HRID – Phase 6

Every impaired driver who enters the criminal justice system should be screened and assessed to determine whether treatment is needed to address the underlying causes of their actions. A significant percentage of offenders have severe substance use disorders and co-occurring mental health disorders. The prevalence of these issues is high among high-risk and repeat offenders. Protecting society, therefore, means matching these individuals with treatment interventions that are tailored for risk, needs, and responsivity. 

Individual and group counseling along with more intensive psychotherapy are common approaches used with impaired drivers. Other common approaches include brief interventions, motivational interviewing, cognitive behavioral therapy, self-help and 12-step groups. 

To achieve reductions in recidivism, treatment, rehabilitation, and behavior change must be prioritized and offered in a way that produces maximum benefits for each individual client. Overly prescriptive or generic programming will lead to poor outcomes. Tailored interventions are far more likely to facilitate sustained behavior change. 

Treatment: Goals and barriers to entry 

When treating substance abuse or mental health disorders, the first step is to identify the nature and severity of the disorder(s) and then determine the best course of action to alleviate and manage symptoms and then in the case of substance abuse, interrupt addictive behaviors and patterns. 

Goals. DUI offenders have high rates of addiction and mental health disorders. Treatment is designed to lessen and prevent negative consequences associated with substance abuse, such as impaired driving or other criminal behavior. In addition to creating long-term behavior change and improving quality of life, a goal of any treatment program should be to reduce recidivism. Other goals include ceasing substance use, eliminating access to illicit substances, identifying and treating co-occurring mental health disorders, developing techniques to manage stress and anxiety, creating support networks, and developing strategies to prevent or manage relapse. 

Barriers. While society has made great strides to lessen the stigma associated with addiction and mental health, feelings of shame and humiliation remain one of the primary barriers to treatment entry. There tends to be a general lack of empathy for individuals with substance use disorders because a prevailing view is that they chose to consume alcohol or drugs and therefore, they are responsible for their own predicament. If these individuals are also justice-involved, then the likelihood that others will have empathy for their current situation is very low. More education is needed to raise awareness in society that these conditions are not reflective of moral failings but rather brain chemistry, genetics, and lapses in judgment. 

There may be other reasons why individuals fail to enter treatment, but several common themes include the following:

• Denial on the part of the individual that he/she has a substance use problem
• Unwillingness to stop consuming substances because the individual enjoys his/her current lifestyle
• Association with peers who are unlikely to support or facilitate sobriety
• Fear of experiencing severe withdrawal symptoms
• Perception that treatment costs are too high
• Lack of knowledge or awareness about where to go to seek help
• Inability to take time away from work or family commitments to enter into treatment 
• Lack of a support network 

In the case of justice-involved individuals, some of these barriers can be overcome simply because completion of treatment is a requirement of the sentence or supervision and the only options available are to either complete the program or face incarceration. Most will at least enter treatment, though they may be reluctant to engage. 

Addiction and serious mental illness: Definitions and prevalence

The American Society of Addiction Medicine (ASAM) defines addiction as “a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors…. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.”

Addiction and mental health disorders are diagnosed using a set of criteria published by the American Psychiatric Association (APA). Most practitioners rely on the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the principal authority for psychiatric diagnoses. Practitioners may use either the fifth or fourth edition of the DSM, and there are some differences between DSM-IV and DSM-V in diagnosing addiction.

Figure: Comparison of DSM-IV and DSM-5 criteria for diagnosing alcohol abuse and alcohol dependence vs. alcohol use disorder (Source: NIAAA)

In addition to substance use issues, the DSM is also used to diagnose other psychiatric disorders commonly referred to as mental health disorders or serious mental illness. Examples of serious mental illness include schizophrenia, major depression, manic depressive disorder, bipolar disorder, panic disorder, obsessive compulsive disorder, etc. 

Co-occurring disorders (also referred to as psychiatric comorbidity or dual diagnosis) are the presence of a substance use disorder and a mental health disorder. Research has shown that individuals with mental health disorders are more likely to also experience alcohol or drug dependency within their lifetime. It can also be difficult to identify and diagnose co-occurring disorders as the severity of the disorders varies and symptoms can overlap. For example, practitioners may identify signs of substance abuse but fail to identify the post-traumatic stress disorder that leads to alcohol or drug consumption as a way to self-medicate.

Individuals who suffer from multiple disorders may not always receive a complete diagnosis. While they receive treatment for one substance use disorder or mental health condition, their other disorder(s) will go undiagnosed, and, subsequently, untreated. 

The prevalence of addiction and mental health disorders is common among the general public:

• 18.7 million people ages 18 and older suffer from a substance use disorder. This represents 7.6% of the general population.
  • 75.2% of these individuals had an alcohol use disorder.
  • 36.4% of these individuals had a drug use disorder. 
  • 11.5% of these individuals had both an alcohol and drug use disorder.
• 46.4 million people ages 18 and older suffer from mental illness. This represents 18.9% of the general population.
  • Among individuals who had a mental illness, 11.2 million, or 24%, had a serious mental illness.
• 8.5 million people ages 18 and older suffer from both a substance use disorder and a mental illness. This represents 3.4% of the general population.

Overall, 56.8 million adults are affected by either a mental health disorder or substance use disorder. A significant percentage of these individuals will not seek or receive proper treatment for their disorders. Ninety-two percent (92%) of individuals age 18 and over diagnosed with a co-occurring disorder will not receive treatment for both issues. 

Rates of substance use disorders, mental health disorders, and co-occurring disorders are high among DUI populations, particularly repeat offenders.

• Approximately two-thirds of convicted DUI offenders are alcohol dependent (Lapham et al., 2001). 
• 91% of male and 83% of female DUI offenders have met the criteria for alcohol abuse or dependence at some point in their lives (Lapham et al., 2000). 
• Approximately 11-12% of impaired drivers are multiple drug users who report significant involvement in drugs other than alcohol or marijuana (Wanberg et al. 2005). 
• 33% of men and 50% of women with an alcohol use disorder also had at least one other psychiatric disorder (Lapham et al., 2001).
• 45% of repeat DUI offenders had a lifelong major mental disorder in addition to a substance use disorder.

The failure to identify mental health disorders can have negative consequences within the justice system. It misses an opportunity to intervene and treat individuals in an effective way. Many treatment programs, some of which are mandatory, only focus on substance use and fail to take into consideration the mental health issues that may be the cause of the alcohol and/or drug abuse. 

The use of comprehensive screening and assessment in the criminal justice setting is therefore necessary to identify co-occurring disorders among DUI offenders. 

Screening and assessment in a treatment context

The focus of screening and assessment within a treatment environment is slightly different than the process used in the criminal justice system. 

Screening is the first step in the process of determining whether DUI offenders should be referred for treatment. At this stage, offenders who do not have substance use or mental health issues are identified and those who may have issues can be sent for a more in-depth assessment. 

In recent years, there has been some blurring between the use of screening and assessment. In a high-volume system with multiple offenders processed daily, practitioners do not always have the time available to perform lengthier assessments. As a result, a screening may be all that occurs, and the information obtained from that screener is all that is available to guide decision-making. 

Depending on the screener used, clients may complete their own screening and have practitioners score the results. The process can take anywhere from 5 to 45 minutes to complete. The information obtained from screening is valuable for prosecutors, judges, defendants and defense counsel, pre-trial services, probation officers, and clinicians. 

Assessment occurs after the screening process is complete. Offenders who show signs of substance use disorders or mental health issues are commonly referred for further testing to determine whether they meet the diagnostic criteria for specific disorders. Assessments are more formal than screening tools and these instruments are standardized, comprehensive, and explore individual issues in-depth. A formal assessment takes up to several hours and is typically administered by a trained clinician or professional. 

Assessments should be validated for specific populations to ensure accurate results. Treatment providers who work with DUI populations are likely to select assessment instruments that provide detailed information about substance use disorders. These providers should also assess for mental health disorders and trauma in addition to alcohol and drug use disorders. Unfortunately, many treatment providers who handle DUI clients lack training and expertise in the area of mental health. There must be a more concerted effort to refer DUI clients to providers who have the ability to assess and treat clients with a range of disorders. 

Assessments are used to inform treatment plans for individual DUI clients or referrals to other services. Even if DUI clients are screened/assessed during other phases of their involvement in the system, treatment providers almost always perform their own screening and assessment to ascertain clinical information. 

Once screening and assessment are complete, treatment providers make recommendations for interventions based on outcomes. If they do not offer services that are tailored to the needs of individual clients, it is incumbent on providers to match these clients with other treatment programs. In every jurisdiction, there should be a network of treatment options that all providers should be familiar with to facilitate the referral process. Providers might also report back to the court or supervision authority with their recommendations and then probation might assume responsibility for making necessary referrals to programs and interventions.

Extra consideration should be given to female clients or individuals from different ethnic backgrounds as research has shown that gender-sensitive or specific approaches as well as culturally sensitive programs produce better outcomes by creating safer spaces for discussion and sharing. Trauma-informed approaches and treatment for traumatic events and post-traumatic stress disorder should also be considered for clients.

Principles of effective treatment 

According to the National Institute on Drug Abuse (NIDA), there are 13 fundamental and evidence-based principles that treatment programs should embrace to promote effective client care:

1. Addiction is a complex but treatable disease that affects brain function and behavior. 
2. No single treatment is appropriate for everyone. 
3. Treatment must be readily available. 
4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse.  
5. Remaining in treatment for an adequate period of time is critical.  
6. Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment.   
7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.  
8. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs.
9. Many drug-addicted individuals also have other mental disorders.  
10. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse.  
11. Treatment does not need to be voluntary to be effective.  
12. Substance use during treatment must be monitored continuously, as lapses do occur.  
13. Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary.   

Developing the treatment plan

Practitioners should have open dialogue with clients and discuss available treatment options including the strengths and limitations as well as the benefits and risks of various approaches. 

Practitioners recommend that all treatment objectives be SMART: specific, measurable, attainable, realistic, and timely to ensure that clients remain engaged in the process. Common patient responsibilities that are outlined in the treatment plan include the following:

• Keeping all appointments
• Agreeing to alcohol and/or drug testing on a regular basis 
• Taking medications as prescribed by a licensed physician 
• Refraining from drug use in instances where the substance is not prescribed 
• Admitting to use when it occurs
• Allowing and encouraging the involvement of family and friends in the treatment process
• Avoiding the persons, places, and situations that may cause relapse (i.e., identifying and avoiding substance use triggers) 
• Abiding by all provisions outlined in the treatment plan 
• Admitting to non-compliance.

Once the plan is created, it is common practice for clinicians and clients to each sign an agreement about the expectations of each party during treatment. The treatment plan should be considered a dynamic document that is subject to periodic review and modifications based on client experience and progress.  

Clients and clinicians should explore the creation of a strong support network. This network should consist of pro-social peers who support client abstinence and behavior change. Family and friends should participate in the recovery process if they can offer support and do not trigger clients. 

Level of care

One of the first decisions that counselors must make is identifying the appropriate level of service required to address client needs. The American Society of Addiction Medicine (ASAM) has identified five different levels of care with a variety of treatment options available along the continuum. The availability of each of these services may vary depending on the level of resources within individual communities. When clinicians make decisions about client level of care, they often rely on ASAM criteria to determine the most appropriate placement for clients. 

Figure: ASAM Continuum of Care and Treatment Placement Options

Source: ASAM, 2015.

Detailed descriptions about each levels of care, the types of services offered to patients, and how to identify individuals who would most likely benefit from these services are outlined in the ASAM Criteria. 

The most common types of care ordered for DUI offenders include the following:

• Detoxification – ordered for patients who are at-risk of experiencing complications associated with withdrawal. Detox is essentially a withdrawal process that is managed and overseen by medically-trained practitioners who can provide support to individuals who experience significant physical and mental symptoms. Withdrawal symptoms can last up to 10 days depending on the substance but commonly persist between 3-5 days. Withdrawal can cause severe symptoms including vomiting, cramps and sweating but is often not life-threatening if monitored and treated appropriately. Detox is not an active form of treatment.  
• Inpatient services – also commonly referred to as residential services, this level of care is designed as a medically-monitored 24-hour, seven day per week approach to programming. Individuals with severe substance use disorders and a high level of treatment needs are likely to begin treatment in an inpatient setting and then cascade down to lower levels of care once stabilization occurs and there is a period of abstinence. 
• Day treatment – patients who require more than 12 hours of daily intensive therapy are likely to benefit from day treatment as this option provides them with the skills needed to implement an abstinence-based recovery plan.
• Intensive outpatient services – for patients who are able to remain in the community and continue to maintain commitments such as employment, outpatient counseling is frequently the best fit. Individuals are able to access care that is specific to their needs and avoid placement in a residential facility. Most court-ordered treatment for impaired drivers is offered on an outpatient basis.
• Aftercare/relapse prevention – the provision of these services should be part of every treatment plan as relapse is a reality of the cycle of addiction. Aftercare services provide ongoing support for patients who are in the early stages of recovery and who have recently transitioned from more intensive treatment programming. 

Regardless of the approach, the process should always involve the completion of a psychosocial needs assessment, supportive counseling, establishment of a strong support network to facilitate recovery, and referrals to community services to address other foundational needs. 

Treatment planning should include collaboration with licensed behavioral health care providers to determine the optimal type and intensity of psychosocial treatment. These providers should also be consulted when clients fail to adhere to the conditions set forth in the treatment plan or do not follow through with recommendations. 

Treatment is even more individualized than supervision, and approaches that lead to success with one DUI client may not produce positive outcomes with others. Informed decision-making, weighing options, and obtaining client feedback and input are important to arriving at the best possible treatment placements and plans. 

Common treatment approaches

Several treatment approaches are commonly used among impaired driving clients. 

Brief interventions. Brief interventions are designed to identify an individual’s current or potential alcohol problem and motivate him or her to do something about it. It typically consists of a short counseling session (approx. 5-10 minutes), in which a health care provider discusses alcohol consumption and associated consequences with the patient. A behavior change plan is then negotiated. For patients with less severe alcohol problems, a brief intervention may be the only treatment needed to facilitate a change in their drinking behavior. For those who are dependent on alcohol, a brief intervention should be coupled with specialized treatment for chemical dependency. 

Motivational interviewing. Motivational interviewing is one form of brief intervention that is frequently used by community supervision officials. MI involves one-on-one, patient-centered, non-confrontational counseling sessions and may be used at different stages of an offender’s processing. The idea is to encourage the offender to acknowledge and accept substance use problem(s), understand the benefits of behavior change and treatment, and access necessary services that will assist the client in overcoming substance use. The premise is to enable professional staff to build a rapport with offenders and empower them to change on their own.

Cognitive-behavioral therapy. CBT is a form of psychosocial therapy with an action-oriented perspective. CBT encompasses a range of cost-effective psychotherapeutic approaches that deal with thoughts and beliefs as a means to reduce problematic behavior such as substance abuse. The objective is to identify thoughts, assumptions, beliefs, and behaviors that are related to negative emotions and underlying dysfunction (e.g., drinking problems) and to replace these thoughts and behaviors with more realistic, pro-social, and functional patterns and behaviors. 

Medication-assisted treatment. Pharmacotherapy involves the use of prescribed medications to help patients stabilize and control or eliminate the use of particular substances. There are two main types of pharmacological agents: substitution drugs, which are pharmacologically related to the drug producing the dependence; and blocking agents, which do not have any psychotropic effects and block the effects of the substance(s) producing dependence. These medications act on neurotransmitter receptor sites and produce decreases in cravings and, as such, can lead to better treatment and recovery outcomes. 

While MAT is not a substitute for cognitive-behavioral therapy or other forms of counseling, it is another tool to address substance use disorders. 

There are several commonly used medications to treat alcohol use disorder and drug use disorder:

• Methadone – relieves withdrawal and cravings to use other opioids. The goal for a person taking methadone is to feel normal, not intoxicated or in withdrawal. 
• Buprenorphine – reduces opioid cravings and withdrawal symptoms. Many versions of this medication are combined with naloxone to prevent possible misuse. 
• Extended-release naltrexone – blocks opioids from acting on the brain; takes away the feelings of euphoria or the reward of getting high. For some it may stop cravings. This makes naltrexone a good option for preventing relapse among highly motivated patients 
• Naltrexone – available in both oral (ReVia and Depade) and injectable (Vivitrol) form, naltrexone is an opioid antagonist that blocks the rewarding effects of drinking and reduces cravings for alcohol. 
• Acamprosate – available in oral form (Campral), acamprosate is a synthetic compound that reduces the symptoms of prolonged abstinence such as insomnia and anxiety. 
• Disulfiram – also known as Antabuse, this oral medication interferes with the metabolism of alcohol by the liver, which results in severely aversive symptoms such as nausea and palpitations. While this medication has been in use for the longest period of time, its utility and effectiveness are considered limited because compliance is generally poor when patients are given the medication to take at their own discretion.

Medication for addiction works best in the context of psychosocial treatment. Evidence is accumulating that weekly or bi-weekly brief counseling combined with medication is an effective treatment for many patients. The opioid and heroin epidemic has led to greater acceptance of MATs, although pharmacotherapies remain underutilized among the impaired driving population. 

Many of these medications can be taken safely for years and there is no recommended length of time for the use of medication in addiction treatment. While medications can be used as a stabilizing force and safety net, some clients may eventually choose to taper dosages or cease the use of MAT entirely. 

Self-help and 12-step recovery programs. While these are not formal treatment modalities, 12-step programs and support groups are some of the most common approaches utilized to address substance use disorders. Participation in these groups may be required as a condition of supervision or recommended as a supplement to individualized counseling or psychotherapy. Alcoholics Anonymous and Narcotics Anonymous remain the most popular iterations of self-help groups and have proven to be effective in helping individuals enter into and maintain recovery. Groups like AA and NA can be instrumental in building strong networks of recovery support within the community although these programs and their reliance on faith-based tenants do not work well for every individual. Clients should be encouraged to engage in programs that resonate with them, and if other step-based programs prove to be a better fit than traditional AA, clients should pursue these options instead. 

Challenges: Access and capacity issues 

Unfortunately, access to treatment is limited and the need for treatment services greatly exceeds availability, especially in rural areas. In addition to general capacity issues, common barriers to the delivery of treatment include 

• limited staffing and a lack of licensed/accredited treatment providers, 
• myths and misconceptions about the effectiveness of different treatment interventions,
•  delays in the amount of time between arrest and referrals to treatment, 
• inability to coerce treatment among resistant clients, 
• statutory requirements that outline the type of treatment interventions that clients must complete, 
• lack of responsivity, 
• cognitive deficits that are common among repeat impaired drivers, and 
• transportation issues.

Maximizing responsivity and treatment effectiveness

To enhance the quality and delivery of treatment services, agencies and practitioners should consider the following strategies:

• Provide education and cross-training to assist practitioners in understanding evidence-based practices and promising interventions as they relate to the screening, assessment, and treatment of DUI offenders.
• Allocate appropriate levels of resources (both funding and staffing) to accommodate the number of impaired drivers in need of treatment interventions. 
• Offer comprehensive services that combine multiple interventions and move away from the ‘one-size-fits-all’ approach. 
• Consistently identify offenders who are most likely to benefit from and/or need treatment. 
• Utilize screening and assessment instruments that are validated specifically among the impaired driver population to ensure that treatment needs are accurately identified.
• Monitor offender behavior to ensure accountability and offer aftercare services to provide ongoing support. 
• Follow recovery management principles in the form of supportive check-ups by treatment professionals to improve outcomes (preventing relapse or assisting offenders who do relapse to quickly transition back into recovery). 
• Identify appropriate measures of treatment efficacy. Currently, success is defined by the number or percentage of offenders who complete programs. This may not be the best way to gauge whether programs are producing long-term results. 
• Identify strategies and funding options to offset the costs of treatment for clients who are indigent or of lower socioeconomic status. Treatment should not be denied to clients in need simply because they lack the funds to pay for interventions.