Challenges in managing driving licence legislation when using B-Phosphatidylethanol to identify high levels of alcohol use in primary care patients: A qualitative study

INTRODUCTION: Swedish physicians have conflicting obligations when managing harmful alcohol use. They are responsible for identification and treatment, while also being legally required to report unfit driving licence holders. B-Phosphatidylethanol (PEth) is a reliable and specific biomarker for alcohol use and a useful tool in the assessment. We explored general practitioners' experiences of using PEth in the context of their legal obligation to report patients with certain alcohol-related disorders to the Swedish Transport Agency. METHODS: Individual interviews were conducted with physicians (n = 20) from 10 primary healthcare centres with different patterns of PEth utilisation. Interview data were analysed using qualitative content analysis. RESULTS: Results encompassed three categories: 1. Struggling to implement the regulations: difficulties in assessing driving fitness when PEth test results indicated high alcohol intake; 2. Managing reactions and roles: physicians struggled to balance legal obligation while maintaining a confidential physician-patient relationship; 3. Navigating dilemmas arising from implementing the regulations: regulations were burdensome to apply and diverse strategies emerged, where some physicians refrained from PEth testing and others avoided reporting. Some relied on standardised management approaches or used the obligation to report as a motivating factor for patients to reduce their alcohol use. CONCLUSIONS: The results reveal that difficulties in complying with the legal obligation to report unfit drivers prevent the systematic use of PEth, obstructing the identification of harmful alcohol use and dependence. Clearer guidance on the implementation of the driving licence regulations and the clinical use of PEth are necessary to support physicians in handling this complex issue.