Medical students knowledge of medicinal drugs and impairment Evelyn Vingilis, Ph.D Population and Community Health Unit, Faculty of Medicine, The University of Western Ontario, London, Canada In recent years a growing body of evidence has been identifying the impairment properties of many medicinal drugs (Asoh et al., 1995; Berghaus and Guo, 1995; Del Rio and Alvarez, 1995; Freeman and O’Hanlon, 1995; Gengo and Manning, 1990; Moskowitz and Burns, 1988; O'Hanlon and Freeman, 1995). In addition, epidemiological studies have identified medicinal drugs among crashed and DUI drivers. For example, Stoduto et al. (1993) found that of their sample of consecutively admitted motor vehicle crashed drivers to a major trauma centre in Canada, 12.4% tested positive for benzodiazepine, 5% for morphine, 3.8% for codeine, about 3% each for barbiturates and pethidine, and about 2% each for diphenhydramine and pheniramine. Others have similarly found the presence of medicinal drugs among crashed drivers (Christophersen et al., 1995; Farriery et al., 1989; Jeffery et al., 1995). Indeed, De Gier (1993) has estimated that at least 10% of all people injured or killed in road crashes were taking some sort of psychotropic medication that may have been a contributory factor. Unlike alcohol or illicit drugs, medicinal drugs are subjected to tight controls. Pharmacies and physicians are the primary public gatekeepers of medicinal drugs. Only recently have attempts been made to educate the medical profession on the potential risks of patients causing traffic crashes under the influence of prescribed medicinal drugs (Del Rio and Alvarez, 1995; O'Hanlon, 1995a) because the current perception is that physicians have limited knowledge of the impairing properties of various medicines. Unfortunately, little specific information on their knowledge levels is available. The purpose of this study was to assess the level of knowledge on alcohol and drug impairment, and the relative impairment properties of various common medicinal drugs -717-
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Medical students knowledge of medicinal drugs and
impairment
E velyn V in gilis, Ph.D
P opulation and C om m unity H ealth U nit, Faculty o f M edicine, T he U niversity o f W estern
O ntario , L ondon, C anada
In recent years a grow ing body o f ev idence has been identify ing the im pairm ent p roperties o f
m any m edicinal d rugs (A soh et al., 1995; B erghaus and G uo, 1995; Del R io and A lvarez,
1995; F reem an and O ’H anlon, 1995; G engo and M anning, 1990; M oskow itz and B urns,
1988; O 'H an lo n and Freem an, 1995). In addition, epidem iological studies have identified
m edicinal d rugs am ong crashed and D U I drivers. F or exam ple, S todu to e t al. (1993) found
that o f their sam ple o f consecutively adm itted m otor vehicle crashed drivers to a m ajor
traum a cen tre in C anada, 12.4% tested positive fo r benzodiazepine , 5% fo r m orphine , 3.8%
for codeine, about 3% each fo r barb itu rates and peth id ine, and about 2% each for
d iphenhydram ine and pheniram ine. O thers have sim ilarly found the presence o f m edicinal
d rugs am ong crashed drivers (C hristophersen et al., 1995; Farriery et al., 1989; Jeffery et al.,
1995). Indeed, D e G ier (1993) has estim ated that at least 10% o f all peop le in ju red o r killed
in road crashes w ere taking som e sort o f psychotropic m edication that m ay have been a
con tribu to ry factor.
U nlike alcohol o r illicit drugs, m edicinal d rugs are subjected to tight contro ls. P harm acies and
physic ians are the prim ary public gatekeepers o f m edicinal drugs. O nly recen tly have
a ttem pts been m ade to educate the m edical p rofession on the poten tial risks o f patien ts
causing traffic crashes under the influence o f prescribed m edicinal d rugs (D el R io and
A lvarez, 1995; O 'H an lo n , 1995a) because the current perception is that physic ians have
lim ited know ledge o f the im pairing properties o f various m edicines. U nfortunately , little
specific in form ation on their know ledge levels is available.
T he purpose o f th is study w as to assess the level o f know ledge on alcoho l and drug
im pairm ent, and the relative im pairm ent properties o f various com m on m edicinal d rugs
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am ong fourth year m edical students in one o f C an ad a’s 16 m edical schools.
M E T H O D
E ighty studen ts in their last sem ester o f m edical school com pleted the su rvey at the beg inn ing
o f their Population H ealth class. T h is represented 84% o f the m edical studen ts en ro lled in the
program m e. S ix ty-one percen t o f the students w ere m ale and 39% w ere fem ale. A t th is poin t
in their education they w ould have com pleted their all their basic and clin ical tra in ing ,
includ ing tra in ing in pharm acology.
T he survey consisted o f 10 m ultip le-cho ice questions, query ing studen ts on their know ledge
o f prevalence o f alcohol and m edicinal drug use am ong in ju red m oto r veh icle crashed drivers,
the m ain classes o f d rugs considered to im pair driv ing perfo rm ance and the re la tive degrees
o f im pairm en t o f a range o f psychotropic drugs.
R E SU L T S
T he average correc t score out o f 10 w as 4, w ith the range from 1 to 8 . H a lf o f the studen ts
scored 3 o r 4 out o f 10. O nly, 12.5% o f the m edical studen ts ac tually scored above 50% .
Specifica lly
T he students generally underestim ated the p revalence o f alcohol and drugs am ong traum a
victim s. A lm ost 46% correctly identified that 60% o f seriously in ju red m otor veh icle crashed
drivers w ere positive fo r alcohol and/or o ther drugs on adm ission to a m ajo r O ntario traum a
unit. H ow ever, 24% correctly identified that 35% o f d rivers w ere positive fo r a lcohol, and
only 2 .5% felt that 40% o f crashed drivers w ere positive for d rugs (lic it and illicit). A lm ost
h a lf o f the students felt tha t only 1 0 % o f the crashed drivers w ere positive fo r any drugs.
Three quarters o f the students d id correctly identify cannabis and benzodiazep ine as the tw o
drugs o th er than alcohol m ost com m only found am ong in ju red drivers.
A ntid iabetic , card iac, ophthalm ological and an tidepressants are all c lasses o f d rugs considered
to im pair d riv ing perform ance. S lightly over three fifths correctly iden tified all the classes as
poten tially im pairing w hile ano ther one fifth sta ted only antidepressants cou ld im pair driv ing
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performance.
Studen ts w ere also asked about the relative risk o f drivers being invo lved in an in ju ry-
p roducing crash after 2 w k. usage o f benzodiazep ine hypnotic com pared to contro ls. C lose to
18% co rrec tly endorsed the 650% greater risk answ er, w hile alm ost th ree quarters felt the risk
to be 2 0 0 % higher.
F inally the studen ts w ere asked to identify am ong various d rugs and dosages the m ost and
least im pairing drugs. T he drugs w ere diazepam (5m g 3/d fo r a w k), lo razepam (2m g 2/d for
a w k), busp irone (lO m g/d for a w k), B A C .08% and 2 jo in ts o f cannabis/dy . A lm ost 40% o f
students iden tified d iazepam as m ost im pairing , ano ther 38% o f studen ts iden tified alcohol at
B A C o f .08% as m ost im pairing , w hile und er 18% correctly endorsed lo razepam as m ost
im pairing . A lm ost 37% o f the students correctly chose d iazepam as the second m ost
im pairing d rug , a lthough 27% did choose B A C o f .08% .
T he m ajority o f studen ts (62% ) d id correctly chose busp irone as the least im pairing drug,
a lthough alm ost 1 0 % o f the students d id say that lo razepam w as the least im pairing .
Finally , the studen ts w ere asked, w hich o f the fo llow ing drugs, flouxetine , fluvoxam in,
nom ifensine, am itrip ty line and paroxetine, causes the m ost im pairm ent. Seventy tw o percen t
correc tly answ ered am itrip ty line.
D ISC U S SIO N
T hese find ings suggest that at the end o f form al m edical school, m edical students have
lim ited know ledge o f the im pairing properties o f m edicinal drugs. Indeed , one m edical
student w rote on the top o f his questionnaire , «I d o n ’t th ink w e w ere ever taught this in our
four years here. I t 's a sham e». I th ink that sta tem ent says it all. E xcep t fo r the questions on
the im pairm ent levels o f busp irone and am itrip ty line, w here the m ajority o f students scored
co rrec tly , the o th er questions w ere scored at chance levels. P articu la rly o f concern shou ld be
the fact that alm ost 1 0 % o f these fourth year m edical students felt that lo razepam w as the
L E A S T im pairing drug. O ’H anlon (1995b) has stated that « lo razepam should p robab ly never
be p rescribed to patien ts w ho drive, o r at least they should be p roh ib ited from d riv ing for
several w eeks after sta rting m edication , because ...even the low est therapeu tic dose 0 .5 m g,
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three times a day, had more effect on driving performance than BAC=.05%».
In addition , the m edical students clearly underestim ated the ex ten t o f drug use am ong
hosp italized crashed drivers. Y et in O ntario, the m edical p rofession has cause fo r concern.
R ecently , physic ians have been found partly liable fo r car crash aw ards fo r failing to repo rt to
the M in istry o f T ransportation , a legal requirem ent in O ntario , that drivers had conditions that
cou ld affect their driv ing (O nyshko, 1994; O w ens 1993). Furtherm ore, physic ians have been
disc ip lined by the O ntario C ollege o f Physicians and Surgeons (1993) fo r im proper
prescrib ing w hich led to veh icular crashes. F inally , the issue regard ing m edical
conditions/p rob lem s, crash risk and duty to inform the M inistry o f T ransportation has been
described in the C anadian M edical A ssociation Journal (Johnson, 1993). O n an added note,
the H ippocratic O ath requires the physician to «do no harm ». In light o f the fact that our
populations in the industria lized w orld are aging, are m ore p rone to use m any m edicinal
drugs and to have poorer driv ing skills and records, and that trends tow ard de
institu tionalization and post-operative short hospital days o f stay are increasing , the tim e has
com e to transfer the know ledge gleaned from decades o f research by IC A D T S researchers on
the im pairing p roperties o f m edicinal drugs to the m edical schools and m edical profession .
R E F E R E N C E S
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C ollege o f Physicians and Surgeons o f O ntario . (1993). M ediating com plain ts 2: Im proper
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