Getting to Zero Alcohol-Impaired Driving Fatalities A Comprehensive Approach to a Persistent Problem (2018) / Chapter Skim
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5 Postcrash and Arrest Interventions
5 Postcrash and Arrest Interventions
Pages 251-328
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From page 251... ...
. About 20 to 28 percent of first-time DWI offenders will repeat the offense (Lapham et al., 2006; Robertson et al., 2016)
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As discussed in Chapter 2, rural areas are an important target population for alcohol-impaired driving because they account for a large proportion of fatal crashes, and many existing interventions are more relevant to urban areas. The interventions in this chapter engage the range of actors required to enforce laws and detect, prosecute, adjudicate, and treat alcohol-impaired drivers as well as respond to alcohol-impaired driving crashes.
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. Implementing a unified approach to reducing alcohol-impaired driving in communities would require intensive officer training and community engagement to foster cooperation and avoid alienating residents as communities and police work toward a common goal of zero lives lost (Aboelata et al., 2017)
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One challenge that police officers face when it comes to administering alcohol-impairment tests is the possibility that drivers simply refuse to comply with their request for testing. Unless the penalty for refusing a chemical test exceeds the penalty that a driver could incur should they fail the test (e.g., being prosecuted for impaired driving)
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One strategy to increase BAC testing at the time of arrest, and to eliminate the need for retrograde extrapolation, is the use of electronic warrants. In many jurisdictions law enforcement officers are able to contact on-call judges remotely at the time of arrest and have an electronic warrant sent directly to their smartphones or computers to avoid a delay in testing.
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, but the results can inform the prosecutor's proposal to the judge, along with other additional information such as performance on the SFSTs, chemical tests, observations of the driver, 4 Alcohol use disorder, as defined by the Diagnostic and Statistical Manual of Mental Dis orders, Fifth Edition (DSM-5) , is based on the presence of at least two symptoms from a specific set of criteria, with subclassifications of mild, moderate, and severe, whereas the DSM-IV defined two different disorders (alcohol abuse and alcohol dependence)
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. A driver convicted of DWI could also be sentenced to complete a treatment program, participate in a monitoring program, or attend a victim impact panel (Goodwin et al., 2015; SAMHSA, 2005a)
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. The National Highway Traffic Safety Administration (NHTSA)
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. Based on older and mixed evidence on plea agreement restrictions and diversion programs, the committee concludes: Conclusion 5-1: Research is needed on the effects of restrictions on diversion programs that remove alcohol-impaired driving convictions from a driver's record and on the content of plea agreements for alcohol impaired driving offenders as strategies to reduce DWI recidivism.
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. For example, one study found that alcoholimpaired driving crashes and first-time and repeat DWI convictions significantly declined after California's ALS law was enacted (Rogers, 1997)
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This is an important finding because some offenders will continue to drive without a license, and these laws are one measure to deter alcohol-impaired driving among the general driving population. Other interventions, such as treatment, counseling, and ignition interlock devices (all discussed in more detail in this chapter)
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The following sections describe some of these interventions and the individuals who may benefit the most from them, particularly among alcoholimpaired driving offenders. Although alcohol-impaired driving is a crime and law enforcement measures can be very effective, enforcement alone will not fully solve the problem of alcohol-impaired driving.
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(2002) found that more than 80 percent of individuals who drove with a BAC higher than 0.19% were alcoholics in a sample of alcohol-impaired drivers.6 Recent national estimates on how many DWI offenders are diagnosed with AUD in the general population are not available in the published literature.
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. Some forms of treatment for DWI offenders include motivational interviewing, brief interventions, cognitive behavioral therapy (CBT)
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. DWI Courts DWI courts are specialized courts aimed at changing DWI offenders' behavior through comprehensive monitoring and substance abuse treatment.
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Establish the treatment plan: Based on the clinical assessment, implement an individualized treatment plan made up of multiple, high-quality interventions. Monitor the offender: The DWI court team, including the probation division and treatment provider, should supervise the offender in his or her home, work, and community environments.
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. A 2009 systematic review concluded DWI courts are an effective intervention in reducing recidivism, but found many studies were methodologically weak and encouraged additional future research (Marlowe et al., 2009)
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. Additionally, DWI courts may be more effective than hybrid DWI/drug courts in preventing DWI recidivism because drug courts enroll several types of participants and do not specifically target DWI offenders (Sloan et al., 2016)
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To improve health and safety outcomes and reduce recidivism of repeat offenders and high BAC offenders, the committee recommends: Recommendation 5-1: Every state should implement DWI courts, guided by the evidence-based standards set by the National Center for DWI Courts, and all DWI courts should include available consultation or referral for evaluation by an addiction-trained clinician. Screening, Brief Intervention, and Referral to Treatment (SBIRT)
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Several studies present strong evidence that brief interventions can effectively decrease harmful alcohol consumption (Dunn et al., 2001; Moyer et al., 2002; Vasilaki et al., 2006) , especially when conducted in emergency care settings (D'Onofrio and Degutis, 2002; Nilsen et al., 2008)
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. More investigation is also needed into whether brief interventions reduce alcoholimpaired driving (Dill et al., 2004)
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Physicians are required to report "at-risk drivers" to their state Department of Motor Vehicles (DMV) in six states: California, Delaware, Nevada, New Jersey, Oregon, and Pennsylvania (AAA Foundation for Traffic Safety, 2016; State of Nevada, n.d.)
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As discussed in this section, the evidence on SBIRT's efficacy is strong, but it requires resources, training, and time. Many of the barriers outlined above could also be overcome through new technology that electronically administers screening and brief interventions to patients, such as at
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(2014, 2015) found that brief interventions delivered by text messages were successful in reducing selfreported binge drinking among young adults discharged from the ED.
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. It is taken as a 50 mg pill once per day and has been shown to reduce alcohol consumption and cravings in those with alcohol dependence (Lobmaier et al., 2011; SAMHSA, 2016c)
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. Disulfiram, the first medication approved by the FDA to treat alcohol dependence, is an alcohol-sensitizing agent that causes physical reactions such as sweating, hyperventilation, head and neck throbbing, nausea, vomiting, and weakness when the patient consumes any alcohol (Center for Substance Abuse Treatment, 2009)
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and effective in reducing heavy drinking, medications are underused. In 2016, a survey of DWI courts reported that 31 courts used NTX for alcohol 10 Jonas et al.
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. The quality of the evidence for the efficacy of anti-relapse medications is excellent. For NTX, the first such medication approved by FDA for efficacy in preventing relapse, the evidence is based on placebo-controlled, randomized clinical trials conducted in multiple countries throughout the world. The most reliable finding for success is not total abstinence from drinking, but rather a reduction in the number of heavy drinking days. This translates into fewer opportunities to drive a vehicle in an alcohol-impaired state. While there are reports from drug courts on the benefits of using medication as a means of preventing relapse to alcoholimpaired driving, the published controlled trials were not conducted among drug court participants.
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For example, a systematic review found that the community reinforcement approach combined with the medication disulfiram decreased the number of drinking days, but there was conflicting evidence of the impact of a community reinforcement approach on abstinence (Hunt and Azrin, 1973; Roozen et al., 2004)
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. The study found that motor vehicle crashes declined with the study's specific brief intervention, which included two in-person physician visits followed up by two nurse calls and other related activities (e.g., a worksheet and an "agreement")
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Conclusion Assessment, treatment, and monitoring of alcohol-impaired driving offenders remain critical elements in reducing alcohol-impaired driving recidivism and fatal crashes. Therefore, the committee recommends the following: Recommendation 5-2: All health care systems and health insur ers should cover and facilitate effective evaluation, prevention, and treatment strategies for binge drinking and alcohol use disorders including screening, brief intervention, and refer ral to treatment (SBIRT)
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. For example, DWI courts' treatment component includes development of an individual treatment plan that can include participation in a 12-step program to maintain abstinence (NCDC, n.d.-d)
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. Penalties and Sanctions Offender Monitoring: The 24/7 Program and Continuous Alcohol Monitoring Devices Close DWI offender monitoring can be accomplished through a variety of approaches, including intensive supervision programs such as DWI courts (discussed earlier in this chapter)
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While twice-daily PBTs are the most commonly used monitoring method, transdermal continuous alcohol monitoring and testing can also be conducted electronically through the use of ankle bracelet testing, once-per-day PBT, or urinalysis; occasionally these tests are administered contemporaneously or used in conjunction with ignition interlock devices (Loudenburg et al., 2010)
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Based on 9,108 county-month observations, the authors found a 4.2 percent reduction in all-cause mortality since implementation of the 24/7 Sobriety Program. No deterrent effect for first-time DWI arrests was apparent.
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These are two examples of offender monitoring programs (DWI courts and ignition interlock devices also closely monitor offenders and are discussed elsewhere in this chapter)
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The personal alcohol monitoring device assigned to offenders detects even small amounts of alcohol in the perpetrator's system. The county also employs an interlock device strategy to keep repeat offenders from being able to start their vehicles while impaired.
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. Individuals convicted of alcohol-impaired driving, particularly first-time DWI offenders, are commonly court ordered to attend victim impact panels (AAA, 2016)
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A randomized trial of first-time DWI offenders in San Juan County found that alcohol consumption, alcohol-impaired driving, and recidivism within 2 years were no different for those who attended a victim impact panel as part of a 28-day treatment program than for those in the treatment program who did not attend the panel (Wheeler et al., 2004)
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While a number of studies found victim impact panels to be effective at decreasing recidivism rates of DWI offenders (Fors and Rojek, 1999; Joyce and Thompson, 2017) , particularly within the first 2 years after arrest (Rojek et al., 2003)
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The use of ignition interlocks in the United States is generally managed in programs that are administered at the state level and aim to prevent alcohol-impaired driving recidivism among individuals arrested for alcohol-impaired driving. History and legislation Interlock devices were first developed in the United States in 1969, and alcohol-detecting interlocks began to gain traction in the 1980s, when the public's attention to the issue of impaired driving demanded solutions (AAMVA, 2015; Marques and Voas, 2010)
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, indicates that dedicated monitoring can increase compliance with the requirements of an interlock program, and that increased compliance is associated with reductions in impaired driving recidivism after completing a period of interlock monitoring. Compliance is an important component of state interlock programs but is one that has received relatively little research attention in comparison to other program components.
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. In 2013, NHTSA published a Model Guideline to State Ignition Interlock Programs, which provides practical strategies on key program features that are critical for effective delivery.
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Considerable research has been dedicated to evaluating whether ignition interlocks have an impact on recidivism, defined as arrests for alcohol-impaired driving among individuals who have an ignition interlock device installed on their vehicle. The evidence from these studies is compelling and indicates that interlocks reduce alcohol-impaired driving recidivism by 50 to 90 percent while ignition interlock devices are installed (Beck et al., 1999; Bjerre, 2005; Casanova-Powell et al., 2015; Coben and Larkin, 1999; Fiedler et al., 2012; Roth et al., 2007; Willis et al., 2004)
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However, this study found that interlocks appeared not to prevent alcohol-impaired driving crashes for first-time DWI offenders with high BAC levels (DeYoung et al., 2004)
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The program was implemented to change Ontario's preexisting interlock policy, in which DWI offenders served at least a 12-month license suspension and then completed another 12 months with either an interlock or without driving at all, in an attempt to address these issues. The program shortened the license suspension period to 3 or 6 months if an offender agreed to install an interlock, followed by 9 or 12 months with the device installed.
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The authors concluded that policies mandating ignition interlocks for all alcohol-impaired driving convictions were associated with 15 percent fewer alcohol-related driving fatalities; they estimated that 915 lives were saved in the universal interlock states during the period of study. In 2016, McGinty et al.
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A nationally representative survey of the U.S. population revealed that 84 percent of participants supported mandating ignition interlocks for all convicted DWI offenders.
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Interlock devices save the public $3 to $7 on every $1 spent on the devices for DWI offenders, and are cost-effective for this population (MADD, 2013)
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The study concluded that interlock devices are cost-effective in reducing alcoholimpaired driving crashes, most notably among drivers ages 21 to 29. An Australian study by Lahausse and Fildes (2009)
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Given strong scientific evidence that individuals convicted of alcohol-impaired driving who have an interlock installed on their vehicle are less likely than others to be rearrested for alcoholimpaired driving or to crash while the device is installed, the committee finds ignition interlocks to be a beneficial technological intervention for reducing alcohol-impaired driving. This technology is affordable for many individuals, and made affordable for others through indigent funds for low-income offenders.
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Furthermore, given the effectiveness of ignition interlock devices in reducing recidivism, additional research and development into the use of these devices for motorcycles is needed because of the high rates of alcohol-impaired driving fatalities for motorcyclists. Based on the limitations of ignition interlocks (e.g., dissipating effects after removal)
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Clinical staff who provide assessments of offenders and offer treatment suggestions to judges need to be aware of the various effective treatment options. Training for clinicians can include screening for alcohol and/or other drug use, identifying AUD, identifying binge drinking and the relationship of that behavior to alcohol-impaired driving fatalities and injuries, and implementing prevention strategies in the clinical setting.
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IMPROVING EMERGENCY MEDICAL AND TRAUMA SYSTEM SERVICES Surviving injuries and minimizing the harm of crashes from a lcohol-impaired driving require receiving definitive trauma care quickly (MacKenzie et al., 2006)
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. Coordinated efforts are needed to improve access to emergency and trauma care for individuals injured in alcohol-impaired driving crashes in rural areas.
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(2014) conducted a systematic review to assess published tele-emergency models and their associated outcomes.
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, as one study found that patients who were not transferred to trauma centers from nontrauma EDs but should have been were at risk of getting insufficient trauma care (Delgado et al., 2014)
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Trauma centers could be engaged to reduce time to care for rural areas. This section reviews some of the challenges rural regions face in confronting alcohol-impaired driving fatalities, including longer distances to trauma centers and hospital closures.
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. Data linkage is a key component in reducing rural alcohol-impaired driving fatalities.
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2004. Efficacy of brief interventions for hazardous drinkers in primary care: Systematic review and meta analyses.
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2000. Victim impact panels: Who is sentenced to attend?
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gene polymorphism with response to naltrexone in alcohol dependence: A systematic review and meta-analysis. Addiction Biology 17(3)
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2011. Effectiveness of ignition interlocks for preventing alcohol-impaired driving and alcohol-related crashes: A community guide systematic review.
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1999. The effect of victim impact panels on DUI/DWI rearrest rates: A twelve-month follow-up.
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DOT HS 811 836. Washington, DC: National Highway Traffic Safety Administration.
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2017. Do victim impact panels reduce drunk driving recidi vism?
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2011. Naltrexone depot formulations for opioid and alcohol dependence: A systematic review.
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2009. A systematic review of DWI court program evaluations.
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2015. Feasibility of a computer assisted alcohol screening, brief intervention and referral to treatment program for DWI offenders.
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8: Impaired driving. Washington, DC: National Highway Traffic Safety Administration.
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2008. A systematic review of emergency care brief alcohol interventions for injury pa tients.
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2003. The effect of victim impact panels on DUI rearrest rates: A five-year follow-up.
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2006. A systematic review of the effectiveness of naltrexone in the mainte nance treatment of opioid and alcohol dependence.
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1995. Victim impact panels: Their impact on DWI recidivism.
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Washington, DC: National Highway Traffic Safety Administration. Swift, R., D
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2004. Effectiveness of cus tomized victim impact panels on first-time DWI offender inmates.
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2012. Screening, brief intervention, and referral for alcohol use in adolescents: A systematic review.
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