MRR 02/2012
Research Report
Alcohol and Drug Use Among
Fatally Injured Drivers in Urban Area
of Kuala Lumpur
Norlen Mohamed, MD
Wahida Ameer Batcha
Nurul Kharmila Abdullah, MD
Muhammad Fadhli Mohd Yusoff, MD
Sharifah Allyana Syed Mohamed Rahim
Mohd Shah Mahmood, MD
Research Report
Alcohol and Drug Use Among
Fatally Injured Drivers in Urban Area
of Kuala Lumpur
Norlen Mohamed, MD
Wahida Ameer Batcha
Nurul Kharmila Abdullah, MD
Muhammad Fadhli Mohd Yusoff, MD
Sharifah Allyana Syed Mohamed Rahim
Mohd Shah Mahmood, MD
MIROS © 2012 All Rights Reserved
Published by:
Malaysian Institute of Road Safety Research (MIROS)
Lot 125-135, Jalan TKS 1, Taman Kajang Sentral,
43000 Kajang, Selangor Darul Ehsan, Malaysia.
Perpustakaan Negara Malaysia
Cataloguing-in-Publication Data
Research report : alcohol and drug use among fatally injured drivers
In urban area of Kuala Lumpur / Norlen Mohamed ... [et al.]
(Research report. MRR 02/2012)
ISBN 978-967-5967-23-8
1. Drunk driving--Research--Malaysia.
2. Drinking and traffic accidents--Research--Malaysia.
I. Traffic accidents--Research--Malaysia. II. Norlen Mohamed, 1970-.
III. Series.
363.12514072
For citation purposes
Norlen M, Wahida AB, Nurul Kharmila A, Muhammad Fadhli MY, Sharifah Allyana SMR & Mohd Shah M
(2012), Alcohol and Drug use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur, MRR 02/2012,
Kuala Lumpur: Malaysian Institute of Road Safety Research.
Printed by: Publications Unit, MIROS
Typeface: Myriad Pro Light
Size
: 11 pt / 15 pt
DISCLAIMER
None of the materials provided in this report may be used, reproduced or transmitted, in any form or
by any means, electronic or mechanical, including recording or the use of any information storage and
retrieval system, without written permission from MIROS. Any conclusion and opinions in this report
may be subject to reevaluation in the event of any forthcoming additional information or investigations.
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Contents
List of Figures
v
List of Tables
vi
Acknowledgement
vii
Abstract
ix
1.0
1
Introduction
1.1
1.2
Driving Under Influence of Alcohol
1.1.1 How Alcohol Impaired Driving
1.1.2 Risk of Crash Involvement
Driving Under the Influence of Drug
2
3
4
6
2.0
Methods
8
2.1 Design and Study Population
2.2 Data Sources
2.3 Data Collection Process
8
9
10
3.0
Results
13
Section 1: General Road Traffic Deaths
3.1
3.2
3.3
3.4
3.5
3.6
3.7
13
Number of Fatal Road Traffic Deaths
13
Road Traffic Deaths by Gender and Ethnic Group
Composition
14
Age-sex Distribution of Road Traffic Deaths
Presented to the Department of Forensic
Medicine, HKL, 2006–2009
14
Distribution of Road Traffic Deaths
by Types of Road User
15
Distribution of Road Traffic Deaths by Types
of Accident
15
Number of Fatal Cases according to the Types
of Case and Types of Road User
15
Trimodal Death of Road Users
17
iii
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Section 2: Road Traffic Deaths and Driving under the
Influence of Substance Use
18
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
3.21
4.0
Discussion
4.1
4.2
4.3
5.0
Number of Cases Eligible for Analysis of
Substance Use
18
Incidences of Under Influence of Substance
Use Among Fatal Group of Drivers
19
Incidences of Under the Influence by Types of
Substance Use and Types of Case Among Group
of Fatal Drivers
20
Incidences of Substance Use Among Fatal Drivers,
Riders and Cyclists by Year
22
Distribution of Fatal Drivers with Positive
Substance Use by Day of Accident
22
Distribution of Fatal Drivers with Positive
Substance Use by Time of Accident
23
Incidences of Substance Use Among Fatal
Drivers, Motorcyclists and Cyclists by Age
24
Incidences of Substance Use Among Group
of Fatal Drivers by Types of Accident
25
Alcohol Concentration Among Drivers/
Motorcyclists and Cyclists by Types of Case
26
Frequency of Drug Use Among Group
of Fatal Drivers (Drivers, Riders, Cyclists)
27
Incidences of Fatal Drivers (n=391) Under the
Influence by Category of Drugs
27
Categories of Drugs Found Among Positive
Drivers, Motorcyclists and Cyclists
27
Likelihood of Dying on Site of Accident
Due to Very Severe Crash
29
Factors that Predict the Use of Substance
Among Drivers
30
30
Incidences of Road Traffic Deaths related to Driving
Under the Influence of Drug and Alcohol
30
Profile of Cases DUI
33
Blood Alcohol Concentration (BAC), Crash Risk and
Legal Limit
34
Conclusion
40
References
42
iv
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
List of Figures
Page
Figure 1
Relative risk of driver involvement in police-reported
crashes
5
Data collection process at the department of Forensic
Medicine, HKL
11
Flow chart for searching of driving under the influence of
drug and alcohol
12
Figure 4
Number of road traffic deaths presented to HKL
13
Figure 5
Age-sex distributions of fatal road traffic death at the
Department of Forensic Medicine, HKL, 2006–2009
16
Figure 6
Distribution of fatal road traffic deaths by types of road user
16
Figure 7
Road traffic deaths by types of accident
16
Figure 8
Proportion of case by types of road user and types of case
17
Figure 9
Time of death by types of road user
18
Figure 10
Number of road traffic deaths (all road users) by status of
toxicology result
19
Prevalence of substance use among fatal drivers, riders and
cyclists by year
22
Distribution and specific rate of cases with positive
substance use by day
23
Distribution and specific rate of cases with positive
substance use by time
24
Figure 14
Percentage of substance use by age
25
Figure 15
Blood alcohol concentration among drivers, motorcyclists
and cyclists
26
Figure 2
Figure 3
Figure 11
Figure 12
Figure 13
v
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
List of Tables
Page
Table 1
Relative risk of alcohol related road crashes at various BAC
level
7
Gender-ethnic group composition of cases presented to the
Department of Forensic Medicine, HKL, 2006–2009
14
Table 3
Percentage of substance use by types of fatal road user
20
Table 4
Road traffic death cases by types of substance use, types of
case and group of drivers
21
Fatal road traffic cases with positive substance use by types
of accident
25
Table 6
Number of drugs used by drivers, motorcyclists and cyclists
27
Table 7
Incidences of fatal drivers (n=391) under the influence by
categories of drugs
28
Categories of drugs found among group of fatal drivers
positive for drug
28
Chi-square analysis between types of case and status of
substance use
29
Factors associated with outcome of crash (brought-in-dead;
dead-in-department)
29
Factors associated with substance use among group of
drivers (private car, riders and cyclists)
30
Table 12
Blood alcohol concentration (BAC) limits by country or state
36
Table 13
Results of scientific paper reviews on the effect of lowering
the legal BAC limit by Mann et al. (2001)
37
Table 2
Table 5
Table 8
Table 9
Table 10
Table 11
vi
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Acknowledgements
We would like to express our deep appreciation to the Director
General of Malaysian Institute of Road Safety Research (MIROS)
and the Director of Vehicle Safety and Biomechanics Research
Centre for extending full support in producing this report. Our
deep appreciation also goes out to the Department of Forensic
Medicine, Kuala Lumpur Hospital and Accident Database System
& Analysis Unit of MIROS for facilitating the data collection process.
We would also like to thank our research assistant, Muhammad
Mukhlee Shah for assisting us in retrieving the data from the
Department of Forensic Medicine, Kuala Lumpur Hospital. Last
but not least, thanks to the Research and Ethics Committee,
Malaysian Institute of Road Safety Research and Research and
Ethic Committee, National Institute of Health, Ministry of Health,
Malaysia for approving the design and conduct of this study.
vii
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Abstract
The aim of the study is to determine incidences of driving under
the influence of substance use (alcohol and drug) among fatally
injured drivers due to road traffic crashes.
Method and data source: A retrospective cross-sectional study
was conducted based on post-mortem files retrieved from the
Department of Forensic Science, Kuala Lumpur Hospital. A total
of 710 fatal road traffic deaths were registered at the department
for the period of 2006 to 2009. Out of these, 670 (94.4%) were
eligible for data collection as their post-mortem reports had
been completed and not classified as “sensitive cases”. Out of
670 cases, 505 cases had toxicology results attached and eligible
for substance use analysis. The cases were then further classified
into driver and non-driver groups. Of 505 cases, 391 (76.8%) were
classified under the driver group, and hence, eligible for detailed
analysis of driving under the influence of substance use. This
study found that driving under the influence of alcohol and drug
among group of drivers involved in fatal crashes is very alarming.
The study revealed that 23.3% of fatal drivers were positive for
alcohol, 11% positive for drug and 2.3% were positive for both
drug and alcohol. Among illicit drugs, the opiate group is at the
top of the list (5.4%) of drugs detected among fatally injured
drivers. The distribution was, 2.8% positive for amphetamines,
1.02% for cannabis and 0.8% for ketamine. Driving under the
influence of medicinal drug, especially benzodiazepines group
is 6.9%. With regard to alcohol use, 17% of fatally injured drivers
were under the influence of alcohol below the blood alcohol
concentration (BAC) legal limit stipulated in the law. These
findings highlight the need to focus on prevention activities
related to driving under the influence of substance use as part
of the overall strategy for road safety plan. This includes the
need to revise the current BAC legal limit in line with available
scientific evidence as well as to strengthen the target or selected
ix
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
enforcement activities according to the day, time of the day and
type of drivers.
Keyword: driving under the influence, alcohol, drug, crash.
x
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
1.0 Introduction
Driving under the influence of drugs or alcohol (DUI) is one of
the well-documented risk factors for road traffic accident (WHO
2004). It is a public health concern because it puts not only the
driver at risk, but also passengers and other road users. For the
general driving population, the risk of being involved in a crash
starts to rise significantly at a blood alcohol concentration level
(BAC) of 0.04 g/dl (Compton et al. 2002). The principal concern
regarding drugged driving is that driving under the influence of
any drug that acts on the brain could impair one’s motor skill,
cognitive functions, reaction time and other functions that are
required for safe driving. Policies on DUI have been adopted in
most of the countries all over the world including Malaysia.
Based on the Third National Health and Morbidity Survey, the
prevalence of current drinker in this country was about 7.4%,
and in Kuala Lumpur, the prevalence was 12.1% (IPH 2008). With
regards to drug addiction, according to a report by ‘Agensi Anti
Dadah Kebangsaan’, a total of 18 387 drug addicts were detected
from January to September 2010 and about 73% of them
were new cases. In addition, the three most commonly used
addictive drugs within the year are heroin (28.08%) followed
by morphine (22.45%) and Amphetamine-Type-Stimulant
(ATS) synthetic drugs (35.03%) which comprises amphetamine,
methamphetamine and ecstasy (AADK 2010). Regarding
DUI, to date, there is no published report on the status of DUI
problem in this country. No information is available on the type
of illegal drug commonly used by drivers who were involved
in motor vehicle crashes in this country. Distribution of cases
by time, place and person are not known. For alcohol use, the
distribution of blood alcohol level among drivers who were
involved in motor vehicle crashes is also not known. Do those
involve in a crash have blood alcohol level lower that the limit
allowed by the law? In Malaysia, the legal blood alcohol limit is
1
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
set at 0.08 g/100 ml. Information on the status of the problem
especially in this country is very important in setting up priorities
with regards to policy implementation, planning of intervention
programs on targeted groups and deciding on the need to gear
up enforcement activities by relevant agencies.
1.1
Driving Under Influence of Alcohol
Drinking and driving has long been recognised as one of the
most serious public health and traffic safety problems, and
considerable attention as well as corrective efforts are currently
directed at reducing the number of drivers whose driving is
unsafe because of the effects of alcohol. Driving a motor vehicle
after drinking alcohol has the potential to detrimentally affect
any member of the community, including drivers, passengers
and pedestrians. It is an important factor influencing both the risk
of a road traffic crash as well as the severity and outcome of the
injuries that result from it. The frequency of drinking and driving
may vary among countries, but many findings have shown that
drink drivers have significantly higher risk of being involved in a
road crash than drivers who have not consumed alcohol.
Since driving under the influence of alcohol is proven to increase
the risk of road accident injuries and fatalities, many efforts as
well as interventions were set up in order to deter drivers from
driving just after drinking. A variety of BAC legal limits across the
world ranging from 0.08 mg/ml to 0.02 mg/ml is shown in Table
1. In Malaysia, as mentioned in Road Traffic Act under section 45G
which is for all types of drivers, it is an offence to drive a vehicle
with a BAC over the legal limit of 0.08 g/dl (RTA 1987).
However, some of the countries had reviewed the BAC level
and reduced it to a much lower legal limit. The World Health
Organization in the WHO World Report on Road Traffic Injury
Prevention (2004) highlighted some recommendations on
interventions of driving under influence which are generally
considered as being the best practice at this time. The
recommendations are;
2
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
•
upper limits of 0.05 g/dl for the general driving population;
and
•
0.02 g/dl for young drivers and motorcycle riders (WHO
2004).
The basis of this recommendation was based on the evidence
that provide strong support of setting up BAC limit of 0.05 mg/
ml. At this level or even lower level, driving skills are significantly
impaired. Besides that, studies have proven that risk of crash
involvement start to increase significantly at the level higher
than 0.04 mg/dl. In addition to this, international review on
effectiveness of introducing BAC limit has shown decrease in
number of accident, injuries and fatalities due drink driving.
Further initiatives taken by certain country to lower the existing
BAC limit had shown further reduction in number of alcohol
related road crashes, injuries and fatalities in their country (WHO
2004).
1.1.1 How Alcohol Impaired Driving
In order to identify the mechanisms by which alcohol affects
individual skills related to safe driving, numerous well-controlled
laboratory experimentation have been used. These laboratory
experiments have examined a wide range of BACs from low to
relatively high and have found that numerous driving-related
skills are degraded even at low BACs.
Alcohol has been shown to adversely affect tasks such as
tracking, perception of distance and speed, and reaction times
to respond to changes in road conditions. In addition, alcohol
cause the dis-inhibition effects on the cerebral cortex of the
brain, which can increase aggressive and risk taking behaviour in
some individuals (Burke 2007). Howat et al. (1991) had conducted
reviews on the findings of experimental and laboratory research
in order to identify the effects of alcohol on human behaviour
especially on driving skill. Many of the studies reviewed showed
statistically significant decrements in driving performance at a
BAC of 0.05 or lower. The authors found out that complex tasks
3
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
such as performed on driving simulators, or tracking with divided
attention are adversely affected by BACs of 0.05. Simpler tasks
such as simple reaction time is affected by higher BAC. However,
complex tasks have more relevance to the operation of a vehicle
compared to the simpler tasks.
Howat et al. (1991) al also added that, sufficient evidence from
the experimental study indicated that BACs of 0.05 or higher can
cause impairment of the major components of driving skill for
most people. They recommended that the setting of a uniform
0.05 statutory limit should be one measure in a comprehensive
approach to reducing impaired driving including other legal,
social, behavioural, and environmental strategies to deal with the
problem. Chamberlain and Solomon (2002) reviewed findings
of laboratory and field studies regarding the potential benefits
of creating 0.05 BAC in Canada. The authors found out that
the laboratory and field studies showed that important driving
related skills are adversely affected by relatively small amount
of alcohol. The affected driving related skills are vision, steering,
braking, vigilance as well as information processing and divided
attention tasks. Since the studies have never been seriously
challenged, there is reasonable consensus among experts
regarding the adverse effect on driving related skills by small and
moderate amounts of alcohol.
1.1.2 Risk of Crash Involvement
The assessment of the risk of crash involvement by drivers at
various BACs has been carried out using epidemiological research
methods. In these studies, a relative risk function was determined
which indicated the likelihood of a driver at specified BAC being
involved in a crash compared to a similar driver under the same
conditions at 0.00 BAC. These relative risk functions have been
widely used as a ground for setting up the legal limits for driving
under the influence of alcohol. Perhaps the most widely cited
epidemiological study of the crash risk produced by alcohol is
the Borkenstein Grand Rapids Study (Compton et al. 2002).
4
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Findings from the Grand Rapid Study, which was done in 1964,
showed that drivers who had consumed alcohol had a higher
risk of crash involvement in comparison to drivers with a zero
BAC. The finding also indicated that the risk of crash involvement
increased rapidly as the BAC rose as shown in Figure 1. These
results provided the basis for setting up legal blood alcohol limits
and breathe content limits in many countries around the world,
typically at 0.08 g/dl (WHO 2004).
Figure 1 Relative risk of driver involvement in police-reported crashes (Source: WHO World Report 2004)
Compton et al. (2002) conducted a case control study with
improvements on the study design. The study was designed
to determine the relative risk of crash involvement by BAC by
controlling the confounding factor such as age, gender and
alcohol consumption. They come out with three relative risk
models as presented in Table 1. The first model, which contains
no covariates, showed similar pattern of risk of crash as reported
in Grand Rapid Study. The model showed a decrease in relative
risk at very low BAC levels as the Grand Rapid “dip”. The second
model which included covariates such as gender, age and other
demographic covariates showed that relative risk was elevated
as BAC increased, with a marked increased of risk BACs of more
than 0.10. The third model that was adjusted for biases indicated
5
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
that the relative risk was significantly elevated starting at BAC
0.04. The model also showed that the relative risk for BAC below
0.04 was not significantly different from the risk at 0.00 which
was still above 1.0 at each BAC level.
In a recent study, Peck and his colleague conducted a case-control
study using data from a Blomberg study (Peck et al. 2008). In this
study, relative risk was computed using correlation regression of
BAC age interaction. They reported that the estimated relative
risks for drivers under age of 21 are clearly elevated at all BACs,
even as low as 0.01. As illustrated in Table 1, the other age groups
which were above 21 years showed small non-significant risk
reductions until their BACs reached 0.05, at which point, all
showed an increase in crash risk compared to zero BAC drivers.
1.2 Driving Under the Influence of Drug
Driving under the influence of drug is not a light issue nowadays.
The problem of drugs and driving is rapidly growing. In Finland,
the number of road traffic accidents involving intoxicants other
than alcohol has risen sharply (Penttilä et al. 2002). Similarly,
a study conducted in Europe shows the prevalence of driving
under influence as 1% to 5% for illicit drug and 5% to 10% for the
licit drug and that the most commonly used medicinal drug is
benzodiazepine (Verstraete 2003).
The medicinal drug used in treating diseases or illnesses can either
be prescribed by medical doctor or bought over the counter, and
many times these drugs are taken for recreational rather than for
medical purpose (for example opiod and sleeping pills). Some of
these medicinal drugs are dangerous after an overdose, but large
number of them are considered to be a danger to road safety
even when taken in therapeutic doses (Schneider et al. 2009). In
addition, the risk of accident is higher when prescription drug
was taken together with alcohol (Forney et al. 1974).
6
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Table 1 Relative risk of alcohol related road crashes at various BAC level
BAC
level
0.00
0.01
0.02
0.03
0.04
0.05
0.06
0.07
0.08
0.09
0.10
0.11
0.12
0.13
0.14
0.15
0.16
0.17
0.18
0.19
0.20
0.21
0.22
0.23
0.24
0.25+
Peck et al. study
(2008)
Under 21 21–24 25–54
1.00
1.13
1.34
1.64
2.09
2.75
3.72
5.19
7.40
10.8
16.0
24.1
36.7
56.3
87.1
135
209
324
497
756
1135
1684
2448
3485
1.00
0.94
0.93
0.95
1.01
1.11
1.25
1.45
1.73
2.10
2.59
3.25
4.13
5.29
6.82
8.82
11.4
14.7
18.8
23.9
29.9
36.9
44.7
53.1
1.00
0.94
0.92
0.94
1.00
1.09
1.23
1.42
1.69
2.04
2.51
3.15
3.98
5.09
6.54
8.43
10.9
14.0
17.8
22.5
28.2
34.7
41.9
49.5
55+
1.00
0.93
0.90
0.90
0.94
1.02
1.13
1.29
1.51
1.80
2.19
2.70
3.38
4.26
5.40
6.86
8.72
11.0
13.9
17.4
21.4
26.0
30.9
36.1
Compton et al. study
(2002)
21-55+
Combined
1.00
0.94
0.92
0.93
0.98
1.07
1.20
1.39
1.64
1.98
2.43
3.03
3.83
4.88
6.25
8.04
10.3
13.2
16.8
21.3
26.5
32.5
39.2
46.2
Non-reactive
No
demographic
covariates
covariates
1.00
0.91
0.87
0.87
0.92
1.00
1.13
1.32
1.57
1.92
2.37
2.98
3.77
4.78
6.05
7.61
9.48
11.64
14.00
16.45
18.78
20.74
22.07
22.51
21.92
20.29
1.00
0.94
0.92
0.94
1.00
1.10
1.25
1.46
1.74
2.12
2.62
3.28
4.14
5.23
6.60
8.31
10.35
12.74
15.43
18.31
21.20
23.85
25.99
27.30
27.55
26.60
Recreational drugs are used for their narcotics and stimulant
effect. These include legal drugs such as nicotine and caffeine,
and illegal drugs such as heroin, cocaine, amphetamines, ecstasy,
LSD and cannabis. According to National Anti-Drug Agency
(AADK 2010), 15 736 drug addicts were recorded in 2009 and the
number had increased in 2010 to 18 387 people, most noticeably
among adults (aged 19 to 39). In 2010, the top three popular
drugs used in Malaysia were cannabis @ ganja, heroin and
morphine. In addition, the three most common addictive drugs
in 2010 were heroin (28.08%) followed by morphine (22.45%)
and Amphetamine-Type-Stimulant (ATS) synthetic drugs
7
Final
adjusted
estimate
1.00
1.03
1.03
1.06
1.18
1.38
1.63
2.09
2.69
3.54
4.79
6.41
8.90
12.60
16.36
22.10
29.48
39.05
50.99
65.32
81.79
99.78
117.72
134.26
146.90
153.68
Grand
Rapid
Study
(1964)
1.00
0.92
0.96
0.80
1.08
1.21
1.41
1.52
1.88
1.95
5.93
4.94
10.44
21.38
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
(35.03%) which comprised amphetamine, methamphetamine
and ecstasy, as well as cannabis@ganja (12.5%) (AADK 2010).
Drugs can affect a driver’s behaviour in a variety of ways
(depending on the type of drug). These include slower reactions,
drowsiness, dizziness, poor co-ordination (RSM 2006). However,
the effect of the drug is not the same among all individuals. It
depends on the type of substances they contained, the dosage,
way of administration, and combinations of drugs used (Forney
et al. 1974). Ramaekers et al. (2006) reported that an acute dose
of 75mg Methylenedioxymethamphetamine (MDMA) improved
tracking accuracy, but impaired speed adaptation during carfollowing. This effect can lead to road traffic death and it was
supported by Verschraagen et al. (2007) who reported more
fatalities involving MDMA than amphetamine.
The main purpose of this study was to determine the status
of driving under the influences of drug and alcohol among
fatal road accident cases in this country. The study also aims
to investigate the epidemiologic pattern of DUI cases in this
country. In addition, the distribution of blood alcohol level was
also presented based on the toxicology results tested.
2.0 Methods
2.1
Design and Study Population
This was a retrospective cross-sectional study, which included
all road traffic death presented to the Department of Forensic
Medicine, Kuala Lumpur Hospital (HKL) from 2006 to 2009.
The protocol of the study was approved by MIROS’ Research
Committee and Research and Ethic Committee, National Institute
of Health, Ministry of Health Malaysia. The study’s findings
represented the DUI problem in the area of Kuala Lumpur.
8
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
2.2
Data Sources
Two data source were used, the post-mortem files which include
(post-mortem reports, police 61 forms, post-mortem drafts, and
toxicology reports) obtained from the Department of Forensic
Medicine, Kuala Lumpur Hospital and the police-based accident
data obtained from MIROS Road Accident Analysis and Database
System.
Data collected from the post-mortem files include post-mortem
report number, police report number, personal identification
number, age, gender, ethnic group, time of crash, date of crash,
type of crash, type of road user, type of vehicle, type of case, type
of substance use, concentration of substance use, and injury
details.
Based on personal identification number and police report
number, the records from the post-mortem files were matched
with the police-based accident data. Information on time of
crash, date of crash, type of crash, type of road user, type of
vehicle were cross-checked with the police-based data. With
regard to crash information, the police-based accident data will
be used if there was any discrepancy among the sources of data.
The results of alcohol or drug use were also cross-checked with
the police-based data.
Since the study is retrospective in nature, all data obtained
were from secondary data source. With regard to toxicology
sample, preservation material used and procedures of sample
transportation and data analysis were not intervened in this study.
However, for the purpose of the report, it is explained in this
paragraph. All samples were sent for toxicology analysis according
to the standard procedure practiced by the department of
Forensic Medicine. The sample bottles used were free of alcohol
preservative. Since 2006, they have been using sample bottles that
contained Natrium Flouride (NaF) as preservative. The Specimen
Security Seal from the Forensic Medicine Department, Kuala
Lumpur Hospital were affixed before the samples were sent to an
accredited laboratory at the Department of Chemistry Malaysia.
9
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
2.3
Data Collection Process
Information from the post-mortem files was retrieved by a
trained research officer at the Department of Forensic Medicine,
HKL. Steps for data collection process are shown in Figure 2.
Definition of Driving Under the Influence of Substance Use
In this study, driving under the influence of alcohol is defined as
when the blood alcohol level (BAC) is > 0.02 g/100 ml. The cut off
limit was decided based on the recent evidence on the effects of
BAC on safe driving function and it has been used as a legal limit
by many countries.
For driving under the influence of drug, for illicit drug such
as Opiates (heroin, morphine, codeine), Cannabis (THC),
Amphetamines (MDMA, Methamphetamine), Ketamine and
Cocaine, a driver is said to test positive for drugs if the result
of the blood test is positive. However, for medicinal drugs
such as diazepam, aprazolam, midazolam, benzodiazepines,
chloraphenyramine and carbamazephine, the therapeutic dose
range was considered before decision was made whether it
could be classified as a case of driving under the influence. This is
because within the therapeutic dose range, the drugs are known
to compromise some components of function for safe driving
such as alertness level. Those drugs with concentrations below
the therapeutic dose range will be excluded from under the
influence even though this might have effects on safe driving
function.
To avoid misclassifying drugs that was administered by health
personnel when attending or treating the case, the case of death
was first classified into either Brought-in-Dead (BID) or Deadin-Department (DID) cases. For BID cases, the positive drug test
results were not due to administered drug by health personnel
but it could have been taken by the drivers before the accident.
For DID cases, a positive drug test results will be reviewed case by
case by a forensic doctor to exclude drugs that was administered
to treat the subjects. Then, the drugs and their concentration
10
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
level were listed for each positive case. For medicinal drugs,
before the final list for driving under the influence of drug was
issued, second opinion from a clinical toxicologist was sought.
All Road Traffic Accident (RTA) deaths from 2006–2009 were traced from
the Death Registry Book, Forensic Medicine Department, HKL
Post-mortem numbers of RTA cases were retrieved
List of post-mortem number was submitted to Assistant Officer of Medical Record, Record
Management Unit, Forensic Medicine Department, HKL
Post-mortem’s files were obtained from staff of Record Management Unit.
Chain of custody (CoC) of post-mortem’s file was documented
Data collection (Accident data, injury details and toxicology results were recorded into
data collection template)
Post-mortem file was returned to Record Management Unit.
Chain of Custody (CoC) of post-mortem’s file were documented
Matching with police-based data were done based on police report number and personal
identification number
Figure 2 Data collection process at the department of Forensic Medicine, HKL
Data Analysis
A descriptive analysis was carried out to describe victims’
characteristics, crash details, and substance use details.
Prevalence and 95% confidence interval were determined for
each relevant output. To derive the incidence of substance use
by group of driver and the proportion of death related to driving
under the influence of substance use, the following work process
in Figure 3 was used;
11
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
•
No. of RTA deaths registered at the Department of Forensic Medicine, HKL
750
•
670
•
•
509
•
391
No. of RTA deaths eligible for data collection after excluding misclassified cases
and sensitive cases that were under court proceedings
This number of cases were used for analysis of general road traffic deaths
No. of RTA deaths that have toxicology results either negative or positive
(alcohol and drug)
•
No. of RTA deaths classified as group of drivers (four wheel vehicle drivers, riders
and cyclists)
Final number of cases eligible for analysis of driving under the influence of
substance use
•
Positive for alcohol and drugs
143
•
•
91/43/9 •
91 positive for alcohol
43 positive for drug
9 positive for alcohol and drug
Figure 3 Flow chart for searching of driving under the influence of drug and alcohol
To determine factors associated with positive substance use
among fatal road traffic death, logistic regression analysis was
performed. The dependent variable was the status of substance
use (positive or negative) as reported in the post-mortem
toxicology report. The independent variables were ethnic group,
age group, gender, type of road user, day of the week, type of
road user, type of crash, and time of the day. All analyses were
performed using SPSS V17.0.
12
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.0 Results
Section 1: General Road Traffic Deaths
3.1
Number of Fatal Road Traffic Deaths
A total of 710 fatal road traffic deaths were registered at the
Department of Forensic Medicine, HKL during the study period
of 2006 to 2009. Out of these numbers, 40 cases were excluded
for analysis as the post-mortem report details had not been
finalised by the attending forensic doctors. This left 670 cases
of fatal road traffic deaths eligible for the study. Distribution of
cases presented to the Department of Forensic Medicine, HKL
and analysed in the study by year is shown Figure 4. In general,
there was a declining trend in the number of road traffic death
presented to the Department of Forensic Medicine, HKL with
the highest number recorded in 2006 (209 cases) followed by
2008 and 2009 with 189 and 178 cases respectively. The drastic
reduction in 2007 cases as compared to earlier and the following
years were due to administrative reason as no post-mortem data
were made available for the months of January and February.
Figure 4 Number of road traffic deaths presented to HKL
13
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.2
Road Traffic Deaths by Gender and Ethnic Group Composition
Table 2 shows the gender-ethnic composition of cases in this
study. Males were predominantly represented in the database
(90.1%) followed by females who only accounted for 9.9% of the
cases. Data breakdown based on ethnic group shows that the
Malay ethnic group accounted for 42.5% of cases followed by
Chinese (22.6%) and Indian (20.9%).
Table 2 Gender-ethnic group composition of cases presented to the Department of Forensic Medicine, HKL, 2006–2009
Sex
Ethnic group
Number
Percentage (%)
All sex
Malay
285
42.5
Chinese
151
22.5
Indian
140
20.9
Others
Male
Female
14.1
670
Malay
261
43.2
Chinese
133
22.0
Indian
123
20.4
Others
87
14.4
100
Total
604
Malay
24
36.4
Chinese
18
27.3
Indian
17
25.8
Others
Total
3.3
94
Total
7
66
100
10.5
100
Age-sex Distribution of Road Traffic Deaths Presented to the Department of Forensic Medicine, HKL, 2006–2009
Figure 5 shows the trend of cases by age group and gender.
There was a drastic increase in the number of fatal road traffic
death among male road users until the age group of 20–29 and
the number started to decrease afterward. Road traffic deaths
14
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
among males (age group 29 and below) account for 54.6%. For
the female road users, the highest number was from the 20–29
age group with 20 cases, followed by those from age group
30–39.
3.4
Distribution of Road Traffic Deaths by Types of Road User
Figure 6 presents the distribution of deaths by road user types.
Motorcyclists contributed to more than half of the total number
of deaths with 377 cases (56.3%) followed by drivers, pedestrians
and pillion riders, with 110 cases (16.4%), 74 cases (11.0%) and
34 cases (5.1%) respectively. The cyclists contributed the smallest
number with four cases (0.6%). Front and back passengers
contributed only 3.9% and 3.3% of the cases respectively.
3.5
Distribution of Road Traffic Deaths by Types of Accident
In this study, crashes involving more than one vehicles (Multiple
Vehicle Crash) contributed the highest number of road traffic
deaths, accounting for 64.9% of the cases and followed by single
vehicle crashes that accounted for 32.4% of the total cases
(Figure 7).
3.6
Number of Fatal Cases according to the Types of Case and Types of Road User
The cases included in this study are divided into two different
categories; Brought-in-Dead (BID) and Dead-in-Department
(DID). BID case is defined as a case in which the victim is
pronounced dead before arrival at the hospital. A DID case is
defined as any case in which the victim dies in the Emergency
Department or in the ward. The majority of cases presented to
HKL were BID cases which accounted for 80% of the total cases,
as shown in Figure 8. The Dead-in-Department (DID) cases
accounted for 20% of the total cases.
15
Number
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Age
Figure 5 Age-sex distributions of fatal road traffic death at the Department of Forensic Medicine, HKL, 2006–2009
Figure 6 Distribution of fatal road traffic deaths by types of road user
Figure 7 Road traffic deaths by types of accident
16
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Figure 8 Proportion of case by types of road user and types of case
3.7
Trimodal Death of Road Users
There were 532 BID cases and 138 DID cases recorded for this
study. Data breakdown based on DID cases for vulnerable road
users (motorcyclists, pillion riders, pedestrians and cyclists)
shows that most of the deaths for DID cases happened on the
same day of the accident. Motorcyclists accounted for the largest
number with 52 cases of death occurring within one (1) day of
the accident, followed by pedestrians and pillion riders with
12 and six cases respectively. In addition, there were two cases
of death among motorcyclists recorded within two days after
the accident, and three cases after three days of the accident.
Besides that, there was one case of death each recorded for
cyclist and pedestrian three days after the accident. The detailed
comparison for all road users can be referred to in Figure 9.
17
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Percentage of death by day of death
Number of deaths by types road user
Time of Death
M
PR
D
FP
BP
P
C
302
27
92
21
16
56
4
14
Less than 1
day
52
6
13
3
6
12
0
5
1 day
11
2
5
1
0
4
0
1
2 days
2
0
0
0
0
0
0
0
3 days
1
0
0
0
0
0
0
0
More than 3
days
3
0
0
1
0
1
0
0
Unknown
6
0
0
0
0
1
0
0
377
35
110
26
22
74
4
20
BID
Total
Unknown Total
670
Figure 9 Time of death by types of road user
Section 2: Road Traffic Deaths and Driving Under the Influence of Substance Use
3.8
Number of Cases Eligible for Analysis of Substance Use
Out of 670 cases, 509 (76.0%) cases were eligible for analysis of
substance use related problem. The other 24.0% of cases were
excluded for detailed analysis of substance use, as toxicology
result was not available due to pending results or samples not
collected. Of the 670 cases comprising all types of road user, 112
18
Number of death
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Test result
Figure 10 Number of road traffic deaths (all road users) by status of toxicology result
cases (16.7%) were tested positive for “alcohol only” and 54 cases
(8.1%) were tested positive for “drug only”. In addition, 16 cases
(2.5%) were tested positive for both alcohol and drug (Figure 10).
3.9
Incidences of Under Influence of Substance Use Among Fatal Group of Drivers
Out of 509 cases eligible for detailed analysis for substance use,
391 (76.8%) of them were individuals who operated the vehicle
during the accident. This group will be noted as group of drivers.
14.2% were pedestrians. Others were either back or front seat
passengers or pillion riders. Because pillion riders, back, and front
seat passengers were not of primary concern for driving under
the influence, the subsequent analysis focuses on the group
of drivers that included four wheels vehicle drivers, riders, and
cyclist.
Table 3 shows the percentage of overall substance use by types
of road user of concern. The percentage of substance use was
highest among drivers (52.8%) followed by motorcyclists (33.9%),
cyclists and pedestrians (23.0%). Among those who operated the
vehicles (drivers, riders, cyclist) the percentage of substance use
was 36.6%.
19
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Table 3 Percentage of substance use by types of fatal road user
Types of occupant
Number
of road
users
Number
of positive
substance
use
(Alcohol &
drug)
% of substance
use (ci 95%)
[(X/specific no. Of
road users(y)]
(Y)
(X)
298
101
33.9 (28.5–39.3)
Drivers
89
41
52.8 (42.4–63.2)
Pedestrians
74
17
23.0 (13.4–32.6)
4
1
25.0 (-17.4–42.4)
391
143
36.6 (31.8–41.4)
Motorcyclists
Cyclists
Total number of
those who operated
the vehicles (drivers,
motorcyclists, and
cyclists)
3.10 Incidences of Under the Influence by Types of Substance Use and Types of
Case Among Group of Fatal Driver
Table 4 presents the results of substance use by groups of drivers
and types of cases.
Alcohol use only; In general, the percentage of alcohol-positiveonly among all drivers (driver, riders, and cyclist) was 23.3%. The
breakdown by types of cases shows that the percentage of
alcohol-positive-only was higher among BID cases (25.3%) as
compared to DID cases (13.4%). The breakdown by types of road
users reveals that alcohol-positive-only among motorcyclists,
drivers, and cyclists was 22.1, 28.1, and 0% respectively.
Drug use only; In general, the percentage of drug-positiveonly among all drivers (driver, riders, and cyclist) was 11.0%. The
breakdown by types of cases shows that the percentage of drugpositive-only was higher among BID cases (11.4%) as compared
to DID cases (9.0%). The breakdown by types of road users shows
that drug-positive-only among motorcyclists, drivers, and cyclists
was 10.6, 13.5, and 25% respectively.
20
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Drug and alcohol use; In general, only 2.3% of cases were
positive for both alcohol and drug. All cases of positive for both
alcohol and drug were classified BID.
Table 4 Road traffic death cases by types of substance use, types of case and group of drivers
Types of Types of
cases road users
No. of
road
users
Alcoholpositiveonly
N (%)
(95%CI)
BID
All
types
of cases
(BID &
DID)
Positive
both
(Alcohol &
drug)
N (%) (95%CI)
N (%)
(95%CI)
Total
positive
substance
use
N (%)
(95%CI)
M
246
62 (25.2%)
(19.8–30.6)
26 (10.6%)
(6.8–14.4)
6 (2.4%)
(0.5–4.3)
94 (38.2%)
(32.1–44.3)
D
74
20 (27%)
(17–37)
10 (13.5)
(5.7–21.3)
3 (4.1%)
(-0.4–8.6)
33 (44.6)
(33.3–55.9)
C
4
0
1 (25%)
(-17.4–67.4)
0
1 (25%)
(-17.4–67.4)
324
82 (25.3%)
(20.6–30)
37 (11.4%)
(8–14.8)
9 (2.8%)
(1.0–4.6)
128 (39.5%)
(34.2–44.8)
M
52
4 (7.7%)
(0.5–15.0)
3 (5.8%)
(-0.6–12.2)
0
7 (13.5%)
(4.2–22.8)
D
15
5 (33.3%)
(9.4–57.2)
3 (20%)
(-0.2–40.2)
0
8 (53.3%)
(28.1–78.5)
Total
DID
Drugpositive-only
C
0
0
0
0
0
Total
67
9 (13.4%)
(5.2–21.6)
6 (9%)
(2.1–15.9)
0
15 (22.4%)
(12.4–32.4)
M
298
66 (22.1%)
(17.4–26.8)
29 (9.7%)
(6.3–13.1)
6 (2.0%)
(0.4–3.6)
101 (33.9)
(28.5–39.3)
D
89
25 (28.1)
(18.7–37.4)
13 (14.6)
(7.3–21.9)
3 (3.4)
(-0.4–7.2)
41 (52.8)
(42.4–63.2)
C
4
0
1 (25)
(-17.4–67.4)
0
1 (25.0)
(-17.4–67.4)
391
91 (23.3)
(19.1–27.5)
43 (11)
(7.9–14.1)
9 (2.3)
(0.8–3.8)
143 (36.6)
(31.8–41.4)
Total
21
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.11 Incidences of Substance Use Among
Fatal Drivers, Riders and Cyclists by Year
Figure 11 shows the percentage of substance use by year. There
was a drastic increased from 16.8% (95% CI; 9.9–23.7) in 2006 to
38.3% (95% CI; 27.7–48.9) and 52.8% (95% CI; 43.4–62.2) in 2007
and 2008 respectively. However, the percentage of substance
use decreased to 40.4% (95% CI; 30.2–50.6) in 2009. The period
prevalence for 2006 to 2009 was (36.6%) (95% CI; 31.9–41.3)
Figure 11 Prevalence of substance use among fatal drivers, riders and cyclists by year
3.12 Distribution of Fatal Drivers with Positive
Substance Use by Day of Accident
It was noted that the distribution of positive substance cases (the
number of cases with positive substance use in a day divided by
the total number of cases) is highest on Saturday (20.3%) followed
by Sunday (17.5%) and Wednesday (16.1%). The day with the
lowest percentage is Monday (4.9%). However, when the data
was presented in the form of rate (total number of death with
positive substance use in a day divided by the number of total
deaths on that specific day), the highest percentage of death
due to positive substance use is on Saturday (33.7%) followed
Wednesday (32.4%), Tuesday (30.8%) and Sunday (30.5%). The
22
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
lowest rate is still on Monday (13.5%). This indicates the risk of
dying in road traffic accident due to substance use would be
highest on Saturday followed by Wednesday, Tuesday, Sunday,
Friday and Monday (Figure 12).
Distribution of cases (%) with substance use by day
Specific rate (%) of substance use by day
Figure 12 Distribution and specific rate of cases with positive substance use by day
3.13 Distribution of Fatal Drivers with Positive
Substance Use by Time of Accident
Figure 13 shows the percentage distribution and rate of accidents
among DUI cases by time. The trend of accident and DUI cases
increase from 0000–0600 hours. The highest number of DUI
cases occur between 0400–0559 hours with 20.3%, followed by
0200–0359 with 19.6%. After 0600 hours, the number of accident
and DUI cases decrease and increase again after 1200 hours. The
distribution pattern of deaths due to driving under influence
of substance use cases is similar with the pattern of specific
death rate by day. The majority of DUI cases occurred in the
early morning (0000–0559) compared to the rest of the day. The
23
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
highest percentage of DUI still occurred between 0400–0559
hours with 54.7% (CI 95%; 41.3–68.1) but the second highest
is between 0200–0359 hours with 47.5% (CI 95%; 34.8–60.2)
followed by 0000–0159 hours with 41.7% (CI 95%; 27.8–55.6). The
rest of the hours accounted for less than 30%.
Distribution (%) of road traffic death cases (+ve substance use) by time
Specific fatality rate (%) of cases with positive substance use by time
Figure 13 Distribution and specific rate of cases with positive substance use by time
3.14 Incidences of Substance Use Among Fatal Drivers, Motorcyclists and Cyclists by Age
Driving under influence of substance use (su) is associated with
age. The highest percentage among the drivers of the age group
(30–39) with 43.3% (CI 95%; 33.1–53.5) followed by (20–29) and
(40–49) with 39.7% (CI 95%; 32.4–47.0) and 41.2% (CI 95%; 25.1–
57.3) cases respectively. The clear comparison can be seen in
Figure 14.
24
Percentage
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Age
Figure 14 Percentage of substance use by age
3.15 Incidences of Substance Use Among
Group of Fatal Drivers by Types of Accident
In general, the proportion of DUI cases is higher among single
vehicle accidents (47.7%) as compared to multiple vehicle
accidents (29.5%). Comparing by types of substance use, alcohol
use was higher among SVA cases (35.9%) compared to MVA
cases (8.5%). However, under the influence of drug, in contrast,
the cases were higher among MVA (15.2%) cases than among
SVA cases (12.7%) (as shown in Table 5).
Table 5 Fatal road traffic cases with positive substance use by types of accident
Types of accident
SVA
MVA
Fatal cases with
substance use
N (%) (CI 95%)
Alcohol
55 (35.9) (28.3–43.5)
Drug
13 (8.5) (4.1–12.9)
Both
3 (2.0) (-0.2–4.2)
Total
73 (47.7) (39.8–55.6)
Alcohol
36 (15.2) (10.6–19.8)
Drug
30 (12.7) (8.5–16.9)
Both
4 (1.7) (0.1–3.3)
Total
70 (29.5) (23.7–35.3)
25
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.16 Alcohol Concentration Among Drivers/
Motorcyclists and Cyclists by Types of Case
Figure 15 shows the distribution of blood alcohol level among
cases positive for alcohol. The mean (sd) of BAC was 176.56 (77.7).
The breakdown of cases by different levels of BAC revealed that
82% of fatal accident cases occured with BAC levels of 80 mg/100
ml and above. 11% of fatal cases occurred at BAC level between
<50<x≤80 and 6.6% occurred at BAC levels of 50 mg/ml and below.
This indicates that 17.6% of road traffic deaths related to under the
influence of alcohol occured at BAC level of 80 mg/100 ml and
below.
Mean
= 178.56
Std. Dev. = 77.725
N
= 91
Limit 20 mg /
100 ml
Limit 80 mg /
100 ml
Limit 50 mg /
100 ml
Alcohol concentration (mg/100 ml)
Alcohol concentration
(mg/100ml)
Number of death
Percentage (%)
≤20
0
0
<20<X≤50
6
6.6
<50<X≤80
10
11.0
>80
75
82.4
Figure 15 Blood alcohol concentration among drivers, motorcyclists and cyclists
26
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.17 Frequency of Drug Use Among Group of Fatal Drivers (Drivers, Riders, Cyclists)
Among those who operated the vehicles (drivers, riders and
cyclists) 65.4% were single drug users, followed by two drugs
users (28.8%) and more than three drugs users (5.7%) (Table 6).
Table 6 Number of drugs used by drivers, motorcyclists and cyclists
Case
Types of
road users
Single
drug
Two
drugs
Three
and more
Total
BID
Drivers/
motorcyclists/
cyclists
30
14
2
46
DID
Drivers/
motorcyclists/
cyclists
4
1
1
6
All case
Drivers/
motorcyclists/
cyclists
34
(65.4%)
3
(5.7%)
52
15
(28.8%)
3.18 Incidences of Fatal Drivers (n=391) Under
the Influence by Categories of Drugs
The incidences of fatal drivers positive for illicit drugs was 10%,
with opiates group at the top of the list (5.4%) followed by
amphetamines (2.8%), cannabis (1.02%) and ketamine (0.8%). For
medicinal drug, the benzodiazepines group is at the top of the
list with incidences of 6.9% (refer Table 7).
3.19 Categories of Drugs Found Among Positive Drivers, Motorcyclists and Cyclists
Table 8 shows the categories of drugs used by fatal drivers. Illicit
drug accounts for 55.7% of positive cases. The balance, 44.2% of
drivers, were positive for medicinal type of drugs. The opiates
group of drugs is the most common illicit drug found positive
among fatal group of drivers. The amphetamines group accounts
for 15.7% as the second most common illicit drug found. For
27
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
medicinal drug type, benzodiazepines is the most common drug
used followed by the anti-histamine group.
Table 7
Incidences of fatal drivers (n=391) under the influence by categories of drugs
Type
Illicit drug
Category
*N (%)
Opiates
21 (5.4%)
Amphetamines (ecstasy)
11 (2.8%)
Cannabis (Ganja)
4 (1.02%)
Ketamine (Pil Kuda)
Medicinal drug
3 (0.8%)
Total illicit drug
39 (10.0%)
Benzodiazepines
27 (6.9%)
Anti-histamine
3 (0.8%)
Anti-epileptic
1 (0.3%)
Total medicinal drug
31 (7.9%)
*Given some cases may have multiple drugs
Table 8 Categories of drugs found among group of fatal drivers positive for drug
Type
Illicit drug
Medicinal
drug
Category
Generic name
*N (%)
Opiates
Morphine, Codeine,
heroin, methadone
21 (30.0%)
Amphetamines
(ecstasy)
Amphetamine,
methamphetamine,
MDA, MDMA
11 (15.7%)
Cannabis (Ganja)
THC
4 (5.7%)
Ketamine (Pil Kuda)
Ketamine
3 (4.3%)
Total illicit drug
-
39 (55.7%)
Benzodiazepines
Aprazolam,
Nordiazepam,
diazepam,
temazepam,
midazolam
27 (38.6%)
Anti-histamine
Chlorpheniramine &
Diphenylhydramine
3 (4.3%)
Anti-epileptic
Carbamazepine
1 (1.4%)
Total medicinal drug
Total N
*Considering some cases have multiple drugs
28
31 (44.2%)
70*
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.20 Likelihood of Dying on Site of Accident Due to Very Severe Crash
Based on Chi-square analysis of BID and DID cases as the
surrogate indicator for severity of injury and crashes, it is found
that crashes involving group of drivers who were under the
influence of substance use has the risk of dying before reaching
the hospital at 2.26 (95% CI of OR: 1.18–4.40) (Table 9). When
adjusted for other variables, substance use variables remain
significantly associated with status of outcome with adjusted OR
of 2.21 (95% CI: 1.17–4.19) (Table 10). This indicates that crashes
as a result of driving under the influence is more than twice to
likely to cause very severe injuries that result in immediate death.
Table 9 Chi-square analysis between types of case and status of substance use
Substance
use
BID case DID case Total
Positive
128
15
143
Negative
196
52
248
Total
324
67
391
Chisquare
Yates
corrected
OR (95 %
CI)
P
value
6.29
2.26
(1.18–4.40)
0.012
Table 10 Factors associated with outcome of crash (brought-in-dead; dead-
in-department)
Wald
df
P
value
OR
95% C.I.for OR
Lower
Upper
Sex
.453
1
.501
.994
.977
1.011
Ethnic
.220
1
.639
1.004
.987
1.021
1.037
1
.308
1.070
.939
1.220
Type of driver
.168
1
.682
1.062
.796
1.417
Age group
.016
1
.899
1.022
.730
1.431
Night vs. day
.036
1
.849
.946
.535
1.672
5.953
1
.015
2.212
1.169
4.187
Day
Substance use
status
29
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
3.21 Factors that Predict the Use of Substance
Among Drivers
Table 11 shows factors associated with status of substance use.
It is noted that two factors are significantly associated with
substance use among all type of drivers. It occurrence is more
common among driver who involved in single vehicle accident
with odd ratio of 1.94 (95 % CI: 1.23–3.04) and during night time
with odd ratio of 2.74 (95 % CI: 1.70–4.40).
Table 11 Factors associated with substance use among group of drivers (private car, riders, and cyclists)
Wald
df
Sig.
OR
95% C.I.for OR
Lower
Upper
Sex
.000
1
.991
1.000
.996
1.004
Ethnic
.118
1
.731
1.000
.998
1.003
3.794
1
.051
1.112
.999
1.238
Type of driver
.335
1
.563
1.067
.857
1.329
Age group
.615
1
.433
.890
.666
1.190
SVA vs. MVA
8.252
1
.004
1.935
1.233
3.035
Night vs. day
17.206
1
.000
2.737
1.701
4.403
Day
4.0 Discussion
4.1
Incidences of Road Traffic Deaths related
to Driving Under the Influence of Drug and Alcohol
This study found that driving under the influence of alcohol and
drug among groups of drivers involved in fatal crashes is very
alarming. The study revealed that 23.3% of the fatal drivers were
positive for alcohol, 11% positive for drug and 2.3% were positive
for both drug and alcohol. When combined (all those who tested
positive for substance use for either alcohol or drug), the study
30
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
found that 36.6% of fatal drivers were under the influence of
substance use when the crash happened. As mentioned in the
methodology section, driving under the influence of alcohol
is defined when BAC is > 0.02 g/100 ml. The cut off limit was
decided based on the recent evidence on the effects of BAC
on safe driving function and it has been used as a legal limit by
many countries. For medicinal drug such as benzodiazepines
group and anti-histamine group, the therapeutic dose range
was considered before decision was made whether it could be
classified as driving under the influence case. This is because
within the therapeutic dose range, the drugs are known to
compromise some functional components for safe driving
such as alertness level. Those drugs with concentrations below
therapeutic dose range had been excluded as under the
influence even though they might have given some effects on
safe driving function.
Among illicit drugs detected among fatally injured drivers
reported in this study, the opiates group is at the top of the list
with 5.4%. 2.8% drivers were positive for amphetamines, 1.02%
for cannabis and 0.8 % for ketamine. This pattern is similar with
the pattern of drug addiction in this country. Compared with
other countries, this pattern is slightly different as most of them
reported that cannabis is at the top of the list detected among
fatal or injured drivers followed by opiates, and amphetamines
(Biecheler et al. 2008; Biecheler et al. 2006; Drummer et al. 2003;
Health Canada 2004; Walsh and Mann 1999; Macdonald et al.
2003).
The high incidence of alcohol or drug uses among the population
of drivers involved in fatal accidents highlights its significant
relevance to road safety. However, the incidence rates reported
in this study could not be compared with previous data as no
published information were found. Therefore, the rate reported
here could not suggest whether there was an increase in the
proportion of drivers involved in accidents who were under the
influence of alcohol or drugs over the past years. However, it
is surprising to note that when compared to the data on fatal
drivers from police-based database, the rate reported in this
31
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
study is very much higher. This might reflect under reporting of
police-based data. As the process of investigating the driving
under the influence of alcohol and drug is mainly done by police
order, some further investigations are necessary to clarify under
reporting issues especially related to the practice of data entry
into the police-based database system.
It is very important here to note that driving under the influence
of medicinal drug especially benzodiazepines group is at the
top of the list for driving under the influence. Benzodiazepines
are prescribed to relieve anxiety and aid sleep. It is commonly
known as tranquilizers and sleeping pills. They can also be used
recreationally, though using them without a prescription is
illegal in many parts of the world including in this country. In
pharmacological terms, benzodiazepines enhance inhibitory
neurotransmitters that slow down central nervous system
electrical signals (Ree and Cannard 2006). Adverse effects can
include over sedation, memory impairment and depression.
Both the intended and adverse effects can influence the central
nervous system producing drowsiness, poor concentration, lack
of coordination and mental confusion, all of which can impair a
person’s ability to drive safely. Epidemiological studies in Canada,
Australia, and Europe indicate that prevalence of benzodiazepines
used is approximately 3–6% among drivers involved in fatal
crashes (Cimbura et al. 1982; Mercer and Jeffrey 1995; Drummer
et al. 2003; Carmen et al. 2002; Sjogren et al. 1997). With incidence
of 6.9%, this study reported a relatively higher incidences of
benzodiazepines use among fatal drivers as compared to other
studies. This carries a very important message for prevention of
crashes especially to medical practitioners that use to prescribes
benzodiazepines to their patients. Special emphasis on warning
regarding benzodiazepine’s impact on a person’s ability to drive
safely need to be given to their patients. This is truly important,
as benzodiazepines group of drug is not an illegal drug and thus
cannot be enforced. Benzodiazepines also should not be sold to
any patient without a prescription by a medical practitioner. Given
the growing regarding benzodiazepines and risk of crash, the
American Medical Association (AMA) recommends that patients
of all ages be prescribed the shortest-acting benzodiazepines
32
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
appropriate for their condition (Wang et al. 2003). Additionally,
the AMA recommends that these patients should be advised
to avoid driving, particularly during the initial phase of dosing
(Wang et al. 2003).
4.2
Profile of Cases DUI
Driving under the influence of substance use (either alcohol
or drugs) involved all age groups but is more predominant
among young adults in the age group of 40–49 and below. A
breakdown by types of substances revealed that driving under
the influence of alcohol is most prevalent among young adults
between 20 and 29 years old (28.8%). However, for driving under
the influence of drugs, it is most prevalent among an older
age group (30–39 years) which accounts for 22.2%. By types
of vehicles, the incidence of alcohol and drug use is relatively
higher among four wheeled vehicle drivers as compared to
motorcyclists. However, this could be related to small number
of four wheeled vehicle drivers (89) included in the study, as
compared to motorcyclists (298).
It is surprising to note that the specific incidence rate of
substance use (alcohol and drug) by day reveals Saturday (33.7%)
at the top of the list, followed closely by Wednesday (32.8%) and
Tuesday. Sunday is in fourth place. The pattern might be related
to promotional activities done by various entertainment and pub
outlets during Wednesday. Examination of pattern by time of the
day clearly indicates that the cases was over represented during
night time and peaked at 4:00 a.m. to 6:00 a.m. in the morning.
When logistic regression analysis was performed, time of the day
and type of crash (incidence of substance use is higher among
SVA) were among the significant predictors for substance use
among fatally injured drivers. Those findings are very important
for traffic safety countermeasures. Enforcement activities
targeted at drivers or motorcyclists driving or riding alone during
night time on Saturday, Wednesday, and Tuesday would give
better results. However, traffic safety countermeasures that
focus on traffic behaviour alone are not likely to be effective
in preventing substance use among drivers. It has to include
33
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
broader socio-psychological measures to change overall
behaviour. This is because substance uses among drivers are
commonly connected to a risky lifestyle in general. The results of
driver rehabilitation courses have also supported this method of
intervention (Bart et al. 2002).
4.3
Blood Alcohol Concentration (BAC), Crash Risk and Legal Limit
This study highlights findings that revealed a significant
proportion (17%) of fatal crashes related to driving under the
influence of alcohol occurred with drivers with BACs that were
below the legal limit of 0.08 g/100 ml as stipulated in the Road
Traffic Act 1987. This indicates that the current legal limit may
not be adequate and should be revised in accordance with
the development of scientific evidence. In fact, many countries
including Asian countries have already revised their BAC legal
limit in line with these scientific findings. However, among the
countries themselves, the limit varies, ranging from 0.02 to
0.08 g/100 ml. More than 50% of the countries set up a BAC
limit of 0.05 g/100 ml. Countries such as Japan, China, India
and Sweden implemented even lower limit, ranging from
0.02 to 0.03 g/100 ml. More specifically, some of the countries,
such as Australia, United States, Netherland, Spain and Austria,
implemented BAC limits by categories of drivers. In those
countries, much lower BAC limit was set up for novice or young
drivers as well as commercial vehicle drivers. The details of BAC
levels by countries are shown in Table 12.
The positive effects of lowering the BAC legal limit have been
documented globally. For example, in Austria, after the legal
BAC limit was lowered from 0.08 to 0.05 in 1998, Bartl and
Esbenger (2000) conducted a short term evaluation on the
effects of lowering the legal BAC limit in the country. The authors
concluded that the short term evaluation indicated a significant
reduction of drunk driving in combination with intensive police
enforcement and reporting in the media. They also stated that
the number of drivers with 0.08 or higher decreased at the same
34
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
time by 22.9%. Mann et al. (2001) reviewed the findings of studies
evaluating a reduction of the legal BAC limit to 0.05 or 0.08. The
author summarised the findings of the studies in table as shown
in Table 13. From the summary, they concluded that in most
jurisdictions in which a legal limit has been introduced or lowered,
there was evidence that reductions in alcohol-related accidents,
fatalities and injuries have occurred.
Limitations of Study
As the source of fatally injured drivers is only from the
Department of Forensic Medicine of Kuala Lumpur Hospital,
the findings of the study could only be generalized to the
population of drivers in the city of Kuala Lumpur. The actual
burden of driving under the influence of substance use among
injured drivers or uninjured driver could not be quantified, as
the study subjects were limited to fatally injured drivers.
35
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Table 12 Blood alcohol concentration (BAC) limits by country or state
Country/state
Maximum BAC legal limit (g/100ml)
For general driver
For novice/young driver
For commercial vehicle
driver
Australia
0.05*
0.02
0.05
Japan
0.03
0.03
0.03
Philippine
-
-
-
Singapore
0.08
0.08
0.08
Republic of Korea
0.05
0.05
0.05
China
0.02
0.02
0.02
Brunei
Darussalam
0.08
0.08
0.08
Vietnam
0.08
0.08
0.08
India
0.03
0.03
0.03
United Kingdom
0.08
0.08
0.08
Denmark
0.05
0.05
0.05
Germany
United States
Canada
0.05
0.05
0.10 or 0.08*
0.00–0.02
0.08*
0.08
0.05
0.04 for commercial
driving license (Any
alcohol is ground for
removal from service for
24 hours)
0.08
France
0.05
0.05
0.05
Finland
0.05 , 0.12 (for severe
drunken driver)
0.05
0.05
Sweden
0.02
0.02
0.02
Thailand
0.05
Turkey
0.05
South Africa
0.05
Netherland
0.05
0.02
0.05
Italy
0.05
0.05
0.05
Spain
0.05
0.05
0.03
Austria
0.05
Estonia
0.02
Ireland
0.08
n/a
n/a
Russian
Federation
0.02
n/a
n/a
0.01 or .05 mg/l in breath
for novice drivers during
a 2-year probation
period and for riders of
motorcycles and other
vehicles age 20 or less
0.01 or .05 mg/l in breath
for drivers of vehicles over
7.5 tons or buses.
*Country which the BAC limits varies between states/provinces.
(Source: WHO Western Pacific Region 2009; WHO World Report 2004; NHTSA 2000; ICAP 1995–2011)
36
Several indicators of drinking-driving and Pre-post
alcohol involvement in collisions
comparisons
Australia, reduction of the legal limit Brooks and Zaal
in the Australian Capital Territory from (1993)
80 to 50mg% in 1991
Distribution of BACs among drivers in Pre-post
Adelaide
comparisons
Distribution of BACs in fatally injured Pre-post
drivers and drivers tested in roadside comparisons
surveys in Adelaide
Numbers of serious collisions, fatal Time series
collisions and single vehicle night-time analysis
collisions
Australia, reduction of the legal limit Kloeden and
from 80 to 50 mg% in 1991 in South McLean (1994)
Australia
Australia, reduction of the legal limit McLean et al.
from 80 to 50 mg% in 1991 in South (1995)
Australia
Australia, reduction of the legal limit Henstridge et al.
in New South Wales and Queensland (1997)
from 80 to 50 mg% between 1982
and 1992
Pre-post
comparisons
Collisions involving drinking-drivers
Design/
analysis
Australia, reduction of the legal limit Smith (1986)
in Queensland from 80 to 50 mg% in
1983
Measures
Proportion of fatal collisions involving Time series
alcohol, plus various secondary measures analysis
of awareness, impact and enforcement
of the law
Author
Canada, introducing the 50 mg% Vingilis et al.
12–h suspension provision of the (1988)
Ontario Highway Traffic Act (HTA)
in 1981
Location
Table 13 Results of scientific paper reviews on the effect of lowering the legal BAC limit by Mann et al. (2001)
37
(continue)
Reduction of the limit to 50 mg% resulted
in significant reductions in all collision and
fatality measures in both states.
Reduction of the limit to 50 mg% resulted
in a temporary reduction in the BACs of
night-time drivers and a reduction in the
proportion of fatally injured drivers with
BACs over 80 mg% - no statistical analyses
reported.
Reduction of the limit to 50 mg% resulted
in significant in the BACs of drivers breathtested in road-side surveys.
Reduction of the limit to 50 mg% resulted
in significant reduction in BACs of collisioninvolved drivers who had been drinking,
and in the BACs of drivers breath-tested by
police.
Reduction of the limit to 50 mg% resulted
in significant reduction in numbers of
collision-involved drivers who had been
drinking.
Introduction of the 50 mg% HTA provision
had significant but apparently temporary
impact on alcohol-related collisions, perhaps
due to lack of awareness and enforcement.
Impact
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
Fatal collisions involving alcohol
United States, reduction of limit to Scopatz (1998)
80 mg% in five states between 1983
and 1991
Significant reductions in nine of the 30
comparisons. Only one state (Maine) had
no significant effects on any measures.
Impact
38
Various measures of fatal collisions Multiple time Significant reductions in alcohol-related
involving alcohol
series analysis fatalities in nine out of 33 analyses.
Fatal collisions involving drinking-drivers Weighted
with low BACs (10–90 mg%) and fatal least-squares
collisions involving drivers with high regression
BACs (100 mg% and above)
Numbers of fatal collisions, single vehicle Time series
collisions and total collisions
analysis
United States, reduction of limit to Apsler et al.
80 mg% in 11 states between 1983 (1999)
and 1994
United states, reduction of limit to 80 Vaos et al. (2000)
mg% by 1997
Sweden, reduction of the lower legal Nostrum and
limit from 50 to 20 mg% in 1990
Laurell (1997)
(continue)
Reduction of the lower limit to 20 mg%
resulted in significant reductions in all
collisions and fatality measures.
Significant reductions in drivers with low
BACs and with high BACs involved in fatal
collisions.
Various measures of alcohol involvement Multiple
in collisions; BAC levels of fatally injured time series
drivers
analysis with
comparison
states
Significant reductions in police-reported
alcohol fatalities; no other significant effects
observed.
Significant reductions in proportion of
collisions involving a driver with a BAC
of 80 mg% or higher, but the magnitude
varies depending on which states are
used as comparisons.
United States, reduction of limit to 80 Foss et al. (1999)
mg% in North Carolina in 1993
Pre-post
comparisons,
with matched
control states
Pre-post
Significant reductions (16%) in proportion
comparisons, of collisions involving a driver with a BAC of
with matched 80 mg% or higher.
control states
Fatal collisions involving alcohol
Design/
analysis
United States, reduction of limit to Hingson et al.
80 mg% in five states between 1983 (1996)
and 1991
Measures
Fatal collisions involving alcohol (six Pre-post
measures)
comparisons
Author
United States, reduction of limit to Johnson and Fell
80 mg% in five states between 1983 (1995)
and 1990
Location
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
(Source: Mann et. al. 2001)
Proportion of injury and fatal collisions
classed as DUI
Denmark, reduction of the legal limit Bernhoft (2000)
from 80 to 50 mg% in 1998
Pre-post
comparisons
Numbers of fatalities involving a Pre-post
drinking-driver in Haute-Savoie
comparisons
Design/
analysis
France, reduction of the legal limit Mercier-Guyon
from 80 to 50 mg% in 1996
(1998)
Measures
Numbers of fatal collisions and severe Time series
injury collisions
analysis
Author
Sweden, reduction of the upper legal Borchos (2000)
limit from 150 to 100 mg% in 1994
Location
Reduction of the limit to 50 mg% was
associated with a decline in the proportion
of injury collisions and an increase in the
proportion of fatal collisions classed as DUI;
no analysis reported.
Reduction of the limit to 50 mg% was
associated with a decline in the numbers
of fatalities involving a drinking-driver;
no analysis reported.
Reduction of the upper limit to 100 mg%
resulted in significant reductions in fatal
collisions; the impact on severe injury
collisions was similar but more variable.
Impact
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
39
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
5.0 Conclusion
This study shows alarming results of driving under the influence
of alcohol and drugs among fatally injured drivers. Alcohol use
detected among fatally injured drivers was 23.3% followed
by drugs (11%). These findings reflect the under reporting of
alcohol and drug use among drivers involved in fatal crashes
as reported by police-based data system. It is also important to
note that a significant proportion of fatally injured drivers (17%)
was under the influence of alcohol below the BAC legal limit
stipulated in the law. This may indicate that the current BAC legal
limit of 0.08 g/100ml is no longer suitable in preventing road
traffic death related to alcohol use and should be reviewed in
line with the available scientific evidence, as recommended by
the World Health Organization. As reported in the World Report
on Road Traffic Injury Prevention (2004), the following BAC limit
is recommended for all countries;
• Upper limits of 0.05 g/dl for the general driving population and;
• 0.02 g/dl for young drivers and motorcycle riders.
Under the existing law, efforts in preventing deaths related to
substance use should be strengthened and targeted on specific
days (Saturday, Wednesday, Tuesday, Sunday), and time (midnight
till dawn), which are recorded to have the highest incidence of
substance use. High suspicion of driving under the influence of
substance use should be given on middle age and young drivers
that drive alone. It is also interesting to note that beside illicit
drugs, driving under the influence of medicinal drugs especially
the benzodiazepines group (commonly known as sleeping pills)
is relatively high (6.9%). This is very important because the drivers
taking this group of drugs could not be easily identified and
fined under the road transport act. Therefore, it is vital to ensure
that the medical practitioners take special precautions when
prescribing benzodiazepines to their patients. This includes
40
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
advising patients to avoid driving especially during the early
phase of dosing. When appropriate with patient conditions,
short-acting benzodiazepines should be used instead of longacting benzodiazepines.
41
Alcohol and Drug Use Among Fatally Injured Drivers in Urban Area of Kuala Lumpur
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Research Report
Alcohol and Drug Use Among
Fatally Injured Drivers in Urban Area
of Kuala Lumpur
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