Progress in reducing road traffic crashes related to driving while impaired (DWI) by alcohol has stalled in the first decade of the twenty-first century after 3 decades of significant improvement (Vanlaar et al., 2012). In part, this loss of momentum is attributable to the intervention refractoriness of a more “hard-core” group of repeated offenders (Simpson et al., 2004). More than other drunk drivers, these offenders have severer drinking problems, drive more frequently with higher blood alcohol levels, demonstrate limited problem recognition (Nochajski and Stasiewicz, 2006), and engage in other risky driving behaviors (e.g., speeding, reckless and unbelted driving; Donovan, 1989; Jonah et al., 2001)—factors that converge to further amplify their crash risk.
Both administrative and psychosocial remedial strategies are deployed to counter recidivism following a DWI arrest. While certain administrative strategies such as interlock programs have been associated with reductions in DWI recidivism and crashes while installed (Voas et al., 2010a), high-quality evidence of the lasting effects from most contemporary psychosocial intervention approaches either is unavailable or provides only marginal support for their effectiveness (Anderson et al., 2009; C'de Baca et al., 2001; Dill and Wells-Parker, 2006; Elder et al., 2005; Timko et al., 2011; Voas and Fisher, 2001; Williams et al., 2007). Moreover, many convicted DWI offenders (higher than 50% in some jurisdictions) choose to either not engage or significantly delay participation in remedial programs required for relicensing often involving evaluation and/or treatment of alcohol misuse. Their reluctance to participate appears to stem from a combination of factors, including limited problem recognition, ambivalence about the need to alter drinking behavior, and little readiness to pay relicensing costs. The result is that these individuals might be at greater risk of further drink-driving compared with drivers who more promptly participate in DWI remedial relicensing programs (Brown et al., 2008; Voas et al., 2010b).
The high rate of nonengagement in remedial programs among the riskiest offenders has led to interest in opportunistic, brief motivation-enhancing interventions that could heighten their readiness to change and reduce their alcohol misuse (Dill and Wells-Parker, 2006; Freeman et al., 2005; Nochajski and Stasiewicz, 2006). Motivational interviewing (MI; Miller and Rose, 2009) represents the motivational approach with the most support for its effectiveness in reducing alcohol-related problems in diverse contexts and populations (Dunn et al., 2001; Smedslund et al., 2011). There is emerging evidence that MI may be beneficial in reducing drinking in DWI offenders and self-reported DWI events as well. A randomized controlled trial by our research group (Brown et al., 2010) investigated the impact of one 30-minute session of brief motivational interviewing (BMI) versus a 30-minute information control intervention (CTL). In a nonclinical sample of DWI recidivists diagnosed with alcohol abuse (N = 184), many of whom had significantly delayed participation in relicensing remediation, both interventions reduced days of risky drinking at 6- and 12-month follow-up. BMI, however, produced significantly greater reductions in an alcohol biomarker of excessive drinking at 6-month follow-up as well as in self-reported risky drinking days from the 6- to 12-month follow-ups compared with CTL. This demonstration of BMI's effectiveness in reducing both self-report and biologic indices of alcohol misuse in a community-recruited, nonclinical sample of recidivists extended the results of 2 previous controlled trials that indicated the self-reported benefits of MI in reducing both problem drinking (Woodall et al., 2007) and drink-driving behaviors (Stein et al., 2006) in forensic samples. In addition, subsequent fine-grained analyses of our 1-year outcomes (Brown et al., 2010) indicated that younger age, lower readiness to change, and severity of alcohol use symptoms and consequences were associated with the greatest benefits following exposure to the brief interventions provided (Brown et al., 2012), findings that have been observed in other populations (Heather et al., 1996; Mallett et al., 2010; Witkiewitz et al., 2010). Finally, DWI offenders with antisocial personality disorder tended to fare better with exposure to MI compared with those with no disorder (Woodall et al., 2007). Overall, these strands of evidence hint that brief interventions may hold selective benefits for DWI recidivists possessing certain characteristics associated with high risk.
A reduction in alcohol misuse in DWI recidivists represents an important public health outcome. Nevertheless, our preliminary results did not directly address BMI's advantage of reducing alcohol-related driving risk indicators over time, such as the number of alcohol-related road traffic crashes or DWI reconvictions. At the same time, while possessing more ecological validity, these dependent variables pose important shortcomings that vex most DWI research. Both variables reflect infrequent events subject to bias from arbitrary factors (e.g., enfor-cement practices, incomplete documentation, court delay, frequent plea bargaining to a lesser charge; Dill and Wells-Parker, 2006; Meyer and Gray, 1997; Rauch et al., 2010). As well, many offenders continue to drive under the influence of elevated but under per se blood alcohol concentration limits and under the influence of drug use, which individually or synergistically significantly impair their safe driving ability (C'de Baca et al., 2009). Drug-impaired driving, although increasingly prevalent, is more difficult to detect than alcohol-impaired driving (Brown and Ouimet, 2012; Lapham et al., 2002). Alternatively, self-reported information concerning DWI events is also problematic. It is subjective, often unreliable (Lapham et al., 2002), and when used in outcome studies, vulnerable to bias from sample attrition when follow-up durations are lengthy. To overcome these hurdles, a multidimensional approach to the measurement of alcohol-related driving risks, including using indicators of risky driving behavior (e.g., speeding), can increase the comprehensiveness and sensitivity of analyses (Nochajski and Stasiewicz, 2006; Rauch et al., 2010).
The present study extends Brown and colleagues' (2010) evaluation of the impact of 2 brief interventions in DWI recidivists. Whereas the initial study examined 12-month outcomes via self-reported and biologic markers of alcohol misuse, the present study examined outcomes related to risky driving convictions and crashes over a 5-year period following intervention. Two principal hypotheses were tested in the current study: (i) in DWI recidivists, exposure to BMI significantly delays a subsequent crash or arrest (followed by a conviction) for DWI, speeding, or other moving traffic violations compared with exposure to CTL; and (ii) recidivist characteristics, specifically age, readiness to change, alcohol misuse severity, and intervention refractoriness, moderate the long-term benefits of BMI.
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- Materials and Methods
The present study investigated the outcomes of DWI recidivists randomly assigned to receive either BMI or CTL intervention. Follow-up durations ranged from a minimum of approximately 4 years to a maximum of over 5 years. The main finding was that while group membership alone was not associated with significantly different outcomes across all participants, better outcome with exposure to BMI compared with CTL was uncovered when the effect of age was accounted for: that is, a significantly longer delay in a subsequent conviction for DWI, speeding, or another moving traffic violation was found in the youngest offenders exposed to BMI compared with CTL. As such, BMI is more advantageous in delaying convictions for offenses associated with DWI recidivism status in a particularly at-risk group, namely younger drivers.
This study is unique among the rare investigations evaluating BMI for DWI (for review, see McMurran, 2009) for its combination of randomized controlled trial methodology, length of follow-up, use of objective documented outcome indicators, and recruitment of a naturalistic, nonclinical sample potentially more akin to the DWI recidivist population than undertaken in previous studies. These distinctions also mean that direct comparisons between this study and most previous ones must be undertaken cautiously. Nevertheless, 2 well-controlled studies with random assignment and objective long-term outcomes (i.e., DWI reconviction events) explored the effect of exposure to BMI variants versus no exposure, one with imprisoned DWI offenders and a 24-month follow-up period (Woodall et al., 2007) and the other with DWI remedial program participants and a 6-year follow-up period (Wells-Parker and Williams, 2002). Both studies failed to reject the null hypothesis for a main effect of intervention exposure. In 2 other investigations, however, an effect of BMI exposure was detected. A randomized controlled study with incarcerated adolescents (Stein et al., 2006) found that those exposed to BMI had reduced DWI behavior over a 3-month follow-up period, although its short-term follow-up and reliance on self-report are important methodological shortcomings. The other study (Marques et al., 1999) looked at an objective indicator of elevated blood alcohol levels via alcohol interlock devices installed in the vehicles of convicted offenders for up to a 2-year follow-up duration. It found that offenders from a city where BMI was provided in addition to interlock installation had fewer positive blows than offenders from a city where BMI was not provided. This study more objectively assessed DWI behavior than the Stein and colleagues' (2006) investigation. At the same time, its findings were also potentially confounded by its quasi-experimental methodology and sampling limited to the minority of offenders willing to volunteer for participation in an interlock program. No other studies to our knowledge have explored the impact of BMI on crashes. Overall, when considering heterogeneous samples of DWI offenders and longer-term outcomes, the strongest evidence suggests that exposure to BMI is not more advantageous than a CTL in reducing reconvictions and crashes.
Analyses to discern moderation of effects by participant characteristics on outcome revealed a more nuanced impact of BMI. Understanding characteristics of individuals most apt to benefit from treatment is of enduring clinical and research interest in the substance abuse field. Some selective responsivity in younger individuals to common DWI interventions has been reported (Brown et al., 2012; Wells-Parker et al., 1989). Nevertheless, aside from a few notable exceptions (Wells-Parker and Williams, 2002), subgroup analyses looking at long-term effects of BMI on DWI and other risky driving behavior are rare. Investigation of age-related moderation in BMI's effectiveness in the more extensive substance abuse literature has yielded mixed results regarding substance use outcomes (Foxcroft et al., 2002; Mallett et al., 2010; McCambridge and Strang, 2005). The present findings extend previous support for BMI (Dill et al., 2004; D'Onofrio and Degutis, 2004; Monti et al., 1999) as an appropriate brief intervention strategy for achieving reductions in DWI and other risky driving behavior in younger offenders. More research is needed to understand why BMI is selectively advantageous for younger client groups.
In considering the implications of the findings to applied settings, several features of the present study are worth noting. Delivery of both interventions was manualized and highly controlled for fidelity, including the use of the Motivational Interviewing Treatment Integrity protocol (Moyers et al., 2005) and an iterative supervision procedure (for details, see Brown et al., 2010). This level of control is not likely to be feasible in most of the applied settings. Moreover, mandated DWI relicensing programs represent a unique set of conditions and therapeutic challenges (Lapham et al., 2006) and are characterized by the frequent simultaneous use of remedial and deterrence strategies. These distinctions underscore the well-established gap between data garnered from efficacy studies and their real-world deployment. Despite these caveats, the results of the present study, based on a very brief delivery format and a sample of non-help-seeking DWI recidivists, lend support for BMI's potential as an intervention that could be opportunistically and advantageously deployed in settings where younger non-help-seeking DWI offenders are encountered (e.g., emergency rooms, court settings soon after an arrest, frontline health settings). Confirmation of its benefits for reducing driving risks when embedded into these and other specific contexts (e.g., mandated relicensing programs) awaits further effectiveness research.
Limits in the generalizability of the findings to mandated DWI remedial programs have been noted above. Arrests/convictions and crashes are rare events (Beitel et al., 2000), a problem that vexes the orchestration of controlled studies in the area (Dill and Wells-Parker, 2006). Measurement of these phenomena would benefit from a much larger sample to better power and stabilize the analyses. Replication of this study using larger samples is warranted to confirm the results. In addition, several local factors may influence convictions for DWI, speeding, or other moving traffic violations, including enforcement rigor and legal dispositions. As a result, the findings may not be readily generalizable to offenders from jurisdictions with significantly different approaches to DWI deterrence and intervention from those in force in the province of Quebec.