This past Friday I had the honor of speaking to the Oregon house and senate committees on Judiciary about the effectiveness of Oregon’s DUII reduction approach. My friend and colleague, Heidi Brockman-Astrue, joined me to also share her experience as someone working in the trenches daily treating DUII offenders. One reason for our testimony, is that despite the good work being done by many people to address this public health problem, about 14,000 Oregonians are arrested each year for driving under the influence of some drug (alcohol obviously being the most common). Most of these are first time offenders, but the total number of arrests only provide a metric for those that get caught, which to a large extent is based on law enforcement resources. Add more patrols to the roads and arrests would increase.
- 86 drunk driving deaths in 2012
- 10 of those under the age of 21
We need to do all we can to reduce these tragedies. While I appreciated the opportunity to speak, as I have reflected on the experience, a number of things have come up for me that I thought I would share.
There were a total of five speakers, myself included, that testified in about an hour’s time. This meant I needed to reduce my normal hour-long talk about addiction and treatment down to about 15 minutes, which in all honesty, I don’t think worked very well. I had to rush through parts, cut stories short, and was not able to link the problem and solution together in a cohesive way. I know many TED talks brilliantly reduce complex topics down to 18 minute presentations, so I know it’ possible, I just need a lot more practice!
The power of one
One individual on the committee who made it known he has been in recovery for decades, believed addiction treatment has not progressed in 40 years. I was saddened by the comment because I have seen many times how one very opinionated individual can influence group process.
While I share his frustrations about the pace of progress, it’s simply not true that treatment has not improved in four decades. Since 2000 the National Drug Abuse Treatment Clinical Trials Network (CTN) has significantly increased the collaboration between clinicians and researchers, pushing use of evidence-based practices like never before. It’s important to acknowledge just how how hard so many people have worked to improve treatment, even though we have a long ways to go.
Top 5 recommendations
While I will not speak to all recommendations made by those who testified, here were the ones I pushed:
#1 Length of time
Extend length of time in treatment for first time DUIIs to a minimum of 6 months and one year for multiple DUII offenders. Treatment now averages 3-4 months for most offenders, which is far too short a time period based on what we know about the brain and behavior change.
#2 Evaluation process
Improve the evaluation process. Some discussion included whether the Alcohol and Drug Evaluation and Screening Specialists (ADES) provide effective evaluations and should continue to be part of the system. Their primary purpose is determining level of treatment independent of treatment programs as an oversight function.
In my opinion, there is incredible leverage in dialing in effective treatment from a solid evaluation, but doing one requires a lot of clinical skill. There are concerns about the quality of ADES evaluations, and the fact that treatment programs have to do one anyways seems like a waste of time and resources.
In the future I hope we can leverage technology to improve the quality, consistency, and accuracy of evaluations (see my previous post on prison education and treatment).
#3 Evidence-based practices
Encourage use of evidence-based practices in treatment. This includes use of addiction medications such as Vivitrol for alcohol and opioid use disorders, increased attention to the treatment of underlying adverse childhood experiences, and interventions such as the Community Reinforcement Approach (CRA).
#4 Address entire package
Treatment needs to address the entire package of addictive behavior. Heidi testified that a quarter of her clients now report an opioid being their primary drug of choice, even though most received a DUII for alcohol. Programs that focus on alcohol and ignore other addictions and co-occurring disorders will never produce good outcomes.
#5 Positive psychology
Recognize that DUII offenders are more than the constellation of their life problems, and all stakeholders involved in their cases should consider the value of interventions from the field of positive psychology. I have written about this before, but the idea is that the best relapse prevention plans facilitate leveraging the natural talents of those getting treatment.
We need to help offenders move beyond their pathologies and problems, and find constructive ways to engage in society. If you doubt how powerful this approach can be, check out SAMHSA’s Eight Dimensions of Wellness.
A final story
A client I was treating for multiple DUIIs was sentenced to two weeks in jail. He told me that his sanction would consume all of his vacation time for the year, which would mean he would get no extended periods of time with his five-year old daughter.
We talked about his situation at great lengths until he agreed that he would remain in treatment with me – or someone at our clinic if I left – for a total of fives years in exchange for not having to do the jail time. It was not that he was afraid to do it, he had done it before, and knew it had little impact on his drinking behavior.
It was more that he knew he would never get that time back with his daughter. We put together a packet of journal articles related to addiction being a chronic relapsing medical condition, and the benefits to society by having him stay connected with treatment for five years, and sent it off to his Judge.
When the final verdict came in, I knew we had a long way to go in educating stakeholders about addiction. He denied the request. While I understand the value of sanctions, if they do the opposite of their intended purpose, then it’s time we reconsider their use in our overall DUII reduction approach.
There are no simple solutions to addiction, or for reducing impaired driving from substance abuse. I do worry that as marijuana becomes legally more available in Oregon, risks for impaired driving will increase. While most would agree that our best method of intervention for offenders is a combination of sanctions and treatment, there are no studies to my knowledge that help answer what is the correct formula or recipe. Clearly, until science can provide more direction, an individualized approach makes the most sense.
Maksat Brooks says
“despite the good work being done by many people to address this public health problem, about 14,000 Oregonians are arrested each year for driving under the influence of some drug (alcohol obviously being the most common).” 86 drunk driving deaths in 2012, 10 of those under the age of 21. To me, this screams failed education on alcohol and alcohol abuse. I am a firm believer in proper education. Just like when we are little children and we try to touch fire or insert a folk into an outlet, not everybody has to get shocked or burned in order to learn that doing such things is dangerous and will cause harm. When being properly educated by your parent or guardian about the risks and factors, we grow up knowing and avoiding those foolish activities. Education is a valuable asset.
Much like our educational system in general, out education about alcohol and substance abuse is not of high quality. A collective effort should be set forth to reconstruct and re-evaluate what works and what does not. Health class in high school and awareness programs though school do not have a long lasting impact on kids. They are not educated and they do not value the knowledge that they receive about the topic.
Although treatment has improved over the course of decades, why are we a country of reaction? why wait till after the fact to step in? Our efforts should be PRE-problem not POST-problem. I am not saying that we should shift away from treatment programs, but rather that we should put more focus and emphasis on the early stages of development than what is set up currently.
“There are no simple solutions to addiction, or for reducing impaired driving from substance abuse.” I agree 110%, there are no simple solutions to anything in life. Human nature and human behavior mixed with the many elements of our society is a dangerous combination. But just as nature evolves and adapts, our programs, policies and approaches should as well. We need to nip the problems in the bud and tackle it head on. We allow ourselves to suffer by not helping one another.
John Fitzgerald says
Maksat, very well said! I could not agree more that our educational system needs work, particularly when it comes to approaches to educating our youth. When most who develop addiction begin the behaviors prior to age 15, our prevention efforts really need to begin well before high school in my opinion. There are some groups doing amazing work in this area, like the Oregon Social Learning Center. It’s not easy intervening on root causes, but addressing problems like you say POST-problem is more challenging and costly. Recently I wrote a post about root causes of school shootings that you may find interesting.
Bao Luong says
As a person who grew up in two different education systems, I could get why your request was denied. I was born in Viet Nam, and I went to school there until 9th grade and moved to the U.S. In Viet Nam, my friends and I were “trained” to obey teachers’ or elders’ words. We also had been taught to follow rules and laws, but Viet Nam was such a poor, corrupted country, that laws are basically nothing. When I moved to the U.S., I was taught entirely different. I must obey the laws, and they even put this in the citizenship test. Teachers don’t get the same respect as the teachers in Viet Nam do. Yes, as we all know; the laws are not perfect, and they contain flaws and problems just like anything else in this world. In addition to that, we are humans, not robots. Each of us has problems that the laws can’t be applied. Viet Nam and the U.S. are in two different ends. One country doesn’t have real laws, and the U.S. relies in laws most of the time. None of them works. Laws are very important, but in some situations, therapies and treatments are better for the individuals. I hope we will soon have effective changes that lives of many people will be better.
John Fitzgerald says
Bao, thanks for your insightful comments. While the countries are very different, the human needs of safety, love, connection, and purpose are the same. You are right about laws, they can be useful, but they are no substitute for needs. I believe the most important thing we can all do to effect change is develop and embrace a contemplative side where we learn to quiet the chatter in our brains and listen to our heart.
Joanna Chan says
I too grew up in a different country, Hong Kong. I am the only child in my family so my parents are really protective. I was raised to be respectful and obey our teachers and elders. I was also told that if I get in trouble then there will be consequences and punishments. I’ve had alcohol when I was a kid, but only when I’m with my parents. I’ve never had alcohol outside of my own house until I moved to Portland six years ago. That was the first time when I saw all those underage drinking parties and they drove home when they were still drunk. I personally couldn’t do it because I was raised to be responsible but I think it’s a big issue here in the United States that so many people drink and drive, and lots of underage parties going on. It’s good that our laws are trying to protect us from getting harm by people who are selfish and not responsible. But I feel like there are better ways than locking them up, such as educate them and have programs for people who have trouble with drinking. There are programs like that but it’s not enough and not good enough. I really hope it will change because this happen with my friends and I’m concern about them.
John Fitzgerald says
Joanna, thanks for the comment. I wish others were as responsible as you, and never drink and drive. As you say, so much begins early in life in the family. And I agree locking folks up is just a temporary solution. In a some cases it does have an impact, for those who have an alcohol use disorder, treatment is the answer, not jail.
I would agree with you that the programs offered for DUI’s offenders are not long enough. My daughter received a DUI back in June and was put in diversion meaning that she had to take a 12 week class and also 12 hours of community service. The classes were once a week in a group setting and then also once a month an individual class. She had to call a UA line every day and gave random UA’s. She is no still in diversion meaning that she can not drink alcohol till her time is up in June of 2015. Even though I feel she is aware of her mistake of drinking and driving, I am not sure if it is enough time for her to change her behavior. She is not aware of that she will ever be able to drink or if she will be one of the people that will not be able to drink at all. I personally would like her to be supervised for a while longer, and receive additional information on abusing alcohol. I feel the classes did help her, but I also feel that 12 weeks are simply not long enough to really get a handle on the habit or addiction of alcohol.
John Fitzgerald says
Yes, we need to extend time of DUII treatment, in part to do better treatment, but also because staying in contact with a client for a longer period of time is beneficial for all stakeholders. Clients get more help, therapists enjoy longer term relationships, and the longer term connection between client and therapist means less chance of drinking and driving, which means a safer society. Thanks for the feedback!
Heather O'Malley says
I am the (adult) child of an addict. My father was both an alcoholic and addicted to methamphetamine – although he would deny both. He was in a motorcycle accident that probably would have killed any other normal human being and nearly killed him. He had a BAC of 0.05%, there were no other vehicles involved, and for all intents and purposes it was a freak accident (says the witnesses). Most people who get arrested for DUI in California ultimately get charged with two separate misdemeanor offenses:
1. driving under the influence of alcohol and/or drugs, under California Vehicle Code 23152(a) VC, and
2. driving with a blood alcohol content of 0.08% or greater, pursuant to California Vehicle Code 23152(b) VC.2
He was charged with the first one only, driving under the influence of alcohol and/or drugs, under California Vehicle Code 23152(a) VC, because he was in an accident involving alcohol. So after spending 3 months in the hospital recovering from a shattered rib cage, punctured lung, broken back (in 3 places), amongst various other injuries, he had to go back and spend 10 days in jail in the county where he was in the accident. 10 days and some fines, he wasn’t required to go to a DUI program, and he was extremely angry that he had to deal with any of it.
I believe DUI programs are important, but I’ve seen time and time again where they don’t work – especially when they involve repeat offenders, actual substance abuse treatment, and the person doesn’t believe they need treatment. It’s that whole “a person has to want help” reaction. But, I think that something needs to be done and even if the programs only help a few people (I know they help more than that) that’s still a few more people who won’t be out on the road under the influence. I think they may be most effective on first time offenders, going through the whole process would hopefully be at least enough to scare them straight – or have the process be such an inconvenience they wouldn’t want to experience it again.
I have a friend who just finished an 18 month program after receiving her 2nd DUI, she still drives under the influence and she definitely has a drinking problem. She doesn’t see anything wrong with her actions and still blames both DUIs on other factors, basically as far as she’s concerned they weren’t her fault. Her 2nd DUI came only months after we had lost two other friends to an accident caused by a drunk driver.
Driving under the influence seems to be a continuing problem, with a high level of repeat offending. Some “sobering” statistics from Mothers Against Drunk Driving:
• An average drunk driver has driven drunk 80 times before first arrest – See more at: http://www.madd.org/drunk-driving/about/drunk-driving-statistics.html#sthash.Pno9oSl9.dpuf
• Each day, people drive drunk almost 300,000 times, but fewer than 4,000 are arrested. – See more at: http://www.madd.org/drunk-driving/about/drunk-driving-statistics.html#sthash.Pno9oSl9.dpuf
• About one-third of all drivers arrested or convicted of drunk driving are repeat offenders. – See more at: http://www.madd.org/drunk-driving/about/drunk-driving-statistics.html#sthash.Pno9oSl9.dpuf
Some sad statistics from the CDC regarding the death of children 0-14 years in alcohol involved accidents:
• Of the 1,168 traffic deaths among children ages 0 to 14 years in 2012, 239 (20%) involved an alcohol-impaired driver.
• Of the 239 child passengers ages 14 and younger who died in alcohol-impaired driving crashes in 2012, over half (124) were riding in the vehicle with the alcohol-impaired driver.
I know my father didn’t set a good example, but I guess you could say he served as a cautionary tale. I saw what he did and who he was and learned what and who I didn’t/don’t want to be. I know that I could never live with myself if I were to drive under the influence and caused an accident and injury or death to another person. If someone wants to put their own life at risk, that’s their prerogative. But when someone drives under the influence they aren’t just putting their lives at risk, their putting the lives of anyone on the road at risk and they have no right to do that.
You bring up the interesting point of the unknown effect the legalization of marijuana may have on impaired driving; I find this especially interesting because how exactly will they be able to test for marijuana? I know they can test for it, but THC stays in your system for an extended period of time – long after a person has smoked/ingested/etc. and the effects are gone – so would they test for the amount of THC? How are those tests going to hold up in court? The legalization of marijuana in Oregon, Washington, Colorado, and Alaska definitely make things more complicated as far as impaired driving goes. I guess it will be one of the growing pains of the new laws, one of many things that will need to be figured out as the occasion arises.
John Fitzgerald says
Heather, I agree that many of our present programs don’t result in lasting change, and that the legalization of marijuana will open a new can of worms. Thanks also for the links!
Nick Formanek says
I think your 3rd recommendation, evidence-based practices, is one of the most important ways to help improve DUII treatment with the other being educating children, teenagers, and even adults about possible consequences. One way I have heard that works well is through the use of DWI Courts. I think that making sure we can hold these offenders accountable for their actions by placing them in a treatment program will be beneficial in their recovery and by providing them a learning opportunity. If there is no one making sure offenders are getting proper treatment, the odds of them going back to their original ways increase and that will lead to them committing more DUII offenses. The increase in the number of DWI courts shows that the strategies they are using to rehabilitate these offenders are working. If all a person gets for driving under the influence is jail time, no learning or progress will have been made. Not only will jail not rehabilitate them, but it will take away certain privileges they would have if they completed a certain rehabilitation program instead.
John Fitzgerald says
Nick, indeed drug courts have replaced jail in ways that have evolved our treatment system for the better. For those who have never seen a drug court in action, I encourage you to visit one if available in your local town. The courts are public and experiencing in person can be eye-opening.
Thanks for the comment
Chris Miley says
Unfortunately, I’ve had personal experience with Oregon’s DUII process. When I was 21 I got a DUII and went through a diversion program. The program was a 90-day group treatment program. Since then, I’ve drastically decreased the amount that I drink and drive. I am still not perfect, however, but I am definitely being more responsible than I was before. Going through the legal formalities and having my license suspended were pretty horrible and embarrassing experiences. The treatment program was okay, I learned some things from the guy leading the group and even from other testimonials within the group. The group required 90 days of sobriety, consisted of about 12 people (people came and went depending where they were with their 90 days), and included users of all different types of substances. It was an eye opener for me, but I think the system could be better. I think longer treatment with more individualized interactions could be beneficial. Building a relationship with a counselor could be very impactful, I think think the only 1:1 meetings were my intake and exit interviews to the program. The other issue is that this was all reactive, it took me getting a DUII to trigger the treatment/awareness. I’m not sure if it’s possible to really have the legal and group work set in prior to an event like a DUII so that it would occur in the first place. Proactive treatment would be great to help prevent DUII’s from occurring, but I don’t really know how that can be implement. Thanks for the post, John.
John Fitzgerald says
Chris, appreciate you sharing your experience. I agree we need to do more, and at the same time, am glad to hear that what we have now seems to also be making a difference.