The State of DUI Treatment — What We Know from Latest Research

Kelly CowgerDUI, NTP, CJ (DNCJ) Branch

Substance Use Disorder Compliance DivisionDepartment of Health Care Services

Sacramento, CA 95899-7413

Why DUI Sanctions• Deterrence– Quick, certain, sufficient to deter general public from

drinking and driving

• Retribution– Punishment that expresses social disapproval of DUI

and exacts ‘justice’

• Incapacitation– Preventing offender from repeating offense

• Rehabilitation– Creating long-term change in offender behavior

Variety of Sanctions

• Incarceration• Drivers License suspension• Vehicle impounding• Monitoring (ignition interlock)• Mandated substance abuse treatment• DUI Courts• Victim Impact Panels

Dealing with DUI Offenders• Depending on several factors

– Underage vs. adult– First offense or repeat offenses– BAC level

• Education-based programs (varied widely from state to state)• Counseling/psychosocial programs (varied widely from state to

state)• In-patient and out-patient programs (varied widely from state

to state)• Jail time• Vehicle immobilization devices• Fine• Often a combination of punishment/treatment

CHALLENGES TO MEASURING SUCCESS

Challenges to Measuring ‘Success’

• Programs vary state by state• Difficult to use random assignment in studies• Multiple definitions of ‘effectiveness’ based on

chosen outcome measures• Multiple types of deterrents, sometimes used in

conjunction—difficult to tease out individual pieces

• Not all offenders complete programs• Offenders are varied

Outcome Measures• Studies use varying outcome measures

including subsequent…– Crashes– Alcohol-related crashes– Alcohol convictions– Fatal or injury crashes– Traffic convictions

• Studies take post-treatment measures at different times (some at 1 year, some at 3 year, etc.)

More Than One Type of Offender

• First time offenders may be different from multiple offenders

• Some studies suggest different types of offenders– Social drinkers– Alcoholics– Problem drivers

• Offenders may have varying comorbid factors– Depression, anxiety disorders, mood disorders,

PTSD, etc.

A BRIEF HISTORY OF DUI PREVENTION TOOLS

Brief History of DUI Tools

• Pre-1950:– Principal tools:• Fines• License suspension• Jails (primarily applied to multiple offenders or

offenders who caused injury or death)

Brief History: 1970s

• DOT founded in 1966– First publication was on Alcohol and Highway Safety

• Congress authorized national program of 35 Alcohol Safety Action Projects mandating treatment programs– Key feature of program:

• Identified 2 levels of offenders:– Social drinkers (first time offenders)– Problem drinkers (multiple offenders or those with high BAC or prior

alcohol problems

• ASAP evaluated, but not shown to be effective• Continued because low cost

Brief History: 1980s

• Emergence of MADD changed environment– Strong opposition to letting offenders off with

fine– Pressure for longer and more certain license

suspension penalties

• Emphasis on incarceration of both first and multiple offenders– However, jail not found to be effective beyond

time of incarceration

Brief History: 1990s

• Emergence of monitoring technologies reducing need for jail facilities– Electronically monitored home confinement– Portable GPS to monitor location of criminal

offenders– Vehicle alcohol ignition interlock

• Extensive evidence for interlock effectiveness (while in use)

Current Developments

• Advances in monitoring technology– Transdermal alcohol monitoring systems– Advances in ability to monitor alcohol consumption in

urine, oral fluid, hair, and blood– Portable alcohol test equipment allowing multiple daily

tests

• DUI courts– Supervised intervention program for 12 months or

more– Regular court appearances– Initial evaluations suggest DUI courts can be effective

EFFECTIVENESS OF CURRENTLY USED SANCTIONS

Jail

• Unclear whether has general deterrent effect

• Has specific deterrent effect during time offenders are incarcerated

• Does not reduce likelihood of re-offending

Chodrow & Hora, 2011

BAC Laws

• Effective at general level in reducing (overall) drunk-driving casualties

• No effect found on recidivism

Anderson et al, 2009; Shults et al, 2001; Wieczorek, 2013

Sobriety Checkpoints and Random Breath Testing

• Effective in reducing – overall numbers of alcohol-related crashes – fatal and nonfatal injuries

Anderson et al, 2009; Elder et al, 2002; Kilmer et al, 2013

Vehicle Sanctions

• Vehicle Sanctions include:– Ignition interlock devices– Vehicle, registration or license plate

confiscation– Special license plates identifying offenders

Ignition Interlocks

• Based on evidence from multiple studies, interlocks are effective while in place

• Effects dissipate after interlocks are removed

Elder et al, 2011

License Suspension

• Both a general and a specific deterrent• Mixed evidence re: effectiveness • Limitations:– Is widely violated

– Up to 75% of those with suspended licenses continue to drive

– Does not break pattern of problem drinking

Chodrow & Hora, 2011

Victim Impact Panels

• Designed to increase offender’s empathy for victims

• No conclusive evidence of effectiveness in reducing recidivism

Chodrow & Hora, 2011

DUI Courts: Description

• Provide coordinated judiciary, prosecution, probation, defense, law enforcement, social services, mental health and treatment

• Include– Regularly scheduled judicial status hearings– Sanctions and rewards for compliance– Collaborative treatment– Legal team case decision-making– Individualized alcohol treatment– Regular alcohol testing

10 Guiding Principles of DWI Court1. Determine the population2. Perform a clinical assessment3. Develop the treatment plan4. Supervise the offender5. Forge agency, organization and community partnerships6. Take a judicial leadership role7. Develop case management strategies8. Address transportation issues9. Evaluate the program10. Ensure a sustainable program

http://www.dwicourts.org/learn/about-dwi-court/-guiding-principles

DUI Courts: Effectiveness• Some studies have found promising

outcome results including – Reduced DUI recidivism– Increased time to re-arrest– Fewer traffic accidents– Lower rate of drivers license

suspensions/revocations– Reduced levels of substance abuse

Breckenridge et al, 2000; Chodrow and Hora, 2011; Fell et al, 2011; Marlowe et al, 2009; Petrucci, 2011

Dedicated Detention Facilities

• Provide confinement with supervised treatment services

• Statistics indicate facilities have substantial effect on recidivism

• Examples:– Baltimore County DWI Correctional Treatment Facility– Suffolk County DWI Alternative Facility– North Coast Correctional Treatment Facility– New Hampshire’s Multiple DWI Offender Intervention

Detention Center

National Hardcore Drunk Driver Project, 2003

TREATMENT

Evidenced-Based Clinical Interventions for Substance Abuse

• Brief Interventions• Motivational Interviewing• CBT/Coping-Skills Training• Contingency Management/Community

Reinforcement• 12-Step Approaches• Pharmacotherapy

Eight Evidence-Based Principles for Effective Interventions*

1. Assess risk/needs2. Enhance intrinsic motivation3. Target interventions

– Prioritize supervision and treatment resources for high-risk offenders– Target interventions to criminogenic needs– Be responsive to temperament, learning style, motivation, culture and

gender when assigning programs– Prescribe adequate dosage (3-9 months)– Integrate treatment into sentence/sanctions

4. Use CBT skills training5. Increase positive reinforcement6. Engage in ongoing support in natural communities7. Measure relevant processes/practices8. Provide measurement feedback

*Recommended by the National Institute of Corrections and the Crime and Justice Institute

TREATMENT TYPES

Brief Interventions

• Designed to identify current or potential alcohol problem and motivate change

• Consists of short (5-10 min) counseling session– Discussion of alcohol use and consequences– Negotiation of behavior change plan

• Evidence of effectiveness with offenders with less severe alcohol problems

Traffic Injury Research Foundation, 2011; Brown et al, 2010

Education

• Used for ‘social drinkers’ not assessed with alcohol use disorder

• Appears to be most effective for first time offenders/“social drinkers”

Chodrow & Hora, 2011

Motivational Interviewing

• Non-confrontational counseling• Encourages offender to – Accept their alcohol problem– Understand treatment benefits– Access needed services– Supporting self-efficacy

• Evidence of effectiveness in improving drinking outcomes

Traffic Injury Research Foundation, 2011

Coping Skills Training (CBT)

• Emphasizes teaching new strategies and skills to address problem thoughts and behaviors, using:– Modeling– Behavioral practice– Homework assignments

• Assumes offender is motivated to change• Much evidence of effectiveness

Emmelkamp and Vedel, 2006; Little et al, 2010; Moore et al, 2008

Alcoholics Anonymous(12-Step Approach)

• Self-help support groups • Not much literature on mandated AA

attendance as DUI intervention– 2 studies of mandated AA participation alone

showed no effect– Other studies suggest that AA in combination

with other treatments were effective

Dill and Wells-Parker, 2006; Wells-Parker et al, 1995

2012 Annual Report of the CA DUI Management System

• Evaluation of CA DUI programs for reckless offenders and 1st offenders– 3 month program resulted in significant

reduction in subsequent DUI incidents in year following program

– 9 month program did not improve results further

• No evaluation included for repeat offender programs

California Department of Motor Vehicles, 2012

Treatment Effectiveness

• Treatment is effective in reducing recidivism

• Treatment is most effective when used in combination with long-term counseling, education and supervision, probation, structured interaction with self-help groups, fines, penalties and sanctions

• Effective treatment requires compliance

National Hardcore Drunk Driver Project; Chodrow & Hora, 2011

Proposed Model for Managing DUI Offenders*

• Voas et al., 2011 proposed that a national model with the following seven points:– Emphasis on replacement of jail with low-cost monitoring programs

paid for by offender– Sanction alternatives maximized to increase flexibility in meeting

offender’s needs– Behavioral triage used to create performance-based sanctions– Control of consumption emphasized– Treatment focused on offender’s needs in meeting monitoring

requirements– Monitoring data are available to enhance offender screening and

assessment– Rapid development of new technologies will increase requirement for

program evaluation.

Voas et al, 2011

Takeaways• 1st offenders and repeat offenders benefit from different treatment

protocols

• To date, no individual program deemed to be most effective

• Research indicates that most effective sanction is combination of vehicle/license-based sanctions with alcohol treatment

• Treatment programs based on varying theories have proven effective

• Effective treatment should include– Education– Motivational enhancement– Skills training– Brief interventions– Sanctions– Celerity (close proximity to arrest)– Efforts to ensure compliance

DeYoung, 1997; Dill & Parker, 2006; Warren et al, 2010; Chodrow & Hora, 2011

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