Illicit drugs - common

Illicit drugs - rarer

Medicines  

Alcohol & benzo tranquilisers

Road Victim Rights

Land Transport Act - seeking safer laws

METHADONE INTRODUCTION - CASES 2004 - 2007 

There have been many serious crashes contributed to by methadone treatment in NZ, which the Council of Europe has warned is not always safe for driving. Usually the crashes involve repeat DUI offenders or repeat convicted careless drivers (not drug tested by Police so not earlier charged with DUI). Statistics released by Police to Candor Trust show methadone patients die in droves in the road toll, in fact at about 4x the rate of untreated opiate addicts.

• Two patients were lately jailed after killing innocent pensioners in centre line crossings. One nodded out (on benzos and sub-therapeutic methadone levels) and killed a 60 year old Christchurch Nurse and her dog at lunchtime August 2004. This resulted in a warning from the Health and Disability Commission to the Ministry of Health and services.... leading to inaction and even more preventable death!

This year another patient crossed over due to distracted poorly attentive driving under the infuence - the recidivist claimed she was fumbling about for a drink bottle, when she killed a man on a mobility scooter, around lunchtime May 2006. Both of these ill supervised patients had their kids aboard and had to deal with their trauma.

• Another South Island patient featured on tv news in January 2007 after her distressed child was retrieved from her weaving car by passing motorists, just before she crashed.
• Two South Island teens were lucky to survive but crippled by another methadone impaired driving patient who crossed the centreline, in 2004. Only now are they up to telling the story.
• A Hawkes Bay truck driver and family man who had been relapsed to alcohol and opiate abuse for weeks crashed and died while working on his rig impaired on both methadone and iv opiates.
• A machinary operator lately lost his arm in the Bay of Plenty (over-sedation).
• A maniac driving patient was this year found asleep in her car after being observed driving erratically - her young children climbing up on the roof....

Most often this impairment (often not well recognised, or seen as risky by the driver) will occur because methadone has been taken in combination with other drugs, to get high. Sometimes it occurs in part due to an unstable dosing regimen - too much or too little can cause drowsiness. Too little methadone can cause 'self medicating' of withdrawals with street bought drugs of abuse resulting in DUI.

Fatigue given generally poorer patient health status, and sometimes fueled by the patient P epidemic (using patients may not eat or sleep for days), is often a factor exacerbating the risk of those driving with CNS depressant drugs in their systems.

Intoxication albeit on alcohol or drug cocktails is associated with crashes at the more serious end of the spectrum for the 20-45 age group.

Opioids are found too frequently in the crash dead drivers compared to the proportion of drivers likely using such drugs. And evidence of driving safety for all but the most stable methadone patients (about half of patients)is absent.

Of the crash dead in West Virginia in 2004-5 7.3% had used opioid analgesics - the same number as had used benzodiazepines, a much commoner risk drug. Methadone was used by 7 dead drivers , oxycodone by 9, hydrocodone by 13 and other opioids by 15. These results came from a State with strict program rules but similar opioid dependency rates to NZ.

Australia's system is closer to ours and their Police drug tested 200 bad or crashing drivers in 1992. 24 were found to have used methadone. Drivers blood levels ranged from 0.09 mg/l to 0.35mg/l. Heroin or morphine was found in 43 drivers.

The task force on drug abuse in Western Australia Statistical Bulletin on Drug Related Deaths in Western Australia reported that between July 1992 and Dec 1995 as a %age of fatalities involving drugs these drugs appeared most often -

1) alcohol 49% and about half of them had used cannabis while another 35% involved other risk drugs .
2) cannabis 48%
3) opioids 23%
4) psychostimulants 11%

In 2011 the same statistics set will be available in NZ (ESR / Police study) but early data shows strong parallels, while suggesting a greater methadone problem relative to heroin harm on roads. 'Fewer users, equal involvement'.

LOWERING RISK TO PATIENTS AND OTHERS 
 
Avoid driving in the first 5 days of treatment and for a similar time after dose increases, driving whenever drowsy and when the fatigue
or anxiety of withdrawal is present too.

The fact oral methadone doesn't produce a big euphoric rush initially is not relevant to driving impairment, which it causes a degree of in many patients. Often a degree that is not so great that it would fit the description of criminal negligence if one drove, however.

Risk for sole methadone users may be a little raised as with having one or 2 drinks but not being over the limit. For others - as with alcohol use at low levels (in urban traffic) the relaxing effect of a regular dose may even lower crash risk.

But people who 'feel' their methadone ie the warm fuzzy feeling, through to experiencing 'the nods' should be especially cautious. Some may find it is even best to plan no driving when blood levels peak around 2-5 hours post dose - perhaps forevermore while on the program.

You will likely be more impaired than a drink driver (at the limit) if you 'cocktail' with other intoxicant drugs, 'double up' or inject your methadone. Recreational benzodiazepine use makes crash risk skyrocket.

Combining benzodiazepines or cannabis & methadone gives a heroin high = hi risk IV use of psycho-actives increases acute effects by 3x and driving after such use is inadvisable for a full 12 hours, so get to your destination before injecting - an arrest for possession beats sudden death every time.

 EFFECTS IMPACTING DRIVING SKILL (like heroin but less pronounced).

• It lowers natural emotional tone (AT watchdog report) & therefore anxiety levels which partly explains the well evidenced tendency of MMT patients to be less careful than unmedicated people in traffic.
• This problem is likely only half as bad as with IV opiate users whose natural emotions are shown in PET scans to be very blunted.
• Can make you see more space available on the road around you than is there and less conscious of things in periphery of the visual field.
• Delayed reactions and more incorrect reactions (likely correlates to higher doses).
• Drowsiness due to too much, too little or medicine interacting with other factors, like fatigue, poor nutrition or viral illness, can put you at risk for microsleep or inattention .

POLY-DRUGGING (ultra high risk) REMAINS AN ISSUE FOR MANY ON MMT 

1. adding heroin can reduce methadones effects but will be extremely impairing
2. common drugs requiring some caution due to increased sedation potential as a result of interactions include; grapefruit, older tricyclic antidepressants, cyclizine anti nausea tablets, migraine pills containing ergotamine, ritalin, promethazine (phenergan), some antibiotics and some herbal and dietary supplements.
3. if pot, or any alcohol or extra methadone is added to the mix the impairing effects of methadone you're normally tolerant to can rise up again greatly and atop the effects of the extra drug make you unfit to drive.
4. the same result can be expected if benzodiazepines (Moggies, Rolies, Nazis etc)are used and that use is not medically supervised. Particularly when tolerance to either the benzos or methadones psychoactive effects or the combinations effects hasn't developed over 2 weeks or so.
   A benzodiazepine when taken alone for a disorder under medical supervision does not greatly increase the risk of a serious crash - and may actually reduce personal risk eg for anxiety sufferers. But great caution is needed eg daytime sleepiness assessment, if the patient uses a second depressant like methadone.
   Whether 2 risk drugs like methadone and benzos can be combined as treatment without being too handicapping on driving ability is an individual thing. The evidence suggest it is not a very safe mixture for most people - especially if daytime doses of short acting drugs are prescribed.
   People who are noticed by Police driving badly on benzos have normally (8x out of 10) used another risk drug as well eg methadone or pot. Combining drugs whether uppers or downers turbopowers the intoxication.... and the impairment.
   Of the 12% of drivers that died on NZs road toll having used risky controlled drugs (notably benzodiazepines) in 2004 and 2005 2/3rds of them did not have a prescription - ongoing ESR / Police study findings.
   They clearly took the diverted drugs for intoxicant effect sporadically, so they were not tolerant to intoxicant effects of therapeutic blood levels, less often the dead prescription drug abusers have simply used heaps to get the desired effect.
   If benzodiazepines are required for medical reasons caution is needed to get doses of both methadone and the benzo right so that sedation is not an issue at driving times. Some people may not ever be fit to drive if the combination is used.
5. Methamphetamine and other stimulants may not be a great risk for the occasional light user, but when used by opiate dependent clients the result is quite likely to be terrible on driving.

Minor visual problems caused by both drugs (altered depth and peripheral vision) become magnified. Fatigue can be masked from ones awareness then people nod out without any warning, with devastating consequences on road.

 THE LAW AND DRIVING IN NZ / AOTEAROA 
 
Only 'stable' methadone users who are under regular medical review may drive and street methadone users may not drive 

--  LTNZ guidelines for Drs.

If you have a disability or treatment that can affect driving you are supposed to advise Land Transport NZ. Opiaite dependency and persistent drug misuse are relevant.

Notification can result in further assessment or advice being sought from your Dr. This can result in license conditions being set or in temporary or permanent license loss - until stability is established.

The Land Transport Act prohibits driving when alcohol or any drug makes you incapable of proper control of a vehicle ie if you're noticeably impaired. An amendment to the Land Transport Act will make it illegal to drive while impaired by illicit drugs.

This simply means no driving while adversely affected at all. The definition of an illicit drug in the National Drug Policy 2007 - 11 includes all the controlled medicines that are popularly abused.

Candor Trust will be submitting as regards the amendment that if a medicine is taken responsibly ie exactly as per the Drs current prescription and with due regard to any cautionary advice given by treatment providers, that this may be offered as a defense to a drug driving charge.
 
WHAT CAN YOU AND YOUR PROVIDER DO TO REDUCE RISK IF ISSUES ARISE? 
 
Modify travel schedules or means, avoid risky travel eg motorway driving, avoid driving at certain times of day if necessary.

Undergo peaks and trough tests to ensure you have the best dose to keep you craving and sedation free.

Change dose times or try split doses if you have takeaways or could metabolise methadone fast, resulting in varying effects on alertness throughout the day.

Provide a mobile dosing or assessment service if you are unstable and live remote, or if the clinic can't do this, perhaps unstable patients can car pool with stable ones for appointments made back to back.

Avoid polypharmacy with other psychiatric drugs, and if they are needed be aware of the driving risks and monitor yourself for impairment - tell the Dr if problems.

Avoid illicit drugs altogether or arrange alternate transport if you intend or may get high or drunk and then need to relocate to another address.

Ensure you are not fatigued through having withdrawals disturb sleep at night due to tolerance and consider a raised dose. If still fatigued or 'noddy' get examined for sleep apnoea (disrupted night breathing due to weight gain or medicine).

Do not use coffee or other stimulants to fight fatigue or drug sedation as it does not work well enough to increase road safety. As with alcohol impairment only time and perhaps sleep will help. A 20 minute powernap works for fatigue.

Seek counseling or attend support groups for relapse prevention - NA is in most main centres, MA is on the net, AT Watchdog on the net also offers good support

Do not taper too quickly as withdrawals are also bad for driving. Or if you use heroin to taper avoid driving altogether until you have 'kicked'.

Perhaps consider switching to buprenorphine if methadone is too heavy for you, and be cautious re driving in the changeover period.

Apply for a WINZ transport allowance if the Dr says you'll be unlikely to drive for 6 months - ask Corrections for help to plan transport so you won't re-offend if you are on their books, a scheme for this aid is in planning.

If other addictions are destroying the sought after benefits of methadone treatment then perhaps consider a medical detox. Or maybe have a go at non substitution assisted treatment ie abstinence based recovery.

Antidepressant medicines may help as 50% of kiwis on methadone reported some depression in a recent survey but be wary of sedation from the older types too.

Your clinic may be required to report you to the driver licensing authority if drug misuse is persistent, and you are a risk to yourself and the public on the road despite reasonable efforts helping you to address the problem.

Take service warnings about not letting a known or related patient drive you or any minors who are at risk from someone with low insight to risk very seriously.

Intervention is not aggression, it could save lives. Report people of concern to Drs or the Police. Penalties are minor and short term versus possible consequences.

LAB STUDIES (look at psycho-motor difficulties as result of drug intake) 
 
Ortner, Fischer et al 2004 – methadone versus buprenorphine During a task to test attention under monotonous circumstances (Q1 test), patients had a significantly greater number of reactions (p = 0.027) and a significantly higher percentage of incorrect reactions than control subjects. 
 
When driving in a dynamic environment (DR2 test) patients had a significantly longer mean decision time (p = 0.029) and mean reaction time (p = 0.009) compared with control subjects. 
 
Interestingly, when separated into treatment groups, the mean decision and reaction times of  buprenorphine-maintained patients in the DR2 test did not differ from controls, whereas patients maintained on methadone showed prolonged mean decision (p = 0.009) and reaction times (p = 0.004). 
 
Giacomuzzi et al (University of Innsbruck) – this study found significantly lower working time and time for correct reactions in methadone treated patients in the cognitrome test. The Austrians found slow release morphine (used there substitution) was even more impairing than methadone. 
 
Opiates can effect visual depth perception which can cause risky distance misjudgements as things may seem further away. This effect may be worsened by use of amphetamines, certain antidepressants and other drugs. 

Recovery from night glare effected. 
 
REAL WORLD STUDIES 
(Show worse crash risks than lab studies suggest as drug effects on mood etc have impact).

 Mura et al – studied a large group of actual crash victims which presented in an emergency room finding opiate users were significantly more likely to be involved in crashes at the more serious end of the spectrum when they crashed as compared to others. The risk was 8 x the normal but likely much higher in reality as opiate users in France chalk up less mileage than other people due to restrictions upon addicts driving.

Western Australian Study showed recently that though less than 1% of their population use opiates they are found to be involved in 23% of crashes. A renegade Australian study in contrast to balance of all others showed no problem with opiates (with policy impacts) - ? funded by drug company or Oz Government and biased via methodology in order to justify inaction on the risk reducing front.

Strathclyde study (Seymour / Oliver) showed that of people arrested for drug impaired driving 69% had poly-drugged on average taking 2-3 risk drugs at therapeutic levels of each, commonest drugs were benzodiazepines followed by opiates especially morphine then cannabis. The combinations most often seen to to be both popular and to cause OD correlated well to combinations which bought attention for impairment.

Detection of benzodiazepine abuse in opiate addicts (R Browne et al) – this study explored the effects of combining bnzodiazepines with opiates which were; euphoria, dis-inhibition, feeling invincible – all of which combined led to increased recklessness, greater ability or urge to criminally offend (Dutch Courage) and generally just more hazardous behaviour eg unsafe sex. The implications for road safety are clear – like drunks "mixers" will more likely chose to drive impaired on this combination than if only effected by one drug.

ICADTS study in Norway of apprehended impaired drivers; for hi dose pain medicine users – few arrests, sole methadone impairment 5, methadone combined with benzodiazepines 100, abused morphine or heroin 400.

Due to lesser number of methadone than street opiate users it is safe to assume the methadone benzodiazepine mix would appear to cause even greater problems than injected heroin (a high risk) in real road conditions.

A Sydney study of IV drug using drivers found horrifying crash rates and that many said they will inject in the car before driving home rather than wait till they get home after scoring as they had greater fear of being caught by Police "with the drugs on me than in me". The results of this fear are clearly evident in iv user crash statistics. Addicts were generally well aware they were behaving unsafely and appeared somewhat regretful in attitude.

FRIEDEL / BERGHAUS STUDY SUMMARY  

The research findings indicated heroin addicts treated with methadone due to other drug use (typically) are in general not fit to drive. A positive evaluation might be possible in exceptional cases when there are special circumstances justifying it. Among these are, for instance, a period of methadone substitution of more than a year, stable psychosocial integration, no evidence of the consumption of additional psychotropic substances, incl. alcohol, evidence of a subject's readiness to feel responsible for himself/herself and of therapy compliance, and no evidence of serious defects of the personality as a whole.

OPIATE DRIVING POLICIES ROUND THE WORLD  

Are many and varied. Depending on whether addicts typically drive and other factors like whether goals of methadone treatment are to aim for abstinence or not, and how much other drug abuse ongoing if any is tolerated in local clinics.

Sweden - No driving on methadone first 6 months, 2 relapses including benzo use result in a "countdown" (termination of treatment), any offending involving drugs then same result, illegal to seek medicines from a different Dr. A lot of European countries prohibit driving by addicts full stop or else forbid driving in the 5 days after commencing methadone or after dose increases.

Germans require driving assessments once addict are "stable" in methadone before driving privilege is granted.

In the UK those prescribed heroin substitution may not drive at all.

US Federal workers and heavy trade or those with passenger licenses may not be using illicit drugs, opiates or methadone. And there the law requires regular urine tests so that Drs can make appropriate safety calls. In the USA patients who are not stable on their methadone or who abuse the system by mixing it with other drugs are put into 8 weeks of relapse prevention classes then "counted down".

In NZ (Austroads) methadone prescribers are required to assess for driving risk, report medication related accidents if issues unresolved and to report those driving against advice eg due to poly-drugging, who will be further assessed and a licensing decision made by LTNZ based upon recommendations of designated Drs ideally.

Resourcing means the 'designated Dr' is often not used.

In Australia pharmacists are trained to detect intoxication in methadone users so they will not risk causing overdose by dosing inappropriately. Drug intoxication is harder to recognise than that from alcohol so special training is required.