This is the first study to follow a large cohort of DWI offenders for an extended time period. Our findings show that in this sample a DWI conviction, even in the distant past, identifies a subgroup of people with high rates of current substance use disorders. Rates of alcohol abuse or dependence in the DWI population are more than five times higher than in the comparable general population sample. This has important public health implications, for those in our study with lifetime alcohol dependence reported twice the rate of driving over the limit, compared with subjects reporting no diagnosis or alcohol abuse. The first-offender population in our study also was at high risk for crash involvement. Of the 1,396 offenders in the initial study, 588 (42%) were subsequently involved in a crash, with 347 (24.9%) involved in one crash, 158 (11.3%) in two crashes, and 83 (5.9%) three or more crashes.28
Based on these findings, we recommend enlisting health and mental health care providers to address DWI issues in clinical contexts to help identify and intervene with those at risk for chronic impaired-driving behavior. We suggest asking directly about a patient’s DWI history. Clinical practice guidelines for those with chronic addictions recommend intensive addiction treatment followed by outpatient treatment for a period of time.29
These individuals also may benefit from ongoing monitoring and early reintervention, following treatment discharge.30
Such practices promote abstinence and reduce the likelihood of re-arrest.30
Medication-assisted treatment is another promising, if underutilized, treatment modality.31
One preliminary study revealed that an extended-release form of injectable naltrexone reduced drinking in a small sample of chronic DWI offenders.32
Moreover, a post-hoc analysis showed an association between this medication, combined with psychosocial support among alcohol-dependent patients who had maintained at least 4 days of continuous abstinence before starting treatment, and a significant reduction in alcohol consumption during holiday periods, when alcohol-related crashes peak.33
Excessive alcohol intake during major holidays contributes to about 40% of all traffic fatalities.34
These studies suggest that treatment including medication and monitoring of sobriety may be an effective means for reducing chronic recidivism.
This study is the first to determine the persistence of addictive disorders in a nontreatment DWI sample having a high prevalence of addictive and other psychiatric disorders. Alcohol and drug use disorders are chronic relapsing conditions.35
Thus, we anticipated that rates of alcohol and drug use disorders among DWI offenders with a demonstrated high prevalence of addictive disorders might continue to exceed those found in a community sample. Several longitudinal studies have followed patients treated for alcohol dependence for 10 years or more to determine long-term outcomes.36-40
Remission rates vary tremendously in these samples, and methodological differences make it difficult to compare recovery rates.41
Findings for treatment samples do not generalize to DWI offenders, as treated populations are more likely than community samples to have severe dependence and other comorbid psychiatric disorders.42
We found that rates of current substance use disorders decreased substantially from those ascertained at the initial interview. This is consistent with findings that prevalence rates of substance use disorders decline with age.43
Subjects with substance use disorders in the original sample were also more likely to be deceased at the 15-year follow-up interview than those interviewed initially.28
Rates of alcohol use disorders found in the DWI sample exceeded prevalence rates from other national surveys that did not use the CIDI to determine diagnoses. Two nationally representative surveys—the National Institute on Alcohol Abuse and Alcoholism 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions and the National Institute for Alcohol Abuse and Alcoholism 1991–1992 National Longitudinal Alcohol Epidemiologic Survey—ascertained prevalence rates of 12-month DSM-IV alcohol abuse and dependence in 2001–2002 using face-to-face interviews. In the National Epidemiologic Survey on Alcohol and Related Conditions and the National Longitudinal Alcohol Epidemiologic Survey, the prevalences were 6.93% for males and 2.55% for females.44
The NCS-R, National Epidemiologic Survey on Alcohol and Related Conditions, and National Longitudinal Alcohol Epidemiologic Survey studies all found that alcohol use disorders are much more prevalent among males than females. It is noteworthy that the discrepancy between rates of addictive disorders in the DWI and Comparison groups in our study was much higher for females than for males, with both genders in the DWI sample having nearly equal rates of alcohol and drug use disorders. Rates of nicotine dependence were particularly elevated in the female offender subgroups. These findings are consistent with other studies in which the percentage of DWI offenders meeting lifetime criteria for alcohol dependence is similar to, or higher, among women than men.45-47
In contrast to findings in the initial study,18
rates of MDD and PTSD in this study were comparable to those found in the community sample. For the analysis we used a multiple imputation procedure that accounted for deaths and other possible biases, and the sample sizes were adequate. Therefore, the lack of significance probably is not due to selective attrition, though we cannot rule that out entirely.
A major limitation of this study is the low participation rate, a problem inherent to longitudinal studies of criminal justice populations.48-51
Those with a good reason to avoid detection (those with arrest warrants or who were in the country illegally), as well as hard-to-reach subjects with no telephones, were either not located or were more likely to refuse participation. Although we attempted to adjust for biases introduced due to loss to follow-up, rates of psychiatric disorders in this population may not be representative of the general U.S. population of DWI offenders. The sensitivity analysis confirmed the direction of results in all instances, however. Another study limitation is that the interview used for both studies, the NCS-R version of the CIDI, may have underestimated the prevalence of substance dependence symptoms unless the respondents were positive for abuse. DWI offenders may be more likely to qualify for a diagnosis of abuse, as repeated driving under the influence of alcohol is one criterion for alcohol abuse.52
Other study limitations are the limited number of psychiatric diagnoses compared, sampling from a single locale, the use of self-report measures to ascertain psychiatric diagnoses using structured interviews for both the DWI and NCS-R studies, and no clinical confirmation of psychiatric disorders. We had to eliminate Native Americans and those of other races from the primary analysis because of insufficient sample sizes.
In conclusion, compared with a matched community sample, this longitudinal study found extremely high rates of addictive disorders among convicted first DWI offenders, particularly among women, 15 years after a screening referral, and similar rates of MDD and PTSD.