This session will provide information on drivers’ use of prescription medications, poly-pharmacy, alcohol, “medical” marijuana, and illegal drugs and the impact these substances may have on one’s ability to safely operate a motor vehicle

Maguire, Mary

Matthews, Michele

Thomka, Joanne

Walsh, Stephen J.

English

University of Massachusetts Boston: ScholarWorks at UMass

Michele L. Matthews, PharmD, CPE, BCACP Associate Professor of Pharmacy Practice MCPHS University Advanced Pharmacist Practitioner – Pain Management Brigham and Women’s Hospital aking d     Learning Objectives Identify factors that affect drug response in older adults.  List medications and substances that can impair driving and list their common side effects.  Identify methods to improve driving safety in older adults. Case Scenario  GG is a 68 year-old woman who presents to her primary care doctor for a follow-up visit.  She has a history of lung cancer (now in remission), chronic low back pain, chronic kidney disease, hepatitis C, osteoporosis, urinary incontinence, anxiety, and depression.  Her husband just bought her a new car, and she would like to know if it safe for her to drive on her current medications.  Case Scenario (cont’d) Her current medications include: Depression  Aripiprazole (Abilify®) 15 mg by mouth every day   Bupropion SR (Wellbutrin®) 100 mg by mouth twice a day Osteoporosis  Calcium carbonate  500 mg by mouth twice a day  Vitamin D 1000 IU by mouth once a day Anxiety  Diazepam (Valium®) 10 mg by mouth three times a day Chronic pain  Gabapentin (Neurontin®) 1200 mg by mouth three times a day  Ibuprofen 800 mg by mouth every 6 hours Urinary incontinence  Tolterodine (Detrol®) 2 mg by mouth twice a day  Case Scenario (cont’d) GG reports drinking 1 glass of red wine each night with dinner and admits to smoking marijuana on occasion for chronic pain and anxiety. Upon review of systems, GG reports the following symptoms: Blurry vision, impaired balance, memory impairment, constipation, and decreased urination  Case Scenario (cont’d) What medications are contributing to GG’s current symptoms?  What are the effects associated with combining alcohol and marijuana with her current medications?  Is it safe for GG to drive? Factors Affecting Drug Response in Older Adults Increased cognitive impairment Increased sensitivity to sedating drugs Less binding sites for drugs in the blood Less volume of distribution Slower drug metabolism Decreased drug clearance Increased risk of drug-induced kidney damage Decreased drug absorption Delayed gastric emptying Increased risk of constipation, ulcers Decreased muscle mass Increased body fat Increased bone loss Increased thinning of skin Prescription Medications that Can Impair Driving Barbiturates Butalbital-based drugs   (Fiorinal®, Fioricet®) Benzodiazepines Alprazolam (Xanax®) Clonazepam (Klonopin®) Diazepam (Valium®)  Lorazepam (Ativan®) Sedative-Hypnotics Belsomra (Suvorexant®) Eszopiclone (Lunesta®) Ramelteon (Rozerem®) Zaleplon (Sonata®) Zolpidem (Ambien®) • Increased sedation  • Diminished coordination  • Weakness  • Clumsiness  • Loss of balance  • Distorted vision  • Sleep driving (zolpidem) Prescription Medications that Can Impair Driving (cont’d) Antidepressants Amitriptyline (Elavil®) Bupropion (Wellbutrin®) Duloxetine (Cymbalta®) Fluoxetine (Prozac®) Paroxetine (Paxil®) Trazodone (Desyrel®) Venlafaxine (Effexor®) Antipsychotics Aripiprazole (Abilify®) Haloperidol (Haldol®) Quetiapine (Seroquel®) • Increased sedation  • Diminished coordination  • Decreased blood pressure  • Tremor  • Altered sleep architecture  • Visual disturbances  • Confusion Prescription Medications that Can Impair Driving (cont’d) Anticonvulsants Gabapentin (Neurontin®) Pregabalin (Lyrica®) Topiramate (Topamax®) Muscle relaxants Carisoprodol (Soma®) Cyclobenzaprine (Flexeril®) Antihistamines Diphenhydramine (Benadryl®) Hydroxyzine (Vistaril®) Antiparkinsonians Carbidopa/levidopa                                                (Sinemet®)  • Increased sedation  • Slowed psychomotor function  • “Sleep attacks”  • Dyskinesia  • Blurred vision  • Impaired balance Prescription Medications that Can Impair Driving (cont’d) Opioid analgesics Buprenorphine (Suboxone®, Butrans®) Codeine (Tylenol #3®) Fentanyl (Duragesic®, Actiq®) Hydrocodone (Vicodin®, Zohydro®) Hydromorphone (Dilaudid®, Exalgo®) Methadone Morphine (MS Contin®) Oxycodone (Percocet®, Oxycontin®) Oxymorphone (Opana®) Tapentadol (Nucynta®) Tramadol (Ultram®)    • Increased sedation  • Decreased breathing  • Fatigue  • Lightheadedness  • Vision changes Prescription Medications that Can Impair Driving (cont’d) Antihypertensives  Atenolol (Tenormin®)  Hydrochlorothiazide   Lisinopril (Zestril®) Metoprolol (Toprol®) Antidiabetic agents Glyburide (DiaBeta®)  Insulin (Humulin®, Lantus®) Metformin (Glucophage®)  Intestinal agents  Dicyclomine (Bentyl®)  Hyoscyamine (Levsin®)  Prochlorperazine (Compazine®) Ophthalmic agents     • Dizziness  • Lightheadedness  • Drowsiness  • Blurred vision  • Delirium Over-the-Counter Medications/Supplements that Can Impair Driving Antihistamines Chlorpheniramine (Chlor-Trimeton®) Diphenhydramine (Benadryl®, ZzzQuil®) Doxylamine (NyQuil®, Unisom®) Meclizine (Bonine®, Dramamine®) Analgesics Acetaminophen + diphenhydramine (Tylenol PM®)  Ibuprofen + diphenhydramine (Motrin PM®, Advil PM®) Naproxen + diphenhydramine (Aleve PM®)  Over-the-Counter Medications/Supplements that Can Impair Driving Sedatives Chamomile Kava Lavender Melatonin St. John’s wort Valerian   Alcohol Effects on Driving Skills Alterations in: Concentration Judgement Comprehension Coordination Vision and hearing acuity Reaction time Mixing Drugs with Alcohol: A Prescription for Disaster Medication Effect when Combined with Alcohol Benzodiazepines (e.g Valium) Sedation Dizziness Slowed breathing Impaired motor control Increased risk for overdose      Opioids (e.g. Morphine)      Muscle relaxers (e.g. Soma)      Sedatives (e.g. Ambien)    Antidepressants (e.g. Prozac)    Antihistamines (e.g. Benadryl)   Marijuana Effects on Driving Skills Alterations in:  Reaction time Perception Short-term memory Attention Motor skills http://www.drugabuse.gov/publications/research-reports/marijuana/does-marijuana-use-affect-driving “Cross Fading”: Marijuana and Alcohol Combined use can lead to: Performance impairment  Increased loss of control  Impaired judgment  Impaired reaction time Some studies have suggested a “cancellation of effects” Marijuana in Massachusetts Chapter 369 of the Acts of 2012: An Act for the Humanitarian Medical Use of Marijuana Eliminates state criminal and civil penalties for the medical use of marijuana by qualifying patients Allows patients to possess up to a 60-day supply of marijuana for their personal medical use Allows for non-profit medical marijuana treatment centers to grow, process and provide marijuana to patients or their caregivers 105 CMR 725.000: IMPLEMENTATION OF AN ACT FOR THE HUMANITARIAN MEDICAL USE OF MARIJUANA Final Regulations on Use of Marijuana for Medicinal Purposes in Massachusetts   https://malegislature.gov/Laws/SessionLaws/Acts/2012/Chapter369 http://www.mass.gov/eohhs/docs/dph/regs/105cmr725.pdf  Marijuana in Massachusetts (cont’d) The law does NOT: Allow the operation of a motor vehicle, boat, or aircraft while under the influence of marijuana; Require any health insurance provider, or any government agency or authority, to reimburse any person for the expenses of the medical use of marijuana; Require any health care professional to authorize the use of medical marijuana for a patient; Require any accommodation of any on-site medical use of marijuana in any place of employment, school bus or on school grounds, in any youth center, in any correctional facility, or of smoking medical marijuana in any public place; Marijuana in Massachusetts (cont’d) The law does NOT: Supersede Massachusetts law prohibiting the possession, cultivation, transport, distribution, or sale of marijuana for nonmedical purposes; Require the violation of federal law or purports to give immunity under federal law; or Pose an obstacle to federal enforcement of federal law Is it Safe for GG to Drive? Recommendations Avoid alcohol and marijuana Consider medication changes: Adjust the dose Adjust the timing or frequency of doses   Identify non-drug ways of managing medical conditions, if possible Change medications to those that cause less impairment Monitor medication effects closely Consider alternative forms of transportation  Summary Many commonly used prescription and over-the-counter medications can impair driving when used alone or in combination Risks are increased when combined with alcohol and/or marijuana An open dialogue with regard to driving safety should be encouraged between the driver, family/caregivers, and health care team Alternative forms of transportation should be considered in patients who require the need for certain high-risk medications  Thank You!   Michele L. Matthews, PharmD, CPE, BCACP Email: michele.matthews@mcphs.edu       Law Enforcement’s Role in Dealing with “Older” Drivers       Lieutenant Stephen J. Walsh BABY BOOMERS COMING OF AGE  By 2030, twenty-three percent of licensed drivers in the USA will be over 65-years-of-age (NHTSA), a mobile generation reluctant to stop driving;    Lack of significant administrative oversight of this aging driving population often places the onus of dealing with “elderly” drivers directly on law enforcement    While the focus of this forum is on older or “elderly” drivers, the statutes and procedures addressed apply to all motorists in the Commonwealth of Massachusetts ABSTRACT  In general, Massachusetts LEO’s lack the training and resources to effectively deal with “elderly” drivers that exhibit signs indicating that cognitive or physical impairment may limit their ability to operate a motor vehicle safely; as well as the roadside resources to remove them from the public way   LAW ENFORCEMENT ENCOUNTERS WITH ELDERLY DRIVERS Motor vehicle crashes  Violations of law  Other! ROADSIDE ASSESSMENT  Is an “elderly” driver’s seemingly diminished capacity the results of cognitive impairment (Alzheimer's/dementia) or drugs/medications?   Do they have physical limitations that prevent safe operation?  Is it all of the above! IS THE OPERATOR OUI OR IS IT A MEDICAL CONDITION? MGLC 90 §24(1): Operating under the influence of alcohol, marijuana, narcotic drugs, depressants, stimulants, or vapors of glue;  Many medications that diminish the capacity to operate a motor vehicle do not fall into these categories!  Standardized Field Sobriety Testing (SFST) has not been validated for individuals over 65 years-of-age!  How is probable cause developed?  Drug Recognition Experts?  ROADSIDE OPTIONS  Arrest!;  *Absent arrest or applicable vehicle violation LE has no statutory authority to remove an operator or tow a vehicle if the operator displays cues that indicate that they should not be driving;  Call a family member or friend;  EMS;   Caretaker function? POST ROADSIDE OPTIONS   MGLC 90 §22: Registrars authority to suspend/ revoke license to operate w ithout a hearing  Request for Immediate Threat  Request for Medical Evaluation (Law Enforcement) Request for Immediate Threat License Suspension/Revocation   Request for Medical Evaluation    NATIONAL ASSOCIATION OF TRIADS  Partnership of law  enforcement, older adults, and community groups such as AARP, promoting older adult Safety;  Triad LEO’s follow-up on crash reports, motor vehicle stops, family concerns, etc., to assess older drivers in their community and determine if they are “at risk” and if their continued license status should be referred to the RMV        RECOMMENDATIONS      Assessment of older drivers is essential to identify those that pose a risk to public safety. The responsibility for the assessment process must be shared by LE, medical professionals, RMV, family members, and the “elderly” driver LAW ENFORCEMENT MUST BE TRAINED Recognize cues that indicate a driver’s cognitive and physical limitations;  Develop strategies to identify “at risk” drivers that pose a threat to public safety;  Document encounters with “at risk” motorists;  Refer “at risk” drivers to the RMV (Immediate Threat);  Serve as a resource to assist aging drivers and their families    Contact Information Lieutenant Stephen J. Walsh Massachusetts State Police Station Commander 31 Gould Road – Andover, MA 01810 (978)475-3800 stephen.walsh@massmail.state.ma.us  Joanne E. Thomka Director, National Traffic Law Center National District Attorneys Association jthomka@ndaa.org This presentation contains the creative works of others which are used either by permission, license, or under 17 U.S.C. 107 (fair use).  The presentation was created under the Fair Use Guidelines and further use or distribution of the presentation is not permitted.     U.S. expected to have 56 million people the age of 65+ by 20201    http://www.aoa.acl.gov/Aging_Statistics/Profile/2013/docs/2013_Profile.pdf  Overall, 3,952 fatally injured drivers tested positive for drug involvement in 2009 of 33,808 traffic fatalities   2013: United States  Fatalities:     32, 719  Injured:     2,313,000  Alcohol Impaired Fatalities: 10,076  Driver .08+ BAC 65+ years old: 13%  NHTSA DOT HS 812 100, NHTSA DOT HS 811 415, https://www.whitehouse.gov/ondcp/drugged-driving,  Data from: Older Population, DOT HS 812 005  http://www-nrd.nhtsa.dot.gov/Pubs/812005.pdf   Duties and responsibilities encompass public safety and justice   Do the right thing to the right person for the right reason   Ethical and statutory guidelines    Prevent recidivism    Change behavior   Maintain integrity of the case   MASS. GEN. LAWS 90 § 24(1)(a)  Whoever: “Operates a motor vehicle. . . while under the influence[. . .] of marijuana, narcotic drugs, depressants or stimulant substances”  First offense:   Up to 2.5 years imprisonment  Fine: $500-$5,000  Second offense:  60 days – 2.5 years (judge may reduce to 30 days)  Fine: $600-$10,000  MASS. GEN. LAWS 90 § 24G: Vehicular homicide  Whoever, while under the influence: “. . . so operates a motor vehicle recklessly or negligently so that the lives or safety of the public might be endangered, and by any such operation so described causes the death of another person . . .”  2.5 years to 15 years imprisonment  Fine: Up to $5,000  License sanction: Revocation for 15 years   Commonwealth v. Daniel, 464 Mass. 746, 756, 985 N.E.2d 843, 851-852 (2013).  A driver may be found to have been “under the influence” when her consumption of such substances “diminished [her] ability to operate a motor vehicle safely [citation omitted].   Failing a breath test:  Over 21 years of age & .08 BAC – 30 day suspension   Refusing a chemical test:  Over 21 years of age, no priors – 180 day suspension  Over 21 years of age, one prior – 3 year suspension   Upon conviction  1st offense – 1 year suspension  2nd offense – 2 year suspension  3rd offense – 8 year suspension  4th offense – 10 year suspension  5th offense – lifetime suspension  Second or subsequent suspension requires IID installation upon reinstatement   Mass. Gen. Laws. Ann. ch. 94C App.  $50 yearly fee  May possess up to a sixty day supply  § 1-7(A): “Nothing in this law allows the operation of a motor vehicle, boat, or aircraft while under the influence of marijuana.”  Legalization  State laws and policies which make possession and use legal under state law   Decriminalization  State laws and policies which reduce the penalties for possession and use of small amounts from criminal to fines or civil penalties   Medical  State laws which allow person to defend against criminal charges of possession if can prove medical need under state law   Law enforcement  Prosecutors  Courts: DWI Courts  Probation and Parole  DMV  Treatment providers  Other partners: aging services providers, DOT  Towing      $75 +  Car Storage      $45 + (per day)  Defense Attorney     $1,500 +  Bail Fee      $0 - $500 +  DWI Fine      $350 - $1,000  State Surcharges     $245 - $395  Ignition Interlock     $75 - $100 +  Ignition Interlock Monthly Fee    $420 - $600 +  Alcohol Evaluation     $100 +  DWI Victim Impact Panel Session    $25  Probation Supervision Fees    $0 - $250  Conditional License     $75  Drinking Driver Program Fee    $175 - $300 +  DMV Civil Penalty     $125  DMV License Reinstatement Fee    $150  Driver Responsibility Assessment Fee (annual for three years) $250  Auto Insurance (additional cost per year)   $2,000 - $3,000 +    TOTAL: $5,595 - $9,140 Source: http://stopdwi.org/sites/default/files/downloads/Electronic%20Version%202010.pdf  2013-14 National Roadside Survey of Alcohol and Drug Use by Drivers (Berning, et al 2015)  Traffic Safety Facts; Crash*Stat - Drug Involvement of Fatally Injured Drivers (NHTSA 2010)  Drugged Driving Expert Panel Report: A Consensus Protocol for Assessing the Potential of Drugs to Impair Driving (Kay, Logan 2011)  Drug-Impaired Driving: Understanding the Problem & Ways to Reduce It (Compton, Vegega, Smither 2009)  Drugged Driving Research: A White Paper (DuPont, 2011)      www.NDAA.org   www.NHTSA.gov   www.whitehouse.gov   www.theiacp.org  

Plenary Session II – Medical Track: Substance and Medication Use

https://scholarworks.umb.edu/cgi/viewcontent.cgi?article=1014&amp;context=olderdriversafetysummit

Plenary Session II – Medical Track: Substance and Medication Use

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