Asleep at the Wheel: Drowsy Driving as a Public Health Crisis

This post originally appeared in CommonHealth , a blog of WBUR/Boston.

It’s midafternoon and I’m fighting to keep my eyes open. It’s a matter of life and death. That’s because I’m northbound on I-93, going 65 miles an hour — with many cars passing me.

Once or twice on the monotonous two-hour drive, a jolt of adrenaline surges through my bloodstream as I suddenly realize I’ve actually drifted off for a micromoment. Thankfully I get home without killing myself or anybody else.

If you say you haven’t had the same experience behind the wheel, I don’t believe you.

The National Highway Transportation Safety Administration (NHTSA) says there were more than 72,000 documented accidents involving drowsy drivers between 2009 and 2013. But that’s just from official police reports, so experts say it’s a gross under-estimate.

After all, there’s no sleep-a-lyzer test for drowsiness like the blood alcohol-level test for drunk drivers. And it’s harder for a cop to spot a drowsy driver than one distracted by a smart phone.

“Twenty to twenty-five percent of all crashes could be fatigue-related — drowsy drivers,” says Dr. Mark Rosekind, the NHTSA administrator. “We could be looking at over a million crashes and potentially up to 8,000 lives lost.”

Rosekind made those remarks during a webcast this week sponsored by the Harvard T. H. Chan School of Public Health and The Huffington Post. The discussion included HuffPost editor-in-chief Arianna Huffington, Harvard sleep expert Charles Czeisler, and Jay Winsten, associate dean for health communication at the Harvard Chan School.

The forum is part of a national campaign against drowsy driving that’s just getting underway.

The idea is to treat drowsy driving as the public health issue that many believe it is and to bring to the campaign the same strategies that stigmatized drunk driving. Winsten master-minded that effort 28 years ago when he coined the term “designated driver” and nagged movie and TV producers to insinuate it into their scripts.

I moderated the online discussion. Here are some highlights:

The Brain Split

Czeisler, who’s the head of the division of sleep and circadian disorders at Brigham and Women’s Hospital, says the sleep-deprived brain can split itself in two. One part goes through the motions of a “highly over-learned task” such as driving. Meanwhile, cognitive centers involuntarily transition from wakefulness to sleep.

“So it’s particularly concerning that 56 million Americans a month admit that they drive when they haven’t gotten enough sleep and they’re exhausted,” Czeisler says. “Eight million of them lose the struggle to stay awake and actually admit to falling asleep at the wheel every month.”

My powerful mid-afternoon drowsiness was typical. “It used to be thought that [drowsiness-related crashes] only happened at night, but that’s because people weren’t looking,” Czeisler says. “Most sleep-deficient driving incidents happen during the daytime because there are so many more drivers on the road.”

And there’s a physiological factor. Mid-afternoon is before the brain’s internal clock “has given us a second wind to help us stay awake in the evening,” he says.

Who Falls Asleep Most?

Three groups are particularly vulnerable to falling asleep at the wheel, Czeisler says: young people, night-shift workers, and the millions of people who suffer from sleep apnea.

“Young people think that because they’re young, they’re fit, they can do anything,” the Harvard sleep researcher says. “But actually, young people are the most vulnerable. More than half of fatigue-related accidents are in people under 25 years of age.”

It’s not because – or not just because – they’re out carousing. There’s a biological reason. As we age, the brain’s “sleep switch” – the cluster of neurons in the hypothalamus that governs the transition from wakefulness to sleep – gets sluggish. That’s why many older people have trouble falling asleep. But young people’s brains have an efficient sleep switch that can “seize control” and cause involuntary sleep in the face of sleep deprivation.

“When we keep an 18-year-old awake all night and compare that to keeping a 70-year-old awake all night, the 18-year-old will have 10 times as many involuntary lapses in attention,” Czeisler says.

Many studies show that the nation’s nearly 10 million night-shift workers, who have disrupted sleep patterns and often suffer from sleep deprivation, are much more likely to crash their cars – especially on their way home after a shift. The Harvard researchers had night-shift workers drive on a test track at the time they’d be commuting home and found nearly 40 percent of them had a near-crash event.

Sleep apnea — pauses in breathing that disrupt deep sleep, often many times a night – afflict one in three men and one in six women. The vast majority don’t know they have it.

Czeisler’s group recently found that truck drivers with sleep apnea are 400 percent more likely to have a serious, preventable crash.

Driverless Cars: A Fix?

One powerful argument for driverless cars is they’ll prevent crashes, especially by drowsy or distracted drivers.

Of course, they’ll have to be perfected first . Then lawmakers and regulators will have to decide whether to allow them on the road. And the public will have to be convinced they’re safe. There are sure to be bumps along that road.

Rosekind, the NHTSA chief, says we can’t wait.

“If you had the perfect self-driving car tomorrow … it takes 20 to 30 years for new technology to fully penetrate our vehicle fleet,” he says. “So you can’t have this tomorrow.”

But technology already exists that could make a big difference. My new Subaru (not a top-of-the-line model) senses traffic flow and keeps me three car lengths behind the next vehicle. It brakes when needed in case I don’t. And it sounds an alarm if I stray outside my lane. (Of course, I still have to stay awake and alert.)

Rosekind says NHTSA has just finalized an agreement with 20 car manufacturers that promises 99 percent of all new vehicles will have automatic braking by 2022. Toyota tells the government its cars will have automatic braking by 2017.

Like ‘Coming To Work Drunk’

Our panelists — admittedly a missionary group — were unanimous in urging immediate action to minimize drowsy driving, not remote technofixes. And that requires changing cultural attitudes about sleep.

Case in point: During a recent NPR interview , Sen. Jon Tester, of Montana, mentioned he’d gotten only two hours of sleep the night before. “That’s plenty,” he told Morning Edition host David Greene. “Sleep is totally overrated.”

That sends Arianna Huffington up the wall. “We have a lot of examples of … bragging about sleep deprivation and congratulating employees for working 24/7,” she says. “It’s the cognitive equivalent of coming to work drunk. And you wouldn’t tell someone, ‘Hey … great, you’ve just had five shots and now you’re at work! Good for you!’ But it’s the same thing.”

But Huffington perceives change. She says business leaders are beginning to recognize the importance of adequate sleep. For instance, the global consulting firm McKinsey & Company , recently published a widely read paper on “The Organizational Cost of Insufficient Sleep.” Aetna, the nation’s third-largest health insurer, is paying employees a bonus if their company-provided Fit Bit shows they’re getting enough sleep.

What To Do Now

The panelists had a wide range of strategies to reduce drowsy driving, such as:

–Require education about drowsy driving on licensure tests, as only two states (New Jersey and Arizona) do now.

–Screen truck drivers and other professional (e.g., bus drivers, train engineers, airline pilots) for sleep apnea and, if positive, require them to comply with treatment.

–Change laws to reflect new scientific consensus that driving with less than two hours of sleep in the previous 24 hours constitutes negligence.

–Incorporate rumble strips on highways to warn drivers who stray out-of-lane.

–Make it OK to take naps.

On that last point, Rosekind notes there’s solid evidence that naps work. When he was at NASA, he did a study that showed a 26-minute nap boosted pilots’ performance by 34 percent and alertness by 54 percent. “A nap is one of the most powerful strategies you can have to boost your performance,” he says.

And what about caffeine? “If you use caffeine correctly – not all the time, but strategically – you can get over a 30 percent boost,” Rosekind says. But don’t rely on super-caffeinated energy drinks to substitute for sleep.

“You can’t paper over this problem with caffeine,” Czeisler says. “The problem is it pushes people to be even more sleep-deprived, and it also interferes with the restorative value of sleep once they do get to sleep because caffeine has a six- to nine-hour half-life.”