Best Practices - Treatment and Rehabilitation for Driving While Impaired Offenders

1. Introduction

Key Points

• This study focusses on both educational and therapeutic remedial programs for people charged with or convicted of alcohol- and/or drug-related driving offences.
• Specific interventions of interest include 1) education typical of specialized DWI programs, and 2) interventions similar to those found in general addiction treatment programs. Both emphasize the importance of separating drinking/substance use from driving.

1.1 Purpose

In most industrialized countries, impaired driving is one of the most common crimes and a significant cause of alcohol- and drug-related mortality and morbidity. Most countries, including Canada, have therefore introduced measures to prevent impaired driving and to punish offenders. Many countries have also developed programs to educate, treat and/or rehabilitate people charged or convicted for driving while impaired (DWI) by alcohol and/or other drugs.

There is now a reasonably extensive literature concerning education, and treatment and rehabilitation programs for impaired driving offenders and also good scientific evidence for their effectiveness. The aim of this report is to bring together current knowledge on the planning and delivery of DWI education, and treatment and rehabilitation programs, particularly pertaining to the following issues:

• overall effectiveness of education and treatment programs for impaired drivers;
• effectiveness of different types of such remedial interventions for different types of impaired drivers;
• identifying impaired drivers who may benefit from substance abuse education or treatment;
• effectiveness of programs that combine treatment and rehabilitation with licence suspension or other methods for limiting driving opportunities;
• need for interventions that target impaired drivers who are apprehended but not processed through the courts;
• DWI program governance and provider training issues;
• relationships between remedial programs and licensing authorities;
• offender payments for services; and
• program evaluation and research.

Beyond these main questions, the research team was also asked to give attention to current knowledge on remedial programs for drivers impaired by drugs other than alcohol, and to be alert to issues of gender, ethnicity, place of residence (rural vs. urban), and clinician liability during the research.

The project was initiated by Health Canada as part of a research agenda developed by the Federal/Provincial/Territorial Working Group on Accountability and Evaluation Framework and Research Agenda (ADTR Working Group). Part of the mandate of the working group is to oversee the development and implementation of research studies that contribute to innovative substance abuse treatment and rehabilitation programs by identifying best practices, evaluating model treatment and rehabilitation programs, and identifying emerging issues. The knowledge is then disseminated across the country.

This project builds on a series of best practices publications including: Best Practices - Substance Abuse Treatment and Rehabilitation (Health Canada, 1999); Best Practices - Fetal Alcohol Syndrome/Fetal Alcohol Effects and the Effects of Other Substance Use During Pregnancy (Health Canada, 2001a); Best Practices - Treatment and Rehabilitation for Women with Substance Use Problems (Health Canada, 2001b); Best Practices - Treatment and Rehabilitation for Youth with Substance Use Problems (Health Canada, 2001c); Best Practices - Concurrent Mental Health and Substance Use Disorders (Health Canada, 2001d); Best Practices - Methadone Maintenance Treatment (Health Canada, 2002a); and Best Practices - Treatment and Rehabilitation for Seniors with Substance Use Problems (Health Canada, 2002b)

1.2 Study parameters and definitions

Following initial discussions with members of the ADTR Working Group, it was determined that the study would focus on educational and therapeutic remedial programs¹ for people charged with or convicted of alcohol- and/or drug-related driving offences. Efforts were also made to identify knowledge on the identification and treatment of substance use problems² among those charged with other traffic offences (e.g. dangerous driving, leaving the scene of an accident), and impaired drivers who are apprehended by the police, but not processed through the justice system. These latter types of offenders are given roadside or administrative licence suspensions, but are not subsequently prosecuted.

Interventions of concern were those typically used in specialized remedial programs for DWI offenders and those used in programs indicated in the 1998 Canada's Drug Strategy planning document, namely:

…detoxification services, early identification and intervention, assessment and referral, basic counselling and case management, therapeutic intervention, and aftercare and clinical follow-up. … offered on an out-patient, day-patient or in-patient basis including short-term and long-term residential care.

Specific interventions of interest included education typical of specialized DWI programs that focus on substance use and driving, and the importance of separating the two, as well as interventions similar to those found in general addiction treatment programs in Canada (e.g. counselling, self-help, cognitive-behaviour therapy, family therapy, guided self-change), but also have a focus on separating drinking and driving.

Some reports of interventions that specifically target impaired drivers in emergency rooms or other medical settings were found (e.g. Gentilello et al., 1999; Monti et al., 1999). However, these were considered to be beyond the scope of this project, because they are interventions with impaired drivers who have not been apprehended by the police. Victim impact panels are a common, yet largely ineffective, form of remediation that were considered beyond the scope of this report (C'de Baca et al., 2001; Polacsek et al., 2001; Shinar and Compton, 1995).

Other interventions, such as mandatory use of ignition interlock devices, fines and electronically monitored home confinement, were considered beyond the present scope of this report. However, as will be seen, there is evidence that education and treatment programs are most effective when combined with licence suspension and other measures, such as impounding offenders' vehicles or licence plates, installing ignition interlocks, or requiring electronic home monitoring or house arrest.

The definition of best practice as it relates to program delivery in the health field has been approached with varying degrees of rigour. For the purposes of this project, best practices are emerging guidelines, gleaned from key expert perspectives and supported by the literature, on the approaches and elements of treatment that appear to result in successful treatment outcomes. Given this definition, best practices are recommendations that may evolve, based on ongoing key expert experience, judgment, perspective and continued research.

1.3 Structure of the report

The report first provides a general overview of the impaired driving situation in Canada. The main body of the report is structured around the nine main issues identified in the introduction; current knowledge drawn from the literature and key informants is summarized in each section, and when the level of knowledge warrants, best practice statements are presented. Gender, ethnicity, place of residence (rural vs. urban) and other issues are variously addressed under the main topic headings. Concluding the report is an inventory of Canadian DWI programs.

1.4 Methodology

For the best practices, two sources of information were drawn upon:

• a review of published and unpublished research reports on DWI treatment and rehabilitation; and
• interviews with experts in the field of DWI program development and delivery.

For the Inventory of Canadian DWI Programs (see Section 6), information was gathered through the administration of a written survey completed by persons responsible for provincial/ territorial impaired driving programs in Canada.

1.4.1 Literature review

The primary sources used to identify research reports were:

• Alcohol and Alcohol Problems Science Database (ETOH) of the US National Institute on Drug Abuse (NIDA);
• the web site of the US National Commission Against Drunk Driving (www.ncadd.com);
• a recent review of DWI literature (Beirness, Mayhew and Simpson, 1997);
• MEDLINE (Database of the National Library of Medicine, National Institutes of Health, U.S.);
• CANBASE (the database of Canadian addiction library holdings);
• CCSADOCS (the database of holdings of the Canadian Centre on Substance Abuse); and
• reports identified by members of the steering committee.

Priority for review was given to reports of controlled studies pertaining to the issues of concern. A number of reports or publications by expert panels or internationally respected authorities were examined for knowledge pertaining to the aims of this report. These are referenced in various sections that follow. A scale (see Appendix A) was developed to rate each study on the quality of the research and strength of outcomes. The ratings are presented in Table 2.

1.4.2 Key informant interviews

The project steering committee nominated 12 key experts (e.g. directors, managers and medical consultants for DWI programs) on the basis of their expertise in various aspects of DWI remedial programming, and on the basis of regional representation. The key experts were contacted by the project team to solicit their participation in a telephone interview of approximately 90 minutes. A standard interview guide was used during the interview, but with particular emphasis given to the key informant's specific area of expertise.

In the interviews, key informants were asked for their advice on the following issues drawn from the main research questions: screening for substance use problems; assessment and treatment assignment; effectiveness of educational and therapeutic interventions; administrative or judicial compliance mechanisms; effectiveness of programs that combine treatment with licence suspension or some other method of limiting driving opportunities; case monitoring, evaluation and research; provider training; recovery of costs for education/treatment programs; relationships between education or treatment services and motor vehicle registration departments; and programming for youth DWI offenders. Key informants were also asked about any recent developments in DWI remedial measures programming in their jurisdiction.

1.4.3 Inventory of Canadian DWI programs

Program inventories from Bierness, Simpson and Desmond (1994) and Stoduto et al. (1998) were used to identify respondents for a survey of Canadian DWI programs. Key personnel were contacted in the fall of 2002 and asked to provide a profile of their program by completing a survey questionnaire. In many cases, follow-up phone calls were made to clarify or elaborate on information given

¹ The term "remedial programs" in the context of this report, refers to education and therapeutic programs for DWI offenders.

² The term "substance use problems" is used to cover both substance abuse and substance dependence, as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM)-IV (1994)