is always available at: https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-formedical-professionals Medication can improve driving performance in individuals with well-controlled conditions but side effects must be considered. Effects of medication that can impair driving ability include: o Sedation and dizziness o Concentration difficulties o Postural hypotension o Blurred vision o Impaired coordination o Extrapyramidal adverse effects, eg muscle stiffness Drivers taking prescribed drugs subject to the drug-driving legislation will need to be advised to carry confirmation that these were prescribed by a registered medical practitioner. Licence holders are legally required to notify the DVLA of any injury or illness that would have a likely impact on safe driving ability. By law, driving licences are classified into Group 1 (motorcycles and cars) and Group 2 (heavy goods vehicles and passenger vehicles). The rules that apply may be different depending on the group involved. Relevant guidelines Assessing fitness to drive: a guide for medical professionals: https://www.gov.uk/government/publications/assessing-fitness-to-drive-a-guide-formedical-professionals GMC guidance from www.gmc-uk.org Royal College of Psychiatrists guidance from https://www.rcpsych.ac.uk/ Driving and Mental Health Conditions and Treatments Review June 2017 2
Mental Health Condition and Fitness to Drive ADHD May be able to drive but must notify the DVLA Licensing may continue provided no factors that render driving dangerous Consider factors such as impulsivity, lack of awareness of the impact of own behaviours on self or others need. Anxiety disorders Poor concentration and attention may impair driving. Other symptoms that may affect driving include suicidal ideation. Notify the DVLA only if severe with significant memory and concentration problems, agitation, behavioural disturbance or suicidal thoughts Relicensing will depend on the outcome of the DVLA enquiry Group 2 driver should have recovered and be stable for a period of six months before resuming driving. Bipolar affective disorder: Several symptoms of this disorder may affect driving: suicidal ideation, impaired judgment with over confidence and risk-taking behaviour, poor concentration and attention, etc. Must notify the DVLA and driving must cease Relicensing may be considered if all DVLA conditions met There must be no driving during any acute illness Driving and Mental Health Conditions and Treatments Review June 2017 3
Mental Health Condition and Fitness to Drive - continued Depression: The cognitive impairment caused by severe depression can be important and involves all cognitive abilities including slowing of reaction time. Other symptoms that may affect driving include suicidal ideation In non-complicated, minor or short-lived depressive episodes without significant memory problems, concentration difficulties, agitation, behavioural disturbance or suicidal thoughts, the DVLA need not be notified and driving may continue. However, the effects of medication should be considered. Where there are moderate to severe symptoms of depression: notify the DVLA and stop driving pending the outcome. Driving may only resume following a period of stability of six months for group 2 drivers. Patients should not drive during a course of ECT. Dementias Mild Cognitive Impairment Dementia May drive and need not notify the DVLA but see note below. Notification to the DVLA of mild cognitive impairment is not required unless there are objective indicators of possible driving impairments or a diagnosis of mild dementia, in which case driving must cease pending individual DVLA enquiry. It is difficult to assess driving ability in people with dementia. Progressive deterioration in memory, reactions and perception will interfere with driving skills Notify the DVLA. Depending on the outcome of enquiry, Group 1 drivers may be able to drive but must notify the DVLA. Group 2 drivers must not drive and must notify the DVLA. Licensing will be refused or revoked. Regular formal driving assessments may be necessary Driving and Mental Health Conditions and Treatments Review June 2017 4
Mental Health Condition and Fitness to Drive- continued Neurological Disorders Epilepsy/Seizures Post Head Injury Learning disabilities Mild learning disability Severe learning disability Autism, Asperger s syndrome Personality disorders Epileptic seizures are the most common medical cause of collapse at the wheel. Must not drive and must notify Depending on the circumstances and outcome of DVLA medical enquiry, driving may resume following a period of stability. See DVLA. Must not drive and must notify and await DVLA decision. Licensing will be refused or revoked if there is serious disturbance for example, violent behaviour or alcohol abuse likely to be a source of danger at the wheel Notify DVLA In mild learning disability, provided there are no other relevant problems, it may be possible to hold a driving licence, but it will be necessary to demonstrate adequate functional ability at the wheel. There should not be any comorbid mental or physical illness affecting driving ability. Notify the DVLA and must not drive Severe learning disability is not compatible with driving and licensing will be refuse. May be able to drive but must notify Patients with a diagnosis of autism, Asperger s syndrome may be permitted to drive provided they do not suffer from factors that render driving dangerous. Aggressive and impulsive behaviour may affect driving. Other traits exhibited in these disorder will also interfere eg intolerance or frustration Group 1 drivers may be able to drive but must notify the DVLA and await outcome. Group 2 drivers must not drive and must notify the DVLA and await outcome. Licences will be revoked or refused for patients who suffer from personality disorders with marked impulsivity, as this may affect driving Driving and Mental Health Conditions and Treatments Review June 2017 5
Mental Health Condition and Fitness to Drive - continued Psychosis and Schizophrenia Several symptoms of this disorder may affect driving: suicidal ideation, impaired concentration and memory, impaired judgment, delusions, hallucinations, confused thinking, agitated behaviour, etc. Must notify the DVLA. Driving should cease during any acute illness and will only be considered if all DVLA conditions are met. Group 2 will require a period of wellness and stability before relicensing. Substance Misuse Alcohol Drivers with a history of instability or relapse and/or poor engagement with treatment will be required not to drive for a longer period before any relicensing. Alcohol can affect a driver s behaviour and body in all sorts of dangerous and unpredictable ways. Driving while on the influence of alcohol substances will lead to licence refusal or revocation. Persistent harmful alcohol misuse - Must not drive and must notify the DVLA. A Group 2 licence will only be issued after a stable period of at least one year of abstinence or controlled drinking and at least six months for Group 1 drivers. Alcohol dependence-- Must not drive and must notify the DVLA. A diagnosis of alcohol dependence would normally result in the licence being revoked or refused until a one-year alcohol-free period has been achieved for Group 1 drivers and a three-year period for Group 2 drivers. People with alcohol related disorders like cirrhosis with neuropsychiatric impairment or alcohol-induced psychosis may not drive until recovery is demonstrated satisfactorily. Alcohol related solitary seizure - Must not drive and must notify the DVLA. (If more than 1 seizure, as for epilepsy)license will be refused or revoked for a minimum of six months from the date of the seizure in Group 1 drivers and five years for Group 2 drivers. The stricter epilepsy regulations will apply if there has been more than one seizure. Driving and Mental Health Conditions and Treatments Review June 2017 6
Mental Health Condition and Fitness to Drive - continued Substance Misuse Drug misuse Drug dependence heroin morphine methadone cocaine methamphetamine Must not drive and must notify the DVLA with persistent misuse or dependence. Persistent harmful use of cannabis, amphetamines, ecstasy (MDMA), ketamine, LSD and other hallucinogens will lead to licence refusal or revocation until a minimum six-month period of abstinence has been attained in Group 1 drivers and a minimum one-year period in Group 2 drivers. There are different rules for ketamine. Must not drive and must notify the DVLA with persistent misuse or dependence. Persistent misuse of or dependence on opiates will lead to licence refusal or revocation until a minimum one-year period of abstinence in Group 1 drivers and at least three years in Group 2 drivers. Full compliance with an oral methadone maintenance programme supervised by a consultant specialist may allow licensing subject to favourable assessment and, usually, annual medical review. Similar criteria may apply for an oral buprenorphine programme. There should be no evidence of continued use of other substances, including cannabis. Drug-induced solitary seizure: Must not drive and must notify the DVLA. Licence will be refused or revoked for a minimum of 6 months after the seizure for group 1 and 5 years for group 2 drivers. Benzodiazepines: If a person misuses benzodiazepines or has been prescribed supra-therapeutic doses, a Group 1 licence will be revoked for a period of one year and a Group 2 licence for three years. The prescribed use of these drugs at the therapeutic doses listed in the BNF, without evidence of impairment, does not amount to misuse or dependence for licensing purposes. Driving and Mental Health Conditions and Treatments Review June 2017 7
Psychotropic medication and Fitness to Drive Antipsychotics: Antipsychotics Chlorpromazine, levomepromazine, and promazine Pericyazine and pipotiazine Fluphenazine, perphenazine, prochlorperazine, and trifluoperazine Haloperidol Flupentixol and zuclopentixol Pimozide and sulpiride Clozapine Quetiapine Olanzapine Risperidone Antidepressants Tricyclic antidepressants They may cause varying levels of motor and extrapyramidal adverse effects, sedation and poor concentration. In susceptible individuals, drugs with antimuscarinic may potentially precipitate or worsen glaucoma, blurred vision and mydriasis. Epileptogenic effects should be considered. Pronounced sedative effects and moderate antimuscarinic and extrapyramidal side-effects. They may cause hypotension and blurred vision. Moderate sedative effects and extrapyramidal side-effects Low sedative and antimuscarinic effects, high incidence of extrapyramidal side-effects Low sedative and antimuscarinic effects, high incidence of extrapyramidal side-effects Moderate sedative, antimuscarinic effects, and extrapyramidal effects Reduced sedative, antimuscarinic, and extrapyramidal effects. Hypotension and sedation. Antimuscarinic effects Hypotension and sedation Causes sedation and dizziness Minor or moderate influence on the ability to drive and use machines due to potential nervous system and visual effects Have pronounced anticholinergic and antihistaminic effects. They may cause varying levels of sedation, concentration difficulties and postural hypotension. These symptoms may impair psychomotor skills and therefore driving. In susceptible individuals, drugs with antimuscarinic may potentially precipitate or worsen glaucoma, blurred vision and mydriasis Driving and Mental Health Conditions and Treatments Review June 2017 8
Psychotropic medication and Fitness to Drive (continued) Trazodone Mirtazapine MAOI SSRIs, venlafaxine, duloxetine ECT Mood Stabilisers: Lithium Antiepileptic drugs Antidementia medication: Rivastigmine Donepezil Galantamine Others Benzodiazepines It has sedating properties, it can also cause confusional states and blurred vision Has sedating properties that may affect driving by reducing concentration and alertness Small or no effect on orthostatic hypotension, sedation or psychomotor impairment but like with any psychoactive medicinal product patients should still be cautioned about their ability to drive or operate hazardous machinery. Small or no effect on orthostatic hypotension, sedation or psychomotor impairment but like with any psychoactive medicinal product patients should still be cautioned about their ability to drive or operate hazardous machinery. Consider effects from the ECT treatment itself, from the anaesthesia and from the underlying condition. Driving must stop during an acute course of treatment with ECT and is not permitted until the relevant medical standards and observation periods associated with underlying conditions have been met Lithium slows reaction time and may cause dizziness, memory problems, impaired consciousness and extrapyramidal disorders They may produce CNS-related adverse effects, including dizziness, drowsiness and ataxia. Antiepileptic drugs have been associated with visual effects such as diplopia, blurred vision and impaired eye accommodation. It may induce syncope or delirium. It can induce fatigue, dizziness and muscle cramps It can cause dizziness and somnolence Benzodiazepines are the psychotropic medication most likely to impair driving performance. The effects are particularly severe with the long-acting compounds such as diazepam. Subjected to drug screening driving excess limits from 2015. Driving and Mental Health Conditions and Treatments Review June 2017 9
Psychotropic medication and Fitness to Drive (continued) Opioid analgesics Methadone Buprenorphine Zopiclone, zolpidem, zaleplon ADHD medication Bupropion Varenicline Opioids may reduce cognitive performance especially at the start of treatment; cause sedation and affect the driving ability by causing impaired coordination, slow reflexes and miosis and blurred vision. Subject to drug screening driving excess limits from 2015. Notify the DVLA. Driving may be allowed while taking methadone, only after regular assessment which will include urine screen for drugs. Subject to drug screening driving excess limits from 2015. Notify the DVLA. Driving may be allowed while taking buprenorphine, only after regular assessment which will include urine screen for drugs. They may have residual effects the next day which include sedation, amnesia, impaired concentration and impaired muscular function which may adversely affect the ability to drive. Patient should be advised not to drive if affected. They may have a variety of adverse effects that may impair driving including: dizziness, drowsiness and visual disturbances including difficulties with accommodation, diplopia and blurred vision. Bupropion may impair performance of skilled tasks (e.g. driving) Varenicline may have minor or moderate influence on the ability to drive and use machines. It may cause dizziness and somnolence and therefore may influence the ability to drive and use machines. Patients are advised not to drive, operate complex machinery or engage in other potentially hazardous activities until it is known whether this medicinal product affects their ability to perform these activities. Driving and Mental Health Conditions and Treatments Review June 2017 10
References Assessing fitness to drive: a guide for medical professionals: https://www.gov.uk/government/publications/assessing-fitness-to-drive-aguide-for-medical-professionals Driver and Vehicle Licensing Agency (DVLA). https://www.gov.uk/government/organisations/driver-and-vehicle-licensing-agency Drugs and driving: the law. https://www.gov.uk/drug-driving-law GMC guidelines at www.gmc-uk.org Royal College of Psychiatrists https://www.rcpsych.ac.uk/ SPCs for all the drugs referred to in this guideline can be found in the Electronic Medicines Compendium (http://emc.medicines.org.uk/) Driving and Mental Health Conditions and Treatments Review June 2017 11