Alcohol and Other Drug Abuse among Cases of Road Traffic Crashes In Port-Said General Hospitals, Egypt 2014

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Introduction
ort Said is one of the urban governorates of Egypt. It is located in the north-eastern part of the country with a distinguished location overlooking the Suez Canal and the Mediterranean Sea. Its distinguished location gave it its worldwide economic importance and placed it as a trade link. People's main activities are focused on ports services, transit trade, fishing and, recently, industrial activity. Road traffic crashes pose a significant threat to the Egyptian population. Recent estimates revealed that Egypt experiences 42 road traffic deaths per 100,000 populations, which is the highest death rate as ranked by the World Health Organization (WHO) Eastern Mediterranean Region (EMR). Despite the significance of this public health problem, very little risk factor information currently exists regarding alcohol and drugs and its prevalence among driver's cases in Road traffic crash, as well as, studies surrounding this topic are scarce (WHO, 2010) Traffic accidents represent a major public health issue and alcohol is a well-recognized risk factor for road traffic crashes (RTC) . Driving under the influence of drugs (DUID) other than alcohol is now considered to be an increasing cause of RTC worldwide(Bogstran, Gjerde , and Ekeberg ,2012).Exposure to illicit drugs impairs driving ability owing to their effects on the central nervous system, psychomotor performance, and risktaking behavior. Studies have shown the association between the use of psychoactive substances other than alcohol and increased crash risk ( Morland,2011) .
Driving under the influence of drugs happens for several reasons. Recreational drug use may be prevalent among people who drive (Honkanen et al., 2012).Drugged driving happens if the driver is a drug user also happen among professional drivers who drive long distances. Drivers who drive under the influence of drugs pose serious risk to others on the road. Although various drugs have different effects, most substances affect driving tasks, even in low dosages. Drug use also increases the probability of poor outcomes following car accidents. It has been shown that risk of death following traffic accidents increases when it is secondary to substance use ( Skolnick,2015) . Prevention of drugged driving is an essential strategy for prevention of mortalities and morbidities due to unintentional injuries. Authorities, however, cannot design evidence-based policies and programs such as continued drug use education and screening programs if they do not have access to epidemiological information. Such information is essential for the design and implementation of policies that should be enforced to reduce traffic accidents attributed to drugs ( Calaft et al .,2012).
As the epidemiological pattern of substance use varies from one geographic location to another, knowledge of local epidemiological patterns of drugged driving is necessary for the improvement of road safety. Screening tests for substances in suspected cases are designed based on the epidemiological information about the type of drugs that are commonly used by drivers who are at high risk of RTC ( Soderstrom, Dischinger and Scalea 2014) . Almost all published epidemiological knowledge in this field originates from North America, Europe, and Australia Different populations are being enrolled to the epidemiological studies on drugged driving. This includes general populations, drivers, professional drivers, and drivers who become involved in crashes (Mason and McBay ,2014). There is very limited information regarding drugged driving in Egypt. The main purpose of the current descriptive study was to investigate the problem of drugged driving in RTC in one of the important trade link city in Egypt.

Aim Of The Work
This study aims to estimate the prevalence of drug and/or alcohol use in cases of road traffic crashes admitted to emergency departments of Port Said general hospitals. Methods 1. Study setting: This study was conducted in Port Said governorate catchment area and emergency departments of three of its general hospitals, which is designated first target trauma care facility for road traffic victims.
2. Study design and duration : It was a descriptive study, started from first of January to 31 st of December 2014. All motor vehicle driver casualties who presented to the emergency department for treatment of injuries after a crash were approached for assessment. Fatal cases (certified dead in the emergency room) were excluded from the sample. All other injured drivers were considered eligible for recruitment, whatever their outcome after admission with the total number of 1200 cases. All the studied cases were driving the vehicles during the accidents. a) Inclusion Criteria All the cases exposed to road traffic injuries were included in this study. Able and willing to provide informed consent. b) Exclusion Criteria An injury on road without involvement of the vehicle. (E.g. person slipping or/and falling on the road and sustaining injury).An injury involving a stationary vehicle (e.g. Person getting injured while washing, cleaning and loading a vehicle) People who are not willing to give consent for participation and died cases. c) Ethical consideration The urine tests were performed if written informed consent was obtained from the patient or if deemed strongly indicated by the in-charge doctor; to assist management when consciousness was impaired. All eligible injured drivers who were screened had puff of exhaled breath , urine and blood samples and were compared using equivalent cut off concentrations testing for abusive drug exposure, if there were clinical indications for drug screening or if written consent could be obtained. Consenting drivers were reassured that all information obtained would be kept confidential and used for scientific and not legal purposes. All cases were subjected to the study of the following parameters: a. Socio-demographic profile : Including age, sex, marital status , education , place of accident and occupation. Also the season at which the road traffic crashes occurred and the day of maximum occurrence . b

b) Enzyme linked Immunosorbent Assay ELISA
The use of enzyme immunoassay for the detection of drugs, e.g. ELISA is a quick and convenient method for the analysis of drugs in urine and blood samples and even tissue homogenates. This has been shown to achieve sensitivities and specificities comparable with those of radioimmunoassay, and has the advantage of automation .The advantages of using ELISA are; a) no pretreatment as for enzyme multiplied immunoassay technique EMIT, b) small volume of blood (100 L), and c) sensitivity (10 ng/mL cut-offs for benzodiazepines, cannabinoids, cocaine, opioids). The prevalence of drugs following ELISA analysis and confirmation, will be presented from motor vehicle drivers suspected of driving under the influence of drugs (DUID cases) and also from persons injured in RTC ( Spiehler et al., 2014)

II-Confirmation Test
Gas Chromatography Mass Spectrometry GC-MS Is an analytical method that combines the features of gas-liquid chromatography and mass spectrometry to identify different substances within a test sample. Applications of GC-MS include drug detection (Amirav,Poliak and Fialkov 2011). The cut off level for detection of drugs and /or their metabolites in urine measured by GC-MS are as follow: Tetra hydro cannabinol (THC) 15 ng/ml, benzoylecgonine as cocaine metabolite is 150 ng/ml, codeine 2000 ng/ml , morphine 2000 ng/ml , 6-acetylmorphine 10 ng/ml , phencyclidine PCP 25 ng/ml , methadone 300 ng/ml , tramadol 10 ng/ml. Amphetamine cut off level is 200ng/ml and its metabolites metamphetamine is 500 ng/ml . Barbiturates metabolites cut off value for amobarbital, secobarbital and others is 200 ng/ml . Benzodiazepines detection level for oxazepam, clonazepam , zolam and diazepam is 200 ng/ml  III-Clinical outcome of cases c. Calculation of the APACHE equation to assess the clinical outcome of the studied cases: This equation is a computerized equation must be done by computer system. It is the result of interaction of the physiological state of the patient, the age and the chronic health problem of the patient. First introduce the lowest and the highest values for the parameter of physiologic state in the 1 st 24h which include (temp in C°, arterial pressure in mm Hg, heart rate in beats/minute, respiratory rate in breaths/min, oxygenation, arterial PH, serum glucose, sodium, creatinine, blood urea nitrogen BUN, albumin, bilirubin , hematocrit in percent, white blood cell WBC count in thousands, urine output UOP and Glasgow Coma Score GCS ). Then the sheet continue to be completed and mention if the patient had chronic health problem, the age of the patient and the detected substance or drug abuse, then press on the calculate icon, and the score will be displayed , the predicted mortality and the predicted length of stay will be displayed on the screen (Mazen Kherallah , 2005).

Statistical Analysis
was done using SPSS windows-version 19. Chi square test was done to test the relation between two variables .In all tests the probability (P) was used; If P>0.05 the relation is non significant. If P≤0.05 the relation is significant. If P≤0.001 the relation is highly significant. P≤0.0001 the relation is very highly significant. The results of statistical analysis were then presented in tables and charts for interpretation and discussion.

Results
Socio-demographic profile of the studied victims: In the current study it was found that most of cases were between 21-40 years age group, accounting for 67.5% of the total . The male cases represented 93.25% of them while females were only 6.75%. Regarding the marital status, 80% were single. Place of accidents showed that 67.5% of RTC were occurred in urban high speed roads , while the other 32.5% were occurred in rural areas. All the studied cases were driving the vehicles during the accidents, however, not all of them work as a driver; 91.67% of them were drivers but the rest 8.33% were students. In this study 680 cases(56.67%) were from intermediate and higher school education and 420 (35%) were graduates . Most of the accidents occurred during winter( December-February) accounted for 70.83% .During this study, it was observed that RTC occurred in different frequencies for the days of the week. Fridays represented the most RTC by 34.2%. as shown in table (1). As regards to types of motor vehicles involved in RTC it was found that trucks were involved in 68%, next to it comes taxi by 12%, while bus, private car and motorcyclist represented 9%, 8% and 3% respectively, as shown in figure (1). Toxicological screening for Alcohol and substance abuse Breath analyzer for screening of alcohol as well as enzyme immunoassay were performed to detect drugs and substances abuse for all cases exposed to RTC and the results revealed 220 (18.33%) were positive for alcohol, 210 (17.5%) were positive for marijuana, 570 ( 47.5%) were positive for tramadol, 56 of cases were positive for sedative hypnotics in the form of 33(2.75%)for barbiturates and 23 (1.9% )for benzodiazepines and 14(1.16%) for amphetamine as shown in table 2 .
Enzyme Linked Immunosorbent assay (ELISA) screening test was performed to the studied cases to detect the presence of drugs and/or their metabolites. Then, a confirmatory test, Gas chromatography mass spectrometry (GC/MS) was performed later to detect drug metabolites for confirmation. Cutoff levels of the detected drugs and drug metabolites were determined at each test, as shown in table (3).
Alcohol in breath of cases exposed to RTC was detected by breath analyzer screening test followed by confirmation by detection of alcohol in total blood by GC-MS as shown in table 4 Chi square correlation test was done between drugs of abuse cut off levels confirmed by GC-MS and number and percentage of cases exposed to RTC among cases admitted to emergency department of general hospitals in Port Said governorate during 2014 showed that there was very highly significant value (P ** ≤0.0001) of drug of abuse cut off level and number and percentage of cases exposed to RTC as shown in table 5 .
Chi square correlation test was done between alcohol cut off levels confirmed by GC-MS and occurrence of RTC among cases admitted to emergency department of general hospitals in Port Said governorate during 2014 showed that there was very highly significant value (P ** ≤0.0001) of alcohol cut off level and number and percentage of cases exposed to RTC as shown in Table 6 . Outcome results Acute Physiology And Chronic Health Evaluation (APACHE) score was measured and was higher for the died cases (n=130) than for the survived cases (n=1070). This difference was highly statistically significant (pvalue <0.001).     *t-test is statistically significant at level of confidence of 95%.

Discussion
This study revealed that alcohol and other psychoactive drugs misuse was of high prevalence among the cases involved in RTC. The socio demographic profile of the studied cases showed that most of them were in 21-40 years age group, accounting for 67.5% of the total. Males were much more exposed to RTCs than females. Maximum sex differentiation was observed in age group of 21-40 years with male and female ratio of 19.5:1. Most cases were married and coming from urban residence (67.5%). Almost 91.67 % of cases were drivers .High and intermediate school education account for 56.67%. Crashes occurred more in winter season being maximum on Fridays .
Similar results were also observed by Ganveer and Tiwari (2010 ) in their cross sectional study in central China, where the highest age group of accidents was between 18 to 37 years. Fitzgerald et al ., (2014) had observed the age groups from 15 to 49 years and 31.3 years were the most vulnerable group for the road traffic injuries . Youth, burden of responsibilities, stress, type A' behavioral personality, abuse of alcohol and drugs contribute to the age specificity Young adults less than 21 years were prone to RTC due to more free time and inefficient driving experience. In addition, they are more likely to engage in "distracted driving" behavior, which describes activities that can endanger the safety of drivers, passengers, and pedestrians as using a cell phone while driving a motor vehicle.
Sex or gender in the road traffic crashes cases was dominated by males. This was due to the obvious reasons like male dominance in driver job performance, lower literacy, family norms, and cultural aspects forcing females to stay at home. This observation was supported by the previous studies by Ngo Anh et al., (2012) who observed the remarkable difference in the gender variation in the cases of road traffic accidents.
In developing countries like Egypt with large clusters of rural populations, RTC might be occur with low or nil education and in urban sectors RTC may be

Alcohol
Cut off level milligrams of alcohol per 100 milliliters of blood high due to density of population, narrow or single roads, intoxicating personal habits etc, though the education was present.
In the current study the higher frequency of road traffic crashes in winter season might be explained by the visibility impairments by early fog and mist, high winds, and rain falls . The study revealed that road traffic crashes were maximum on Fridays this could be explained by the fact that Friday is the week end and a holiday that allow many drivers to drive fast as the roads were less busy with vehicles .
On the other hand the NHTSA (2012) reported that the weekend is the most dangerous day of the week to drive, primarily because there are more cars and more drunk driverson the road than any other day. According to the American Foundation for Traffic Safety, 31% of fatal drunk-driving accidents occur on the weekend, and the highest number of drunk drivers is on the road between midnight and 3 a.m. Fatal crashes are also four times higher at night than during the day.
In the current study, it was found that trucks were involved in most (68%)of RTC. This result goes with result identical to that of the American National Highway Traffic and Safety Administration done by RamchandR , et al. (2014) attributing truck accidents to result from driving under influence of alcohol . Moreover, truck accidents are five times more likely to cause serious injuries and death than accidents involving two or more passenger vehicles Movig et al ., (2014).
Alcohol and illicit drugs could affect the driving skills of drivers .Drugs can affect a number of brain functions that adversely influence the ability to drive safely. These can be best categorized as psychomotor and cognitive functions. Psychomotor skills include reaction times and hand-eye coordination while the ability to make appropriate decisions relates to cognitive skills. Foremost among the skills required for safe driving are vigilance, and the ability to interpret traffic situations and to divide attention between tasks. The driver's behavior and attitude also contribute to the risk of having an accident (Blomberg , Peck and Fiorentino ,2013).
The results of present study revealed that there was a highly significant correlation between alcohol and drug abuse cut off level and number and percentage of RTC . This could be explained by the fact that alcohol and drugs acting on the central nervous system have potential adversely effects on the driving skills. Central nervous system depressants reduce vigilance, increase reaction times and increase errors associated with decision making and speed control in a very similar manner to tramadol, alcohol, benzodiazepines and barbiturates . Drugs that affect behavior may exaggerate adverse behavioral traits and risk-taking behavior. On the other hand during the acute phase of activity, central nervous system stimulants such as amphetamines , cocaine and cannabis tend to reduce performance on divided attention tasks, cause tunnel vision and increase risk taking (Ramaekers, Berghaus and Drummer 2012).They can also cause rebound fatigue, inattention and hyper somnolence when the stimulatory effects wear off (Gjerde et al., 2014) . Opioid analgesics such as hydromorphone, morphine ,oxycodone and tramadol have direct effects on driving behavior. Cognitive performance is reduced, largely due to their sedative effects, but neuro adaptation rapidly sets in. Driving at night may be a problem due to the persistent miotic effects of these drugs reducing peripheral vision ( Karjalainen , Blencowe and Lillsunde,2014 ).Other studies have also found significantly increased risk for crashes associated with the use of alcohol. For instance Soderstrom et al ., (2014) Study found Blood Alcohol concentration (BAC) levels above 0.04% to be associated with increased accident rates, and higher BAC levels gave higher accident rates.
In the Netherlands, Movig and his colleagues (2014) found that drivers who tested positive for alcohol (BAC above 0.8 g/l) had an increased likelihood of being injured in RTC.A previous study has shown that the prevalence of alcohol above the legal BAC limit in normal traffic is relatively low in Norway compared to other European countries, which is probably due to the restrictive BAC limits (0.2 g/kg) and related sanctions in Norway (Gjerde et al , 2014).
Reviewing the literature on the effect of cannabis compared with alcohol on driving , Sewell and his colleagues (2013) concluded that combining alcohol with marijuana results in impairment even at doses which would be insignificant were they of either drug alone. Moreover, any combination of multiple psychoactive substances was associated with an increased risk of road traffic crashes.
The current work presents good evidence that drivers exposed to road traffic crashes and taking psychoactive drugs, particularly tramadol, cannabis and strong stimulants, or two or more drugs in combination were more likely to be responsible for the crash than those taking neither drugs nor alcohol. Moreover, the combination of psychoactive drugs with alcohol further increased the likelihood that drivers caused the crash in which they died. (Ogden and Moskowitz, 2014) . It is concluded that tramadol, THC ,amphetamines and combinations of psychoactive drugs significantly increase drivers' risk of a serious road crashes.
The current study revealed that higher APACHE score was associated with greater mortality where there is highly significant increase in the APACHE score of died cases when compared to the survived cases.
These results are in agreement with Zimmerman et al. (2013) who assessed the accuracy of APACHE IV score Among 116 ICU admissions and they found that the ratio of observed to predicted mortality was not significantly different and concluded that APACHE IV predictions of ICU mortality are well calibrated and can provide useful marks for evaluating clinical outcome of severe cases. Conclusion  The risk of accident is greatly increased among drivers who tested positive for alcohol, in particular, those who had also ingested one or more psychoactive substances.  Tramadol was the most abundant drug screened and confirmed in urine of examined cases.  APACHE IV score is useful tool in predicting of mortality and hospital length of stays in acute intoxicated patients. It can be used as an index of severity in cases exposed to RTC and driving under influence of alcohol and drug abuse .

Recommendation
Planning and implementing a national RTC risk management strategy for prevention of mortalities and morbidities due to driving under the influence of drugs. Toxicological screening should be done by immunoassay method followed by confirmation by GC-MS method .
World Health Organization(2010):Summary of the report