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lnternational Medical Journal Vol. 23, No. 2, pp. 192 - 194, April 2016
EMERGENCY MEDICINE
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Traumatic Motor Vehicle Accidents of Malaysia: Implications of Illicit Drugs Use Nasir Mohamad 1>, Maslina Muhammad2>, Mainul Haque 1>, Zaid Kadhum Jaw�d2>, NorHidayah Binti Abu Bakar3>, Salwani Ismai11 >, Nordin Simbak 1> ABSTRACT Objectives: Driving under illicit drugs is one of the 1rnblic health problems. It may raise the probability of car accidents worldwide. Therefore, this study is conducted to recognize the prevalence of drug users and the factors influence the severity of injury in motor vehicle accidents (MVA). Design: Prospective cohort study. Materials and Method: The urine test was performed to detect the presence of drugs. The Injury Severity Score (ISS) system was applied to measure the severity of injury in patients. Results: The findings revealed that out of 92 patients, 38% of patients were drug users. Cannabis was the most frequently detected drug representing 49%. The multiple logistic analysis revealed that age (P = 0.039) and safety precaution (P < 0 .001) were determined as a significant factors associated with the severity of injury among patients. Conclusions: Forbidden drug users were prevalent among drivers in Malaysian population. Age and safety factors might give implication to severity of accident.
KEY WORDS illicit drugs, motor vehicle accidents, severity of injury
INTRODUCTION In this day and age, an increasing number of illicit drugs use among drivers lead to focus on research of driving under psychoactive sub stances worldwide. The most common found drugs were cannabis, amphetamines, benzodiazepines and opioids (Holmgren et al., 2005). The effects of these illegal drugs include sleepiness, drowsiness, disori entation and sedation (EMCDDA, 2013). Thus, this result in decreasing of car handling performance subsequently may expand the probability of motor vehicle accidents (MVA). It was noted that 5-25% of crash victims were positive for drugs particularly cannabis (Kelly et al., 2004). It is reported that prohibited drug users are 1-5% among car drivers of some European countries. But the figure in those countries is much higher 5-15% among car drivers with legitimate drug users (EMCDDA, 1997). Malaysian Institute Road of Safety revealed that 11 % of fatal drivers were positive for drugs (Mohamed et al., 2012). It was suggested that various factors increase the chances of being involved in a traffic crash. There are attitude, safety, vehicle as well as environmental factors. Several studies indicate that safety factors such as unused of seat belt, helmet and the poor road condition shown associ ation with fatality in MVA (Shibata and Fukuda, 1994; Boufousa et al., 2008). Therefore, the main focus is to recognize the prevalence of illegiti mate drugs use among traumatic patients in Malaysian population.
Research also tried to identify the several factors influence in severity of injury. The information was important to set up the strategies and imple mentation for our road safety as well as for developing effective preven tive measure targeted to drug driving particularly on preventive policies.
METHODOLOGY
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The study was a prospective cohort study conducted from I" November 2011 until 31" October 2012 conducted at the Emergency Department, Hospital Universiti Sains Malaysia (HUSM), Kelantan, Malaysia. The protocols in the study were approved by ethical commit tee;- Universiti Sains Malaysia (USMKK/PPP/JEPeM [242.3. (8)]. The source populations were patients admitted to Emergency Department, HUSM. All the study subjects were above the age of 12 years. The study subjects fulfil the inclusion criteria to be enrolled in this study. The patients who have any chronic disease that need drug usage were excluded from this study. Baseline characteristics of the study subjects were inquired. All selected patients underwent urine drug test using the F.A.C.T.S Drug of Abuse Test. It is a rapid, screening test for simultaneous, qualitative detection of multiple drugs and drug metabolites in human urine. This urine test for drug is specific for detecting the presence of cannabis, amphetamine, morphine and benzodiazepine. This test was conducted as 3"' party so the result will not be known to the researcher until the end of
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Received on February I 0, 2014 and accepted on March 25, 2015 I) Faculty of Medicine and Health Science, Universiti Sultan Zainal Abidin Kampus Kota, Jalan Sultan Mahmud, 20400 Kuala Tercngganu, Terengganu, Malaysia 2) Department of Emergency Medicine, Hospital Universiti Sains Malaysia 16150 Kubang Kerian, Kelantan, Malaysia 3) Department of Pathology, Hospital Sultanah Zainab II 15860 Kola Bharu, Kelantan, Malaysia Correspondence to: Nasir Mohamad (e-mail:
[email protected])
© 2016
Japan Health Sciences University & Japan International Cultural Exchange Foundation
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data collection. The injuries were initially assessed and graded using the Abbreviated Injury Scale (AJS), followed by Injury Severity Scale (SIS). . All the data were analyzed using Statistical Package for Social Sciences (SPSS) Software version 20.0. Numerical variables were checked for normality and presented as mean and standard deviation or median and interquartile range (lqR) where appropriate. The results of simple logistic regression, independent variables that have p value less than 0.25 or clinically important will be included. Meanwhile for the multiple logistic regressions, independent variables that have p value less than 0.05 will be included at 95% confidence interval.
RESULTS There were 92 patients enrolled in the study. Overall, the prevalence of drug user among injured patients was 38%. Cannabis stood first and the highest detected drug with 49% in our study population. Most of drug users were single drug use (32%). Genderwise, males were preva lent (87%) in the traumatic vehicle accidents than females (13%). The mean age of the selected patients was 24 years. Thirty four percentages of drug users sustained injury severity scores less than 16 whereas 4% show score 16 and above. The distribu tions of baseline characteristics were dideded in two groups. Group I: drug user and Group II: non-drug user were summarized in Table I. Table 2 represent result of multiple logistic regressions on several factors associate with severity of injury. Adjusting for other cofounders, age (P value = 0.039) and using seat belt or helmet (either use or not use) (P value < 0.00 l ) were determined as the significant factor that influence the severity of injury among injured patients.
DISCUSSION Drug abuse was considered a serious social burden in Malaysia. Malaysian Institute Road of Safety Research demonstrated a high inci-
dence of driving under the influence of alcohol and drugs among fatally injured drivers. The government of Malaysia to overcome this problem atic issue has implemented various strategies with the aim to achieve a drug free society by 2015. Despite the enforcement of rigorous drug policy, the number of illicit drug users is however still worryingly increasing. In recent year, driving under the influence of illicit drugs is becoming a potential threat to road traffic safety. Also, current research found that cannabis is the most common psy choactive substance use (49%). Among the driver that show similar finding with several studies done before (Kelly el al., 2009; Lillsunde el al., 1996; Legrand et al., 20 I 3). However, researchers also reveal that the prevalence of drivers tested positive for cannabis is only between 0.3% and 7.4% in Denmark, Netherlands, Norway, United Kingdom (EMCDDA, 1999). Combinations of psychoactive substances are asso ciated with variable health risks to the person. It depends not only to the pharmacological properties and amounts of the substances used but also on the individual characteristics. Drivers who were using multiple drugs or drug combined with alcohol were considered to have a high risk for traffic crash due to dangerous driving. The prevalence of multiple drugs use is higher among young people were reported across the Europe reported. It is predominant among young male clubbers (Legrand et al., 2013). Males have been found to be over represented among illic;it drug users and more likely to engage in risky driving behaviour (Jonah, 1990). Present study demonstrate that male (85.7%) were predominant than women (14.3%) in drug-related accidents. This finding was consis tent with majority of studies which revealed male are more likely to have positive urine test (Carmen el al., 2002; Walsh et al., 2005). Male were found to be frequently involved with risky driving. Those who are consumed alcohol and cannabis were in adolescence group (Fergusson et al., 2003). There is known association of younger age at driving and the ten dency for increased driving risk. Young drivers had a greater risk for being involved in traffic crash. It is because of limited driving experi ence and unsafe driving practices compared to older people (Blows el al., 2005). This fact is corroborated by current study that demonstrated that those who involved in traffic crash were among young people. It also reported that the psychoactive medicinal drugs were more frequent ly found in older drivers while illicit drugs were found more in younger drivers (Gjerde et al., 2008). Differences in the age and gender of drug affected drivers have implications for the responsible authorities to develop suitable counter measures to reduce the prevalence of driving under illicit drugs use. . . Young driver with age of 17-29, also report�d to have twice likely of traffic crash when compared to those older driver age over 50 years old. Meanwhile male driver were also reported twice likely to be involved in traffic crash compared to female (Turner and McClure, 2003). Also, another study found that there were an association ?f a�e with the severity of injury (Abdel-Aty el al., l 998). The older driver ts more likely to be involved in fatal crash while middle age group more likely to be involved in some crash. A seat belt is a safety device that is designed to secure the occupant of a vehicle against harmful movement that may occur during a traffic crash or a sudden stop. It is very effective safety measure in reducing the number of accident injuries and can also minim.ize the extent of inju ries (Evans, 1996; Koushki et al., 1996). It also noted that unbelted elderly drivers also showed to have higher morbidity and mortality with high incidence of head injury and chest injury. The overall risk of injury also reduced for those using seat belt alone or combined with airbag with a relative risk, 0.42 and 0.71, respectively (McGwin el al., 2003).
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Traumatic Motor Vehicle Accidents and Implications of lllicit Drugs Use
Improper usage of seat belt can also cause serious abdominal injuries. Even though, seat belt is one of the safety measures in reducing the fatality in traffic crash, the usage of seat belt is still underuse. In Malaysia seat belt law is reinforced in early seventies. Since that, the number of car driver using seat belt is believed been increased with the campaign and awareness by the responsible authorities. Crash helmet or safety helmet is compulsory and mandatory by law to use while driving motorcycle in Malaysia. A good helmet should be with full face helmet as it has a protection for maxillofacial injury. A brief overview on the helmet use and its legislative process revealed that helmet can reduce the fatality (Kelly et al., 1 99 1 ; Brown et al., 2009). Pattern of injuries for occupant whether using helmet or not using hel met are varies. Cervical neck trauma is thought to be the most devastat ing injury to those not using helmet. Using helmet reduce the like hood of head injury and neck injury (Keng, 2005). The lower extremities in the other hand are the commonest site for injuries despite all the head chest and abdominal injuries that causing death to the occupant of motorcyclist (Bachulis et al., 1 988). In fact, a safety helmet is the best equipment to prevent and reduce morbidity and mortality (Rowland et al., 1 996).
Brown CV. Hejl K. Bui E. Tips G. Coopwood 13. (2009). Risk factors for riding and crash ing a motorcycle unhelmetcd. J Emcrg Med. 41(4). 441-6. /111p://dx.doi.org!IO. /0/6/ j.jemermed. 2009. 07. 024
Carmen del Rio M. Gomez J. Sancho M, Alvarez FJ. (2002). Alcohol, illicit drugs and medicinal drugs in fatally injured drivers in Spain between 1991 and 2000. Forensic Sci Int. 127(1), 63-70. PMID: 12098527 European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), 28 May 2013. EMCDDA drug profiles (Accessed December 26. 2013. at lr11p:/!www.e111cdda.europa. e1,lp11blicatio11sldr11g-profiles)
European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). ( 1997). Methodological Pilot Study of Local Level Prevalence Estimates. Lisbon, EMCDDA, 49-69. European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). (1 999). Literature review on the relation between drug use. impaired driving and traffic accidents (CT.97.EP. 14). Lisbon. EMCDDA. February 1999. Evans L. ( t 996). Safcty:belt effectiveness: The inlluence of crash sc:vcrity and selective recruitment. Accid Anal Prev. 28(4). 423-33. lrttp:lldx.doi.org//0. 1016/000J4575(96)00006-J
CONCLUSION
Fergusson D. Swain-Campbell N. Horwood J. (2003). Risky driving behaviour in young people: prevalence. personal characteristics and lraffic accidents. Aust N Z J Public Health. 27(3), 337-42. lrttp:l!dx. doi.org/10. Ill1/j. 1467-842X.2003.tb00404.x Gjerde H. Normann PT. Pettersen BS. et a/.(2008). Prevalence of alcohol and drugs among Norwegian motor vehicle drivers: a roadside survey. Accid Anal Prev. 40(5), 1765-72.
Finally in conclusion, illegitimate drugs use was prevalent among drivers in our population. Moreover, age and safety precaution imple ments such as helmet and seatbelt were determined as influence factors contribute to traumatic vehicle accidents. Therefore, these findings may give an idea to the relevant organizations to modify the safety measures to reduce the occurrence of severe traffic accident in our country. Hence, well designed prospective and systematic follow up studies on drug abuse and driving will help to monitor the problem and better esti mate the extent of it. Therefore, the people of Malaysia and also rest of the world will be benefitted from the cruse of drug abuse and motor vehicle accident related disability.
Holmgren P. Holmgren A. Ahlner J. (2005). Alcohol and drugs in drivers fatally injured in tramc accidents in Sweden during the years 2000 002. Forensic Sci Int. 151(1). 1 1-7. lrttp:!ldx.doi.orglI 0. IO16/jforsciint. 2004. 06. 03 I Jonah BA. (1990). Age differences in risky driving. Health Educ Res. 5(2), 1 39-49. http:!! dx. doi.01g!I0. I093/her/5. 2. I39 Kelly E, Darke S, Ross J. (2004). A review of drug use and driving: epidemiology. impair ment. risk factors and risk perceptions. Drug Alcohol Rev, 23(3), 3 1 9-44. lrttp:!!d.,.doi. org/10. /080/095952304I233 I289482 Kelly P, Sanson T. Strange G, Orsay E. (1991). A prospective study of the impact of helmet usage on motorcycle trauma. Ann Emerg Med. 20(8). 852-6. /111p:!ldx.doi.org!IO. 10161 SOI96-06U(05)8/ 426-X Kcng SH. (2005). Helrnet use and motorcycle fatalities in "faiwan. Accid Anal Prev. 37(2).
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349-55. /111p:lldx.doi.orgl/O. 1016/j.aap.2004.09.006
ACKNOWLEDGEMENT We thank Universiti Sains Malaysia for funding this research via Research University Grant (304/PPSP/613 1 208). Authors are much grateful to those patients who participate in the study and also to the hospital authority. Authors are much grateful to Dr Md. Zakirul Islam, Associate Professor, Eastern Medical College, Comilla, Bangladesh for correcting the reference section.
Koushki PA, Vassen Ali S, Al-Saleh 01. (1996). Safety-belt law in Kuwait: Observed and reported compliance and impacts on road safety. Transportation Research Record: Journal of the Transportation Research Board. 1560( I), 1 3 - 1 7 . /rrtp:lldx.doi. org!IO. 3I 4III560-03 Legrand SA. ls�lberti C, dcr Linden TV, et al. (2013). Alcohol and drugs in seriously injured drivers in six European countries. Drug Test Anal, 5(3). 156-65. /111p:/ldx.doi. org/10. 1002/dta. /393
Lillsunde I', Korte T, Michelson L, et al. (1996). Drugs usage of drivers suspected of driv ing under the influence of alcohol and/or drugs. A study of one week's samples in
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