Abstract
Drug misuse is common in the UK; inevitably, general practitioners treat patients who misuse drugs. Drug misuse and dependence can seriously impair driving ability. Driving while impaired by drug use poses a risk of criminal prosecution, as well as a risk of death or injury to the driver, their passengers and others. As doctors we have a duty of care to our patients and we are generally bound by confidentiality. However, we also have a wider duty of care to protect the general public from serious harm. This article looks at UK law alongside guidance from the General Medical Council and Driver and Vehicle Licensing Agency to guide medical practice around this difficult area.
Clinical case scenario
Gary, 38 years old, normally consults with one of your colleagues who is away this week. Gary comes to you wanting some pregabalin for his sciatica. On delving into his social history, you find out that Gary lives with his girlfriend in a council flat only a mile away from the surgery. Gary is prescribed 60 mg methadone daily by the local drug service and he smokes heroin three times per week, with some occasional crack cocaine use on weekends. Gary is pleased to be using fewer drugs than he used to and is now back at work as a joiner. He mentions it has been a bad week for him as he had a flat tyre when driving to work in his van. You have enough on your plate trying to deal with his request for pregabalin. What do you say about his driving?
Background
Drug misuse is common in UK. The independent government review by Dame Carol Black into UK drug use revealed the true extent of the nation’s drug problem, with an estimated 3 000 000 users of illicit drugs, of which 300 000 are users of opiates and crack cocaine (Black, 2021). Black put the total cost of drug driving (separate from drink driving) to the British economy as £374 000 000 (Black, 2020). In 2019, 12 391 people were convicted of a drug driving offence (Webster, 2021). Surprisingly, the Office for National Statistics (2021) claims there are no figures on the number of deaths due to drug driving in the UK.
Alcohol is the most well-known substance that impairs driving ability. The dangers of ‘drink driving’ are well embedded in the public consciousness, through years of television advertisements. These repeated national campaigns have sought to tackle the human and financial costs of driving under the influence of alcohol, and have changed our culture regarding the acceptability of such practices. In comparison, drug driving has taken the back seat. The role of the doctor when it comes to drink driving has been well discussed elsewhere (Seddon, 2015), whereas drug driving remains a topic that is rarely discussed. With more drivers than ever on our nation’s roads, as doctors we have both a moral and professional duty to know how to broach these issues with our patients.
What does the law say?
The Road Traffic Act 1988 made it an offence to drive dangerously under the influence of drugs in England, Scotland, and Wales. In this original legislation there were no specific legal limits for particular drugs. Rather, drivers were guilty if:
A drug was proven to be present in their body They were impaired in their driving Their impaired driving was indeed due to the drug in question
This law was not very objective and did not lead to many convictions. This law remains in place, but subsequent amendments in 2015 for England and Wales (The Drug Driving (Specified Limits) (England and Wales) (Amendment) Regulations, 2015) and in 2019 for Scotland (The Drug Driving (Specified Limits) (Scotland) Regulations, 2019) have introduced specific legal limits for certain drugs, much akin to drink driving legislation. For drugs without these specific limits, drivers may still be convicted under the older legislation if all three points can be proven beyond reasonable doubt. For drivers in Northern Ireland there are still no specific legal limits; rather, drivers are put through a ‘Field Impairment Test’ by police (akin to the American police sobriety tests often depicted in film and television) to gauge their level of impairment.
Table of drugs and limits.
Adapted from Department for Transport (2017)
What is the role of the Driver and Vehicle Licensing Agency
The Driver and Vehicle Licensing Agency (DVLA) is the government organisation responsible for licensing drivers in Britain (with its sister agency, the Driver and Vehicle Agency (DVA) performing this role in Northern Ireland) and offers clear guidance to medical professionals on how to assess fitness to drive (DVLA, 2021). These organisations bear the ultimate legal responsibility as to whether a driver is medically fit to drive. This article will focus on the British DVLA, but principles will be very similar for doctors in Northern Ireland, since the Northern Irish DVA does not produce its own fitness-to-drive guidance for doctors.
The DVLA considers drug misuse or dependence as a medical disorder with the potential to affect fitness to drive, just as it does seizures or strokes. The DVLA advises that doctors should: advise the individual on the impact of their medical condition for safe driving ability, advise the individual on their legal requirement to notify DVLA of any relevant condition, notify DVLA directly of an individual’s medical condition or fitness to drive, where they cannot or will not notify DVLA themselves (DVLA, 2021) (Box 1).
The DVLA's expectations of doctors regarding fitness to drive.
Source: DVLA (2021)
DVLA rules on driving and substance misuse.
Source: DVLA (2021)
The DVLA allows drivers with persistent substance misuse who are established on prescribed opiate substitution therapy (OST), such as methadone or buprenorphine, to apply for relicensing provided they meet a number of specific criteria, including being stable on treatment for at least a year, under the care of a consultant/specialist GP, compliant with treatment and toxicology testing, not ‘topping-up’ their OST, not taking non-prescribed psychoactive drugs and no concurrent alcohol misuse/dependence (DVLA, 2021).
What do medical organisations say?
The General Medical Council (GMC) regulates doctors in the UK and has specific guidance on fitness to drive and reporting concerns to the DVLA or DVA. This guidance advises: doctors owe a duty of confidentiality to their patients, but they also have a wider duty to protect and promote the health of patients and the public (GMC, 2017).
The GMC is clear that the DVLA bears the ultimate responsibility of deciding who is unfit to drive; however, doctors are advised to inform patients when their medical condition(s) (substance misuse or dependence is classed by the DVLA as a condition) may render them unfit to drive. Doctors are expected to inform patients of their duty to inform the DVLA. Where patients continue to drive, then doctors are expected to persuade them to stop driving and inform the DVLA. Should this persuasive approach fail, a doctor is expected to contact the DVLA themselves if there is a risk of death or serious harm to the public. In most circumstances, the doctor should inform the patient of this disclosure of the patient’s confidential information before doing it.
Prescription medication and driving
Many patients who drive may have been legitimately prescribed drugs such as opioids and benzodiazepines by their doctor. Even when legitimately prescribed, these medications still have a potential to impair driving. If a driver is proven to be impaired in their driving due to any drugs (prescription or otherwise) they can be charged under the Road Traffic Act 1988, regardless of whether they exceed a specific legal limit. Both the Medical Defence Union (2021) and Medical Protection Society (2017) warn doctors to counsel patients that some prescribed medications may impair driving, and the GMC (2021) specifies that doctors should advise patients on ‘serious and common side effects’ of the medications we prescribe. The guidance is clear that doctors should warn patients about the risk of impairment to driving for any relevant medication and patients should be advised not to drive if impaired.
What if a patient is prescribed a drug such as codeine or diazepam, but their driving is not impaired? Whereas there are low legal driving limits set for drugs such as LSD or cocaine, the drugs which are more commonly used therapeutically have higher legal limits. The Department for Transport (2014) advises healthcare professionals that these higher limits are: generally above the normal therapeutic range so most patients are unlikely to be driving with a concentration of a specified drug in their body above the specified limit.
Nevertheless, for drivers found to be over the legal limit of any drug (whether high-limit or low-limit) there is also a ‘medical defence’ written into the amended Road Traffic Act 1988 for circumstances where:
The specified controlled drug had been prescribed or supplied for medical or dental purposes The person took the drug in accordance with any directions given by the person by whom the drug was prescribed or supplied, and with any accompanying instructions (so far as consistent with any such directions) given by the manufacturer or distributor of the drug (Box 1).
Patients who are prescribed drugs that can impair driving should be counselled on the importance of only taking their medication as prescribed and not driving if they are impaired by the medication. Patients may wish to keep a prescription with them as evidence to provide to the police in case they are stopped while driving.
What do I say to patients?
As doctors, we have a duty to the patient in front of us and are their advocate. We also have a wider duty of care to society and a role in road safety. Doctors are used to giving advice regarding driving to patients who have had seizures or transient ischaemic attacks, but advising patients with drug misuse or dependence may be less familiar territory for many doctors in primary care. These are not easy consultations and are understandably emotive, with patients’ livelihoods often being dependent on driving. Sensitivity and empathy are required while having these difficult discussions.
It is not the doctor’s duty to legally determine whether a driver is unfit to drive, as that responsibility belongs to the DVLA (or DVA in Northern Ireland) and their specialist doctors. However, we do have an obligation to tell patients their duty to stop driving and inform the DVLA if they have persistent misuse or dependence on cannabis, synthetic cannabinoids, amphetamines, MDMA, ketamine, psychoactive substances, opiates/opioids, benzodiazepines, methadone, cocaine, and methamphetamine. If the DVLA confirms the drug abuse/dependence then their licence will be refused or revoked for at least 6 months, depending on the drug involved (as seen in Table 2).
Patients stable on OST for at least a year can reapply for their licence, but are required to be stable in OST treatment supervised by a consultant/specialist GP with no evidence of topping-up their prescribed OST and no other drug use.
A study published in 2018 surveyed 246 recovering alcoholics in Alcoholics Anonymous meetings in Ayrshire, Scotland (Collier et al., 2015). Of the 246 surveyed, all had previously consumed more than 100 units of alcohol per week and all were driving at the time of the survey. None of those surveyed recalled ever receiving advice from a GP or hospital doctor regarding their driving, and none of those surveyed ever informed the DVLA. No such data are available regarding substance misuse and driving; however, it is reasonable to assume a similar problem may exist with drug driving and we need to improve our advice to patients.
Our duty is to inform patients who drive that their substance misuse or dependence may severely impair their ability to drive. Both drug intoxication and withdrawal have the potential to reduce driving ability, and this puts the driver, passengers and public at risk of serious harm or death. The driver is at risk of criminal conviction if stopped by police when driving above the legal limit for certain drugs. It is the patient’s duty to inform the DVLA. The doctor can warn the patient that they may need to inform the DVLA themselves should the patient refuse to do so, but should ask the patient for consent. If the patient is refusing to stop driving then the doctor is duty-bound to inform the DVLA (with or without consent), where there is a risk of serious harm to the public. In most instances doctors should tell the patient before reporting to the DVLA, and inform the patient of the disclosure in writing, giving the reasons for making the disclosure.
So, what does this mean for Gary? Gary’s persistent drug misuse will be impairing his driving and it is important to discuss this with him. When driving while intoxicated or with withdrawal symptoms, Gary poses a serious risk of harm or death to himself and pedestrians or other drivers. You need to tell Gary that he has a duty to stop driving and inform the DVLA so they can assess his fitness to drive. This will doubtless be an emotive issue and this will need to be raised sensitively and empathetically. If Gary says he plans to continue to drive, then you should warn him that you may be duty-bound to inform the DVLA yourself if he continues to drive.
Should Gary continue to drive, the GMC advises: If you consider that failure to disclose the information would leave individuals or society exposed to a risk so serious that it outweighs the patient’s and the public interest in maintaining confidentiality, you should disclose relevant information promptly to an appropriate person or authority (GMC, 2017).
These decisions are difficult and should be made thoughtfully and carefully. GP trainees should discuss these cases with their trainers, whereas GPs can consult colleagues for a second opinion or seek advice from their medical defence organisation. Any decision should be clearly documented in the notes. The GMC advises: before contacting the DVLA or DVA, you should try to inform the patient of your intention to disclose personal information. If the patient objects to the disclosure, you should consider any reasons they give for objecting. If you decide to contact the DVLA or DVA, you should tell your patient in writing once you have done so (DVLA, 2021).
Much akin to safeguarding discussions, these are challenging consultations. As doctors we like being advocates for our patients and to feel we are ‘on the patient’s side’, but we have to balance our duty of care to the patient with our duty of care to prevent serious harm to the general public and wider society. As with any difficult decision in medicine there is always advice available, whether anonymously from a DVLA doctor, from colleagues, or from your medical defence organisation. It is key to document in the notes what you have done and why.
KEY POINTS
The GMC is clear that our duty of care extends beyond our patients to the wider public The DVLA considers drug misuse or dependence as a medical disorder with the potential to affect fitness to drive, just as it does seizures or strokes Doctors have a duty to tell patients with drug misuse or dependence to stop driving and inform the DVLA If a patient with substance misuse/dependence persistently continues to drive against advice, then you should breach patient confidentiality and inform the DVLA yourself if the driver poses a serious risk to the public The doctor should keep clear documentation of their decisions and inform the patient in writing of a disclosure to the DVLA Clear guidelines are available from the GMC and advice can be sought from the DVLA and medical defence organisations
