In India, it is illegal to drive with a blood alcohol concentration (BAC) exceeding 30 mg per 100 mL, reflecting a broader recognition of the dangers posed by both alcohol and drug use while driving. With BAC legally capped, there is a global understanding that impairment due to drugs also warrants strict regulation [16]. Indian demographic patterns of RTCs highlight a concerning trend: young male drivers, who comprise the majority of both registered drivers and those involved in RTCs, often exhibit higher rates of substance use prior to driving [17]. Data indicate that young male drivers are disproportionately involved in RTCs, accounting for the majority of fatalities; males represent about 87.3% of all road accident deaths, compared to 12.7% for females [18]. WHO data show that road traffic deaths are higher among men due to greater risk exposure and risk-taking behaviour [17,18]. An extensive review of 46 studies in low- and middle-income countries found that males are involved in 80% of crashes and represent 87% to 100% of drivers [19]. Although females represent only 6.8% of registered drivers in India, their involvement in accidents is relatively low [20].

The findings of our study substantiate this observation. As per the Ministry of Road Transport & Highways report on “Road Accidents in India 2020,” around 70% of fatal road accident victims were between the ages of 18 and 45 [17]. Our study corroborated this national data, with 82% of the injured drivers being between the ages of 18 and 46 years. A total of 64% of female participants were between the ages of 18 and 32 years. There were no female participants under 18 or over 60 in our study. It can be concluded from the above data that RTCs primarily involve young adults. For a variety of reasons, people in this age group are more vulnerable to RTCs.

According to the NCRB 2021 report, 62% of road accidents occur in rural areas, while 40% happen in urban areas [5]. In contrast, our study found that 42% of participants were from rural areas and 58% from urban areas. This difference is likely because many urban residents seek treatment at our national institute, while we mainly receive referrals from remote rural areas. Notably, 94% of the female participants were from urban backgrounds, reflecting greater empowerment and independence among urban women, compared to those in rural settings.

In a study by Kumar et al. in northwestern India, 60% of injured drivers who tested positive for psychoactive substances were under 34 years old, aligning with our findings in Central India. Kumar et al. reported a high percentage of participants aged 18-34 who tested positive for alcohol and opiates, while most cases positive for cannabis and benzodiazepines were in the 55-plus age group, which differs from our study results [11]. Similarly, a study in Australia by Ch’ng et al. found that cannabis use was most common among those aged 15 to 44, with a significant percentage of participants across all age groups testing positive for benzodiazepines and opiates. The findings of our study are more in agreement with those of the Australian study [21]. In terms of alcohol and cannabis use, a recent study from the USA by Derefinko et al. showed that rural students were less likely to use them as beginners than their urban counterparts [22]. According to an article published in the USA by Bunn et al., most fatal crashes were reported from rural areas, but there was no significant variation in alcohol or drug testing of fatally injured drivers between rural and urban areas [23]. According to our study, about two-thirds of participants from rural areas tested positive for substance abuse, compared to 45% of those from urban areas. In terms of individual substances, rural areas accounted for about 58% of alcohol-positive cases. We also found that cannabis-positive cases accounted for 59.1%, benzodiazepine-positive cases for 75%, and opium-positive cases constituted almost 83% of injured drivers. This could probably be due to the greater availability of psychotropic substances in the urban setting. Considering the above findings, alcohol is the main substance abused in rural areas, while in urban areas, it is often used in combination with other drugs. Most participants in this study had formal education (66.5%), with 26.5% being graduates and 6.4% postgraduates. Only one participant was illiterate. In a similar study conducted in India, Farooqui et al. found that 56% of cases were at the junior college level, and 16% were graduate and postgraduate students [24]. Our study found that 8% of participants were unemployed, 26.5% were self-employed, 20.6% worked in service, 16% worked as labourers, and 8.2% worked as commercial drivers. The unemployed category also included students and housewives. Self-employed individuals included those who ran their own businesses. The study by Farooqui et al. reported findings that were consistent with our study [24].

Iranian researchers Divsalar et al. [25] found a significant correlation between substance use and low education levels in a study conducted in a similar setting. We find this study to be in accordance with our findings. According to the epidemiological study by Ghulam et al. [26], with literacy rates rising, abuse rates increase as well. The authors explained that illiterate and low-income groups have less purchasing power compared to literate and high-income groups. In contrast, the lower incidence of substance use among highly educated individuals may be due to increased awareness about the harmful effects of substance use [26]. In our study, 14% of participants were in a life-threatening condition. Among those with non-life-threatening injuries, 49.3% tested positive for substance abuse, while 79.2% of participants with life-threatening conditions tested positive for psychotropic substances, showing a statistically significant difference between the groups. According to Odoardi et al., drug abuse was more prevalent among fatally injured drivers than non-fatally injured drivers [27]. This is consistent with our study findings. The use of psychotropic substances is harmful to an individual's health and destroys the harmony of the family. In addition, it damages the social and economic status of both the family and society. Driving under the influence of these substances can lead to injury and death for the driver, as well as for other road users, and this, in turn, can cause an economic burden on society.

Recommendations

Although Indian law prohibits the use of alcohol and drugs while driving, drug testing is rarely conducted. India penalises drunk drivers through roadside breath alcohol testing; however, no protocols are in place to screen for other psychotropic drugs. Further research involving quantitative analyses of substances abused by drivers involved in vehicle crashes is needed.

Limitations of the study

Psychotropic substances were only screened for in injured drivers, without a control group. Therefore, it is difficult to determine whether injured drivers use psychotropic substances more frequently than the general population. Testing positive for a drug does not necessarily indicate driving impairment, as the time and dose of drug intake may have occurred many hours before urine sample collection. Some drug screening tests detect inactive metabolites of abused drugs, and cross-reactivity can produce false positives in immunoassays.