Who are they that drink and drive?

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“Who are they that drink and drive?”

By Carol Ann Worthing, Ph.D.

Re-Printed from: The Forensic Therapist, Vol. 5(2).

Driving while impaired (DWI) represents one of America’s most insidious social problems. In 2002, the Federal Bureau of Investigation (FBI) reported that the nearly 1.5 million (1,461,746) arrests for driving while impaired accounted for 10.6% of all arrests. Estimates indicate that only one arrest is made for every 300 to 1,000 drunk-driving trips (Voas and Lacey, 1989). According to the National Highway Traffic Safety Administration (1996) and the National Institute on Alcohol Abuse and Alcoholism (1996), approximately three in five Americans will be involved in an alcohol-related crash at some point in their lives. Over 60% of nighttime, weekend, and single vehicle crashes involve a driver, pedestrian, or a bicyclist with a positive blood alcohol concentration (BAC) (Fell, 1990). Fatal crash risk nearly doubles with each 0.02% increase in BAC (Zador, 1991), and is approximately 11 times higher for drivers with BAC levels of 0.08% than for drivers with zero BAC levels (Hingson & Winter, 2003).

The most recent comprehensive Colorado statistics on DWI offenders was submitted by the Alcohol and Drug Abuse Division (ADAD) for fiscal year July 1,2002 to June 30, 2003. During this time period, almost 40,000 individuals were arrested for DWIs, DUIs, or DWAIs. In the Drinking Driver Program, 36,926 clients were evaluated and assessed. Agencies licensed by AD AD treated 28,194 DWI clients with a 74% completion rate (ADAD, 2003). According to ADAD (2003), Colorado ranks 16% higher than the national average in per capita consumption of beverage alcohol. In 1999 Coloradoans drank 2.1 gallons per person of absolute alcohol compared to 1.77 gallons per person nationally (ADAD, 2003). Nationwide, Colorado ranks fifth on the Alcohol Problem Index (McAuliffe, Mellitt, LaBrie, Woodworth, Stablein & Haddad, 2001).

Little systematic research has examined the substance abuse and dependence of convicted DWI offenders (Lapham, Smith, C’de Baca & Chang, 2001). No specific data was found for the prevalence of alcohol abuse and dependence among Colorado DWI offenders. Past efforts to assess the definitive abuse and dependence status of DWI offenders have been seriously limited by inconsistencies in the terminology used to specify drinking behavior (e.g., problem or social drinkers, alcoholics). Instead of using collective measures that are often indicative of the research instrument used, established psychiatric diagnostic classifications, such as the most current edition of the American Psychiatric Association’s DSM criteria for alcohol abuse or dependence, should be used. Assessment and differentiation between non-problem drinkers with no prior DWI offenses and those diagnosed with alcohol abuse/dependence and/or prior offenses and/or higher BACs are valuable in tailoring education, therapeutic interventions, and other sanctions for those likely to re-offend.

This study was an investigation of alcohol abuse and dependence among Colorado DWI offenders. The correlation between BAC level at time of arrest and number of self-reported lifetime DWI offenses was examined among the DWI subjects for the following three categories of alcohol use: 1) no alcohol abuse or dependence, 2) alcohol abuse, or 3) alcohol dependence. Hypothesis One stated that the category of alcohol use us estimated to be found in the following incidence in the Colorado DWI offender population: 10% no abuse or dependence; 30% abuse; and 60% dependence. Hypothesis Two stated that there would be a positive relationship between category of alcohol use and number of self-reported DWI offenses. Hypothesis Three stated that there would be a positive relationship between category of alcohol use and B AC level at time of arrest. The frequencies of demographic and other informational categories were also investigated.

This study was conducted with DWI offenders who were arrested under the DWI laws prior to July 1,2004. A Driving While Impaired (DWI) offender was someone cited with a Driving While Ability Impaired (DWAI) (observed erratic driving and BAC level range was .05 to .099%); a Driving Under the Influence (DUI) Presumptive (observed erratic driving and BAC was .10% or greater); or a Driving with Excessive Content (DUI per se) (BAC of .10% or greater) (Wanberg, Milkman & Timken, 2002). The blood alcohol concentration (BAC) is operationally defined as the percentage of alcohol in deciliters of blood (Carson-DeWitt, 2003). For purposes of this study, BAC level at time of arrest and number of prior DWI offenses were self-reported by the DWI offender.

A total of 180 male DWI offenders from 12 licensed ADAD treatment agencies in the greater Denver, Colorado area were interviewed over the phone using the Triage Assessment for Addictive Disorders (TAAD) screening instrument. These DWI offenders were male, 18 years of age or older at the time of arrest and were participants or had recently completed one of three groups, Level I or II Education or Level II Therapy, of the “Driving with Care Program” (Wanberg, Milkman & Timken, 2003a, 2003b, and 2003c).

The TAAD was chosen because it documents distinct profiles of a dependence syndrome for alcohol (Hoffmann, 2000), has existing reliability measures of .81 to .84% for abuse and over .92% for dependence (as measured by the current DSM criteria), and could be delivered over the phone.

In response to the TAAD, the participant variable (alcohol abuse, alcohol dependence, or neither) appeared in the sample of 180 at the following incidence: 25% (n = 45) no abuse; 11.7% (n = 21) alcohol abuse; and 63.3% (n = 114) alcohol dependence. Of those participants who were alcohol dependent, 58.3% (n = 105) also met the criteria for alcohol abuse. A Chi-Square test was used to analyze the data and evaluate the hypothesis that the category of alcohol use was estimated to be found in the following incidence in the Colorado DWI offender population: 10% no alcohol abuse or dependence; 30% alcohol abuse; and 60% alcohol dependence. The test was significant, X2=6l.0, p< .0001; and the results were not consistent with the research hypothesis. This balance was relatively consistent through age, ethnicity, employment, and marital and income status. Among non abusers, the frequency of DWI offenses was greatest for those with an income of $50,001 and above (40 8%. n = 20) whereas the frequency of  DWI offenses for those who were alcohol dependent was consistent across income. The presence of disposable income may contribute to the frequency of DWI offenses among non abusers; whereas the chronic nature of dependence may have been reflected in its consistency across income.

The number of prior self-reported DWI offenses of all 180 participants ranged from zero to nine. These prior offenses occurred with the following frequency: 40.6% (n = 73) reported no priors; 36.7% (n = 66) reported one prior; 16.7% (n = 30) reported two priors; 3.9% (n = 7) reported three priors; and four, five, six, and nine priors were respectively reported by a total of 2.4% (n = 4). Of non abusers, 53.3% were repeat offenders; 62% of alcohol abusers were repeat offenders; and 61.4% of those who were alcohol dependent were repeat offenders.

An ANOVA was conducted to evaluate the hypotheses that there would be a positive relationship between the category of alcohol use and number of self-reported DWI offenses. The ANOVA groups and their three means were: (1) no abuse (M= 0.78); (2) abuse (M= 0.86); and (3) dependence (M= 1.04). The ANOVA was non significant, F(2)=1.855, n.s., and the results were not in agreement with the research hypothesis (no abuse, M= 0.78, SD = 0.85, Std. Error = 0.13; abuse, M= 0.86, SD = 1.11, Std. Error = 0.24; and dependence, M=1.04, SD = 1.28, Std. Error = 0.12). Though not significant the results did vary in the direction hypothesized. The likelihood of treatment resistance, readiness to change, the prevalence of antisocial personality factors, the presence of untreated dual-diagnoses, drinking habits, or treatment matching issues (Wieczorek, 1992) may account for these moderate to high percentages of recidivism.

The BAC level was reported for 87.8% (n = 158) of the sample with a range from .05 to .35% (M= . 1667, SD = .06049, and Mode of. 10%). The means for each category of use were: no abuse, .1369; abuse, .1618; and dependence, .1782). An ANOVA was computed to evaluate the hypothesis that there would be a positive relationship between category of alcohol use and BAC level at time of arrest. The results were positive and significant, F(2)=6.734, p = .002 and were in agreement with the research hypothesis. Tukey HSD post hoc tests were conducted to evaluate pairwise differences among the means. There was a significant difference in the means between alcohol dependence and no alcohol abuse/dependence (p < .05). The difference between the means of alcohol abuse and dependence, and no alcohol abuse/dependence and abuse was not significant.

An additional Chi-Square test was conducted of the 22 participants (12.2%) who were not aware of their BAC level at time of arrest because they refused to be tested, or were partially or completely unconscious. The category of alcohol use was examined in this sample and produced the following incidence: 40.9% (n = 9) no abuse; 4.5% (n = 1) abuse; and 54.5% (n = 12) dependent. The results of the Chi-Square were non significant, X2(2)=4.321 when comparing the 22 that did not know their BAC to the full sample with regards to categories of alcohol use. There is no significant difference among categories of alcohol use. Regardless of category of alcohol use, subjects were equally unlikely to know their own BAC at time of arrest and therefore refuse a BAC level test.

Of the total 180 participants, 48.9% (n = 88) reported they quit drinking within one month of their DWI offense; 17.2% (n = 31) within six months; 16.1% (n = 29), more than six months after; and 17.8% (n = 32) did not stop drinking after their DWI. Of those who did not stop drinking, 72% (n = 23) were alcohol abusers or dependent. Those who reported they did not discontinue drinking after their DWI offense attributed their reasoning to one of the following: they didn’t think they had a drinking problem; they drank but stopped drinking and driving; or drank less since their DWI offense.

A comprehensive picture of the demographic subgroups of this study was similar to the trends and frequencies reported by the Colorado ADAD male DWI offender statistics for 2003. For both, DWI offenses were most frequent among those who are White, employed, age 21 to 34, and single (whether never married, separated, divorced, or widowed) with 12 or more years of education.

This study indicates the majority of DWI offenders are not social drinkers; they are seriously impaired by their alcohol abuse and/or alcohol dependence. Compared to the American Psychiatric Association’s DSM-IV-TR (2000) text revision prior 12-month rate of 5% and a life-time rate of 15% for alcohol dependence in the U.S. general population, the incidence of alcohol abuse (11.7%) and alcohol dependence (63.3%) of DWI offenders in this study is substantial (75%). Seventy-eight percent of those positive for alcohol dependence (n = 89) met five or more criteria for alcohol dependence; 57.8% (n = 66) met 6 or 7; and 30.7% (n = 35) met all 7 criteria. Of those subjects positive for alcohol abuse, 100% (n = 21) met 2 or more criteria for alcohol abuse; 76.1% (n = 16) met 3 or 4 criteria; and 19% (n = 4) met all criteria.

From no alcohol abuse to alcohol abuse to alcohol dependence, the BAC and numbers of priors increase. The number and prevalence of DWI offenders who continue drinking while in treatment and on probation should be of concern to the judicial system and to treatment agencies. In essence, this length of time represents how long DWI offenders took to comply with their directive not to drink while on probation. For the first month after their DWI offense, 51.1 % (n = 92) of subjects were violating their probation by continuing to drink; within the first six months of their DWI offense, 33.9% (n = 61) of subjects were continuing to violate their probation; and 17.8% (n = 32) of subjects did not stop drinking and continued to violate their probation. Of those who did not stop drinking, 12.5% (n = 4) were alcohol abusers and 59.4% (n = 19) were alcohol dependent. This prevalence may be reflective of an antisocial attitude toward compliance, lack of adequate education and/or treatment, the difficulty of discontinuing drinking, and/or the complexity of enforcement. The implication is that until discontinuance takes place, the possibility of drinking and driving (recidivism) is present, in addition to the potential for more severe consequences.

Recommendations

Extensive evidence suggests that alcohol abuse and dependence occur more frequently with coexisting Axis I (National Institute on Alcohol Abuse and Alcoholism, 1994; Regier, Farmer, Rae, Locke, Keith, Judd & Goodwin, 1990; Ross, Glaser & Germanson, 1988) and Axis II disorders (Rounsaville, Kranzler, Ball, Tennen, Poling & Triffleman, 1998) than they occur alone. This psychiatric co-morbidity may prompt DWI offenders to self-medicate their symptoms through chronic alcohol use while their chronic alcohol use condition contributes to the persistence of  their psychiatric condition (Verheul, Kranzler, Poling, Tennen, Ball & Rounsaville, 2000). Research has confirmed that individuals with alcohol abuse or dependence and antisocial personality (ASP) have an earlier onset and a more severe course of abuse or dependence compared to those with no other psychiatric disorders (Liskow, Powell, Nickel & Penick, 1991). Knowing the DWI offenders’ diagnosis of alcohol abuse or dependence is just the beginning of uncovering the mental health complexities that are present in people who commit DWI offenses.

If alcohol abuse and dependence are best considered a chronic condition, acute care strategies for DWI offender offenses may be an effective treatment strategy for the DWI offender with no alcohol diagnosis; however, an extensive aftercare approach is a more appropriate treatment intervention for those who are alcohol abusers or alcohol dependent (McLellan, 2002) whether co-occurring mental disorders are present or not present. These DWI offenders often remain in the criminal justice system because their disorders make it very difficult to complete probation satisfactorily on their own and are likely to recidivate (Godley, Finch, Dougan, McDonnell, McDermeit & Carey, 2000). From a fiscal perspective, treatment imposes a lower cost on society than the costs of recidivism, re-arrest, court, incarceration, probation/parole, criminal activity, and victimization (Godley et al., 2000).

While Colorado DWI offenders are evaluated using a checklist based on the most current American Psychiatric Association’s DSM criteria, Colorado probation evaluators do not use a screening instrument with established internal consistency or reliability for abuse or dependence such as the TAAD instrument. Without a reliable validity, a diagnosis cannot be accurately made. Without that diagnosis, Colorado does not and cannot track the valuable information about DWI subgroups that is needed for assignment to treatment. Considering almost 40,000 DWI arrests were made and 28,194 DWI offenders were treated in Colorado in 2003 (ADAD), this presents a significant need. Thus, it is strongly recommended that Colorado DWI evaluators fully assess DWI offenders for alcohol abuse, alcohol dependence, or neither with a diagnostic instrument that has a reliable internal consistency, based on the most current edition of the American Psychiatric Association’s DSM criteria for alcohol abuse and dependence. It is recommended that the collection of that data be used to refer DWI offenders to an appropriate treatment path which may extend to supplementary therapeutic interventions for the chronic care needed for alcohol abuse/dependence and/or other mental health disorders. These individual treatment plans may go beyond DWI education and therapy treatment groups. The clinical course needed may extend to relapse prevention, intensive outpatient, or anger management groups; one-on-one psychotherapy; and mental health evaluations to assess additional mental health aftercare.