Best Practices - Treatment and Rehabilitation for Driving While Impaired Offenders

3. Current Treatment Practice Issues (continued)

3.3 Identifying impaired drivers who may benefit from particular levels of substance abuse education or treatment

Key Points

• There is a need for different levels of interventions for different DWI offenders as research indicates that they differ in the extent of their substance use and other ways that can influence DWI recidivism.
• There is no simple or reliable method for identifying those most in need of any particular type or level of education or treatment.
• A clearly delineated screening/assessment process is important to support the decisions around matching.
• Several screening instruments, validated using DWI populations and programs, have been identified, and their use is consistent with best practice.

3.3.1 Indications from the literature

As evidenced by the previous section, the population of impaired drivers includes people who differ with respect to many factors that might indicate their need for substance abuse education, treatment or rehabilitation (e.g. frequency of drinking and drug use, severity of substance use problem, impaired driving charges, criminality, personality, motivation to change and psychopathology). They also differ with respect to age, gender, social circumstances and other factors that could influence the outcomes of remedial interventions (Applegate, Langworth and Latessa, 1997; C'de Baca, Miller and Lapham, 2001; Health Canada, 1999; Van Whitloc and Lubin, 1998; Wells-Parker et al., 2000). There is, however, no simple or consistently reliable method for identifying those most in need of any particular type or level of education or treatment.

A major challenge in the identification of DWI offenders who may benefit from a particular type of remedial program is their tendency to deny or otherwise misrepresent their drinking and drug use behaviours and problems (Lapham et al., 2001). For this reason, some screening and assessment instruments and procedures use objective and/or "disguised" indicators of substance use problems. The most commonly used objective indicators include DWI arrest history and BAC level at the time of arrest. However, in neither case do these provide reliable indications of problem severity. Many first-time offenders have significant substance use problems, and BAC at the time of arrest is a poor indicator of alcohol use problems as indicated by other measures (Wieczorek, Miller and Nochajski, 1992). However, BAC level at the time of arrest has been shown to be highly correlated with recidivism (Gjerde and Morland, 1988). Some experts therefore recommend that both arrest history and BAC level at the time of arrest be considered in the context of comprehensive screening and assessment programs.

Screening and assessment⁴ instruments that feature at least some disguised or indirect indicators of substance use and related problems are the Mortimer-Filkins questionnaire (Mortimer, Filkins and Lower, 1971), the MacAndrew Alcoholism Scale (Revised) (MacAndrew, 1965), the Research Institute on Addictions Self-Inventory (RIASI) (Nochajski and Miller, 1995; Nochajski et al., 1993), and the Substance Abuse Subtle Screening Inventory-ll (SASSI) (Miller, 1994). Brief descriptions are given in Table 2.

Table 2: Selected Characteristics of Commonly Used Questionnaires and Inventories for Identifying or Assessing DWI Offenders with Alcohol or Drug Use Problems⁵

Instrument	Description
Mortimer-Filkins Test (Mortimer, Filkins and Lower, 1971)	58 yes/no and short answer items plus structured interview. Items concern drinking patterns, problems and attitudes, personal/social problems and lifestyle issues.
MacAndrew Alcoholism Scale - Revised (MAC-R) (MacAndrew, 1965)	49 true/false items derived from the Minnesota Multiphasic Personality Inventory (MMPI), a widely used clinical assessment instrument; has no questions about drinking or drug use.
Substance Abuse Subtle Screening Inventory-ll (SASSI) (Miller, 1994)	62 true/false items with low face validity for chemical abuse, and 26 questions that help clients identify negative consequences of their use of alcohol and other drugs.
Research Institute on Addictions Self-Inventory (RIASI) (Nochajski and Miller, 1995)	52 yes/no items directly or indirectly related to, or indicative of, drinking problems.
Michigan Alcoholism Screening Test (MAST) (Selzer, 1971)	25 weighted yes/no items concerning drinking habits, alcohol dependence symptoms and drinking-related problems.
Driver Risk Inventory-ll (DRI) (Lindeman and Scrimgemour, 1999)	140 items directly or indirectly related to, or indicative of, drinking problems.
Substance Abuse Life/Circumstances Evaluation (SALCE) (ADE Inc., 1986)	85 true/false or Likert items designed to identify behavioural, attitudinal and clinical indicators of an individual's need to alter alcohol or drug use.
Drug Use Screening Inventory (DUSI) (Tarter and Hegedus, 1991)	149 yes/no items concerning substance use, behaviour patterns, health status, psychiatric disorders, social competence, family systems, school performance, work, peer relationships and leisure activity.
Drug Abuse Screening Test (DAST) (Skinner, 1982)	28 yes/no items concerning drug taking, drug dependence symptoms and drug-related problems--similar to items on the MAST.
Alcohol Use Inventory (AUI) (Horn, Wanberg and Foster, 1987)	228 items concerning benefits of alcohol use, styles of use, negative consequences of use, concerns about use and acknowledgement that use causes problems.
Alcohol Use Disorders Identification Test (AUDIT) (Bohn, Babor & Kranzler (1995)	10 items concerning amount and frequency of drinking, alcohol dependence, and problems caused by alcohol.

Table 2 also includes selected information on commonly used screening questionnaires and inventories that use only "non-disguised" items concerning alcohol or drug use. Thus, the intent of the items is obvious to the respondent and the responses can be influenced by a strong desire to minimize the extent of the problem. In all cases, the choice of cut-off scores influences the percentage of cases correctly identified (true positives) and percentage of cases wrongly identified as having substance use problems (false positives).

Structured interviews can also be used to identify DWI offenders with substance use problems. The gold standard is the Structured Clinical Interview (SCID) for the Diagnostic and Statistical Manual III-R (DSM-III-R) (Spitzer et al., 1990). This requires an experienced interviewer who is required to make clinical judgments regarding the meaning and interpretation of client responses. Each section of the SCID corresponds with one of the major diagnostic categories of the DSM-III-R and, when used to screen cases for alcohol or drug use problems, only those sections that concern substance abuse or dependence are used. The disadvantages of the SCID are that it is time consuming and requires skilled interviewers.

An alternative to the SCID is the Diagnostic Interview Schedule or DIS (Robins et al., 1982). This is simpler to administer and requires very little decision making by the interviewer. The results indicate if the client qualifies for a diagnosis of alcohol or drug abuse or dependence. The DIS has mainly been used in research, but it can also be used clinically. A disadvantage is that, as with other direct screening and assessment instruments, offenders may intentionally minimize the severity of their problem. The same limitation pertains to other structured interviews such as the Addiction Severity Index or ASI (McLellan et al., 1992), the Comprehensive Drinker Profile or CDP (Marlatt and Miller, 1984) and the Timeline Follow Back (Sobell and Sobell, 1992).

Although quite widely used, the SASSI has not been validated with DWI samples, nor has it been shown to be superior to other instruments for detecting people with alcohol or drug use problems in other settings. Gray (2001) found that reliability was generally good for the direct scales but poor for the indirect scales. Neither the Driver Risk Inventory nor the SALCE has been widely validated (Chang, Gregory and Lapham, 2002).

The RIASI has been shown to be superior to the MAST and the Mortimer-Filkins for identifying cases that qualify for DSM-II-R diagnoses of alcohol abuse or dependence (Nochajski, Miller and Parks, 1994). In one study, the RIASI identified 69% of cases known to have had a lifetime diagnosis of alcohol abuse or dependence, while the MAST identified only 49% of these cases. The RIASI also identified 79% of cases with drug-related problems and 80% of cases that reported driving after using drugs. The corresponding percentages for the MAST were both 38%. These findings have led to the use of the RIASI in place of the MAST and the Mortimer-Filkins instruments in some DWI programs in the United States. However, a recent review of commonly used assessment instruments found that the evidence for predictive validity was strongest for the MacAndrew Alcoholism Scale and the Alcohol Use Inventory (Chang, Gregory and Lapham, 2002). These instruments have been shown to detect about 70% of DWI recidivists.

There are, however, no clear indications of the superiority of any one screening instrument or set of instruments and procedures, and experts agree that the selection of specific instruments and procedures should be guided by the needs and resources in particular jurisdictions (Beirness, Mayhew and Simpson, 1997). Further information on screening instruments and various issues in the screening of impaired drivers can be found in two recent publications: Cavaiola and Wuth, 2002, pp. 75-111; and Chang, Gregory and Lapham, 2002.

All of these instruments and procedures can, of course, be used to identify people with substance use problems in other clinical or criminal justice populations or in the general population. This includes drivers charged with traffic offences that are not specifically related to alcohol or drugs. No studies providing advice for substance abuse screening of these drivers were identified in this review. It is of note that Donovan et al. (1985) found that men with multiple non-alcohol-related traffic convictions or accidents had higher levels of drinking than those in the general population of drivers, but not as high as repeat DWI offenders. However, they were similar to repeat DWI offenders on measures of personality, depression and hostility. These results suggest the need for more research concerning substance abuse in the general population of repeat traffic offenders.

3.3.2 Key informant interviews

There was agreement among key informants that anyone convicted of a DWI offence, whether a first offence or a repeat offence, should be screened and assessed in order to assign the offender to an appropriate level of intervention. Though not all jurisdictions currently assess first offenders, there was recognition that many first offenders have driven after drinking on many previous occasions, and doing a comprehensive work-up provides an opportunity for earlier intervention.

Most (but not all) key informants also agreed that all offenders should receive some type of intervention, regardless of the results of the screening/assessment, though one jurisdiction provides for a "no further action" option.

There was no agreement among key informants as to whether screening or assessment should occur only after a conviction or after an administrative suspension or charge. Some felt that waiting until a conviction would unduly delay the start of education or treatment, while others felt that proceeding with assessment prior to conviction might infringe on civil liberties.

Most key informants felt that screening/assessment procedures should also be applied to drivers of vehicles other than cars, particularly snowmobiles, since alcohol is frequently a factor in snowmobile deaths. Impaired drivers of these other vehicles could be charged under the Criminal Code, but Motor Vehicles Departments would not necessarily be notified.

Several concerns were raised about individuals driving while impaired by psychoactive medication (prescribed or over-the-counter), particularly since people may not recognize the impairing effects of medication. In this context, several key informants commented on the need for tools/ methods to help police in detecting people driving while impaired by substances other than alcohol.

Several key informants noted the importance of having information on arrest BAC, driver history (lifetime) and previous history of education/ treatment as part of the assessment information. It should be noted that for youth, information on arrest BAC and driver history is not available because of provisions under the Youth Criminal Justice Act. The need for BAC information was not, however, supported by all key informants. One noted that a high BAC may or may not indicate a general pattern of heavy consumption.

In addition to the instruments identified in Table 2, one or more key informants mentioned the CAGE (King, 1986), Alcohol Risk Assessment and Intervention (ARAI) Guidelines (by the College of Family Physicians of Canada, 1994), the 20 questions of Alcoholics Anonymous (Alcoholics Anonymous n.d.), and the Personal Experience Screening Questionnaire (PESQ) for youth (Winters, 1991). One key informant emphasized the need to use standardized instruments administered by a qualified professional so that results could be defended in a court of law.

A number of key informants raised the issue of the validity of self-report information and concerns that DWI clients "fake good" or minimize the extent of problem substance use. In this context, several key informants noted the importance of using psychometric instruments that include some type of "lie scale"; several mentioned other sources of information, such as information from family, friends or employer. One key informant identified the need for a traffic safety risk assessment, based on such information as history of traffic violations and crashes. This key informant was particularly concerned about the validity of self-report information. Generally, it was felt, and reported as being the practice, that screening/assessment should be done by substance abuse counsellors.

There were mixed responses to the issue of gathering collateral information from family members or others such as friends, physicians and employers, as part of the assessment process. In terms of family members, some key informants indicated that their involvement was critical, particularly for youth, or where there was contradictory information; others raised some concerns about putting family members at risk in situations of domestic violence, the ethical problem in requiring family member involvement, and what information provided by the family could be appropriately shared with the client in the assessment feedback process.

There was no consensus regarding the assessment of client readiness to change and use of motivational interviewing approaches with DWI offenders. Some key informants indicated that offender stage of readiness for change was critical in terms of matching the offender to the appropriate type and level of intervention and engaging them in the intervention process, while others indicated that either they had no experience applying this model to a DWI population and/or that it was not appropriate, given that offenders were mandated to treatment thereby limiting the options available to the counsellor.

Most key informants indicated that the majority of offenders were male. Other population groups for which some special provisions need to be made were noted as follows:

1. Women: Ideally, there should be gender-specific screening/assessment (if done as a group process) and intervention, but in most (but not all) jurisdictions this is not practical because of low numbers. In some jurisdictions, particularly large urban areas, women can be referred to gender-specific treatment programs.
   
   
2. Aboriginals: For this group, there are issues of language, cultural appropriateness of screening/assessment tools, and process and intervention (in one jurisdiction, they do their own DWI programming).
   
   
3. Rural residents: These residents may experience difficulty accessing DWI programs because of distance and lack of public transportation, thus sanctions may be more severe for them; one key informant mentioned rural women in particular because of such barriers as child care and having only one family car.
   
   
4. Youth: Some key informants indicated there should, ideally, be specialized programming, while others felt that youth could be part of an adult intervention. Several key informants mentioned the importance of graduated licences and having lower thresholds to trigger sanctions.
   
   
5. Older adults: Key informants identified the following issues: stigma; being reluctant to attend an intervention program; and difficulty understanding some of the instruments.
   
   
6. Deaf clients and those with low literacy skills: These offenders were also mentioned as needing specialized approaches.

3.3.3 Best practices

In principle, it may be possible to identify individuals for whom a remedial program would serve no benefit. Previous practices in many Canadian jurisdictions, where courts assigned some people but not others to remedial programs, were based on this assumption. This practice is still followed in some jurisdictions in the United States and elsewhere. However, there is no support in the research literature for this practice. No methods are currently available that can reliably identify those individuals who will and those who will not benefit from remedial programs. In the face of compelling evidence that these programs do have benefits to participants in the aggregate, the best practice is (as identified in best practice statements 1 and 2) to require that all DWI offenders attend some type of remedial program.

The fact that research indicates that DWI offenders differ in the extent of their substance use problems and other ways that can influence the risk of DWI recidivism suggests the need for different levels or types of interventions for different individuals. Although the best ways to match offenders with level or types of treatment have not been determined, in general more intensive interventions may be appropriate for those with more serious problems, and a clearly delineated screening/assessment process is important to support these decisions.

Best Practice 6
All convicted DWI offenders should complete a screening/assessment process to inform decisions about the most appropriate level or type of intervention.

Several screening instruments that have been validated using DWI populations and programs have been identified, and the use of these instruments by those familiar with their strengths and limitations should be considered consistent with best practice.

Best Practice 7
Instruments that have been shown to be of value in assessing alcohol and drug use problems and recidivism risk should form part of the screening procedure. The performance of these instruments should be monitored on an ongoing basis.

3.4 Effectiveness of programs that combine treatment and rehabilitation with licence suspension or other methods for limiting driving opportunities

Key Points

• Greater reductions in impaired driving recidivism and collisions are obtained with a combination of remedial programming and licensing actions such as suspensions and interlock requirements.

3.4.1 Indications from the literature

When rehabilitation programs were first being introduced, one strategy that was frequently used to encourage offenders to attend a remedial program was for courts or licensing authorities to offer to reduce or waive the period of licence suspension, which typically is a consequence of a conviction for impaired driving (Mann et al., 1983). However, this substitution strategy proved to be a serious mistake, at least from a traffic safety perspective. Several evaluations comparing offenders sent to rehabilitative programs (who had a licence returned) to control groups not sent to such a program (who were subject to a licence suspension) revealed that those sent to rehabilitation usually had as many or more collisions and convictions at follow-up (e.g. Preusser, Ulmer and Adams, 1978). This occurred because licence suspensions have important traffic safety benefits (Mann et al., 1991) that are forgone when they are substituted for another measure like rehabilitation.

A subset of the studies included in the Wells-Parker et al. (1995) analysis involved cases with varying levels or types of education or treatment and/or licensing penalties. It was thus possible to explore the relative influence of education/treatment and legal sanctions or combinations of both. The results indicated that the greatest positive impact on alcohol-related traffic events and more general traffic safety occurs when offenders receive both education or treatment and licence suspensions.

This conclusion is reinforced by the previously noted study by DeYoung (1997). Also, as previously noted, this was the conclusion reached by the panel of experts convened by the Century Council (1997). Other experts have reached similar conclusions (e.g. National Commission Against Drunk Driving, 2002; Nichols, 1990; Voas and Fisher, 2001;).

3.4.2 Key informant interviews

Key informants supported the need for legal sanctions to be combined with educational or treatment interventions. Several emphasized the importance of a balance between education/ treatment and legal sanctions, and raised concerns that making legal sanctions too severe can reduce offenders' motivation to change and encourage driving without a licence. Some key informants raised the importance of offenders taking responsibility for their offence, and the role of the administrative model (see below) in putting the onus on the offender to follow through on requirements for licence reinstatement.

In addition, several key informants indicated that the current system can be confusing for clients because highway traffic acts in different provincial/territorial jurisdictions can increase penalties beyond those imposed under the Criminal Code. Almost all key informants emphasized the need for standardization across provinces/territories in terms of legal sanctions and education/treatment interventions.

3.4.3 Best practices

The evidence indicates that greater reductions in impaired driving recidivism and collisions are obtained with a combination of remedial programming and licensing actions such as suspensions and interlock requirements. Previous efforts to use reductions in licensing actions as an incentive to enter remedial programs have found that this policy discards any traffic safety benefits that accrue as a result of remedial programs.

Best Practice 8
Remedial programs should supplement, not replace, licensing actions.

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⁴ Screening generally refers to a relatively brief process designed to identify probable cases (in this instance, cases with substance use problems) and assessment to a more detailed and extended process designed to confirm the results of screening and to generate more detailed information for treatment planning.

⁵ A number of other instruments with limited research support are used in some US states (Chang, Gregory and Lapham, 2002)