Feature Article: Driving and epilepsy: both sides of the argument
In many parts of the US, driving is essential to get anywhere and to be able to participate in the most mundane everyday activities (e.g. shopping for food, going to work, getting the kids to school, going out to the movies, etc.). Not being allowed to drive can affect quality of life, lower self-esteem, affect someone's feelings of independence, and increase social isolation.
However, if a patient with uncontrolled epilepsy drives a motor vehicle, there is a risk for accidents, which could end up damaging property and even injuring or killing the driver and others. In this article we will go over the two sides of this argument and offer some resources.
The reason that the Department of Motor Vehicles has the rules it does regarding driving and seizures is to ensure the public's safety. However, how long driving restrictions should last or whether deciding not to drive is the patient's personal responsibility or whether the doctor must report the patient to the local motor vehicles agency, varies from state to state.
For the most part, driving restrictions are based on expert opinion rather than on actual scientific evidence which may partly explain why different states (and countries!) have different regulations. (Krumholz, 2009). Although all states allow people with epilepsy to drive, the details vary from one place to another. To check your state's regulations you can either contact your local state's Motor Vehicles Department (MVD) or search for the Epilepsy Foundation's database of state regulations on its website (https://www.webmd.com/epilepsy/guide/seizures-driving).
How risky is epilepsy and driving?
Some risks are "somewhat predictable based on identifiable factors, such as relative seizure frequency" (Krumholz, 2009). The main risk factors that have been identified in driving with epilepsy include: *Not taking prescribed medications in the way the doctor recommended or missing regular medical visits, * recent alcohol or drug abuse, * frequent seizure recurrences after seizure-free intervals, * prior crashes caused by seizures.
So, should someone with epilepsy be allowed to drive?
If we compare motor vehicle accidents caused by a seizure to accidents caused by alcohol, it is "estimated that the percentage of fatal driver crashes caused by a seizure is only 0.2% as compared with 30% caused by alcohol" (Sheth et al, 2004; National Center for Health Statistics). In fact, in people with epilepsy it is estimated that only 11% of all car crashes are due to seizures themselves (rather than medication side effects or lowered levels of alertness). However, possibly due to epilepsy stigma, it has been pointed out that seizure disorders are reported at a disproportionate level compared with other equally serious neurologic conditions, such as Parkinson's disease, migraines, and sleep apnea. And let's not get started with the number of accidents caused by cell phone use and other distractions while driving.So, while having a seizure while driving is dangerous, it appears that the risks are somewhat circumscribed. However, it has been demonstrated that "the risk for any type of crash is estimated to be nearly two-fold higher for people with epilepsy than for the general population." So, we can conclude from all this data that it seems that current regulations that do not allow drivers with active epilepsy to drive, but permit drivers with controlled seizures to drive, are warranted.
How long should driving restrictions be?
It was found that a 12-month seizure-free interval restriction was estimated to prevent about 80% of all crashes associated with seizures. In contrast, a 3-month seizure-free requirement was estimated to prevent about 50% (Krumholz, 2009). New Jersey has a 6-month driving restriction and mandatory-physician reporting while New York has a 12-month driving restriction but does not have mandatory-physician reporting.
What is mandatory reporting by physicians?
Some states hold doctors liable if they were aware that a patient had an epileptic seizure and did not report it to the state. Basically, these states expect a doctor to contact the Department of Motor Vehicles as soon as they can, informing the state that the patient had a seizure. The patient's license is officially revoked as a result and the patient receives an official notice in the mail (which can be a shock). Most doctors are opposed to mandatory reporting because it negatively affects the patient-doctor relationship. Patients frequently feel betrayed and can become angry at the doctor. Because patients are afraid of being reported, they may not tell the doctor if they had a breakthrough seizure. As a result, the doctor cannot make necessary treatment adjustments because no seizures have been reported. This is negative for the patient's health and wellbeing and can also increase public risk. Note, New Jersey, Delaware and Nevada require mandatory reporting. Most states rely on patient responsibility and self-reporting. In these states, the doctor explains the risks of driving with seizures to the patient and instructs them to stop driving until they have achieved the state mandated period of seizure-freedom. The patient is expected to self-report to the Motor Vehicle Administration. A study that compared jurisdictions with and without mandatory reporting, found that mandatory physician reporting increased the percentage of patients with epilepsy known to the state but did not reduce the crash rate or really improve the public's safety (McLachlan RS et al. 2007). So, maybe we should do away with mandatory reporting....
Is there anything we can do to make changes?
Physicians can work with their patients and through professional organizations to improve regulations for drivers with epilepsy and seizures. These efforts can be successful. For example, in 2011 and 2012, health professionals and epilepsy advocates collaborated in a workgroup in the State of New Jersey and concluded with a recommendation to the New Jersey Motor Vehicle Commission to ease the restrictive suspension of driving privileges from one year after any seizure event to six months. Their recommendation was heard! This change came into effect on November 19, 2012 and has made a huge difference in the lives of many people with epilepsy. Perhaps this model could be used to tackle mandatory-physician reporting in New Jersey.
What if I want to get a commercial driver's license or pilot a plane?
Driving restrictions for the operation of commercial vehicles are typically more stringent than for other vehicles. However, the US Department of Transportation (DOT) does allow those who have been seizure-free and off medication for 10 years to obtain a commercial driver's license. Check with your local Motor Vehicles Department for additional federal and state laws.
The Federal Aviation Administration (FAA) prohibits anyone with epilepsy from obtaining a piloting license, even if the seizures are well controlled by medications or complete seizure-freedom has been achieved.
How can I get around if I am not seizure-free?
Unfortunately, some patients may never be completely seizure-free. They too need to be able to participate in society and for this to happen, they need to be able to get from point A to B. Therefore, our communities need to establish efficient public transportation options (e.g. trains, buses, subways, trams) and specifically for epilepsy, perhaps state-subsidized or foundation-supported car ride services, car-pooling apps and accessible ride options for persons with medical conditions. In New York and New Jersey, there are ADA (American with Disabilities Act) paratransit programs. In New York, it is called Access-a-Ride (https://new.mta.info/accessibility/paratransit) and in New Jersey, it is called Access Link (https://www.njtransit.com/tm/tm_servlet.srv?hdnPageAction=AccessLinkTo). Lastly, and maybe in the not-so-distant future, we may have access to driverless cars that will chauffer us from here to there without needing our human input.
Allan Krumholz, MD, Epilepsy Curr. 2009 Mar; 9(2): 31--35. doi: 10.1111/j.1535-7511.2008.01283.x PMCID: PMC2673400 PMID: 19421374 Driving Issues in Epilepsy: Past, Present, and Future
SG, Krauss G, Krumholz A, Li G. Mortality in epilepsy: Driving fatalities vs. other causes of death in patients with epilepsy. Neurology. 2004;63:1002--1007
McLachlan RS, Starreveld E, Lee MA. Impact of mandatory physician reporting on accident risk in epilepsy. Epilepsia. 2007;48:1500--1505.
