When prescribing or renewing medications, should clinicians systematically counsel patients on the potential dangers of driving under their influence; of drugged driving? While considering your response to this question, bear in mind that the
“prevalence of prescribed controlled substances among drivers has been well-documented among fatally injured drivers, drivers involved in crashes, and drivers suspected of driving under the influence (DUI)”.(1)
I’ll state up front that my perspective is that of bioethics (more specifically clinical research ethics), with its 4 underlying or foundational principles:
1. Autonomy (that an individual has the right to make their own decisions, to the extent of their capacities; from this principle follows, for example, the concept of assent for those who are unable to provide consent)
2. Beneficence (that those in healthcare act in the best interest of their patients)
3. Non-maleficence (that those in healthcare follow the maxim ‘above all, do no harm’)
4. Justice (that individuals must be treated with equity and fairness; within the realm of clinical research, this could entail providing research participants with access to study product during – and possibly after – the submission, review, and approval process)
A recent bioethical study stated that:
“people state they value these ethical principles but they do not actually use them directly in the decision making process. It is possible that people do not base their decisions in ethical situations on abstract ethical principles, and that they only respond to very unique situational information… most likely that the absence of predictive power of the principles in this study is due to the absence of a behavioural model explaining how individuals cognitively use these principles in their decision making”.(2)
It might be interesting to view the question I’ve posed in terms of how much value physicians place on these bioethical principles, and how/whether they apply them in clinical practice.
So, what’s your view of the question posed above: Should clinicians systematically counsel patients on the potential dangers of driving under the influence of the medications they prescribe and/or renew?
In my view, physicians should – at the very least – recommend that each patient avoid driving until they can evaluate their response to a new medication (or to an increased dosage).
At this point, I’m fairly certain that some readers will retort that physicians already have far too little time to spend with each patient; that this type of DUI risk conversation would take time away from purely medical counselling. Let’s look at the abstract principles to which I’ve referred above.
My response to this question flows from the bioethical principles of both autonomy and beneficence. To take an example from clinical trials, informed consent is – with some specific exceptions – required for an individual to participate in research.
The concept is that a person can’t provide valid consent to participate in something that they don’t understand; there exists a duty, on the part of the principal investigator (or clinical investigator, in the US), to ensure that the potential participant understands the protocol sufficiently to make an informed decision.
In clinical research, autonomy requires that a person possess sufficient understanding of a clinical trial to make an informed decision as to their participation. Beneficence, in conjunction, requires that the interests of the individual be placed above those of the investigator. This combination sometimes requires more time than expected, however we call all (hopefully!) agree on the importance of respecting these principles.
When a patient is prescribed a medication – and takes it – they’re acting in good faith on the expert advice of their physician. Ideally, they’ll take the product as recommended. If the physician includes instructions for how to take the medication, when issuing a prescription, why not add a note for any products with the potential to cause impaired driving?
This would, ideally, trigger a similar warning to their patient from the dispensing pharmacist. Renewals of prescriptions were included in my query, as these instances would provide opportunities for clinicians to verify for any concomitant medication(s) that could create additive risk of adverse events – and the risk of unexpected and unintentional DUI for their patient.
Richard Marottoli, MD of the Yale University School of Medicine consults for the (US) Department of Transportation. He suggests that patients be counselled that a:
“good rule of thumb is to avoid driving for the first week after starting a new medication or changing the dose… It takes time to know how your body will respond”.(3)
If this suggestion is too burdensome, across all classes of medications, then it could perhaps be limited to “the potential impairing effects on driving of benzodiazepines and z-hypnotics, marijuana, central nervous system stimulants, gamma-hydroxybutyrate (GHB), hallucinogens and opioids”.(1)
The latter would be particularly important, as we know that prescriptions of narcotics for pain has “increased sixfold, from 30 million to 180 million”.(3)
A broader list of medications for which clinicians should counsel patients on driving risks has also been proposed; “sleep medications, sedatives, antidepressants, ACE inhibitors, nicotine-receptor blockers, and even OTC antihistamines and cough suppressants — any drug that can cause drowsiness, dizziness, blurred vision, slowed reflexes, impaired judgment, or similarly hazardous side effects”.(3)
I became aware of another relevant consideration for prescription medications when I took an on-line course a few years ago; “Science of Sex and Gender in Human Health”(4) is offered as a partnership between the NIH Office of Research on Women’s Health (ORWH) and the FDA Office of Women’s Health (OWH).
One of the important messages of this course was that women and men often don’t metabolize medications in the same ways, and fluctuations of hormones can also impact the effect of medications on women. A well-known example of this would be longer-lasting sedative effects in women than in men.(3)
If we can agree on the importance of the principles of patient autonomy and clinician beneficence in healthcare, can we also agree that clinicians could – at the very least – add a ‘driving risk’ note to their prescriptions for any medications known to entail a DUI risk?
References:
(1) Voas RB, DuPont RL, Shea CL, et al. Prescription drugs, drugged driving and per se laws. Injury Prevention 2013; 19: 218-221. First published 28 Sept 2012:
http://injuryprevention.bmj.com/content/19/3/218.info
(2) Page, Katie. The four principles: Can they be measured and do they predict ethical decision making? BMC Medical Ethics 2012: 13:10. 20 May 2012:
https://doi.org/10.1186/1472-6939-13-10
(3) Miller K. Are You Driving Drugged? Prevention 2012: 14 Feb 2012. Web:
https://www.prevention.com/health/healthy-living/over-counter-medications-could-make-deadly-driving
(4) The Science of Sex & Gender in Human Health: Online Course. Office of Research on Women’s Health, Office of the Director, National Institutes of Health (NIH); and The Office of Women’s Health, U.S. Food and Drug Administration (FDA). Web:
https://sexandgendercourse.od.nih.gov