TO PUNISH AND/OR TO TREAT THE DRIVER UNDER THE INFLUENCE OF ALCOHOL AND/OR OTHER DRUGS. M. R. Valverius, M.D. SYNOPSIS

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1 TO PUNISH AND/OR TO TREAT THE DRIVER UNDER THE INFLUENCE OF ALCOHOL AND/OR OTHER DRUGS M. R. Valverius, M.D. * SYNOPSIS This is a review of the reported incidences of driving under the influence (DWI) of alcohol and the efforts to rehabilitate drivers, in various countries. The reports from Europe have been accentuated because the language barriers have made the methods employed in Europe unknown to the scientists in the other, mainly English-speaking countries. The basic problem is not the question of punishment vs treatment. If we accept the proposition that punishment is basic for crime prevention, we acknowledge that punishment is a prerequisite for the prevention of unsafe driving. The coordination of punishment with rehabilitation is the main issue in our efforts to make transportation safe. The epidemiological data about driving under the influence (DWI) of alcohol in various countries give the impression that a certain percentage of drivers on the roads are driving under the influence, despite all efforts of the authorities jail, fines, suspension of driving privileges to keep the drivers involved "off the roads." Take, as examples, the figures from Sweden, Australia (Victoria), and the Federal Republic of Germany (FRG): In Sweden, of approximately 3.5 million licensed drivers, about 18,000 each year are convicted for driving with illegal blood alcohol concentrations (above 0.5 permill or 0.05%). In the State of Victoria (Australia), each year approximately 14,000 drivers are convicted for drinking-and-driving, from a total population of 2 million drivers. In the FRG, the number is about 120,000 drivers convicted for drinking and driving with illegal blood alcohol levels, each year. From the roadside surveys in various countries, we can state the results in a more positive way: a high proportion * Kommendorsg 25, S Stockholm, SWEDEN. 51

2 of the driving population is taking part in the traffic flow without illegal blood alcohol levels. For example, we found, from our analyses with breath tests followed by blood alcohol determinations of 1.0 million drivers at road blocks during in Sweden, that 99.88% of the drivers were sober (i.e., blood alcohol levels under the legal limit) and only 0.12% with blood alcohol levels over the legal limit (0.5 permill). Similarly, for the year 1977 in France, some have estimated that 92.4% of the drivers were driving with no alcohol in the blood or with blood alcohol levels under the legal limit. (I note here that the legal and illegal blood alcohol levels differ substantially in the various countries and, therefore, that the statistical comparisons are only conjectural: the sober driver with a legal blood alcohol level in France may be punished in Sweden for driving with a blood alcohol level well over the Swedish legal limit.) While accepting the reality that the number of drivers with illegal blood alcohol levels is low, the traffic authorities must still be able to identify those drivers. Further, this identification must be emphasized not only by the authorities but also by the great majority of people who participate in all types of transportation. For the purpose of prevention of accidents, with personal injury and property damage, the drinking drivers must be identified and dealt with before becoming involved in such eventualities. The results of studies dealing with the problem of such drinking drivers as may be involved in serious mishaps show that it is possible to describe the relevant characteristics or dimensions of these "high-risk" drivers as a group. Yet difficulties remain in the identification of the specific individual who is a high-risk driver. Analyzing official records of police and/or motor vehicle authorities and combining the observations with personal interviews with specifically-targeted groups, such as convicted drivers, crash-involved drivers, and drivers with positive breath tests at road blocks, makes possible the specification of the relevant variables and their parameters. The combination of biographical background variables with drinkingand-driving variables should enable the identification of persons in danger and the introduction of countermeasures if the local legislation allows such. Several countries in Europe accept by legislation rehabilitation of drinking drivers: the FRG, Austria, and Switzerland must be mentioned prominently. The beginnings of such efforts can be noticed in The Netherlands and, to a 52

3 lesser extent, also in France. But in the Spanish- and Italian-speaking countries and in the countries of East Europe, any organized system of rehabilitation of drinking drivers is unknown; punishment by incarceration, fines, and the withdrawal of driving licenses are the only recognized countermeasures against drinking-and-driving. Also in the Scandinavian countries Denmark, Finland, Norway, and Sweden the countermeasures are punishment with jail and fines; the withdrawal of driving licenses is an administrative procedure, not a punishment! (I note again the differences which exist between countries, here the Scandinavian countries: the legal limit which is 0.5 permill in Sweden is 0.8 and 1.2 permill in Denmark. For the same blood alcohol level, the drinking driver receives a mandatory jail sentence in Sweden but is levied only a moderate fine in Denmark, never incarceration.) Let us concentrate on Sweden. The studies published in the 1950's reported that persons injured in traffic accidents with high blood alcohol levels are alcoholics. This observation was confirmed in the 1970's and 1980's, in the analyses of drivers with blood alcohol levels over the legal limit, at road blocks arranged by the police in Sweden. Goldberg (1980), at the 8th International Conference in Stockholm, summarized the results of these analyses as follows: two groups of drivers are apprehended at roadblocks with blood alcohol levels over the legal limit, one with relatively low alcohol levels and without alcohol (drinking) problems and the other with high blood alcohol levels (over 1.8 permill) and with serious drinking problems and/or alcoholism. From my own investigation of 10,515 drivers during in northern Sweden (Valverius et al., 1982) I came to the same conclusion. Despite these observations published over a period of 30 years, only in 1983 was the discussion opened regarding the possibility of use of some form of rehabilitation/treatment for drinking drivers. In my opinion the reason for this delay is that only recently were the economic and humanitarian aspects recognized; the society now demands that drivers with alcohol problems not only be jailed but be treated, yet the cost of the former (incarceration) has become too expensive. It is my conviction that we must have in Sweden punishment in some form but, also, we must have the possibility of rehabilitation or treatment, as needed. Therefore, the question is not the abolishment of punishment to be replaced by rehabilitation only. Speaking from the experiences in Sweden, I maintain that the punishment is an essential deterrent in the prevention of driving with blood alcohol levels over the legal limit. The statistical evaluation of the roadside surveys in Sweden gives evidence that of the small percentage of drivers (0.12% of the total) with blood 53

4 alcohol levels in excess of the legal limit, some 50-70% have alcohol problems. Punishment with jail, fines, and the withdrawal of driving privileges does not protect them and our society from traffic mishaps; only the combination of punishment with appropriate rehabilitation can have the desired preventative effects in connection with traffic safety. The experiences in the FRG, that license withdrawal and punishment with fines and incarceration do not prevent drivers from drinking-and-driving, have been the basis for the introduction in 1977 of special treatment programs for drivers with two or more DWI offenses. Winkler concluded from his experiences that the programs have to be embedded in a system of punitive and rehabilitative measures which complement and support each other. In his opinion, alcoholics, drivers with psycho-pathological disorders, and drivers with a serious and acute personal conflicts are not suitable for rehabilitation with the type of programs introduced; the participants must be carefully selected and the instructors, well trained. The experiences from the FRG and Austria also confirm those from Sweden in that the group of drinking drivers comprises drivers of many kinds of drinking habits and attitudes, not simply alcoholics and non-alcoholics, as some have assumed. Approximately 30% of the drivers with high blood alcohol levels in the FRG are alcoholics or chronic heavy drinkers; the figure in Sweden is about 70% (Valverius et al., 1982) or, even, 90% (Liljenberg, 1983). The experiences from the FRG also substantiate the observation that alcoholics are not suitable for the conventional type of rehabilitation. To identify and select those drivers who are suitable is one of the primary goals in the establishment of a rehabilitation program. In Europe, the use of psychological tests, as is usual in the United States (USA) and Canada, is complemented with the use of biochemical tests, as, for example, the tests for the enzyme GGT (gamma glutamyl transpeptidase) or the analyses for methanol concentration as indicants of alcoholism. A review of the experiences in the USA suggests that the role of the psychological tests there is exaggerated and the use of the biochemical tests (e.g., the enzyme tests), neglected, at least in contrast with the European experiences. This difference is probably due to the practices in Europe whereby blood alcohol tests are used which enable concurrently the enzyme tests. Breath tests, prominently used throughout the USA, Canada, and Australia to measure 54

5 alcohol concentration, are not suitable for the estimation of methanol concentration or of enzyme levels. (The latter require blood samples.) Here lies the principal difference between the European and the American programs. Programs for the treatment/rehabilitation of convicted drinking drivers have been developed in the USA during the last 30 years. However, the fact that over 1500 DWI correction programs presently exist in the USA and Canada does not mean that the programs have had the anticipated positive impact on drinking-driving. Studying Reed's evaluation (Reed, 1982) of the drinking-driving programs we ought to be depressed: in general, educational/therapeutic treatment is more expensive than punishment, but not necessarily more effective in the prevention of accidents. Reed, summarizing the literature on evaluation, stated that no credible evaluation has shown any educational/therapeutic treatment reduces the likelihood of future accidents for a person arrested for DWI any more than does punitive treatment. However, we must recognize that any evaluation should be based on precisely-defined terms, as for "alcoholics," "problem drinkers," "heavy drinkers," "social drinkers," and "drunk drivers," to list only a few of the terms cited in the reports. The definitions if published are often ambiguous, variable in application, and subjective in origin. We can give as an example the definition recommended by the National Council on Alcoholism (USA) for the diagnosis of alcoholism: an individual with a blood alcohol level over 0.15% without gross evidence of intoxication or one arrested for driving while intoxicated. Applying this definition to the driving drivers we would have to accept that all DWI's can be, or are, alcoholics. Moreover, the psychological tests developed in order to detect alcoholics among drinking drivers, for example, the Michigan Alcoholism Screening Test (MAST), may give the investigator may false positive identifications. Therefore, the data concerned with alcoholism in the driving population must be evaluated very carefully. We must define precisely the nomenclature used in the evaluation and must employ accepted operational definitions when comparing results of rehabilitation and treatment of the DWI. Further, the results of the studies in the USA and in the FRG suggest that alcoholics and drinking drivers are not one and the same population as may be the case in Sweden but that drinking-and-driving may be an early sign of alcoholism. Road blocks can be used under these circumstances not only as legal proceedings but also as humane procedures for the early identification of predilection towards alcoholism. 55

6 In reviewing the literature on rehabilitation/treatment of DWI's, I found few references dealing with drug use (including addiction) and driving. Although DWI with alcohol is still the greater problem, the influence of drugs mainly the narcotics, such as cannabis, amphetamines, cocaine, and heroin on traffic safety, in light of the growing use of these agents, must be carefully considered. Specific guidelines for the rehabilitation of drug addicts in connection with automobile use and traffic violations do not exist, despite the existence of treatment programs in many countries. We must understand the long-term effects of drug abuse in connection with driving and traffic mishaps, with consequences for rehabilitation. Perhaps at our next international conference, we should activate and catalyze the research on drugs and narcotics in the field of transportation. Further, we should discuss at least the interaction between alcohol and drugs as another serious problem in connection with rehabilitation. For example, Gerchow (1983) has called attention to this connection with regard to the working women influenced by drugs to prevent fatigue or stress, a significant problem in our industrialized societies. The problem of whether to punish or to treat is not a question of punishment or treatment. Our experiences in Sweden, despite the comments about "the Scandinavian myths" (Ross, 1982), indicate that punishment is a prerequisite for crime prevention. The problem we must deal with now is the coordination of punishment and rehabilitation/treatment. (Preparing this plenary forced upon me the following interesting observation regarding the language barrier between the German- and the English-speaking scientists working in the field of rehabilitation: no American author mentioned the experiences of German authors working in this field; very few German authors cited papers written in English. Both are working with the same issue: the drinking driver. Why not learn from the mistakes and the success of the other? Why make the same mistakes in both languages? One can only wonder why [how?] this disparateness exists is this age of computerized translation and computerized information storage and retrieval.) REFERENCES Gerchow, J. (1983). Sucht und Delinquenz unter Beriicksichtigung ihrer Bdeutung in der Personlichkeitsentwicklung. In, Sucht und Deliquenzrechtsfragen und therapeutische MSglichkeiten. Hamm: Hoheneck-Verlag. 56

7 Goldberg, L. (1980). Random road tests in non-accident and accident-involved drivers: Epidemiological data, differential characteristics and role of alcoholism. In Goldberg, L. (ed.), Alcohol, Drugs, and Traffic Safety. Stockholm: Almqvist & Wiksell International. Pp Liljenberg, J. (1983). Personal communication. Reed, D. S. (1982). Drinking and driving programs. In, Prevention, Intervention, and Treatment: Concerns and Models. Alcohol and Health Monograph No. 3. Rockville, Maryland: National Institute on Alcohol Abuse and Alcoholism. Pp Ross, H. L. (1982). Deterring the Drinking Driver: Legal Policy and Social Control. Lexington, Massachusetts: Lexington Books. 129 pp. Valverius, M., Moberg, J., and Linden, Ch. (1982). Roadside survey in northern Sweden. In, Valverius, M. R. (ed.), Roadside Surveys. Stockholm: CANs. Pp

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