Patterns o f Drug Abuse and Their Relationship to Traffic AccidentsB. M. K a p u r1

Most drugs seen in cases presented in the emergency rooms of hospitals and those that are involved in traffic accidents are very similar. Apart from alcohol, most of these drugs originate as “over the counter” and prescription drugs. There are very few reports in the literature (1-4) on actual screening of body fluids on non-fatal cases, and a few (5, 7 ,9 ) where a questionnaire type of survey has been done.

Drug screening on a wider scale is now becoming available in most of the hos­pitals in large metropolitan centres. Some findings concerning cases seen in the emer­gency rooms of hospitals will be reviewed here and compared with the few published reports in the literature.

In 1962 Wagner (9) questioned 2,060 persons who were under the influence of alcohol and were involved in traffic accidents. He showed that 11% used one or more drugs. A variety of drugs such as gastrointestinal, sedatives, drugs with metabolic effects, spasmolytics, antibiotics, hypnotics, were found. At that time he concluded that a series of investigations should be performed, especially on individuals who were not showing the presence of alcohol.

A number of other such surveys appeared in the German literature (5, 7) in the 1960s. Gupta (4) carried out a ten year survey on barbiturate and other sedative tranquilizers in Ontario, and showed an increase in barbiturates and tranquilizer usage in traffic accidents.

It was in 1968 that Finkle et al. (2) did both a questionnaire and a chemical analysis on body fluids of people involved in traffic accidents. They showed that 705 (21%) of the 3,409 drinking drivers had engaged in some concurrent drug usage. The largest categories of drugs were tranquilizers (19.3%), analgesics and antipyretics (15.7%), sedatives and hypnotics (7.5%) and analgesic narcotics (3.8%). Therefore, these categories make up 46.3% of the sample of 705. However, in all, at least 107 different types of drugs were named.

They only performed analyses for drugs other than alcohol on those who showed signs of intoxication but had a blood alcohol concentration of less than 150 mg/100 ml. Out of the 180 cases in this group, 38 (21%) showed the presence of drugs. The categories were: sedative hypnotics 67%, tranquilizers 16%, analgesics 10%. Sedative hypnotics, tranquilizers and analgesics are the recurring names in the different categories reported.1 Addiction Research Foundation, 33 Russell Street, Toronto, Ontario, Canada M5S 2S1.

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The Clinical Laboratory of the Addiction Research Foundation has been ana­lysing body fluids of patients suspected of drug involvement, for the past few years. Samples have been coming to us from the emergency rooms of all the University of Toronto’s teaching hospitals and many other hospitals in Ontario. In all cases, unless otherwise specifically requested, a comprehensive drug screening is done. This includes the drugs listed in Table 1, and a screening of any other drug, if requested, is at­tempted. Techniques used here are Thin Layer Chromatography, Gas Liquid Chrom­atography and Colourimetric.

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TABLE I Drugs Screened Routinely

Amphetamine Isopropyl AlcoholAmitriptyline Methyl AlcoholBarbiturates: GlutethimideAmobarb MethyprylonSecobarb MeprobamateButabarb MethamphetaminePentobarb PhenothiazinePhenobarb PerphenazineBarbital Phencycledine (PCP)Bromides PropoxypheneCodeine QuinineChlorpromazine Ethyl Alcohol Salicylates

TABLE II Emergency Analyses for DrugsPattern of Drugs detected

(October 1972 - June 1973)Barbiturates:

Single Barbiturate 159Barbiturate Combination 132Barbiturates + Ethanol 58Barbiturates + Other Drugs 22Total, alone or in combination 371 371 (39.5%)

Other Sedative-Hypnoticsa ................................................................................ 91 ( 9.7%)Ethanolb ................................................................................................................ 324 (34.5%)Salicylates............................................................................................................. 5 1 ( 5.4%)Salicylates + E th an o l........................................................................................... 1 2 ( 1.2%)Opiates or A m phetam ine.................................................................................. 1 8 ( 1.9%)Phenothiazines..................................................................................................... 1 9 ( 2.0%)Isopropanol........................................................................................................... 9 ( 0.9%)Other Drug Combinations0 ................................................................................ 43 ( 4.6%)TOTAL .......................................................................................................... 938aSedatives and hypnotics collectively alone or in combination = 487 (51.9%)“Ethanol in combination with other drugs = 4 1 9 (44.6%)cOf the 43 “other drug combinations” 25 were sedatives with ethanol

Drug Abuse and Traffic Accidents 71TABLE III Drugs Suspected and Found in 722 Patient Samples

(November 1973 - June 1974)

Drug Suspected Found Percentage

Number of patients not suspected but positive on screening

% of total number of positives seen in the laboratory

Barbiturate and Non-Barbiturate Sedative Hypnotics

Barbiturates3 215 132 61.3 54 29.0Methyprylon 34 32 94.1 30 48.3Methaqualone 30 25 83.3 8 24.2Meprobamate 5 4 80 4 50Glutethimide 9 8 89 4 33.3Ethchlorvynol 8 3 37 2 40

Salicylates and AlcoholSalicylates 80 40 50 25 38.4Alcohol 181 130 71.8 6 8 34.3

Other CompoundsOpiates'3 24 8 33.3 1 0 55.5Phenothiazines 35 1 2 34.2 6 33.3Amphetamine 1 2 0 0 4 1 0 0Darvon 4 2 50 1 33Amitriptyline 19 9 47.3 1 1 0P.C.P. 5 2 33 1 33Demerol 2 2 1 0 0 0 0

aAmobarbital •’MorphinePhenobarbital CodeineSecobarbital MethadoneBarbital Butabarbital Pentobarbital

Over the 9 month period from October 1972 to June 1973, we did a 1,560 case study of which 938 (60.1%) were positive for one or more drugs, including ethanol. Table II shows the patterns of drugs detected in the 938 cases.

A questionnaire type survey (6 ) has already been shown to be very conservative in that few of the drugs used are reported. Information accompanying the potential overdose case, although helpful, is not sufficient. In trying to find out which drugs must be screened for, and how much one can rely on the information presented to the examining physician, a correlation of drugs suspected to drugs found, was made. This was carried out on patients presented in the emergency room between November 1973 and June 1974. The suspicion of the physician is based on, (a) presenting symptoms,(b) information supplied to the physician, through a friend or the patient himself, and(c) drugs found on the body of the patient. Table III shows these results.

The suspicion proved to be correct for barbiturates 61% of the time. However, 29% of the total positive cases were missed. Methyprylon, a sedative hypnotic, ap­peared very high on the suspicion list. However, 48% of the total positives were missed. Approximately 37% of the sedative hypnotic compounds were missed. The

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same holds true for ethanol. Therefore screening for one drug or another on individual patients can easily be ruled out, and a comprehensive drug screening must be per­formed on every person. The same conclusion applies in the case of traffic accidents.

CONCLUSIONThe patterns of drugs seen in the emergency rooms are very similar to those seen in the drinking driver cases. Although not many reports are available, preliminary work (8 ) has just appeared in the literature. A very large number of cases with drug involvement are seen in hospital emergency rooms. By monitoring the overdose scene in the local hospital, a minimum comprehensive list of drugs could be drawn up. This would not only help towards a more thorough investigation, but would also save time so that the special ‘tough cases’ can be done by the more sophisticated instrumentation, e.g. Gas Chromatography/Mass Spectrometry/Computer.

REFERENCES1. Allgen, L-G., Bejerot, N., Bergsman, A., Hellstrom, L. and Sandberg, A., Alcohol and Drugsin the Blood and Urine o f 142 Persons Suspected o f Driving while Intoxicated, Ldkartidnin-

gen 70, 1169 ,(1973).2. Finkle, B. S., Biasotti, A. A. and Bradford, L. W., The Occurrence o f Some Drugs and ToxicAgents Encountered in Drinking Driver Investigations. Journal o f Forensic Sciences 13, 236 (1968).3. Finkle, B. S., Drugs in Drinking Drivers: A Study o f 2,500 Cases. Journal o f Safety Research

1, 179 (1969).4. Gupta, R. C., and Kofoed, J. Toxicological Statistics for Barbiturates, Other Sedatives, and Tranquilizers in Ontario: A 10-Year Survey. Canadian Medical Association Journal 94, 863

(1966).5. Kessler, A. The Combined Influence o f Drugs and A lcohol Threshold Concentrations on Traffic Safety, Based on the Survey o f 2 ,500 Cases. Dissertation, Medical Faculty o f the

University o f Mainz, West Germany, 1963.6. Kilbrick, E., and Smart, R. G., Psychotropic Drug Use and Driving Risk: A Review and

Analysis. Journal o f Safety Research 212, 73 (1970).7. Romeyke, C., Alcohol and Drugs: Statistical Investigations on Incidence and Effect with

Reference to Forensic Medical Blood A lcohol Tests. Dissertation, Medical Faculty of Christian-Albrechts University, Kiel, West Germany.

8. Turk, R. F., McBay, A. J. and Hudson, P., Drug Involvement in Automobile Driver and Pedestrian Fatalities. Journal o f Forensic Sciences 19, 90 (1974).

9. Wagner, H-J., Die Bedeutung der Untersuchung von Blut- bzw. Harnproben auf Arzneimittel nach Verkehrsunfallen auf Grund der Uberpriifung von 2060 Personen. Arzneimit- telforschong 11 992 (1962).