Dependence and Misuse of Alcohol: Genetic, Medical and Psychological Criteria for the Prognosis of Future Drunken Driving

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1 Dependence and Misuse of Alcohol: Genetic, Medical and Psychological Criteria for the Prognosis of Future Drunken Driving Stephan, Prof. Dr. E. U niversität zu K öln Psychologisches Institut H erbert-l ew in-str K öln 41 On the basis of empirical information and clinical experience it is possible to formulate the following hypotheses regarding the scientific psychological prognosis of future driving problems. These predictions underly character assessments carried out under the auspicies of the German government traffic regulation and safety institutions (see conference contribution by Undeutsch) 1. H ypothesis The relationship between alcohol misuse, alcohol dependence and drinking and driving problems is of central importance in the expert assessment of a convicted drinking driver C om m ent The average yearly consumption of alcohol in the population lies around 12 1 of pure alcohol per person. What has to be considered is that many individuals drink a little and a small number of individuals drink a lot of alcohol. According to Wieser (1973, Das Trinkverhalten der Deutschen, Herford: Nicolai) only 5% of the population drink in the order of 36% of the alcohol. This means that the per capita consumption of this 5% is about 86 1 of pure alcohol per year! This suggests for this 5% a daily intake of alcohol of approximately 186 g, representing consumption of 4.61 beer or 2.3 1wine or 0.51 spirits. Therefore, through regular drinking it is possible for the members of this group of the population to reach daily blood alcohol levels of over 1.6 g/1! Of concern here are men between 20 and 50 years old, which is also the same group of the population who are most likely in possession of a driving license and who have been found to drive the most! With respect to data collected on individuals in the area of the former West Germany this group of 5% represents 3 million individuals from whom approximately 2 million may have a driving license. Stephan (1988, Blutalkohol, Vol. 25, Nr.4, S ) established on the basis of 300 individuals in inpatient treatment for alcohol problems that 90% of the individuals had at some point been in possession of a driving license. That approximately 67% of the heavy drinkers, i.e. 2 million, are in possession of a license, is probably an un Alcohol, Drugs and Traffic Safety - T92 Ed. by Utzelmann / Berghaus / Kroj Verlag TÜV Rheinland GmbH, Köln

2 derestimate. Even cautious estimates that individuals from this group drive only every third day while drunk would result in an estimated 2 million instances of drunken driving per year. In contrast to this, there are only about 110,000 revocations of driving licenses. With regard to this ratio of 1 to 2,000 and a mean bloodalcohol level of 1.5 g/1 during drunken driving offenses, one can conclude that the driving license revocation almost exclusively comes from the group of heavy drinkers who at the time are alcohol dependent and not from individuals without problem alcohol drinking who just "slipped up" (see also Stephan 1988). It remains noteworthy that the proportion of excessive drinking persons is probably higher today than in 1973 and lies over 5%. The mean alcohol blood level is 1.5 g/1 for convicted drinking drivers in former West Germany. Assuming a safety factor of 0.1 g/1 for inexact blood alcohol measurements it can be inferred that traffic offenders with more than 1.6 g/1 belong to a negative selection ("the worst half") of the entire group with unusually heavy alcohol consumption. Results from drinking tests confirm the assumption that the intoxicated offender who has problems with driving at alcohol levels of 1.6 g/1 or more comes as a rule from the group of individuals in the society with problem drinkers and alcohol dependent individuals. A "social drinker" will as a rule have difficulties attaining a blood alcohol concentration of more than 1.3 g/1 even when he/she has no intention to drive. Basically it is not possible to make assumptions about the uniqueness of an alcohol-related offence or offences found in an individual's records. In general, at the time of the character assessment information is only supplied the fact that over the years, and quite often, the driving of a vehicle has been associated with high blood alcohol concentrations. In this respect the alleged uniqueness of the documented event of breaking of the law (driving under the influence) requires conclusive proof. Without this evidence it has to be assumed that there has been a frequent association between unacceptably high levels of alcohol intake and driving. From the estimated blood alcohol concentration associated with the recorded illegal act one can make a minimum estimate of the strength of the individual's tolerance. The chronic alcohol consumption, i.e. alcohol misuse, that can be estimated lies at least so high as can be found from the blood alcohol concentrations found in the police records. It is in general to be assumed that the problem is likely more severe, because it is problably unlikely that the individual will engage in driving and also be caught exactly at that point when the capacity for alcohol consumption has reached its absolute maximum. It is as a rule not justifiable when an expert examiner bases a traffic prognosis on the assumption that only in the officially registered case did the individual engage in an unusually high level of alcohol intake C onclusion Epidemiological research on alcohol as well as results from drinking experiments provide evidence that chronic alcohol misuse is usually at the forefront for driving offenders who were caught with more than 1.6 g/1, and that this alcohol misuse has led to or is leading to considerable burdens of a personal, social and/or health nature. 230

3 Because this deals with consumption that has damaging consequences on the individual it is appropriate to speak of a misuse tolerance with regard to the habituation that results from this. 2. H ypothesis The negative effects of chronic alcohol misuse which results in misuse tolerance is not equivalent to alcohol dependence C om m ent Although the duration and extent of alcohol misuse increases the probability that alcohol dependence appears, dependence will not necessarily appear even with heavy chronic abuse. On the basis of recent evidence it appears possible that differential genetic dispositions play a role such that with comparable misuse only misuse tolerance will appear in one situation, whereas in another case this will appear together with dependence C onclusion Among the drunken offenders who were caught with more than 1.6 g/1 there exist persons with alcohol misuse alone as well as those who also have alcohol dependence. Their only common denominator is, however, the misuse tolerance which results from chronic alcohol misuse. It is specifically this misuse tolerance which is present in the two groups that has central meaning for the traffic prognosis. 3. H ypothesis In the situation of the expert examination the demonstrating of physical signs of withdrawal to determine the presence of physical dependence is impossible; it is also only with considerable difficulty that subjective experiences dealing with compulsive uncontrolled drinking can be used to provide evidence for psychological dependence C om m ent Severe physical withdrawal signs are rather the exception than the rule. In addition they disappear within a few days such that one cannot expect that a individual will specifically present himself in this state for expert examination. Because the individuals in an expert examination are fighting for their driving license, they are understandably careful about presenting anything which could evidence uncontrolled drinking or exceptionally strong motivation to drink. Through specialised psychological exploration and biographical analysis it is possible to collect some evidence for psychological dependence and other evidence for alcohol dependence such as social losses, frequent changes in jobs and many other pieces of information (not the least of which is the driving license revocation). However, it should be pointed out that the former indicator could be due to other factors and therefore only provides circumstantial evidence. 231

4 3.2. C onclusion As a rule neither physical nor psychological dependence can be diagnosed in the expert assessment in a fashion that is forensically conclusive, because the individual strives to decicvc. Also, indicators that can be established on the basis of biographies and not involving the subject do not provide any useful forensic proof of alcohol dependence, because of their lack of specificity. The biographical characteristic of "in-patient alcoholism therapy" is not useful because of the small number (20-30,000) of therapy places (beds) in contrast to the approximately 1.8 million alcohol-sick individuals. 4. H ypothesis Biological aspects in the area of alcohol tolerance and biochemical effects of alcohol consumption are in the end more important for traffic prognosis - as behaviour prognoses - than the relationship between genetic disposition and the risk of becoming alcohol dependent. In all consumers of alcohol, particularly after the start of the alcohol effect, an interest for drinking comes about and increases and this is considerably less when the starting point is in a completely sober state C om m ent From a current review of the literature by Sander et al. (1992, Sucht, 4, ) it is argued that animal models, twin, adoption and family studies provide evidence for a genetic disposition towards alcohol dependence, with the hereditary factors interacting with environmental influences in the production of alcohol dependence (see Sander et al. 1992, p.272). At the present time the findings of a genetic predisposition are in our opinion not yet certain enough to warrent application. However, even if we already had an adequate database at our disposal this would have only indirect meaning for the traffic prognosis. Of greater importance may be the repeatedly confirmed observation from expert assessments that previously acquired tolerance can be much more quickly reinstated even after a long period of abstinence. Besides these case observations in humans, laboratory investigations with animals provide conclusive evidence of a carry-over effect of acquired tolerance that can be seen even after very long periods of abstinence. Independent of the various genetic dispositions one can assume a biologically-based, life-long disposition towards the development of high alcohol tolerance which is acquired by the organism through alcohol misuse. The previously-acquired misuse tolerance subsides only for short periods as a result of periods of abstention; however, with the reinitiation of alcohol consumption/misuse it reappears within a short period of time, compared to the original period of training. In persons who have reached the state of misuse tolerance through alcohol misuse there will be a lifelong lack of responsiveness to the negative sensations produced by alcohol intake, which will be reacquired with little "training" after reinstatement of toxic loads of alcohol. These individuals lack the subjective (negative) states produced by the alcohol, which in turn probably serve to control behaviour (avoidance of driving with unacceptable levels of blood alcohol). The remaining 232

5 conscious control of drinking is, except in exceptional cases, too unreliable to be considered important for general traffic safety. With regard to the question of whether dependant individuals with misuse tolerance can learn to handle alcohol consumption responsibly, it is not only the biological factors with regard to alcohol tolerance that we have to consider, but the biochemical processes which have been set off through alcohol consumption. Associated with this are the biochemical processes in the brain that occur with the psychotropic effect of alcohol. In the reinforcement system of the limbic system biochemically-produced euphoria subsequently leads to a small degree of depression. This can, though it is small, be viewed as a withdrawal sign. Even the average alcohol consumer could without being aware of it try to avoid this through further intake of alcohol. It should be assumed here that the consumed amount of alcohol is sufficient to elicit euphoric effect. In individuals with misuse tolerance the euphoria only appears after heavy consumption if at all and it is exactly in this group that striving to reach and to maintain euphoria leads to the intake of particularly high levels of alcohol, because of the existing misuse tolerance. At the same time there is a lack of any (braking) toxic effect. In addition to this, alcohol is a diuretic amongst other things and in so far as the fluid loss produced by the alcohol intake is larger than the amount taken in with the alcoholic beverage. This means that beer which is usually thought of as thirst quenching leads to a fluid loss in the end. The more that it is consumed the more the organism "dries out". This explains the "the morning-after thirst" the day after an episode of excessive drinking. Podschus et al. (1992,Sucht 38,2,p.97-99) established during a study involving 30 alcohol dependent patients that the desire for alcohol during the period when alcohol was consumed was higher than that during the withdrawal and abstinence phase. This contradicts the prevalent view that the "physical lust" for alcohol reaches its high point in the withdrawal phase. The alcohol produced biochemical momentum can lead basically in every alcohol consumer to a trend to continue alcohol consumption. Naturally this will be counteracted through conscious control in normal consumers and in a good proportion of individuals with chronic alcohol misuse. This conscious control may however most likely fail just when particular circumstances mean increased risk for consumption of higher levels of alcohol (special distractions, certain types of anger or joys and so on). In persons with normal alcohol tolerance, biochemical and psychic dynamics activated by alcohol will as a rule be stopped without targeted controls, i.e. without conscious voluntary action, as a result of the negative sensations from the intake of high doses of alcohol. In individuals with misuse tolerance these "natural braking reactions" of the larger amounts of alcohol are absent or are switched on later than normally. The victim passes through the spiral alcohol intoxication, "driven" unknowingly by biochemical causes without particular toxic effects to such an extent that the individual blood alcohol level surpasses the legal level (0.8 g/1, 1.1 g/1). This occurs without intending to do so and without being able to assess on the basis of physical sensations whether high degrees of alcohol levels have been reached. Because of the former issue a systematic separation of unacceptable alcohol intoxication and involvement in traffic by individuals with misuse tolerance is made 233

6 very difficult Conclusion The misuse tolerance is of primary importance for the traffic prognosis. Even individuals who have misuse tolerance but are not dependant have to expect blood alcohol levels over 1.1 g/1 when for whatever reasons control over the amount consumed is lost; this can also occur during involvement with driving. This can be the case even when the individual is said to be previously successful at reducing levels of alcohol consumption in drinking situations. For the traffic prognosis a useful criterion is chronic alcohol misuse without dependence. Genetic information concerned with congenital disposition for the development of alcohol disease or dependence is in this regard of secondary importance, since the previously mentioned biochemical process can apply for every alcohol consumer; this is particularly the case for those individuals without any genetic risk factors who have misused alcohol over a long period. The dry alcohol dependant individual who is in a state of "content abstinence" and a regular member of a self-help group has a better traffic prognosis than individuals who "only" provide evidence for chronic alcohol misuse without wanting to forgo alcohol. 5. Hypothesis For a positive traffic prognosis "content abstinence" is evidenced by "controlled dealings" with alcohol, rather than by a pause in drinking or a forced giving up of alcohol consumption, implemented by the individual with only considerable effort Comment In our alcohol permissive society consequent alcohol abstinence is only possible in the long term when the individual has reached a state of "content abstinence". This means that his life without alcohol is more meaningful and more at peace than with alcohol. Temporary pauses in drinking do not guarantee controlled dealings with alcohol, they only lead to temporary improvement of physical signs Conclusion It can be expected that a individual has sufficient motivation to forsake alcohol in the long term only when psychological explorations reveal that the subject is in "contented abstinence". This demand is the most important for a positive traffic prognosis. 6. Hypothesis A forensically acceptable positive traffic prognosis is more likely to be found through evidence for the presence of a " content abstinence" than it is with determining alcohol dependence. 234

7 6.1. Comment A change in drinking behaviour comprises an intervention in the total life structure. This means not only a break between well-integrated personal drinking habits and the drinking norms of the respective social environment but also fundamental changes in work and leisure activities. A strong source of motivation is required for abstinence. Such a source of motivation can be derived from the alleviation of particular problems in other areas of the person's life which were caused by alcohol misuse (appetite, sleeping, social contacts, etc.). This is supported by considering that negative effects (for example family and health problems) increase with magnitude of consumption; at the same time, in a state of advanced tolerance the positive psychotropic effects are only reached with high amounts of drinking. Through abstinence it is therefore possible for the respective heavy drinker, assuming that he/she was not dependant, to experience a number of positive effects. Prerequisites for successful collection of positive evidence for traffic prognosis are in the expert assessment situation more favourable than the collection of negative predictive evidence. This is the case because the subject is as a rule more open and co-operative towards this goal. Finally, demands for the traffic prognosis in the course of legal proceedings are less rigorous for positive data/evidence than for data/evidence making a negative prediction Conclusion The assertion by an individual that he/she is alcohol abstinence must, from a psychological perspective, have consequences that the individual has perceived. These can be established during appropriate psychological interviewing and can be demonstrated to be forensically acceptable. 7. Hypothesis It is not appropriate to draw any conclusion of unproblematic dealings with alcohol in the past or in the future on the basis of (current) absence of abnormal organic and chemical findings Comment In the last 30 years more than 40 single parameters have been investigated, which evidence changes resulting from and after alcohol consumption. The parameters include, among others, liver values (Haffner 1989, Blutalkohol 26, ), blood values (Heidemann et al. 1981, Can. med. Ass. 124, ), fat and protein metabolism (Castelli et al 1977, Lancet II, ; Salaspuro 1987, Enzyme 37, ), immunological changes (Shigeta et al 1980, Pharmacol. Biochem. Behav. 13, 89-94; van de Wiel et al.1987, Scand J Gastroenterol 22, ) as well as parameters which can reflect changes in central nervous system functions (Wiberg et al. 1977, Medical Biology 55, ). However, these studies were carried out to a large extent in order to assess non-symptomatic individuals for their risk for alcoholism (Screening). The published data for these are primarily presented as averages, the diagnostic criteria as cut-off points (in comparison with the normal population). While these allow trends in drinking behaviour of groups to be characterised the data are less 235

8 helpful for the diagnosis of critical changes in alcohol consumption by an individual. In other words the changes in critical laboratory parameters seen during abstinence may occur both above and below a cut-off point and would not be detected by a criterion; it also must be pointed out that our understanding of "normal" is not yet fully clarified (Komhuber et al. 1989, Vers. med. 3, 78-81). Thus changes for example in SGGT, SGOT (Wietholtz & Colombo 1976, Schweiz. Med. Wochenschrift 106, ; Weil et al 1988, Alcohol) and MCV (Morgan 1980, Pharmaco. Biochem. Behav. 13,1-8) can be seen, even when "normal values" have been reached. It is also possible in cases of highly pathological starting points that abstinence will produce a fall, but the laboratory values never fully reach the level of normality. The medical norms for laboratory values refer to statistical norms of healthy groups of individuals where only a small proportion experience alcohol consumption problems; these norms are not designed to assess health and sickness (see Komhuber et al. 1989, see above) Conclusion Organic evidence is too unspecific to evidence alcohol misuse or dependence. Also laboratory values are too unspecific and may in addition be intentionally manipulated through specifically-designed pauses in drinking. In general the medical normal values refer to alcohol consumers and within this also to persons who experience at least minor degrees of problems due to alcohol. Findings from medical examinations are in general important but in the end of secondary significance. Establishment of whether the expected "content abstinence" has been reached, which is an essential precondition for a positive traffic prognosis, can only be clarified in the psychological exploration, as this is a question of attitude investigation. 236