Memorandum from the Chronic Pain Policy
Coalition (CPPC) (DDD 38)
The Chronic Pain Policy Coalition (CPPC) welcomes
the opportunity to contribute to the Transport Select Committee
consultation on drink and drug driving law.
The CPPC executive committee members have studied
Sir Peter North's report and welcome proposed legislative changes
expected to improve safety for drivers and members of the public.
The principal interest of the CPPC in relation to this consultation
relates to drivers who may be using prescribed or over the counter
(OTC) medications for pain relief and the impact on them and on
healthcare professionals.
SUMMARY
— Patients with persistent pain may have
mobility problems and driving may be important for them to enhance
vocational and social function.
— Persistent pain and associated morbidities
(including fatigue) may impair ability to drive.
— Medications for pain relief (including
controlled drugs) may have side effects which impair ability to
drive. Patients may be taking more than one class of drug. Medications
are not always taken as prescribed.
— Current research suggests that stable
doses of opioid drugs do not impair driving ability.
— Drivers using opioids illegally may not
be comparable to those using prescribed controlled drugs or OTC
medications.
— Collaboration between service users and
healthcare providers underpins successful long-term condition
management and this includes decisions about medications.
— Advice about fitness to drive should
be given when prescribing medications for pain.
— The balance of benefits and harms of
treatments must be considered. Patients may only achieve useful
pain relief at medication doses which make them unfit to drive.
— Healthcare providers must ensure that
patients understand the rationale behind drug driving laws and
that concerns regarding fitness to drive relate to their safety
and that of others.
— A patient has a responsibility to consider
their fitness to drive.
— Current best practice guidance in relation
to opioid prescribing includes advice to patients regarding driving.
— The effect of a given dose of medication
on patient function will vary between individuals and in a given
individual at different times. Driving ability cannot be inferred
from drug dose.
— Assessment of impairment should acknowledge
limitations relating to underlying physical disability.
1. Pain and driving
Management of long term pain is focused toward
improving patients' quality of life and supporting independence.
Many patients with persistent pain have activity related symptoms
and mobility is often, in consequence, impaired. The ability to
drive can help a patient with pain to improve not only their self-sufficiency
but also function in social and vocational domains. Patients who
are unable to drive may become socially isolated and dependent
on others.
Pain impairs the ability to drive. There is
robust experimental research to demonstrate that pain can interrupt
the performance of attentionally demanding tasks including driving.
Intense pain interrupts more than mild pain. Vigilance/attention,
psychomotor speed, and working memory may be significantly impaired
in patients with persistent pain with impairment being correlated
with pain severity. Pain associated with cancer may impair neuropsychological
performance to a greater degree than pain medication. In addition,
patients with pain may have associated physical difficulties which
make driving difficult. Pain frequently interrupts sleep so patients
may be tired when driving but also here is a strong association
between persistent pain and the symptom of fatigue (this may be
related to common aetiology) which might be expected to further
impair the ability to drive safely.
2. Pain medication and driving
Medications used to treat pain are usually centrally
acting and may have central nervous system effects such as somnolence
which impair ability to drive. Patients with persistent pain may
be taking other classes of drugs for symptom relief including
tricyclic antidepressants and anti-epileptic drugs. Sedative side
effects are more likely to occur when such medications are taken
in combination.
The discussion document rightly highlights the
need for research into the effect of drugs on driving but there
exists a significant body of literature in relation to driving
ability and medicinal use of drugs. This includes:
Role of medications in motor vehicle accidents
An epidemiological review of the role of opioids
in motor vehicle accidents found that opioid use in subjects found
intoxicated whilst driving was 10% that in the general population
and. The same review found that experimental studies showed that
opioids did not seem to play a role in motor vehicle accidents
or motor vehicle related fatalities.
Studies of relevant psychomotor skills
Short term ingestion of opioid drugs can cause
central side effects such as dizziness and somnolence but when
taken regularly patients become tolerant to these side effects.
Several studies show that stable doses of opioids do not impair
performance skills related to driving. Furthermore, relevant skills
(including attention) may improve if effective pain relief is
achieved by opioid therapy. Side effects may appear after upwards
dose titration but these usually disappear within a few days of
dose change.
In respect of inferences drawn from studies
of patients being prescribed opioids for pain relief, these data
are unlikely to be generalizable to individuals using opioids
illicitly. Opioids used as medication are of defined dose and
are under the supervision of the prescriber in relation to effectiveness
and adverse effects and the two subject populations are likely
to be different in regard to other physical and mental health
morbidities.
3. Advice on medication and driving
Collaboration between service users and healthcare
providers underpins successful long-term condition management
and this includes decisions about medications. The balance of
benefits and harms of treatments must be considered. If pa patient
wishes to continue driving they must understand that the end point
of medication treatment may be partial pain relief only. Similarly,
patients should understand that they may only achieve useful pain
relief at medication doses which make them unfit to drive. Many
patients do not take medication as prescribed and the risks of
this in relation to driving need to be highlighted.
Healthcare providers must ensure that patients
understand the rationale behind drug driving laws and that concerns
regarding fitness to drive relate to their safety and that of
others. Advice about fitness to drive should be given when prescribing
medications for pain but the patient has responsibility to consider
their fitness to drive and they should make this on every occasion
that they wish to drive a car.
Recent guidance on prescription of opioids for
persistent pain has been issued to healthcare professionals and
service users. The current advice regarding driving states:
"Patients being treated with opioids should
be advised to avoid driving when:
— the condition for which they are being
treated has physical consequences that might impair their driving
ability;
— they feel unfit to drive;
— they have just started opioid treatment;
— their dose of opioids has been recently
adjusted upwards or downwards (as withdrawal may have an impact
on capability); and
— they have consumed alcohol or other drugs
that can produce an additive sedative effect.
The only body that can advise a patient about
their legal right to hold a driving licence is the Driving and
Vehicle Licensing Authority (DVLA).
Patients starting opioids should be advised to
inform the DVLA that they are taking opioids. Prescribers should
document that this advice has been given."
"Can I drive if I am on opioids?
The law in the UK allows you to drive if you
are taking opioid medicines. You should not drive if you have
changed your dose or if you feel unsafe. You are responsible for
making sure you are fit to drive. The only organisation that can
advise you about your legal right to hold a driving licence is
the Driving and Vehicle Licensing Authority (DVLA). You should
let DVLA know that you are taking opioid medicines."
This guidance will need to be expanded to support
new drug driving legislation. Technology in relation to electronic
prescribing is available that would allow the prescriber to be
prompted to discuss specific driving related issues with the patient
and this could be accompanied by a patient information sheet with
each opioid prescription.
4. Assessing fitness to drive
The effect of a given dose of medication on
patient function will vary between individuals and in a given
individual at different times. Although for a given individual
being treated with opioid medication, any impairment is generally
dose related, the degree to which a patient is impaired may depend,
amongst other factors, on the intensity of their pain, other medications
they have been taking and the length of time that they have been
taking the drug. It is not possible to define a dose of medication
at and above which a patient is likely to be impaired. Assessment
of impairment would be necessary to objectively assess and individual's
fitness to drive. Such assessment should acknowledge that patients
with pain may have physical difficulties which might affect their
ability to perform some components of testing as currently described.
FURTHER READINGDagtekin
O, Gerbergshaben H J, Wagner W et al. Assessing cognitive
and psychomotor performance under long-term treatment with transdermal
buprenorphine in chronic noncancer pain patients. Anesth Analg.
2007;105(5):1442-8.
Fishbain D A, Cutler R B, Rosomoff H L, Rosomoff
R S. an Patients taking opioids drive safely? A structured evidence-based
review J Pain Palliat Care Pharmacother. 2002;16(1):9-28.
Gaertner J, Elsner F, Radbruch L et al Influence
of changes to daily dose of opioids on aspects of cognitive and
psychomotor performance involved in driving Schmerz. 2008;22(4):433-41.
Gaertner J, Radbruch L, Giesecke T et al Assessing
cognition and psychomotor function under long-term treatment with
controlled release oxycodone in non-cancer pain patients. Acta
Anaesthesiol Scand. 2006;50(6):664-72.
Kress H G, Kraft B Opioid medication and driving
ability Eur J Pain 2005;9(2): 141-4.
Menefee L A, Frank E D, Crerand C et al The
effects of transdermal fentanyl on driving, cognitive performance,
and balance in patients with chronic nonmalignant pain conditions.
Pain Med. 2004;5(1):42-9.
Sabatowski R, Berghaus G, Lorenz J et al Current
recommendations on the evaluation of the impact of opioids on
driving ability Dtsch Med Wochenschr. 2008;133 Suppl 2:S47-50.
Sabatowski R, Kaiser U, Gossrau G. Opioids in the
management of chronic pain and driving ability Anasthesiol
Intensivmed Notfallmed Schmerzther. 2010;45(6):384-5.
Sabatowski R, Schwalen S, Rettig K et al Driving
ability under long-term treatment with transdermal fentanyl J
Pain Symptom Manage. 2003;25(1):38-47.
Sjögren H, Eriksson A, Oström M. Role of
disease in initiating the crashes of fatally injured drivers.
Accid Anal Prev; 28(3):307-14.
Sjøgren P, Olsen A K, Thomsen A B, Dalberg
J. Neuropsychological performance in cancer patients: the role
of oral opioids, pain and performance status. Pain. 2000;86(3):237-45.
Sjøgren P, Thomsen A B, Olsen A K. Impaired
neuropsychological performance in chronic nonmalignant pain patients
receiving long-term oral opioid therapy. J Pain Symptom Manage.
2000;19(2):100-8.
The British Pain Society 2010 Opioids for Persistent
Pain: Good Practice
http://www.britishpainsociety.org/book_opioid_main.pdf
The British Pain Society 2010 Opioids for persistent
Pain: Information for Patients
http://www.britishpainsociety.org/book_opioid_patient.pdf
The Chronic Pain Policy Coalition is a forum
established in 2006 to unite patients, professionals and parliamentarians
in a mission to develop an improved strategy for the prevention,
treatment and management of chronic pain and its associated conditions.www.policyconnect.org.uk/cppc
September 2010
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