In Episode 1 of Sleep Review Conversations, three sleep medicine experts share their insights on drowsy driving prevention challenges and solutions. The panelists speak to where change must start, drowsy driving in commercial transportation, prevention technologies, and societal trends.
Push play to stream the audio podcast above. Run time: 25:41 seconds.
From healthcare publisher Allied 360, this is Sleep Review Conversations. I’m Sree Roy, editor of Sleep Review magazine and sleepreviewmag.com.
This episode’s topic is drowsy driving.
Driving while sleepy is similar to driving under the influence of alcohol. Both compromise the driver’s alertness, reaction times, and decision-making skills. But preventing drowsy driving presents unique challenges.
To speak on these challenges and possible solutions are our distinguished panelists:
Nathaniel F. Watson, MD, MSc, is the president-elect of the American Academy of Sleep Medicine (AASM) and is board-certified in sleep medicine and neurology. Dr Watson is a professor of neurology at the University of Washington in Seattle. He is co-director of the University of Washington Medicine Sleep Center and director of the Harborview Medical Center Sleep Clinic.
David Davila, MD, is a National Sleep Foundation board member and medical director at the Baptist Health Medical Center Sleep Center in Little Rock, Arkansas. He is the current chair of the NSF Public Awareness Committee and a member of the Government Affairs Committee.
Jeffrey Durmer, MD, PhD, is an adjunct professor at Georgia State University Department of Health Professions, and co-founder, chief medical officer of FusionHealth, an Atlanta-based sleep health technology company. He is a neurologist, systems neuroscientist, and sleep medicine physician with particular expertise in technology enabled sleep-health delivery systems.
Welcome and thank you for joining me.
SR: We know that more than 1 in 5 fatal crashes involve driver fatigue. That’s according to research from the AAA Foundation for Traffic Safety. But where should change start?
Dr Watson, what is your perspective on this?
Watson: I think one thing we need to do is acknowledge right up front that drowsy driving is dangerous and completely preventable. The American Academy of Sleep Medicine encourages every driver to take responsibility for staying awake at the wheel by making it a daily priority to get sufficient sleep, not driving when sleep deprived, and recognizing the signs of drowsiness. So pulling off the road to take a nap, or get some caffeine, or doing whatever is necessary to not drive while drowsy.
I think you know we have to begin this conversation acknowledging we live, in many ways, in a society that has created a toxic environment for sleep, where sleep is considered non-compulsory. It’s really compromised for all the other activities of life that people consider to be more important. I think this conversation can begin by trying to focus on ways to elevate the importance of sleep to individual health in the general community to the level that they consider diet and exercise.
The Academy is currently focusing its efforts on drowsy driving in younger or novice drivers. What we’re trying to do is to increase awareness of the perils of drowsy driving by getting consistent drowsy driving education into driver’s education curricula across the country. Getting standard materials that are accurate into driver’s manuals. Also trying to get exam questions on the driver’s education exams focused on the drowsy driving issue, in order to bring this to the attention of new drivers right off the bat so they understand the importance of this.
Young drivers are actually the most susceptible to the effects of drowsy driving. Not only are they novice drivers, not only do they not have the expertise and experience in driving, but they’re also susceptible to the effects of drowsy driving more so than more experienced drivers. We feel this is a good group to focus on in order to improve roadway safety.
SR: Excellent response.
Dr Davila, can you talk a little bit about the volunteering that you’ve done at middle and high schools?
Davila: I’ve been involved with the [National] Sleep Foundation for quite a few years now. We’ve been trying to raise awareness about drowsy driving through our Sleep in America poll, and Drowsy Driving Prevention Week. When I go to schools and try to talk about sleep in general, I try to weave in issues about drowsy driving because we also realize that this pertains to teens in particular. We’re trying to figure out how to hone our methods more and more about the driving to make it really resonate with the teens and with the public so that they’ll have buy-in. You know we’ve been talking about this issue for quite a while. We’re trying to get it to stick in some way.
On the other end of the spectrum from just talking to teens directly, we’re, at the Foundation, also interested in some of the law making that’s been going on with drowsy driving. We’ll be proposing our Drowsy Driving Reduction Act this year to all the states to see if they’ll adopt it to analyze whether they need to make laws or tweaks to their policies regarding drowsy driving.
Dr Durmer, do you want to weigh in on where you think change should start for preventing drowsy driving?
Durmer: Sure. Actually the programs that we work with, large multi-national companies and transportation, manufacturing, logistics companies, and many other fields, I think one of the aspects of education that has been quite successful is speaking directly to large employers. They have some of the largest amount of influence on healthcare and healthcare reform, just because they cover so many lives in the United States.
In our programs, we’ve had the experience of educating large groups of employers and employees in the science behind drowsy driving and those associations that were mentioned earlier with things like impairment related to alcohol ingestion; some of the studies that demonstrate the effects of staying up over 15 hours and the impairment of driving tasks; as well as other cognitive impairments that increase the chances of driving accidents as well as other accidents in the workplace. Once companies realize that there are these significant liabilities within their own workforces, that’s one area that does help us to move this agenda of drowsy driving in particular, into the lexicon of the average United States citizen.
SR: Those are some very good points. The next thing I’d like to talk about is, when talking about drowsy driving, transportation workers, such as truckers and pilots, inevitably enter the conversation. Within the next five years, what changes do you think will be implemented in the transportation industry with regard to drowsy driving?
Dr Durmer, what is your opinion on this?
Durmer: Well, it’s actually a very interesting area of rapid development right now in terms of transportation workers. I’ve worked with the FAA work group in 2012 to develop some of the hours of service regulations and even some of the awareness around sleep apnea for pilots and air traffic controllers. In that discussion, it was clear that we have a large amount of work to do just in terms of education in this population.
But in terms of actually combating the causes for drowsy driving, the DOT (the Department of Transportation) and its agencies, like the FAA and FMCSA, already have rules in place that specify hours of service for transportation workers in various positions. Groups like the FMCSA are actively in the process of developing, with formal rulemaking procedures, as mandated by President Obama in 2013, how to handle other causes for drowsy driving, like prevalent sleep disorders such as obstructive sleep apnea.
I think in the next five years what we’re going to see is concise rules that are regulating the behaviors of transportation workers through hours of service logging that are all electronic at this point, as well as obstructive sleep apnea screening, testing, and management. The real issue is getting those folks that are walking around not understanding that they have a risk for safety, but also their health, get them to the right medical management, and help them stay on therapy over the course of time. That’s something I think for sure we’ll see in the next five years.
Other things that may also come into awareness will be more technologies. Technologies that offer a range of awareness enhancement for the roadway, for other drivers, objects and obstacles that appear or that suddenly appear within the driving scene. There are going to be also technologies that improve detection of the condition of the drivers themselves, just like we have alcohol detection systems currently in use in automobiles, just to turn on the vehicle; we may have some that also help us with detection of fitness for duty related to fatigue.
Certainly these are not going to be standardized, but certainly they are going to be technologies that will be put into place, similar to how Mercedes and Daimler Chrysler are doing this with trucks and cars with radar systems for brake assist. They’ll be probably more related directly to the drivers themselves.
SR: Would anybody else want to weigh in on what they see for the future of transportation workers and drowsy driving?
Watson: I’ll weigh in on that. I agree that the hours of service regulations are an important step in the right direction here. This is a huge problem. On US roads in 2012, there were nearly 4,000 deaths involving large trucks, which comes to about 11 deaths per day. Clearly this is an area that we really need to focus on and make progress. The FMCSA is estimating that this hours of service rule will prevent nearly 1,500 crashes and save 19 lives per year.
One issue with the hours of service rule, however, is the fact that the truckers that reach the 70 hour limit are required to rest for 34 consecutive hours, which ostensibly allows enough time for two nights of recovery sleep. Of course, at the end of the day, it’s up to the trucker whether or not they’re spending that time sleeping. I think once again the onus is on us to elevate the importance of sleep and really drive the message home so that these truckers will use that time wisely and get the sleep that they need.
The other thing is healthy sleep requires not only adequate duration but also appropriate timing and the absence of sleep disorders. We really need to focus on screening these truckers for sleep disorders such as sleep apnea. I think that will be an important component of making headway on this issue.
The other development that’s important is the creation of the North American Fatigue Management Program for the commercial motor carrier industry, which provides comprehensive educational resources that address fatigue, prevention, and management, and also addresses this notion of screening for sleep disorders and helping with appropriate scheduling of work shifts. I think progress is being made in these areas and hopefully this will continue.
(Editor’s Note: Dr Davila provided some additional insights on hours of service for our readers, pasted below. As these insights were provided after taping, these are not included in the audio podcast itself.)
Davila: The other panelists did factually note that hours of service for trucking pertaining to the 34-hour-forced rest issue had been changed from a discretionary option per FMCSA and forced into the rulemaking process, per President Obama’s order. It should be noted this was a significant loss to those who had labored for years to try to improve truckers’ hours of service conditions by limiting their exposure time on the road when they would be sleepiest and at risk for drowsy driver crashes. The better news was that the FAA flight surgeon did retain such discretionary authority over pilots’ hours of service. Another loss was the shelving of the automatic triggering of a sleep study for OSA if the body mass index (BMI) is more than 40. While some in industry will criticize individual proscriptions targeting hours of service and BMI, others believe they form important parts of overall fatigue/risk management programs. Indeed a number of larger trucking companies, such as Schneider, do have active programs that address these issues. I know from discussions with my local occupational-med physicians that they send drivers for testing based on their overall clinical suspicion, no matter what the BMI.
SR: Let’s discuss some of these technologies that were alluded to. So there are several new technologies that claim to prevent drowsy driving, for instance by tracking driver movements and sounding an alert when movements begin to deviate from the norm. Should drowsy driving technology be legally mandated? Dr Davila, what is your take on this?
Davila: We at the Foundation are excited by some of the developments in these in-cab monitoring systems and have been following it and think that they are getting a good look from NHTSA and are showing some efficacy in testing. The question is going to be: Are they ready for prime time out on the road? Obviously some car manufacturers have already gone there and many drivers are opting for them.
The big question still remains: If a coffee cup flashes up on your dashboard screen, are you really going to react appropriately? Are you going to get off and go to the rest stop? I think this is a help, this is going to be a prompt for drowsy drivers. We just hope that we can get the message through so they will take appropriate action.
SR: Good point. Does anybody else want to weigh in on if you think drowsy driving technologies should be mandated?
Durmer: Sure, I could say something on that. In particular, one of the things that we’re talking about here are technologies that compensate for drowsy driving. That’s something I think it’s important to make clear. The technology about movement of the head or eyes or even the car and the position of the individual in the car or truck is really only there to mitigate urgent changes in the environment. Some of the technology, even things like back up cameras or radar detection systems, are great, but they don’t actually directly impact drowsy driving itself.
One of the areas of technology development that I believe is coming, that I think is going to be even more important, but perhaps not legally mandated, is how do we predict and prevent drowsy driving itself? In that regard, I think what Dr Watson and Dr Davila both said earlier in terms of us being able to figure out who are those folks that are at highest risk before they get themselves into a position of drowsy driving; that’s where we need to also put a lot of our effort. Some of the population management technology out there that is starting to emerge to detect people who are at higher risk for things like drowsy driving. I think that’s where we’re going to get a significant effect.
Just like Dr Davila mentioned, having a coffee cup show up on your dashboard really may not do anything. Perhaps it’d be a lot better if it also had the annoying sound like a seat belt alert, then people would do something to stop the sound. That’s really only at the moment of the drowsy driving itself occurring. So is there a way to prevent or predict those people that would be at highest risk such as people with sleep apnea, undiagnosed sleep disorders, or even hours of fatigue prior to them getting to those hours? That’s the sort of thing that I think that technologies coming soon will also be a major benefit for individuals in the driving public.
Watson: I’d just like to piggy-back on that message because I totally agree. We need to be working to avoid the situation where such technology is needed and just focus on making sure drivers are not in a position where that type of technology would have to come into play. I think one of the issues is the notion that we don’t really have a great biomarker, a roadside biomarker, of drowsy driving at present. This is really touching more on enforcement.
You have Maggie’s Law in New Jersey, which deems it illegal to drive while drowsy. If you should accidentally kill somebody, you could be culpable for vehicular homicide. The problem is: How do you prove that somebody was driving drowsy? You may have some on-board technologies that can help give some information in that regard, touching on braking and steering wheel movements, and things like that prior to the accident. Of course, whether or not that type of information that’s built into a car would be used in a courtroom is an ethical issue that probably would need to be discussed as well. I think the sleep community needs to work to try to find a good roadside biomarker, call it a “sleepalyzer” if you want, that could really move this field forward.
The other thing regarding technology that I think is on the horizon—that is not necessarily something that would be mandated but would have a potentially large impact on drowsy driving—is the notion of self-driving cars. That is the kind of thing that obviously could flip this whole issue, at least for non-commercial drivers, on its head, where we take drowsy driving really away from the issue and could potentially allow a person to catch up on their sleep while their car is driving them to work. That’s kind of futuristic, but I think that would be one area where the sleep community would be, I would imagine, in favor of developing technology for self-driving cars.
SR: Great. The final question I wanted to discuss today is that there have been quite a few published research studies showing the consequences of drowsy driving. For example, one found teens with earlier school start times have higher crash rates. To your knowledge, have any changes been implemented in light of scientific research illuminating drowsy driving?
Dr Watson, can you shed any light on this?
Watson: The American Academy of Pediatrics came out with a recent position statement supporting school start time of 8:30 or later for high schools. There’s a lot of good evidence to suggest that if that change is made, that would positively impact on the health and well-being of teenagers, not only from a driving perspective, but also from performance in school, mood, and other health-related issues.
This is really a community by community type of initiative. Change is really only made here if you have a coalition of knowledgeable sleep experts along with community leaders and parents that spend a lot of time at school board meetings convincing the leadership that this is a good thing for their students. It’s a multifaceted issue because it really affects busing schedules and athletic schedules in the afternoon. There are a number of issues that need to be dealt with in order to achieve the goals of later start time. It’s certainly a worthy pursuit.
Perhaps the most important thing that’s been done in regard to novice drivers, which I think touches on the drowsy driving issue, is the notion of graduated driver’s licenses, where states prevent young drivers from driving at nighttime hours. Obviously, having that stipulation and that law really reduces drowsy driving as this would be most likely to be occurring at those hours.
SR: Excellent response. Would anyone else like to share anything related to scientific research and drowsy driving or even any final thoughts on this drowsy driving issue today?
Davila: I would just like to say I think the drowsy driving issue is just part of a larger issue of insufficient sleep syndrome that we’re facing with the public. Of course, it directly affects teens. I think that, along with the cognitive and performance issues that we’re worried about with students, this fits in there with the drowsy driving. I think the other stakeholders—insurance companies, safety experts, school boards—they’re all watching this to see where it’s going to go in terms of the drowsy driving. I think this might help push that issue along with school start times.
Durmer: I think I can add a little bit more to this too from the perspective of the need to get the information into the hands of decision makers and working with companies and corporate executives to get them aware of these issues. As Dr Watson mentioned, these are well-researched and well-versed data sets that we know a lot about from the work of Dr Mary Carskadon, Dr Wolfson, and many others who’ve done great work in the area of drowsy driving, particularly with kids. Especially when we know that a third of teen fatalities are related to auto crashes, this is a significant issue.
But getting it to the hands of folks that actually can help to make change is one of the areas that I think all of us in sleep medicine should start thinking about. How do we interact with not just patients or legislators, but how do we interact with folks that can make decisions for large populations like employees? Using data that we have from the NIH, from the CDC, and particularly the CDC Healthy People 2020 initiative (sleep health itself is one of the 42 topics on Healthy People 2020) and getting decision makers to understand that this is already in our public lexicon. Our discussion about public health and that the rate of vehicular crashes is one of the four main tenets to the sleep health initiative.
That’s something that we need to get them to understand, that this is a significant impact on public health and they have also responsibility as employers and as corporate citizens to make change in their populations, not just for wellness, but also for safety and for the benefit of even the economics of their companies. There are a number of studies demonstrating—some estimates from groups like the Brookings Institution—that when we even find children who are sleeping poorly and we increase their sleep time, their outcome and their earnings actually have a significant increase over the course of their lives, just related to those extra hours of sleep. These are data points that we need to get to the folks that can make decisions and really influence policy.
SR: Terrific. I want to say thank you to all three of today’s panelists for your insights on drowsy driving.
Coming up later this year on Sleep Review Conversations, we’ll talk about sleep techs’ evolving roles, pediatric sleep, and insourcing versus outsourcing of home sleep testing. Thank you for listening. Until next time, visit us at www.sleepreviewmag.com for the latest news on drowsy driving and other sleep medicine issues.