SCREENING OF ARRESTED DRUNKEN DRIVERS FOR ALCOHOLISM. 1 2 J. Pikkarainen and A. Penttila

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1 SCREENING OF ARRESTED DRUNKEN DRIVERS FOR ALCOHOLISM 1 2 J. Pikkarainen and A. Penttila ^Central Public Health Laboratory, Helsinki, and ^Department of Forensic Medicine, University of Helsinki, Finland INTRODUCTION Since the beginning of a person-based file X ) consisting of all drivers suspected for drunken driving in Finland was conduncted in the Public Health Laboratory responsible for the blood alcohol determinations of the whole country. The great number of the drivers arrested repeatedly even in the same fiscal year was surprisingly high. In 1978 the total of the arrests for drunken driving was 20,487 in Finland from which 1,056 renewed cases accounted for 2,716 arrests (13 %). Mainly this finding promted this study to find out the rate of the social drinkers and heavy alcohol abusers and alcoholics, if possible. Much attention has previously been paid to the profile and the relative proportion of the problem drinkers among the drunken drivers, and some results of these studies have been discussed also in these meetings. The results vary considerably depending on the definitions of an alcoholic, a problem drinker, a heavy drinker, v) According to the Finnish legislation a driver with a BAC at least 0.50 ptr mille (w/w) is considered as a drunken driver.

2 etc. An another confusing fact are the different drinking habits in various countries as described by Selzer (9). Goldberg made the first observations connecting alcoholims to drunken driving (3). Several studies from Canada and USA suggest that about 2/3 of the drunken drivers could be concluded as alcoholics. In this study we have tried to estimate the number of the heavy alcohol abusers among drunken drivers 1 ) by interviewing the arrested drivers at the time of blood sampling, 2) by applying the criteria of the National Council on Alcoholism, and 3) by measuring the enzyme activities of serum aspartate aminotransferase, alanine aminotransferase and gammaglutamyl transpeptidase. MATERIAL AND METHODS The material consisted of 387 Finns suspected of drunken driving in 1979 in Helsinki and Espoo and Vantaa, the towns adjacent to the capital area. Fourteen drivers denied to answer any questions and they are excluded from the material. The drivers were investigated and interviewed by one of us (A.P.) when being on duty at the Forensic Medical Station of Helsinki. This station is serving the police in the forensic affairs in the great metropolitan area of Helsinki including the surrounding towns. The drivers were examined by the request of the police. An analysis of these consecutive drivers indicated that the present material represents an ordinary cross section of the Finnish drunken drivers (6 ). Most of the drivers were males (95 %) which corresponds to the recent national statistics. The relative number of younger people was more marked than in the statistics, and this was also reflected in the higher number of students (11 vs. 6.1 %). The clinical examination was made and the stage of inebriation estimated. All diseases, use of drugs etc. background factors which may have an effect on the result 289

3 of the clinical examination were recorded in this connection. Plain and fluoride-oxalate containing vacuum tubes were used to obtain serum for enzyme determinations and whole blood for determination of the blood alcohol concentration, respectively (2). At the end of the examination all suspects were interviewed for their drinkinghabits as well as for eventual social or physical complications of drinking. The reliability of the answers was controlled in several ways; - by comparing the informed arrests for public intoxication rand - by comparing the informed previous convictions for drunken driving with the data obtained from the files of the Bureau of Alcohol and Drug Abuse of Helsinki, and the statistics of the Public Health Laboratory, respectively. - by comparing the difference between the amount of the ethanol ingested and that calculated from the BAC. The activities of serum aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) were determined according to the recommendations of the Scandinavian Society for Clinical Chemistry and Clinical Physiology (7). For the determination of gammaglutamyl transpeptidase activity (GGT) the reagent kit of J.T.Baker and the method of Szasz were used (12). In order to find the alcohol abusers among the drunken drivers two different classification systems were used. System I was based on the major criteria for the diagnosis of alcoholism compiled by a committee of medical authorities from the National Council on Alcoholism (1). According to these criteria it is sufficient for the diagnosis of alcoholism if one or more of the major criteria are satisfied. We tested four of these criteria which are given in Table I. In addition, we used another criteria system to classify the alcohol abusers. This system II is based only on the information 290

4 given by the suspects. The various criteria of this system are presented in Table II. We believe that each one of these criteria is an expression of a heavy alcohol abuse, if not alcoholism. TABLE I The criteria of system I for alcoholism Tolerance to the effects of alcohol - BAC U9 0/00 without signs of inebriation, or /00 with a mild stage of inebriation, or /00 or more with a moderate stage of inebriation - Consumption alcohol beverages of more than 150 g calculated as absolute ethanol daily, every second day or twice a week Alcohol-associated illnesses - Present or previous hepatitis or liver cirrhosis or pancreatitis Psychological dependence on alcohol - One or more arrests for public intoxication in 1977 or 1978 Each of these four criteria when satisfied gives a score of 1 with a maximal score of U. TABLE II The criteria of System II for alcohol abuse Alcohol-associated illnesses - Neurological disorders of heavy drinking - Hospital treatment because of excessive alcohol use Behavioral, psychological and attitudinal criteria - Neglecting job for more than h times because of alcohol use - Arrests for public intoxication for more than twice - One or more previous arrests for drunken driving - Self-condemnation as an alcohol abuser - Attendance at the Alcoholics Anonymous Each of these seven criteria when satisfied gives a score of 1 with a maximal score of 7- RESULTS Admitted use of alcohol. More than half of the drivers (58 %) reported that they drank at least once a week 291

5 (Table III). About a half (49 %) more often from which about a half only during the weekends, and 12 % of the drivers admitted the daily use of alcohol. Only 11 % of the drivers were satisfied with only a few drinks. Usually the suspects (46 %) admitted to consume more TABLE III Results of the interview Variable 1 Variable % Frequency of drinking Arrest for public intoxication - daily 12 - never 60 - every second day 3 - once 13 - weekends times 17 - twice a week 8-4 times or more 10 - once a week 9 Previous arrest for drunken - once in two weeks driving times a month 20 - more infrequently 8 - never 66 - once 22 Amount of drinks times 9 - few beers or drinks 11 - k times or more bottles of beer or 43 Neglecting job for alcohol 1/2 of liquor (75 g ) - more than 10 bottles of h6 - never 86 beer or one liquor (I50g) - once It times Beverages 7 - h times or more 3 - beer 31 Treatment for alcoholism - liquor 30 - wine 12 - never 92 - beer & liquor 12 - once 5 - beer & wine times 1 - liquor & wine 3 - U times or more 1 - beer, liquor & wine 7 CNS-sequelae Drinking to intoxication at a time - never 95 - never 60 - presently 5 - often 3b - earlier seldom 6 Pancreatitis Self-condemnation as an alcohol - never 98 abuser - presently 2 - no 80 - earlier yes 17 Hepatitis/cirrhosis - do not know 3 Attendance at Alcoholics Anonymous - never 98 - presently 1 - never 93 - earlier 1 - presently - earlier 4 292

6 than ten bottles of beer (150 g of absolute ethanol) or the equivalent amount of liquor at one time. One third of these heavy drinkers concentrated their alcohol use to the weekends. About every second driver (40 %) admitted to drink in general so much at one time that they became heavily intoxicated. The popularity of beer and liquor was equal and twice that of wine. Twenty per cent of the whole material considered themselves as alcohol abusers, but only 7.0 % had participated in the meetings of the Alcoholics Anonymous. Social complications. The majority (86 %) of the drivers insisted that they had never neglected their work because of drinking, and only 2.8 % admitted nonattending work more often than four times. The percentage of the drivers admitted have being arrested for public intoxication (40 %) was equal to the number of the drivers who admitted to drink to the stage of intoxication at a time. However, only about a third of the latter cases had been arrested at least twice for public intoxication or drunken driving. The number of the drivers who admitted previous convictions for drunken driving was considerable (34 %) in the present material. These drivers had heavy drinking habits. Half of them had been arrested for public intoxication earlier. Medical complications. The abuse of alcohol had resulted in a hospital treatment in 30 cases (8.1 %). Twenty drivers (5.4 %) had suffered from various alcoholderived neurological disorders, and 15 (4.0 %) from either pancreatitis, hepatitis or liver cirrhosis. Classification of alcohol abusers-systems I and II. Table IV presents the distribution of the material by the two classification systems. The arabic numbers from 0 to 4 and from 0 to 7 show how many of the criteria (Table IV) are satisfied in the systems I and II, respectively. Both systems seem to correlate. According 293

7 to the System I or System II 167 of 373 drivers or 45 % should be classified as non-alcoholics. If they are simultaneously subjected to the criteria of both systems the number 167 decreases to 103 drivers or 28 %. The percentage of alcoholics is at least 10 % (two scores by both systems). If only the criteria of the National Council classification are applied the percentage of alcoholics is 19 % or 55 % by two or one satisfied criteria, respectively. TABLE IV Comparison of Systems I and II used for scoring of suspected drunken drivers for alcoholism. For criteria of alcoholism, see the Tables I and II System II Drivers divided for alcoholism Total System I I-b % % lo I % n II b, b b Total % n ! Reliability of the interview results. The results given above are mainly based on the answers given by the drivers about one hour after arrest. About one fourth of the suspected drunken drivers belonging to the groups 1-1, 1-2, and by their alcohol abuse lied their previous arrests for drunken driving or public intoxication. However, when the amount of alcohol drunken before the actual arrest was compared to that calculated from the BAC the number of the drivers not telling the truth was 50 % if a miscalculation of 60 grams of absolute ethanol (about 4 drinks & 4 cl) is allowed (Table V ). The percentages correlated positively to the score of the 294

8 alcohol abuse; in the group 1-0 the relative number of the liars was 33 %, in %, and in the combined group %. The corresponding rate for the combined "control group" or the real non-alcoholics according to the classifications used in this study (I-O+II-O) was 24 %. The above calculation could be made only for 183 drivers (49 %) due to the incomplete drinking data obtained from the request form of the police. TABLE V The difference in grams of ethanol between the claimed and calculated amount. For criteria of alcoholism, see the Tables I and II Difference Drivers divided for alcoholism in grams P I I-O+II-O % % 1 % Over ^ 5 ; over Total t n Mean + S.D g g g g ASAT, ALAT and GGT activities. Either an elevated ASAT, ALAT, or GGT activity or some combination of these enzymes was detected in the serum of 109 cases (29 %) (Table VI). The activity of GGT alone was elevated in 4.8 % and together with ASAT and/or ALAT in 13.1 % of the drivers. The frequency of the increased GGT activity correlated positively in the different subgroups of System I to the severity of the diagnostic score (alcohol abuse). However, even in the combined subgroup I-O+II-O, regarded as non-alcoholics, one could find elevated enzyme activities in a considereable number of cases suggesting a liver involvement. 295

9 TABLE VI The frequency of elevated serum aspartate aminotransferase (ASAT>40 U/l), alanine aminotransferase (ALAT?" 40 U/l) and gammaglutamyl transpeptidase (GGT>50 in males or >30 U/l in females) activities in 373 suspected drunken drivers. For criteria of alcoholism, see the Tables I and II Serum enzyme All n cases % Drivers divided for alcoholism 1-0 % 1-1 % % I-O+II-O n % ASAT ALAT GGT 18 It ASAT+ALAT ASAT or ALAT+GGT ASAT+ALAT+GGT Non-elevated Total % n DISCUSSION Because the results of the interview as well as those of the two classification systems, allthough this regards in a lesser degree System I (National Council on Alcoholism), depend on the reliability of the answers of the suspects, it is important to know the rate of the people omitting the truth. People usually do not exaggerate their drinking habits nor its consequencies and our results indicated that every fourth of the interviewed drivers was not telling the truth which rate must be taken as a minimum. On the other hand, the previous convictions for drunken driving (34 %) admitted in the present study is rather high. There is, however, a considerable difference in the tendency to lie when the drivers were asked about their drinking habits connected to the present arrest. The rate of alcoholics in the present material depends considerably on the classification system. Since the National Council criteria are widely accepted we may conclude that the percentage of alcoholics is at least 296

10 19 %. This rate was obtained when we made a condition that two criteria were fullfilled. We considered that important because the first criterion used for tolerance (Table I) could be discussed. The purpose to use the other classification system (II) was to strenghten discrimination between alcoholics and non-alcoholics because we applied only four criteria of the National Council system. When the material was subjected to both classification systems simultaneously the rate of non-alcoholics was found to be 28 % which may be taken as a minimum. The percentage of alcohol abusers (consumption more than 10 litres of alcohol calculated as absolute ethanol) is about 12 % in the corresponding male Finnish population againg years (10). These results show that there are considerably more alcoholics among the drunken drivers than is the rate of alcoholism in Finland. This is further augmented by the fact that 69 % of the drivers in the present study had been arrested earlier for public intoxication or drunken driving or considered themselves as alcohol abusers. The published values of diagnostic sensitivity for the different enzymes in alcoholism vary considerably: GGT , ASAT , and ALAT U/l (5,8,11,13). If the prevalence of alcoholism is 12 % and the diagnostic sensitivity 0.69 is taken for GGT (4), the predictive values for the positive and negative GGT values in alcoholism are 0.79 and 0.96, respectively. One can predict from the elevation of the GGT activity that there are about 15 % of alcoholics in the present material. This is good agreement with 13 % when aminotransferase and GGT activities are simultaneously elevated. Compared to GGT the aminotransferases alone are of minor importance in screening for alcoholism since they increase from many non-liver related reasons, too. 297

11 SUMMARY AND CONCLUSIONS 373 arrested drunken drivers were screened for alcohol abuse and eventual alcoholism, with the following main conclusions. (1) About 11 % of the drivers admitted the daily use of alcohol and 49 % drank more than once a week. About every second (40 %) drank for heavy intoxication at a time. Every fifth considered himself as an alcohol abuser but only 7 % had participated in Alcoholics Anonymous. About 40 % admitted an arrest for public intoxication and 34 % had one or more previous convictions for drunken driving. (2) According to the criteria of National Council on Alcoholism 45 % of the drivers could be considered as non-alcoholics and by two scores 19 % as alcoholics. (3) The serum activities of gammaglutamyl transpeptidase, aspartate aminotransferase, and alanine aminotransferase were determined. On the basis of the elevated GGT activity about 15 % of the drivers could be considered alcoholics. (4) The present results show that there are significantly more alcoholics among the drunken drivers than is the rate of alcoholism in Finland. REFERENCES 1. Criteria Committee, National Council on Alcoholism, Criteria for the diagnosis of alcoholism, Annals of Internal Medicine, 77: , Elg, P. and Portman, M., Experience with an ADHmethod for the determination of blood alcohol concentration using the LKB-2086 Reaction Rate Analyzer, Blutalkohol, 1980 (in press). 3. Goldberg, L., Drunken Drivers in Sweden, Proceedings of the 2nd International Conference on Alcohol and Road Traffic, Toronto, Jacobsson, K., Gerhardt, W., Skude, G. and Tryding, N., S-GT och alkoholism-nyktert sett, Lakartidningerv 77: , Konttinen, A., Hartel, G. and Louhija, A., Multiple serum enzyme analyses in chronic alcoholics, Acta 298

12 Medica Scandinavica,188: , Lindbohm, R., Maki', M., Penttila, A. and Pikkarainen, J., Drunken driving in Finland. I. The profile of all arrested drivers in , Proceedings of the 8th International Conference on Alcohol, Drugs and Traffic Safety, Stockholm, Recommended methods for the determination of four enzymes in blood. Committee on Enzymes, the Scandinavian Society for Clinical Chemistry and Clinical Physiology, Scandinavian Journal of Clinical Laboratory Investigation,33: , Rosalki, S.B., Enzyme tests for alcoholism, Revue de Epidemiologie et de Sante Publique, 25:158, Selzer, M.L., Alcoholics and social drinkers: Characteristics and differentiation, Proceedings of the 6th International Conference on Alcohol, Drugs and Traffic Safety, pp , Toronto, Finnish drinking habits in 1969 and Alcohol consumption and alcohol problems in demographic groups (in Finnish), Reports from the Social Research Institute of Alcohol Studies, 114/ Skude, G. and Wadstein, J., Amylase, hepatic enzymes and bilirubin in serum of chronic alcoholics, Acta Medica Scandinavica,201:53-58, Szasz, G., A kinetic photometric method for serumy^glutamyl transpeptidase, Clinical Chemistry 15: , Wietholtz, H. and Colombo, J.P., Das Verhalten der V-Glutamyltranspeptidase und anderer Leberenzyme im Plasma wahrend der Alkohol-Entziehungskur, Schweizerische medizinische Wochenschrift, 106: ,