Assessing Fitness to Drive

In this section

2.2.1. Assessing medical conditions

2.2.2. Conditions not covered explicitly in this publication

2.2.3. Temporary conditions

2.2.4. Undifferentiated conditions

2.2.5. Progressive conditions

2.2.6. Congenital conditions, disability and driving

2.2.7. Older drivers and age-related changes

2.2.8. Multiple medical conditions

2.2.9. Drugs and driving

Reflecting the requirements of the driving task (section 2.1. The driving task), the key domains to consider when assessing the impact of medical conditions and disabilities on driving are:

• impairment of:
  • sensory function (in particular, visual acuity and visual fields but also cutaneous, muscle and joint sensation)
  • motor function (e.g. joint movements, strength, endurance and coordination)
  • cognition (e.g. attention, concentration, memory, problem-solving skills, thought processing, visuospatial skills, insight and judgement)
• the risk of sudden incapacity (leading to sudden loss of control of the vehicle).

Such impacts may be associated with a range of medical conditions. Conditions with the potential to cause significant impairment and/or sudden incapacity are the focus of this publication and include:

• blackouts
• cardiovascular conditions
• diabetes
• hearing loss and deafness
• musculoskeletal conditions
• neurological conditions
• psychiatric conditions
• substance misuse/dependency
• sleep disorders
• vision problems.

The impairments/impacts associated with medical conditions may be framed in a number of ways. For example, impairments may:

• Be persistent (e.g. visual impairment) or episodic (e.g. seizure, severe hypoglycaemic event). Drivers with persistent impairments can be assessed based on observations and measures of their functional capacity. Those with episodic impairment must be assessed based on a risk analysis that considers the probability and consequence of the episode, as well as any triggering factors and whether they can be avoided.
• Fluctuate, for example, the capacity of people living with dementia can fluctuate both day to day and within a 24-hour period. It is important that the assessor considers the potential of fluctuating capacity and the impact these factors may have on driving ability.
• Be progressive (e.g. dementia, progressive neurological conditions, end-organ affects associated with diabetes) or static (permanent disabilities), which has implications for ongoing monitoring (refer to section 2.2.5. Progressive conditions). Many people with a long-term condition or disability may have developed coping strategies to enable safe driving (refer to section 2.2.6. Congenital conditions, disability and driving).
• Become introduced through use of medications that effect cognition and reaction time (refer to section 2.2.9. Drugs and driving).
• Resolve with treatment (e.g. following rehabilitation for stroke), which has implications for reinstating of unconditional licences (refer to section 4.5. Reinstatement of licences or removal or variation of licence conditions).

This publication does not attempt to define all clinical situations that may influence safe driving ability.

It is accepted that other medical conditions or combinations of conditions may also be relevant and that it is not possible to define all clinical situations where an individual’s overall function would compromise public safety. A degree of professional judgement is therefore required in assessing fitness to drive.

The examining health professional should follow general principles when assessing these patients including consideration of the driving task and the potential impact of the condition on requirements such as sensory, motor and cognitive skills. Episodic conditions need consideration regarding the likelihood of recurrence. A more stringent threshold should be applied to drivers of commercial vehicles than to private vehicle drivers. An appropriate period should be advised for review, depending on the natural history of the condition.

This publication does not attempt to address every condition or situation that might temporarily affect safe driving ability.

There are a wide range of conditions that temporarily affect the ability to drive safely. These include conditions such as post-surgery recovery, severe migraine or injuries to limbs. These conditions are self-limiting and hence do not affect licence status; therefore, the licensing authority does not need to be informed.

The treating health professional should provide suitable advice to such patients about driving safely including recommended periods of abstinence from driving, particularly for commercial vehicle drivers. Such advice should consider the likely impact of the patient’s condition and their specific circumstances on the driving task as well as their specific driving requirements. Table 1 provides guidance on some common conditions that may temporarily affect driving ability.

A patient may present with symptoms that could have implications for their licence status but where the diagnosis is not clear. Investigating the symptoms will mean there is a period of uncertainty before a definitive diagnosis is made and before the licensing requirements can be confidently applied.

Each situation will need to be assessed individually, with due consideration given to the probability of a serious disease or long-term injury or illness that may affect driving, and to the circumstances in which driving is required. However, patients presenting with symptoms of a serious nature – for example, chest pains, dizzy spells, blackouts or delusional states – should be advised not to drive until their condition can be adequately assessed. During this interim period, in the case of private vehicle drivers, no formal communication with the driver licensing authority is required unless there is significant risk to public health (refer to section 3.3.1. Confidentiality, privacy and reporting to the driver licensing authority). After a diagnosis is firmly established and the standards applied, normal notification procedures apply.

In the case of a commercial vehicle driver presenting with symptoms of a potentially serious nature, the driver should be advised to stop driving and to notify the driver licensing authority. The health professional should consider the impact on the driver’s livelihood and investigate the condition as quickly as possible.

Often diagnoses of progressive conditions are made well before there is a need to question whether the patient remains safe to drive (e.g. multiple sclerosis, early dementia). However, it is important to raise issues relating to the likely effects of these disorders on personal independent mobility early in the management process.

The patient should be advised appropriately where a progressive condition is diagnosed that may result in future restrictions on driving. It is important to give the patient as much lead time as possible to make the lifestyle changes that may later be required (e.g. adaptation to using public transport and/or a motorised mobility device). Assistance from an occupational therapist may be valuable in such instances (refer to Part B section 6.1. Dementia).

Congenital conditions and long-term or permanent disabilities may have an impact on a person’s ability to drive safely. The physical and cognitive implications of such conditions may include (but are not limited to):

• difficulty sustaining concentration or switching attention between multiple driving tasks
• reduced cognitive and perceptual processing speeds, including reaction times
• reduced performance in complex situations (e.g. when there are multiple distractions)
• reduced information processing and judgement
• difficulty anticipating and responding to other road users
• difficulty controlling movement
• reduced joint range of motion and muscle strength.

These impacts vary and many people develop coping strategies to enable safe driving.

Individual assessment is therefore required based the general principles, the stability of the disability and bodily systems that underpin any adaptive behaviours for driving.

Legal obligations for reporting to the driver licensing authority apply (refer to section 3.2. Roles and responsibilities of drivers). This may trigger the need to provide a medical report and/or an occupational therapy driving assessment. An occupational therapist driver assessor can provide information about how a condition or disability may affect driving or learning to drive. They can also offer advice about potential aids, vehicle modifications or training strategies that may assist the individual.

The outcomes of the assessment may result in the requirement of a conditional licence relating to the driver (e.g. prosthesis must be worn) or the vehicle (e.g. can only drive a vehicle with certain modifications); refer to section 4.4. Conditional licences. If the condition or disability is assessed as static, then it is unlikely to require periodic review.

Learning to drive

People with a disability that may impact their ability to drive can seek the opportunity to gain a driver licence. This opportunity is increasingly available through the National Disability Insurance Scheme. To ensure they receive informed advice and reasonable opportunities for training, it is helpful if they are trained by a driving instructor with experience in teaching drivers with disabilities. An initial assessment with an occupational therapist specialised in driver evaluation may help to identify the pre- requisite functional capacity requirements to realistically aspire to driving independence, need for adaptive devices, vehicle modifications or special driving techniques.

National Disability Insurance Scheme

There are support options to help drivers with a disability through the National Disability Insurance Scheme (NDIS). The NDIS provides all Australians under the age of 65 who have a permanent and significant disability with reasonable and necessary supports.

The NDIS may provide assistance with the medical review process including obtaining a driver licence, medical reports, occupational therapist driving assessments, driver training and vehicle modifications. Further information about the support provided by the NDIS and how to access the services can be found on the NDIS website at www.ndis.gov.au.

While advanced age in itself is not a barrier to safe driving, age-related physical and mental changes will eventually affect a person’s ability to drive safely. Given the association between health outcomes, mobility and social connectedness, fitness to drive should be proactively managed, with the goal of enabling older people to continue to drive for as long as it is safe to do so.

Crash data points to some of the vulnerabilities of older drivers, showing that they are more likely to crash at intersections and with other vehicles (multi-vehicle crashes). Frailty of older drivers is also associated with higher risk of injury and death. At the same time, safety risks for older drivers may be mitigated by their extensive driving experience and their tendency to modify their driving to suit their capabilities, including avoiding peak-hour traffic, poor weather and night driving, and driving at slower speeds.

Management approach

A proactive approach to management of older drivers encompasses primary, secondary and tertiary prevention.

Discussions about mobility and driving

Talking with an older person about their driving can be difficult, particularly if it is delayed until the conversation is about ceasing driving. Early conversations focused on maintenance of driving ability in the context of their general health, mobility needs and other activities of daily living can help build self-awareness, enable self- monitoring and normalise the eventual transition to non-driving. Driver licensing authorities provide resources to support conversations with older drivers and their carers/families.

Active observation and screening

Routine care of the older person should include monitoring for decline in the functions necessary for driving, including vision, cognition and motor/sensory functions (see below). This is also an opportunity to pick up on ‘red flags’ such as falls, memory problems, confusion, caregiver concerns or a sudden change in social circumstances. Annual checks, such as through the Medicare 75 Plus health check, provide an opportunity for screening and for considering the overall impacts of ageing and multiple medical conditions on driving.

Early intervention

Early identification of functional decline can provide opportunities to address driving skills and capabilities in at-risk drivers. This may involve referral for relevant assessment and management (e.g. allied health, driver assessment), including treatments, driving rehabilitation, vehicle modifications and driving restrictions (refer to section 2.3. Assessing and supporting functional driver capacity). In cases where an older person is not fully fit to drive in all circumstances, the health professional may advise conditions under which driving could be performed safely (refer to section 4.4. Conditional licences). Referral to a geriatrician may also assist if there is doubt about a patient’s fitness to drive or about remedial strategies.

Considering the impact of medical conditions on driving

Most older adults have at least one chronic medical condition. The most common conditions include cardiovascular disease, stroke, Parkinson’s disease, sleep disorders, cataracts, glaucoma, musculoskeletal impairments including arthritis, depression, dementia and diabetes. The overall impact of multiple conditions on driving will need to be considered (refer to section 2.2.8. Multiple medical conditions). A new diagnosis or change in any condition, or an acute medical event, is a trigger to revisit driving, so too is the addition of a new medication or treatment. Older adults often take multiple medications, and this is associated with increased crash risk. Counselling regarding medications should specifically address potential safety concerns for driving, including any age-associated effects such as changed drug metabolism (refer to section 2.2.9. Drugs and driving).

Transition to alternative means of transport

Ultimately, when a person’s functioning is no longer compatible with safe driving, they will need to be supported in relinquishing their licence and seeking alternative modes of transport. There is a role for ongoing monitoring of health and social consequences and compliance with advice not to drive. Caregivers play an important role in encouraging the older person to cease driving and to help the individual find alternatives.

Assessing older drivers

Age-related physical and mental changes vary greatly between individuals. The three main functional areas to consider for the assessment and routine care of older drivers are described below. Health professionals should be mindful that a driver may have several minor impairments that alone may not affect driving but when taken together may make risks associated with driving unacceptable (refer to section 2.2.8. Multiple medical conditions).

Some driver licensing authorities require regular medical examination or assessment of drivers beyond a specified age. These requirements vary between jurisdictions and may be viewed in Appendix 1. Regulatory requirements for driver testing.

Vision

Various aspects of vision may decline with age, including acuity, visual fields and contrast sensitivity. Eye conditions such as cataracts, glaucoma and macular degeneration are also more common in older people. The gradual changes associated with ageing and the gradual onset of eye conditions may not be noticed by the driver. Regular eye health checks may facilitate early detection and management for changes in vision. Difficulty driving at night and problems with glare may be early signs of age- related visual decline and may be investigated in routine conversations. Driving restrictions/ conditions such as no-night driving can help maintain safe driving, while removal of cataracts can effectively restore vision for driving. (Refer also to section 4.4. Conditional licences and Part B section 10. Vision and eye disorders).

Cognition

Various aspects of cognitive processing required for safe driving can decline with age, including memory, working memory, visual processing, visuospatial skills, attention functioning, executive functioning and insight. These impairments can affect a person’s ability to process and respond to the complex road environment. The impairments can vary from day to day, which can present a challenge for definitive assessment in relation to driving. Dementia is a particular concern as older adults with dementia often lack insight into their deficits and may be more likely to drive when it is unsafe (refer also to Part B section 6.1. Dementia).

Motor and somatosensory function

Ageing generally results in a decline in muscle strength and endurance, as well as reduced flexibility, range of movement and joint stability. Musculoskeletal conditions such as arthritis are also more prevalent in older adults. These and other general health conditions may be associated with chronic pain and fatigue. Proprioception may also be an issue.

Older adults with these impairments may have difficulties getting in and out of the car, using the seatbelt and ignition key, adjusting mirrors and seats, steering, turning to reverse, and using foot pedals. Adaptive equipment, some requiring professional recommendation, is available to support drivers experiencing pain, reduced reach or reduced strength. Rehabilitative therapies may improve the older driver’s functioning and endurance (refer to section 2.3.2 Driver rehabilitation, Part B section 5. Musculoskeletal conditions).

More information

Reference to the Royal Australian College of General Practitioners’ Guidelines for preventative activities in general practice (the ‘Red Book’) and the Aged care clinical guide (the ‘Silver Book’) may assist in assessing older drivers.^3,4 Additional resources and references that may support assessment are provided in Part A, References and further reading.^{5,6,7,8,9,10,11}

Where a vehicle driver has multiple conditions or a condition that affects multiple body systems, there may be an additive or a compounding detrimental effect on driving abilities – for example in:

• congenital disabilities such as cerebral palsy, spina bifida and various syndromes
• multiple trauma causing orthopaedic and neurological injuries as well as psychiatric sequelae
• multi-system diseases such as diabetes, connective tissue disease, multiple sclerosis and systemic lupus erythematosus
• dual diagnoses involving psychiatric illness and drug or alcohol addiction
• ageing-related changes in motor, cognitive and sensory abilities together with degenerative disease
• chronic pain.

Although these medical standards are designed principally around individual conditions, clinical judgement is needed to integrate and consider the effects on safe driving of any medical conditions and disabilities that a patient may present with. However, it is insufficient simply to apply the medical standards contained in this publication for each condition separately because a driver may have several minor impairments that alone may not affect driving but when taken together may make risks associated with driving unacceptable. Therefore, it is necessary to integrate all clinical information, bearing in mind the additive or compounding effect of each condition on the overall capacity of the patient to drive safely.

Where one or more conditions are progressive, it may be important to reduce driving exposure and ensure ongoing monitoring of the patient (refer to section 2.2.5. Progressive conditions). Conditional licences that may limit the driver (e.g. no night driving) or place requirements on the vehicle (e.g. automatic transmission only) are an option in these circumstances (refer to section 4.4. Conditional licences). The requirement for periodic reviews can be included as recommendations on driver licences.

Periodic reviews are also important for drivers with conditions likely to be associated with future reductions in insight and self-regulation. If lack of insight may become an issue in the future, it is important to advise the patient to report the condition(s) to the driver licensing authority. Where lack of insight already appears to impair self-assessment and judgement, public safety interests should prevail, and the health professional should report the matter directly to the driver licensing authority and, if appropriate, seek the support of the patient’s family members.

Any drug that acts on the central nervous system has the potential to adversely affect driving skills. Central nervous system depressants, for example, may reduce vigilance, increase reaction times and impair decision making in a very similar way to alcohol. In addition, drugs that affect behaviour may exaggerate adverse behavioural traits and introduce risk- taking behaviours.

Where medication is relevant to the overall assessment of fitness to drive in managing specific conditions such as diabetes, epilepsy and psychiatric conditions, this is covered in the respective chapters. Prescribing doctors and dispensing pharmacists do, however, need to be mindful of the potential effects of all prescribed and over-the-counter medicines and to advise patients accordingly. Patients receiving continuing long-term drug treatment should be evaluated for their reliability in taking the drug according to directions. They should also be assessed for their understanding that medicines can have undesired consequences that may impair their ability to drive safely and this may be unexpectedly affected by other factors such as drug interactions.

General guidance for prescription drugs and driving

While many drugs have effects on the central nervous system, most, with the exception of benzodiazepines, tend not to pose a significantly increased crash risk when the drugs are used as prescribed and once the patient is stabilised on the treatment. This may also relate to drivers self-regulating their driving behaviour. When advising patients and considering their general fitness to drive, whether in the short or longer term, health professionals should consider:

• the balance between potential impairment due to the drug and the patient’s improvement in health on safe driving ability
• the individual response of the patient – some people are more affected than others
• the type of licence held and the nature of the driving task (i.e. commercial vehicle driver assessments should be more stringent)
• the added risks of combining two or more drugs capable of causing impairment, including alcohol
• the added risks of sleep deprivation on fatigue while driving, which is particularly relevant to commercial vehicle drivers
• the potential impact of changing medications or changing dosage
• the cumulative effects of medications
• the presence of other medical conditions that may combine to adversely affect driving ability
• other factors that may exacerbate risks such as known history of alcohol or drug misuse.

Acute alcohol and drug intoxication

Acute impairment due to alcohol or drugs (including illicit, prescription and over-the- counter drugs) is managed through specific road safety legislation that prohibits driving over a certain blood alcohol concentration (BAC), with the presence of certain drugs in bodily fluids, or when driving is impaired by drugs (refer to Appendix 4. Drivers’ legal BAC limits). This may include requirements for using alcohol interlocks, the application of which varies between jurisdictions (refer to Appendix 5. Alcohol interlock programs). This is a separate consideration to long-term medical fitness to drive and licensing, therefore specific medical requirements are not provided in this publication. Dependency and substance misuse, including chronic misuse of illicit, non-prescription and prescription drugs, is a licensing issue and standards are outlined in Part B section 9. Substance misuse.

Further guidance for prescribing drugs of dependence can be found in the Royal Australian College of General Practitioners’ guide Prescribing drugs of dependence in general practice (visit www.racgp.org.au).

The effects of specific drug classes^13,14

Medicinal cannabis (cannabinoids)^{15,16,17,18,19,20,21,22,23,24,25,36,37}

Medicinal cannabis refers to medically prescribed cannabis preparations intended for therapeutic use, including pharmaceutical cannabis preparations with set amounts of cannabinoids such as oils, tinctures, sprays and other extracts. The main active components of cannabis (medicinal or recreational) are delta- 9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC, the psychoactive ingredient in cannabis (including medicinal), can cause cognitive and psychomotor impairments that degrade the ability to drive safely including attention and concentration deficits, mild cognitive impairment, dizziness and anxiety. These deficits can begin at low doses and are highly individualised.

The pharmacokinetics of cannabinoids are complex, making it difficult to predict the severity of impairment. Other influencing factors include the history of use, frequency of dose, ratio of cannabinoids and route of administration (vaporised, oral, oral-mucosal, transdermal). The onset and duration of impairing effects can vary significantly between individuals. The effects can typically last for three to six hours after inhalation or five to eight hours after oral administration, but may be significantly longer for either route of administration and should be determined individually. Further information on the route of administration and THC pharmacokinetic/ pharmacodynamics can be found in the TGA’s Guidance for the use of medicinal cannabis in Australia – overview (https://www.tga.gov.au/publication/guidance-use-medicinal-cannabis-australia-overview).

Based on current evidence, CBD does not cause psychomotor or cognitive impairment or strong psychoactive effects. CBD may produce side effects including sedation or fatigue, which can be more pronounced at higher doses. CBD may interact with other prescribed medication, potentially increasing the risk of driving impairment. The effects of other cannabinoids have not been systematically studied.

Managing medicinal cannabis and driving

Strategies to mitigate or manage THC impairments include a ‘start low, go slow’ approach to treatment and administration during periods when an individual is unlikely to drive (e.g. at night before sleep). A period of restricted or non-driving, generally a minimum of four weeks, may be considered while adaptation to medication and treatment outcomes are determined.

Medicinal cannabis (THC and CBD) can interact with other medications, impairing the metabolism of other drugs or causing cumulative effects such as sedation, which can increase the road safety risk. Alcohol should be avoided when taking medicinal cannabis due to the significant additive effects and the increased risk of having a crash. CBD may effect the metabolism of certain antiseizure drugs, elevating plasma levels of other drugs, including some benzodiazepines.

Assessing fitness to drive

Fitness-to-drive assessments for the underlying chronic medical condition or disability treated with medicinal cannabis can be undertaken as per the applicable standards. The assessment should consider the nature of the driving task, impairment of cognitive, visuospatial and motor control functions from the condition or medications, and treatment outcomes. Conditions with specific standards, such as seizures (Part B section 6.2. Seizures and epilepsy) or chronic pain (Part B section 5. Musculoskeletal conditions), may consider medicinal cannabis under the existing criteria. Conditions without specific criteria in Part B. Medical standards may be assessed according to section 2. Assessing fitness to drive – general guidance.

Medicinal cannabis and commercial licence holders

Assessments against the commercial licensing medical standards are more stringent than the private standards and reflect increased driver exposure and the increased risk associated with motor vehicle crashes involving these vehicles. Sleep deprivation or fatigue while driving are common risks among commercial vehicle drivers. Particular attention should be paid to the commercial vehicle driving task. Considerations may include the vehicle type, the nature of goods transported, the distances and roads being travelled, the cumulative time driving over a work period, and whether driving will occur at night or disrupt normal sleep patterns. Impacts of driving patterns on dosage requirements may also be relevant.

Medicinal cannabis and drug driving laws

Drug driving and enforcement laws for cannabis are established through state and territory legislation and can vary. In general, it is against the law for a person to drive with any amount of THC present in their bodily fluids (blood, saliva or urine). In most states and territories there are no exceptions to these laws, including therapeutic use. Tasmanian law provides a medical defence for driving with the presence of THC in bodily fluids. The medical defence only applies if the medicinal cannabis is obtained and administered in accordance with the Poisons Act 1971 (Tas). It remains illegal for these patients to drive if impaired by THC and they must still comply with directions given by law enforcement regarding roadside testing.

Drivers prescribed medicinal cannabis in one jurisdiction may be treated differently if driving in another. The individual’s driving needs, including interstate travel and licensing classes, should be discussed when considering prescribing medicinal cannabis, and it is critical to identify if driving is required as part of their occupation.

Point-of-prescription advice regarding medicinal cannabis and driving

The implications of drug driving regulations and THC should be discussed at the point of prescription and reviewed routinely with the patient as part of good fitness-to-drive medical management. In addition to the legal consequences, there may also be insurance implications for patients who are convicted of drug driving offences. CBD is not subject to these controls and can be used while driving, so long as treatment is free of side effects or drug interactions that may cause impairment. Specific information can be sourced from local driver licensing authorities, health departments or law enforcement agencies and should be consulted alongside the information presented here.

Possible drug-seeking behaviour in those directly requesting cannabis as an alternative to, or to supplement, medicinal cannabis should be kept in mind. Medically prescribed cannabis is distinct from other sources of cannabis that people may access for illicit or unregulated medicinal purposes. These other products are highly variable in their cannabinoid content and can significantly increase the road safety risk. More information can be found in Part B section 9. Substance misuse.

Benzodiazepines²⁶

Benzodiazepines are well known to increase the risk of a crash and are found in about 4 per cent of fatalities and 16 per cent of injured drivers taken to hospital. In many of these cases benzodiazepines were either abused or used in combination with other impairing substances. If a hypnotic is needed, a shorter acting drug is preferred. Tolerance to the sedative effects of the longer acting benzodiazepines used to treat anxiety gradually reduces their adverse impact on driving skills.

Antidepressants

Although antidepressants are one of the more commonly detected drug groups in fatally injured drivers, this tends to reflect their wide use in the community. The ability to impair is greater with sedating tricyclic antidepressants (e.g. amitriptyline and dothiepin) than with the less sedating serotonin and mixed reuptake inhibitors such as fluoxetine and sertraline. However, antidepressants can reduce the psychomotor and cognitive impairment caused by depression and return mood towards normal. This can improve driving performance.

Antipsychotics

This diverse class of drugs can improve performance if substantial psychotic-related cognitive deficits are present. However, most antipsychotics are sedating and have the potential to adversely affect driving skills through blocking central dopaminergic and other receptors. Older drugs such as chlorpromazine are very sedating due to their additional actions on the cholinergic and histamine receptors. Some newer drugs (clozapine, olanzapine, quetiapine) are also sedating, while others (aripiprazole, risperidone and ziprasidone) are less sedating. Sedation may be a particular problem early in treatment and at higher doses.

Opioids^{27,28,29,30,31}

Opioid analgesics are central nervous system depressants and as such can suppress cognitive and psychomotor responses in driving situations. While cognitive performance is reduced early in treatment (largely due to their sedative effects) neuroadaptation is rapidly established. This means that patients on a stable dose of an opioid may not have a higher risk of a crash. This includes patients on buprenorphine and methadone for their opioid dependency, providing the dose has been stabilised over some weeks and they are not abusing other impairing drugs. Driving at night may be a problem due to the persistent miotic effects of these drugs reducing peripheral vision.

Further guidance on opiate prescribing can be found from:

• the Royal Australian College of Physicians’ Prescription Opioid Policy: Improving management of chronic non-malignant pain and prevention of problems associated with prescription opioid use²⁷
• the Australian and New Zealand College of Anaesthetists and Faculty of Pain Management’s Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain³¹
• the Royal Australian College of General Practitioners’ Prescribing drugs of dependence in general practice^28,29,30
• local health agency websites.