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Programs and policies for reducing alcohol-related motor vehicle deaths and injuries.

In Canada, motor vehicle crashes are the leading cause of death among persons under 45 years of age (Statistics Canada, 1996) and the second most prominent cause of potential years of life lost to age 75 (Wilkins and Mark, 1991). Alcohol is a factor in almost half of these fatal collisions (Mayhew et al., 1997). During the decade of the 1980s, however, efforts to reduce the deaths and injuries associated with driving after drinking reached unprecedented levels. New, more stringent laws were passed, the severity of penalties increased, and enforcement became more frequent and effective. The public grew more intolerant of impaired driving, and it became increasingly socially unacceptable to drive after having consumed too much alcohol.

The intensity and diversity of the efforts during the 1980s did not go unrewarded. Population surveys revealed fewer persons were driving after consuming alcohol (e.g., Health and Welfare Canada, 1988; Simpson et al., 1992); the number of drivers charged by police with an impaired-driving offense decreased dramatically (Canadian Centre for Justice Statistics, 1995); and roadside surveys found fewer drinking drivers Mayhew et al., 1996). More importantly, the bottom line changed as well. To illustrate, Figure 1 shows the annual number and percentage of fatally injured drinking drivers in seven provinces in Canada(*) from 1980 through 1995. Between 1980 and 1990 the number of drinking drivers decreased substantially, from a high of 822 in 1981 to a low of 497 in 1990. In 1981 drinking drivers accounted for 62% of all driver fatalities that were tested for alcohol. In 1990 only 43% of drivers involved in fatalities had been drinking (Mayhew et al., 1997). Since then, the large annual decreases in drinking-driver fatalities have been replaced with smaller changes--first increasing, then decreasing. In 1995, 43% of driver fatalities involved alcohol.

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The problem is not limited to operators of highway vehicles. Drivers of other types of vehicles (snowmobiles, all-terrain vehicles, bicycles) as well as passengers and pedestrians also contribute to the problem. To illustrate, Figure 2 displays the number of all motor vehicle fatalities in Ontario and the percentage that involved alcohol for the three-year period 1992-1994 according to the victim and vehicle type. Drivers of automobiles comprise the largest group of motor vehicle fatalities; alcohol was involved in 45% of these cases. Vehicle passengers account for 25% of all motor vehicle fatalities, and just over one-third of these passengers died in a crash involving a driver who had been drinking. In 45% of all pedestrian fatalities, either the vehicle operator or the pedestrian had been drinking. The incidence of alcohol involvement among fatally injured drivers of other vehicles varies considerably, from 15%-20% among drivers of large trucks and other vehicles (e.g., farm tractors) to over 70% among operators of snowmobiles and all-terrain vehicles.

[Figure 2 ILLUSTRATION OMITTED]

Although it is apparent that substantial progress has been made in dealing with the drinking-driving problem, at the same time it is obvious that a problem of substantial magnitude remains. In this context, the major gains experienced in the 1980s have not been evident in the past five years, suggesting that the countermeasure programs and policies that were instrumental in helping to reduce the problem during the 1980s may have reached the limits of their effectiveness. Indeed, some scholars have suggested that the countermeasure efforts of the 1980s had their greatest impact on those who were the easiest to persuade and the easiest to change--i.e., socially responsible light and moderate drinkers (L'Hoste and Papoz, 1985; Moskowitz, 1990). They contend that the challenge for the next decade is to identify programs and policies that will change the behavior of those drinking drivers who persist in the behavior. The remainder of this paper identifies the magnitude and characteristics of this more resistant group of offenders--variously called the hardcore drinking driver, the persistent drinking driver, the chronic drunk driver, the repeat offender--and outlines some of the policies and programs that have the potential to effect change in this high-risk target group.

Who is the hard-core drinking driver?

In recent years the heavy/problem drinker has become widely recognized as an important segment of the drinking-driving problem. Indeed, this group has been the focus of a number of recent conferences, symposia and papers (Simpson and Mayhew, 1991; Simpson, Mayhew and Beirness, 1996; Sweedler, 1995; Wilson, 1991). The key attributes and characteristics of this group:

1. They repeatedly drive after drinking.

2. They often drive after drinking with high blood alcohol concentrations (BACs)--i.e., 150-200 mg% or more.

3. They appear relatively resistant to changing this behavior.

Magnitude of the problem

Determining the magnitude of the hard-core drinking driver problem ultimately depends on the ability to identify members of the target group. In this context, the three criteria used to define hard-core drinking drivers are particularly useful. When these criteria are applied to various groups of drinking drivers--i.e., crash-involved drinking drivers, drinking drivers identified at roadside, self-reported drinking drivers, convicted DWI offenders--it is possible to estimate the magnitude of the hard-core drinking driver problem.

Population surveys

The results of population surveys indicate that drinking-driving behavior is not uncommon. For example, one such survey was the National Survey on Drinking and Driving conducted in Canada during 1988 by Health and Welfare (Simpson et al., 1992). Among respondents who reported that they consumed alcohol and operated a vehicle, 25% reported occasionally driving after drinking. Among these drinking drivers, 51% reported having done so on two or more occasions; 17% did so at least once a week. Using those data it was determined that 90% of all drinking-driving trips were accounted for by frequent drinking drivers--i.e., persons who reported doing so on more than one occasion in the past 30 days.

Hence, although driving after drinking is not uncommon, a relatively small proportion of drivers is responsible for the vast majority of all drinking-driving occasions.

Roadside surveys

Consistent with the findings from population surveys, data from breathtesting surveys conducted at roadside also find that driving after drinking is not uncommon. However, these surveys also find that most drinking drivers have relatively low BACs. The most recent surveys conducted in Canada found that although about 12% of nighttime drivers had been drinking (Mayhew et al., 1996), over 80% of them had BACs below the statutory limit (i.e., 80 mg%). Drivers with BACs in excess of 150 mg% comprised less than 2% of drivers on the road at night. In the 1993 roadside surveys in Nova Scotia and Saskatchewan, only 0.9% of nighttime drivers had a BAC over 150 mg% (Mayhew et al., 1996). In British Columbia in 1995, the prevalence of high BACs was only 0.14% (Beirness, Foss, and Mercer, 1997). These data clearly show that although driving after drinking is not uncommon, drivers with high BACs are found infrequently among the driving population at risk.

Driver fatalities

Although the absolute number of drivers with high BACs is relatively small, they account for a substantial proportion of drinking driver fatalities. Figure 3 presents the BAC distribution among fatally injured drinking drivers in Canada in 1988 and 1995. The pie on the left side of each figure shows that in 1988, 51% of fatally injured drivers tested positive for alcohol; by 1995, this had decreased to 43%. The bar on the right of each figure shows the BAC distribution among fatally injured drinking drivers. In both 1988 and 1995 the vast majority of fatally injured drinking drivers--80% in 1988 and 82% in 1995--had BACs in excess of the statutory limit. Moreover, drivers with BACs in excess of 150 mg%--nearly twice the legal limit--accounted for 59% and 62% of the fatally injured drinking drivers in 1988 and 1995, respectively. Although the overall percentage of driver fatalities involving alcohol has decreased, the proportion with high BACs has actually increased.

It should be noted that drivers with BACs of 150 mg% and over have not simply had a drink or two before getting behind the wheel. Rather, these are persons who have consumed a considerable quantity of alcohol--at least seven or eight drinks in an hour for a 75 kg male. Many are likely either binge drinkers or chronic heavy drinkers who regularly consume large amounts of alcohol and drive afterwards.

DWI offenders

Drinking drivers with high BACs also account for a substantial proportion of all persons charged with a DWI offense. For example, a special study conducted several years ago in Canada found the average BAC among arrested DWI offenders was 170 mg% (Donelson et al., 1985). More recently, in a survey of 19 U.S. states, Simpson et al. (1996) found the average BAC at the time of arrest was 167 mg%. Importantly, the average BAC among repeat offenders was higher than that among first-time offenders. Other studies have demonstrated that high BACs at the time of first offense are associated with a higher likelihood of repeating the offense (Gjerde and Morland, 1990).

Repeat DWI offenders have also been shown to be responsible for a substantial proportion of alcohol-related fatal crashes. For example, in a detailed examination of all fatal road crashes in British Columbia, Donelson et al. (1989) determined that about one-third of drivers responsible for alcohol-related fatal crashes had been previously convicted of DWI. Other studies have reported similar results. In Minnesota, Simon (1992) found that 35% of alcohol-related fatal crashes involved a driver with a previous DWI offense. In New Zealand, Bailey (1993) reported that one-quarter of the drinking drivers fatally injured in at-fault road crashes had a previous conviction for drinking and driving.

Relative risk

The data indicate that drinking drivers with high BACs comprise a relatively small group of drinking drivers, yet they account for a substantial proportion of drinking-driving problems. This group comprises less than 1% of drinking drivers on the road at night but accounts for over 60% of fatally injured drinking drivers. The increased risk of fatal crash involvement for drivers with high BACs can be determined from these two pieces of data: the low frequency of high BAC drivers on the road and the high proportion of fatally injured drinking drivers with high BACs. All other factors being equal, drivers with BACs in excess of 150 mg% are over 200 times more likely to be involved in a fatal crash than the average non-drinking driver. Those with BACs in excess of 200 mg% are about 460 times more likely to be involved (Mayhew et al., 1996; Simpson et al., 1996).

Conclusion

Hard-core drinking drivers represent a significant threat to the safety of all road users. Clearly efforts to change the behavior of this relatively small but high-risk group of drinking drivers could have a tremendous impact on the overall magnitude of the alcohol-crash problem.

Characteristics of hard-core drinking drivers

Numerous studies have examined the characteristics of this high-risk group of DWI offenders that distinguish them from the general driving population. Recent reviews of the literature have identified several prominent demographic, psychosocial and behavioral characteristics that can be used to distinguish hard-core drinking drivers from the general population and create a descriptive profile of this high-risk group (e.g., Beirness, Mayhew & Simpson, 1997; Hedlund, 1995; Simpson and Mayhew, 1991). These reports indicate that hard-core drinking drivers are predominantly male (>90%) and are most likely to be between 25 and 44 years old. Among this group there is a greater proportion of single, separated and divorced individuals than among the general population. Most individuals in the target population have completed high school, and approximately one-third have attended some type of postsecondary educational institution.

DWI offenders who could be considered part of the hard-core group often exhibit a variety of antisocial and deviant tendencies that distinguish them from the general population. For example, studies have shown this population to display significantly higher levels than others on measures of hostility (McMillen et al., 1992), assaultiveness (Wilson, 1992), sensation seeking (McMillen et al., 1992; Wilson, 1992), and depression (Donovan and Marlatt, 1983). Previous criminal arrests (Argeriou et al., 1985) and illicit drug use (Donovan, 1993; Elliott, 1987; Wilson, 1992) are also more common among this group than among the general population.

Perhaps the most universally recognized characteristic of hard-core offenders is the extent of their involvement with alcohol. The literature is replete with references to the high incidence of excessive drinking and its associated problems among this population (e.g., Donovan et al., 1985; Perrine et al., 1989; Vingilis, 1983: Wilson, 1992). To illustrate, in a comprehensive examination of DWI offenders, Nochajski et al. (1994) found that 45% of repeat offenders met the DSMIII criteria for a clinical diagnosis of alcohol dependence; 35% were diagnosed as having an alcohol abuse disorder. In addition, 33% reported prior treatment for alcohol and drug problems, and 54% had a family history of alcohol or drug problems. Evidence such as this serves to demonstrate the high incidence of heavy drinking and alcohol-related problems among hard-core drinking drivers.

The profile of the hard-core drinking driver that begins to emerge from these studies is that of a young-adult to middle-aged male who drinks heavily and exhibits a variety of antisocial and deviant behaviors. This profile of hard-core drinking drivers, although having some descriptive advantages, is an average that belies the substantial variability often found within this group. The fact is that hard-core offenders are indeed a very heterogeneous group. Drivers become hard-core drinking drivers for a variety of reasons, and the reasons for their persistence in the behavior are equally varied. Within this population, various characteristics may be more or less prominent, creating the possibility that there may in fact be definable subgroups.

Several studies have been able to identify distinct and clinically relevant subgroups of DWI offenders (e.g., Arstein-Kerslake & Peck, 1986; Donovan and Marlatt, 1983; Wells-Parker et al., 1986; Wilson, 1991), some of which appear to describe hard-core offenders. For example, Wells-Parker and colleagues classified 353 DWI offenders into five groups on the basis of their traffic and criminal offense records. The largest group, labeled "Low Offense," accounted for 57% of the sample. Although most were repeat offenders, they had the smallest number of DWI and other offenses and were considered the least deviant. Subsequent analysis revealed that they had the lowest Mortimer-Filkins scores (a scale for assessing alcohol problems) and the lowest average BAC at arrest.

The "Traffic" group (16%) was characterized by the highest number of moving traffic violations. They were the youngest group (mean age = 33.1) but were similar to the "Low Offense" group in terms of Mortimer-Filkins scores and arrest BACs. The "Mixed" group (18%) was similar to the "Low Offense" group but had more offenses in all categories.

The two smallest groups, accounting for 4.5% and 4.0% of the sample, respectively, were the most deviant in terms of their previous offenses and alcohol use. One group, referred to as "Public Drunkenness," was distinguished by the high number of DWI public drunkenness, causing a disturbance, and assault charges. The other group, referred to as "License," also had a high number of DWI charges as well as the most license and equipment violations. Offenders in these two groups were older than other offenders, had the highest average BACs at the time of arrest, and had the highest average scores on the Mortimer-Filkins test.

Using a somewhat different approach, Wilson (1991) classified a sample of 523 DWI offenders, high violation drivers, and crash-involved drivers into groups based on three psychological factors: thrill seeking, hostility, and personal adjustment. The analysis revealed four distinct subtypes of offenders, labeled "well-adjusted," "deviant," "irresponsible," and "hostile/responsible." The "well-adjusted" group, almost half (46%) of the sample, displayed relatively low levels of hostility and sensation seeking and the lowest incidence of personal problems.

The "irresponsible" group (22% of the sample) combined good personal adjustment with high levels of hostility, thrill-seeking, and irresponsible values and behavior. The "hostile/responsible" group (19%) was most comparable to the "well-adjusted" group but displayed relatively high levels of hostility.

The group labeled "deviant" was the smallest, accounting for about 12% of the sample. This group was characterized by high levels of sensation seeking, impulsiveness and hostility, a low value on responsibility, and a high incidence of personal problems. Subsequent examination of variables not used in the derivation of subgroups revealed this "deviant" group to score the highest on all measures of alcohol consumption and driving after drinking.

These two studies, based on different samples and using different methods, serve to illustrate the existence of different subtypes of DWI offenders. Some of these typologies appear to fit closely with the definition of the hard-core offender. Even groups of repeat offenders can be classified into relatively distinct subgroups. Research in this area is, however, in its infancy, and considerably more work is necessary to determine the most prominent subgroups of offenders and the nature of the factors that best differentiate them. The value of identifying subgroups of offenders lies in the implications for rehabilitation. The derivation of clinically relevant subgroups would be an essential step in determining which types of rehabilitation programs would be most effective for particular types of offenders.

Programs and policies for effecting change

To a large extent, the DWI countermeasures introduced during the 1980s involved increasing public awareness of the problem, enhancing enforcement, and implementing ever more stringent sanctions for the behavior. These programs, targeted primarily at the general population, were based on the assumption that greater awareness combined with an increase in the perceived probability of apprehension and the threat of severe penalties would deter most people from driving after drinking. But successful as this approach appears to have been in reducing the overall magnitude of the problem, it has had little impact on the hard-core offender. New measures directed specifically at this high-risk target group are needed to effect further reductions in the problem.

A variety of approaches have been suggested for dealing effectively with hard-core drinking drivers. The remainder of this paper outlines two program and policy options for dealing with this target group: assessment and rehabilitation, and alcohol ignition interlocks. One, alcohol ignition interlocks, is intended to prevent offenders from repeating the offense in the short term. The other, assessment and rehabilitation, deals with the problems that give rise to the behavior and is intended to provide a longer-term solution.

Alcohol ignition interlocks

A defining characteristic of hard-core drinking drivers is that they repeatedly drive after consuming large amounts of alcohol. One of the most promising strategies to prevent a subsequent occurrence of DWI behavior among high-risk offenders is the alcohol ignition interlock. This device is a small breath-testing unit installed in the vehicle and linked to the ignition. In order to start the vehicle, the driver must provide a breath sample that registers a BAC less than a preset value (e.g., 20 mg%). BACs in excess of the threshold value prevent the vehicle from starting.

Recent developments in interlock technology and the development of specifications for interlock devices (e.g., Electronics Test Centre, 1992; NHTSA, 1992) have resulted in a reliable and practical device that is available for widespread use. Numerous technological innovations have been implemented to address the concerns of earlier interlock devices, thereby creating a system that can effectively prevent an impaired individual from operating the vehicle in which it is installed.

Interlocks are not intended to replace existing sanctions, but rather to provide an additional option for preventing repeat offenses. Following a period of license suspension, an ignition interlock gives convicted DWI offenders the opportunity to re-enter the driving population legally, with insurance, while at the same time offering some assurance to society that they will drive only when sober. The requirement for periodic service of the interlock also allows for routine monitoring of the offender. In many respects the installation of an ignition interlock can be viewed as part of the transition between full license suspension and full driving privileges. In this context, in recognition of the fact that treatment for alcohol abuse can be a lengthy process with a high likelihood of setbacks or relapses, interlocks provide society with a safety net to ensure that such relapses do not result in an impaired-driving incident. In this sense, alcohol ignition interlocks can serve as a very useful adjunct to alcohol treatment.

A number of studies published over the past several years have demonstrated the effectiveness of ignition interlocks in preventing recidivism among DWI offenders (EMT Group, 1990; Morse and Elliott, 1992; Weinrath, 1997). The participants in these studies were ordered by the court to have an ignition interlock installed. Offenders who participated in an alcohol ignition interlock program had a significantly lower re-offense rate than offenders who did not. For example, the effectiveness of the ignition interlock program in Hamilton County, Ohio, was examined among a sample of 273 DWI offenders selected from a population of repeat offenders, first-time offenders with a BAC of 20 mg% or over, and offenders who refused a breath test. Each interlock participant was matched with a comparison offender on the basis of problem drinker status, number of previous alcohol- and drug-related arrests and previous DWI arrests. After 30 months only 3.4% of the interlock group had been rear-rested for DWI compared with 9.8% of the control group (Morse and Elliott, 1992).

A preliminary examination of the effectiveness of the ignition interlock program in Alberta, Canada, compared the subsequent driving records of the first 1,007 interlock participants (all of whom were repeat DWI offenders) with 11,127 DWI repeat offenders who did not have an interlock installed (Beirness, Marques et al., 1997). Over a 36-month period, only 7.2% of interlock participants had been reconvicted of DWI compared with 22.2% of the comparison group.

Although the results of ignition interlock studies to date show encouraging results, they are by no means definitive. Methodological problems plague studies in this area. Most of the difficulties involve the ability to select a comparison group equivalent to the interlock group. DWI offenders assigned to an interlock program are often those who present the highest risk of reconviction--i.e., those with more prior offenses, higher arrest BACs, or more severe alcohol problems. The inability to find a truly comparable control population actually introduces a bias against finding a positive impact of the interlock. Further evaluation research is necessary, however, to determine which types of DWI offenders are most likely to benefit from participation in an ignition interlock program.

The available research to date also indicates that ignition interlocks have a beneficial impact on recidivism only as long as the device is installed in the vehicle (Jones, 1993; Popkin et al., 1993). Once the device is removed, recidivism rates return to levels comparable to rates of those who did not have an interlock installed. The fact that re-arrest rates increase after the interlock has been removed is perhaps not unexpected, nor should it necessarily be used to discredit or discount the beneficial effects of interlock programs. Many of the offenders assigned to interlock programs have serious problems of alcohol abuse. Interlocks are not intended as a treatment for alcohol abuse. Rather, their purpose is to prevent an individual with a high BAC from driving the vehicle in which the device is installed. The evidence clearly shows that interlocks accomplish this objective. The observed increase in recidivism following removal of the interlock indicates the need to incorporate interlocks into a more comprehensive rehabilitation program that deals effectively with the problems that underlie DWI behavior.

One approach designed to facilitate the long-term success of ignition interlock programs is to incorporate case managers or service coordinators into existing interlock programs. A test of this approach is currently being conducted in Alberta (Beirness, 1996; Marques et al., 1997). The principal objective of the case manager is to facilitate clients' utilization of appropriate health and social services. In this sense the case manager serves to help span the cultural and resource gaps that typically divide the criminal justice, highway safety, health, and social service systems and acts as a liaison between the offender and the health and social service networks. In doing so, the case manager plays the role of advocate, counselor, linkage resource, and behavioral coach to help the offender accomplish the goals of an individualized plan to prevent a return to drinking and driving. In this way, the time on the interlock is not simply time spent waiting for full reinstatement, but rather time spent productively working toward the fulfillment of the objectives of rehabilitation.

Assessment and rehabilitation

The rationale for assessment and rehabilitation is based on the hypothesis that the problem of the hard-core drinking driver could be best resolved by addressing the underlying problems that give rise to the behavior most--notably alcohol abuse.

The first step in this approach involves the assessment--or, at a minimum, screening--of all persons arrested or convicted of a DWI offense. The primary purposes of assessment are to distinguish between low- and high-risk offenders and to identify which offenders are most in need of which types of rehabilitation programs.

The assessment of all DWI offenders is a vital component of the rehabilitation process and is critical for the matching of offenders to treatments (Timken et al., 1995). In the past, rehabilitation programs for DWI offenders have almost exclusively focused on treatment for alcohol abuse/dependence. However, contemporary research suggests that such programs should not be based on substance abuse alone. There is a need to be more comprehensive and to consider factors such as personality and risk-taking behaviors. An effective rehabilitation paradigm must address the critical lifestyle and personality factors that combine to create, shape and perpetuate the DWI behavior. It is therefore essential that the assessment be designed so as to obtain a thorough and complete understanding of the nature and extent of the offender's involvement with alcohol as well as the nature and extent of other contributing problems. In this context, assessment should also include an evaluation of the social, environmental, attitudinal, interpersonal and psychological factors as a means to develop a better understanding of the factors that contribute to the offender's DWI behavior (Timken et al., 1995). In this way the assessment will provide a guide for assigning offenders to the most efficient and effective rehabilitation program (e.g., Landrum et al., 1987; Wells-Parker et al., 1979).

Having identified those DWI offenders deemed in need of some type of rehabilitation program, the next step is to ensure that they receive the appropriate type of rehabilitation. There exist numerous approaches to the rehabilitation of DWI offenders. They vary in orientation, guiding philosophy, content, goals, objectives and duration. No one approach has emerged as the most effective for all offenders. Indeed, different types of programs may be more effective for different subgroups of offenders. It is therefore advantageous to have available a variety of programs to which different types of offenders can be assigned.

Most rehabilitation programs for DWI offenders can be divided into two categories' those that are primarily educational in nature, and those that deal directly with alcohol abuse.

Educational programs have become a very common approach for dealing with convicted DWI offenders. Underlying the educational approach is the assumption that convicted offenders do not have the knowledge or skills necessary to avoid subsequent offenses. Providing offenders with information about alcohol, its effects on behavior, the relationship between amount of alcohol consumed and BAC, and the law concerning alcohol and driving would presumably correct the situation and reduce the incidence of repeat offenses. Although intuitively compelling, a major obstacle to this approach lies in the inability to link, either conceptually or empirically, knowledge about alcohol and a change in drinking-driving behavior (Mann et al., 1983).

Studies of the effectiveness of educational programs for DWI offenders have

typically found the evidence to be at best equivocal (Foon, 1988; Mann et al., 1983). Although some programs have demonstrated modest success among lighter drinkers, the overall effectiveness of such programs is questionable. Most of the beneficial changes that have been reported are in terms of improved knowledge and attitude. Little change is evident in drinking patterns or improved re-offense rates. Recent evidence indicates, however, that there may be a long-term benefit on mortality associated with this type of program (Mann et al., 1993).

The limited effectiveness of educational programs for DWI offenders is undoubtedly diminished by the heterogeneous mix of the participant population. Foon (1998) suggested that many course participants might not have been suitable intellectually, cognitively, or socially for the nature of the programs and therefore failed to derive significant benefit from them. Many of these individuals probably have a severe problem with alcohol and are in need of more intensive treatment.

In recent years an increasing number of jurisdictions have implemented some form of mandatory treatment for alcohol abuse for DWI offenders. The general rationale for having offenders attend an alcohol treatment program is based on the argument that a DWI conviction may be but one manifestation of an underlying problem; most often that problem involves alcohol abuse. The problem might very well pervade all aspects of the individual's life but has come to public attention only as a result of a DWI conviction. From a public health perspective, arrests for DWI could serve as a mechanism for the early identification of problem drinkers, who could then be directed into the health care system for treatment. Conceptually, reducing the extent of problem drinking and/or the alcohol problem through treatment should decrease the incidence of recidivism by reducing the likelihood of drinking to excess.

Approaches to the treatment of alcohol problems are numerous and vary greatly both conceptually and in practice. Various types of programs have been used with DWI offenders, including individual and group counseling, inpatient treatment, Alcoholics Anonymous, disulfiram therapy, behavior modification, and social-cognitive approaches. The length of treatment can also range from a few sessions to several months to a year or more. No one approach seems to have emerged as the most efficient or effective for all types of problem drinkers.

Just as the assessment of DWI offenders needs to go beyond substance abuse, the range of rehabilitation options should not be limited to treatment for alcohol abuse. For example, marital problems, coping skills deficits, and depression are other issues (albeit often related to alcohol) that often appear among DWI offenders and need to be dealt with. This does not mean that new programs need to be developed for every possible problem that may arise. Rather, existing programs within the community can and should be utilized whenever possible.

Evaluation studies of rehabilitation programs that focus on the treatment of alcohol abuse have generally shown positive results. Offenders attending treatment usually show reductions in problem levels of alcohol consumption, fewer alcohol-related problems, and a reduced incidence of recidivism (e.g., Donovan et al., 1990; Neff and Landrum, 1983; Temer et al., 1987; Wells-Parker et al., 1988).

In summary, there exists a wide variety of DWI rehabilitation programs. The effectiveness of these programs varies greatly. None has proven effective for all types of offenders, but some programs appear to have better success with particular groups. Nevertheless, many programs have been shown to have positive results. In fact, a recent meta-analysis of the impact of all types of DWI rehabilitation programs found an average 8%-9% improvement in DWI recidivism and alcohol-related crashes over no rehabilitation (Wells-Parker et al., 1995). However, this estimate of the magnitude of the effect of rehabilitation programs represents an average across all types of offenders and programs. Programs that combined approaches (e.g., education and monitoring) were more effective than single approaches for both multiple and first-time offenders.

Although the effect of rehabilitation programs does not appear to be great and may not match expectations, it is nonetheless substantial and important. When translated into reduced deaths, injuries and crashes, the impact can be significant. Moreover, the demonstration of small positive effects of rehabilitation programs is encouraging and warrants further study and continued effort.

Summary and conclusion

After several years of intensive countermeasure activities, the drinking-driving problem is considerably smaller today than it was when the 1980s began. At the core of the remaining problem is a relatively small group of high-risk drivers who account for a substantial proportion of it. This hard-core group of offenders drives repeatedly after drinking, often with high BACs, and appears relatively resistant to changing this behavior. This paper outlined two of the most promising approaches for dealing effectively with this high-risk group: alcohol ignition interlocks, and assessment and rehabilitation. Alcohol ignition interlocks are generally a short-term measure intended to prevent drivers with high BACs from driving. Assessment and rehabilitation provides a longer-range solution by identifying and treating the problems that give rise to drinking-driving behavior.

The two measures described in this paper are by no means the only ones that hold promise for dealing with the problem of the hard-core drinking driver. Other program and policy initiatives, such as vehicle impoundment or immobilization, intensive supervision and probation, tiered BAC systems, designated-driver campaigns, and server intervention programs specifically targeted at hard-core offenders, also hold promise for effecting change. The implementation of such measures requires political will, community support, and the resolve to go one step further to bring about change for the collective good of all.

Note

(*) These data are from the Fatality Database that was developed and is maintained by TIRF under funding from Transport Canada and the Canadian Conference of Motor Transport Administrators. The seven provinces are: British Columbia, Alberta, Saskatchewan, Manitoba, Ontario, New Brunswick, and Prince Edward Island. In 1987 the Fatality Database was expanded to include all ten provinces and two territories.

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AUTHORS' NOTE: Send correspondence to: Douglas J. Beirness, PhD, Vice President, Research, Traffic Injury Research Foundation, 171 Nepean Street, Suite 200. Ottawa, Ontario, Canada K2P OB4. E-mail: dougb@trafficinjuryresearch.com.

DOUGLAS BEIRNESS is vice president, research, of the Traffic Injury Research Foundation (171 Nepean St., Suite 200, Ottawa, Ontario K2P OB4, Canada), a nonprofit Canadian road safety institute. HERB SIMPSON is president and CEO, and DANIEL MAYHEW is senior vice president with the same institution. All three authors have participated in experimental and epidemiological studies in traffic safety and have published articles in the area of impaired driving, young drivers, the development of high-risk lifestyles, and the perception of intoxication and impairment.
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Author:Beirness, Douglas J.; Simpson, Herb M.; Mayhew, Daniel R.
Publication:Contemporary Drug Problems
Geographic Code:1CANA
Date:Sep 22, 1998
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