7.3 Education Regarding Medications

Overall Effectiveness Concerns: This countermeasure has only been examined in a few studies. Although some of the studies report increased awareness by pharmacists of the effects of medication, there is no evidence of increased awareness among drivers. Overall, there are insufficient evaluation data available to conclude that the countermeasure is effective.

Some medications prescribed by doctors can pose a risk for drivers. Prescription or OTC medication use was found in about 13.0% (daytime) and 9.4% (nighttime) of all drivers in a nationally representative roadside survey conducted in 2013 and 2014 (Kelley-Baker et al., 2017). It is important that physicians, pharmacists, and patients receive information about the potential risk of motor vehicle crashes associated with certain medications. Medscape offers continuing medical education on medication-related driving impairments. NHTSA and the American Geriatrics Society provide guidance for clinicians on counseling patients, particularly older adults, on the potential for medication-related driving impairments. The report lists common impairing classes of medication and their symptoms (see section 13 of Chapter 9 in AGS & Pomidor, 2016). Clinicians are recommended to select non-impairing alternative medication (if possible) and to consider the patients’ medication regime (e.g., other drugs, substances) to avoid drug-additive driving impairment effects (AGS & Pomidor, 2016). The AAA Foundation provides a free online tool that patients can use to check which of their medications may potentially impair driving (www.roadwiserx.com).

The International Council on Alcohol, Drugs, and Traffic Safety has developed a categorization system for medicinal drugs that can affect driving performance (Alvarez et al., 2007). The list was intended for physicians and pharmacists, so they could better identify medications that could impair driving skills and look for safer alternatives when possible. In 2008 and 2009 NHTSA convened an expert panel to develop a list of medications or classes of medications that may be “safe” for driving; however, the panel found inadequate information about specific medications to develop such a list (Kay & Logan, 2011). The FDA published guidance for evaluating the effects of psychoactive drugs on drivers’ ability to operate motor vehicles, Evaluating Drug Effects on the Ability to Operate a Motor Vehicle: Guidance for Industry (82 Fed. Reg. 52052, November 9, 2017). The FDA recommends a tiered approach consisting of pharmacology/toxicology testing, epidemiology, and standardized behavioral/clinical assessments of functional driving ability (e.g., executive functions, psychomotor performance). The FDA also recommends the inclusion of driving impairment effects in the product labeling.

The effects of medications on driving are a particular concern with older drivers. Nearly 70% of people 55 and older each use at least one prescription medication that could potentially impair driving (MacLennan et al., 2009). In addition, research shows that older drivers taking three or more impairing medications are 87% more likely to be involved in crashes (LeRoy & Morse, 2008). For reviews on medications and road safety, see De Gier (2006), Vandrevala et al. (2010), and Smith et al. (2018).

The AAA Foundation for Traffic Safety conducted a study of countermeasures for driving impairments due to prescription and OTC drugs (Smith et al., 2018). The study included literature reviews, panel and individual interviews with experts, and reviews of existing data. The author summary noted that patient counseling, prescription labeling, placing impairing OTC drugs behind the pharmacy counter, and implementation of new technologies such as electronic pharmacy prompts show promise in preventing impaired driving. Other recommendations included the push for States and localities to develop their own material targeting education around specific medications or populations (see Colorado DOT’s campaign material at www.codot.gov/safety/alcohol-and-impaired-driving/druggeddriving/assets/2016-campaign-materials/dui-poster-espanol.pdf). Challenges to implementation of these measures included the lack of deterministic research on drug-specific driving impairments and sparse availability of patient counseling time across healthcare units.

Use and Effectiveness: There is little information available on how frequently this countermeasure is used in the United States, or how effective it has been in raising awareness, increasing knowledge, or changing behavior. NHTSA worked with Walgreens, the country's largest drugstore chain, to develop a curriculum for pharmacists on medication-impaired driving. The curriculum modules covered potentially driver-impairing prescription drugs, laws relating to medication use and DWI, and the role of pharmacists in counseling patients regarding medications and driving risk. A pilot test with 640 pharmacists showed that the curriculum was effective in increasing pharmacists’ knowledge of medication-related impaired driving (Lococo & Tyree, 2007). The complete curriculum has not yet been evaluated.

Legrand et al. (2012) tested several methods of training and administering the DRUID[1] system with pharmacists in Belgium. Following training, more pharmacists reported being aware of the effects of medications on driving, and more pharmacists talked with their patients about driving-related risks. The results were strongest among pharmacists who had the DRUID system integrated into their existing computer software for dispensing medications.

Studies with patients have been less encouraging. Smyth et al. (2013) conducted interviews with patients who were using medications that could influence their driving. Half (49%) did not recall seeing the warning label on the medication. Instead, there was a high level of confidence among patients that they could determine themselves whether it was safe to drive. Monteiro et al. (2013) investigated the effectiveness of pictograms in communicating the degree of driving risk associated with certain medications. It was apparent that many patients failed to fully understand what was being conveyed by pictograms, and often misjudged how risky it would be to drive while taking the medication. Smith et al. (2018) also arrived at similar findings from expert interviews, including the insight that many Americans do not associate the warning to “not operate heavy machinery” to driving their vehicles. The experts in their study suggested adding visual indicators such as changes to the color of the driving-specific warning label, color of the prescription bottle, and increasing the minimum font size to accommodate older drivers.

Part of the 2013-2014 National Roadside Survey of Alcohol and Drug Use surveyed drivers and collected data on prescription drug use. Questions on the frequency of use of potentially impairing prescription drugs, types of medication warnings, and perceptions of risk were included in the survey. Of the 7,405 drivers who completed the survey, 19.7% reported taking at least one potentially impairing drug in the past 2 days, and of these, 78.2% reported that the drug was prescribed for use. Sedatives (8.0%), antidepressants (7.7%), and narcotics (7.5%) were the most commonly prescribed drugs, followed by stimulants (3.9%). Most of the drivers taking sedatives (85.8%) and narcotics (85.1%) reported receiving warnings from their health care provider or the medication label; however, fewer people reported the same for antidepressants (62.6%) and stimulants (57.7%). Drivers perceived sleep aids, morphine/codeine, amphetamines, and relaxants as most likely to affect safe driving, whereas, ADHD medications were perceived least likely to affect safety. These results provide direction on specific medications and patient populations that may be chosen to receive increased education from healthcare providers (and warning labels) (Pollini et al., 2017).

Costs: Targeted education to physicians and pharmacists through drug categorization systems and to drivers through warning labels would be needed. The former would likely be costlier.

Time to implement: Targeted communications could require a year or more to plan, produce, and distribute.

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